September/October 2020 Common Sense

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 27, ISSUE 5 SEPTEMBER/OCTOBER 2020

What’s With All These Position Statements?

Page 12

President’s Message:

Leadership in a Time of Crisis

3

From the Editor’s Desk:

People are People

5

EM Workforce:

Will There Be a Doctor in the House?

29

Young Physicians Section:

44

2020 Graduates: You Don’t Have to Go it Alone After Residency!

AAEM/RSA President’s Message:

What’s Going on with the Emergency Medicine Job Market?

48

Table of Contents TM

Officers President Lisa A. Moreno, MD MS MSCR FIFEM President-Elect Jonathan S. Jones, MD Secretary-Treasurer Robert Frolichstein, MD Immediate Past President David A. Farcy, MD FCCM Past Presidents Council Representative Joseph Wood, MD JD Board of Directors L.E. Gomez, MD MBA Bobby Kapur, MD MPH CPE Bruce Lo, MD MBA RDMS Evie Marcolini, MD FCCM Sergey M. Motov, MD Terrence Mulligan, DO MPH Vicki Norton, MD Carol Pak-Teng, MD YPS Director Phillip Dixon, MD MPH AAEM/RSA President Haig Aintablian, MD Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD Editor, Common Sense Andy Mayer, MD Executive Director Missy Zagroba, CAE Executive Director Emeritus Kay Whalen, MBA CAE AAEM/RSA Executive Director Madeleine Hanan, MSM Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Alexandria Gregory, MD, Resident Editor Cassidy Davis, Managing Editor Articles appearing in Common Sense are intended for the individual use of AAEM members. Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA. Articles may not be duplicated or distributed without the explicit permission of AAEM. Permission is granted in some instances in the interest of public education. Requests for reprints should be directed to AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM is a non-profit, professional organization.

Our mailing list is private.

2

COMMON SENSE SEPTEMBER/OCTOBER 2020

COMMONSENSE

Regular Features President’s Message: Leadership in a Time of Crisis.............................................................................3 From the Editor’s Desk: People are People.............................................................................................5 Foundation Donations.............................................................................................................................7 PAC Donations........................................................................................................................................7 LEAD-EM Donations...............................................................................................................................8 Upcoming Conferences ........................................................................................................................10 AAEM/RSA President’s Message: What’s Going on with the Emergency Medicine Job Market?.........48 AAEM/RSA Editor: “Zooming” into a New Era of Clinical Education.....................................................50 Resident Journal Review: Do Adjunctive Therapies Beyond Infection Control and Appropriate Fluid Resuscitation Change Outcomes in Sepsis and Septic Shock?.....................................................52 Medical Student Council President’s Message: The Open Door...........................................................56 Job Bank...............................................................................................................................................58 Special Articles A Letter to All People Staying Neutral about Black Lives Matter...........................................................16 When Do Things in Medicine Start to Become Common Knowledge?.................................................20 Telehealth and Emergency Medicine: Our Virtual Practice...................................................................22 Human Trafficking: A Review for Health Care Providers.......................................................................24 EM Workforce: Will There Be a Doctor in the House?...........................................................................29 EM Workforce: Maybe July 1st Isn’t so Dangerous After All..................................................................31 Wellness: Gratitude and Appreciation Amidst Chaos and Uncertainty: Awaken Humanity at Work......35 Critical Care Medicine: To Those Who Initiate Critical Care..................................................................37 Women in EM: Mothering in the Time of COVID...................................................................................39 Emergency Ultrasound: Making Point of Care Ultrasound Accessible for All........................................41 Young Physicians: Resiliency in Medicine.............................................................................................46 Updates and Announcements AAEM Board: What’s With All These Position Statements?..................................................................12 AAEM Signs on to Joint Letter to CMS to Sunset Waivers When PHE Concludes...............................14 New Cancer Diagnoses during COVID.................................................................................................18 ABEM News..........................................................................................................................................26 Social EM & Population Health: Social EM: What it is and Why it Matters........................................... 27 Ethics: A Novel Committee on a Very Important Directive....................................................................34 Young Physicians: 2020 Graduates: You Don’t Have to Go it Alone After Residency!..........................44 Mission Statement

The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles: 1. Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine.

2. The practice of emergency medicine is best conducted by a specialist in emergency medicine.

3. A specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).

4. The personal and professional welfare of the individual specialist in emergency medicine is a primary concern to the AAEM. 5. The Academy supports fair and equitable practice environments necessary to allow the specialist in emergency medicine to deliver the highest quality of patient care. Such an environment includes provisions for due process and the absence of restrictive covenants.

6. The Academy supports residency programs and graduate medical education, which are essential to the continued enrichment of emergency medicine and to ensure a high quallity of care for the patients.

7. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members.

8. The Academy supports the establishment and recognition of emergency medicine internationally as an independent specialty and is committed to its role in the advancement of emergency medicine worldwide.

Membership Information

Fellow and Full Voting Member (FAAEM): $525* (Must be ABEM or AOBEM certified, or have recertified for 25 years or more in EM or Pediatric EM) Affiliate Member: $365 (Non-voting status; must have been, but is no longer ABEM or AOBEM certified in EM) Associate: $150 (Limited to graduates of an ACGME or AOA approved emergency medicine program within their first year out of residency) or $250 ( Limited to graduates of an ACGME or AOA approved emergency medicine program more than one year out of residency) Fellow-in-Training Member: $75 (Must be graduates of an ACGME or AOA approved emergency medicine program and be enrolled in a fellowship) Emeritus Member: $250 (Please visit www.aaem.org for special eligibility criteria) International Member: $150 (Non-voting status) Resident Member: $60 (voting in AAEM/RSA elections only) Transitional Member: $60 (voting in AAEM/RSA elections only) International Resident Member: $30 (voting in AAEM/RSA elections only) Student Member: $40 (voting in AAEM/RSA elections only) International Student Member: $30 (voting in AAEM/RSA elections only) Pay dues online at www.aaem.org or send check or money order to: AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM-0720-337

AAEM NEWS PRESIDENT’S MESSAGE

Leadership in a Time of Crisis Lisa A. Moreno, MD MS MSCR FAAEM FIFEM

One of the many wonderful opportunities I have had in the past couple of years has been acceptance into the prestigious Chair’s Development Program (CDP) sponsored by the Association of Academic Chairs in Emergency Medicine in collaboration with the Society for Academic Emergency Medicine. At our most recent virtual meeting, Dr. Susan Stern, one of the course leaders, spoke on Leadership during Times of Crisis. I learned a lot, but I also realized that the Academy and our members are providing exemplary leadership during the current COVID pandemic and this time of political crisis. Here is some of what I learned: Be present and visible. Leaders need to be seen and heard. During the early days of the COVID crisis, the Board was called to many ad hoc meetings to deal with issues that our members brought to our attention. Members reported that their employment was terminated or threatened with termination when they brought attention to the fact that they had inadequate PPE. Members did, in fact, have inadequate PPE and were genuinely concerned about their health and safety and that of their families.

Members were told that they would be asked to ration resources and to send patients home who they would have admitted prior to the pandemic. They were concerned about possible malpractice litigation in these circumstances.

The Board not only read their emails, we called each member who had contacted us. We created position statements, collaborated with other EM organizations to take a stand, wrote to legislators in all 50 states and the federal government, and convened task forces under the able leadership of Drs. Walker, Wood, Walters, Pickens, and Mulligan to organize our ongoing response. We were out there: present and visible.

The Board not only read their emails, we called each member who had contacted us.”

Work alongside your team. The AAEM Board are all board certified working emergency physicians. What you do, we do. The problems you are experiencing, we are experiencing.

This is critical to informed leadership. How can your elected representatives represent you if we don’t know what your workday life is like?

Everyone in the Academy’s leadership is out there getting their hands dirty and doing the work of emergency medicine.

Listen to all voices. Often, this is the hardest part of leadership. AAEM is strongly opposed to the corporate practice of medicine. We don’t budge on this. But when Academy members are concerned about pay and hours cuts, we do need to listen to the rationale that the corporations have for making these cuts. We found that democratic groups were also dealing with decreased volumes, and university employees were looking at hours cuts. We listened, and we had to accept that decreased revenues would need to be absorbed by the physician group.

While physicians understandably don’t want a cut in pay or hours, democratic groups dealt with this by listening to all voices as well, and they reached consensus on how to cope. By listening to all voices, we realized that the principles on which the Academy stands hold true: Emergency docs will own a solution they come to democratically and solutions should not be dictated by administrators.

We became present and visible, and we accepted the criticism that being visible often begets because no patient should be denied health care because of race, ethnicity, gender, gender identity, insurance status, citizenship, disability, or any human condition.”

Another voice we are listening to is that of the residents and students. There is a lot of anxiety out there this year, as students entering the match will not have the opportunity to do any away rotations in EM. This is of more concern to those students whose medical schools do not have an EM residency, and this is true of every HBCU medical school. AAEM has responded by working with our AAEM/RSA leaders, Dr. Haig Aintablian and Dr. Dany Accillien in collaboration with SAEM RAMS to offer the HOME AWAY FROM HOME webinar program for these students to meet and be mentored by program directors from around the country.

Our Academic Affairs Committee leaders, Drs. Josh Joseph and Leslie Bilello, will be front and center on this program, along with Drs. Mark Reiter, Mike Dalley, Marianne Haughey, Tiffany Murano, Edgar Ordonez, and many others.

>>

COMMON SENSE SEPTEMBER/OCTOBER 2020

3

AAEM NEWS PRESIDENT’S MESSAGE

Don’t offer a solution before you hear the thoughts of the team. Dr. Stern pointed out that one group of individuals may not know the issues facing another group of individuals. She found this to be true when planning for the influx of COVID-19 patients led her to consult with not just doctors and nurses, but environmental service workers, hospital police and radiology technicians. The Academy does not endorse any specific sexual orientation or gender identity. Our mission statement supports unencumbered access of all patients to emergency care. We were approached by members of the trans-health community immediately following the recent reversal of a federal health regulation. They informed us that there was concern over trans people being denied access to COVID testing in testing centers run by religious organizations. We listened.

Patients worried that they are COVID infected and unable to get a test end up in our EDs or if they are undiagnosed positives, end up infecting others who we will later care for. We listened. We recognized the potential problems because we work alongside our team. We became present and visible, and we accepted the criticism that being visible often begets because no patient should be denied health care because of race, ethnicity, gender, gender identity, insurance status, citizenship, disability, or any human condition.

Be generous with information. When people don’t know what’s going on, they will fill the gap with speculation. It is human to wonder what is going on, to speculate on what is likely and to develop a credible explanation when information is not forthcoming.

The Academy provided updates on our website whenever information became available.

We updated it sometimes daily during the height of the pandemic. We provide a resources page. We make phone calls to every member who emails us or calls the office.

Our Legal Committee member Dr. Mitchell Li developed a tracking form to keep us on target with responses to every member expressing employment related concerns.

Dr. Fliescher-Black’s Palliative Care Interest Group paired with Dr. Giwa’s new Ethics Committee to work out ways to provide information to community doctors who may not have access to Palliative Care consults and need to have difficult conversations. Through our partnership with the American College of Medical Toxicology, we continue to offer a weekly webinar with top level CDC, OSHA, and FDA scientists and practicing physicians from around the country and the world on the status of vaccine development, critical care best practices, the safest ways to re-use PPE, and how infection is developing and being combated in various cities.

Have a plan. We do. The Academy has a mission statement that is totally transparent and unambiguous. We support the right of every patient to unencumbered care by a specialist in emergency medicine. We support the individual emergency physician’s right to a fair workplace environment and the right to make the medical decisions she has been trained to make without corporate interference. We support residency training and continued medical education.

We support the development of our specialty throughout the globe as a medical specialty and not a corporate enterprise.

Everyone in the Academy’s leadership is out there getting their hands dirty and doing the work of emergency medicine.”

It seems quite clear that the Academy is a GREAT leader in this time of crisis. Part of this is down to our sound and ethical mission. Part of this is down to our members, every one of whom is a leader in our specialty, whether in his own shop or in our numerous committees, interest groups, chapters and sections. Shakespeare said of Hermia in A Midsummer Night’s Dream, “though she be but little, she is fierce.” This is so true of the Academy. While we may not be the largest EM organization in the nation, our power comes from the integrity of our mission and our members. 

AAEM Antitrust Compliance Plan: As part of AAEM’s antitrust compliance plan, we invite all readers of Common Sense to report any AAEM publication or activity which may restrain trade or limit competition. You may confidentially file a report at info@aaem.org or by calling 800-884-AAEM.

AAEM NEWS

In an effort to keep our members connected, Common Sense will begin a column of member updates submitted by our members. We ask you to submit brief updates related to your career. We will also publish the unfortunate news of the passing of current or former members.

Visit the Common Sense website to learn more and submit your updates for publication! www.aaem.org/resources/publications/common-sense

4

COMMON SENSE SEPTEMBER/OCTOBER 2020

AAEM NEWS FROM THE EDITOR’S DESK

People are People Andy Mayer, MD FAAEM — Editor, Common Sense

So how do you spend your COVID downtime? Some of us have been working extremely hard in extraordinarily difficult circumstances. Other emergency physicians who work in less affected areas have seen huge decreases in patient volumes or decreased hours and shifts. Even those who are not in hot spots when not working are similarly affected by the bunker mentality, which has been part of our new normal. What do you do instead of meeting family or friends or pursing your previously normal pre-COVID pursuits? I write this at the end of June, but the world may be very different even by the time it is published. We of course hope that this is a temporary issue, but as with all things COVID the truth is that most predictions which have been made during this time have simply been proven wrong. It is hard to be accurate when working from the dark hole, which is COVID. People who know me realize that I like books and intermittently feel the need to read old books and talk about them. One of my personal COVID wellness programs has been to try and increase the time I spend reading in an effort to distract myself from what is going on in the world as the news is often simply too depressing. A positive side effect of this activity was to try and work through that stack of unread books in my office. I also like to read books with my adult children and discuss the books with them to keep in touch. My adult children were all fortunate in that they were able to stay employed, but they also have had more free time as their social lives took a more solitary turn. Everyone is looking for something to fill the hours, which used to be spent in more social situations, so we increased our reading. I saw on my shelf two plague related books and decided to read these. What better time to read about a plague than during a pandemic? This may sound strange, but I wanted to see how people from the past thought about an event like this before humans even knew that a bacteria or virus existed.

IT REALLY SURPRISED ME THE SIMILARITIES BETWEEN THESE EVENTS REGARDING HOW THE AVERAGE PERSON DEALT WITH THE STRESS AND DANGERS, WHICH WERE PRESENTED TO THEM WHETHER IT BE FROM THE BUBONIC PLAGUE OR COVID.”

The first book we tried was the Decameron, which to be honest I did not like and abandoned about a half the way through. It is really a comedy and deals with a group of young people hiding out in the countryside outside Florence during a 14th century bubonic plague outbreak. It contains a series of humorous and irreverent stories, which the characters take turns telling. It was surprisingly risqué and anticlerical for the 14th century. It is fun but seemed redundant to me.

The other book, which we read was Daniel Defoe’s A Journal of the Plague Year. This book is set in London during another bubonic plague outbreak, which occurred in 1665. It is a narrative by a man who stayed in London throughout the plague and tells an account of what he saw and read. I did enjoy this book and was amazed by the similarities between people hundreds of years apart in time regarding their thoughts, feelings, and reactions to a threat like a plague. It really surprised me the similarities between these events regarding how the average person dealt with the stress and dangers, which were presented to them whether it be from the bubonic plague or COVID.

One of the first things to strike me were the many “Bills of Mortality” which are present in the book. Defoe details the spread of the plague by parish across London during the year.

The various parishes made a weekly report of the number of people who died and often compared the numbers to their normal death rates. It is easy to compare these to the daily charts of positive COVID tests and death by county, state, or country. They too watched the disease spread from one area to another. They also noted small areas with an increased rate of illness suddenly explode with cases. Another fascinating thing was that they quickly realized that many deaths were being misidentified as not being from the plague when they probably had simply not been properly diagnosed. This sounds much like all the talk about “excess deaths” related to COVID in our current world.

“The most controversial containment measure ordered by the Lord Mayor’s Office was the policy of shutting up houses. If illness was evident or suspected, the City had the power to sequester a property and shut it up, along with its inhabitants, for a period of one month, or until the virus had passed.”

– Daniel Defoe, A Journal of the Plague Year

The government’s response to individuals also warrants some comparisons. The city of London decided to quarantine people at home and required the whole family to stay inside until the family either died or recovered by the end of a month of isolation. This entailed the government hiring a “watcher” who was stationed outside the house to make sure that the family did not try and escape. There was incredible fear related to been “shut up” in a

>> COMMON SENSE SEPTEMBER/OCTOBER 2020

5

AAEM NEWS FROM THE EDITOR’S DESK

One of my personal COVID wellness programs has been to try and increase the time I spend reading in an effort to distract myself from what is going on in the world as the news is often simply too depressing.”

house. Many people fled the city during this time and went to go live with their relatives in the countryside or in other towns. This helped spread the disease as has the return of students, tourists, and others home has led to a spread of COVID across the world in the past few months. Defoe states, “I am speaking now of People made desperate, by the Apprehensions of this being shut up, and their breaking out by Stratagem or Force.”

Individuals and families had to hire nurses to care for the sick in the home and have relatives bring them food to leave outside for the family to collect. The U.S. has not gone to these lengths but how many people have you told to “home quarantine” and have their family and friends bring them the necessary items of life?

The intrusion of any government into the lives of these ill or potentially ill people and constricting their movement has a modern tone to it. We as Americans and all citizens of any nation are facing these same issues with COVID. Each country is restricting their citizens to a different extent and the debate will rage for years regarding how much government authority to regulate our lives is appropriate.

6

Consequences, nay even not sensible of it themselves, as many were not for several days: these breathed Death in every Place, and upon every Body who came near them; nay their Cloaths retain’d the Infection, their Hands would infect the Things they touch’d.” He continued, “but that one Man, who may have really receiv’d the Infection, and knows it not, but goes Abroad, and about as a sound Person, may give the Plague to a thousand People, and they to a greater Number in Proportion, and neither the Person giving the Infection, or the Person receiving it, know anything of it, and perhaps not feel the Effects of it for several Days after.” This sounds familiar to me as a public health official briefing today explaining the importance of social distancing, compliance with mask wearing regulations, and home quarantining.

The effect of the plague on the economy of London sounds very familiar. Defoe states,”all trades being stopt, Employment ceased; the Labour, and by that, the bread of the Poor were cut off; and at first indeed, the Cries of the poor were most lamentable to hear; tho’ by the Distribution of Charity, their Misery that way was greatly abated.” He was complimentary to the public officials in London for the most part as they helped give out food to the needy. The city also hired the “watchers” to enforce the quarantine. This would seem to not be a great job but during the time there were thousands out of work who would jump at the chance to find even this type of work. Does this sound like the current hiring of thousands of contact tracers?

The response of the medical profession to the bubonic plague also is interesting. Medical knowledge at the time had little understanding of the disease and had no effective treatments.

We certainly have had a vast increase in our understanding of disease, but the helplessness expressed at the time in terms of treatment seem familiar as we have tried numerous types of treatments for COVID with varied and often disappointing results. Defoe discussed numerous arguments among physicians at the time related to the value of one treatment or another which sounded like debates held today for and against various medicines and treatment regiments. One theme related to the medical profession resonated loudly to me. Defoe wrote “the Plague defied all Medicines, the very Physicians were seized with it….and they dropt down dead, destroyed by the very Enemy, they directed others to oppose.” Many of us sadly know of physicians, nurses, or other health care professionals who have succumbed to COVID or have been debilitated by the illness.

Although the medical profession in 1665 did not know about microbiology, they did understand what we would call a latent period and fully feared the associated danger to the population.

Defoe wrote, “By the Well, I mean such as had received the Contagion, and had it really upon them, and in their blood, yet did not show the

In late June of 2020 as I write this, there is a spike in COVID cases across sections of the country. This has been attributed by some pundits as an expression of rebellion against the frustration associated with the recent prolonged period of self-isolation. There is a fatigue with following rules and guidelines from

COMMON SENSE SEPTEMBER/OCTOBER 2020

the various sources of this type of information.

The politicization of these recommendations has been a factor in using non-compliance with them as a means of self-expression and to some as an act of rebellion against what many consider an infringement of their rights by the government. Many people, especially young adults, seem to just want to get on with their lives and simply stop worrying about COVID. Certainly, in our current crisis only time will reveal the full consequences of this defiance.

In 1665, a similar situation occurred when the number of deaths from the plague started to decrease in London but certainly were not gone. Defoe noted an almost identical sense of restlessness in the population and related what could almost using modern prose be a press release related to COVID. He stated, “the Reason I take to be the Peoples running so rashly into Danger, giving up all their former Cautions, and Care, and all the Shyness which they used to practice; depending that the Sickness would not reach them or that if it did they should not die. The Physicians oppos’d this thoughtless Humour of the People with all their Might; and gave out printed Directions, Spreading them all over the City and Suburbs, advising the People to continue reserv’d, and to use still the utmost Caution in their ordinary Conduct; notwithstanding the decrease of the distemper, terrfying them with the Danger of bringing a Relapse upon the whole City, and telling them how much a Relapse might be more fatal and dangerous than the whole Visitation that had been already.” It is fascinating to read the results in London when people took to the streets when the case count seemed to be waning (might we say “flattening the curve”) and the resultant spike in deaths.

The stories of 1665 and 2020 seem to parallel each other almost exactly to me and really show me that people are just people and that we have not really changed much as individual humans in the past few hundred years. Our emotions, ambitions, tolerance levels, and the like have not really evolved to a higher level. Could we learn from our predecessor’s mistakes and use the lessons, which people 400 years ago learned to help us in our own modern pandemic? 

AAEM Foundation Contributors – Thank You! Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 1-1-2020 to 8-1-2020.

AAEM established its Foundation for the purposes of (1) studying and providing education relating to the access and availability of emergency medical care and (2) defending the rights of patients to receive such care and emergency physicians to provide such care. The latter purpose may include providing financial support for litigation to further these objectives. The Foundation will limit financial support to cases involving physician practice rights and cases involving a broad public interest. Contributions to the Foundation are tax deductible.

Contributions $500-$999

David A. Farcy, MD FAAEM FCCM

Contributions $250-$499

Maxime J. Berube, MD Mark Avery Boney, MD FAAEM Michael R. Burton, MD FAAEM Anthony J. Callisto, MD FAAEM Eric D. Ferraris, MD FAAEM William E. Franklin, DO FAAEM Sarah Hemming-Meyer, DO FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT Bruce E. Lohman, MD FAAEM Kevin C. Reed, MD FAAEM James Francis Rowley III, MD FAAEM Eric M. Sergienko, MD FAAEM Mark O. Simon, MD FAAEM Douglas P. Slabaugh, DO FAAEM William E. Swigart, MD FAAEM Chad Viscusi, MD FAAEM Kay Whalen, MBA CAE R. Keith Winkle, MD FAAEM

George Robert Woodward, DO FAAEM Zachary Worley, DO FAAEM Missy Zagroba, CAE Gregory S. Zahn, MD FAAEM

Contributions $100-$249

Justin P. Anderson, MD FAAEM Dale S. Birenbaum, MD FAAEM Laura J. Bontempo, MD MEd FAAEM Karen Carothers, MD FAAEM R. Lee Chilton III, MD FAAEM Matthew K. Fischer, MD FAAEM Paul W. Gabriel, MD FAAEM Scott C. Gibson, MD FAAEM Edward T. Grove, MD FAAEM MSPH Regina Hammock, DO FAAEM William E. Hauter, MD FAAEM Kathleen Hayward, MD FAAEM Jacob Hennings Patrick Holland, MD FAAEM Stefan Jensen Kevin T. Jordan, MD FACEP FAAEM

Stephen J. Koczirka Jr., MD FAAEM FACEP Jessica Neidig Leffler, MD FAAEM Kari A. Lemme, MD FAAEM, FAAP Michael P. Lucarelli-Cowles Gerald E. Maloney Jr., DO FAAEM Kerry McCabe, MD FAAEM Gregory S. McCarty, MD FAAEM Valerie G. McLaughlin, MD FAAEM Marcus Obeius, DO FAAEM John O’Neill, FAAEM Patricia Phan, MD FAAEM Jeffrey A. Rey, MD FAAEM Jason T. Schaffer, MD FAAEM Richard D. Shih, MD FAAEM Jennica Siddle, MD-MPH David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM

Contributions up to $60

Robert Bassett, DO FAAEM Jordan R. Chanler-Berat, MD FAAEM

Francis X. Del Vecchio, MD FAAEM Sean L. Finnerty, DO FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeremy A. Hall, MD FAAEM James W. Hickerson Jr., MD Irving P. Huber, MD FAAEM Stacey M. Jolley, MD FAAEM Emily R. Knoble, DO FAAEM Jinyue Li, MD FAAEM James Arnold Nichols, MD FAAEM Scott Pasichow, MD Tracy R. Rahall, MD FAAEM Saba A. Rizvi, MD FAAEM Girish Sethuraman, MD FAAEM Marc D. Squillante, DO FAAEM Sarah Todd, MD MPH FAAEM Katherine F. Tyler Maura Walsh, MD Michael E. Winters, MD MBA FAAEM Molly Wormley, MD Andrew Yocum, MD FAAEM



AAEM PAC Contributors – Thank You! AAEM PAC is the political action committee of the American Academy of Emergency Medicine. Through AAEM PAC, the Academy is able to support legislation and effect change on behalf of its members and with consideration to their unique concerns. Our dedicated efforts will help to improve the overall quality of health care in our country and to improve the lot of all emergency physicians.

