President
Jonathan S. Jones, MD FAAEM
President-Elect
Robert Frolichstein, MD FAAEM
Secretary-Treasurer
L.E. Gomez, MD MBA FAAEM
Immediate Past President
Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
Past Presidents Council Representative
William T. Durkin, Jr., MD MBA MAAEM FAAEM
Board of Directors
Kimberly M. Brown, MD MPH FAAEM
Phillip A. Dixon, MD MBA MPH FAAEM CHCQMPHYADV
Al O. Giwa, LLB MD MBA MBE FAAEM
Robert P. Lam, MD FAAEM
Bruce Lo, MD MBA RDMS FAAEM
Vicki Norton, MD FAAEM
Carol Pak-Teng, MD FAAEM
Kraftin Schreyer, MD MBA FAAEM
YPS Director
Fred E. Kency, Jr., MD FAAEM
AAEM/RSA President
Leah Colucci, MD MS
Editor, JEM
Ex-Officio Board Member
Stephen R. Hayden, MD FAAEM
Editor, Common Sense
Ex-Officio Board Member Andy Mayer, MD FAAEM
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
Alessandra Della Porta, MD, 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.
President’s Message: An Academy, If You Can Keep It 3 Editor’s Message: The Agency Trap 7 Heart of a Doctor: Heart of a Loved One 13 AAEM/RSA President’s Message: My Specialty of Choice 33 AAEM/RSA Editor’s Message: Let’s Make a Deal: What Physicians Can Learn from Hostage Negotiators 34 Medical Student Council Chair’s Message: Tips and Pearls for a Successful Interview Season 36 Letter to the Editor 9 Foundation Contributions 10 PAC Contributions 11 LEAD-EM Contributions 12 Upcoming Conferences 12 Board of Directors Meeting Summary: September 47 AAEM Job Bank 48
Operations Management Committee: Addressing Psychiatric Boarding within the Emergency Department 15 Ethics Committee: Respect for Autonomy 17 Wellness Committee: Why Emergency Medicine, #StopTheStigmaEM, and the Future of our Specialty 19 A Tennessee Physician Advocates for Change to Abortion Laws ...............................................21 Women in Emergency Medicine Section: Imposter Syndrome .......................................................22 Social EM & Population Health Committee: Championing U.S.-Mexico Border Partnerships and Collaboration through Point-of-Care Ultrasound Education: An Interview with Eva Tovar Hirashima, MD MPH 24 Emergency Ultrasound Section: PA and NP Use of POCUS in the ED 27 Critical Care Medicine Section: Critical Care Education: How Early is Too Early? Part Two: A Follow-Up on the Novel “AAEM/RSA Introduction to Critical Care in Emergency Medicine” Curriculum 28
Interview with Sara Heinert, PhD MPH 30 Justice, Equity, Diversity, and Inclusion Section: Back to the Business at Hand! 32 Emergency Ultrasound Section: Regional Hands-On Ultrasound Course 37 Good Microbes Gone Bad: A Case Report of Meningitis from Commensal Oral Bacteria 38 Post-Intubation Sedation in the Emergency Department: Bridging the Gap between ED and ICU Sedation .......................................................................................................................................40
Resident Journal Review: What is the Ideal Anticoagulant for Malignancy-Related Venous Thromboembolism? 43
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, regardless of race, ethnicity, sexual identity or orientation, religion, age, socioeconomic or immigration status, physical or mental disability must have unencumbered access to quality emergency care.
2. The practice of emergency medicine is best conducted by a physician who is board certified or eligible by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).
3. The Academy is committed to the personal and professional well-being of every emergency physician which must include fair and equitable practice environments and due process.
4. The Academy supports residency programs and graduate medical education free of harassment or discrimination, which are essential to the continued enrichment of emergency medicine, and to ensure a high quality of care for the patient.
5. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members.
6. 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.
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, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org
Jonathan S. Jones, MD FAAEM
An Academy, if you can keep it.
In my last article, I dis cussed the purpose of academies in general and of ours in particular. I am glad that we have an Academy. But how long will we have it?
Is emergency medicine in a crisis? Probably. But it also seems to me that most everything is in crisis now. War in Ukraine, nuclear weapons in Iran and North Korea, inflation, global warming, partisanship, and the fact that one day
limited, it is fascinating talking to our founders about this period. Challenges were made to the legitimacy of residency training and board certification. The exploitation of emergency medicine physicians was growing exponentially. Even the specialty societies tasked with de fending the specialty of emergency medicine were failing and actively subverting the interests of individual residency trained, board certified, EM physicians.1
For true EM physicians at that time, it was a crisis. And while crises don’t make visionaries or leaders, they sure help differentiate true
stronger than ever.
The first step is understanding a bit of history. That’s why I wrote these first few paragraphs. If I don’t understand the environment in which the Academy was formed and the purposes for which it was formed, it will be hard for me to be a good steward. That is not to say that the goals now are the same as the goals 30 years ago. No, some goals’ importance fades away while other new ones rise to prominence. And hopefully some goals get accomplished and checked off the list. But the thought process, the impetus behind the goals, and the reasons those goals were set 30 years ago should likely remain unchanged or minimally changed. And if you haven’t surmised from some of my com ments in previous reports or my paraphrasing of Benjamin Franklin to start this column, I find history quite interesting in general.
recently the school lunch was supposed to be pancakes, but they did tacos instead. For some reason, my daughter most definitely does not like tacos. I don’t add the last remark to belittle the preceding issues, but rather to suggest that a crisis is subjective.
Just over 30 years ago, I think emergency med icine was in a crisis. EM residency programs had been founded, the American Board of Emergency Medicine (ABEM) was adminis tering exams, and in 1982 the Accreditation Council for Graduate Medical Education (ACGME) approved specialty requirements for residency training in emergency medicine. This all sounds great and the opposite of crisis. But there were problems. And while my direct knowledge of the situation in the early 80s is
leaders and hone their skills. Luckily, almost 30 years ago (next year, 2023, will be our 30th anniversary), there were leaders and they were brave enough to found the American Academy of Emergency Medicine. They saw a problem and determined the best way to address the problem was to reorganize and form the Academy to be the Champion of the Emergency Physician. We are all reaping the benefits of their action. But now it’s on us to keep the Academy. I suppose the pressure is most specifically on me as President and on our Board. My last few columns discussed ac tions the Academy can do to improve EM for all of us. Now I focus on how we actually improve the Academy and ensure that we’ll not just be around for another 30 years, but that we will be
The second step is reading and contemplat ing on the official Vision and Mission of the Academy. Ours can easily be found online or on the inside front cover of every issue of Common Sense. We currently list six specific items in our Mission. And while they may be listed somewhat based on priority, each one is vitally important. We recently updated our Mission Statement and formally changed it during a Board meeting at AAEM22 in Baltimore. Significant work went into examin ing and updating the statement. Wisely and with full Board support, my predecessor as President, Dr. Lisa Moreno, appointed a task force to study and examine the issue over several months. She and I both served on this task force. Why did she ask so many people to spend so much time examining one statement? Because updates to the Mission should not be taken lightly. The changes made were vitally im portant, but also relatively minor or incremental. This is not contradictory, rather it was deliber ate. For what good is a Mission if wholesale changes are quickly made? To me, that would have been the definition of those tasked with ensuring the success of the Academy of not “keeping it.”
>> BUT AS DANGEROUS AS MAKING SWEEPING CHANGES WOULD BE, SINGLEMINDED OR ABSOLUTE DEVOTION TO ANY ONE SINGLE ASPECT OF THE MISSION IS ALSO DANGEROUS.
But as dangerous as making sweeping chang es would be, single-minded or absolute devo tion to any one single aspect of the Mission is also dangerous. While each one of us values each of the six pillars of our Mission differently, we must support them all. As President, one of the most difficult challenges I have faced is defending the Academy as a whole from being subsumed by any one single special interest. Seeing, hearing, and experiencing some of our member’s incredible passion for certain as pects of emergency medicine is enthralling. But while I am excited by passion, it is my duty as President to at times check that passion if it en dangers the Academy as a whole. For example, we are not the Academy of Emergency Access, nor the Academy of Physician Wellness, nor the Academy of Diversity, nor the Academy of Emergency Education, nor the Academy of International Emergency Medicine. We are the Academy of Emergency Medicine. We stand for all of the above so long as they don’t interfere with our ability to accomplish initiatives in any of the others. This is nuanced, subjective, and difficult, and in my opinion, is the primary duty of the President, and it weighs on me heavily.
Now that we have an Academy, “keeping it” is not just the duty of the President, the Board, or the committee chairs. Every member has an obligation to help “keep it.” Fulfilling that obligation is best accomplished by being active in the Academy. Sure, we don’t mind that much if someone just pays their dues and then never does anything, but that actually does not help the Academy very much. While there are many ways to be active, for this column, I want to focus not on committee involvement, rather on attention to leadership and direction. While the Board of Directors is tasked with leading the Academy, the Board is fully and directly respon sible to every member. Unlike the vast majority of medical societies, the at-large Board posi tions as well as all Officer positions are directly and democratically elected by members. So…
Do you vote?
Did you vote last year? And the year prior?
Do you know how to vote?
Do you know the requirements to vote? To run for any position?
And slightly different, but perhaps more important…
Did you know the platforms and agendas of each candidate running last year?
Do you know how the current Board members and officers represent the Academy?
If the answers to all of those are yes, then you may actually be doing better than I am. (Well, I have at least voted in every single election since I became a full member, and I have also selfishly voted for myself every time I had the opportunity.) But going back to the above ques tions, I suspect there will be many answers in the negative. Why is this and how do we fix it?
I view the situation similarly to how at times patients don’t do exactly what we as their physician would like them to. Why? The cynics blame lazy patients. But in my experience, I have seen very, very few lazy patients. I have seen patients who don’t know that hypertension is the same as high blood pressure, patients who can’t afford their prescriptions, patients who can’t make the follow-up appointment be cause they were the sole caregiver for a child or elder, and so on. Just as the solution to ensure better medical compliance isn’t criticizing the patient, so the solution to ensuring better Academy leadership isn’t criticizing members.
Possible solutions, among many others, may be to: make voting easier (but still secure and accurate), advertise pertinent Academy policies pertaining to elections, encourage more can didates, ensure member access to candidates
prior to elections, clearly publicize candidates’ statements as well as answers to pre-set questions, increase communication from sitting Board members and officers, and increase town-hall style opportunities to engage with Board members and officers.
This can all be done. And we are working towards some of this already. The PastPresidents’ Council as well as the Women in Emergency Medicine Section have spearheaded some excellent recent improvements to the elections process. In an attempt to build on their progress, several months ago, I appointed an Elections Task Force chaired by Dr. Bruce Lo to examine the state of our elections and suggest possible improvements. Work is pro gressing well and should dramatically improve the election process.
Ultimately though, the Academy needs you. The Academy needs each and every one of us. I need you. I need you to engage with our new election initiatives. I need you to learn about each candidate. Before and during candidate forums, I need you to ask questions, hard ques tions. I need you to follow-up after the elections to check-in and ensure that, once elected, we are doing what we said we’d do.
More important that any of that, I need you to run. I need you to be a candidate. Yes, it is difficult, but also enormously rewarding. It can also be a bit intimidating, but it needn’t be. I can help, all of the Board can help. Staff can help. But still, why should you run? Maybe you’re not
>> JUST AS THE SOLUTION TO ENSURE BETTER MEDICAL COMPLIANCE ISN’T CRITICIZING THE PATIENT, SO THE SOLUTION TO ENSURING BETTER ACADEMY LEADERSHIP ISN’T CRITICIZING MEMBERS.
a committee chair, or you’re still relatively new to the Academy, or you’re unsure if you have anything valuable to offer. None of those matter. Think of being a candidate like how most of us (OK, at least my generation) were taught about doing a lumbar puncture, which went something like, “If you think the patient may need an LP, then they do need an LP.” Well, if you think you may run for the Board, even if only to think of reasons why you shouldn’t, well, it’s been decided, you should run for the board (unless of course you’d rather have an LP).
A Republic, if you can keep it.
An interesting aspect of the English language is that the singular and plural of the second-person pronoun is the same, you. When Benjamin Franklin uttered that reply, I think he was both referring to the citizenry as a whole as well as to individuals. While no individual can accomplish nearly as much as a group, no group can accomplish anything without the dedication of individuals.
You have an Academy. Can you keep it?
1. For more in depth discussion, see “History | AAEM - American Academy of Emergency Medicine” at aaem.org/about-us/our-values/history, and please also review the 1994 Macy Foundation Report “The Role of Emergency Medicine in the Future of American Medical Care.”
AAEM was established in 1993 to promote fair and equitable practice environments necessary to allow emergency physicians to deliver the highest quality of patient care. AAEM later established the AAEM Foundation to defend the rights of such care and the emergency physicians who provide it.
Recently, AAEM-Physician Group, a subsidiary of the American Academy of Emergency Medicine (AAEM), filed suit in the Superior Court of California against Envision Healthcare Corporation to avoid a takeover of an emergency department contract that was held by and independent group. Issues at stake include lay influence over the patient-physician relationship, control of the fees charged, prohibited remuneration for referrals, and unfair restraint of the practice of a profession. Our specialty is in crisis. We cannot let these practices continue here and across the country. AAEM
nless your hospi tal is extremely unusual, you have been dealing with the wave after wave of agency nurses coming through your emer gency department and the rest of your hospital. Nurses are desperately needed everywhere and they seem to have disappeared. The bid ding war of incentive pay, sign on bonuses, and other means of attracting nurses to our hospitals has reached insane levels and yet has not produced the number of nurses needed to staff our hospitals. Many hospitals have closed beds due to understaffing and surgeries are delayed. The level of patient boarding in emergency de partments is untenable. Every hospital adminis trator is frantically trying to scour the Earth trying to find any available nurse. Nursing short ages are not new but it seems Covid has pushed us over the brink to a new and unsus tainable level.
American health care goes through cycles of an adequate supplies of nurses to times like now of extreme shortages. This current cycle seems different to me as more and more nurses are opting out of bedside care. Is this just Covid? Certainly, no one can blame an older nurse with health issues from deciding not to go into the Covid pit. Many nurses, especially more seasoned ones have decided to fill one of the ever-expanding number of quality and adminis trative jobs which have bloated modern health care. More and more of our experienced middle and late career nurses leave clinical nursing for the allure of regular hours and no bedside care. Their work product instead of direct pa tient care is meeting attendance and reports which closely monitor compliance with the ever increasingly burdensome quality and patient satisfaction requirements. Their efforts validate their salaries as they continue to bludgeon the few remaining bedside nurses into submission. I believe that instead of improving quality these nurses have helped lead to the highest levels of dissatisfaction with clinical nursing which I have ever seen.
UAlso, many of our best and brightest new nurses quickly decide to go to one of the plethora of often online nurse practitioner programs further depleting the supply of experienced nurses. Nursing schools are also in trouble due to a lack of an adequate number of faculty. The rapidly rising salaries for travel and agency nurses have depleted nursing school faculties preventing many from increasing nursing school class sizes even though they are desperately needed. This combination of threats to our nursing labor supply has pushed us to the brink.
Hospitals cannot pay a big enough sign on bonus to attract an adequate number of regular nursing staff. Brand new nursing school graduates are bid over and can work almost anywhere they chose. Any rules about new graduates needing experi ence before working in an emergency department or critical care setting have been discarded as almost any warm body who can click on a mouse in your electronic medical record will do. Hospital administrators are often left with no choice but to pay whatever a nursing agency asks to provide nurses to the hospital. No concern can be considered related to what hospital is losing this nurse used to fill the gap in your hospital’s schedule. This same nurse will be recruited to another hospital when their contract is up perpetuating the arms race which is the current state of American nursing recruitment.
The expanding use of agency nurses has been a catalyst for a further worsening of the already low morale of the remaining full-time nursing staff. Remember that these nurses have lived through Covid and were the ones who spent the most time in the rooms with the sick and dying Covid patients. They were the
ones most frequently helping the dying say goodbye to their families who were not allowed in the room let alone the hospital during Covid. During all of this, they had been required to stretch their nurse to patient ratios to frequently unsustainable and unsafe levels. These same nurses have also been hit with call-offs and less scheduled shifts during Covid when patient volumes have plummeted and were then later asked to work multiple overtime shifts when the
next surge arrived. Does anyone fault any of these nurses for leaving nursing or chasing the agency money?
I have seen wonderful long term skilled and dedicated nurses become totally disillusioned when they are forced to work with agency nurses. Like all groups of people, the range of skills and dedication of agency nurses runs all over the spectrum. Some are wonderful and remind me of military family members who are used to moving to new places and quickly fitting in and learning the ropes. They quickly become part of your team and then one day they have disappeared and are replaced by a new face. On the other end of this quality spectrum, there are many who are simply chas ing a big paycheck and have little interest in joining even temporarily your care team. Every nurse like every person has a unique story as
>> WE WORRY ABOUT OUR WELLNESS AND BURNOUT AS EMERGENCY PHYSICIANS BUT NURSING NEEDS HELP NOW."
to why they are willing and able to chase the travel and agency money. Some are young and love seeing new places and delight in having a much higher income than they ever expected out of nursing. No one can blame them for this. However, some of these nurses will endlessly ask how things are done. They cannot be blamed for not knowing when supplies are lo cated or how a specific process is done at your hospital. Who do they ask but your tired over worked and burned out nurse who never left?
The remaining battle hardened full time nurses who have survived Covid and are dedicated to your facility are left holding the bag. They are required to answer the endless questions from the endless parade of agency nurses passing through your department. Also, when times are tough, we as physicians go to our experienced nurses for help because we can trust them to get things done. How would you feel in this situation? They know that our patients are sick and need nursing and they pitch in for the good of the patient and the department. At the same
time, while they are frantically working usually without lunch or a break, they know that the agency nurse that they are stretching to help is making twice as much as they are at that moment.
We worry about our wellness and burnout as emergency phy sicians but nursing needs help now. How do we stop this unsustainable process where nurses from one state go to another to work for an agency while their nurses come to your state? Hospitals will not be able to sustain this level of expenditure on staffing. How do we attract new nurses and keep the ones we have from leaving the field? Money does not seem to be the answer. Nurses willing to work could work every day if they wanted and make a huge paycheck.
What are possible solutions to this crisis? I think that a hospital must make their nurses feel special and make them feel that they are a part of a team. They cannot be begged to work one week and then called off for work the next. These nurses are people with families who have bills and expenses which cannot be met if suddenly their ability to work is endangered. Our nurses need to know they have stability and support. They want lunch and scheduled breaks. They want security to protect them from dangerous and frightening patients. Our nurses are willing to pitch in and work extremely hard
when a particular shift calls for it. However, they cannot be expected to work short every day without lunch while working beside nurses who are making double their pay. An administrator bringing a cookie or a T-shirt to them will not endear them to your hospital. Also, nursing administrations demanding higher patient satisfaction scores does not help. Administrators already know that the way to make patients happy is by seeing them promptly and admitting or discharging them within reasonable times. Administrators yelling at nurses for low satisfac tion scores when they are caring for four board ing nursing home patients or violent psychiatric patients waiting days for placement will not be any more fruitful than yelling at the physicians. Nurses need our respect and support.
What ideas do people have to fix or at least slow down this crisis? I am a free market cap italist at heart but the market forces currently driving nursing are pushing health care off of a cliff. Something drastic needs to be done. The federal government has used executive orders to produce baby formula and ventilators. Could the federal government use its powers to staff our hospitals with an adequate number of nurses? I believe that this is a real national crisis and that action needs to take place. Could the Defense Production Act play a role in regulating nursing? I am sure many people would hate this idea and think that we need to let Adam Smith’s “invisible hand” guide the market for nurses. I certainly see this argument but I also see the weariness in our nurse’s eyes every time I start a shift. If someone does not intervene in some way, our situation will only worsen. What do you propose?
>> I AM A FREE MARKET CAPITALIST AT HEART BUT THE MARKET FORCES CURRENTLY DRIVING NURSING ARE PUSHING HEALTH CARE OFF OF A CLIFF.
Bravo, President Jones. Your summer message was a great read. I want to add a hospital marketing experience I had. I once worked in the emergency department of a “boutique” hospital that advertised its emergency room doctors as being all board certified. This statement was made in writing and on TV. I was the only emergency medicine trained physician on staff. The others were all family practice trained. When one of them did not want to renew his family practice board certification, he was told he just had to be board certified in any medical profession so he became board certified in urgent care medicine. The hospital continued to maintain that all of its ED physicians were board certified.
Tony D. Anthony B. DeMond, MD MAAEM, RetiredFellow 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 Dues: $150 Physicians with an interest in emergency medicine who practice outside of the United States or Canada Emeritus Member
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.
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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
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.
Learn more and join today at: www.aaem.org/membership
AAEM offers group memberships to allow hospitals/groups to pay for the memberships of all their EM board certified & board eligible physicians.
100% ED Group Membership Criteria: All board certified and board eligible physicians at your hospital/group must be members
Discount: 10% discount on membership dues
ED Group Membership
Criteria: Two-thirds of all board certified and board eligible physicians at your hospital/ group must be members
Discount: 5% discount on membership dues
For group memberships, AAEM will invoice the group directly. If you are interested in learning more about the benefits of belonging to an AAEM ED group, please contact us at info@aaem.org or (800) 884-2236.
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.
