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Author: Anthony Rodigin, USA
I have practiced clinical EM at a community hospital in San Francisco Bay Area since graduating residency in 2010. As assistant medical director of my ED I cover education, EMS relations and midlevel practice. Volunteer as EMS medical advisor for US national parks close to SF Bay, stay active in Bay Area Paramedic Journal Club (bapjc.org) and serve as ACEP ambassador to Russia. Biggest EM passions are education, EMS and international EM (especially focusing on EM and EMS in Eastern Europe and former USSR states).
During your emergency care career, you will not be able to avoid seeing the so-called VIP (very important…) patients from time to time. Whether it’s a VIP according to someone else higher up, general society or even your own perceptions actually does not matter – the end game is one and the same.
The best time to ponder and prepare regarding your future approach to VIP patients is now – before you are in the midst of the actual situation.
Now, if you are an idealist, things may seem blatantly easy. You shall and you of course will evaluate each one of your patients the same, regardless of anything about them! It may in fact feel insulting if someone were to insinuate that this case deserves or requires that “special” or “above and beyond” care. Doesn’t that imply that all of your other patients so far have been getting just average or so-so treatment?
A VIP patient is like a parcel box that arrives with a “handle with care” stamp. And the question is – are we not caring that way already?
Unfortunately, that is now how things may appear to others – exactly why patients and family members put on institutional badges or start mentioning names as you walk in the room. In a short while, random suits whom you have never met or knew existed descend from upstairs to “check on things”, as they seek you out to shake hands and make eye contact. And the general atmosphere affecting not only yourself, but also your nurses and everyone around slowly starts to resemble the buzz felt near a transformer booth.
The ethics and the philosophy of VIP-EM (I’m patenting the podcast name if you’re not) would take up a heavy volume. For our purposes, we will make it simple:
VIP-EM situations will potentially push you toward one of two things: either withholding what you normally would have done, or doing what you otherwise wouldn’t have done.
Let’s take an example of either situation to illustrate.
A secretary of a hospital network CEO arrives with her 3-week old having a fever at home. Someone had called the charge nurse ahead of time, and they are given a priority room, ahead of others. The baby looks fine and is, oh, so cute! You, unfortunately, know what needs to happen, and so does the useless WBC count. But…lumbar punctures hurt, and the mother is seeking out in your eyes the permission to defer it. So you send the happy baby home to its life-saving next day pediatrician follow up appointment and its Listeria meningitis demise…or do you?
A local TV station news anchor, and a friend of the Chief of the surgery department, pulls a shoulder while attempting a muscle up as part of the new IM-50X weight loss program. Physical exam findings are minimal, the XRay is normal and there is no concern for any neurological or vascular injury. You are requested to order a STAT MRI and to perform a shoulder steroid injection. Instead of the orthopedist on call, a special sports specialist catering to the town football team will be arriving in 3 hours to evaluate the patient, who will continue to hold up the ED bed. You will of course be prescribing narcotics for home…or will you?
Thinking about such hypothetical scenarios now to understand who you are and how you would behave will serve you well when the time comes. Regrettably, such education is often omitted from official medical school “handling difficult patients” curricula and cultural sensitivity training.
While I’m not an ethics professor, I do think there are three special circumstances within the entire VIP conundrum to consider.
The first is about returning someone injured in the line of public service to active duty. Whether it’s a colleague with a needle stick, a fireman needing clearance from minor inhalation or a police officer inadvertently embedded with a taser dart by one of his own – if you can return them to work rapidly and ahead of others, you should probably do it. First heal the healer goes a long way not only in major disasters, but in everyday life as well. It’s the basic utilitarian argument.
The second has to do with taking extra steps to ensure someone’s privacy. If the patient is the kind of a persona who has paparazzi following them day and night, going the extra mile to create conditions of confidentiality that are no more than usual is probably okay.
Third, I do want to mention that while the sense of entitlement to extra or special care among the VIPs may be prevalent, the latter trend does not encompass everyone. Just like you will never plant the seed of suicidality by asking a patient if he or she is suicidal, you are unlikely to offend a potential VIP by asking directly if it is okay for you to treat them as everyone else. You will be amazed, but quite a few people who have to carry out their lives in full view of the public or are subjected to immense professional responsibilities never want to be treated differently in the first place. Getting what I call a brief “fame holiday” may in fact be therapeutic and exactly what they need.
There are very few things in EM that are both deadlier and more unfair than VIP-medicine. Anticipating and mitigating potential fallout before it happens is a tough skill to learn. Knowing that such situations are unavoidable is the first step.
Last, while dignitary emergency medicine (DEM?) is not (yet) a legitimate EM fellowship, you can certainly read more about what’s being thought on this topic within the general medical field:
Al Mulhim MA, Darling RG, Kamal H, Voskanyan A, Ciottone G. Dignitary Medicine: A Novel Area of Medical Training. Cureus. 2019 Oct 22;11(10):e5962. doi: 10.7759/cureus.5962. PMID: 31799098; PMCID: PMC6863586.
The necessity of introducing emergency medicine (EM) into undergraduate medical education (here – medical school level) has been discussed, if not debated, for over four decades (1,2). More recently, two additional trends have become apparent. One speaks to the mutual co-integration and interdependence of all emergency care field components including EM (3). The other is the emergence of a keen interest in global health exhibited by both medical students and emergency medicine trainees alike (4-6).
Here we wish to present and describe a novel program for medical students that aims to address and integrate all of the three phenomena under one umbrella.
ACEP’s Global Emergency Medicine Student Leadership Program (GEMS LP) is now in its third year, with eighteen students from various medical schools learning about topics in global health through the guidance and shared experiences of internationally minded emergency physicians.
The International Section of the American College of Emergency Physicians (ACEP) is one of ACEP’s largest, with over 2600 members currently (7). In 2013 the Section’s first annual ACEP International Ambassador Conference took place in Seattle. The meeting formalized and accentuated the common vision shared by those section members who had already been actively involved in global health and international EM development in their respective nation(s) of interest (8).
In 2017 members of Emergency Medicine Resident Association (EMRA) approached ACEP’s International Ambassador Program with the idea of mentorship for medical students interested in both EM and medical work globally.
Through a collaborative effort the Ambassador Mentorship Program (AMP) was born and welcomed its inaugural class of eight medical students in 2018 (9).
