The Facebook group EM Docs, launched in April 2013, was started by a small group of friends and has become a forum to discuss common and uncommon issues and situations that emergency physicians face. It exploded in size and posting volume in October 2015 when it changed the settings to allow current EM Docs group members to invite their colleagues to its discussions. It’s empowering to have colleagues come together to share the joys and challenges of emergency medicine. Emergency physicians are fiercely passionate trailblazers with high expectations of themselves and others and are always advocates for patients.

As the EM Docs numbers have grown, the group has shared articles, crowd-sourced difficult cases, encouraged colleagues not to be bullied by attorneys, enjoyed emotional support after pediatric codes and full-moon shifts, laughed at one another’s sarcastic dark humor, shared success stories, and sent words of support with virtual pats on the back to say, “I’ve been there” when a colleague had a rough shift.

The discussions range from absurd and silly to life-changing because EM physicians can see this range on every shift and in their own lives. When a member gets a little out of line, other members declare a “meme war” (ie, they post “too numerous to count” funny captioned photos) until enough comic humor makes everyone forget the controversial post.

In this column, I plan to highlight and summarize some of the conversations for those who aren’t on Facebook. However, if you want to be included in the conversation, ask a colleague to add you. Chances are someone in your department is on EM Docs. There are currently more than 6,200 of us, representing every state and some countries outside the United States. I’ll maintain the privacy of the group, so there won’t be personal attribution or details provided in this column. I will, however, summarize the most interesting/impactful posts.

A Few Helpful Discussions

(click for larger image)
Figure 1. ECG with a complete right coronary artery occlusion that was a STEMI equivalent with Sgarbossa criteria in a symptomatic patient.
PHOTO: TRENT STEPHENSON, DO.

Sgarbossa criteria: Remember that Sgarbossa criteria applies to paced rhythms as well as left bundle branch block (LBBB). Figure 1 shows an ECG with a paced rhythm that was an ST elevation myocardial infarction (STEMI) equivalent with Sgarbossa criteria in a symptomatic patient. Three criteria are included in Sgarbossa criteria:

• ST elevation ≥1 mm in a lead with a positive QRS complex (ie, concordance): 5 points
• ST depression ≥1 mm in lead V1, V2, or V3: 3 points
• ST elevation ≥5 mm in a lead with a negative (discordant) QRS complex: 2 points

≥3 points = 90 percent specificity of STEMI (sensitivity of 36 percent)

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.

Dr. Moody, founder of the EM Docs Facebook group, is president of the Tennessee College of Emergency Physicians and former emergency department chair for Mountain States Health Alliance.