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 1/1/22 to 10/31/22
Contributions $1000 and above
Anisha Malhotra, MD
John V. Murray, MD FAAEM
Jonathan S. Jones, MD FAAEM
Megan Long, MD FAAEM
Nathan J. McNeil, MD FAAEM
Peter G. Anderson, MD FAAEM
Timothy E. Korber, MD FAAEM
William A. Berk, MD FAAEM
Contributions $500-$999
Bret M. Birrer, MD FAAEM
David A. Farcy, MD MAAEM FAAEM
FCCM
David E. Ramos, MD FAAEM
Kathleen P. Kelly, MD FAAEM
Lillian Oshva, MD FAAEM
Mark Reiter, MD MBA MAAEM FAAEM
Philip Beattie, MD FAAEM
Vladana Aleman
Contributions $250-$499
Alex Flaxman, MD MSE
Alexander Riss, DO FAAEM
Algis J. Baliunas, MD FAAEM
Allison Zanaboni, MD FAAEM
Andy Walker, MD MAAEM
Azalea Saemi, MD FAAEM
Benjamin J. Ricke, MD FAAEM
Bradley Judson, MD FAAEM
Bruce E. Lohman, MD FAAEM
Bryan K. Miksanek, MD FAAEM
Charles Chris Mickelson, MD FAAEM
Daniel F. Danzl, MD MAAEM
Daniel Nelson, MD FAAEM
David Thomas Williams, MD FAAEM
Deborah D. Fletcher, MD FAAEM
Domenic F. Coletta Jr., MD FAAEM
Douglas W. McFarland, MD FAAEM
Eric D. Lucas, MD FAAEM
Eric W. Brader, MD FAAEM
Frosso Adamakos, MD FACEP FAAEM
James W. Small, MD FAAEM
Jamie Kuo, MD FAAEM
Jason Reaves, MD FAAEM
John H. Kelsey, MD FAAEM
John R. Matjucha, MD FAAEM
Joseph W. Raziano, MD FAAEM
Justin Barrett Williams, MD FAAEM
Larry D. Weiss, MD JD MAAEM FAAEM
Michael Luszczak, DO FAAEM
Peter B. Mishky, MD FAAEM
Phillip L. Rice Jr., MD FAAEM
Robert Hanrahan, MD
Ron Koury, DO FAAEM
Sahibzadah M. Ihsanullah, MD FAAEM
Teresa Camp-Rogers, MD MS FAAEM
Contributions $100-$249
Allen L. Roberts, MD FAAEM
Allie Min, MD FAAEM
Amanda Dinsmore, FAAEM
Ann Loudermilk, MD FAAEM
Anthony J. Callisto, MD FAAEM
Anthony R. Rosania III, MD FAAEM
Arjun Banerjee, MD
Brent R. King, MD FAAEM FACEP FAAP
Brian R. Potts, MD MBA FAAEM
Bryan Beaver, MD FAAEM
Bunmi Olarewaju, DO FAAEM
Carlos F. Garcia-Gubern, MD FAAEM
Catherine V. Perry, MD FAAEM
Chaiya Laoteppitaks, MD FAAEM
Christopher F. Tana, FAAEM
Clayton J. Overton III, MD MPH MSPH
FAAEM
Clayton Ludlow, DO FAAEM
Dan M. Mayer, MD FAAEM, FACEP
Daniel S. Medina, DO
Darin E. Neven, MD FAAEM
David W. Kelton, MD FAAEM
David W. Lawhorn, MD MAAEM
Donald L. Slack, MD FAAEM
Elizabeth C. Ritz, MD FAAEM
Eric J. Muehlbauer, MJ CAE
Eric S. Kenley, MD FAAEM
Floyd W. Hartsell, MD FAAEM
Fred Earl Kency Jr., MD FAAEM FACEP
Gary M. Gaddis, MD PhD MAAEM
FAAEM FIFEM
Gayle Galletta, MD FAAEM
Heather M. Mezzadra, MD FAAEM
Holly A. Gardner, MD FAAEM
Ian R. Symons, MD FAAEM
Isaac A. Odudu, MD FAAEM
James A. Pfaff, MD FAAEM
James G. Sowards, MD FAAEM
James R. Gill, MD MBA FAAEM
James Webley, MD FAAEM
Jamie J. Adamski, DO FAAEM
Jeffrey A. Rey, MD FAAEM
Jeffrey John Glinski, MD FAAEM
Jorge L. Infante, MD FAAEM
Joshua A. Pruitt, MD FAAEM CMTE
Julia D. Whiting, MD FAAEM
Julianne Wysocki Broadwater, DO FAAEM
Justin P. Anderson, MD FAAEM
Karl A. Nibbelink, MD FAAEM
Kathleen Hayward, MD FAAEM
Kathryn Getzewich, MD FAAEM
Kathryn Kirsch, MD, FAAEM
Kevin S. Barlotta, MD FAAEM
Kraftin E. Schreyer, MD MBA FAAEM
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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.
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Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the differ ent levels of contributions. The PAC would like to thank the individuals below who contributed from 1/1/22 to 10/31/22
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The AAEM Institute for Leadership, Education & Advancement in the Development of Emergency Medicine, Inc. (LEAD-EM) was estab lished after the tragic and unexpected death of AAEM president, Dr. Kevin G. Rodgers.
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AAEM is featuring the following upcoming conferences and activities for your consideration. For a complete listing of upcoming conferences and other meetings, please visit: aaem.org/education/events
November 30 and December 1, 2022
Virtual Oral Board Review Courses aaem.org/education/events/oral-boards
April 21-25, 2023
29th Annual Scientific Assembly (New Orleans, LA) www.aaem.org/aaem23
Unmute Your Probe: Virtual Ultrasound Webinar Series
Jointly provided by EUS-AAEM aaem.org/eus
Spanish Education Series* – Jointly provided by the AAEM International Committee https://www.aaem.org/get-involved/committees/committee-groups/ international/spanish-education-series
December 7-10, 2022
Emirates Society of Emergency Medicine Conference 2022 (ESEM22)* (Abu Dhabi, United Arab Emirates) https://esemconference.ae
*CME not available
My parents grew up in Southern India in middle class families that loved and cherished them. They studied in a punishing educational environment, where dreams had to be solidified by high school and one poor grade on a standardized exam was all it took to change a course of a young learner’s career. While in their youth, they dreamt of being physicians—of being healers and scientists—but as life would have it, they ended up pursuing other careers.
My father’s dream was cut short with an accidental nick on a frog’s aorta during dissection for an anatomy exam. My mother’s dream lost marks when a final exam she took in high school while feeling under the weather went awry. Yet, their love and respect for medicine never extinguished and they ended up passing it along to me.
Me? I stumbled into medicine because I loved working with people in their greatest time of need. To this day, I enjoy the fact that being a physician also means being a guide and educator for my patients and their loved ones. Though exercising empathy in understanding our patients’ and their loved ones’ experiences can be emotionally challenging, I have always thought of it as a blessing and a privilege.
Appropriately, however, it is universally acknowledged that the emo tional labor of being a physician is nowhere near as taxing as that of being a loved one caring for an acutely ill patient. For a daugh ter, son, grandchild, partner, or sibling, time stops a little when a family member becomes acutely ill. Priorities become a constant struggle, with work, emotional exhaustion, and other relatives demanding time that could be spent with their sick family member. When a patient is hospital ized, loved ones who live nearby move into the hospital with them. Those who live further away have their phones nearby at all times, wondering if the next phone call will give them hope or crush their hearts.
The emotional challenges of being a physician who is also the loved one of an ailing patient are unique. On one hand, as a physician, I know the odds—I understand logically how likely a family member is to have a good or poor quality of life given their clinical scenario. I understand how important it is to uphold their wishes and make decisions that would mirror what they would have wanted for themselves. However, knowing what may be best for a family member can fly directly in the face of what I wish would happen for them instead as a loved one.
As the only physician in my immediate family, I have always joked that my parents, grandparents, aunts, and uncles would call me for advice on any little thing that went wrong. I enjoyed being able to advise on their concerns and direct them to their primary care physicians and the emer gency room when appropriate. As I write this, I grapple with something
far more challenging: having to guide my family on whether my elderly grandmother—my last living grandparent—should be intubated for hyper capneic respiratory failure or not.
My grandmother is 86. She has been like a second mother to me all my life. This was the woman who fed me as a child, whose soft cool skin I can still feel in my imagination on command, whose smell I would find comfort in every time I traveled to India. I had seen her mere months ago, walked with her, dined at home with her, and had seen her functional capacity improve before things took a turn for the worse. It didn’t feel right that a woman who seemed to be on the upswing so recently would now be in the hospital fighting for her life.
A DAUGHTER, SON, GRANDCHILD, PARTNER, OR SIBLING, TIME STOPS A LITTLE WHEN A FAMILY MEMBER BECOMES ACUTELY ILL.
She and I get along so well because our personalities are symbiotic. As a driven and motivated millennial, I broaden her worldview, and as a woman who has lived through an entire country’s revolution and fight for independence, she broadens mine. We share a self-assuredness and mutual respect for each other’s experiences that that bonds us. When we disagree, we settle our debates with logic and persistence. Yet, both characteristics were challenged as I struggled with the task of having to advise on an intubation for her when all I wanted to do was yell across space and time, “You just can’t leave yet, it’s not your time.”
My grandmother has had a long hospitalization, requiring emergent dialysis and intermittent respiratory support. Many days, she seems to be doing better—looking over at me on the phone, smiling, speaking. Some days, she seems worse, barely uttering a word. She was fatigued after dialysis, then somewhat somnolent, then found to have carbon dioxide narcosis. Struggling on aggressive BiPAP settings, the physicians in India gave us three hours to decide—tube or not. For days, my heart had leapt up to my throat every time I heard my phone ring. For days, I had to fight to keep my head in the game at work, knowing that I was to my patients and their loved ones what my grandmother’s doctors were to her and me.
Culturally, my family was struggling with a paternalistic take on medicine, with physicians barely providing them with information, reasoning, or guidance on the implications of the treatment options offered. Her doctors refused to speak with me over the phone, instead opting to speak only with family members who were physically present. Even then, if a question or explanation could be avoided, they avoided it. Limited laboratory and imaging studies were ordered, lead ing to delays in diagnosing changes in my grandmother’s condition. My family would dutifully relay what was said to them and ask me to interpret as best as I could. It was the worst game of telephone imaginable, because a loved one’s life and desires were at stake.
For people of my grandmother’s age, intubation often becomes a way of life. I’ve seen it rob people in her condition of the ability to communi cate towards the end of their lives and I pondered this as we prayed for the BiPAP to work better than it had in the past hour. If intubated, her chances of extubation would be low. I couldn’t imagine my animated and capable grandmother wanting to be intubated if it meant she would likely have to live long term on a ventilator. My grandmother, a vocalist who taught me some of my first songs, would never want to be robbed of her voice, her awareness, and her ability to communicate with her family at the end of her life.
This is a woman whose face lights up when reminiscing with her brother and sisters and telling me stories about her time with my grandfather, who passed away just a few years earlier. She can identify the key and pitch of any song she hears. The thought of her life passing her by as she lays there intubated is too much to bear. It was obvious to me that choosing an intervention that bore a significant possibility of that happen ing to her is an injustice to everything she has lived for so far in her life.
I knew that seeing a family member become acutely ill was painful, but this was the first time I personally felt the pain of my patients’ loved ones.
The pain of potential loss combines with a fervent desire to honor our ailing family member, creating a seemingly impossible and inescapable situation. As a physician, I have the added burden of knowing what is probable while simultaneously having my emotions carry me towards what is possible. Do I hope my grandmother is in the minority or do I succumb to accepting that probabilities are probable for a reason? If I succumb, is the science of medicine making me give up prematurely on hope for my grandmother? If I hope, will I be providing false hope for my family, who sees me as a source of objective medical information?
My grandmother isn’t my patient, but I feel powerless and paralyzed as a physician in the wake of her health crisis—unable to help, unable to change the course of her life, unable to provide answers in the face of uncertainty. Contrary to the resilience that should come with medical knowledge, being a physician and a loved one feels more emotionally deadening than if I were to be just one or the other. Though my career has been defined by a desire to heal and guide my patients and their loved ones, I find myself in a predicament where I feel broken and unable to put my pieces back together. It’s a raw feeling that I am realizing no phy sician can really help heal for a loved one. Perhaps that’s why family is so important in trying times or in times of loss—after all, we may be the only ones who can truly pull together to heal our own hearts as loved ones.
>> FOR DAYS, I HAD TO FIGHT TO KEEP MY HEAD IN THE GAME AT WORK, KNOWING THAT I WAS TO MY PATIENTS AND THEIR LOVED ONES WHAT MY GRANDMOTHER’S DOCTORS WERE TO HER AND ME.
Aislinn D. Black, DO MPH FACEP, Brian Kenny, DO MA, and Akiva Dym, MD FAAEM
are forced to employ ED techs or even nurses as psychiatric sitters. While some institutions are attempting to alleviate the staffing shortages by hiring additional dedicated patient sitters, this option is not always available or financially feasible.
As emergency department visits in the United States continue to increase year over year, overcrowding and understaffing within emer gency departments has become a growing concern and unfortunately the “new normal.” Few EDs within the country have been immune from the troubling phenomenon of overcrowding and understaffing. The spe cific causes of ED overcrowding and understaffing are numerous. One specific area which has contributed to ED overcrowding and staffing shortages relates to the rising number of ED visits for psychiatric causes. Psychiatric visits to EDs have been increasing at a steady rate over the past two decades, with a recent surge noted during the COVID pandem ic. Mental health complaints make up 7-10% of all ED visits, and nearly 80% of EDs have reported boarding psychiatric patients in their ED, often with extended lengths of stay. Numerous issues have led to the current psychiatric crisis in EDs across the country, including a shortage of mental health professionals, limited access to out-patient psychiatric care, and severe shortages of in-patient psychiatric beds across the country. Over the past 40 years, inpatient psychiatric beds have shrunk to nearly 20% of previous peak levels. As psychiatric ED volumes continue to increase, emergency departments must be pre pared to address the impacts this will have on ED operations.
The boarding of psychiatric patients in emergency departments has widespread effects on overall ED operations. In its simplest form, boarding psychiatric patients in emergency departments reduces the functional capacity of the ED and thus reduces throughput capacity. Furthermore, psychiatric patients board in an ED bed significantly longer on average than medical patients, often upwards of three times as long. The near-constant use of ED beds for boarding psychiatric patients thus effectively reduces the overall capacity of an ED, and can have a significant impact on overall ED operations. Furthermore, if psychiatric volumes continue to increase yearly as many predict, the detrimental effect of psychiatric boarding will only continue to worsen and continue to affect ED throughput and capacity.
The increase in psychiatric boarding also has a major impact on staff ing levels. As a majority of psychiatric patients require some form of constant observation, ED staff must frequently be utilized as “sitters” to monitor these patients. While institutions have varying guidelines regard ing the staff to patient ratios required (e.g. 1:1, 1:2, or higher), this will effectively reduce the volume of staff available to assist with performing EKGs, drawing labs, or performing other patient care tasks. Many EDs
In addition to the effects on ED bed availability and ED staffing, the boarding of psychiatric patients in an ED also poses safety risks to the patient themselves, to other patients and visitors, and to ED staff. The ED is frequently a noisy and chaotic place, which can be very disturbing and nontherapeutic to the potentially unstable psychiatric patient. Psychiatric patients ideally require a calm and therapeutic environment, which the average ED unfortunately cannot provide. These patients paradoxically suffer from both overstimulation—alarms, constant bright lights—and un derstimulation—lack of any recreational or therapeutic activity. As such, psychiatric patients remaining in an ED for extended periods of time may be more prone to developing agitation or violent outbursts. These patients are exposed to the risks of repeated restraint and sedation in an effort to protect the patients themselves, other patients and visitors nearby, and ED staff.
Lastly, like any other form of boarding, the increase in psychiatric boarding can increase the workload of both the physician and nursing staff. Physicians will have to spend an increasing amount of time man aging psychiatric patients, many of whom may be acutely agitated or psychotic and who would benefit from being cared for by a dedicated psychiatric team. Furthermore, as patients become agitated within the ED, physicians will have to further divide their time to manage psychiatric patients to prevent further patient harm and ensure overall patient safety. Similarly, the ED nursing staff will have increased tasks to be performed for psychiatric patients with regards to frequent medication management and screening checks.
Faced with the many problems of psychiatric boarding, there are many potential strategies which can be implemented to help alleviate some of these specific concerns. Developing a close working relationship
>>IF PSYCHIATRIC VOLUMES CONTINUE TO INCREASE YEARLY AS MANY PREDICT, THE DETRIMENTAL EFFECT OF PSYCHIATRIC BOARDING WILL ONLY CONTINUE TO WORSEN AND CONTINUE TO AFFECT ED THROUGHPUT AND CAPACITY.
>>BY
WORKING WITH HOSPITAL LEADERSHIPAND PSYCHIATRY, THE DEVELOPMENT OF A DEDICATED CLINICAL AREA WITHIN THE HOSPITAL CAN BE EXTREMELY BENEFICIALTO ADDRESSING ED OVERCROWDING AND PSYCHIATRIC BOARDING.
between the emergency department and psychiatry department is critical to ensure a streamlined process and to help reduce the ED length of stay. Streamlining the process for medical clearance and consultation can ensure a smoother process and potentially shorter ED length of stay.
By standardizing the requirements to “medically clear” a psychiatric patient, it can reduce provider variability and potentially prevent delays due to being unable to medically clear a patient. Identifying subsets of psychiatric patients who do not require any specific testing in order to be medically cleared can also help reduce patient LOS and reduce asso ciated costs/resource utilization. The criteria required to medically clear a patient will likely vary from institution to institution, but often involves a combination of screening labs (including a EtOH level, urine drug screen, and metabolic workup), EKG, and/or chest X-ray. By working with your psychiatric service to standardize these requirements, it can help reduce the time needed for a patient disposition. The development of dedicated order sets within your EMR can also help ensure standard ization of workups and reduce unnecessary testing. It is also critical to work with local psychiatric admitting facilities to determine any specific admission requirements that they may require for an inpatient admission. Furthermore, streamlining the consultation process can help reduce delays in obtaining psychiatric evaluation. In our facility, we have devel oped a process by which the psychiatrist on call can be reached 24/7 via a direct dedicated phone number. In addition, the use of real-time Epic chat can help with communication regarding consult status and psychiat ric recommendations/disposition.
Another strategy to help reduce ED psychiatric boarding and poten tially improve throughout is the use of twice daily “psych huddles”. Multidisciplinary psychiatric rounds (MDR) should involve the ED phy sician, psychiatrist, social worker, case manager, nurse manager, case workers, and psychiatric screeners. MDR can provide a time for an overview of the status of every psychiatric patient, including the status of medical clearance, psychiatric recommendations, placement concerns, or potential re-evaluation for discharge. The use of MDR within our facility has allowed us to update the entire clinical team regarding patient status, as well as ensure that patient disposition (e.g. transfer to outside facility) was not delayed due to a missing facility admission requirement such as urinalysis or chest X-ray.
Addressing the staffing shortage requires a more creative approach. Unfortunately, many EDs do not have the ability to have a dedicat ed psych ED or “crisis” area, and as such, are often forced to board
psychiatric patients within the main ED. However, by identifying a specific area within the ED to dedicate to psychiatric boarding, this can potentially reduce the required number of staff to be utilized as patient sitters, as well as potentially reduce the rate of agitation and violence and its effects on other patients within the ED. In our ED, we were able to convert a smaller clinical space within our ED into a makeshift overflow psychiatric boarding area, which helped reduce the required number of psychiatric sitters and staff uti lized, as well reduced the risk of elopement or acute agitation. Another potential solution for both staffing shortages and ED boarding would be the development of a short-stay psychiatric observation unit within another area of the hospital. This area could then be utilized for psy chiatric patients who have been identified as likely only requiring shorter periods of psychiatric monitoring and observation before being cleared for discharge home. The use of such observation units can help reduce ED boarding and potentially reduce the staffing required for dedicated constant observation sitters. By working with hospital leadership and psychiatry, the development of a dedicated clinical area within the hospital can be extremely beneficial to addressing ED overcrowding and psychiat ric boarding. Studies have shown that dedicated Psychiatric Observation units (such as an EmPATH units—Emergency Psychiatric Assessment, Treatment, and Healing units) can help reduce psychiatric LOS as well as reduce the overall ED rate of patient left without being seen by freeing up ED capacity.
As the volume of patients presenting to emergency departments for psy chiatric care continues to increase, EDs will continue to face increasing challenges with ED staffing, psychiatric boarding, and other associated ef fects. By proactively working with hospital leadership, psychiatric services, and receiving facilities to identify and address these concerns, multiple strategies can be undertaken towards improving psychiatric care within the ED and reducing the effects of psychiatric boarding in the ED.
1. Hazlett, S.B. (2004) “Epidemiology of adult psychiatric visits to U.S. emergency departments,” Academic Emergency Medicine, 11(2), pp. 193–195.
2. Nicks, B.A. and Manthey, D.M. (2012) “The impact of psychiatric patient boarding in emergency departments,” Emergency Medicine International, 2012, pp. 1–5.
3. Alakeson, V., Pande, N. and Ludwig, M. (2010) “A plan to reduce emergency room ‘boarding’ of psychiatric patients,” Health Affairs, 29(9), pp. 1637–1642.
4. Purushothaman, S. (2020) “Patient flow from Emergency Department to Inpatient Psychiatric Unit – A narrative review,” Australasian Psychiatry, 29(1), pp. 41–46.
5. Zhu, J.M., Singhal, A. and Hsia, R.Y. (2016) “Emergency department length-of-stay for psychiatric visits was significantly longer than for nonpsychiatric visits, 2002–11,” Health Affairs, 35(9), pp. 1698–1706.
Melissa Myers, MD FAAEM and Alfredo Urdaneta, MD FAAEM
Emergency physicians (EP) deal with ethical dilemmas every day while on shift. Without guidance, EPs do their best, which is often based on their individual training and, to a lesser extent, on the sum total of expe riences in their lives. Cultural, religious, and other environmental factors all play a role in influencing these experiences. As a result EPs are at risk of allowing their personal biases influence their decisions to the detriment of patients. Becoming aware of and respecting others’ values can help minimize such biases. Emotional Intelligence, or EQ as it is commonly referred, is one such skill that is important in an EP’s relations with all individuals. Learning bioethical principles and what underlies these
decisions can help overcome inherent uncon scious biases and improve patient care on a daily basis. The AAEM Ethics Committee has been tasked with ensuring that AAEM members are aware of these core bioethical principles and how they are applied in daily interactions EP have with patients. There are seven bioethical principles, which we will cover in articles in Common Sense over the course of the year. These principles are respect for autonomy, non-maleficence, beneficence, justice, health maximization, efficiency, and proportionality.
The first bioethical prin ciple we will cover is the principle of autonomy also known as the “right to self-determination.” This bioethical principle states that a person who has capacity has the right to make deci sions for themselves, even if those decisions go against the advice of a physician or loved one. Medicine in the United States has moved from a benefi cence model, in which the physician dictates care, to an autonomy model. In this model, we acknowledge that a patient has the right to make decisions about their own health, and has information regarding their life and health which is unavailable to the physician.
The classic example of this principle is the patient who declines a blood transfusion for religious reasons. Take the case of a 30-yearold woman who presents after a year of heavy menstrual bleeding, tachycardic, and hypoten sive. Lab work demonstrates severe anemia.
While a blood transfusion would be the typically recommended medical option, the principle of autonomy says that the patient has the right to refuse that transfusion for reasons which make sense to her, even if they don’t make sense to the treating physician. She could refuse this transfusion, even if refusal would result in harm or death. It then becomes the responsibility of the treating physician to find an alternative acceptable treatment. When this case was presented to emergency medicine trainees recently, their suggestions for alternative care included tranexamic acid, estrogen, and iron transfusions. This is a relatively straightforward example, let us go a step further. What if the same 30-year-old woman is being admitted to the hospital for her alternative therapy and monitoring. She informs the hospital staff that she has not been vaccinated against COVID19, and refuses to wear a mask or be tested for the virus prior to being admitted to the hospital, as is required by hospital policy. She tells you that she will leave the hospital if she is required to do any of these things.
She has the right to autonomy and to decline these tests. However, where do her rights end and those of the other patients in the hospital begin? Does her autonomy over her own body mean that she has the right to expose others to risk? As demonstrated with this case, bioethics is not simple, and often multiple principles will be in conflict. While we may not agree with the patient, based upon the bioethical principle of autonomy they have the right to make the deci sion they feel is best for them, as long as they are provided with the appropriate information about risks, benefits, and alternatives. However, the bioethical principles are not absolute. Imagine an intoxicated patient with a severe injury who desires to leave the hospital against medical advice. If they leave, they will sustain irreparable harm. If they are unable to demon strate the capacity to understand the harm that will result from their decision to decline care and leave the hospital, then the principle of nonmaleficence or “do no harm” requires
ETHICS COMMITTEEBIOETHICS IS NOT SIMPLE OR STRAIGHT FORWARD. RIGHTS AND DUTIES HAVE LIMITS AND ARE NOT ABSOLUTES.