To better align our name with the program’s vision, AMP was renamed the Global Emergency Medicine Student Leadership Program (GEMS LP) in 2020. Currently GEMS LP is open to medical students at all levels of training (prior to graduation) who are members of EMRA.
The nine month curriculum consists of several integral components, including global health knowledge development, research, personal mentorship and networking.
Focus on global health (GH): GH has become a field that aims to transcend not only the borders among nations, cultures, governments and organizations, but also the distinction between what is narrowly medical and what is widely ethical and social – as in rooted in people’s daily living conditions (10). It has been a consensus among GEMS LP’s participants that efforts to improve development of EM and regional emergency care systems around the world cannot be studied or pursued outside of the global health context.
The program runs a structured journal club done via video platforms which includes review and discussions of textbooks and original literature pertinent to GH topics. Since 2020, journal clubs have also included a new component where students prepare local health improvement project proposals (based on their geographic or cultural area of interest or prior experience). These “mock” project proposals are then discussed by the journal club group at large as another way of learning.
Examples of monthly focus themes have included global health inequity, sustainability in global health, ethics of humanitarian work, need for EM expertise in low resource settings, language justice in healthcare and the future of global health.
We welcome all members of the ACEP International Section and current GEM fellows (ask us how to get involved at infoGEMSLP@gmail.com) – international voices add much to the discussion!
Focus on mentorship and networking: Through one-on-one guided phone calls with GEMS LP faculty and other International Section physician members, students are exposed to multiple examples of individual professional paths and are offered guidance in exploring their options for future training, careers and work/life balance. Student participants also have access to globally involved EM physicians across the entire Ambassador Program and the Section, both domestically and internationally. Mentors and guest speakers have also given presentations on career paths in global EM during journal club sessions to give mentees a variety of perspectives on the diverse training and career options available.
Focus on scholarship and research: Mentors involved in academic research have had mentees collaborate in groups of 2-5 on research projects. Examples have included: state of emergency care in the post-USSR zone – a literature review, Ugandan emergency mid-level training curriculum work, a review of pre-hospital medicine in resource-restrained areas within India and Sri Lanka, assisting with the ACEP Ambassador Program Country Reports, and others.
Group projects are a great way for mentees to network and build lasting working relationships, not only with the mentor leading the project, but also with their peers. While mentees are not traveling for program projects in light of the COVID-19 pandemic, the projects are still a way in which the program helps mentees build real world skills for future GH ground work.
During the course of the program each student will participate in all virtual journal clubs, and will be responsible for at least one presentation of a book chapter, an original research paper or a global health project proposal. Longitudinally, students are paired up with a faculty’s research project in small groups, and as mentioned, also participate in a minimum of three one-one-one mentorship phone or video calls with different mentors focusing on various aspects of career planning. Students may also be introduced to and connected with ACEP’s international section members based on mutual backgrounds, cultural and language skills or GH interests. Finally, students are invited to attend the annual ACEP Ambassador Conference (virtually during COVID restrictions) and are expected to attend the GEMS LP program orientation and close out sessions.
Mentee retention: All mentees are invited to get involved with program leadership when they graduate the program, which is a constant source of energy and new ideas. This will ensure the program’s sustainability, as we build successive generations of program leadership from the trainees who themselves benefited from the program previously.
Expanding number of students and faculty mentors: As medical student interest in GEM opportunities and mentorship increases, we hope to continue expanding the program and recruit a diverse group of mentees, including international medical students. In order to facilitate this, additional faculty members will also be needed. The program hopes to continue recruiting diverse mentors, including those from international institutions (especially those from low- and middle-income countries), humanitarian organizations, community and academic emergency departments.
Expanding the research component and publications: Giving GEMS LP participants adequate exposure to academic global emergency medicine through participation in research projects and in peer-reviewed publications. Planned publications for the 2020-2021 year include: GEMS LP milestones study and a concept paper on the program. Currently mentees are interviewing the ACEP Ambassador team working in their country or region of interest on the state of emergency medicine development. We hope to publish an EM around the world country highlights article based on these interviews. Also, be on the lookout for an EM Resident piece in the April/May issue showcasing the projects that the 2019/2020 class completed.
Connecting with other organizations: GEMS LP is actively seeking to form mutually beneficial relationships with other organizations involved with EM, emergency care and global health domestically and internationally. Currently, we are working to expand collaboration with GEM fellows.
Please get in touch if your organization would be interested in collaborating at info.GEMSLP@gmail.com!
Information sharing: The program is interested in building an information repository to share research, advice and resources that accumulate within the program over the years that are useful for medical students interested in EM and global health around the world.
Impact evaluation: To formally evaluate the impact of the GEMS LP program on participant’s careers going forward, starting with the 2020-2021 class, students will be given pre- and post- program surveys using modified methodology described by Douglass et al. in “Development of a Global Health Milestones Tool for Learners in Emergency Medicine” (11). The milestones study is planned to track participants at 1, 2, 3, 5, 7 and 10 years post-graduation from the GEMS LP program to assess long-term impact on careers.
Relevance for the global EM-trainee community
GEMS LP’s current hybrid educational model has evolved to match the diversity of our mentees with their need to simultaneously gain knowledge in several interconnected areas: emergency medicine, international emergency care systems and global health and planning one’s future career as a medical student.
We hope that the GEMS LP program may serve as a potential model for others involved in global EM education such as medical schools, residency programs, or international colleges of emergency medicine to create opportunities and resources for their students to grow into thoughtful and successful leaders in the field of global EM.
In the current era of COVID-19, this virtual program may also serve to engage students and trainees in global EM work despite limitations on travel, as well as to expand access to formal mentorship opportunities for students who may not have these opportunities at their home institutions.
For more information on GEMS LP and how you can get involved as a mentor, mentee, or a journal club participant please visit the page below or email us!
The 2021/22 GEMS LP application will open for students this spring, with a deadline of June 30, 2021. We are always recruiting faculty mentors!
Cite this article as: Anthony Rodigin, Stephanie Garbern, Ashley Pickering, Alexandra Digenakis, Elizabeth DeVos, Jerry Oommen, “ACEP’s shiny new GEMS: the Who, What and Why that make this LP worth playing,” in International Emergency Medicine Education Project, February 21, 2021, https://iem-student.org/?p=17057, date accessed: February 21, 2021
Guidelines for Undergraduate Education in Emergency Medicine. Ann Emerg Med. 2016 Jul;68(1):150. doi: 10.1016/j.annemergmed.2016.04.049. PMID: 27343670.
