Interview Tips from the PEMNetwork

We’re deep into interview season for PEM fellowships. In addition, many senior fellows are back on the interview trail looking for the perfect job(!). Since none of us completed that “How to actually interview for PEM” elective rotation, we asked our PEMNetwork staff of PEM faculty from around the country about how to get the most out of your interview day. Here is what they said.

Know something about your interviewer.

todd-changTodd Chang, CHLA: Do a background search (not the criminal kind, though) on your interviewers and find out a bit about their clinical and non-clinical academic interests. It will better frame the discussion because you will know if your interviewer can offer support for your intended career. Even if there is nothing in common, they may recommend someone. If the interviewer can’t recommend anyone, that’s very useful information too!

If you want to meet someone specific at your interview day, be proactive.

Marc Auerbach, Yale: If you have a particular area of interest, request an interview with that individual. Or at least try to find a time to meet them on the day before or after the session.

Brad SoboBrad Sobolewski, Cincinnati Children’s: Reach out to the program leadership and coordinators well in advance. Don’t wait until the day of to ask to meet a specific person. Schedules are tight. Giving busy faculty 2-3 weeks to find time to meet with a motivated applicant will help make sure the interview day is filled with maximum contact with people who will be able to help you form an accurate impression.

Make it an inside job.

dkDavid Kessler, Columbia: Invoke 6 degrees of separation. If you look close enough, we all have somebody at each place who we are connected to. For example, consider alumni from medical school or residency. Reach out to that person and say you’ll be in town and see if you can grab coffee. This can really help go get a sense of the culture and may even create some buzz about you.

Your first interviewer should be you.

Brad: Anyone who is going for an interview (PEM or otherwise) should answer the following question about themselves:

  1. What gets under your skin the most about (chosen field)
  2. How will you go about fixing it.

I think this creates a thematic starting point for career-niche development. Interviewers don’t want to just hear that you think sepsis is bad and that you had a cool case. We want to know why you can’t stand that we aren’t recognizing it fast enough or why treatment is sometimes delayed. This is essentially about creating the “elevator pitch” for who want to be in PEM. You should be able to explain who you are, what you want to do, and who you want to be in a succinct and concise manner.

Think about how you are different than other applicants.

Todd: Every applicant probably wants great clinical experience, procedures, resuscitations, ultrasound, global health, QI, and education. But are there unique questions within these fields that you’d like to explore? How do you want to improve in any of those fields?

Don’t let your interview feel like a daylong sprint.

lumba_angela_0_0_0Angela Lumba-Brown, Washington University: Approach your interview with the enthusiasm of a marathon runner. The interview days are long. All too often candidates can’t stop yawning post-lunch, which doesn’t leave a warm fuzzy feeling despite an interviewer’s empathy. You get one shot on the interview so nail it.

The whole visit is an interview.

marcMarc: Treat everyone from the parking attendant to the front desk staff, fellows, residents, co-applicants with respect and as if they are interviewing you. we have had a few applicants who really “let loose” at lunch with language/disrespectful behavior. These things are noticed and come up later.

Treat your interview like an interview.

Todd: I tend to be more specific and detail-oriented. So folks who are looking to just chat and talk are in for a tough time.

BrianWagersBrian Wagers, Riley Children’s: Using concrete examples from your career/fellowship/residency/life during an interview helps you better express the idea you want to get across. And if you’re asking a question, relating your question to an example makes your question easier to understand.

Back up your ideas with your own experience.

S TatSonny Tat, UCSF: Connecting at least some of your answers intelligently to your own real experience or skill demonstrates both some personal insight and shows that you are speaking more than abstractly. Anyone can say anything but being able to back up what you’re saying with supporting evidence makes your grand ideas seem plausible.

Interviews may open other doors down the road.

maneeshaManeesha Agarwal, Emory: Interviews are an awesome way to connect with individuals in PEM that you will hear from over the course of their career. Don’t burn bridges, because you may that former interviewer is now the division chief! Interviews are a way to connect with people and potentially garner new opportunities in the future. I interviewed at Boston Medical Center for fellowship and really clicked with one of their fellows. I didn’t go to there for fellowship but fast forward 6 years, she’s now joined my division as an attending!

Some general dos and don’ts of interviewing to consider. Always.

Marc:

  • DO NOT come off as stressed or crazy—Even if you have a crappy day and flights delayed and snow in your boots.
  • DO enjoy your day and time.
  • DO NOT reiterate your CV and publications/personal statement (They will have read them) .
  • DO be honest. If you are thinking location Q is not ideal for you and have concerns because family is on other side of country explore that before the interview and have an answer to those sort of questions.
  • DO NOT B.S. If you do not know what you want to do and are undifferentiated that is okay. You can say that. When you say you want to grow up to be like all four of your interviewers, this comes up in our discussions.