Irecently started rewatching the TV show ER. It’s a great reminder of why I went into emergency medicine (EM). I was struck by the very realistic depic tion of many of the conditions and cases they tackled as well as the very unrealistic heroic portrayals of some of their characters—Dr. Greene, Dr. Weaver, and Dr. Ross, among others. There were several inaccuracies though—the county hospital being a stone’s throw away from the Chicago River or the Chicago “L” train stop for the hospital situated within the Loop for example. Clinical scenarios have also evolved—giving “Pavunol and Sux” for every intubation, diagnostic peritoneal lavages during trauma, or even resuscitating without masks and sometimes gloves. And then, there are common threads of vicarious trauma from the perspective of physi cians and nurses due to gun violence, intimate partner violence, racism, and discrimination against people with HIV.
Dr. Bessel van der Kolk, author of “The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma,” talks about emotional and sensory manifestations of trauma that we experience throughout our lives. Because EM physicians see patients at their worst, we’ve mastered compartmentalizing repeated traumatic experiences. Dr. van der Kolk shares that healing comes from addressing these past traumas, which requires personal contemplative training and working with trained experts. Yet, even in 2022, decades after the hit show ER, many of us still do not consider attending to our mental and emotional needs as important as tending to our physical needs.
October started the interview season for future EM-bound medical stu dents. As I read through personal statements and met candidates during their interviews, I wondered how much, as a specialty, we’re doing to emphasize the importance of selfcare and boundary-setting.
Yes, many would point out that conditions in our work drive the majority of trauma that we experience, and therefore, the institutions should address inefficiencies in practice and create better cultures for wellness. They are not wrong. However, as EM physicians, we cannot simply wait for the system to change itself. We can and must be part of the change that prioritizes our own well-being.
As we forge ahead three years into the pandemic, while many archaic practices are no longer mainstay occurrences, some things are still common: Dr. Weaver getting sick while on shift after chemical exposure and insisting on working, or Dr. Morgenstern suffering an MI while working and trying to convince everyone alternative rationales for his symptoms, or Dr. Greene, having been attacked in the ED bathroom and how this im pacted the way he viewed his patients and staff. Just like them, we’re not so great at taking care of ourselves as physicians. These are but three examples of physical trauma that many of us, just like the characters, easily ignore because of our commitment to our work or the misconception that we are less if we take the time to acknowledge our own needs. Another underlying theme is the hidden curriculum of expecting individual physicians to manage our daily work’s emotional and mental impact.
This past October, AAEM joined the Society of Academic Emergency Medicine (SAEM) and other national EM organiza tions to make October the first ever #StopTheStigmaEM Month. October is an important month to pause and reflect on our purpose in medicine and to prepare us for the busy winter that awaits us. October 9 is Dr. Lorna Breen’s birthday, having died of suicide as a result of the cumula tive pressures of the profession and the pandemic. October 10 is World Mental Health Day, aimed to raise awareness of mental health issues worldwide. The #StopTheStigmaEM campaign aims to normalize mental health care among EM physicians like you and me.
Each year roughly 300-400 physicians die by suicide, like Dr. Breen, numbers that are higher than the prevalence of suicide rates among US workers in other fields. Before the pandemic, 1 in 15 US physicians had
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AS EM PHYSICIANS, WE CANNOT SIMPLY WAIT FOR THE SYSTEM TO CHANGE ITSELF. WE CAN AND MUST BE PART OF THE CHANGE THAT PRIORITIZES OUR OWN WELL-BEING.”
considered dying by suicide.1 Now, more than half of physicians know of a physician who has thought, attempted, or died by suicide. Since the COVID-19 pandemic, 9 out of 10 EM physicians are more stressed, and 72% report more burnout.2,3 Despite this growing toll on EM physicians’ mental health and well-being, nearly half are hesitant to seek mental health treatment due to the stigma in the workplace.
As a specialty with the highest levels of burnout, we need to do better to help break down barriers and stigma and normalize physicians seeking mental health support. 4 While we cannot resilience our way out of this, it is also not okay to ignore the struggles and trauma we experience. It is okay not to be okay. We can start by having conversations about our work challenges, raising awareness of compromised mental health many of us in health care experience, and participating in several ongoing #StopTheStigmaEM campaigns.5
Changing organizational culture is a multistep process that evolves over the years.6 This requires brave spaces for discussions that openly achieve more than simply supporting one another. Residents and medical students watching this unfold can look forward to a profession that humanizes our work, and each other. The days of measuring strength by stoicism will eventually be a thing of the past.
While October is behind us, situations and experiences that erode our mental health continue, and in our profession, will always continue. We have a role in helping our colleagues feel that they are not alone in this experience. We have a role in humanizing physicians. And we each have a role in stopping the stigma in EM for mental health care. Join our effort.
*Quinnipiac University, EM Bound, Class of 2025. @stephfosterski1 †Harbor-UCLA, EM Resident Class of 2024. @EmergencyArt ‡Stanford Emergency Medicine, EM Physician Wellness Fellow. @ amandajdeutsch §Chair, AAEM Wellness Committee. Assistant Dean, Career Development, Office of Faculty Affairs. Professor, Emergency Medicine, University of Arizona College of Medicine – Tucson. @allieminMD ¶Stanford Emergency Medicine, Director of Well-Being. Vice-Chair, AAEM Wellness Committee. @alvarezzzy
1. Shanafelt TD, Dyrbye LN, West CP, et al. Suicidal Ideation and Attitudes Regarding Help Seeking in US Physicians Relative to the US Working Population. Mayo Clin Proc. 2021;96(8):2067-2080. doi:10.1016/j. mayocp.2021.01.033
2. Sexton JB, Adair KC, Proulx J. Emotional Exhaustion Among US Health Care Workers Before and During the COVID-19 Pandemic, 2019-2021 | Health Care Workforce | JAMA Network Open | JAMA Network. JAMA Netw Open. 2022;5(9):e2232748. doi:doi:10.1001/ jamanetworkopen.2022.32748
3. Shanafelt TD, West CP, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians Over the First 2 Years of the COVID-19 Pandemic. Mayo Clin Proc. Published online September 14, 2022. doi:10.1016/j.mayocp.2022.09.002
4. Physician Burnout & Depression Report 2022: Stress, Anxiety, and Anger. Medscape. Accessed September 21, 2022. https://www.medscape.com/ slideshow/2022-lifestyle-burnout-6014664
5. “Stop the Stigma EM” at https://bit.ly/StopTheStigmaEM and “Art of Emergency Medicine” at https://www.artofemergencymedicine.com/
6. Willis CD, Saul J, Bevan H, et al. Sustaining organizational culture change in health systems. J Health Organ Manag. 2016;30(1):2-30. doi:10.1108/ JHOM-07-2014-0117
the EP to admit the patient to the hospital against their will until they are sober enough to make their own medical decisions. Bioethics is not simple or straight forward. Rights and duties have limits and are not absolutes. We live in a community, and in doing so an individ ual cannot have unlimited rights that infringe on the rights of others or the community. There is a balance between an individual’s liberties/rights and those of others and the community. Ethical dilemmas do not often have simple answers, and the purpose of this series is not to tell you what to
do in a specific circumstance. A full discussion is not possible in this ar ticle and series. Rather, we want to describe the bioethical principles you are likely relying on during every shift when making difficult decisions.
Author’s Note: The views expressed herein are those of the author(s) and do not reflect the official policy or positon of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense, or the U.S. Government.
Katrina Green, MD FAAEM
everal months have passed since the United States Supreme Court ruled on Dobbs v. Jackson Women’s Health Organization and in so doing, overturned Roe v. Wade and fifty years of precedent. Since that day, multiple states, mostly in the South and Midwest, have passed strict laws regulating or completely out lawing abortion.
I currently live and practice in Tennessee, a state that now has one of the strictest abortion bans in the country. The Tennessee law bans abortion from the moment of conception with out any exceptions. There are no exceptions for victims of rape or incest. No exceptions for non-survivable fetal abnormalities. And no exceptions for the life or health of the pregnant person.
What we do have is something called an “affirmative defense.” This allows physicians who perform or are involved in performing an abortion to defend themselves in court after being arrested and indicted for the crime of providing medically necessary health care to a patient in distress. This “crime” is now a class C felony and carries the sentence of 3 to 15
Syears in prison. Tennessee also has a “truth in sentencing law” which means that any physician convicted under this law would be forced to serve the entire sentence. And likely be stripped of their medical license as well since they would be a convicted felon.
Basically in Tennessee, we are guilty until proven innocent, not the other way around. And this should scare every physician, not just those who practice emergency medicine or OB/gyn. How did we go from “health care heroes” to being guilty until proven innocent? What other professionals are under threat of imprisonment for following evidence based best practices?
All of us could be arrested for doing our jobs. We are now under suspicion for providing health care to patients with ectopic pregnancies, incomplete miscarriages, preterm premature rupture of membranes, eclampsia, and many other obstetrical emergencies that we see in our emergency departments.
I have been following the national news closely and have seen several accounts of patients with increased morbidity due to extreme abortion laws around the country. Many of these have originated in Texas as that was one of the first states to pass a strict abortion ban. I’ve also seen reports of patients harmed in Ohio, Missouri, and Georgia, as well as in Tennessee. In Nashville, a pa tient waited over nine hours to have surgery for an ectopic pregnancy while the hospital lawyers and admin istrators decided on the legality of the procedure.
We should not be delaying treatment for emergent medical conditions be cause of fear of prosecution. When we do this, we not only violate our sacred oath to do no harm, but we also expose ourselves to potential malpractice lawsuits and EMTALA violations.
We are now in between that meta phorical rock and a hard place. On the
one hand we can be prosecuted as criminals and defend ourselves in criminal court if we practice evidence based care along with our OB colleagues. On the other hand, we can be sued for failing to act in an appropriate, timely manner if our patients suffer poor outcomes while waiting for approval to perform a medical ly necessary procedure.
It seems like a bad dream from which I have yet to wake. Unfortunately this waking night mare is our current reality.
One thing that gives me hope is seeing other physicians and medical societies speaking up for reproductive rights and health care. We cannot be silent on this issue.
What can we do to prevent the prosecution of ourselves and our colleagues? How can we ensure our patients receive the best possible care for obstetrical emergencies?
We use our voices. And the voices of our med ical societies. There is power and strength in solidarity. We must stand with our brothers and sisters in obstetrics and gynecology. Because they are not the only physicians with targets on their backs. We are at risk as well.
What the legislators are doing here in Tennessee and elsewhere is inserting the government into our patient-physician relationship. As was stated by a fellow physician at a recent press conference, “they are practicing medicine without a medical license.” And that is dangerous.
Now is the time to lobby your local, state, and federally elected representatives. Call, email, or write to them and tell them that reproductive health care is necessary and should be as much of a right as all of health care. Tell the legislators that physicians should not be crimi nalized for practicing evidence based medicine.
We can and must use our voices to lobby for better laws and practice environments, not only for our wellbeing, but for that of our patients.
Because the rallying cry of reproductive rights organizations is true: Abortion is health care.
>> HOW DID WE GO FROM ‘HEALTH CARE HEROES’ TO BEING GUILTY UNTIL PROVEN INNOCENT?
FAAEM FACEP and Molly Estes, MD FAAEM FACEP
o start, we begin with our own imposter syndrome confession: we are not experts in imposter syndrome. Our in terest in this topic came out of a side project, prompted by a question posed by one of our trainees that became more intriguing as we dove deeper into the available literature. Our resulting discussion comes from experience, many hours of conversation with colleagues, and a drive to understand ourselves better.
Imposter syndrome was first described by Dr. Pauline Clance in 1985 and was initially thought to be predominant in professional women. Since that first definition over 40 years ago, imposter syndrome has been found to be pervasive amongst most high achieving individuals across all fields of professional and personal accomplishment. It is loosely defined as a variety of negative feelings projected inward. An individual might doubt their mental or physical abilities or feel like they have everyone around them fooled as to their abilities; in other words, feeling like a fraud. When receiving praise, they might not think they are deserving of it. Ultimately, imposter syndrome is an individual being unable to accept the accolades that come with their accomplishments.
We have a bone to pick with the word “imposter”—it implies conscious awareness that you are not qualified, which could imply criminal fraud ulence if you continue to do something for which you “know” you aren’t qualified. It’s important to realize that although imposter syndrome may be conscious at some times, the vast majority of people who experience it are not truly lacking in the skills they doubt they have.
Who suffers from imposter syndrome? As we’ve said, it tends to be high achieving individuals who find it difficult to accept their own success. And we want to also reiterate, even though the first studies were done in women, newer data shows that imposter syndrome likely affects genders
Tequally. In fact, it has been estimated that 70% of most individu als will feel like an imposter at some point in their lives/ careers.
How does imposter syndrome work? Dr. Clance first postulated the Imposter Cycle.
It begins with any assignment. The individual begins to feel anxiety and self-doubt regarding the assignment, a classic, “I don’t think I’m qualified for this,” moment, which then results in one of two innate responses: either they procrastinate starting it or they immediately begin over-prepar ing. Ultimately, they succeed in the assignment, but their transient feeling of relief is quickly usurped by one of two thought processes. For the pro crastinator, it’s the thought of “oh, I just got lucky, I put things off so long.” And for the over-preparer it’s, “oh, but you have no idea how hard I had to work to get that result. I’m not good I just work hard.” Both of these result in the individual essentially pushing away their success and instead feeling like they are a fake and not qualified.
Some might see this constant cycle of self-doubt as the impetus to pro vide the drive to keep bettering yourself. And while imposter syndrome may provide motivation for some professionals, these perpetual feelings of self-doubt have also been linked to increased work-related stress, depression, anxiety, burnout, and even suicide. The problem becomes that this actually feeds back into the imposter syndrome process; many individuals feel as if they are not anxious/depressed enough in order to need help.
What about us specifically? The subgroup of medical professionals who have trained in a world where we are told to fake it ‘til you make it. Well, as you might predict, imposter syndrome runs rampant through medicine. As a profession, emergency medicine has really only seriously started looking at this phenomenon since 2016. Based off of literature reviews, we know that imposter syndrome is present in anywhere from 22-60% of individuals at any given time, and that even higher numbers identify feel ing symptoms of imposter syndrome in the past. This contributes greatly to rates of burnout as we’ve already mentioned. This effect is not limited only to medical students and residents. A small survey done of attending physicians, some at a very advanced stage of their career, revealed many of these same feelings despite years of achievement. Of especial
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[B]Y HAVING MORE AWARENESS OF IMPOSTER SYNDROME, WE CAN BEGIN TO CREATE WITHIN OURSELVES LEARNED BEHAVIORS TO HELP COMBAT THE NEGATIVE FEEDBACK LOOP.”
MD
>> ULTIMATELY, IMPOSTER SYNDROME IS AN INDIVIDUAL BEING UNABLE TO ACCEPT THE ACCOLADES THAT COME WITH THEIR ACCOMPLISHMENTS.
concern was that most who responded revealed they had never shared these feelings with anyone else due to fear of judgement.
Imposter syndrome also feeds back into our ability to be able to grow our skills. For many, the response to feeling like an imposter is to display over-confidence in your skills. This is not the true narcissistic person, but rather you are trying to convince yourself as well as everyone else that you know what you are doing. This can be seen in all levels of learners, and it is important to consider, because actually validating some of that confidence is key. Let that individual know what they are truly doing well, and allow your own vulnerability and doubts to create a safe space for them to be real and express their own vulnerabilities. It’s not all doom and gloom. Actually, by having more awareness of imposter syndrome, we can begin to create within ourselves learned behaviors to help combat the negative feedback loop. One published study explored a simulation session started with the program’s interns in order to mimic scenarios where imposter syndrome might pop up (for example, overnight call and having to answer pages). It had the residents consciously explore those instinctive panicked feelings and come up with exercises to deescalate their own responses. So hopefully by now you will be realizing that true imposter syndrome is not feeling unsure about yourself, your actions, or your decisions. We all
From a couple of imposters to all of you reading out there, let’s lead the charge of changing the fake-it-‘til-you-make-it stigma.
1. Abrams, Abigail. “Yes, Impostor Syndrome Is Real: Here’s How to Deal With It.” Time, Time, 20 June 2018, time.com/5312483/how-to-deal-withimpostor-syndrome/.
2. Gottlieb M. More than meets the eye: The impact of imposter syndrome on feedback receptivity. Med Educ. 2021 Feb;55(2):144-145. doi: 10.1111/ medu.14412. Epub 2020 Nov 18. PMID: 33155297.
3. Gottlieb M, Chung A, Battaglioli N, Sebok-Syer SS, Kalantari A. Impostor syndrome among physicians and physicians in training: A scoping review. Med Educ. 2020 Feb;54(2):116-124. doi: 10.1111/medu.13956. Epub 2019 Nov 6. PMID: 31692028.
4. “Impostor Syndrome.” Wikipedia, Wikimedia Foundation, 21 Mar. 2021, en.wikipedia.org/wiki/Impostor_syndrome.
5. LaDonna KA, Ginsburg S, Watling C. “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Acad Med. 2018 May;93(5):763-768. doi: 10.1097/ACM.0000000000002046. PMID: 29116983.
6. Mullangi S, Jagsi R. Imposter Syndrome: Treat the Cause, Not the Symptom. JAMA. 2019;322(5):403–404. doi:10.1001/jama.2019.9788
7. Ramsey JL, Spencer AL. Interns and imposter syndrome: proactively addressing resilience. Med Educ. 2019 May;53(5):504-505. doi: 10.1111/ medu.13852. Epub 2019 Mar 28. PMID: 30924160. Sakulku, J. (1). The Impostor Phenomenon. The Journal of Behavioral (1), 75-97. https://doi.org/10.14456/ijbs.2011.6
Faith Quenzer, DO MPH
The practice of emergency medicine (EM) is quickly spreading throughout the world. The integration of point-of-care ultrasound (POCUS) has been an important part of in delivering health care in both rural settings and lowand middle-income countries because of portability and cost. Currently, very little information is known about the practice and use of POCUS in Mexico in delivering health care. Information regarding EM trained phy sicians who utilize both POCUS and education in these global settings is scarcer. Our piece this month highlights the educational and economic needs among the U.S.-Mexico border region and the goals of creating equal partnerships and collaborations in the vast border city of Tijuana.
My interview is with the founding member of Ultrasonido en el Punto de Atencion (UPA) del Norte, Eva Tovar Hirashima, MD MPH, who is an Assistant Professor at University of California, Riverside and Ultrasound Fellowship Director at Riverside Community Hospital in Riverside, California. She is currently the Emergency Medical Services (EMS) Director at Cruz Roja in Tijuana. Through her organization, UPA del Norte in conjunction with Cruz Roja Tijuana (CRTJ), Dr. Tovar has suc cessfully created a monthly point-of-care ultrasound (POCUS) interest group comprising of emergency medical services (EMS) personnel, medical students, general practitioners (GPs), midwives, EM and IM residents, and attending physicians.
Our interview shares her story and her journey as a foreign-born Latina emergency medicine physician who is not only giving back to the com munity and country she comes from, but raising awareness to the educa tional needs and equipping our Mexican colleagues south of the border with high quality POCUS education and mentorship. She has hopes that her efforts could give her colleagues have boundless opportunities to contribute to EM education and our practice.
Faith Quenzer (FQ): Tell me about how you decided to become an emergency medicine physician.
Eva Tovar (ET): My first “real” encounter with the ED was as an internal medicine (IM) resident in Mexico City. The teaching hospital where I trained did not have an EM residency. As IM residents, we ran the ED. Among my classmates, the ED was known as the “salt mines” and most were relieved once their time in the ED ended. I learned to love it. The unpredictability and the need to make decisions with incomplete information were welcomed challenges. But what I think made me fall for EM was its complex simplicity: “There is someone who has self-selected and presents to the ED asking for your help. Your job is to help them. The challenge is figuring out how to do that despite everything and everyone
else.” It seemed like a just fight, something worth pursuing. What I came to realize was that as an IM resident I was lacking the skill set that al lowed me to provide timely and high-quality emergency care. I had found a purpose. The next decision point was simple, I needed to train in EM.
FQ: Where did you study medicine in Mexico? What was your path to studying in the United States?
ET: In Mexico, you start medical school right after high school. I studied at the School of Medicine (SOM) in the National Autonomous University of Mexico (UNAM by its acronym in Spanish), in Mexico City. It was a six and a half year endeavor. I spent the first two years in the classroom, and the next two and a half years doing clerkships in different public hospitals in Mexico City. I spent the fifth year, which is called an “intern ship,” in a public hospital in Ensenada, Baja California, where I became part of the treating team and functioned as a PGY1. During my final year I was deployed to a critical access clinic in Baja California Sur, where I served as the community’s general practitioner. As a public university, the tuition at UNAM is affordable. I paid less than a dollar a year. As a middle-class, female medical student in the 90s, studying at UNAM was an eye-opening experience where I was abruptly confronted with the social and health disparities, as well as the institutional barriers that prevent equitable and high-quality care in the public health care system. The contradiction of knowing that health care is a constitutional right compounded with the understanding that you have individually benefitted by having the tuition practically waived stood in stark opposition with a
>> ANYONE, ANYTHING, ANYTIME/QUIEN SEA, LO QUE SEA, CUANDO SEA.
languishing public health care infrastructure where the most vulnerable are the most expendable.
After medical school, I earned a scholarship to study public health at the University of California, Berkeley. During those two years, I learned a new lexicon: “social determinants of health,” “structural violence,” “health disparities and inequities,” but also “empowerment” and “community-level action.” In addition, I learned that I was unapologetically Mexican. As the daughter of a biracial couple (my mother is Japanese, my father is Mexican) I had always felt as a foreigner. Once I became a foreigner, I embraced Mexico. After graduate studies, I returned to Mexico City to train in a tertiary-care public hospital in IM. It was a four year residency. As described above I spent a lot of time in the ED. In Mexico, laws like EMTALA exist but are rarely enforced. The learned hopelessness and moral injury medical professionals endure is shadowed only by the too-of ten preventable individual tragedies of our patients. Once I decided on EM, I opted out of that system. “Anyone, anything, anytime” seemed like a place I wanted to train-in.
FQ: Who were those who mentored and inspired you to study in the United States?
ET: I didn’t have a specific mentor. But I have been very fortunate and privileged. My parents supported me both financially and emotionally throughout medical school and up to my time as an IM resident, well into my late 20s. This included paying for the exams and licensing International Medical Graduates’ (IMGs) require to be eligible for the Match. The hardest thing for me was letting go of Mexico where there is a greater need. It was my mother who told me in her broken Spanish after a particular harrowing event during residency that it was ok to let go. That I needed to focus on myself and my well-being. An uncle who practices medicine in the US bought me the first USMLE-prep books and I spent the next two years studying for these as I concluded my IM train ing. When I was ready for the Match, my first choice was the Bay Area where I had seen medical students organize and run a free clinic for the homeless. However, the state of California then required a Postgraduate Training Authorization Letter which I did not have. In 2010, I was very fortunate to match into the Harvard Affiliated Emergency Medicine Residency in Boston. When I learned that Massachusetts had recently undergone a health care reform to achieve near-universal insurance cov erage, I was ecstatic. “Anyone, anything, anytime” had become more than a catchy phrase.
FQ: How did you grow your interest in medical education and point-ofcare ultrasound?
ET: After EM residency, I was torn between Global Health versus an Emergency Ultrasound Fellowship (EUF). I decided on the latter because it seemed like a tangible skill that could be translatable to different set tings. I chose to pursue this at the University of Maryland. During this time, I worked clinically at a critical access hospital on the Eastern Shore. Being able to perform POCUS was an obvious advantage and allowed me to provide better and timelier care. It was also during this period that
I relied heavily on Free Open Access Medical Education (FOAMed) pod casts and blogs to learn about the most recent and relevant studies and stay up to date with the newest POCUS applications.
