Emergency Medicine Research Associates

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The Emergency Medicine Conference I attended on Tuesday was very informative and touched on a wide variety of topics from rare diseases to venomous fish. The conference started off with a presentation by Dr. Haase about a particular case of HLH, or hemophagocytic lymphohistiocytosis. Slides contained vitals, exam details, and test results. After a brief overview, we broke out into breakout rooms to discuss this case with a smaller group. It was a really interesting case presentation, and I enjoyed hearing the residents and attendings discuss the details of the case with one another. I also enjoyed being able to understand the progression of a case from presentation to the ER to the implementation of treatment. I gained a deeper understanding of the process of doing an exam, running tests, and interpreting the results in hopes of finding a diagnosis. The next segment of the conference was a Q&A style presentation about chemical toxicity led by Dr. Levine in light of recent articles in the news. Dr. Levine showed slides containing pairs of chemicals and discussed the product that forms once these chemicals are mixed, which is often very toxic and harmful to the human body. He discussed common symptoms of being exposed to these harmful chemicals for long periods of time and gave some ways in which these symptoms could be treated in the ER. Dr. Levine then furthered the discussion on toxicity with a presentation about toxic fish and seafood. He discussed the varying levels of toxicity in a variety of sea creatures including jellyfish, sea urchins, stingrays, and other fish. For each species he talked about he gave a brief overview of where to find this animal, its level of toxicity, and what could happen if this animal came into contact with a human – more specifically, if the result would cause mechanical pain or a release of toxic venom. Dr. Levine’s presentation was very informative and was a chance for me to learn about a unique topic that I had never been exposed to before. Overall, the Emergency Medicine Conference brought to my attention just the wide variety of cases and that can show up to the ER on any given day. From rare diseases to jellyfish stings, emergency medicine doctors must be prepared for every possible scenario. I really enjoyed my EM Conference experience and am grateful for the opportunity to attend through EMRA. Attending Emergency Medicine Conferences are a great way to get introduced to a wide range of really interesting topics, gain a deeper understanding of the medical field, and learn from esteemed medical professionals.
 

Last week I had the privilege of attending an Emergency Medicine Departmental Conference that featured presentations on well-being and nutrition, as well as case studies that highlighted the assessment of patients with complex diagnoses. The conference included a presentation by Dr. Annum Bhullar who addressed long-standing concerns regarding the global increase in the number of hypertension cases. She drew upon a variety of studies that touched on the effects of sodium and meat consumption on high blood pressure, indicating that a meal with a high concentration of salt can decrease blood flow for up to two hours. Dr. Bhullar suggested that cutting down on alcohol intake and transitioning to a plant-based diet can significantly bring down systolic blood pressure levels by up to eighteen points. She closed her presentation by identifying the drawbacks of nutrition research, noting that it takes about seventeen years for the integration of research into clinical practice to commence. She reiterated the fact that the competing interests of the nutrition research landscape make it difficult to staunchly support one particular lifestyle or the consumption of certain foods as opposed to others. This presentation was of particular interest to me as I have a family history of hypertension and cardiovascular disease. Growing up, I watched family members make alterations to their diets, shifting to low-sodium and plant-based meals as a means of combatting hypertension. I appreciated Dr. Bhullar’s talk as I was able to apply some takeaways from her presentation to my daily life: facilitating preventative measures early-on and encouraging family members with hypertension to consider her recommendations. The conference shifted to a case study presentation organized by Dr. Elizabeth Ferreira and Dr. Jacqueline Kurth that focused on sigmoid volvulus and contrast allergy in elderly patients. Dr. Ferreira and Dr. Kurth introduced the case in a way that I thought was incredibly engaging and creative. Dr. Ferreira took on the role of a radiology intern who was unsure of how to assess a patient after receiving inconclusive test results, while Dr. Kurth was her attending who offered guidance. We were divided into breakout rooms multiple times during the presentation, which facilitated collaboration of residents with different levels of training experience. We worked to identify the possible symptoms of a particular condition, the different tests and medications that could be administered (Benadryl, prednisone, etc.), and the procedures that could be performed. I had the opportunity to gain exclusive insight regarding the decision-making and problem-solving process that doctors engage in. I learned about different imaging procedures, the complications associated with specific diseases, and that tell-tale signs of a patient’s declining health present differently in older populations (less likely to mount fevers). I realized how important collaboration and partnership are in administering medical care and developing a treatment plan. Overall, this was an incredible learning experience and I am so grateful to have been able to attend the conference.
 

