SEPTEMBER-OCTOBER 2021 | VOLUME XXXVI NUMBER 5
SECURING THE FUTURE OF THE EM WORKFORCE An Interview with
Jamie Jasti, MD
HEADS-UP CPR: A NEW METHOD TO AN OLD PRACTICE? page 50
Leading the advancement of emergency care through education and research, advocacy, and professional development in academic emergency medicine.
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2021–2022 BOARD OF DIRECTORS Amy H. Kaji, MD, PhD President Harbor-UCLA Medical Center
Wendy C. Coates, MD Secretary Treasurer Harbor-UCLA Medical Center
Angela M. Mills, MD President Elect Columbia University, Vagelos College of Physicians and Surgeons
James F. Holmes, Jr., MD, MPH Immediate Past President University of California Davis Health System
Pooja Agrawal, MD, MPH Yale University School of Medicine
Ava Pierce, MD UT Southwestern Medical Center, Dallas
Christopher R. Carpenter, MD, MSc Washington University in St. Louis School of Medicine
Ali S. Raja, MD Massachusetts General Hospital/Harvard
Jamie Jasti, MD, MS Medical College of Wisconsin Michelle D. Lall, MD Emory University
Jody A. Vogel, MD, MSc, MSW Stanford Medicine
President’s Comments Updated Strategic Plan Addresses Specialty Development, Equity, and Well-Being
Spotlight Priority #1: Securing the Future of the EM Workforce – An Interview with Jamie Jasti, MD
Climate Change and Health Facing a Hotter Future: Reflections from the 2021 Pacific Northwest Heat Wave
Wilderness Medicine Suspension Trauma
Women in Academic EM Why Leadership in Medicine Needs Women
Critical Care NETCCN: Delivering Needed Critical Care Expertise “From Anywhere, to Anywhere”
Thank You for Championing SAEMF’s Vision of Becoming the Premier Foundation Transforming the Science and Practice of Emergency Medicine
Diversity, Equity & Inclusion Back to Basics: Key Terms in Diversity, Equity, and Inclusion
Our Grantees: Even More to Celebrate!
Ethics in Action Who’s in Charge Here?
Have You Considered a Legacy Gift to Benefit Emergency Medicine?
Geriatric Emergency Medicine How Medical Care Was Brought Into the Home in 2020: Interviews with Physicians
Global Emergency Medicine The COVID-19 Pandemic Fight on the Ground: Experiences from Nepal
Heads-Up CPR: A New Method to an Old Practice?
From Tuk Tuks to Ambulances: Setting up a Universal Access Prehospital System in a Developing Country
The Benefits of SAEM Membership for Medical Students
SGEM: Did You Know? Differences in the Treatment and Outcomes of Patients with Acute Coronary Syndrome
From Zoom Medicine to Real Medicine
GRACE Recurrent, Low-risk Chest Pain: A User’s Guide
Succeeding in the Virtual World: Online Interviewing Best Practices
#Match2021: Virtual Residency Interviews
Education Innovations The New Frontier in Academic Emergency Medicine: A Tale of Two EDs
Medical Education “All in the Family”: A Unique Mentorship Structure for ARMED MedEd
Virtual Realities Website Usability: Assessing What Makes a Website “Good”
Wellness “You’ve got 1,000 Emails!” The Joys and Pains of Returning to Work
Briefs and Bullet Points
Committee, Academy, IG Reports
SAEM Pulse is published bimonthly by the Society for Academic Emergency Medicine,1111 East Touhy Ave., Ste. 540, Des Plaines, IL 60018. (847) 813-9823 Disclaimer: The views and opinions expressed in this publication are those of the authors and do not necessarily reflect the official policies, positions, opinions, or views of the Society for Academic Emergency Medicine or its members. © 2021 Society for Academic Emergency Medicine. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means without prior permission in writing from the copyright holder.
PRESIDENT’S COMMENTS Amy Kaji, MD, PhD Harbor-UCLA Medical Center 2021–2022 President, SAEM
Updated Strategic Plan Addresses Specialty Development, Equity, and Well-Being
“Our long-term vision is to be the premier organization for developing and supporting academic leaders and shaping the future science, education, and practice of emergency and acute care.”
Every three years, SAEM reviews and updates the organization’s strategic plan to better serve its members and adapt to changes in the academic, economic, and sociopolitical environment. This written document is critical, as it defines our organization, serves as a guide to our long-term envisioned future (10+ years) and our short-term (3-5 year) goals. The envisioned future includes SAEM’s vision and a vivid description of what it will be like to achieve the vision. Over the last few months, the SAEM Board of Directors and staff have been working diligently on the 2022-24 strategic plan. The basis of this document is to describe our core ideology, which describes SAEM’s identity. The core ideology is further composed of two elements: the core purpose (SAEM’s mission and reason for being) and its core values, which are the essential and enduring principles that guide SAEM’s actions and behavior. To that end, we reiterate that SAEM’s core purpose is to lead the advancement of academic emergency medicine through education, research, and professional development. Reflecting SAEM’s focus on equity and well-being, our newest core organizational values are knowledge and discovery; equity; health and wellbeing; and collaboration. Our long-term vision is to be the premier organization for developing and supporting academic leaders and shaping the future science, education, and practice of emergency and acute care. Three pillars — leader development, research impact, and medical education — continue to serve as the foundation of SAEM and as priorities in our plan. Whereas digital relevance was included in the 2020-22 strategic plan as a major area of focus to achieve goals, we have
made tremendous strides with our prior goals to increase our digital presence, improve the website, expand social media presence, and allow for easy but secure communications between members of academies, committees, and interest groups. Having successfully operationalized how we achieved the digital relevance goals these are thus no longer a strategic plan focus. SAEM members have voiced their concerns about recent workforce predictions. The number of residency training programs has increased tremendously over the last decade, as has the use of nonphysician providers (NPP) in the emergency department. Thus, a new priority in our strategic plan focuses on specialty (or workforce) development. The overarching goal of this strategic plan pillar is that SAEM defines the evolving landscape and workforce of academic emergency and acute care medicine. In turn, the objectives that were created to meet this goal include the following: 1) explore opportunities to expand scope of practice including informatics and artificial intelligence; 2) increase evidence in support of emergency medicine physicians, 3) increase role in ensuring a robust EM pipeline, and 4) increased understanding of future workforce needs. SAEM will continue to remain thoughtful and prepared to shape the future of academic emergency medicine by coming together and solving the problems and ramifications that face our specialty.
ABOUT DR. KAJI: Amy Kaji, MD, PhD is a professor of clinical emergency medicine and vice chair of academic affairs in the department of emergency medicine at Harbor-UCLA Medical Center at the David Geffen School of Medicine at UCLA.
PRIORITY #1: SECURING THE FUTURE OF THE EM WORKFORCE An Interview With Jamie Jasti, MD Jamie Jasti, MD, is a PGY-2 at the Medical College of Wisconsin (MCW) in Milwaukee, Wisconsin, where he also completed medical school and obtained a Master of Science in translational research. He currently serves as the resident member of the SAEM Board of Directors. He grew up in Milwaukee and is the proud dad of two rambunctious young boys and a beautiful 5-month-old baby girl. Congratulations on being elected as the resident representative to the SAEM Board of Directors. What do you personally hope to accomplish during your term? The ACEP workforce study, which was released after I initially ran for this position, has certainly changed my goals for this term. My number one priority now is thoroughly evaluating potential challenges to our emergency medicine workforce. Our residents are the future of our specialty and I want to quickly identify any changes we need to make to help secure that future.
As the resident representative to the SAEM Board of Directors, what issues do you feel are most germane to current and future emergency medicine trainees? As uniquely rewarding as our specialty is, it does have many mental, emotional, and physical stressors. We need to continually assess how we can either reduce certain stressors through system-level changes or better support each other to cope with others. This is even more important as we fight this ongoing pandemic. We continue to treat a rapidly spreading infectious disease with high risk of exposure to ourselves. And we are handling surges in patient volumes by seeing more patients in the same amount of time. So in addition to the workforce, I think fostering the mental and physical well-being of our emergency medicine residents is another critical issue.
From Left to Right: Jude (5yrs), Sarah, Nina (1 month old at the time), Jamie, Ari (3yrs)
Who or what influenced your decision to choose the academic/EM specialty and if you were not doing what you do, what would you be doing instead? Prior to medical school, I had the privilege of conducting clinical research with my mentor Dr. Tom Aufderheide at the Resuscitation Research Center at the Medical College of Wisconsin. I am truly grateful for his ongoing mentorship and would not be where I am today without him. He has such an extraordinary passion for improving the care of critically ill patients through knowledge discovery and translation. Without a doubt, he inspired me to pursue a career in academic emergency medicine and expand my impact beyond one-toone patient care through education and research. If I wasn’t an emergency medicine physician, I think I would enjoy being a stay-at-home dad to my three kids.
How did you first become involved with SAEM? Shortly after starting residency, Dr. Ian Martin convinced me that an important next step in my pursuit of an academic emergency medicine career was actively engaging with SAEM. He also gave me insight into the resident member role and the unique opportunity to advocate for over half of SAEM’s membership. Although I was just trying to survive in medical school while raising kids, I do wish I had become involved sooner! Regardless, I know this role is just the start and I am very excited to expand my involvement in SAEM in the future.
What experiences in your life outside of medicine have made you a better physician and educator? Prior to being a research manager, I worked as a research coordinator and enrolled patients suffering from cardiac arrest, stroke, or traumatic injury in clinical studies. Many patients were either in severe distress during the consenting process or were unconscious and required consent from family. I think this experience enhanced my ability to communicate as an EM physician and taught me how to convey complex clinical information in an understandable and empathetic manner while maintaining urgency. Being a dad has certainly made me a better educator. I have become used to answering 10-step questions that all start with “but why dad?” that have forced me to challenge my understanding and assumptions of many basic things. I think an important skill of being a clinician educator is continually asking “why?” yourself, which enables you to fundamentally understand concepts so that you can more effectively distill and convey information.
What is the most important lesson working as an emergency medicine physician has taught you so far? The importance of humility in our profession. Making quick decisions with a limited amount of information is incredibly challenging. Being humble means I should continually reflect on what I don’t know and learn how I can better diagnose and treat my patients. It also means recognizing that I can’t effectively care for my patients by myself — emergency medicine is such team-based specialty. I must rely on the multidisciplinary group of professionals around me: pharmacists, nurses, techs, social workers, registrars, communicators, translators, environmental service workers, etc. Humility should also influence how I
Medical College of Wisconsin Emergency Residency Class of 2023
“I think an important skill of being a clinician educator is continually asking “why?”... which enables you to fundamentally understand concepts so that you can more effectively distill and convey information.” interact with and communicate with my patients. I shouldn’t assume I know what they are going through or what factors led to their illness or symptoms. I should continually challenge my assumptions and biases about patients and seek to be more empathetic and understanding regardless of the circumstances.
What do you find most challenging about the work you do? Balancing residency and family. It is very hard coming home sometimes without seeing my kids before they go to bed. It is also difficult spending time studying, doing research, or writing notes when I am not on shift and I just want to spend time with them. Thankfully, I have an amazing wife and family support system that makes things a little better. continued on Page 6
continued from Page 5
What do you find most rewarding about the work you do? Getting to work in a team-based environment to care for people in the worst times of their lives. During a resuscitation, I sometimes step back and reflect in amazement on just how many health care professionals are simultaneously working to care for the patient. I love knowing that if I can’t do something, someone will help me. I love knowing that if I don’t realize the answer, someone will teach me. And I love knowing that during the sad and difficult moments, someone will support me.
Where do you see yourself in five years? Twenty-five? I see myself as an academic emergency medicine faculty member. In 25 years, maybe in an administrative position since I love leadership.
SAEM PULSE | SEPTEMBER-OCTOBER 2021
How has the COVID-19 pandemic affected you, your practice, your family, and your colleagues and coworkers? What has been your biggest challenges and greatest lessons learned during this time?
I think one of the most prominent effects of this pandemic has been how much it has negatively impacted human connection. A few weeks from now, I will finally get to meet my brother’s new baby girl for the first time when she is already over a year old. In the few times my residents and I have gotten together, we have realized just how helpful it is to hear that we are struggling with the same issues in residency. In terms of my practice, I have recognized how much wearing a mask takes away from my ability to connect and communicate with my patients. I find that I need to focus on my eye contact as well as the pace and intonation of my voice to try to overcome what is lost from them not being able to see my face. I think one of the greatest lessons from this pandemic will be how we in the medical and scientific community can most effectively communicate with the public in this digital age. There are now so many sources for information, many of which are inaccurate. In addition, the public has been forced to grapple with what we deal with everyday in medicine – uncertainty. They are being presented with data in terms of percentages and probabilities, not absolutes. How can we best convey that uncertainty while maintaining the public’s trust? How can we best communicate changes to public health recommendations in the face of new data while minimizing confusion? I am hoping that we will learn the best strategies to apply for this ongoing pandemic and for future public health crises.
How do you personally manage stress and maintain work/life balance, particularly during this unprecedented time of COVID? Second, what advice would you give to an individual who is struggling? And finally, what do you think our specialty as a whole can do to address COVID-related stress and improve physician well-being? I cannot imagine going through this time without having my wife and three kids. Seeing them after coming home is
From Left to Right: Samuel (Dad), Jamie, Lydia (Mom)
“I think one of the greatest lessons from this pandemic will be how we in the medical and scientific community can most effectively communicate with the public in this digital age.” immediately refreshing and recharging. I definitely don’ think I’m the best person to give advice to those that are struggling given how privileged I am. But I would just say that please don’t hesitate to reach out to someone around you. And that ties into how I think our specialty can best improve physician well-being. Our community clearly needs to improve how quickly we both recognize those that are struggling as well as proactively reach out to them to offer support so that it is not on them to take the first step. While there are certainly personal factors and behaviors that we have control over to improve our own wellness, our specialty needs to prioritize system-level changes over requests for resilience.
Any tips on surviving, perhaps even thriving, during residency, especially during this time of COVID? Continually schedule and prioritize spending time with family, friends, and other residents. Often, you don’t realize how much you needed it until after you connected with them.
From Left to Right: Jude (5yrs), Jamie, Sarah (Wife - Emergency Nurse Manager), Nina (4months), Ari (3yrs)
Up Close and Personal What one word would your friends use to describe you? Reflective Who would play you in the film of your life and what would that film be called? Extremely wishful thinking, but I would say Dwyane “The Rock” Johnson because he is brown and bald — like me, but tall and very physically fit — unlike me. And if that happened, the film would have to be called “Jamie Jasti: A Very Fictional Account of His Life.” What is your guilty pleasure? Grilling and smoking meat. I love trying new recipes and enjoying them with a refreshing alcohol beverage.
What is at the top of your bucket list? A trip around Italy with my wife. Who would you invite to your dream dinner party? John Krasinski and Emily Blunt. I’m a huge fan of “The Office” but also think it would be incredibly cool to talk about our similar experiences of raising kids with these seemingly very down-to-earth and hilarious celebrities. What’s one book you’ve read (fiction or nonfiction) that has had a lasting effect on you? “Thinking Fast and Slow,” by Daniel Kahneman
CLIMATE CHANGE AND HEALTH
Facing a Hotter Future: Reflections from the 2021 Pacific Northwest Heat Wave
SAEM PULSE | SEPTEMBER-OCTOBER 2021
By Zachary S. Wettstein, MD; Lucy Goodson, MD; Eleanor Ganz, MD; and Jeremy Hess, MD, MPH, on behalf of the SAEM Climate Change and Health Interest Group
At the end of June 2021, an unprecedented heat dome settled over the Pacific Northwest, trapping the region under a stalled high-pressure system of hot air. The temperatures crushed previous records not only for the region, but for the country. Temperatures in Seattle hit 108°F and Portland surged to 116°F, surpassing temperature records in Miami, Atlanta, and Chicago, and resulting in the hottest June for North America ever recorded. These broiling temperatures hit suddenly and persisted for days, leaving little time for acclimatization in a region suddenly 30°F hotter than average. A rare combination of factors appears to have driven this heat surge — a strong ridge of high pressure over the region as well as a low pressure trough that drew warm air from the south. Climatologists and atmospheric scientists have noted that while it is challenging to attribute this particular heat wave exclusively to climate change, the science is clear that temperatures are increasing, heat waves are becoming more frequent and intense, and this event would have been very unlikely without the contributions of anthropogenic climate change.
There is an underappreciated human health cost due to extreme heat, which we witnessed first-hand in our emergency department (ED). During the peak of the heat wave, our regional Disaster Medical Coordination Center was activated to redistribute the influx of patients among overwhelmed area hospitals. According to initial data from the county health department, over 10% of emergency department visits that day were heat-related, and EMS responded to many more calls than those who were transported. Early on, patients presented with classic heat illness: hot to the touch, fatigued, nauseous — an elderly woman stuck in a blistering third story apartment; a patient in supportive housing too weak to get down the stairs. After an ice bath and some fluids, these patients brightened up, and calls were made to relatives and case workers to arrange for a cooler place to spend the night. When sunset didn’t break the heat, paramedic calls grew more frequent and dire: intoxicated patients found unresponsive and hyperthermic on the sidewalk, some with third-degree burns from walking on hot asphalt; frail elderly
patients intubated because they had lost consciousness. By midnight, paramedics called to warn of their arrivals every other minute. Each call seemed a version of the last: a vulnerable person, found unconscious or confused, hot to the touch, needing emergent intervention. Hospitals depleted their supply of ventilators. One medical center lost its own air conditioning for several hours. Laboratory equipment overheated. Within a thirty-minute period, three asystolic arrests were terminated in the field. Patients arrived to an overwhelmed emergency department with asthma exacerbations, hemorrhagic strokes, and stab wounds. A network of resources already stretched thin found itself reaching a boiling point. As previously reviewed in SAEM Pulse by our colleagues from the SAEM Climate Change and Health Interest Group, the spectrum of heat illness ranges from minor symptoms to major illness such as heat stroke, the mortality of which is exceedingly high. Those at greater risk of heat illness are the young and old, athletes and outdoor workers, military, and those with lower income and resources. Chronic diseases such
“As emergency medicine providers, we have an opportunity to prepare our patients and coordinate with community partners to mitigate effects of extreme climate events.” as diabetes, hypertension, renal failure, heart failure, and obesity increase the risk of complications from heat illness, as do substance use and psychiatric conditions. Medications needed to manage these conditions can influence electrolyte levels, fluid balance, and thermoregulation, driving acute decompensation in overheated patients.
persisted longer, in neighborhoods with less tree cover and higher concentration of roads, parking structures, and industrial activity. The regions most affected on this map coincide with other predictors of health outcomes such as income and socioeconomic status, comorbid conditions, frequency of ED use, and firearm violence.