Once I moved to San Diego in 2017, I soon got invited and actively sought teaching opportunities in Tijuana (TJ), Mexico. Even though POCUS was a well-established clinical tool considered a core clinical competency for EM residents in the U.S., it was infrequently discussed, rarely used, and literally kept under lock and key in TJs teaching hospital. It seemed ironic that a technology that could have such a large impact in scarce-resource settings if used correctly was so underutilized. But despite my personal enthusiasm with POCUS, there seemed to be other more pressing priorities. Then came COVID-19. The Mexico-U.S. Border closed, the global North went into shut down, the global South struggled even further. Handheld ultrasound probes made their way even into peo ple’s homes and images of b-lines and pleural sliding flooded #medtwit ter. POCUS suddenly became globally relevant. But means were not coupled with need.
A major limitation for the Spanish-speaking physicians was a lack of FOAMed POCUS resources. Simple, visually appealing, mobile-friendly learning material was needed in Spanish. This is how we started UPAndo Latinoamerica 1 Four EM female attendings, three of whom live and prac tice in Mexico, got together to fill the gap. To quote Dr. Mandeep Dhillon one of the cofounders, “[it is] a collective project started in 2021 with a focus on creating open access educational materials in Spanish which cover different aspects of POCUS for EM, primary care, and prehospital settings. We work in a horizontal manner, prioritizing the participation of voices that are often overlooked in medicine and POCUS. Our aim is to contribute to the integration of POCUS in the practice of medicine in Latin America as part of providing just and dignified health care for all.”
FQ: Why did you start UPA del Norte? How did you start UPA del Norte?
ET: The Mexico-U.S. border opened at the end of 2021. By then we had close to a year’s worth of POCUS content in UPAndo, and I thought it was time to put words into action. A local POCUS focus group was created made up of EM attendings from different residency programs in the region (Ensenada, Tijuana, Tecate, Mexicali), EM and IM residents, GPs, EMTs, medical students, and most recently midwives. I designed a longitudinal curriculum to cover core competencies like those taught to EM residents in the U.S. In addition, being acutely aware of the stark pain management gap many public EDs in Mexico lack or have limited access to intravenous analgesics, I added ultrasound-guided nerve blocks as a main learning objective. We have been fortunate to have the support of CRTJs medical director, Dr. Aldo Diaz, and the participation of a considerable number of their ED physicians who have provided the space and the equipment for the workshops and shown a commitment with the project. To date it continues to grow and is driven by our group effort, where we have all contributed with our individual handhelds or portable ultrasound machines, lectures, POCUS cases, bodies (medical
students have graciously allowed us to scan away!), food, and humor. It needs tailoring and more structure, but it is a proof-of-concept effort. There’s graffiti on the border wall in TJ that reads “tambien de este lado hay sueños” or “we dream on this side too.” UPA del Norte is collective action through POCUS.
FQ: What moment help cement your passion to pursue U.S.-Mexico border emergency medicine?
ET: I wanted to be at the Mexico-U.S. border before I knew I wanted to do EM. For me the border is both a geographic space as well as a state of mind. A place where you are after leaving something behind but also a place where you become. What cemented my passion was learning about the struggles migrants face during their journey through Mexico. While in EM residency, I received a grant to do fieldwork in southern and central Mexico. I visited shelters and interviewed refugees and volun teers. I was fortunate to meet Gabriela Hernández, a human rights activ ist that manages a volunteer-based shelter in Mexico City called “Casa Tochan.”2 Back then, I helped organize a free medical clinic that thanks to the perseverance and ingenuity of Casa Tochan’s team still runs today.
What gave me purpose was my role as the EMS medical director at CRTJ. In 2018, I was invited by Dr. Andres Smith, an EM physician and medical director at Sharp Chula in San Diego, and current President of CRTJ, to join their team. Other than my EMS elective and my role as an EP at a base-hospital in the U.S., I had little prehospital experience. The emergency care system in Mexico is fragmented, uncoordinated, and un der-resourced. EM specialists in Mexico do not receive any formal train ing in prehospital care which likely contributes to an often confrontational handover between the ambulance crew and the ED staff and delays on ambulance patient offload. TJ is one of the largest cities with a population of 2.2 million. CRTJ serves as its main ambulance provider, responsible for close to 98% of the 911 medical services. The EMS Chief, Valeria De La Torre and Deputy EMS Chief, Ulises Rodriguez, command a crew of
100 EMTs and one prehospital MD who staff 9 to 12 ambulances distrib uted in six bases and one rapid response vehicle. The prehospital ser vice is free of charge to the patient. However, we do not have a defined budget, and our service and equipment depends on donations. With response times close to 30 minutes and transport times of 40 minutes (EMTs need to request receipt prior to hospital transport for uninsured patients), our EMTs function as EM providers and are frequently tasked with the emergency care during the critical “golden hour.” The work that our EMS brothers and sisters do 24/7/365 north and south of the border, despite the lack of resources and/or recognition and benefits, has un doubtedly cemented my commitment with the binational region. “Anyone, anything, anytime/Quien sea, Lo que sea, Cuando sea.”
FQ: What do you think are most important in growing UPA in Latin America?
ET: Latin America is a vast region plagued with economic, racial/ ethnic, and class inequalities which are linked to health disparities. The answer to your question will vary depending on where you are and who you serve. Because of this, each region and specialty within regions will have to organize and create their guidelines and define core applications, scope of practice, credentialing, and quality assurance. However, there are few essential components where the solidarity and advocacy of those of us who reside in the global North can be helpful.
Affordable ultrasound machines and hand-helds. Physicians are found ers, CEOs, and/or consultants of companies focused on medical technol ogy and portable ultrasound. Understanding the global health inequities and adjusting the cost of their equipment by region, profession and population served whilst continuing to provide the technical support and software updates would help with accessibility.
Affordable middleware solutions. For most public health care systems and EM physician groups in Latin America, the cost of current middle ware solutions used for image archiving, reporting, educational feedback, and image review is prohibitive. Innovative, affordable, and language-ap propriate solutions for low- and middle-income countries are a priority. Companies who advertise their products touting to democratize ultra sound access, need to consider adding middleware solutions in order to help with Q&A and responsible usage of their technology.
Collaboration and reciprocity. In my experience, Mexico, and I suspect other regions in Latin America, lack the systems and institutional support to streamline processes such as POCUS integration. However, there are individuals within these regions who despite the systemic deficiencies they are subject to, have become experts on POCUS usage and are ex ploring and expanding its clinical applications. Recognizing these voices in international forums may provide them with domestic/regional credibility. Specialty rivalry similar to what occurred in the U.S. between EM versus radiology/anesthesiology/etc., are prevalent and continue to limit EM POCUS growth in regions where POCUS champions are silenced or ignored.
‘TAMBIEN DE ESTE LADO HAY SUEÑOS’ OR ‘WE DREAM ON THIS SIDE TOO.’
>> THERE’S GRAFFITI ON THE BORDER WALL IN [TIJUANA] THAT READS
As many as one in seven emergency department patients in the United States are seen by a PA or NP.1 Often these patients are seen in an urgent care or fast track area. Patients in this area may present with musculoskeletal complaints, concern for abscess, or retained foreign body and may benefit from the use of point-of-care ultrasound in their care. Point-of-care ultrasound has been previously shown to change the management in the diagnosis and treatment of abscess and cellulitis and is effective in the diagnosis of tendon injuries.2-3
In addition to the benefits for patient care, the use of ultrasound by PAs and NPs can decrease length of stay in the emergency department. Performing ultrasound in the ED instead of referring to radiology can decrease length of stay which can increase the overall efficiency of the department.
Training programs exist where PAs and NPs can receive appropriate training in the use of ultrasound. As an example, my home hospital offers an emergency medicine fellowship for PAs which includes a one month rotation with the same ultrasound requirements as the emergency medicine interns. These PAs graduate and are able to perform POCUS and should be able to use this skill set in addition to their other training.
This is not, however, to say that anyone should be using ultrasound without proper training. Any PA or NP using ultrasound in the emergency department should undergo the same rigorous training as a physician performing the same exam. Emergency departments should establish baseline standards for credentialing based on previous instruction and number of exams performed for anyone performing ultrasound. These standards should be the same as any physician performing ultrasound in the emergency department.
Performing POCUS safely is complex and is highly operator depen dent. It requires three separate sets of skills: image acquisition, image interpretation, and clinical integration. Like any complex skill, becoming proficient means spending time learning and practicing prior to safe independent use. Emergency medicine (EM) residents spend a minimum of two weeks in dedicated POCUS education during their PGY1 year, often taught by EM faculty who are fellowship-trained in POCUS. Residents then have the rest of their residency to hone their skills and learn clinical integration. They graduate with a minimum of 150 complet ed scans (many residencies require a minimum of 300 scans). Physician assistants (PA) do not have this kind of robust training. In 2019, a survey of PA program directors found that 23% of PA programs use POCUS in their curriculum with many using it in the basic sciences section.4 Even
then, supervision and access to skilled faculty is variable. There are, however, over 200 medical schools that integrate ultrasound into medical school education.5 Nurse practitioners (NP) training is also variable, with no standardized curriculum and no endorsed training pathways from NP societies.6 Currently, many PAs and NPs learn POCUS “on the job,” where supervision can be minimal or non-existent.
While POCUS is a powerful diagnostic and procedural tool, improper training can lead to important patient safety consequences, such as mis diagnosis and procedural error. False positive exams from misinterpre tation can lead to unnecessary tests and consultations which increase patient length of stay and cost. False negatives can lead to inappropri ate reassurance and discharge.
PAs and NPs are skilled practitioners who are certainly capable of learning POCUS and integrating it into clinical care.7-8 However, current training is insufficient to allow independent use of POCUS. POCUS is simply not a “see one, do one, teach one” skill. EDs wanting PAs, NPs, or nurses to utilize POCUS in clinical care must develop a robust train ing program, including didactics and safety training, supervised bedside practice, and a quality assurance program to assure high standards of care are met.
1. Brown, D. F., Sullivan, A. F., Espinola, J. A., & Camargo, C. A. (2012). Continued rise in the use of mid-level providers in US emergency departments, 1993–2009. International journal of emergency medicine, 5(1), 1-5.
2. Tayal, V. S., Hasan, N., Norton, H. J., & Tomaszewski, C. A. (2006). The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Academic emergency medicine, 13(4), 384-388.
3. Wu, T. S., Roque, P. J., Green, J., Drachman, D., Khor, K. N., Rosenberg, M., & Simpson, C. (2012). Bedside ultrasound evaluation of tendon injuries. The American journal of emergency medicine, 30(8), 16171621.
During part one of the “Critical Care Education: How Early is Too Early” series, we explained the basic concepts of critical care, it’s continuing influence on emergency medicine (EM), and how early education in this field starting at the medical student and intern level may expand decision-making, critical thinking, and overall confidence as they continue their journey through EM. Part two focuses on the deficiency of educational platforms which in struct students in these critical care concepts and support for further curricula, as well as discussing the novel “AAEM/RSA Introduction to Critical Care in Emergency Medicine” program as its second iteration begins, and its primary aim of filling this educational gap.
Many medical schools and residencies offer “selectives” or “electives” in critical care ed ucation, which focus on the diagnosis and treatment of this unique population, while also offering the student or intern an early oppor tunity to investigate this field. However, formal medical school curriculums, which educate this populace prior to an intensive care rotation, seem to be mostly absent or deficient in current medical training. The proposed notion is that critical care may be too advanced for a student or intern with a background medical knowledge of solely undergraduate education. However, following implementation of an intensive care unit (ICU) curriculum, a student’s self-perceived confidence in critically ill patient management and medical knowledge may improve.1 Many professional organizations and schools offer virtual rounds, simulation sessions, or journal clubs to students who have an interest in critical care. However, some of these opportunities
come at costly prices or may be too advanced for a medical student to understand without a critical care foundation to build upon. In an article by Ansari et al., there is a continued need for institutional support and endorsement of undergraduate critical care exposure and edu cation to both better prepare medical students for their imminent exposure to ill patients and to help close the deficit of critical care phy sicians by promoting the specialty.2 One key teaching prin ciple underpinning education design for undergraduate intensive care place ments should be a clearly articulated learning curriculum.3 Therefore, it is imper ative that a course be created which supports the basic framework of critical care and then builds towards further ad vanced topics using a combined theoretical and practical incre mental model. Only then will a student or EM intern, especially anyone interested in applying to anesthesia or neurocritical care with early fellowship application cycles, have an adequate background to be confident in this proposed path and have the educational competency to understand critical care concepts.
The “AAEM/RSA Introduction to Critical Care in Emergency Medicine” course is comprised of multidisciplinary topics aimed at creating a firm intensive care medicine foundation for students. The eight part online lecture series was presented in a flipped-classroom method over a period of two months prior to the 2022 AAEM Scientific Assembly. The topics included
critical care pharmacology, arterial blood gas interpretation, oxygen therapy and mechanical ventilation, intra-aortic balloon pump therapy and extracorporeal membrane oxygenation, pe diatric and neonatal critical care, hemodynamic and intracranial monitoring, cardiac pacing, fluid therapy, and a brief overview of obstetric
emergencies. There was an optional ninth lecture on point-of-care ultra sonography. The practical portion of the course was completed over a four hour period, divided into two sections: hands-on advanced airway management and mechanical ventilation knobology.
Students were asked to anonymously complete a post-course survey which utilized a Likert scale to identify their perceived value of the course and comfort level with critical care topics. The Likert scale split students into those with either “no,” “some,” or “extensive” experience in critical care prior to the start of the course. From there, they were then asked their comfort level with critical care topics after completing the course, ranging from “much more post-course,” “more post-course,” and “the same post-course.” Overall, students indicated they had “some” to “no” previous critical experience prior to the start of the course. Upon course completion, all students regardless of experience prior to the course, reported that they had enhanced confidence with the founda tional topics of critical care. Those with “some” experience in critical care felt they had “more” knowledge in critical care post-course. This in dicates that even though a student may have had a prior understanding of critical care in the past, most indicating as paramedics or nurses, they felt the course had further increased their understanding of critical care medicine. Those stating they had “no” experience in critical care prior to the course felt they had “much more” of an understanding on course completion. This indicates a critical care fundamentals course is crucial for those without prior intensive care medicine experience, especially those seeking these fields in the future.
Critical care is a specialized field encompassing fundamental concepts which apply to every avenue of medicine. Many medical schools de emphasize critical care concepts into their curriculums based on the presumed complexity of the specialty. However, judging from the interest
in the “AAEM/RSA Introduction to Critical Care in Emergency Medicine” course, many students are seeking additional extracurricular opportunities to understand the basics of critical care. Medical students would benefit from having a basic understanding of the fundamentals of critical care, es pecially those who wish to aspire to career specialties such as emergency medicine, anesthesia, pulmonary medicine, and/or critical care.
Further research into the inclusion of critical care topics during medical school curriculum should be reviewed. However, the initial post-course results of the “AAEM/RSA Introduction to Critical Care in Emergency Medicine” program were promising. Due to the persistent demand for this course it will be offered once again to medical students and EM interns next year. We hope that our course demonstrates that early critical care knowledge acquisition will benefit the next generation of physicians.
Editor’s Note: Part one of “Critical Care Education: How Early is Too Early?” appeared on page 53 in the March/April 2022 issue of Common Sense.
1. Gergen D, Raines J, Lublin B, Neumeier A, et al. Integrated critical care curriculum for the third-year internal medicine clerkship. MedEdPORTAL 2020;16;11032. doi: 10.15766/mep_2374-8265.11032.
2. Ansari MA, Bshabshe AA, Otair HA, Layqah L, et al. Knowledge and confidence of final-year medical students regarding critical care core concepts, a comparison between problem-based learning and a traditional curriculum. J Med Educ Curric Dev. 2021;8: 2382120521999669. doi: 10.1177/2382120521999669.
3. O’Connor E, Martin-Loeches I. A blueprint for improving undergraduate education in intensive care medicine. Crit Care. 2016;20:12. PMID: 27461415.
" W h e n I f i r s t s i g n e d u p t o t a k e t h e c o u r s e , I w a s i n t i m i d a t e d a n d t h o u g h t m a y b e m y k n o w l e d g e b a s e a n d s k i l l s w e r e n ' t a s a d v a n c e d a s s o m e o f t h e o t h e r s i n t h e c l a s s I q u i c k l y r e a l i z e d t h a t t h i s c o u r s e i s d e s i g n e d t o t e a c h a n d b r i d g e t h e g a p s i n k n o w l e d g e a n d u n d e r s t a n d i n g r e g a r d i n g c r i t i c a l c a r e a n d E M r e g a r d l e s s o f y o u r i n i t i a l s k i l l l e v e l I f e e l m o r e c o n f i d e n t i n m y u p c o m i n g 4 t h y e a r e l e c t i v e s b y p a r t i c i p a t i n g w i t h h a n d s o n c a s e s d u e t o t h e s k i l l s e t w e p r a c t i c e d a t A A E M ’ s S c i e n t i f i c A s s e m b l y " - E m i l y A E s p o s i t o
I N T R O T O I N T R O T O C R I T I C A L C A R E C R I T I C A L C A R E I N E M E R G E N C Y I N E M E R G E N C Y M E D I C I N E M E D I C I N E
Kelsey Thompson: What is your role in the emergency department?
Sara Heinert: I am an assistant professor. I conduct my own research and I mentor clinical faculty, junior faculty in the department who might not have any expe rience with research methods, designs, or processes. I also work with undergrad students and med students to teach them about research and incorporate them into some of the department’s ongoing projects.
KT: What drew you to the field?
SH: I was in public health exclusively until my time in emergency medi cine (EM). When interviewing with my former institution, I heard how their mission was grounded in care, research around underserved patients, and community engagement. Social emergency medicine has been a good fit for me because of my public health background. It was exciting that EM physicians were thinking beyond the patient visit and about the social determinants of health affecting their patients.
KT: How do you design projects? How do you scale them when you start, and how do you find ways to build them up?
SH: Doctors see individual patients, while being in public health I look at the bigger picture. They think of research questions we can ask based on what they see in the emergency room. If there’s a gap to fil in a research question or the field, then apply for funding. As researchers, as physicians, people have their own notions of what interventions will work for a project. Until we talk to the stakeholders, the people affected by it, then what we think could work might be a waste of time. It’s something I’ve emphasized—get that input before we do too much development.
Recently there is increased focus not only on clinical and behavioral outcomes but implementation outcomes, looking at as interventions are
implemented, how are they implemented, and what of the outcomes we can measure in terms of how they’re imple mented to help us refine the interventions for the future and to implement them across other sites as we scale a study.
Scaling—pilot testing. Ideally doing a multi-site trial provides a nice opportunity to scale an interven tion and expand it. Building relationships with other sites within the health system and across the country is pretty easy these days with Zoom.
KT: When you move geographic areas or start a project, what strate gies do you use to understand the needs in the area you are in?
SH: I like to look at the data. Every hospital conducts a community needs assessment every three years and they have to make it pub licly available. Looking at census data gives a sense of the makeup of the community outside of the hospital and of the emergency de partment (ED) itself. Get to know community partners. Engaging local groups to get to know the community has been helpful to get a better understanding.
KT: What strategies do you use to find effective ways for community engagement? Who are your most common community partners? What are some pitfalls to avoid when starting these partnerships?
SH: I ask my collaborators who engage with the community for the landscape and community groups with similar interests. It’s helpful to find opportunities that are beneficial to both the academic partner and the community. My most common community groups have been high
>>Before
COVID there was a lot of talk about ED overcrowding and people wanted to decrease ED visits and were looking for ways to help frequent ED visitors. Quickly people realized that those frequent ED visitors could be helped by addressing their social needs.
schools, because I do a lot of my research on youth or adolescent lead health initiatives, advocacy, and health promotion. Right now, I am teaching a public health class at a local high school in New Brunswick. They get public health expertise for their students, and they are collecting commu nity health assessment data and co-developing some interventions for the community.
Pitfalls are coming in and thinking you know everything. Let the community partner have at least equal input about how they think that the community will best respond.
KT: Who are your internal partners in your institute and in the hospital when you work on programs? How do you make the case to these folks about investment in your projects?
SH: I have collaborators in social work, nursing, community health, and family medicine. There hasn’t been a huge need to make the case about investment in projects. A lot of projects want to involve the ED in recruit ment for a variety of studies because they have seen that the ED patients are more representative of the community than other clinical settings.
KT: How do you measure success with your projects?
SH: The easiest answer is that if you see clinical outcomes change for the better, then that is considered successful. Qualitatively, getting to a place where the members of a community get excited about the project being there. There are different ways to measure success.
KT: What advice do you have for physicians interested in engaging with social EM?
SH: If you’re a physician who doesn’t have a lot of research experience, talk to people who have done social EM research or projects. It’s best to engage those mentors at the beginning so there’s a nice path to measure outcomes and see if a project is successful. There are people doing similar work in public health, social work, nursing, even communication that might have similar interests and be able to be collaborators or mentors in the world of social EM.
KT: What are the biggest mistakes and pitfalls emergency departments make and face when trying to start work in the social EM sphere?
SH: Not talking to patients, community members or the community at large, before planning a project. Like I said, we might think one thing but the people it affects might think something totally different. It’s going to improve the project to get that feedback.
KT: What resources or communities do you recommend for physicians interested in research and project building in social EM?
SH: Reach out to collaborators within your institution who are in similar fields with more of a research background. They can help with research and funding, and they may have done projects outside of the ED that have
the potential to help ED patients. Joining social EM interest groups is helpful. They can pique interest about what projects to think about doing in the future. Multisite collaboration with other EM researchers who have similar interests is also great.
KT: Are there different considerations for different ED settings (com munity, academic, etc.)? Common lessons for all settings?
SH: There are different considerations because academics tend to be more research focused. They have more research resources and exper tise than community settings. I think what is important to think about is how academic EDs can provide mentorships to community ED settings. Community ED settings can be helpful for recruiting diverse patients that may not have access to the academic resources for clinical care, so it can be important to include those EDs from a research perspective. Common lessons—start early and figure out what your resources are. And reach out for help from the settings that do have more experience, especially if they’re in your health system.
KT: What do you say to folks who say this type of work is “outside the scope” of emergency medicine? Any other common myths you must dispel?
SH: Social EM programs should keep the regular flow of ED clinical care in mind and should not interfere with it. It is generally difficult for EM physicians to be involved in social EM during clinical time, but they can take their insight and experiences from being in the ED to inform social EM projects. It usually makes the most sense for researchers and sup port staff to take the lead on carrying out social EM research projects and should not fall on EM physicians to carry it out, but their insight is vital to program development.
Social EM has changed quite a bit in the past few years, it has more mo mentum. Before COVID there was a lot of talk about ED overcrowding and people wanted to decrease ED visits and were looking for ways to help frequent ED visitors. Quickly people realized that those frequent ED visitors could be helped by addressing their social needs. COVID really exposed a lot about the social determinants of health and their relation ship with health. Over the years people have come to realize addressing them is important as we think about emergency department research and the care that people are receiving. We’re going in a good direction as far as it not being “outside the scope” of emergency medicine.