But what I really want to know: Do people still write thank you notes?

David: Nobody expects a thank you afterwards but everyone appreciates it. It’s like bringing wine to a dinner party. And email is acceptable. Handwritten notes are nicer but don’t always reach people in the hospital mail system.

Angela: I like receiving thank you notes but maybe it’s just me. Coming for a second look shows dedication.

Only do it if you mean it.

Marc: If you are excited about the program let them know but if you are not do not fake it (we can tell). Avoid sending the same stock thank you note to all programs. If you do write them, make them personal.

David: They say thank you notes don’t matter and that’s mostly true. But I’ve seen some game time decisions go to the person who wrote a nice (and genuine) thank you.

Good luck on your interviews! Let us know your own tips for interviewing on our Facebook page or by commenting below.

Tricks and Treats and a Visit to the ER

In the 1980’s, my mother used to make me wait to eat my Halloween candy until she could sort through it for needles. Sound like an urban legend? Well it is…almost! Due to media sensationalism by Ann Landers, Dear Abby, and even the New York Times urban legends of malicious candy tampering ran rampant during my youth.

Take, for example, that plump red apple that Junior gets from a kindly old woman down the block. It may have a razor blade hidden inside. The chocolate candy bar may be a laxative, the bubble gum may be sprinkled with lye, the popcorn balls may be coated with camphor, the candy may turn out to be packets containing sleeping pills… wrote Judy Klemesrud on October 28th, 1970 in “Those Treats May Be Tricks” for The New York Times.

Very few stories of candy tampering were ever determined to be true and the majority were speculations spurred by fear. There are, however, other dangers lurking in the streets during Halloween. The following is what you will most likely see in your ED on October 31st, and what you can preventatively counsel for this week.

1. Pedestrian injuries
The National Highway Traffic Safety Administration and the Centers for Disease Control reported that for 1975-2002, Halloween was one of the 3 deadliest days of the year for pedestrians with Halloween being the deadliest day of the year for specifically children on foot. The majority of these injuries involved motor vehicle accidents.
Prevention: Wear bright, reflective costumes or add strips of reflective tape to improve visibility. Do not wear masks or other costume components that obscure vision. Do not drink and drive.

2. Falls resulting in orthopedic injuries, head injuries, and soft tissue injuries
Again, Halloween is the deadliest day of the year for children on foot and though most critical injuries involve MVA’s, serious injuries can occur from simple falls as well. Take for example ICD-10 code W22.02- Walked into a lamppost.
Prevention: Make sure the costumes aren’t so long that a child is in danger of tripping. Do not wear masks or other costume components that obscure vision. The AAP also cautions to make sure that shoes fit well.

3. Choking
Prevention: Cargivers will hopefully evaluate for choking hazards on Halloween costumes or in treats and take proper precautions. However, if they don’t, a child may come to your ED choking, remember PALS procedures for FB removal, including finger sweep, back blows/chest thrusts, and the Heimlich maneuver. A free review can be found on WebMD. baby choking

4. Dermatitis following novelty face/body paints
The FDA recommends checking their “Summary of Color Additives” prior to purchasing face paints, however on my review of this site, I found it to be unhelpful. In addition to coding for dermatitis for this ED visit, you may also choose to add R46.1- Bizarre personal appearance.
Prevention: Test an area of skin with the paint a few days prior to assess for any reaction and only use paints as directed. If a child does present to your ED with dermatitis secondary to make-up, thoroughly wash and remove any paint from the body and recommend supportive care with mild fragrance free soaps and moisturizers until the rash resolves.

5. Burns
A Halloween costume should have the designation of “Flame Resistant.” But even then, the US Consumer Product Safety Commission warns that this doesn’t mean that the clothing cannot burn.
Prevention: Minimize costumes made with flimsy materials and with billowing sleeves and skirts as well as obviously avoiding flames. Of course, do not forget to counsel on burn-type frost-bite injuries following dry ice encounters, consider W93.02- Inhalation of dry ice.

6. Licorice
For those licorice-lovers over 40, the U.S. FDA warns against excessive black licorice ingestion in your Halloween goodie bags. Black licorice contains glycyrrhizic acid that has a mineralocorticoid effect causing renal excretion of potassium. Consuming multiple 2oz bags of black licorice every day for 14 days or longer can result in hypokalemia, muscle weakness, arrhythmias, hypertension, and edema.
Prevention: Do not eat obscene amounts of licorice.