As we continue to learn more about this heat wave, we’re beginning to understand the true toll on our community and emergency medical services. At the time of this writing, the death count is estimated at 100 each in Washington and Oregon and more than 500 in British Columbia, with thousands more presenting to EDs throughout the region. These numbers certainly underestimate the true toll, as deaths are newly discovered, aggregated and analyzed. Indeed, this event now has the distinction of being the deadliest weather event in Washington state history as additional deaths have been attributed to the heat wave. From a health perspective, the extreme heat event constitutes a massive disease outbreak and mass casualty event for our region, though it has not yet been referred to in these terms.
Heat early warning systems and action plans are proven to reduce heatrelated health risks. Community-level interventions to mitigate the effects of heat waves include establishing early warning systems to communicate health risks and protective actions to the public, opening community cooling centers, and providing access to drinking fountains and swimming pools. Changes to the built environment, such as green roofs and increased vegetation in urban environments, can significantly curtail the urban heat island effect and improve energy efficiency.
According to an MMWR Early Release from the CDC, the Northwest saw more then 3,500 heat-related illness ED visits in May and June, of which 79% occurred during six days at the end of June and represented a 69-fold increase compared to the year prior. Previous estimates attribute 618 deaths annually to heat illness in the U.S., although another study found this to be significantly underestimated by a factor of 10. Of all environmental hazards, heat exposure is responsible for the greatest number of fatalities. Severe heat and its resulting impacts are not equitably distributed — a heat mapping project conducted by the City of Seattle and King County in 2020 demonstrated that the surface temperatures were higher, and the heat
As emergency medicine providers, we have an opportunity to prepare our patients and coordinate with community partners to mitigate effects of extreme climate events. In the days preceding heat waves, we can educate patients on signs of heat illness and opportunities for prevention. We can identify available cooling centers in case of emergency and encourage our patients to stay indoors, hydrated, and connected with vulnerable family and community members. In anticipation of an extreme heat event, hospital administrators, EM practitioners and EMS organizations need to collaborate to anticipate staffing needs, hospital bed and ventilator capacity, and availability of tools for rapid patient cooling, as well as the capacity to maintain these resources during a prolonged heat event. Climate change will make compound events, such as a heat wave combined with a smoke wave and rolling blackouts, more likely — which will truly test our system’s capacity in a crisis. As climate change drives temperatures higher and increases the frequency
and duration of heat waves, it acts as a threat-multiplier to exacerbate existing morbidity and mortality from inequality and chronic disease. We have an opportunity to advocate for a reduction of healthcare-related greenhouse gas emissions to limit our own contribution towards the increasing frequency of these events. Though this is the hottest summer on record so far, it may be the coolest for years to come. Emergency physicians are on the front lines, caring for the most vulnerable patients at greatest risk for heat illness. It is crucial that we understand the implications of heat waves on patient care, as well as the opportunities we have for the prevention of illness and mortality in collaboration with patients, their families, and the public health community at large.
ABOUT THE AUTHORS Dr. Wettstein is a fourth-year emergency medicine resident at the University of Washington.
Dr. Goodson is a third-year emergency medicine resident at the University of Washington.
Dr. Ganz is a third-year emergency medicine resident at the University of Washington.
Dr. Hess is professor of environmental and occupational health sciences, global health and emergency medicine at the University of Washington.
NETCCN: Delivering Needed Critical Care Expertise “From Anywhere, to Anywhere” SAEM PULSE | SEPTEMBER-OCTOBER 2021
By Matt Quinn, MBA; Jarone Lee, MD, MPH; and Jeremy Pamplin, MD on behalf of the SAEM Critical Care Interest Group
The National Emergency and Critical Care Network (NETCCN)
The COVID-19 pandemic stressed the U.S. health care system. In response, many health care systems rapidly expanded Intensive Care Unit (ICU) beds and scrambled to find ventilators and other specialized equipment. Urban centers with abundant resources were overwhelmed and rural areas that lacked ICUs were forced to manage patients beyond their normal scope of expertise. Informed by experience in combat casualty care and work by the Society of Critical Care Medicine’s Tele-Critical Care Committee, the Army’s Telemedicine & Advanced Technology
“NETCCN consists of teams of remote experts supporting patient care anywhere via secure, HIPAA compliant, live video, messaging, phone, and file sharing.” Research Center (TATRC) formulated an approach to deliver needed critical care expertise “from anywhere to anywhere” in support of local-, regional-, and national-level demands imposed by the COVID-19 pandemic.
With funding from The Coronavirus Aid, Relief, and Economic Security (CARES) Act, TATRC developed and deployed a National Tele-Critical Care Network (NETCCN) to assist hospitals and other
“NETCCN has helped with services that would ordinarily be unavailable at the supported hospital: palliative services, ventilator expertise and critical care expertise.” sites in the care of severely ill COVID patients. NETCCN consists of teams of remote experts supporting patient care anywhere via secure, HIPAA compliant, live video, messaging, phone, and file sharing. NETCCN delivers on-demand expertise using simple smartphone applications that require only cellular networks to operate and delivers support faster than “boots on the ground” contracted or federal response clinicians. In June 2020, TATRC awarded nine clinical-technical teams funding to build NETCCN. Through two “sprints” and 82 days during which teams configured their systems, gathered feedback from local and distance clinicians, and conducted care simulations with their teams and systems, TATRC selected four finalists to begin supporting care across the nation.
Capabilities and Successes
NETCCN teams have supported hospitals in Guam, Puerto Rico, North Dakota, South Dakota, Iowa, and Minnesota. Hospitals that received support from NETCCN can have virtual clinical teams assisting them within hours, as there is no need for hardware beyond a smart phone. NETCCN has filled in multiple clinical gaps over the last year. Primarily, NETCCN has helped with services that would ordinarily be unavailable at the supported hospital: palliative services, ventilator expertise and critical care expertise. One hospital had a nurse
caring for multiple, intubated COVID patients and no local physician available. NETCCN’s remote physician helped this bedside nurse diagnose and treat a tension pneumothorax — something she had not seen before. Other hospitals used NETCCN to cover shifts during nights and weekends, which offered relief to over-extended staff. NETCCN has also helped manage patients at home and kept them out of emergency departments and hospitals. For this, NETCCN clinicians communicated with patients at home, who otherwise would have been hospitalized, to monitor their pulse oximeter readings and deliver oxygen when needed. Finally, NETCCN has been available and provided continuity when other systems fail, such as during a local power and network outage. As COVID continues to surge with the Delta variant, NETCCN continues to support hospitals throughout the U.S.
In September 2020, TATRC established a four-year partnership with the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response (HHS/ ASPR) to provide additional funding to not only scale and enhance NETCCN for COVID-19, but also to integrate NETCCN into ASPR programs for future national all-hazard responses, including conducting joint simulation exercises to optimize use of technology in disaster environments.
ABOUT THE AUTHORS Matt Quinn is the science director for the U.S. Army's Telemedicine & Advanced Technology Research Center (TATRC). Prior, he served as senior advisor for health technology at the Health Resources and Services Administration (HRSA) and managing director for healthcare and life sciences at Intel Corporation. Dr. Lee is an associate professor at Harvard Medical School, director of the Blake 12 ICU at Massachusetts General Hospital and board member of the SAEM CCIG. As a medical officer in the National Disaster Medical System, he deploys in response to disasters and other major events. Twitter: @ JaroneLeeMD Dr. Pamplin is the commander of the U.S. Army’s Telemedicine and Advanced Technology Research Center. He deployed to Iraq and Afghanistan, has directed medical, surgical, trauma, and burn ICUs, leads development of the military’s synchronous operational virtual health solution, and cofounded the Joint Tele-Critical Care Network.
Join the SAEM Critical Care Interest Group If you are an SAEM member and are interested in joining the SAEM Critical Care Interest Group (CCIG) to your membership, simply sign in to your SAEM profile and join today. SAEM members who are already part of the CCIG can find more information and resources by visiting the SAEM CCIG Community Site. 11
DIVERSITY, EQUITY & INCLUSION
Back to Basics: Key Terms in Diversity, Equity, and Inclusion
SAEM PULSE | SEPTEMBER-OCTOBER 2021
By Alden Landry, MD, MPH and Italo Brown, MD, MPH on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine
For 40 years, the phrase “health disparities” has been present in medical literature. In research, these disparities were commonly described as Blackwhite differences until 2003 when the Institute of Medicine (now the National Academy of Medicine) formally defined health disparities in their publication, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The applied terminology often raised concern about why these differences existed — a question that has yet to be effectively answered. While the discussion in academic journals has since flourished, the original relationship and terminology used to describe its existence has evolved. Unfortunately, inconsistency in nomenclature, similarity of terms, and overlap of definitions has led to ambiguity, especially when
used improperly or if the reader lacks foundational understanding of the terms. In parallel, another discussion emerged about (the lack of) workforce diversity, noting that the number of Black, Latinx and Native American/ Pacific Islanders accepted into medical school and as practicing physicians is low relative to their composition of the U.S. demographics. The reasons behind this issue are multifactorial and, as we address representation in medicine, we have coined terms to identify groups and address the issues that plague their success. As emergency medicine continues to confront health inequities in our field and address workforce diversity, it is paramount that we all have a foundational knowledge and
understanding of key terms related to diversity, equity, and inclusion. Moreover, it is important for us to know that while these terms are commonly used, there is a shift in language that takes place over time with terms being retired and better terms being infused into the literature, didactics, and conversations throughout the hospital. Health Disparity Discrepancy in health outcomes that is closely linked to economic, social, or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender
“As emergency medicine continues to confront health inequities in our field and address workforce diversity, it is paramount that we all have a foundational knowledge and understanding of key terms related to diversity, equity, and inclusion.” identity; geographic location; or other characteristics historically linked to discrimination or exclusion. (Health People 2020) Health Equity The expectation that everyone has a fair and just opportunity to achieve optimal health. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care. Social Determinant of Health The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social Justice (in Health) The view that everyone deserves equal rights and opportunities — this includes the right to good health.
experience in daily interactions with persons who may be unaware they have engaged in demeaning ways. Minority Tax The tax of extra responsibilities placed on minority faculty in the name of efforts to achieve diversity. Upstander A person who speaks or acts in support of an individual or cause. Ally A person who uses their privilege to advocate on behalf of someone else who doesn’t hold that same privilege. When discussing the presence of bias in medicine these can be used to assuage the conversation to make it more palatable for an uneasy audience; however, it is important to use accurate terms such as racism, misogyny, homophobia, xenophobia to call out the issues in medicine by name.
Underrepresented in Medicine (UiM) Those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.
While some of these terms are fixed, others have evolved over time or will evolve in the future. For example, “underrepresented minorities” (URM) has been replaced by “underrepresented in medicine” (UiM), in part due to a shift in language from AAMC. However, some argue that while UiM is the current accepted term, “historically excluded from medicine” is the more accurate term. “Historically excluded from medicine” elevates the fact that the historical barriers impacting the access to education, in particular higher education and medical school, should be emphasized when discussing populations who are underrepresented in medicine.
Microaggressions The everyday slights, insults, putdowns, invalidations, and offensive behaviors that people
An example of upcoming evolution is the use of the phrase “social determinants of health.” One argument
Bias Both implicit stereotypes and prejudices that raise serious concerns in health care. Structural Racism A system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity.
is that “social” should be replaced by “structures” since these issues are often structural, relating to the arrangement of and relations between the parts or elements of a complex whole. Likewise, “determinants” should be replaced with “drivers,” given that these factors cause a particular phenomenon, in this case health, to happen or develop. While the language remains up for debate, we know that issues related to diversity, equity, and inclusion persist. Our energies, strategies, and commitment to addressing these disparities must be consistent throughout all iterations. We must be consistent in our efforts to address disparities.
ABOUT THE AUTHORS Dr. Landry is assistant dean, Office for Diversity Inclusion and Community Partnership and associate director and advisor, Castle Society, Harvard Medical School Dr. Brown is an assistant professor in emergency medicine and the health equity and social justice curriculum lead at Stanford University School of Medicine. He also serves as the chief impact officer of T.R.A.P. Medicine, a barbershop-based wellness initiative that leverages the cultural capital of barbershops to address the physical and emotional health of Black men and boys.
About ADIEM The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the realization of our common goals of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Joining ADIEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
SAEM PULSE | SEPTEMBER-OCTOBER 2021
ETHICS IN ACTION
“It is not a small matter to terminate a surrogate’s right to decide, as they are the ones who are generally best placed to understand a patient’s desires and values.”
Who’s in Charge Here? By Jeremy R. Simon, MD, PhD on behalf of the SAEM Ethics Committee The patient, a 56-year-old male with a glioblastoma multiforme that has progressed despite resection and chemotherapy, arrives with his wife and other members of the family, including a nephew. Prior to arrival in the emergency department (ED), the patient had been on home hospice under the care of his wife and a visiting nurse service. However, on the day of his admission, other members of the family, including the patient’s nephew and sister, had called EMS. They were concerned because they believed the wife was mismanaging the patient, mixing up his medications, and physically abusing him. They claimed to have video of the wife hitting the patient and stated they had opened a case with Adult Protective Services (APS) earlier that day. Although as recently as four months ago the patient had been participating in his care, recently he had been lethargic and non-verbal. It was this rapid decline that led to his placement in hospice. Aside from this abnormal mental status, the only positive finding on exam was a 2 cm ecchymosis on his right biceps. The nephew claimed this was a result of the wife’s abuse. The patient is otherwise well-appearing and does not appear malnourished or dehydrated on either exam or labs. Despite the obvious difference in perspective between the wife and other family members, they all agreed that that the patient should be DNR/DNI, and that he should be transferred to inpatient hospice. Furthermore, social work contacted APS which said that while they had not yet begun investigating the case, given the allegations were concerning her, they did not want the patient discharged with the wife. The decision was therefore made to admit the patient to the floor to facilitate placement. After the decision to admit was made, the patient’s sister approached the
team and asked that the wife not be allowed to make decisions for the patient regarding which hospice to send him to. The team was unsure whether to grant this request. Although in most states, in the absence of a designated health care agent or proxy, a spouse, if available, would be the surrogate decision maker for an incapacitated patient, the team was concerned about the seriousness of the allegation and therefore consulted ethics. While this decision would likely not be made until the patient was accepted by the inpatient team, in our hospital there is often a substantial delay before this happens, and the ED team felt they should be able to respond to the request. Also, although it appeared unlikely that there would be any other decisions that needed to be made for the patient, who was clinically stable, they wanted to be prepared in case there were. It is not a small matter to terminate a surrogate’s right to decide, as they are the ones who are generally best placed to understand a patient’s desires and values. They are given the right to make decisions not only for their own sake, but also for the patient’s sake. All other things being equal, a wife is likely to know better than a child what a patient would want. In circumstances such as these we must consider both the nature of the concerns as well as the nature of the decisions under consideration. Regarding the concerns, here we have only an unsubstantiated report of abuse. Accusations do not generally rise to the standard we need to reach to terminate a surrogate’s rights. Anyone can file a report. Indeed, in this case, it was worth noting that wife was a second wife and not the mother of his children. It does not take much imagination to think of scenarios where an accusation of abuse might be made in bad faith under such circumstances. Therefore,
unless the hospital staff itself witnessed abuse in the hospital, only once the report is investigated and substantiated can the staff take the charge of abuse as an unproblematic basis for making decisions. Nor is the hospital, and certainly not the treating team or ethics consultant, properly placed or prepared to carry out such an investigation. However, given the seriousness of the allegations, it might be best, for the patient’s safety, to remove the wife from the decision pathway as a precaution. While there may be circumstances where this could be the case, this does not appear necessary or appropriate in this situation. The only decision that anyone anticipates needs to be made for the patient at this time is to which facility to send him. The wife is unable to put the patient at risk through this decision, thus there is no reason to suspend the wife’s rights “as a precaution” under these circumstances. In this case, the ethics consultant told the team that unless and until APS found that the wife had abused the patient (or as noted above, staff had witnessed abuse), she should be given the benefit of the doubt, and the family’s request should not be granted. Indeed, unless or until something changed, it was the wife who had the authority to exclude the rest of the family from visiting, and not the other way around.
ABOUT THE AUTHOR Dr. Simon is a professor of emergency medicine at Columbia University and serves on the ethics committees of Columbia University Medical Center, SAEM, and ACEP.