Editor’s Note: Sara Heinert, PhD MPH, is an Assistant Professor of the Department of Emergency Medicine at Rutgers Robert Wood Johnson Medical School. Her professional biography can be accessed here: https://njacts.rbhs.rutgers.edu/education-training/workforce-develop ment/kl2-mentored-career-development-awards/sara-heinert/
s a founding member of the Academy, I can no longer hold my peace! The Academy was “established in 1993 to promote fair and equitable practice environments necessary to allow emergency physicians to deliver the highest quality of patient care.” To my knowledge, I am the only founding member of African descent. I have always been con cerned that there should be “more raisins in the oatmeal.”
Shirley Chisholm (1924-2005) was the first Black Congresswoman. She said, “If they don’t give you a seat at the table, bring a folding chair.” Through the years we members of color have had to bring our own folding chairs. The truth must be told whether we like it or not! Racism in the house of emergency medicine is real! I grew up in the Jim Crow error and know all too well overt and “subtle” racism. A Caucasian colleague asked me back in the day if I thought he was a racist. My answer to
Ahim, “Ask the man in mirror as only he and he alone can answer that question.”
I have been faced with racism from patients and colleagues through the years. The worst years of my career facing racism were at LAC+USC Medical Center (the Keck School of Medicine of USC). I was the first African American woman faculty in the history of that emergency medicine department. I was trans ferred there when racism and politics caused the closure of my beloved institution, Martin Luther King Jr./Charles R. Drew Medical Center in South Los Angeles where I was instrumental in the training of hundreds of emergency medi cine interns and residents from 1989 to 2007. I had not been at LAC+USC for six months when the chair at the time had the audacity to tell me that the interns and residents didn’t think I was qualified to teach them! None of those interns and residents were eligible to sit for the EM qualifying boards (I had been board certified and recertified by then) and many of them weren’t even licensed to practice medicine yet! I had forgotten some things that they had yet to learn!
I am compelled to voice my concern about conversation in response to an article in Common Sense by Dr. L.E. Gomez and Ms. Jada Watts. In my humble opinion, the article did not label anyone a racist and had nothing to do with “tactics.” All are entitled to their opinion, but one should not take someone else’s opinion personally! Ms. Watts was expressing how she felt in a particular situation. I, as a patient in an ED and on a post-op ward, have experienced racism firsthand. Unfortunately, attitudes changed drastically when the fact that I was a physician was revealed. I was asked “why didn’t you tell us you were a doctor?” My response, “I’m not, at this time and place, I’m a patient!” Unless one has experienced racism, one knows nothing of what I speak!
As I mentioned before, racism in the house of emergency medicine and medicine in general is real! The question is, how are we in the Academy going to “take the bull by the horns?” Black, Brown, Asian, Native Americans and the LGBTQ community are bringing folding chairs to the table. The Academy must take advantage of the brilliance of all! Diversity will ensure our survival! It is time to unite and get back to the business at hand, promoting “fair and equitable practice environments necessary to allow emergency physicians to deliver the highest quality of patient care.”
Every day I am impressed by the physicians who have chosen our specialty. We are surrounded by BAFERD’s who save lives in between their mundane tasks daily. We are the front door of the hospi tal and there are few people who can do our job, especially in the fast-paced chaotic environment in which we work. I am proud to be an emergency medicine physician, although I realize we are often the butt of the joke.
I remember, as a third-year medi cal student, telling attendings that I wanted to go into emergency medicine. I was consistently met by comments denigrating our specialty and trying to talk me out of it. One well-meaning surgeon said, “Why do you want to waste your talent to just become a glorified triage nurse?” That back handed comment stuck with me. The perception of our specialty, depending on the hospital, is not always a positive one.
I have never been one to care what people think of me. However, I would be lying if I said it does not bother me when I call a consultant and the resident on the end of the line sounds exasperated that I either; did not have time to do the thing I am calling them for help with, or that we don’t already know the answer to our consulting question. The rub is that these are the same residents who turn to our ED residents to ask for help with an intubation or line when on an off-service rotation, because deep down they trust and admire our skill set. These same residents find difficulty managing the patient volume that we carry when they rotate with us in the ED.
Recently a viral tik tok was made describing EM docs as “dumb.” I will summarize the best I can. It started with a medical assistant criticizing an EM doctor. An ER doctor responded explaining why her video was offen sive, only to have a popular GI physician respond saying—not all of you are dumb, but a lot are, and when you consult us with stupid questions that is what we remember. At first, I was annoyed, but then a pediatrician responded to the GI physician. She pointed out that while he knows a
ton about GI, we are the jack of all trades and must know about so many different specialties, so it is his job to complete the care team for his patients. She also pointed out that physicians refer their patients directly to the ED after hours or in unusual and emergent situations. Her pointing out the value in our expertise spoke volumes.
As a first-year resident I responded to an inflight emergency. Other passengers with medical training and many with more experience asked me to take over when they heard me say emergency medicine. I made it clear that I was a resident and in my first year of training, but to them I was more prepared for this sort of situation despite them having additional training in other specialties. All of this reminded me that no matter what anybody says, when they have an emergency, they turn to us for help.
If you are a medical student reading this, I want to empower you. This is an incredible spe cialty. We are strong. We are the resuscitation experts, the people who quickly evaluate acute undifferentiated patients. We set the tone for a patient’s entire hospital visit because our initial workup dictates their disposition. Further, as we are seeing right now, when the ED is suffering or overburdened the rest of the hospital is impacted. Do not let the naysayers shake your opinion on just how cool being an ER doctor is.
That being said, this specialty is not for everyone. It is hard. You see tragedy daily. You see people (sometimes the same ones every night) struggling with addiction and mental illness. You see plenty of horrible things that you often will not be able to do anything about. You may never know the answer to what was wrong with that sick patient you stabilized, and that uncertainty is difficult for many. However, if you still cannot see yourself doing any other specialty then come join us—and let’s save some lives.
DO NOT LET THE NAYSAYERS SHAKE YOUR OPINION ON JUST HOW COOL BEING AN ER DOCTOR IS.
All I knew was that she was going to kill her self, and yet somehow, in the anxiety of each ring back tone, my mind could not detach from one central thought: how could someone who once feared calling to schedule their own doctor’s appointments be the best person to handle this situation right now? But with the cessation of the tones went my own fears too, and I was greeted with a solemn “Hello?” And so began the 1 ½ hour phone call whereby I gradually and eventually talked “Taylor” out of suicide.
As it happens, this was just one of our final training exercises, not a real incident—after all, I was in a crisis negotiations course, and it had been an exhausting day. My small team of four had already negotiated our way through a variety of different crises: a violent, intoxicated hostage-taker, a knife-brandishing woman with schizophrenia in acute psychosis, a barri caded kidnapper, and now, a depressed, transgender woman about to end her life (for which I was the primary negotiator). As a nonbinary individual, this hit close to home, my sweat-drenched t-shirt an attestation to the realism of the training, evidence that I had completely forgotten that this was an exercise.
I have been asked on several occasions why I, a medical student and emergency medical technician, decided to fly halfway across the coun try to train in negotiations. Sponsored by the National Tactical Officers Association, Basic Crisis Negotiations is a course typically taken by law enforcement officers and agency-affiliated psychologists who are already on or seeking to join a crisis/hostage negotiations team. Admittedly, I felt out of place at first. However, one need not be on such a team to benefit from this training, and in fact, I can confidently say that no other course of study, even in medical school, has better prepared me to communicate with patients than this.
Why is that so? Surely, most physicians are not regularly in the position of mitigating crises similar in nature, acuity, and severity to those de scribed above. Yet, communicating with and tending to the medical and psychosocial needs of individuals experiencing behavioral emergencies is not outside the reality or scope of practice of an emergency physician. Looking more broadly, negotiating with patients is an everyday task of practically every patient-facing physician: working to find an acceptable solution to a problem, providing options, and convincing patients of cer tain recommendations are essential job functions.
So, how does one learn to listen actively? Let me introduce “MOREPIES,” an acronym developed by FBI Crisis Negotiation Unit for remembering the fundamental active listening techniques.4,5
Minimal encouragers can include simple phrases like “I see” or sounds like “Mhm.”
These are your typical “what,” “when,” “where,” “why,” and “how” ques tions that are similarly an important component of standard patient-centered interviewing.
Reflecting, or mirroring, involves repeating the last part of an individual’s message. If someone were to say, “I just feel like a such a huge burden,” you could mirror by replying, “A huge burden?”
Emotion labeling is simply the act of identifying what someone appears to be feeling. “You sound _____” ensures that you are only stating your observations/interpretations and not telling the person what they are or should be feeling.
Synonymous with its definition outside of the world of negotiations, paraphrasing is just a restatement of an individual’s previous state ment. Contrast this with summarizing, which involves the review of a larger story.
I - “I”
Think of “I” messages as self-emotion-labeling. Rather than saying something like “You’re making me upset because…,” you might in stead say, “I feel upset because…”
Sometimes a little bit of silence can do more than the best words. It may be especially suitable for conversations that become volatile, to encourage response by the individual with whom you are speaking, or to increase the impact of a preceding statement.
This involves recapping an individual’s story and/or associated emotions. Not only does it let the individual know that you have been listening, but it also provides an opportunity to ensure that you have understood everything correctly.
Crisis negotiation, like patient-centered interviewing, is rooted in active listening. But what does active listening really entail? More than just lis tening without distraction, active listening “requires that we get inside the speaker, that we grasp, from his point of view, just what it is he is com municating to us. More than that, we must convey to the speaker that we are seeing things from his point of view.”1 This demands more than just a distraction-free environment, more than just remembering the details of the sender’s message with the sole purpose of articulating a response. Active listening is a skill, one that, like any medical procedure, requires continual training and practice to avoid deterioration.
Due to the cardinal role it plays in the patient encounter, active lis tening should be a core component of all levels of physician training, especially in medical school, where communication fundamentals are first taught and before styles and habits are solidified. Unfortunately, however, standardization and assessment of specific listening skills in undergraduate medical education is lacking.2,3 I personally only recall learning the NURSE mnemonic for expressing empathy and the SPIKES mnemonic for delivery of bad news—never specific active listening skills. Considering the only recent apparent increase in focus on soft skills
within the medical school curriculum, it seems that the need for active listening training is applicable across all stages of physicianhood.
The techniques in MOREPIES create the foundation for effective active listening and will serve as a guide for even the most intense crises. However, memorizing the acronym is insufficient preparation for these situations—practicing the implementation of these techniques is crucial. Interested individuals should research “back-to-back” exercises and investigate the NTOA Basic Crisis Negotiations course, especially emer gency physicians who serve as medical directors for law enforcement agencies or are on tactical teams. Even if you are never involved in a crisis in the future, the skills learned are beneficial and applicable to every conversation—and if you are, you may just save a life.
1. Rogers, C. R., & Farson, R. E. (1957). Active listening. Chicago, IL: Industrial Relations Center of the University of Chicago.
2. Boudreau, J. D., Cassell, E., & Fuks, A. (2009). Preparing medical students to become attentive listeners. Medical teacher, 31(1), 22–29. https://doi.org/10.1080/01421590802350776
3. Meldrum, H., & Apple, R. (2020). Listening Education in the Medical Curriculum. In D. L. Worthington & G. D. Bodie (Eds.), The Handbook of Listening. John Wiley & Sons, Inc. https://onlinelibrary.wiley.com/doi/ book/10.1002/9781119554189
4. Noesner, G. W., & Webster, M. (1997, August). Crisis Intervention: Using Active Listening Skills in Negotiations. FBI Law Enforcement Bulletin, 13–18. https://leb.fbi.gov/file-repository/archives/august-1997.pdf/view
5. Dalfonzo, V. A., & Deitrick, M. L. (2015, October 9). Focus on Training: An Evaluation Tool for Crisis Negotiators. FBI Law Enforcement Bulletin. https://leb.fbi.gov/articles/focus/focus-on-training-an-evaluation-tool-forcrisis-negotiator
Considering scholarship or discounted prices based on the income dif ferential for training, courses, and workshops could help with knowledge dissemination. Finally, collaborative efforts looking to host and/or mentor international EM trainees or junior faculty can lead to effective knowl edge exchange.
ET: Thank you for your interest and thought-provoking questions.
FQ: Thank you so much for your time and for championing EM through your work with UPA del Norte at the U.S.-Mexico border.
1. Interview date: September 30, 2022 2. www.upandolatinoamerica.com 3. https://casatochan.wixsite.com/casatochan
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AND CONVINCING PATIENTS OF CERTAIN RECOMMENDATIONS ARE ESSENTIAL JOB FUNCTIONS.
Mary Unanyan, OMSIV
nterview preparation is essential to successfully matching at your desired residency program. NRMP data shows that programs rank communication skills and interactions with staff/faculty as key influencers of their ranking decisions. Your interview can make or break your chances of matching. When you receive an interview invita tion, that generally means you have met a program’s criteria on paper. The purpose of the inter view is to get to know who you are as a person and see if you would fit in with their residents, faculty, and staff. It is also your chance to get to know the pro gram itself and determine if you see yourself spending the next few years there. Ask the program about your interests. Do not be afraid to ask a challenging question if it is something you are truly curious about. Be authentic to yourself and do not try to answer how you think the program wants you to answer. Interviews should allow each party to better understand each other. The only way you will be able to gauge if you will be happy at a program is to be yourself.
Interview invitations will be sent via a sched uling system (e.g. Interview Broker, ERAS Interview Scheduler) or sent directly to your email. In either case you will receive an email notification. Thus, it is imperative to have your email accessible on your phone so that you do not miss any invites. Respond as soon as you can. A helpful scheduling tip is to have your calendar sync among your devices so that you can keep track of when your other interviews are and can plan accordingly. If you have multiple interviews, you may choose to use the first few as “test runs” by scheduling programs that may not be your top choice. Avoid double booking or hoarding your interview invites.
IAccording to NRMP, an applicant has >95% chance of matching with 11-12 interviews. If you do overbook yourself or cannot attend for any reason, make sure to cancel an interview in a timely manner—usually not shorter than two weeks prior but ideally at least a month or more so that programs have time to invite other candidates.
case they ask you to elaborate on a portion of it. It would be helpful to reflect critically about the image you want to portray—your “personal brand.” Identifying and highlighting your person al strengths and attributes will help you remain unique and memorable. Be aware that the in terviewer may also ask about any potential “red flags” in your application. Thus, it would be wise to plan ahead so that you can speak about how it impacted you and how you changed/improved as a result of it.
Interviews will still be virtual for the vast ma jority of programs. A virtual interview is an official interview and should be treated as any formal interview would. Thus, location matters! Find a clean, quiet area and make sure your background is appropriate. Remind your house mates or family about your interview to ensure there will be no loud noises or distractions like someone walking behind you. Dress for suc cess. Show up on time. Make eye contact with the camera as much as possible, especially when responding to questions. This will show your interviewer that you are engaged and cre ates a sense of genuine connection.
Make sure to reread your entire ERAS ap plication so that you are prepared to speak about any aspect of it. Be ready to discuss any of your hobbies, extracurriculars, or other experiences noted in your application. Make sure to also reread your personal statement in
Interviews are the final step in the residency application. It is understandable why they can be a significant source of anxiety for students. However, it is import ant to remember that you have made it this far and the finish line is just around the corner. An interview is a solid indicator that the program likes you. You have passed significant screening and were awarded with an invite to interview. At this point, the main objective of interviews is for you and the program to better understand each other and to see if you “fit” together well. Thus, you should be genuine and authentic to yourself. Before each interview, take a deep breath and remind yourself that you are there for a reason. You are deserving and you are worthy. So, walk into the interview with confidence. Be yourself. This will guarantee that you find the program that will best serve you.
I wish the best of luck to all my fellow EM applicants during this residency cycle. I hope you find the program that will best serve you as you start the next chapter of your medical career. Keep faith in yourself. You have come this far and, in about six months, you will be a physician. You will have achieved what you have worked so diligently towards for the past decade. Be proud of yourself. I wish you all good fortune!
Point-of-care ultrasound (POCUS) is an in valuable tool for the emergency physician, aiding in workup and diagnosis, intervention guidance, and re-evaluations in patients presenting with a vast array of complaints. POCUS improves diagnostic accuracy,1,2,3 reduces length of stay,4,5 and increases patient satisfaction.6 Additionally, point-ofcare ultrasound is considered standard of care in the management of hy potensive traumatically injured patients and for the insertion of central lines.
As a reflection of the ever-expanding role of POCUS in the emergency department, ultrasound has been recognized as a core skill in emergen cy medicine residency training. First included in the Emergency Medicine Milestones in 2012, the current milestone framework puts POCUS on par with EKG in terms of achievement level, further highlighting the essential role POCUS plays in emergency care.
As Dr. Myers discussed in the May/June 2022 issue of Common Sense, many practicing emergency physicians did not have POCUS training during residency, while others may have experienced skill decay since training. Performing an ultrasound exam without sufficient training in creases the chance of missing an important finding or misinterpretation of the findings.7 Obtaining further POCUS education, particularly affordable, high quality, hands-on training, can be limited by time constraints and lack of access to skilled educators.8
Opportunities for comprehensive, hands-on, directed POCUS educa tion exists through AAEM and the pre-conference ultrasound courses. However, the Emergency Ultrasound Section (EUS) recognizes that attending AAEM Scientific Assembly may not be feasible for certain individuals who are interested in incorporating more ultrasound into their practice. For these individuals and groups who are eager for education and hands-on training, the Emergency Ultrasound Section is now offering a portable course structured to bring ultrasound education close to home.
The EUS-AAEM Regional Hands-On Ultrasound Course has been designed to be the ultimate custom izable training, tailored to the needs of the participants. Through a combination of didactic education and ample time for scanning in small groups led by skilled faculty, participants will learn core ultrasound modalities with an emphasis on clinical implementation. For additional information and to inquire about setting up a Regional Course, please visit the EUS webpage by scanning the code below.
1. Buhumaid, Rasha E., et al. “Integrating Point-of-Care Ultrasound in the ED Evaluation of Patients Presenting with Chest Pain and Shortness of Breath.” The American Journal of Emergency Medicine, vol. 37, no. 2, 2019, pp. 298–303., https://doi.org/10.1016/j.ajem.2018.10.059.
2. Russell, Frances M., et al. “Diagnosing Acute Heart Failure in Patients with Undifferentiated Dyspnea: A Lung and Cardiac Ultrasound (Lucus) Protocol.” Academic Emergency Medicine, vol. 22, no. 2, 2015, pp. 182–191., https://doi.org/10.1111/acem.12570.
3. Barbic, David, et al. “In Patients Presenting to the Emergency Department with Skin and Soft Tissue Infections What Is the Diagnostic Accuracy of Point-of-Care Ultrasonography for the Diagnosis of Abscess Compared to the Current Standard of Care? A Systematic Review and Meta-Analysis.” BMJ Open, vol. 7, no. 1, 2017, https://doi.org/10.1136/ bmjopen-2016-013688.
4. Beals, Tyler, et al. “Point of Care Ultrasound Is Associated with Decreased Ed Length of Stay for Symptomatic Early Pregnancy.” The American Journal of Emergency Medicine, vol. 37, no. 6, 2019, pp. 1165–1168., https://doi.org/10.1016/j.ajem.2019.03.025.
5. Blaivas, Michael, et al. “Decreasing Length of Stay with Emergency Ultrasound Examination of the Gallbladder.” Academic Emergency Medicine, vol. 6, no. 10, 1999, pp. 1020–1023., https://doi. org/10.1111/j.1553-2712.1999.tb01186.x.
6. Howard, Zoe D., et al. “Bedside Ultrasound Maximizes Patient Satisfaction.” The Journal of Emergency Medicine, vol. 46, no. 1, 2014, pp. 46–53., https://doi.org/10.1016/j.jemermed.2013.05.044.
7. Myers, M. “Education in Point of Care Ultrasound.” Common Sense, vol. 29, no 3, 2022, pp 29.
8. Russell, Frances M., et al. “Design and Implementation of a Basic and Global Point of Care Ultrasound (Pocus) Certification Curriculum for Emergency Medicine Faculty.” The Ultrasound Journal, vol. 14, no. 1, 2022, https://doi.org/10.1186/s13089-022-00260-y.
Meningitis is one of the most critical diagnoses made in the emergency department. This disease can present in multiple different ways. Bacteria causing meningitis differ by age group. In adults, the most common pathogens include Streptococcus pneumoniae, Neisseria meningitidis, and Listeria monocytogenes. However, uncommon bacteria found in healthy human flora can also cause meningitis, such as Streptococcus Mitis.
The purpose of this ca se report is to discuss one of the uncommon bacteria that resides in human oral flora, namely S. mitis. Our case report aims to highlight the importance of its microbiology to better understand its pathogenesis and associated risk factors.
A 42-year-old male with a past medical history of recurrent frontal mi graines and non-insulin-dependent diabetes mellitus presented to the emergency department for evaluation of a headache starting two days before arrival. The headache was localized to the posterior head and radiated down the patient’s neck. Symptoms were exacerbated with neck movement and lying flat. A review of systems was positive for nausea and a few episodes of non-bloody, non-bilious emesis.
Vital signs on arrival were notable for a temperature of 97.9 degrees Fahrenheit, heart rate 122 beats per minute, respiratory rate 18 breaths per minute, blood pressure 131/68 mmHg, and oxygen saturation 98% on room air. Physical exam was significant for an uncomfortable, ill-appearing male, lying in a fetal position with eyes closed and actively vomiting. The patient did not have any neurologic deficits on physical exam.
Notable labs during the initial evaluation included bicarbonate (17 mmol/ dL), anion gap (33 mmol/dL), glucose (72 mmol/dL), serum osmolality (321 mOsmol/kg), lactic acidosis (6.9 mmol/L), leukocytosis (26.6 B/L), and thrombocytosis (552 B/L). The chest X-ray revealed a consolidation in the right upper and middle lobes, and the CT brain showed no acute findings. A lumbar puncture was attempted by the emergency depart ment team but was unsuccessful.
The patient received three liters of normal saline and was started on an insulin infusion for hyperglycemic hyperosmolar syndrome. The patient also received two grams of cefepime and two grams of vancomycin. The patient was admitted to the medicine service for hyperosmolar hyper glycemic syndrome and sepsis secondary to pneumonia and possibly meningitis.
During the inpatient course, a lumbar puncture was performed by inter ventional radiology. It yielded purulent cerebrospinal fluid (CSF), with an elevated opening pressure of 27 cm H2O. Fluid analysis revealed RBC greater than 50,000 µ/L, WBC equal to 50,500 µ/L, glucose less than 2 µ/L, and protein greater than 600 µ/L. The CSF culture grew al pha-hemolytic Streptococcus, which speciated to S. mitis. Upon further questioning, the patient reported having dental work performed prior to admission. The remainder of the infectious work-up, including HIV 1,2 PCR returned negative. The cefepime was replaced with ampicillin per culture sensitivity. The patient was successfully discharged after complet ing a full course of intravenous antibiotics.
