November/December 2021 Common Sense

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 28, ISSUE 6 NOVEMBER/DECEMBER 2021

Heart of a Doctor Page 9

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President’s Message:

The Principle of Moral Proximity

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From the Editor’s Desk:

We Need to Take Care of Our Children

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Legislators in the News:

An Interview with Congresswoman Dr. Kim Schrier

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Young Physicians:

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Transition from Resident to Attending Practice

AAEM/RSA President’s Message

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Physician Suicide Awareness

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 William T. Durkin Jr., MD MBA Board of Directors Phillip Dixon, MD MPH Al O. Giwa, LLB MD MBA MBE L.E. Gomez, MD MBA Robert P. Lam, MD Bruce Lo, MD MBA RDMS Terrence Mulligan, DO MPH Vicki Norton, MD Carol Pak-Teng, MD YPS Director Fred E. Kency, JR., MD AAEM/RSA President Lauren Lamparter, MD Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD Editor, Common Sense Ex-Officio Board Member 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 Kasha Bornstein, MD MPH MSC Pharm EMT-P, Resident Editor Stephanie Burmeister, MLIS, 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 2021

COMMONSENSE

Regular Features President’s Message: The Principle of Moral Proximity....................................................................... 3 From the Editor’s Desk: We Need to Take Care of Our Children......................................................... 6 Legislators in the News: An Interview with Congresswoman Dr. Kim Schrier...................................... 9 Foundation Contributors.................................................................................................................... 14 PAC Contributors............................................................................................................................... 15 LEAD-EM Contributors...................................................................................................................... 15 Upcoming Conferences..................................................................................................................... 16 AAEM/RSA President’s Message: Physician Suicide Awareness...................................................... 46 New Column: Heart of a Doctor........................................................................................................ 11 Board of Directors Meeting Summary: November............................................................................. 52 Job Bank............................................................................................................................................ 53 Featured Articles Academic Affairs Committee: Resilience Lesson: Giving Negative Feedback................................... 18 Medication Prescribing in Time of COVID, Unproven Remedies, Overstepped Autonomy, Known Harms: A Toxicologic Argument Against Ivermectin for COVID-19.................................. 21 Opinion: An Ethical Mandate for Federal Law: Vaccination Against COVID-19................................. 24 Wellness Committee: From Hero to Zero: Naiken, COVID-19, and Ways to Develop Empathy Despite Patients’ Challenging Life Choices.................................................................. 26 Wellness Committee: Perfectionism: Our Dangerous Frenemy.......................................................... 28 AAEM Financial Update: Investing Your Money in You!..................................................................... 30 Advocacy: AAEM’s New Action Center: Grassroots Advocacy Made Simple.................................... 31 Emergency Medicine Workforce Committee: ‘Tis the Season........................................................... 32 Operations Management Committee: Geriatric Patient Experience in the Emergency Department.. 33 Women in Emergency Medicine: Infertility: Using Knowledge to Advocate for Change..................... 35 Emergency Ultrasound Section: EUS-AAEM 2020-2021 Round Up.................................................. 36 Emergency Ultrasound Section: Give Me a Break: Ultrasound Guided Serratus Anterior Plane Block.................................................................................................................... 38 Ethics Committee: Not Burnout: Moral Injury in the ED..................................................................... 42 Young Physicians Section: Understanding the Transition from Resident to Attending Practice.......... 44 Gallbladder Wall Thickening: Not Always Acute Chotecystitis........................................................... 47 Pre-hospital Shortness of Breath...................................................................................................... 48 Critical Care Medicine Section: Bougie Conundrum: Airway Adjunct or Secret to 1st Pass Success?

Should We Incorporate into Routine Practice and How?............................................................. 49 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) 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-1121-126 AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

The Principle of Moral Proximity

AAEM PRESIDENT’S MESSAGE

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM — President, AAEM

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character in a novel I recently read learned that a colleague was making defamatory statements about a senior member of their profession who had not selected the colleague for an important committee. The statements were untrue and were damaging to the senior person’s reputation. Should she, the novel’s protagonist, confront her colleague, who was making these statements? Should she tell the person who was being gossiped about unfairly? What was her moral obligation? Is this her business?

After the Allied Forces liberated the Schutzstaffel camps, allied soldiers were assigned to take local citizens on mandatory tours of the camps. The soldiers reported that many of the citizens cried, but some others held their heads high, with defiance in their eyes, and challenged the soldiers to blame or shame them. How, the soldiers wondered, could people have lived with the smell of burning human flesh, in a village where grey ash fell from the sky almost daily, and not have questioned what was going on in these camps?

More proximal geographically and temporally, an American court will be considering whether Alex Kueng, Thomas Lane, and Tou Thao had a moral obligation to act to attempt to stop the murder of George Floyd by Derek Chauvin.

Even more proximal are the daily questions that we are confronted with as emergency physicians. What is my obligation to treat the patients lingering at the border between Afghanistan and Pakistan, begging to enter Pakistan for necessary medical care? What is my obligation to treat patients in Haiti who have been struck by another earthquake? What is my obligation to act when my colleague has been terminated without due process and escorted out of the hospital by security staff and a Team Health executive? What is my obligation when the admitting team refuses to admit my homeless patient with second degree burns and no access to water, wound care materials, or transportation to the clinic? What is my

obligation to intercede when I hear a patient call a female resident “dumb bitch”?

A colleague of mine who worked in a Pakistani refugee camp years ago told the story of a mother of six whose husband had died. She

his confession in this column before. Niemöller was a German Lutheran pastor and theologian born in Germany. In 1892, the Reverend was an anti-communist and so he supported Hitler’s rise to power. But he quickly realized the evil

THANK YOURSELF EACH DAY FOR THE WORK THAT YOU DO,

WITH THE HIGHEST LEVEL OF INTEGRITY, ETHICS, AND AUTHENTICITY, TO SERVE THOSE INDIVIDUALS WHO ARE FRIGHTENED, IN PAIN, AND IN THE MOST NEED OF HELP.”

had lost track of her extended family and his, due to migration during the political turmoil.

She had no work skills and she and her children were facing starvation. A 60-year-old widower offered a bride price for the woman’s 12-year-old daughter that would allow her to feed her other five children for at least another three years. She sold her 12-year-old daughter.

“How,” my friend asked, “could any mother condemn her little girl to that life? I don’t understand how a mother could do that to her own child.” “Indeed, you don’t understand,” I told her.

“And I pray you never have to, but she chose to sacrifice one child to save five.” And then we discussed our moral responsibility to eliminate situations in which mothers are forced to make such decisions.

We all know the words of the confession of the Reverend Martin Niemöller, and I have quoted

of Hitler’s plan. After the liberation of Dachau, where Niemöller was imprisoned, he wrote this confession: First, they came for the Communists, and I did not speak out— Because I was not a Communist.

Then, they came for the socialists, and I did not speak out— Because I was not a socialist.

Then they came for the trade unionists, and I did not speak out— Because I was not a trade unionist.

Then they came for the Jews, and I did not speak out— Because I was not a Jew. Then they came for me—and there was no one left to speak for me.

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AAEM PRESIDENT’S MESSAGE

His message, clearly, is that we must speak for others, most especially those who cannot speak for themselves. The message deeply touches the core of what we do for emergency patients and what AAEM does for emergency physicians. There is so much to be done, and often, it feels overwhelming, which leads to feeling ineffectual, which leads to burnout. So, as we strive towards self-care and work to avoid burnout, balancing that with our sense of responsibility to the platform and privilege that we have as emergency physicians, and as we strive to protect ourselves from moral injury, how do we decide where our responsibility lies and how can we exercise our privilege in a way that is effective?

The concept I recently came across is called MORAL PROXIMITY. The principle holds that your moral obligation, first and foremost, is to the person with whom you interact. Moral proximity takes the ethical approaches: VIRTUE ethics (to be good, do good), DUTY ethics (to be good, do your duty/follow the rules), UTILITY ethics (the greatest good for the greatest number), and DISCOURSE ethics (something is good because EVERYONE who it effects agrees it is good) and distills them down to the individual relationships we engage in daily. Proximity ethics looks at our duty in the here and the now to the person or people who are here with us.

A wonderful article “Between You and Me: A Comparison of Proximity Ethics and Process Education” by Hintze, et al (International Journal of Process Education, June 2015, Volume 7 Issue 1) discusses the implications of moral proximity ethics to health care providers and educators. Many of us are both by profession, but all of us are both in practice since we educate patients, families, and non-physician health care professionals daily. And while I am definitely someone who likes to go way off

into the weeds to have discussions about ethics and philosophy, what I found most attractive about this principle is its simplicity and relevance to what we do. Moral proximity ethics is principally based on the works of Martin Buber,

6. When in a position of power over another, we are obliged to act in his best interest, not our own.

7. A relationship of caring has as its goal that of helping the other to gain his autonomy.

When we compare the mission and vision of AAEM, and when we compare the work of AAEM to the Ethics of Moral Proximity, it is extremely clear that AAEM operates as an organization of the highest ethical standards.

We recognize our obligation to help our fellow emergency physicians and to do so with respect for their autonomy. We authentically engage in dialog exploring controversial and opposing opinions. We regard respect for each other as a primary virtue. We uphold the values of diversity, equity, and inclusion and eschew preconceptions and prejudgments. Unlike the corporate medical groups we oppose, we believe that those in a position of power are obligated to act in the best interests of those we serve, not in our own best interests. And as we support those who have been unfairly terminated without due process, and those who are subjected to metrics and processes not patient outcome focused and not physician led, we work with them to regain autonomy over their professional practices. Yes, we do live in a professional environment that seems to support burnout and sustain moral injury, but AAEM stands firm and true to the ethical principles that only mark a good standard of medical practice, but that also mark a good standard of ethics.

HOW DO WE DECIDE WHERE OUR

RESPONSIBILITY LIES AND HOW CAN WE EXERCISE OUR PRIVILEGE IN A WAY THAT IS EFFECTIVE?”

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Emmanuel Levinas, and Knud Logstrup, if you want to read more, but the article I reference summarizes the core principles elegantly (and I quote): 1. When interacting with another, we have an ethical obligation to help the other.

2. What constitutes “helping” can be defined through discourse but must always respect the other’s self-determination.

3. To interact authentically with the other is to risk ourselves and give up some of our control over where the dialogue between us takes us.

4. Do what works in the particular situation, taking from any other ethical field (especially discourse ethics, but also virtue, utility, or duty) but always respecting the other as the primary virtue.

5. In bringing preconceptions and prejudgments to our interaction with the other, we dismiss his needs.

When you move through your workday, reflect on how beautifully emergency medicine creates opportunities for you to practice in a truly ethical way. You come to work to help your patients, and you respect their self-determination through

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AAEM PRESIDENT’S MESSAGE

shared decision making. You give up control not only over where the dialog in the ED will take you, but over everything that you will encounter during your shift, and then create order and healing in the environment of the unexpected. You do what works in each situation.

You consciously put aside your prejudgments and preconceptions so that you can engage authentically and with respect. You put the patient’s needs above your own. And you strive to give the gift of health and wellness to each patient so that s/he can live as autonomously as possible.

It is easy for us to feel diminished by the loss of autonomy we ourselves feel as we see our meaningful work impeded by corporate medical groups, private equity, and regulations created

and in the most need of help. We have your by non-physicians. I urge you to look at these back, so that you can continue to have their basic principles of moral proximity ethics periodically and remind yourself that you belong to back in the way that only a board certified, residency trained emergency physician can. Thank an organization that holds itself to the highest you for all you do each and everyday to make ethical standards, even if our position is not your shop, the Academy, our nation, and our supported by those who put profit over patient world a better place because you are in it. and who find it in their best financial interests to provide inferior care or inadequately trained non-physician practitioners for their patients.

Thank yourself each day for the work that you do, with the highAAEM Antitrust Compliance Plan: est level of integrity, As part of AAEM’s antitrust compliance plan, we invite all readers of ethics, and authenCommon Sense to report any AAEM publication or activity which may restrain trade or limit competition. You may confidentially file a report at ticity, to serve those info@aaem.org or by calling 800-884-AAEM. individuals who are frightened, in pain,

In an effort to keep our members connected, Common Sense began 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

COMMON SENSE NOVEMBER/DECEMBER 2021

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AAEM NEWS FROM THE EDITOR’S DESK

We Need To Take Care of Our Children Andy Mayer, MD FAAEM

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he statement above was made at a recent AAEM Board of Directors meeting. It may sound like a strange statement to be made at such a meeting but it carries great significance. Most physicians believe that there is a duty for each physician to encourage, mentor, educate, protect, and to take care of the next generation of physicians. Our profession is both an art and a science and we learned our skills from physicians who came before us and we owe a debt to those who will follow us. Emergency physicians need to look at the looming workforce issue with an eye towards protecting our patients and the young, dedicated, idealistic physicians who are looking to emergency medicine as a career. Choosing a specialty in which there is a rising certainty that new emergency medicine residency graduates will be unable to be empowered to advocate for their patients or have any control over their careers is disturbing at best and disastrous at worst. The health and safety of both these young physicians and the patients who they will care for in the coming years is at stake.

There were lengthy discussions during this meeting related to the looming workforce issue which emergency medicine is facing. The projected surplus of graduating emergency physicians in the coming decade is something which cannot be ignored and certainly the time for action is now. The consequences of the projected glut on the house of emergency medicine is now the big hot topic. The roles of private equity and corporate management groups in this coming crisis are actively being discussed in many forums. The time for endless discussion and study is past and now is the time to do something to prevent a catastrophe for a generation of young intelligent physicians who will be entering a supersaturated job market with few reasonable options. These physicians will typically be shouldering a huge student loan debt at a time when most plan to be starting families and settling down into a long and fruitful career. What will be their reality and what viable options for a successful career will be available to them?

Each emergency medicine organization looks at this issue from its own perspective and often with their own best interest in mind. The house of emergency medicine needs to put aside any self-interest or self-protective instincts and do what is right for our patients and our profession.

The specialty has to come together and work in unison on this issue.

Concerns about membership numbers and advertisement income need to be put aside. Letting private equity inflate a labor pool for shareholder’s profit at the expense of patient safety is such a strange and absurd concept to me that it is hard to believe our healthcare system could be so broken as to permit this onerous outcome.

Let’s just consider if a glut of thousands of unemployable or under employable residency trained emergency physicians is good for our

patients? One might think that oversupply would lead to lower costs for the patient and therefore could be considered a good thing. I suspect few of you believe that any money saved, any significant salary reductions will be passed on to the patient. Do you think that the private equity and corporate management groups which are leading the push to produce this glut are doing this for the good of the American people? They want cheap labor who they can hire to work for a lower salary and at the same time require them to supervise more non-physician providers. These physicians will have to accept any job which they can get often with virtually no power to advocate for the health and safety of the patients. These young emergency physicians will be left alone in the middle of the night to treat and care for the sick while the corporate management group executives and the owners of private equity firms are sleeping soundly in their beds. Will these physicians be willing to speak out when they have a patient care or safety concerns related to staffing, boarding, or the increasing requirement for them to sign non-physician provider charts? I suspect these vulnerable physicians will feel compelled to remain silent to protect their fragile job security. They will not feel that they can afford to risk their job as they will know there will be another wave each year of new graduates competing for their job who will work for less and under worse conditions.

AAEM is trying to take action and stop talking. We are encouraging other emergency medicine organizations to do the same. Dr. Mark Reiter, a past president of AAEM has done significant work on this issue and made a proposal to the board which was accepted as the policy statement below.

Raising Emergency Medicine Residency Standards Introduction AAEM has received much feedback from our members regarding concerns that the rapid proliferation in the number of emergency medicine resident positions, and increased utilization of non-physician practitioners at emergency department training sites has negatively impacted the quality of emergency medicine resident education.

Position Statement AAEM suggests the ACGME Emergency Medicine Residency Review Committee take action to raise emergency medicine training and quality standards by setting a minimum number of patients at the primary site emergency department per resident and setting a maximum percentage of emergency department patients seen by non-physician practitioners (NPPs). Specifically, AAEM advocates for the implementation of a standard of one resident per 3,600 patient volume at the primary residency training site and a maximum of 25% of patients seen by NPPs. Residency programs will be able to devote

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AAEM NEWS FROM THE EDITOR’S DESK

more resources to each resident and faculty/resident ratios would improve. Emergency medicine residents would benefit from exposure to more emergency patients, resuscitations, and procedures, and would have increased faculty access and supervision. Expected shortages in other medical specialties can be addressed by reallocating excess emergency medicine resident positions.

Earlier this year the RSA and AAEM sent a letter to Douglas McGee, DO who is the Chair of the ACGME Review Committee. The letter asks the ACGME to look into the rapid expansion of residency programs in for-profit hospitals where the staff are employed by for-profit staffing companies. The letter also expressed the concern that emergency medicine residents were simply being used as “cheap labor” by these for-profit entities with links to private equity. AAEM and the RSA asked for an investigation into this issue. A copy of the letter is below.

Dr. McGee responded in a letter which essentially cites a 1984 policy in which the ACGME claims that it can only accredit residencies and that it has no power to limit any program who meets the minimum standards for institutional and program requirements. It essentially claims that they have no ability or responsibility in regards to the future emergency medicine workforce. To be fair, when these policies were made no one would have thought that any for-profit entity would come to control emergency medicine programs or find a profit motive for the training of residents so they could cheaply staff their for-profit emergency departments. Most reasonable people would determine that the ACGME does now have a duty to change their policy and ensure that the training of emergency medicine residents is done in an ethical and prudent manner for the protection of our patients and the healthcare system. A copy of his letter back to AAEM and the RSA is below.

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AAEM NEWS FROM THE EDITOR’S DESK

Attn: Felicia Davis, MHA Executive Director RC for Emergency Medicine ACGME Suite 2000 401 North Michigan Ave Chicago, IL 60611 Dear Ms. Davis and ACGME Emergency Medicine Review Committee, Due to the proliferation of emergency medicine programs, I am concerned regarding the standards of resident education. Emergency medicine residents benefit from exposure to more emergency patients, resuscitations, and procedures, and should have increased faculty access and supervision. For this reason, I would support the implementation of a standard of one resident per 3,600 patient volume at the primary residency training site. Also, more and more non-physician practitioners (NPPs) are staffing emergency departments and their presence may hinder the access to procedures and training opportunity for residents. I would also implore the Review Committee to institute a limit on the number of NPPs staffing emergency medicine training sites. Thank you for considering these very important issues and for your commitment to emergency medicine resident education.

Sincerely, Andrew Mayer, MD

What can be done? First, we must try and strongly encourage the ACGME to reconsider and revise their 1984 policy position on accrediting new residency programs. Second, we need to educate and convince the ACGME that many of the new residency programs which they have accredited are actually not providing adequate training. It is hard for a reasonable person to believe that many of these new small to medium residency programs at smaller community settings could possibly provide an adequate number of patient contacts or procedures for each resident. Simulation is great but actual real world procedural and patient care experience is needed to protect our patients. I ask each of you to send a letter to the ACGME today. Dr. Vicki Norton has done great work on AAEM’s advocacy page and I hope you will explore the site and become involved in more than this one issue. All you need to do is go to AAEM Advocacy page and click on the TAKE ACTION NOW tab on the top right. Then click ACTIVE CAMPAIGNS and finally RAISING EM RESIDENCY STANDARDS. A letter will be generated for you like the one below which I sent. It is very easy and quick and please also take a look at the other campaigns which AAEM is working on.

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The last action which I want to ask for you to consider doing is the hard one. Dr. McGee in his letter to AAEM and the RSA proposes an idea.

On page two of his letter he suggests that individuals provide specific complaints and concerns to the ACGME. He asks for specific concerns “regarding the educational environment in a program, including the balance of education and service.” He states that such claims will be taken seriously and that they will be “diligently” addressed. He asks for “explicit comments detailing the incidents which led to these concerns.” Are you a current resident, graduate or attending of such a program? Do you have legitimate concerns about the adequacy of the training at such a program and be willing to stand up for the future of our specialty and the future safety of our patients? I strongly encourage you to consider taking action. Remember that we do need to take care of our children!

