November/December 2020 Common Sense

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 27, ISSUE 6 NOVEMBER/DECEMBER 2020

Update from the Government and National Affairs Committee Page 25

President’s Message:

Controlling What You Can When Things Feel Out of Control

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From the Editor’s Desk:

The Rape of Emergency Medicine

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Young Physicians Section:

Hero

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AAEM/RSA President’s Message:

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Aerospace Medicine — The Final Frontier of Emergency Medicine

Board of Directors Meeting Summary:

September

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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 Ryan Gibney, 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.

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COMMON SENSE NOVEMBER/DECEMBER 2020

COMMONSENSE

Regular Features President’s Message: Controlling What You Can When Things Feel Out of Control...............................3 From the Editor’s Desk: The Rape of Emergency Medicine....................................................................6 Foundation Donations.............................................................................................................................8 PAC Donations........................................................................................................................................9 LEAD-EM Donations.............................................................................................................................10 Upcoming Conferences ........................................................................................................................10 AAEM/RSA President’s Message: Aerospace Medicine — The Final Frontier of Emergency Medicine......................................................................................................................38 AAEM/RSA Editor: Virtual Insanity: Adapting Curriculum to the Virtual Environment...........................39 Resident Journal Review: End-Tidal Carbon Dioxide Monitoring in Cardiopulmonary Resuscitation...42 Medical Student Council President’s Message: The EM Interview: Advice from Your AAEM/RSA Resident Board..............................................................................................................................46 Board of Directors Meeting Summary: September...............................................................................48 Job Bank...............................................................................................................................................50 Special Articles ABEM Press Releases..........................................................................................................................11 The Bare Bones — Ultrasound Assisted Fracture Reduction................................................................12 COVID Lays Bare an Emergency Medicine Crisis.................................................................................16 COVID-19 and the Bursting Bubble of ER Management......................................................................18 Social EM & Population Health: Social EM Spotlight: Dr. Darin Neven – Putting Emergency Medicine Ingenuity to Work in Service of Marginalized Patients................................................... 22 Operations Management: Why Residents Should See the Waiting Room: A Case for an Introduction to Patient Experience Earlier in Postgraduate Training.....................................26 Critical Care Medicine: Non-Invasive Average Volume Assured Pressure Support for Acute Hypercapnic Respiratory Failure: A Case Study and Novel Approach............................28 Women in EM: Domestic? Help!...........................................................................................................31 Young Physicians: Hero........................................................................................................................36 Updates and Announcements AAEMLa: Women Leading the Way in Emergency Medicine................................................................20 Palliative Care: Create a LIFEMAP for Goals of Care Discussions during a Pandemic........................24 Government and National Affairs Committee: Update from the Government and National Affairs Committee......................................................................................................................................25 Emergency Ultrasound: Utilization of Point-of-Care Ultrasound during COVID-19................................33 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-0920-435 AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

AAEM NEWS PRESIDENT’S MESSAGE

Controlling What You Can When Things Feel Out of Control Lisa A. Moreno, MD MS MSCR FAAEM FIFEM — President, AAEM

Being President of an organization

like AAEM has already been a blessing to me in more ways than I can possibly express. One of those ways is the opportunity to form close working relationships with the incredible people who are part of the Academy. Recently, the Wellness Committee has been a special source of inspiration with its focus on mitigating the isolation created by COVID-19, and the Women in EM Section has been equally inspiring with its focus on combating physician suicide. Physician suicide rates are more than twice those of the general population.1 The well-known Maslach Burnout Scale considers emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment to correlate highly with depression and burnout.2 In 2020, emergency physicians are increasingly experiencing these factors. We are seeing needless death in unprecedented numbers. We are discouraged by patients dying alone, and by our inability to touch our patients and our colleagues, to have in-person conferences and meetings, and to gather socially. Our personal impact is diminished by the conditions in which we are working, including the increasing takeovers of our departments by corporate medical groups. Employers, legislators, and insurers purport that the years of extra training and study EPs undertake brings no increased value to our patients and that we are easily replaced by NPs and PAs. A recent study shows that “younger age, surgical specialty, low academic rank, academic main practice, female gender, numerous night shifts, and living alone” most highly correlate with high levels of burnout.3 At home and at work, we are surrounded by people who feel unable to cope. Tempers are flaring. Many people need someone to blame. The slow return to normal is not coming fast enough, and things feel out of our control. Over and over, the wisdom of a children’s film comes to mind: “We’re calling this ‘Controlling what you can when things feel out of control’.”4 And as Olaf pointed out, there is indeed a great deal that we can control.

the best treat we can give ourselves. With gyms closed, many people are slacking off on exercise. Work outs help both our physical and our mental health. Get a buddy to work out with, and be accountable to each other for healthy eating, working out, and getting enough sleep.

We Can Protect Our Mental Health “It’s okay to not be okay” is more than just the title of a Korean TV series.

This phrase has been reassuring health care professionals that there is no stigma in needing help. The stigma of mental illness is giving way to the image of strength shown by asking for help when we need it. One of the highest compliments we can pay another is to admit our vulnerability and ask them for help. Opening up about our own doubts and emotional exhaustion gives permission to those around us to own theirs. Being human does not equate to being weak. Take time each day to meditate or pray. Connect to the Higher Power who is in control. Write poetry, keep a journal, listen to music (literature shows it is a mood changer!), and follow the advice of the Wellness Committee from the last issue of Common Sense.5

We are discouraged by patients dying alone, and by our inability to touch our patients and our colleagues, to have in-person conferences and meetings, and to gather socially.

We Can Protect Our Physical Health There is no longer any doubt that masks/face covers work.

The CDC has shown them to be 97% effective in the prevention of COVID-19 transmission. Beyond this single most important thing that we can do to protect our health, we also need to ensure that no matter how hard and how long we are working, we must take time to eat well, exercise well, and sleep well. Busy people get too much “take out,” depressed people feel like they’ve “earned a treat,” and lots of kindness has been shown to us by local restaurants sending food to the ED. But let’s reframe that: What we sometimes think of as “treating ourselves” with sugar, fat, and processed food is really hurting ourselves. A fresh, natural plant-based diet is COMMON SENSE NOVEMBER/DECEMBER 2020

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AAEM NEWS PRESIDENT’S MESSAGE

We Can Protect the Health of the People We Love After we get everyone to mask up and socially distance, be accountable to each other for eating healthy natural food, exercising daily, and sleeping 7-8 hours Q 24, stay connected! We all know that the mind-body connection is powerful, and the literature shows that a purposeful and connected life is more likely to be a long and healthy one.6 Text and call, send cards, drop off food or flowers to neighbors who live alone. Doing this is protecting your own health, since doing good makes us feel good!

Many years ago, my husband got me into this habit: Each night before I go to bed, I think of three people who made my day easier, happier, or nicer and I send them a thank you text or email. I’m always pleasantly surprised by how much this means to people.

When things feel out of control, there really is a lot that we can control.

someone doesn’t seem at their baseline. And if they insist they’re okay but you don’t think so, kick it up a notch and tell someone else. Create opportunities for social connections through invites to Zoom cocktail parties, chats after meetings or during shifts, and pick one person a week to just call or text for no reason other than to say “I enjoy working with you, and here’s one thing I learned from you that means a lot to me.”

We Can Protect the Future of Our Specialty The AAEM Board of Directors recently held a highly successful virtual Advocacy Day. We met with Matt Hoekstra, our lobbyist from Williams and Jensen, to discuss the issues of paramount importance to the Academy: due process and balance billing. We celebrated the successful introduction of HR 6910 by Dr. Raul Ruiz and Dr. Roger Marshall, which will bar third party contractors from requiring emergency physicians to waive their due process rights as a condition of employment. Dr. Ruiz, Democratic Congressman from the 36th Congressional District in California brought eight of his Democratic colleagues in Congress who

We Can Protect Our Patients Model the practices of hand sanitizing, social distancing, and masking.

Talk about their concerns. Take the couple of extra minutes to answer their questions and be sure you understand what they are really worried about today. And show them love. My colleague, Dr. Heather Murphy, says that before leaving the room, she asks if the patient needs water or a blanket, since caring is part of medical care. Realize that clinics have been cancelled and people have been isolated and ask if they have their medications and follow up appointments taken care of or if you need to help with that. Ask how they are finding a way to combine childcare or eldercare with work now that many schools and day cares are closed.

Is there any concern for domestic violence or substance abuse in these days of out of work and stuck at home? We, the emergency physicians, are the nation’s doctors and if we don’t talk about what’s really the problem, no one else will. Remember: Emergency physicians = the brain of a doctor and the heart of a doctor.

We Can Protect Our Colleagues “Fine” is not an answer to “How ya doing?” Don’t accept that answer. Ask how people are really doing, how they are coping and if there is anything you can do to help. It’s sometimes a shock to realize how little we know about the people we work with every day. Who is a single parent?

Whose relative just started chemotherapy? Whose parent was recently diagnosed with Alzheimer’s? Whose partner just lost their job? Notice if

AAEM NEWS

We, the emergency physicians, are the nation’s doctors and if we don’t talk about what’s really the problem, no one else will. support the bill and emergency physicians to a virtual celebration with us.

We also met with other staffers and Members to advocate for physician and patient rights. (See Dr. Kevin Beier’s full report about Advocacy Day in this issue of Common Sense.) AAEM joined with several other EM organizations in a statement that the words “resident, residency, fellow, fellowship” should be restricted to post-graduate medical training and that ED based post-graduate PA and NP training programs should not be initiated without the involvement and consent of EM residency program leadership. Our Scientific Assembly Subcommittee is hard at work against all odds designing an AAEM21 that will uphold our reputation as the best EM conference in the world. The Government and National Affairs

>> 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.

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

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COMMON SENSE NOVEMBER/DECEMBER 2020

AAEM NEWS PRESIDENT’S MESSAGE

Committee is working in Tennessee to eliminate the option of hospitals to require merit badge certifications. The Critical Care Medicine Section has developed a mentorship program to work with residents interested in this specialty. As staff likes to say, “There are over 40 ways to get involved with AAEM.” When things feel out of control, there really is a lot that we can control.

We can, as Gandhi said, “Be the change you want to see in the world,” and as Angela Davis said, “I am no longer accepting the things I cannot change. I am changing the things I cannot accept.” The best way to avoid burnout is to be empowered, and you are empowered as a member of AAEM. We are the Champion of the Emergency Physician. We fight for you, and we also empower you to fight for yourself, your colleagues, your patients, and the future of our specialty. 

References 1. Schernhammer, E. S., & Colditz, G. A. (2004). Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis).

American Journal of Psychiatry AJP, 161(12), 2295-2302. doi:10.1176/ appi.ajp.161.12.2295 2. Maslach C. Burnout. Hum. Behav. 1976;5:16–22. [Google Scholar] 3. Nassar, A. K., Reid, S., Kahnamoui, K., Tuma, F., Waheed, A., & McConnell, M. (2020). Burnout among Academic Clinicians as It Correlates with Workload and Demographic Variables. Behavioral sciences (Basel, Switzerland), 10(6), 94. https://doi.org/10.3390/ bs10060094 4. Olaf, in Frozen 2 5. Alvarez, A., & Lam, R. (2020). Gratitude and Appreciation Amidst Chaos and Uncertainty: Awaken Humanity at Work. Common Sense 26(5) 35-36. www.aaem.org/UserFiles/file/CS20_SepOct_AAEM_Wellness.pdf 6. https://www.health.harvard.edu/blog/will-a-purpose-driven-life-help-youlive-longer-2019112818378

A Strong Voice Assembly 27th Annual Scientific 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.

Now Accepting 2021 Membership Applications!

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

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.

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

COMMON SENSE NOVEMBER/DECEMBER 2020

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AAEM NEWS FROM THE EDITOR’S DESK

The Rape of Emergency Medicine Andy Mayer, MD FAAEM — Editor, Common Sense

The morals and lessons from Keaney’s book sound as true to me today as they did almost thirty years ago when I first read it.

I would like to propose a challenge to each

of you and it is to read a book. Have you ever read Jim Keaney’s “The Rape of Emergency Medicine?” If so, how long ago? Maybe now is the time to read it for the first time or to reread what to many was the call to arms for action when the Academy was founded. It was initially released in 1992 anonymously by “The Phoenix.” At the time, there was a significant danger of losing your job for speaking out for many of the issues which led to the founding of the American Academy of Emergency Medicine (AAEM). Many of you might consider it ancient history but the themes are relevant today. The book is available for free on the AAEM website to read online or download. It is a quick read and will not take much time.

Read “The Rape of Emergency Medicine” here: https://www.aaem.org/about-us/our-values/history The characters and business practices portrayed in the book may seem humorous and on a superficial analysis only relate to controversies of the past. The book decries the rise of the corporate practice of emergency medicine and the attempt to destroy the independent practice of our specialty. The rise of the “suits” from kitchen schedulers to the goliath corporate management groups is portrayed by some memorable characters. The exploitation of the “scrubs” by these nonpracticing physicians and their relation to the early leadership of organized emergency medicine is a topic which each of you needs to know about, understand, and reflect upon. Please consider that these issues are not things of the past. They are not historical curiosities to be relegated to the dustbin. The suits have in many cases sold out for untold millions of dollars to private equity corporations. These corporations are often publically traded for-profit multibillion dollar corporations as opposed to the kitchen scheduler of old. This makes them more and not less dangerous to our profession. These corporations control the careers of thousands of emergency physicians and it is hard to believe that their motivation is anything but the bottom line and the return on investment to their shareholders.

Improvements have been made by the organizations who are supposed to represent and protect each of us and our specialty. Hard lessons have been learned and some of the situations described in the book have been at least partially corrected. Some battles have been hard fought and won and others have been lost. Sadly, our profession contains a large number of “scrubs” who have become the automatons which some of the characters portrayed in the book. These clinicians do not concern themselves with the “business” of emergency medicine and continue

These clinicians do not concern themselves with the “business” of emergency medicine and continue to sign the non-compete clauses humorously described in the book. They surrender their due process rights and continue not knowing what is billed and collected in their name.

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COMMON SENSE NOVEMBER/DECEMBER 2020

VS to sign the non-compete clauses humorously described in the book. They surrender their due process rights and continue not knowing what is billed and collected in their name.

Maybe you say that it does not matter and that the suits have won and that there is no point in struggling against the system. Maybe you will doggedly work with blinders on while striving to meet whatever metric is thrown in front of you.

Your only ambition may be able to ignore the rest and complete your career by checking off the shifts on each schedule. However, maybe now in the time of COVID you may rekindle the spirit and be spurred into action or at least interest.

The morals and lessons from Keaney’s book sound as true to me today as they did almost thirty years ago when I first read it. At that time, I was working part-time at an EmCare facility and I felt exploited and was outraged. Consider the irony of AAEM’s long fight for the value of board certification in emergency medicine.

The Academy fought long and hard and made this the core issue for our organization. The numbers of board certified emergency physicians are growing and more and more of our emergency departments are becoming staffed with all board certified emergency physicians.

That sounds great but new obstacles have arisen which also threaten our future. There had always been a presumed logic that there were not enough board certified emergency physicians to staff all of our nations emergency

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AAEM NEWS FROM THE EDITOR’S DESK

departments. Recently, concerns are being raised that this supposition is not true and that in fact there may soon be an actual oversupply of emergency physicians as the number of residency programs run by CMGs blossom.

The real fight may now be on another front.

We now may be losing the fight to midlevels.

Corporate management groups are quickly learning that they can replace us with cheaper labor. They sponsor training courses for physician assistants and nurse practitioners to make them specialists in emergency medicine and boldly support independent practice for these same midlevels. COVID is being used as the excuse to permanently change the staffing of emergency departments. How many of you have had your pay cut, hours or shifts reduced, or been terminated with the explanation that the current pandemic requires changes in staffing levels? Certainly, the decrease in volumes related to COVID has caused some of even the most independent and democratic of groups to change their staffing levels and hourly wage.

We all do work in a business, and business

This practice continues to this day and has been highlighted during this pandemic by emergency physicians who have been terminated when they have complained about the lack of personal protective equipment and other safety concerns related to COVID.

decisions are often painful. I cannot say that any group can put their head in the sand and not do what it takes to survive. My concern is that many corporate management groups are using the crisis as an excuse to decrease long-term costs by placing a midlevel as the backbone of their department’s staffing. This tendency which had previously started is now accelerating. These CMGs simply reduce or eliminated physician double or triple coverage and keep adding midlevels. In doing so, they can pocket the saved labor costs. These corporations are not motivated by an altruistic desire to protect the public or our profession during a pandemic. Are they simply using this crisis as a means to decrease their hourly costs in the long run in an effort to improve their profit margin? It is hard to believe this is being done to improve patient care or satisfaction.

Some organizations representing the nurse practitioners and physician assistants are also using the pandemic to push forward their effort towards total practice independence in the various state legislatures. Many rationalize that the need for expanded practice rights is due to the labor shortages caused by COVID and relate horror stories of overrun emergency departments and hospitals as a justification for independent practice. How many of you are short labor and need to expand the independent practice capabilities of midlevels to meet the care needs of your department?

Most places except in a current hot spot have an excessive or even a glut of labor and certainly do not have a shortage of emergency physicians. COVID is simply being used as a cover to distract legislators from the real situation.

Keaney’s book clearly describes the still continuing practice of termination without cause when a physician complains or causes any sort of trouble for the corporate management group. This practice continues to this day and has been highlighted during this pandemic by emergency physicians who have been terminated when they have complained about the lack of personal protective equipment and other safety concerns related to COVID. These terminations are made a simple and quick process because many of us are required to give up our federally required due process rights to obtain a job. This process of “forfeiting” your rights to obtain a job sounds ridiculous and I bet that many of you reading this did so not even knowing it. Who bothers to read all of that fine print when you sign a contract? You think all of those confusing paragraphs buried in the bowels of your contract are not important? You just skipped to the salary part and signed.