Streptococci are gram-positive organisms that are omnipotent in healthy oral microbiota. They are further classified as alpha-hemolytic, be ta-hemolytic, or gamma-hemolytic based on their behavior on agar. The alpha-hemolytic group is further divided into Streptococcus pneumoniae and Streptococcus viridans. The latter, which is the commensal type, can become pathogenic under the right circumstances. This discussion will focus on S. mitis
To understand the risk factors it is essential to understand the organism’s virulence factors and recognize its genetic similarity to S. pneumoniae S. mitis begins its crusade against the immune system by expressing pro teins allowing it to adhere to oral epithelial cells and evade the immune system by cleaving immunoglobulins.2 S. mitis then orchestrates a proinflammatory state by increasing interleukin production.2 The genetic similarities between the Streptococcus species can allow a commensal strain, such as S. mitis to become pathogenic. This is due to its ability to encode the same virulence factors used by S. pneumoniae. 2,4
After the initial infection, S. mitis can translocate to the cerebrospinal fluid. This is likely possible because of its ability to express lipoteicho ic acid (LTA). Researchers discovered that group B Streptococcus (Streptococcus agalactiae), another strain that is genetically similar to S. mitis, uses LTA to interact with the blood-brain barrier.3 Several genes have been identified in S. mitis that allow the synthesis of LTA.
S. mitis and other oral streptococci are known to cause endocarditis due to their ability to form dextrans allowing adherence to heart valves. S. mitis has been reported to also cause meningitis in the setting of spinal anesthesia, neurosurgical procedures, congenital ENT malformations, malignancy, and neurological complications of endocarditis.8 Bacterial meningitis secondary to S. mitis has been reported in children and adults with cerebrospinal fluid leaks as well.1
Initial treatment can take one of two approaches. The first involves anti biotics tailored to a specific organism, guided by the clinical situation and CSF analysis. The second is to cast a broad net to cover a handful of the most common organisms, followed by adjustments per culture results, CSF analysis, and clinical course. Most Streptococci are sensitive to penicillin.7 However, there are emerging strains, even some identified in dental plaques, that display resistance to penicillins.6 Additional strains from the S. viridans group with varying degrees of sensitivity to penicillin have been identified in patients with endocarditis.5,6
A third-generation cephalosporin such as ceftriaxone is the treatment of choice for bacterial meningitis. It would treat most penicillin-sensitive Streptococcal organisms such as S. pneumoniae and S. mitis, as well as N. meningitidis. Unfortunately, due to the rising incidence of penicillin-re sistant Streptococcus the addition of vancomycin is required as well.9 If there is a concern for L. monocytogenes (gram-positive bacillus) then ampicillin should be added.10 Antibiotics should ultimately be tailored per culture results.
Genetic relationships between the various Streptococcal species can enable communal organisms to produce dangerous pathology. This specific patient did not have any of the above risk factors, but the right combination of virulence factors led to pneumonia and meningitis, per our infectious disease colleagues. We believe additional research needs to be performed on the various genes and proteins that enable commensal organisms such as S. mitis to become deadly pathogens. Finally, it is par amount to be wary of risk factors that predispose patients to infection by otherwise harmless organisms.
* Jefferson Northeast, Philadelphia, PA
1. Fukayama, H., Shoji, K., Yoshida, M., Iijima, H., Maekawa, T., Ishiguro, A., & Miyairi, I. (2022). Bacterial meningitis due to the Streptococcus mitis group in children with cerebrospinal fluid leak. IDCases, 27, e01406. https://doi.org/10.1016/j.idcr.2022.e01406
2. Kilian, M., & Tettelin, H. (2019). Identification of Virulence-Associated Properties by Comparative Genome Analysis of Streptococcus pneumoniae, S. pseudopneumoniae, S. mitis, Three S. oralis Subspecies, and S. infantis. mBio, 10(5), e01985-19. https://doi.org/10.1128/ mBio.01985-19
3. Doran, K. S., Engelson, E. J., Khosravi, A., Maisey, H. C., Fedtke, I., Equils, O., Michelsen, K. S., Arditi, M., Peschel, A., & Nizet, V. (2005). Blood-brain barrier invasion by group B Streptococcus depends upon proper cell-surface anchoring of lipoteichoic acid. The Journal of clinical investigation, 115(9), 2499–2507. https://doi.org/10.1172/JCI23829
4. Mitchell J. (2011). Streptococcus mitis: walking the line between commensalism and pathogenesis. Molecular oral microbiology, 26(2), 89–98. https://doi.org/10.1111/j.2041-1014.2010.00601.x
5. Süzük, S., Kaşkatepe, B., & Çetin, M. (2016). Antimicrobial susceptibility against penicillin, ampicillin and vancomycin of viridans group Streptococcus in oral microbiota of patients at risk of infective endocarditis. Le infezioni in medicina, 24(3), 190–193.
6. Seppälä, H., Haanperä, M., Al-Juhaish, M., Järvinen, H., Jalava, J., & Huovinen, P. (2003). Antimicrobial susceptibility patterns and macrolide resistance genes of viridans group streptococci from normal flora. The Journal of antimicrobial chemotherapy, 52(4), 636–644. https://doi. org/10.1093/jac/dkg423
7. Tuohy, M., & Washington, J. A. (1997). Antimicrobial susceptibility of viridans group streptococci. Diagnostic microbiology and infectious disease, 29(4), 277–280. https://doi.org/10.1016/s0732-8893(97)00140-5
8. Kutlu, S. S., Sacar, S., Cevahir, N., & Turgut, H. (2008). Communityacquired Streptococcus mitis meningitis: a case report. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases, 12(6), e107–e109. https:// doi.org/10.1016/j.ijid.2008.01.003
9. Clauss, H. E., & Lorber, B. (2008). Central nervous system infection with Listeria monocytogenes. Current infectious disease reports, 10(4), 300–306. https://doi.org/10.1007/s11908-008-0049-0
10. Sinner, S. W., & Tunkel, A. R. (2004). Antimicrobial agents in the treatment of bacterial meningitis. Infectious disease clinics of North America, 18(3), 581–ix. https://doi.org/10.1016/j.idc.2004.04.005
4. Rizzolo D, Krackov RE. Integration of Ultrasound Into the Physician
Assistant Curriculum. J Physician Assist Educ. 2019 Jun;30(2):103-110. doi: 10.1097/JPA.0000000000000251. PMID: 31124808.
5. American Institute of Ultrasound in Medicine, Ultrasound in medical education portal: medicals schools. http://meded.aium.org/medicalschools, accessed September 20, 2022.
6. Chen LL. Standardized adult-gerontology acute care nurse practitioner point-of-care ultrasound training: A new perspective in the age of a pandemic. J Am Assoc Nurse Pract. 2020 Jun;32(6):416-418. doi: 10.1097/JXX.0000000000000448. PMID: 32511190.
7. Snelling PJ, Jones P, Keijzers G, Bade D, Herd DW, Ware RS. Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study. Emerg Med J. 2021 Feb;38(2):139-145. doi: 10.1136/ emermed-2020-209689. Epub 2020 Sep 8. PMID: 32900856.
8. Huang C, Morone C, Parente J, Taylor S, Springer C, Doyle P, Temin E, Shokoohi H, Liteplo A. Advanced practice providers proficiency-based model of ultrasound training and practice in the ED. J Am Coll Emerg Physicians Open. 2022 Jan 11;3(1):e12645. doi: 10.1002/emp2.12645. PMID: 35036994; PMCID: PMC8749492.
he emergency depart ment (ED) is often the landing zone for a crashing patient, and intubation by ED physi cians saves lives. However, the patient may have an extended layover in the ED before transfer to the intensive care unit (ICU), and care during this time is also crucial. Sedation received in the ED may have a signifi cant adverse impact on hospital length of stay and mortality.1 While intu bated patients remain in the ED, emergency physicians should tailor sedation and analgesic regimen to patient needs.
As demonstrated in the 2012 SPICE trial, early deep sedation beginning within the first four hours of intubation predicts prolonged intubation and increased risk of hospital death and long-term mortality. 2 However, seda tion often must be initiated as soon as mechanical ventilation is begun, because the neuromuscular blockade induced during rapid sequence intubation (RSI) may outlast the effects of the sedative administered. For instance, patients that receive etomidate and rocuronium for RSI may remain paralyzed for over an hour, long after the three to five minute dura tion of etomidate has ended, risking ongoing patient paralysis without an algesia or sedation.3,4 Deep sedation may be pursued for some patients with severe hypoxemic respiratory failure. Conversely, some patients may not require any ongoing sedation, as is often the case with patients intu bated in the setting of reduced level of consciousness for whom unnec essary sedation may prohibit accurate neurological examination.
To guide sedative dosing, the depth of patient sedation should be deter mined using scoring systems such as the Richmond Agitation-Sedation Scale (RASS), which utilizes observations of patient behavior and patient response to verbal and physical stimuli.5 Society of Critical Care Medicine (SCCM) guidelines recommend targeting a “light” level of sedation, which can decrease time to extubation and rates of tracheostomy.6 On RASS assessment, this corresponds to awakening and making eye contact when the patient is given a verbal stimulus. Though some patients may require deeper sedation to adequately control agitation or pain, increas ing sedation intensity in the first 48 hours of intubation can increase 180day mortality in a dose-dependent fashion.7
SCCM guidelines also recommend “analgesia-first sedation;” pain control should be prioritized prior to implementation of sedating medications. Opioids such as fentanyl, morphine, hydromorphone, and remifentanil are the preferred agents for analgesia. Fentanyl infusions are commonly used for this purpose, though in one study evaluating patients sedated follow ing RSI in the ED, intermittent boluses rather than continuous infusions of fentanyl resulted in lower cumulative ED fentanyl doses and a lower risk of delirium.8
TContinuous infusion of propofol is a common component of ICU sedation regimens that offers attractive pharmacokinetics, including a rapid onset and a short duration of action. Propofol acts on γ-aminobutyric acid type A receptors and has anti-convulsant properties; it is frequently used in the treatment of status epilepticus. The short half-life allows for interruption of sedation for serial neurologic assessments. It often causes hypo tension, which may necessitate the use of vasopressors, and it induces significant respiratory depression. Other adverse effects, including hyper triglyceridemia, pancreatitis, and propofol-related infusion syndrome, are generally limited to infusions lasting greater than 48 hours.9 Compared to benzodiazepines, sedation with propofol is associated with decreased mortality and duration of mechanical ventilation.10
Dexmedetomidine is an -2 adrenoceptor agonist that provides sedative, anxiolytic, and some analgesic effects without inducing significant respi ratory depression, which also allows its use in the absence of invasive mechanical ventilation. It is administered as a titratable continuous infu sion, and dosing may be limited by bradycardia and hypotension. When compared to propofol, dexmedetomidine-based sedation regimens have comparable outcomes including rates of delirium, duration of mechanical ventilation, and mortality rates.11
Benzodiazepine-based sedation regimens are no longer routinely employed due to the risk of increased duration of mechanical ventila tion, ICU length of stay, and mortality.12,13 With prolonged or repeated administration, benzodiazepines accumulate in adipose tissue, causing an unfavorably long duration of effect. Though propofol and dexmedeto midine are more appropriate as first-line sedatives, benzodiazepines are indicated in some clinical scenarios including refractory status epilepticus and alcohol withdrawal.
Post-intubation sedation is an important component of ED management of critically ill patients. Pharmacotherapeutic interventions undertaken in the ED can affect outcomes in the ICU and beyond. Evidence-based strategies, including titration of sedation to a light level of sedation, may later help the critical care team in their efforts to liberate the patient from the mechanical ventilator, the ICU, and the hospital.
* Louisiana State University Health Sciences Center, Baton Rouge
1. Stephens RJ, Ablordeppey E, Drewry AM, et al. Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED: A Cohort Study. Chest 2017;152(5):963-971. doi:10.1016/j.chest.2017.05.041
2. S Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012;186(8):724-731. doi:10.1164/rccm.201203-0522OC
3. Johnson EG, Meier A, Shirakbari A, Weant K, Baker Justice S. Impact of Rocuronium and Succinylcholine on Sedation Initiation After Rapid Sequence Intubation. J Emerg Med. 2015;49(1):43-49. doi:10.1016/j. jemermed.2014.12.028
4. Kendrick DB, Monroe KW, Bernard DW, Tofil NM. Sedation after intubation using etomidate and a long-acting neuromuscular blocker. Pediatr Emerg Care. 2009;25(6):393-396. doi:10.1097/PEC.0b013e3181a7923b
5. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond AgitationSedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338-1344. doi:10.1164/ rccm.2107138
6. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e873. doi:10.1097/CCM.0000000000003299
7. Shehabi Y, Bellomo R, Kadiman S, et al. Sedation Intensity in the First 48 Hours of Mechanical Ventilation and 180-Day Mortality: A Multinational Prospective Longitudinal Cohort Study. Crit Care Med. 2018;46(6):850859. doi:10.1097/CCM.0000000000003071
8. Wolf L, Messana E, Wilson SS, Park L. Impact of intermittent versus continuous infusion of fentanyl after rapid sequence intubation on intensive care unit delirium. Ann Emerg Med. 2017; 70(4 Supplement 1), S37. https://doi.org/10.1016/j.annemergmed.2017.07.116
9. McKeage K, Perry CM. Propofol: a review of its use in intensive care sedation of adults. CNS Drugs. 2003;17(4):235-272. doi:10.2165/00023210-200317040-00003
10. Lo Lonardo NW, Mone MC, Nirula R, et al. Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients [published correction appears in Am J Respir Crit Care Med. 2014 Jun 1;189(11):e70]. Am J Respir Crit Care Med. 2014;189(11):1383-1394. doi:10.1164/rccm.201312-2291OC
11. Hughes CG, Mailloux PT, Devlin JW, et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med 2021;384(15):1424-1436. doi:10.1056/NEJMoa2024922
12. Fraser GL, Devlin JW, Worby CP, et al. Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med. 2013;41(9 Suppl 1):S30-S38. doi:10.1097/ CCM.0b013e3182a16898
13. Lee H, Choi S, Jang EJ, et al. Effect of Sedatives on In-hospital and Longterm Mortality of Critically Ill Patients Requiring Extended Mechanical Ventilation for ≥ 48 Hours. J Korean Med Sci. 2021;36(34):e221. Published 2021 Aug 30. doi:10.3346/jkms.2021.36.e221
Zachary R. Wynne, MD, Kyle A. Glose, MD, Samantha J. Yarmis, MD, Cody Couperus, MD, John B. Harringa, MD, and Zachary J. Rogers, MD
Editors: Kami M. Hu, MD FAAEM and Donald Doukas, MD
Question: In the treatment of cancer-related venous thromboembolism, is there a difference between low molecular weight heparin and direct oral anticoagulants regarding rates of recurrent venous thromboembolism and major bleeding events?
Malignancy represents a significant risk factor for the development of venous thromboembolism (VTE). An estimated 4-20% of patients with cancer will develop VTE during their treatment course, and patients with a history of malignancy have a five-fold chance of developing VTE com pared to the general population (0.5% vs. 0.1%, respectively).1 For some time, low molecular weight heparins (LMWH) such as enoxaparin and dalteparin remained the standard of care in this population after several studies showed improved safety benefits compared to vitamin K antag onists like warfarin.2,3 Over the past decade, there has been a significant rise in the use of direct oral anticoagulants (DOACs) such as rivaroxaban, edoxaban, and apixaban for VTE and atrial fibrillation. This review aims to determine if the current body of literature supports the use of DOACs over low molecular weight heparin in the treatment of cancer-related VTE, specifically in terms of recurrent VTE, clinically relevant bleeding, and mortality.
Kraaijpoel N, Di Nisio M, Mulder FI, et al. Clinical Impact of Bleeding in Cancer-Associated Venous Thromboembolism: Results from the Hokusai VTE Cancer Study. Thromb Haemost. 2018;118(8):14391449.
This study was a secondary analysis of the Hokusai VTE Cancer study, which compared edoxaban to dalteparin, looking at the outcomes of recurrent VTE or major bleeding events. The original study found that the primary composite outcome of recurrent VTE and/or major bleeding occurred more frequently in the dalteparin group (13.5% vs. 12.8%, p = 0.006). However, when these two endpoints were analyzed independent of each other, the absolute rate of recurrent VTE was 3.4% lower in the edoxaban group, while the absolute rate of major bleeding was 2.9% higher. The purpose of this secondary study was to identify sites of major bleeding, bleeding associated with various tumor types, and to character ize bleeding events from the original study.
The original Hokusai VTE Cancer study was a randomized, open-label, blinded outcome evaluation, non-inferiority trial. Patients with a history of malignancy with symptomatic or incidental deep vein thrombosis (DVT), pulmonary embolism (PE), or both were included. Exclusion criteria included pretreatment with anticoagulant longer than 72 hours, active bleeding, creatinine clearance less than 30 mL/min, platelet count less than 50,000, or chronic nonsteroidal anti-inflammatory drug (NSAID) therapy. Patients were randomized to either edoxaban or dalteparin and
treated for 6 to 12 months with follow-up at day 31, three months, six months, nine months, and 12 months after randomization. Bleeding events were classified as major bleeding (MB) or clinically relevant non-major bleeding (CRNMB) events. Major bleeding was defined as clinically evident bleeding with a decrease in hemoglobin by ≥ 2 g/dL, transfusion of ≥ 2 units of packed red blood cells, occurring at a critical site, or fatal bleeding. MB severity was then categorized from one (mini mal intervention) to four (unavoidable death). Clinically relevant non-ma jor bleeding was defined as clinically evident bleeding requiring medical evaluation.
1,050 patients were enrolled in the study, with similar baseline char acteristics between groups. Solid tumors made up most of the study population (89.1%), with distant metastasis present in over half (53.0%). Gastrointestinal (GI) cancer was present in 29.2% of the study popula tion. Edoxaban had a higher risk of MB than dalteparin (6.1% vs. 3.1%, HR 2.0, 95% CI 1.09–3.66; p=0.025). This increased risk was driven by the increase in MB with edoxaban compared to dalteparin in gastroin testinal malignancies (12.7% vs. 3.6%, HR 4.0, 95% CI 1.5-10.6; p = 0.005). Rates of MB were comparable in non-GI malignancies, but there was more GI bleeding in the edoxaban group overall (4.2% vs. 1%), with upper GI bleeds making up 71.4% of overall MB events. Dalteparin had a higher proportion of category three and four bleeding course severities compared to edoxaban (25.0% vs. 9.4% and 6.3% vs. 0%, respectively). More CRNMB events occurred in the edoxaban group (13.4% vs. 9.2%). Bleeding events occurred throughout the treatment course and did not specifically appear to be associated with the duration of therapy. Strengths of this analysis include the strengths of the original study: randomization, blinding of the outcome, and diverse mix of malignancy types. Categorization of bleed severity was separately and independently adjudicated, but the open-label nature of the trial may have influenced clinicians’ desire to transfuse blood products when reversal agents were not readily available. Of note, several investigators received funding from the pharmaceutical companies that make edoxaban (Daiichi Sankyo) and dalteparin (Pfizer). While edoxaban seems to be a similarly safe and more effective alternative to dalteparin for non-GI malignancy-related VTE, the increase in MB associated with GI malignancies should give prescribers pause when determining appropriate therapy in that patient population.
Young AM, Marshall A, Thirlwall J, et al. Comparison of an Oral Factor Xa Inhibitor with Low Molecular Weight Heparin in Patients with Cancer with Venous Thromboembolism: Results of a Randomized Trial (SELECT-D). J Clin Oncol. 2018;36(20):2017-2023.
This study was a randomized, open-label, multicenter pilot trial that assessed VTE recurrence rates in patients with active cancer treated with either rivaroxaban or dalteparin. Patients were included if they had active cancer (either solid or hematologic) and were found to have DVT or PE. Once enrolled, patients were assigned 1:1 to either dalteparin or rivar oxaban, centrally randomized with stratification according to malignancy stage, baseline platelet count, type of VTE, and risk of clotting by tumor type. The dose of dalteparin was 200 IU/kg administered subcutaneously once per day for 30 days, followed by 150 IU/kg subcutaneously once per day for an additional five months. Those patients randomly assigned to ri varoxaban were given 15 mg orally twice per day for 21 days, followed by 20 mg tablets given orally daily for a total treatment time of six months. The dosing for both medications was adjusted or held as necessary for severe thrombocytopenia or renal dysfunction. The primary outcome was VTE recurrence, with secondary outcomes of MB and CRNMB. Outcome events were adjudicated by committees unaware of treatment allocation. Patients were assessed at three-month intervals. At the five-month mark, patients with an initial DVT were re-screened to assess for residual clot burden using compressive venous ultrasonography. Otherwise, venous ultrasound and computerized tomography (CT) scans to evaluate for DVT or PE were only repeated if clinically indicated.
Of 670 patients eligible for enrollment, 264 declined, leaving 406 pa tients, with 203 patients randomized to each arm. Baseline character istics were similar between groups. The study population was primarily white (95%), with colorectal malignancy as the most common cancer (25%) and incidental PE (53%), and symptomatic DVT (26%) as the most common VTE types. Only 216 patients (54%) completed the entire six months of therapy. The main reason for patients not completing treatment was death (in approximately a third of patients), but VTE recur rence, “clinical decision” by treating clinicians, and withdrawal of consent/ participant decision were other notable causes.
The recurrence rate for VTE at six months for patients receiving dalte parin was 11% compared to 4% in the rivaroxaban group (HR 0.43, 95% CI 0.19-0.99). Of the recurrent VTEs, 8/18 in the dalteparin group were PEs compared to 3/8 in the rivaroxaban group. Each group had a single fatal PE occurrence. With respect to secondary outcomes, there was no statistical difference in the rate of MB (4% in the dalteparin group vs. 6% in the rivaroxaban group). Most MB events were gastrointestinal (GI) in origin, with no CNS bleeding in either group. CRNMB occurred more frequently in the rivaroxaban group (13% vs. 4%, HR 3.76, 95%CI 1.638.69) and was predominantly from a GI source. Of note, the Data Safety and Monitoring Committee identified a statistically significant increase in MB events with rivaroxaban (4/11 patients, 36%) in patients with esoph ageal/gastroesophageal junction malignancies enrolled early in the study leading to a halt in further enrollment of patients with these malignancies. The MB bleeding rate for dalteparin in this subgroup was 1/19 patients, or 11%. There was no difference in overall survival at six months be tween the two treatment arms.
Several limitations listed by the authors included slow recruitment with a high mortality rate and a high rate of discontinuation of study medication (only 54% of patients completed the full six months of treatment). Additionally, the long-term effects past six months cannot be determined based on this study. It is worth noting that rivaroxaban’s superiority in preventing recurrent VTE was largely based on the identification of as ymptomatic PEs found on CTs for cancer staging, the size and clinical relevance of which are not disclosed. Removal of these incidental find ings from both arms of the study would have resulted in a nonstatistical difference between both medications. While overall rates of MB were not different, the signal towards increased GI CRNMB and increased MB in upper GI malignancies with rivaroxaban still warrants attention.
Agnelli G, Becattini C, Meyer G, et al. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med. 2020;382(17):1599-1607.
This study was a multinational, open-label, randomized controlled, non inferiority trial comparing apixaban to subcutaneous dalteparin for the treatment of cancer-associated VTE. A central adjudication committee managed this trial. Adult patients with confirmed active cancer other than squamous or basal cell carcinoma, primary brain tumors, known intracerebral metastases, or acute leukemia were eligible for the study if they had a newly diagnosed proximal lower-limb DVT or PE. Patients with both symptomatic and incidental DVT/PE were eligible for the study. Additional major exclusion criteria included life expectancy of less than six months, increased bleeding risk, and contraindications to antico agulation. Randomization occurred in a stratified 1:1 fashion and was performed through a central system. The intervention group received apixaban 10mg twice daily for seven days and 5mg twice daily afterward. The comparison group received 200 IU/kg of subcutaneous dalteparin for the first month and 150 IU/kg daily thereafter (up to a maximum daily dose of 18,000 IU).