LEGISLATORS IN THE NEWS

An Interview with Congresswoman Dr. Kim Schrier Lisa Moreno, MD MS MSCR FAAEM FIFEM — President, American Academy of Emergency Medicine

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elcome to the next installment of Legislators in the News. In this issue, we interview Congresswoman Dr. Kim Schrier (D-WA, US House of Representatives) who is a board certified pediatrician and only one of two female physicians, and the only Democratic female physician, currently serving in Congress. The Congresswoman is a staunch advocate of children and public health and supports the role of women in public policy. She generously accepted AAEM’s invitation to do a presentation at our annual Health Policy in Emergency Medicine Day, held on October 19, 2021, and allowed me to interview her on that day.

KS: Well, I certainly experienced this as an undergraduate. I was an astrophysics major and I was often the only woman in the room. But in Congress? Never!

Remember, I was elected as part of the group of Democratic women who turned Congress. This is the Grand Sisterhood, and we are focusing on legislation that supports women in their roles as working mothers and supports children as the future leaders of our nation.

LM: Dr. Schrier, was there a particular event or series of events that led you to change your primary service focus from medicine to politics, or was it a more organic transition?

(Author’s note: Dr. Schrier joined the House of Representatives in a cohort of remarkable, record breaking women: Congresswoman Ayanna Pressley, the first Black to represent Massachusetts; Congresswoman Alexandria Ocasio-Cortez, the youngest woman ever elected to Congress; Congresswomen Ilhan Omar and Rashida Tlaib, the first Muslim women ever elected to Congress; and Congresswomen Deb Haaland and Sharice Davids, the first Native American women ever elected to Congress.)

KS: I’ll tell you very simply what it was: Trump got elected. I started to think about the implications of that election on my patients and their families. I realized that this election had the potential to have significant adverse impacts on the lives of children and on their health care. Many of our nation’s children were able to get quality healthcare under the Affordable Care Act (ACA). ACA’s exchanges have provided coverage for upwards of 10 million people annually. The Trump Administration reduced the support for advertising the program and reduced the annual enrollment period by almost half. There was a plan to exclude pre-existing conditions. This impacted me directly, as a Type 1 diabetic. It was disturbing to realize how many families and children would be left without medication, without care for congenital conditions, without the vaccines, and early detection that is facilitated by regular well child visits to the pediatrician that become impossible for those without insurance. Under that administration, immigrant children were not accorded the Child Tax Credit on the income tax returns of their parents, directly impacting the money available for food and housing. Public education was under attack during the campaign, with talk of issuing school credits that could be used at charter schools and religious schools, most of which are unaffordable or not accessible to our most vulnerable families. This plan threatened to decrease the support for public schools and increase the disparities in education that the poor are already experiencing. Even the general tenor of the conversation during that campaign was troubling. There was name calling, mocking of individuals with disabilities, disparagement of women.

As a pediatrician, I know that the morale of children, of all individuals, is related to their mental health and to their ability to succeed. I felt it was my responsibility as a pediatrician and as a citizen to take a stand for the rights and wellbeing of children and families, and so I ran, and I won.

LM: Many women in leadership experience “the only woman in the room” or “the only woman at the table” phenomenon. How does this play out for you in Congress?

LM: How does your knowledge and experience as a physician empower you in your interactions with other lawmakers?

KS: Who better to take on information sharing than a physician in Congress! Everything I do carries additional weight because I’m a doctor.

I can help set the trend for healthy behavior. Members watch to see, “Does Schrier replace her mask between sips and bites?” Other members even ask me to diagnose their kids; they seek my opinion about their children’s medical care. Concern for your children is bipartisan; it knows no bounds, and this fosters good relationships with other members, regardless of party or political stance. And MDs speak the same language, so it’s easy to gain bipartisanship with the other doctors serving in Congress. We understand the priorities. I worked with Republican Congressman John Joyce, MD (Pennsylvania), on strengthening the Vaccines for Children Program. This is a program that provides free vaccines for children whose families are unable to afford them and covers not just vaccines given at clinics or vaccine centers, but also in the pediatrician’s office. The VACCINES Act of 2019 is another example. This bill requires the Centers for Disease Control and Prevention (CDC) to develop a national surveillance system to monitor vaccination rates, and to conduct a national campaign to increase awareness of the importance of vaccines. These are non-partisan issues that physicians agree on, and physicians are regarded as experts on these issues by other members of Congress. We were able to come together with the same passion as the antivaxxers bring to their movement. Some of the older physician members who saw the results of unvaccinated kids who got polio were able to share their experiences. This carries weight. You have actual

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LEGISLATORS IN THE NEWS

I FELT IT WAS MY RESPONSIBILITY AS A PEDIATRICIAN AND AS A CITIZEN TO TAKE A STAND FOR THE RIGHTS AND WELLBEING OF CHILDREN AND FAMILIES.”

physicians who are your colleagues in Congress reporting on actual patient cases that are relevant to what we are working on in the House of Representatives.

I’ve also been able to help other members to make the connection between housing and health, a connection that is critical not just for kids, but for our constituents at every age. I can communicate with the Health and Human Services officials and with the White House regarding creative ideas to get kids vaccinated, such as school parties. Our expertise and experience are respected when health policy is under consideration.

LM: What do you see as a woman leader’s responsibility for mentorship and how do you choose who to mentor from the myriad requests you must receive?

KS: I share advice with everyone! But since there is only so much time available, the caliber of the candidate impacts the extent of the help I give. If a woman is running for office, this would be a strong consideration. Also, I want to be pretty certain that the people I am helping are intent on helping other people. I try to be visible in a way that will inspire girls to think of politics as a real career option. You give a press conference, or you speak to a student body, and you never know who will suddenly realize, “I could do that, too. That could be me up there someday.”

LM: From your vantage point as a physician legislator, what do you believe are the three most critical legislative issues that physicians need to focus on in the coming year?

KS: I would love to see physicians working with legislators to get home COVID test kits to be readily available to the public, but when I think of the three major legislative issues that practicing physicians should focus on, they would be these: 1. Universal access to affordable medical care 2. Physician autonomy in practice, and this includes in prescribing and in the development of telemedicine services 3. Fair reimbursement for all physicians. Physicians should not have to be responsible for fighting for reimbursement; they should be able to spend their time taking care of patients.

And while this is not necessarily a legislative issue, we all need to be concerned about the mental health of the nation’s physicians.

LM: Congresswoman Schrier, you are reflecting many of the issues that are core to the mission of AAEM. We support the right of every patient with an emergency condition to be cared for by a board certified emergency physician, and we hold that the physician, based on training and experience, is best positioned to make decisions regarding treatment within the privacy and sanctity of the physician-patient relationship, and that these decisions should not be legislated or controlled by non-physicians. The Academy has been

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active in the movement to de-stigmatize mental health disorders and to eliminate penalties for physicians who seek help for depression, burnout, and moral injury. We value your support of physician legislators such as yourself. Thank you so much for your support of our Health Policy in Emergency Medicine seminar and for taking the time to meet with me today.

KS: It was my pleasure. I certainly look forward to seeing healthier children and stronger families as a result of all of our combined efforts.

About Dr. Kim Schrier Congresswoman Kim Schrier represents Washington’s 8th Congressional District, which includes much of King, Pierce, Kittitas, and Chelan Counties, and portions of Douglas County.

Prior to being elected to Congress on November 6, 2018, Dr. Schrier spent her career as a pediatrician in Issaquah, working with children across the Puget Sound region and helping families navigate the health care system. In Congress, Dr. Schrier uses this expertise to inform her work on issues that improve the lives, health, and wellbeing of children.

As the first pediatrician in Congress, Dr. Schrier brings a critical voice to issues related to health care. Through her own experience as a patient living with Type 1 diabetes, Dr. Schrier understands the very real fear of health care costs and access for people living with pre-existing conditions. And as a physician who has worked in a broken health care system, Dr. Schrier understands what changes need to be made to make it work better for both patients and providers.

Dr. Schrier grew up the daughter of a public school teacher and an engineer. Her father, an engineer, instilled in Dr. Schrier a love for science, a passion that led Dr. Schrier to a degree in Astrophysics at U.C. Berkeley and then to medical school. Her mother taught her the value of education and teachers, and the importance of unions and collective bargaining. As a child, Dr. Schrier watched her mother’s union successfully negotiate for increased school funding, smaller class size, and improved benefits.

The product of public education from elementary through medical school, Dr. Schrier is passionate about helping every child thrive in school. After graduating from U.C. Berkeley Phi Beta Kappa, Dr. Schrier spent a year working at the EPA before attending medical school at U.C. Davis School of Medicine. She completed her residency at the Lucile Packard Children’s Hospital at Stanford University. In 2013, Dr. Schrier was named Best Pediatrician in the Greater Seattle Area by Parents Map Magazine.

Dr. Schrier’s experience as a pediatrician gives her a unique understanding of the needs and struggles facing 8th District families. She lives in Sammamish with her husband, David, and son, Sam.

Heart of a Doctor

STORIES FROM THE ED

Pavitra P. Krishnamani, MD MS

I

n the past few years, the AANP—America’s professional organization for nurse practitioners—has sadly capitalized on the slogan “Brain of a Doctor, Heart of a Nurse,” with other NP news outlets routinely implying or outright stating that an NP’s compassion for patients is unmatched by a physician’s. Informal social media campaigns have played into this new stereotype, wherein it is implied that a physician does not participate in patient-centered care. The implication that those who once served as nurses and later become NPs have a monopoly on “heart” is a grossly false representation and a frank disservice to our patients.

As a young physician who has completed years of clinical training, I single-mindedly became a physician in order to help people in their time of greatest need. My colleagues and I devote our twenties to advancing our medical education, often sacrificing the hours following a shift to further serve our patients. This practical education and the many hours we spend studying medicine outside the hospital contribute to our ability to minimize the risk of medical error and maximize the benefit our patients receive in their interactions with us as physicians. I personally invest in my patients, setting aside the emotional toll a death or unfortunate outcome takes on me so that I may approach my other patients with positivity and compassion.

“Heart of a Doctor” is the story of just one patient I had the privilege of caring for during the 72+ hour-long weeks I spent in the Medical Intensive Care Unit (MICU): Mr. Rahil Aslam “Mr. Aslam! You’ve got the same last name as the famous singer I see,” I smiled as I walked into the room. Mr. Aslam looked confused at first before shooting me a wide grin though the BiPAP (bilevel positive airway pressure) device that was keeping his oxygen levels up. He came to the MICU because he was at high risk of hypoxic respiratory failure.

“Ah yes yes,” he said through forced breaths, “Voice of gold.”

I sat down by his bedside before introducing myself, “I’m Dr. Pavitra, I’ll be the resident physician taking care of you here in the ICU. Tell me more about what brought you in.”

Mr. Aslam told me about his history of lung cancer, now metastatic to his spine, but possibly improving with a new line of chemotherapy his oncologists had recently placed him on. It was a last line therapy with a low chance of success, but Mr. Aslam was young and wanted to give this fight his best shot. He had, after all just been married to a beautiful young lady from his home country just a few years earlier, before they had discovered the cancer. Earlier in the week, he was having a bit of trouble breathing. His symptoms waxed and waned, but today they became constant and he just couldn’t move around like usual. Given his history of cancer, his family brought him straight in to get evaluated.

AS A YOUNG PHYSICIAN WHO HAS COMPLETED YEARS OF CLINICAL TRAINING,

I SINGLE-MINDEDLY BECAME A PHYSICIAN IN ORDER TO HELP PEOPLE IN THEIR TIME OF GREATEST NEED.”

“He’s had multiple pneumonias in the past, I just wanted to make sure he gets through this,” his brother said through the phone. “His wife is his primary decision maker, but of course she discusses those decisions with the family. I’m not sure when she might be available to speak with you all.”

“Well, Mr. Aslam,” I told him after our first visit together, “it looks like you may have another bout of pneumonia, which is making it quite hard for you to breathe right now. The good news is that you’re holding steady with the BiPAP right now, so we will not have to think about putting you on a ventilator at this moment. I’ll check in on you throughout the day and tomorrow as well to see how you’re doing and we’ll adjust accordingly, does that sound good?”

“Sounds good,” Mr. Aslam sounded fatigued between breaths. “I don’t want to be placed on a ventilator though,” he managed to say.

“Okay. Let me see if I can update your wife as well.” I spent the rest of the day trying to get a hold of his wife. Meanwhile, Mr. Aslam’s breathing became more and more strained throughout the day. He remained insistent that we not intubate him and better control his breathing on a ventilator. Finally, his brother called, saying that Mrs. Aslam was aware of her husband’s condition and would be in the next day to discuss further.

I checked Mr. Aslam’s oxygen saturation that evening after 14 hours at the hospital before leaving—it teetered around 91-92% at the highest settings we could place Mr. Aslam on before intubation. “Please don’t crash,” I uttered a silent prayer before leaving the monitoring station to go home.

The next day continued to be rocky with Mr. Aslam’s oxygenation threatening to drop dangerously low multiple times. It was in this setting that I finally met Mrs. Aslam, a petite young woman with her hair pulled back into a short ponytail and a scarf wrapped loosely around her neck. She sat by Mr. Aslam’s bedside, holding his hand and occasionally texting him. Mr. Aslam was too tired by now to talk and breathe at the same time. She knew she was tasked with convincing her husband to undergo

>> COMMON SENSE NOVEMBER/DECEMBER 2021

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STORIES FROM THE ED

intubation. She knew the BiPAP was simply not sustainable unless something drastically changed for the better.

Three days later, she was finally successful, with Mr. Aslam agreeing to an elective intubation with the caveat that we would keep him as awake as possible so he could still interact with his surroundings and his wife. The way they smiled at each other brought a degree of sunshine into the room that one doesn’t expect to see in a closed intensive care unit during the

A long pause followed before Mrs. Aslam answered. “If he needs it in order to breathe well, then I don’t think we have an option. I just wish I had stayed a little bit longer yesterday while he was awake.” She came into the hospital every day, sitting by her husband’s side. First, she talked with him, then she spoke less. Over a week and a half into his hospitalization, she just sat by his side, holding his hand.

Meanwhile, it had become my practice to check Mr. Aslam’s oxygen saturations the second I

 PLEASE DON’T

CRASH,” I UTTERED A SILENT PRAYER BEFORE LEAVING THE MONITORING STATION TO GO HOME.”

with Mrs. Aslam’s eyes downcast, every so often glancing up at me, begging me to give her some good news about the man who she had moved across the globe to be with. As I got to know her and her story more, I felt just a glimmer of Mrs. Aslam’s pain.

Mr. Aslam became the patient I thought constantly about at work and checked constantly on over my EMR during my one day off a week.

I knew everything there was to medically know about him and his condition—it consumed my every waking second and kept me up at night. He is the first patient my nurses saw me cry over and the gentleman for whom I once marched into my supervising physician’s office, refusing to leave without a good explanation as to why we weren’t choosing to prone or use adjuncts to clear his airway. Mr. Aslam had so little to lose.

Recognizing how personally invested I was in his care, the supervising physician looked at me and said, “I want you to know that medically, this may do very little for the patient, but the fact that you are here instead of finishing up your notes and thinking about how you may get out of here on time today, tells me you care deeply about at least trying it. We’ll give it our best shot.” Nothing helped.

“If you’d like,” my supervising physician finally said, “I can have the end of life conversation with his family…”

winter months. Mr. Aslam was intubated without incident until one night, he nearly stopped breathing on the vent. At that point, he needed to be sedated emergently to protect his life.

Mrs. Aslam found out the next day when I finally reached her and recounted the events that had transpired.

“So, he’s not awake anymore?” she asked. My heart broke hearing her voice on the other end of the phone.

“No,” I said, “we’re helping him stay asleep with some medications because he wasn’t able to breathe while he was awake. If we remove the sedation at this time, I can’t guarantee he will be able to breathe well, but I want to make sure we’re talking about this because I remember he wished to stay awake as much as possible during his hospital visit.”

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walked into the ICU before even putting my things down and settling in at my desk, and right as I was about to leave. He had developed Acute Respiratory Distress Syndrome (ARDS), a condition that was not easily fixable. Out of all of my patients, he was the most “touch and go” so I sat by his bedside trying to figure out what else I could do in order to improve his ventilation. Every day, the ventilator settings required to improve his breathing increased. Every day, his breathing became a little worse. Every improvement in his chest X-ray was a small ray of hope that was quickly dashed by his condition the following day.

Discussing his condition with Mrs. Aslam became excruciating as I seldom had good news to give. We would sit in the family room,

I sighed, knowing we had done all we could do. “Let me,” I volunteered, “I owe it to Mrs. Aslam.” That conversation with Mrs. Aslam was the most painful I’ve ever had. We sat side by side on the stale brown couch in the family conference room and I started the conversation slowly until Mrs. Aslam interrupted.

“He’s not going to make it, is he?” she asked, her eyes welling up with tears. I stared directly at her question and finally shook my head, unable to say the single syllable in the English language that Mrs. Aslam least wished to hear at the time. I handed her a tissue, fighting back tears myself.

“I’m sorry,” I said.

>>

STORIES FROM THE ED

“I understand. I know you’re a doctor, this is probably somewhat normal for you,” she said, “You’re probably used to it.”

“No,” I replied, “I don’t think I’ll ever be used to it.” Mrs. Aslam looked up and noticed the lone tear that had adamantly fought its way out of my left eye. She handed me a tissue.

“He has been an amazing husband, you know?” she said, “When I first came to this country, he wanted to make sure I could take care of myself. He helped me go to community college here, taught me how to drive, told me how important it was for me to be able to get around this new society. The last thing he said to me was that he loved me and wanted me to be happy. I wish I had a chance to say goodbye,” she cried.

I sat by her side, holding her hand.

“Want to see some pictures?” she asked. I nodded yes before she opened up an album on her phone and scrolled through, reminiscing about the first apartment they had together, their first car, the house they had just bought months ago in order to make space for the new child they were planning on having once this round of chemo concluded for Mr. Aslam.

“Rahil was my life,” she said, “Many husbands, they aren’t as good, but I got so lucky. If even to have him for a few years of my life, I got so lucky to have such an amazing, kind, and caring man for a husband. We were really in love, we were really happy,” she choked up.

THE NEXT DAY, HIS ROOM WAS EMPTY — CLEAN WHITE

SHEETS DRAPED THE BED, BECKONING FOR ANOTHER PATIENT TO OCCUPY WHAT HAD BECOME “MR. ASLAM’S ROOM” IN MY MIND.”

I put on a smile and saw my other patients that day. And before I left, I checked on Mr. Aslam’s oxygen saturation as I usually did and sat by his side, uttering the prayer of gratitude under my breath that I did for all my patients when I was no longer sure I would see them the next day:

“Thank you,” I said, “for giving me a chance to get to know you and the honor of taking care of you over the past almost month now, Mr. Aslam. I saw your wife today too, I think I may have dashed her hopes, but I promise I sat by her side and held her hand until she was all out of tears. This is not the ending I foresaw for us, but I want you to know that I cared for you the best that I possibly could. And, if this is the last time we have a chance to speak, I want you to know that your family and your care team— we’ve all witnessed the ferocious fight you’ve put up this month as well. Thank you.”

I left that day, still checking all of Mr. Aslam’s labs through the evening. I checked his notes, his progress, secretly hoping that the universe would prove me and every medical professional wrong by saving Mr. Aslam’s life. I lost my appetite for dinner and ate a small breakfast the next morning before heading to a massage I had booked for my one day off. He was alive

REFER A COLLEAGUE TO JOIN OR RENEW WITH AAEM

before I walked into my massage and by that evening, his soul had moved on. I sat on my couch for what felt like an eternity, staring at his medical chart and imagining what the process of withdrawing care must have felt like for his family and for Mrs. Aslam.