We are running out of oxygen”, “At this point, we don’t know”, “We have over 920 patients in an 850 bed hospital”. Amidst this trying time in the middle of the COVID-19 pandemic, the UCLA Emergency Department (ED) is gearing up for a future of uncertainty. This resident conference was spent learning from other physicians’ experiences and preparing for COVID-19. Residents, alumni, and faculty of the UCLA Ronald Reagan Medical Center (RRMC), Olive View (OV), and Antelope Valley (AV) emergency departments came together to gain as much wisdom as possible from each other. Dr. David Talan began discussing various challenging infectious disease cases and what to expect with COVID studies currently being onboard for the ED. After going over these rare and now more common diagnoses, Dr. Soni Chawla, a diagnostic radiologist for UCLA RRMC, presented chest x rays and CT images to demonstrate common findings (halos and hazy ground-glass opacities in the bilateral peripheral posterior lungs) she has observed to be associated with the positive COVID patients that have come through the UCLA ED. Next was a panel discussion with Dr. Crager, Dr. Barot, Dr. Kamangar, and Dr. Melamed, critical care team leaders in the intensive care units (ICUs) at RRMC, OV, and AV. What type of treatment were they giving these patients? When are you intubating them? Is early intubation better and what is the extubation timeline? What ventilation setting do you use? While these questions were being answered, one thing was clear: nothing was certain. Different patients responded differently to the same treatment and there was not enough data or literature to say that anything worked better than the other. To dive more into recently published literature on COVID-19 largely from China, Dr. Akie and Dr. Lai led a panel of the RRMC faculty on various papers comparing treatments, risk factors, and cardiac complications. The end result of this discussion: these papers are ultimately not reliable. Dr. Waxman gave a brief discussion on the epidemiology of COVID and what we should expect for California given current mathematical models (ie University of Washington’s Institute for Health Metrics and Evaluation); however, the models were also not considered reliable. Given that the peak is getting closer and closer, what information do you rely on then? Experience. The next part of the conference was a panel from physicians at the front lines of the pandemic in NYC (Dr. Daniel Rolston from Northwell Health, Long Island, Dr. Richard Shin from New York Presbyterian in Queens, Dr. Allison Regan from SUNY Downstate, and Dr. Neil Christoper, Dr. Danish Ahmad, and Dr. Jonathan Schimmel from Mt Sinai). These moments when the residents could listen to anecdotes were the most valuable. The discussion even between the panelists about various protocols each institution was using and changes in PPE style were extremely informative. Because really how do you treat a patient with a pulse ox in the single digits? How do you tell a 65 year old patient they will automatically need a palliative care consult? How do you respond to a code or intubate a patient without risking exposure to yourself and your fellow ED staff? We can only hope to learn from each other and prepare for what’s next together.
 

The process of containing contaminants and maintaining safety when engaging with potentially hazardous situations has become especially important in light of recent events involving COVID-19. The Emergency Department (ED) is particularly aware of this danger given their role likely as the first point of contact for any of these conditions. Understanding the available resources and correct procedures is not only important to provide the best care to your patients but also to protect yourself as a caregiver. A few weeks ago I had the privilege of attending an Emergency Medicine (EM) Resident Conference. The topic of this conference? HazMat exposure along with field-based and hospital-based decontamination. The conference was held in Tamkin Auditorium and opened with a brief introduction followed by a lecture about field decontamination procedures. The majority of the conference, however, was based on educating the residents on hospital-based decontamination. Camile Collins gave a great presentation on the available resources, including personal protective equipment (PPE), at Ronald Reagan Medical Center and the procedures put in place to maintain safety. After covering all this information we were split into two groups and given the chance to actually see all the facilities and equipment available. The first group was assigned to the ED where we gathered in the ambulance bay. Collins showed us a smaller decon room with isolated water and air circulation systems. The majority of safety stations, however, can be found at a designated decontamination trailer down the street. Group 2 headed to this location and was able to observe the majority of UCLA’s decontamination resources. After touring the ED, residents were allowed to try on the decon PPE, including head-to-toe suits and powered air purifying respirators (PAPRs). While everything Collins said was listened to seriously, the atmosphere was casual as the residents put on equipment. It was a remarkable thing to be standing next to these residents, some of the most qualified, talented individuals, in my suit and tie while they jokingly stomped around the ambulance bay wearing crazy HazMat suits and respirators. Up to this point, I had learned an incredible amount about UCLA’s decon process and how the hospital could potentially deal with a pandemic such as COVID-19. I had conversed with many residents, toured various decon facilities, learned about high-tech PPE, but my biggest takeaway from the conference might have been from those moments where I was able to see another side to these intense individuals who I interact with frequently in the ED. I felt like I now knew these people on a deeper level. I understood more about who they are behind the scrubs and stethoscopes and what it takes to work at one of the top medical centers in the world. I had an incredible time attending this EM Conference and highly recommend any EMRA’s attend in the future if possible. And even to those people thinking about applying to this program, these are the experiences that I am so grateful for as an EMRA and make this program so special.
 

