VOTW: A real gut-wrenching situation!

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Hello all! This week’s VOTW is brought to you by yours truly!

Hospital course

83 y/o F with PMH esophageal hernia presented to the ED with 2 days of abdominal fullness, nausea, and vomiting. Last bowel movement was 2 days ago. Bedside ultrasound was done.

This is small bowel. How do we know this? Note the small finger-like projections from the inner wall (yellow arrows). These are called plicae circulares, which are  mucosal folds of the small intestine. Also note that the bowel diameter is dilated up to 3.2 cm (blue arrow).

Note the transverse view of the small bowel below the stomach. The bowel wall appears thicker than normal, measuring 0.88 cm. Also note that the stomach itself appears very dilated!

In the clip above, we can see multiple loops of dilated small bowel. We can see hyperechoic specs of intestinal contents within the bowel making a “to-and-fro” motion instead of normal unidirectional peristalsis.

In the clip above, we can see dilated small bowel with no movement of the intestinal contents at all!

Case Conclusion

The patient was found to have a small bowel obstruction with an incarcerated femoral hernia on CT imaging. NG tube was placed in the ED and patient was admitted for surgical intervention.

Characteristic Findings of SBO

·       In normal small bowel, the regular bowel diameter is < 2.5 cm and we expect to see normal peristalsis with unidirectional flow.

·       A small bowel obstruction on ultrasound will show multiple loops of bowel with a diameter > 2.5 cm. The intestinal contents will appear to move back and forth with “to-and-fro” movement. Sometimes the distal obstruction will prevent the intestinal contents from moving at all!

·       A small bowel obstruction will also lead to bowel wall edema, which causes a wall thickness > 4 mm. The bowel wall edema and dilated diameter will make the intestinal folds or plicae circulares appear more prominent, leading to the “key board” sign seen in the image above.

 

Happy scanning!

Sono team

 

Resources to review:

·       https://coreultrasound.com/small-bowel-obstruction/

·       https://www.emdocs.net/us-probe-ultrasound-for-small-bowel-obstruction/

·       https://www.acep.org/sonoguide/advanced/gi---bowel-obstruction

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VOTW: The chamber that bounced back!

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Hello all! Check out this week’s VOTW by yours truly!

Hospital course

A 60 y/o M with extensive PMH including ESRD on dialysis and CHF presented to the ED complaining of generalized weakness and SOB. He was hypotensive and anemic. Bedside TTE was performed.

In both parasternal and short axis views seen above, there is a circumferential pericardial effusion surrounding the entire heart.

Parasternal long view: We can see the RV collapse during diastole. How do we know this is diastole? Note that we can see the opening of both the mitral valve and the tricuspid valve to allow for ventricular filling, which occurs during the diastolic phase of cardiac contraction. See clip #1 to see a video of this RV diastolic collapse.

Short axis view: Here we see an example of ‘trampoline sign’, which is the characteristic bouncing motion of the RV. In the image above, we see inversion of the RV wall during diastole (arrow). How do we know this is diastole? Again, note that we can see the opening of the mitral valve in the LV when the RV wall inverts. See clip #2 to see a video of the ‘trampoline sign’.

IVC: In clip #3, we see a very distended plethoric IVC without respiratory variation.

Case Conclusion

The patient was found to have a large pericardial effusion with tamponade. He was stabilized and admitted to cardiology for a pericardial window.

Characteristic Findings of Cardiac Tamponade on POCUS

·       The transition from a pericardial effusion to tamponade is due to the rate of fluid accumulation within the pericardial sac, not the total volume of effusion. The right heart is a low-pressure system and collapses when it is unable to accommodate the acute increase in pressure seen when fluid quickly fills the surrounding pericardial sac.  

·       Thus, the earliest sonographic finding of cardiac tamponade is RA collapse during systole. This is typically followed by RV collapse during diastole, which has both high sensitivity and specificity for cardiac tamponade.

·       A non-collapsible plethoric IVC is the most sensitive sign of cardiac tamponade.

 

Happy scanning!

Sono team

 

Resources to review:

·       https://coreultrasound.com/pericardial-tamponade/

·       https://www.acep.org/emultrasound/newsroom/may-2024/cardiac-tamponade

·       https://www.aliem.com/differentiating-pericardial-effusion-tamponade-ultrasound/

·       https://www.emra.org/emresident/article/us-cardiac-tamponade

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CIR Union Benefits (July 2025)

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Since today is the first day of the new academic year and we have many new faces joining us, I thought it would be a great time to review our union's benefits once again (shout out to our ex-resident Dr. Jeff Yang for his detailed table that he made for POTD a few years back). 

I recommend setting up Direct Deposit at the CIR portal: https://cirmp.novus-360.com/cirmpprod as you can receive your reimbursement back in 7 days after you file a claim, in comparison to 4-6 weeks of a mailed check from the union. 

Professional Education Benefit (also known as CME money)

Our union will pay $1250 annually (benefits renew July 1st every year) with the following caveats:

  • Electronic devices are only reimbursed at 75%, up to the full $1250.