COVID does present us with an opportunity in this regard. The Academy has been a champion of legislation to insure the preservation of due process rights for all emergency physicians. Larry Weiss, a past president of AAEM, has been the long-time champion of this effort. AAEM has been attempting to pass legislation and has also tried to work with CMS in this regard. There has been a petition on AAEM’s webpage in this regard for several years. Have you signed it?

Sign the Due Process Petition: https://www.aaem.org/due-process/petition/index.php Currently, there is again proposed legislation in Congress to help guaranty the due process rights, which are frequently “voluntarily” relinquished by emergency physicians in order to get a job especially with a corporate management group. COVID is providing an impetus to actually pass legislation in this regard. The bill is called the “ER Hero and Patient Protection Act” which has sponsors from both sides of the aisle. Hopefully with the support of the extended medical community this will become law. Several medical organizations have signed on as supporters of this bill including the American College of Surgeons. Please consider reading more about this and becoming involved in this important effort of passing this legislation which is still needed thirty years after the original publication of “The Rape of Emergency Medicine.” Please follow this issue as it progresses through our legislative process. Please help our profession grow from the “scrubs” of old into what we all know is an exceptional rich and vital medical specialty filled with incredibly trained professionals. 

COMMON SENSE NOVEMBER/DECEMBER 2020

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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 10-1-2020.

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

Pamela A. Ross, MD FAAEM Mary Ann H. Trephan, MD FAAEM David Thomas Williams, MD FAAEM Harry Charles Wolf IV, MD FAAEM

Contributions $250-$499

Kevin Allen, MD FAAEM Justin P. Anderson, MD FAAEM Peter G. Anderson, MD FAAEM Michael R. Burton, MD FAAEM Walter M. D’Alonzo, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM Kathleen Hayward, MD FAAEM Jerris R. Hedges, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT Stephanie Kok, MD FAAEM Ron Koury, DO FAAEM Bruce E. Lohman, MD FAAEM Bryan K. Miksanek, MD FAAEM Isaac A. Odudu, MD FAAEM Phillip L. Rice Jr., MD FAAEM James Francis Rowley III, MD FAAEM Keith D. Stamler, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM

Contributions $100-$249

Lydia L. Baltarowich, MD FAAEM FACMT Mark Avery Boney, MD FAAEM

Anthony J. Callisto, MD FAAEM David C. Crutchfield, MD FAAEM Robert J. Darzynkiewicz, MD FAAEM Jason W. David, MD Angel Feliciano, MD FAAEM Matthew K. Fischer, MD FAAEM Taylor G. Fletcher, MD FAAEM Paul W. Gabriel, MD FAAEM Gary M. Gaddis, MD PhD FAAEM FIFEM Albert L. Gest, DO FAAEM Kathryn Getzewich, MD FAAEM Regina Hammock, DO FAAEM Neal Handly, MD FAAEM Dennis P. Hanlon, MD FAAEM William E. Hauter, MD FAAEM Jacob Hennings Jessica Herrera, MD FAAEM Thomas Isenovski, DO FAAEM Kevin T. Jordan, MD FACEP FAAEM John H. Kelsey, MD FAAEM Katrina Kissman, MD FAAEM Hannah J. Kleiman, MD H. Samuel Ko, MD MBA FAAEM Stephen J. Koczirka Jr., MD FAAEM FACEP Benjamin Krater, DO FAAEM Calvin C. Krom III, DO FAAEM David W. Lawhorn, MD MAAEM FAAEM Rebecca Liggin, MD FAAP FAAEM FACEP Robert D. Londeree III, MD FAAEM

William M. Maguire, MD FAAEM Gregory S. McCarty, MD FAAEM Nevin G. McGinley, MD MBA FAAEM Rick A. McPheeters, DO FAAEM James Arnold Nichols, MD FAAEM Frank B. Parks, DO FAAEM FACEM FAWM Patricia Phan, MD FAAEM Jobin J. Philip, MD Jeffery M. Pinnow, MD FAAEM FACEP Matthew C. Ponder, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE George J. Reimann, MD FAAEM Scott D. Reiter, MD FAAEM Jeffrey A. Rey, MD FAAEM Teresa M. Ross, MD FAAEM H. Edward Seibert, MD FAAEM Eric M. Sergienko, MD FAAEM Sachin J. Shah, MD FAAEM Richard D. Shih, MD FAAEM Jonathan F. Shultz, MD FAAEM Douglas P. Slabaugh, DO FAAEM Susan Socha, DO FAAEM Robert E. Stambaugh, MD FAAEM David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM Jalil A. Thurber, MD FAAEM Andy Walker, MD FAAEM Joanne Williams, MD MAAEM FAAEM Kary Wisniewski, MD FAAEM

ED Management Solutions: Principles and Practice January 12-14, 2021 Lifelong learning opportunities that aim to improve ED management & leadership www.aaem.org/ed-management-solutions

On Demand and Live Webinar Sessions 8

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George Robert Woodward, DO FAAEM Leonard A. Yontz, MD FAAEM

Contributions up to $50

NanaEfua Afoh Manin, MD MPH Sameer M. Alhamid Jr., MD FRCPC FACEP FAAEM Robert Bassett, DO FAAEM James Butler, MD Jordan R. Chanler-Berat, MD FAAEM Patrick D. Cichon, MD JD MSE FAAEM Francis X. Del Vecchio, MD FAAEM Jeremy A. Hall, MD FAAEM Adriana M. Horner, MD Alex Kaplan, MD FAAEM Edgar A. Marin, MD Jennifer A. Martin, MD FAAEM Syed-Ghazanfar A. Naqvi, MD Melissa Natale, MD FAAEM Ramon J. Pabalan, MD FAAEM Jeremiah Phelps Veerendra Kumar Nanjundaiah Ramasamudra Louis L. Rolston-Cregler, MD FAAEM Gholamreza Sadeghipour Roodsari Katherine F. Tyler Patricia L. VanDevander, MD MBA FAAEM

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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 10-1-2020.

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 Shane R. Sergent, DO 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 Stephanie Eden, MD FAAEM Matthew K. Fischer, MD FAAEM Deborah D. Fletcher, MD FAAEM Steven H. Gartzman, MD FAAEM Albert L. Gest, DO 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

Mercy M. Hylton, 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 Wendi S. Miller, MD FAAEM James Arnold Nichols, MD FAAEM Gabriel Ochoa 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 Brendan P. Sheridan, 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 Allyson F. Coopersmith 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



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.

Submit a Letter to the Editor at:

www.aaem.org/resources/publications/commonsense/letters-to-the-editor COMMON SENSE NOVEMBER/DECEMBER 2020

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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 10-1-2020.

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 Daniel F. Danzl, MD MAAEM FAAEM Eric D. Ferraris, MD FAAEM William E. Franklin, DO FAAEM Albert L. Gest, 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 Kristina Noelle Tune, 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 Mercy M. Hylton, MD FAAEM Stefan Jensen Kevin T. Jordan, MD FACEP FAAEM H. Samuel Ko, MD MBA 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 P. Daniel McConnell, 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 Allyson F. Coopersmith 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 Alexis Koda, MD Jinyue Li, MD FAAEM James Arnold Nichols, MD FAAEM Scott Pasichow, MD Tracy R. Rahall, MD FAAEM Saba A. Rizvi, MD FAAEM Joshua A. Sawyer, OMS IV, RN 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

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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

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

November 13-15, 2020 The Difficult Airway Course: EmergencyTM Nashville, TN www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency

January 12-14, 2021 ED Management Solutions: Principles and Practice Online www.aaem.org/ed-management-solutions

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November 21, 2020 Advances in Cancer ImmunotherapyTM — SITC Tampa, FL (VIRTUAL) www.sitcancer.org/education/aci

June 19-23, 2021 27th Annual Scientific Assembly – AAEM21 St. Louis, MO www.aaem.org/AAEM21

December 3, 2020 Advances in Cancer ImmunotherapyTM - SITC Indianapolis, IN (VIRTUAL) www.sitcancer.org/education/aci

9-12 September 2021 XIth Mediterranean Emergency Medicine Congress – MEMC21 St. Julian’s, Malta www.aaem.org/MEMC21

December 8, 2020 Advances in Cancer ImmunotherapyTM — SITC Toronto, ON (VIRTUAL) www.sitcancer.org/education/aci

COMMON SENSE NOVEMBER/DECEMBER 2020

December 10, 2020 Advances in Cancer ImmunotherapyTM — SITC Louisville, KY (VIRTUAL) www.sitcancer.org/education/aci December 12, 2020 Advances in Cancer ImmunotherapyTM — SITC San Antonio, TX www.sitcancer.org/education/aci February 5-19, 2021 2021 ACMT Total Tox Course Virtual www.acmt.net/cgi/page.cgi/_evtcal. html?evt=670

ABEM NEWS

ABEM Press Releases

ABEM Position Statement: Delivery of Emergency Care is Best Led by ABEM-Certified Physicians: ABEM Issues Statement on Advance Practice Providers in the ED The American Board of Emergency Medicine To become certified by ABEM, physicians Physicians must also demonstrate that they (ABEM) believes that the delivery of emercomplete an undergraduate degree, four years are keeping up to date with key advances gency care is best led by physicians with EM of medical school, followed by an Accreditation and meeting national standards in the field training, experience, and ABEM certification.

Council for Graduate Medical Education– acof Emergency Medicine to stay certified.

While ABEM honors the contributions to credited Emergency Medicine residency Minimally, indirect but real-time supervision by emergency care by other providers, the path to program. (This is five more clinical years of an ABEM-certified physician must be available become a nurse practitioner (NP) or physician’s supervised training than is required of an in the emergency department. Additionally, the assistant (PA) is not equivalent to the complex NP or PA.) The physician must then pass a patient should always be afforded the choice training required to become an ABEM-certified highstakes, secure, written examination, and and opportunity to speak with a supervising physician. An ABEM-certified physician should a rigorous oral examination to become ABEM physician. therefore lead team-based care in the emercertified.

The entire statement is available here: gency department. www.abem.org/public/docs/default-source/default-document-library abem-statement-on-advance-practice-providers. 

ABEM Prepares to Pilot New Assessment – MyEMCert: Additional Resources on MyEMCert Now Available The American Board of Emergency Medicine (ABEM) will soon launch a three-month pilot of MyEMCert, the newly developed alternative to the high-stakes ConCert Exam (the traditional recertification exam).

Approximately 1,500 physicians, representative of the ABEM-certified physician population, will be participating and providing input and feedback on MyEMCert.

Core elements of MyEMCert modules: • Topic-specific: incorporate the “bread and butter” issues of Emergency Medicine • Open-book: can be completed anywhere, anytime • Immediate feedback: scores, correct answers, and rationales • Content that keeps you informed: key advances in the specialty

REFER A COLLEAGUE TO JOIN OR RENEW WITH AAEM

As an open-book assessment, study requirements should be minimal.

Physicians may wish to study the topic and review the resources provided before beginning a module.

Additional resources on MyEMCert module content, including presentation scenarios and key advances, and details on taking MyEMCert modules are now available on the ABEM website.

• Details on module content including presentation scenarios • Key advances in the practice of Emergency Medicine and synopses • Information on taking MyEMCert modules and a Module Basics video Learn more at www.abem.org/MyEMCert. 

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

If you agree, tell your colleagues about us!

NEW: AAEM Member Referral Program Follow these short and easy steps to refer your colleague to join or renew with AAEM: • Gather your colleagues name(s) and email(s) • Log in to your member profile and click on the AAEM Member Referral Program • Select the pre-scripted email you’d like to send • Personalize it or just send it as is

LEARN MORE AT:

Learn more at: www.aaem.org/forms/membership_referral.php COMMON SENSE NOVEMBER/DECEMBER 2020

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AAEM NEWS

The Bare Bones — Ultrasound Assisted Fracture Reduction Joseph Zarraga, DO; Carissa Jeannette, DO; Max Cooper, MD RDMS

Figure 1: Radiographs of the distal humerus fracture, described as oblique, angulated, comminuted fracture of the distal diaphysis of the humerus. Shown as pre-and and post reduction. (a) Pre-reduction x-ray shows significant displacement, read by radiology as “a varus angulation” of the distal fragment by 43 degrees. A distance of the overriding part of the distal fragment was found to be 1.02 cm. (b) Post reduction x-ray showing significant reduction of displacement. Read by radiology as “significantly improved alignment following reduction with no significant residual angulation.”

Abstract

Case

Extremity fractures are common injures that are evaluated and treated daily in the ED.1 The vast majority of fractures require conservative management in the ED and orthopedic surgery follow up as an outpatient for definitive treatment and management. However, in cases where there is significant displacement, angulation, and or neurovascular compromise, reduction of these fractures in the ED should be promptly pursued. Point of care ultrasound (POCUS) is a readily available tool in EDs worldwide that can be useful during fracture reductions to ensure adequate reduction and overall procedural success. In this case report, we review basic steps for management of displaced fractures and how POCUS can assist in successful reduction.

A 23-year-old female with no known past medical history, presented to the ED from home for a right arm injury. Just prior to arrival, the patient states that she was wrestling with her siblings, when one of them accidentally fell on her upper arm. She states that she immediately had pain in her upper arm and near her elbow, prompting her to immediately call 911.

Intro We present a case of a distal humerus fracture with moderate displacement, angulation, and comminution. The ED course of these cases is usually straightforward, with pain control, reduction with or without sedation, and post reduction splinting being the mainstays of management.

However, difficult cases tend to require multiple reduction attempts and X-rays to guide effort. These procedures can be labor-intensive, siphoning providers and resources away from the rest of the department. We demonstrate the utility of POCUS as an adjunct that can give near realtime feedback during fracture reductions, which can not only potentially lower the number of attempts, radiation exposure, and resource utilization but also allow for better overall outcomes.

Point of care ultrasound (POCUS) is a readily available tool in emergency departments worldwide that can be useful during fracture reductions to ensure adequate reduction and overall procedural success.

The Emergency Medical Service (EMS) providers called our medical command physician for clearance to administer fentanyl for analgesia, as she was in severe pain. EMS also stated that she had an obvious deformity of the distal humerus, just proximal to the elbow. Initial evaluation by medics reported no immediate neurovascular compromise, with intact sensation, motor, and pulses distal to the injury.

Upon arrival to the ED, she had improvement in her pain status. EMS had placed her arm in a position of comfort and applied a temporary splint to the affected area. She was placed on the monitor and had normal vital signs. Removal of the temporary splint revealed a right arm deformity of the posterolateral aspect of the humerus, just proximal to the elbow.

There was no tenting of skin, open wounds, or ecchymosis, and distal sensation, motor function, and pulses were intact. Physical exam did not reveal additional signs of trauma.

X-rays were performed of the right shoulder, humerus, and elbow and demonstrated an oblique, angulated, comminuted fracture of the distal diaphysis of the humerus. The radiologist measured a varus angulation of the distal fracture fragment of 43 degrees and a distance of the overriding part of the distal fragment of 1.02 cm.

She was consented for procedural sedation using propofol and ketamine.

Given the amount of displacement, we brought the ultrasound to the bedside to obtain real time feedback of our reduction efforts. When the patient was adequately sedated, the dressing was removed and the displacement of the fractured humerus was measured to be 0.82 cm using a linear ultrasound probe in a longitudinal view. After one attempt at reduction, we remeasured the displacement at 0.75 cm, though the

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AAEM NEWS The Bare Bones — Ultrasound Assisted Fracture Reduction

external angulation seemed to improve. After our second attempt, the segment was measured at 0.11 cm. She was splinted and a repeat portable X-ray showed “significantly improved of alignment following reduction with no significant residual angulation.”

Discussion Extremity fractures are commonly seen in the ED and diagnosis is often accomplished by X-ray. Fractures requiring sedation and reduction are often very apparent to ED physicians on presentation. This case is an example of such a fracture. Upon initial X-ray, the degree of angulation and displacement was noted to be significant and we believed that multiple attempts at reduction would be required for satisfactory alignment.

These cases are optimal for utilization of POCUS as an adjunct for successful reduction. To do this, pre-reduction ultrasound of the affected extremity is performed at the bedside, looking for disruption of cortical alignment. The disruption is measured with calipers and saved in order to compare with after reduction results ─ reduction is considered successful when there is satisfactory reduction in displacement and angulation as noted on POCUS.

reductions, X-rays may indeed show inadequate approximation, requiring removal of the splint and further attempts. In addition, it can lead to increased resource utilization and decreased procedural efficiency, which could affect department flow and wait times.3 Radiation exposure as well as sedation time and medication usage could rise with repeated reduction attempts. In this case of a 23-year-old female with a distal humerus fracture that required sedation and reduction, we were able to avoid additional intra-reduction X-rays, further medication, and achieve a relatively quick reduction.

>> Figure 2: US of the distal humerus fracture pre-reduction, measured to be displaced at 0.83 cm.

Few studies regarding outcomes of US assisted fracture reductions have been performed. Sensitivity and specificity of determining successful reduction under US guidance has been found to be 97.5% and 95%, respectively.2 Successful reduction of fractures may not be affected by using POCUS in combination with traditional X-ray. However, there are additional benefits that ease the process.

