CIR Union Benefits (July 2025)

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

VBG + Vibes

Our ED has experienced several times when the lab goes down and none of our labs return. On days like these, our team coined the term “VBG + Vibes” to describe the clinical atmosphere. But all jokes aside: is our reliance on VBGs truly justified?

When ICU teams arrive, their residents and fellows sometimes request arterial blood gases (ABGs) instead. While there are certain indications for ABGs—particularly when assessing oxygenation or in unstable patients—a VBG typically provides enough clinical information for most ED decisions.

We also routinely turn to VBGs for electrolytes, especially when a hemolyzed BMP gives us a suspiciously elevated potassium level (e.g., K = 7). If the VBG potassium is normal, we often proceed based on that value. But how accurate and dependable are these VBG electrolytes?

In this POTD, we’ll explore the evidence behind VBG use—its accuracy, limitations, and when it truly matters to make the distinction. Let’s clarify when “VBG + Vibes” is solid clinical practice—and when it might not be enough.

Origins and Uses of VBGs

• Faster, less painful alternative to ABGs for acid–base assessment

• Widely adopted in EDs for evaluating pH, bicarbonate, CO₂, and lactate

• Particularly useful in DKA, sepsis, and undifferentiated shock

• Modern analyzers also provide electrolytes and hemoglobin, expanding utility

VBG vs. ABG 

• Advantages of VBG

  • Easier, safer, and faster to obtain than ABG

  • Less painful; no arterial puncture needed

  • Suitable for most acid–base and perfusion assessments

• Limitations of VBG

  • Cannot measure PaO₂ – use SpO₂ for oxygenation (unless severe hypoxemia suspected)

  • Less reliable at extremes (e.g., shock, hypercapnia >45 mmHg)

  • If VBG PCO₂ is elevated or oxygenation is unclear, follow with ABG

Accuracy of VBG Parameters

• pH & Bicarbonate

  • pH difference vs ABG: ~0.03–0.05 units → clinically negligible

  • Bicarbonate (HCO₃⁻) closely mirrors ABG and serum values (within ~2 mEq/L)

  • Reliable for assessing acidosis/alkalosis, including in DKA and renal failure

• CO₂ (PCO₂)

  • Correlates well when normal or mildly elevated

  • PCO₂ >45 mmHg → correlation worsens, may under- or overestimate PaCO₂ by ±10 mmHg

  • Use VBG to rule out hypercapnia; ABG needed if VBG CO₂ is high or patient is unstable

• Electrolytes

  • Potassium & sodium from VBG strongly correlate with serum values (r > 0.9)

  • Good enough to trust for clinical decisions (e.g., hyperkalemia)

  • Caution: Blood gas analyzers don’t detect hemolysis – falsely elevated K⁺ possible

• Hemoglobin & Hematocrit

  • Reliable from VBG analyzers (via co-oximetry)

  • Sufficient for ED decision-making, including transfusions and anemia eval

• Lactate

  • Venous lactate is accurate for diagnosis and trending in sepsis and shock

  • Normal VBG lactate rules out tissue hypoperfusion

  • Trending must be done using same sample type (venous vs arterial)

Common ED Use Cases

• Diabetic Ketoacidosis (DKA)

  • Venous pH and HCO₃⁻ are adequate to diagnose and monitor DKA

  • VBG electrolytes (Na⁺, K⁺, bicarb, AG) reliably match BMP

  • No need for ABG unless coexisting respiratory failure

• Sepsis

  • VBG lactate + base deficit reflect perfusion status

  • Serial VBGs are reliable for lactate clearance

  • ABG only if oxygenation unclear or patient in severe distress

• Undifferentiated Shock

  • VBG rapidly identifies metabolic or respiratory acidosis

  • Helps differentiate between shock types early

  • ABG may follow if VBG is highly abnormal or clinical picture unclear

When to Use ABG Instead

• Need exact PaO₂ (e.g., ARDS, unclear oxygenation despite high SpO₂)

• Suspected severe hypercapnia or respiratory failure (e.g., altered COPD)

• Mixed acid–base disorder with unclear etiology

• Consultant or protocol explicitly requires it (e.g., trauma base deficit)

Takeaways

• VBG + SpO₂ + clinical judgment is accurate, safe, and efficient in most ED patients

• ABG should be selective, not routine

• Embracing VBGs reduces pain, speeds care, and provides reliable data in:

  • DKA

  • Sepsis

  • Shock

  • COPD/asthma exacerbations

• Knowing when a VBG is enough is essential; use ABG only when it changes management

References:

Kelly, A. M., McAlpine, R., Kyle, E., & Klim, S. (2018). How accurate are blood gas electrolyte measurements? REBEL EM. https://rebelem.com/how-accurate-are-blood-gas-electrolyte-measurements/

LITFL. (2023). VBG versus ABG. Life in the Fast Lane. https://litfl.com/vbg-versus-abg/

