EM Collective Wisdom: Larissa Velez

Author: Larissa Velez, MD (EM Program Director / Professor of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

1) Why still Emergency Medicine?

Wow! Many reasons.

We are still one of the few specialists that can take care of everything and anyone.

We are one of the few who see the truly undifferentiated patient.

We do lots of procedures, where, again, many other specialists are running the other way.

Our work is never, ever boring.

Our learning never ends and is always evolving.

We get to learn the most interesting part of every specialty.

Our work isn’t confined to an emergency “room”. We can work in a poison center, an HBO chamber, a critical care unit, an ambulance. We can work in both high tech and very austere environments.

My colleagues are awesome: fun people who can talk about anything and who aren’t grossed out by anything.

I love my personal life more than I love EM, and my career allows me to have time away, time to explore my interests and passions, time to be a wife and a mother.

2) Most impactful case. 

Every death takes a toll. Every save is equally important. Having been in EM for more than 20 years, I still clearly remember a handful of cases that shook me, humbled me, and also that filled me with joy. Hold on to each of those. They keep you sane, keep you humble, keep you grateful, and remind you why what you do is so important.

I was a resident. This family was brought in after a head-on collision. Our small ED was wrapping up the overnight shift. We all got ready, and, in a minute, we received 2 coding pediatric trauma patients, one critically injured pediatric patient, and the injured adult, the mother who was driving them to school. We divided the work as best as we could. At some point during the event, the woman holds the arm of one of our nurses, and I heard a gasp. As our nurse turned and looked, she recognized one of our ED nurses. She lost all three kids that day. Months later, she returned to work in the ED. I think we all struggled every time we saw her. At least, I know I did.

The day after Thanksgiving a few years back – longer than a decade ago now. This young boy fell onto a huge pot of soup his family was cooking outdoors for a picnic. I’d never heard screaming like that. He was completely burned, and had ingested and aspirated this boiling liquid too. There was not much we could do but give pain medicines, get an IO from the ambulance who brought him, intubate him, and get him to the burn unit, where he died later that night. I did not have kids at the time, but I’ll never forget the grief and the horror.

3) Most important career decision leading to satisfaction.

To speak up when the former APD of the EM program quit. I didn’t think I was ready to assume the position, but I asked my mentor, and she told me to “go for it”. I am PD now, and grateful that I had the courage to ask to be considered way back then, and to have been given the opportunity.

4) What does future of EM look like?

I know that it’ll be very different. One thing for sure is that we will always have plenty of patients. I hope that technology continues to help us – ultrasound in particular. I hope also telemedicine helps us with things like follow ups, and with providing certain services in underserved areas. I am worried about the tidal wave of APPs with very variable quality of training taking over portions of the specialty. I am worried about the increased government and administrative pressures on dashboards and metrics. I know we will be OK, but we need to be engaged and good advocates for our specialty and our patients.

5) Greatest achievement / why giving back is important.

Graduating a resident who has struggled is always a great achievement. Teaching the exceptional resident is easy. Teaching those who are struggling, and guiding them through residency, and seeing them succeed is tough, sometimes very tough.

However, my biggest achievement in general will never be work-related. Having a loving, caring family is by far, my greatest achievement.

6) Favorite failure.

Missing a procedure that I’m trying to teach. It sucks to fail in front of those you are teaching, but it shows them that failure is always present in our careers, and how to move forward and have a contingency plan is critical.

One of my residents was trying to intubate a patient. He could not pass the tube and seemed to feel some sort of obstruction just past the cords. He tried a couple of times, and I asked if he wanted me to try. I used the VL, and could see the cords, but tried to pass a tube, tried to put a bougie through the tube, but something wasn’t letting the tube go more than perhaps one cm past the cords. I left the tube there, as we could bag well, and we called for help from anesthesia and ENT. The anesthesia service tried to troubleshoot with the fiberoptic, but some airway tissue would not allow for intubation. They thought it would be too risky to move the patient to the OR. It was decided to do a trach in the ED (we see a tracheostomy scar that was barely visible to us at first). The trauma surgery attending in house supervised the ENT resident and anesthesia brought the OR down to the ED. It took about 20 minutes to get a tracheostomy after setting everything up. I could not tube that day, but both the resident and I gained a lot from troubleshooting and mobilizing hospital resources. The patient did well.

7) One thing you would change about our field.

All of the administrative pressures…. the paperwork…. the obtrusive electronic health record which is supposed to help us but it is more of a mountain of hurdles.

8) Something that you love that has indirectly impacted your EM career.

Reading. I read a lot, about everything. I skim through a lot of information every day, from recipes, to science and technology, to news and politics, to, yes, emergency medicine. It is a great habit.


3 people you’d like to see fill this out

1) Kathleen Delaney

2) Andra Blomkalns

3) Angela Gardner

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