By using the US at bedside, it is much easier to monitor reduction progress with the ultrasound after each attempt. Traditionally, when adequate reduction is believed to be achieved by the performing physician, the extremity is splinted and confirmatory X-ray is performed. In difficult

Figure 3: US of distal humerus after first attempt at reduction under conscious sedation, measured to have displacement at 0.75 cm, with a 0.08 cm difference. After first reduction, a satisfactory “clunk” was felt, but bedside US showed that there was room for further improvement.

Figure 4: US of distal humerus after second attempt at reduction under continued conscious sedation, with successful approximation. Distance measured to be 0.11 cm, significantly improved from the first displacement measurement of 0.83 cm.

COMMON SENSE NOVEMBER/DECEMBER 2020

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AAEM NEWS The Bare Bones — Ultrasound Assisted Fracture Reduction

Questions and Takeaways What makes this presentation and management reportable?

This case shows the ability of POCUS to assist in guiding fracture reductions.

What is the major learning point?

This report highlights the potential for utilizing POCUS during difficult fracture reductions in order to potentially reduce time to reduction, overall radiation, medications used, and number of reduction attempts.

How might this improve emergency medicine practice?

This case hopes to demonstrate to ED physicians of an underutilized tool that has multiple benefits in a common EM procedure.

References 1. 1. Kozaci N, Ay MO, Akcimen M, et al. Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures. The American Journal of Emergency Medicine.

2015;33(1):67-71.

2. Bozkurt O, Ersel M, Akarca FK, Yalcinli S, Midik S, Kucuk L. The diagnostic accuracy of ultrasonography in determining the reduction success of distal radius fractures. Turkish Journal of Emergency Medicine. 2018;18(3):111-118.

3. Socransky S, Skinner A, Bromley M, et al. (July 07, 2016) UltrasoundAssisted Distal Radius Fracture Reduction. Cureus 8(7): e674.

4. 4. Ultrasound G.E.L. - POCUS in the Reduction of Distal Radius Fractures. emDOCs.net - Emergency Medicine Education. http://www. emdocs.net/ultrasound-g-e-l-pocus-in-the-reduction-of-distal-radiusfractures. Published February 7, 2020.

Conclusion Displaced extremity fractures are a common presentation in the ED that can be time and resource intensive. This case report highlights using POCUS not as a replacement, but rather a supplement to traditional X-ray to assist in reduction that can increase efficiency and efficacy.

POCUS is an effective tool and aid in displaced extremity fractures. 

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 • We’re committed to diversity, equity, and inclusion – The AAEM closely with the sponsors of newly introduced legislation.

Diversity, Equity, and Inclusion Committee is working hard to bring members resources and awareness, including statement on the Death of • We’ve had your back during COVID-19 — Read our position statements George Floyd and the Statement Against Federal Regulation. and letters to government officials advocating for you during this pandemic.

• We joined the clear message being sent that #ThisIsOurLane. We are the front line providers, and we will be at the forefront of the • We protect your practice rights — We’re actively working to address solution, which is why we signed on to support AFFIRM. 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 Learn more at www.aaem.org/whyaaem with the newly formed EM Workforce Committee for a future with a balanced work force.

Join/renew today: www.aaem.org/membership

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COMMON SENSE NOVEMBER/DECEMBER 2020

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AAEM NEWS

COVID Lays Bare an Emergency Medicine Crisis Terrence M. Mulligan, DO MPH FAAEM

Many people who are involved in emergency medicine got into it for the right reasons: wanting to help people, wanting to be able to take care of anyone, anything, anytime, being able to offer assistance when nobody else has been able to in the health care system. However, the emergency department has turned into something else. It has been turned into an overflow pressure valve on a mismanaged hospital system, like on a bathtub.

If the hospital is getting full or if it’s too expensive to staff a hospital the way it should be, hospitals turn the emergency department into an extra catchment area. Hospitals should be run at 85% capacity with a lot of room for overage and surges, with a system for calling in extra staff and capabilities when necessary. Instead, hospitals often choose to run on very thin margin: 95% capacity, shutting down wards and wings of the hospital on a weekly or monthly basis because of the cost of staffing.

Emergency departments then swell and become overcrowded.

One of the characteristics of the emergency department is an open front door. You cannot close the front door and we do not want to close the front door. We want to be open 24/7/365 for anyone, anything, anytime.

The problem is, the back door of the ER is often closed, at least partially.

Therefore, when people come in, they’re seen by emergency physicians and the emergency professionals and we do our emergency care and we make a decision of whether the patient needs to be admitted or whether they are able to be discharged. We intend to provide definitive care or appropriate care with definitive care to follow such as at referral clinics, et cetera. However, when we make the decision to admit, we often cannot because the hospital is mismanaged or full because of mismanagement. We can’t make proper decisions of proper follow-up.

Sending patients to other primary care doctors, specialists, social workers, behavioral health resources, or drug and substance abuse referral agencies is often dysfunctional because those agencies are not staffed well. After their initial acute, episodic treatment, patients come right back to us because of improper admission capability or improper follow up. We really are Jacks-Of-All-Trades, and we are being taken advantage of.

We want to be open 24/7/365 for anyone, anything, anytime.

This is the situation I think that this pandemic has shined a giant spotlight on: the emergency department is taking care of much more than just sick people. The department takes care of hospital problems, staffing problems, hospital management problems, insurance problems, economic problems, social problems, and we’re really the catch all of the health care system. A lot of this contributes to the emergency system being run in the red for too long.

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Every now and then, a crisis such as this once in a hundred year viral pandemic comes on.

However, the crisis of emergency medicine is not a one in a hundred-year crisis — it is ongoing. This pandemic is just pulling the curtain aside to show the real state of the emergency system: it is running on fumes. People are running to take care of too many patients. I often think of the video of Lucille Ball and Ethel Mertz from the I Love Lucy show, where they are standing at the conveyor belt trying to wrap up chocolate. I think that is a good analogy of us in the emergency department. We do incredible work. We see patient after patient. Fifty one percent of all hospital care in the U.S.A. is delivered in the emergency department, and one third of all the patients who come in the emergency department are sick enough to be admitted. Additionally, between 60-80% of all hospital income comes from emergency department admissions. Therefore, within the hospital, the emergency department is the economic engine, the admissions engine, and the patient safety engine. When we do things right in the emergency department, it makes the whole hospital run better.

This pademic is like a stress test for the whole health care system.

When we run the emergency department well, we diagnose and stabilize patients as much as we can. That makes a hospital run better. We streamline systems hospital by hospital, it makes all the hospitals run better. In turn, the situation on the floor of the hospital becomes a slow simmering boil instead of a rolling boil flowing over the top of the pan.

Emergency physicians provide tremendous value to our patients’ safety, and to hospitals’ stability. Despite this, emergency physicians do not own or control the value we create. Our created value has been usurped and taken away from emergency physicians, then dispersed to contact management groups, hospital management groups, insurance companies, and other administrative groups. Each of these parties is taking the value created by emergency physicians, profiting off of it, and sometimes mis-managing it. We are then asked to work harder: to pick up the slack and take care of more and more. Imagine a hospital with an emergency department on the first floor. The patients come in the front door of the hospital: the ER. They don’t go into the hospital correctly and they don’t

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AAEM NEWS The Bare Bones — COVID Lays Bare an Emergency Medicine Crisis

get out of the hospital directly. The emergency department is left getting more and more full. The patients only get sicker. It is like stepping on a hose. You step on the hose and it starts to swell, but there’s only so much swelling the system can handle. I think the emergency department in almost every hospital is running at or very near the breaking point.

The COVID-19 crisis has pushed us over the edge. It is a curse, but also brings blessings by forcing everyone outside our environment to cast the curtain aside and see what is truly happening.

The pandemic has revealed how our health care systems lead to mismanaged emergency rooms, and exploited emergency physicians.

The people who are employing emergency departments are benefiting off the extreme value we offer. They are not reinvesting that value in emergency departments, but instead taking advantage of it and asking for more. That is part of what led to the burn out we see in emergency physicians. Fifty years ago, the people who were working in emergency departments were not trained in emergency medicine because there was no formal training. After the first fifteen or so years of training, we found burnout levels went down amongst emergency physicians because they were trained. It makes sense that if you train people to work in a certain stressful environment and show them how to manage some chaos, their stress levels go down. Unfortunately, burnout rates have gone up again in the last ten or so years, particularly for emergency physicians.

medicine organizations to respond well to this crisis-- not just the pandemic, but the underlying emergency medicine crisis. Then, if and when things re-normalize, we can move forward to a new normal: a better normal. Somebody did a study of CPR and defibrillation depictions on television and in the movies. The study showed that on television, something like eighty percent of people who undergo CPR wake up, start walking, and are fine. Real statistics show CPR is usually not successful.

The real survival rate is more like 15% than 80%. There is an analogy here for the emergency system. Right now, the emergency system is undergoing CPR. The emergency system is failing its stress test. When you push the emergency system too far, not only does it threaten itself but it poses a risk to the general health care system because of its crucial role.

So it’s like a stress test: a patient undergoing a stress test whose heart and system can’t handle running at their peak speed will sometimes collapse and have a heart attack. Our community is on the brink of that happening.

In the past, I’ve always said running an emergency patient through the health care system is like a stress test for the hospital. This pandemic is like a stress test for the whole health care system. The results are in, and we see the emergency system failing. Emergency care has been run at near capacity or overcapacity levels for decades. Now, this crisis is pulling the curtain aside and shining a spotlight on the long-term effects of this chronic mismanagement. As a board member of the American Academy The reason for an increase in burnout is not because doctors have an of Emergency Medicine, as a vice president of the International imbalance between work and home life, nor is it due to a lack of proper Federation for emergency medicine, and as somebody who’s been helpmindfulness. We are suffering from abuse. In a sense, burnout is not the ing build emergency medicine systems in over proper term because it places all the blame on the forty countries for the last twenty years, I’m very victim. It would be like blaming soldiers for the shell concerned. I am concerned about building sustainshock or post-traumatic stress disorder they have able emergency systems in other countries, so they The department takes endured. Burnout is not the fault of the physician. don’t fall victim to their own success the same way Burnout is abuse. Emergency health professionals care of hospital problems, we have here in our country. of all titles are being abused. The department is staffing problems, hospital suffering abuse by systems: corporations, insurTranscribed and edited by L. Esther Hibbs, management problems, ance companies, hospitals. There is only so much Managing Editor, EPi Magazine. more abuse that we can take before the system will insurance problems, This article was first published by Emergency crack. In this way, though the underlying crisis has economic problems, social Physicians International and is reprinted with perbeen made worse by the pandemic, we can now missions. ©2020 EPi www.epijournal.com/about problems, and we’re really shine a big spotlight on the harsh realities of emerDr. Mulligan also runs the the Global Emergency gency medicine right now. the catch all of the health Medicine Initiative blog. Learn more at www.gemi. care system.

This crisis offers the opportunity to position ourhealth/blog.  selves as individuals and the greater emergency

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AAEM NEWS

COVID-19 and the Bursting Bubble of ER Management Terrence M. Mulligan, DO MPH FAAEM

My name is Terry Mulligan. I’m on the Board of Directors of the American Academy of Emergency Medicine (AAEM), and I’m currently the Vice President of the International Federation of Emergency Medicine (IFEM).

Over the last 20-25 years or so, I have been deeply involved in emergency medicine, international emergency medicine, and global emergency medicine development. I think all of us are up to our ears with working in the ER and taking care of all of our emergency patients – a job that’s been increased and intensified especially the last six or eight months because of the unfortunate COVID-19 pandemic. I say this is unfortunate because a lot of this overwork and high stress for emergency physicians and for the health care system potentially could have been avoided.

I think over the last weeks and months, this pandemic and its crippling impact on our emergency care system within the health care system has pulled the curtain aside and laid bare the already overwhelming, overworked, overstressed state of emergency medicine, the emergency departments of hospital care, and the health care system in general. I think it’s obvious that this pandemic has had a huge effect on almost every aspect of our society – not just health care. It’s also shown how many of these different systems previously looked at as standalone or disconnected are deeply connected.

For example, the economic impact of the pandemic is directly affecting the health care system and its proper functioning because so

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much of the United States’ health care system depends on the state of the general economy, the state of people’s employment, and the insurance that often comes with the people’s employment (or the lack thereof. I think this pandemic has the chance to pull the curtain aside on a crisis we’ve been facing in emergency medicine for probably 15 or 20 years.

The crisis is that in lots of areas of medicine and in health care in general, but in the emergency department specifically, the current business and economic structure of the health care system forces us to run health care on a very thin margin. Now, it is being laid bare and made obvious to almost anybody who wants to or cares to look at it.

problem even before the COVID-19 crisis, but I think the pandemic really put this into the forefront of our minds. The pandemic has served as a stress test for the health care system. It shows the system was already running in the red. Under standard circumstances, it is not safe to keep an engine running in the red, and we are running at 7000-8000 RPM. Then, when a crisis such as the pandemic comes along, it becomes clear there is not any extra capacity in the system left over to take care of even a small surge, much less a giant surge like what has happened here. Maybe one of the only good things to come out of this is the giant spotlight now shining on how the health care system and the emergency system has been running on very low resources. Hopefully, people outside the field of Emergency medicine will see how the system can really improve itself after we get through the current crisis.

The health care system is looking to the emergency department as a cleanup crew the emergency department serves a multiple layered safety net.

This pandemic has hit the emergency department in a multitude of ways. In a material sense, the effects include shortages of personal protective equipment (PPE), of ventilators and medications, and other emergency care resources. Interpersonally, effects include staffing problems with physicians and other health care workers becoming sick and risking their lives along with those of their family, and risking being fired for speaking out against patient safety issues or PPE issues. Being fired or transferred for this is unfortunately common for us. It is important to show how the corporate practice of medicine has crippled emergency services in the USA. This was an obvious

In the next 6 to 12 months, we will probably have some sort of vaccine. Within the next 12 to 18 months, we could potentially be out on the other side of this crisis. Between now and then, I hope we will continue to shine the spotlight on the emergency care system’s vital role in hospitals, the greater health care system, and the general economy.

Training people to take care of acute unscheduled emergencies is a relatively new concept.

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COMMON SENSE NOVEMBER/DECEMBER 2020

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AAEM NEWS The Bare Bones — COVID-19 and the Bursting Bubble of ER Management

Emergency medicine is just about 55 years old in the United States and the United Kingdom. In most other places around the world, it is much younger than that. This skillset has not been adopted around the world, but unfortunately has also been abused in the USA.

go to their primary care doctor or didn’t take their medicines, so they come in with an acute emergency that potentially could have been prevented with good primary care coverage. We are also the safety net for patients who have conditions their primary care services cannot care for. We do not know everything about medicine yet, so sometimes when you have an acute medical emergency it does not matter if you’ve had good primary health care: you still need acute care now. If somebody has chest pain or breaks their arm right in front of their primary care physician’s office, those people often still go to the emergency department.

In each sense, we are the primary safety net for patients.

One of the books that has been written about emergency medicine history in the USA by Dr. Brian Zink is entitled “Anyone, Anything, Anytime.” The book explains how we have prepared ourselves to take care of all emergencies. I think we have done this very well clinically, scientifically, and academically. After a very initial, short period of inquisitiveness and resistance from the rest of the health care world, It has turned into a harsh remindThe second layer of the I like to imagine the er to “be careful what you safety net is for other emergency department as the ask for, because you just specialists. Almost cleanup crew following behind the might get it.” When we everywhere, inside and asked for “anyone, anyMardi Gras parade, sweeping up debris outside of the U.S.A., thing, anytime,” the rest there is a huge shortand the refuse left behind after of the health care system age of other medical the parade goes through. eventually said, “Fine, take specialists: neurosurgeons, it! You want the nights, you neurologists, orthopedists, want the weekends, you want the cardiologists, pediatricians, etc. holidays, you want social problems, you Not only do patients have trouble getwant the behavioral health problems, you want ting timely appointments, but specialists are the patients who have fallen through the cracks few and far between, with restricted hours. of the rest of the health care system – you can They often cover multiple hospital systems have them!” The health care system is looking and patients must wait weeks or months for an to the emergency department as a cleanup appointment or a referral, even from the emercrew the emergency department serves a mulgency department. In turn, we act as a safety tiple layered safety net. net for the other specialists.

I think a lot of people might be familiar with how the emergency departments serve as a safety net for patients: patients who have nowhere else to go. These are patients who might not have insurance, patients who have no insurance or are underinsured and therefore did not

To me, the most important part offered by emergency department services is the third layer: we are really the safety net for the cracks and the holes in the health care system. Our health care system is not perfect. We have tens of millions of people who are underinsured or

uninsured. The health care system does not give equal health care to people from different types of socio-economic status and different geographic areas. The system has a lot of cracks and people who are not treated well either intentionally or unintentionally by the health care system often come into the system as emergencies. This completes the triple safety net: we’re the safety net for patients with nowhere else to go, we’re the safety net for the specialists, and we’re also the safety net for the hospital and for the health care system in general. We are there to catch people who fall through the cracks.

I like to imagine the emergency department as the cleanup crew following behind the Mardi Gras parade, sweeping up debris and the refuse left behind after the parade goes through. I think our health care system is surprisingly good, but it doesn’t serve everything. The system does not serve patients in the emergency department. In one sense, we are victims of our own success. We have accomplished a significant amount, well: critical care, emergency care, acute episodic care, and streamlined patient entry into the health care system. In fact, we have done it so well that the rest of the hospital system relies on us. They take advantage of us.

Transcribed and edited by L. Esther Hibbs, Managing Editor, EPi Magazine.

This article was first published by Emergency Physicians International and is reprinted with permissions. ©2020 EPi www.epijournal.com/ about Dr. Mulligan also runs the the Global Emergency Medicine Initiative blog. Learn more at www.gemi.health/blog. 