Koul, P. A., Khan, U. H., Wani, A. A., Ahangar, A. G., & Ahmad, M. (2024). Venous versus arterial blood gases in patients with COPD exacerbation: A clinical equivalence study. Journal of Emergency Medicine, 66(2), 142–148. https://doi.org/10.1016/j.jemermed.2024.01.003

Zeserson, E., Goodgame, B., Hess, J. D., Satty, T., Walker, C., Diercks, D. B., & Clancy, T. V. (2018). Correlation of venous blood gas and pulse oximetry with arterial blood gas in the undifferentiated critically ill patient. Western Journal of Emergency Medicine, 19(2), 403–408. https://doi.org/10.5811/westjem.2017.11.35191

Gokel, Y., Paydas, S., Koseoglu, Z., Seydaoglu, G., & Tan, M. E. (2000). Comparison of blood gas and electrolyte values in arterial and venous blood samples in patients with uremic acidosis and other acid-base disturbances. American Journal of Nephrology, 20(4), 319–323. https://doi.org/10.1159/000013601

ALLNYCEM - Women's Health and Emergency Medicine

The ALLNYCEM Spring Conference, at The New York Academy of Medicine. This year’s theme — Women’s Health and Emergency Medicine — brought together leaders in emergency medicine, advocacy, and education to address issues of women health in emergency medicine, and as an added bonus, gave an overview of the new ABEM oral boards! Today's presentations featured our own Dr. Julie Cueva and Dr. Smruti Desai, along with Maimo EM alum Dr. Sabena Vaswani. Here is a recap of the day!

Welcome and Introductions

Dr. Laura Melville (NYP-BMH) and Dr. Diksha Mishra (NYP-Cornell) set the stage for a day focused on equity, advocacy, and excellence in women-centered emergency care.

FemInEM is Back!

Dr. Dara Kass (FemInEM)

• Reintroduced FemInEM's leadership team and core mission: equity, mentorship, research, and clinical innovation.

• Announced new initiatives including updates in reproductive healthcare in Texas and a Women in Medicine Summit (Sept 18–20, 2025).

• Encouraged participation in advocacy and leadership programs.

Rethinking Chest Pain in Women

Dr. Julie Cueva (Maimonides)

• Women comprise 57% of ED chest pain visits but receive delayed and differential care

• Are less likely to receive an early EKG

• Wait an average of 11 minutes longer than men to be evaluated

• Have higher rates of major adverse cardiovascular events (MACE)

• Only 30% of STEMIs in ED patients occur in women — often under-identified

• High cardiovascular disease (CVD) burden:  CVD is the leading cause of death in women

• 1 in 3 women die of cardiovascular-related illness

• Traditional risk tools may underestimate women's risk, especially premenopause or perimenopause

• Less likely to report classic "crushing" chest pain

• More likely to present with:  Jaw, neck, back pain, Exertional symptoms or fatigue/malaise, Shortness of breath, nausea, or palpitations

• Women more commonly present with ACS mimics, including: 

• MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries)

• Etiologies include coronary vasospasm, thromboembolism, SCAD, microvascular dysfunction

• Treated based on etiology: antiplatelets, statins, CCBs, ACEi, BB

• SCAD (Spontaneous Coronary Artery Dissection)

• Seen in women ages 24–89, often peri- or post-menopausal

• Avoid anticoagulation; treat with DAPT and beta-blockers

• Takotsubo Cardiomyopathy (Stress-Induced)

• Diagnosed by cath and echo

• Managed with ACE inhibitors, beta-blockers, and supportive care

• Endocrine and life-phase considerations:  Estrogen is cardioprotective, but also prothrombotic

• Consider cardiovascular pathology across age brackets: 

• Premenopausal: PE, autoimmune vasculitis

• Perimenopausal (~40s): ACS, PE, breast pathology

• Menopausal (~51+): ACS, aortic pathology

• Advocate for sex-specific troponin thresholds and protocols

• Improve documentation of atypical symptoms

• Educate colleagues on female-specific risk factors (e.g., gestational HTN/DM, early menopause, PCOS)

• Support gender-specific decision-making tools and diagnostic pathways

Reproductive Health in the ED

Dr. Sabena Vaswani (NYP-Q)

• The ED is a key access point for reproductive health care, particularly for underserved populations.

• ContraceptED is a framework for emergency clinicians to counsel and initiate contraception in the ED.

• Same-day options include progestin-only pills (OTC), combined hormonal methods (pill, patch, ring), and Depo injection.

• Use CDC MEC criteria to determine safe prescribing based on comorbidities and patient history.

• Bridge patients to LARC (implants, IUDs) with prescriptions and follow-up referrals.

• Initiate medication abortion for patients eligible and interested: mifepristone + misoprostol protocol.

• Manage early pregnancy loss with patient-centered language and shared decision-making.

• Counsel on HIV prevention and prescribe PrEP to high-risk patients when indicated.

• Offer expedited partner therapy for STI treatment with take-home prescriptions.

• Reframe reproductive health as essential emergency care, not a separate or optional service.