Heart defects, boards review, toxicology case reports, and… penguins? This past week, I had the privilege of attending the Emergency Medicine (EM) Departmental Conference held on February 18th. The conference began with a presentation by Dr. Michelle Brennan, a second-year resident, on the various factors that should be considered when assessing patients presenting with a potential perforated foramen ovale (PFO) in their heart. Following the presentation, the attendings and residents in the room critically discussed the utility of the findings presented in relation to their efficacy in the Emergency Department setting. Upon conclusion of the team’s assessment of this often-undiscussed condition’s treatment, Dr. Joanne Feldman presented on her recent trip to the South Sandwich Islands as a part of a research team consisting of volcanologists, geologists, documentarians, and ecologists studying the penguins and surrounding topography of the area. Educational anecdotes of the at-risk Antarctic wildlife were mixed with jovial stories of stubborn penguins during blood draws and cellular devices being lost to the unforgiving sea. Dr. Feldman then closed her talk by informing the residents in the room of the diversity of ways in which a medical degree can be utilized outside of the hospital setting. Dr. Lee, the chief resident facilitating the conference, then proceeded to shift the discussion to boards exam review with Dr. Grock. The review session was organized as a group Jeopardy activity where teams of residents would formulate answers and compete with their peers in a friendly manner for bragging rights. In all honesty, majority of the information was foreign and new to myself and the medical students also attending the event; however, what I could ascertain from the residents’ group discussions was the importance of a continuous education on the practitioners of medicine. Following this activity, Dr. Grock transitioned to discussing a personal patient case related to taking toxicology histories. Jokes were mixed into the case review to foster increased camaraderie of the attendees; however, this environment swiftly changed when Dr. Grock informed the attendees of the reason for this particular presentation: the loss of the aforementioned patient due to the informational gaps being presented. Suddenly, the room fell into a noticeable state of mournful silence. In a matter of seconds, soft-spoken banter became unspoken condolences. Although everyone outside of Dr. Grock had likely never interacted with this patient, each individual in the auditorium—regardless of whether they were a newly-minted medical student or a seasoned attending—was impacted on a personal level by the loss of his patient. It was in this moment that even the most tired physicians in the room remembered why each and every one of them had taken the time out of their busy schedules to convene at the crack of dawn to discuss how to better care for their patients. And it is because of experiences such as these that I earnestly feel that every EMRA should make the time to attend EM Conferences as often as possible during their time in the program.
 

As part of EMRA, we get some amazing opportunities to participate in medical events, usually only available to doctors or medical students. One such event is an annual ultrasound-training conference for first-year David Geffen medical school students called Ultrafest. During this student-organized event, future doctors have the opportunity to practice ultrasound techniques on both mannequins and volunteers alike, which greatly enriches their standard curriculum. This year, Ultrafest consisted of several stations, including an abdominal ultrasound station, a pelvic ultrasound station, a chest ultrasound station, a pregnancy ultrasound station, and a transvaginal ultrasound station. The stations were run by physicians from various departments who taught groups of students important ultrasound techniques. As EMRAs, we got the opportunity to volunteer at Ultrafest, serving as live subjects, helping out the pregnant volunteers, and helping the organizers ensure that the event was running smoothly. Not only did we get to interact with industry professionals and medical students, but we also got to form beneficial professional connections and learn alongside the students. Many of the supervising doctors urged the volunteers to participate in the event, allowing us to obtain some hands-on ultrasound experience. Amongst other things, I got to try out the pregnancy ultrasound and learned about the immediate markers of a healthy baby, as well as the hospital process when someone comes into the emergency room in labor. It was an amazing experience I would recommend to anyone looking to go into the medical field!
 