Beyene T, Tupesis JP, Azazh A. Attitude of interns towards implementation and contribution of undergraduate Emergency Medicine training: Experience of an Ethiopian Medical School. Afr J Emerg Med. 2017 Sep;7(3):108-112. doi: 10.1016/j.afjem.2017.04.008. Epub 2017 Apr 20. Erratum in: Afr J Emerg Med. 2017 Dec;7(4):189. PMID: 30456120; PMCID: PMC6234139.
Carlson LC, Reynolds TA, Wallis LA, Calvello Hynes EJ. Reconceptualizing the role of emergency care in the context of global healthcare delivery. Health Policy Plan. 2019 Feb 1;34(1):78-82. doi: 10.1093/heapol/czy111. PMID: 30689851
Havryliuk, Tatiana et al. Global Health Education in Emergency Medicine Residency Programs. Journal of Emergency Medicine, Volume 46, Issue 6, 847 – 852. March 7, 2014.
Dey CC, Grabowski JG, Gebreyes K, et al. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med 2002;9:679–83.
Cox JT, Kironji AG, Edwardson J, Moran D, Aluri J, Carroll B, Warren N, Chen CCG. Global Health Career Interest among Medical and Nursing Students: Survey and Analysis. Ann Glob Health. 2017 May-Aug;83(3-4):588-595. doi: 10.1016/j.aogh.2017.07.002. Epub 2017 Aug 30. PMID: 29221533.
Douglass KA, Jacquet GA, Hayward AS, Dreifuss BA, Tupesis JP, Acerra J, Bloem C, Brenner J, DeVos E, Douglass K, Dreifuss B, Hayward AS, Hilbert SL, Jacquet GA, Lin J, Muck A, Nasser S, Oteng R, Powell NN, Rybarczyk MM, Schmidt J, Svenson J, Tupesis JP, Yoder K. Development of a Global Health Milestones Tool for Learners in Emergency Medicine: A Pilot Project. AEM Educ Train. 2017 Sep 11;1(4):269-279. doi: 10.1002/aet2.10046. PMID: 30051044; PMCID: PMC6001724.
A 52-year-old woman presents to the ED from an outpatient dialysis center with a rather vague history. She has no symptoms and feels normal, but she was told something “was either too low or too high” on her vital signs at dialysis, so dialysis staff did not perform her scheduled dialysis session. No one had called ahead to alert the emergency department, and the patient had driven herself to the ED, as she was instructed. Vitals show a normal temperature, respiratory rate, oxygen saturation, blood pressure of 102/47 mm Hg, and a heart rate of 138 beats per minute. The physical exam is normal besides a mild regular tachycardia and a working AV dialysis fistula on the right arm. EKG is done, and a representative portion is shown below:
EKG from the prior year is shown for comparison.
How would you interpret the first EKG, and what are your next steps?
While you are thinking, I will discuss a few of my practical observations from working in the pit. I want to focus not so much on the diagnosis but on working with these types of scenarios.
Treat the patient and not the chief complaint, vitals, labs, EKGs, studies, or referral information.
When they are feeling great and have no symptoms, they are feeling great and have no symptoms! Your nurses will not necessarily think this way, but one does not feel great while having a real STEMI apparent on the triage EKG. So what is it then, if the patient is here for a contact lens stuck in their eye, but has an EKG STEMI? Worst case – a prior STEMI that never corrected or evolved on the EKG. A ventricular aneurysm? Leads misplaced? Did your EKG tech do an EKG on themselves? A silent MI can occur, but an incidental STEMI is unlikely.
Of course, the patient has to be alert, competent, and not intoxicated. They should not be lying about or hiding their symptoms and should not have a secondary interest like the need to make it to a daughter’s wedding - live or die. The easiest thing is to ask directly.
What is the rhythm's rate doing when it is left alone?
Afibs and MATs will tend to vary greatly in the second to second heart rate, sinus tachycardias will fluctuate some, while A-flutters and SVTs will tend to stick to a single number no matter what you do and no matter if the patient is walking, talking, or snoozing. Stable Vtachs will depend on a number of factors like being monomorphic or polymorphic – but we are talking about narrow QRS dysrhythmias or ones with an obvious bundle.
So if you cannot tell from the EKG – observe what the thing does while left alone. As long as the patient is otherwise stable or has had symptoms for a while, you have some time.
Adenosine – not just for SVT conversion
“SVT = adenosine” should not be an automatic equation. First of all, there are contraindications to adenosine based on past history or current medications taken. But adenosine can also be used to “stretch out” weird or equivocal fast rhythms to make flutter waves or hidden P waves come out, so you can see and diagnose the arrhythmia vs. sinus.
You have to have continuous EKG recording going or printing the monitor strip to spot the temporary effect.
Hypotension + tachy-dysrhythmia: does not necessarily add up to Joules.
The textbook mantra of shocking any dysrhythmia associated with hypotension does not hold up in reality. In reality, you will find that most of your Afibs with a rapid response, your new-onset atrial flutters and your SVTs will have a lousy blood pressure: systolic of 80s and 90s are almost to be expected, and may even dip down to 70s on occasion. It also depends on a prior BP baseline, if the person is petite or dehydrated. But if the patient is mentating well and is not suffocating or experiencing crushing chest pain with diaphoresis, please don’t feel like you have to shock them. The body is not used to the new arrhythmia, and the rapid rate compromises the cardiac output.
Yes, you can still use your rate and rhythm controllers. Give the patient a gentle fluid bolus if you must. Of course, pacer pads do have to be on ahead of time.
Be afraid of shocking dialysis patients. Check electrolytes.
Hypotension with normal mentation is much better than a PEA arrest. Shocking extremes of electrolyte and acid/base abnormalities, whether due to TCA and other overdoses or in dialysis patients, will give you exactly that. This is especially true for the so-called “slow-X” arrhythmias: slow Afib, slow SVT, or even V-slow (Vtach with a rate of 130) that dialysis patients like to present in.
Just like airplane travel in transportation, electricity is in general the safest rhythm conversion strategy. But there are exceptions, and you only need to crash once.
A-flutter and the stuck rate of 150
You already know this, but just as a reminder. If the rate is a steady 150, plus or minus, and it is stuck there, you should think of atrial flutter.