Beyond Microaggressions

Dr. Smruti Desai (Maimonides)

• Interactive session on how to recognize, respond to, and grow from moments of bias

• Microaggressions are subtle slights that undermine psychological safety and reinforce bias.

• Impact matters more than intent—harm can occur even without malicious intent.

• Prepare to intervene with the same mindset as a safety check: is the scene safe and private?

• Effective responses include microaffirmations, clarifying questions, and naming behaviors—not people.

• Assume best intent but always redirect attention to the impact of the statement or action.

• Stay calm and disarm defensiveness—frame your feedback as an invitation to growth.

• Support colleagues targeted by microaggressions with follow-up, validation, and direct intervention.

• When called out yourself, respond with humility: pause, apologize, reflect, and adjust.

• Promote institutional DEI efforts through skill-building, not just policy statements.

• Practice allyship as an ongoing process that requires reflection, action, and resilience.

Gender-Based Violence and Strangulation

Jennifer DeCarli, Esq., LMSW (Deputy Commissioner, ENDGBV)

• Gender-based violence (GBV) includes intimate partner violence (IPV), sexual violence, stalking, trafficking, elder abuse, and female genital mutilation (FGM).

• NYC Family Justice Centers (FJCs) provide wraparound services for survivors across all five boroughs.

• In 2023, NYPD reported over 245,000 domestic incident reports; FJCs saw more than 57,000 client visits.

• Homicide data shows 32 intimate partner homicides and 41 family-related homicides in 2023 alone.

• The HOPE domestic violence hotline received over 87,000 calls last year.

• Medical providers are often first responders—strangulation must be recognized as a high-risk, high-lethality indicator.

• Documenting non-visible injuries (e.g., hoarseness, petechiae, dysphagia) is critical in EDs.

• Multidisciplinary collaboration between healthcare, law enforcement, and advocacy agencies improves survivor outcomes.

• Mandatory reporting is complex—know state-specific laws and always center patient autonomy and safety.

• Emergency departments are uniquely positioned to initiate trauma-informed, life-saving interventions.

Knocking on a Closed Door: Emotional Intelligence in EM

Dr. Shorok Hassan (SIUH)

• Emotional intelligence (EQ) is the ability to recognize, understand, and manage your own emotions while navigating those of others.

• EQ is composed of five key domains: self-awareness, self-regulation, motivation, empathy, and social skills.

• Self-awareness allows for insight into your strengths, limitations, and emotional responses during clinical care.

• Self-regulation means pausing before reacting, managing stress productively, and staying adaptable under pressure.

• Motivation involves setting personal goals and aligning your work with values and purpose.

• Empathy is the cornerstone of EQ—connect with patients and colleagues through genuine understanding.

• Social skills include teamwork, verbal/nonverbal communication, and conflict resolution.

• The Johari Window model helps identify blind spots, hidden strengths, and areas for growth.

• Reflective practice enhances your ability to remain mindful, reduce bias, and avoid burnout.

• EQ is a leadership skill—high-EQ clinicians build trust, improve team dynamics, and deliver better patient care.

Telehealth Abortion Management

Drs. Langan, O’Callaghan, Nadas (NYC H+H)

• Nearly two-thirds of all abortions in the U.S. are now medical abortions, most initiated via telehealth.

• NYC’s post-Dobbs policy response includes building telehealth hubs for abortion access through ExpressCare.

• Mifepristone (REMS-restricted) and misoprostol are the two medications used in safe, effective early termination protocols.

• No-test medication abortion is supported by ACOG, WHO, NAF, and studies showing 95% success and <0.3% complication rate.

• Aiken et al. 2021 cohort study confirms safety of mail-in and virtual abortion services.

• The Reproductive Health Act (2019) legalizes abortion in NY and allows advanced practice clinicians to provide care within scope.

• Legal protection varies by state—ED clinicians must be aware of cross-jurisdictional issues, especially for traveling patients.

• Survey data show that while 70% of EM clinicians support abortion care in the ED, only 10% feel trained to provide it.

• ExpressCare infrastructure integrates scheduling, documentation, and virtual visits through Epic/MyChart/Bluesky platforms.

• TeleMAB in NYC expands equitable access and reduces geographic, economic, and legal barriers to reproductive autonomy.

ABEM and the New Oral Boards

Dr. Theodore Gaeta (ABEM Board of Directors)

• ABEM is transitioning to a new oral board format designed to better assess clinical reasoning and judgment.

• The exam features updated content areas and structured interview formats aligned with modern EM practice.

• Candidates will complete a series of structured cases with standardized prompts, focusing on safety, efficiency, and communication.

• Core competencies tested include diagnosis, management, disposition, interpersonal skills, and patient-centered care.

• Scoring rubrics are more transparent and emphasize reproducibility and fairness.

• Preparation strategies should include structured practice, case-based group sessions, and mock exams.

• Simulation and role-play are essential tools for improving confidence and pacing under exam conditions.

• Programs are encouraged to build peer-led oral board prep initiatives for residents and recent grads.

• ABEM provides official study resources and updates through its portal—residents should review regularly.