This was a packed journal club, as residents met to discuss papers comparing second-line (backup) medications for status epilepticus (prolonged/recurrent seizure activity) and the utility of tranexamic acid, TXA (used to inhibit degradation of fibrin blood clots in certain types of hemorrhage), on traumatic brain injury. We started off with a great explanation by our EMRA founder, Dr. Mower, on protocol requirements necessary to prevent bias in research pharmaceutical trials. Later, Dr. Schriger explained the usefulness of adaptive enrollment in which computer analysis can increase enrollment to certain study arms to help obtain certain data points sooner, thus reducing the time and cost of the study, while still keeping it blinded and overall randomized. We also discussed possible enrollment variations that may occur when studies take place at multiple sites. We also learned events that may lead to a change of protocol mid-study, such as when data from related studies are released. We also discussed conclusions that might be gleaned from looking at subgroup analysis versus overall results. This led to more discussion on usefulness of large studies enrolling patients from widely differing populations and healthcare systems versus studies that look at less variable populations. What confounders might we consider? A recurring theme was keeping in mind exactly what each study was designed and powered to conclude. One must keep in mind the limitations of each study and thus the conclusions that can be drawn. For example, while some studies attempt to show superiority of an intervention, others may simply be showing non-inferiority. One must also differentiate whether a particular study shows actual efficacy of a drug or simply that it outperforms another drug. This requires the clinician to draw on outside knowledge (and analysis of past studies) when drawing conclusions for clinical practice. Differentiations were also made between conclusions that can be made based on primary versus secondary outcomes. Secondary outcomes help point us in the direction of future studies by being hypothesis generators, but we should not be making actual conclusions from them. This was overall a great journal club session, as we got to apply multiple statistical and research method concepts to actual studies, and discuss their usefulness in actual clinical practice. I definitely encourage all members to attend any future sessions. (The residents were all very friendly, as well!)
 

I attended Dr. Steven Bolger’s senior talk which reviewed approaches to resuscitating cardiac arrest patients. I really enjoyed the talk because it gave me the opportunity to learn about emergency medicine research and observe how residents analyze and interpret study results to potentially incorporate information into their own protocols. One of the topics that stood out to me was epinephrine use in cardiac arrest. I was unaware of the controversy concerning its use in cardiac arrest, so it was interesting to hear how research studies addressed the question of how epinephrine use may affect the neurological outcome of cardiac arrest patients. I enjoyed listening to Dr. Bolger and the audience members discuss how pitfalls in the study may change interpretations of the study’s results. Another topic that piqued my interest was the mention of therapeutic hypothermia in cardiac arrests. Because a potential EMRA study may research the impact of cooling duration on patients who receive therapeutic hypothermia, it was exciting to see how EMRA may contribute to the existing literature that helps ED residents better treat patients.
 

Part of the opportunities EMRA offers is the chance to attend simulations of traumas that Emergency Medicine residents could face while on the job. Attending one of these simulations really showed me the importance of collaboration in the medical field. One would usually think of collaboration as being common to only the classroom, but as it turns out it actually is a large factor in training the next generation of physicians in all aspects of medicine. There were a number of different actors in the simulations including senior residents, fellow residents playing roles such as a nurse, and a team of residents working together to assess each simulation and acting strategically to ensure the most effective plan of care for the patients. Experiences such as these are rare and give insight into a very mythicized portion of medicine, residency. Thus, these encounters expose the true purpose and specificities that make up medical residencies.
 