Even if you do not see obvious classic flutter waves, there is a high chance of 2:1 conduction. In this case, I thought of it. Fortunately, it did not think of me.
Adenosine (again)….the 6, the 12…the 24??
Sometimes adenosine is not pushed correctly, but sometimes it just does not work or only works for a few seconds. Sometimes the patient’s Mom knows best what works, so you should listen. Sometimes the last time it was used, the patient really did feel like they were going to die – so they do not ever want it again. Ever. That you should try 6mg, then 12mg, then stop is generally true, but it is also a dead-end. What is your back up plan? Electricity? In the past I have given the doses in reverse, combined 6mg with the Valsalva maneuver and had given a preemptive beta-blocker or calcium channel blocker dose 10-15 minutes before adenosine to massage a stubborn heart into adenosine submission. It is ok to experiment a little. Another practical point – how much does your ED freak an SVT patient out while he or she is being triaged and roomed? I still do not completely understand why an SVT tends to be rushed up in the same fashion as a STEMI with cardiogenic shock and bradycardia, judging from staff adrenaline levels.
Calm the patient down, turn the lights off and let them change. It's like a kid with croup. Remember, it is lack of the sympathetic influx that we want, not an excess. Otherwise, why try the Valsalva at all? Has anyone attempted a stellate ganglion block Vfib-style for a refractory SVT? An overkill, I know….but could be fun, and practice for the real deal.
Aren’t all AVNRTs verapamil sensitive?
Years ago, in my first year of solo practice, I had a case of a refractory SVT in a young teenager, which a pediatric cardiologist consulting by phone called a “verapamil-sensitive AVNRT” based on the EKG alone. I was impressed. Hours later, I decided to flash my newly acquired cool knowledge and relayed the same to my in-house cardiologist, who looked at me with a grin and a raised eyebrow and said, “Anthony, all AVNRTs are verapamil sensitive”. At that time, I was also sensitive, and so my feelings were hurt. Lately I have gotten into the habit of treating my SVTs with diltiazem – as a purer verapamil relative. With generally good results and no need to stand in front of the patient during administration by the nurse.
The bottom line is – you have choices. Especially, if the patient is already on a beta-blocker or a calcium channel blocker, give them a beta or a calcium blocker IV, see what happens.
Despite a single nadir of blood pressure of 75 systolic, the rest holding steadily in the high 90s, the patient received a single dose of IV diltiazem and a small IV fluid bolus. Labs reviewed prior showed normal potassium, calcium, sodium, magnesium and the rest of them. Her average heart rate reduced to about 106 and a repeat EKG is shown, accidentally capturing an event:
She, of course, had a “verapamil sensitive” SVT. The patient’s new right bundle block had also improved to an incomplete, proving to be either SVT- or rate-related. The patient had never experienced any symptoms while in the ED. She was observed for a short time, scheduled for an out-of-sequence dialysis the next day and discharged home with a normal heart rate. I guess, in this case, we did treat the EKG and not the patient.
For a trainee in EM, it is useful to know about three types of cognitive practice that require caution.
While a knee jerk reaction may sometimes save time, a shotgun investigation may improve billing and a kitchen sink therapy may create the illusion of therapeutic rigor, arguably that’s all there is to it.
In reality, there is not much true value to any of these three missed approaches.
We will look at each one with a few examples and then briefly discuss below.
When I was rotating in the ED as an MS4, a visiting EM attending once told me that “adding a Type and Rh should become a knee jerk” for any patient with vaginal bleeding in early pregnancy. Whether or not taking the extra 30 seconds to scroll through the EMR for a previously documented Rh likely to be on file is a better strategy, this one is fairly simple.
Not all of our knee jerk reactions are equally simple or harmless.
I have seen adenosine being pushed before one could say “Mama” for anything from sinus tach to atrial flutter and A-fib with RVR: paramedics, physicians and even unsupervised nurses all being equally guilty. Why? Because a sustained heart rate above 180 is scary to some. And the reflex is to do something quickly because we don’t like to remain scared.
Nursing staff going straight for IV placement while forgetting not only the basic ABCs of resuscitation but even to disrobe the patient is another example. Starting any patient at 100% oxygen saturation who is short of breath on nasal cannula oxygen is yet another.
We like to do what we are trained to do well and/or what is easy. Our brains then compel us to prioritize doing it.
Once my ED team halted a verbal order for a whopping dose of colchicine blurted out to nursing by a careless consulting cardiology fellow – the patient had mentioned his ankle pain to the fellow in passing. The man was in acute renal failure and ended up with a septic ankle joint diagnosed later. Knee jerk is in part responsible for well-perpetuated ED mental formulas such as “gout = colchicine”, “fever = paracetamol”, “wheezing = albuterol” and “hypotension = 2 liter IV fluid bolus”.
The knee jerk is how we pick from our favorite antibiotics and how we generally prescribe, how we diagnose and order things on lobby and triage patients and how we even decide on CT scans and dispositions. Frequently, our hospitalist medicine colleagues will utilize the same reflex and unnecessarily or prematurely consult specialists.
On occasion, when the arrow released via a knee jerk reaction hits the bull’s eye, it feels and looks great. Knee jerk, unfortunately, is also how we assume, stereotype, over-simplify, ignore and ultimately miss.
This one does not have to be shot from the hip, though it certainly looks cooler that way. Often this is done thoughtfully, with a pseudo-scientific aroma to it.
I was on my MS3 internal medicine rotation when one day, the dreaded ED handed us an elderly female with a congratulatory thick paper chart, a bouquet of vague complaints and no clear diagnosis. When I asked my senior resident what we should do, the answer was a shoulder shrug and a confident “Lab ‘er up!”.
Shotgunning is not just about shooting out labs in the dark, however. It usually refers to a much wider “strategy” (actually, a lack thereof) of checking anyone for “anything” so as to not miss “something”.
Consider an ED evaluation of a headache involving some component of facial pain. Let’s order a migraine cocktail, CT and CTA of the head and neck, ESR to check for temporal arteritis; and when we find nothing, let’s do antibiotics in case of possible dental caries, otitis, mastoiditis or sinusitis. Sounds pretty thorough and terrific, doesn’t it? In fact, many patients would tend to think so. Clearly, after all that, we just could not miss something real badTM. We should remember that in EM you are worth every test that you order.
Hyperlaboratoremia and panscanosis are not the only clinical manifestations of the shotgun approach.