SAEM PULSE | SEPTEMBER-OCTOBER 2021
GERIATRIC EMERGENCY MEDICINE
How Medical Care Was Brought Into the Home in 2020: Interviews with Physicians By Elizabeth M. Goldberg, MD, ScM on behalf of the SAEM Academy of Geriatric Emergency Medicine Normally, I spend my time working clinically at our academic emergency departments (EDs) and leading studies on the most common reason for injuryrelated ED visits among older adults: falls. But in early 2020 a more pressing problem surfaced among our geriatric patients: COVID-19. The National Institutes of Health soon followed with a call for COVID-19 supplements to existing grants and we were lucky to receive funding to interview physicians on the front lines of geriatric care
(emergency physicians, geriatricians, and primary care doctors) about how they met the medical needs of older adults during the early phases of the pandemic, from March 2020 to November 2020. Although many of us will remember those days as the darkest weeks for emergency medicine, it was also a major turning point in how we deliver health care. ED visits plummeted — most saw a 40% reduction in visits — and the growth of telemedicine offset
two-thirds of the decline in in-person visit volume. We wanted to know how this major change in health care delivery was affecting older adults from the perspective of the physicians caring for them. A study in 2018 of 4,525 Americans aged 65 and older living at home revealed that 38% were not ready for video visits and only 80% could participate in a telephone visit due to a physical disability, dementia, hearing difficulties, or technology challenges. Many were concerned that
the telehealth boon would exacerbate disparities and older patients would be left behind. In the beginning of the pandemic many medical offices closed and within two weeks several of the physicians we interviewed had moved to 100% telehealth visits. They described this adoption as “chaotic” and a “disaster,” but also acknowledged that despite the “glitches” they were able to connect with patients after an initial learning curve. One geriatrician in the southern U.S. noted, “we certainly had plenty of patients and, frankly, a couple of doctors who just did not take to it at first, but we've been able to bring it along with some coaching and hand-holding.” Emergency physicians described using technology to reduce their COVID-19 exposure during personal protective equipment shortages and to reach patients remotely who wanted to avoid their own risk of exposure. Thirteen of the
15 physicians we interviewed described using phone calls, iPads, and robots with mounted screens to do in-ED patient assessments. Eleven physicians said they provided medical care to patients outside of the ED as part of virtual urgent care, occupational health, or chat-based visits. In the first few months of the pandemic these visits focused on providing public health guidance (e.g., how to obtain testing, whether to come to the hospital) and addressing traditional primary care complaints when offices were closed. Over time, physicians learned to overcome barriers to connecting to older adults by leveraging caregivers and their devices, asking home visiting nurses or facility staff to conduct visits, or having office staff or students conduct pre-visit technology education. Although video visits weren’t always possible, most physicians said they could address patient needs with telephone calls, and after using telehealth they realized many visits — such as those for palliative
care concerns, mental health needs, medication refills, and other urgent complaints — could successfully be completed remotely. Read more about this study on interviewing physicians about their experiences using telehealth during COVID-19.
ABOUT THE AUTHOR Dr. Goldberg is an associate professor of emergency medicine, and associate professor of health services, policy and practice at Brown University. She is the physician lead for geriatric emergency care initiatives for the Lifespan health system and treasurer on the 2021-2022 Executive Committee for SAEM’s Academy for Geriatric Emergency Medicine.
About AGEM The Academy of Geriatric Emergency Medicine (AGEM) works to improve the clinical care of older patients, prepare trainees to care for older patients, and advance the geriatric EM research agenda. Joining AGEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
GLOBAL EMERGENCY MEDICINE
SAEM PULSE | SEPTEMBER-OCTOBER 2021
The HAPSA team and partners gather to assemble the home isolation kits
The COVID-19 Pandemic Fight on the Ground: Experiences from Nepal By Ramu Kharel, MD, MPH on behalf of the SAEM Global Emergency Medicine Academy When I returned to Nepal on April 1, 2021, it felt as though life had returned to normal for the first time since the pandemic began: airports and streets were packed, fewer people were wearing masks, and wedding season was in full swing. While Nepal had seemingly moved past the pandemic, India’s daily case count was slowly creeping up. As a global emergency medicine fellow at Brown University, I had been serving on the front lines of the COVID-19 pandemic in the U.S., staying active on social media and
television, writing frequently in Nepali newspapers, and conducting COVID-19 training around the world over the last year. Even I was convinced that somehow Nepal had beaten COVID-19, although less than 5% of the population had been vaccinated. I was born in a small village in Nepal and moved to the U.S. at the age of 13. Over the years, I have returned to Nepal frequently, mostly for health advancement projects through a nonprofit organization I founded years ago called HAPSA. Now, amid the
pandemic, I had received a grant and gotten approval from my university to travel and assess emergency care at seven tertiary hospitals in Nepal. Strong emergency care is recognized by the World Health Organization and many countries around the globe as a key to universal health coverage, and the first step is to understand the current landscape of emergency care. Within a few weeks of my arrival, Nepal overtook India as the country with the worst per capita COVID-19 cases and the highest viral replication in
In-person training of health care workers at the Kathmandu municipality isolation center
“For nearly 30 million people, Nepal has 1,200 ICU beds, less than 500 ventilators, and a major lack of health care human resources.” the world. With world news focused on the Indian COVID-19 crises, Nepal was overshadowed and forgotten globally. This reality became clear to me when I received an SMS (Short Message Service) text from a close friend in the U.S.: “Hey man, how are you? I heard things are bad in India. Stay safe in Nepal.” Unlike previous disasters, it felt as though Nepal was alone in its response to this crisis. This is what motivated me to join a newly formed group, COVID Alliance for Nepal, which included volunteers and organizations working from different sectors. The Alliance had two main goals: 1) Raise awareness about the situation in Nepal to the world. 2) Keep as many people at home as possible to reduce the strain on the health system. We worked on these goals through vaccine advocacy, creating protocols, conducting training, and providing service.
COVID-19 vaccines have highlighted the pre-existing worldwide inequities in global health. While Nepal has only fully vaccinated 5.3% of its population, vaccines are being wasted in developed countries. Our first focus was on vaccine advocacy for Nepal. We started a petition to the United States government with support from influential Nepalis and concomitant support by our partners in the U.S. through phone call-in campaigns
to U.S. lawmakers. This led to Nepal’s situation being discussed during a congressional hearing, and our petition being delivered to the White House. I personally called in to shows like The Brian Lehrer Show to discuss Nepal's situation and global vaccine inequity. Our efforts were followed by other groups in the United Kingdom and Canada launching their own advocacy campaigns. In the recent weeks, Nepal has received vaccine donation commitments from a few countries, including Japan and the U.S. In Nepal, we frequently met with the mayors from Kathmandu, the capital city, and other municipalities across the country. Furthermore, we met with officials from the Ministry of Health, the Department of Health Services, and the COVID Crises Management Center to discuss vaccine distribution and supply chain, and provide our time and expertise as needed. The fight to procure adequate amounts of vaccines in Nepal will likely need continued advocacy in and outside of Nepal for years to come.
Protocols and Training
I had gained significant experiences managing COVID-19 while working in the U.S. during the peak of the pandemic, as well as closely with a surge hospital in Rhode Island. Furthermore, I have been one of the trainers for a Project HOPEled virtual, four-day COVID-19 training
around the world since June 2020, and have conducted multiple trainings globally. I felt equipped to help in Nepal. For nearly 30 million people, Nepal has 1,200 ICU beds, less than 500 ventilators, and a major lack of health care human resources. One of the key strategies to help the health system during a surge is to establish alternate hospitals, like surge sites or isolation centers, and to keep as many people at home as possible. Our team from COVID Alliance created a guide/blueprint for local officials, administrators, and health care workers on starting their own isolation/surge center to manage COVID-19 patients. We listed necessary supplies, defined service delivery, created specific treatment protocols based on the Nepal Medical Council’s guideline, and made these resources publicly available. Using this guide, we conducted numerous in-person and virtual trainings at surge/isolation centers. I remember one question from a pre-and post-test survey after a two-hour training on key management guidelines where we asked if participants felt comfortable managing mild COVID-19 cases. While before the training 37% had said yes, after the training 98% said yes. We knew these training sessions were helping the management of COVID-19.
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All items that are included in the home isolation kits
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On a near-daily basis, I attended multiple social media interviews and hosted several social media platform events (namastedoctor). I have appeared on multiple national TV/ radio news networks, and have written articles in Nepali and English to dispel myths and answer questions related to COVID-19.
Service COVID Alliance Nepal team was directly involved in providing essential services like food distribution, oxygen cylinder and plant procurement, and home isolation kits delivery. Through HAPSA, I led the effort in designing home isolation kits, raising funds, and distributing them across the country. The kit included medications like paracetamol and cough syrup, with detailed instructions on dosing, masks, soap, sanitizer, vitamins, thermometer, and quality-checked pulse oximeters. It also included a detailed
instructional video link/QR code on how to use the kit and a 90-minute public health COVID-19 information session. In order to coordinate relief efforts with the local government, we partnered with local municipalities to distribute these kits. As of July 18, 2021, we had raised nearly $65K US via a crowdfunding campaign and other organizational donors. We have delivered home isolation kits to nearly 25 municipalities across the country. As Nepal is heading towards a third wave, we hope to have the resources to support anyone in home-isolation with these essential kits. While I was fortunate to have access to the COVID-19 vaccine, many around the world, including my fellow Nepalis, have no idea when they will get vaccinated. Nepal has a great vaccine delivery infrastructure, and our recent survey has shown that nearly 95% of people in Nepal are willing to take the vaccines. Vaccines must be prioritized to prevent further devastation. I left Nepal heavy-hearted while the country was still on lockdown, but I
continue to work with the team there virtually. With the rise of monsoon floods, we have adjusted our home isolation kits to include water purifiers, and continue to raise funds to support them. While the current focus has been on acute response, these few months have highlighted the importance of developing a strong emergency care infrastructure.
ABOUT THE AUTHOR Dr. Kharel is a global emergency medicine fellow in the department of emergency medicine at Brown University. His research focuses on emergency system strengthening in Nepal. He is the founder of HAPSA, a grassroots non-profit organization based in Nepal. firstname.lastname@example.org @erdockharel
From Tuk Tuks to Ambulances: Setting up a Universal Access Prehospital System in a Developing Country By Kaushila Thilakasiri, MD, MRCEM on behalf of the SAEM Global Emergency Medicine Academy While driving 60 kilometers away from Colombo, the capital city of Sri Lanka, one Saturday night, we became stopped in traffic created by a road accident. Two motorcycle riders were lying on the ground — one mortally wounded and lying in a pool of blood with both lower limbs amputated at mid-thigh, the other unconscious with a mangled left leg below the knee. As my husband checked the response of the two injured, I called an ambulance. In two minutes, the ambulance arrived and rushed the two men to the nearest hospital. I serve as a registrar of emergency medicine at the National Hospital Accident Service (the largest trauma center in Southeast Asia). The next day I saw the patient with the mangled limb, transferred from the regional hospital for a belowknee amputation. This story would have been very different five years ago. Until 2016, Sri Lanka did not have an organized prehospital emergency medical service.
How Patients Reach Hospitals in the Developing World Sri Lanka is a lower middle-income island country in South Asia with a population of 21.2 million. In 2016, 3,000 road fatalities were registered, according to data from the World Health Organization (WHO). Sri Lanka’s reported annual road accident deaths per capita of 17.4 are double the average rate in high-income countries and five times that of the world’s bestperforming countries. Until four years
ago, all road traffic victims were primarily transported to hospital by three-wheeled motorized rickshaws, known locally as “Tuk Tuks.” When emergencies occurred at night, people often would not present to the hospital due to fear of snake bites and elephant attacks on the way to the hospital. In urban areas, people would not touch a traffic accident patient for hours because of fear of litigation. The likelihood of an accident patient being transported to a hospital in a timely manner was grim, leading to substantial but unreported prehospital mortality. Similar situations are common in other developing countries.
What Is Unique About Health Care in Sri Lanka
Sri Lanka has a universal free health care system that covers antenatal health, child health, including vaccination and prevention of communicable and non-communicable diseases and has achieved impressive results, including a high life expectancy of 77 years and a low maternal mortality rate (MMR) comparable to high-income countries; however, free, universal, reliable transport of emergency patients to the hospital was a fundamental gap in the national health care system until 2016 when the 1990 Suwa Seriya Ambulance Service was introduced.
How Suwa Seriya Started
Dr. Harsha De Silva, the former deputy minister of National Policies and Economic Affairs, led the development of Suwa
Seriya in 2016. The Indian government’s grant of $7.55 million to Sri Lanka was established as a token of friendship between the two nations. Phase 1 of this project was launched on July 28, 2016 and provided 88 ambulances for the southern and western provinces, funding for call center development, and the running cost for one year. Commencing July 21, 2018, under Phase II, 209 ambulances covered the rest of the country with another grant from the people of India of $15 million. Since 2018, 297 ambulances have operated under the 1990 Suwa Seriya Foundation set up by an act of parliament in 2018.
Operational Procedures of the Suwa Seriya
The public can access the Emergency Command and Control Center (ECCC) through the 1990 unified number or a free 1990 mobile application, which allows for identification of the patient’s location. The public are encouraged to use the app, rather than a direct number, to place an incident. This island-wide ambulance service is centrally managed from the state-of-the-art ECCC in Colombo. Call to wheel time (time from assigning the case to leaving the base) should be less than 90 seconds. Response time varies by province due to geographic factors, population density, access to good
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continued from Page 21 roads, and patient location. The average response time is 11 minutes and 52 seconds island-wide and eight minutes and 32 seconds inside Colombo. To date, approximately 908,371 incidents have been attended by Suwa Seriya. Of these calls, 26% were due to road traffic accidents. The service has been highly efficient, particularly in major mass casualty incidences like building collapses, major bus accidents, floods, and the Easter Sunday-terrorist bomb attack in 2019 when nine locations, including churches and luxury hotels, were simultaneously bombed, injuring more than 500 people and resulting in more than 250 casualties, including 38 foreign tourists.
Training of Staff
New emergency medical technician (EMT) recruits are sent for two months of initial training in Hyderabad, India. EMT recruits undergo classroom training (including BLS and Intermediate Life Support), simulation training, hospital training, and field training in the ambulance. Upon return, they receive another training on practical and communication skills and a onemonth internship, prior to assignment to a location, under the supervision of a senior EMT. All EMTs and pilots need recertification regularly.
SAEM PULSE | SEPTEMBER-OCTOBER 2021
Collaboration with Emergency Medicine
The doctor of medicine (MD) degree in emergency medicine specialty by the Postgraduate Institute of Sri Lanka took place independently prior to the launch of Suwa Seriya with the first cohort of emergency medicine trainees recruited in 2013. The Sri Lankan Society of Critical Care and Emergency Medicine (SSCCEM), established in 2002, became actively involved in teaching emergency medicine and critical care from 2006 with the help of Australian emergency physicians. Simulationbased refresher training, including
“The likelihood of an accident patient being transported to a hospital in a timely manner was grim, leading to substantial but unreported prehospital mortality.” adult and pediatric BLS for EMTs, is organized by the emergency medicine registrars, SSCCEM, and led by Dr. Sanj Fernado, an emergency physician in NSW, Australia. The emergency trainees also work shifts at the head office to guide EMTs over the phone to stabilize before transportation. Suwa Seriya is working on the accreditation process for the EMTs through the SSCCEM under the guidance of the Australian and New Zealand College of Paramedicine.
Rising With the COVID-19 Waves
Suwa Seriya transferred the first COVID-19 patient identified in Sri Lanka — a Chinese national — in 2020. During both pandemic waves, Suwa Seriya provided both emergency services and pandemic-related requests, straining the limits of this free emergency service in the nation. Suwa Seriya used to receive approximately 5,300 calls and handle an average of 1,000 cases a day. The calls rose to over 9,000 calls and 1,500 cases per day during the first wave of the pandemic; however, transmission of the disease would have been much greater if patients had been transported by public transport or personal cars. Some exciting developments planned in the future include: • Plans with the National Institute of Mental Health and the Ministry of Health to implement a standard operational procedure for safe transportation of violent patients with psychiatric illness • Collaboration with the Sri Lanka Heart Association to develop a STEMI early detection and fast track PCI program • Telephone CPR project
• Implementation of a triage system based on patient’s illness severity
Perception of the Public
This service has achieved great popularity among the public and is available free-of-charge for Sri Lankans and foreign nationals irrespective of their backgrounds; however, further public awareness is needed. Being unaware of the role of coordinated prehospital EMS services may lead to hesitancy to call an ambulance or move out of the way when an ambulance with flashing beacons approaches. Also, appropriate first aid and bystander CPR is essential to prehospital care.1990 Suwa Seriya was also a part of “World Restart Heart Day 2019,” which encouraged bystander CPR and prompt transport to the hospital. With continued support, this service can thrive and save many lives in the future, potentially serving as a benchmark for similar prehospital systems in other developing countries. This article was reviewed by - Dr. Asanka Migelheva, MD, MRCEM, consultant emergency physician, Teaching Hospital Karapitiya. - Dr. Sri Lal De Silva, MD, chief medical officer 1990 Suwa Seriya Foundation - Mr. Sohan De Silva, CEO 1990 Suwa Seriya Foundation
ABOUT THE AUTHOR Dr. Thilakasiri is senior registrar in emergency medicine, PGIM, University of Colombo, Sri Lanka.
About GEMA The Global Emergency Medicine Academy (GEMA) focuses on improvement of the worldwide delivery of emergency medical care. Joining GEMA is free! Just log in to your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
SGEM: DID YOU KNOW? Differences in the Treatment and Outcomes of Patients with Acute Coronary Syndrome By Kathryn Wiesendanger, BSc, and Angela Jarman, MD, MPH, on behalf of the SAEM Sex and Gender in Emergency Medicine Interest Group The sex-specific pathophysiology of coronary artery disease is complex and involves differences in anatomy, hormonal profile, and comorbid risk factors. Despite this, women have historically been underrepresented in clinical trials of cardiovascular disease, contributing to the predominantly male-centric model for diagnosis and management. When we visualize a patient presenting with acute coronary syndrome (ACS), we see an obese, older man clutching his chest and gasping for air. Women, however, more commonly experience nonspecific symptoms such as nausea, vomiting, malaise, palpitations and epigastric pain. Lack of public knowledge of these differences make women more likely to delay seeking medical care. This, in combination with clinician failure to acknowledge and understand sex-based differences, may make women presenting with ACS more likely to be misdiagnosed and mistreated, contributing to worse clinical outcomes and higher mortality. In contrast to men, who typically present with obstructive coronary disease, women are more likely to suffer from myocardial infarction with nonobstructive coronaries (MINOCA), caused by microvascular coronary disease. Estrogen is thought to be cardioprotective making women more likely to develop coronary artery disease later in life as estrogen levels decline. Attention should thus be made to consider alternative causes of myocardial infarction in younger women, before these estrogen-mediated effects take place. Commonly ordered cardiac investigations such as troponins and EKGs are thus less sensitive for women than men, and may contribute to improper diagnosis in a clinical setting. Emergency department providers are the first physicians to evaluate undifferentiated patients, giving them the unique opportunity to consider sex and gender differences in ACS etiology, presentation, management, and clinical outcome. Efforts should be made to educate
communities and medical providers alike on the sex and gender differences in presentation, and institutions should encourage implicit bias training to combat the disparities in treatments provided. Further, more women should be included in clinical trials to further establish sex-specific guidelines for management of acute coronary syndromes.