7. Gastric distension and hyperglycemia with or without emesis secondary to excessive candy eating
Well, my PubMed search did not have any evidence to support such presentations or treatments. But based on clinical experience, this child will be ok. Consider R10.84, generalized abdominal pain…but don’t bother searching for “chocolate” – the only listing you will find will be “chocolate cyst”.
Prevention: Chocolate candy bar mini’s are an average of 60-90 calories each – don’t eat too many of them!

Termination of Pediatric Resuscitation – the Elephant in the Room, PART 2

elephant-in-the-room

The acuity of the pediatric emergency department at St. Louis Children’s Hospital is the highest I have encountered. While this has been an excellent experience for me as a junior faculty member, those instances requiring me to terminate resuscitation in a child have been difficult clinically and emotionally – driving me to analyze the process and sit with the “elephant in the room” previously introduced in the PEMNetwork’s Termination of Pediatric Resuscitation PART 1.

I cared for Child A that sustained a gun shot wound to the head. The child arrived to my care within 30 min of the injury and our resuscitation with trauma and neurosurgery went smoothly in the emergency department, in the operating room, and in the PICU. That child walked out of the hospital a month later. Shortly thereafter, I cared for Child B who also sustained a gun shot wound to the head. That child arrived to my care within 4 hours of injury and in cardiac arrest. Initial resuscitation provided a return of spontaneous circulation, but that child ultimately died in the emergency department after prolonged efforts. While there were clear differences in the presentation and course of resuscitation for Child A and Child B despite similar injuries, they had vastly different outcomes. My positive experience with Child A made it even more emotionally difficult to ultimately terminate resuscitation in Child B.

I utilized the CEASE method published in 2015 in the Annals of the American Thoracic Society to aid in termination of resusucitation. CEASE represents a loose guide for the termination of resuscitation efforts evaluating: Clinical features that predict survival; Effectiveness of resuscitation efforts; Ask the other clinicians present; Stop resuscitation efforts; Explain what has happened to the family. It was clear that Child B had many clinical predictors of increased risk of mortality described by a 2005 Resuscitation publication. Child B had: an out-of-hospital cardiac arrest; had undergone resuscitation longer than 8 min, and had pulseless electrical activity.

Initial resuscitative measures with epinephrine and vasopressor infusions as well as hypertonic saline were effective and Child B had return of spontaneous circulation. However, cardiac arrest recurred. I continued resuscitative efforts for more than 20 min – such prolonged efforts were one of the best indicators of mortality following pediatric cardiac arrest in a 2005 study.

At this point, I reviewed the course with the trauma team and asked our trauma attending what he thought of terminating resuscitation at that point – he agreed that the resuscitation was no longer effective.

I generally invite caregivers to be present during resuscitations, and prior to terminating efforts, I updated Child B’s caregiver of our plan to discontinue resuscitation. I have found that when the caregiver is present during the resuscitation, there is less of a shock when I have this conversation with them. A 2014 multicenter randomized controlled trial published in the New England Journal of Medicine showed that families who were present during (adult) cardiopulmonary resuscitation had positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medico-legal conflicts. A prospective pediatric trauma study showed that family presence during pediatric trauma resuscitation did not prolong time to CT imaging or to resuscitation completion, and families believed that their presence was helpful to their child and themselves.

I told our team we were stopping resuscitation efforts and noted the time of death. We ensured that Child B was clean, without ET tube/stickers/lines in place, while the family grieved and I explained the course of events to them.

I followed this resuscitation with a debriefing of my emergency department team later during our shift when time permitted. A 2014 study demonstrated that 88% of pediatric ED nurses, fellows, and attendings believed that debriefing was an important process, but half of respondents reported that it occurred less than 25% of the time at their institution.

Stopping a code always feels strangely anti-climatic after the intensity of resuscitative measures. Most of the ED team seems to leave the room within seconds to care for the 20 other patients that have been waiting. I recently read an article that described “The Pause” which is essentially taking a moment with the ED team to acknowledge the efforts of the resuscitation and the passing life of the patient. This silent pause could represent a meditative, spiritual, or simply quiet moment following a clinically and emotionally intense experience to those who partake. I think a pause would have been helpful following the termination of resuscitation in Child B – and I plan to initiate this practice into my future clinical care.

Termination of Pediatric Resuscitation – the Elephant in the Room, Part 1

grieving-doctor-viral-image

The picture of the grieving emergency physician who “couldn’t save” a patient went viral in common media. However emergency physicians know that their emotions run even higher after we “couldn’t save” someone because we are the “final call”, the decision maker, the one that says “stop…right now.” That responsibility in itself can make what might have been already a futile case feel gut-wrenching – especially when it involves a child. As pediatric emergency medicine physicians, we will all be faced with the decision to terminate a resuscitation following cardiac arrest. Clinically, this may be an obvious decision. However, this decision emotionally and ethically looms like an elephant in the resuscitation room, until it is the last one at the bedside…and then it will often follow you home.