The next day, his room was empty—clean white sheets draped the bed, beckoning for another patient to occupy what had become “Mr. Aslam’s room” in my mind. Shortly thereafter, Ms. Vega was admitted to that room. I took a deep breath, reminding myself that Ms. Vega didn’t know of the previous occupant of her room or his untimely demise.

Putting on a smile, I walked in, “Ms. Vega!” I exclaimed, “I’m Dr. Pavitra, I’ll be the resident physician taking care of you here in the ICU. Tell me more about what brought you in.”

Pavitra P. Krishnamani is a graduating EM resident physician with a background in global health interested in innovating how we deliver healthcare to our patients at home and abroad.

More information about her and her work, is available at www.pavitramd.com.

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!

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:

www.aaem.org/membership/referral COMMON SENSE NOVEMBER/DECEMBER 2021

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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 1-1-2021 to 10-31-2021.

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 Stephanie Kok, MD FAAEM

Contributions $250-$499

Albert L. Gest, DO FAAEM Alison S. Hayward, MD MPH FAAEM Andrew P. Mayer, MD FAAEM Bruce E. Lohman, MD FAAEM David T. Williams, DO FAAEM David W. Lawhorn, MD MAAEM FAAEM Dirk C. Schrader, MD FAAEM Edgar McPherson, MD FAAEM Fred Earl Kency Jr., MD FAAEM Garrett Clanton II, MD FAAEM Joanne Williams, MD MAAEM FAAEM John E. Hunt III, MD FAAEM Julie A. Littwin, DO FAAEM Keith D. Stamler, MD FAAEM Kevin Allen, MD FAAEM Kevin S. Barlotta, MD FAAEM Mary Jane Brown, MD FAAEM Neal Handly, MD FAAEM Prasanth Boyareddigari, MD William K. Clegg, MD FAAEM William T. Durkin, Jr., MD MBA MAAEM FAAEM

Contributions $100-$249

Angel Feliciano, MD FAAEM Ann Loudermilk, MD FAAEM Anthony J. Callisto, MD FAAEM Brian J. Wieczorek, MD FAAEM Brian Kenny, DO Brian R. Potts, MD MBA FAAEM Carol Lynn Clark, MD FAAEM

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COMMON SENSE NOVEMBER/DECEMBER 2021

Carole D. Levy, MD MPH FAAEM Chad David Listrom, MD FAAEM Chaiya Laoteppitaks, MD FAAEM Clifford J. Fields, DO FAAEM David Baumgartner, MD MBA FAAEM David R. Steinbruner, MD FAAEM David W. Kelton, MD FAAEM Deborah D. Fletcher, MD FAAEM Don L. Snyder, MD FAAEM Donald J. Linder, DO FAAEM Dusan Barisic, MD FAAEM Eric M. Ketcham, MD MBA FAAEM FASAM Gary M. Gaddis, MD PhD FAAEM FIFEM Heath A. Jolliff, DO FAAEM Hemali Shah, MD FAAEM Holly A. Gardner, MD FAAEM Ian Glen Ferguson, DO FAAEM Isaac A. Odudu, MD FAAEM Isaac Philip, MD Jacob Lentz, MD FAAEM Jalil A. Thurber, MD FAAEM James A. Pfaff, MD FAAEM James R. Gill, MD MBA FAAEM Jane Wieler, DO Jeffery D. Hillesland, MD FAAEM Jeffery M. Pinnow, MD FAAEM FACEP Jeffrey A. Rey, MD FAAEM Johnathon K. Lowe, DO Jon T. Beezley, DO FAAEM Jonathan D. Apfelbaum, MD FAAEM Jonathan F. Shultz, MD FAAEM Joseph Flynn, DO FAAEM Joseph R. Twanmoh, MD MBA FAAEM

Joshua Tiao, MD Juan F. Acosta, DO MS FAAEM Justin P. Anderson, MD FAAEM Karl A. Nibbelink, MD FAAEM Kathleen Hayward, MD FAAEM Kathryn Getzewich, MD FAAEM Kevin C. Reed, MD FAAEM Kimberly M. Brown, MD MPH FAAEM Lance H. Hoffman, MD FAAEM Leah Houston Leonardo L. Alonso, DO FAAEM Marc B. Ydenberg, MD FAAEM Marianne Haughey, MD FAAEM Mary Ann H. Trephan, MD FAAEM Michael S. Ritter, MD FAAEM Michael Slater, MD FAAEM Michelle E. Clinton, MD FAAEM Michelle M. Walther, MD FAAEM Neena Gupta, MD FAAEM Pamela A. Ross, MD FAAEM Patrick G. Woods, MD FAAEM Paul W. Gabriel, MD FAAEM R. Sean Lenahan, MD FAAEM Regina Hammock, DO FAAEM Richard D. Brantner, MD FAAEM Richard E. Daily, MD FAAEM Robert Kogel, MD FAAEM Robert R. Westermeyer II, MD FAAEM Sachin J. Shah, MD FAAEM Scott Beaudoin, MD FAAEM Scott Leuchten, DO FAAEM Shannon M. Alwood, MD FAAEM Shayne Gue, MD FAAEM Steve C. Christos, DO MS FACEP FAAEM

Susan Socha, DO FAAEM Tara Shapiro, DO FAAEM Teresa M. Ross, MD FAAEM Theodore G. Lawson, MD FAAEM Tito Suero Salvador, MD Travis Omura, MD FAAEM Ugo E. Gallo, MD FAAEM William E. Franklin, DO, MBA, FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT

Contributions up to $75

Alex Kaplan, MD FAAEM Allan Ricardo Preciado Tolano, MD Charles Spencer III, MD FAAEM David C. Crutchfield, MD FAAEM Dean J. Williams, MD FAAEM Freya Dittrich, DO FAAEM Gholamreza Sadeghipour Roodsari Giorgi Maziashvili James Arnold Nichols, MD FAAEM James J. Suel, MD FAAEM James P. Alva, MD FAAEM James T. Buchanan Jr., MD FAAEM Katrina Landa, MD FAAEM Matt Rudy, MD FAAEM Michelle C. Pesek-McCoy, MD FAAEM Monisha Bindra, FAAEM Nathan J. Borden, MD FAAEM Orlando J. Encarnacion, MD FAAEM Robert Bassett, DO FAAEM Seth Lotterman, MD FAAEM Shireen Khan, MD T. Andrew Windsor, MD RDMS FAAEM Timothy J. Durkin, DO FAAEM CAQSM Timothy P. Dotzler, DO FAAEM

AAEM PAC Contributors – Thank You!

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

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

Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the different levels of contributions. The PAC would like to thank the individuals below who contributed from 1-1-2021 to 10-31-2021.

Contributions $500-$999

Bao L. Dang David A. Farcy, MD FAAEM FCCM Seth Womack, MD FAAEM William T. Durkin, Jr., MD MBA MAAEM FAAEM

Contributions $250-$499

Albert L. Gest, DO FAAEM Alison S. Hayward, MD MPH FAAEM Brian J. Wieczorek, MD FAAEM Bruce E. Lohman, MD FAAEM David T. Williams, DO FAAEM Dirk C. Schrader, MD FAAEM Edgar McPherson, MD FAAEM Eric S. Kenley, MD FAAEM Eric W. Brader, MD FAAEM Garrett Clanton II, MD FAAEM Jacob Lentz, MD FAAEM James Webley, MD FAAEM Joseph T. Bleier, MD FAAEM Julie A. Littwin, DO FAAEM Kathryn Getzewich, MD FAAEM Michael Rosselli, MD FAAEM Prasanth Boyareddigari, MD Robert A. Frolichstein, MD FAAEM Sameer D. Mistry, MD CPE FAAEM Stewart M. Wente, MD

Contributions $100-$249

Adria Ottoboni, MD FAAEM Andrew P. Mayer, MD FAAEM Benjamin P. Davis, MD FAAEM FACEP Brandon Faza, MD MBA FAAEM FACEP

Brendon L. Gelford, MD FAAEM Brian R. Potts, MD MBA FAAEM Chaiya Laoteppitaks, MD FAAEM Christine Coleman, MD FAAEM Christopher Luttig, MD FAAEM Clifford J. Fields, DO FAAEM Cynthia Martinez-Capolino, MD FAAEM Daniel T. McDermott, DO FAAEM David A. Halperin, MD FAAEM David Baumgartner, MD MBA FAAEM David R. Hoyer Jr., MD FAAEM David R. Steinbruner, MD FAAEM David W. Kelton, MD FAAEM Deborah D. Fletcher, MD FAAEM Deborah M. Fernon, DO FAAEM Derek L. Marcantel, MD FAAEM Elizabeth Bockewitz, MD FAAEM Evan Jackson, DO, MPH Felipe H. Grimaldo Jr., MD FAAEM Haley R. Davis, MD FAAEM Heath A. Jolliff, DO FAAEM Jalil A. Thurber, MD FAAEM James Webley, MD FAAEM Jeffrey A. Rey, MD FAAEM John R. Matjucha, MD FAAEM Joseph W. Hensley, DO FAAEM Julie A. Littwin, DO FAAEM Justin P. Anderson, MD FAAEM Kevin Allen, MD FAAEM Kevin S. Barlotta, MD FAAEM Kimberly K. Getzinger, FAAEM Kurt E. Urban, DO FAAEM Larisa M. Traill, MD FAAEM

Leah Houston Linda Sanders, MD Liza Chopra, MD FAAEM Marc B. Ydenberg, MD FAAEM Marc D. Squillante, DO FAAEM Marco Anshien, MD Margaret R. Lewis, MD FAAEM Marianne Sacasa De Strasberg, MD FAAEM Marianne Sacasa De Strasberg, MD FAAEM Mark A. Newberry, DO FAAEM FACEP Mark O. Simon, MD FAAEM Matthew B. Underwood, MD FAAEM Michelle C. Pesek-McCoy, MD FAAEM Michelle E. Clinton, MD FAAEM Miguel L. Terrazas III, MD FAAEM Orlando J. Encarnacion, MD FAAEM Paul W. Gabriel, MD FAAEM Peter M.C. DeBlieux, MD FAAEM R. Gentry Wilkerson, MD FAAEM Sachin J. Shah, MD FAAEM Scott Beaudoin, MD FAAEM Scott P. Marquis, MD FAAEM Shireen Khan, MD Stefan Jensen Steven Parr, DO FAAEM Teresa M. Ross, MD FAAEM Tiffany Alima, MD FAAEM Tomer Begaz, MD FAAEM Travis Omura, MD FAAEM Ugo E. Gallo, MD FAAEM Vicki Norton, MD FAAEM

Vinicius Knabben, MD William K. Clegg, MD FAAEM

Contributions up to $75

Alexei Adan, MD Ameer Sharifzadeh, MD Ann Loudermilk, MD FAAEM Benjamin Bloom, MD Charles Spencer III, MD FAAEM Curtis Lee Lowery III, MD, PhD Gholamreza Sadeghipour Roodsari Jake Gold, MD James J. Suel, MD FAAEM Katrina Landa, MD FAAEM Laura Barrera Lauren Murphy, MD FAAEM Lisa A. Lyons, MD FAAEM Matthew Mosko Mass, DO Matthew R. Brewer, MD Michael A. Cecilia, DO Michael S. Oertly, MD FAAEM Michael Slater, MD FAAEM Natasha Trainer Paulette Gori, MD FAAEM Ramon J. Pabalan, MD FAAEM Robert Bassett, DO FAAEM Ryan Horton, MD FAAEM Scott Wiesenborn, MD FAAEM Sean M. Abraham, DO FAAEM Timothy J. Durkin, DO FAAEM CAQSM Timothy P. Dotzler, DO FAAEM Ziyad Khesbak, MD FAAEM

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. LEAD-EM would like to thank the individuals below who contributed from 1-1-2021 to 10-31-2021.

Contributions $500-$999

David A. Farcy, MD FAAEM FCCM

Contributions $250-$499

Albert L. Gest, DO FAAEM Andrew P. Mayer, MD FAAEM Carol Pak-Teng, MD FAAEM Dale S. Birenbaum, MD FAAEM Daniel F. Danzl, MD MAAEM FAAEM David W. Lawhorn, MD MAAEM FAAEM Eric W. Brader, MD FAAEM Fred Earl Kency Jr., MD FAAEM Kathleen Hayward, MD FAAEM Keith D. Stamler, MD FAAEM Sarah Hemming-Meyer, DO FAAEM

Contributions $100-$249

Alison S. Hayward, MD MPH FAAEM Ann Loudermilk, MD FAAEM Brian J. Wieczorek, MD FAAEM Brian R. Potts, MD MBA FAAEM Bruce M. Lo, MD MBA RDMS FAAEM Casey Brock Patrick, MD FAAEM FAEMS Christopher Kang, MD FAAEM David Baumgartner, MD MBA FAAEM David P. Mason, MD FAAEM FACEP David W. Kelton, MD FAAEM Eric M. Ketcham, MD MBA FAAEM FASAM Frank L. Christopher, MD FAAEM Gerald E. Maloney Jr., DO FAAEM Hemali Shah, MD FAAEM

Kailyn Kahre-Sights, MD FAAEM Kevin T. Jordan, MD FACEP FAAEM Kimberly Marie Henley, MD FAAEM Laura Ortiz, MD FAAEM Lee D. Raube, DO FAAEM Marc B. Ydenberg, MD FAAEM Michelle E. Clinton, MD FAAEM Regina Hammock, DO FAAEM Sarah B. Dubbs, MD FAAEM Sudhir Baliga, MD FAAEM Travis Omura, MD FAAEM Ugo E. Gallo, MD FAAEM

Contributions up to $75

Benjamin P. Davis, MD FAAEM FACEP Charles R. Phillips, MD David R. Steinbruner, MD FAAEM

Edward T. Grove, MD FAAEM MSPH George Robert Woodward, DO FAAEM Howard E. Jarvis III, MD FAAEM Jacob Lentz, MD FAAEM Joel Mosley, MD FAAEM John K. Wall, MD FAAEM Joseph Flynn, DO FAAEM Marc D. Squillante, DO FAAEM Michael Slater, MD FAAEM Ramon J. Pabalan, MD FAAEM Richard D. Brantner, MD FAAEM Robert Bassett, DO FAAEM Robert W. Bankov, MD FAAEM FACEP Seth Lotterman, MD FAAEM Theodore M. Willmore, MD FAAEM

COMMON SENSE NOVEMBER/DECEMBER 2021

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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/events

AAEM Events

Recommended

April 23-27, 2022 AAEM’s 28th Annual Scientific Assembly (Baltimore, MD) https://www.aaem.org/aaem22

December 16-17, 2021 A Look Forward at New Psychoactive Substances and a Look BAC at Ethanol – American College of Medical Toxicology https://www.acmt.net/ForensicOverview.html

21-24 September 2022 XIth Mediterranean Emergency Medicine Congress (St. Julian, Malta) https://www.aaem.org/memc21

March 11-13, 2022 2022 ACMT Annual Scientific Meeting (San Antonio, TX) https://www.acmt.net/cgi/page.cgi/Annual_Scientific_Meeting.html

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March 31-April 2, 2022 ASRA Regional Anesthesiology and Acute Pain Medicine Meeting (Las Vegas, NV) https://www.asra.com/events-education/ra-acute-meeting

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17

Resilience Lesson: Giving Negative Feedback

COMMITTEE REPORT ACADEMIC AFFAIRS

Mary Claire O’Brien, MD FAAEM

O

ne of the things that used to be stressful for me as a young attending was giving negative feedback to a resident. I suppose my own training still felt very fresh and I was sorry for them: the anxiety, the exhaustion, the constant criticism. But it’s the duty of faculty to offer verbal performance evaluations to trainees, both positive and negative.

As part of my own personal resilience plan, I have learned to “frame” this feedback as an opportunity.

“Framing” begins with the premise that you can’t control how you feel, but you can control how you think — which influences how you feel. Framing doesn’t change a given situation but can influence what we get from it.

Author Trevor Ragan says: There are three big ways we can frame a situation: • As an opportunity • As a threat • As useless.1 Balancing “opportunity” and “threat” is key to avoiding burnout. Framing negative feedback as opportunity means it is no longer stressful for me and it’s not as painful for the recipient. Medical education is very different from my time as a trainee, when our weekly conferences included a healthy dose of Vitamin WhoopAss. These days we focus on the learner and how he or she will feel when corrected. We try not to make learners feel bad because they made a mistake or forgot to do something important. Early career physicians are especially vulnerable to burnout. A trainee is less likely to be defensive if the supervisor focuses on the error itself and not on the person who made it. After all, the purpose of feedback is learning, not public humiliation.

“Well,” I say. “Did you ever take piano lessons?”

This gets their attention — there’s that (old) Dr. O’Brien again. What the heck is she talking about? Just gimme the darn feedback.

COMMON SENSE NOVEMBER/DECEMBER 2021

“Here’s the thing,” I say. “When you were a kid, your parents paid for your music lessons. What would it have been like if every week your piano teacher watched you for an hour and then said, ‘That was great, you did fine!’ Would you have ever made any progress? What if your coach never corrected you, would you have ever learned how to play?”

ENOUGH THAT THEY DESERVE FEEDBACK, BECAUSE YOU HAVE CONFIDENCE IN THEIR ABILITY TO USE IT TO IMPROVE THEIR PERFORMANCE.”

Sometimes trainees do not want an answer. They have just worked eight grueling hours; they are fatigued, they are hungry, they want to go home.

They also have another two to three hours of charting to do on the computer. “Do you have any feedback” is sometimes code for “I’m required to ask for feedback, but have mercy on me, we just got our asses kicked, and for God’s sake, I need to pee. Just say, ‘You did fine.’ I’ll nod, you’ll nod, and we can both get out of here.”

18

Now I’ve got them. They are jiggling their feet at this point, looking around the department to see if anyone is listening. They still need to pee. And they want to get out of there before another patient codes!

 TELL THEM THAT THEY ARE IMPORTANT

“Do you have any feedback?” the resident will say.

“Piano lessons,” I repeat. “Did your parents make you take piano lessons? If not piano, some other instrument.”

Almost everyone says yes. If they say no, I ask whether they ever played sports and had a coach.

They look at the floor. By now they can guess where this is going.

“You paid to be criticized,” I say. “Well, your parents did. If you were not criticized, they were not getting their money’s worth.”

Occasionally a smart aleck resident will interrupt, glancing at the departmental mayhem, “I sure as hell didn’t pay for THIS!” “Listen,” I say. “You are a hospital resident. You are paying with time. With your hard work and time, you PAY me to criticize you. And I wouldn’t be doing my job if I didn’t criticize you. I get paid to criticize you.”

They sigh, resigned. Shoot me, Dr. O’Brien, if you must. Just get it over with so I can leave this zoo. Please.

Then gently I say something like, “Don’t stand with your hands on your hips when you talk with families. I know you are tired and just resting your arms, but how does it look when I do this to you?”

>>

COMMITTEE REPORT ACADEMIC AFFAIRS

A TRAINEE IS LESS LIKELY TO BE DEFENSIVE IF THE SUPERVISOR

FOCUSES ON THE ERROR ITSELF AND NOT ON THE PERSON WHO MADE IT. AFTER ALL, THE PURPOSE OF FEEDBACK IS LEARNING, NOT PUBLIC HUMILIATION.” (SEE! Active Learning! Boomer Attending Demonstrates Millennial Learner’s Mistake in a Gentle and Non-Critical Appropriate Feedback Fashion!)

“I look bored, or angry, huh? But I am not bored. I am not angry. Adopt a rest position like this…arms down, hands clasped gently in front of your waist, yes, see how much nicer that is? Good job today, by the way, good job. Excellent job! Pleasure working with you, as always.”

As a professional, you are going to have to give negative feedback to subordinates, to colleagues, and occasionally even to your boss. Here’s what I’ve learned: It takes some of the sting out of negative performance feedback if you frame it as something to which the recipient is entitled.