Though in all places, it is well-intended, there is a more buried shotgun in standardized chest pain workups, ED triage scales, pre-conceived clinical pathways and universal screenings than you may think.
One might say that kitchen sink is the therapeutic twin of shotgun diagnostics, though one does not need to stem from the other.
The kitchen sink is how you and I treat most non-threatening and hence not easily identifiable ED rashes. As one of my professors once said: the rule of dermatology is that “if it is dry, use a wetting agent, if it is wet, use a drying agent, plus steroids and antibiotics for everyone”.
At its core, any kitchen sink approach violates two key pillars of modern medicine – evidence-based practice and personalized therapy.
Another example is the kitchen sink phase of resuscitation in a soon to be aborted CPR effort. While in the beginning, we do tend to follow certain parameters and algorithms, towards the end and well into the “futile” stage of CPR remedies like calcium, magnesium, bicarbonate, second and third anti-arrhythmic and so on all inevitably flow one after another regardless of the suspected cause of cardiac arrest or objective facts known.
While benign rashes are benign, and futile CPR is futile, most of the kitchen sink does not involve such obvious extremes. In fact, some of it is perfectly legitimized and even justified – have you ever thought of what “broad-spectrum antibiotics” in sepsis really implies?
Reasons For Need To Know
Why is knowing about the knee jerk, the shotgun and the kitchen sink ahead of time important?
First, the cognitive action patterns described are unavoidable and inescapable. It is precise because we will not be able to fully stop using all three on occasion, that we should know about them ahead of time.
Second, there is something positive and well-thought-out corresponding to the other side of each of the three behaviors:
Fundamentally, knee-jerk reactions rest on pattern recognition as the predominant cognitive pathway at work – something that physicians start to rely upon more and more as they mature. While risking the error of premature diagnostic closure (among others), pattern recognition does save time and resources. This mode is why, as some studies suggest, senior-most providers may be more effective in triage.
On the opposing side of the shotgun coin are the well-accepted mantras of keeping one’s differentials broad and of thinking outside the box. Such forced mental efforts help avoid anchoring among other cognitive errors.
Last, kitchen sink elements may indeed be acceptable in salvage type of situations or in uncharted waters, given multiple paucities in our scientific evidence and in our full understanding of physiologic processes. In such select cases, we humbly admit our limits and hope that something unknown may work at the last minute, while there is no further harm that can be done.
It would be a mistake, however, to confuse each of the positives described with the three patterns we started with when taken in their pure form.
Third, the limitations and harms encountered by not keeping the three tendencies in check are real and immediate:
Knee-jerk reactions do not yield beneficial results when the situation encountered is new and principally different from those experienced before, yet it has the external appearance of something familiar. Think of COVID.
Shotgun-galore practices subject multiple patients to unnecessary tests and to potentially harmful procedures and interventions that inevitably follow, further inflating the costs of healthcare.
Perpetuating myths and unmerited traditional practices, kitchen sink therapies also coach our patients into expecting both the unreasonable and the unnecessary for the next visit, undermining any accepted standard of care at its very core.
A more in-depth discussion of all three phenomena presented would indeed be appropriate, including an investigation into any viable alternatives.
For now, I encourage all trainees to look further into the general and well-researched topic of cognitive errors in emergency medicine.
We should also all strive to practice based on best available evidence and not to be coerced into questionable behaviors by external pressures such as performance metrics that may lurk as false substitutes for quality.
References and Further Reading
Frye KL, Adewale A, Martinez Martinez CJ, Mora Montero C. Cognitive Errors and Risks Associated with Provider Handoffs. Cureus. 2018;10(10):e3442. Published 2018 Oct 12. doi:10.7759/cureus.3442
Oliver G, Oliver G, Body R. BET 2: Poor evidence on whether teaching cognitive debiasing, or cognitive forcing strategies, lead to a reduction in errors attributable to cognition in emergency medicine students or doctors. Emerg Med J. 2017;34(8):553-554. doi:10.1136/emermed-2017-206976.2
Schnapp BH, Sun JE, Kim JL, Strayer RJ, Shah KH. Cognitive error in an academic emergency department. Diagnosis (Berl). 2018;5(3):135-142. doi:10.1515/dx-2018-0011
Whether you are an optimist, a pessimist, or a strict realist is likely to impact how you would project potential effects of COVID on the post-COVID world.
I would argue that from the medical-practical perspective, the three attitudes above are not mutually exclusive. As we often conclude when reading pro- and con- arguments for a new legislature, unrefined reality allows for enough mixed data and scattered observations upon which to base and justify either stance.
My approach here is more of realistic anticipation: what changes to our global emergency care practice environment may result from what we are experiencing today? Undoubtedly, such changes will affect trainees a lot more than seasoned EM providers.
While by no means a new thing, Telemedicine has advanced exponentially over the last few months and has come to the forefront of medical care in terms of its scope, breadth, and practical applications.
I am what my spouse would call “technologically challenged” (if she were to put it kindly). Yet even a tech-doofus (me) has had to dabble in Telehealth over the last few weeks – both inside my ED and to reach patients thousands of miles away.
TAKE-HOME: The earlier and the more you get exposed to Telemedicine, the smoother your future tele-practice will be. Telemedicine to EM today is sort of like what Ultrasound was to EM twenty years ago. I see an EM Telemedicine fellowship coming your way.
Local Resource Preparedness
Everyone now realizes that you need to have tucked away but keep readily available roughly two N-95 masks per healthcare worker per day for three hundred and sixty-five days, amen.
Which changes in how entire healthcare systems are financed are necessary is a huge comprehensive topic. But point-preparedness, as in being ready at the actual place where you and I live and work locally, is a much easier thing to wrap our heads around and become directly involved in.
TAKE-HOME: Find others like you, cooperate, get involved, and make your voices and opinions heard and count. We do not know when the Penguin flu or SARS-5 will hit us, but surely they will and with a vengeance. There is a tacit hope we will be smarter and more prepared next time.
I do not know if golf practice makes you better at playing basketball or swimming at karate. But I do know that we have become so specialized, it is almost like there are hand specialists nowadays who will only deal with the left index finger.
COVID has shown all of us that it is not helpful to only possess knowledge and skills within the comfort zone of your specialty or sub-specialty.