ABOUT THE AUTHORS
Kathryn Wiesendanger is a fourth-year medical student at the Royal College of Surgeons in Ireland. Dr. Jarman is an assistant clinical professor in the department of emergency medicine at UC Davis. She is fellowship-trained in sex and gender in emergency medicine and studies sex differences in the acute presentations of disease.
SGEM "Did You Know?" is a recurring SAEM Pulse submission designed to represent concise facts that demonstrate how patient sex and gender effect emergency care. We welcome submissions. Please send contributions to the coeditors Lauren Walter and Alyson J. McGregor at email@example.com.
Recurrent, Low-risk Chest Pain: A User’s Guide SAEM PULSE | SEPTEMBER-OCTOBER 2021
By D. Mark Courtney, MD, MSc and Eddy Lang, MD
The July 2021 issue of Academic Emergency Medicine (AEM) contains two articles (Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department and Navigating Uncertainty with GRACE) that are at the same time a culmination of a multiyear effort but also the first early steps of the journal and the Society for Academic Emergency Medicine (SAEM) leadership into the science of practice guideline creation and dissemination. It is anticipated that readers could raise three basic questions about this endeavor: (1) What is the rationale for this effort and how is it unique relative to what has been
done to date? (2) What can I take to the bedside regarding chest pain? and (3) What can we learn from this first effort — to provide evidence-based guidance for undifferentiated repeat chest pain — that might inform future guidelines on other topics?
What is the Rationale for this Effort?
Emergency physicians have a love–hate relationship with clinical practice guidelines. On one end of the spectrum, guidelines in cardiopulmonary resuscitation have been at the heart of our specialty's development guiding practice and training for nearly 30 years. These guidelines developed through the International Liaison
Committee on Resuscitation (ILCOR) and adopted by seven resuscitation councils around the world are widely implemented across emergency care and CPR education systems with each update eagerly awaited by millions of end-users. On the other end of the spectrum, guideline recommendations on thrombolytic therapy for acute stroke within a 3- to 4.5-hour window has raised the ire of many emergency physicians, resulted in deep examination and debate of source research studies, and resulted in iterative modification of initial recommendations. Moreover, guidelines may not result in practice change, as suggested by an analysis of syncope care, including neuroimaging
“With this GRADE process as the current benchmark for guideline creation, the article by Musey et al. describes the laborious tasks undertaken by an expert group to arrive at a guideline for emergency clinicians in the care of recurrent low-risk chest pain.” and hospitalization rates before versus after guideline publication. This varied life trajectory of guidelines may be due to several factors, but chief among these may be varying perceptions of what constitutes a “trustworthy guideline.” In its landmark 2013 report the then Institute of Medicine defined clinical practice guidelines as “statements that include recommendations that are intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” The report's title, “Clinical Practice Guidelines We Can Trust,” spoke volumes to the general state of guideline development and impact at the time. While problems identified were wide-ranging, key recommendations emphasized the importance of a systematic review supporting the guideline and emphasis on an explicit and transparent processes to make clear how recommendations were determined and that the process was conducted in an unbiased manner as much as possible. Description of this process has become known as GRADE (Grading of Recommendations Assessment, Development and Evaluation). With this GRADE process as the current benchmark for guideline creation, the article by Musey et al. describes the laborious tasks undertaken by an expert group to arrive at a guideline for emergency clinicians in the care of recurrent low-risk chest pain. This is a much different question and process than prior guidelines. The authors address an undifferentiated symptom rather than the evaluation of “non-ST elevation coronary syndrome.” The focus is on recurrent low-risk chest pain, acknowledging that a significant proportion of who we see in the emergency department (ED) are recurrent visits for chest pain defined here as patients who have had a previous visit to an ED with chest pain in the past 12 months that led to a diagnostic
protocol for evaluation but did not demonstrate acute coronary syndrome (ACS) or flow-limiting coronary stenosis. This is a common, but previously unaddressed, scenario that readers will not find addressed in any cardiology, general medical, or emergency medicine textbook—hardcover or online. There are several further methodological reasons why this GRADE approach applied to chest pain is unique relative to prior work, state of the art, and potentially likely to impact care. First, the GRACE approach, which is Academic Emergency Medicine's (AEM) term for this guideline effort (Guidelines for Reasonable and Appropriate Care in the ED) fulfilled the systematic review criteria, adhering to current standards for the conduct and reporting of this category of scientific literature. Second, in keeping with GRADE guidance, outcomes of interest were selected and prioritized for importance and impact on the final seven recommendations. This recognizes that not all outcomes are created equal and thus may not carry the same value for patients. The GRADE approach being outcome-centric characterizes the certainty in evidence for each outcome across studies as would be standard in a systematic review. Third, GRADE deviates from most other guideline frameworks by not relying on study design alone to drive the evaluation of evidence. Typically, this plays out with the strongest category of recommendation invoked if randomized controlled trials (RCTs) exist to inform a question. GRADE takes a more critical approach, as we do in our journal clubs, applying standardized, reproducible assessments of evidence certainty so that even RCTs may land in the lowest category thus unlikely to support strong recommendations. Similarly, non-RCTs with compelling effect sizes that are at low risk of bias due to confounding can rise to the high-certainty category and drive a strong recommendation.
What Can We Take to the Bedside?
Low-risk chest pain in this guideline will be most typically defined by clinicians as a HEART score of <4 (history, EKG, age, risk factors, and troponin) in the context of a non-concerning (electrocardiogram) ECG. This is very common among patients who have had a prior unremarkable ED evaluation with testing unrevealing of ACS or flowlimiting stenosis in the prior 12 months, which meets this guideline's definition of “recurrent.” There are some caveats important for clinicians to consider prior to implementation. (1) These definitions of low risk and recurrent; (2) importance of evaluating an initial ECG; and (3) diligent review of the electronic medical records and patient's history as to prior ED visits, testing, and outcome of that testing. The highest level of evidence supports what is still an uncommon scenario: prior coronary computed tomographic angiography with no stenosis may be considered for no further testing after a single high-sensitivity troponin. Low certainty in evidence was noted for much of the other recommendations thus deemed conditional, including cases of recurrent low risk chest pain of >3-hour duration where a single negative high-sensitivity troponin may reasonably exclude ACS within the subsequent 30 days. Also importantly, in patients with recurrent low-risk chest pain and a normal stress test in the prior 12 months, it is not recommended to employ routine further stress testing to reduce subsequent 30-day major adverse cardiac events (MACE). In our opinion the other important statement is that there is insufficient evidence to recommend hospitalization (either inpatient admission or observation) versus discharge as a strategy to mitigate 30-day MACE. Further recommendations including screening and referral for anxiety and continued on Page 26
continued from Page 25 depression, previously unexplored topics in the context of chest pain, should also be noted in this novel work. Table 1 of the GRACE guidelines make clear that conditional recommendations, while usually directional that is, for or against, are ideally suited to a personalized approach with patients that sees key decisions driven by their own values and preferences.
What Can We Learn From This First Effort to Provide Evidence-Based Guidance for Undifferentiated Repeat Chest Pain That Might Inform Future AEM GRACE Guidelines?
While AEM's GRACE effort is a laudable and important first foray into GRADEbased guidelines with tremendous potential for future endeavors, some improvements can still be attained. These include a more transparent, structured, and prioritized process for guideline topic selection. Also important is the ability to engage educated and trained patients more constructively into the relevant components of the guideline development process and to
do so in a manner that optimally reflects the heterogeneity of patients seeking care and the optimal goal of delivery of care in an equitable manner. An essential GRADE feature that merits emphasis in future GRACE iterations is the evidence-to-decision framework. This approach explicitly laid out in formatted tables of this manuscript's electronic supplemental content encourages consideration of a wide range of relevant factors. These items include the balance between the overall benefits and harms of a given approach, an assessment of patient values and preferences either known or supposed, equity and resource considerations, and acceptability and feasibility. GRACE holds the promise, therefore, of rendering care more rational, efficient, and cost-effective; reducing the harms of over-testing and
referral; and preserving health care resources for those in need. At the end of the day, the worst fate that can come to a clinical practice guideline is to have it gather virtual dust on the journal's server as an academic exercise, unknown and unused by the desired end-users. Multistakeholder engagement by organizations and societies that can see the merit of the GRACE recommendations and be willing to serve as avenues for endorsement and dissemination could be critical. This step can catapult these recommendations into decision support within electronic health records and implementation for millions of chest pain visits across the United States and beyond transforming these recommendations into shared decision making with patients at the point of care.
SAEM PULSE | SEPTEMBER-OCTOBER 2021
What Is GRACE and Why Low-Risk Chest Pain?
SAEM’s Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) emerged to address the critical need for evidence-based and expert-driven, trustworthy, and transparent recommendations for the clinical care of common chief complaints and syndromes, prioritizing those with demonstrable practice variability and significant malpractice angst that often elicit decisional conflict or treatment uncertainty. To accommodate meaningful recommendations for questions that reside at the intersection of evidence and clinical expertise, GRACE uses the widely adopted Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to facilitate transparency in weighing the strength of evidence balanced against pragmatic constructs of health equity, potential harms, and costs. The first publication in the GRACE series focuses on low-risk chest pain, titled "Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE Recurrent, Low-risk Chest Pain in the Emergency Department." Chest pain is the second most common chief complaint in the emergency department (ED), with only five percent of patients diagnosed with an acute, life-threatening condition. There are significant physician and institutional variations in diagnostic testing and admission of these patients, creating a need for clinical practice guidelines to aid in the evaluation and treatment specific to the ED population. See also: GRACE-1 Recurrent Low-Risk Chest Pain in the ED Recommendations
GRACE-1: Recurrent, Low-Risk Chest Pain in the ED RECURRENT CHEST PAIN: Defined as patients who have had a previous visit to an emergency department (ED) with chest pain that led to a diagnostic protocol for its evaluation that did not demonstrate evidence of acute coronary syndrome or flow-limiting coronary stenosis. This included two or more ED visits for chest pain in a 12-month period. LOW RISK: Low risk was defined by HEART score <4 points (and other scores validated in the ED setting such as the HEART pathway or TIMI score) for disease-related poor outcomes within 30 days, all of which require an electrocardiogram (ECG) for risk stratification.
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(P) In adult patients with recurrent, low-risk chest pain, (I) is a single troponin vs (C) serial troponins needed for (O) ACS outcomes within 30 days? (P) In adult patients with recurrent, low-risk chest pain, and normal or non-diagnostic stress testing within the last 12 months, (I) does repeat stress testing vs (C) no stress test have an effect on (O) MACE within 30 days? (P) In adult patients with recurrent, low-risk chest pain, is (I) admission to the hospital versus (C) stay in the ED observation unit versus (C) outpatient follow up recommended for (O) ACS outcomes within 30 days? (P) In adult patients with recurrent, low-risk chest pain and a negative cardiac catheterization defined as less than 50% stenosis (E) what is their risk of subsequent ACS and time to ACS? (P) In adult patients with recurrent, low-risk chest pain and a negative cardiac catheterization defined as no coronary disease (0% stenosis) (E) what is their risk of subsequent ACS and time to ACS? (P) In adult patients with recurrent, low-risk chest pain and a negative coronary CT angiogram (E) what is their risk of subsequent ACS and time to ACS? (P) In adult patients with recurrent, low-risk chest pain, (I) what is the yield of depression and anxiety screening tools in (O) healthcare use and return ED visits? (P) In adult patients with recurrent, low-risk chest pain, (I) what is the role of referral for anxiety/depression in (O) healthcare use and return ED visits?
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In adult patients with recurrent, low-risk chest pain, for greater than 3 hours duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude ACS within 30 days. (Conditional, For) [Low level of evidence] In adult patients with recurrent, low-risk chest pain, and a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of MACE at 30 days. (Conditional, Against) [Low level of evidence] In adult patients with recurrent, low-risk chest pain, there is insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days. (No evidence, Either) In adult patients with recurrent, low-risk chest pain and non-obstructive (< 50% stenosis) CAD on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation. (Conditional, For) [Low level of evidence] In adult patients with recurrent, low-risk chest pain and no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation. (Conditional, For) [Low level of evidence] In adult patients with recurrent, low-risk chest pain and prior CCTA within the past two years with no coronary stenosis, we suggest no further diagnostic testing other than a single, high-sensitivity troponin below a validated threshold to exclude ACS within that two-year time frame. (Conditional, For) [Moderate level of evidence] In adult patients with recurrent, low-risk chest pain, we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return ED visits. (Conditional, Either) [Very low level of evidence] In adult patients with recurrent, low-risk chest pain, we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits. (Conditional, Either) [Low level of evidence]
The New Frontier in Academic Emergency Medicine: A Tale of Two EDs SAEM PULSE | SEPTEMBER-OCTOBER 2021
By Nicholas Stark, MD; William Baker, MD; Zaid Altawil, MD; Stephanie Stapleton, MD; and Christopher Peabody, MD, MPH on behalf of SAEM’s ED Administration and Clinical Operations Committee
Adjusting to constant change and thriving amid limited resources is the bedrock of emergency medicine (EM). While EM physicians are experts in making rapid decisions and adjusting them based on new information in the clinical environment, emergency department (ED) systems are often much less agile. The unprecedented challenges presented by the COVID-19 pandemic highlighted weaknesses in these existing systems, whether in the realm of disrupted supply chains for personal protective equipment (PPE), weakened physical infrastructure, or interrupted clinical communication platforms. These challenges created a profound sense of urgency that
catalyzed a new wave of innovation across the field that continues to grow. This article highlights innovations developed by two large academic EDs in response to the COVID-19 pandemic and explores the potential for incorporating innovation into the academic EM environment. Innovation (i.e., the creation, development and implementation of a new product or process with the aim of improving a system or creating new value) has become increasingly vital in health care. Innovation within EM — especially at large, academic centers — is often challenged by complex problems involving multiple systems and stakeholders. Work toward change
is traditionally focused on discovering convergent solutions for these oftendivergent problems, where flexible, multi-element solutions that can quickly evolve may be both timelier and have greater impact. Two academic EDs — Boston University affiliated Boston Medical Center (BMC) and the University of California San Francisco affiliated S.F. General Hospital (SFGH) — worked to transform weaknesses exposed by the COVID-19 pandemic into meaningful opportunities for rapid-cycle innovation in large academic settings. By utilizing key principles of engaging stakeholders, design thinking, rapidcycle optimization, and working closely
“By utilizing key principles of engaging stakeholders, design thinking, rapid-cycle optimization, and working closely with department and hospital leadership, their experiences serve as beacons for others working to incorporate innovation into the academic EM environment.” with department and hospital leadership, their experiences serve as beacons for others working to incorporate innovation into the academic EM environment. BMC’s experience highlights many of the product-based innovations rising to the forefront of EM. For example, when BMC experienced a severe shortage of PPE due to disrupted supply chains, their team of clinical innovators quickly assembled a coalition of manufacturers to develop new modalities for sourcing and creating PPE, created a workflow for vetting PPE donations, and sourced expertise to replace out-of-stock parts with 3D-printed analogues. Their team partnered with MIT Project Manus and the MIT Center for Bits and Atoms in
developing and testing face shields, and also worked with teams at MIT to develop an advanced display for the aging LTV-1200 ventilator. Other collaborative projects included the development of intubation hoods and HEPA filtered negative pressure enclosures for intubation and aerosolizing procedures. These collaborations involved BMC serving both as a subject matter expert and as a platform for iterative product testing. This process was the subject of BMC’s presentation at Global Response to COVID-19 (timestamp 38:43) FabXLive 2020. While SFGH experienced many of the same product-related challenges early in the COVID-19 pandemic, their innovation team recognized an even more pressing issue for their ED: access to rapidly changing clinical protocols and information. Using a designthinking approach, their team ultimately replaced a disparate array of daily emails and online folders with a centralized, standardized digital platform. This physician-led open access platform (E*Drive) is accessible on any device with an internet connection, is able to be updated multiple times per day, and has since evolved to encompass all types of clinical information from clinical guidelines to discharge resources. These homegrown solutions to democratizing clinical information involved close collaboration with both leadership and end-users to rapidly develop digital tools that can evolve as needs change. BMC and SFGH EM physiciandriven innovations were successfully implemented during the COVID-19 pandemic. These groups represent a small fraction of the EM grassroots innovation that has been ubiquitous
throughout the pandemic. Even prior to the COVID-19 pandemic, we EM physicians prided ourselves with our “MacGyver” spirit: we can find solutions to anything! Our field is hallmarked by an ability to adapt to constant change, and we have the potential to not only drive innovative change within academic EM during a pandemic, but within health care.
ABOUT THE AUTHORS Dr. Stark is chief resident and assistant director of the Acute Care Innovation Center, University of California San Francisco, department of emergency medicine. @NickStarkMD Dr. Baker is senior vice chair and clinical associate professor, Boston Medical Center, department of emergency medicine. @EMDocBaker Dr. Altawil is adjunct assistant professor of emergency medicine, Boston Medical Center, Department of Emergency Medicine. @zaidaltawil Dr. Stapleton is director of emergency medicine simulation and assistant professor of emergency medicine, Boston University School of Medicine. Dr. Peabody is director of quality and performance improvement and director of the Acute Care Innovation Center, University of California San Francisco, department of emergency medicine. @ToffPeabody
“All in the Family”: A Unique Mentorship Structure for ARMED MedEd
SAEM PULSE | SEPTEMBER-OCTOBER 2021
By Wendy C. Coates, MD and Lalena M. Yarris, MD, MCR, ARMED MedEd Co-Chairs on behalf of the ARMED MedEd Steering Committee
In February 2021, a talented and enthusiastic cadre of emerging leaders in health professions education research logged into “another Zoom session” to meet one other and the experts who would be serving as course faculty and their personal mentors. There was palpable excitement on the screen to begin the inaugural ARMED MedEd course (Advanced Research Methodology, Evaluation, Design for Medical Education). The 21 participants range from fellows to department chairs and share an interest in creating a collaborative network of rigorously trained health professions education researchers within SAEM. Each will write a grant proposal and conduct a multi-institutional study with faculty mentorship through our innovative structure, culminating with a research fair where they’ll present their work followed by a graduation celebration at SAEM22. Mentorship is widely valued as an integral component of personal fulfillment and career success. The concept of modern mentorship arose in both the business world and in K-12
“The family structure is awesome. My ‘family’ provides experienced perspectives from amazing researchers around the country (and Canada!) who help shape and refine my project and keep things on track.”