How can a person improve if their deficiencies are not identified? Whose responsibility is it to offer them the opportunity to do better? Yours! It is much easier to gloss over someone’s performance problems than it is to look them in the eye and give candid criticism. But you owe it to them because you care about them and believe they can do better. Tell them that they are important enough that they deserve feedback, because you have confidence in their ability to use it to improve their performance.

Frame the situation as opportunity, not threat.

References 1. trainugly.com/resilience/

COMMON SENSE NOVEMBER/DECEMBER 2021

19

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

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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.

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TOXICOLOGY

Medication Prescribing in Time of COVID, Unproven Remedies, Overstepped Autonomy, Known Harms: A Toxicologic Argument Against Ivermectin for COVID-19 Noah Berland, MD MS, Mehruba Anwar Parris, MD FAAEM

I

t has always been attributed to Paracelsus the toxicologic axiom that the dose makes the poison, one of the main tenets of modern day medical toxicology. And today, toxicologists are more than familiar with the EBM world’s issues with a large proportion of toxicologic research and treatments, so it is us toxicologists that are possibly the most informed on the weaknesses to be aware of when trying to treat a disease process without good evidence. In toxicology the rea-

• There is no other alternative treatment and it is believed that the potential benefits outweigh the risks.

Treating patients with COVID-19 using ivermectin does not follow any of the above three points. This has been true for a number of months. At present there are three systematic reviews that we are aware of, 1) is a Cochrane Review1 showing no statistical benefit and clearly relates the clear uncertainty and poor quality of studies, 2) by Roman et al.2 also showing no benefit, noting the paucity and poor quality of evidence, and 3) Bryant et al.3with antiviral and anti-inflammatory properties, has now been tested in numerous clinical trials. AREAS OF UNCERTAINTY: We assessed the efficacy of ivermectin treatment in reducing mortality, in secondary outcomes, and in chemoprophylaxis, among people with, or at high risk of, COVID19 infection. DATA SOURCES: We searched bibliographic databases up to April 25, 2021.

Two review authors sifted for studies, extracted data, and assessed risk of bias. Meta-analyses were conducted and certainty of the evidence was assessed using the GRADE approach and additionally in trial sequential analyses for mortality. Twenty-four randomized controlled trials involving 3406 participants met review inclusion.

Figure 1, Prescribing Patterns of Ivermectin from March 22, 2019 though August 13, 2021. https://emergency.

THERAPEUTIC ADVANCES: Meta-analysis of cdc.gov/han/images/graph_449.png4 15 trials found that ivermectin reduced risk of death compared with no ivermectin (average risk ratio 0.38, 95% confidence interval 0.190.73; n = 2438; I2 = 49%; moderate-certainty evidence which includes many non-peer-reviewed studies, performs questionable statistical techniques, and includes the now retracted Elgazzar et al paper, showing possible statistical Figure 2, Google Trends Data comparing internet searches for Ivermectin (Blue) with Scabies (Red), significance, but even on rudimentary viewing normalized to a maximal scale of 100. https://trends.google.com/trends/explore?date=2019-08-06 2021-09-06&geo=US&q=ivermectin,scabies6 of the results, does not appear to hold up.

Lawrence et al. summarized the inherent risks in relying on meta-analyses of poor-quality data best in their corresponsons to provide treatment recommendations that are not based on randence in Nature titled “The lesson of ivermectin: meta-analyses based domized controlled trials are the following: on summary data alone are inherently unreliable.” Yet, many physicians • The current treatment is well established with studies/case series that continue to prescribe ivermectin to their patients. Just as in the opioid overdose epidemic, we physicians are not blameless on promulgating demonstrate a benefit and it would be unethical to withhold the treatthis false hope, with prescriptions up from a pre-pandemic baseline of ment to perform a trial.

• The overdose is lethal and withholding any treatment is likely to cause about five thousand a month, week to the week of August 13th of 88 thousand prescriptions, a 24-fold increase (Figure 1).4 The American death, and the mechanism of the treatment is biologically plausible.

>>

COMMON SENSE NOVEMBER/DECEMBER 2021

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TOXICOLOGY

Board of Emergency Medicine recently released a statement stating that spreading misinformation.5 It is the role of physicians, and as an emergency medicine physician and toxicologist, to educate and inform our patients and provide the best possible care, which for most people was found on the internet, you can certainly see the surge in internet searches for ivermectin since the start of the COVID-19 pandemic, up 100 fold, while searches for scabies (one of the FDA approved indications) have not increased (Figure 2).6 As toxicologists and emergency physicians, we must educate and dispel this disinformation. To help better inform emergency medicine physicians, we would like to review some of the basics of ivermectin. Ivermectin is an avermectin, which is a class of potent anthelmintic and insecticidal agents. Avermectin earned its discoverer Dr. Satoshi Omura a Nobel prize in medicine due to its effectiveness in treating river blindness, lymphatic filariasis, and other parasitic diseases. It is even on the WHO’s essential drug list, which also goes into exhausting supplies and likely increasing the cost of an essential drug that poorer nations require for proven susceptible diseases.7 Q: What are the approved indications for ivermectin in the U.S.?

A: Ivermectin tablets are approved for use in humans for the treatment of some parasitic worms (intestinal strongyloidiasis and onchocerciasis) and ivermectin topical formulations are approved for human use by prescription only for the treatment of external parasites such as headlice and for skin conditions such as rosacea.

Ivermectin is FDA-approved for use in animals for prevention of heartworm disease in some small animal species and for treatment of certain internal and external parasites in various animal species. Humans should not take animal drugs, as the FDA has only evaluated their safety and effectiveness in the particular species for which they are labeled. Using these products in humans could cause serious harm.

Avermectins, including ivermectin, generally function by amplifying the effects of invertebrate-specific gated chloride channels at the neuromuscular junction, leading to hyperpolarization and subsequent paralysis.8 This is generally well tolerated in mammalians, but as Paracelsus postulated, the dose makes the poison, at higher doses this specificity for the invertebrate receptor can be lost and avermectins can become more promiscuous. It can lead to effects on mammalian GABA-A receptors but is fairly non-specific and also have an effects on glutamate and possibly GABA-B receptors.8 These effects in higher doses, is what causes the main known toxicity of avermectins in humans, namely encephalopathy and coma. The effects can be greatly potentiated or altered via drugs that impact the blood brain barrier, especially p-glycoproteins modulators, which regulate uptake and efflux across the blood brain barrier.8 Further inflammation may weaken the blood brain barrier increasing the risk of neurotoxicity.8 For COVID-19 the theory is that ivermectin binds to and destabilizes the Impα/β1 heterodimer, which is necessary for nuclear transport and preventing transport of a SARS-COV-2 cargo protein,

22

COMMON SENSE NOVEMBER/DECEMBER 2021

which is thought to inhibit host viral infection response.9 Thus, ivermectin is thought to enhance the bodies response to SARS-COV-2, by inhibiting SARS-COV-2’s inhibition of host viral defenses mainly in lung tissue.

Essentially, even in the best-case scenario, and only looking at the lungs, we know SARS COV-2 impacts many other organ systems, that ivermectin is unlikely to ever reach theoretical potential therapeutic levels.

As of now we are still pending high quality randomized controlled trials, as noted on clinicaltrials.org and as referenced by the Cochrane Review.1 So far one double blind randomized controlled trial for ivermectin in mild disease has been published in JAMA (Lopez-Medina et al12) which shows no benefit to ivermectin over placebo. However, currently due to a large amount of disinformation and misinformation, many people are clutching to the idea of ivermectin saving the lives of their loved ones who are critically ill. Though we do not have an absolute number, some of these families, when their responsible doctors refuse to prescribe ivermetin, have gone to court. They sought the aid of a small number of physicians who are pro-ivermectin and several other medications and have managed to get court ordered injunctions requiring the administration of ivermectin.

At present the majority of these cases appear to not actually attempt to rule on the medical indication of ivermectin, rather in the absence of time they have ordered injunctions requiring certain treatment to be provided until the court is able to actually rule on the merits. The best example is a case in Cincinnati, which was first hailed by these groups as a major success of the courts ordering physicians to give ivermectin, but has now recently had the injunction overturned, with the court ruling that they cannot compel the physicians to provide specific treatments.13 This is far from the only case.

At present, most of the adverse events appear to be from people using veterinary ivermectin or topical preparations, both of which can have much higher drug concentrations, or simply be difficult for patients to accurately dose. So, one might say that from a harm reduction standpoint it is safer to prescribe a medication than force people to go to the vet, just like in Seinfeld, season eight, episode ten, where Kramer who does not have health insurance gets medications prescribed for a dog. However, in this case, the very act of physicians prescribing ivermectin legitimizes ivermectin as a treatment for COVID-19, which appears to be enabling individuals to forgo proven preventative measures, including vaccines and mask wearing. At the end of the day, more high quality randomized controlled trials are still forthcoming, but at present, there really is no good signal that it has benefit, and there are clear harms beyond just toxicity and adverse events.

References: 1. PoppM WS. Cochrane Library Cochrane Database of Systematic Reviews Ivermectin for preventing and treating COVID-19 (Review). 2021. doi:10.1002/14651858.CD015017.pub2 2. Roman YM, Burela PA, Pasupuleti V, Piscoya A, Vidal JE, Hernandez A V. Ivermectin for the treatment of COVID-19: A systematic review and meta-analysis of randomized controlled trials. Clin Infect Dis. 2021;101(Xx Xxxx):1-8. doi:10.1093/cid/ciab591 >>

TOXICOLOGY

3. Bryant A, Lawrie TA, Dowswell T, et al. Ivermectin for Prevention and Treatment of COVID-19 Infection: A Systematic Review, Meta-analysis, and Trial Sequential Analysis to Inform Clinical Guidelines. Am J Ther.

2021;28(4):e434-e460. doi:10.1097/MJT.0000000000001402 4. HAN Archive - 00449 | Health Alert Network (HAN). https://emergency. cdc.gov/han/2021/han00449.asp. Accessed September 6, 2021.

5. ABEM Statement about ABEM-Certified Physicians Providing Misleading and Inaccurate Information to the Public. https://www.abem.org/public/ news-events/news/2021/08/27/abem-statement-about-abem-certifiedphysicians-providing-misleading-and-inaccurate-information-to-the-public.

Accessed September 6, 2021.

6. ivermectin, scabies - Explore - Google Trends. https:// trends.google.com/trends/explore?date=2019-08-06 2021-09-06&geo=US&q=ivermectin,scabies. Accessed September 6, 2021.

7. FAQ: COVID-19 and Ivermectin Intended for Animals | FDA. https://www. fda.gov/animal-veterinary/product-safety-information/faq-covid-19-andivermectin-intended-animals. Accessed September 6, 2021.

8. El-Saber Batiha G, Alqahtani A, Ilesanmi OB, et al. pharmaceuticals Avermectin Derivatives, Pharmacokinetics, Therapeutic and Toxic Dosages, Mechanism of Action, and Their Biological Effects. 2020. doi:10.3390/ph13080196

9. Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. 2020. doi:10.1016/j.antiviral.2020.104787 10. Guzzo CA, Furtek CI, Porras AG, et al. Safety, Tolerability, and Pharmacokinetics of Escalating High Doses of Ivermectin in Healthy Adult Subjects. doi:10.1177/009127002237994 11. Lespine A, Alvinerie M, Sutra JF, Pors I, Chartier C. Influence of the route of administration on efficacy and tissue distribution of ivermectin in goat.

Vet Parasitol. 2005;128(3-4):251-260. doi:10.1016/j.vetpar.2004.11.028 12. López-Medina E, López P, Hurtado IC, et al. Effect of Ivermectin on Time to Resolution of Symptoms among Adults with Mild COVID-19: A Randomized Clinical Trial. JAMA - J Am Med Assoc. 2021;325(14):14261435. doi:10.1001/jama.2021.3071 13. Knight C. Judge rules hospital cannot be forced to give ivermectin.

Cincinnati Enquirer. https://www.cincinnati.com/story/news/2021/09/06/ judge-rules-hospital-cannot-forced-give-ivermectin/5746518001/.

Published September 6, 2021. Accessed September 6, 2021.

COMMON SENSE NOVEMBER/DECEMBER 2021

23

YET SOME OF US ACCEPT THE

OPINION

An Ethical Mandate for Federal Law: Vaccination Against COVID-19 L.E. Gomez, MD MBA

A

n Emergency Medicine View of Vaccines and Treatment No doubt all of you have seen the joint AAEM, ACMT, and ACEP Statement in support of the COVID-19 Vaccines. Our online assertion that toxicologists, pharmacologists, and emergency medicine specialists “highly recommend the vaccination” seems erstwhile, if cautious enough, let alone the call for universal vaccination from public health officials that had been out there for months before. Fewer of you may be familiar with a similar call for a universal vaccine mandate from the Association of Bioethics Program Directors. Yet, personally, some among us are still entertaining the legitimacy of fearing infringement on personal liberties or religious freedom.

I would almost excuse our less experienced members for not being for passionately convicted of the ethical dimensions. Not so for those, like myself, who have had enough!

Twenty-four years as an emergency physician, over 100,000 patients seen, 1 in 500 of them so critically injured or with such advanced disease they couldn’t be saved, takes its toll.1 I think of the lives I’ve helped save and the ones I couldn’t, the ones I’ve had to tell they had a lethal condition, and worst, sit in a cramped, undecorated room with their families to tell them their loved one had died. It alters one’s tolerance for taking reckless risks with human lives. Every life we lose, we consider the cause.

Most are inevitable, a biologic failure of senescence, a system collapse, a personal one. Every one saved we think: a gift, a miracle of modern medicine, and for some, an act of God. Way before we give ourselves any credit as doctors, we are grateful for having had great luck.

Now comes this COVID-19 pandemic, syndemic, and deaths increase exponentially, especially among the most marginated and most vulnerable. Many of us fighting it so hard it leads to being fired for calling out an unethical, unjust healthcare system. A few of us even quitting on ourselves, taking our own lives. Over 100,000 hospitalized and more than 1,000 dying from it every day.2 Yet some of us accept the surreal situation that an individual should have the right to invite that harm into their homes, their families, their bodies, knowing there is a solution. It should be unconscionable for any educated person, let alone a physician, to imagine all those souls might have been saved but for the fact that they were not forced them to take a life-saving treatment with, at

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COMMON SENSE NOVEMBER/DECEMBER 2021

SURREAL SITUATION THAT AN INDIVIDUAL SHOULD HAVE THE RIGHT TO INVITE THAT HARM INTO THEIR HOMES, THEIR FAMILIES, THEIR BODIES, KNOWING THERE IS A SOLUTION.”

worst, unpleasant non-lethal side effects.3 Yes, that’s right, no one has died of that anaphylaxis reaction we all know to fear. What experienced physicians do know: that none refuse life-saving treatment when there is a chance to recuperate, and that families often demand it screaming in tears at the top of their lungs even when they know there is no chance of recovery. The obvious answer: a federal mandate for universal vaccination.4

Vaccination and Safety Measures Debate Fuel Elections This is not the first health crisis leading to vaccine mandates in the U.S. history, as courts clearly supported them in the case of smallpox over 100 years ago.5 Never has the issue been more politicized than during this COVID-19 disaster. Emergency physicians in the eye of this storm of now over half a million pandemic deaths, shaking our heads as CDC epidemiologists continue to report 98% of those deaths occur in unvaccinated patients, while conservative politicians and their allies continue to mislead the public.6 Despite the rising death toll, particularly where poverty and neglect limit access to vaccines for marginalized populations, those politicians turn a blind eye.7 Emergency physicians cannot afford to put partisan politics ahead of saving lives and are well-aware we have long enforced other vaccination mandates, such as for measles in the public school system.8 We are cannot stand by and allow this needless loss of life fueled by greed, facilitated by the spread misinformation, remove undermine disease mitigating safety measures, and potentiate refusal of vaccination, allowing unethical leaders to maintain power over the most vulnerable, poor, and uneducated, leading them to slaughter.9 I have no issue with rare allowances made for medically justified exemptions, such as for immune compromised patients. But we must stop allowing oft cited excuses of ‘philosophical’ differences or religious exemptions as reasons to put others at risk. Not only should requirement of vaccination for admission to public schools be on the table and any forward-facing business should be required to comply, exceptional reasons for exclusion such as allergy to vaccination vehicle (the injectable solution itself) must require documentation, as the small percentage of allergic reactions have not been lethal and this represents an exceedingly small percentage of anti-vaxxers (no more than seven in one million according to one study on the Pfizer vaccine).9 Other commonly voiced

>>

SOCIAL EM & POPULATION HEALTH COMMITTEE

concerns such as that the vaccine alters native DNA, causes infertility, or was developed too quickly correlate with a lack of information, education, and poverty. They are largely the result of willful political misinformation that has been shown, ultimately, to lead to economic failure, as even conservative economists acknowledge vaccination is not only key to the health of the public, but commercial interests that align them with public health interests.10



THE TIME IS NOW FOR CLEAR LEGISLATION TO SERVE OUR ENTIRE SOCIETY AND FULFILL OUR COMMITMENT TO PUBLIC HEALTH.” The Occupational Safety and Health Administration (OSHA) Rule is Not Enough The Biden-Harris Administration recently announced expanded vaccination requirements will include staff within all Medicare and Medicaidcertified facilities, an incremental step after directing OSHA to write a rule requiring employers to force employees to be vaccinated or be tested weekly to prove they remain COVID free last month. As expected, healthcare organizations across the country announced vaccine mandates are set to be enforced, not as a matter of medical ethics, duty to care or guarantee of best health outcomes, but because non-compliance with federal requirements would have a devastating negative economic impact on the bottom line and equity investment that drives operations in our US health care industry. Under this economic pressure, no amount of protest over resignations and suspensions of staff (even if whole service lines are forced to close temporarily) will carry the day. But we need a mandate that applies to EVERYONE, not just forward facing business and health care workers.

The COVID-19 pandemic exposes some of the greatest weaknesses our for-profit health care system faces now and into the future. In the face of a lethal disease that has infected over a quarter of a billion and killed over seven million world-wide to date, including over 700 thousand deaths in the US, we cannot afford a debate, especially one fueled by disinformation from partisan political leaders, about whether vaccination should be mandated.11 That wasteful process, multi-factorially fueled by greed-driven interests will result in short-term profits from restaurants, concerts, public gatherings, pollical rallies generating revenue keeping us in close proximity driving the spread of disease will continue to kill us all.

Not just the most at risk are the most socially vulnerable: low education, poverty, food-insecure and insecure housing, limited access to health insurance and lack of representational leadership, and clinical caretakers, but ALL of us. The strong correlation between lower educational level and death from COVID will put everyone at risk.12 If we wanted to reduce our $3.8 trillion outlay on health care, we should invest in vaccination rather than fuel the cost of treatment.13 The time is now for clear legislation to serve our entire society and fulfill our commitment to public health. A federal law, mandating universal vaccination is long past due. Anything short of that, is fundamentally unethical.

References 1. https://www.cdc.gov/nchs/fastats/emergency-department.htm 2. https://www.reuters.com/world/us/us-reports-more-than-1000-coviddeaths-single-day-2021-08-18/ 3. https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccinemonitor-dashboard/ 4. https://www.nature.com/articles/d41586-019-03642-w 5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449224/ 6. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverseevents.html 7. https://www.who.int/news/item/05-12-2019-more-than-140-000-die-frommeasles-as-cases-surge-worldwide 8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067842/ 9. https://www.cdc.gov/mmwr/volumes/70/wr/mm7002e1.htm 10. https://knowledge.wharton.upenn.edu/article/how-economic-recoveryhinges-on-the-vaccine-rollout/ 11. https://www.worldometers.info/coronavirus/country/us/ 12. https://www.hsph.harvard.edu/population-development/2021/02/24/finallya-look-at-covid-19-mortality-rates-by-race-ethnicity-and-educational-level/ 13. https://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/ NationalHealthAccountsHistorical

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WELLNESS COMMITTEE

From dglaucomflecken on twitter:

From Hero to Zero: Naiken, COVID-19, and Ways to Develop Empathy Despite Patients’ Challenging Life Choices Andrew Grock, MD*, Al’ai Alvarez, MD FAAEM†, and Ilene Claudius, MD FAAEM‡

2020

MD 1: Hey, do you know everyone is cheering for us out there?