All contributions are voluntary and the suggested amount of contribution is only a suggestion. The amount given by the contributor, or the refusal to give, will not benefit or disadvantage the person being solicited.

Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the different levels of contributions. The PAC would like to thank the individuals below who contributed from 1-1-2020 to 8-1-2020.

Contributions $1,000+

David A. Farcy, MD FAAEM FCCM

Contributions $500-$999

Michael R. Burton, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM

Contributions $250-$499

Mina Altwail, MD Eric W. Brader, MD FAAEM Jerris R. Hedges, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM Ron Koury, DO FAAEM Bruce E. Lohman, MD FAAEM Bryan K. Miksanek, MD FAAEM Vicki Norton, MD FAAEM James Francis Rowley III, MD FAAEM Don L. Snyder, MD FAAEM Keith D. Stamler, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM Andy Walker, MD FAAEM

Contributions $100-$249 Kevin Allen, MD FAAEM

Justin P. Anderson, MD FAAEM Peter G. Anderson, MD FAAEM Jonathan Balakumar, MD Maxime J. Berube, MD Mark Avery Boney, MD FAAEM Anthony J. Callisto, MD FAAEM R. Lee Chilton III, MD FAAEM Liza Chopra, MD FAAEM Jacob Tyler Clark, MD Martinez E. Clement, MD FAAEM Walter M. D’Alonzo, MD FAAEM Francis X. Del Vecchio, MD FAAEM Jonethan P. DeLaughter, DO FAAEM John T. Downing, DO FAAEM Matthew K. Fischer, MD FAAEM Deborah D. Fletcher, MD FAAEM Steven H. Gartzman, MD FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeffrey Gordon, MD MBA FAAEM Neena Gupta, MD FAAEM Gregory T. Hartt, MD, PHD FAAEM Jacob Hennings Jessica Herrera, MD FAAEM Alice Horrell, DO FAAEM

David R. Hoyer Jr., MD FAAEM Thomas Isenovski, DO FAAEM John H. Kelsey, MD FAAEM Shireen Khan, MD Stephen J. Koczirka Jr., MD FAAEM FACEP Michael Lajeunesse, MD Jessica Neidig Leffler, MD FAAEM Kerry McCabe, MD FAAEM Gregory S. McCarty, MD FAAEM James Arnold Nichols, MD FAAEM Isaac A. Odudu, MD FAAEM Ramon J. Pabalan, MD FAAEM Patricia Phan, MD FAAEM Nicholas R. Reinhart, DO, FACEP FAAEM Jeffrey A. Rey, MD FAAEM Jada Lane Roe, MD FAAEM Javier E. Rosario, MD FACEP FAAEM H. Edward Seibert, MD FAAEM Jonathan F. Shultz, MD FAAEM David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM Thomas Jerome Sugarman, MD FAAEM FACEP

Matthew Szymaszek, DO FAAEM Jalil A. Thurber, MD FAAEM Matthew J. Vreeland, MD FAAEM Regan Wylie, MD FAAEM

Contributions up to $50

Robert Bassett, DO FAAEM Doug Benkelman, MD FAAEM Jordan R. Chanler-Berat, MD FAAEM Jeremy A. Hall, MD FAAEM Kathleen Hayward, MD FAAEM James W. Hickerson Jr., MD Ryan Horton, MD FAAEM Stefan Jensen Alex Kaplan, MD FAAEM Julie A. Littwin, DO FAAEM Melissa Natale, MD FAAEM Lindsey C. Remme, DO FAAEM Dion R. Samerson, MD FAAEM Linda Sanders, MD Michael Sherman, MD Marc D. Squillante, DO FAAEM Camilla Sulak, MD Katherine F. Tyler



COMMON SENSE SEPTEMBER/OCTOBER 2020

7

LEAD-EM Contributors – Thank You! The AAEM Institute for Leadership, Education & Advancement in the Development of Emergency Medicine, Inc. (LEAD-EM) was established after the tragic and unexpected death of AAEM president, Dr. Kevin G. Rodgers.

The Kevin G. Rodgers Fund and the Institute will LEAD-EM just like Dr. Rodgers did. The funds will support important projects such as development of leadership qualities, and clinical and operational knowledge of emergency physicians with a view toward improving and advancing the quality of medical care in emergency medicine, and public health, safety and well-being overall. LEADEM would like to thank the individuals below who contributed from 1-1-2020 to 8-1-2020.

Contributions $500-$999

David A. Farcy, MD FAAEM FCCM

Contributions $250-$499

Maxime J. Berube, MD Mark Avery Boney, MD FAAEM Michael R. Burton, MD FAAEM Anthony J. Callisto, MD FAAEM Eric D. Ferraris, MD FAAEM William E. Franklin, DO FAAEM Sarah Hemming-Meyer, DO FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT Bruce E. Lohman, MD FAAEM Kevin C. Reed, MD FAAEM James Francis Rowley III, MD FAAEM Eric M. Sergienko, MD FAAEM Mark O. Simon, MD FAAEM Douglas P. Slabaugh, DO FAAEM William E. Swigart, MD FAAEM Chad Viscusi, MD FAAEM Kay Whalen, MBA CAE R. Keith Winkle, MD FAAEM

George Robert Woodward, DO FAAEM Zachary Worley, DO FAAEM Missy Zagroba, CAE Gregory S. Zahn, MD FAAEM

Contributions $100-$249

Justin P. Anderson, MD FAAEM Dale S. Birenbaum, MD FAAEM Laura J. Bontempo, MD MEd FAAEM Karen Carothers, MD FAAEM R. Lee Chilton III, MD FAAEM Matthew K. Fischer, MD FAAEM Paul W. Gabriel, MD FAAEM Scott C. Gibson, MD FAAEM Edward T. Grove, MD FAAEM MSPH Regina Hammock, DO FAAEM William E. Hauter, MD FAAEM Kathleen Hayward, MD FAAEM Jacob Hennings Patrick Holland, MD FAAEM Stefan Jensen Kevin T. Jordan, MD FACEP FAAEM

Stephen J. Koczirka Jr., MD FAAEM FACEP Jessica Neidig Leffler, MD FAAEM Kari A. Lemme, MD FAAEM, FAAP Michael P. Lucarelli-Cowles Gerald E. Maloney Jr., DO FAAEM Kerry McCabe, MD FAAEM Gregory S. McCarty, MD FAAEM Valerie G. McLaughlin, MD FAAEM Marcus Obeius, DO FAAEM John O’Neill, FAAEM Patricia Phan, MD FAAEM Jeffrey A. Rey, MD FAAEM Jason T. Schaffer, MD FAAEM Richard D. Shih, MD FAAEM Jennica Siddle, MD-MPH David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM

Contributions up to $60

Robert Bassett, DO FAAEM Jordan R. Chanler-Berat, MD FAAEM

ED Management Solutions: Principles and Practice www.aaem.org/ed-management-solutions

Lifelong learning opportunities that aim to improve ED management & leadership

On Demand and Live Webinar Sessions

8

COMMON SENSE SEPTEMBER/OCTOBER 2020

Francis X. Del Vecchio, MD FAAEM Sean L. Finnerty, DO FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeremy A. Hall, MD FAAEM James W. Hickerson Jr., MD Irving P. Huber, MD FAAEM Stacey M. Jolley, MD FAAEM Emily R. Knoble, DO FAAEM Jinyue Li, MD FAAEM James Arnold Nichols, MD FAAEM Scott Pasichow, MD Tracy R. Rahall, MD FAAEM Saba A. Rizvi, MD FAAEM Girish Sethuraman, MD FAAEM Marc D. Squillante, DO FAAEM Sarah Todd, MD MPH FAAEM Katherine F. Tyler Maura Walsh, MD Michael E. Winters, MD MBA FAAEM Molly Wormley, MD Andrew Yocum, MD FAAEM



Listen and Subscribe – AAEM Podcasts AAEM is pleased to introduce six podcast series for the benefit of our members. Each series focuses on a different area of interest to emergency physicians. The podcasts are available for download directly from the AAEM website, or accessible via iTunes and Google Podcasts. Subscribe for new episodes!

Legal and Policy Issues in Emergency Medicine

Emergency Medicine Operations Management

The Journal of Emergency Medicine Audio Summary

Hosted by: Larry Weiss, MD JD MAAEM FAAEM and Cedric Dark, MD MPH

Hosted by: Joseph Guarisco, MD FAAEM and Tom Scaletta, MD FAAEM

Hosted by: Matthew Kostura, MD FAAEM

In this podcast series, Larry Weiss, MD JD FAAEM, Joseph Wood, MD JD MAAEM FAAEM, and Cedric Dark, MD MPH, discuss timely advocacy issues for the emergency physician. Drs. Weiss and Wood are practicing emergency physicians, attorneys, and past-presidents of AAEM. Dr. Dark is Assistant Professor of Medicine at the Emergency Medicine Residency Program at Baylor College of Medicine and is the founder & executive editor of the Policy Prescriptions® blog. Join them each month as they discuss issues of importance to emergency physicians.

In this podcast series, Joseph Guarisco, MD FAAEM, ED Chair at Ochsner Hospital (New Orleans, LA), is joined by guests to discuss operations management issues for the emergency physician. Dr. Guarisco is the chair of the Operations Management Committee of the American Academy of Emergency Medicine (AAEM). Join him each month as he discusses issues of importance to emergency physicians.

Critical Care in Emergency Medicine Hosted by: David Farcy, MD FAAEM FCCM David Farcy, MD FAAEM FCCM, Chairman, Department of Emergency Medicine at Mount Sinai Medical in Miami Beach, Florida, speaks with national and international experts in the field of critical care in emergency medicine. Join us each month for insights on a timely topic of importance for emergency physicians.

Emergency Medicine Breve Dulce Talks Breve Dulce (formerly known as the PK Talks), which is derived from breve et dulce – Latin for “short and sweet” are rapid-fire talks that cover a variety of important topics. The Breve format is a succinct, high-level overview in less than seven minutes (short) of EM pearls that you can immediately put to use in your everyday practice (sweet). These talks are from the American Academy of Emergency Medicine’s Annual Scientific Assemblies.

For more educational content, including video and slides, visit AAEM Online.

Monthly audio podcast summary of important articles from the Journal of Emergency Medicine, the official journal of the American Academy of Emergency Medicine (AAEM) and discussion of emergency medicine board review topics.

Women’s Wisdom: Our Journey in Emergency Medicine Hosted by: Adria Ottoboni, MD FAAEM and Faith C. Quenzer, DO Women’s Wisdom: Our Journey in Emergency Medicine is a podcast created by the AAEM Women in Emergency Medicine Section to highlight the journeys of prominent women emergency physicians. Join us every other month as we explore a new path and share our stories as women physicians.

Listen and subscribe www.aaem.org/resources/ publications/podcasts

COMMON SENSE SEPTEMBER/OCTOBER 2020

9

Upcoming Conferences: AAEM Directly, Jointly Provided, & Recommended AAEM is featuring the following upcoming conferences and activities for your consideration. For a complete listing of upcoming conferences and other meetings, please visit: www.aaem.org/education/aaem-recommended-conferences-and-activities.

AAEM Conferences

AAEM Recommended Conferences

FALL 2020 ED Management Solutions: Principles and Practice Online www.aaem.org/ed-management-solutions

September 25-27, 2020 The Difficult Airway Course: EmergencyTM New Orleans, LA www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency

Ongoing through December 31, 2020 Written Board Review Online www.aaem.org/written-board-review

October 8, 2020 Advances in Cancer ImmunotherapyTM — SITC Washington, DC www.sitcancer.org/education/aci

Jointly Provided

October 16-18, 2020 The Difficult Airway Course: EmergencyTM San Diego, CA www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency

October 7, 2020 AAEMLa Residents’ Day and Meeting Baton Rouge, LA www.aaem.org/get-involved/chapter-divisions/ aaemla/residents-day-and-meeting October 10-12, 2020 Red Sea Emergency Medicine Conference Riyadh, Saudi Arabia www.redseaem.com November 3-7, 2020 Emergency Medicine Update Hot Topics 2020 (Jointly provided by UC Davis Health) Oahu, Hawaii ces.ucdavis.edu/confreg/?confid=1120

October 31, 2020 Advances in Cancer ImmunotherapyTM — SITC Seattle, WA www.sitcancer.org/education/aci

November 13-15, 2020 The Difficult Airway Course: EmergencyTM Nashville, TN www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency November 21, 2020 Advances in Cancer ImmunotherapyTM — SITC Tampa, FL www.sitcancer.org/education/aci December 12, 2020 Advances in Cancer ImmunotherapyTM — SITC San Antonio, TX www.sitcancer.org/education/aci December 17, 2020 Advances in Cancer ImmunotherapyTM — SITC Toronto, ON www.sitcancer.org/education/aci

November 3-7, 2020 EM Updates: Hot Topics jointly provided with UC Davis Maui, HI ces-apps.ucdavis.edu/confreg/index. cfm?confid=1120&webid=5362

AAEM Online New and Improved AAEM Online AAEM Online is not only getting a new look, but will be completely revamped to offer a much more robust online learning experience. The new AAEM Online will premiere this spring. The library will consist of AAEM19 and select AAEM20 content. AAEM20 content will be added on a rolling basis.

Watch your weekly Insights newsletter for new content.

New Features: • CME now available for educational activities • Social Chat – network with your colleagues • FREE for AAEM and AAEM/RSA members • Accessible to non-members for $99/year Access AAEM Online at: www.aaem.org/aaem-online 10

COMMON SENSE SEPTEMBER/OCTOBER 2020

Over

100 videos available!

Over

50 credits available!

Log-in and Start Watching Today!

www.aaem.org/aaem-online

COMMON SENSE SEPTEMBER/OCTOBER 2020

11

Regardless of who approves the statement, we always look at AAEM’s mission statement and values in determining our stance.”

AAEM NEWS BOARD OF DIRECTORS

What’s With All These Position Statements?

Jonathan S. Jones, MD FAAEM

You have likely noticed many recent position statements from the Academy. Some of these statements have been written by AAEM, while some are written by other organizations and endorsed by AAEM. All of the Academy’s position statements are published online at: www.aaem. org/resources/statements There are several different types of statements, just click the corresponding links. AAEM has always held transparency in high regard as this is why you will always find all of the statements we have ever issued, openly published and accessible to everyone (members and non-members alike). If we feel strongly enough to issue a statement, then we won’t ever try to hide it.

Dates of passage or endorsement can also be found. Due to the rapidly changing clinical and political environment, the last several months have seen a dramatic increase in the number of published and endorsed statements.

Given multiple recent questions as to why the Academy is releasing so many position statements, as well as several inquiries as to the content of the statements, on behalf of the board, I want to explain the process and answer some questions which the board has received.

All members are encouraged to communicate their thoughts to any AAEM board member, staff member, or other leader.”

How does AAEM decide what issues to address and what positions to take?

Issues are frequently presented by board members or officers. However, any AAEM member is welcome to bring any issue to the board. Other times, different medical organizations write a statement and ask AAEM to endorse it.

Decisions to publish or endorse a position statement are made by either the AAEM Board of Directors or the Executive Committee depending on the nature of the statement and timeliness of a reply. The Executive Committee is composed of the President, President-Elect, Immediate Past Present, Secretary-Treasurer, and Past-President’s Council Representative. It is much quicker for the Executive Committee to discuss issues and so for timeliness sake, some statements are published or endorsed by with only the approval of the Executive Committee as per AAEM bylaws.

Regardless of who approves the statement, we always look at AAEM’s mission statement and values in determining our stance. As all of our members, AAEM board members and officers have diverse viewpoints on many issues. Some would likely be described as liberal while others conservative. Some are likely democrats while others republicans and I know for a fact that one is proudly

12

COMMON SENSE SEPTEMBER/OCTOBER 2020

libertarian. However, while we have our own personal values and beliefs and do use these to determine the best course of action, when acting on behalf of AAEM, we strive to only consider the values of the Academy.

Why does the board not ask members how they feel prior to issuing a position statement?

The Academy is proud of its democratic principles and election process. However, just as the U.S. government is not a direct democracy, neither is AAEM. AAEM is a representative democracy. Each member has an equal vote in determining the leaders of the Academy.

Those leaders are then entrusted with directing and managing the Academy in the best interest of all members. We function much like the U.S. government. Actually, we function much better with a singular focus. We debate and compromise and I assure you that no statement or position ever approved without genuine discussion.

However, it would be impractical and very nearly impossible to survey membership on every issue. Finally, it would be unclear how a membership survey should impact the decision to issue a statement as likely no issue, save our core mission, would garner unanimous member support.

All members are encouraged to communicate their thoughts to any AAEM board member, staff member, or other leader. Anyone may be contacted through info@aaem.org. Due to spam, etc. no member’s, including no board

>>

AAEM NEWS BOARD OF DIRECTORS

Every individual should have unencumbered access to quality emergency care. It’s really that simple.”

member’s, contact information is published online, but staff will quickly provide any board member’s contact information once membership is verified.

But some of the recent position statements seem too political. Do they really have anything to do with emergency medicine?

The board feels that every position statement directly impacts emergency medicine. Otherwise we would not issue a statement. I will briefly discuss two recent statements which generated questions.

AAEM issued a joint position statement against a federal regulation which excludes transgender status from the legal definition of sex discrimination. It separately eliminated certain requirements for language translation as well as requirements for care of patients with a history of termination of pregnancy. https://www.aaem.org/resources/statements/joint-endorsed/ against-federal-regulation AAEM also issued a joint statement on the death of George Floyd https://www.aaem.org/UserFiles/file/AAEMReleasesStatementwithSAE MontheDeathofGeorgeFloyd.pdf

Why should AAEM get involved in race, police matters, transgender status, abortion, and foreign languages? Simply, AAEM is not getting involved in these issues as a whole. We view the federal regulation and racial inequalities in regards to our mission statement. The first line of AAEM’s mission statement is: Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine.

The board knows that American’s and Academy member’s views differ on these issues and we respect that. The board neither supports nor opposes transgender issues in general, but we do support unencumbered access to emergency care for transgender patients. In our view, the federal regulation eliminated that access. We do not know exactly what happened in the situation with George Floyd and we are not calling for charges against the officers involved. However, we know that health disparities exist. We want every one of every race and every gender to feel welcome in the emergency department. Every individual should have unencumbered access to quality emergency care. It’s really that simple.

I, our president, Dr. Lisa Moreno, and all board members welcome followup questions, comments, and any conversation. Common Sense encourages letters to the editor. Or contact any board member directly. AAEM is strong because of our diverse opinions coupled with our singular focus as the Champion of the Emergency Physician. 

Submit a Letter to the Editor What stood out to you from this issue of Common Sense? Have a question, idea, or opinion? Andy Mayer, MD FAAEM, editor of Common Sense, welcomes your comments and suggestions. Submit a letter to the editor and continue the conversation.

Check out Common Sense online at:

www.aaem.org/resources/publications/common-sense COMMON SENSE SEPTEMBER/OCTOBER 2020

13

AAEM NEWS

AAEM Signs on to Joint Letter to CMS to Sunset Waivers When PHE Concludes

July 22, 2020 The Honorable Seema Verma wCenters for Medicare & Medicaid Services U.S. Department of Health and Human Services Hubert H. Humphrey Building, Room 445-G 200 Independence Avenue, SW Washington, DC 20201 Dear Administrator Verma: The undersigned organizations represent the hundreds of thousands of physicians who provide care for our nation’s Medicare patients every day. We are writing to strongly support the Centers for Medicare & Medicaid Services (CMS) decision to temporarily waive certain regulatory requirements during the COVID-19 pandemic. These temporary waivers, in extraordinary circumstances, have empowered physicians and non-physician health care professionals to focus on their patients and prevented a collapse of the health care system in the hardest hit areas of the country. However, we urge CMS to sunset the waivers involving scope of practice and licensure when the public health emergency (PHE) concludes.

To our dismay, it is our understanding that some organizations have already been advocating to make the temporary waivers permanent—permanently diminishing physician oversight and supervision of patient care. While we are greatly appreciative of CMS’ rapid and substantial removal of regulatory barriers to allow physicians to continue providing care during the PHE, we also strive to continue to work with CMS to support patient access to physician-led care teams during and after the PHE. Throughout the coronavirus pandemic, physicians, nurses, and the entire health care community have been working side-by-side caring for patients and saving lives. Now more than ever, we need health care professionals working together as part of physician-led health care teams.

The pandemic has forced health care systems to reassess how they allocate human resources. Non-essential surgeries have been postponed or cancelled during the pandemic in response to government directives and the necessity for greater flexibility to deploy physicians and other health care professionals to where the need is greatest. As a result, CMS has temporarily relaxed the direct oversight and licensure requirements to allow health care systems to stretch their capacity to treat more patients. While these measures are temporary and limited to the duration of the PHE, our organizations reaffirm our support for the physician-led team-based approach to care and vigorously oppose efforts that undermine the physician-patient relationship during and after the pandemic.

With seven or more years of postgraduate education and more than 10,000 hours of clinical experience, physicians are uniquely qualified to lead health care teams. By contrast, nurse practitioners (NPs) must complete only two to three years of graduate level education and 500-720 hours of clinical training. Physician assistant (PA) programs are two years in length and require 2,000 hours of clinical care. NPs and PAs are integral members of the care team, but the skills and acumen obtained by physicians throughout their extensive education and training make them uniquely qualified to oversee and supervise patients’ care. Physician-led team-based care has a proven track record of success in improving the quality of patient care, reducing costs, and allowing all health care professionals to spend more time with their patients.

Accordingly, the undersigned urge CMS to sunset the waivers involving scope of practice and licensure when the PHE concludes. At a minimum, CMS should postpone any efforts to make these waivers permanent until after the conclusion of the PHE, and pursue such permanent waivers through notice-and-comment rulemaking. This will allow for a thorough and deliberate policy making process that ensures all stakeholders, including patients, are heard and give time for CMS to study the impact of the scope of practice waivers’ on the cost and quality of patient care. We are happy to work with the agency on such studies and to ensure a seamless transition following the PHE. The undersigned organizations believe that policymakers serve patients best by supporting physician-led team-based care that makes the most of the respective education and training of physicians and non-physician health professionals as part of a collaborative framework. Patients deserve to have a physician leading their team, whether that is for the treatment and management of chronic conditions, or for surgery. To that end, the undersigned urge CMS to preserve the highest quality of care by preserving the physician-patient relationship and physician-led team-based care.