The primary outcome of recurrent VTE occurred in 5.6% of patients in the apixaban group and 7.9% of patients in the dalteparin group (HR 0.63, 95% CI 0.37-1.07; p<0.001 for noninferiority). However, on sub group analysis, there was significantly less recurrent VTE in patients younger than 65 years on apixaban compared to dalteparin (3.5% vs. 12.9%, p=0.0065). Major bleeding events were similar between the two groups, with 3.8% in the apixaban group and 4.0% in the dalteparin group (HR 0.82, 95% CI 0.40-1.69; p=0.60). There was no statistically significant difference in the number of deaths due to MB. The combined cumulative incidence of recurrent VTE or MB was also similar between the groups, 8.9% in the apixaban group and 11.4% in the dalteparin group (HR 0.70, 95% CI 0.45-1.07). Death from any cause by study day 210 occurred in 24.4% of patients in the apixaban group and 26.4% of patients in the dalteparin group, with most deaths (>85%) attributable to cancer in each group. Each study group had 4 VTE-related deaths and two bleeding-related deaths.
The most prominent limitation of this trial is that it was open-label. Researchers attempted to mitigate this limitation by central adjudication of the study in a blinded manner. Patients with certain types of cancer were excluded from the trial; as such, these results cannot be general ized to include those patients. Finally, the authors comment that their sample size was appropriately powered for the primary outcome of recurrent VTE but was not appropriately powered to make definitive conclusions regarding bleeding risk. Overall, this trial suggests that apixaban is non-inferior to dalteparin in the treatment of cancer-associated VTE and does not appear to carry an increased risk of MB.
Cohen A, Keshishian A, Lee T, et al. Effectiveness and Safety of Apixaban, Low-MolecularWeight Heparin, and Warfarin among Venous Thromboembolism Patients with Active Cancer: A U.S. Claims Data Analysis. Thromb Haemost. 2021;121(3):383-395.
This retrospective study reviewed United States commercial insurance claims data to investigate changes in anticoagulant prescriptions in pa tients with diagnoses of VTE and cancer. It included patients 18 years or older with at least one claim for VTE between September 1, 2014, and March 1, 2018, and at least two claims for cancer (diagnosis and/ or treatment) between six months prior and 30 days after the index VTE claim. Patients also had to have a claim for either apixaban, warfarin, or LMWH in the 30 days after the index VTE claim. Exclusion criteria included claims for atrial fibrillation, mechanical heart valve, prior anticoagulant therapy within six months prior to the current study period, inferior vena cava filter, pregnancy, and MB on LMWH as a bridge to warfarin. Treatment patterns were measured to determine discontinu ation or switch in anticoagulants at six months and for the rest of the follow-up period. Outcomes measures included claims for recurrent VTE within seven days of index event, MB, and CRNMB, defined as noncritical bleeding requiring hospitalization or documented as an outpatient claim. Inverse-probability treatment weighting (IPTW), a technique using pro pensity scores, was used to match the three treatment arms. Incidence rates were calculated for outcomes and demonstrated on Kaplan-Meier curves, with 95% confidence intervals.
A total of 14,086 patients were included in the analysis (24.1% apixaban, 43.4% LMWH, 32.5% warfarin). Using a modified Khorana VTE-risk scale, 20.6% of the LMWH group were determined to have high-risk cancer, compared to 9.5% in the warfarin group and 9.6% in the apixaban group. At the six-month follow-up, apixaban had the highest persistence of treatment (60.1%), followed by warfarin (50.1%) and LMWH (38.9%). The adjusted incidence rate of recurrent VTE was 15.8 per 100 person-years for apixaban, compared to 22.2 for warfarin and 28.8 for LMWH. Apixaban had a lower risk of recurrent VTE (HR 0.61, 95% CI 0.47-0.81; p=0.001), MB, (HR 0.63, 95% CI 0.47-0.86, p=0.003), and CRNMB (HR 0.81, 95% CI 0.70-0.94; p=0.006) compared to LMWH at six months. Apixaban also had a lower risk of recurrent VTE compared to warfarin (HR 0.68, 95% CI 0.52-0.90; p=0.007), but no statistically significant difference in MB and CRNMB. There were no significant differ ences between warfarin and LMWH in rates of recurrent VTE or bleeding
events at six months. When analyzed for the remainder of the study, re sults were similar, except apixaban was found to have a lower risk of MB than warfarin (HR 0.72, 95% CI 0.55-0.95, p=0.018) after a longer period.
The major limitation of this study is its dependence on ICD-10 codes, which are open to miscoding and could not be verified by actual health records or biochemical data. Additionally, the study was retrospective, giving only correlative rather than causative conclusions to the data. There is the risk of duplicate information in the claims databases, but the researchers felt this to be less than one percent. The methods used to identify MB and CRNMB using ICD-10 codes have not been validated in the literature and could have potentially miscategorized some bleed ing episodes. Mortality was not included in claims data, which could confound outcomes but is also an important clinically relevant outcome missing from this data set. This study suggests that, when treating can cer-related VTE, apixaban may be both safer and more effective than either warfarin or LMWH. Though the larger data set increases external validity, the clinical question could benefit from randomized clinical trials or prospective data based on direct patient data with additional key out come measures such as mortality.
McBane, R.D., Wysokinski, W.E., Le-Rademacher, J.G. et al. Apixaban and dalteparin in active malignancy-associated venous thromboembolism: The ADAM VTE trial. J Thromb Haemost. 2020 Feb;18(2):411-421.
This randomized, open-label trial compared the risk of bleeding between apixaban and dalteparin in treating VTE among cancer patients. Patients were eligible for inclusion if they were above 18 years of age and had confirmed active cancer and an acute thrombus of any location (extrem ity, pulmonary, splanchnic, or cerebral vein). Additional inclusion criteria were life expectancy > 60 days, Eastern Cooperative Oncology Group (ECOG) performance status score ≤ 2, platelet count ≤ 50,000/µL, transaminases greater than three times the upper limit of normal, international normalized ratio (INR) ≤ 1.6, creatinine clearance ≥ 30mL/min, and a negative pregnancy test. Exclusion criteria were anticoagulant use for > seven days prior to randomization, active bleeding, cirrhosis with Childs Pugh class B or C, known failure of anticoagulant treatment, or prior heparin-induced thrombocytopenia. Patients were randomized to receive either apixaban (10mg twice daily for seven days followed by 5mg twice daily) or dalteparin (200 IU/kg daily for one month, followed by 150 IU/kg) for a total of six months. There were predetermined dose adjustments for invasive procedures, acute kidney injury, thrombocytopenia, and certain drug-drug interactions. The primary outcome was any MB during the six months of treatment, defined as “overt bleeding plus a hemoglobin decrease of greater than or equal to 2 g/dL; or transfusion of two units or more of packed red blood cells; or intracranial, intraspinal/epidural, intraocular, retroperitoneal, pericardial, intraarticular, intramuscular with compartment syndrome, or fatal bleeding.” Secondary outcomes includ ed CRNMB (i.e., bleeding not meeting the above criteria but requiring medical intervention, unscheduled health care contact, or temporary anticoagulant cessation) and recurrent thromboembolism.
In total, 300 patients were enrolled and divided equally among the two groups. For the primary outcome, zero patients in the apixaban group (0%) compared to two patients in the dalteparin group (1.4%) had major bleeding (p=0.138). There were nine CRNMB events in the apixaban group (6.2%) compared to seven in the dalteparin group (4.2%); these were not analyzed on their own for statistical significance, but when comparing overall bleeding, there was no difference between the groups (p=0.8816). For the secondary endpoint, recurrent VTE, there was a statistically significantly lower rate in the apixaban group compared with the dalteparin group (0.7% vs. 6.3%, HR 0.099, 95% CI 0.013-0.780; p=0.0281). There was no difference in mortality between groups. Of note, more patients randomized to dalteparin chose to stop therapy com pared to those randomized to apixaban (22 vs. 6, p=0.0012).
Overall, this study supports the safety and efficacy of apixaban for ma lignancy-related VTE. Bleeding risk was similar between the two agents studied, but recurrent VTE and patient refusal rates were lower in the apixaban group. Limitations of this study include small sample size, an unblinded format, and a per-protocol analysis as opposed to an inten tion-to-treat analysis. Regarding this last point, the authors state that the analysis was similar but do not provide these numbers specifically; however, given the relatively low number of patients who dropped out or refused treatment, this is unlikely to cause significant attrition bias. While larger studies would be needed to demonstrate the superiority of apixaban or other DOACs, this study adds to existing data that apixaban is at least non-inferior to LMWH for the treatment of malignancy-related VTE.
Mokadem ME, Hassan A, Algaby AZ. Efficacy and safety of apixaban in patients with active malignancy and acute deep venous thrombosis. Vascular. 2021 Oct;29(5):745-750.
This study was a single-center, randomized controlled trial designed to assess whether apixaban is non-inferior compared to LMWH for treat ing acute malignancy-related DVT. Patients presenting to an outpatient oncology clinic with acute DVT were screened for enrollment from July 2019 until June 2020. Inclusion criteria were active malignancy and ongoing treatment with chemotherapy. Exclusion criteria included: he modynamically unstable PE, history of prior VTE, treatment with LMWH or unfractionated heparin before enrollment, presence of brain tumor or cerebral metastases, severe hepatic impairment, recent or current active or life-threatening bleeding, platelets less than 100,000/µL, severe chronic kidney disease, and pregnancy. Patients were randomized to receive either apixaban 10mg twice daily for seven days followed by 5mg twice daily or enoxaparin 1mg/kg twice daily. The dosing of apixaban was reduced to 2.5mg twice daily in patients with age over 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 1.5mg/dL. Patients were followed for six months with weekly pill or syringe counts and monthly office visits. The primary outcome was fatal or major bleeding, defined as a decrease in hemoglobin by at least 2 g/dL and/or need for at least two units of whole blood or packed red blood cells, or bleeding in a vital organ or critical region (e.g., intracranial, pericardial, retroperitoneal). Secondary outcomes were recurrent VTE within six months of treatment initiation,
the occurrence of nonfatal or minor bleeding, and mortality related to massive PE.
There were 138 patients randomized equally to the two treatment groups. 26 patients were lost due to death, and 12 were lost to follow-up, leaving 50 patients in each group who remained for the six-month follow-up anal ysis. Baseline characteristics were well-balanced between the groups, in cluding age, malignancy location and staging, and co-morbid conditions. The most common malignancy was colon cancer (46% apixaban, 38% LMWH; p=0.63), and stage 4 cancer was present in most study partici pants (80% apixaban, 88% LMWH, p=0.16). Mortality at six months was similar between the groups (22% apixaban, 16% LMWH). The primary outcome of major bleeding was identified in 4% (2/50) of patients in the apixaban group and 8% (4/50) in the LMWH group (p=0.4). Five of the six patients with MB were patients with colon cancer and GIB. Recurrent DVT was identified in 6% (3/50) of the apixaban group and 10% (5/50) of the LMWH group (p=0.46). Minor bleeding was similar between the groups, and no patients died due to massive PE.
This study’s limitations include its small sample size and complete exclusion of patients who died or were lost to follow-up during the in vestigation. The investigators did not define a noninferiority margin, and the generalizability of this single center’s results is limited. Despite a predominance of GI malignancies (46%), differing rates of MB between treatment groups were not seen, although rates of MB were increased in this subgroup overall. The study was unfortunately not powered to evalu ate the secondary endpoints.
The existing data supports the use of DOACs in treating VTE in patients with malignancy, with apparent noninferiority to LMWH in the prevention of recurrent VTE, and no increase in overall bleeding events, whether major bleeding or clinically relevant minor bleeding. In the subgroup of GI malignancies, there is data to suggest an increased bleeding risk in these studies, including rivaroxaban and edoxaban but not apixaban. Data examining efficacy and safety between the different DOACs is limited at this time, however, and could be a future avenue of research, as could specific investigations into GI-malignancy-related VTE therapies. Overall, this data supports the relatively recent shift from the paradigm of LMWH being the preferred treatment for malignancy-related VTE.
Question: In the treatment of cancer-related venous thromboembolism, is there a difference between low molecular weight heparin and direct oral anticoagulants regarding rates of recurrent venous thromboembo lism and major bleeding events?
Answer: The factor Xa inhibitors apixaban, edoxaban, and rivaroxaban are at least non-inferior to LMWH in preventing recurrent VTE, with no increase in major bleeding events and no differences in mortality. Apixaban appears to be the safest, given a higher incidence of bleeding with the use of the other DOACs in GI malignancies. There are no studies com paring dabigatran with LMWH.
The members of the AAEM Board of Directors met in-person at the XIth Mediterranean Emergency Medicine Congress at the InterContinental Hotel Malta on September 21, 2022, 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:
President Jonathan S. Jones, MD FAAEM, pre sented his President’s report which highlighted the many activities that he and other leaders have been involved in.
Treasurer L. E. Gomez, MD MBA, reported on AAEM and AAEM subsidiaries financial perfor mance through July 31, 2022.
A number of approvals took place during the meeting including:
• The Journal of Emergency Medicine (JEM) will move to electronic only format starting January 1, 2023
• The merger of the International and International Conference Committees will be combined under the International Committee
• The locations of the 2025 and 2026 Scientific Assembly were determined to be Miami, FL and Seattle, WA respectively
• No live stream of the 2023 Scientific Assembly but presentations will still be avail able on the LMS after the Assembly
• Change in AAEM-LG leadership
The following task forces were also created: a Lobbyist Task Force to updating lobbyist scope of work, the Leadership Academy Task Force to review current leadership development and explore other leadership development models, and the Board Election Task Force to evaluate current AAEM Board of Directors elections. The Board also approved the publication of the Pain and Addiction White Paper as well as ap proved the Operations Management Committee
2022-2023 Elected Board of Directors
Statement, EM Workforce Statements, and Excited Delirium Statement. The BOD also had a meeting on November 15, 2022 in Tampa, FL. Details from this meeting will appear in the January/February issue of Common Sense
When January, 31, 2023
Where Grand Hyatt | Dallas/Fort Worth, TX
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.
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 repre sentative from the recruiting hospital/group.
Direct all inquiries to: www.aaem.org/membership/benefits/job-bank or email info@aaem.org.
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 pro bationary 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 resi dency 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.
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.
Section IV: Position listings that are independent contractor positions rather than owner-partner or employee positions.
(Below are hospitals, non-profit or medical school employed positions.)
Residency Program Director, Emergency Medicine Chandler, Arizona Dignity Health Medical Group – Arizona (DHMG-AZ) seeks an experienced leader and visionary to serve as the Founding Program Director, Emergency Medicine in East Valley Phoenix at Chandler Regional Medical Center and Mercy Gilbert Medical Center. This is an exciting opportunity to help establish, build, and lead a new residency program from the ground up. The ideal candidate will have strong experience in administrative, educational, and clinical services, BC in Emergency Medicine, an unrestricted Arizona medical license, and 3+ years of educational experience. Send CV to providers@dignityhealth. org or call (888) 599-7787. dignityphysiciancareers.org (PA 1917)
Email: providers@dignityhealth.org
Website: https://dignityphysiciancareers.org/
The Department of Emergency Medicine at Stanford University is seeking a Board-Certified Emergency Medicine physician to join the department in the role of Section Chief of Ultrasound. The position includes a full-time faculty appointment in the Clinician Educator Line. Rank will be determined by the qualifications and experience of the successful candidate. Applicants who meet criteria for the rank of Associate Professor or Professor are preferred. Stanford Emergency Medicine is dedicated to transforming healthcare for all by leading in the advancement of emergency medicine through innovation and scientific discovery. We have a strong focus on precision emergency medicine - the use of information and technology to improve the care of individual patients and their communities. Key areas of focus include optimizing access to care; capitalizing on technology and digital health tools; leveraging human-centered data to individualize treatment decisions; advancing population and global health; and redesigning medical education. Of particular interest are candidates who have experience in health innovation and information technology to advance and optimize the delivery of emergency care. The Section Chief of
Ultrasound will serve as our departmental leader in ultrasound, supporting the operational, educational, and administrative missions, as well as interdepartmental point-of-care ultrasound (POCUS) projects, and research and scholarship in ultrasound to facilitate the ongoing academic productivity and success of our ultrasound section. In addition, this position will serve as Co-Director of the Stanford Hospital and Clinics POCUS enterprise initiative. Clinical responsibilities will include patient care in the emergency department at Stanford Hospital, a world-renowned, academic medical center with approximately 90,000 adult Emergency Department visits annually. Our faculty consists of over 100 board-certified emergency physicians with broad scholarly interests and extramural funding. We sponsor 13 fellowship programs, a four-year residency program, required and advanced student clerkships, and several courses available to learners throughout our university. Stanford is an equal employment opportunity and affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law. Stanford welcomes applications from all who would bring additional dimensions to the University’s research, teaching and clinical missions. The Department of Emergency Medicine, School of Medicine and Stanford University value faculty who are committed to advancing diversity, equity, and inclusion. Candidates may optionally include as part of their application a statement or a brief discussion of how their work will further these ideals. Please submit a letter of interest and curriculum vitae to: Jody Vogel, MD, MSc Vice Chair for Academic Affairs
Email: emedacademicaffairs@stanford.edu (PA 1900) Email: emedacademicaffairs@stanford.edu Website: http://www.emed.stanford.edu
The Emergency Medicine Residency at Denver Health Medical Center is recruiting for a Program Director to lead our Emergency Medicine Residency Program. The following position description outlines the specific duties of the Denver Health Residency in Emergency Medicine Program Director necessary to meet the requirements of the ACGME Next Accreditation System (NAS). The Program Director has authority and accountability for the operation of the program and has broad responsibilities that
encompass every aspect of postgraduate medical education training. This includes oversight of: · Curriculum and evaluation as well as the learning environment · Faculty as teachers, coaches, mentors, advisors and role models · Supervision of residents and fellows, including duty hours, and · Program management (e.g., program evaluation and improvement, communications, ACGME accreditation, program resources). The Program Director must ensure continuing accreditation of the program by being familiar with and complying with the ACGME Institutional Requirements Common Program Requirements(CPR) and Emergency Medicine Program Requirements, as well as ACGME and Review Committee Policies and Procedures and the CU SOM GME Policies and Procedures. The Program Director should monitor his or her specialty Review Committee activities, and be familiar with the ACGME Program Directors’ “Virtual Handbook” Minimum Qualifications Experience: Minimum of 3-5 years of participation as a core faculty member in an ACGME-accredited emergency medicine residency program and graduate medical education administrative and leadership experience. Applicants should submit CV and cover letter/statement of interest to: Aaron Ortiz, Manager Provider Recruitment aaron.ortiz@dhha.org P: 303-602-4992 (PA 1932)
Email: aaron.ortiz@dhha.org Website: https://www.denverhealth.org/services/emergencymedicine
Trinity Health Of New England seeks BC/BE EM Physicians to join our emergency medicine teams at Mercy Medical Center in Springfield, Massachusetts, Saint Francis Hospital and Medical Center in Hartford, Connecticut and Saint Mary’s Hospital in Waterbury, Connecticut. Our practice model empowers our physicians to work at their highest level, while allowing time for professional development and family life. Whether you are focused on providing outstanding patient-centered care or driven to grow into a leadership role, you will thrive at Trinity Health Of New England. To learn more visit our provider portal at www. JoinTrinityNE.org (PA 1939)
Email: dhowe@TrinityHealthofNE.org Website: https://www.jointrinityne.org/Physicians
The Indiana University School of Medicine (IUSM) Department of Emergency Medicine is seeking applications for Division
Chief of Simulation. We are a statewide network of emergency departments striving to set new standards of training for medical students, residents, fellows, and pre-hospital providers while providing quality care for a diverse patient population. The vision of the department is to improve the health and well-being of every life entrusted to us. The Simulation Division within the Department of Emergency Medicine is in the second year of an ambitious five-year plan with the goal of becoming one of the top five simulation divisions in the United States. The work of the division is completed under the direction of the chief and five additional faculty members. Further, the division has a fellowship program. Fellows can develop expertise in the educational, administrative, and research aspects of simulation and receive the leadership training necessary to direct their own simulation program. Simulation training takes place at the 30,000 square foot Indiana University Health (IUH) Simulation Center at Fairbanks Hall, which is led by a member of the division. The fellowship program ranges from one to two years and accepts up to three fellows per year. While the division’s primary focus is emergency medicine, the team provides consultation and simulation tools for other specialties, such as surgery, pediatrics, anesthesia, and obstetrics, to train health care providers how to respond in high-intensity crisis situations. For the long term, however, the division expects to broaden its scope to any specialty or interprofessional group with an educational goal that is best served by immersive training. As the nation’s largest medical school, IUSM is committed to being an institution that not only reflects the diversity of the learners we teach and the patient populations we serve, but also pursues the values of diversity, equity and inclusion that inform academic excellence. We desire candidates who enhance our representational diversity, as well as those whose work contributes to equitable and inclusive learning and working environments for our students, staff, and faculty. IUSM strives to take an anti-racist stance, regularly evaluating and updating its policies, procedures, and practices to confer equitable opportunities for contribution and advancement for all members of our community. We invite individuals who will join us in our mission to advance racial equity to transform health and wellbeing for all throughout the state of Indiana. IUSM provides concierge and dual career services to assist new faculty with their personal or family’s relocation needs. Requirements Doctorate or Terminal Degree Required; Boardcertified MD or DO We are seeking someone who has at least five years of experience post-GME training, is well-established in medical simulation, and would qualify to be hired at the rank of associate or full professor. Individuals can apply to fill the division chief and fellowship director role or conduct a search for a fellowship director upon hire. https://indiana.peopleadmin.com/ postings/12748 (PA 1899)
Email: kimgibso@iu.edu Website: https://medicine.iu.edu/emergency-medicine
The Indiana University School of Medicine (IUSM) Department of Emergency Medicine seeks a strong academic leader to serve as the Program Director for the IUSM Emergency Medicine Residency Program. Our residency program is one of the largest three-year ACGME accredited training programs in the country with 73 residents between the categorical EM and combined EM/Peds training programs. IUSM has long been regarded as one of the premier training programs for emergency medicine and continually seeks to improve the educational experience for our residents through a continuous improvement mindset. Demonstrated leadership ability in medical education is essential. Experience working in a culturally diverse environment is highly preferred. The IUSM EM Residency is led by a collaborative team of faculty to include the Program Director (PD), Associate Program Director and multiple Assistant Program Directors. The PD will represent the department as a leader in graduate medical education. Responsibilities and expectations for the PD include but are not limited to: · Maintain an effective educational environment allowing our residents to be educated across all ACGME competencies · Comply with all ACGME training requirements for all clinical and didactic educational experiences · Educational innovation for curriculum development and implementation · Professional development of the residency leadership team · Demonstrate a commitment to Diversity, Equity and Inclusion with vision to increase the representational diversity in the residency program to improve care for our patient population · Use a scholarly approach in the administration of the residency program and disseminate innovations and outcomes in internal, external and peer-reviewed presentations and publications. · Annual strategic planning and continuous quality improvement · Resident assessment,