As an EM doc, I have been okay with my ventilator and ARDS management skills. But the last few weeks have been extraordinary in reading up on anything from the forgotten basics of epidemiology and virology to palliative care. And that’s a good habit of keeping up for the future.
TAKE-HOME: Get out of your profession’s shell and encourage others to do the same. EM standing for Everything Medicine has never been more true. We are kind of lucky that way.
Sorting Out The Trash In Medical Literature
It is one thing to be able to verbally shred a New England or a Lancet paper at a leisurely journal club; it is quite another to be able to apply new (or old) reported research to clinical practice without harming anyone.
In the times of YouTube anxieties and misinformation, the latter task becomes even more crucial yet difficult. COVID controversies ranging from antimalarials to early intubation are a prime example.
But the good news with COVID is that I think we have just been handed the requirement for a free refresher course on how to appraise medical literature critically. We have to do this under pressure, without much time, and, arguably, fighting with our own natural inclination that “to do something is better than doing nothing.”
TAKE-HOME: Less YouTube, more journal clubs. Our relatively young standard of evidence-based medicine is being tested worldwide like never before. Let us wish for it to perform well and withstand all the temptations. And yes, you do need to become a pro with this one.
Patient Privacy and Empty EDs - As They Were Intended?
These points are controversial. But with medical information privacy requirements being loosened in many locations and with fewer non-COVID patients going to EDs, it is a valid question to ask: is right now how things should have always been?
Whether certain patients do not belong to an ED is a complex topic. Finding the golden middle between protecting confidential patient information and enabling providers to reach and treat patients most efficiently is likewise easier said than done.
For now, I am just inviting you to think about it.
TAKE-HOME: It may be that things will never go back to how they were. Perhaps we have all overdid it with patient privacy laws that, for a long time, had trumped basic common sense. It may also prove that no one will suffer a dire consequence because they chose to call a doctor via video rather than to drive to an ED. Keep a lookout for good data.
Viruses In Focus
After decades and billions poured into research, we finally have stuff against HIV. Hepatitis and the herpes families are the two runners up, plus we developed a few effective vaccines like the MMR – but that’s about it really.
So much time and focus have gone into killing bacteria, we have somewhat neglected the other big guy. Until now.
TAKE-HOME: Nobel price winner Joshua Lederberg once said that “The single biggest threat to man’s continued dominance on this planet is the virus.” You will likely be practicing during an era of unprecedented anti-viral efforts. Just like with bacteria, we may not succeed all the way. But as long as we do not all turn into zombies, it’s okay.
The Cure For The Common Burnout
Emotional exhaustion may indeed be the key factor in professional burnout for emergency care providers. But other factors contribute as well – including feeling unappreciated or not needed, and work seems routine and mundane.
We now have COVID, which has reignited the fire for many EM providers, no matter how deep are those post-N95 facial marks. Otherwise, why would one fly to New York or elsewhere right now “to help”?
Frontline medicine certainly takes its toll on you. But hardly anyone in our specialty should feel not needed or unappreciated anymore.
TAKE-HOME: Wake up and go to bed humbled, proud, and lucky to be able to do this work.
The few changes I have listed come from a very long list. Whether they will prove to be overwhelmingly positive remains to be seen. Of course, future benefits do not negate the tremendous harm and suffering the pandemic has already brought and will continue to bring in the months to come.
But one thing is for sure: COVID is not the last time we are dealing with something like this. What your attitude and knowledge will be then, is up to you.
A 47 year old woman comes to a community ED complaining of pain and redness in her right foot developing quickly over two days. She denies any trauma and otherwise feels well. She is not sure, but may have had a “sore” near her toes that has already healed. Patient has diabetes but is normoglycemic. She has no prior history of cellulitis, joint infections or gout. There is no history of immunocompromise, including steroids, or any IV drug use. All vitals are within normal limits and review of systems is negative for fever, chills, respiratory or gastrointestinal symptoms.
On exam, there is generalized edema, erythema and tenderness, but no tenderness out of proportion, and no open sores or ulcerations. A sub-acute appearing callus is apparent on the plantar surface opposite fifth and fourth distal metatarsals. The ankle joint is tender but less so than the foot, and ranging it does not elicit more pain than at baseline. Distal sensation, pulses and toe motion are intact, though capillary refill is slightly delayed.
What would be your plan? And when and how would you present this case to an attending?
Are labs indicated, which ones, and what are they expected to show? Will that change your plan?
Any imaging? Your choices range from nothing, to bedside US to look for an abscess, to XR, CT scan or even an MRI, if available.
Is she a candidate for oral antibiotics and discharge? If so, what sort of follow up does she need?
Is there any benefit of IV antibiotics if the patient is going to go home?
What is the worst case scenario here that may not be apparent? Is there any threat to life, limb or both?
Basic labs obtained are unremarkable and patient is receiving IV broad spectrum antibiotics, including MRSA coverage. Plain films are obtained, and there is some concern for small air pockets in the soft tissues.
A phone consultation with podiatry is obtained. A decision is made to take the patient to the OR on the same evening. No further imaging or diagnostic studies are advised.
What if there is no podiatry, and your general or orthopedic surgeon does not handle foot cases? What if there is no surgical coverage at all?
Would there be a role for a limited ED I&D or needle aspiration in this case?
Would you transfer this case? How do you justify it, if all the labs and vitals are normal?
After the callus is taken off in the OR, large amount of frank pus is obtained that tracks all the way to the third metatarsal. A debridement is performed, and long term antibiotics with close follow up are needed. Overall impression was that while no necrotizing infection was found, any further delay would have risked a trans-metatarsal amputation (at the least).
While we do not have room for a lengthy discussion on differentiating plain cellulitis from “other”, it is worthwhile to note several things:
Do not get locked in onto cellulitis as the diagnosis. Abscesses, necrotizing infections and septic joints need to be considered and ruled out at all times.
Susceptible populations such as diabetics and IV drug users are easy. But the rapidity of symptom development is just as important in any population.
Beware even chronic appearing calluses as masking places for pus and as barriers to its natural drainage.
More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
To I&D or not to I&D is often the question. Good news is that more often than not I&D is the right answer. There is a reason you have already thought of it. You are in the ED - the last line of defense for many patients. Pus needs to come out. The surgeons are not the only guys with knives. Don’t let yourself or anyone talk you out of it. For the tremulous patients (and providers), there is ketamine.