Sincerely,

14

COMMON SENSE SEPTEMBER/OCTOBER 2020

>>

AAEM NEWS

American Medical Association American Academy of Child & Adolescent Psychiatry American Academy of Dermatology Association American Academy of Emergency Medicine American Academy of Facial Plastic and Reconstructive Surgery American Academy of Family Physicians American Academy of Neurology American Academy of Ophthalmology American Academy of Otolaryngic Allergy American Academy of Otolaryngology- Head and Neck Surgery American Academy of Pediatrics American Academy of Physical Medicine and Rehabilitation American Association for Hand Surgery American Association for Physician Leadership American Association of Clinical Urologists American Association of Hip and Knee Surgeons Honorable Seema Verma July 22, 2020 Page 3 American Association of Neurological Surgeons American Association of Orthopaedic Surgeons American College of Allergy, Asthma and Immunology American College of Emergency Physicians American College of Medical Genetics and Genomics American College of Osteopathic Internists American College of Osteopathic Surgeons American College of Radiation Oncology American College of Radiology American College of Surgeons American Gastroenterological Association American Medical Women's Association American Osteopathic Association American Psychiatric Association

American Society for Aesthetic Plastic Surgery American Society for Clinical Pathology American Society for Dermatologic Surgery American Society for Gastrointestinal Endoscopy American Society for Laser Medicine and Surgery American Society for Radiation Oncology American Society for Regional Anesthesia and Pain Medicine American Society for Surgery of the Hand American Society of Cataract & Refractive Surgery American Society of Dermatopathology American Society of Echocardiography American Society of Neuroradiology American Society of Plastic Surgeons American Urological Association American Vein & Lymphatic Society American Academy of Ophthalmology College of American Pathologists Congress of Neurological Surgeons Heart Rhythm Society National Association of Medical Examiners North American Neuromodulation Society North American Spine Society Outpatient Endovascular & Interventional Society Renal Physicians Association Society of Interventional Radiology Spine Intervention Society Medical Association of the State of Alabama Arizona Medical Association Arkansas Medical Society Honorable Seema Verma July 22, 2020 Page 4 California Medical Association Colorado Medical Society Connecticut State Medical Society Medical Society of Delaware Medical Society of the District of Columbia Florida Medical Association Inc

Medical Association of Georgia Hawaii Medical Association Idaho Medical Association Illinois State Medical Society Indiana State Medical Association Iowa Medical Society Kansas Medical Society Kentucky Medical Association Louisiana State Medical Society Maine Medical Association MedChi, The Maryland State Medical Society Massachusetts Medical Society Michigan State Medical Society Minnesota Medical Association Mississippi State Medical Association Missouri State Medical Association Montana Medical Association Nebraska Medical Association Nevada State Medical Association Medical Society of New Jersey New Mexico Medical Society Medical Society of the State of New York North Dakota Medical Association Ohio State Medical Association Oklahoma State Medical Association Pennsylvania Medical Society Rhode Island Medical Society South Carolina Medical Association South Dakota State Medical Association Tennessee Medical Association Texas Medical Association Utah Medical Association Vermont Medical Society Medical Society of Virginia Washington State Medical Association Honorable Seema Verma July 22, 2020 Page 5 West Virginia State Medical Association Wisconsin Medical Society Wyoming Medical Society



COMMON SENSE SEPTEMBER/OCTOBER 2020

15

AAEM NEWS

A Letter to All People Staying Neutral about Black Lives Matter Al Giwa, LLB MD MBA MBE FAAEM

Just when we thought life

These last few years (and weeks) have revealed the continued racial disharmony that exists in America, most pronounced between Blacks and whites.

in 2020 couldn’t get any worse after the COVID-19 pandemic wreaked havoc on all of us, we are now in what to many seems like an uprising; while others see it as another series of lynchings. And then there are the rest of us, who just don’t want to be bothered, and are not taking a stand or even having an opinion. So it is you my fellow “stay out of it” colleagues that I’d like to talk to.

I was like so many of you when it came to all these cases of people crying injustice at the hands of the police. I refused to fall prey to the cop-bashing or the twisting of the narrative from an unarmed person being shot to it being justice for a “bad hombre.” Personally, I think I was in denial, because in my mind that was “their” problem. But in reality, I am one of them.

These last few years (and weeks) have revealed the continued racial disharmony that exists in America, most pronounced between Blacks and whites. Sadly, many briefly focused their hate on Asians during the height of the COVID-19 pandemic but have now returned to hating and killing Black people. From these repeated killings of unarmed Black people came forth the “Black Lives Matter” movement, and I must say I was initially conflicted about it. After all, I drank the Kool-Aid; I was a good Negro and moved to the suburbs and did all the acceptable things to be accepted by white America. Most importantly, I never brought attention to my Blackness, nor involved myself in anything that could be considered divisive or offensive, lest I offended anyone’s sensibilities. I supported arguments that seemed on the surface to make sense, and even echoed that “All Lives Matter.” Why were those Black troublemakers being so divisive and running counter to a united people? So when unarmed Black men and women started dying again and again at the hands of police officers, I largely ignored discussing it and listened to the narrative of trying not to second guess police officers who must make life or death decisions in a split second that can understandably not be exactly how the media portrayed it. However, when I would ruminate out loud about my own, or most especially my kids’ safety at the hands of a police officer, I was reassured that those Black people were different. After all, why were they struggling with the officer(s)? Why were they running away if

they were innocent? Why were they speaking back to the officer(s) so rudely? Innocent people don’t do that…or do they? Then George Floyd happened. And it became painfully clear, I am one of them.

Despite my being part of a respected profession, when I enter a convenience store, no one seems to recognize my half a dozen degrees.

Instead, I become just another Black man, and hence require that additional scrutiny afforded only to people of color in the United States of America. Until you have been profiled and assumed to be a criminal just because of the color of your skin, it is very hard to say things are “fair,” or that one should be “grateful” for the opportunities and “privileges” to be in this country. One thing that white privilege has made painfully obvious, is their lack of awareness of racial injustices that are realities for people of color. And despite my upbringing, education, and current living circumstances, I am one of them.

One of my proudest accomplishments to date was becoming an officer in the U.S. Armed Forces, where I work alongside courageous men and women from all socioeconomic, racial, and national origins. My desire to serve was borne out of an upbringing based on hard work, dedication, responsibility, as well as a belief in the duty to serve to one’s nation. I accepted the calling, and now proudly take care of the men and women of the Armed Forces who ensure the liberties for each and every one of us in this country. My military service has taken me to many parts of this country where race relations are not always the best, but generally wearing this uniform has given me great access to a people I would normally never be able to speak to. I am happy that I have been able to present a real-life person who shattered negative preconceptions of Black people to those willing to listen. But at the end of the day, I am still one of them.

Sadly, it has taken my accidentally stumbling across Trevor Noah’s poignant discussions on what the Black Lives movement truly meant, for me to finally understand that unless Black Lives Matter, All Lives cannot matter. I missed in the screaming and protesting by angry Black people,

>> 16

COMMON SENSE SEPTEMBER/OCTOBER 2020

AAEM NEWS

Until you have been profiled and assumed to be a criminal just because of the color of your skin, it is very hard to say things are “fair,” or that one should be “grateful” for the opportunities and “privileges” to be in this country.

that their anger was my anger. Their screams were my screams. Their injustices were the same as mine even in the ivory towers of academic medicine. I could have been George Floyd; in fact, I was George Floyd.

Each and every person of color in America is George Floyd; all of us are just an incident away from having our breath permanently taken away for doing nothing except living Black in America. All lives do matter, but only when every life is respected or cared for like every other life. So let’s fix it. Let’s ensure that Black lives, Brown lives, and all other lives matter the same. Let’s stop just watching others’ lives being subjugated to unfair treatment hoping to avoid controversy. The controversy is here, and continuing to ignore it is no better than someone kneeling on a Black man’s neck for nine minutes.

SO LET’S FIX IT. LET’S ENSURE THAT BLACK LIVES, BROWN LIVES, AND ALL OTHER LIVES MATTER THE SAME.

FR

EE

FO

R

As Desmond Tutu famously said, “If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse and you say that you are neutral, the mouse will not appreciate your neutrality.” 

M

EM

BE

Now Offered Online

RS

FO

Written Board Review Course Unmatched preparation for the Qualifying and ConCertTM Exams

R

A

LI

M

IT

ED

TI

M

E

COMMON SENSE SEPTEMBER/OCTOBER 2020

17

AAEM NEWS

New Cancer Diagnoses during COVID Sabena Vaswani, MD (@sabenavaswani)

Ever since the coronavirus pandemic began in March, emergency rooms across the country have been experiencing lower volumes and higher acuity. Due to the widespread clinic closures and fear of viral exposure, patients are delaying seeking medical care. Thus, the secondary effects of COVID-19 are rising. Emergency physicians around the country are now seeing more mental health crises, acute on chronic disease, and late stage presentations of new diagnoses. As the first New York coronavirus surge comes to a lull in the late spring, recently, my C-word has not been “COVID,” but “cancer.” For the past few weeks, I have been diagnosing metastatic disease on nearly every shift – from pancreatic adenocarcinoma with hepatic invasion, to ovarian cancer with severe ascites, to esophageal cancer with obstructive dysphagia, to laryngeal carcinoma with stridor.

Recently, cancer barged through my family’s front door. Within minutes, our lives were changed. Priorities shifted. Expectations of the future paused. My family member’s story is similar to so many of my patients’ experiences. “I haven’t been feeling well, but I’ve been too scared to see the doctor. I thought I wasn’t supposed to come in...” During the peak of the pandemic, patients were also attributing their symptoms to coronavirus. Fevers – it must be COVID; back pain – possibly viral myalgias; weight loss – perhaps deconditioning from quarantine. As a result, his diagnosis was delayed.

As emergency physicians, we have unparalleled access to lab tests, EKGs, point-of-care ultrasounds, imaging, and consultants. Tests result in minutes to hours. Given our diagnostic power and breadth of knowledge, we can diagnose diseases faster than most other fields of medicine.

Emergency physicians can give patients answers the same day. However, diagnoses carry weight. Due to the fast-paced work up, many patients are never warned of the possibility of cancer, making the news even more jarring.

Approximately 11% of new cancer diagnoses are ED-mediated.1 Historically, this disproportionately affects medically underserved patients with more advanced disease.

COVID is likely pushing even more of these late new cancer diagnoses to the ER. Therefore, it is important for all practitioners to develop a compassionate and deliberate approach when informing patients in the ER. The SPIKES2 framework (setting, perception, invitation, knowledge, empathy, and summary) lays the foundation for breaking bad news in medicine. In addition, I recommend the following methods to supplement SPIKES for ED cancer diagnoses.

Emergency physicians around the country are now seeing more mental health crises, acute on chronic disease, and late stage presentations of new diagnoses.”

Discuss the radiology results. Many patients I interviewed with ED-mediated cancer diagnoses said that their primary emergency physician never communicated the radiology results to them. As such, patients incidentally found out from the incoming physician or from the nurse in passing. Therefore, before leaving a shift, it is imperative to ask yourself: does the patient know about the diagnosis? If not, who will tell them, when, and how? During my intern year, I consistently had to train myself that explaining the lab results, diagnosis, and treatment plan to the patient was just as important as the medical work-up. This is especially important with cancer.

18

COMMON SENSE SEPTEMBER/OCTOBER 2020

Say “cancer.” There is no substitute for the word “cancer.” Even the words “malignant,” “metastatic,” or “tumor” will not suffice. If it is high on your differential, it is important to communicate this possibility while still leaving room for alternate diagnoses. Patients will inevitably pepper you with questions about the staging, the treatment plan, and the prognosis, but try to remember your own limitations and encourage them to write down questions for the specialist. It is important to emphasize that nothing is proven until the biopsy.

Pause. After informing the patient, stop and allow them to process the information. I typically walk away to give them a moment of privacy to talk to family while I quickly attend to another task. Within a few minutes, I return to the patient with a glass of water, and I provide them with more details and answer their questions.

>>

AAEM/RSA NEWS

Emphasize speed. Oncologic work-ups take time, especially for final pathology processing. The lag between diagnosis and initiating treatment is anxiety-inducing, so encourage your patients to be expeditious in scheduling a biopsy and follow-up care in a timely manner. The goal is to start the appropriate treatment as quickly as possible.

Compassion and hope are key. A cancer survivor advised me that just simply saying, “I’m sorry, I know this isn’t fair, and it sucks,” is often more appropriate than offering platitudes. Through intentional verbal and nonverbal communication, try to convey empathy and set the tone that physicians genuinely care. Lastly, even with the grimmest diagnosis, always leave room for hope.

Cancer is a life-altering diagnosis, so as emergency physicians we must develop a deliberate approach to convey this information clearly and compassionately.”

Takeaways: Between the fast-paced nature of the ER and shift changes, providers often forget to inform patients of their diagnoses. Cancer is a life-altering diagnosis, so as emergency physicians we must develop a deliberate approach to convey this information clearly and compassionately.  References: 1. Rogers MJ, Matheson LM, Garrard B, et al. Cancer diagnosed in the Emergency Department of a Regional Health Service. Aust J Rural Health. 2016;24(6):409-414. doi:10.1111/ajr.12280 2. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311. doi:10.1634/theoncologist.5-4-302 3. Hitoshi Okamura, Yosuke Uchitomi, Mitsuru Sasako, Kenji Eguchi, Tadao Kakizoe, Guidelines for Telling the Truth to Cancer Patients, Japanese Journal of Clinical Oncology, Volume 28, Issue 1, January 1998, Pages 1–4, https://doi.org/10.1093/jjco/28.1.1

AAEM20 Virtual 5k Fun Run and Walk Thank you to the participants of the AAEM Wellness Committee’s Virtual 5k Fun Run and Walk! We were excited to be able to still hold this event virtually this year and thank everyone for sharing their photos with us!

COMMON SENSE SEPTEMBER/OCTOBER 2020

19

AAEM/RSA NEWS

When Do Things in Medicine Start to Become Common Knowledge?

Shaughnelene D. Smith, BSc (Hons); Eddie K. Maybury, BSc

Several weeks ago, I finished my first year of medical school and began the arborous drive from Kansas City, Missouri, to California for a summer research position. When I was just six minutes away from my destination, my car of 21 years decided to break down. It is important to note that I am studying in the United States as an international student from Canada, and despite growing up as a neighbor from the north, much of the U.S. and its various systems are foreign to me.

What is considered common sense to someone from the United States is not what is considered to be general knowledge to someone international. Having to explain why I did not have a social security number and uncovering the process to obtain one proved to require more effort than some of my classes in medical school. I had to do the research not only for myself but also for those attempting to help me. In uncharted territory, stuck in an endless feedback loop of frustrating conversations, I couldn’t help but think of the ironic similarity to the U.S. health care system.

If I had an accident and end up in the emergency room, I wouldn’t even know what would As midnight approached and the smoke started be considered good practice. Do I have to pay billowing out of the front bonnet, I found myself before you treat me? Yes, I have insurance, pulling off to the side of the road in a city unfabut what does that mean? Am I supposed to miliar to myself. I quickly took all the essential learn about this in medical school, or does it paperwork from my vehicle – F1-student visa, come naturally over the years as you spend time in a hospital? When My car experience taught me that despite English being do these essential details become my first language, being well educated, and growing up in common sense as I continue on the a country that is arguably culturally similar to the United trajectory from student to doctor?

States, I still had an element of vulnerability.”

passport, insurance papers – and found a rock a safe distance away, where I proceeded to call my parents and quickly realized how clueless I was in navigating what to do next.

The following day, in the early hours of the morning, a tow truck transported my car to the nearest dealership, where the diagnosis was made that I had injured the radiator driving through an extreme heatwave. The vehicle’s internal damage wasn’t worth the cost of repairs, and so began the days of paperwork and arduous tasks to find a new car. Much of this headache included learning about the processes trying to purchase a vehicle as an international student, surrender my Canadian license plate, change insurance companies, and finding a way to scrap an unwanted foreign car with an odometer tainted in kilometers rather than miles.

20

COMMON SENSE SEPTEMBER/OCTOBER 2020

As I advance in my medical training, I have good faith that I will slowly learn these various processes; however, I often question how disorientating this might seem to a patient unfamiliar with a country’s medical system. How often do they experience distress and uncertainty due to a lack of knowledge that others have subconsciously acquired by growing up within the U.S.? It was reported in 2018 that more than 44.7 million immigrants lived in the United States.1 Although I am not an immigrant per se, I would speculate that this would indicate that there is a sizable population just as lost and confused as myself when it comes to navigating these systems both within and outside of health care. My car experience taught me that despite English being my first language, being well educated, and growing up in a country that is arguably culturally similar to

the United States, I still had an element of vulnerability. Most of the newly-discovered tasks I encountered seemed like a different language and left me feeling like I didn’t have full control of my situation. Taking into consideration a patient’s perspective, I can only begin to imagine how troubling this must be, especially when we start to consider differences in language, cultural, and past experience regarding medical care.

We are taught as medical students not to use medical jargon when communicating with standardized patients. This rule is implemented so that we don’t overwhelm the patient with words that they may not understand; however, I never considered that even if everything was explained in lay terminology, the process may still not be intuitive. As physicians, we need to consider this as a part of our efforts better to

WHAT IS CONSIDERED COMMON SENSE TO SOMEONE FROM THE UNITED STATES IS NOT WHAT IS CONSIDERED TO BE GENERAL KNOWLEDGE TO SOMEONE INTERNATIONAL.” improve immigrant status as a social determinant of health. It has long been established that immigrants have higher morbidity and mortality rates than their non-immigrant counterparts.

>>

AAEM/RSA NEWS

These poorer health outcomes can be attributed to various factors such as lower English proficiency, socioeconomic status, marginalization, and inferior treatment on behalf of the practicing health care personnel.2 It is often overlooked that navigating a system unfamiliar to oneself can be intimidating, and this can be a deterrent when seeking treatment, leading to less access to care. This experience has taught me the need to be respectful, patient, and empathetic with our communication as a health care team because what may be common knowledge to one person isn’t necessarily common knowledge to another. 

References: 1. Batalova J, Blizzard B, Bolter J. Frequently Requested Statistics on Immigrants and Immigration in the United States [Internet]. The Online Journal of the Migration Policy Institute. 2020. Available from: https://www. migrationpolicy.org/article/frequently-requested-statistics-immigrants-andimmigration-united-states 2. Derose KP, Escarce JJ, Lurie N. Immigrants And Health Care: Sources Of Vulnerability. Health Aff (Millwood). 2007 Sep;26(5):1258–68. W

In uncharted territory, stuck in an endless feedback loop of frustrating conversations, I couldn’t help but think of the ironic similarity to the U.S. health care system.”

MEMC21 Malta 9-12 September 2021 St. Julian’s

XIth Mediterranean Emergency Medicine Congress

#MEMC21

www.aaem.org/MEMC21 COMMON SENSE SEPTEMBER/OCTOBER 2020

21

AAEM NEWS

Telehealth and Emergency Medicine: Our Virtual Practice Aditi U. Joshi, MD MSc FACEP

Despite the recent uptick in interest in virtual care, telehealth has actually existed for decades, used initially by the military and NASA to increase health access to those needing remote care. In general, telehealth is defined as using technology to have a remote medical encounter between two parties. It can refer to chat, store and forward, video, or telephone, the latter two generally being synchronous. Historically, there has been low engagement for various reasons; reimbursement, lack of understanding of use cases, lack of training, no implementation within health care systems and general slow uptake of technology.

In general, telehealth is defined as using technology to have a remote medical encounter between two parties.

THE CRUCIAL NEED TO DISTANCE, SCREEN, EVALUATE, AND PRESERVE PPE FOR THOSE NOT CRITICALLY ILL HAS ALLOWED USING REMOTE VIRTUAL CARE TO GROW IN BOTH ITS UTILITY AND ENGAGEMENT.

Nothing has changed the trajectory of using telehealth more than the recent COVID pandemic. The crucial need to distance, screen, evaluate, and preserve PPE for those not critically ill has allowed using remote virtual care to grow in both its utility and engagement. It is likely that while the stages of the pandemic ebb and flow, the use of telehealth will continue to expand within health care. For emergency medicine practitioners, who straddle prehospital and inpatient, there are three main ways telehealth has and is being used:

Provider to patient acute care: this is also called direct to consumer and is initially offered by large national companies to treat acute care complaints from wherever the patient is calling. Currently, much of the care is done without adjunct devices or apps unless a patient already has them; this has necessitated creative ways to do physical exam. It also has been limited by the patient’s accessible technology and connectivity leading to understandable concerns of increasing inequity in health care. In general, this allows convenience of care and future use in EM can allow for efficient triage and prehospital care.

Tele-triage: is something unique to emergency medicine. Increased ED visits over the last few years has led to longer wait times, overcrowding, and increased left without being seen all of which lead to worse patient outcomes. A number of interventions have been trialed such as RN orders from triage, placing a physician, resident or advanced practice provider (APP) in triage for order placement or discharge, more provider engagement and transparent metrics. Much of this has not worked or required increased staffing. Tele-triage allows a physician or APP to perform a remote virtual triage visit with a nurse or tech, write a note and put in orders, allowing patients earlier entrance to the ED process. This can substantially decrease left without being seen and time to provider. It can potentially affect length of stay; however, studies have not yet supported this likely due to other factors affecting ED throughput such as boarding.

Provider to provider or remote consults: Programs such as tele-stroke, allowing a hub hospital team to consult and advise treatment or transfer for ‘spoke’ hospitals are an example of this type of telehealth. There is a tendency to think of these in relation to their originating specialty, such as transplant, specialist, or stroke networks. However, many of these specialists are consulting in remote EDs or those without that particular specialist access. These consults allow for a specialist team to evaluate a patient and prepare for transfer. However, another benefit is decreasing transfers by advising on site care and allowing patients to be treated at their home hospital safely.

>> 22

COMMON SENSE SEPTEMBER/OCTOBER 2020

AAEM NEWS

It is both an exciting and uncomfortable time in medicine as we imagine the far-reaching consequences.

For those wanting to setup a program, the high level is knowing the needs of the practice, hospital, and community. The details are outside the scope of this article, however, keep the following in mind: Use case: Be clear the problem you are trying to solve whether decreasing transfer, improving throughput measures etc. as that will dictate the type of program to create.

Create a team: this includes administrative, tech, compliance, legal, and billing Choose platform: Again, this will be based on the use case. It should be secure, easy to use for both patients and clinicians, and easy to troubleshoot. Many do not automatically integrate into the electronic medical record (EMR) so keep that in mind when thinking through workflows.

Understand billing/reimbursement: Working with the billing department to understand what types of services you can and will bill for.

Credentialing and regulatory: Ensuring all providers have proper licensing based on state and federal laws.

Training: Ensuring all know not only how to use the platform but understand workflows, processes, and how to have effective virtual encounters (webside manner, physical exam, clinical guides).

Quality Assurance: Reassessment of clinical outcomes, whether the program is fulfilling its intended purpose and changing as needed.

The ability to see patients at a distance and expand our area of care will create some interesting questions for ourselves as emergency medicine: how far does our specialty expand?

How will we ensure safe practices and quality visits for patients in and outside the emergency department? How will this impact our education and need to train our undergraduate and graduate medical students for this future? It is both an exciting and uncomfortable time in medicine as we imagine the far-reaching consequences.

However, it’s important to remember that telehealth is simply a modality to help us understand our patients home environments, improve access within our communities and neighborhoods, and be able to advocate for our patients in a much larger way. 

Why AAEM? AAEM is the leader within our field in preserving the integrity

of the physician-patient relationship by fighting for a future in which all patients have access to board certified emergency physicians and physician rights are protected.

It’s a challenging time for emergency physicians AAEM recognizes that and were doing something about it.

• We’ve continued to fight for your due process rights — AAEM worked closely with the sponsors of newly introduced legislation.

• We’ve had your back during COVID-19 — Read our position statements and letters to government officials advocating for you during this pandemic.

• We protect your practice rights — We’re actively working to address APP independent practice to create a balanced workforce through both position and policy statements.

• We’re advocating for a solid future for our specialty - we’re working with the newly formed EM Workforce Committee for a future with a balanced work force.

• We’re committed to diversity, equity, and inclusion – The AAEM Diversity, Equity, and Inclusion Committee is working hard to bring members resources and awareness, including statement on the Death of George Floyd and the Statement Against Federal Regulation.

• We joined the clear message being sent that #ThisIsOurLane. We are the front line providers, and we will be at the forefront of the solution, which is why we signed on to support AFFIRM.