MD 2: Yeah, they are thanking us for working so hard to save people’s lives during the pandemic.

W

orking in the ED has always been difficult.

We do the best we can, the fastest we can, in order to help the most people that we can, regardless of their ability to pay, the severity of their illness, often while ignoring our own physical and emotional needs. On top of this stressful environment, we often bear the brunt of our patients’ anger and frustration at illness, at waits, or at stressors unrelated to our care.1 Hence, much has been written on the limits and importance of physician empathy. Then the COVID-19 pandemic happened, placing us in the center of a passionate and often political debate. Heated conversations over vaccines and masking interrupt our provision of care, and we subject ourselves to the potential of direct harm from getting infected to care for patients who deny the very existence of the disease for which we treat them.2 While caring for patients who make self-destructive decisions is not new to emergency medicine, the pandemic is different. The impact of COVID-19 on our daily lives has been overwhelming to many. Staff, families, and other patients are at risk of exposure. Patients coming in for other illnesses can wait longer for both emergency and definitive care because of COVID-19 overcrowding. There are conversations with patients demanding unproven therapeutics or those for which they don’t qualify. Worse, protesters are vilifying instead of appreciating the efforts of the medical community

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to prevent and treat Covid. In short, we’re exhausted, depleted, worse, feeling betrayed. Now, more than ever, we face an enormous gap in the amount of empathy we want to give and what little we have left.

While we can work to remedy this problem (strengthening our public health sector, educating our population, promoting societal leaders who defer to experts and promote truth over political capital, and crafting limitations that spread harmful misinformation on social media), we must also address our own struggles with burnout and decline in empathy. Several techniques have been described across a range of populations. This article will focus on one such technique known as Naiken.

Naikan is a Japanese introspection practice, which literally means “inner-looking” or “introspection.” It involves an examination of past deeds from both their own perspective and from the perspective of others. It consists of asking oneself the following three questions: • What did I receive from this person?

• What did I return to this person?

• What troubles, worries, unhappiness did I cause this person?3 More traditional Naikan practice consists of 15 hours of contemplation, divided into two-hourly periods. The participant engages in personal reflection on the three pre-set questions then

reports thoughts back to a “guide” who listens and allows the participant to contemplate.

While this time commitment may be unrealistic for many physicians and trainees, the essence of Naikan can be incorporated into meditation, debriefing, or wellness sessions.

The Naikan-based compassion training program emphasizes our interdependency with others and appreciating the kindness of others.

Gratitude toward patients and sympathy for the pain that our long wait times, bad news, and other inconveniences we have caused them enable us to develop endearment and compassion for them. Improvements in interdependency and gratitude develop quickly and have been demonstrated in a short period of only one week of Naikan practice. >>

2021

MD 1: Hey, why are all those people booing and yelling at us out there?

MD 2: Yeah, they are protesting us for trying to save people’s lives during the pandemic.

WHILE WE CANNOT SIMPLY “COMPASSION” OUR WAY INTO ALL THE CHALLENGES  WE ENCOUNTER IN HEALTHCARE…THE NAIKAN PHILOSOPHY OFFERS AN OPPORTUNITY FOR US TO REMAIN OPEN AND COMMITTED DESPITE MANY CHALLENGES. CHOOSING COMPASSION IS WITHIN OUR CONTROL.”

WELLNESS COMMITTEE

References

The Naikan process also has a role in self-compassion by emphasizing healthy remorse for our omission, at times, to reciprocate kindness, patience, and forgiveness offered to us.4 It is easy to focus on a few negative interactions during a shift. Still, by contemplating these Naikan questions, one can identify and acknowledge the multitude of ways that others have offered us their trust, gratitude, and patience.5 We can see each other and the world around us more realistically. And the fact that we can never directly return these kindnesses provokes the desire to pass that goodwill along to others, which can help deepen the meaning and purpose we feel in our own lives.4 When meaning and purpose find their way into one’s life, it can replace some of the focus on our own suffering. When compassion is engendered in oneself, it calms fear and self-protection and pacifies competitiveness.

UCLA Emergency Medicine Department, @AndyGrock Director of Well-Being, Stanford Emergency Medicine, @alvarezzzy ‡ Director of Quality Improvement, Harbor-UCLA Medical Center *

†

The Dalai Lama describes compassion as “an openness to the suffering of others with a commitment to relieve it.” While we cannot simply “compassion” our way into all the challenges we encounter in healthcare, many of which are systems-driven inefficiencies beyond our control, the Naikan philosophy offers an opportunity for us to remain open and committed despite many challenges. Choosing compassion is within our control.

1. Lall MD, Bilimoria KY, Lu DW, et al. Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US. JAMA Netw Open. 2021;4(8):e2121706.

2. Bergwerk M, Gonen T, Lustig Y, et al. Covid-19 Breakthrough Infections in Vaccinated Health Care Workers. N Engl J Med. 2021;0(0):null.

3. Naikan. In: Wikipedia. ; 2021.

4. Hedstrom LJ. Morita and Naikan therapies: American applications.

Psychother Theory Res Pract Train. 1994;31(1):154-160.

5. Krech G. Naikan: Gratitude, Grace, and the Japanese Art of SelfReflection. Berkeley, Calif.: Stone Bridge Press; 2006.

6. Goleman D and Davidson RJ. Altered Traits : Science Reveals How Meditation Changes Your Mind, Brain, and Body. New York, NY: Avery, an imprint of Penguin Random House; 2018.

Annual Scientific Assembly American27th Academy of Emergency Medicine 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 Today’s emergency physician has a lot to navigate. That’s why AAEM is in your corner providing advocacy and education.

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

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

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

Now Accepting 2022 Membership Applications!

Effective Advocacy For over 25 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 2021

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WELLNESS COMMITTEE

Perfectionism: Our Dangerous Frenemy Ilene Claudius, MD FAAEM*, Al’ai Alvarez, MD FAAEM†, and Andrew Grock, MD‡

once we complete our medical training we overcome this and leave each shift focused on our triumphs and pleased with our contributions, and not haunted by self-doubt.5

H

ave you ever been terrified of failure? If so, did it keep you going— studying and working long past when you otherwise would have stopped?

For so many physicians, perfectionism is a reliable companion in the struggle for success. It pours that third cup of coffee during an all-nighter study session and tells us to ignore a party within earshot of our dorm in order to continue memorizing the Krebs cycle. The goal for perfection and its accompanying fear of failure, drives us to meet the seemingly unattainable standards of high GPAs, stellar test scores, robust extracurriculars, near clairvoyant communication skills, and excellent clinical performance.1 And so, by the time we are conferred with a medical degree, this companion has become indispensable. And unfortunately, it has a cost.

In the long term, perfectionism evolves into less of a friend and more of a “frenemy.” Though it facilitates accomplishing our goals, it can simultaneously lead to many problems. Maladaptive perfectionism correlates significantly with depression, hopelessness, and suicidal ideation.2 A German study found maladaptive perfectionism to be the strongest predictor of depression and anxiety.3 The associated self-doubt can lead to imposter syndrome, which, if unchecked, becomes a self-fulfilling prophecy. Each success is attributed to luck or over-preparation instead of a deserved recognition, and each failure is viewed as a reinforcement of fraudulence, further driving the need to conceal imperfections.4 Thus, perfectionism is an all-or-nothing perception of success based on unrealistic standards. And with a 58.2% prevalence of depression for US medical students and 40% for post-graduate physicians, it seems unlikely that



BUT WE CAN ALSO CREATE RESILIENCE TO DEAL WITH THESE STRESSORS BY ENJOYING THE DAILY FULFILLMENT ASSOCIATED WITH ACHIEVING TANGIBLE, REASONABLE GOALS AND ENCOURAGING OTHERS TO DO THE SAME.”

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This perfectionism problem is addressed by Benjamin Hardy, an organizational psychologist and author of The Gap and The Gain: The High Achievers’ Guide to Happiness, Confidence, and Success, who suggests separating ideals from goals.6 Ideals are non-specific and immeasurable, e.g., being excellent at procedures. Goals are specific, measurable, and attainable, such as successfully completing a lumbar puncture 80% of the time. As such, ideals are amorphous, difficult to quantify, and therefore, unachievable. Because of our fear of failure, we are then inundated with intrusive thoughts of the shoulda-coulda-woulda. On the other hand, goals are plausible to achieve through deliberate practice. Goals incorporate mistakes as part of the iterative process, and can be continually refined once met. Aberrantly attempting to meet ideals instead of goals constantly threatens to leave us in the hopeless “gap” of failure. Instead, attempting to meet reasonable goals both inspires us and assures the possibility of success, allowing the perspective needed for a growth mindset.7 Many of our favorite faculty members may have unwittingly propagated perfectionism through their own example when we were junior learners.

They were excellent clinically, had a long list of publications, were unflappable in stressful situations, always knew just what to say, and had the key trick to nailing a difficult procedure—all while raising the “perfect” family, having an active social life, or telling stories of exciting travel or hobbies. As we look up to them, we idealize their persona and ask, “how does she do it?” or “how did he know that?” This sets us up for unrealistic expectations of ourselves instead of recognizing that clinical excellence is built on both diagnostic successes and failures and the learning that occurs from these moments throughout our careers. It trains us to respect the veneer of perfection and not accept the reality that no one is perfect in every sphere of work and life every day. Even though others may seem to float serenely through their shifts, we are all frantically kicking under the water just to keep afloat.8 Unquestionably, personal or professional challenges will arise throughout our careers, and empowering students and physicians alike to take time for self-care and attend to our well-being, including normalizing seeking help, is invaluable. But we can also create resilience to deal with these stressors by enjoying the daily fulfillment associated with achieving tangible, reasonable goals and encouraging others to do the same. Even as we practice inward compassion for ourselves, we must extend empathy to those around us. Let them know that we are not some flawless ideal. We must not let our fear of vulnerability prevent

>>

WELLNESS COMMITTEE



GOALS INCORPORATE MISTAKES AS PART OF THE ITERATIVE PROCESS, AND CAN BE CONTINUALLY REFINED ONCE MET.”

us from normalizing our own inability to be perfect. We should strive to help those junior to us bridge the gap between the ideal and the reality by sharing our own experiences with failures and struggles. We must change our expectations of doing everything perfectly and set reasonable targets for ourselves and our trainees, leaving room for the occasional imperfection. Only then can we truly help them answer, “What is my ideal outcome, and what reasonably achievable goals will move me in that direction?”

References Director of Quality Improvement, Harbor-UCLA Medical Center Director of Well-Being, Stanford Emergency Medicine, @alvarezzzy ‡ UCLA Emergency Medicine Department, @AndyGrock *

†

1. Neff KD, Hsieh Y-P, Dejitterat K. Self-compassion, Achievement Goals, and Coping with Academic Failure. Self Identity. 2005;4(3):263-287. doi:https://doi.org/10.1080/13576500444000317 2. Enns MW, Cox BJ, Sareen J, Freeman P. Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation. Med Educ.

2001;35(11):1034-1042. doi:10.1046/j.1365-2923.2001.01044.x

3. Seeliger H, Harendza S. Is perfect good? - Dimensions of perfectionism in newly admitted medical students. BMC Med Educ. 2017;17(1):206. doi:10.1186/s12909-017-1034-9 4. Clance PR, Imes SA. The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychother Theory Res Pract. 1978;15(3):241-247. doi:10.1037/h0086006 5. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med J Assoc Am Med Coll. 2014;89(3):443-451. doi:10.1097/ACM.0000000000000134 6. Sullivan D, Hardy B. The Gap and The Gain: The High Achievers’ Guide to Happiness, Confidence, and Success. Hay House Business; 2021.

Accessed September 4, 2021. https://www.penguinrandomhouse.ca/ books/679143/the-gap-and-the-gain-by-dan-sullivan/9781401964368 7. Developing a Growth Mindset by Carol Dweck.; 2014. Accessed September 4, 2021. https://www.youtube.com/watch?v=hiiEeMN7vbQ 8. Rahman A. Duck Syndrome. KQED. Published July 26, 2019. Accessed September 4, 2021. https://www.kqed.org/perspectives/201601138907/ duck-syndrome

ED Operations Certificate Course Optimizing the management of your ED: patient flow, experience, quality, and safety

www.aaem.org/education/events/edocc

COMMON SENSE NOVEMBER/DECEMBER 2021

29

AAEM Financial Update: Investing Your Money in You!

AAEM FINANCES

Robert A. Frolichstein, MD FAAEM

T

he Secretary-Treasurer of AAEM has the responsibility of periodically reviewing the financial statement of The Academy and presenting a report to the AAEM Board of Directors (BOD) at each meeting. Additionally, the SecretaryTreasurer participates in the annual budget development process and the annual audit. I have been your SecretaryTreasurer for the last 18 months and am struck by the integrity and judiciousness of your BOD as it applies to your money.

The financial report is presented monthly. We have made some changes to make it more informational to the BOD, but it really is just a bunch of financial statements that can be mind-numbing. There is the temptation to gloss over this information and move on to other business but I am consistently impressed that board members have questions and interest in the finances. It is obvious that they read and analyze the data each time it is presented.



MORE THAN 75% OF THE ANNUAL INCOME OF AAEM COMES FROM THE DUES YOU PAY TO MAINTAIN YOUR MEMBERSHIP.”

More than 75% of the annual income of AAEM comes from the dues you pay to maintain your membership. Most of the remainder comes from educational courses AAEM provides including the Scientific Assembly and Oral Boards Review.

The associated costs of those courses means that, in practical sense, all the income to do the work of the Academy comes from the dues you pay.

The BOD understands this and is very careful about how we spend money. It is not uncommon to have discussions at board meetings about items that would have very little financial impact on AAEM. The question is always raised “is this a wise use of our members money?”

There is no willingness to squander money or use it in ways we feel will not help our members or specialty.

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Early in 2021 I had the “privilege” of participating in our annual audit. Because of our tax status, best practice is that each year we have an external auditor pour over our finances and then present a summary of their findings to our accountant, Executive Director, and the Secretary-Treasurer. During the hour-long presentation it was clear that they traced nearly every dollar AAEM received and spent. They looked at bank statements, credit card statements, invoices, phone bills, etc., and I was impressed at their exhaustive review. I was delighted when we received a “clean audit” which

means we have processes and procedures in place that allow full transparency to the BOD. There is no way money can be used for purposes other than those approved by the BOD and cannot be “lost” or used in nefarious ways.

Every dollar has been recorded.

At the time of this writing I am preparing to present our annual budget to the BOD. The top five items in our expense column after what we pay to run the organization are: the Scientific Assembly, MEMC, Oral Boards Review Course, Legislative Advocacy (for individual physicians or groups) and JEM. Those items are certainly consistent with our Mission Statement.

Our budget projects a small “profit” for 2022. This is consistent with many previous years and The Academy has some money in reserve. We are in a very good financial position.

We have invested in some projects (check out the new advocacy page on our web site) and have a few in the works that are intended to meet your needs and the needs of our specialty. As I mentioned, your BOD is prudent with our member’s money but also anxious to hear how we can use those funds to serve you better. Get involved. Join a committee. Develop some proposals on how your dollars can make our specialty better and our physicians more satisfied.

ADVOCACY

AAEM’s New Action Center: Grassroots Advocacy Made Simple Vicki Norton, MD FAAEM

E

THE AAEM ACTION CENTER  CAN SIMPLIFY THIS PROCESS

AND MAKE US ALL ADVOCATES: FOR OUR PATIENTS, OUR SPECIALTY, AND OURSELVES.”

mergency Medicine is under attack from many different angles. Like it or not, our specialty is being subjected to trauma from corporate control, a lack of due process, burdensome metrics, and replacement of physicians with non-physician practitioners. I have personally felt frustrated, feeling like there is nothing I can do to change things for the better. That is what prompted me to become so involved with AAEM and join the Board of Directors. Now we ALL have an opportunity to make a difference!

And it can be as easy as the click of a button.

The AAEM Board recently approved a new bill tracker and grassroots action center using a software called Quorum. AAEM’s Advocacy Action Center (https://aaem.quorum.us) will be your onestop shop to view upcoming state legislation that could impact your practice, take action to write and call your local and federal legislators, and be informed about all the issues affecting emergency medicine today and in the future.

Our current letter writing campaigns and other calls-to-action can be accessed from the “Active Campaigns” tab on the top of the screen. One such campaign, “Raising Residency Standards,” allows members to send a letter to the ACGME over concerns related to current EM training program standards which could greatly impact future workforce concerns related to the projected oversupply.1 AAEM’s proposed solution would be to limit the number of residents at the program’s primary site to one resident per 3600 patient volume, in order to have a more robust and standardized educational experience.2 This would also prevent programs from “gaming” the system in order to increase resident class size or open new programs.

The AAEM Board wants to empower all emergency physicians to have their voices heard on these important issues. We are all leading busy, full lives. It takes time and effort to build relationships with or reach out to legislators, policymakers, and regulatory bodies. The AAEM Action Center can simplify this process and make us all advocates: for our patients, our specialty, and ourselves.

Check it out today!

References 1. Marco MD, et al. The Emergency Medicine Physician Workforce: Projections for 2030. Annals of Emerg Medicine, Aug 2, 2021. https://www.annemergmed.com/article/S0196-0644(21)00439-X/ fulltext 2. AAEM Position Statement: Raising Emergency Medicine Residency Standards, July 7, 2021. https://www.aaem.org/resources/statements/position/raising-em-residency-standards

COMMON SENSE NOVEMBER/DECEMBER 2021

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EMERGENCY MEDICINE WORKFORCE COMMITTEE



MANY OF US DID NOT GO INTO MEDICINE TO WORK IN THE LEGISLATIVE ARENA…AND OUR RECOLLECTION OF A HOW A BILL BECOMES A LAW IS FROM MRS. SMITH’S FIFTH GRADE SOCIAL STUDIES CLASS.”

‘Tis the Season…

Julie Vieth, MBChB FAAEM

F

… or state legislative work to begin! Over the next few weeks and months, many states will begin their 2022 legislative sessions. The Workforce Committee will be using our new Action Center1 to help track important scope of practice and other related emergency medicine workforce bills that are introduced. But, we need your help! If you know of a bill in your state that is introduced that will expand the scope of practice for non-physician practitioners or remove the physician from the patient care team, please let the Workforce Committee know.

In addition, we encourage you all to become members of your state medical society. This is truly where you can have an impact with your state. Many state medical societies are begging for active engagement, particularly from younger physicians. Your views and impact can be longstanding.

Many of us did not go into medicine to work in the legislative arena. In fact, most of us have never been taught how to do this work, and our recollection of a how a bill becomes a law is from Mrs. Smith’s fifth grade social studies class. However, you are an expert in patient care—specifically in emergency care when patients often have nowhere else to turn. All of us know someone who has been a patient at some point in the emergency department and they definitely all have an opinion of that visit and that doctor they saw. Legislators are no different—they rely on their constituents to bring issues to them and to impact how they vote. But, they also rely on content experts—and that can be you. These relationships take time to build, but it can start through your medical society or just as a local constituent of their district.

The Workforce Committee has put together a handbook of how to effectively do this work and we invite you to take a look at the Lobbying Primer for Emergency Physicians.2 Throughout the next few months, we will also be hosting multiple online interactive sessions to help you get involved, know the issues, and move you step by step through the process of connecting with your legislator and becoming a content expert. Look for those to be advertised in your weekly AAEM Insights email.

If you’re interested in joining the Workforce Committee, please submit an application.3 We would love to hear from you!