Whenever I bring my two kids to their pediatrician, there are two entrances labeled “sick kids” and “well kids”. Self-explanatory – except that both doors lead to the same shared air… so go figure.
But in emergency medicine, the word SICK takes on a very different meaning.
By SICK, we do not mean “ill” or “not-well,” “not feeling all-right,” or just having a complaint. In EM, SICK means something is very wrong with the patient, regardless of the body system affected or injured. “This particular person is sick” is how you would start your sign out to a colleague. Translation – I am actually worried about this one.
A SICK story
I was a junior resident co-managing the Trauma Bay with my senior, when among multiple other patients a middle aged man was brought in by EMS with a chief complaint of “struck by a car”. It turned out that after finishing their mutual project, a fellow handyman was backing out from the client driveway in a van and inadvertently hit his buddy. Low speed, no head injury, stable vitals and no real complaints beyond some abrasions: no problem, right?
Within 10 minutes, the patient had developed tachycardia, dumped his pressure and then became altered. “This guy is sick!” blurted by chief with some dismay, as he was already busy with several other traumas that were much more obvious. Within a minute, we had intubated the patient and activated the surgical team response. Needless to say, the FAST was very positive.
Unfortunately, the patient never made it to the OR. He coded and died in the ED before any surgical intervention could be done from what was later determined to be a massive splenic injury. No external signs for concern on the initial physical exam. It was the unlucky height of the rear bumper and the force of the van that did it.
Searching for the SICK
Hunting for the SICK remains the cornerstone of EM. Like seeping through muddy waters, we first have to find them – before “stabilizing, treating and dispositioning”, as our mandate proclaims.
Many tools are, of course, available for this task. They range from internationally accepted nursing triage scales, abnormal vitals and “scary” labs like bandemia, sky-high CRPs and lactates to sophisticated risk stratification systems. But no lab or objective score algorithm can replace your high level of suspicion, formal training, experience and clinical gestalt.
In your EM rotations, you will hopefully encounter and be taught from all of the following: high risk chief complaints (testicular pain, sudden onset headache, tearing chest pain, etc.); susceptible populations (neonates, dialysis patients, elderly, IV drug users, returning patients and so on); ominous physical exam signs (anisocoria, tongue bed elevation, extremity pallor, Cullen’s and Grey-Turner’s, abdominal rigidity, Cushing’s triad, etc.).
The hidden SICK
Not too far from the Trauma Bay within my residency’s ED resided the Behavioral Care Unit also known as the BCU. A designated holding place for patients requiring a psychiatric evaluation, the BCU was a favorite place to go to for any resident who desired to increase her productivity numbers via rapid medical clearance of multiple psychiatric holds.
Yet for many trainees, especially seniors, BCU was also a place to hunt for the SICK amongst the crazy. Many a hypoglycemia, a hyponatremia, a sepsis or a subdural hematoma were found there on numerous occasions, often with a delay from the ideal timeline.
Here are a few more phenomena to be on the lookout for:
The very quiet elderly – grandma is not peacefully asleep…she’s morbidly ill
Inappropriate and unexplained vitals – especially tachycardia at intended discharge
Lack of GCS improvement with time – the alcoholic who is not really intoxicated at all
Worse after IV fluids – is there tamponade-type physiology, a ruptured heart valve, or internal bleeding?
Will not walk – no one should be discharged in a wheelchair who did not come in one
First-time migraine or psychosis at age forty – nope! thou shalt look again
Anxiety – the real anxiety should be claiming that as your sole diagnosis
This list is yours to expand.
Finding the SICK - it’s you and your environment
Two things – First, as a trainee, you should always be more paranoid and suspicious of hidden pathology than your supervisors and teachers, not less so. They have the mentioned training, experience and gestalt in their arsenal, you don’t. You are thus stuck with the first item. I am often responsible for teaching newly graduated physician assistants at my work – and it really rocks my boat when I hear “I think it’s just a cold” theme from a newbie.
Second, chances are your training is currently happening at the happening place: some huge university hospital. It is currently very likely and thus very easy to find the SICK. But you are not really honing your skills for working at such places. EM life in virtually any other setting will be much more like trying to find the needle in a haystack. Think about it.
When I was rotating on surgery as a medical student, our attending once asked of our small group what may be concerning in the differential for right upper quadrant abdominal pain. A very eager and a somewhat brash student blurted immediately: “Echinococcal cyst!” The attending replied, “Well, that’s true, but if Echinococcal cyst is the first thing you think of as a surgical consultant, you’re crazy!”
On the other hand, take a practicing internal medicine physician like my Dad. He formulates his differentials with a very different strategy, which is: what is the most likely? A chronic cough is bronchitis (even with hemoptysis), pneumonia, GERD or postnasal drip. Shoulder pain is, of course, a sprain, bursitis, or some referred cervical impingement. And so on.
Unfortunately, neither hunting for zebras (an unofficial US name for exciting but rare diagnoses) nor settling for the most common works for emergency medicine. In fact, that is how true diagnoses may get missed and patients may start dying.
Why we are different
The EM differential diagnosis is a pyramid tipped on its head. It is therefore different from how differentials are approached by many other specialties.
In EM, we first have to think of and rule out the most severe or threatening pathology. That’s a given. But our choices have to come from among the common killers, not Martian viruses or unheard of tumors from a medical encyclopedia.
Amoebic meningitis is exciting to encounter in your practice. But guess what? Your patient won’t have it. At the same time, for EM physicians things like pulmonary embolus, aneurysm of the abdominal aorta, subarachnoid hemorrhage and necrotizing fasciitis are everyday icons on our cognitive desktops. While less common than a common cold, these things are by no means rare.
Why it is difficult
In EM, one can rest assured that common pathology will present atypically and not quite like the textbook.
Things are further complicated by confounders, mimics and the disjunction of concern.
Confounders are concurrent pathologic processes that the patient already has, which tend to get worse due to any new significant disease process or general body stress. CHF and COPD get exacerbated, kidneys become insufficient, anxiety and psychoses go florid and atrial fibrillation accelerates to rapid. How do you spot sepsis or an MI, which is the true cause of it all, underneath layers and layers of abnormal vitals and test results?
Mimics are things that pretend to be other diseases. PE presenting with a low-grade fever and a cough, carbon monoxide poisoning posing as geriatric altered mental status, and severe sepsis arriving as chest pain, dizziness and a bumped troponin. Such has happened many times in the past and continues to happen daily at all EDs globally.