Learn more at www.aaem.org/whyaaem Join/renew today: www.aaem.org/membership COMMON SENSE SEPTEMBER/OCTOBER 2020

23

AAEM/RSA NEWS

Human Trafficking: A Review for Health Care Providers Nicole E. McAmis; Angela C. Mirabella; Elizabeth M. McCarthy; Cara A. Cama, MBA; and Frank H. Netter, MD

Background

The U.S. Department of State defines human trafficking in The Trafficking Victims Protection Act of 2000 as:

Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age; or

The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.1

Introduction Human trafficking is a violation of human rights and a global pandemic. Health care providers are often the first group of professionals to interact with victims of human trafficking with over 88% of victims seeking medical care in a variety of health care settings.2,3 These health care professionals provide not only medical care for various concerns, but also emotional and psychological support.

Medical complaints can include infectious diseases, physical violence, sexual abuse, pelvic pain, hazardous working conditions, unintended pregnancies, abortions, malnutrition, dental disease, anxiety, chronic pain, posttraumatic stress disorder (PTSD), depression, substance use disorders, suicidal ideations, or suicide attempt.4 Unfortunately, many health care providers lack the knowledge and tools needed to recognize these victims. In this post, we will dive into some basic information that all health care providers need to identify victims of human trafficking.

24

Risk Factors

Red Flags + Indicators6

Poverty

Racial/ethnic minority status

Marginalized individuals: LGBTQ, runaway youth, Native Americans, indigenous people

Rural location

Lack of education

Disability

Inadequate family support and protection

Migration

Someone else is speaking for the patient and refuses to let the patient have privacy

Exhibits fear, anxiety, or tension

Reluctant to explain his/her injuries or shared a scripted/inconsistent history

Tattoos or other forms of branding are visible

Reports an unusually high number of sexual partners, STDs, pregnancies, miscarriages, or terminations

Uses language [or slang] common in the commercial sex industry

COMMON SENSE SEPTEMBER/OCTOBER 2020

Appropriate Questions + Screening Tools6,7

What are your working or living conditions like?

Have you ever been deprived of food, water, sleep, or medical care?

Can you leave your job or situation if you want?

Can you come and go as you please?

Who is the person who came with you today? Can you tell me about them?

Have you ever been threatened or intimidated?

Has anyone threatened to hurt you or your family if you leave?

Do you have a debt to someone you cannot pay off?

Is someone holding your identification documents (passport, visa, driver’s license)?

Did you ever feel pressured to do something that you didn’t want to do or felt uncomfortable doing?

Have you ever been told to have sex with people you don’t want to have sex with?

Have you been forced to engage in sexual acts for money or favors?

Does anyone take all or part of the money you earn?

Do you have to meet a quota of money each night before you return home?

>>

AAEM RSA NEWS

Next Steps After addressing the immediate needs of your patient and obtaining informed consent, consider calling the National Human Trafficking Resource Center (NHTRC) hotline at 1-888373-7888.8 The NHTRC can help assess the current level of danger, provide further recommendations, identify local resources, and potentially involve law enforcement. In situations of life-threatening danger, follow your institutional policies for reporting to law enforcement.

When Approaching Questions

Conduct the assessment in a comfortable, private location with a social worker or advocate present whenever possible

Conduct the interview in the potential victim’s native language and use a professional, neutral interpreter if needed

Ask others present to leave for the interview and examination

Use an approachable tone, demeanor, and body language that remains neutral and is non-judgmental

Refrain from taking notes while in the room to promote active listening

Assure confidentiality, unless the situation invokes state mandatory reporting laws (i.e. persons in grave danger, minors under the age of 18 years, or persons with disabilities)

Victims may find it easier to speak with a provider who is of the same sex, ethnicity, or age range

Reference existing institutional protocols for victims of abuse

Before you begin, do a safety check: – Is it safe for you to talk with me right now?

– Do you feel safe right now?

– Do you feel like you are in any kind of danger for speaking with me?

Some items to consider include:

Presence of the trafficker in patient room, waiting room, or home

Potential that calling the hotline may put the patient or the patient’s family in danger

Age of patient It is vital that you help the patient memorize the phone number, so they can call 1-888-3737888 or text HELP or INFO to BeFree (233733) at a later time. Please avoid giving the patient physical materials including written notes or brochures that could place them at increased risk if detected.

Health care providers are in a unique and powerful position to serve as the first responders for victims of human trafficking.

Closing Health care providers are in a unique and powerful position to serve as the first responders for victims of human trafficking. We hope this article has provided you with some tips and tools to utilize in your practice and profession.

Many health care professionals have shared concerns about the lack of quality training available on this topic. As such, we sought to identify the self-reported knowledge level of providers on the global issue of human trafficking. Please keep an eye out for the results of our study in a future publication. 

These health care professionals provide not only medical care for various concerns, but also emotional and psychological support.

References: 1. U.S. Department of State. Trafficking in Persons Report June 2019. Available at: https://www.state.gov/wp-content/ uploads/2019/06/2019-Trafficking-in-PersonsReport.pdf. Accessed May 2020.

2. Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):36-49.

3. Isaac R, Solak J, Giardino AP. Health Care Providers’ Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene. Journal of Applied Research on Children: Informing Policy for Children at Risk. 2011;2(1).

4. Lederer, Laura. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Health care Facilities.

Annals of Health Law. 2014;23(61).

5. Zimmerman C, Yun K, Shvab I, et al. The health risks and consequences of trafficking in women and adolescents. Findings from a European study. London: London School of Hygiene & Tropical Medicine (LSHTM). 2003.

6. Chohaney ML. Minor and Adult Domestic Sex Trafficking Risk Factors in Ohio.

Journal of the Society for Social Work and Research.2016;7(1):117-141.

7. National Human Trafficking Resource Center.

Identifying Victims of Human Trafficking: What to Look for in a Health care Setting. Available at: https://humantraffickinghotline.org/sites/ default/files/What%20to%20Look%20for%20 during%20a%20Medical%20Exam%20-%20 FINAL%20-%202-16-16_0.pdf. Accessed May 2020.

8. National Human Trafficking Resource Center. Comprehensive Human Trafficking Assessment. Available at: https:// humantraffickinghotline.org/sites/default/ files/Comprehensive%20Trafficking%20 Assessment.pdf. Accessed May 2020.

9. National Human Trafficking Hotline. Available at: https://humantraffickinghotline.org.

Accessed May 2020.

COMMON SENSE SEPTEMBER/OCTOBER 2020

25

ABEM Announces Important Continuing Certification Changes

ABEM NEWS

ABEM listened to suggestions from the Emergency Medicine community and is pleased to announce improvements in how ABEM-certified physicians can stay certified.

ABEM to Pilot Virtual Oral Exam in 2021 The COVID-19 pandemic has resulted in ABEM adapting to the ever-changing environment. The most recent development is the aggressive exploration of transitioning the current Oral Exam format to a virtual Oral Exam. The virtual Oral Exam will be piloted and then fully implemented in 2021; information from the pilot experience will inform further design, development, and administration of a virtual Oral Exam, post-COVID. ABEM recognizes that certification is an important milestone in a physician’s career, both personally and financially. A letter is available for current Oral Exam candidates to provide to their employers that verifies their successful completion of the Qualifying Examination and states that they are awaiting assignment to take the Oral Certification Examination.

ABEM will provide additional details as they become finalized. Updates will be posted on the ABEM website. 

Starting in 2021, ABEM will move to a 5-year certification period for physicians when they next recertify. It’s important to note the move from a 10-year to 5-year certification length will not increase total requirements or increase the cost to stay certified.

As physicians move to a 5-year certification period, ABEM will also move to an annual fee structure. ABEM has set a cap on fees paid by physicians so no physician will pay more than $1,400 to renew their certification.

ABEM recognizes these changes affect physicians differently depending on where they are in their certification. We have developed a tool “✔ABEM Reqs” to help emergency physicians view their ABEM requirements based on when their current ABEM certification expires. Visit www.abem.org/public/stay-certified/cert-requirements/ Read the full news release here: www.abem.org/public/news-events/news/2020/08/04/ abem-continuing-certification-updates. 

Mary Nan S. Mallory, MD MBA, Elected President of ABEM

School of Medicine, and an attending physician at the University of Louisville Hospital.

Mary Nan S. Mallory, MD MBA, has been elected President of the American Board of Emergency Medicine (ABEM). Dr. Mallory has been a member of the Board of Directors since July 2012 and was elected to the Executive Committee in 2019. She has served ABEM in a number of capacities, including as Chief Examiner and Editor for the Oral Certification Examination and Co-editor of the In-training Examination. Dr. Mallory also has served as Secretary-Treasurer and Chair of the Finance, Bylaws, and Continuing Certification committees.

Others elected to the Executive Committee are:

Dr. Mallory received a medical degree from the Joan C. Edwards School of Medicine at Marshall University and completed residency training in Emergency Medicine at the University of Louisville School of Medicine. She also earned an M.B.A. from University of Louisville College of Business. Dr. Mallory is currently Vice Dean for Clinical Affairs and Professor of Emergency Medicine for the Department of Emergency Medicine at University of Louisville 26

Beginning in spring 2021, ABEM-certified physicians will be able to meet continuing certification requirements by completing 4 MyEMCert modules (online and open book, approximately 50 questions each) instead of taking the ConCert Exam. The switch to MyEMCert will emphasize relevant content, save emergency physicians time and money, and better accommodate their busy schedule. ABEM will no longer offer ConCert after 2022.

COMMON SENSE SEPTEMBER/OCTOBER 2020

“I look forward to my role as ABEM President and continuing conversations with diplomates and candidates, navigating certification examination transitions, and ensuring certification standards and value as we move through these challenging times together” said Dr. Mallory.

Jill M. Baren, MD MS MBA, ImmediatePast-President. Dr. Baren is provost and vice president of academic affairs at University of the Sciences in Philadelphia. She is Emeritus Professor of Emergency Medicine, Pediatrics, and Medical Ethics at the Perelman School of Medicine, University of Pennsylvania. Dr. Baren practices clinically at Penn Medicine and The Children’s Hospital of Philadelphia.

Marianne Gausche-Hill, MD, President-Elect.

Dr. Gausche-Hill is Medical Director of the Los Angeles County Emergency Medical Services Agency, Professor of Emergency Medicine and Pediatrics at the David Geffen School of Medicine at UCLA, and clinical faculty member at Harbor-UCLA Medical Center Departments of

Emergency Medicine and Pediatrics.

Samuel M. Keim, MD MS, SecretaryTreasurer. Dr. Keim is Professor and Chair of the Department of Emergency Medicine at the University of Arizona College of Medicine, and a professor in the Division of Epidemiology and Biostatistics at the Mel and Enid Zuckerman College of Public Health. He practices clinically at Banner University Medical Center in Tucson.

Ramon W. Johnson, MD MBA, Memberat-Large. Dr. Johnson is a full-time partner in Mission Viejo Emergency Medicine Associates at Mission Hospital Regional Medical Center in Mission Viejo, California, and Medical Director of the Doctor’s Ambulance Company, Laguna Hills, California.

Lewis S. Nelson, MD, Senior-Member-atLarge. Dr. Nelson is Chair of the Department of Emergency Medicine, and Chief of the Division of Medical Toxicology at Rutgers New Jersey Medical School; and Chief of Service at the University Hospital of Newark.

All ABEM Executive Committee members are clinically active emergency physicians. 

Social EM: What it is and Why it Matters

INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

Sara Urquhart, RN MA and Megan Healy, MD FAAEM

Social EM: An emerging branch of emergency medicine focused on the social forces affecting patients and communities and their interplay with the emergency care system. Social EM examines health inequities, social needs contributing to disease, and the emergency department’s important role in reducing health disparities.

How many times have you discharged a patient knowing they would likely be back within days? Or worried they might transmit COVID-19 in their homeless shelter, but felt ill equipped to address the root issue: unstable housing? We all regularly encounter the patient with asthma who cannot fill their albuterol inhaler due to recent layoffs and lost health insurance or the uninsured patient with substance use disorder who cannot afford outpatient treatment. At some point, we’ve all wished we could snap our fingers and give someone a safe place to quarantine, an albuterol inhaler, or a bed in a rehabilitation facility.

As emergency physicians, we take pride in our ability to care for any patient that walks in the door. We also recognize our unique role in caring for many of society’s most at-risk groups. We see the downstream effects of upstream social and structural determinants of health every single shift. We also often experience the sting of moral injury when we discharge patients back to a living situation where they seem destined for continued poor health. We can suture a wound, reduce a fracture, recalibrate electrolytes, and resuscitate like none other, but we so often feel powerless to address underlying problems determining the health status of our communities such as violence, food and housing insecurity, poverty, and racism.

What are social determinants of health?

Income Education Employment Early childhood development

Food insecurity Housing Social safety network Social exclusion

Health services Gender Race Disability

Figure 1

Social emergency medicine aspires to a world where we – on the frontline in the ED – are a part of the solution to health disparities. In 2009, the term social emergency medicine was introduced when the family of Andrew Levitt founded the Levitt Center for Social Emergency Medicine in Oakland, CA. Over the following decade, a growing body of philosophy and research culminated in the invitational consensus conference Inventing Social Emergency Medicine in September 2017.1 Social emergency medicine now has professional subgroups in the three major emergency medicine organizations in the U.S. (ACEP, SAEM, and now AAEM) with a growing number of fellowship programs as well.

Emergency medicine as a specialty grew out of necessity. The need was clear: a highly specialized and skilled group to take care of undifferentiated patients when care was not available elsewhere.

Emergency medicine stepped into this essential role that others didn’t want or were not equipped to fill. EM’s adaptability, innovation, and systems view for problems and solutions is a natural fit for addressing the increasingly complex and interwoven social determinants of health for the most disadvantaged communities.

The newly formed AAEM Social EM & Population Health Interest Group would like to introduce some central social EM tenants, which will hopefully inspire you to become involved in this movement. Core principles of social emergency medicine include the following2,3,4

• Emergency physicians can individualize care for each patient by recognizing the impact of social factors. For example: – Include questions about social determinants in the HPI – Address specific social determinants in discharge instructions and callbacks – Gain awareness of the challenges facing patients through increased community engagement • The ED itself can become more responsive to the social needs of our patients. For example: – Provide increased availability of testing for infectious diseases, such as HIV and Hepatitis C – Develop programs to address infectious disease outbreaks that affect high risk groups, such as flu and Hepatitis A vaccination programs – Build robust treatment algorithms for patients suffering from substance use disorder • The ED can design projects in their communities to address health care inequities. For example: – Follow-up programs such as standardized callbacks and visiting nurse programs – Expanded case management and social work resources in the ED to help frequent visitors and patients with social needs – Keep an updated list of shelters and food banks and provide opportunities for all staff to visit and volunteer there • Emergency physicians can advocate for social change. For example: – Participate in advocacy groups and lobby days at a local, state, and/or national level – Write tweets, articles, op-eds, and/or do interviews for media outlets about issues facing patients – Join the AAEM Social EM & Population Health Interest Group

>> COMMON SENSE SEPTEMBER/OCTOBER 2020

27

INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

The need was clear: a highly specialized and skilled group to take care of undifferentiated patients when care was not available elsewhere.

Many AAEM members are already involved in some of these activities and we look forward to partnering with you and highlighting your stories. Many others may feel that their plate is too full to take on “extra” social issues. But to the contrary, many projects like these were initiated by physicians whose departments, wait times, and unfinished charts were overflowing. EDs that have implemented social support programs have shown measurable reductions in ED visits, bouncebacks, and readmissions in.3,4 Increased engagement, connection with patients and sense of purpose can also mitigate physician burnout and dissatisfaction.

Rather than viewing social EM work as an additional burden, try viewing it as an evolution of focus. Emergency physicians can step back and say, “What are the problems facing my patients’ communities and what can be done to address them?” The social EM lens brings the focus away from health care and towards health. For many of us, that is why we dedicated our lives to medicine in the first place.

In addition, AAEM has long stood as the champion of the emergency physician, advocating for the sanctity of the physician-patient relationship above all else. The Academy’s mission and values align clearly with the values of social EM: keeping the patient at the center of the decision making and acting in the patient’s best interest, even and especially when the right thing may conflict with the interests of other parties such as hospital administration, oversight bodies, and corporations with lay ownership. As the role of the emergency physician continues to expand and evolve to meet the complex needs of our patients, we know AAEM members are up to the challenge. The new AAEM Social EM & Population Health Interest Group hopes you will consider joining our ranks as we look for new ways to advance the health of our communities. Sign up here to get involved and help make a difference: www.aaem.org/get-involved/committees/ interest-groups/social-em. 

The Academy’s mission and values align clearly with the values of social EM: keeping the patient at the center of the decision making and acting in the patient’s best interest, even and especially when the right thing may conflict with the interests of other parties such as hospital administration, oversight bodies, and corporations with lay ownership.

References: 1. Alter, Harrison J. Foreword to Conference Proceedings, Inventing Social Emergency Medicine. Annals of Emergency Medicine.

2019; 74(5) 2. Cheng T, Samuels E. Reflection: An ecologic model of social emergency medicine. Annals of Emergency Medicine. 2019; 74(5):S71-73 3. Tam V, Targonsky E. Social emergency medicine: A way forward for training.

Canadian Journal of Emergency Medicine.

2020; 1-4.

4. Losonczy L, Hsieh D, Wang M, et al. The Highland Health Advocates: a preliminary evaluation of a novel programme addressing the social needs of emergency department patients. Emergency Medicine Journal. 2017; 34:599-605.

Social emergency medicine aspires to a world where we – on the frontline in the ED – are a part of the solution to health disparities.

28

COMMON SENSE SEPTEMBER/OCTOBER 2020

COMMITTEE REPORT EM WORKFORCE

board certification in a specialty. The AANP has been lobbying for years for NPs to penetrate the highest levels of government, and they want to practice medicine.

As physicians, it is imperative that we start paying attention and protect our patients and our profession.

In the U.S., we have created a multitiered health care system with variance in access based upon where you live and what you can afford. It happened while most of us were not paying attention. Yet this is where we are. We cannot sit on the sidelines anymore. We have no central coordination of health care oversight, health care quality, or health care cost in this country. We need physicians to become active in defending the practice of medicine at the state and federal levels to ensure that patients receive care from those with the most expertise.

Will There Be a Doctor in the House?

As of this writing, the SARS-CoV-2 virus has killed more than 129,000 and infected 2.8 million people in the United States. There have been more than 11 million documented infections worldwide.1 Throughout the coronavirus pandemic, physicians, nurses, and the entire health care community have been working side-by-side caring for patients and saving what lives they could. Yet, while many see a national emergency as a time to come together in unity, others have utilized this time of crisis for political gain.2 The pandemic has created an opportunity for an abundance of nonphysician advocacy groups to lobby for permanent independent practice.

Nearly every non-physician group has rallied at the local, state, and federal level to permanently codify their “independent practice.” As physicians, it is imperative that we start paying attention and protect our patients and our profession. We value all members of the health care team, especially during this time of crisis. Yet, non-physicians are not physicians. We went to medical school for a reason. To become a doctor.

When COVID-19 management had no proven therapies and required clinical judgment based on years of intense apprenticeship and a deep understanding of fundamental pathophysiology and biochemistry, physicians drew on their unparalleled expertise to steer the teams through unchartered waters.

Nonetheless, the American Association of Nurse Practitioners (AANP) with one of the largest and most active lobbying groups in the country has, as one of its primary strategic goals that: “nurse practitioners will have parity with physicians and other providers in reimbursement payment and government funding.” 3 Yes, you read that correctly. Pay parity suggests to policymakers that replacing physicians with non-physicians is an acceptable alternative: same pay for the same work. We, as physicians, wholeheartedly disagree. We believe the independent practice of medicine follows a rigorous path of medical school, then residency, then

Please consider this analogy as you are trying to clarify our passion around physician-led care in the U.S. to thought leaders and policy makers.

Many politicians are lawyers, so perhaps this could help them understand. If you are arrested in the United States, you have a right to an attorney. You have a right to due process. The Miranda warning offers, “If you cannot afford an attorney, one will be provided for you.” The answer to challenges within the criminal justice system has not been, “let’s advance the training of paralegals to provide legal services to those

We need physicians to become active in defending the practice of medicine at the state and federal levels to ensure that patients receive care from those with the most expertise who cannot afford an attorney.” Let that sit with you. Would you want a paralegal defending you in a trial?

The pandemic has inspired lobbyists from non-physician groups to urge politicians to advocate for their independent practice. If states allow the unsupervised practice of medicine without a medical license, why go to medical school? Why devote the time? Why spend the money?

The most assertive lobbying to date centered on the Veterans Administration (VA) System with the Health Care Professional Practice in VA Memorandum (www.va.gov/vhapublications/ViewPublication. asp?pub_ID=8794) and underlying Directive 1899. This directive would allow NPs, PAs, CRNAs, and 29 other non-physician providers the privilege of unsupervised practice within the VA. On June 24, 2020, a letter was signed by 89 organizations and specialty groups (including the American Medical Association and AAEM)4 to protest this free reign of non-physicians to practice medicine within the VA health system.

The document states: “Such a far-reaching expansion is overly broad,

>> COMMON SENSE SEPTEMBER/OCTOBER 2020

29

COMMITTEE REPORT EM WORKFORCE

unnecessary and threatens the health and safety of patients within the VA system.” At the time of this writing, the fate of the memorandum— and that of millions of VA patients—remains in the balance.

Aggressive politicking has used the backdrop of the pandemic as subterfuge. Yet, as of the first six months of this crisis, the vast majority of states have not needed to recruit non-physicians to assist in the care of patients with COVID-19 since many patients have deferred their care. ED and hospital censuses have dwindled during the peak COVID months to date. In fact, many hospital systems are struggling. The economic impact on the health care system has resulted in physician salary cuts and layoffs. Yet, NPs and PAs are lobbying heavily for continued and persistent unsupervised practice. Non-physician specialties haven’t wasted the opportunity of a crisis to advance their agenda of unsupervised practice.

Physicians need to realize that our patients’ health and our profession as a whole is threatened.

Patients do not know who is and who is not a physician. They do not know the credentials of the person to whom they are trusting their lives.

As the most recent AMA Truth in Advertising Survey explains, the lay public – with rare exception – does not understand the difference in training of each team member. When patients call to make an appointment with a doctor or present to the emergency department, they expect to see a doctor. Understanding who is a physician and what that means is even more confusing now that many NPs with a DNP degree are introducing themselves as “doctor.”5 Please help. Please find a way to get involved. The coronavirus epidemic has reinforced our understanding that emergency medicine physicians on the frontline are a tremendous asset to the health and well-being of the population. For many weeks, communities celebrated with a nightly ritual to recognize the sacrifice and commitment of health care professionals with sirens, noisemakers, and the banging of pots and pans. It was nice to feel the love for little while. That was then. This is now.

We are by no means out of the woods with this pandemic. It has exposed a lot of the good, bad, and ugly of health care. AAEM was founded on the principles of defending the practice of emergency medicine as a physician specialty. The corporate practice of medicine is taking over and making decisions of profit over patient care. This issue impacts

all physicians in the U.S. Internists, family medicine, and critical care physicians are being replaced by non-physician providers. As a specialty, AAEM has been the society advocating for our rights as physicians to lead care and to make a living practicing our profession.

“The Academy is what it always has been: the champion of the emergency physician, the uncompromising proponent of workplace fairness, a consistent voice for the emergency patient, reliably putting patient before profit.” 6 It is time to get involved. It is time to make a stand. Physicians have no unifying group to defend the practice of medicine. We need to join together across specialties to defend physician-led care.  References: 1. COVID-19 Map. Johns Hopkins Center for Systems Science and Engineering. (Accessed 5 July 2020, at https://coronavirus.jhu.edu/map. html.)

2. Taking advantage of a crisis for political gain is wrong. (Published 11 April 2020, Accessed 27 June 2020.); Available from: https://www. physiciansforpatientprotection.org/taking-advantage-of-a-crisis-forpolitical-gain-is-wrong/.

3. Fleeger, D. I Won’t Take the Nurse Practitioners’ Bait. (Accessed July 20, 2020); Available from: https://www.texmed.org/TexasMedicineDetail. aspx?id=52583&utm_source=Informz&utm_medium=Email&utm_ campaign=TMT&_zs=w23eA1&_zl=AHNb5 4. Letter to the Honorable Robert Wilkie, Secretary U.S. Department of Veterans Affairs. (Published 24 June 2020, Accessed 5 July 2020); Available from: https://www.acponline.org/acp_policy/letters/sign-on_letter_ regarding_the_health_care_professional_practice_in_va_memorandum_ june_2020.pdf.