— Ben Schnapp, MD, MEd, ARMED MedEd Participant
education. Benefits extend beyond the obvious mentee target to include mentors and organizations whose leaders make it a strategic priority and cultivate a culture of mentorship. Mentorship based on race and/or gender in academics and biomedical research has positive impacts on productivity, career advancement,
and research funding. The resulting community of professional networks facilitates scholarly productivity and career satisfaction. In designing ARMED MedEd, a task force of experts recognized the need to create a successful environment for researchers that focused on three pillars of success: knowledge, mentorship,
Figure 1: ARMED MedEd Mentorship Family Structure. Each family consists of three participant/mentor dyads and a senior mentor, methodologist, subject experts, and one mentor who is a member of the ARMED MedEd Steering Committee, to ensure sharing of best practices.
and collaborative networks. In order to build a strong knowledge base, ARMED MedEd holds monthly seminars via Zoom that highlight important topics in health professions education research. The program also features in-person meetings, beginning with a two-day launch at SAEM headquarters in Chicago and daylong workshops at the SAEM and ACEP annual meetings. Recognizing the importance of mentorship and networks, and with the aim of creating a diverse training program that promotes equity
in education research, ARMED MedEd was envisioned as a health professions education community of practice with a nested intentional mentorship program. We describe the innovation and development of this mentorship structure implemented to promote a sense of community and support scholars in grant writing and completing a collaborative education research project. Historically, research in the educational domain has been criticized for lack of generalizability since many studies occur
in a single institution. Individuals may require additional mentorship beyond what a single mentor may provide and to develop the future pool of mentors, novices require guided experience in mentoring. To address these needs, we created the “ARMED MedEd Family Mentorship Program” to provide a multilayered mentoring structure that fosters
continued on Page 32
Figure 2: A mentor family meeting (representing California, Massachusetts, New York, Ontario, Pennsylvania, Wisconsin) to discuss the development of three unique research projects: (1) identifying real-time interventions to mitigate gender disparities in narrative comments to EM trainees; (2) resident dashboards to mitigate differences in clinical exposure; (3) Debrief it all: Inclusion of Safety-II in health care debriefing
“The ARMED MedEd mentor family experience personalizes what it means to be part of a community of practice. I cannot think of a better way to share my expertise and foster the next generation of medical education
SAEM PULSE | SEPTEMBER-OCTOBER 2021
— Stefanie Sebok-Syer, PhD, ARMED MedEd methodology mentor
continued from Page 31
mentorship from peers, content experts, methodologists, and senior career mentors with research expertise (Figure 1). Each participant is paired with an individual mentor to form a dyad. The two are in close contact about the research project (and grant proposal) and address challenges that are important to academic researchers. Groups of three dyads comprise a family, along with a senior mentor who serves to advise and participate in
discussions but is not a part of a dyad. Individual dyads and families meet on a regular basis. A list of suggested topics for discussion is provided to guide these discussions, but we expect that most meetings will address issues that arise throughout the course in an organic way. Individual dyad meetings focus on one-on-one mentoring, and mentor families meet monthly via Zoom to present their project progress to the rest of the family members. (Figure 2) All family members participate substantially in refining the study designs and provide support to the principal investigators.
In this way, each participant may benefit from the mentorship of the methodologist (PhD and/or MD/DO), content experts (e.g., assessment, curriculum development, diversity, faculty development, simulation, ultrasound, etc.) and senior mentor of the family. At the same time, the remaining two participants are guided in serving as peer mentors and eventual coinvestigators on each other’s projects, thus facilitating three multi-institutional studies for each family. We hope this will lay the foundation for a broad network of collaborators in the future and foster meaningful professional relationships
“ARMED MedEd has been a fantastic learning experience and offers unique and innovative mentoring and collaboration through its use of mentor families. The course provides the advanced framework necessary for MedEd research and has offered an unprecedented opportunity to learn, be mentored by, and collaborate with many of the wisest, biggest names in medical education research. The mentor families provide not just a single mentor but multiple with strategically varied areas of expertise coupled with the chance to learn with two other ARMED MedEd scholars.”
— Suzanne Bentley, MD, MPH, ARMED MedEd participant
“The mentor family structure provides the framework, resources, and support to successfully conceptualize and implement innovate projects. The key, in my opinion, is both the composition of members of the team as well as the consistency of the meetings. This set up is integral in forcing the mentee to think creatively and stay on track.”
— Mira Mamtani, MD, ARMED MedEd participant
that endure long after the course is completed. In summary, the ARMED MedEd program is piloting a family mentorship program that builds upon literature suggesting the benefits of mentoring, community of practice, and networks for professional development, career advancement, research productivity, and increasing diversity and equity in research collaboratives. The family structure
maintains the flexibility and benefits of one-on-one mentoring while scaffolding each dyad with a built-in community to promote, collaborate, and enhance accessibility to expertise and resources. This mentorship structure may be applied to other professional development programs, either locally or nationally, and program evaluation will focus on determining the effectiveness of the structure in achieving the ARMED MedEd aims.
ABOUT THE AUTHORS Dr. Coates is a professor of emergency medicine at UCLA Geffen School of Medicine/ Harbor-UCLA Emergency Medicine where she specializes in education research. She currently serves as the secretary-treasurer on the SAEM Board of Directors and is a co-chair of ARMED MedEd. Dr. Yarris is professor of emergency medicine at Oregon Health & Science University and vice chair for faculty development, education section director, and co-director of the education scholarship fellowship. She is deputy editor for the Journal of Graduate Medical Education and co-chair of ARMED MedEd. ARMED MedEd Steering Committee: Drs. Holly Caretta-Weyer, Teresa Chan, Sam Clarke, Wendy Coates, Michael Gottlieb, Jon Ilgen, Jaime Jordan, Anne Messman, Teresa Smith, Stefanie Sebok-Syer, Lainie Yarris. With special thanks to the SAEM task force that created the ARMED MedEd program: Drs. Teresa Chan, Sam Clarke, Wendy Coates, Michael Gottlieb, Jon Ilgen, Jaime Jordan, LuAnn Lawson, Anne Messman, Phillip Moschella, Dan Runde, Sally Santen, Lainie Yarris.
SAEM PULSE | SEPTEMBER-OCTOBER 2021
Website Usability: Assessing What Makes a Website “Good” By Helena Halasz, MD and Shuhan He, MD, on behalf of the SAEM Virtual Presence Committee In the fall of 2020, emergency medicine residency programs were faced with an unprecedented application season, which entailed not only fighting COVID-19 at the frontlines, but also meeting and interviewing applications virtually for the first time. Programs that had previously had minimal online presence scrambled to improve outreach when the Council of Residency Directions of Emergency Medicine (CORD-EM) recommendation was announced, and emergency medicine programs across the country found that they had to rely on their websites and social media pages to connect with applicants. Now, as our specialty is gearing up for another residency application cycle, the recommendation for interviews will likely remain the same: stay safe, stay virtual. This time around, however, programs have a little more time to prepare and thus a singular chance to improve their digital presence. For those without a background in computer science, it can be difficult to ascertain what makes a website “good.” A study published in June 2021 in SAEM AEM Education and Training (Website usability analysis of United States emergency medicine residencies) conducted a cross-sectional usability audit of emergency medicine residency program websites and used four quantifiable characteristics to analyze each one. In total, it studied 55 emergency medicine programs and evaluated each based on accessibility, marketing, content quality and technology. Accessibility analyzed the ability of users with lower levels of computer literacy to successfully navigate a website. It considered the meta description, or “snippet” page summary that appears on search engines, the functionality, the readability, and the overall layout. Content quality looked at relevance of written text, including content related to application requirements, curriculum details, benefits, etc., as well as grammar and spelling. It also analyzed the
generated metadata, which functions as important supporting information (for example, descriptions of photos), and scored multimedia based on quantity and quality (i.e., resolution). Marketing examined the ease of discovery of each website, based on the order in which websites are displayed in search engine searches. This property, known as a search engine results pages (SERPs), determines which website has better discoverability, and is intricately intertwined with search engine optimization (SEO). Technology addressed a website’s technical functionality, looking at the quality of technological design and performance. It examined both front-end design (which is what the user can see when visiting a webpage), and back-end design (which is the code that runs the website). The study determined a general usability score, which used the previous four metrics to assess the overall quality of a website; this was found to be low performing across most EM residency programs. This information can serve as a starting point for EM residencies to begin an audit of their own websites. The study further found that content quality was the highest mean scoring category and that
technology was the lowest performing category. It is clear that EM residencies have placed heavy emphasis on providing accurate and relevant information about their programs, which is important, but this usability analysis demonstrates that upon closer inspection, there are many aspects that programs could improve. Using the results of this study, emergency medicine programs have the unique ability to troubleshoot their own websites and make improvements, thus facilitating the spreading of information as more and more applicants browse their websites.
ABOUT THE AUTHORS Dr. Halasz is a recent graduate of Semmelweis University (Budapest, Hungary) and an aspiring emergency medicine physician, with a special interest in social EM and bedside ultrasonography Dr. He is an emergency medicine physician and faculty member of Harvard Medical School and in the Lab of Computer Science at Massachusetts General Hospital
Recommendations for improving website usability for EM residency programs: • perform frequent audits, ensuring information is up to date • assess relevance of information to current applicants • evaluate quality and quantity of multimedia (resolution, layout) • optimize outreach (drive traffic from social media, collaborate with SEO experts) • improve front-end design (make website scalable across devices, enhance navigation) 35
“You’ve got 1,000 Emails!” The Joys and Pains of Returning to Work
SAEM PULSE | SEPTEMBER-OCTOBER 2021
By Al’ai Alvarez, MD; Angela Lumba-Brown, MD; and Stefanie Sebok-Syer, PhD on behalf of the SAEM Wellness Committee
It’s summer, and you recently took two weeks of a much-needed vacation. Pandemic restrictions eased up, and you were able to travel, spend time with family and friends, enjoy new scenes and cuisines, and take lots of photos. It was exactly what you needed to fill your buckets of play, love, and health. The night before your first day back to work, you open your mailbox to find 1,000 emails. *Sigh. Your heart sinks, and the feelings of rest and relaxation are suddenly replaced with anxiety — “How am I going to get through all of these?” As many of us continue to work from remote office spaces, the translation from previous in-person interactions has led to more emails than pre-pandemic times. In academia, we are constantly challenged to manage our inbox — now more than ever. Endless emails and bottomless inboxes create a wellness tax that is either paid upfront or deferred for our time away from work. It’s no surprise that returning to work from any
leave, planned or otherwise, is often met with a stark realization that we’re again already behind. In anticipation of this, most of us do not really go on vacation when we are on vacation. Instead, we continue to sift through messages, responding “only to the really important stuff,” and may even take a meeting or two while “off.” When did the “really important stuff” not include unplugging for well-being? Practicing mindfulness and being present during vacation result in lasting impacts beyond time off. Vacation often spurs creativity, connectivity, and renewed energy and enthusiasm in returning to the workplace — but not for those who take work with them. How, then, do we make the most of our time away without feeling overwhelmed about returning to work? We reached out to several colleagues in academia and social media to better understand ways of easing back to work.
Here are some tips: 1. Begin at the beginning. Schedule dedicated time in the two weeks before taking leave to notify appropriate administrative staff, leadership, and project collaborators. Make a plan of action with these stakeholders to manage urgent issues while you are gone. Dr. Adolfo Barraza Muñoz adds creating a plan of action that includes delegating who will solve contingencies while you are away. Wellness is a team sport. Having someone manage our emails or delegate tasks when we are away allows us to tackle those that immediately require our attention when we return. This supports everyone to take a break and minimizes the guilt of not contributing while away. 2. Set up expectations using an away message. Dr. David Marcus shares setting expectations of when you’ll be
responding to emails and recommends including a request to resend the email again after your return for a faster response. A stronger yet simpler stance would be to state in your away message that emails received during vacation will be deleted. Clare Murphy, an internationally renowned storyteller, shares this away message: Happy August wherever you are. Listen, I’ve snuck away for a much needed holiday, a real break. And so to do that effectively I will not be checking my emails. I’m off to the sea and the woods and the wild open spaces. I’ll get back online Aug 17th, so why not get in touch with me then? Hope you are well in this paradoxical time. Holidaying, Clare 3. Extend the auto-reply away message a few days after your return. This allows senders to know that your inbox will be extra full and that you are working your way to reply to correspondence. 4. Schedule allotted time during your return to tackle your inbox, and stick to it. Often, we’re prone to use the inbox as a to-do list, which adds to our cognitive distractions. Dr. Wendy Coates shares that “vacations make [us] healthier and better at [our] job.” She suggests “scheduling a buffer
day or two upon return to get reintegrated” and “scheduling time blocks to sort/respond.” She also suggests “sorting inbox by sender” and “creating rules to filter out junk emails.” Dr. Teresa Chan outlines these other helpful ways of managing the inbox. Dr. Adaira Landry and Dr. Resa E. Lewiss share what a compassionate email culture can look like in this Harvard Business Review article. 5. Practice self-compassion. Everyone (including YOU, your department leadership, the trainees and administrative staff) deserves time off from work. Leaders may feel particularly guilty taking a break; unfortunately, not taking a vacation may translate to an unrealistic expectation for everyone. We earn our vacation; it is not something to feel bad about. Part of self-care is setting boundaries, recognizing your limits, and doing your best without overdoing your best. 6. Finally, inbox hygiene is not a once-ayear visit — consider scheduling a set time every day to review and respond. This is best done at an ergonomic workspace that allows for comfortable and efficient reading and typing instead of lying in bed at 2 am, thumbing responses on your smartphone with a blanket pulled over your face to shield your partner from blue light.
As champions in our field, how else can we help each other and our colleagues be more present when they are away from work? In what ways can help to set standards for achieving work-life balance that can shift our current culture? And when will unplugging for personal rest and recovery be considered vital and fully supported in our profession? Join the conversation, but please, don’t send it as an email.
ABOUT THE AUTHORS Dr. Alvarez is director of wellbeing, Stanford Emergency Medicine, @alvarezzzy
Dr. Lumba-Brown is associate vice chair, Stanford Emergency Medicine
Dr. Sebok-Syer is an instructor, Stanford Emergency Medicine, @stefsebok
WILDERNESS MEDICINE Suspension Trauma By Alexis Corcoran, MD, on behalf of the SAEM Wilderness Medicine Interest Group
“Climb if you will, but remember that courage and strength are nought without prudence…do nothing in haste; look well to each step, and from the beginning think what may be the end.” —Edward Whymper Background
Suspension trauma, also called harness hang syndrome or orthostatic intolerance, results from hanging in a motionless vertical position suspended by a harness for a prolonged period. Any hobby or occupation that requires the use of a harness could potentially result in suspension trauma, so rock climbers, ice climbers, spelunkers, hunters in elevated stands, parachutists, other avid adventurists, electricians, and construction/high rise workers are at risk of life-threatening or fatal suspension sequelae. A large fall leading to extremity fracture(s), a head injury from falling debris, or any other medical problem or mechanism that leads to impaired awareness, decreased consciousness, or impaired mobility can lead to hanging suspended vertically and immobile in the harness. Suspension trauma is a true emergency, as it can cause death in as little as 10 minutes, though, if it occurs, death typically takes place between 15 and 40 minutes. This article will review current literature surrounding suspension trauma, rescue, and management. SAEM PULSE | SEPTEMBER-OCTOBER 2021
Harnesses connect outdoor enthusiasts or high-rise workers to an anchor point with a rope as they ascend or descend a wall or structure. Different types of harnesses are used for different activities, as each call for different features, styles, and capacities to hold gear. Climbing harnesses focus their support on the waist and legs, while high rise/construction harnesses focus their support on the waist, legs, shoulders, and chest. The following two figures highlight the main features and differences between these two categories of harnesses, while Table 1 identifies more distinguishing features between harness types.
Figure 1: Basic Climbing Harness Features • The waistbelt is the wide opening at the top that tightens above the waist. Padding depends on harness type. • Leg loops can, but don’t always, adjust around each leg for comfort. These keep the person upright during a fall and help disperse weight when hanging. Padding depends on harness type. • The belay loop attaches to the carabiner and belay device for the belayer. • Tie-in-points (aka hard points) are a redundant system where a rope runs through for the climber. This is the point of connection for fall arrest. • Elastic risers adjust the distance between the waistbelt and leg loops.
There is debate of the pathophysiology of harness hang syndrome; however, the most accepted mechanism is a failure of the passive venous pump system. In normal physiologic states, blood pooling dependently is forced
back towards the heart with flexion/ movement of the lower extremities and one-way valves within the venous system. When someone is hanging motionless in a harness, their femoral veins may have decreased flow due to external pressure from the harness
as well as decreased lower extremity movement which may be secondary to the position of the harness, fatigue, hypothermia, injury, or unconsciousness. The degree of risk of suspension trauma is increased with blood loss and prior cardiovascular disease. The combination of decreased flow from external pressure and decreased flow from lack of movement can lead to a decreased effective circulating volume (by up to 20%) mimicking hypovolemic shock. Some people have been observed to lose consciousness within minutes of being suspended, potentially secondary to this decreased effective circulating volume of blood and reduction in cerebral perfusion thereafter. Presyncopal signs and symptoms in this case may include dizziness, pallor, shortness of breath, blurred vision, nausea, diaphoresis, numbness of the legs, decreasing blood pressure, and increasing heart rate. Without suspension in a harness, syncope will usually resolve the underlying pathophysiology of orthostatic hypotension as the body will become horizontal and the blood will return to the heart and subsequently to the brain. However, when people are suspended in a harness, they are unable to turn horizontally which leaves this compensatory mechanism useless. During rescue from suspension, there is some danger of post-rescue death as the person is turned horizontal from vertical, although the literature has conflicting hypotheses behind the mechanism. In some studies, there are reports of “reflow syndrome,” which results from systemic release of toxin buildup in the hypoxic lower extremities. These toxins can lead to acute kidney injury, cardiac arrythmias, and disseminated intravascular coagulation much like rhabdomyolysis. In other studies, there are reports of the heart’s inability to tolerate the abruptly increased blood flow, leading to a clinical picture much like high output cardiac failure. While these complications are severe and life-threatening, it seems as though many guidelines for rescue follow studies such as Thomassen et al. (2015), and Lee and Porter (2007) who report there is no evidence of reflow syndrome in suspension trauma and the safest rescue technique is quickly turning the person horizontally given the risks of maintaining the vertical position. Various
Figure 2: Basic Construction/High Rise Harness Features • The dorsal large D ring is the point of connection for the fall of arrest. • The chest buckle adjusts the size of the harness to the wearer. • The friction torso buckle adjusts the length of the harness, but if installed improperly by the worker there is risk of falling out of the harness. • The right and left D rings are used for positioning of applications when the worker needs their hands to be free. • Leg straps are like those on climbing harnesses.