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It has been a great experience watching the growth that has occurred for women in emergency medicine.

CHAPTER DIVISION REPORT AAEMLa

Women Leading the Way in Emergency Medicine Meredith Hall, MD FAAEM and Vanessa Piazza, MD FAAEM

The Louisiana Chapter Division of AAEM was guided by an all female executive board for the 2019-2020 term. AAEM’s National Women in Emergency Medicine Section has a purpose to “champion the recruitment, retention, and advancement of women in emergency medicine through the pillars of advocacy, leadership, and education.” In October of 2019, Louisiana held its elections for its chapter division of AAEM. For the first time, the executive board consisted of all females. Dr. Meredith Hall, who took the reigns from her friend Dr. Shannon Matthews as President states, “I had served AAEMLa on the board in a minor role, and I felt it important to seek leadership in a primary role.

I learned about AAEM from Dr. Larry Weiss, one of the faculty who trained me at Charity Hospital and a former AAEM President. He helped me get involved in AAEM Oral Board Review Courses as a mock examiner, but I had never taken on a leadership role. After working as an At-Large Director and planning our state Residency day the year before, I felt I was in a position to lead. It was important for me to

recruit strong members of our profession. When no one stepped up, I turned to some of my female colleagues, who all accepted the challenge.” The Vice Presidency position was held by Dr. Vanessa Piazza and the Treasurer Position was held by Dr. Christine Butts. All of these women, including Dr. Matthews, trained in New Orleans at Charity Hospital with just a few years separating them. Dr. Piazza states, “I felt honored to be invited by Meredith Hall to the leadership role of Vice President of AAEMLa. As there are several other women on the board for our residency program, I commend Dr. Van Meter, our section head at Charity Hospital, for fostering an environment which promotes female leaders and motivates faculty development. Personally, I believe that doing your best at the moment puts you in the best position for the next moment. Regarding females in leadership roles, I feel women make great leaders because we are strong communicators, flexible, compassionate, good at multitasking, team players, and can leave our egos in check.” Hall added, “My biggest challenge has been to expand our leadership role beyond just faculty attendings. Last year, my personal resident representative was one of our female chiefs, Dr. Jen Oswald. Following that, Dr. Brianna Wapples was elected, and the

membership of our extended board includes other exceptional female physicians, including Dr. Luann Barnett and Dr. Eden Hamyouen.”

The female leadership in Louisiana extends even farther as one of New Orleans second year residents currently serves on AAEM/RSA Board for AAEM, Dr. Jordan Vaughan. Recently, Dr. Hall was able to add a medical student back to the board by holding a statewide election which resulted in, yes, another female, Abby Olinde, a student at LSU New Orleans, taking that role. Of course, it goes without saying that the national president, Dr. Lisa A. Moreno, is currently a fellow faculty member in New Orleans. And all of them are guided nationally by AAEM Staff, Mrs. Kathy Uy. September is Women in Medicine month, as recognized by the American Medical Association. The theme for 2020 is: Advancing Equity, Creating Change. Dr. Hall recognizes the changes that have occurred with regards to women in medicine over the past 20 years. “We are respected by our peers for our knowledge, we are regarded as equals, and the births of our children are celebrated. It has been a great experience watching the growth that has occurred for women in emergency medicine. I know we will continue to lead and create a better path for the women who will follow us.” 

Personally, I believe that doing your best at the moment puts you in the best position for the next moment.

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COMMON SENSE NOVEMBER/DECEMBER 2020

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INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

SOCIAL EM SPOTLIGHT: DR. DARIN NEVEN

Putting Emergency Medicine Ingenuity to Work in Service of Marginalized Patients Sara Urquhart, BSN MEd and Megan Healy, MD FAAEM

Tell us about your practice.

I’m in an independent democratic practice at a 600-bed hospital that has 90,000 visits per year in Spokane, WA, which is in Eastern Washington near Idaho.

How did you first become interested in social EM?

This month we spoke with AAEM member and Social EM pioneer, Dr. Darin Neven. Dr. Neven introduced impactful programs beginning in his home hospital, then expanded to state and regional initiatives. He also founded and serves as CEO of the medical professional services company Consistent Care.

I moved to Spokane in 2005 and there were a lot of social needs in a downtown area with a lot of homelessness and drug use. I felt like we weren’t helping some patients and I had to do something about it if I were to continue working there. The one patient that got me started had 80 visits in a year related to alcohol use. There were resources to help him outside the ER, and if I went through his hundreds of records, I could figure out his story.

What was your first social EM endeavor?

At the time, all hospitals in Spokane used the same EMR. We created a module in the shared EMR so that every doctor could see a summary of the patient’s story and recommendations for their care. Together with software developers, we created an ED care guideline summary. A multidisciplinary committee developed the plans with social work, pharmacy, and nursing input. We included the patient’s case manager and contact information. The plan allowed the doctor to build upon what had been done before.

The biggest challenge is patient buy-in and funding—you have to get health programs to realize they need to invest in their “costliest” patients.

How did you generate these reports and get buy-in from your team?

We generated these reports on patients with frequent visits and we had a dedicated case manager funded quarter-time. She wrote the guidelines, presented at an interdisciplinary meeting, and reached out to the patient to help with medical and mental health treatment. ER doctors love already-synthesized information, so if there is a concise summary from a reliable source, they use it.

Many emergency physicians struggle to address seemingly intractable challenges like homelessness and substance use disorder. They feel burned out, disempowered and disincentivized from helping. Others see opportunity to make change and put the strengths of our specialty — empathy, creativity, adaptability, and systems expertise — to work for patients most in need.

In this feature, we will spotlight AAEM members changing the game for patients and physicians by addressing social emergency medicine issues head on.

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What other social EM programs have you initiated?

Many of the programs involve intensive case management in partnership with nurses. I believe that nurses are uniquely qualified to do medical social work because they can help the patient navigate the system. We developed a readmission avoidance program with an assessment and checklist where we see discharged patients within a day of being discharged and then follow them for a month.

We also developed the Bridges program for patients that are homeless and have debilitating conditions. Our intensive nurse case management team can take them all the way through rehab, substance use disorder treatment, and outpatient mental health. We then have employment and housing navigators that help find housing and jobs. The biggest challenge is patient buy-in and funding—-you have to get health programs to realize they need to invest in their “costliest” patients.

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INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

What would you say are aspects of a successful social EM endeavor?

I like to look for the triple wins—something that is not only good for the patients, but that is also good for the community and health plans. If the health plan sees savings and you’re helping the patient and community, it’s a triple win. Having connections in the community is vital. The ER can often be isolated, which makes social EM impossible.

While social EM endeavors benefit both the hospital and community, the fact that it’s independent groups coming up with these shows the value they have to their community.

How do you go about approaching your hospital administration or the health plans to get something going?

If you have a few cases, you can go to your hospital or health plan and show it can be done.

In medicine there is a lot of inertia not to change, but if you can show that you’ve already successfully done it and you can pencil out the savings, you can get a pilot. Say “we just want to do one patient a month or 10 patients a year.” Let the program speak for itself and show the staff that you’re finally doing something about a problem. You have to be unafraid to cold call and use connections. Pick up the phone or email the medical director—outline the problem and your solution.

Why should AAEM members in particular be interested in social EM topics?

There is an economic case to be made for social emergency medicine. We are spending a lot to incarcerate, hospitalize, and put patients in homeless shelters and multiple rounds of treatment.

That spending is hard to measure, but if you have a program that can show those savings, it’s an entrepreneurial opportunity. I have also not seen CMGs come up with these programs. While social EM endeavors benefit both the hospital and community, the fact that it’s independent groups coming up with these shows the value they have to their community.

What is your response to physicians who say “this isn’t my job?”

It will make your life easier. Once, in the history of emergency medicine, trauma was seen as a drudgery. It was hard to get various specialists to rally around a complex patient with severe trauma. Now we have developed trauma teams, trauma surgeons, trauma ICUs. In EM, if it’s something you hate, it’s probably because you don’t have the resources to deal with it. I’ve found it’s very rewarding to learn ways to help vulnerable people because then it’s another tool you have and you don’t feel you’re letting people down. If you feel you can’t address problems like SUD and homelessness in the ER, you’re going to feel inadequate. But if you learn these ways, it is very rewarding. I love going into a room and seeing a patient with a horrible addiction and knowing exactly what I’m talking about with regards to addiction treatment, housing, and being able to do a really good referral. That is one of the most rewarding parts of my job.

References 1. Murphy SM, Howell D, McPherson S, Grohs R, Roll J, Neven D. A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation. J Emerg Med. 2017 Aug;53(2):186-194.

2. Neven D, Paulozzi L, Howell D, McPherson S, Murphy SM, Grohs B, Marsh L, Lederhos C, Roll J. A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

J Emerg Med. 2016 Nov;51(5):498-507.

3. Murphy SM, Neven D. Cost-effective: emergency department care coordination with a regional hospital information system. J Emerg Med. 2014 Aug;47(2):223-31.

Do you know an AAEM member who should be featured for their social emergency medicine or population health expertise? Send ideas to: info@aaem.org. 

COMMON SENSE NOVEMBER/DECEMBER 2020

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INTEREST GROUP REPORT PALLIATIVE CARE

Create a LIFEMAP for Goals of Care Discussions during a Pandemic Austin J. Causey, MD

After searching through the nursing home records, you’ve finally found a family member’s phone number. Your patient is a 91-year-old woman with a history of dementia, hypertension, and kidney disease. She just arrived from a nursing home where residents have tested positive for COVID-19. Her temperature is 39°C; she’s hypoxic and tachycardic.

After you dial her daughter’s number and wait for an answer, you realize you don’t know what to say. Is there a tactful way to ask about code status? Should you tell the daughter that her mother may be critically ill

or dying? Will you have the time to understand the patient and family’s wishes before your next critical patient arrives?

As emergency medicine physicians we are trained to be proceduralists.

Procedures have steps. In a lumbar puncture, first we position, then we sterilize, and finally we insert the needle. Goals of care conversations are no different. To reinforce consistency and efficiency, goals of care conversations should be discussed in a stepwise manner. The following is an approach to COVID-19 goals of care conversations for emergency medicine physicians adapted from VitalTalk.

M Map Important Values 

L Lead the Conversation

Take initiative and start the difficult conversation. Oftentimes, people are eager to talk. “How are you feeling about this? Would it be okay if we talk about what happens if your mom gets worse?”

I Invite Perspective

Most likely, patients and families have thought about COVID-19 before arriving in the emergency department. Inquire about their thoughts: “Have you or your family thought about what might happen if you are infected with COVID-19?”

Always remember to document the conversation in the patient’s chart so their wishes are carried out by other providers. As with any procedure, goals of care discussions are billable when well documented. Mention who was involved in the decision making, how long the discussion lasted, and what was decided. Fill out any POLST or power of attorney forms if necessary.

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F Focus on Accurate Understanding

It’s important that patients’ and their families have an accurate picture of the clinical situation. Be open with them and always ask permission first. “Would it be okay if I add my perspective on what COVID-19 might mean for you?” Be clear: “Unfortunately, many patients with your illnesses who are infected with COVID-19 are unlikely to survive if they are put on a ventilator.”

E Expect Emotion and Demonstrate  Empathy Offer understanding “I can’t imagine how difficult this news is to hear.” And try naming their emotions “Anyone in your shoes would feel overwhelmed and scared.”

These conversations are very challenging and it can be helpful to know what to say. Don’t be afraid to refer back to these phrases to spark a more meaningful discussion. Unlike many procedures, goals of care discussions can be especially hard on the physicians initiating them.

Your patients and their families will be thankful you spent the time to understand their wishes.

You’re trying to understand your patient’s wishes so that you can make a recommendation that will stick. Ask about hopes and worries. “Given what COVID could mean for you, what are you worried about? Is there anything you’re hoping for right now?” “If we think this disease could be fatal, can you let us know what’s most important for you/your family member?”

A Align Yourself Explicitly

Before you suggest next steps, make sure your patient or their family knows that you’ve heard them. “I want to make sure I am understanding you correctly, this is what I have heard so far.”

“It sounds like your mother wanted to die as peacefully as possible, is that right?”

P Plan and Personally Reflect

Ask permission and make a recommendation; patients and families are looking for guidance.

“Given what we talked about, I recommend we move forward like this...” “What we will do… what we won’t do…”

Curious about ways to access this information quickly on a busy shift? Try downloading VitalTalk’s iPhone or Android app “VitalTips.”

On the app, you can find COVID specific guides on how to talk about various COVID related topics from grieving to resource allocation.

Learn more at: www.vitaltalk.org. 

COMMITTEE REPORT GOVERNMENT AND NATIONAL AFFAIRS

Update from the Government and National Affairs Committee Kevin H. Beier, MD FAAEM

With fall upon us and the year so far consumed with the stress

We remain active on several important issues, including peer review/due process, balance/ surprise billing, and independent/ unsupervised practice by PAs and NPs.

While it was certainly a unique experience to do these visits virtually, the Academy felt it was important to convey our message to Congress even while the Capitol remained closed to the public.

We are monitoring the activity of these bills and intervening on the state level when appropriate. The Academy encourages all its members to be active at the state level and to become familiar with your state representative and senator.

of the novel coronavirus, many of us would be willing to take a mulligan for 2020. We all hope for a better next year and a vaccine. Nevertheless, the leadership of AAEM continues to fight for the Academy’s membership at both the federal and state levels. We remain active on several important issues, including peer review/due process, balance/surprise billing, and independent/unsupervised practice by PAs and NPs. Academy leaders and other selected AAEM members typically visit Washington, D.C. at least once a year, to sit down with Members of Congress and staff, as well as executive branch regulators, to discuss issues important to emergency physicians and our patients. Due to SARS-CoV-19, our visit on September 15, 2020 was virtual instead of actual. During these many virtual visits we shared our insights on the pandemic and the other issues mentioned above with Members on both sides of the aisle.

We accomplished a number of things, including securing additional support for federal legislation (HR 6910) to guarantee due process rights for emergency physicians. This is one of AAEM’s highest legislative priorities and one we have been pushing for several years. Medical staff due process rights are critical to emergency physicians, and afford us the protection from arbitrary and unfair treatment we need to be strong advocates for our patients. We also continued to educate legislators and staffers on solutions to the balance/surprise billing problem, emphasizing the importance of protecting patients rather than the insurance industry, while making sure rural hospitals and independent physician groups aren’t wiped out in the process. A memorable highlight of these virtual visits was a Zoom meeting with eight Members of Congress hosted by Rep. Raul Ruiz (D-CA), an emergency physician and a champion of our specialty. We also had a great conversation with Rep. Mark Green (R-TN), the House’s other emergency physician. Our final meeting of the day was with Dr. Ronny Jackson, a Texas emergency physician who will soon join Drs. Ruiz and Green in Congress. While it was certainly a unique experience to do these visits virtually, the Academy felt it was important to convey our message to Congress even while the Capitol remained closed to the public. We were excited by the level of engagement we saw from the Members and senior staff we met with, and it was a highly productive day of virtual meetings.

On a state legislative note, Dr. Maria Paone and the EM Workforce Committee have been very active on the independent/unsupervised PA and NP practice issue, which the Academy views as a threat to patient welfare and safety. We are monitoring the activity of these bills and intervening on the state level when appropriate. The Academy encourages all its members to be active at the state level and to become familiar with your state representative and senator. Another great way to become engaged at the state level is join your state medical association. The expense is well worth it and many states have very engaged and active medical associations. And join your AAEM state chapter division if you have one!

Don’t forget to vote on or before November 3. Keep safe, and if you have any questions on legislative or regulatory issues, AAEM’s Government and National Affairs Committee is always ready to help. 

COMMON SENSE NOVEMBER/DECEMBER 2020

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COMMITTEE REPORT OPERATIONS MANAGEMENT

Why Residents Should See the Waiting Room: A Case for an Introduction to Patient Experience Earlier in Postgraduate Training Kelsey Dorwart, MD and Kraftin E. Schreyer, MD CMQ FAAEM

During postgraduate medical education, emergency medicine (EM) residents spend countless hours honing their clinical skills. By the end of intern year, trainees gain procedural competence, manage many patients autonomously and have begun to develop the backbone for their future clinical practice. While clinical competence is an essential component of the practice of EM, a well-rounded physician must also have knowledge of how their patients experience the clinical care they receive.

Emergency department (ED) administration encompasses many of the nonclinical aspects of EM, including ED throughput, operational metrics, financial principles, policies and procedures, and patient experience.1 While few studies directly assess the quantity, quality and duration of EM resident exposure to ED administration, a 2014 study reported that 93% of EM residencies included at least one administration lecture and roughly half had a formal administration curriculum.2 As of 2018, 53% of three-year programs and 70% of four-year EM programs designate administrative blocks within the curriculum ranging from one to five weeks in duration. Across all programs, administrative blocks are scheduled almost exclusively during the final year of residency.3

While a complete overhaul of administrative education in most EM curricula is not feasible, introducing patient experience early in residency has few drawbacks and many potential benefits.

Reserving curricular inclusion of ED administration until late in training may be doing learners a disservice. An informal survey of EM residents at an urban academic medial center in January of 2019 demonstrated that most EM interns could not accurately describe the path of a patient from the hospital parking lot to an ED treatment bed. It is likely that this finding is generalizable to other ED training programs, and that processes such as triage, specific departmental protocols and procedures, and the geographic location of the waiting room, all of which are at the intersection of patient experience and clinical care, had not been addressed in the first six months of training. Just as we expect residents to take clinical “ownership” of their patients starting on July 1st, trainees should also have an understanding of patient

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experience and how they, and their department, influence that experience. This “ownership” of their patients’ experiences, should parallel their growth in clinical accountability.