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Links 1. https://aaem.quorum.us/home/ 2. https://www.aaem.org/UserFiles/file/ EMWFlobbyingprimer.pdf 3. https://www.aaem.org/get-involved/ committees/committee-groups/em-workforce

OPERATIONS MANAGEMENT COMMITTEE

Geriatric Patient Experience in the Emergency Department Samita M. Heslin, MD MBA MPH MA and Eric J Morley, MD MHA MS

T

here are 54 million Americans who are 65 or older, a 30% increase in the last decade and it is predicted this population will almost double by 2060.1,2 Geriatric patients currently comprise more than 15% of Emergency Department (ED) visits and over 35% of hospital admissions.3,4 Caring for older adults requires attention to atypical disease presentations, polypharmacy, and more complicated transitions of care and social needs.4 Geriatric patients are also more likely to have a longer length of stay in the ED.5,6 It is important to engage this population and address their specific needs to improve their satisfaction and overall care. Below we highlight some ideas and initiatives that can dramatically improve the experience geriatric patients have while in the ED. • Access to food and water. We often fail to attend to these basic needs of our geriatric patients. We can increase access to food and water by placing NPO orders only when absolutely required (i.e., dysphagia) and having refrigerators stocked with food in multiple zones in the ED where patients and staff can access them. We should also communicate with patients regularly about when they can eat. Since many of these patients have challenges related to problems with ambulation and vision, we recommend that ED staff frequently round on these patients and supply them with food and drink when appropriate.

• Access to toileting. Toileting can be challenging for some older patients. Since most patients will have to walk to a communal bathroom in the ED, this might be a difficult task for some and may lead to falls.

We recommend that bedside commodes be available in patient rooms so that ED staff don’t have to search for these items. Particular attention should be paid to patients who may have dementia or delirium and others who cannot advocate for themselves. Screening programs can be implemented in the ED to help identify these patients early in their hospital course. These patients may need assistance with toileting, including using the bedside commode.7 Patients who are fall risks should be offered bed pans and non-invasive urinary catheters (i.e., non-invasive suction catheters for women and condom catheters for men). In-dwelling urinary catheters increase the risk of infections and should only be used when absolutely required.8 • Ambulation and Sensory aides. Many geriatric patients have difficulty hearing and seeing, which may lead to difficulty communicating with medical providers and may also trigger delirium.9 It is useful to keep reading glasses, magnifying glasses, and auditory aides (i.e., hearing aids, audio amplifiers) in the ED. Additionally, dry erase boards and point-to-boards in multiple languages can also assist patients with communicating with ED staff. We also recommend maintaining a supply of four-point canes and rolling walkers for patients to use while in the ED.

• Engaging the patients’ family and primary care physicians. Aftercare and transition of care for our geriatric patients is critical.10 Many patients will have challenges with home care, getting prescriptions, accessing outpatient follow-up care, and addressing other needs.

Engaging the family and primary care physician (PCP) is important to help produce a positive outcome. We recommend that families and PCPs be notified when geriatric patients are admitted to the hospital.

If possible, notifying families and PCPs of the ED workup and results for patients being discharged can also be beneficial. Of course, permission should be first granted by the patients if they have capacity.

Physical Therapy, Social Work, and Case Management consults may be needed to provide a safe discharge for the geriatric patient.11,12



BUILDING A SYSTEM THAT ADDRESSES THESE NEEDS IS IMPORTANT TO MAKE SURE THEIR EXPERIENCE IS OPTIMAL DURING THE ED STAY.”

Geriatric ED patients have unique needs. Building a system that addresses these needs is important to make sure their experience is optimal during the ED stay. Additional geriatric-specific policies and procedures, such as screening tools, fall risk protocols, and delirium and dementia prevention guidelines, can help us better identify and care for at-risk geriatric patients and improve the overall care we give in the ED.

COMMON SENSE NOVEMBER/DECEMBER 2021

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OPERATIONS MANAGEMENT COMMITTEE

References: 1. Albert M, McCaig LF, Ashman JJ. Emergency department visits by persons aged 65 and over: United States, 2009-2010. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2013.

2. 2020 Profile of Older Americans. US Department of Health and Human Services, The Administration for Community Living; 2021.

3. Alexander X. Lo, Kellie L. Flood, Kevin Biese, Timothy F. Platts-Mills, John P. Donnelly, Christopher R. Carpenter, Factors Associated With Hospital Admission for Older Adults Receiving Care in U.S. Emergency Departments, The Journals of Gerontology: Series A, Volume 72, Issue 8, August 2017, Pages 1105–1109, https://doi.org/10.1093/gerona/glw207 4. Shenvi CL, Platts-Mills TF. Managing the elderly emergency department patient. Annals of emergency medicine. 2019 Mar 1;73(3):302-7.

5. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: projections from a multicenter data base. Annals of emergency medicine. 1992 Jul 1;21(7):819-24.

6. Latham LP, Ackroyd-Stolarz S. Emergency department utilization by older adults: a descriptive study. Canadian Geriatrics Journal. 2014 Dec;17(4):118.

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7. Lee EA, Gibbs NE, Fahey L, Whiffen TL. Making hospitals safer for older adults: updating quality metrics by understanding hospital-acquired delirium and its link to falls. The Permanente Journal. 2013;17(4):32.

8. Girard R, Gaujard S, Pergay V, Pornon P, Martin-Gaujard G, Bourguignon L, UTIC Group. Risk factors for urinary tract infections in geriatric hospitals. Journal of Hospital Infection. 2017 Sep 1;97(1):74-8.

9. Morandi A, Inzitari M, Udina C, Gual N, Mota M, Tassistro E, Andreano A, Cherubini A, Gentile S, Mossello E, Marengoni A. Visual and hearing impairment are associated with delirium in hospitalized patients: results of a multisite prevalence study. Journal of the American Medical Directors Association. 2021 Jun 1;22(6):1162-7.

10. Hwang U, Shah MN, Han JH, Carpenter CR, Siu AL, Adams JG. Transforming emergency care for older adults. Health Affairs. 2013 Dec 1;32(12):2116-21.

11. Lesser A, Israni J, Kent T, Ko KJ. Association between physical therapy in the emergency department and emergency department revisits for older adult fallers: a nationally representative analysis. Journal of the American Geriatrics Society. 2018 Nov;66(11):2205-12.

12. Sanon M, Hwang U, Abraham G, Goldhirsch S, Richardson LD. ACE model for older adults in ED. Geriatrics. 2019 Mar;4(1):24.

WOMEN IN EMERGENCY MEDICINE

Infertility: Using Knowledge to Advocate for Change Danielle Goodrich, MD FAAEM FACEP

E

retrospective study showing that female physicians appear to delay childrin Andrews, an American sportscaster and tele- bearing compared to females in other fields. This is not surprising given the extensive schooling and training it takes to be a practicing physician. vision personality, recently spoke with People When physicians and nonphysicians were compared, it was found that Magazine about her infertility journey. This singular physicians were less likely to have children at younger ages and more interview was monumental. In our culture, infertility likely to delay having children until older ages. This delay in childbearing treatments are commonplace, and yet it is far less common to hear open contributes to more potential risks of infertility as well as adverse materdiscussions in the media regarding infertility or even within the medical nal and fetal risks. Another study, in JAMA Surgery, demonstrated that community. Let’s follow Erin Andrews’ lead. female surgeons, in particular, were more likely to delay childbearing, more likely to use assisted reproductive technology, and also more likely to experience pregnancy loss compared to the general population. The article also showed that female surgeons had 1.7x higher odds of pregnancy complications THE ABILITY TO including more musculoskeletal complaints and preeclampsia.



OPENLY DISCUSS FERTILITY CONVERSATIONALLY IS CRITICAL TO INCREASING AWARENESS AND FOSTERING EMPATHY.”

The first step towards addressing our cultural blindness to the issue is acknowledging and understanding how widespread it is in our society.

Infertility is defined as the inability to conceive after a year of unprotected, regular intercourse. Infertility has historically been considered a female issue with current estimates suggesting that one in eight women in the United States are affected by infertility. However, fertility affects all persons, men and women, including those who are practicing physicians.

It can also affect physicians who have same sex partners and/or opposite sex partners, as well as physicians who are transgender or nonbinary, single physicians, and it can affect those physicians with underlying medical comorbidities. Many of our own colleagues are experiencing fertility difficulties, but may be keeping their struggles to themselves. The ability to openly discuss fertility conversationally is critical to increasing awareness and fostering empathy.

In the medical field, it is estimated that one in four female physicians are diagnosed with infertility and research is just beginning to shed light on how widespread infertility (and its related complications) is within the physician workforce. JAMA Internal Medicine recently published a

Whether or not you have personally experienced this, there are things that we all can do to address this common medical condition. First, advocate for your colleagues. A number of states mandate coverage of fertility benefits, but very few healthcare organizations outside of these states offer any form of fertility coverage at all. This is highly problematic, but change may be on the horizon. Several notable, large corporations, including Google, Facebook, and others have now upgraded their employee health benefits to include fertility coverage in order to improve employee recruitment and retention. The same can and should be done on a local level within your organization, at least until we can build a critical mass of advocacy to effect change on a national level with mandated coverage across the country.

Additionally, you can also educate your colleagues and your trainees.

Consider adding family planning as a part of your wellness curriculum.

By helping to reduce the stigma and by having open conversations with residents and trainees about family planning and infertility, we can enable students and trainees to make more informed decisions regarding their futures.

Infertility is common and through knowledge and advocacy we can make changes to support our colleagues and future physicians.

References 1. Rangel, Erika L., et al. “Incidence of Infertility and Pregnancy Complications in Us Female Surgeons.” JAMA Surgery, 2021, doi:10.1001/jamasurg.2021.3301.

2. Cusimano, Maria C., et al. “Delay of Pregnancy Among Physicians vs Nonphysicians.” JAMA Internal Medicine, vol. 181, no. 7, 3 May 2021, pp.

905–912.

COMMON SENSE NOVEMBER/DECEMBER 2021

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EMERGENCY ULTRASOUND SECTION

EUS-AAEM 2020-2021 Round Up Alexis Salerno, MD FAAEM

O

ver the last few years, the EUS-AAEM Section of AAEM has become one of the largest member sections. The section was created with the objective of disseminating information about ultrasound amongst emergency medicine practitioners regardless of practice setting and experience.

One of our biggest accomplishments this year was the Unmute Your Probe virtual series.

Since meeting in-person during the COVID pandemic was limited, many of us looked for other sources of continuing education and critical discussion. The Unmute Your Probe series was created in response to this. The EUS-AAEM sponsored didactic webinar series covers both basic and advanced POCUS topics and is taught by national speakers.

Furthermore, members can obtain up to 22 hours of CME credits for webinar attendance.

The Unmute Your Probe series has lectures scheduled until January 2022, so members still have time to participate if any prior lectures were missed.

As meeting restrictions began to lift, AAEM was able to hold a hybrid scientific assembly in St. Louis in June. During the main conference, the EUS-AAEM section coordinated three targeted ultrasound workshops. This was the first year offering these workshops. We covered upper and lower extremity regional anesthesia as well as an introduction to point of care echocardiogram. These workshops filled quickly with great attendance and was a success we hope to repeat in future years.

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Post-conference, we also offered beginner and advanced ultrasound courses. As a supplement, we offered for the first time a Skills Verification Program (SVP). The SVP provided an opportunity for participants to obtain proctored FAST ultrasound exams with a signed record that can be used as part of the privileging/credentialing process at their individual institutions. There were six participants in the very first SVP and 11 EUS-AAEM ultrasound faculty were able to proctor a total of 95 FAST exams during the post-conference Ultrasound Courses. We look forward to the continuation of this program at future Scientific Assemblies and hope to expand our focus to include echocardiography, vascular access, and additional ultrasound skills useful to Emergency Physicians.

In February of 2020, we held our first regional course. Over the next year, we hope to renew our commitment to serving the community physician by holding regional courses throughout the year. We hope to add the Skills Verification Program to our regional courses, this would serve to help providers at local hospitals obtain scans for the privileging/credentialing process. If you are part of a regional AAEM chapter division and are interested in holding a regional ultrasound course, please let us know by email.

The EUS-AAEM section will also continue to publish our biannual section publication, The POCUS Report. Our summer edition was recently published in early July and we hope to have our winter edition published in late November. We encourage all members at different stages of medical education to submit articles for this publication as editors will work with potential authors to develop articles. In between editions, we hope to hold forums on our new MyAAEM community page listserv. This platform will be used to answer questions from our members and distribute information about important ultrasound news.

Lastly, we would like to send a big thank you to our outgoing board members: Dr. Chin, Dr. Burns, and Dr. Pounds for their contributions to the section and would like to welcome our newest board members Dr. Cohen, Dr. Newberry, and Dr. Eberle.

waiting for answers

EMERGENCY ULTRASOUND SECTION

Give Me a Break: Ultrasound Guided Serratus Anterior Plane Block Shawn Sethi, DO*

Y

ou are treating an elderly man who slipped and fell down several steps just prior to his arrival in the emergency department.

He is in severe pain, gripping his right chest wall and flank. After a chest x-ray, you note fractures of ribs five through eight on the right. An attempt of multimodal pain control with oral analgesics, a lidocaine patch, and IV opioids is made but the patient continues to have pain. You are worried about respiratory splinting and are hesitant to continue with high doses of opioids. Is there an alternative?

You roll over the ultrasound machine to perform a serratus anterior muscle (SAM) plane block for more effective (and longer lasting) analgesia. This block is ideal for anterior or lateral rib fractures given the area of anesthetic coverage (T2 through T9 dermatomes, see figure 1). It is less likely to be effective for posterior rib injury. This plane block can be used in other scenarios, not just rib fractures, including chest wall abscess drainage, large burns, or peri-procedural anesthesia for chest tube placement.

To perform this block, you ask the patient to lay on their left side (with the affected side facing upwards, towards you). Next, the T4 to T5 space in their mid-axillary line is identified. This marks the approximate area of injection for maximal coverage. You place the high frequency linear probe, in the transverse plane, on the patient’s right chest wall with your probe marker facing to the patient’s right (figure 2). You see the two major anatomical landmarks, the latissimus dorsi muscle superficially and just deep to that, the SAM (figure 3). Above these muscle groups you can visualize soft tissue, and below, the ribs (with posterior shadowing) and the pleural line. The SAM block is a type of regional anesthesia known as a “plane” block. Plane blocks don’t target a single nerve, but rather a group of nerves traversing the same fascial plane.

In this case, the fascial plane allows our anesthetic to bathe the lateral intercostal nerves which traverse this area. As seen in figure 3, the fascial plane surrounding the SAM is the target. Either the superficial (yellow dotted line) or deep fascial plane (blue dotted line) can be chosen for placement of the anesthetic. There is no consensus in the literature on whether performing the block superficial or deep to the SAM is superior.1,2 Our practice is to block superficial to the SAM due to it being technically easier to perform and to avoid traversing the SAM, thereby possibly decreasing complications and pain related to the procedure.

Using an in-plane approach, you first guide your needle to the fascial plane and inject a small aliquot of saline just below the fascia. The will allow separation of the fascial plane from the muscle, also known as hydro-dissection, to ensure the proper placement of the anesthetic. Once the potential space between the fascia and muscle layer has been opened, injection of the anesthetic of choice can occur. An 18 to 22 gauge spinal needle with 20 to 40 cc of total volume will be required for this block— enough to adequately cover the fascial plane. As it is less cumbersome, you have the nurse hold the syringe with IV tubing and inject while you hold the needle and probe.

To avoid local anesthetic systemic toxicity (LAST), you have mixed normal saline with the anesthetic to achieve the desired volume. As with all high volume regional anesthesia techniques, lipid emulsion therapy is nearby and the patient is on the cardiac

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Figure 1: Serratus anterior muscle plane block area of anesthetic coverage (T2 through T9 dermatomes).

Figure 2: Patient positioning for right sided SAM block.

Figure 3: Anatomical landmarks for SAM block.

an incomplete picture

EMERGENCY ULTRASOUND SECTION

monitor in case the patient develops LAST. You take care to avoid the thoracodorsal artery (of which color doppler can aid in visualization) and the pleura, just deep to the serratus muscle body. Following a successful block the patient feels relief, is spared further opioids and is able to take deep breaths with minimal pain.

This block should not be performed if there is evidence of soft tissue infection in the immediate area of injection. There is a low risk of complication with this block as the pleural line can be visualized the entire time, ensuring avoidance. And there is little risk of direct nerve injury as the needle is being directed to the fascial plane, instead of a specific nerve bundle.

Multiple studies from the anesthesiology literature have found decreased pain reduction, reduced need for opioids, and low rate of complication.3,4 Additionally, teaching this technique to new learners is feasible. A 2020 study found that EM residents were able to achieve mastery and increased confidence in this block after a combination of simulated model training and instructional videos.5 So, the next time you encounter a patient with multiple rib fractures, large burns, soft tissue infection of the chest wall, or requiring a chest tube, consider the ultrasound guided serratus anterior plane block for effective analgesia.

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Refe/rences 1. *Clinical Ultrasound Fellow, Emory University 2. Bhoi D, Selvam V, Yadav P, Talawar P. Comparison of two different techniques of serratus anterior plane block: A clinical experience. J Anaesthesiol Clin Pharmacol. 2018 Apr-Jun;34(2):251-253. doi: 10.4103/ joacp.JOACP_294_16. PMID: 30104841; PMCID: PMC6066876.

3. Piracha MM, Thorp SL, Puttanniah V, Gulati A. “A Tale of Two Planes”: Deep Versus Superficial Serratus Plane Block for Postmastectomy Pain Syndrome. Reg Anesth Pain Med. 2017 Mar/Apr;42(2):259-262. doi: 10.1097/AAP.0000000000000555. PMID: 28079733.

4. Park MH, Kim JA, Ahn HJ, Yang MK, Son HJ, Seong BG. A randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery. Anaesthesia. 2018 Oct;73(10):1260-1264. doi: 10.1111/ anae.14424. Epub 2018 Aug 18. PMID: 30120832.

5. Khalil AE, Abdallah NM, Bashandy GM, Kaddah TA. Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. J Cardiothorac Vasc Anesth. 2017 Feb;31(1):152-158. doi: 10.1053/j.jvca.2016.08.023. Epub 2016 Aug 21. PMID: 27939192.

6. Rider AC, et al. Using a Simulated Model and Mastery Learning Approach to Teach the Ultrasound-guided Serratus Anterior Plane Block to Emergency Medicine Residents: A Pilot Study. AEM Educ Train. 2020 Sep 27;5(3):e10525. doi: 10.1002/aet2.10525. PMID: 34041432; PMCID: PMC8138100.

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ETHICS COMMITTEE

Not Burnout: Moral Injury in the ED Melissa Myers, MD FAAEM, Jennifer Gemmil, MD FAAEM, Al O. Giwa, LLB MD MBA FAAEM

O

ver the last year, we’ve all read countless articles about “burnout” and “wellness.” These articles fail to address one of the chief causes of this burnout epidemic amongst emergency medicine (EM) physicians, the broken system in which we work. In the chaos of the COVID pandemic, we’ve focused on new problems but the systemic problems that we face in EM still exist.

These problems were present before the pandemic and have only been exacerbated by the stress COVID-19 has placed on our healthcare system. In putting the burden on the physician to be “resilient” we ignore the systemic problems which we face every day on shift. Yoga and CrossFit will not fix a dire need for a better healthcare infrastructure and there is a limit to personal resilience, one which I believe many physicians are approaching or have already passed. I believe that at the root of burnout for many emergency physicians lies the moral injury we incur with each shift in the emergency department (ED). In the article “Moral Injury in Emergency Medicine,” recently published in The Journal of Emergency Medicine, the authors describe moral injury as being required to do something which violates our moral code.