“When someone is hanging motionless in a harness, their femoral veins may have decreased flow due to external pressure from the harness as well as decreased lower extremity movement which may be secondary to the position of the harness, fatigue, hypothermia, injury, or unconsciousness.”
continued on Page 40
Table 1: Harness types: (many are interchangeable and can be used for various activities) SPORT/GYM CLIMBING HARNESS
TRAD (TRADITIONAL) CLIMBING HARNESS
• heavier than sport
• padded waist belts and leg loops
• light or no padding
• multiple gear loops
• multiple gear loops
• supports the upper legs and waist
• supports the upper legs and waist
Figure 3: Foothold deployment. WILDERNESS MEDICINE
continued from Page 39
rescue techniques are detailed in the following section.
SAEM PULSE | SEPTEMBER-OCTOBER 2021
Rescue Techniques and Postrescue Management
Under 29 CFR 1926.502 (d) (Fall Protection Systems Criteria and Practices), Occupational Safety and Health Administration (OSHA) in the United States requires that employers provide for “prompt rescue of employees in the event of a fall or shall assure that employees are able to rescue themselves.” OSHA and National Standards Institute of the United States recommend contact to the suspended person within four to six minutes and prompt rescue to follow. The suspended person should initially attempt self-rescue, but if this fails, they should “pump” their legs frequently to activate the muscles and reduce the risk of venous pooling until rescue. If
possible, the harness should come equipped with deployable footholds that can be used to alleviate pressure, delay symptoms, and provide support for shifting position frequently and for muscle pumping. A cordelette (large sling) or etrier (webbing/ladder) can be attached inside small storage packs to the sides of a body harness to easily be deployed as shown in Figure 3. The suspended person should ideally try to position themselves as horizontally as possible. This can be done with use of footholds, placing feet on the structure/ wall near them, or attempting a sitting position in the harness. For rescue, bystanders or rescue teams can use pulley systems, brake-tube systems, winch systems, controlled descent devices, and/or rope ladders. Special care should be taken to control profuse bleeding prior to or during rescue to maintain as much circulating volume as possible.
After rescue, OSHA guidelines currently advise to place person in a sitting position with their knees close to their chest in a “W” position. They do not recommend placing person horizontally if possible. However, multiple reviews, including by the Health and Safety Executive in the U.K. in 2009 and Mortimer (2011) recommend that all post-suspension patients be immediately placed in a fully horizontal position for recovery and treatment to restore circulation to vital organs. Many of these reviews argue that the potential risk of reperfusion injury or reflow syndrome is much lower than that of continued effective hypovolemia and hypoxia. In conclusion, rescuers should be aware of the risks of maintaining a more vertical position during rescue and the risks of immediate horizontal positioning, and they should be prepared to manage the potential sequelae of whichever rescue position they choose.
BIG WALL CLIMBING HARNESS
FULL BODY HARNESS
• copious padding
• minimal to no padding
• larger and stronger gear loops
• less padding (reduced moisture absorption and freezing)
• supports the upper legs, waist, shoulders, and chest
• full strength loop in back for attaching a haul line • supports the upper legs and waist
• ample gear loops • dedicated ice clipper slots • supports the upper legs and waist
Suspension trauma is a potential serious complication in outdoor recreation and certain occupations. Further understanding of its physiology and treatment may improve management of this specific condition.
Resources: • Suspension Syndrome: Hanging by a Thread (and a Rope) • Does the horizontal position increase risk of rescue death following suspension trauma?
ABOUT THE AUTHOR
• Suspension trauma
Alexis Corcoran is a fourthyear medical student at Albert Einstein College of Medicine who will be applying into emergency medicine with the Class of 2022. While in medical school, she organized multiple emergency simulations, trained with wilderness survival and medical experts in Colorado and Utah, and formed a team of 50 volunteers who produced and distributed over 9,700 face shields and surgical masks for COVID-19 PPE
• Self-Rescue: The Best Fall Protection Equipment for It • Harness fitting part 1: number & type of adjusters • Best climbing harness review • Harness Safety • Preventing Suspension Trauma, fact sheet 5. • Ask a Pro: What is suspension trauma (AKA harness hang syndrome)? • Will your safety harness kill you? • Suspension Trauma/Orthostatic Intolerance: Safety and Health Information Bulletin • Harness Suspension: review and evaluation of existing information • Risks and management of prolonged suspension in an Alpine harness
SAEM PULSE | SEPTEMBER-OCTOBER 2021
WOMEN IN ACADEMIC EM
Why Leadership in Medicine Needs Women By Anita Chary, MD, PhD and Ynhi Thomas, MD on behalf of the SAEM Academy for Women in Academic Emergency Medicine Authors’ Note: In this article, we use the word “female” as an adjective and “women” as a noun by convention but recognize this language does not accurately reflect distinctions between gender and sex. An inherent limitation of writing about “women in medicine” is that the terms we use and the studies we cite may not accurately depict how individuals identify their gender. Despite women accounting for more than half of all medical students in the United States, leadership in medicine is largely male and white. Gender gaps in leadership widen as one ascends institutional hierarchies: while a recent national survey in our specialty, emergency medicine, demonstrates equal proportions of female and male chief residents, in medicine in general, less than 10% of department chairs, division chiefs, chief medical officers, and health care CEOs are women. Both of us identify as women in medicine. We served as chief residents for our emergency medicine (EM) training programs, and Dr. Thomas subsequently completed an administrative fellowship focused on sex and gender equity. For context, our field is numerically maledominated: women represent about one-third of academic emergency physicians, about one-third of resident physicians, and a little over a one-quarter of emergency physicians in general. Our experiences reinforced a lesson that women, and particularly women of color, need a seat at the leadership table. As women in medicine, we face too many issues in the workplace that will not be improved for future generations if we do not have a platform. We would like to offer some examples of how we, as women, tried to effect change in our institutions, in some cases regarding issues that were not on the radar of male colleagues in leadership, and in many cases regarding issues that benefited from the involvement and support of male allies and leaders in medicine. We also reflect on some crucial lessons and limitations from our experiences.
Being a Sounding Board for Navigating Difficult Workplace Experiences… Dr. Chary: For many women, the early years of hospital life are characterized by hazing and exclusion by colleagues
“For many women, the early years of hospital life are characterized by hazing and exclusion by colleagues and the constant experience of patients mistaking us for nurses or other nonphysician roles.” and the constant experience of patients mistaking us for nurses or other nonphysician roles. The cumulative daily experiences of being addressed as “miss” or “honey” in the hospital and patients’ frequent requests for blankets, food, and/ or water — directed to us but not our male colleagues — can be incredibly tiresome. It is imperative for interns and junior residents to have seniors with whom they can debrief about such experiences. As an intern, I went to my residency’s female chief, who helped me through these experiences. Going to male seniors and faculty members — who were far more numerous — felt less natural, and when I did, many of them were at a loss on how to advise me. As a senior resident, I was able to draw from my own experiences to teach juniors about strategies to establish authority, respectfully reinforce their roles as physicians, and develop positive (or at least neutral) interprofessional relationships. Part of my formal work in this area involved developing training for my residency, hospital system, and within my specialty at the national level, around how to respond to microaggressions. Notably, most of my colleagues in this work have been women.
On Creating Policies That Support Pregnant and Breastfeeding Women… Dr. Thomas: For many women in medicine, our reproductive lives
coincide with our early and mid-careers; however, medical training and workplace environments are rarely designed to consider women’s reproductive health needs. For example, consider that at some hospitals, initial COVID-19 vaccination policies did not include information for health care workers who were pregnant and/or breastfeeding. Pregnant women were not included in initial COVID vaccination trials, which likely shaped the lack of institutional guidance offered. Failure to mention these populations in initial recommendations was a large oversight. Female leaders in medicine can play important roles in recognizing and addressing such institutional omissions. For instance, women may be scheduled to avoid working night shifts during their first and third trimesters of pregnancy to reduce complication risks. Similarly, a lactation support policy could be implemented to provide protected time for mothers to pump, as well as the creation of a dedicated pumping room within the ED, equipped with a chair, desk, sink, fridge, computer, and phone. As chief resident, I wrote our department’s lactation support policy and secured a hospital grade breast pump, which empowered our breastfeeding women to be excellent clinicians, without sacrificing their personal commitments. continued on Page 44
WOMEN IN ACADEMIC EM
SAEM PULSE | SEPTEMBER-OCTOBER 2021
continued from Page 43
We offer the important acknowledgment that not every woman in medicine pursues a family life. Furthermore, the pursuit of family life is not straightforward for everyone in medicine, as many struggle with infertility. Our advocacy for female physicians’ reproductive needs is in no way intended to diminish these experiences.
On Rethinking Honors, Recognitions, and Amplification… Dr. Chary: Over my years of residency, I noticed that male physicians tended to win annual departmental awards and women seemed less likely to promote themselves or be recognized at the departmental level as leaders, champions, and mentors. In the last two years, I critically discussed these observations with the resident and faculty leaders of our Women’s Initiative. We created new award categories
to recognize female physicians for academic excellence, leadership, and outstanding mentoring in diversity and inclusion. At the same time, through discussions with our program leadership, we made efforts to diversify speaker series and guest lectures, which historically predominantly featured male physicians and occasionally white female physicians. Dr. Thomas: At the national level, I serve as the cochair for the awards committee for SAEM’s Academy for Women in Academic Emergency Medicine (AWAEM), and we have the honor of recognizing dozens of incredible women in our field. One lesson I’ve learned is that women are more critical of their accomplishments than my male colleagues. There are many qualified women who, when asked if they would apply for an award, discounted their incredible achievements. I have also noticed that, as women, we are more likely to believe that we need additional experience or education before we consider an opportunity. We need women in leadership to not only amplify these
women and their accomplishments, but to remind them that they are qualified. As cochair, I have focused on reaching out to female colleagues individually to discuss the awards and reasons why they are well-suited candidates. My observation is that sometimes a simple word of encouragement can have a significant impact.
On Creating and Using Evidence… Dr. Chary: A common experience within a minority group can be questioned or dismissed as anecdotal by a majority group, particularly in medicine, which favors evidence from randomized controlled trials. Frequently, to start conversations about sex and gender equity, female leaders must collect data — whether through research or quality improvement initiatives — to create evidence that others will accept. For example, women in my residency had a common experience of feeling like we had to fight for opportunities to do procedures. We noticed that male senior residents in the critical care area would pull male interns from the minor care area to perform intubations on overnight
“For many women in medicine, our reproductive lives coincide with our early and mid-careers; however, medical training and workplace environments are rarely designed to consider women’s reproductive health needs.” shifts but did not seem to pull us when we worked overnights in the minor care area. We felt like our male colleagues who wanted to place central lines enjoyed support from floor supervisors and nurses, whereas we encountered resistance and friction and were told lines could be placed in the intensive care units. When we brought up our experiences as junior female residents, the reactions of male senior resident attendings ranged widely from shock and support to invalidation and dismissal of our concerns. When I became a senior resident, I turned to a coresident with expertise in data science who helped pull all residents’ procedure notes from the electronic medical record over a yearlong period. His analysis showed that there was a relatively equal distribution of procedures for male and female residents. I worked with my program’s leadership to have the data presented at our didactic conference, which led to a residency-wide conversation about the gap between the numerical findings and female residents’ experiences. Ultimately, this led to broader awareness in our departments about advocating for female residents’ procedural experiences.
Being in a leadership position as a woman is a privilege and a valuable opportunity to shift the culture of medicine; however, we want to offer caveats about the ways it can feel burdensome. The time commitment associated with mentoring juniors and advocating for change should not be underestimated, even in early career stages. Female junior colleagues seek out female senior colleagues in leadership roles, and because there are fewer female leaders in medicine, women in leadership roles tend to end up with a disproportionate load of mentees when compared to male colleagues. While this problem is well-recognized at the faculty level, the
same happens to female senior residents. A mentorship burden exists not only in developing relationships at one’s own institution but in employee recruitment. For example, say that in the spirit of exposing female residency applicants to female mentors a residency program in a predominantly male specialty strives to have every female candidate (about half of the applicant pool) be interviewed by a female faculty member and a female resident (about one-quarter to one-third of the department). At the same time, female residents are disproportionately contacted by female applicants hoping to get a feel for the program. This mentoring and networking work usually does not result in a reduced clinical burden for female physicians. These situations reflect a “minority tax,” in which those in a lessrepresented group are assigned greater workloads in the name of diversity on the basis of their social identity. Regardless of how rewarding this can be, mentoring junior colleagues takes time and often feels underrecognized and undervalued by administrators. Being recognized as a point person for gender equity issues entails being asked to tackle projects that do not contribute to one’s professional aspirations or promotion. For example, women, and particularly women of color, are often asked to serve on not just one, but multiple diversity committees at the departmental and hospital level, and sometimes across multiple institutions. We have said yes to these asks because it felt like the right thing to do. Even when we felt we did not have the time or expertise, it was hard to turn down requests to take on gender equity initiatives, because a lot is at stake in saying no: Would we be disappointing our leadership? Would we diminish our status as “team players” or “good citizens” of our departments? Would the issues stagnate or remain unresolved if we did not take them on? As women, we feel like we have disproportionately more
of these service commitments, which are not as highly valued for academic career advancement as publishing papers or obtaining grants. Advocating for sex and gender equity in medicine can be isolating and lead to worry about one’s professional reputation. Becoming respectfully vocal about the numerous ways that sex and gender affect our training and work experiences can be isolating. Our supervisors may be unaware of the extent of the issues at hand and speaking up can be perceived as hypercritical or perseverative. We appreciate that this problem is amplified for women from racial and ethnic minority backgrounds (i.e., Black and Latinx women) who face greater stereotypes about being angry or impassioned. As such, we need to work towards consensus building by continuing to share and amplify our stories. Ultimately, despite these challenges, we have felt privileged to play any role, however small, in ushering in improvements for future generations of women in medicine. We hope that we see within our careers a time in which female leadership in medicine is not the exception, but a norm.
ABOUT THE AUTHORS Dr. Chary is a faculty member in the department of emergency medicine at Baylor College of Medicine.
Dr. Thomas is a faculty member in the department of emergency medicine at Baylor College of Medicine.
Thank You for Championing SAEMF’S Vision of Becoming The Premier Foundation Transforming The Science and Practice of Emergency Medicine A vision is more than words — it is words that catalyze action — and action that leads to results. Thanks to SAEMF’s thoughtful leaders, dedicated volunteers, inspired grantees, and the amazing generosity of our Annual Alliance donors we are one step closer to realizing our vision of becoming the premier foundation transforming the science and practice of this vibrant field of emergency medicine. Each of you plays an important role in bringing this vision to life and building the pipeline of talented researchers and educators who will lead the specialty in the future. We are grateful.
REASON TO CELEBRATE!
This year, SAEMF celebrates that our research and education grants initiative, mostly funded through the generosity of SAEM members and donors, continues to flourish, even when many organizations are still weathering the impact of the pandemic. Through sound board leadership, energetic participation from grants and fundraising committees, brilliant young investigators and educators, and generous donors, we have been able to: • Award close to $700,000 for the research and education projects of the 2021 SAEMF Grantees • Announce a new funding opportunity of $100,000: Emerging Infectious Disease and Preparedness Grant
• Fund Dr. Bernard Chang and Dr. Evan Bradley, two grantees’ who received SAEMF COVID-19 grants in 2020/21 • Introduce enhancements to the grants portfolio, including flexibility for Research Training Grant budget allowances, opportunities for more team science through a new multiple principal investigator plan, and a new Notice of Special Interest (NOSI) for Wellness • Create a new career development opportunity for Resident Reviewers to participate in the SAEM Grants Committee’s annual grant review process • Raise $113,836 for the 2021 Chairs’ Challenge competition – the highest total since inception of the Challenge • Launch a new website for the SAEMF to engage more researchers and donors through robust content, including a new section dedicated to researcher updates and donor impact There is still so much to be accomplished as we journey along the path to realizing SAEMF’s vision. It’s good to take stock along the way. Thank you for being a part of the journey.
Why I Give “During the 25 years I served as department chair at Harbor-UCLA Medical Center I had numerous faculty (including Drs. Jim Niemann, Roger Lewis, Wendy Coates, Marianne Gausche-Hill, Diane Birnbaumer, and Amy Kaji) whose careers benefited greatly from their involvement in SAEM. My support of the SAEMF is my thanks to the organization and my contribution to its future success.” — Robert S. Hockberger, MD, SAEMF Board of Trustees 46
Our Grantees: Even More to Celebrate! 2021 EMF/SAEMF Medical Student Research Grantees
2021 SAEMF Emergency Medicine Interest Group (EMIG) Grantees
The Emergency Medicine Foundation (EMF) and Society for Academic Emergency Medicine Foundation (SAEMF) jointly award stipends to encourage medical students (our future emergency medicine researchers and educators) to engage in and to be exposed to emergency medicine research. We applaud this year’s cohort of grantees and wish them all the best as they move forward with their research training.