Knowing the facts about pediatric cardiac arrest gives perspective to an emergency department resuscitation. A prospective multi-center study of 283 children reported that cardiac arrest at the scene is associated with a higher mortality rate as compared to those with arrest occurring in the emergency department or hospital (73% vs. 65%). A retrospective PECARN study in 2009 evaluated 493 children that suffered either out-of-hospital or in-hospital cardiac arrest. This study demonstrated that the incidence of past medical history, baseline neurologic ability, etiologies of arrest, and post arrest outcome vary between both groups. Also, time courses of survival and live discharge between children with out-of-hospital versus in-hospital cardiac arrest were different. In the out-of-hospital arrest group, children were far more likely to sustain neurological injury as well as subsequently die from it.

Regardless of the setting, overall survival to ultimate hospital discharge following cardiac arrest in children is poor (13%) with good neurologic outcome occurring in only 62% of this small fraction of children. A pediatric study in 2004 reported that the best indicator of mortality was a duration of cardiopulmonary resuscitation of over 20 min (odds ratio: 10.35; 95% CI 4.59-23.32). The same authors also reported in 2005 that other risk factors for mortality following pediatric cardiac arrest included: out-of-hospital arrest; more than 8 min elapsed from arrest to resuscitation attempts; and asystole/slow initial rhythms/pulseless electrical activity. Regardless of our best efforts, mortality following cardiac arrest in children is high and prolonged efforts rarely have successful outcomes. Knowing this, it is still difficult to make the final decision to stop resuscitation.

The American Heart Association, the Neonatal Resuscitation Program, and the European Resuscitation Guidelines (Pediatric) all describe discontinuing support in the newborn without signs of heart rate after 10 min of resuscitation. However none of these organizations describe specifics for discontinuation of support in children. A 2015 study in the Annals of the American Thoracic Society addresses this issue in children and adults with the concept of “CEASE.” CEASE stands for: Clinical features that predict survival; Effectiveness of resuscitation efforts; Ask the other clinicians present; Stop resuscitation efforts; Explain what has happened to the family.” Though this article is vague in its recommendations, the value in it is the mantra like pneumonic. In the hectic setting of a pediatric resuscitation, reviewing the CEASE mnemonic can provide a framework for discontinuing resuscitation.

In the Part 2 follow-up post, I will discuss evidence based recommendations as well as personal experience following the termination of resuscitation in a pediatric patient.

Welcoming the Worst: Breathing Life into your Trauma Resuscitation

Trauma-Team---Elevator

Being one of the few pediatric emergency departments to care for pediatric trauma patients up to age 18, St. Louis Children’s Hospital sees more than its fair share of action.  While this exposure catapulted my experience, confidence, and clinical skills, hearing the trauma pager beep during my first few months as an attending evoked a Pavlovian response only completely summarized as nail-biting,  diaphoretic anxiety.  While the butterflies still flutter away to this day when that pager goes off, I learned to “welcome the worst” into the ED by taking several fast and easy steps to anticipate a trauma resuscitation.

The following are my personal strategies in the 5-10 minutes we often have before EMS arrive to begin a resuscitation before the patient arrives.

1. Prepare myself: Don appropriate PPE an be physically present in the trauma bay before the patient arrives.  Scan a PALS or other type of resuscitation card/sheet to bring focus away from the rest of the busy ED and to the potential serious injury soon to arrive.  If enough information about the patient is known, mentally run through the most likely workup and consider entering preliminary orders into the electronic ordering system for quick review and signature finalization after patient evaluation.  Consider what RSI medications and code drug dosages to use.

2. Prepare my nurses: Review what en-route details are known about the patient.  Discuss what fluid resuscitation may be needed an consider prepping a pressure bag or rapid infuser.  Discuss how many lines of access to prepare for and what labs are likely to be needed.

3. Prepare my pharmacist: Using the estimated weight of the patient, review potential RSI medications and dosages, discuss pain control medications, consider osmotic agents and doses, and review code medications.

4. Prepare my radiology techs: Discuss any images the patient may have already had (if transferred from another hospital) or what imaging will likely be ordered.

5. Know my team: Know the name of everyone in the room and what role they are playing to facilitate closed loop communication.  If the patient is expected to have brain, orthopedic, or facial injuries – alert subspecialty surgeons to the patient’s impending arrival.

6. Know my trauma bay: Be familiar with where the doppler, chest tubes, O negative blood, and other lesser used supplies are that may be needed without delay.

These small steps in discussing the patient and anticipating a work up in advance solidify an ED team and support efficiency.