Last Tuesday, I had the opportunity to attend a portion of an EM Resident Conference that presented information on how to correctly assess and handle burns in the Emergency Department. Prior to this conference, I knew little to nothing about burns. The conference covered how burns are classified, how to estimate burn size, how much fluids should be given to burn victims, how and when to perform an escharotomy, and how to prepare patients for transport. To me, the most interesting aspect of the conference was the discussion of common pitfalls in burn evaluation and treatment. Accurately assessing burn classification is important for treatment; however, burns may be complex, with one burn containing multiple burn depths. I learned that correctly identifying the degree of burn is important for correctly treating the patient as the size and classification of the burn is essential in estimating how much fluids a burn patient should receive. I was intrigued by the many questions that the presenter and residents posed about burn care that have yet to be thoroughly researched. I was surprised to learn about how much more is still needed to be known about burns. Overall, I had an amazing and informative experience. It was nice to observe how learning continues through residency and beyond.
 

As EMRAs, we are exposed to many different methods used in clinical study designs when we enroll patients into numerous trials in the ED. Journal Clubs are amazing opportunities to step outside of the ED and see the present and future of the clinical research similar to what we do and how it will ultimately impact the healthcare industry. Ever since the Research Committee was founded, I have had the honor of not only presenting clinical studies and their impact to my peers, but also discussing the different ethical, statistical and social implications different types of research can have. I truly believe that these conversations are extremely important in opening our eyes to the reality of the work we do in the hospital, and applying our understanding of basic research to a broader perspective of emergency medicine. They allow us to look around and see where the innovations in science are taking us and how they will impact us as aspiring health professionals. This past JC was a truly valuable experience, especially with the presence of Dr. Ichwan, who joined us in our conversation on Pediatric Emergency Medicine. As the first EMRA JC with a resident in attendance, this meeting was extra memorable for me as we were able to ask questions and have a conversation with a physician whose daily work is directly impacted by the different topics discussed during the presentations. Dr. Ichwan added valuable insights from a different, but highly relevant perspective to our discussions on machine learning in the ED, diabetic ketoacidosis, e-cigarettes and acute appendicitis. It was exciting to be a part of these discussions with my fellow EMRAs in hopes of educating ourselves on the kinds of current research pushing the frontier of medicine. I look forward to more of these conversations in the upcoming JCs!

This week I had the privilege to attend an Emergency Medicine Conference and SIM session for EM Residents at Ronald Reagan. The day started off with presentations by residents and an attending, varying from case presentations on past patients to new research done on infectious diseases! The case presentations are really intriguing because you get to see the doctor’s thought process through ordering labs, localizing the source of the chief complaint, to creating a diagnosis. All throughout these presentations, other residents and attendings are sharing their thoughts and asking questions, which made it feel more like a discussion than a lecture. After the conference, we were split up into smaller groups with the residents, and participated in various activities. One station was dedicated to matching various pictures of eyes and the hypothetical situations that could have caused the different conditions. Throughout these activities the residents evaluated each option and even asked for my opinion sometimes! If we had extra time at a station, they would explain what each image represented and what they were looking for. One of the residents I worked with actually attended UCLA as an undergrad!  Finally, we attended a SIM session, which simulates a patient through a life-like model. As the residents assessed the patient’s condition, they could order medication, do compressions, and even intubate! It was a valuable learning experience to see how the doctors evaluated all of the information and decided how to treat them. After the simulation, attendings came into the room and discussed what happened during the simulation with some tips and criticism. Each of these SIM sessions gives residents and students an opportunity to review how they treated the patient and assess what they could have done differently in that situation. Overall, I found my first EM Conference and SIM session to be really eye-opening and valuable. You get to see everything, from research to the process of a diagnosis. It’s an amazing learning opportunity and I would definitely do it again. 
 

Through EMRA, I was fortunate to have the opportunity to attend and listen in on a resident journal club. As I have never previously attended a clinical research journal club, this experience greatly expanded my understanding of clinical research from the residents perspective. I found it fascinating to listen to the residents’ criticisms of the paper, in addition to how the results of the paper may or may not be implicated in clinical practice. In one of the papers, the data had been collected by undergraduates like EMRA, allowing me to better understand how my work in EMRA contributes to and is essential for clinical papers.
 