SAEMF recognizes the valuable role of emergency medicine medical student interest groups (EMIGs), and awards $500 grants to support the educational activities of these groups. EMIG grant goals are:
Kavya Davuluri University of Michigan Medical School
Optimizing the UME to GME Liminal Space: Identification of the Need for Diversity, Equity, and Inclusion Competencies as Core Entrustable Professional Activities
• To promote growth of emergency medicine education at the medical student level, • To identify new educational methodologies advancing undergraduate education in emergency medicine, and • To support educational endeavors of an EMIG.
Loyola University Chicago, Stritch School of Medicine Effectiveness of Online Workshops for Teaching Introductory Suturing Skills Compared to In-Person Instruction
Thomas Jefferson University Exploration of U-Scale Use in Patients with Potential Acute Coronary Syndrome
Harvard Medical School Trauma-Informed Care Practices in Acute-Care Settings: Training for Medical Students
Thomas Jefferson University Framing and Constrained Time Considering Heuristics in Emergency Clinical Knowledge (FACT-CHECK)
Kalani Nakashima Saint Louis University
A Suture Lending Library for Medical Students
University of Maryland School of Medicine The Ideal Transcutaneous Cardiac Pacer Pad Study
For more information, or to apply for these grants, please visit our website. Join the Annual Alliance today to support more future leaders like these grantees. 47
Have You Considered a Legacy Gift to Benefit Emergency Medicine? A legacy gift to SAEMF is an opportunity to write a stirring epilogue to the story of your life. Remembering SAEMF in your planned giving is a profoundly meaningful way to leave a legacy that will benefit generations of emergency medicine researchers beyond your lifetime. You will feel a deep sense of satisfaction knowing that your generosity and good works will live on to benefit the future of emergency medicine for years to come.
Visionary Donors Committed to Supporting Emergency Medicine Research Beyond their Lifetimes The SAEMF Legacy Society is a cohort of visionary leaders who have invested in the future of emergency medicine by donating a portion of their estate to SAEMF. By including SAEMF in your planned giving, you will help ensure the SAEMF has the resources to continue supporting new investigators long into the future.
When Is the Right Time to Make A Legacy Gift?
Experts recommend you review your estate plan and will throughout your lifetime, but especially when these 12 life events occur. When you update your will is also a good time to consider adding SAEMF as a beneficiary.
Are You Ready?
If you are prepared to make a legacy gift decision now, there are a few options for your consideration on the next page or see our planned giving resources online. A simple bequest is often the easiest. Each donor’s goals are unique so we recommend consulting with your financial advisor to identify a planned gift that aligns with your intentions. Let us know if you’d like to visit with one of our Legacy Gifts Committee members about their SAEMF planned gift experiences. Contact our Development staff at firstname.lastname@example.org for more information.
Legacy Gift Goal Options Identify Your Goal Make a gift that costs you nothing during your lifetime
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Make a large gift at little cost
Consider Gift Option with Advisor Bequests - gifts through your will/trust
Method Include a gift of cash, property, or share of your estate in your will or trust. *See Bequest/Trust Language below
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Name us as the charitable beneficiary of your retirement plan and pass less taxed assets to your heirs. Check with your advisor about gifting a portion of your IRA during your life and receiving a charitable deduction.
Avoid income tax on assets; pass more of your estate to your heirs.
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With a charitable remainder trust, you or other named individuals, can receive income for life or a period not exceeding 20 years from assets you give to the trust you create. By designating the SAEMF as a beneficiary, you are helping to secure the future of SAEMF.
Diversify assets, avoid or defer capital gains, receive charitable deduction, secure future income.
Name SAEMF as beneficiary or transfer ownership of a policy you no longer need.
Take a tax deduction for the cash value now; potential future deductions through gifts to pay policy premiums.
*Bequest and/or Trust Language: I give, devise, and bequeath to The SAEM Foundation, a 501(c)(3) charitable organization having its principal offices in Des Plaines, Illinois: the sum of $_____ or _____ percent of my estate. [or all (or _____ percentage of) the rest, residue and remainder of my estate.] This gift is to be used to further the charitable purposes of The SAEM Foundation, the philanthropic arm of the Society for Academic Emergency Medicine, at the discretion of the foundation's board of trustees. The SAEM Foundation Taxpayer Identification Number is 26-2371803.
ON THE CUTTING EDGE
HEADS-UP CPR: A NEW METHOD TO AN OLD PRACTICE? By Glenn Goodwin, DO, Kristina Atuna, and Jackie Nguyen From intravenous drugs and genetic engineering to highly advanced equipment, to mind-blowing surgical techniques, medicine continues to evolve at an exponential pace. In an almost comedic way, despite this evolution, the crude practice “good old-fashioned” chest compressions are the only consistent intervention found to improve outcomes in cardiac arrest. Cardiopulmonary resuscitation (CPR), however, is not immune to this omnipresent evolution. We are perhaps, embarking on a whole new way of performing this life-saving practice: heads-up CPR. The objective of CPR is to take the place of nonfunctional heart in delivering blood, and therefore oxygen and other essential products, to the body. Traditionally, the heart is compressed between the sternum, posterior rib cage, and spine in a supine position. Over the course of the last several years, however, many theories began to emerge regarding optimization of this practice. Different experiments were done, mostly in pigs, tracking the amount of blood flow that travels to the brain and other organs depending on certain positions of the body. The pigs were sedated and thrown into cardiac arrest, after which they underwent CPR in supine, Trendelenburg (head and torso angled inferiorly), and reverse Trendelenburg positions. As it turns out, the reverse Trendelenburg position was consistently found to increase perfusion to the brain by 15-20%. Interestingly, Trendelenburg resulted in cerebral venous pooling, compromising blood flow to the brain, as well as reducing venous return and subsequent blood flow to other distal organs. Consequently, many of the pigs ended up with cerebral swelling along with a marked decrease in perfusion to the rest of the body. By angling the body in the opposite direction, venous drainage was optimized as well as distal perfusion. The primary mechanism of benefit behind heads-up CPR is the use of gravity to enhance venous drainage not only from the brain and cerebral venous sinuses, but also the paravertebral venous plexus, thereby decreasing ICP and facilitating distal blood flow. A secondary mechanism of benefit is thought to be the concept of decreasing the pressure transmitted to the brain via both the venous and arterial vasculature during CPR, effectively reducing a concussive injury with compression. A third mechanism involves redistributing blood flow through the lungs in a manner similarly to when patients with respiratory distress/ failure sit upright (“tripoding”). Standing and sitting upright
are the optimal positions for breathing and circulation. It wasn’t long before these exciting effects made it to the attention of EMS medical directors and fire chiefs. Historically, return of spontaneous circulation (ROSC) rates of out-of-hospital cardiac arrest (OHCA) have ranged between 20-30%. In other words, only 20-30% of patients who suffer OHCA ever regain a pulse. Many of these patients who regain a pulse, only do so for a short period of time, rarely making it to being discharged from the hospital; survival to hospital discharge (SHD) being around 8-9% according to some studies. Even more unattractive, the neurological outcomes of these few that have survived are almost always dire. In a ground-breaking trial, the Rialto Fire Department (RFD) in California, began performing heads-up CPR for their cardiac arrest patients. The results have been exhilarating. Previously, Rialto’s ROSC rates have been around 23%, meaning that only 23% of cardiac arrest patients ended up regaining a pulse. Since employing heads-up-CPR protocol, ROSC rates are averaging 51% for the past three years (2016—2018), regardless of the rhythm the patient was found in, if the arrest was witnessed, or if CPR was applied prior to arrival. Additionally, SHD has ranged from 12–14%. Asystole is ubiquitously regarded as the rhythm with the poorest prognosis in cardiac arrest. What is perhaps the most astounding, the RFD rate of ROSC for the initial presenting rhythm of asystole, including unwitnessed arrests, is 26%. While the ROSC rates have
"THE OPTIMAL MECHANISM FOR PERFORMING HEADS-UP CPR HAS NOT BEEN RIGOROUSLY STUDIED YET, HOWEVER, RIALTO HAS PAVED THE WAY FOR A SOLID STARTING POINT." been extremely encouraging, several studies are underway to track the neurological outcomes of OHCA survivors who received heads-up CPR. There is often a conflicted sense of accomplishment when achieving ROSC in a patient who has no chance at any sort of neurological recovery. The optimal mechanism for performing heads-up CPR has not been rigorously studied yet, however, Rialto has paved the way for a solid starting point. One must first perform CPR flat before elevation, which is thought to prime the cardiocerebral circuit. Once primed, the head is to be elevated 30 degrees. Interestingly, prior pig studies found diminishing returns and harm when elevating the head greater than and below 30 degrees. For the moment, 30 degrees is the ideal “sweet spot.” Regarding how to perform the compressions with this new angle, the ideal method is to use an automated CPR device (Lucas, Autopulse, etc.) Performing human-powered chest compressions on an angled patient could potentially compromise the quality of those compressions, especially in the prehospital setting, making these automated CPR devices crucial. Additionally, RFD used an Impedance Threshold Device (ITD). This is a small device that attaches in between the ET tube and bag valve. It acts as a one-way valve, allowing oxygen to be delivered during ventilations while restricting ambient air from entering the thoracic cavity during the recoil phase of chest compressions. This increases negative intrathoracic pressure creating a vacuum which pulls more blood back to the heart, increasing preload and decreasing intracranial pressure (ICP), allowing for quality cerebral perfusion. While theoretically beneficial, when the ITD has been used on its own, studies have been mixed regarding effectiveness and differences in actual outcomes. It appears to have a synergistic and multiplicative effect when used in heads-up CPR, however. This synergy seems to be evidenced by abrupt increases in ETCO2 values following ITD placement, in the setting heads-up CPR already being performed. It is unclear as to how much of a ETCO2 increase occurs from heads-up CPR on its own though. Capnography and ETCO2 monitoring have been used to guide CPR quality and prognosis. Generally, ETCO2 greater than 15mmhg during CPR is regarded as an encouraging value, indicating good compressions and relatively increased chances of ROSC. Below 10mmhg is usually regarded as reasonable evidence to cease CPR.
The encouraging numbers from RFD may not have been due to heads-up CPR alone. RFD developed a set of seven practices that had to be employed while utilizing heads-up CPR: 1. Continuous uninterrupted compressions utilizing an automated CPR device 2. Apneic oxygenation. Placement of nasal cannula 15L/min prior to and during ventilations 3. Use of an impedance threshold device (ITD) 4. Heads-up CPR 5. Delaying defibrillation for a certain subset of patient presentations. Prolonged downtime patients, fine V-fib, and having ETCO2 reading <20mmhg were not defibrillated. Once ETCO2 20mmhg or greater, or change into shockable rhythm occurred, defibrillation was performed. The theory is that the acidotic heart is less receptive to electrical current. 6. Utilization of waveform capnography 7. Deprioritizing epinephrine in the order of intervention. Not administering epinephrine until ETCO2 values were ideal and/ or until CPR had been underway for a certain period of time. It is believed that by administering epinephrine in less acidic and more perfused environment, it has greater chances of benefit. In conclusion, the practice of heads-up CPR is exciting and encouraging but much more data is needed before global implementation. RFD continues to utilize heads-up CPR and several other fire departments are also implementing it, most notably Palm Beach Fire Department in Florida. Additionally, several studies are currently being conducted in a controlled setting, attempting to identify survivability and neurological outcomes. Perhaps in several years data will be robust enough to prove or disprove its perceived benefits. ABOUT THE AUTHORS: Dr. Goodwin is a PGY2 at Aventura Medical Center’s EM program in Miami, FL. He has extensive experience as a former paramedic, pediatric phlebotomist, and an emergency department registered nurse. His interests are cardiac arrest, pediatrics, and EMS. ristina Antuna is a fourth-year medical K student at Nova Scotia University Dr. Kiran C. Patel College of Allopathic Medicine in Fort Lauderdale, Florida. Upon completion of medical school, she aspires to become an emergency medicine physician aiming to expand her expertise surrounding point-of-care ultrasound, particularly in the trauma setting. Jackie Nguyen is a fourth-year medical student at Nova Scotia University Dr. Kiran C. Patel College of Allopathic Medicine in Fort Lauderdale, Florida. She is passionate about emergency medicine with interests in critical care and women’s health.
WHAT’S IN IT FOR ME?
THE BENEFITS OF SAEM MEMBERSHIP FOR MEDICAL STUDENTS By Nick Giordano and Erin Simon on behalf of the RAMS Membership Committee With the growing trend of medical schools turning to pass/ fail grading systems and the revision of United States Medical Licensing Examination Step 1 to follow with a non-numerical score, extra curriculars have come to the forefront of applications for residency. Additionally, with the integration of socially distant technologies and internships, so many more opportunities to network and engage in the emergency medicine community have presented themselves. Now, more than ever before, building a professional network to learn more about emergency medicine and gain experience to bolster your residency application is paramount. SAEM’s new website now streamlines opportunities for mentorship, leadership, advocacy, and education. Below we have highlighted a couple of these resources:
"WORKING ALONGSIDE SENIOR MEMBERS WITH LIKE INTERESTS IS A NATURAL WAY TO FIND MENTORSHIP WITHIN THE SAEM COMMUNITY AND BUILD UP YOUR NATIONAL REPUTATION." Mentorship
There are 30 interest groups within SAEM and that number continues to grow. Except for some career-specific groups (e.g., Research Directors, Vice Chairs, etc.) almost all interest groups are amenable to having medical students join. If the objectives of a group align themselves with your interest, reaching out and joining as a member to work on group initiatives will not only give you leadership experience in your field, but also serves as a great networking opportunity. Working alongside senior members with like interests is a natural way to find mentorship within the SAEM community and build up your national reputation. We also have an active emergency medicine (EM) resident membership base. Working alongside a current EM resident is a great way to learn about how you can best prepare yourself for an EM residency and source information about EM residency programs you might be interested in applying to.
If you are looking for some more formalized leadership opportunities through SAEM there is a dedicated program for medical students to get exposure to emergency medicine. The Medical Student Ambassadors Program (MSA) is always looking for interested students to join in the planning, coordination, and execution of SAEM’s Annual Meeting. This group of medical students acts as liaisons to speakers during the annual meeting, and the premeeting audio/visual
"WHETHER YOU ARE A JUNIOR MEDICAL STUDENT LOOKING FOR EXPOSURE TO THE FIELD OF EMERGENCY MEDICINE OR A SENIOR MEDICAL STUDENT WHO IS LOOKING TO SEE IF AN ACADEMIC CAREER IS RIGHT FOR YOU, SAEM HAS THE RESOURCES TO AID IN YOUR CAREER DEVELOPMENT."
soundchecks serve as the perfect time to network during the event. Once you complete the program, a personalized letter from the SAEM Program Committee Chair will be given to your dean of student affairs to thank you for your contributions.
SAEM also has a dedicated community for medical students and residents, affectionally referred to as RAMS (Resident and Medical Students). Within RAMS are various communities and initiatives specifically geared towards medical students and their transition to an EM residency. RAMS committees are always open to medical students joining and leading objectives.
Whether you are interested in advocating for your junior colleagues, social or health disparities, SAEM has outlets to pursue your passion. While there are dedicated avenues to work on advancing initiatives with like-minded peers in evidence-based health care, population health, or sex and gender in emergency medicine, if there is a cause or an initiative that is not currently being pursued by SAEM, resources are available to either fund that project or start your own interest group to pursue it.
Current, applicable podcasts and webinars from real-world experts in the field are available to supplement the training you receive in medical school. Additionally, the Clerkship Directors in Emergency Medicine (CDEM) and the Emergency Medicine Residents Association (EMRA) have put together resources to help you thrive in medical school, plan EM away rotations and apply to EM residency programs. Whether you are a junior medical student looking for exposure to the field of emergency medicine or a senior medical student who is looking to see if an academic career is right for you, SAEM has the resources to aid in your career development. Once you make the jump to residency, SAEM has additional resources that will continue to advance your professional growth as an academic EM physician.
SAEM's Membership Guide Helps You Make the Most of Your SAEM Membership The SAEM Membership Guide highlights all the programs, services, and opportunities the Society offers its members, takes new members through the ins and outs of the organization, and shows them the ropes, and gives all members the tools and information to make the most of their SAEM membership… all in one fun, easy-touse, interactive format.
FROM ZOOM MEDICINE TO REAL MEDICINE By Jennifer Geller "Follow that one; that is going to be interesting," a voice pierces through the hustle of the emergency department. After spending my first year of medical school learning from behind a computer screen, it is a breath of fresh air to be surrounded by passionate medical providers. All year, I desired to put the skills I was learning into practice. Sitting for hours with my laptop being my primary connection to medicine, I had to keep reminding myself what was at the end of this tunnel. Zoom fatigue from long lecture days intersected with long studying nights created a cyclical routine where I longed to get back into the clinic — meeting patients and thinking through complex medical challenges. Today was much awaited.
I fly after the patient's medical team, unsure where they are headed but eager to learn no matter what. Just as the team prepares to intubate this patient at one of the department's resuscitation bays, one nurse feels for the patient’s carotid pulse. Nothing. Now, I am not a doctor yet; however, my years of EMS have made me familiar with what comes next when a patient has no pulse. Grabbing a stool and lowering the stretcher, CPR is started. As someone begins chest compressions, I realize that this is something I can do to help. "What am I allowed to do to help?" I ask the patient's attending — a mentor of mine since the first day of medical school as a small-group instructor for one of my Zoom courses. Answer: Chest compressions.
"I can go next!" I jumped in and performed chest compressions and to my amazement, a pulse was palpated. CPR stops, and more advanced health care and medications are administered to maintain her pulse and blood pressure. At this time, before care is transferred to another department, my job changes on the team but is still present. As a urinary catheter is inserted, I grasp the patient's hand, anticipating her to feel pain because while she may not be conscious enough to feel the pain, there is a chance she does; we have no way of knowing. However, when she squeezes my hand back, my jaw drops under my N95 mask as I turn to tell the nurse on my right. Standing on the patient's right side, I hold her hand with my right hand and play with her hair with my left as I look into her open blue eyes that stare back at me. Can she see that I am there? Does she know what medical care we are providing her? Regardless of the answers, she is a person. One who is alone in a hospital emergency room surrounded by strangers, and if she is at all conscious, she must be in pain. The least I could do is stay by her side while she goes through each medical treatment. The attending tells us that this patient has no family and that her emergency contacts were her neighbor and her dog walker. Moreover, while I am so happy to help comfort her in one of the scariest times of her life, I am still a stranger. Not just a stranger — but one hiding behind a giant face mask and glasses. At the same time, though, the comfort of human touch, particularly in holding someone's hand, can mean the world of a difference in just knowing someone cares, even if it is from a medical student who is just trying to do the best she can to help. In my first year of medical school, I have taken several courses, and of course, the science classes are indeed important. However, through the year I spent with this attending who taught me what compassionate care looks like, I gained the confidence to act, jump in, and play an even more significant role in my learning. The year had come full circle as someone so influential in my learning and drive to become the best future physician I could be this far continued into this new and crucial setting.