mentorship and improvement plans · National presence in Emergency Medicine organizations · Accreditation monitoring and preparation. The Program Director reports to the Vice Chair of Education and the Chair in the Department of Emergency Medicine. The Department of Emergency Medicine includes a statewide network of emergency departments striving to set new standards of training for medical students, residents, fellows and pre-hospital providers while providing quality care for a diverse patient population. The Department is ranked in the top 15 for NIH funded research nationally in Emergency Medicine and is home to one of the oldest residency programs in the country. We work in an environment that has rich research infrastructure, including the highest-ranked Clinical and Translational Science Institute (CTSI) in the United States and a nationally ranked medical bio-informatics institution. Candidates must have an MD or DO and be board certified in Emergency Medicine with the ability to obtain a license to practice medicine in Indiana. All candidates must also have educational leadership experience with experience and knowledge of the Electronic Residency Application Service (ERAS) and National Residency Matching Program (NRMP) match process. Doctorate or terminal degree required. Interested candidates should attach a letter of interest addressed to the attention of Peter Pang, MD, MS, FACC FACEP, Rolly McGrath Chair and Professor, Department of Emergency Medicine, Indiana University School of Medicine. (PA 1913) Email: kimgibso@iu.edu Website: https://indiana.peopleadmin.com/postings/12938
Mercy Clinic is seeking an Emergency Medicine Physician to work in a state-of-the-art emergency department on campus of Mercy Hospital in Washington, MO (near St Louis, MO). Mercy Clinic is a physician-led and professionally managed multi-specialty group. With over 2,500 primary care and specialty physicians, Mercy Clinic is the fourth largest integrated physician organization in the country. The Position Offers: • Competitive hourly rate with productivity bonus • Ability to moonlight at other Mercy Hospitals in St. Louis and surrounding area • Comprehensive benefits including health, dental, vision and CME • Relocation assistance and professional liability coverage • System-wide EPIC EMR About Mercy Hospital Washington: • 187-bed acute care hospital • Only Level III Trauma Center between St. Louis and Jefferson City • Close to 40,000 Emergency visits annually • Mercy offers an experienced medical staff that is specially trained in trauma care. • Medical Director for eight EMS communities (PA 1919) Email: emily.feuerstein@mercy.net Website: https://careers.mercy.net
Bon Secours Charity Medical Group has an excellent opportunity for a BC/BE emergency department Assistant Medical Director to provide administrative support and medical care to patients of all ages presenting to the Emergency Department. In this role, you will also develop short/long term plans for on-going improvement of the clinical, operational, and administrative quality of the department. In addition to current New York State license to practice medicine, active unrestricted DEA license to prescribe medications, ideal candidates will have: • Prior emergency medicine leadership experience or completion of fellowship training in emergency department administration. • Proficiency in all procedures, techniques and skills listed in the delineation of privileges for emergency department physicians. • Completion of at least three years of post-graduate training in emergency medicine. A great place to live and work. In addition to an excellent salary and comprehensive benefits package, the Hudson Valley offers magnificent scenery, historic mansions, cultural treasures, and unique attractions. From great restaurants to beautiful gardens and performing arts, creativity thrives amid inspiring landscapes. For your enjoyment, farm-totable cuisine is created at country inns and the world-famous Culinary Institute of America by legendary chefs. With abundant farmers markets, award-winning wineries, craft-breweries and food festivals, Hudson Valley dining is legendary. If great schools are top of mind, the Hudson Valley is the place to be. Good Samaritan Hospital in Suffern, NY, is a 286-bed hospital providing emergency, medical, surgical, obstetrical/gynecological, and acute-care services to residents of Rockland and southern Orange counties in New York; and northern Bergen County, NJ. The hospital is home to a recognized cardiovascular program, comprehensive cancer-treatment services, the area’s leading Wound and Hyperbaric Institute and outstanding maternal/ child services that includes a Children’s Diagnostic Center. Good Samaritan Hospital also provides social, psychiatric, and substance-abuse services and its certified home-care agency
supports residents of the Hudson Valley and beyond. Bon Secours Charity Medical Group part of Bon Secours Charity Health Systems (BSCHS), a regional network of more than 120 primary care physicians and specialists from a broad array of medical specialties. BSCHS, a member of the Westchester Medical Center Health Network (WMCHealth), includes Good Samaritan Hospital in Suffern, NY, Bon Secours Community Hospital in Port Jervis, NY, and St. Anthony Community Hospital in Warwick, NY. WMCHealth is an Equal Opportunity Employer. It is the policy of Westchester Medical Center Health Network to provide equal employment opportunities without regard to race, color, religion, gender, national or ethnic origin, sex, sexual orientation, gender identity or expression, age (40 or older), marital status, genetic information or carrier status, disability (mental or physical), citizenship status, pregnancy, military service or veteran status, arrest or criminal accusation, domestic violence victim status or any other status protected by federal, state, or local law. (PA 1946)
Email: claire@fusionideas.com
Wake Forest School of Medicine has a rare opportunity to join our academic faculty team as a Clinical Assistant Professor dedicated to clinical teaching and patient care activities during overnight hours. This permanent nocturnist position will be responsible for excellent patient care, bedside teaching of residents and medical students, and participation in the teaching academic mission. A full clinical faculty appointment at the School of Medicine will align this position with opportunities for academic advancement. Our ED features a Level 1 trauma center, an accredited chest pain center, stroke center, a burn center and full subspecialty backup. (PA 1897)
Email: michael.ginsberg@wakehealth.edu Website: https://school.wakehealth.edu/
Duke Pediatrics is seeking an innovative physician leader to serve as Division Chief for Pediatric Emergency Medicine. Proven leadership and excellence in clinical care, education, scholarship, and administrative experience are required. Duke Children’s is ranked among the nation's finest for pediatric care and the department is #1 in NIH funding for pediatric clinical science departments. The Greater Triangle area of Raleigh, Durham, Chapel Hill is culturally diverse, economically resilient and nationally recognized as a great place to live and work. Interested individuals should submit a statement of academic interest and curriculum vitae prior to May 27, 2022 to: http://www. practicematch.com/physicians/job-details.cfm/699090 (PA 1904) Email: debbie.hackney@duke.edu Website: https://pdc.dukehealth.org/
Wake Forest Emergency Providers is currently seeking to add to our team of exceptional patient-centered emergency physicians in the Blue Ridge Mountains due to our continued expansion and growth. We offer a unique employment model inclusive of salary, RVU based incentive, paid malpractice, benefits, CME allowance and relocation. Our physicians have local influence on practice decisions, and a strong provider voice in care delivery. These positions are located in Boone, North Carolina, a beautiful town in the Blue Ridge Mountains with a booming local economy, friendly people, thriving arts and food cultures and a wide variety of indoor and outdoor recreational activities in both the community and on the campus of Appalachian State University. Boone is 84 miles from Asheville, 100 miles to Charlotte and 87 miles to the Piedmont Triad. (PA 1927)
Email: michael.ginsberg@wakehealth.edu Website: http://www.wakehealth.edu
Wake Forest Emergency Providers is seeking to add to our team in the Greensboro NC metro region. We are the contracted service provider for Cone Health Emergency Medicine. These full-time (144 hours/month) positions rotate across all of Cone Health’s hospitals, including a 628-bed teaching hospital with a Level 2 Trauma Center and community hospitals of 238 beds, 175 beds and 80 beds. We offer a unique employment model inclusive of salary, RVU based incentive, paid malpractice, benefits, CME allowance and relocation. Our physicians have local influence on practice decisions, and a strong provider voice in care delivery. Greensboro is in North Carolina's Piedmont Triad region and features a moderate climate with all four seasons and housing costs ˜38% below the national average. Residents enjoy a vibrant restaurant scene, a wide variety of indoor and
outdoor recreational opportunities and close proximity to the Appalachian Mountains and Atlantic Coast beaches. (PA 1928)
Email: michael.ginsberg@wakehealth.edu Website: http://wakehealth.edu
Wake Forest Emergency Providers is currently seeking to add to our team of exceptional patient-centered emergency physicians in the Blue Ridge Mountains due to our continued expansion and growth. We offer a unique employment model inclusive of salary, RVU based incentive, paid malpractice, benefits, CME allowance and relocation. Our physicians have local influence on practice decisions, and a strong provider voice in care delivery. These positions are located in Boone, North Carolina, a beautiful town in the Blue Ridge Mountains with a booming local economy, friendly people, thriving arts and food cultures and a wide variety of indoor and outdoor recreational activities in both the community and on the campus of Appalachian State University. Boone is 84 miles from Asheville, 100 miles to Charlotte and 87 miles to the Piedmont Triad. (PA 1941)
Email: michael.ginsberg@wakehealth.edu Website: http://www.wakehealth.edu
Wake Forest University School of Medicine’s Department of Emergency Medicine has a unique opportunity to join our faculty as an Assistant or Associate Professor with a scholarly focus on Diversity, Equity, and Inclusion. This position will be an integral part of our ongoing EM DEI initiatives. The successful candidate will have career development and leadership opportunities within our active DEI committee. Our ED includes a Level 1 trauma center, accredited chest pain center, stroke center, and a burn centers. Our clinical affiliate physicians staff 18 EDs across the state, providing services to >500,000 patients annually, with patient acuity in the 95th percentile and an admission rate of 30 percent. In 2020, Wake Forest Baptist Health and Atrium Health joined together in a strategic partnership to operate as a single enterprise. As part of this new enterprise, Atrium Health has announced $3.4 billion in planned investments in our health system and the communities we serve. The growth of the school of medicine, including the building of a new medical school campus in Charlotte, will expand existing academic research capabilities and opportunities for clinical trials across a large, diverse market with some of the nation’s leading medical experts. (PA 1944)
Email: michael.ginsberg@wakehealth.edu Website: http://www.wakehealth.edu
Located in beautiful Windsor, Ontario, Canada, our client, Windsor Regional Hospital (WRH), is situated directly across the border from Detroit, Michigan. WRH is the regional provider of advanced care in complex trauma, renal dialysis, cardiac care, stroke and neurosurgery, and intensive care. WRH is seeking fulltime or part-time Emergency Medicine Physicians to contribute to the top tier care provided in the Department of Emergency Medicine. Pathway licensure is available for US Board Certified Physicians through WRH and the College of Physicians of Ontario. Please forward a CV in confidence to: Robb Callaghan, E-mail: rcallaghan@medfall.com Tel: 289-238-9079 (PA 1921) Email: medfall@medfall.com Website: https://www.medfall.com/
WellSpan Health’s vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass nearly 1,900 employed providers, 220 locations, eight award-winning hospitals, home care and a behavioral health organization serving South Central Pennsylvania and northern Maryland. Our clinically integrated network of 2,600 aligned physicians and advanced practice providers provide the highest quality and safety, inspiring our patients and communities to be their healthiest. Position Highlights: Looking for a board certified/eligible emergency medicine physician for York, Pennsylvania This position is designed to have split responsibilities which would include 40% Clinical and 60% administrative Successful candidate will possess considerable clinical, resident teaching and leadership experience York Hospital (YH) is a Level 1 Regional Resource Trauma Center serving an annual volume of over 80,000+ visits per year York Hospital is designated as a Comprehensive Stroke Center Work with a team of physicians, advanced practice providers
and 38 residents Support includes lab turnaround in an hour or less, a large hospitalist team to facilitate admissions, two digital imaging exam rooms & two 128 CT Scanners WellSpan Emergency department is a busy department seeing an average of 240 patients per day In 2017 a renovation was completed to incorporate WellSpan’s own helipad and branded helicopter
Our Commitment to You: Competitive Compensation Signing bonus 6 weeks of Scheduled Time Off Relocation Retirement Savings Plan Full Malpractice Coverage Including Tail About the Community: Conveniently situated within a short drive of major cities like Philadelphia, Baltimore and Washington, D.C., WellSpan Health’s service area is made up of a diverse mix of welcoming communities that you will love to call home. South Central Pennsylvania offers an idyllic blend of unique cities and towns including Lancaster, York, Gettysburg, Lebanon, Chambersburg and Waynesboro. For Confidential Consideration Contact: Tammie Chute, Provider Recruitment WellSpan Health tchute@wellspan.org Office (717) 267-7780 (PA 1929) Email: jsteffen4@wellspan.org Website: https://www.joinwellspan.org/jobs/Emergency_ Medicine_-_Chair/York_Pennsylvania/100/290719/
Chair, Department of Emergency Medicine The University of Virginia School of Medicine invites applications and nominations for the position of Chair, Department of Emergency Medicine. Founded in 1819 as just the 10th medical school in America, the University of Virginia School of Medicine (UVA School of Medicine) – with 21 clinical departments, 8 research departments, and 6 research centers – consistently attracts some of the nation’s most prominent researchers to develop breakthrough treatments to benefit patients around the world. Those research efforts are backed by more than $230 million in grant funding. UVA Health is a world-class academic medical center and health system with a level 1 trauma center, a NCI comprehensive cancer center, and UVA Children’s Hospital. Its footprint encompasses 4 hospitals and 2 physician groups with an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, and Northern Virginia. In September of 2021, Dr. Melina Kibbe began her tenure as Dean of the School of Medicine and Chief Health Affairs Officer. With this new leadership, the UVA School of Medicine is poised to undertake new directions in all four missions, including clinical strategy and growth, expansion of research in collaboration with other UVA schools, the promotion of educational programs of the highest caliber, and developing partnerships within the community. Integral to the success of this vision will be the recruitment of a dynamic and aspirational leader to serve as Chair, Department of Emergency Medicine. The Chair of Emergency Medicine will be an outstanding leader, communicator, and skilled physician, widely recognized in the field with a strong track record of program building and innovation. The Chair will be responsible for clinical, academic, and administrative activities of the Department and therefore they must have a deep knowledge of clinical practice; a strong commitment to training and career development in research and clinical care; and demonstrated leadership and administrative ability in complex clinical enterprise. The Chair must bring vision to the task of drafting the Department’s future, coupled with an ability to communicate in a fashion that inspires others to follow. The Chair will be a consensus builder, while also capable of serving as an agent for change. The Chair will evaluate the current strengths of the Department, and identify areas for productive growth in clinical, educational, and research programs. From that assessment, they will establish a strategic overarching long-term plan for the Department. The Chair must demonstrate a passion for mentoring and development of faculty and fellows, including interpersonal skills that will assure successful relationship building with a variety of internal and external stakeholders. The Chair will work with leadership to foster a collective and collaborative culture within the Department and beyond, bringing together the multidisciplinary people and programs with a shared vision and purpose, and thereby enhancing faculty engagement and development. Korn Ferry is assisting the University of Virginia School of Medicine with this important search. Please forward, as soon as possible, applications or nominations of appropriate candidates, in confidence, to: c/o Alana Aisthorpe, Korn Ferry Email: alana. aisthorpe@kornferry.com (PA 1940) Email: alana.aisthorpe@kornferry.com Website: https://med.virginia.edu/
Virginia Mason Franciscan Health is seeking an emergency medicine residency-trained BC BE physician to join our group in beautiful Seattle, Washington. Virginia Mason, established in 1920 in Seattle, WA, is internationally recognized as a preeminent health care organization focused on delivering quality services to our patients. We have a 336-bed hospital in Seattle and multispecialty medical group practice with more than 450 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best practices and a model that is the benchmark for other medical organizations. Join us, and find out how many ways Virginia Mason offers you the chance to focus on what really matters—your patients. Highlights of position 0.5 FTE with opportunities to increase. Competitive compensation and benefits package. Exceptional specialty support. Annual volume 24,000. Shifts 8-10 hours. No night shifts. Admission rate 28%. Comprehensive Stroke Center with onsite Neurohospitalist. Regional hyperbaric medicine referral center. Qualifications ABEM or AOBEM BC/BE Ability to obtain a medical professional license in the State of WA Ability to obtain a DEA with full prescriptive authority needed for specific practice ACLS PALS Diversity, Equity and Inclusion at Virginia Mason We commit to fostering an equitable, diverse and intentionally inclusive environment – we strive for all to feel valued, respected and that they belong. Our unique life experiences and backgrounds make our patient care extraordinary. Our diversity fuels our culture of innovation and transformative health care. Our differences are our strengths and inspire a promising future. About Virginia Mason Franciscan Health Virginia Mason Franciscan Health brings together two award winning health systems in Washington State – CHI Franciscan and Virginia Mason. As one integrated health system with the most patient access points in western Washington our team includes 18,000 staff and nearly 5,000 employed physicians and affiliated providers. At Virginia Mason Franciscan Health you will find the safest and highest quality of care provided by our expert, compassionate medical care team at 11 hospitals and nearly 300 sites throughout the greater Puget Sound region. Our integrated health system has nearly 1,500 hospital beds including Bailey-Boushay House, the first skillednursing and outpatient chronic care management program in the United States designed specifically to meet the needs of people with HIV/AIDS; Benaroya Research Institute, internationally recognized for autoimmune disease research; and Virginia Mason Institute, a teaching organization which coaches health care professionals and others around the world in the Virginia Mason Production System, an innovative lean management method for improving quality and safety. (PA 1930)
Email: stephanie.collins-russell@virginiamason.org Website: https://www.commonspirit.careers/job/seattle/ emergency-medicine-downtown-seattle/35300/33248729232
(Below are hospitals, non-profit or medical school employed positions.)Come live the SLO life! Central Coast Emergency Physicians is seeking to hire a full-time BC/BE emergency physician. We are a fully independent ER physician owned group staffing two local community emergency rooms in Paso Robles and San Luis Obispo. We have a healthy call panel, easy access to imaging and ancillary resources, and staff to the mindset of practicing in this speciality is a marathon and not a sprint. We do not staff any mid-levels. A full time position involves at least 100 hours/month and includes full benefits, paid CME and vacation, malpractice and disability coverage, as well as living in one of the state’s most beautiful places! (PA 1896)
Email: bcknox@gmail.com Website: https://ccepslo.com/
Seeking EM Physician for democratic two-hospital group in Berkeley/Oakland Berkeley Emergency Medical Group (BEMG) is a democratic EM practice serving two Sutter Health hospitals in the San Francisco Bay Area. We are seeking an EM Physician candidate to serve our diverse patient population at Alta Bates Summit Medical Center’s two emergency departments in Berkeley and Oakland. Combined volumes of 85,000/year. BEMG employs 45 Physicians. The group has outstanding staffing, flexible schedules, and paid occurrence malpractice coverage. In addition, we offer competitive compensation and a flexible benefits package. Send CV and cover letter to jobs@ bayem.org . (PA 1924)
Email: admin@bayem.org Website: http://bemg.org/
EMERGENCY MEDICINE PHYSICIANS Full-Time and Per Diem opportunities in Southern California Southern California Permanente Medical Group (SCPMG) is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. In Southern California, you'll enjoy amazing recreational activities, spectacular natural sceneries, and an exceptional climate. SCPMG is proud to offer its physicians: • An organization that has served the communities of Southern California for more than 65 years • A physician-led practice that equally emphasizes professional autonomy and cross-specialty collaboration • Comprehensive administrative support • An environment that promotes excellent service to patients • A fully implemented electronic medical record system Full-time: partnership eligibility after 3 years, malpractice insurance and tail coverage provided, comprehensive benefits package, and excellent salary. Contact Michael Truong at 800-541-7946 or Michael.V.Truong@kp.org. Per Diem: flexible schedule, malpractice insurance and tail coverage provided, and non-benefitted. Must have CA medical license and paid DEA certificate. Contact Quan Nguyen at 800-541-7946 or Quan.D.Nguyen@kp.org. For consideration or to apply, visit https://scpmgphysiciancareers.com/emergency-medicine/. We are an AAP/EEO employer. (PA 1943)
Email: Michael.V.Truong@kp.org
SDG in Colorado is hiring a full time EM physician to join our group this fall. We staff Platte Valley Medical Center in Brighton, CO. Both our hospital and community are rapidly expanding and we are hiring to accommodate increasing volumes. We are a close-knit group with very little turnover; this is a rare opportunity for the Denver metro area. Pay and benefits are very competitive for Colorado and our group places high value on work life balance. Please contact candace.harrod@bcephealth.com and ryan.klemt@bcephealth.com for more information, as well as to provide CVs. (PA 1911)
Email: candacemd11@yahoo.com Website: http://bcephealth.com
We believe in giving physicians what they need to succeed! Summit Health is actively recruiting for an experienced board certified/board eligible Family Medicine, Internal Medicine or Emergency Medicine Physician to work with our dedicated team of Clinical professionals in our Urgent Care Centers. Summit Health includes more than 150 providers and 30 specialties and services providing care to over 50,000 attributed lives in Central Oregon and is launching the community’s first full spectrum Accountable Care Organization (ACO) in 2022. Summit Health is Central Oregon’s largest multispecialty group and is a for-profit, physician led/professionally managed practice with multiple locations in Bend, Redmond, and Sisters. Health is committed to maintaining a full-service Urgent Care for our community in Central Oregon including Bend, Redmond, Mt. Bachelor (limited in scope during the ski season) and currently looking to expand into additional locations. Summit Health will further advance our group’s mission of lowering the total cost of care for all patients in Central Oregon by continuing to offer and expand outpatient services throughout the community. You will be joining a team of 150 Providers within Summit Health and a total catchment area of 250,000 people throughout four locations within the group. As part of our team, you’ll enjoy: Physician led and professionally managed medical group. Market competitive rates with high earning potential and a quality bonus program. Shareholder opportunity. Team based approach focused on patient centered care. An established and growing integrated multispecialty medical practice. Comprehensive administrative and clinical support. Easy access to resources. Located east of the Cascade Mountains, Bend enjoys 300 days of sunshine and a wonderful high desert climate. World class skiing, renowned fishing and amazing golf, water sports, cycling and trail running are all part of a quality lifestyle for Central Oregon residents. Our community also offers excellent schools, a variety of cultural activities, great food, and entertainment, and is noted as one of the best places to live for outdoor activity by Sunset Magazine, Bike Magazine, CNN, Newsweek, and Golf Magazine. We offer competitive compensation, comprehensive benefits package, and a dynamic practice experience. (PA 1937)
Email: slameira@summithealth.com Website: https://smgoregon.com
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Victoria Emergency Associates (VEA) is an established private group of EM, PedsEM and HM physicians, servicing 19 hospital locations in South Texas. VEA is one of the few physician-owned and managed practices in TX. We have solid relationships and steady growth with our partner facilities, and achieve high physician retention by sustaining a culture reflective of our values: compassion, quality, community, accountability, and transparency. Our goal is to offer physicians a meaningful career, not just a job. We are seeking dedicated FT/PT BC EM and/or BC/FP/IM w/ED physicians for our San Antonio and surroundings areas. "Compassion Is Our Specialty" (PA 1942)
Email: april@victoriaemergency.com Website: https://www.victoriaemergency.com/
North Sound Emergency Medicine, a well-established, large democratic provider group in Everett, Washington, is looking for an EM residency-trained BC/BE physician. This is a tremendous opportunity to join an exceptional team of clinicians who are dedicated to excellence, providing evidence-based patient care in a supportive environment, while offering opportunities for professional growth, education, and development. Our practice site has a very stable contract and sees more than 80,000 patients annually in a state-of-the-art 79-bed ED: the largest and busiest ED in the state of Washington and one of the busiest in the nation. One of the most desirable places to live, the greater Seattle area offers an abundance of recreational activities from scuba diving and skiing to backpacking the Pacific Crest Trail, professional sports teams, and a myriad of cultural amenities, ranging from opera and ballet to museums and theater. (PA 1903)
Email: cmgilliland@northsoundem.com Website: http://www.northsoundem.com
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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.) SECTION IV: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA