The residents would like to thank and congratulate Dr. Beth Pontius as our selected Faculty of the 1st Quarter. We very much appreciate all that she does for us and see her as an essential piece of our program! Here are some of the things our residents have said about Dr. Pontius…

“Not only is she very smart and a great teacher, both generally and of ultrasound, but she is a pleasure to work with.”

“Dr. Pontius is a great mentor and clinician. She is very approachable and seriously considers your clinical opinion. A shift with her is always a great experience.”

“Welcoming and unintimidating…wonderful female role model.”

“Dr. Pontius found opportunities to incorporate clinical teaching and ultrasound multiple times during all shifts I worked with her. She also brings her good mood and humor to the table, which makes working shifts with her particularly rewarding.”

“Beth is always a pleasure to work with. She is excited and passionate about her work and that energy is infectious.  She is always willing to take the time to teach and when she needs to correct you she does so in a way that is constructive and never makes you feel bad for not knowing.”

“Beth is a great down to earth person who always gives helpful and practical clinical advice and guidance. I feel very lucky to have her as part of our education team!”

Thank you for all that you do for us, Dr. Pontius!

GUH/WHC Emergency Medicine Residents

Sports Medicine Fellowship

On January 7, 2015, the NRMP will release the results of the MedStar’s Emergency Medicine/Sports Medicine match. MedStar’s Emergency Medicine/Sports Medicine Fellowship program has completed its interview days for 2015-2016 year. We look forward to our 2nd match as we continue to grow and nurture this evolving fellowship.

Ultrasound Fellowship

First and foremost Dr. Layman wishes to thank everyone for their help in their most recent fellowship interview season. November 13th marked the offer date for Emergency Ultrasound Fellowships across the country and we are happy to announce that we have matched two outstanding candidates.

Katie Voss, MD, current chief resident at MedStar Washington Hospital Center, will be joining us as a fellow for the year 2015. Our second fellow will be Erica Peethumnongsin, MD PhD, who will be joining us from The University of Wisconsin Residency Program. Previous to her training there she completed medical school and a PhD at Baylor College of medicine.  Dr. Peethumnongsin is looking forward to a move to the DC area.

It was a competitive match this year with many strong candidates and Dr. Layman and team are happy to have matched two great people.

Dr. Mike Ybarra
 

The MedStar Emergency Medicine Health Policy Fellowship is a one-year immersion in the Nation’s Capital with an anticipated launch in July of 2015!

There is no greater place in the country to learn health policy than in the city where policies are made, regulations are set, and major research is accomplished.

This unique fellowship has three main pillars: policy education, policy experience, and clinical work. The core of the fellowship program is experiential learning in health policy. Most of the fellow’s time will be spent on site at agencies or with organizations that do substantial policy work.

The three experiences include: the Legislative Experience; the Organizational Experience; and the Lobbying Experience. The fellow will have the opportunity to moonlight with MedStar Emergency Physicians.

The clinical sites include high acuity, high volume emergency departments in Washington, DC with the opportunity to teach and mentor medical students and residents.

We look forward to accepting our newest fellow for 2015-2016.

Application requirements include: Curriculum vitae, Letter of Interest (this must include a statement of interest in the McCourt School of Public Policy Certificate Program), two letters of recommendation (including one from the Department Chair or Program Director), and an undergraduate transcript (for the graduate program).

MEP Day 2014

Pearls from Dr. Antonis Lectures [July]

Push Dose Pressors:
The following is true regarding the literature on push dose pressors:

A) Unequivocally supports there usage on all hypotensive patients
B) The dosage of Epinephrine for hypotensive patients is 1mg IVP of 1:10,000
C) Phenylephrine has been used on pregnant females undergoing spinal anesthesia
D) Phenylephrine is a pure Beta agonist and increases heart rate dramatically
E) All of the above

REFERENCES:
• Heffner AC et al.  Predictors of the complication of postintubation hypotension during emergency airway management.  J Crit Care, 2012 Dec;27(6):587-593.
• Thiele RH et al.  The clinical implications of isolated alpha (1) adrenergic stimulation.  AnesthAnalg.  2011 Aug;113(2):284-296.
• Magder et al.  Phenylephrine and tangible bias.  AnesthAnalg.  2011 Aug; 113(2): 211-213.