  • Only 1 electronic device will be reimbursed per year.

  • Eligible electronic devices include laptops, phones, tablets. Things that are not eligible include smart watches, phone plans, cameras, eBooks/Kindles.

  • Electronic devices must be purchased before the last 6 months of residency. PGY3s, this means you must buy one BEFORE Saturday 12/30 to be reimbursed.

  • Interns: you can use this money to pay for your Step 3/Level 3 board exam fees and/or UWorld subscription to study for the exam 

Other things that are eligible include: 

  • Audio materials

  • Board Exam Fees

  • Books and eBooks

  • COVID-19 Medical Equipment

  • Conferences/Courses

  • Dues & Journals for Medical Specialty Society

  • Equipment (ie. scrubs, stethoscope, etc.)--FIGS ARE INCLUDED 

  • License Application and Examination Fees. Per the Internal Revenue Service, initial medical and/or dental licensing reimbursements are taxable. A 1099 tax statement will be issued to anyone who receives reimbursement for initial licensing totaling $600.00 or more per calendar year.

  • Software or electronic medical apps

  • Fellowship Application Fee

Discounted Contract Review

Important Information for the graduating PGY3's: 

CIR members are eligible  to receive a review of their post-residency employment contract by a participating lawyer at a substantially discounted rate of $400.


Meal allowances

  • $1100 per year, does not roll over

  • Places freedom pass accepted at that I’m aware of: 3 in 1, Maimoni, the place next door to Maimoni, Leah’s Kitchen (formerly J&J), D&D, La Strada, Kaff Bakery, and now Bora Bora

  • Check balance at next time you buy something at Maimoni Deli or https://my.freedompay.com/MemberServices/BalanceCheck.aspx

Parking

  • Opt-in program. Email academic affairs, Robin Gitman and Lindsay Macchia to sign up

  • 12 vouchers per month or $36/month (discounted from $54) for unlimited parking

Uberhealth

  • $25 limit. Ride must originate from Maimonides.

  • Can use 10pm – 5:30am 

  • Does not work from your home to Maimo, only the other way around 

  • Please be mindful of utilizing this precious resource, as if you use it out of the hour range listed above, the cost of the Uber ride will be deducted from your paycheck (or so we have been told)

Discounts

In addition, CIR in partnership with SEIU (Services Employee International Union), has plenty of discounts through their member portal: https://www.seiumb.com/

Some highlights are: 

  • Get a $40 Costco Gift card when you apply for a new membership

  • Get up to 40% off on concert/amusement park tickets 


FSA/Commuter Benefits  

  • Manage both at https://participant.briweb.com/dashboard

  • FSA (flexible spending account): Use pretax money towards healthcare spending. This includes contact lens solution, sunscreen SPF 15+, tampons/liners/pads, OTC medications.

    • These accounts are not the same as HSA. Use-it-or-lose-it by 12/31 each year.

    • You can only add money during enrollment periods which already passed for next year (11/6/23-11/27/23)

  • Commuter Benefits: Use pretax money towards transportation. Includes subways, busses, ferries, and trains (e.g. Amtrak). Does not include taxi, uber, tolls. You can change how much you put in before any pay cycle.
     

 

Benefit

Amount

Comments

PEB (CME)

$1250

Submit claims:

https://cirmp.novus-360.com/cirmpprod

Meal allowance

$1100

Does not rollover

Check balance:

https://my.freedompay.com/MemberServices/BalanceCheck.aspx

Parking

12 vouchers/month or $36/month

Sign up by emailing Robin Gitman and Lindsay Macchia (Academic Affairs)

UberHealth

≤ $25/night

10pm-5:30am or after shift from MMCH

Mental Health

$5,000 / year

Max $200 / visit

Submit claims:

https://cirmp.novus-360.com/cirmpprod

Paid Family Leave

Up to 12 weeks, up to $1131/wk

This is a NY state benefit. For new children, ill family members, family members called in to military.

FutureMoms

N/A

Access OB nurse coach, dietitians, pharmacists, social workers.

Rx Benefit

$5 - $60 copay

ExpressScripts

http://www.express-scripts.com/

Dental

Its… ok. Annual cleanings are covered.

Guardian

http://www.guardiananytime.com/

Vision

$100-125 towards frames/contacts

Davis Vision

http://www.davisvision.com/

Disability

Short term: 60% weekly salary up to $692/wk x 26 wks

Long term: 60% monthly salary up to $3,5000/month

Life

Your beneficiary gets $125,000 if you die. You get $20,000 if your spouse dies.  

Language

Rosetta Stone.

https://www.cirseiu.org/opportunity-to-learn-a-new-language-with-rosetta-stone-2/

Legal

Includes landlord, immigration, bankruptcy issues among others. Refer to following to see if CIR lawyers can cover you.

https://www.cirseiu.org/wp-content/uploads/2016/03/CIRLS-VH-SPD-2014-w-cover.pdf

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