Early introduction of patient experience would benefit EM resident education in several ways.

Gaining appreciation for patient experience and patient facing processes will likely help residents empathize with patients in the setting of long wait times and through potentially challenging interactions with staff. Learning how nurses see orders and the many tasks they perform will likely foster a sense of multidisciplinary camaraderie and team dynamic, which may allow for better interactions in front of patients. Additionally, it would provide insight into the structure behind how clinical care is actually delivered.

Most EM programs include an intern orientation as part of the curriculum.5,6 According to the most recent survey of EM training programs, 9.6% include some form of administrative activity.6 However, patient experience was not a routine component of clinical, didactic, or administrative activities.

Our newly revamped orientation program attempts to address patient experience through a four-hour session titled the “ED Experience.”

This session begins with a 50-minute tour of the department lead by senior residents featuring all patient facing processes preceding physician evaluation, including Triage 1, Triage 2, and the waiting room. Each intern spends time in each area, as if they were a patient.

The tour then transitions to each type of treatment room or space in the department, such as the resuscitation bay, high acuity zone, and low acuity zone, and encourages attendees to imagine how they would perceive being treated in each area.

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COMMITEE REPORT OPERATIONS MANAGEMENT

As patient experience also hinges on ED flow and wait times for each phase of care, the following two-hours are dedicated one on one direct shadowing of veteran ED nurses. In this part of the session, new residents learn about nuanced aspects of care, such as the tube system, printing labels for blood samples, nursing evaluations, bedside triage, and operating the monitors and beds, among others. The final hour is spent shadowing senior residents working clinically and encouraging attendees to appreciate how many essential background processes in the ED are nearly invisible during the practice of clinical EM. An awareness and acknowledgment of these hidden processes should help trainees keep their patients updated and better explain the clinical care they are providing and any waits associated with that care.

While a complete overhaul of administrative education in most EM curricula is not feasible, introducing patient experience early in residency has few drawbacks and many potential benefits.  ď Ź References 1. Perina DG, Brunett CP, Caro DA, et al. The 2011 Model of the Clinical Practice of Emergency Medicine. Acad Emerg Med. 2012;19(7):e19-e40. doi:10.1111/j.1553-2712.2012.01385.x 2. Watase T, Yarris LM, Fu R, Handel DA. Educating Emergency Medicine Residents in Emergency Department Administration and Operations: Needs and Current Practice. J Grad Med Educ. 2014;6(4):770-773. doi:10.4300/JGME-D-14-00192.1 3. Gottlieb M, Arno K, Kuhns M, Chan TM. Distribution of Clinical Rotations Among Emergency Medicine Residency Programs in the United States.

AEM Educ Train. 2018;2(4):288-292. doi:10.1002/aet2.10117 4. Dawson B, Carter K, Brewer K, Lawson L. Chart Smart: A Need for Documentation and Billing Education Among Emergency Medicine Residents? West J Emerg Med. 2010;11(2):116-119.

5. Brillman JC, Sklar DP, Viccellio P. Characteristics of Emergency Medicine Resident Orientation Programs. Acad Emerg Med. 1995;2(1):25-31. doi:10.1111/j.1553-2712.1995.tb03075.x 6. McGrath J, Barrie M, Way DP. Emergency Medicine Resident Orientation: How Training Programs Get Their Residents Started. West J Emerg Med. 2017;18(1):97-104. doi:10.5811/westjem.2016.10.31275

While clinical competence is an essential component of the practice of EM, a well-rounded physician must also have knowledge of how their patients experience the clinical care they receive.

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Non-Invasive Average Volume Assured Pressure Support for Acute Hypercapnic Respiratory Failure: A Case Study and Novel Approach John O’Donnell, DO; Nicholas Roy, DO; Jonas Salna, DO; and Joan Wiley, DO

Introduction Key Words AVAPS, acute hypercapnia, average volume assured pressure support, noninvasive positive pressure ventilation

Abbreviations ABG: Arterial blood gas AVAPS: Average volume assured pressure support BiPAP: Bilevel positive airway pressure COPD: Chronic obstructive pulmonary disease CPAP: Continuous positive airway pressure EIP: Effective inspiratory pressure IBW: Ideal body weight ICU: Intensive care unit IPAP: Inspiratory positive airway pressure IPAPmin: Minimum inspiratory pressure NIPPV: Non-invasive positive pressure ventilation Vt: Tidal volume

Non-invasive positive pressure ventilation (NIPPV), delivered via a facemask, has been shown to reduce morbidity and mortality in acute hypercapnic respiratory failure.1-3 Traditionally, non-invasive ventilatory support is provided using continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) modes. Average volume assured pressure support (AVAPS) has been studied extensively in the treatment of chronic hypercapnic respiratory failure, yet there is limited data regarding its use in the acute setting.3 We present a case followed by a novel approach to the treatment of acute hypercapnic respiratory failure utilizing AVAPS mode.

Case A 54-year-old female with a past medical history significant for chronic hypercapnic respiratory failure, tobacco abuse and chronic obstructive pulmonary disease (COPD) presented with increasing shortness of breath and somnolence. She was found obtunded by her family and brought via ambulance to the emergency department for evaluation. An arterial blood gas (ABG) was obtained on 6 Lpm via nasal cannula: pH 7.29, PaCO2 82 mmHg, PaO2 74 mmHg, HCO3 39 mEq/L. The patient was placed on BiPAP 14/6 mm H2O and admitted to the telemetry floor. While on the medical floor, a rapid response was called for persistent hypersomnolence. During the rapid response, a second ABG was performed and was unchanged at pH 7.29, PaCO2 84 mmHg, PaO2 75 mmHg, HCO3 40 mEq/L. Her BiPAP was titrated to 20/6 mm H2O and she was moved to the intensive care unit (ICU). Despite titration of her inspiratory pressures, she remained somnolent and a third ABG revealed continued hypercapnia with a pH 7.24 and a PaCO2 of 84 mmHg. Discussion with the family included a recommendation to proceed with endotracheal intubation. Due to the patient’s underlying COPD, the family expressed concern regarding intubation and the possibility of failure to wean and subsequent need for tracheostomy. The decision was therefore made to trial her on AVAPS before proceeding with endotracheal intubation. She was placed on AVAPS with a goal tidal volume (Vt) of 400 ml. Within one hour, her encephalopathy and hypersomnolence resolved.

Repeat ABG showed improvement with a pH of 7.37 and a PACO2 67 mmHg. She was transitioned to nasal cannula several hours later and had an uneventful stay upon downgrade from the ICU.

Discussion NIPPV administered via a face mask has been shown to significantly reduce the need for intubation, the duration of mechanical ventilation, and ICU length of stay in patients with acute hypercapnic respiratory failure.1-4 Over the past decade, utilization of NIPPV in the inpatient setting has become the standard of care for patients with acute COPD exacerbation and acute hypercapnic respiratory failure. Several factors have been shown as indicators for NIPPV success, including a skilled and motivated clinical team, comfortable patient-ventilator interface, careful monitoring, and continued support and coaching of the patient.4,5 Despite the proven efficacy of NIPPV, it is not uncommon for patients to fail a trial of BiPAP and ultimately require mechanical intubation. Elevated PaCO2 and low pH levels at the time of BiPAP initiation and failure to correct PaCO2 and pH within 30-60 minutes have been shown to be predictors of failure.6,7

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Clinician inexperience likely contributes to failure of NIPPV, particularly in training institutions, where inexperienced medical staff have to select the initial ventilator settings.8 Frequently, improper inspiratory or expiratory pressure selection can be identified as the etiology of NIPPV failure resulting in persistent obstruction and/or decreased minute ventilation.9 Selection of a “one size fits all” ventilation strategy or a reluctance to select a high initial inspiratory pressure will directly result in worsening hypercapnia and clinical deterioration.9 Therefore, it is imperative to confirm that initial inspiratory pressures yield adequate tidal volumes and subsequent minute ventilation.10 Advances in NIPPV technology over the past decade give clinicians the ability to benefit from a non-invasive volume targeted approach to ventilation, potentially reducing the incidence of NIPPV failure secondary to inadequate initial settings. AVAPS has the unique ability to auto-titrate the delivered inspiratory support to maintain a goal Vt and thus maintain an adequate minimum minute ventilation. This ventilation mode has been studied extensively in the setting of chronic respiratory failure from chronic obstructive pulmonary disease, obstructive sleep apnea, and obesity hypoventilation syndrome. AVAPS was initially developed as a hybrid mode of ventilation allowing for a consistent tidal volume while delivering the comfort and advantages of pressure support ventilation.11 AVAPS ventilators estimate the expiratory tidal volume and respond by titrating the inspiratory positive airway pressure (IPAP) to maintain user set Vt. From a physiologic perspective, as a volume targeted mode of ventilation, AVAPS’ advantages over traditional BiPAP include its ability to control minute ventilation and more efficiently decrease pCO2.12,13 This would seem to make it a favorable choice in the acute setting, but there is a paucity of data supporting its use.12,14

Managing the Acutely Hypercapnic Patient with AVAPS When initiating AVAPS, the clinician must designate a minimum inspiratory pressure, maximum inspiratory pressure, expiratory pressure, Vt and respiratory rate. Utilizing a computer algorithm, the ventilator will begin delivering breaths at the set minimum inspiratory pressure and titrate every one to two minutes by 1 cm/H20 until the goal Vt is achieved. The patient’s acid-base status must be carefully monitored during the inherent delay period in achieving the goal Vt. In patients with a preexisting respiratory acidosis, this delay could theoretically precipitate a life-threatening rise in carbon dioxide and subsequent drop in arterial pH. Because of this risk, AVAPS initiation in the acute setting requires a modified approach.

One small study by Claudett et al. evaluated the safety of AVAPS in the acute setting.15 In this study, 11 patients presenting to the emergency department with acute hypercapnic encephalopathy secondary to COPD were immediately placed on AVAPS. AVAPS with goal Vt of 8 to 12 ml/kg ideal body weight were initiated and serial blood gases obtained. The average inspiratory pressure requirement for patients in this study was 19 mm H2O and it was shown that AVAPS facilitated a more rapid recovery of consciousness than traditional BiPAP. The small number of study participants must be noted; however, no larger-scale studies have been published to date. This study also failed to address the potential for clinical decompensation due to the delay in achieving adequate minute ventilation during the initial titration phase.

The case described above illustrates how early intervention and correction of the patient’s hypercapnic respiratory failure in the emergency department could have prevented a rapid response and ICU upgrade. Another small study by Canpolat demonstrated a significantly improved pH and patient compliance with therapy compared to BiPAP in acute respiratory failure.16 We argue that AVAPS should be the preferred NIPPV modality for any patient with acute hypercapnic respiratory failure especially in the acute setting. Based on the data provided by the publications above and the clinical practice of the authors, we recommend the following strategy. When initiating AVAPS in the setting of acute hypercapnia, we suggest the initial minimum inspiratory pressure be identified using a traditional BiPAP mode. (Figure 1) The patient should be placed on BiPAP with initial inspiratory pressures deemed appropriate by the initiating physician. The resulting Vt should be noted and the inspiratory pressure adjusted to produce a Vt of 8-12 ml/kg ideal body weight (IBW).

Figure 1.

Once an effective starting inspiratory pressure has been identified, the patient can safely be switched to AVAPS mode with initial minimum inspiratory pressure set at this newly identified level. The patient should be monitored for several minutes as the AVAPS ventilator continues to optimize the Vt. At this point, the minimum inspiratory pressure can be set to a lower value and the ventilator will titrate as needed in order to maintain consistent minute ventilation as compliance changes in the dynamic patient.

Utilizing this approach, the AVAPS initial titration phase will not result in an acute worsening of the patient’s hypercapnia and will improve the time needed to reach the goal minute ventilation by up to 30 minutes. Once the patient’s

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respiratory status has stabilized, with improvement in the patient’s mental status or ABG, the Vt can be reduced to 6-8 mL/kg IBW.

Conclusion The utilization of AVAPS in the setting of acute respiratory acidosis is promising; however, there has not been significant published research on the topic. Furthermore, there has been a failure of the literature to address the potential for worsening hypercapnia during the initial titration phase. After performing a literature review of the few existing publications using AVAPS in the inpatient setting for acute hypercapnic respiratory failure and our clinical practice we believe that this method of initiating AVAPS in this patient population to be effective in correcting the respiratory acidosis and decreasing the need for endotracheal intubation especially in the COVID era. Although, further randomized studies evaluating its efficacy are warranted to detect the potential degree of benefit, we believe this strategy to be simple yet effective and easily utilized by any emergency department physician with the assistance of a certified respiratory therapist especially for those patients who require rapid or large corrections in their CO2, or those who are “do not intubate.”  References 1. Brochard L, Isabey D, Piquet J, et al. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. N Engl J Med 1990; 323:1523–1530 2. Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A et al .

Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;333:817–822.

3. Coleman, John M, III ; Wolfe, Lisa F ; Kalhan, Ravi . Annals of the American Thoracic Society ; New York Vol. 16, Iss. 9, (Sep 2019): 1091–1098. DOI:10.1513/AnnalsATS.201810-657CME 4. Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicenter randomized controlled trial. Lancet 2000; 355:1931–1935 5. Antonelli, M., et al. “Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multicenter study.” Intensive care medicine 27.11 (2001): 1718-1728.

6. Anton A, Guell R, Gomez J, et al. Predicting the result of noninvasive ventilation in severe acute exacerbations of patients with chronic airflow limitation. Chest 2000; 117: 828–833 7. Poponick JM, Renston JP, Bennett RP, et al. Use of a ventilatory support system (BiPAP) for acute respiratory failure in the emergency department.

Chest 1999; 116:166–171 8. Mahmud, Imran, et al. “Training and confidence in the use of NIV/BiPAP amongst front-line medical staff in a teaching hospital setting.” European Respiratory Journal 40.Suppl 56 (2012): P2044.

9. Carron, M., et al. “Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.” British journal of anaesthesia (2013): aet070.

10. Schönhofer, B., and S. Sortor-Leger. “Equipment needs for noninvasive mechanical ventilation.” European Respiratory Journal 20.4 (2002): 10291036.

11. Oscroft, Nicholas Stephen, et al. “A randomised crossover trial comparing volume assured and pressure preset noninvasive ventilation in stable hypercapnic COPD.” COPD: Journal of Chronic Obstructive Pulmonary Disease 7.6 (2010): 398-403.

12. Storre, Jan Hendrik, et al. “Average volume-assured pressure support in obesity hypoventilation: a randomized crossover trial.” CHEST Journal 130.3 (2006): 815-821.

13. Girault, Christophe, et al. “Comparative physiologic effects of noninvasive assist-control and pressure support ventilation in acute hypercapnic respiratory failure.” CHEST Journal 111.6 (1997): 1639-1648.

14. Crisafulli, Ernesto, et al. “Subjective sleep quality during average volume assured pressure support (AVAPS) ventilation in patients with hypercapnic COPD: a physiological pilot study.” Lung 187.5 (2009): 299-305.

15. Claudett, Killen Harold Briones, et al. “Noninvasive mechanical ventilation with average volume assured pressure support (AVAPS) in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy.”

BMC pulmonary medicine 13.1 (2013): 12.

16. Canpolat G, Ozgultekin A, Boran ÖF. Comparison of bilevel positive airway pressure and average volume-assured pressure support mode in terms of patient compliance and treatment success in hypercapnic patients. A cross-sectional study. Ann Ital Chir . 2019;90:392-397.

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

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

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COVID-19 Resources

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SECTON REPORT WOMEN IN EM

Domestic? Help!

Shannon Moffett, MD FAAEM

As we all struggle to re-arrange our work/ home lives to meet our current COVID-infused reality, I’d like to do my part to bust the myth that persists — more perniciously in the pandemic era—that it is possible to be an emergency physician in a two-career family and also do all the work of a standard American household. I’d like to alleviate the palpable shame I’ve felt coming from women confessing that they are drowning and can’t seem to find enough hours in the day to do all that is expected of them. To start, I’ll lay bare my own domestic set-up, in place before the pandemic. My cleaning lady — you don’t so much hear the phrase “cleaning guy,” probably because in the U.S., 91.5% of the 2.2 million people working as domestic help are women1 — comes twice a week, for four to six hours each time. She does all the laundry, any dishes we’ve left in the sink, and cleans and organizes every room in the house, including the au pair’s apartment.

Yes, I have an au pair, too. And my mom lives with us (well, did until we sent her on what I hope is a temporary break from our high-COVID-risk house). She cooks dinner most nights, and does the dishes then and on the rare nights when I cook. She also does the bedtime ritual with I don’t want my kids to see my youngest most evenings, and the housework as our job, wakes him up in the mornings, too, because I don’t want to spread if I sleep in after a late shift, or am up early trying to get to an early the dangerous fiction that shift, or am trying to get some adit’s possible to do the jobs we ministrative work done in the morndo and also deal with all the ing — so basically all the time.

housework.

I know my mom can do all those things because when I was a kid, she did them while working full-time as a journalist. On the nights she wasn’t home because she was working, I — starting at 10-years-old or so — made dinner for myself and my sister. I doubt I did the dishes — she must have done them when she got home. My dad….didn’t. When I try to think about what he did do around the house — not taking out the trash (that was my mom), not home repairs (my mom), not making the larger salary (you guessed it) — I have two pictures in my head: one, of him hunched over the paper-strewn dining room table, demanding absolute silence while he did the taxes (that’s another thing I have someone else do now).

