Remember to look at lead I and aVL: An ECG with ST elevations in I and aVL that are cath lab criteria represents a probable occlusion of the diagonal branch of the left anterior descending artery. However, the inclusion of hyperacute T waves in V4 and V5 may indicate the circumflex instead.

Medico-legal: One recently graduated EM Docs member posted about a subpoena from an attorney to be present to testify as a witness in a case with fewer than 48 hours’ notice. The doc was scheduled to work and couldn’t get coverage. The threat was that the physician would be arrested if they didn’t show up for the court date. When the doc turned to the EM Docs group for help, there was a flood of support including written documents that helped the doc file the refusal to appear due to such short notice.

Mental health boarding: In May, there was a post from an EM Docs member with concerns regarding psychiatric boarding. Within hours, there were more than 40 responses reporting length of stays ranging from 16 hours to 30 days for psychiatric patients awaiting an inpatient bed! This information was taken to each congressional and senate visit in every state during the ACEP Leadership and Advocacy Conference. The data from this exchange provided real-world examples for lawmakers that resonated with them, helping ACEP better lobby for improved access and resources for mental health patients presenting to the emergency department.

Crowd-sourcing: When an EM Docs member has a “zebra” and has run out of ideas, they crowd-source the group. Recently, someone mentioned that when a young patient arrived with Wolff-Parkinson-White syndrome (WPW) and a heart rate 180–200, they realized that their hospital didn’t have procainamide. Twenty-eight docs responded. Many had also had similar situations. The following week, other EM Docs members had the exact situation, and because so many had mentioned other options, it was fresh in their minds. Other options listed were Valsalva, sedation and cardioversion (the most frequent suggestion), adenosine, and/or amiodarone if the ECG showed narrow complex with a warning to never use an atrioventricular nodal blocker in wide complex tachycardia with a history of WPW—especially with an irregular rhythm and changing morphologies. Check with your hospital pharmacy to see if you have procainamide before you need it!

Financial considerations: There are occasional discussions within the group regarding contracts. About 50 percent of responding EM Docs members had an attorney look at their contracts, and many of those who did not wished they had. They shared information on mortgage lenders that offer physician loans, including Wells Fargo (relocation loans for medical student/residents to cover moving expenses with no payment for 60 months), Bank of America (90–95 percent financing on mortgages up to $1.5 million with no required private mortgage insurance [PMI] and a signed contract qualifies the physician before starting their new attending job, student loan debt that is deferred is not calculated into the debt/income ratio), and SunTrust (up to 90–100 percent financing with limits of $750,000 and $1.5 million, respectively, and no PMI requirement). It was noted that MyFedLoan.org has information about public student loan forgiveness programs. Finally, a suggested resource for investing is the personal finance blog The White Coat Investor (WhiteCoatInvestor.com), written by EM physician and ACEP Now columnist James Dahle.