The disjunction of concern is when your patient is not worried about what you are worried about. They don’t want to get cancer like their neighbor, but they have never heard of a TIA or an AAA. Kawasaki disease? Why don’t you just give my daughter better antibiotics? My uncle died of a heart attack at 35, not a “bisection” or whatever you called it…So I don’t want a CT scan!
An EM physician’s focus on ruling out worst-case scenariosmay paradoxically contribute to a patient’s distrust at the end of the encounter. The patient’s agenda is to leave knowing what disease they have, while we are often satisfied knowing which horrible things a patient does do not have.
It may take years of practice to be able to persuade someone that you have done due diligence and your professional duty by excluding a whole lot of deadly things, while the exact diagnosis still remains elusive.
Secretly paranoid, openly confident and always nice
We are confident, but also afraid. We have to think of the worst yet possible scenario for any complaint, yet of course anticipate that the actual diagnosis will hopefully be something less severe and quite common – like a migraine. After all, after most CT scans and lumbar punctures, it is not a subarachnoid hemorrhage.
In EM, we are in this perpetual struggle with having to be professionally pessimistic and paranoid on the one hand, yet emotionally supportive and reassuring for the patient on the other. I always teach my students, even nursing trainees, that no one should be leaving an emergency department more scared or anxious than when they came in.
Your job as a rotating trainee in EM is to understand and learn this exact interplay.
For your attending, but more importantly for yourself and your patients, you have to be as concerned with sepsis from PID on a 16-year-old young woman with fever and abdominal pain as you are with appendicitis. The 86 year old grandmother with Afib but on no anti-coagulation, because she falls a lot is not just TIA or CVA prone. Her embolic clots may just as well be traveling downstream, causing that intermittent or out of proportion abdominal pain called mesenteric ischemia – for which you do not have a good lab test or imaging, by the way.
Here is a brief checklist:
For any anatomic complaint or a chief complaint type
think of several real worst-case scenarios that are not zebras. Can something horrible yet by no means unheard of be presenting atypically? What steps can you take to prove or disprove it?
Think of confounders and mimics.
What else could be going on? Like a stack of dominoes: what happened first, what happened next?
Address the patient’s concerns
while carefully and patiently pursuing your own professional agenda.
When it turns out to be something common or benign,
don’t forget to discuss worrisome signs for which to return. What if you’re still wrong?
A few years ago, a staff pediatrician at my hospital asked me who ranked higher - a paramedic or an Emergency Medical Technician (EMT)? I remember thinking two things: first was the obvious "duh!", but the second was "hmm...maybe some things are not so obvious to non-Emergency Medicine (EM) physicians."
If you are already doing an EM rotation at an Emergency Department (ED), then chances are that EM is already established or is being established at that locale. Chances are, your ED is receiving ambulance traffic and of course you know the answer to the above question.
So why even talk about pre-hospital emergency medical services (EMS) at all? What does that have to do with your EM/ED rotation, or even with your future EM practice?
Receive your information about a patient directly from the ambulance personnel.
For one thing, it’s simply prudent and efficient. What was happening at the scene? Who called? Who else is coming? What did the EMS medics do or not do? What is the patient’s primary concern, and does that match or not match the ambulance crew’s primary concern? Much information can be lost or misconstrued if we solely rely on the nurses, even worse – on paper, to tell us the full story.
Watch the patient on the EMS gurney carefully
Often their facial mimics, gestures and the way they are looking around the ED will tell you a lot. Can they transfer to the ED bed themselves? What’s their body mechanics while doing that? There is much to learn here in just a few seconds – trust me. The patient may not end up being yours, but in a little bit of time, an hour or two, look them up on the ED board and see if your own initial impression was right: sick or not sick? Serious or so-so? Admitted or discharged? This is a critical skill to hone for any EM provider.
Anticipate EMS patient needs even before they are roomed.
While it is true that most of our ED patients are walk-ins, multiple analyses have shown in multiple locations around the world that the EMS patient population tend to be sicker. So this population is where some of those cool and awesome procedures that you want to see, learn or perform are often found. Healthy 18-year-old man, tall, suddenly short of breath while playing basketball with his friends – there is your chest tube arriving, see?
Your main task is to learn to comprehend the entire emergency care system. EM providers in EDs do not function in isolation. We are part of the emergency care continuum and should thus be those most proficient is seeing and knowing the big picture. EMS is the beginning of that picture.
EM physicians all around the world participate in pre-hospital work via multiple avenues: supporting public and sporting events, serving as cruise physicians, staffing ICU-ambulances and EMS support vehicles, flying on medical helicopters, writing EMS protocols, training paramedics and providing real-time phone, radio or teleconsultations. Chances are, you will too!
So while you are rotating at an ED, especially a foreign ED or one away from your home base, take a small effort to learn about the local EMS. Talk to the medics, talk to ED personnel taking EMS radio calls and look pertinent things up on the internet on your own (like local EMS protocols). Talk to the attending EM physicians in your ED – chances are, one of them is the local EMS guru!
Some simple things you may wish to focus on to gauge any EMS system anywhere
Is there a single EMS emergency number for the public to call?
Is there a centralized EMS dispatch? Are they Fire, Police or EMS-proper?
Can an ambulance crew be re-directed away from the ED to take a patient to some alternative location or treat and leave the patient at home?
Are there criteria for Trauma Center, Stroke Center and STEMI Center destinations? What about sick kids and neuro-trauma?
Is there a global positioning system on the ambulances? Can they transmit EKGs or other information to the ED?
Are there different types of ambulances, and different response types? For instance, when are two ambulances or an ambulance plus a fire engine sent to the same call?
Who staffs the ambulance? Is it paramedics, EMTs, nurses, nurse practitioners or physicians? In what numbers? Are they understaffed?
Is the paramedic scope of practice truly that of a paramedic? Can they intubate? Can they push IV medications or run drips?
What medications and equipment do ambulances carry? Is there CPAP, LMAs, IO needles or devices? Are there automated chest compression devices (and does the literature support their use)?
Are ambulances services public or private, or is there a mix? How are they funded?
Who determines their number and distribution at a given geographic location? Is that enough?
How are inter-facility transports handled? Is it the same ambulances who bring you the patients?
Finally, many an interesting medical student or resident research project began out of some EMS-related consideration or observation, so keep your eyes and ears open for those research ideas! Good luck!.