The other is of the Christmas morning my father set himself up on a chair in the center of the kitchen, newspaper in hand, and declared — after consulting the baking instructions affixed to the ham we would be eating — that his task would be “bringing

the ham to room temperature” so it would be ready for my mom to put it in the oven.

My best friend from residency told me on the phone the other day that she doesn’t want to increase her cleaning lady’s hours, even though with everyone home there is more cleaning to do, because the thought of her three sons sitting there and watching someone else clean up their stuff is like nails on a blackboard to her.

Which I get: No one needs three more ham-warmers.

Then in the same breath she told me she didn’t mind if they saw her cleaning.

I’d like to alleviate the palpable shame I’ve felt coming from women confessing that they are drowning and can’t seem to find enough hours in the day to do all that is expected of them.

Personally, I hate it when my kids catch me cleaning (cue my mom’s voice in my head saying “pffft, well, fat chance of that happening”). I am an emergency physician and an educator, both of which I think are really important jobs. As is cleaning the house. But it’s not my job. It’s not, frankly, my husband’s, either — he has a different important job, one that keeps him traveling. So even if he wanted to do more around the house — which, to be fair, I actually think he does, but don’t get me started on how the assuming of rote chores allows those so inclined to avoid the specific, time-sensitive, and exhausting emotional work required for a functioning household — half the time he physically can’t. I don’t want my kids to see the housework as our job, because I don’t want to spread the dangerous fiction that it’s possible to do the jobs we do and also deal with all the housework. And I really don’t want them to think that, at points when the task allocation has broken down, it’s the woman career-haver that should step in to take up the slack.

Those reading this will mainly have the means to hire domestic help, and even to do so without engaging in the exploitation of those workers that some say led to the decline of their role as an integral part American life after the 1950’s. At that time, ironically, as more and more women went to work, fewer and fewer households had outside help to get the housework done.2 >>

I am an emergency physician and an educator, both of which I think are really important jobs. As is cleaning the house. But it’s not my job.

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It is discomfiting, for sure, that for us having the means to engage others in our household work has basically meant the transfer of that work onto the backs of other women. But on the other hand, each of the women involved in the care of my house — including my mom — had some choice in the matter, and a chance to negotiate (and renegotiate) their roles absent any concern that a disagreement would lead to the break-up of their family. At least as of 2010, most male academic physicians had a spouse who did not work full-time (86% of women had spouses that worked full-time).3 Assuming that the men’s non-working spouses were mainly women, one has to assume that the male physicians’ success also relied on the labor of a woman, one who might have a harder time renegotiating.

It’s too early to have anything reliable to cite, but our current global catastrophe has likely affected U.S. domestic workers disproportionately, as they tend to be non-white, under-insured and without labor protections. While my friend wants to hide her cleaning lady from her children,

I want my kids to see us giving paid vacation to ours, paying her through the shelter-in-place orders even though they meant she couldn’t come to our house, and respecting the job she does as a vital one. Ditto the au pair. Ditto the lawn guys. Ditto the math tutor. And my mom? I want my kids to see my mom teasing me for not doing housework and me laughing, shamelessly — because I feel no shame.  References 1. Economic Policy Institute. 2020. Current Population Survey Extracts, Version 1.0.8, https://microdata.epi.org.

2. Bloom, E. The Decline of Domestic Help. The Atlantic, Sept 23, 2015, accessed online 08-26-20 at https://www.theatlantic.com/business/ archive/2015/09/decline-domestic-help-maid/406798/ 3. Jolly et al. Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers. Ann Intern Med 2014 Mar 4;160(5):344-53

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:

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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.

SECTON REPORT EMERGENCY ULTRASOUND

Utilization of Point-of-Care Ultrasound during COVID-19 Michael Gottlieb, MD FAAEM @MGottliebMD

Background The coronavirus disease of 2019 (COVID-19) has infected nearly 20 million people around the world, resulting in over 700,000 deaths.1 Studies have demonstrated that chest computed tomography (CT) is 97-98% sensitive, with some cases identified on chest CT before a positive reverse transcriptase polymerase chain reaction (RT-PCR) test result.2,3 Patients will commonly present with ground glass opacities, consolidations, and interlobular septal thickening on CT.4 Interestingly, studies have found that most lesions are located peripherally, which would make them amenable to visualization with point-of-care ultrasound (POCUS).5,6 In fact, early literature has demonstrated that lung POCUS correlates well with CT findings.7

Alternatively, lung POCUS can be performed rapidly at the bedside during the initial encounter without the patient needing to leave the room. Moreover, lung POCUS can be rapidly repeated to monitor responses to interventions and changes in symptoms.

Despite the diagnostic benefits of CT, there are significant risks to the patient and staff. CT exposes patients to radiation. It also increases the risk of transmission to staff who are involved in transporting the patient and performing the CT. In addition, the CT room may subsequently be unavailable for a length of time while undergoing cleaning, which can impact the care of subsequent patients.

Alternatively, lung POCUS can be performed rapidly at the bedside during the initial encounter without the patient needing to leave the room.

Moreover, lung POCUS can be rapidly repeated to monitor responses to interventions and changes in symptoms. This may be particularly valuable in locations with limited access to CT.

Table 1. 14-zone Ultrasound Imaging Protocol

Right Anterior

Mid-clavicular line below the internipple line

Consequently, lung POCUS has been proposed as a potential tool for COVID-19 patients. While the role is still being fully elucidated, this could have value for assessing disease severity, evolution of the disease, and monitoring the response to different interventions (e.g., prone positioning and recruitment maneuvers).8

Lateral

Mid-axillary line above the internipple line Mid-axillary line below the internipple line

Posterior

Paravertebral line at the spine of the shoulder blade Paravertebral line at the inferior angle of the shoulder blade

Technique The literature describes three main techniques for lung POCUS among COVID-19 patients. The 8-zone technique involves assessment of anterior-superior and anterior-inferior (mid-clavicular line), as well as the posterior-superior and posterior-inferior lung zones (mid-scapular line) bilaterally.9,10 The 12-zone technique is similar to the 8-zone technique with the addition of the lateral-superior and lateral-inferior zones (mid-axillary line).8,11,12 More recently, a 14-zone technique has been recommended, which includes two anterior, two lateral, and three posterior views on each side (Table 1, Figure 1).13 This latter approach offers the benefit of improved assessment of the posterior lung fields, where COVID-19 findings are more commonly found.9,11 Typically, a phased array or curvilinear probe is used, though a linear probe may be better for visualizing the pleural line.

Mid-clavicular line above the internipple line

Paravertebral line above the edge of the diaphragm Left

Anterior

Mid-clavicular line above the internipple line Mid-clavicular line below the internipple line

Lateral

Mid-axillary line above the internipple line Mid-axillary line below the internipple line

Posterior

Paravertebral line at the spine of the shoulder blade Paravertebral line at the inferior angle of the shoulder blade Paravertebral line above the edge of the diaphragm

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Figure 1a. 14-zone Ultrasound Imaging Protocol (image courtesy of Dr. Thomas del Ninno)

Figure 2. Irregular Pleural Line in a COVID-19 Patient (image courtesy of Dr. Jacob Danoff)

Figure 1b. 14-zone Ultrasound Imaging Protocol

Ultrasound Findings Characteristic findings include thickening of the pleural line with focal irregularities (Figure 2) 8-10,12 and B lines in a variety of patterns including focal, multifocal, and confluent (Figure 3).8-12 B lines are vertical, hyperechoic lines extending from the pleura to the bottom of the screen that occur due to increased fluid in the lungs.14 Consolidations and air bronchograms are less common and are generally associated with more severe illness.8-12 B lines and consolidations are more common in the posterior and lateral locations, particularly in the interscapular and infrascapular areas.9,11 Often, they will present in clusters with areas of lung sparing, as opposed to cardiogenic pulmonary edema which is more generalized to entire lung regions.15 Bilateral involvement is also very common.9-11 However, pleural effusions are relatively rare, and are typically small when they are present.8-10 As patients begin to recover, the B lines begin to disappear and A lines can re-appear.8,16 While most studies have been conducted in adults, similar findings have been noted in pediatric patients.17 A summary of these findings and comparison with CT are presented in Table 2.

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Figure 3. B Lines in a COVID-19 Patient Table 2. Comparison of CT and Ultrasound Findings

CT Findings

US Findings

Thickened pleura

Thickened, irregular pleural line

Ground glass shadow and effusion

B lines (multifocal, discrete, confluent)

Pulmonary infiltrating shadow

Confluent B lines

Subpleural consolidation

Small consolidations

Translobar consolidation

Translobar consolidation with air bronchograms

More than two lobes affected

Multilobar distribution

Pleural effusions are rare

Pleural effusions are rare

*Modified from Peng et al.

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Ultrasound Machine and Transducer Cleaning

References

Given the infectivity of COVID-19, it is important to take measures to reduce potential transmission via the ultrasound machine. The American College of Emergency Physicians released a policy statement regarding ultrasound machines infection prevention and cleaning to assist clinicians.18 They recommend removing all non-essential equipment from the machine before entering the room. For low-risk patients who are not on droplet precautions, clinicians should disinfect any surface that was in contact with the patient or clinician using approved cleaning wipes. When aerosolization or high-risk procedures may occur, the machine should be protected with a transparent cover, if possible, or the entire machine should be disinfected after use. Handheld devices may be placed in a sterile plastic bag or probe cover.10,12 High-level disinfection is not required. However, it is important to use a wipe approved by the United States Environmental Protection Agency. A full list of approved products is located here: www.epa.gov/pesticide-registration/ list-n-disinfectants-use-against-sars-cov-2-covid-19.

1. World Health Organization. Coronavirus disease (COVID-19) Situation Report – 202. Available at: https://www.who.int/emergencies/diseases/ novel-coronavirus-2019/situation-reports/. Last accessed: August 9th, 2020.

2. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, Tao Q, Sun Z, Xia L. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology 2020.

3. Fang Y, Zhang H, Xie J, et al. Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR. Radiology. 2020;296(2):E115-E117.

4. Wu J, Wu X, Zeng W, et al. Chest CT Findings in Patients With Coronavirus Disease 2019 and Its Relationship With Clinical Features. Invest Radiol.

2020;55(5):257-261.

5. Pan F, Ye T, Sun P, et al. Time Course of Lung Changes at Chest CT during Recovery from Coronavirus Disease 2019 (COVID-19). Radiology.

2020;295(3):715-721.

6. Shi H, Han X, Jiang N, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis. 2020;20(4):425-434.

7. Poggiali E, Dacrema A, Bastoni D, et al. Can Lung US Help Critical Care Clinicians in the Early Diagnosis of Novel Coronavirus (COVID-19) Pneumonia?. Radiology. 2020;295(3):E6.

8. Peng QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med. 2020;46(5):849-850.

9. Xing C, Li Q, Du H, Kang W, Lian J, Yuan L. Lung ultrasound findings in patients with COVID-19 pneumonia. Crit Care. 2020;24(1):174.

10. Yasukawa K, Minami T. Point-of-Care Lung Ultrasound Findings in Patients with COVID-19 Pneumonia. Am J Trop Med Hyg. 2020;102(6):1198-1202.

11. Huang Y, Wang S, Liu Y, et al. A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (COVID-19) (February 26, 2020). Available at SSRN: https:// ssrn.com/abstract=3544750. http://dx.doi.org/10.2139/ssrn.3544750.

12. Buonsenso D, Piano A, Raffaelli F, Bonadia N, de Gaetano Donati K, Franceschi F. Point-of-Care Lung Ultrasound findings in novel coronavirus disease-19 pnemoniae: a case report and potential applications during COVID-19 outbreak. Eur Rev Med Pharmacol Sci. 2020;24(5):2776-2780.

13. Soldati G, Smargiassi A, Inchingolo R, et al. Proposal for International Standardization of the Use of Lung Ultrasound for Patients With COVID-19: A Simple, Quantitative, Reproducible Method. J Ultrasound Med. 2020;39(7):1413-1419.

14. Gargani L, Volpicelli G. How I do it: lung ultrasound. Cardiovasc Ultrasound. 2014;12:25 15. Volpicelli G, Gargani L. Sonographic signs and patterns of COVID-19 pneumonia. Ultrasound J. 2020;12(1):22.

16. Fiala MJ. Ultrasound in COVID-19: a timeline of ultrasound findings in relation to CT. Clin Radiol. 2020;75(7):553-554.

17. Denina M, Scolfaro C, Silvestro E, et al. Lung Ultrasound in Children With COVID-19. Pediatrics. 2020;146(1):e20201157.

18. American College of Emergency Physicians. ACEP Guideline on COVID-19: Ultrasound Machine and Transducer Cleaning. Available at: https://www.acep.org/globalassets/new-pdfs/guideline-on-covid-19-ultrasound-machine-and-transducer-cleaning_policy_033120.pdf. Last accessed: August 9th, 2020.

These findings should increase one’s suspicion of COVID-19, while more prominent or diffuse findings should prompt consideration of more severe disease.

Limitations Despite the early literature in support of POCUS, this should not be utilized to exclude COVID-19 in isolation at this time, as it may miss some subtle findings or more central lesions that have not extended to the pleural area.8 Additionally, it is important to combine this with the clinical picture, as many of the findings may overlap with other conditions (e.g., cardiogenic pulmonary edema, bacterial pneumonia, interstitial lung disease). Finally, like other POCUS examinations, this is a user-dependent skill. It is important to ensure sufficient practice and training to maintain this skill set.

Conclusion In summary, it is important to be aware of the lung POCUS findings associated with COVID-19. These findings should increase one’s suspicion of COVID-19, while more prominent or diffuse findings should prompt consideration of more severe disease. Finally, serial exams may be valuable to assess disease progression and response to interventions. 

COMMON SENSE NOVEMBER/DECEMBER 2020

35

SECTON REPORT YOUNG PHYSICIANS

Hero Priya J. Ghelani, DO FAAEM

I have heard this word in a variety

What is it about the word “hero” then that feels so unsettling?

of permutations over the past few months, whether on social media platforms, in the news, or when friends and family address me as the emergency medicine physician taking care of coronavirus patients. Caring citizens have sent care packages and kind notes letting me know they are thinking of me. My fellow colleagues say they have been going through some of the same, and it feels equally strange. While the appreciative gestures have been nice, the question remains. Do you feel like a hero?

If there is a specialty in the house of medicine that is generally even-tempered, ready to resuscitate at the drop of a hat, and constantly humbled by the pathology we too often diagnose and see, it is the field of emergency medicine. There is a certain personality that is associated with the willingness to be able to function with maximum unpredictability with often minimal recognition, while facing an indefinite number of stressors at any given time. Taking care of exceptionally sick, often unconscious, and sometimes dying patients on a regular basis, some of the most vulnerable in our society, requires a certain resiliency and hardening of the human spirit. It is with great pride that we refer to our specialty as the one in which the lights are always on.

What is it about the word “hero” then that feels so unsettling? Why have we as emergency medicine physicians been labeled as heroes, almost overnight? My fellow EM colleagues consistently come early, stay late, and work hard each shift as we took an oath to do long ago — that hasn’t changed. Is it because now our own lives are in jeopardy, and we are subsequently putting our families’ lives at risk? Is it because we are some of the few who are qualified to be on the frontline, and therefore some of the most likely to be sacrificed? Is it because during this pandemic, our ERs have turned into war zones, with patients dying in droves, and there is now a greater sense of empathy for those who witness death at such a scale?

We as physicians strive to deliver the best care for our patients. So do many of our coworkers on the frontlines – paramedics, nurses, custodial staff, respiratory therapists, patient care assistants, security staff, and countless others. We are undeniably only one piece of the puzzle, lost without the rest. While we were frustrated by the lack of protective equipment, our medics routinely brought in the masses wearing only a mask. For those of us at county hospitals, resources on a good day are stretched thin. Our ICUs and medical floors frequently have no beds available, leading to lengthy boarding times, sometimes days at a time. The areas with the lowest socioeconomic populations in New York City transformed overnight into petri dishes of coronavirus infections and our ED, as it often does, became overwhelmed as the volume of critical patients skyrocketed. Our underprivileged communities became an abysmal example of health disparities. However, our staff, despite a sense of palpable fear, took this in stride, and got to work.

I do not feel like a hero. When we first encountered coronavirus patients, we relied on minimal data we had from across the world. A lack of tests, we repetitively explained to patients, was the reason as to why they could not be diagnosed appropriately. Each radiograph looked nearly the same, a disastrous chaos of white-out multilobar pneumonia, as did their clinical presentation, varying degrees of hypoxemia. In the beginning, we intubated early, trialed high levels of alveolar pressure, and calculated each patient’s P:F ratios. Hospital administrators were fearful of utilizing non-invasive ventilation strategies, and our pendulum of management swung accordingly. We kept

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COMMON SENSE NOVEMBER/DECEMBER 2020

We are undeniably only one piece of the puzzle, lost without the rest.

SECTION REPORT YOUNG PHYSICIANS SECTION

Taking care of exceptionally sick, often unconscious, and sometimes dying patients on a regular basis, some of the most vulnerable in our society, requires a certain resiliency and hardening of the human spirit. patients dry as the limited data recommended, arguably plunging many into renal failure, and ultimately into multiorgan failure. Despite spending our time away from work reading data, listening to our colleagues in China and Italy, and studying complicated ventilation strategies, we were driving blind, often with ever-changing data. We followed our admitted patients, realizing many of them were decompensating quickly. There is perhaps nothing more heartbreaking than realizing a patient you took care of who seemed to be improving, later died. Or to take care of a critically ill colleague, one of your very own. A dull record player droned on repeat in the background, constantly reminding us of the fragility of our own lives.

likely futile treatment strategies. The new normal became seeing patients on a non-rebreather mask and nasal cannula tubing underneath, sometimes on a morphine drip, which seemed to cure their air hunger as much as it cured our own anxiety of seeing patients in distress. Stretchers had a paper attached to them dated and timed with their oxygen saturations on their oxygen flow rates, and boarded patients in the ED were flipped around the clock like rotisserie chickens.

