Monday, March 31, 2014

R.E.B.E.L. EM and the Importance of Airway

In this brave new world of FOAMed one of the big challenges is vetting which sources of information are worth following. The work of Salim Rezaie (@SRRezaie) on his R.E.B.E.L. EM blog, should be a a must read for anyone trying to keep up in EM. He is a prolific contributor to #FOAMed with recent posts exploring the need for an insulin bolus in DKA and what actually matters in post-LP headaches.  But the one that prompted this long over-do "shout out" was a review of preoxygenation and apneic oxygenation that you should go read right now.

Your communication skills are probably those most critical to your overall success in medicine, but you can argue that airway skills come in a close second. If you train at an ACGME-approved residency program in the U.S. you will be required to perform 35 intubations to meet requirements.  Ask any Emergency Physician and they will tell you that 35 is just the beginning. Real competence likely happens somewhere around "triple digits". 

You have to start somewhere, and early in the development of your airway skills you are going to need some extra time to figure out where you are and what you are looking at.  These techniques for maintaining excessive oxygenation during the peri-intubation period are good for the patient and great for your chances of completing the intubation. The FOAMed world is full of wonderful Airway resources, and R.E.B.E.L. EM is a good place to start.  

Also see this primer on intubation from The Short Coat by Lauren Westafer (@LWestafer) and this lecture by Rich Levitan posted on the EMCrit blog by Scott Weingart (@emcrit).

Monday, March 24, 2014

Choose EM?

Most people reading this have probably already made their choice of specialty and have chosen EM.   But if you are undecided, having "buyer's remorse", or someone recently disappointed in not matching into what has become a very competitive specialty in the U.S., have a look at this recent post from Life in the Fast Lane on "Choose EM".

The first picture is as good a summary as I have found of what makes this specialty wonderful and unique.  

The second picture is a reminder that even the best job in the world has it's drawbacks.  If this was easy, everyone would do it.   

Congratulations to everyone who successfully matched in 2014!

Wednesday, March 12, 2014

So you did not match...

If you are reading this you are in the unfortunate position of having NOT matched in Emergency Medicine (or you have a degree of morbid curiosity).  The advice that follows is based on the experiences of applicants who did not match in recent years and the compilation of a discussion from the list serve used by most Program Directors in Emergency Medicine. 

First take a breath, your life is not over. While it is impossible to see now, the hurdles, trips, and falls teach us more than our successes. You will grow and learn from this and become a better care giver for having struggled through this. 

You are now faced with a big decision:  

Do you want to scramble into something else with the plan to train in that specialty? 
Or are you still intent on EM even if it is not this year?

The following advice is for those not willing to give up on EM.  One key thing to remember when deciding which group you are in: not matching this year does not mean you would not be an outstanding Emergency Physician. There are many great unmatched candidates out there who would have a spot if it were not for late applications, poor advising, a bad test score, or just bad luck.   

So what are your options if you are still intent on EM?
Most people come up with one or more of the following plans:
  1. Scramble into an open EM spot at a program they had not previously applied to.
  2. Scramble into another discipline with the intention of reapplying next year.
  3. Take a year off and do research or pursue a graduate degree like an MPH to improve your CV.

Scrambling into an open categorical PG1 EM spot is almost impossible.  There were 2 spots in 2013, with 686 US seniors without a match in EM. The chance of getting one of those 2 spots is 0.2%.  To put it another way 99.8% of US seniors who did not match in EM did not get a scramble spot in EM.

There is near universal agreement that taking a year off for research will hurt you more than it helps you.  Program Directors just do not care that much, especially about the kind of research you can set up and complete in one year (just not rigorous/impressive enough).  Many Program Directors are happy to interview re-applicants who have gained some clinical experience, but often do not bother if an applicant did research for the year.  There is significantly less agreement about what a degree like an MPH would do for you - which means that some people will be interested and others will not. 

So that leaves the most common reality of doing a year of something else.  The clinical experience will make you a stronger candidate and better prepare you for your EM internship.  Putting yourself through the application process again will enhance the perception of your commitment (something that often suffers in the applications of late converts to EM).  There are two primary considerations in this decision:  What kind of year to do?  Where to do it?

There is significant disagreement about what kind of prelim PG1 year is best, or if you should go for a categorical program (contract for full course of training) instead.  Here are the options and some explanation:

Transitional prelim year - thought of by the majority of Program Directors to be the best option for a re-applicant.  You split the year between surgery and medicine and get to do many of the things you would be doing as an EM1.  It is more rigorous and impressive than a year of IM and your future EM program may be able to give you credit for some of the months.  The downside is finding a suitable one that fits your other needs (see below).  There is also possible lack of flexibility for doing EM months and interviewing (if you belong to surgery during those months), and at the end of it you are left without a job if you do not match into something else.  In recent years these have become increasingly difficult to find in the scramble as less are available with other specialties incorporating internship into their training program.  The best way to have a Transitional year as back-up is to apply and interview for it, not to scramble.

Surgery prelim year - students choose to do this but few Program Directors think it is necessary, or even more helpful than a Transition or IM year.  That being said, there are some who think the more rigorous/abusive Surgery year is more impressive.  Again, you are left without a job after one year.

Medicine prelim year - often provides greater flexibility for getting EM elective time early (when you can get a new letter) and for interviewing.  And you will usually be treated better. Some Program Directors are less impressed because it is not as punishing and at the end you don’t have a job.  Finding a categorical IM program that will let you start as a PG2 should be an option if matching into EM does not work.  

Medicine or Family categorical spot - same benefits and downsides as a one year Medicine spot but with the advantage that you still have a training position should you be unable to jump to EM.  There is an additional downside of needing to break a contract should you match in EM.  This rarely is a problem so long as people are open and upfront with their IM Program Director.  Re-application is hard, and they know they have a good chance of keeping you, so being supportive of your plans keeps you happy with them.  After a Transition year this is the second most recommended option by EM Program Directors because you have a fallback position if you do not match in EM.

Where you do your year is MORE important than what kind of year you do: 

Location, Location, Location

The ideal position is one where you will have the opportunity to do an EM elective early (August, September) in an ED that has a residency program you are interested in joining.  This gives you access to new letters from people in an EM residency.  Most EM Program Directors agree that these letters will be the most important part of your re-application.  You are better off doing a conditional Medicine year at a hospital with an EM residency than doing a Transitional year at a hospital without an EM residency.  You need access to EM faculty who teach EM residents, and the EM Program Director at your hospital can be your best advisor in getting a spot in their program or another.  

Finally, something you can do now:  

Schedule EM electives for as much of the rest of this year as you can.  Get SLOE’s from all of these rotations.  These letters will help your re-application and you get to know more people within the specialty.  Unforeseen openings happen, even as soon as July 1, and the more people who know you, the better your chance at getting one of those.

I hope you find this advice helpful and I strongly encourage you to contact me if you have any questions.  I am happy to be of help.
Best of luck.


Lucienne Lutfy-Clayton M.D. FACEP
Assistant Professor of Emergency Medicine
Tufts University School of Medicine
Emergency Medicine Clerkship Director
Co-Director Emergency Medicine Simulation

Baystate Medical Center
759 Chestnut St
Springfield MA 01199
tel: 413-794-5999