The causes may differ by practice site or individual circumstances but we are all familiar with the phenomenon even if we call it by different names. Our patients present with preventable diseases which could be managed outpatient by specialists without the damage to their bodies and disruption to their lives that they incur through repeated ED visits. Take the example of a patient I recently saw who presented with diabetic ketoacidosis (DKA), as he had every few weeks for the past year. Treating DKA is straightforward for any EP, just start the insulin drip and call the ICU. But that’s not the real solution to his problem which is that he’s

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uninsured and can’t afford insulin or access to an endocrinologist to manage his condition. He’s accepted this revolving cycle of admission and discharge as being the best he can expect.

Providing crisis care without any ability to solve the root problem becomes frustrating. It’s hard to take pride in providing care which provides a short-term solution without solving the patient’s real problem. And therein lies the moral distress. I know I should do more, but the issue is much bigger than I or any one of us individually can fix. We all know what the “right” is but how do we achieve it on a global scale in the current US healthcare system?

This year, with the pandemic raging and volumes high, many of us are tired both physically and mentally and may not live up to the high standards we set for ourselves. During a recent shift at a rural facility, I cared for a patient at the end of life who died from COVID pneumonia.

Following the declaration of death, I walked into a room where a patient just diagnosed with COVID pneumonia became very frustrated and angry when I declined to give him a shot of ceftriaxone. He didn’t believe me when I tried to explain that his symptoms were from the coronavirus, not a bacterial infection. Normally, I would have sat down with this patient and done my best to explain the difference and to answer

his questions. This time I didn’t. I reiterated that this was viral, not bacterial, advised him to get vaccinated after he recovered, and I left the room. He left the ED angry and I was frustrated with myself for not being the caring, empathic physician I had promised myself I would be at my white coat ceremony.

I believe a combination of systemic problems and disappointment in ourselves for failing to live up to an impossible standard is leading to widespread moral injury amongst EPs. We need to accept that we will not always be “right” morally or otherwise, especially when there are circumstances beyond our control. This is not saying that we should stop trying as our patients will always continue to deserve our best efforts. We need to accept, however, that we may not handle every encounter without issues and move on from these without self-deprecating browbeating. We need to remember to take pride in providing the best care we can to those who can’t access it otherwise. Maybe what you do for the patient isn’t the final answer he or she needs, but it’s what they need today and you are the one who can provide that.

We can also take steps to address the systemic failures in medicine. As emergency physicians, we have seen some of the difficulties our patients face and can provide them with a voice.

We can advocate for our patients through our

YOGA AND CROSSFIT WILL NOT FIX A DIRE NEED FOR A

>>

BETTER HEALTHCARE INFRASTRUCTURE AND THERE IS A LIMIT TO PERSONAL RESILIENCE, ONE WHICH I BELIEVE MANY PHYSICIANS ARE APPROACHING OR HAVE ALREADY PASSED.”

COMMITTEE REPORT ETHICS

MAYBE WHAT YOU DO FOR THE PATIENT ISN’T

THE FINAL ANSWER HE OR SHE NEEDS, BUT IT’S WHAT THEY NEED TODAY AND YOU ARE THE ONE WHO CAN PROVIDE THAT.”

hospital systems by serving on committees focused on patient access to care and providing equity of care. As members of the American Academy of Emergency Medicine (AAEM) we have access to many ways to work to improve our medical system. For example, members of

the Ethics Committee work to provide ethical guidelines for physicians facing difficult situations, to bring attention to the stories of this pandemic through collaboration with the Palliative Care Committee, and to provide advice on ethical dilemmas for the leaders of AAEM. Each of us will ultimately find our own ways to make peace with the systems we work in and the events of

the past two years. For myself, I will continue to look for ways to advocate for my patients. I will recognize when I fail to live up to the expectations I’ve set for myself and both forgive myself and continuously work to do better. Doing these things has brought me some peace in knowing that while I can’t fix the entire system, I can work to improve my part in it.

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#MEMC22 COMMON SENSE NOVEMBER/DECEMBER 2021

43

Understanding the Transition from Resident to Attending Practice

YOUNG PHYSICIANS SECTION

Jessica Fujimoto, MD FAAEM

T



As new attending physicians, we are still developing our professional identity and we still have unmet learning needs.”

he transition from resident to attending physician is a time of many challenges and immense growth.

As new attending physicians, we are still developing our professional identity and we still have unmet learning needs. Yet, paradoxically, this comes a time when we are removed from all of the structure and guidance that has supported us thus far in our medical training.

Framing the Problem. Clearly, this is a critical time in a physician’s development, yet, its challenges are poorly understood, which in turn makes it a difficult process to improve. Fortunately, Westerman et al. introduced a framework for conceptualizing this transition from resident to attending practice, with influence from research in medical education and transition psychology.

In this framework, the authors propose that novel disruptions arise in this transition, which leads to coping, subsequently fostering personal development. Issues that fall under each of these themes can be further categorized into issues arising from novel tasks, roles, and contexts.1 Disruptive Novel Elements. These deal with differences between practicing medicine as a resident in training as opposed to practicing as an attending. They are subcategorized into novel tasks, novel roles, and novel contexts, and they apply to both clinical and nonclinical work.1 Some disruptive novel elements in Emergency Medicine include: • Novel Tasks: billing and coding, navigating the logistics of patient care, ensuring patient satisfaction, becoming board certified, managing personal finances • Novel Role: being a team leader, having the final say in medical decision making • Novel Context: working in a new system, working at a faster pace, working with new nurses and staff, working with consultants who are not in house, achieving work-life balance1,2,3,4,5,6,7,8 Perception and Coping. New attendings have varying reactions to the changes that come with this transition. Interestingly, surveyed new attending felt well prepared in medical knowledge and clinical skills, but felt poorly prepared for nonclinical aspects of work such as supervision of residents.1 Some perceptions and coping in Emergency Medicine include: • Novel Tasks: feelings of failure or incompetence, not knowing how to supervise NPs and PAs, feeling uncertain about EKG interpretation skills, learning how to avoid burnout

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• Novel Role: uncertainty about others’ expectations, lack of conflict resolution skills, learning how to be the face of the hospital, learning how to be a good employee, being a good role model for learners • Novel Context: needing colleague support in a safe space, continued engagement with professional development1,2,3,4,5,6,7,8 Personal Development and Outcome. The process of perceiving and coping in response to disruptive novel elements leads to personal development and growth. New attendings came to realize that this transition and growth was a more gradual process, and their fear of failure faded as they developed task mastery.1 Solutions. Using this framework, we can identify some strategies to ease this transition. We should minimize disruptive novel elements. Specifically, we should aim to reduce undesirable difficulties, while still allowing new attendings to experience disruptive novel elements that will lead to growth. We should also provide resources, space, and time to promote coping and reflection.

• Minimizing Disruptive Novel Elements: Residency programs should teach nonclinical skills (e.g. supervising residents, PAs, NPs) so that program graduates are better prepared to perform these tasks in their new attending roles. In addition, employers should develop social programs to help introduce new hires to their group’s culture and expectations.1 • Providing Resources to Promote Coping: This is traditionally achieved via one-on-one mentorship that pairs a senior and junior attending.

However, new attendings should also engage in peer group mentorship. A successful example was published by MacMillan et al., in which a group of new attendings started a journal club, meeting regularly to share practice-changing articles and ‘transition to practice’ topics amongst peers.9

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YOUNG PHYSICIANS SECTION

The transition from resident to attending physician is complex and poorly 4. Thomas B. Lessons Learned During My First Year as an Attending Physician. ACEP Now. https://www.acepnow.com/article/lessons-learnedunderstood. Through the framework presented by Westerman et al., we during-my-first-year-as-an-attending-physician/. Published November 24, can begin to understand the challenges that arise, and how we can help 2019. Accessed June 15, 2021. ease this transition for future generations.

5. Roberts JR. How to Survive as a New Attending. Emerg Med News.

2001;23(8):4.

References 6. Garmel G. Letter to Graduating EM Residents. EMRA. Accessed June 1. Westerman M, Teunissen PW, van der Vleuten CPM, et al. Understanding 15, 2021. http://www.emra.org/residents-fellows/career-planning/letter-tothe Transition From Resident to Attending Physician: A Transdisciplinary, graduating-em-residents/ Qualitative Study: Acad Med. 2010;85(12):1914-1919. doi:10.1097/ 7. Vega D, Scaletta T. Rules of the Road for Young Emergency Physicians.; ACM.0b013e3181fa2913 2009.

2. Lin M. Doing well as a new EM attending physician. ALiEM. Published 8. Rules of the Road: Tips for the New Class. Emergency Physicians July 14, 2011. Accessed June 15, 2021. https://www.aliem.com/doingMonthly. Accessed June 15, 2021. https://epmonthly.com/article/rules-ofwell-as-new-em-attending/ the-road-tips-for-the-new-class/ 3. Cosgrove A. Here Goes Nothing: Confessions of a New Attending. EPIC 9. MacMillan TE, Rawal S, Cram P, Liu J. A journal club for peer mentorship: - The Official Newsletter of MOCEP. https://mocep.org/2019/03/herehelping to navigate the transition to independent practice. Perspect Med goes-nothing-confessions-of-a-new-attending/. Published February 2019.

Educ. 2016;5(5):312-315. doi:10.1007/s40037-016-0292-2 Accessed June 15, 2021.

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45

AAEM/RSA PRESIDENT’S MESSAGE

Physician Suicide Awareness Lauren Lamparter, MD

A

s President of AAEM/ RSA and as we head into the holiday season, I wanted to take the time to re-share this special message about physician suicide awareness.

Death by suicide is one of the leading causes of death in the United States, and it claims the lives of about 300 physicians every year.1,2 Depression is three times more prevalent among residents than their peers and suicide is the first and second leading cause of death for male and female residents, respectively.3,4 Emergency medicine, in particular, is a field with one of the leading rates of burnout, and the persistent impact of the global pandemic has done nothing to ease this burden for physicians.

Advocacy for the preservation of physicians’ lives and the support of their mental health is incredibly important to me as throughout my own short career in medicine I have been directly impacted by the loss of my own coworkers and friends by suicide. Too many resident and medical student lives have ended secondary to depression and suicide. It is clear that as a society, we need to step up and something needs to change.

At AAEM/RSA, we are dedicated to supporting the well-being of our residents and medical students. We will continue to work tirelessly to be your advocate and to be a place you can turn to for resources and support.5 We are extremely proud to have endorsed a bipartisan & bicameral resolution to recognize National Physician Suicide Awareness Day on September 17. This resolution aims to raise awareness, reduce the stigma of mental health issues, and promote a national discussion about physician suicide.

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We take September 17—and every day—to remember those who have died by suicide and the impact their lives had on their family, friends, and acquaintances. Today, we are also hopeful that by taking the necessary actions to recognize the signs of someone who is struggling and encouraging our friends and coworkers to seek help, we can preserve the lives of those who might be struggling with depression, burnout, and thoughts of suicide.

I hope you know that we care deeply about you. Whether you are a resident or a medical student—you matter. Every day, what you do is not only important to the specialty of emergency medicine, but also to the people around you.

Please do not hesitate to reach out for help.

If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. You can also text HOME to 741-741 for free, 24-hour support from the Crisis Text Line.

References 1. https://www.nimh.nih.gov/health/statistics/ suicide 2. https://www.acgme.org/Portals/0/PDFs/ten%20 facts%20about%20physician%20suicide.pdf 3. https://www.aamc.org/news-insights/healingvery-youngest-healers 4. https://www.cdc.gov/mmwr/volumes/69/wr/ mm6932a1.htm 5. https://www.aaemrsa.org/get-involved/ committees/wellness/resources



TODAY, WE ARE ALSO HOPEFUL THAT BY TAKING THE NECESSARY ACTIONS TO RECOGNIZE THE SIGNS OF SOMEONE WHO IS STRUGGLING AND ENCOURAGING OUR FRIENDS AND COWORKERS TO SEEK HELP, WE CAN PRESERVE THE LIVES OF THOSE WHO MIGHT BE STRUGGLING WITH DEPRESSION, BURNOUT, AND THOUGHTS OF SUICIDE.”

Gallbladder Wall Thickening: Not Always Acute Cholecystitis…

Denis Ostick, MD, James Longenbach, MD, and Max Cooper, MD RDMS

C

ase

A 58-year-old male with a past medical history of COPD, hypertension, congestive heart failure with EF 20%, AICD, and atrial fibrillation presented to the Emergency Department with a chief complaint of near syncope, chest pain, and abdominal pain. The patient was at his cardiology appointment when he felt lightheaded, became diaphoretic, and had epigastric pain and nausea. These symptoms resolved on their own, but his cardiologist sent him to the ER via EMS for evaluation.

Discussion Diffuse gallbladder wall thickening seen on ultrasound (>3 mm) is commonly thought to be due to cholecystitis.1 Given it is a necessary finding in those with acute cholecystitis, it is within reason to obtain a surgicalconsult in the ED. However, in this case, the ultrasound finding is due to gallbladder wall edema. Therefore, multiple processes can create this ultrasonographic and CT finding. There is still a differential to consider when a thickened gallbladder is encountered.

Review of systems was positive for left sided chest pain and two months of abdominal pain with nausea and vomiting. The abdominal pain was associated with eating.

Previous GI workup with upper endoscopy was unremarkable besides reflux esophagitis. Physical exam was notable for lungs with rales bilaterally. Cardiovascular exam was tachycardic, with normal heart sounds. His abdomen was mildly tender in the epigastric region. The patient had no allergies and took atorvastatin, albuterol, apixaban, carvedilol, furosemide, metformin, and Figure 1. Gallbladder wall thickening of 0.46cm omeprazole.

Notable lab work included a non-detectable initial troponin, BNP 3988, non-elevated white blood cell count, bilirubin 2.7, AST 15, ALT 16, and lactate of 2.3. CT of the abdomen showed a markedly distended IVC and hepatic veins consistent with right heart failure. Abdominal ultrasound showed gallbladder sludge with pericholecystic fluid, diffuse “top-normal” gallbladder wall thickening, and no stones.

Surgery was consulted for potential acalculous cholecystitis given the physical exam and ultrasound findings. They evaluated the patient at bedside and believed the thickened gallbladder wall was secondary to the patient’s heart failure. His right sided heart failure likely led to liver congestion and stretching of Glisson’s capsule which resulted in his pain.

They recommended CTA abdomen and HIDA scan to rule out acute acalculous cholecystitis or mesenteric ischemia.

Primary gallbladder inflammation seen in acute, chronic, and acalculous cholecystitis is the classic culprit.2 Other primary gallbladder diseases such as gallbladder carcinoma or adenomyomatosis could also confuse the ultrasonographer.1 As was in our case above, gallbladder thickening can also be attributed to a secondary process. Factors leading to gallbladder wall edema include elevated portal venous pressure, systemic venous pressure, or decreased intravascular osmotic pressure.1 Therefore, pathologic conditions like cirrhosis, hepatitis, and congestive right heart failure can be attributed to the finding.1 In our patient’s case, it was likely secondary to his heart failure with EF of 20%.

Gallbladder wall thickness may return to within normal limits with time or adequate control of the primary etiology.1 It is important to always combine imaging and lab findings with the clinical picture to determine the most appropriate diagnosis. When it comes to the RUQ ultrasound, remember that the differential for gallbladder wall thickening is broader than just cholecystitis. You may save your patient an unneeded trip to the OR.

References 1. van Breda Vriesman, A. C., Engelbrecht, M. R., Smithuis, R. H., & Puylaert, J. B. (2007). Diffuse gallbladder wall thickening: Differential diagnosis. American Journal of Roentgenology, 188(2), 495–501. https:// doi.org/10.2214/ajr.05.1712.

2. Runner, G. J., Corwin, M. T., Siewert, B., & Eisenberg, R. L. (2014).

Gallbladder wall thickening. American Journal of Roentgenology, 202(1). https://doi.org/10.2214/ajr.12.10386.

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Pre-hospital Shortness of Breath Raghav Sahni, DO, Morgan Ritz, MD, and Maxwell Cooper, MD

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hortness of breath, or dyspnea, is a common complaint that can present to an emergency department (ED) caused by an exacerbation of either Congestive Heart Failure (CHF) or Chronic Obstructive Pulmonary Disease (COPD). At our campus over the past 1-year, more than 200 calls were made for shortness of breath with patients having a history of CHF or COPD. In the last year, from February 2019-2020, ten pre-hospital cases were treated for shortness of breath, usually with nebulizer treatments, but were then found to have a CHF exacerbation after ED work-up and were subsequently started on the appropriate treatment of nitrates, diuretics, or non-invasive positive pressure ventilation. A large portion of our population has a history of both CHF and COPD, which can make the pre-hospital treatment of dyspnea more complicated. For example, six different prehospital cases of shortness of breath were diagnosed with both CHF and COPD exacerbations upon ED work up.

Several studies have demonstrated the increased sensitivity and specificity of point-of-care ultrasound (POCUS) in appropriately diagnosing CHF versus COPD. Pulmonary edema in a CHF exacerbation can be identified on ultrasound by B-lines, a comet-tail reverberation artifact.

A two-patient case series in 2010 expanded upon this knowledge and illustrated how pre-hospital POCUS when used by EMS for the chief complaint of shortness of breath could appropriately diagnose and assist in the correct management of the undifferentiated dyspneic patient.

Case A 57-year-old female with a past medical history of CHF and COPD on 2L home oxygen, diabetes mellitus type 2, hypertension, and hyperlipidemia called emergency medical services (EMS) complaining of shortness of breath. Patient described symptoms developing over the past two days with increased lower extremity swelling. Patient noted that she is supposed to be on several medications including furosemide but has not taken it in several days. Patient said she has tried an albuterol inhaler with minimal relief of her symptoms. The patient admitted to being intubated one time in the past for similar symptoms.

On arrival by EMS, the patient was saturating 99% on 2L nasal cannula, blood pressure of 155/90, and respiratory rate of 28. She was sitting upright and leaning forward with increased work of breathing. On auscultation, the patient had diffuse wheezing in all lung fields and bibasilar rales.

The patient had symmetric +2 edema in her lower extremities.

Portable ultrasound exam was performed by a PGY-2 emergency medicine resident in the ambulance during transport. The exam showed more than three B-lines per high-powered field in bilateral anterior and lateral lung fields suggesting pulmonary edema. The exam showed lung

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markings with lung slide in all fields. Portable ultrasound and physical exam findings suggested a multifactorial cause of the patient’s dyspnea, which included suspicion for both CHF and COPD exacerbations with less clinical concern for pneumothorax.

Due to the moderate to severe respiratory distress, the patient was placed on non-invasive positive pressure ventilation (NIPPV). Due to diffuse wheezing, the patient was given ipratropium/albuterol en route.

On arrival to the ED, the patient had improved work of breath with respiratory rate improving to 20 breaths per minute and oxygen saturation of 100% and was transitioned from NIPPV to 2L nasal cannula. The physical exam in the ED was noted as scattered wheezing, diminished breath sounds, and pitting lower extremity edema. Her brain natriuretic peptide (BNP) was 504, correlating with a CHF exacerbation. Her chest x-ray was consistent with pulmonary vascular congestion without pneumothorax. A COVID-19 test was negative.

The patient was treated in the ED for COPD exacerbation with albuterol nebulizers and methylprednisolone and for CHF exacerbation with furosemide. Following treatment, the patient had resolved wheezing and improved work of breathing. She was admitted to the hospital under monitored care for further management of CHF and COPD exacerbations.

Pre-hospital pulmonary ultrasound exam, which showed B-lines, alerted the emergency department care team on arrival that that patient’s symptoms included a component of fluid overload. A bedside ultrasound exam in the ED confirmed B-lines bilaterally in the lungs along with a plethoric IVC and decreased cardiac ejection fraction estimated at 30% using E-point septal separation (EPSS).

CHF and COPD are two common comorbidities that present as shortness of breath. Point-of-care ultrasound is often used in the ED to evaluate for pulmonary edema. Pre-hospital ultrasound exams are theorized to further expedite diagnosis of the etiology of shortness of breath. In this patient’s case that was noncompliant on medications, an ultrasound exam expedited her diagnosis as multifactorial including CHF and COPD exacerbations. In addition, NIPPV and albuterol/ipratropium were appropriately started and improved the patient’s symptoms dramatically enough to be transitioned off CPAP and onto nasal cannula upon arrival.