Anticoagulants:
The following is true regarding anticoagulants:

A) New antithrombotics are 100% effective and free of bleeding complications
B) Knowing the generic name of the drug results in 100% accurate medical reconciliation with the patient
C) There are multiple reversal agents with good effectiveness for all the new anticoagulants
D) Some anticoagulants have a narrow therapeutic window and are effected by kidney, bowel, and renal function
E) FFP can completely reverse anticoagulation from Vitamin K antagonists in six hours

REFERENCES:
• Evans G et al.  Beriplex P/N reverses severe warfarin-induced overanticoagulation immediately and completely in patients presenting with major bleeding.  Br J Haematol.  2001.  Dec;115(4):998-1001.
• Connolly SJ et al.  Dabigatran versus warfarin in patients with atrial fibrillation.  N Engl J Med.  2009.  Sep 17;361 (12):1139-51.
• Eerenberg ES et al.  Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects.  Circulation.  2011 Oct 4;124(14):1573-1579.
• Patel MR et al.  Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.  N Engl J Med.  2011 Sep 8;365(10):883-889.
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Pearls from Dr. Pontius's Chemical Injury Lecture [July] 
In general, you can't go wrong with immediate, copious hydrotherapy
 
Special Circumstances: 
--Dry Particles: brush off first 
--Phenol: PEG Swab 
--Chromic Acid: Topical 5% thiosulfate & ascorbic acid
--Hydrofluoric Acid: Calcium (Subcu or IV) after hydrotherapy 
--Oxalic Acid: IV Calcium 
--Elemental Oils: Cover with Mineral Oil -- water causes severe exothermic reaction
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Dr. Lane Lecture Pearls [July]
EM Update: Best Practices in Asthma Management

›Determine the severity (clinical pres, vitals, peak expiratory flow rates)
›Avoid testing
›Treat with albuterol, atrovent, oral steroids
›Consider adjuncts in severe asthma exacerbations (Bipap, Magnesium and IV steroids)
›Patiently watch them
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Dr. Ybarra's Vertigo Lecture Pearls [July]

To follow-up regarding my vertigo lecture. Here are some youtube clips:
Head Impulse Test: https://www.youtube.com/watch?v=Wh2ojfgbC3I
Positive skew test: https://www.youtube.com/watch?v=zgqCXef-qPs
Positive DHP followed by examples of nystagmus: https://www.youtube.com/watch?v=cZlXvRlxrRE

I am unaware of specific studies looking at steroids in cerebellar infarct, however in general there is not a role for steroids in the treatment of ischemic stroke.
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Ectopic Pregnancy Lecture Pearls [July]

Dr Omara gave an excellent summary of the issues surrounding 1st trimester bleeding.  As supplemental info, attached is the powerpoint that was put together for a joint ob/em conference last winter.  The key points are summarized below and were agreed upon by both services.  I also have attached the last version of the guideline on ectopic pregnancy - I have reached out to Jeff Dubin for an updated version.

A few key points -

1. A gestational sac is an ultrasound feature of early pregnancy but is NOT diagnostic of an intrauterine pregnancy.
2. It is difficult to distinguish between a true gestational sac and a pseudo-gestational sac, thus if a yolk sac or fetal pole are not visualized, it is considered a "pregnancy of unknown location (PUL)" and needs to be followed with serial bhcg and ultrasounds if patient is stable.
3. Disposition and management are determined by whether a patient is "stable" - vitals, severity of symptoms, physical exam, whether this is a desired vs undesired pregnancy and whether the patient is reliable. Assisted reproductive fertility increases risk.
4. Methotrexate is a medical option that has risk and should only be ordered by gynecology (probably after a discussion with an OB if practicing in a community setting where OB is not in house 24/7).  Ibuprofen is contraindicated with methotrexate.
5. Bhcg levels should be correlated with clinical context and ultrasound findings (size of gestational sac).  Low bhcg levels may be seen in ectopic pregnancies, missed abortions, and early intrauterine pregnancies.  High Bhcg levels above the discriminatory zone (1500 -3500 but we use 2000) with a non-diagnostic ultrasound raise the suspicion for an ectopic pregnancy or missed abortion.
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Dr. Sudarshan LVAD Lecture Pearls [September]

So take home points:
1. Focus on getting good vitals: either a SBP/DBP if they have a pulse, or a MAP by Doppler. Assess the patient by looking for signs of perfusion
2. Most LVAD patients are not in the ED for LVAD issues...assess other problems as usual
3. Call the heart failure team early if you have any issues
4. Echo, EKG, and coags are useful data points to help you figure out what is going on

November 27, 2014 – NO CONFERENCE in lieu of Thanksgiving Holiday
December 4, 2014 – Special guest lecturer Phil Levy, MD – Detroit
December 11, 2014 – Critical Care of the HIV Positive Patient – Dr. Christian Woods [MWHC Critical Care and Infectious Diseases] – HIV CME Credits
December 25, 2014 – NO CONFERENCE in lieu of Winter Break
January 1, 2015 – NO CONFERNCE in lieu of New Year’s Day
January 8, 2015 – Special guest lecturer David Gaieski, MD – Philadelphia
February 5, 2015 – AIRWAY LAB 2015, STAT Lab at Union Memorial
February 26, 2015 – ABEM In-Training Examination