One of the best things about going to the EM conference was being an undergrad in a room full of residents and attendings outside of the hospital. I went to an EM conference before but this one was different because I was able to recognize many of the physicians’ faces after interacting with them on shift. As a pre-med, my immediate goal is centered on getting into med school so this experience was ultimately worthwhile because it gave me even greater vision for my future. One of the sessions was “ID cases”. During this time, an attending presents a mock scenario from the ED and the residents answer the questions. Seeing all these residents causally interact with one another outside of the ED while having a desire to learn reminded me that they were also in my shoes not too long ago and have already gone through much of what awaits me. This realization made me even more excited and determined to be like one of them in the future.
 

The first JC was an eye-opening experience as I was in a room filled with peers who were genuinely fascinated with clinical research. After presenting myself and then sitting through the well-constructed following presentations I began to realize how my past experiences were very applicable to the discussions we were having. Never before had I truly seen the backgrounds and knowledge of my fellow EMRAs displayed with such confidence and willingness to teach one another. Presenting was easier than I thought it would be as my fellow EMRAs created a welcoming and engaging environment where every member could contribute pieces of their wisdom to the entire group. As a result, we built on each other’s knowledge in a puzzle-like fashion to create an overall mastery of the subject being presented. The journal club made it clear that experience outside of the classroom was of greater importance to clinical research than one originally thought. I look forward to the next JC and hope that all members get to share in this wonderful experience.
 

Attending my very first SIM session will definitely serve as a memorable experience to say the least. To be in a room full of residents while learning about the pediatric traumas really helped me see residents in a different light. These are doctors, the same kind of people I have dreamed of becoming for as long as I can remember. And here I was, an undergraduate student, learning and taking notes next these doctors. This experience really helped me realize that just like me and everyone else, these residents are still learning every day. They are still learning to become the best doctor they can be - the same aspiration I have. After the presentation of pediatric trauma presentation, the residents gathered together to play a fun family feud type of game. To see the residents interact with each other made really made me realize that these people are not that different than I am. They joke around, they talk about their weekends, and they are genuinely normal people. This SIM session helped me realize the fact that I am more similar to these residents than I thought I was, and one day I will become a doctor just like them. 
 

This EM resident conference pertained to strokes and how to go about potential stroke patients in the emergency room. Two separate EMRAs attended the conference and had different takeaways from the sessions. Isabelle, who is a current member of the Student Stroke Team at UCLA, enjoyed the Emergency Medicine conference as it pertains to her own personal experience with neurology. The first session of the conference was dedicated to administering the NIHSS (National Institute of Health Stroke Scale). While Isabelle had great familiarity with this topic, it was an entirely new experience for Erik. Prior to this SIM session, Erik had never heard of the NIHSS - quite frankly he never even thought about what happened when there was a stroke patient in the emergency room. The difference between their experiences lie in the fact that Isabelle took the session to see how neurology was integrated into emergency medicine, while Erik tried to soak up as much of the new material as possible. The next part of the conference had the residents break off into small groups and take part in different scenarios that pertained to stroke patients. Given the new information that they had just learned, they were tasked to apply it to the different scenarios as if it were a real situation in real time. After each simulation there was a critique and deliberation over their performance. Emergency Medicine attendings and Neurology residents and attendings led the deliberation by going over the scenario and asking why they acted in a certain way, what they could do better, and overall ensuring that they are well prepared if a similar situation were to take place in the Emergency Room. This part of the conference had a similar impact on both Isabelle and Erik because it was more about fundamental decision making based on a patient’s presentation to the ER. Despite their differences in familiarity with treatment of stroke, they both gained valuable insight on what a resident is thinking as they take action in treating a patient. This SIM session is a perfect example that even though Isabelle and Erik are both in EMRA, they can certainly have different experiences. Isabelle liked this conference in particular because it integrated a lot of her previous knowledge and experiences in Stroke Team. Altogether it demonstrated to Isabelle how this knowledge can be implemented into different medical spheres, such as emergency medicine. On the other hand, Erik liked the conference because it highlighted the thought process that doctors have to go through when dealing with any patient, not limited to the specific stroke scenarios that were presented. In the end, regardless of what the EMRAs took away from the session, they both agreed that it was a unique experience to witness how the residents learned along the way. It was encouraging to see that even throughout their career they are always learning and continue to be students even after medical school. This is one of the aspects of medicine that is amazing. It is always evolving and progressing in order to create better patient care and treatments for everyone.