In other cases, portable ultrasound exams can allow for more accurate medication therapy decisions during transport such as deciding between albuterol/ipratropium, steroids, or nitroglycerin. Further pre-hospital data can provide a more accurate idea of how this practice can become standard of care for EMS providers in the near future.

CRITICAL CARE MEDICINE SECTION

Bougie Conundrum: Airway Adjunct or Secret to 1st Pass Success? Should We Incorporate into Routine Practice and How? Frederick Gmora, DO*, Skyler Lentz, MD FAAEM†, Elias Wan, MD FAAEM‡

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mergency medicine at its purest form is controlled chaos. Apart from the occasional warning of a potential impending disaster, one can never predict who will present next during a hectic clinical shift. The ability to anticipate, strategize, and react rapidly to disasters are essential qualities of the emergency physician or intensivist. Considering emergency airway management, whether it be within the walls of the emergency department or the intensive care unit, there is no exception. The timing of a patient’s last meal, pre-oxygenation status, or mouth full of emesis matters little when they arrive in extremis. Thus, a well-prepared physician will control the chaos by optimizing the conditions to maximize their first pass success rate.

Fortunately, for the majority, the number of exceptionally difficult airways or complex anatomy scenarios only comprise a small percentage of the overall cases of intubations. Overall, emergency physicians successfully intubate >99% of patients in three attempts or less, with an 83% first pass success rate.1 While few desire more daunting challenges, the smaller integer does pose a unique challenge for trainees to gain experience and be prepared for the worse. How do they build their armory of adjuncts for the difficult airway?

Figure 1. Equipment preparation. Macintosh blade Video Laryngoscope Handle (top item) and preloaded ETT with bougie (bottom item).

One adjunct often included in emergency airway preparations is the tracheal tube introducer or bougie. It is a commonly described difficult airway adjunct for failed intubation attempts or poor initial laryngoscopic view. The bougie itself is certainly not new, described by Macintosh in 1949, nonetheless, it remains utilized in only a small fraction of intubations.1,2

However, in the last several years there has been a paradigm shift towards utilizing the bougie as the initial attempt device. The shift is in large due to two papers by Driver and colleagues at Hennepin County Medical Center in Minneapolis, Minnesota. The first study, published in 2017, is a retrospective, observational study which showed higher first pass success with the bougie vs. the more conventional stylet and endotracheal tube (ETT) combination when accounting for confounding variables.3 The Bougie Use in Emergency Airway Management (BEAM) trial was published a year later out of the same emergency department.4 This was a randomized control trial comparing first attempt intubation success with the bougie vs. ETT and stylet with those individuals with difficult airway characteristics. Again, there was a significant increase in first pass success in the bougie arm in those with at least one difficult airway predictor (96% vs. 82%) and in the whole study population (98% vs. 87%).

Notably, the duration of the first intubation attempt and incidence of hypoxemia was not different between the bougie and stylet groups.4 These two studies though are not without their limitations. Most critical for this discussion is related to their generalizability. They were both conducted at a single center which limits their generalizability. Perhaps more notable for the majority of emergency physicians, located outside this center, was their pre-existing comfort with the bougie as a widely used primary method since 1996. >> COMMON SENSE NOVEMBER/DECEMBER 2021

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The two above papers, however, do suggest that the bougie can be considered an alternative to a traditional stylet, without increased risk of adverse events, and potentially higher success in the hands of an experienced operator. In fact, some prehospital studies, meta-analysis, and simulation studies suggest that bougie as first pass device can be superior. The challenge remains on the best way to enhance expertise in a controlled fashion during real-world applications.5,6,7 Proposed is a method that I began employing as a senior resident and have incorporated into my practice for educating trainees during clinical shifts. Begin with a video laryngoscope with a Macintosh blade. The Macintosh blade allows for both direct or video laryngoscopy, if desired, and avoids the challenge of navigating the hyper-angulated blade. The endotracheal tube should be pre-loaded onto the bougie itself before commencing, similar to the ETT and a stylet (Figure 1). The utilization of the video laryngoscope is twofold. First, it allows for direct supervision of the airway operator in real time. Secondly, the trainee can directly visualize the bougie passing through the vocal cords while experiencing the tactile feedback of the tracheal rings.

To build confidence the learner can use the visualization to practice “traditional” blind techniques when intubating with a bougie. One such technique includes rotating the ETT 90° counter clockwise so the tip is vertical when encountering resistance while passing the ETT over the bougie. Another technique is the “hold up sign” to confirm appropriate position in the airway, which is advancing the bougie in a controlled manner till there is gentle resistance due to tip lodging in the small airways, rather than freely advancing in the esophagus, or a maximum of 35 cm. This is likely to be undertaken with a team comprised of a minimum of two clinicians initially (a second clinician to advance the ETT over the bougie once in place), but will eventually allow the person performing the intubation to master various one-handed grips and single person techniques.

The desired endpoint is to gain confidence and expertise in an ideal controlled setting, allowing translation to a substantially more chaotic one.

While the level of evidence does not yet support the removal of stylets from standard airway boxes, Driver and colleagues provide insight to the routine use of a bougie as a safe and effective alternative, with potentially increased first pass success in the hands of a skilled operator. The ability to incorporate routine bougie usage into practice in a safe and effective manner is paramount to obtaining the same first pass success rates in the BEAM Trial.4 Only time will tell if such success can be replicated and generalizable in a prospective multicenter trial by Driver et al.8 Nonetheless, the method described above is one way to safely obtain this expertise and train the next generation of emergency medicine and critical care physicians.

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References Division of Surgical Critical Care, Traumatology, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania; Philadelphia, PA † Division of Emergency Medicine and Pulmonary Diseases & Critical Care Medicine, University of Vermont Medical Center, Burlington, VT ‡ Department of Surgery and Emergency Medicine, Maimonides Medical Center, Brooklyn, NY *

1. Brown CA 3rd, Bair AE, Pallin DJ, Walls RM; NEAR III Investigators.

Techniques, success, and adverse events of emergency department adult intubations [published correction appears in Ann Emerg Med. 2017 May;69(5):540]. Ann Emerg Med. 2015;65(4):363-370.e1. doi:10.1016/j. annemergmed.2014.10.036 2. Macintosh RR. An Aid to Oral Intubation. Br Med J. 1949;1:28 3. Driver B, Dodd K, Klein LR, et al. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med. 2017;70(4):473-478.e1. doi:10.1016/j.annemergmed.2017.04.033 4. Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179-2189. doi:10.1001/ jama.2018.6496 5. Latimer AJ, Harrington B, Counts CR, Ruark K, Maynard C, Watase T, Sayre MR. Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting. Ann Emerg Med. 2021 Mar;77(3):296-304. doi: 10.1016/j.annemergmed.2020.10.016. Epub 2020 Dec 17. PMID: 33342596.

6. Shah KH, Melville LD. Does the Use of a Bougie Improve First-Attempt Intubation Success Compared With a Stylet? Ann Emerg Med. 2020 May;75(5):640-641. doi: 10.1016/j.annemergmed.2019.09.003. Epub 2019 Nov 20. PMID: 31759751.

7. Baker JB, Maskell KF, Matlock AG, Walsh RM, Skinner CG. Comparison of Preloaded Bougie versus Standard Bougie Technique for Endotracheal Intubation in a Cadaveric Model. West J Emerg Med. 2015 Jul;16(4):58893. doi: 10.5811/westjem.2015.4.22857. Epub 2015 Jun 23. PMID: 26265978; PMCID: PMC4530924.

8. Driver B, Semler MW, Self WH, Ginde AA, Gandotra S, Trent SA, Smith LM, Gaillard JP, Page DB, Whitson MR, Vonderhaar DJ, Joffe AM, West JR, Hughes C, Landsperger JS, Howell MP, Russell DW, Gulati S, Bentov I, Mitchell S, Latimer A, Doerschug K, Koppurapu V, Gibbs KW, Wang L, Lindsell CJ, Janz D, Rice TW, Prekker ME, Casey JD; BOUGIE Investigators# and the Pragmatic Critical Care Research Group. BOugie or stylet in patients UnderGoing Intubation Emergently (BOUGIE): protocol and statistical analysis plan for a randomised clinical trial. BMJ Open. 2021 May 25;11(5):e047790. doi: 10.1136/bmjopen-2020-047790.

PMID: 34035106; PMCID: PMC8154972.

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November Board of Directors Meeting Summary

November Board of Directors Meeting Summary The members of the AAEM Board of Directors met in-person and virtually at Newark Liberty International Airport Marriott on November 10, 2021, to discuss current and future activities. The members of the board appreciate and value the work of AAEM committee, section, interest group, and chapter division members and chairs as they strive toward the AAEM mission and to be the specialty society of emergency medicine. Over the course of the meeting, a number of significant decisions and actions were made. Here are the highlights:

Presentations

Approvals

Miscellaneous

President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM presented her President’s report which highlighted the many activities that she and other leaders have been involved in. Highlights of the report included leadership meetings with other emergency medicine organizations, residency visits, and HPEM & Advocacy Day visits.

A number of approvals took place during the meeting including:

In addition, the board approved a redesign of the AAEM website as well as a comprehensive marketing plan to further the goals and mission of AAEM. The redesigned website is scheduled to launch in 2022.

Treasurer Robert Frolichstein, MD FAAEM reported on AAEM and AAEM subsidiaries financial performance through October 31, 2021.

AAEM’s 2022 budget was approved during the meeting. The board also approved the formation of a taskforce to determine the best strategy for investing AAEM’s financial assets.

Please see the AAEM Financial Updates article on page ##. Overall, AAEM remains in a very good financial situation.

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• The CPC Statement on Palliative Care in the ED (“Risk Stratification Tools Febrile Neutropenic Patients”) • Recognition of the Oral Board Examiners • Palliative Care Interest Group is now the Palliative Care Committee • Creation of an online AAEM merchandise store • Expand residency visits to EMEGS without EM residency programs • Creation of a taskforce to explore what new legislation means to AAEM’s PAC • All AAEM Past Presidents will become lifetime members

The Next Board of Directors Meeting When When: February 10, 2022

Where Where: Miami, FL

AAEM Job Bank Service

Promote Your Open Position

To place an ad in the Job Bank: Equitable positions consistent with the Mission Statement of the American Academy of Emergency Medicine and absent of restrictive covenants, will be published (upon approval). All ads run for a six month period or until canceled and will appear in the AAEM member magazine Common Sense and online.

For pricing and more information visit www.aaem.org/membership/benefits/ job-bank.

Positions Available For further information on a particular listing, please use the contact information listed.

Section I: Positions in full compliance with AAEM’s job bank advertising criteria, meaning the practice is wholly-owned by its physicians, with no lay shareholders; the practice is equitable and democratic; due process is guaranteed after a probationary period of no more than one year; there are no post-employment restrictive covenants; and board certified emergency physicians are treated equally, whether they achieved ABEM/AOBEM/RCPSC certification via residency training or the practice track.

Section II: Positions that cannot be in full compliance with AAEM’s job bank criteria, because they are employee positions with hospitals or medical schools and the practice is not owned by its emergency physicians. Thus there may not be financial transparency or political equity.

Complete a Job Bank registration form, along with the Criteria for Advertising Section, and submit payment. If you are an outside recruiting agent, the Job Bank Criteria for Advertising must be downloaded and completed by a representative from the recruiting hospital/group.

Section III: Positions that cannot be in full compliance with AAEM’s job bank criteria, because they are government or military employee positions.

The practice is not owned by its emergency physicians, and there may not be financial transparency or political equity.

Direct all inquiries to: www.aaem.org/membership/benefits/job-bank or email info@aaem.org.

Section IV: Position listings that are independent contractor positions rather than owner-partner or employee positions.

SECTION I: POSITIONS RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK CRITERIA

INDIANA

South Bend Emergency Physicians, Inc. is a stable, democratic, 30 member group seeking additional BC/BE Emergency Physicians. 60K visits, Level II Trauma Center, double, triple and quad physician coverage at Memorial Hospital of South Bend.

We also have single coverage at a 10K visits suburban branch small, acute-care hospital, as well as single coverage at a 4.5K visits critical access hospital about 20 miles from Memorial Hospital. Equal pay, schedule and your voice is heard from day

one. Over 450K total package with qualified retirement plan; group health plan and disability insurance, CME reimbursement, etc. Favorable Indiana malpractice environment. University town, low cost of living, good schools, 90 minutes to Chicago, 40 minutes to Lake Michigan. Teaching opportunities at four year medical school and with the hospital FP residency program.

Contact Jennifer Burks, Practice Manager, jburks2@r1rcm.com (PA 1859)

SECTION II: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are hospitals, non-profit or medical school employed positions.)

LOUISIANA

Emergency Medicine Physicians The Department of Emergency Medicine at Ochsner Medical Center in New Orleans, Louisiana is a well-established department that sees 75,000+ visits/year as a tertiary referral center for the larger Ochsner Health System.

The department welcomed its first class of Emergency Medicine Residents in 2020 and also has seen continued rapid growth in the clinical enterprise. The department is in search of American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certified/eligible physicians, preferably with fellowship/additional niche training, who can further grow the diversity of excellence within the academic department.

Interested applicants should send Cover Letter / Curriculum Vitae to the Department Chair, Nicole McCoin, MD, at nicole. mccoin@ochsner.org. (PA 1863) Email: morgan.aymond@ochsner.org Website: https://ochsner.wd1.myworkdayjobs.com/en-US/ OchsnerPhysician/job/New-Orleans---New-Orleans-Region--Louisiana/Physician--Emergency-Medicine--All-Regions_ REQ_00022121

NEW JERSEY

The Department of Emergency Medicine at Rutgers New Jersey Medical School is recruiting a board-certified emergency physician and medical toxicologist as Director of our Medical Toxicology Fellowship. The fully-accredited training program is integrated with both our inpatient and outpatient consultation services as well our Poison Control Center. We are committed to developing a diverse faculty. Applicants should have a desire for advancing clinical, educational, academic, and administrative excellence. The ideal candidate is committed to engaging in opportunities for scholarship and collaboration. Three years or more as a core faculty member in an ACGME-accredited medical toxicology program is required. (PA 1869) Email: rosanian@njms.rutgers.edu Website: https://njms.rutgers.edu/departments/emergency_ medicine/

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NEW JERSEY

The Department of Emergency Medicine at Rutgers New Jersey Medical School is actively recruiting talented Emergency Physicians interested in clinical education and professional growth opportunities. We are home to an enthusiastic and diverse group of emergency physicians who are committed to education, scholarship, research, service, and outstanding clinical care. We are committed to fostering a diverse and inclusive faculty. Applicants should have a desire for clinical, educational, or academic advancement. The ideal candidate is committed to engaging in the numerous opportunities for professional development that the department and institution offer, while sharing our commitment to inclusive excellence. (PA 1870) Email: rosanian@njms.rutgers.edu Website: https://njms.rutgers.edu/departments/emergency_ medicine/

NORTH CAROLINA

Wake Forest Emergency Providers is currently seeking to add to our team of exceptional patient-centered emergency physicians due to expansion and growth resulting from our joining together with Atrium Health as a single enterprise. Opportunities exist in Central/Western NC, as well as Charlotte, NC, beginning as early as November 2021. We are open to experienced emergency medicine residency trained physicians as well as recent graduates for these positions. Wake Forest Emergency Providers offers a unique employment model inclusive of comprehensive benefits, local influence on practice decisions, and a strong provider voice in care delivery. (PA 1866) Email: michael.ginsberg@wakehealth.edu Website: http://www.wakehealth.edu

NORTH CAROLINA

Wake Forest School of Medicine’s Department of Emergency Medicine has a rare opportunity to join our academic faculty team as an Assistant or Associate Professor in a position with a scholarly focus on Emergency Medicine Diversity, Equity, and Inclusion. This position will be an integral part of our ongoing EM departmental diversity and inclusion initiatives and the successful candidate will take over leadership of our active DEI committee. There are additional opportunities to participate and lead new and ongoing initiatives that will impact patient care in our local community and throughout our learning healthcare system with Atrium Health. (PA 1867) Email: michael.ginsberg@wakehealth.edu Website: http://www.wakehealth.edu

WEST VIRGINIA

The Charleston Area Medical Center, Department of Emergency Medicine is seeking a pediatric emergency medicine physician to work at Women and Children’s Hospital located in Charleston, WV. This 120-bed dedicated Women and Children’s Hospital is a part of a large university-affiliated regional referral center with a drawing population of 562,000. We have in-house Neonatologist with 24/7 coverage in Level III NICU as well as a PICU with pediatric intensivists. Job Requirements by the time of appointment: • MD, DO degree or foreign equivalent degree from an accredited pediatric emergency medicine fellowship program • Board Certification by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine • Eligible for WV Medical License. Benefits include: • Excellent benefits package with generous PTO • Vibrant community • Superb family environment • Unsurpassed recreational activities • Outstanding school systems. To apply, send your CV to carol.wamsley@camc.org. (PA 1860) Email: carol.wamsley@camc.org Website: http://www.camc.org

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SECTION III: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are military/government employed positions.)

None Available at this time.

SECTION IV: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are independent contractor positions.)

CALIFORNIA

PHYSICIAN - PEDIATRIC ORTHOPAEDIC URGENT CARE CENTER (Los Angeles) SUMMARY: Under the general supervision of the Urgent Care Medical Director, coordinates and delivers the care of pediatric patients in the outpatient and the urgent care settings managing acute, chronic, surgical and congenital musculoskeletal conditions. The Physician is responsible for providing musculoskeletal care in the urgent care setting, including fracture treatment. REQUIRED QUALIFICATIONS: • Graduated from an accredited medical school and residency program AND have a current unrestricted valid license to practice medicine in the State of California, including DEA license. • Fluoroscopy X-Ray Supervisor and Operator Certificate, issued by the California Department of Public Health. • Must be comfortable seeing pediatric patients who are between the ages of 2 and 18 years of age. •ACLS/ PALS certified (PA 1872) Email: mrpeters@mednet.ucla.edu Website: https://workforcenow.adp.com/mascsr/default/mdf/ recruitment/recruitment.html?cid=1fe50326-beac-4a7c-a564-f8 a14f9c5bb0&ccId=19000101_000001&jobId=412173&lang= en_US&source=CC4

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Membership Categories Fellow and Full Voting – FAAEM Dues: $525 Board certified in emergency medicine or pediatric emergency medicine

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

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

International Member 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.

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

Emeritus Member Dues: $250 Full voting member who has practiced emergency medicine for 30 or more years and has been a full voting member for a minimum of 10 years -or- at least 65 years of age and have been a full voting member for a minimum of 10 years Special circumstances may lead to a request for emeritus membership and will be reviewed on a case-by-case basis. See www.aaem.org/membership for more information.

Member Benefits Publications

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

Free subscriptions to the Journal of Emergency Medicine and Common Sense

Group Membership

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

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

Members-Only Section

Criteria: All board certified and board eligible physicians at your hospital/ group must be members

Access the AAEM Job Bank, your Advanced Resuscitation Expertise Card (for Full Voting members), and other academic and career-based benefits Learn more about these and other member benefits at www.aaem.org/membership/benefits American Academy of Emergency Medicine 555 East Wells Street, Suite 1100, Milwaukee, WI 53202-3823 (800) 884-2236 info@aaem.org www.aaem.org

100% ED Group Membership Discount: 10% discount on membership dues

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

Join Today! www.aaem.org/membership COMMON SENSE SEPTEMBER/OCTOBER 2021 COMMON SENSE NOVEMBER/DECEMBER 2021

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

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

28 TH ANNUAL SCIENTIFIC ASSEMBLY Register Today for #AAEM22! aaem.org/aaem22