Welcome to the Mount Sinai Emergency Medicine Residency Website.

Here you will find information regarding rotation schedules, academic resources, wellness and facts about our program and residents. Check out our bios and photos. Please also visit the Emergency Department's official residency website. This site is intended for Mount Sinai EM residency purposes only, and no information on these pages is intended or should be construed as medical advice. Read more.

Interesting Studies About Learners in the Emergency Department

The following study results about learners in the ED are department specific for each study, though they offer a sense of general perspective on the issues at hand.

-  Medical students do not affect attending or resident productivity

- One resident with one attending will see more patients than the attending alone

- mid-level providers consistently see more patients in high and low acuity settings than residents

- In high acuity settings mid-level providers have lower RVUs than residents

- In low acuity settings, mid-level providers have higher RVUs per hour but lower RVUs per patient than residents

- EM interns increase the number of patients seen per shift over the course of the year. Other department interns or EM second years do not.

- EM residents see more patients and bill at higher acuity levels as they progress through residency

Feel free to leave any others in the comments.

Mid-2014 Updates in Emergency Medicine

Some 2014 updates so far…

- age adjusted d-dimer
- ultrasound assisted, catheter directed thrombolysis
- thrombolysis for RV dysfunction (intermediate risk PE)

- sepsis treatment: early recognition, early antibiotics, and attentive care
- restrictive transfusion (Hgb 7-8)

- Good Outcome For Attempted Resuscitation (GO-FAR) score for predicted neuro outcome of in-hospital arrests
- palliative care review on dying with dignity

Do you have any others? Please leave in comments.

Management of Traumatic Subarachnoid Hemorrhage

Prioritization of following steps is based on individual patient needs:

1. Assess stability
- stabilize
- neuroprotective intubation as needed

2. Determine secondary damage
- neuro exam, including GCS
- CT scan

3. Treat (may begin simultaneously with 1 and 2)
- reverse anticoagulation as necessary
- prevent potential seizures
- minimize cerebral edema
- normocapnic, normothermic, normotensive, normovolemic, normal oxygenation
- minimize sympathetic surge
- may need ICP (CPP) monitoring (remember CPP = MAP – ICP)

Some pointers:
Hypertonic saline is preferred to mannitol
Hyperventilation is no longer a mainstay therapy unless the patient is hypercapnic or herniating
Elevate the head of the bed to 1/2 the length of the head of the bed (or 30 degrees)
Consider high dose barbiturates or fentanyl/propofol for inducing a medical coma, intubating where necessary

Haddad and Arabi. Critical care management of severe traumatic brain injury in adults. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:12
Peds Neuroprotective Strategies


Medical Statistics – a Primer on Concepts

Medical statistics review (assuming some basic familiarity):

Mean (average), median (middle number), mode (most common number)

Sensitivity and specificity depend on a specific, pre-determined test. Also, they do NOT depend on prevalence of the condition being tested for.
Positive predictive value and negative predictive value depend on the prevalence of the condition being tested for.

Odds ratio: People who have A,B,C are x times more or less likely to have a certain condition/outcome.
Relative risk: People who have A,B,C are x times more or less at risk to have a certain condition/outcome.
The key difference is that relative risk depends on the prevalence of the condition/outcome. In the situation that the condition/outcome is rare, odds ratio and relative risk approach equivalence.

Equations and examples of these and more medically relevant statistical concepts. 

Continue reading “Medical Statistics – a Primer on Concepts” »

The Normotensive Pulmonary Embolism Patient

Early death (within 7-30 days) in PE patients is concerning. It is relatively easy to identify high-risk PE patients, defined by abnormal vitals SBP < 90 or drop in SBP by 40 for at least 5 min.

Normotensive patients with poor prognostic indicators include (statistically significant odds ratios):
- SBP between 90-100 (OR 2.45)
- HR > 110 (OR 1.87)
- elevated cardiac enzymes (OR 2.49)
- RV dysfunction (abnormal RV function on echo or RV dilation on echo or CT) (2.28)

Patients who have biomarkers for heart strain and RV dysfunction may benefit from some form of interventional therapy:
- lower (half) dose fibrinolytic therapy for patients < 75 years of age
- local, catheter-delivered, ultrasound-assisted thrombolysis

Other things to note:
- intubation increases intrathoracic pressure, which may decrease venous return and further worsen R sided dysfunction
- extracorporeal membrane oxygenation can help temporize heart and lung collapse where available but is not definitive management
- heparin is still mainline therapy for normotensive patients with PE but without any indications of RV dysfunction or no elevated biomarkers

Sanchez O, Planquette B, Meyer G. Management of massive and submassive pulmonary embolism: focus on recent randomized trials. Curr Opin Pulm Med. 2014 Jul 15.