5. Truth in Advertising Survey Results. (Accessed 29 June 2020); Available from: https://www.ama-assn.org/sites/ama-assn.org/files/corp/mediabrowser/premium/arc/tia-survey_0.pdf.

6. Moreno, L. Steadfast in the midst of uncertainty. (Accessed 5 July 2020); Available from: https://www.aaem.org/resources/publications/commonsense/issues/presidents-message/steadfast-in-the-midst-of-uncertainty.

Appendix AAEM APP Workforce Statement January 2019: www.aaem.org/resources/ statements/position/updated-advanced-practice-providers

The Academy is what it always has been: the champion of the emergency physician, the uncompromising proponent of workplace fairness, a consistent voice for the emergency patient, reliably putting patient before profit.

30

COMMON SENSE SEPTEMBER/OCTOBER 2020

COMMITTEE REPORT EM WORKFORCE

Maybe July 1st Isn’t so Dangerous After All Edwin Leap, MD FAAEM

Those new residents are indeed ‘new’ to the world of medicine; but only in the sense that they are, at last, physicians.

However, what made it possible was that I came to residency already in possession of an enormous amount of knowledge and experience, gained over four years of intense medical education.

Every year it’s the same joke. ‘Watch out on July 1st! It’s dangerous out there! The new residents are starting!’ Or this one: ‘It’s the job of nurses to save you from the new residents.’

Fair enough. Young appearing, freshly graduated physicians, medical degrees and stethoscopes in their trembling hands, have been unleashed in hospitals and clinics across the land. That sounds a little scary given the enormous weight of their responsibilities.

Those new residents are indeed ‘new’ to the world of medicine; but only in the sense that they are, at last, physicians. In order to reassure everyone, it might be good to review what those students did to get their degrees and make it to those residencies on July 1.

They finished four years of university and scored very, very well. They dedicated themselves to schoolwork, to other learning experiences like shadowing or part-time jobs in the medical universe.

They were tested and tried over and over. They worked hard to earn shining letters of reference. They endured numerous interviews. They had resumes that would make many people weep at their own inadequacies. Some of them did it while doing other ridiculously impressive things, like running marathons or climbing mountains, or volunteering for international relief organizations.

Many of them had other lives before medical school. Perhaps as nurses, paramedics, firefighters, soldiers, marines, sailors, airmen, engineers, teachers, musicians; almost anything imaginable.

They then embarked on four years of medical school. But let’s briefly break down the medical school experience.

>>

COMMON SENSE SEPTEMBER/OCTOBER 2020

31

COMMITTEE REPORT EM WORKFORCE

The first two years of medical school involve ‘basic sciences’ and amount to about 22-30 credit hours per semester. Per semester, in case you didn’t get that. It’s a crushing academic load during which learning has been compared to ‘drinking from a fire hose.’ After those two years, their ‘fund of knowledge’ is incredible. I still remember things that rise from the depths of my aging brain for no obvious reason except that I was told, decades ago, that they were important. And out of seemingly nowhere, for a single case years later, they are crucial.

The process is intellectually, physically and emotionally exhausting.

Medical education during the academic years involves a lot of tests; and then tests afterward to enter into the second two years of clinical training and another test to go on to residency. (More tests will follow after that.)

What about those clinical years during medical school? Well, according to a comparison chart at www.midlevelu.com/blog, the average medical student logs about 6,000 hours of patient contact time. For comparison, a nurse practitioner (during his or her education) has about 500-1,500 hours (in part depending on whether or not that education was online or in person). A physician assistant student gets about 2,000 clinical hours during his or her one year of clinical rotations.

Now, this is not to denigrate the education of NP or PA students. But only to say that when we suggest that July 1 is a time of terror, a time of remarkable danger because the new residents are starting, we might want to step back and realize the amount of education and experience that they have already logged.

We don’t tend to say the same thing about new NPs or PAs when they are working in new jobs alongside emergency medicine residents,

providing primary care (often independently), rounding with surgeons, working as night-time hospitalists or anything else they do. This is interesting, since their educational experience before starting their jobs is significantly less than that of the graduating medical student (and drastically less than that of an attending).

Yes, residents are still learning and need the guidance and mentoring of seasoned physician educators. When I embarked on my emergency medicine residency, I was green as grass. And I was challenged for three years. From mundane colds and lacerations to transporting trauma victims from accidents by air, my residency instructors shaped me into a solid, qualified emergency physician and labored to fill the gaps in my knowledge and experience.

However, what made it possible was that I came to residency already in possession of an enormous amount of knowledge and experience, gained over four years of intense medical education.

When I finished residency, I still felt frightened. If I’m honest, I’ll tell you that 27 years into my emergency medicine practice (after residency) there are still days I wish I could have my old faculty members nearby.

But let’s give credit where credit is due. The new residents, God bless ’em, have endured a lot, know a lot and care a lot. Maybe, by reflecting on how they got there, we’ll realize that July 1 isn’t as dangerous as we thought it was.

This article was first published by edwinleap.com and is reprinted with permissions. ©2020 edwinleap.com. 

There are over 40 ways to get involved with AAEM Dive deeper with AAEM by joining a committee, interest group, task force, section, or chapter division of AAEM. Network with peers from around the U.S. sharing your clinical and/or professional interests or meet-up on the local level with members in your state.

Visit the AAEM website to browse the 40+ groups you can become a part of today.

Get Started!

www.aaem.org/get-involved

32

COMMON SENSE SEPTEMBER/OCTOBER 2020

STAY CURRENT with

FDA-Approved Immunotherapy Treatments ACI LIVE VIRTUAL PROGRAMS

WHY ATTEND?

Please join us for one of the programs scheduled below!

• Earn CME, CPE and CNE credits and MOC points • Attend for FREE if you are a healthcare professional, student, patient or patient advocate • Hear from and network with local experts in tumor immunology and cancer immunotherapy

• Boston – Sept. 10, 2020+ • Madison, Wis. – Sept. 24, 2020+ • Washington, D.C. – Oct. 8, 2020* • Pittsburgh – Oct. 24, 2020+

• Seattle – Oct. 31, 2020* • Tucson, Ariz. – Oct. 31, 2020* • Tampa, Fla. – Nov. 21, 2020* • San Antonio – Dec. 12, 2020+

Please visit sitcancer.org/aci for more information.

ACI PROGRAM TAKEAWAYS

ACCREDITATION INFORMATION

ACIs are presented by local authorities in tumor immunology and cancer immunotherapy and cover the following topics: • Treating patients with FDA-approved immunotherapies • Interpreting new clinical data supporting the use of checkpoint inhibitors, • CAR T therapies, cytokines, oncolytic viruses and vaccines • Identifying and managing irAEs • Employing strategies to overcome operational and reimbursement barriers to incorporating immunotherapy into your practice • Applying foundational knowledge for clinical implementation of SITC’s Cancer Immunotherapy Guidelines • Anticipating forthcoming immunotherapy trends/treatments/trials and how they impact your patients and practices • Recognizing common and uncommon toxicities in immunotherapy patients and provide solutions/adjustments in treatment to address them

AMA Credit Designation These activities have been approved for AMA PRA Category 1 Credit(s)™.

Pharmacist Credit Designation These activities are eligible for ACPE credit, see final CPE activity announcement for specific details.

Nursing Credit Designation These activities are eligible for ANCC contact hours, see final CNE activity announcement for specific details.

For full accreditation information and to register for these events, please visit:

sitcancer.org/aci

*The 2019–2020 ACI series is jointly provided by Postgraduate Institute for Medicine and the Society for Immunotherapy of Cancer in collaboration with the American Academy of Emergency Medicine, the Association of Community Cancer Centers and the Hematology/Oncology Pharmacy Association. +The 2020–2021 ACI series is jointly provided by Postgraduate Institute for Medicine and the Society for Immunotherapy of Cancer in collaboration with the American Academy of Emergency Medicine and the Association of Community Cancer Centers (as of Aug. 4, 2020). *The 2019–2020 Advances in Cancer Immunotherapy™ educational series is supported, in part, by independent medical education grants from Amgen, AstraZeneca Pharmaceuticals LP, Bristol Myers Squibb, Celgene Corporation, Exelixis, Inc., Genentech (excluding the Toronto program), Incyte Corporation and Merck & Co., Inc. +The 2020–2021 Advances in Cancer Immunotherapy™ educational series is supported, in part, by independent medical education grants from Amgen, AstraZeneca Pharmaceuticals LP, Bristol Myers Squibb, Exelixis, Inc. and Merck & Co., Inc. (as of Aug. 7, 2020).

SITC-0820-052

COMMITTEE REPORT ETHICS

A Novel Committee on a Very Important Directive Jennifer Gemmill, MD FAAEM

As we reach the halfway point of this strange year, I find myself pausing to reflect on what has happened thus far. I am asking myself questions that I have never before had the need to ask. Questions like, “Why can’t my children go to school?” “Where did all the toilet paper go?” “Why can’t I drink wine while I homeschool my kids?” Some of these questions have obvious, albeit unsatisfactory answers. Some questions, however, have answers that are much more vague. Or rather, answers that just lead to more questions. “Where do we put all these sick patients?” “Who should get the last ventilator today?” “Should I really ask my nurses to wear trash bags as PPE?” Barring my brief practice in the austere environment of Afghanistan, all of the emergency departments (EDs) in which I’ve worked in have had more than enough supplies to care for the patients who come through the door. Overseas, however, we were faced with many obstacles. Being in the middle of a combat region, limited human resources was a huge limiting factor for care we could provide. Fortunately, I was filling the place of many who had practiced in this environment before me and we generally followed standard operating procedures that gave us a game plan for most eventualities. For example, we had a well-crafted outflow plan for patients who needed care we couldn’t provide. STEMI without a cath lab? No problem! Give them thrombolytics and put them on a plane! A combat wound that needs extensive plastic surgery? We got this!

Resuscitate, stabilize, and get them on a plane! Crash blood supply exhausted? Easy! Everyone line up for a whole blood drive! Then, put the patient on a plane.

Back on this side of the world, I’ve been lucky to practice mostly in large, urban EDs. The smaller EDs I’ve worked in have all had strong city connections and transfer protocols. I’ve never needed to contemplate rationing ventilators, ET tubes, face masks, or gloves. These are realities that some of us are now facing; and some for a second time. These are all realities that most of us take for granted in a resource rich nation. As such, I am sure that I am not the only physician to feel a bit uncomfortable when faced with having to make these choices on a daily basis. I am used to having a standard of practice, a modus operandi, something solid that I can fall back on to defend my medical choices. Recently, this type of governance resource did not exist. Enter the newly formed AAEM Ethics Committee.

Roberts and Hedges for this new aspect of our job. As we launch this new committee, I am most excited about providing ethical guidance for these extremely difficult daily tasks of which we face, and to provide the basis of support for the decisions we have to make every day.

As I write this today, my city is feeling the effects of a “second wave” of the coronavirus outbreak. We are running out of N95 masks.

We are running out of hospital beds. We have maxed our human resources. Nurses and techs who were previously furloughed are reluctantly trickling back into the hospital. My colleagues and I look to the experience of those practicing in New York, Chicago, Detroit, New Orleans. Those physicians who are finally coming through their toughest stretch will now be guiding lights for those of us just getting into the weeds of this virus. We will use these experiences to help build new clinical practice guidelines. We will draw from the stories of our colleagues to create ethically sound guidance to take with us into the future of our clinical practice. I am confident that as an EM community, we will come through this trial stronger, humbler, and more knowledgeable as we learn from the experiences of those who forged through first.

While I’m not sure we will ever know where all the toilet paper went, I am hopeful that the AAEM Ethics Committee will provide the EM community with thoughtful guidance and support for the non-linear questions that we face today, into the second (hopefully more positive) half of 2020, and into our future as EM physicians. 

AAEM has long since provided support for the practice of emergency medicine. The principles of the group stem from the personal and professional welfare of the practicing emergency physician.

As a democratic organization, AAEM supports fair and equitable practice environments to allow physicians to provide the highest level of care. Keeping with these We are dealing with things like resource principles, the AAEM Ethics Committee was formed earlier this year to provide ethiallocation in the midst of a pandemic, end of cal guidance that supports and mirrors the guidelines of ethical practice needed in life care and preparation, and provider safety EM. Furthermore, our first major initiative is to create a written, standard Code of Ethics for EM and by EM practitioners. As the Vice Chair of this new committee, I am amidst the ever-growing risk of illness. honored to be a part of helping EM docs navigate through the new challenges we are all experiencing daily. We are dealing with things like resource allocation in the midst of a pandemic, end of life care and preparation, and provider safety amidst the ever-growing risk of illness. These issues can make us feel lost, frustrated, or even hopeless. We all know the medicine to provide care for sick patients and the myriad of issues that befall the emergency physician. However, not all of us are prepared for what we are currently facing, nor have we had to make these choices for so many people on a daily basis. Choices like who lives and who dies due to unavailable resources. Few of us have had to watch our EM (and medical) family become sick, incapacitated, or die as a result of just doing their job. There is no 34

COMMON SENSE SEPTEMBER/OCTOBER 2020

COMMITTEE REPORT WELLNESS

Gratitude and Appreciation Amidst Chaos and Uncertainty: Awaken Humanity at Work Al’ai Alvarez, MD FACEP FAAEM (@alvarezzzy) and Robert Lam, MD FAAEM (@doclam01)

Let’s consider individual physicians, as well as the organization.

Physicians tend to have a very low tolerance for failure. We hold our profession to the highest standard and we’re quick to consider any semblance of negative deviation as a failure. The scientist in us quantifies this through metrics and scores. A quick look at how we got here explains why this may be so – we were expected to get A’s in college in order to get into medical school, and similarly, pressured ourselves to try to be in the top of our medical school class in order to match at our number one ranked residency program.

It’s no surprise that in our clinical practice, we expect nothing but excellence. While grades may no longer exist, substandard practices are negatively highlighted through faculty evaluations, near-miss reports, peer review correspondences, and morbidity and mortality rounds. Furthermore, these metrics are high stakes as they are structurally tied to financial penalties. In fact, some metrics are unachievable, not evidenced-based or tied to patient outcomes and rather simply represent meaningless, and often psychologically-harmful feedback. This name, blame, and shame culture, therefore, leads to self-judgment, shame, isolation, and burnout. It’s no surprise that emergency medicine physicians rank one of the highest in burnout across medicine. Worse, this leads to decreased psychological safety where individuals are more likely to hide mistakes, further causing a negative spiral, including patient harm.

How do we reverse this negativity without sacrificing quality and patient safety? While safety II concepts1 are beyond the scope of this month’s wellness column, we can imagine an alternative health care system where a focus on gratitude and appreciation is emphasized. How do we get there?

As human beings, we are wired to look for threats (negative emotions) in order to survive.

Barbara Fredrickson discovered a positive-tonegative emotions ratio: it takes about three positives to overcome one negative perspective.2 It’s important to note that the negative experience is crucial to help steer our direction.

In practice, we, as individuals, can learn to appreciate three good things everyday day to overcome a negative experience. According to Bryan Sexton, recounting three good things at the end of each day for 15 days has been shown to improve health care worker wellbeing.3 Kelly McGonigal refers to this as being detectives of positive encounters.4 The more we take a moment to observe and appreciate positive experiences around us, the more positive we become. Similarly, esteem (appreciation) is

The more we take a moment to observe and appreciate positive experiences around us, the more positive we become. one of Maslow’s hierarchy of needs. Therefore, giving and receiving appreciation have positive effects. Bob Emmons talks about gratitude as an affirmation of goodness around us and that when we express thanks, we are reminded that we are not alone.5 Knowing these positive psychology concepts, organizations can operationalize recognition and appreciation to create a positive environment. Employee recognition programs have multiple benefits including increased employee engagement and satisfaction. This recognition may be highlighted in three forms: formal recognition, informal recognition, and day-to-day recognition.6 Formal recognition includes awards such as “save of the months” or “nurse of the year,”

A simple, timely, genuine acknowledgment shows that we are seen, that our efforts are validated, and that we belong.

promotions, and bonuses for specific service excellence. Chip and Dan Heath, in their book, The Power of Moments, refer to defining moments as being both memorable and meaningful. Celebrating recognition creates a sense of elevation and pride, and by personalizing the experience, we offer insight and connection.7 Informal recognition may be in the form of an email or verbal acknowledgment of nominations and kudos. Lastly, day-to-day recognition refers to the daily practice of thanking the efforts of others. This can be done during shift huddles and signouts. Another approach is positive leader rounds where leaders seek out what is going well as opposed to what needs to be fixed which is linked to improved work satisfaction and burnout.8 Some call these “Amazing and Awesome,” which is a positive spin off the “Morbidity and Mortality” rounds. It is important to note that like any form of feedback, this must be timely and genuine in order to maximize benefits.9

>>

COMMON SENSE SEPTEMBER/OCTOBER 2020

35

COMMITTEE REPORT WELNESS

There’s also a distinction between recognition and appreciation.

Recognition is performance-driven, while appreciation is value-based, and not focused on accomplishments: “recognition is about what people do; appreciation is about who they are.”10 Recognition and appreciation do not always have to be linked with monetary compensation. In fact, one study shows that it may even backfire and affect intrinsic motivations.11 Rather, there is evidence that appreciating others has as much of a positive lasting effect on the one giving the appreciation as the recipient.8 A simple, timely, genuine acknowledgment shows that we are seen, that our efforts are validated, and that we belong.

The practice of emergency medicine is complex and full of uncertainties; we often don’t even know who will be working with us on our next shift, which exacerbates depersonalization, a symptom of burnout. Let us, therefore, re-engage our colleagues by acknowledging their presence and their worth. Let us develop connections by verbalizing our genuine appreciation. Beyond giving orders and closed-loop communication, let us be intentional in sharing with our colleagues how much we care and value them. As an organization, we can create a system that allows for this.12 Because of the nature of our practice, bad things happen. We can choose to focus on the negatives, complain or write hurtful, unconstructive evaluations, or worse, be self-critical. Or, we can choose to be compassionate to ourselves, appreciate our shared common humanity, and start celebrating our wins, recognize each other’s efforts, acknowledge our value in the frontlines, and commit to a daily practice of gratitude.13 Cultivating gratitude and appreciation from an individual and organization perspective requires practice and intentionality, and it can be done. This is how we can awaken humanity at work. 

36

COMMON SENSE SEPTEMBER/OCTOBER 2020

The practice of emergency medicine is complex and full of uncertainties; we often don’t even know who will be working with us on our next shift, which exacerbates depersonalization, a symptom of burnout.

References: 1. Hollnagel E, Wears R, Braithwaite J. From Safety-I to Safety-II: A White Paper. Accessed June 30, 2020. http://www.psnet.ahrq.gov/issue/safety-isafety-ii-white-paper 2. Fredrickson B, Losada M. Positive Affect and the Complex Dynamics of Human Flourishing. Am Psychol. 2005;60(7):678-686. Accessed July 1, 202https://doi.apa.org/doi/10.1037/0003-066X.60.7.678 3. Sexton JB, Adair KC. Forty-five good things: a prospective pilot study of the Three Good Things well-being intervention in the USA for healthcare worker emotional exhaustion, depression, work–life balance and happiness. BMJ Open. 2019;9(3):e022695. doi:10.1136/ bmjopen-2018-022695 4. McGonigal K. The Upside of Stress: Why Stress Is Good for You, and How to Get Good at It.; 2005.

5. Emmons R. Why Gratitude Is Good. Greater Good. Accessed July 1, 2020. https://greatergood.berkeley.edu/article/item/why_gratitude_is_ good 6. Best Practices for Developing an Employee Recognition Program.

Accessed June 30, 2020. https://www.beckershospitalreview.com/hr/bestpractices-for-developing-an-employee-recognition-program.html 7. Heath C, Heath D. The Power of Moments: Why Certain Experiences Have Extraordinary Impact.; 2017.

8. Sexton JB, Adair KC, Leonard MW, et al. Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf. 2018;27(4):261-270. doi:10.1136/bmjqs-2016-006399 9. Novak D. Recognizing Employees Is the Simplest Way to Improve Morale.

Harv Bus Rev. Published online May 9, 2016. Accessed June 30, 2020. https://hbr.org/2016/05/recognizing-employees-is-the-simplest-way-toimprove-morale 10. Robbins M. Why Employees Need Both Recognition and Appreciation.

Harv Bus Rev. Published online November 12, 2019. Accessed June 30, 2020. https://hbr.org/2019/11/why-employees-need-both-recognition-andappreciation 11. Gilbert B. When performance-related pay backfires - 06 - 2009 - News archive. Accessed July 1, 2020. http://www.lse.ac.uk/website-archive/ newsAndMedia/news/archives/2009/06/performancepay.aspx 12. Klyce V. A Secret To Success: Rip ROARing Happiness. FemInEM. Published March 1, 2016. Accessed June 30, 2020. https://feminem. org/2016/03/01/761/ 13. Alvarez A, DeVries P. Rough Day? Be Grateful. ICE Blog. Published March 5, 2019. Accessed June 30, 2020. https://icenetblog.royalcollege. ca/2019/03/05/rough-day-be-grateful/

SECTON REPORT CRITICAL CARE MEDICINE

To Those Who Initiate Critical Care Alex Flaxman, MD MSE FAAEM

Thank you for the opportunity to serve as Secretary/Finance Chair for the Critical Care Medicine Section of AAEM. Since a good leader would never ask of others something they wouldn’t do themselves, the first article of my term is written by yours truly.

The doctor: “This is not that hard. I mean, it’s not rocket science.”

The rocket scientist: “This is not that hard. I mean, it’s not life and death.”

CMS is quick to point out “critical care” is location independent.1 Similarly, anyone could be in the position of providing critical care and so any physician could, theoretically, bill one or both of our two favorite EM codes, 99291 and 99292. Although critical care billing does not carry location information, it is not a far stretch to assert that the majority of critical care provided outside of an intensive care unit is in the emergency department. The challenge of simultaneously resuscitating and stabilizing one or more critically ill patients, teeing them up for the ICU (OR, cath lab, or endoscopy suite), while still maintaining the flow of the rest of the department, is unlike any other specialty. So one might think it presumptuous to ask more of these trench warriors. However, care continues for patients once they leave the ED. As an emergency physician and critical care physician, I would like to give “top 5” requests, items that may not seem like much at the time but, downstream in the ICU, matter. They also may save the patient an intervention and you, time.

2) Stay out of the danger zone. “Two centimeters” is your friend.

We all know practitioners who consider an ETT not in the pharynx or (why bother?) or right mainstem (what exuberance!) to be a win. After all, the ICU can fix it later. But do those people consider an oil change for their car anywhere between 500 miles (exuberance) or 20,000 miles (why bother)? After all, when the engine melts or explodes, the mechanic can fix it.

So, on the post-intubation chest X-ray check the distance from the tip of the ETT to the carina. Then adjust, or order to have adjusted, that distance to be 2 cm. This is high enough to prevent distal movement causing a mainstem intubation, and low enough to prevent accidental extubation. Accidental extubations carry higher morbidity (increased ventilator days, LOS, and therefore risk of VAP), and even mortality.2-3 Plus, accidental extubations are reportable events to CMS. Don’t obscure your skill at obtaining an airway by losing the airway or one of the lungs.

You’ve done the work, get all the credit. Otherwise, your EMR will be telling CMS on you.

>>

As an emergency physician and critical care physician, I would like to give a “top 5” requests, items that may not seem like much at the time but, downstream in the ICU, matter.

1) Bigger is better, at least for endotracheal tubes.

When told the event of childbirth is a beautiful miracle, comedian Jeff Foxworthy declared that a child being born is a beautiful miracle, but the actual event is like a wet St. Bernard trying to come in through the cat door.

The same is true about bronchoscopy through a small endotracheal tube. It is possible to pass a bronchoscope through a size 7-0 ETT. But it requires special (silicone) lubricant, the scope pulls against the ETT and so requires more force to move, it moves the ETT, and overall is unpleasant for everyone involved. So by all means, for the edentulous, C-spine immobilized, micrognathia, smoke-inhaled, morbidly obese, pregnant patient, get something in: ETT 6-0, 5-0, whatever, something. But for most airways, think big: at least 7-5, 8-0 ETT is better, 8-5 is heaven, and a 9-0 should earn you champagne from your admitting intensivist. Also, for patients with secretions (which, let’s face it, is all of them), suctioning and ventilator management are much easier with larger tubes. So don’t commit bigamy, but for ETTs, let’s all be big.

COMMON SENSE SEPTEMBER/OCTOBER 2020

37

SECTON REPORT CRITICAL CARE MEDICINE

Twice the work, twice the liability, and no extra payment.

3) “A tube for every orifice, and an orifice for every tube.”

With multiple trainees, someone can place the ETT, someone the NG tube, and someone the OG tube. Oh, wait, that’s too many. Just because a patient has a nose, does not mean a tube has to be placed in it. Once a patient is intubated, orogastric tubes are preferred over nasogastric tubes. Weak-to-moderate evidence shows that compared to orogastric tubes, nasogastric tubes carry an increased risk of sinusitis.4 So unless a patient is expected to require an NG tube once extubated (for example, a patient going to the OR for bowel surgery), oral is better than nasal. Plus it hurts less.

4) Government spending: doing twice as much for twice the price. Or, if one X-ray is good, two are better. Or, prove your skill by taking a picture at each step.

One you intubate, check a chest X-ray. Then place the OG tube and check a chest X-ray. Or don’t place an OG tube at all, the ICU can do it and get their own X-ray. Nooooo! Once you intubate, and before the chest X-ray, place a gastric tube (preferably an OG tube, see “Orifices,” above). One X-ray can confirm it all. Besides, if you end up ordering two X-rays, you are obligated to check both. Twice the work, twice the liability, and no extra payment. Oh yeah, you don’t need a dedicated abdominal film. As long as the chest X-ray shows the gastric tube going below the diaphragm (and the proximal hole below the diaphragm), the tube is good.

5) Infectious risk, ischemia risk, risk to staff, one more test to review, costs money, and it hurts, too.

ABGs are wonderful. They can highlight hidden disorders, suggest extent of disease process, and help with ventilator management. However, there are many cases where they are not necessary. Do you really need an ABG (or, worse, a VBG) to diagnose DKA? So when you need an ABG, don’t be afraid to order it. But if it’s not necessary, consider holding off.

And specifically for DKA, for the CMS billing requirement for a “blood gas,”5-6 add a line in your note “Blood gas not required.” The text doesn’t risk infection, there’s no risk to staff, you won’t have to review an ABG, it doesn’t cost anything, and the only people it hurts are the CMS reviewers who would otherwise use the absence of an ABG/VBG to not pay you.

“If my shadow has offended, Think but these, and all is mended Heed the above, and be we friends.

Your critical care will return more than dividends.”7 So go forth, provide critical care. Provide care for the moment, but also with an eye to the patient’s journey, of which the ED is just the first stop.  References: 1. CMS Manual System, Pub 100-04 Medicare Claims Processing, Chapter 12, 30.6.12, Section A 2. Epstein SK, Ciubotaru RL: Independent Effects of Etiology of Failure and Time to Reintubation on Outcome for Patients Failing Extubation.

American Journal of Respiratory and Critical Care Medicine.

158:489,1998.

3. Mort TC: Unplanned Tracheal Extubation Outside the Operating Room: A Quality Improvement Audit of Hemodynamic and Tracheal Airway Complications Associated with Emergency Tracheal Reintubation.

Anesthesia & Analgesia. 86:1171,1998.

4. Salord F, Gaussorgues P, Marti-Flich J, et al. Nosocomial maxillary sinusitis during mechanical ventilation: a 5. prospective comparison of orotracheal versus the nasotracheal route for intubation. Intensive Care Med. 6. 1990;16(6):390-393. doi:10.1007/BF01735177 7. American Diabetes Association. Position Statement: Hospital Admission Guidelines for Diabetes Mellitus. Diabetes Care, vol. 15, supplement 2, April 1992.

8. American Diabetes Association. Position Statement: Hyperglycemic Crises in Diabetes. Diabetes Care. Vol 27, supplement 1, January 2004.

9. Adapted from A Midsummer Night’s Dream, William Shakespeare, Prologue.

CCMS Resources Join the Critical Care Medicine Section of AAEM and benefit from the below resources.

Critical Care Speakers Exchange

This member benefit is a resource for conference organizers to recruit top-quality speakers in critical care medicine. All speakers must be members of the Critical Care Medicine Section of AAEM. Join today!

Mentoring Program

In addition to the traditional mentor-mentee relationship, CCMS offers several opportunities for mentors and mentees to create something together. Apply today to become a mentor or mentee!

Critical Care Hacks

This video library provides quick resources for different critical care medicine topics.

Watch today!

COVID-19 Resources

The CCMS Council has created and gathered resources specific to helping members during the COVID-19 pandemic. Join our listerv to connect.

Learn more: www.aaem.org/get-involved/sections/ccms/resources 38

COMMON SENSE SEPTEMBER/OCTOBER 2020

SECTION REPORT WOMEN IN EMERGENCY MEDICINE

Mothering in the Time of COVID Trupti Shah, MD

We knew it was coming but it still blindsided us. On Sunday night, after days of denial and stalling, the mayor finally announced that NYC schools and daycares would be closed starting the next day.

This left my husband and me in a bind. With two active toddlers, what were we going to do with them all day? How will my husband get his work done? How will I rest in between shifts? I was working the overnight shift the next day.

At that time, we were starting to see COVID-19 patients. They started as a few every shift but it was rapidly increasing to the majority. There was so much uncertainty surrounding this disease. What if I bring something home? What if I already had?

Luckily my parents live 30 minutes away and have always been our go-to backup. For their safety, I wanted the kids away from me. As a mom, how could I just send them away? I made the excuse that it was too late in the evening to pack them up and drop them off. In reality, I didn’t want to edit the mental packing list for all the activities they would do without me. It was going to have to wait until the early morning.

“No school tomorrow! You get to see Nani and Nana tomorrow! Now go to sleep; don’t make me tell you again,” we tucked them in. Our two toddlers had no idea what was going on in the world but my husband and I were scared.

The next morning, we packed them up with enough clothes, toys, and books for the week. “Just in case,” I told my husband who would join them. I reasoned that they should have one parent there. “But I’ll see you on Wednesday when I get the day off.” I knew then that I was lying.

I just didn’t realize how far off I was.

I’ve spent a night or two away from the kids before, but this felt different.

Almost immediately, the apartment felt too quiet and too lonely. It was usually me traveling away from them. Here I was all alone in our apartment. Meanwhile, their house had my parents, my sister, my husband, my two kids running around, plus our dog. I would have laughed, if it wasn’t so sad, but the kids were loved and spoiled, and hopefully they were eating and sleeping.

Honestly, that first week without my children went by quickly. I was working a string of shifts, and I was still coming to terms with all that was happening at our hospital and others. I closed the door to their room; I didn’t go in for weeks. Seeing their empty beds and toys made the silence louder. The TV noise felt comforting so it stayed on even when I wasn’t watching.

We ‘Facetimed’ daily. My daughter kept repeating, “Hello mommy,” as she would put the phone to her ear; all I could see was her hair on the screen. My son quizzed me on math and spelling; three questions every day. Neither my son or daughter seemed bothered that they only saw me on the phone. That’s a good thing, right?

I didn’t know what to do with myself on my off days. I wanted to be a mom again. Everyone on Facebook was posting about all their free time. They were baking, cooking, painting, bike riding with their kids. I tried to do a science experiment over the phone. I had my sister gather food coloring, oil, water, and alka-seltzer. I had researched ‘easy toddler science experiments’ on YouTube. My son’s attention span barely lasted the five minutes. I read books over the phone; anything to try to connect with them.

The apartment was so quiet and empty except during Zoom calls with friends & family. I ended up hogging the conversation trying to answer everyone’s questions. I just wanted some human contact.

A reporter from The New Yorker wanted to talk about separating from my kids; a phone call turned into a video interview. A friend wanted me to do a Q&A with viewers on his live streaming platform. “Sure,” anything to avoid isolation.

We all do what we have to do for our jobs and our kids.

We sacrifice one for the other.

By the third weekend in separation, there was no food in the fridge. My husband came to clean our apartment while I was at work, decked out in a garbage bag, painter’s mask and gloves. It felt like my life was on hold. Every spring I took the kids out of daycare to go to the Botanical Gardens for the day. We’d take family photos when the cherry blossoms bloom and they usually make it onto our holiday cards. This year the card would be a screenshot of a Zoom call.

On rare days, I walked outside for a few minutes. I took every chance I got to speak to someone. I hadn’t touched someone without gloves in over three weeks. I asked my parents if I could see the kids through the patio glass doors at their house; I felt so desperate. They wisely declined. A friend asked me why I didn’t quit my job and go to my kids; it’s not worth it. What? I never considered it.

>> COMMON SENSE SEPTEMBER/OCTOBER 2020

39

SECTON REPORT CRITICAL CARE MEDICINE

Seeing their empty beds and toys made the silence louder.

Every night, at 7:00pm, my husband and kids would call. The clapping was bittersweet. My son loved it, proudly shouting, “I’m clapping for you mommy!” My daughter loves clapping for anything.

But within moments of hanging up, it became unbearably quiet again. It was even more lonely. They were one big happy family sitting and playing in the living room after dinner. And I was left with my worries: about my family, my colleagues; worried about my patients, for the world; worried about me, my health, my sanity. I missed my children. I missed being a mom.

Then came the break. Sheltering in place worked and the spread was slowing. The hospital was full but the emergency department volume came to a trickle. I used my vacation time and got an unexpected week off. I didn’t count on how much I needed work to keep me sane. I hadn’t touched – or been touched – by anyone without PPE in over a month.

so much doubt. In the end, without a definitive end in sight, we decided to bring kids home. But Pediatric Inflammatory Multisystem Syndrome (PIMS) was just starting to get into the news. I just held my breath.

NY PAUSE flattened the curve but it wouldn’t end for weeks. For the first time in six weeks, I went to see my kids. I went to my parent’s backyard and stayed six feet away from the house. My mom brought them out.

I was expecting my daughter to be hesitant and my son to be jumping up and down. It was the exact opposite. My daughter clung to me; she rested her head on my shoulder and would not be put down. My son seemed distracted playing. I started to cry; my parents were crying, my sister was tearing. My husband just wanted to pack the car and go home.

I remember that my father left for the U.S. without his family when his green card arrived. It should have been for a few months until he could find a job and get an apartment. But he didn’t know that his wife was pregnant and wouldn’t join him for over a year. He didn’t meet his daughter until she was seven months old. How does my six weeks even compare? We all do what we have to do for our jobs and our kids. We sacrifice one for the other. This is nothing new. It also won’t be the last time.

I didn’t know what to do with myself on my off days. I wanted to be a mom again.

Every day I thought about when I would see my kids again. I kept moving up the date of return: Initially the end of May, then Mother’s Day. I talked about it daily with my husband. He wanted to come back to his home. But I was the one scared. What would we do with the kids? NYC had set up a daycare for essential workers but the idea of sending them to school filled me with dread. Facebook’s Moms groups were full of women who would absolutely not do that. I didn’t know if my loneliness and need to be with them would be putting them in danger.

With full trepidation, I went and visited an essential daycare center. They talked to me about their safety protocols, temperature checks twice a day for staff and kids, cleaning schedule, etc. It eased my guilt. But still

On their first day of their new daycare they were minimally exposed to a sick staff member. Shit, what have I done? It was too late to change my mind and send them back to their grandparents. My husband and I are trying to prepare for the next step. If daycare closes, does my husband stop working? We are not naive to think that this is the end. What about a second wave? Do we separate again? I didn’t want to; I don’t want to. I reasoned it was for their safety and so, I would do it again. I may have to do it again. COVID-19 isn’t over. 

Join the WiEM Section The Women in Emergency Medicine (WiEM) Section is constituted with a vision of equity for AAEM women in emergency medicine and a purpose to champion the recruitment, retention, and advancement of women in emergency medicine through the pillars of advocacy, leadership, and education. The AAEM Women in Emergency Medicine Section membership is free for AAEM and AAEM/RSA members.

Learn more at:

www.aaem.org/wiems

40

COMMON SENSE SEPTEMBER/OCTOBER 2020

WiEM Mentorship Program The WiEM Section provides education that builds mentoring systems for female medical students and emergency physicians at different stages of their careers, whether in an academic or community setting. Apply today to be successfully matched with a mentor/mentee.

SECTION REPORT EMERGENCY ULTRASOUND

Making Point of Care Ultrasound Accessible for All Melissa Meyers, MD FAAEM and Alexis Salerno, MD FAAEM

Point-of-Care Ultrasound (POCUS) has an accessibility problem. This statement is plain, it’s simple, but it is the truth. Physicians in the community may be aware of the potential uses of POCUS but may be unable to access

One of the core missions of the AAEM Emergency Ultrasound Section (EUS-AAEM) is addressing the needs of community physicians. Meeting you in your community is one of the ways we are attempting to do so. This year we implemented emergency ultrasound courses located in communities, with an inaugural course held in Queens, New York. In the future, we plan to expand this to other communities with local AAEM chapter divisions and to continue to offer lectures and small

support you need. There are multiple resources available to address the exams commonly performed by emergency physicians, such as current resident training guidelines and various policy statements.2-3 In addition, there are also guides for approaching credentialing and discussions with other departments with tiered levels of credentialing based on prior training and practice-based pathways to credentialing.4 One way we plan to help our members is by offering targeted teaching with a credentialing certificate for the E-FAST at the 2021 Scientific Assembly. We plan to expand this endeavor to incorporate other imaging studies in the future.

In the future, we plan to expand this to other communities with local AAEM chapter divisions and to continue to offer lectures and small groups during the yearly AAEM Scientific Assembly. equipment or teaching. Perhaps they have difficulty communicating to their hospital the importance of this imaging modality or face conflict about credentialing from other departments in the hospital. Lastly, physicians may also have concerns regarding legal liabilities.

Beginning in 2012, the Accreditation Council for Graduate Medical Education (ACGME) began requiring point of care ultrasound education for emergency medicine residency graduates.

Recent graduates are confident and capable when performing point of care ultrasound. Left unaddressed however, is how to expand this teaching to those who graduated before 2012.

Over the last several years, many in-person ultrasound courses have become available nationally.

However, these courses are often expensive and require time away from work.

groups during the yearly AAEM Scientific Assembly. Lastly, in response to social distancing requirements in the COVID era, we plan to bring you increased online educational opportunities over the next year such as lectures, forums and e-learning courses.

Physicians may also have concerns regarding credentialing and scope of practice.

Currently, physicians are more likely to be credentialed if they work at a clinical site with an ultrasound fellowship.1 While understandable, this current state of affairs is not satisfactory given the potential improvement in patient care POCUS can provide. Physicians at non-academic sites should feel capable of performing these exams and we in the EUS-AAEM are committed to providing the

For those physicians who may have concerns regarding legal liability of performing exams, some may argue that they should be more concerned about not performing an ultrasound. In a 2012 review of lawsuits filed against emergency physicians, no cases were identified where an emergency physicians was found liable for performing a POCUS exam within our scope of practice.5 However, physicians could be found liable if they were unable to diagnose free fluid on an E-FAST for an unstable trauma patient or a ruptured abdominal aortic aneurysm. Physicians in academic centers may wish to perform advanced modalities, but

>>

OVER THE LAST SEVERAL YEARS, MANY IN-PERSON ULTRASOUND COURSES HAVE BECOME AVAILABLE NATIONALLY. HOWEVER, THESE COURSES ARE OFTEN EXPENSIVE AND REQUIRE TIME AWAY FROM WORK.

COMMON SENSE SEPTEMBER/OCTOBER 2020

41

SECTON REPORT EMERGENCY ULTRASOUND

until we are all capable of performing the basic exams, we must focus on reaching all emergency physicians and providing the education and support needed to perform point of care ultrasound. To protect you and your group, it is not only important to be able to perform the basic exams but to also have good documentation and an organized ultrasound system.

Over the next year, we plan to publish newsletter articles, blog posts, and forums about correct documentation and qualitative assessment of ultrasound studies.

The AAEM Emergency Ultrasound Section (EUS-AAEM) is committed to meeting the need of our community emergency medicine colleagues and the ultrasound accessibility problem. We publish a bi-annual newsletter, the POCUS report, with articles on performing ultrasound as well as addressing common administrative concerns. Consider joining the section and becoming the champion for point of care ultrasound in your community. And for those current EUS-AAEM members, we would love to hear your thoughts and suggestions for this upcoming year.  ď Ź

References: 1. Das, D., Kapoor, M., Brown, C., Ndubuisi, A., & Gupta, S. (2016).

Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States. Critical ultrasound journal, 8(1), 1-7.

2. Akhtar S, Theodoro D, Gaspari R, et al. Resident training in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency Medicine Residency Directors Conference. Acad Emerg Med. 2009;16 Suppl 2:S32-S36. doi:10.1111/j.1553-2712.2009.00589.x 3. Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med. 2017;69(5):e27-e54. doi:10.1016/j.annemergmed.2016.08.457 4. Smalley, C. M., Fertel, B. S., & Broderick, E. (2020). Standardizing Pointof-Care Ultrasound Credentialing Across a Large Health Care System.

The Joint Commission Journal on Quality and Patient Safety.

5. Blaivas, M., & Pawl, R. (2012). Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period. The American journal of emergency medicine, 30(2), 338-341.

Join the Emergency Ultrasound Section of AAEM (EUS-AAEM) THE EUS MISSION IS TO FOSTER PROFESSIONAL DEVELOPMENT AND EDUCATE MEMBERS ON POINT OF CARE ULTRASOUND.

EUS-AAEM POCUS Report We are proud to publish the POCUS Report, our e-newsletter with original contributions from many of our members. We encourage all members to submit for future editions. Topics include but are not limited to educational, community focus, interesting cases, resident and student section, and adventures abroad. Catch up on issues and submit an article at: www.aaem.org/get-involved/sections/eus/newsletter

Learn more about EUS-AAEM and join the section at www.aaem.org/eus

42

COMMON SENSE SEPTEMBER/OCTOBER 2020

ACT NOW!

Exclusive 15% Off Discount Code: AAEM15 • Over 1,100 CME lectures • Monthly EMCast with Amal Mattu, MD • Online or offline

Taking an LLSA or COLA Exam This Year?

Sign Up For the EMedHome LLSA or COLA Articles CME Program

COMMON SENSE SEPTEMBER/OCTOBER 2020

43

SECTION REPORT YOUNG PHYSICIANS

2020 Graduates: You Don’t Have to Go it Alone After Residency!

Cara Kanter, MD FAAEM – YPS Chair and Edward Descallar, MD FAAEM – YPS Vice-Chair

Greetings and welcome to the Young Physicians Section! Every academic year brings exciting changes and this year we have many new faces on our YPS Council! We are thrilled to lead this section and hope to build upon the previous council’s accomplishments.

YPS is a champion of the young emergency physician with a goal of providing support specifically for those physicians who are experiencing the exciting, but often challenging transition from resident to full-fledged attending. These truly are unprecedented times and becoming a new attending in the middle of a pandemic is not necessarily what you may have imagined. This phase in your career brings many new challenges and responsibilities. In addition to finally finishing your medical training, you may be moving across the country, or considering starting a family or buying your first home. Where do you begin? We urge you to begin here, with us.

At this moment, the landscape of emergency medicine is rocky, and the Young Physicians Section is here to help you navigate it. One particular challenge as a new attending is losing the inherent support system built into residency. That loss is felt most acutely as we step into new roles often in unfamiliar environments. We aim to provide a community for young physicians that fosters wellness and self-care, in addition to preparing you for the new clinical roles you are stepping in to. All AAEM members are eligible for free YPS membership in their first five years after residency or fellowship. YPS member benefits include:

Board Prep: EM Flash Facts App Board certification is a central aspect of AAEM’s mission. As a newly-minted, fully-trained emergency physician, the board certification process will be an early hurdle in your career. The EM Flash Facts App – created and updated every three years by the YPS Council – is a great supplemental resource in your preparation for the American Board of Emergency Medicine qualifying exam. The app can be downloaded onto your smartphone or tablet and offers quick, high-yield facts to help you prepare for the written exam. Great for on-the-go learning!

CV and Cover Letter Review Take advantage of the free CV and cover letter review service available to all YPS members.

Submit your CV and cover letter through the YPS webpage and it will be reviewed by a YPS Council member and returned to you with edits and comments within two weeks. Indicate your career interests – community, academic, or rural medicine, subspecialty fellowship training, etc.

– and it will be reviewed by someone with a similar career background to insure that your CV is optimized for your desired career!

Mentoring Program The transition from resident to attending involves losing the mentorship and community that residency programs provide. Your geography, hospital system, and practice environment may change drastically with your new job. Apply for an AAEM mentor directly through the YPS webpage.

44

COMMON SENSE SEPTEMBER/OCTOBER 2020

We aim to provide a community for young physicians that fosters wellness and self-care, in addition to preparing you for the new clinical roles you are stepping in to.

Mentors are paired by geography, practice environment and career interests to insure that mentor and mentee share similar interests, experiences and career paths.

Professional Development YPS membership offers additional exclusive opportunities for authorship and networking. Always a strong presence at Scientific Assembly, YPS sponsors both the Open Mic Competition and the YPS Poster Competition on an annual basis. The Open Mic Competition allows 16 new voices the unique opportunity to speak at a national meeting, and the top two speakers are invited to give a formal presentation at the following year’s Scientific Assembly.

The YPS Poster Competition encourages

>>

We want to know the incredible work you are doing to advance our specialty so we can devote our resources to helping you achieve your goals.

SECTON REPORT EMERGENCY ULTRASOUND

members to submit abstracts for original research. The top four abstracts are selected for oral presentation with an honorarium awarded to the top three presenters. Additionally, YPS members are encouraged to submit articles for publication in Common Sense at any time throughout the year. A list of topic ideas can be found on the YPS webpage. These are great ways to continue to build your CV after residency!

Risk Management Monthly YPS members have FREE access to Risk Management Monthly, a monthly podcast hosted by Drs. Greg Henry and Rick Bukata that discusses closed claims and offers advice on risk reduction in emergency medicine. From common clinical mistakes to safe charting practices, this podcast will help you guarantee a long and fulfilling career in a litigious specialty.

AAEM

Rules of the Road for Young Emergency Physicians eBook

The Young Physicians Section only thrives when our members do. We highly encourage you to become involved and join one (or more!) of the YPS Work Groups: Education, Membership, Social Media, and Advocacy. We will be your platform for your ideas and your voice. We want to know the incredible work you are doing to advance our specialty so we can devote our resources to helping you achieve your goals. Please reach out to us with your ideas and let us know how we can better support our members. Follow us on Twitter @AAEMYPS and give us a shout out. 

Finally, all YPS members are provided free access to the Rules of the Road for Young Emergency Physicians eBook. Learn about physician finance and the darker side of modern medicine that may not have been addressed during residency. With contributions from giants in our field, this is an essential resource for the newly minted EM attending! Topics covered includefee splitting and profiteering,the restrictive covenant,and the corporate practice of emergency medicine.

The multimedia eBook can be conveniently accessed from your smartphone, tablet, or computer.

FREE

Young Physicians Section (YPS)

GET PUBLISHED IN COMMON SENSE

MENTORING PROGRAM

EM FLASH FACTS APP

NETWORKING

RULES OF THE ROAD FOR YOUNG EMERGENCY PHYSICIANS

eBOOK

CV REVIEW SERVICE

Personalized resources for your first 5 years out of residency!

WWW.YPSAAEM.ORG

INFO@YPSAAEM.ORG COMMON SENSE SEPTEMBER/OCTOBER 2020

45

SECTION REPORT YOUNG PHYSICIANS

Resiliency in Medicine Reed Wise, MS and Danielle Goodrich, MD FAAEM

With the largest ever wave of older patients due to the aging of the baby boomer generation, rising health care costs, and currently, a pandemic stressing the health care system and those who work within it, it is all the more important that health care promotes skills and attitudes that give our physicians the ability to thrive in the face of adversity. Faced with an ever-changing medical landscape, increasing responsibilities, and often daunting hours, students, residents, and practicing physicians alike will succeed in their careers and provide better care if they develop the ability to spring back from hardship. Now, more than ever, physicians must demonstrate resiliency. Every effort should be made to provide the resources and tools that will allow physicians to thrive, which will ultimately benefit our patients and their care.

Resilience is defined as the “ability to persevere through hardships to meet goals,”1 and health care professionals who advance through their medical education and practice by fostering resilience as a strong facet of their character are better equipped to deal with some of the most difficult aspects of medicine.

In their 2018, Review of Grit and Resilience within Health Professions for the American Journal of Pharmaceutical Education, Stoffel and Cain discuss the correlation between well-being and these qualities. Resilience is a predictor for well-being2 and grit is a predictor for academic success independent of IQ.3 These findings showcase how important it is to value these qualities in our health professionals where providers are often dealing with life and death situations. It is clear that our health care providers are the most successful and effective when they are happy and do not manifest the signs of burnout. This sentiment has shown in

46

COMMON SENSE SEPTEMBER/OCTOBER 2020

various studies including one at the University of Michigan in which a program that actively promotes wellbeing and a supportive work environment resulted in vascular surgeons who were “competent, compassionate and committed.”4 Resiliency is crucial for medical students, residents, and physicians alike because resilience helps to equip health care professions in dealing with grief. Though grief has proven an elusive topic to study and understand, in some ways it runs counter to resilience in that grief perpetuates the anguish and pain that comes from loss or hardship. Grief is a normal part of health care as physicians and medical students often develop strong relationships with their patients who decompensate or die, through no fault of the patient or health care team.5 While pain and empathy are normal responses to such events, students and physicians who do not have the support or the resources to work through these difficult aspects of medicine may be met with compassion fatigue, burnout, and chronic stress.

At the heart of this discussion of building resiliency, to be better prepared to respond to hardship and better deal with grief, has to be a focus on self-care. Often self-care is overlooked because the nature of the medical education system rewards the de-emphasis of it; medical students and residents, neglect self-care in order to pursue short-term gains. Behavioral patterns are reinforced from as early on as high school, which is only the tip of the iceberg of the competitive world of premedical education.

By the time students reach medical school these patterns begin to shine through to the students’ detriment. Full nights of sleep are traded for brief naps between study sessions, exercise is skipped in favor of writing a paper, and healthy food is traded for instant microwaveable meals. This system in which we learn is built on hyper-competitiveness to ensure that the best of the best are the only ones admitted to actually train to become physicians which results in a system that produces students who

are willing to sacrifice large segments of their lives to continue. This system is in dire need of an overhaul.

Fortunately, there are measures that can be taken to help instill resiliency and promote selfcare at all levels of our health care system.

First, grief must be destigmatized. It is a state common to all of humankind, and in order to be properly addressed, physicians need additional training for coping with potential losses and sudden adversity. Emotional validation must be stressed so that grief can be acknowl-

NOW, MORE THAN EVER, PHYSICIANS MUST DEMONSTRATE RESILIENCY. edged and supported before taking the first step towards getting back up for the next fight.

Furthermore, adequate time off is critical so that there is time to process emotion, deal with the stressors of the job, and provide time for self-care. Other potential complementary solutions include a wellness system where physicians and students are automatically signed up for wellness benefits like gym memberships, mindfulness classes, wellness training, and counseling. Programs like these should be standard at hospitals, clinics, and medical

>>

SECTON REPORT YOUNG PHYSICIANS

schools, and each program should be “opt-out” in order to remove any stigma surrounding emotional wellbeing support.

Moreover, grit and resilience are not just qualities that should be sought after in applicants to the health care field, but more importantly, they should be taught in our schools and training programs and fostered in our existing professionals through hospital sponsored wellness programs to promote self-care, curriculum updates that teach innovative coping mechanisms and positive emotional health, and finally through destigmatizing the need for all health care workers to prioritize their personal wellbeing. Many of these interventions are simple and can be easily incorporated into a busy work schedule or lecture, such as taking a few minutes a day for reflection. In the “Three Good Things” intervention, study participants were asked to detail three good things in their lives.

In the study, this simple exercise was shown to be associated with positive emotions that promote positive wellbeing and ultimately foster

Resiliency is crucial for medical students, residents, and physicians alike because resilience helps to equip health care professions in dealing with grief. resilience.6 These are just some interventions that can be taken so that we can better support our colleagues, to better support the patients that we care for each and every day.

It is important to emphasize self-care and wellness in medical schools and hospitals and promote a culture that fosters resilience in our students and physicians. 

References: 1. Stoffel, J. M., & Cain, J. (2018). Review of Grit and Resilience Literature within Health Professions Education. American Journal of Pharmaceutical Education, 82(2), 6150. doi: 10.5688/ajpe6150 2. Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013;88(3):301-303.

3. Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: perseverance and passion for long-term goals. J Pers Soc Psychol.

2007;92(6):1087-1011.

4. Audu, C. O., & Coleman, D. M. (2019).

Prioritizing personal well-being during vascular surgery training. Seminars in Vascular Surgery, 32(1-2), 23–26. doi: 10.1053/j. semvascsurg.2019.01.003 5. Shute, 2019 https://www.physicianspractice. com/article/coping-grief-how-physicians-canheal-after-patient-deaths 6. Rippstein-Leuenberger, K., Mauthner, O., Sexton, J. B., & Schwendimann, R. (2017). A qualitative analysis of the Three Good Things intervention in healthcare workers. BMJ Open, 7(5). doi: 10.1136/bmjopen-2017-015826

AAEM/RSA Podcasts – Subscribe Today!

TOPICS INCLUDE:

Featured podcasts: K is for Komfort: Ketamine for Pain Patient Callbacks Experiences for Women of Color in the Emergency Department Choose Compassion: How We Can Provide Better Care For Our Most Vulnerable Patients Easing the Transition to Attending This podcast series presents emergency medicine leaders speaking with residents and students to share their knowledge on a variety of topics.

Don’t miss an episode - subscribe today!

Ultrasound in the Emergency Department Navigating Your Career Path Post-Residency Crowding in Emergency Departments Myths, Bias, and Lies My Medical School Taught Me

COMMON SENSE SEPTEMBER/OCTOBER 2020

47

AAEM/RSA PRESIDENT’S MESSAGE

What’s Going on with the Emergency Medicine Job Market?

Haig Aintablian, MD, AAEM/RSA President

Over the last few months, the chaos of COVID-19 has manifested in what is sure to become one of the broadest and largest employment destabilizations in history. Every sector in the economy has been affected by the brunt of this virus and its shutdown of the economy. At the onset of the pandemic though, it seemed like being an emergency physician would have been the most stable source of professional security imaginable. Very quickly though, in the depths of the initial pandemic, as patients avoided the ED due to fear of getting this illness, hospital beds lay empty.

Soon we began to see reports of EM physician shift reductions, pay rate cuts, benefits cancellations, and terminations. Many new graduates had their contracts rescinded and their backup options starting to disappear.

The workforce, it seemed, was more fragile than expected.

We must take steps to secure our specialty, especially from creeping interests from midlevels and corporate medicine.

COVID isn’t the only factor that has exposed the fragile marketplace of the EM physician workforce. Mark Reiter et al studied the workforce and published their results recently in the April edition of JEM. In this paper, Reiter et al conservatively calculated the “demand for emergency clinicians to grow by ∼1.8% per year.” The caveat being, “the actual demand for EPs will likely be lower, considering the higher growth rates seen by APPs, likely offsetting the need for increasing numbers of EPs.” Ultimately, Reiter et al summarize the following: “We estimate the overall supply of board-certified or board-eligible EPs to increase by at least 4% in the near-term, which includes losses due to attrition. In light of this, we conservatively estimate the supply of boardcertified or eligible EPs should exceed demand by at least 2.2% per year.

In the intermediate term, it is possible that the supply of board-certified or eligible EPs could exceed demand by 3% or more per year. Using 2.2% growth, we estimate that the number of board-certified or boardeligible EPs should meet the anticipated demand for EPs as early as the start of 2021. Furthermore, extrapolating current trends, we anticipate the EP workforce could be 20–30% oversupplied by 2030.”

The data from Reiter et al, appears to be the most recent set of calculations prior to the COVID-19 pandemic – painting a picture of a marketplace already beginning to saturate. Seeing the effects of COVID now, I think there a few factors to consider, some of which may be good news for the marketplace, and some which may hinder it further.

48

COMMON SENSE SEPTEMBER/OCTOBER 2020

The workforce, it seemed, was more fragile than expected.

Patient Numbers The fear from COVID-19, especially earlier on in the pandemic, led to a transient decrease in patient numbers and ultimately a decrease in the number of ED volumes. However, as we’re beginning to see now with the rise of COVID cases, ED volumes are starting to trend back to normal, if not beginning to exceed prior averages. If the volume of patients increases consistently and EDs and ICUs become more saturated with sick COVID patients, the demand for emergency and intensive care may increase. Given modern medicine and our advances in vaccine production and antiviral therapies, this may only be transient over the course of months to years. However, should COVID be like the flu – constantly mutating and increasingly difficult to vaccinate against, we may not see this as a transient issue, and instead find it as the new norm. In this case, the demand of acute care services will likely increase and the marketplace expand.

Residency Overproduction Emergency medicine residency program expansions by contract management groups have been an increasingly concerning issue for our specialty. While federal funding for new residency slots has had minimal growth, emergency medicine residency programs have continued to increase at an unmatched pace compared to any other specialty, likely via funding efforts from contract management groups. In 2009, there were around 1,500 EM residency spots, while today that number exceeds 2,600. The replacement of non-EM trained physicians staffing EDs with those trained in the specialty may be a significant buffer for this large expansion of EM trained graduates, but what happens once that buffer begins to shrink and essentially all EDs are staffed with EM-trained physicians? There will come a point where supply meets demand, after which the oversupply of EM physicians will lead to more difficult employment opportunities and likely decreasing salaries.

AAEM/RSA PRESIDENT’S MESSAGE

Midlevel Scope Encroachment The significant push for independent practice by lobbying organizations representing NPs and PAs as well as the corporate takeover of medicine, particularly that of emergency medicine, has led to a significant advocacy battle for emergency physicians. Not only are these two components dangerous for patient safety, they are likely detrimental to the future marketplace, especially as these CMGs decrease physician coverage in lieu of increased midlevel coverage, which is much cheaper. Should this trend continue, we may see EDs that historically had dual attending coverage switch to a model of one attending with 1-2 midlevels, ultimately decreasing the demand for EM physicians in exchange for higher profits.

Thankfully, it appears that legislators, lawyers, and patients are starting

COVID isn’t the only factor that has exposed the fragile marketplace of the EM physician workforce.

to notice the patient safety problem with the concept of independent practice of midlevels, with multiple states denying this action, several significant malpractice settlements being reported against midlevels this year, and many proposed pieces of legislation failing to pass in our capitols.

Ultimately, like all job markets, ours will be waxing and waning. As emergency physicians we are trained to deal with multiple pathologies and can staff a variety of patient care settings. Should demand decrease or supply increase to a degree that our physician marketplace be saturated, we can in theory practice primary care or work in urgent care settings.

Obviously though, this shouldn’t be our goal, nor should it be a comfortable backup. We must take steps to secure our specialty, especially from creeping interests from midlevels and corporate medicine. Training to treat an emergent undifferentiated pathology requires years of dedication and skill, and our training should give us some element of job security.

Whether you plan on going into fellowship or joining the community, we should feel comfortable knowing we’ll find a good job in a good emergency department after all of this time and effort training in emergency medicine. 

AAEM/RSA Medical Student Symposia Northeast Medical Student Symposium

Now

Virtual

*Members Only*

September 12, 2020

You must be a member of AAEM/RSA to attend. Paid members of AAEM/RSA will receive a free gift (face mask and paper copy of Medical Student Rules of the Road) with registration.

Midwest Medical Student Symposium

Not a member or need to upgrade from your Student Free membership? Join or renew at www.aaemrsa.org/membership

New York, NY

September 19, 2020

Chicago, IL

Southeast Medical Student Symposium October 3, 2020

New Orleans, LA

Learn more at: www.aaemrsa.org/events/symposia

COMMON SENSE SEPTEMBER/OCTOBER 2020

49

AAEM/RSA EDITOR’S MESSAGE

“Zooming” into a New Era of Clinical Education Alexandria Gregory, MD

If your residency is like most programs, your pre-COVID didactics likely consisted of several hours of in-person conference once a week. That common, traditional way of learning has been turned upside down with the need for social distancing, and most programs have transitioned to virtual conferences. As the reality of COVID persists, it is important to continuously evaluate the effectiveness of virtual learning. Furthermore, in planning for a post-COVID era, it will be beneficial to determine whether virtual learning remains a valid, effective teaching technique despite being able to meet in-person.

Not everyone has access to the internet or computers, and even those that do may have difficulty learning new systems.

To understand how virtual learning affects curriculum design, it is important to start by breaking down what, in general, emergency medicine residency curriculum looks like. Most programs include the following in some fashion: Core Topics Small-Group Sessions/Problem-Based learning Electrocardiogram (EKG)/Radiology Interpretation Morbidity and Mortality/Case Presentations Journal Club Ultrasound Grand Rounds Simulation/Procedure Lab Oral Board Review Asynchronous Learning With a few exceptions, the majority of these can easily be done virtually.

Core topics and grand rounds can be covered with slide-sharing. EKG and radiology interpretation can also be done with slide-sharing and

participation from the audience using the chat or audio functions. Smallgroup/problem-based learning sessions, and even oral board review, can be done using Zoom’s “breakout rooms” feature. Asynchronous learning, of course, remains unaffected. Simulation and procedure labs present the biggest challenge.

Of course, just because something can be done does not mean it should be done. Certainly, there are downsides of virtual learning. One of the underrated features of weekly in-person conference is the social interaction. Lectures are a time for residents to come together and interact informally outside of their shifts, which is especially true if lecture begins with breakfast or ends with lunch. Post-lecture Zoom hangouts, which some programs have tried, will never have quite the same effect. On a more practical level, accessibility, or lack thereof, poses a huge issue for virtual learning in general. Not everyone has access to the internet or computers, and even those that do may have difficulty learning new systems.

During lecture itself, participation may not come as easily as it would during an in-person lecture. It can be an added challenge for lecturers to sit in a room and talk, seemingly to themselves, without real-time feedback from the audience. However, it can be argued that in-person lectures do not necessarily mean automatic audience participation and pose similar issues, and that in fact, use of the chat function actually allows for more discussion than would be possible in person because there is no need to interrupt the lecturer while participants add their thoughts and questions. Lastly, virtual lectures do not offer a suitable substitute for hands-on learning that is crucial for procedures and sim lab.

At the same time, however, virtual lectures do offer things that in-person lectures do not. First, they allow residents time to get things done—such as cooking, cleaning, and laundry—while also participating in lecture.

Especially for residents with busy schedules, that extra time is crucial and much-appreciated. Similarly, lecturers and residents alike can be more easily available for the scheduled time when they do not have to factor in things like transportation time or childcare, which may actually encourage more participation in lectures overall. For those who still cannot make it to lecture, Zoom lectures are easier to record than in-person ones for those wishing to watch later.

Another significant advantage of virtual lectures is the ability to connect residents across the country through national live lectures. Academic Life in Emergency Medicine (ALiEM) Connect, a multiple-part live conference brought residents together nationwide from over sixty programs to learn from

>>

One of the underrated features of weekly in-person conference is the social interaction.

50

COMMON SENSE SEPTEMBER/OCTOBER 2020

AAEM/RSA EDITOR’S MESSAGE

While there are certainly drawbacks to virtual learning, it is worth considering as an increasingly valid teaching technique, even when in-person lectures are again possible. various experts in the field, such as Michelle Lin and Salim Rezaie. The series has been able to offer concise, focused talks that also foster group discussion through the use of Slack channels. Similarly, it is much easier to get experts to give lectures to a given program when they can do so from their own home or institution, rather than having to travel.

While there are certainly drawbacks to virtual learning, it is worth considering as an increasingly valid teaching technique, even when in-person lectures are again possible. The best scenario may be a hybrid model.

For instance, in-person lectures could be replaced by virtual ones once a month, allowing residents a day to learn “conveniently” from home, while also recognizing the value of in-person lectures for activities such as sim lab and other interactive sessions. Regardless of the way lectures are presented, quality education relies on the both the learner and educator to be invested. Ultimately, we are being forced to re-examine the way we teach and the way we learn to foster that investment, which makes this time a pivotal moment in medical education. 

AAEM POSITION STATEMENTS

AAEM COVID-19 RESPONSE

AAEM COVID-19 Resources Page In addition to the above statements, AAEM recognizes the need for resources and supplies, and it is our intent to assist in any way we can. We hope that the following list of resources can assist you in your work. You know better than others that this is a fluid situation, changing every few hours. We will attempt to continue to update our resources both here and on social media as the situation changes.

• AAEM Statement on the Death of Dr. Breen (5/1/2020) • AAEM Position Statement on Interruptions in the Emergency Department (4/19/2020) • AAEM Position Statement on the Firing of Dr. Ming Lin by TeamHealth and PeaceHealth St. Joseph Medical Center (3/28/2020) • AAEM Position Statement on Ensuring that Frontline Personnel Can Provide for their Families (3/23/2020) • AAEM Position Statement Advocating for Immunity From Malpractice Litigation During the COVID-19 Pandemic (3/23/2020) • AAEM Position Statement on Use of SelfSupplied PPE (3/23/2020) • AAEM Position Statement on Protections for Emergency Medicine Physicians during COVID19 (3/20/2020) To read each statement, visit: www.aaem.org/ resources/statements/position

JOINT STATEMENTS • Joint Statement on Excuses from Mask Compliance (7/28/2020) • Consensus Statement on the 2020-2021 Residency Application Process for US Medical Students Planning Careers in Emergency Medicine in the Main Residency Match (5/27/2020) • COMMB Joint Policy Statement on Pediatric Care in the Emergency Department (5/4/2020) • AAEM Statement on the Death of Dr. Breen (5/1/2020)

• AAEM-ACEP Joint Statement on Physician Misinformation (4/27/2020) • AAEM Signs on to Joint Letter to Congress Urging further Protections for Healthcare Workers during COVID-19 (4/15/2020) • AAEM Signs on to Joint Letter to HHS: Emergency Funding for Physicians through the CARES Act (PDF) (4/7/2020) • Solidarity of Purpose to Confront COVID-19 (PDF) (3/23/2020) To read each statement, visit: www.aaem.org/ resources/statements/joint-endorsed

LETTERS SENT • Joint Letter to Congress regarding Surprise Medical Billing in COVID-19 Relief Package (7/29/2020) • Joint Letter to CMS to Sunset Waivers When PHE Concludes (7/22/2020) • Joint Letter to Veterans Health Administration on CRNA Oversight (6/24/2020) • Joint Letter Urging Congress to Extend Eligibility for the PPP Loan Program (6/17/2020) • Joint Letter Encouraging the Passage of the Mainstreaming Addiction Treatment Act (6/1/2020) AAEM Signs on to AMA Letter: Coronavirus Provider Protection Act (6/9/2020) • Letter to All 50 Governors Calling for Immunity from Malpractice during COVID-19 • Letter to President Donald J. Trump Calling for Immunity from Malpractice during COVID-19 • Letter to Congress for Further Financial Support during COVID-19 To read each letter, visit: www.aaem.org/current-news

Access AAEM’s COVID-19 Resources webpage: www.aaem.org/current-news/covid-19-resources

COMMON SENSE SEPTEMBER/OCTOBER 2020

51

AAEM/RSA RESIDENT JOURNAL REVIEW

Do Adjunctive Therapies Beyond Infection Control and Appropriate Fluid Resuscitation Change Outcomes in Sepsis and Septic Shock?

Jordan Parker MD; Sharleen Yuan, MA MD PhD; Megan Donohue, MD; Robert Brown, MD; Mark Sutherland, MD; Hannah Goldberg, MD; Akilesh Honasoge, MD Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM

Introduction Septic shock is an illness with complex pathophysiology and few available therapies, beyond infection control and appropriate fluid resuscitation, to reverse the disease state. It is one of the most prevalent and lethal disease states that a physician may manage, with 1.7 million cases of sepsis in the United States per year and a reported mortality rate of up to 34%.1,2 The pathogenesis of septic shock is thought to be driven by a dysregulated host response3 with the role of adjunctive therapies being to assist in reversing this dysregulated response. Treatments that have more recently been a hot topic of debate include vitamin C, corticosteroids and thiamine. Vitamin C (ascorbic acid) a role in numerous physiologic processes including endothelial permeability, micro and macrovascular function, cellular apoptosis, immune system function and endogenous catecholamines.4 Studies have shown that vitamin C deficiency is present in critically ill patients,4 and its role in these essential functions is the basis for its use as a potential treatment in septic shock.

Thiamine also plays a role in key metabolic processes, including cellular energy production and generation of cellular antioxidants, and thiamine deficiency has been well-documented in sepsis, with observational studies indicating a signal for improved outcomes with supplementation.4 Steroids have been used in refractory septic shock for almost the past two decades5 but the recent rationale for its use includes its synergism with vitamin C. Glucocorticoids may be able to increase the activity of vitamin C by increasing expression of the transporter involved in its uptake into cells, sodium-vitamin C transporter (SVCT2).4 In return, vitamin C, as an antioxidant, may be able to facilitate the binding of glucocorticoids to their receptor, a coupling impeded by oxidizing molecules. We will review several of the high-profile trials that have attempted to elucidate the effectiveness of utilizing corticosteroids, vitamin C, and thiamine in the management of patients with sepsis and septic shock.

Questions Does the treatment of sepsis with a combination of vitamin C, thiamine, and hydrocortisone improve outcomes in septic shock?

Should steroids be used in patients with septic shock?

Marik P, Khangoora V, Rivera R, et al. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study.

Chest. 2017;151(6):1229-38.

This retrospective before-and-after study was conducted at a singlecenter tertiary care referral hospital in the U.S.All patients >18 years of

52

COMMON SENSE SEPTEMBER/OCTOBER 2020

age with primary diagnosis of severe sepsis or septic shock and procalcitonin >2 ng/mlwere enrolled. Patients were excluded if pregnant or had limitations of care. The treatment group received hydrocortisone 50mg every 6 hours for 7 days, IV vitamin C 1.5g every 6 hours for 4 days, and IV thiamine 200 mg every 12 hours for 4 days. All treatments were given for the assigned time frame or until ICU discharge, whichever came first.

In the control group, patients treated for severe sepsis or septic shock in the year prior to the initiation of triple therapy, hydrocortisone was used at the discretion of the intensive care unit (ICU) attending. All patients otherwise received standard treatment including broad-spectrum antibiotics, conservative fluid and vasopressor strategies, lung-protective ventilation, and appropriate prophylaxis.The primary outcome was hospital survival.

Secondary outcomes included duration of vasopressor therapy, requirement for renal replacement therapy, ICU length of stay, and change in serum procalcitonin and sequential organ failure assessment (SOFA) score.

A total of 47 patients were enrolled in each arm of the study. No significant differences in baseline characteristics were reported between the two groups, though it is worth noting that p-values are not presented to support this conclusion. Hospital mortality in the treatment group was 8.5% compared to 40.4% in control group (p<0.001). Discriminant logistic analysis identified three independent predictors of mortality: APACHE IV score, need for mechanical ventilation and the vitamin C protocol (p<0.001). Three secondary outcomes were also statistically significant: duration of vasopressor therapy (18.3 h vs 54.9 h in the treatment vs control group, respectively, p<0.001), procalcitonin clearance (6.4% vs 33.9%, p<0.001), and change in SOFA score (4.8 versus 0.9, p<0.001).

These findings are impressive but exceed expected improvement and should be interpreted cautiously. Marik et al. appropriately acknowledge several major limitations to this study, including small sample size, singlecenter design and non-concurrent enrollment of control and treatment groups. For these reasons, it is imperative the results of this study are reproducible in a large randomized controlled trial before HAT (hydrocortisone, ascorbic acid, thiamine) therapy is accepted as standard treatment.

Fowler AA 3rd, Truwit JD, Hite RD, et al. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients with Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322(13):1261-1270. [published correction appears in JAMA. 2020 Jan 28;323(4):379].

>>

AAEM/RSA RESIDENT JOURNAL REVIEW

The CITRIS-ALI Trial was a randomized, placebo-controlled, doubleblinded study that was conducted in seven medical ICUs. Patients were included if they required mechanical ventilation, met criteria for acute respiratory distress syndrome (ARDS), and had a suspected or proven infection with two of four sepsis inflammatory response syndrome (SIRS) criteria, all with a 24-hour period. A total number of 167 patients were enrolled, the 84 in the treatment arm receiving 50 mg/kg of vitamin C in 5% dextrose in water (D5W) every 6 hours for 96 hours, and the 83 in the placebo arm receiving only 5% D5W every 6 hours for 96 hours.

While the trial was negative for its primary endpoints â&#x20AC;&#x201C; a change in the modified SOFA (Sequential Organ Failure Assessment) score at 96 hours, and improvement in CRP or thrombomodulin levels within 168 hours â&#x20AC;&#x201C; there were some secondary endpoints that reached significance.

There was a reduction in 28-day mortality from 46.3% to 29.8% (p = 0.03) in the vitamin C group, an increase in ICU-free days from 7.7 to 10.7 (p = .03), and an increase in transfer out of the ICU by hour 168 from 12.5% to 25% of patients (p = .03).

Although the mortality and ICU length of stay benefits may seem compelling, there are several issues that may potentially limit the validity of the results. A large portion of screened patients (86.5%) were excluded, and the resulting sample size was perhaps too small to detect differences in primary outcomes. Reconciling a lack of difference in mSOFA scores with an improvement in mortality may be feasible if one considers survivorship bias: the sicker mSOFA scores died with the patients who did not survive. Quite appropriately, the authors point out that 46 secondary endpoints were evaluated, and a correction for multiple comparisons was not conducted, and acknowledge that these secondary results should be viewed as exploratory.

As with many bleeding-edge therapies, how practitioners view this trial will likely depend on their pre-existing beliefs. Proponents will likely point to the positive secondary outcomes of CITRIS-ALI as evidence that vitamin C improves outcomes or fall back on the argument that vitamin C is more effective when administered early in the course of sepsis, rather than after the patient has developed full-blown ARDS. On the other hand, nonbelievers are likely to point out that this was a negative trial, and it is certainly difficult to support the administration of vitamin C in septic ARDS based on this paper.

Fujii T, Luethi N, Young P, et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock. JAMA. 2020;323(5):423-431.

This was a prospective, open-label, randomized controlled trial taking place across 10 ICUs in Australia, New Zealand, and Brazil. Patients were adults with presumed or confirmed infection, increase in SOFA score of at least 2 points, lactate > 2 mmol/L, and vasopressor requirement > 2 hours, enrolled within 24 hours of septic shock diagnosis. The intervention arm received 1.5g of IV ascorbate every 6 hours, 50mg IV hydrocortisone every 6 hours, and 200mg IV thiamine every 12 hours.

The control arm received 50mg IV hydrocortisone every 6 hours and thiamine at the discretion of the intensivist. Treatment continued for 10 days or until the subjects maintained a MAP 65 mmHg or greater for 4 hours without the need for vasopressors.

The primary outcome was the cumulative time alive and free of vasopressors (for at least four hours) at day 7 after randomization.

Predetermined secondary outcomes were mortality at 28 and 90 days, ICU and hospital mortality, 28-day cumulative vasopressor-free days, 28-day cumulative ventilator-free days, 28-day renal replacement therapy-free days, 28-day ICU-free days, hospital length of stay, and change in the SOFA score by day 3.

A total of 211 patients were included in the study: 107 in the intervention arm and 104 in the control arm. The intervention arm had lower baseline APACHE III scores but similar comorbidities, rates of mechanical ventilation and renal replacement therapy, and causes of sepsis. There was no significant difference in the primary outcome between groups (p = 0.83).

There were no significant differences in the secondary outcomes between the groups with the exception of improved SOFA score at 3 days in the intervention arm (p = 0.02) a finding which must be interpreted with caution given it was applied only to patients who were in the ICU on day 3, removing from question both those who improved and left the unit and those who died within 3 days.

Though open label, the introduction of systematic performance bias may be less likely given the scale of the study, with more than 100 attending physician and intensive care fellows. The goal and achieved mean arterial pressures (MAPs) were not provided; these could affect vasopressor use. All patients received antibiotics prior to enrollment, but the time to initial antibiotic was not recorded.

Keh D, Trips E, Marx G, et al. Effect of hydrocortisone on development of shock among patients with severe sepsis: the HYPRESS randomized clinical trial. JAMA. 2016:316(17);1775-85.

The HYPRESS trial was a multicenter, placebo-controlled, double-blinded study examining the utility of hydrocortisone in preventing progression to septic shock. It included adult patients in ICUs, intermediate care units (IMCs), and community hospitals who had evidence of infection, at least 2 SIRS criteria and evidence of organ dysfunction present for < 48 hours. Exclusion criteria included septic shock (hypotension greater than 4 hours despite adequate fluid resuscitation), hydrocortisone or mannitol hypersensitivity, and history of glucocorticoid use with need for continuation of therapy. The treatment group received hydrocortisone as a dose of 50mg followed by a 24-hour infusion of 200mg for 5 days that was then tapered to 100mg on days 6 and 7, 50mg on days 8 and 9, and 25mg on days 10 and 11. The placebo group was given mannitol instead.

The primary end point was the occurrence of septic shock within 14 days. Secondary end points included time to septic shock development, death, ICU and hospital mortality, vital status at days 28, 90, and 180, ICU and hospital LOS, SOFA score, duration of mechanical ventilation,

>> COMMON SENSE SEPTEMBER/OCTOBER 2020

53

AAEM/RSA RESIDENT JOURNAL REVIEW

renal replacement therapy requirement, and various prespecified adverse events.

A total of 380 patients were randomized, 190 to each group. There was no difference between groups in the primary outcome, and there were no significant differences in any of the secondary end points except more hyperglycemia (9.4% difference, p= 0.009) and less delirium (13.3% difference, p=0.01) in the hydrocortisone group.

Limitations include possibly missing patients who quickly developed septic shock and were therefore excluded, and the possibility that hydrocortisone may be more effective in patients who are more severely ill. The major limitation, however, is that the study population’s lowerthan-anticipated incidence of septic shock (23% vs the expected 40%) resulted in an underpowering of the trial and inconclusive results.

Venkatesh B, Finfer S, Cohen J, et al. Adjunctive glucocorticoid therapy in patients with septic shock. New Engl J Med. 2018;378(9):797-808.

The ADRENAL Trial was an investigator-initiated, international, pragmatic, double-blind, parallel-group, randomized, controlled trial that compared IV infusions of hydrocortisone with matched placebo in adult patients with septic shock on vasopressors who were undergoing mechanical ventilation in an ICU. Patients in the experimental arm of the study were given an intravenous infusion of hydrocortisone at a fixed dose of 200 mg per day. Both experimental and control groups were well matched with respect to age, sex, site of infection, and type of ICU. The primary outcome of the study was all-cause mortality at 90 days.

Secondary outcomes included 28-day mortality, time to shock resolution, ICU and hospital length of stay (LOS), mechanical ventilation and renal replacement therapy requirement and duration, incidence of subsequent bacteremia/fungemia, and blood transfusion requirement.

A total of 3,658 patients were enrolled: 1,832 patients randomized to the hydrocortisone group and 1,826 to the control group. At 90 days, there was no significant difference in mortality [27.9% vs 28.8%, (odds ratio, 0.95; 95% confidence interval [CI], 0.82 to 1.10; P=0.50)]. The treatment group had faster shock resolution [3 vs 4 days (hazard ratio [HR] 1.32, 95% CI 1.23-1.41)], more ventilator-free days [6 vs 7 days (HR 1.13, 95% CI 1.05-1.22, p<0.001)], and a shorter ICU LOS [(10 vs 12 days (HR 1.14, 95% CI 1.06-1.23, p<0.001)]. Also, fewer patients in the treatment group received a blood transfusion (37.0% vs. 41.7%; odds ratio, 0.82; 95% CI, 0.72 to 0.94; P=0.004), without a significant between-group difference in mean total volume of blood transfused when examining all patients who received transfusions. There were more adverse events (hyperglycemia, hypernatremia, encephalopathy, myopathy, etcetera) in the hydrocortisone group (1.1 vs 0.3%, p=0.009).

Investigators did not clarify if additional sepsis management was appropriate (i.e., correct antibiotics, appropriate fluid resuscitation), so the potential for confounding remains. They excluded patients who received etomidate, a medication that remains widely used for rapid sequence induction, which limits generalizability of the results, and did not assess for

54

COMMON SENSE SEPTEMBER/OCTOBER 2020

actual adrenal insufficiency. Finally, it remains unclear whether continuous infusion of hydrocortisone is less beneficial than bolus dosing due to slower drug delivery.

Ultimately, the ADRENAL Trial seems to indicate that infusions of hydrocortisone did not improve 90-day mortality in septic shock. It does support consistent findings of earlier shock resolution and ventilator weaning, and in general is unlikely that this paper will change independent physicians’ practice given its limitations, which could be argued for or against its validity.

Annane D, Renault A, Brun-Buisson C, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. New Engl J Med. 2018;378(9): 809-18.

The AProCCHSS trial (Activated Protein C and Corticosteroids for Human Septic Shock), so named because it was initially designed as a 2x2 factorial study investigating hydrocortisone plus fludrocortisone versus droctrecogin alfa versus placebo, was continued as a multicenter randomized controlled trial without droctrecogin after it was pulled from the market.

A total of 1,241 patients were enrolled from 34 different centers, with randomization occurring in a permuted block of eight patients. Major inclusion criteria included an indisputable or probable diagnosis of septic shock, a SOFA score of at least 3-4 in at least two different organs, and a vasopressor requirement for at least 6 hours at a dose of at least 0.25 micrograms per kg per minute (mcg/kg/min) of norepinephrine (or equivalent-dose alternative vasopressor). Major exclusion criteria included presence of septic shock for >24 hours since transfer to the ICU, a high risk of bleeding, pregnancy/lactation, or prior treatment with corticosteroids.

The treatment group received hydrocortisone 50 mg every 6 hours and fludrocortisone 50 mcg daily for 7 days without taper, while the placebo group received mannitol and microcrystalline cellulose. In addition, attempts were made to harmonize non-experimental interventions between centers including anti-infective treatments, hemodynamic and respiratory management, blood glucose control, and neuromuscular blockade use.

A steering committee also judged the adequacy of the anti-infective coverage which was found to be similarly adequate in both the treatment and placebo group (96.9% vs 96.2%).

Patient characteristics were similar between both intervention and placebo groups including an average age of 66 years and male predominance (65.5% vs 67.7%. The majority were admitted as an escalation from the medical wards with pulmonary and urinary infections being the most common. Norepinephrine was the most common vasopressor used. The primary outcome was 90-day all-cause mortality which was found to be significantly lower in the steroid group [43.0% vs 49.1%; RR (relative risk) 0.88 (95% CI 0.78 – 0.99, p=0.03)]. The steroid group also had a decrease in both death from any cause at ICU (35.4% vs 41.0%, p=0.04) and death by day 180 (46.6% vs 52.5%, p=0.04, with significantly more

>>

AAEM/RSA RESIDENT JOURNAL REVIEW

vasopressor-free days through day 28 (17 vs 15 days , p<0.001). With the exception of increased hyperglycemia incidence in the treatment group, rates of adverse events (serious bleeding, superinfections, neurologic sequelae) were similar.

The authors argue two significant differences between the steroid trials that have shown mortality benefit and those that did not: (1) the use of the mineralocorticoid fludrocortisone, which may have contributed to intravascular volume expansion, and (2) the requirement for at least 6 hours of vasopressor therapy, likely selecting for sicker patients who do not improve with the standard 6-hour Surviving Sepsis Campaign bundle of care. They argue that the inclusion and exclusion criteria for this study select for a sicker patient population with worse illness severity scores, which makes them an ideal group for adjunctive therapies. With the confidence interval for mortality reduction approaching 1.0, the benefit should be considered potential and needs replication in additional studies.

Discussion The Marik trial was certainly attention-grabbing and left many feeling hopeful that an effective therapy for septic shock with significant mortality benefit had been discovered, despite its various limitations. The CITRISALI trial showed no benefit in the non-patient-oriented primary outcome of reduction in SOFA scores, CRP or thrombomodulin. Its 28-day mortality benefit, as a secondary outcome in a study that did not adjust for multiple comparisons, can be nothing more than hypothesis-generating.

The VITAMINS trial showed no benefit to adding vitamin C and thiamine to the widely-used hydrocortisone. Ongoing studies including VICTAS (vitamin C, Thiamine, and Steroids in Sepsis),6 ACTS (Ascorbic acid, Corticosteroids, and Thiamine in Sepsis)7 and others will be needed before the universal use of vitamin C, thiamine and corticosteroids is implemented in patients with septic shock.

The controversy regarding the use of steroids has been ongoing for over a decade. Both Annane’s APROCCHSS trial and his trial in 2002 showed a mortality benefit to hydrocortisone and fludrocortisone,12 while the results of the ADRENAL trial mirror those of the CORTICUS trial: no difference in mortality with faster shock resolution.8 It is important to note that the APROCCHSS trial did have patients with higher overall mortality than the ADRENAL and CORTICUS trials, suggesting that the benefit from steroids may only be seen in the sickest of patients. What is most consistent is that several of these studies have demonstrated faster

shock resolution, ventilator weaning, and/or shortened ICU LOS, with slight increase in hypernatremia and hyperglycemia. While steroids for all septic patients does not seem supported, in a patient who is critically ill and not responding to antibiotics, appropriate fluids, and high-dose and/ or multiple vasopressors, it seems reasonable to add steroid therapy to ongoing life-saving efforts.

Answers Existing evidence does not clearly support improved clinical outcomes with the combination of vitamin C, thiamine, and hydrocortisone in septic shock.

For septic shock refractory to standard therapies, steroids hasten shock resolution and are probably worth initiating, but their effect on mortality remains unclear.  References 1. Rhee C, Dantes R, Epstein L, et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA. 2017;318(13):1241-9.

2. Hatfield K, Dantes R, Baggs J, et al. Assessing Variability in HospitalLevel Mortality Among U.S. Medicare Beneficiaries With Hospitalizations for Severe Sepsis and Septic Shock. Crit Care Med. 2018; 46(11):175360.

3. Angus D, van der Poll T. Severe Sepsis and Septic Shock. New Engl J Med. 2013;369(9):840-51.

4. Moskowitz A, Andersen L, Huang D, et al. Ascorbic acid, corticosteroids, and thiamine in sepsis: a review of the biologic rationale and the present state of clinical evaluation. Critical Care. 2018;22(1): 283.

5. Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288(7):862871.

6. Hager D, Hooper M, Bernard G, et al. The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) Protocol: A prospective, multi-center, doubleblind, adaptive sample size, randomized, placebo-controlled, clinical trial.

Trials. 2019. doi: 10.1186/s13063-019-3254-2.

7. Moskowitz A, Yankama T, Andersen LW, et al. Ascorbic Acid, Corticosteroids and Thiamine in Sepsis (ACTS) protocol and statistical analysis plan: a prospective, multicentre, double-blind, randomised, placebo-controlled clinical trial.BMJ Open. 2019;9(12):e034406. doi:10.1136/bmjopen-2019-034406.

8. Sprung CL, Annane D, Keh D, et al. Hydrocortisone Therapy for Patients with Septic Shock. New Engl J Med. 2008;358(2):111-24.

COMMON SENSE SEPTEMBER/OCTOBER 2020

55

MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

The Open Door Lauren Lamparter – Medical Student Council President

One of the reasons I am drawn to and pursuing a career in emergency medicine is its open-door policy — all are welcome, regardless of their ability to pay, the color of their skin, their legal status, or their sexual orientation. The emergency department (ED) is open 24-hours a day, seven days a week, 365 days a year to serve those in need, no matter their ailment or chief complaint. It is a place where there should be no discrimination based on race, religion, insurance status, or gender. All are welcome and will be taken care of with the priority of receiving the best care we can possibly give. I aspire to be an emergency medicine physician so I too can be a champion of health for all; someone who can set aside my implicit biases and provide for a fellow human who is in need of help.

Throughout this year, the many inequalities ingrained into our societal practices, culture, and policy have become even more apparent.

The global pandemic has highlighted health care inequalities across cultural divides right at home, in our neighborhoods, and across the globe. The health disparities and social structures preventing some people the privilege of social distancing or being able to work from home has led to a disproportionate amount of deaths in minority groups and those of lower socioeconomic status. The system is broken and places limits on the value of a human life, and this pandemic has only highlighted the innate disparities in access to care of our health care system. The ED and its open door has remained the safety net for many patients who lack basic, primary preventative health

I am working to educate myself and my colleagues on the importance of understanding both the differences and similarities we, as racially diverse persons, bring to society as a whole.

56

COMMON SENSE SEPTEMBER/OCTOBER 2020

care. Unfortunately, many of these patients often arrive too late in their disease course to actually help preserve their lives.

Moreover, the death of George Floyd and so many other innocent Black people such as Breonna Taylor and Rayshard Brooks, have highlighted the racial injustices and inequalities pervasive in our society.

Discrimination by race devalues human life and communicates to people that just because of the color of their skin, they are not welcome. Across the country, physicians, medical students, and other health care workers have been standing in solidarity with silent reflection over the eight minutes and 45 seconds it took to murder George Floyd. The goal was and is to raise awareness for administration and leadership both in medicine and more broadly across the country to critically examine our own racist history, lack of diversity in leadership, and promotion of policies that will work toward greater racial equality. While this article will be published long after our expressions of unity and solidarity, we cannot return to complacency in regard to racial inequality.

We have to start somewhere and as future physicians, medical students have the ability to create a shift in our thinking now to promote equality for all humans alike. All humans are equal members of American society and are entitled to justice. Human life is worth saving, Black lives are worth saving.

Even as the doors of the ED remain open to all, emergency medicine physicians, residents, and medical students need to be aware of their

We have to start somewhere and as future physicians, medical students have the ability to create a shift in our thinking now to promote equality for all humans alike.

unintentional biases and how this can affect patient care. Many studies have examined bias and shown that disparities exist within the ED, including differences in pain management, triage assessment accuracy, wait times, and resource utilization. I personally was raised with “white privilege,” and I am aware of the assumptions I have made in falsely believing it was better to be “color blind” as a method of seeking equality. I am working to educate myself and my colleagues on the importance of understanding both the differences and similarities we, as racially diverse persons, bring to society as a whole. As we interact with an extremely diverse population and our innate decisions often determine life and death, emergency medicine physicians must stand in that gap and be the difference makers. We stand at the open door, so we must be the first to work toward active change in our mindsets as we pursue justice in both medicine and humanism. 

The global pandemic has highlighted health care inequalities across cultural divides right at home, in our neighborhoods, and across the globe.

Exciting opportunities at our growing organization • Adult and Pediatric Emergency Medicine Faculty positions • Medical Director • Vice Chair, Clinical Operations • Vice Chair, Research • Medical Student Clerkship Director

Penn State Health, Hershey PA, is expanding our health system. We offer multiple new positions for exceptional physicians eager to join our dynamic team of EM and PEM faculty treating patients at the only Level I Adult and Level I Pediatrics Trauma Center in Central Pennsylvania.

What We’re Offering: • Salaries commensurate with qualifications • Sign-on Bonus • Relocation Assistance • Retirement options, Penn State University Tuition Discount, and so much more!

What We’re Seeking: • Emergency Medicine trained physicians with additional training in any of the following: Toxicology, Ultrasound, Geriatric Medicine, Pediatric Emergency Medicine, Research • Completion of an accredited Residency Program.

• BE/BC by ABEM or ABOEM

What the Area Offers: We welcome you to a community that emulates the values Milton Hershey instilled in a town that holds his name.

Located in a safe family-friendly setting, Hershey, PA, our local neighborhoods boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Known as the home of the Hershey chocolate bar, Hershey’s community is rich in history and offers an abundant range of outdoor activities, arts, and diverse experiences.

We’re conveniently located within a short distance to major cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC.

FOR MORE INFORMATION PLEASE CONTACT:

Heather Peffley, PHR FASPR at: hpeffley@pennstatehealth.psu.edu Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

COMMON SENSE SEPTEMBER/OCTOBER 2020

57

Membership Categories Fellow and Full Voting â&#x20AC;&#x201C; FAAEM Dues: $525 Board certified in emergency medicine or pediatric emergency medicine

Associate Dues: $250 Graduate of an ACGME or AOA approved emergency medicine training program and not yet taken or passed your EM board

Fellow-in-Training Dues: $75 Graduate of an ACGME or AOA approved emergency medicine training program and currently enrolled in a fellowship

International Member Dues: $150 Physicians with an interest in emergency medicine who practice outside of the United States or Canada

AAEM is the leader within our field in preserving the integrity of the physician-patient relationship by fighting for a future in which all patients have access to board certified emergency physicians and physician rights are protected.

Affiliate Member Dues: $365 Member in good standing who has been, but is no longer certified in emergency medicine or pediatric emergency medicine

Emeritus Member Dues: $250 Full voting member who has practiced emergency medicine for 30 or more years and has been a full voting member for a minimum of 10 years -or- at least 65 years of age and have been a full voting member for a minimum of 10 years

Member Benefits Publications Free subscriptions to the Journal of Emergency Medicine and Common Sense

Special circumstances may lead to a request for emeritus membership and will be reviewed on a case-by-case basis. See www.aaem.org/membership for more information.

Learn more and join today at: www.aaem.org/membership

Education Free registration to the Annual Scientific Assembly with refundable deposit and discounted registration for other AAEM events

Members-Only Section Access the AAEM Job Bank, your Advanced Resuscitation Expertise Card (for Full Voting members), and other academic and career-based benefits Learn more about these and other member benefits at www.aaem.org/membership/benefits

American Academy of Emergency Medicine 555 East Wells Street, Suite 1100, Milwaukee, WI 53202-3823 (800) 884-2236 info@aaem.org www.aaem.org

Group Membership AAEM offers group memberships to allow hospitals/groups to pay for the memberships of all their EM board certified & board eligible physicians.

100% ED Group Membership Criteria: All board certified and board eligible physicians at your hospital/ group must be members Discount: 10% discount on membership dues

ED Group Membership Criteria: Two-thirds of all board certified and board eligible physicians at your hospital/group must be members Discount: 5% discount on membership dues For group memberships, AAEM will invoice the group directly. If you are interested in learning more about the benefits of belonging to an AAEM ED group, please contact us at info@aaem.org or (800) 884-2236.

Join Today! www.aaem.org/membership COMMON SENSE SEPTEMBER/OCTOBER 2020

59

COMMONSENSE

Pre-Sorted Standard Mail US Postage PAID Milwaukee, WI Permit No. 1310

555 East Wells Street / Suite 1100 Milwaukee, WI 53202-3823

American Academy of Emergency Medicine

C H A M P I O N27th O F Annual T H E E M EScientific R G E N C Y PAssembly H YS I C I A N Today’s emergency physician has a lot to navigate.

That’s why AAEM is in your corner providing advocacy and education.

A Strong Voice Your concerns reach the ears of our leaders in Washington.

AAEM actively works to ensure the needs of EPs are being addressed on the national and state levels.

We offer support & legal assistance to members whose rights are threatened. The strength of the Academy is in your corner.

Effective Advocacy For over 20 years we have been committed to your personal and professional well being. Our primary concern is supporting you: your practice rights, your autonomy, your relationship with your patients.

That’s the AAEM difference.

Why I Joined

Top Tier Education

Hear from fellow EPs why they chose to become a member and how AAEM is addressing APP independent practice.

In addition to the Annual Scientific Assembly, AAEM offers educational opportunities online and in-person at our Oral Board Review, Written Board Review, and ED Management Solutions courses, as well as other regional courses and meetings.

Meaningful Connections

www.aaem.org/whyaaem

C H A M P I O N O F T H E E M E R G E N C Y P H YS I C I A N

AAEM-0819-439

AAEM is over 8,000 members strong and growing.

We offer multiple ways for you to get involved with the topics that matter most to you through engaging committees & projects plus multiple ways to network with fellow members in the U.S. and around the globe.