We became painfully comfortable with resource utilization and when to offer invasive ventilatory options with an ever so depleting supply.

We taped masks delivering life-saving oxygen with Band-Aids on the faces of our patients with dementia, and used vests and soft restraints to prevent them from starving themselves of oxygen, infuriating them all the more. It was difficult to not We eventually recognized that we had it have a sense of near-repulsion with ourselves. backwards, that no hospital has the resources This entire saga felt far from heroic. to care for a few hundred ventilated patients, and that we were rapidly running out of reWould I have appreciated better protective equipsources. Preliminary data associated early ment and more readiness from our government, ventilation strategies with increased mortality, without a string of failures from the CDC? Greatly. and we recalled the dozens of patients we Would I have loved to not come home feeling like had intubated. We offered elderly patients I am putting my family at risk? Of course. But if the minimal management options we had shy we are going to have a candid conversation about of invasive options, recognizing these were risk, let’s be honest. I know I am not the first

AAEM

emergency medicine physician to have been threatened at work, that it hasn’t happened only a few times, and it undoubtedly won’t be the last. Nor will I hold my breath waiting for overdue reform. The idea of putting our lives on the line is not novel, although rarely has it been a conscious decision. I believe those of us who love our field have learned to accept our job wholeheartedly, from the less desirable parts with those that feel reminiscent of our calling. The alcoholic in our hallway may not be dying, but surely deserves care, as does the ruptured ectopic, and the massive hemoptysis.

Perhaps my issue with the word hero is several fold. What we were doing seemed to be nothing new — we have always gone above and beyond, trying to provide the best care we can, even when everything seems to be against us. My humility reminds me I have undoubtedly made painful mistakes along the way, especially early in this pandemic. We as physicians are only one part of the equation, hopeless without the rest, who risk their lives to care for others every day. And this construct we are a part of in health care is a recurring reminder that we continue to fail society’s most vulnerable. I, for one, am earnestly still trying to come to terms with the word “hero,” and can only empathize with my fellow colleagues who feel the same. That said, despite what may come, I take solace in knowing that our light will always be on. 

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37

AAEM/RSA PRESIDENT'S MESSAGE

Aerospace Medicine — The Final Frontier of Emergency Medicine Haig Aintablian, MD — AAEM/RSA President

Today, there are five residency programs for aerospace medicine in the U.S., two of which are military, and three of which are civilian. The civilian programs include the Mayo Clinic in Rochester, Minnesota, the University of Texas-Medical Branch (UTMB) in Galveston, Texas, and the Wright State Program in Dayton, Ohio. The military programs are the Air Force program at Wright-Patterson Air Force Base in Ohio, and the combined Army/Navy program in Pensacola, Florida. Many of these programs are two years long with an integrated Master’s program with an emphasis on public health and preventative medicine. The main differences between these programs are the degrees to which they cover the components of air-flight versus space-flight in their curriculum.

Many people enter the specialty

of emergency medicine to work in the most thrilling department of the hospital. The broad patient presentations, the interesting pathologies, and the breadth of patient encounters makes emergency medicine an exciting and fulfilling profession. The fellowship opportunities in EM are just as diverse as our patients. Aside from health care administration, EMS, ultrasound, and simulation, our specialty offers fellowships in all things land, sea, air, and even space.

Wilderness medicine covers interesting pathologies and clever solutions to survive and treat them on land. Hyperbarics tackles complex disorders that occur due to burns, infections, and diving in the sea. And aerospace medicine handles the limitations of human physiology in air and space. For many in the field of emergency medicine, the sky is the limit regarding the options available for fellowship.

For many, it comes as a surprise that aerospace medicine is not actually a new specialty. Paul Bert, a 19th century French physiologist is generally regarded as the father of modern aerospace (more aero than space) medicine. His work initially focused on the effects of pressure at low and high altitude on the effects of balloon pilots. Much of his work was referenced during World War II as more complex aircraft that could reach higher altitudes began to display the limitations of human physiology. In 1929, the Aerospace Medical Association was formed (and today has become the leading international academic organization in aerospace medicine). In 1948, aerospace medicine was born as a medical subspecialty with prompt designation as a board certified specialty within the American Board of Preventive Medicine in 1955.

It was this year when the U.S. Navy also created their first aerospace medicine residency program.

Over the decades, this subspecialty has mastered concepts relating to pressure changes, ionizing radiation exposure, and gravitational forces on normal human physiology. More complex pathologies like Spaceflight Associated Neuro-occular Syndrome (SANS) and other immunologic derangements related to space travel still have discoveries to be made. With the more time humans are spending in space, the more pathologies are continuing to unravel.

With the more time humans are spending in space, the more pathologies are continuing to unravel.

As our presence in space continues to grow, so will the importance of proper medical training in the complexities of air and space travel. With the recent introduction of the Space Force, as well as the significantly increasing presence of private companies in space, the demand for aerospace trained physicians over the next one to two decades will sky-rocket. For emergency physicians looking for more than just terrestrial illnesses and who want to dive deeper into the unknowns of human physiology in space, aerospace medicine may be the perfect fellowship to take their skills into the final frontier.  References • https://www.asma.org/about-asma/history#:~:text=The%20Aerospace%20 Medical%20Association%20%28AsMA%29%20was%20founded%20 in,of%20Commerce%20%28which%20later%20became%20the%20FAA%29.%20Dr. • https://www.asma.org/about-asma/history/aerospace-medicine-milestones • https://goflightmedicine.com/aerospace-medicine/history-of-flight-medicine/ • https://www.britannica.com/science/aerospace-medicine • https://www.mayoclinic.org/departments-centers/preventive-occupationalaerospace-medicine/aerospace-medicine/overview • https://www.asma.org/for-students-and-residents • https://www.asma.org/about-asma/careers/aerospace-medicine/residencyprograms-related-courses#:~:text=There%20are%20currently%20 five%20accredited%20U.S.%20residency%20programs,and%20the%20 combined%20Army%2FNavy%20program%20in%20Pensacola%2C% 20FL.

As our presence in space continues to grow, so will the importance of proper medical training in the complexities of air and space travel.

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AAEM/RSA EDITOR’S MESSAGE

Virtual Insanity: Adapting Curriculum to the Virtual Environment Ryan Gibney, MD

The sun peaks over the bay, as the crispness evaporates from the morning air to greet, what — in any other normal time — would be the start of a new school year. The traditional morning routine of packing lunch, gathering supplies, and a haphazard scurry to the front door to make it to class on time, has all but disappeared. The start of a new school year as a parent has brought a new face to education across the board. In my home, we have set up a dedicated learning space for both my daughter and I, complete with paper, pens, computers, reference books, and any other tool that may be needed. As I watch my daughter dive into the realm digital learning, I wonder how this generation is going to adapt. How are they going to apply their knowledge? Is this the new norm for education (please, God I hope not)? More im-

1 to pass/fail, the myriad of quality supplemental resources, and question of lecture based teaching’s utility, traditional medical education is rapidly evolving, and the advent of distance learning has introduced a new set of complex problems. What do we, as clinical educators, do to make these sessions valuable? How do we incorporate peer learning to hone intangible skills such as empathy? How do we make it better than before?

Virtual learning can be challenging for even the most skilled clinical educators. The content must be clearly developed and delivered in a way that engages the learner and maintains the quality standards of medical education. Falling back into a purely lecture driven curriculum is an easy way to navigate the virtual realm, but offers little to the learner and has been proven ineffective time and time again. Hands on, group format is limited by many institutions

Falling back into a purely lecture driven curriculum is an easy way to navigate the virtual realm, but offers little to the learner and has been proven ineffective time and time again. portantly, how will the lack of social interaction shape her future? It has been shown that peer education with regards to emotional resiliency, empathy, and problem solving, are attained through social interactions. I believe that the same is true in medical education.

At the same time my daughter embarked on another year in her quest for knowledge, so did a new class of medical students and residents across the nation. However, this time was starkly different from the years before — in-person activities and orientations, social gatherings with colleagues, family and friends, and the time-honored white coat ceremony were noticeably missing. As my colleague Dr. Alexandria Gregory mentioned in the May/June issue of Common Sense, the transition of Step

mandated social distancing and distance learning policies. With a little bit of creativity and a bit more backend effort, educational interactions can be extremely effective, interactive, and fun within the virtual space.

Ways to Augment Your Virtual Learning Environment As an academic chief, the responsibility of curating our weekly conference content is no simple task. The addition of a predominantly virtual learning environment added unique challenges to development of quality content that engages the learner. Through the help of our educational fellows, we have been able to develop many interactive learning modules that translate very well to the virtual learning

environment. Here are a few of those ideas.

The flipped classroom model has long been a staple in MedEd, and works incredibly well in the virtual environment. The flipped classroom focuses on the individual learner gaining and applying new knowledge. Prior to the sessions material is distributed for learning and understanding via email or assigned reading.

Within the digital session application of the new material can be done through case based learning, iRAT-gRAT model, or other TBL/PBL methods. There is little work that needs to be done to translate this to the virtual learning space making it an ideal methodology for quick content integration.

Choose your own adventure is another method that can be a great addition to the virtual curriculum. This allows the learners to engage in breakout rooms and solve a series of problems and clinical scenarios, expanding on the team based and problem based learning approaches.

Web-based platforms, such as Google Forms, can be used to develop logic based clinical games, taking advantage of the sections feature, allowing for variant pathways through clinical scenarios. Adding a theme based on the topic can augment the engagement. For example, a Zombie Apocalypse themed game on toxidromes, or a digital escape room can increase the challenge level. Integration of puzzles requiring application of clinical knowledge allows for stronger memory association and retention. These builds can be customized to fill any amount of time and there are many online resources and how-to videos for creation.

Although these are incredibly engaging and can cover broad swaths of material, there are some considerations when building these. They can be very laborious, so it’s best to start small to get the hang of the logic flow — for example a 90 minute game can take upwards of 12-16 hours to build out the content. Once you have developed a good logic flow, you can readapt it

>> COMMON SENSE NOVEMBER/DECEMBER 2020

39

AAEM/RSA EDITOR’S MESSAGE

to varied content. Secondly, the platform can become unstable when the logic of the form becomes too large—around 70-80 branch points can slow it down significantly. To circumvent this plan small or break it into two smaller branch forms that run in succession. Finally, this platform allows for integration of robust video and image content making the experience that much more engaging, however this can also contribute to slowing.

Overall, this has been well received by learners and builders alike, and offers a change to the traditional learning platforms.

What do we, as clinical educators, do to make these sessions valuable? How do we incorporate peer learning to hone intangible skills such as empathy?

How do we make it better than before?

Integration of high quality asynchronous resources provides a way to focus on the learning and evaluation process, rather than creating anew.

In medical education and emergency medicine there already exists a plethora of excellent resources, such as HIPPO-EM, EMRAP, ROSH, PEER, and others. Integrating these into the digital curriculum can allow for the content developers to focus more on application of these principles. The fact that most learners already use these resources independently, makes the transition and integration more palatable.

With a little bit of creativity and a bit more backend effort, educational interactions can be extremely effective, interactive, and fun within the virtual space.

Simulation has become an integral part of medical education as it allows for hands on application of clinical knowledge in low pressure, low stakes environments, focused on team-based learning in the patient care setting. This can be accomplished in a variety of ways digitally as well.

Using the above described Google build out with sections tied to the user choices, provides a direct feedback component based on their choices.

Integration of the image and video components can increase the reality of the simulation experience. Also, simulation can be facilitated by an operator through shared PowerPoint documents with hyperlinks that correlate to clinical decisions and physiologic changes. The key is to provide a similar experience to the in-person simulation environment, engaging learners of all levels, and providing integration of clinical decision making with focused learning objectives. There are excellent resources for sim cases such as EM Sim Cases, JetEM, and ACEP, to name a few.

How do you teach soft skills virtually? Many institutions have integrated empathy and communication curricula into their standards and goals.

The challenge is that applying these principles virtually becomes difficult for several reasons—body language is often obscured, tonality doesn’t always translate across video conferencing, and there are a lot of distractions that often don’t exist in-person. Having a focused wellness portion of your virtual programming, where learners can gather to discuss relevant social topics, challenges they are currently facing, difficult clinical cases, and process groups can bring about a true human component to the virtual realm effectively. Expanding this beyond the virtual realm to the workroom, rounds, and other in-person settings can further emphasize these skills.

The key to any virtual learning space is adaptability. The truth of the matter is that you will try many different approaches and some of them will just not work. Being flexible and ready to change at a moment’s notice is crucial to effectively delivering your content. Focusing on embracing the virtual environment and making it an enjoyable space for learning is critical for its success. We are truly living through an unprecedented time socially; however, there is real opportunity to innovate in education right now. These are only a few suggestions to augment the digital learning space, and I hope that provides some new ideas to improve the quality of education we provide to our learners. 

AAEM/RSA DIVERSITY & INCLUSION

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COMMON SENSE NOVEMBER/DECEMBER 2020

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41

SITC-1020-052

AAEM/RSA RESIDENT JOURNAL REVIEW

End-Tidal Carbon Dioxide Monitoring in Cardiopulmonary Resuscitation Christianna Sim, MD MPH; Taylor Conrad, MD MS; Taylor M. Douglas, MD; Wesley Chan, MD Editors: Kelly Maurelus, MD FAAEM and Kami Hu, MD FAAEM

Question: How can end-tidal carbon dioxide (ETCO2) monitoring guide our management of cardiac arrest?

In 2010, the American Heart Association (AHA) revised the Advanced Cardiac Life Support (ACLS) guidelines to include the recommendation of using capnography to monitor end-tidal carbon dioxide (ETCO2) during cardiopulmonary resuscitation (CPR),1 and has continued this recommendation to date. Measured ETCO2 during cardiac arrest is a measure of the cardiac output generated by chest compressions but is affected by various other factors including endotracheal tube complications, ventilation, and medications administered. These issues notwithstanding, studies supporting ETCO2 as a surrogate marker of cardiac output outside of cardiac arrest2,3 indicate that ETCO2 could be a non-invasive, more readily available means of providing feedback in real time during resuscitation efforts. Previous studies have shown that low (<10 mmHg) ETCO2 values during resuscitation are predictive of mortality4,5,6 and that initial, average, and final ETCO2 are higher in successfully resuscitated patients,7,8 and there is an emerging possibility that ETCO2 could possibly even predict survival to discharge.7,9 Here we review some of the more recent literature regarding the use of ETCO2 during CPR and evidence on how it can guide resuscitation efforts.

Sheak KR, Wiebe DJ, Leary M, et al. Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest.

Resuscitation. 2015;89:149-154.

Based on previous studies that suggested ETCO2 as an indicator of cardiac output,2,3 Sheak et al. hypothesized that it may also reflect the quality of chest compressions (CC) during CPR, thus giving feedback on resuscitation efforts in real time. They specifically sought to investigate the relationship between ETCO2 and CC depth, CC rate, and ventilation rate in both in-hospital cardiac arrests (IHCA) and out-of-hospital cardiac arrests (OHCA).

They conducted a prospective, multicenter study at hospital sites in the United States in which they were able to capture CPR-recording defibrillator and continuous side-stream CO2 data in patients with an advanced airway (endotracheal tube or laryngeal mask airway), regardless of the etiology of the cardiac arrest or initial rhythm, with at least two minutes of synchronized chest compressions and ETCO2 data. The data metrics were averaged over 15-second epochs. In total, their study included 583 cases, 227 (39%) IHCA and 356 (61%) OHCA. While chest compression rate did not significantly affect ETCO2, the depth of compressions was a significant predictor of ETCO2values independent of CC or ventilation rate. For every 10 mm increase in

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depth there was an associated increase in ETCO2 by an average of 1.4 mmHg (p <0.001), independent of CC rate (slow, medium, fast). Perhaps unsurprisingly, ventilation rate was inversely related to ETCO2 values.

Every additional 10 breath per minute increase in rate lowered ETCO2 by an average of 3.0 mmHg (p <0.001). The overall case-averaged mean ETCO2 values in those with ROSC were higher compared to those who did not achieve ROSC (34.5 ± 4.5 vs 23.1 ± 12.9 mmHg, p <0.001). They also observed a similar relationship seen in regard to survival to hospital discharge (38.2 ±12.9 vs 26.1 ±15.2 mmHg, p <0.001).

The authors found a significant relationship between CC depth and ETCO2 and performed a fairly robust assessment, albeit not without limitations. The inability to assess for the effect ventilatory volume, without which minute ventilation cannot be calculated, leaves a possible confounder of the relationship between CC depth with ETCO2. They list other confounders they were unable to measure, such as the administration of epinephrine, the cause of cardiac arrest, underlying metabolic rate, and any metabolic derangements during the arrest. Also, because they did not know the relationship between the onset of resuscitation and initiation of active recording, they were unable to see if the CC depth- ETCO2 relationship differed depending on the phase of cardiac arrest care. To further understand the influence of CPR performance on ETCO2, there must be further investigations on how this relationship may be affected by these other factors. The authors highlighted the wide variability of the relationship between CC depth and ETCO2 posing a challenge to its applicability to all resuscitation events. As such, despite seeing a clear relationship between CPR quality (as indicated by depth of compressions) and ETCO2, there is no clear benchmark that can be set based on this data alone and would require further evidence to set a specific ETCO2 to aim for during resuscitation efforts.

Pokorná M, Necas E, Kratochvíl J, et al. A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med. 2010;38(5):614-621.

While an increase in partial pressure ETCO2 has been observed after ROSC in both experimental and clinical studies, Pokarnoa et al. set out to determine whether an increase in ETCO2 could be used as a reliable indicator of ROSC in their retrospective case-control study. They looked at two extremes of patients experiencing OHCA: those who had single uncomplicated ROSC followed by stable spontaneous circulation and those with no signs of ROSC who died at the scene.

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AAEM/RSA RESIDENT JOURNAL REVIEW

In total a group of 140 patients were included. ROSC was defined by the researchers as a palpable central pulse with an organized spontaneous ECG rhythm and measurable blood pressure. All patients were intubated in the field by either emergency medicine physicians or anesthesiologists who were part of the EMS personnel, and consistent lung ventilation was maintained for each patient by an automatic device. Patients were reviewed regardless of age, cardiac arrest etiology, first ECG rhythm pattern, or bystander BLS. Exclusion criteria included patients with either capno-sensor moisturization or contamination with blood as well as patients who received sodium bicarbonate. Thirty-two records were excluded from patients in whom ROSC was achieved but the ensuring spontaneous circulation was unstable and failed again or repeatedly, leaving 108 patients for analysis. ETCO2 values were continuously recorded from the time ACLS was administered to when either ACLS was discontinued or when ROSC was achieved. All ETCO2 records were analyzed in two minute intervals and compared with each other against an arbitrarily set of threshold values ranging from two to 20 mmHg. True positive was noted when an increase equaled or exceeded a particular threshold value and ROSC was achieved. Mean values and standard deviations were compared by a two-tailed paired t-test.

Analysis of the ETCO2 recording showed a mean difference of ETCO2 before and after ROSC was 9.95 mmHg (95% CI 6.46 - 13.50 mmHg).

Individual comparisons of ETCO2 readings before and after ROSC showed a significant value of p <0.0001. Notably, patients who were not successfully resuscitated had lower mean ETCO2 values for all time points compared to patients who achieved ROSC. For patients in whom ROSC was achieved, mean ETCO2 values were always higher after ROSC than before.

The authors acknowledge their study examined two extreme situations: uncomplicated ROSC and no signs of ROSC at all. The study did not cover cases when circulation restarted immediately after defibrillation because these patients were not intubated. It is worth mentioning that the majority of the patients who achieved ROSC ultimately were in vegetative states. The authors concluded that ventilated patients undergoing ACLS in out of hospital cardiac arrest have an increase in ETCO2 of about 10 mmHg after ROSC is achieved. They also suggested the increase of ETCO2 could be a suitable moment for checking pulse versus the preselected two minute intervals. Further investigation is needed given small sample size and the two extreme patient populations investigated.

Lui CT, Poon KM, Tsui KL. Abrupt rise of end tidal carbon dioxide level was a specific but non-sensitive marker of return of spontaneous circulation in patients with out-ofhospital cardiac arrest. Resuscitation. 2016;104:53-58.

Lui et al. sought to evaluate the diagnostic accuracy of an “abrupt and sustained increase” in ETCO2 to indicate ROSC in their cross-sectional prospective study. They looked at a relatively narrow population of adult patients in Hong Kong with non-traumatic OHCA who only received basic life support in the field prior to transport to one of two regional hospitals.

All of the data used in the study was prospectively recorded and then later retrieved by researchers from a cardiac arrest registry as well as the electronic health record, except for presumed etiology of arrest, which was determined based on clinical history from the scene, subsequent diagnostic testing, and autopsy data.

They documented any rise of ≥10 mmHg sustained for at least three minutes, specifically noting rises of ≥10 or 20 mmHg, or to the level of ≥40 mmHg. They performed subgroup analysis based on cardiac vs. non-cardiac arrest etiology as well as occurrence of re-arrest. Of the 548 patients fulfilling their inclusion criteria, 370 were excluded due to inadequate documentation of ETCO2 values; comparison analyses between the included and excluded groups demonstrated no difference in baseline characteristics or outcome measures. The only baseline characteristics significantly different within the included cohort were witnessed arrest and ETCO2 change during resuscitation. Within the included cohort, 34% of patients had ROSC achieved, which is relatively in line with the heterogeneous published data. For the four different parameters (rise of 10, rise of 20, rise of 10 to 40, rise of 20 to 40), they found poor sensitivities from 33% to 15%, worsening as the parameters became more restrictive, and excellent specificities from 97% to 99%. They also performed detailed statistical analysis to conclude there was a significant difference between the readings immediately pre-ROSC and post-ROSC. When performing their subgroup analysis based on arrest etiology, they concluded the rise in ETCO2 was higher in the non-cardiac group (17.5 mmHg in non-cardiac vs. 5 mmHg in cardiac) with improved sensitivity (45% in non-cardiac vs. 18% in cardiac).

The authors do identify some major limitations to their study that serve as future areas for investigation. They did not control for other factors that can affect ETCO2 such as tidal volume, medications administered, or quality of compressions. Commonly used ACLS medications such as sodium bicarbonate and epinephrine are documented to alter ETCO2 levels and the interaction of these effects with these data is unknown.10,11 In addition, these conclusions may not be generalizable to IHCA patients, patients on ventilatory support or intubated at the time of arrest, and patients who receive ACLS care in the field prior to arrival at the hospital.

This was a good first prospective study into the accuracy of changes in ETCO2 to indicate ROSC and supported existing data indicating an increase of 10 mmHg or greater is indicative of successful resuscitation.

Paiva EF, Paxton JH, O’Neil BJ. The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review. Resuscitation.

2018;123:1-7.

As part of the 2015 international Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendation (CoSTR) process, this systematic review was performed with the intention to identify whether any level of ETCO2 measured during CPR correlates with return of spontaneous circulation (ROSC) or survival or

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AAEM/RSA RESIDENT JOURNAL REVIEW

survival to discharge, irrespective of cardiac arrest setting. This systematic review included existing studies up to December 13, 2016, and found only five studies that reported enough data allowing them to be used in a quantitative synthesis. Of those five studies, only one single study was able to be included in the relationship between ETCO2 and achievement of ROSC. Only one additional study was designed to study survival at discharge, despite two others being included in the analysis. All studies included were purely observational, with high risks of bias (high rates of convenience sampling, some with >14% having already achieved ROSC, or extremely small numbers of patients).

For the outcome of return of spontaneous circulation, only one study

by Ahrens et al. was included, thus no meta-analysis was actually performed. This showed correlation between initial ETCO2 of ≥ 10mmHg and ≥ 20mmHg and increased rates of ROSC (OR 11.41, 95% CI 1.44 - 90.17 and OR 13.82, 95% CI 3.5 - 53.37, respectively). Increased odds ratios of ROSC were also noted with ETCO2 ≥ 20mmHg for 20 minutes (OR 20, 95% CI 1.97 - 203.32). This study, however, noted that 14% of patients had already achieved ROSC at first measurement of ETCO2.

For the outcome of survival to discharge, a few other studies were included in the meta-analysis, but the primary study that affected the outcomes was the same Ahrens study with weights of >90% in all analysis except one, the correlation between initial ETCO2 ≥10 mmHg in which that study still had a weight of 66%. The pooled odds ratio for survival to discharge for initial ETCO2 ≥10 mmHg was reported as 10.71 (95% CI 5.65 - 20.30). For initial ETCO2 ≥ 20 mmHg, increased odds of survival was noted with OR 12.24 (95% CI 5.13 to 29.22). Increased odds of survival was also reported with ETCO2 ≥10 mmHg and ≥20 mmHg with OR 181.57 (95% CI of 40.08 to 822.61) and OR 234 (95% CI of 19.48 to 2811.42), respectively.

Although reported as a systematic review and meta-analysis, nearly all the results came from a single study by Ahrens et al., which reported rates of >14% ROSC having been achieved prior to measurements and that samples were taken conveniently. As such, the authors conclude that initial ETCO2 should not be used to reliably predict outcomes and should not be used for determination of continuation of resuscitation. They do suggest that late in resuscitation, higher levels of ETCO2 are correlated with increased rates of ROSC and survivability to discharge but based on the poor quality and number of studies available, this is not supported in the literature. Physiologically, it makes since higher ETCO2 levels would indicate improved likelihood of ROSC or survival, but there are large variables that could affect this measurement that are not taken into account in the current available literature (rates and quality of ventilation, timing of intubation, presence of ROSC initially, etc.). As such, it is more reasonable to conclude from this study that insufficient data and research exists to make a claim on the utility of ETCO2 on the guidance of further resuscitative efforts and cardiac arrest outcomes.

Conclusion The American Heart Association’s ACLS guidelines include monitoring ETCO2 as a surrogate marker of cardiac output to help guide resuscitation during cardiac arrest. This concept is appealing given the noninvasive nature and wide availability of ETCO2: real-time feedback during resuscitation, limiting chest compression interruptions, and the ability to decide when to terminate resuscitation efforts. Existing data indicates that, in ventilated patients with a definitive airway, persistent ETCO2 values <10 mmHg despite maximum efforts are predictive of unsuccessful resuscitation, and that higher ETCO2 values are associated with ROSC. It is difficult to create an absolute numeric guide, however, due to the wide variability and inconsistent evidence regarding thresholds, due to many existing variables that may affect ETCO2, especially in causes related to pulmonary function.12 We need further evidence to understand what cutoffs and thresholds to use and how certain variables might affect them.

Answer In the management of patients with cardiac arrest and a definitive airway, a persistent ETCO2 of <10 mmHg, despite maximal resuscitative efforts, is associated with lack of ROSC, while an abrupt increase in ETCO2 of 10 mmHg or greater may be reliably indicative of ROSC. It remains that existing studies do not clearly account for confounding variables to clearly define a threshold to be the single deciding factor as to whether to stop or continue ACLS. Similarly, depth of chest compressions is associated with ETCO2 levels, but there remains no set number or guide by which to adjust chest compressions during cardiac arrest.  References 1. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [published correction appears in Circulation. 2011;123:e236].

Circulation. 2010; 122(suppl 3):S729–67.

2. Jin X, Weil MH, Tang W, et al. End-tidal carbon dioxide as a noninvasive indicator of cardiac index during circulatory shock. Crit Care Med. 2000;28:2415-9.

3. Weil MH, Bisera J, Trevino RP, Rackow EC. Cardiac output and end-tidal carbon dioxide. Crit Care Med. 1985;13:907-9.

4. Sanders AB, Kern KB, Otto CW, et al. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation: a prognostic indicator for survival. JAMA. 1989; 262:1347–51.

5. Cantineau JP, Lambert Y, Merckx P, et al. End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole: a predictor of outcome. Crit Care Med. 1996; 24:791–6.

6. Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997; 337:301–6.

7. Grmec S, Klemen P. Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest? Eur J Emerg Med. 2001;8:263-9.

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8. Kolar M, Krizmaric M, Klemen P, Grmec S. Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study. Crit Care. 2008;12(5):R115.

9. Ahrens T, Schallom L, Bettorf K, et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care. 2001; 10:391–8.

10. Vukmir RB, Bircher N, Safar P. Sodium bicarbonate in cardiac arrest: a reasppraisal. Am J Emerg Med. 1996;14:192–206.

11. Okamoto H, Hoka S, Kawasaki T, et al. Changes in end-tidal carbon dioxide tension following sodium bicarbonate administration: correlation with cardiac output and haemoglobin concentration. Acta Anaesthesiol Scand. 1995;39:79–84.

12. Heradstveit BE, Sunde K, Sunde GA, et al. Factors complicating interpretation of capnography during advanced life support in cardiac arrest - a clinical retrospective study in 575 patients. Resuscitation.

2012;83:813-8.

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

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MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

The EM Interview: Advice from Your AAEM/RSA Resident Board Lauren Lamparter – Medical Student Council President

We are now entering

the thick of interview season in a very unique application cycle! COVID19 has resulted in a massive shift in the residency application cycle, and now you can interview at a program on the East Coast in the morning and the West Coast in the afternoon, all from the comfort of your home. It is more important than ever to try to show a program who you are and assess if they are the right fit for you…

How do we do this well through our computer screen? As a fellow applicant myself, I decided to utilize my resources and poll the AAEM/RSA resident board about their past interview seasons. So here I present to you, my interview with the AAEM/RSA board about how to succeed on the virtual EM interview trail! Good luck to you all.

What did you wish you had known prior to interviewing?

The interviews are mostly relaxed conversations. Try to know what you are looking for in the program and be able to discuss your hobbies genuinely.

What questions did you ask programs while on the interview trail?

• Where do your residents go after residency?

• What changes are going on in the program?

• What are you most proud of about your program?

• What sets you apart from other programs?

• What is the role of the emergency department in the rest of the hospital?

What advice do you have for approaching the interview season?

What questions did you ask residents while on the interview trail?

In the beginning you are focused on performing well during the interviews, but as you feel more comfortable you will realize that you are also interviewing the program. Ask the program about your interests, and do not be afraid to ask a challenging question if it is something you are looking for. They gave you the interview, this program already likes you. Be yourself and discover the program that is the best fit for you.

• What culture exists amongst residents?

• What is your favorite and least favorite thing about the program?

• Is the program what you expected while interviewing?

• What types of activities does the residency set up for wellness?

• Does the residency provide scheduled time for you to be together (even over Zoom!)?

• If you could change one thing about your residency what would it be?

Because of the new format of online interviewing, try to find a quiet place with a chair that does not move. Use headphones to maximize your sound clarity instead of just the computer speakers. Dress professionally despite being in your home. Try to suspend disbelief and act like you would in an in-person interview.

In the interview, make sure that you highlight your strengths and unique application aspects.

Despite COVID-19 making your final medical 46

years different, programs want to get to know the opportunities you took advantage of or the interests you explored.

COMMON SENSE NOVEMBER/DECEMBER 2020

How did you ultimately know a program was right for you?

I assessed my future goals and looked to see if the culture of the program lent itself to what I wanted to do. At your interview, meet the residents and see what their goals are and what past residents have been able to accomplish with their training.

A good way to decide, is to think about what is most important for you to find in a program.

Pick the place where you will thrive geographically and best contribute to your overall happiness and long-term goals. Look at the patient population, where the residents come from, what they do after residency, and what your time will look like outside of the hospital.

You can get the contact information from the residents you meet on your interview to reach out and ask questions if you have any lingering thoughts or concerns.

How does a student continue to show interest in a program if they are at the top of your rank list?

Send thank you letters after your interviews and be specific about the aspects of the program that interest you. It is reasonable to let your top program know they are your first choice by emailing them at the end of the interview season. Be true to your number one program though, as they will find out if you lied to them.

If you want to express interest to your top choices, you can use the phrase “top choice” without committing one to “number one.” Just be careful with telling multiple programs they are your number one. It is unclear if these emails actually have an impact, but if you use the right language it would not hurt you.

Be yourself and discover the program that is the best fit for you.

What advice do you have for people who have a red flag in their application?

Know that the red flag will likely be addressed in the interview. Be prepared to address whatever the red flag is, and to speak about how it impacted you, how you changed as a result of it, etc. If you want to bring it up, do not be afraid to acknowledge it. Just be able to show how you have improved as a result of it.

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MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

Try to know what you are looking for in the program and be able to discuss your hobbies genuinely.

Ultimately, one resident gave the best piece of advice. “The beauty of EM is that there are so many good programs. It can make it difficult to choose, but if you step back and take the pressure of your decision off, you realize how lucky you are to be entering a field with so many good opportunities.” We are very lucky to be pursuing this field. Good luck to everyone interviewing both this year and in the future, may you find the best EM program for you!

Many thanks to the AAEM/RSA Board of Directors for their insight. 

Pick the place where you will thrive geographically and best contribute to your overall happiness and long-term goals.

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

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September Board of Directors Meeting Summary

The members of the AAEM Board of Directors met virtually September 14, 2020 to discuss current and future activities. The members of the Board of Directors appreciate and value the work of AAEM committee, section, interest groups, and chapter division members and chairs as they strive toward the AAEM mission and to be the specialty society of emergency

2021 Elected Board of Directors

medicine. Over the course of the meeting, a number of significant decisions and actions were made. Here are the highlights:

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Presentations

Approvals

Miscellaneous

President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM provided further insights on her presidential activities, interviews, and other updates. Treasurer Robert Frolichstein, MD FAAEM reported on AAEM and AAEM subsidiaries financial performance. AAEM Lobbyist Matt Hoekstra provided a federal update.

AAEM-PG President Mark Reiter, MD MBA MAAEM FAAEM reported on the activities of AAEM-PG.

A number of approvals took place during the meeting, including a new clinical practice statement on how native crotalid envenomation should be managed in the ED. Two updated position statements from the EM Workforce Committee where approved as well as to eliminate the use of the word â&#x20AC;&#x153;providerâ&#x20AC;? in any AAEM statements. The Pain and Procedural Sedation Interest Group will become the Pain and Addiction Committee.

The formation of a joint task force between the AAEM Board and Directors and the AAEM Physicians Group Board of Directors to review the AAEM Certificate of Workplace and Fairness and AAEM-PG Fairness Principles.

COMMON SENSE NOVEMBER/DECEMBER 2020

What

When

Where

The next Board of Directors meeting

November 12, 2020

New Orleans, Louisiana

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.

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COMMONSENSE

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

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27th Annual Scientific Assembly

SAVE THE DATE June 19-23, 2021 Meet Me in St. Louis!

AAEM21 St. Louis, MO

www.aaem.org/AAEM21 #AAEM21

www.aaem.org/AAEM21 #AAEM21