"ZOOM FATIGUE FROM LONG LECTURE DAYS INTERSECTED WITH LONG STUDYING NIGHTS CREATED A CYCLICAL ROUTINE WHERE I LONGED TO GET BACK INTO THE CLINIC — MEETING PATIENTS AND THINKING THROUGH COMPLEX MEDICAL CHALLENGES." So, as I finally stand in this resuscitation bay on my very firsttime shadowing in medical school, comforting this patient who, even if she is conscious, will probably not remember me holding her hand and playing with her hair, I reflect on all I have learned my first year of medical school. I think about how grateful I am for all the individuals who helped us transform into the young budding physicians we are turning into — especially during these unprecedented times. I remind myself yet again how treating the whole patient as a person — and not strictly the physiological and biological — plays a critical role in complete patient-centered medicine. ABOUT THE AUTHOR: Jennifer Geller is a second-year medical student at Rutgers Robert Wood Johnson Medical School.
SUCCEEDING IN THE VIRTUAL WORLD: ONLINE INTERVIEWING BEST PRACTICES Alexandra Nordberg, MD; Allison Beaulieu, MD; Viral Patel, MD; Richard Church, MD; Jennifer Carey, MD on behalf of the SAEM Education Committee Whether you are interviewing for medical school, residency, fellowship, or your next job, an interview is invariably part of the process. This is a key opportunity for you to show your personal strengths and learn about the position. In this piece, we will review a variety of best practices to consider when preparing for your interview.
Do your homework on the program and have several thoughtful questions ready for your interviewers. You can look at your list of questions between interviews, but do not focus on your list during the interview. This is a critical way for you to decide if this position is right for you, so use your time wisely and effectively! On the flip side, be ready to answer questions the interviewer may have for you. In general, you should be prepared to answer the following questions: • Who are you? (Describe yourself) • How did you arrive at this point in your career? • Why are you interested in this position? • What are your goals going forward? • What questions do you have about the program? • What would you bring to the department as a faculty member? If you know ahead of time the names of the individuals who will be interviewing you, find time to read up on them so that you will understand their respective roles and can direct your questions to the most appropriate person.
Keep it Classy
Always look professional at an interview. This means dressing in appropriate attire and appearing well-rested and wellgroomed. You may have attended other virtual lectures or meetings in a dress shirt and your pajama bottoms, but don’t do that for an interview!
The Set Up
Crafting an appropriate set up for virtual interviews is essential. Select a location you are comfortable with and a place where you will be able to have a private, uninterrupted conversation. Review these five tips to ensure a successful interview day: 1. Lighting. Have a light source in front of you and avoid a light source behind you. Underlit spaces can make it difficult for an interviewer to see you, and lighting from behind can create a washed-out appearance.
"YOU MAY HAVE ATTENDED OTHER VIRTUAL LECTURES OR MEETINGS IN A DRESS SHIRT AND YOUR PAJAMA BOTTOMS, BUT DON’T DO THAT FOR AN INTERVIEW!" 2. Noise. To the best of your ability, control the ambient noise around you. If someone else is in the vicinity where you are interviewing, let them know so they won’t unknowingly disturb you. You can also place a “do not disturb” sign on your closed door or find another way to communicate “please no interruptions.” Be conscientious of your pets; move them to somewhere they will not interrupt you. 3. Background. There are varying opinions surrounding this topic. Some individuals opt for a blank, neutral background, while others prefer to employ backgrounds that display their personalities and interests. If you are interviewing from your home or office, keep it tidy. Close your closet doors and put away that laundry on the bed behind you! If you do need to interview in a space such as your bedroom, consider positioning your camera so that your bedroom furniture is not visible. If you are unable to do so, you may consider selecting a virtual background. Test out virtual backgrounds ahead of time and ensure the background is not overly busy or distracting. 4. Audio. Test your audio with a practice interview session. If you are using earbuds or headphones make sure your Wi-Fi connection is secure and have a backup option available in case of malfunction. Make sure your headphones are fully charged prior to the interview. If you are unable to get your audio to work, message your interviewer and/or hold up a note with your phone number so you can continue the interview in a slightly different format.
5. C amera focus. Check your camera prior to starting a virtual interview. Ensure the camera lens is clean and your head and shoulders are in appropriate focus. Prop up your computer on a large textbook or elevated surface so the camera is close to eye level to avoid an upward angle towards your nose or in a way that only captures only part of your head and shoulders.
Buzzing, dinging, and spilling water on your laptop can detract from the interview. Below are some tips and tricks to ensure the interview runs smoothly and without distractions. • Disable notifications on your laptop • Turn off messaging alerts and ensure they are not synced with your phone • Silence your phone or turn it off • Have a spare headset and/or earbuds handy in case you have difficulty with your sound • Keep your computer connected to a power source to avoid a low battery and needing to find a power source mid-interview • Stay focused on the interviewer and do not open additional screens
• Sit in a non-mobile chair to avoid spinning or rocking from side to side • Do not have food or drink at your desk • If possible, use an ethernet connection rather than WiFi
Be on Time
No one plans to be late, so set yourself up for success by logging into the virtual platform a few minutes early. This will give you time to troubleshoot links and equipment and lets the appropriate staff know you are present. It is essential you have the correct time zone when interviewing virtually; however, sometimes life gets in the way. If you realize you are going to be even a few minutes late, make sure you contact the coordinator/ employer.
Body Language and Nonverbal Cues
It can be difficult to convey interest in a virtual format, so be fully present in the moment and convey interest in the interview, position, and institution. Make sure your entire face is in view, look directly into the camera, and interact with the interviewer as though you are truly face to face. continued on Page 58
VIRTUAL REALITIES continued from Page 57 For both virtual and in person interviews, avoid fidgeting. Maintain good posture and eye contact and avoid excessive movement such as swiveling back and forth in your chair or clicking your pen. Silence your phone or turn it off.
Keep it Real
If you listed something on your application, you should be able to discuss it. This includes everything from research projects to craft beer brewing. Do not over emphasize something on your application if you are unable to speak knowledgeably about it during the interview. Additionally, if there are less desirable topics within your application, be ready to discuss these as well. Rather than avoiding difficult discussions and sweeping things under the rug, take ownership of them and discuss what you learned from the experiences.
Navigating “Illegal Questions”
The National Resident Matching Program® (NRMP®) Match Communication Code of Conduct includes question topics that are off-limits for interviewers. If you are asked these questions, there are different ways to respond:
"DO YOUR HOMEWORK ON THE PROGRAM AND HAVE SEVERAL THOUGHTFUL QUESTIONS READY FOR YOUR INTERVIEWERS"
• Answer the question, but only if you feel comfortable doing so • Provide a response that does not answer the question • Deflect the question and move on with the interview • Inform the interviewer you do not feel comfortable answering the question as you were told by your institution that such questions are not allowed to be asked during interviews
Contract and Negotiations
In a job search, the interview may or may not discuss contract and salary details. If this is the case, the interview is largely for you to learn more about the position, the institution, and expectations. You want to make sure this would be a good place for you and the employer wants to make sure you would succeed in the position. After the interview, it is acceptable to ask for a copy of a sample contract for you to review. Additionally, salary details are typically negotiated after the interview itself. For residency and fellowship interviews, you should be provided a copy of the appropriate contract, benefits, and obligations. Happy interviewing!
"DO NOT OVER EMPHASIZE SOMETHING ON YOUR APPLICATION IF YOU ARE UNABLE TO SPEAK KNOWLEDGEABLY ABOUT IT DURING THE INTERVIEW." 58
ABOUT THE AUTHORS: Dr. Nordberg is an assistant professor and the assistant program director for the emergency medicine residency program at the University of Massachusetts in Worcester, MA
Dr. Beaulieu is a medical education fellow and interim assistant program director for the Combined Emergency Medicine and Internal Medicine Residency Program at The Ohio State Wexner Medical Center. Dr. Patel is an assistant professor and the associate program director for the emergency medicine residency program at the University of Massachusetts in Worcester, MA.
Dr. Church is an associate professor and the University of Massachusetts Emergency Medicine Residency Program Director in Worcester, MA.
Dr. Carey is an assistant professor and the Director of Emergency Medicine Undergraduate Education at the University of Massachusetts in Worcester, MA.
#MATCH2021: VIRTUAL RESIDENCY INTERVIEWS By Addie Burtle, MD; Stephanie Cortes, MD, MS, MA; Reba Gillis, MD, MBS; and Al’ai Alvarez, MD on behalf of the SAEM Clerkship Directors in Emergency Medicine Academy and Academy for Diversity and Inclusion in Emergency Medicine, and Equity and Inclusion Committee Residency recruitment requires significant time and financial investments for students. It took a pandemic to change our recruitment practices in medicine, forcing the first large-scale experiment on virtual interviewing feasibility. Further, the murders of George Floyd, Breonna Taylor, and several others during the pandemic reignited national attention to the need for addressing structural racism and inequities, including within health care. In turn, diversity, equity, and inclusion became an even bigger priority for residency programs during the pandemic. According to the Coalition on Physician Accountability (CoPA), all interviews for the #Match2022 will be virtual. CoPA also recommends an “ongoing study on the impact and benefits of virtual interviewing as a permanent means of interviewing for residency.”
Several underrepresented trainees in medicine (UiM) who successfully Matched in EM in 2021 share their reflections on their virtual interview experience.
PRO: Cost Savings
Traveling for interviews costs the average student several thousands of dollars to cover transportation, hotels, and food in a new city. Data from the AAMC and others suggest that more than half of applicants limit their interviewing due to the financial burden. Students of lower socioeconomic status, and those from geographically isolated regions, are more likely affected. Unfortunately, these students may also be the least
continued on Page 60
PERSPECTIVES continued from Page 59 able to afford the risk of declining interviews due to their intersectional identities as underrepresented in medicine (UiM). Virtual interviews allowed students to focus on more critical factors when deciding where to apply and interview, thus creating a better playing field for all applicants. “It saved me a lot of money and stress. I didn’t have to worry about scheduling a flight/hotel/rental car. I didn’t have to worry about adding to my loan burden. I didn’t have to worry about where I would be getting this money from if loans didn’t cover my expenses. I also saved money on interview clothes.” “The cost of setting up my background with ring lights, a camera, and a microphone is a lot less than the price of traveling and staying in a different state.”
PRO: Increased Number and Geographic Opportunities to Apply
The extra funds saved by doing virtual interviews allowed those who might not have had the most competitive academic portfolio to apply to additional programs, increasing their chances of matching. The savings also allowed candidates to expand the breadth of their geographic search and to explore programs beyond certain proximity. “Without the need to travel, I was able to have interviews in different states in the same week. I could interview with a program in CA one day, and then interview in NY the next day.”
PRO: Easier to Schedule Virtually
A significant benefit for candidates was the ease of scheduling across different programs because several critical travel logistics were no longer needed. Students were better able to balance their rotation requirements and other curricular commitments with interviews, despite disruptions due to the pandemic. “I learned some important organizational skills navigating and balancing multiple residency program events.”
PRO: Time Savings
Forgoing travel allowed candidates to focus their time on interview preparation instead of worrying about flight disruptions, inclement weather, and scheduling interviews during their clinical rotations. “Interview days were shorter. Because I did not have to travel, most interviews were between 4-6 hours long.”
PRO: Convenience and More Time to Prepare Since interviews were done from the comforts of one’s home, the interview experience was more relaxed. Instead of stressing over traffic and flight delays, candidates spent their time reviewing their application material and notes about programs.
“The small breaks allowed me to walk around my apartment to grab some coffee/food and prepare for my next interview without feeling like I’m “on” for the whole interview. I even had my pets around so I could just pick them up and show the interviewer.”
PRO: Better Access to Faculty and Residents for Networking The virtual space allowed programs to be more creative with how candidates would interact with them. Virtual social events and faculty office hours offered more diversity of interactions. Faculty and residents only needed to log on for a fraction of the time instead of blocking bigger chunks of their day as would have been necessary during in-person interview events.
“I was able to meet so many faculty and residents virtually, and I hope to maintain those relationships despite not matching at those institutions.”
CON: It’s Not the Same
The virtual platform made it challenging for candidates to truly experience the sights, sounds, and smells of the program. Because of the interview schedule structure, there was limited time to have more candid conversations since everyone was always “on” camera. “I couldn’t really see the environment I would be exposed to during residency.” “Social events didn’t seem very personal. The interviewees to residents/faculty ratio were skewed heavily towards applicants, which did not allow for direct, one-on-one interactions.” “Interviews with faculty sometimes felt rushed.”
CON: IT Issues
Because this platform was new for most, unanticipated bandwidth issues and technological glitches were common. “My microphone didn’t work during one of my interviews, and I had to call each interviewer individually.”
“The internet went out once hours before the interview, and I had to call the internet company to help fix it; otherwise, I would have had to reschedule.”
CON: Zoom Fatigue
Unlike in-person interviews, where candidates must physically move from one room to another, staring at the same screen for four hours was draining.
CON: Lack of Standardization
Because last year was the first year for programs to adapt to the virtual interview platform, standardization across programs was difficult. Programs had variable pre-interview social events, swag, and schedules. Some offered lunch breaks with residents; some did not. Interview length varied from short interviews to all-day events. Availability of information regarding salary, benefits, and residency life varied. This made comparing programs objectively challenging for candidates.
CON: New Forms of Bias
While virtual interviews offer an even playing field regarding cost and availability, new forms of inequity existed, including variable access to better audio-video equipment, better lighting, staging, a quiet room, faster internet, and even hoarding of interview spots. Many virtual backgrounds may also not work well with certain skin tones and hairstyles. Furthermore, while many welcomed the chance to offer a glimpse into their homes as a way of humanizing and personalizing themselves, the lack of standardization also had the potential to magnify implicit bias.
Virtual Interviews for the Win!
Overall, universally requiring virtual interviews offered several wins for the candidates. While there are drawbacks to virtual recruitment, these can be opportunities for programs to improve for the upcoming interview season. As the pandemic continues, it is reassuring to know that EM-bound candidates
will not have to worry about traveling for their interviews this year. With enough planning and preparation, we can help future EM physicians succeed in “The Match.” As we move toward a more inclusive recruitment cycle, hopefully someday we can find the right balance between individualized and standardized recruitment experiences.
ABOUT THE AUTHORS:
Dr. Burtle is a PGY-1, Washington University in St. Louis Emergency Medicine Residency, @SocialMeasures
Dr. Cortes is a PGY-1, Indiana University Emergency Medicine Residency @Stephanie_C21
Dr. Gillis is PGY-1, Yale-New Haven Emergency Medicine Residency, @RPG_MD21
Dr. Alvarez is the director of Well-Being, Stanford Emergency Medicine, @alvarezzzy
BRIEFS AND BULLET POINTS SAEM22
Now Accepting SAEM22 Didactic Submissions!
The submission window for SAEM22 didactics is now open. Didactics will be presented in person, May 11-13 during the SAEM annual meeting in New Orleans. The SAEM22 Program Committee will place a premium on innovative and interactive didactic sessions that provide a robust educational experience. Didactic sessions in the areas of pediatric emergency medicine research, teaching, and practice, are highly recommended. Deadline for submissions is October 1, 2021, at 5 p.m. CT. Please visit our website for full submission guidelines and instructions.
SAEM22 Submission Dates! • Advanced EM Workshops Aug 2–Sept 15 • Didactics Aug 16–Oct 1, 2021 • Abstracts Nov 1, 2021–Jan 4, 2022 • Innovations Nov 1, 2021–Jan 11, 2022 • IGNITE! Nov 1, 2021–Jan 11, 2022 Workshop Submissions Close September 15
The submission window for Advanced EM Workshops is open. Authors are invited to submit novel topics, in-depth subject matter, or cutting-edge research related to academic emergency medicine
in the following categories: clinical innovations, communication, gender and bias, research, teaching, other. Advanced EM Workshop Day is May 10, 2022. Submission deadline: September 15, 2021. Visit the website for details.
SAEM NEWS & INFO
This year’s Challenge concluded on August 31, 2021. A mighty thanks to all SAEM members who donated and to the SAEM’s group leaders who championed the Challenge. While the publication process didn’t leave time to update this issue of SAEM Pulse with the winners, we will be celebrating winning groups at ACEP in October, in the November/ December issue, and throughout the rest of the year and into 2022. Please visit the Challenge update page for details of this year’s winning groups! Even though the Challenge has concluded, your gift today will help us fund tomorrow’s grantees.
Join a Committee!
A valuable benefit of SAEM membership is the opportunity to participate on one or more SAEM committee. Serving on a committee furthers your professional development by providing leadership experience, expanding your professional network, and strengthening your ties within the specialty. Committee members are involved in identifying new opportunities, guiding projects, and offering expertise...so you will have a direct hand in helping the Society achieve its goals. Review the SAEM committee descriptions and sign up for the SAEM committee or RAMS committee that best match your interests and expertise. Signups close October 15.
SAEMF Challenge...The Results Are Almost In
Claim SAEM21 Enduring Content CME Through October 31
Claim up to 260+ hours of CME credit through our SAEM21 enduring materials offered through October 31, 2021. Log into https://saem.junolive.co/live and click “On Demand” found at the top left-hand corner of the page. After viewing a presentation, complete the short questionnaire at bottom of page to receive CME.
ARMED Scholarship Recipients Share Their Experiences
Every year SAEM seeks enthusiastic senior residents or fellows who demonstrate early interest in pursuing a research-oriented career to apply to the ARMED course. Through the generosity of SAEM RAMS and several SAEM academies, scholarships are available to offset the costs associated with attending the various on-site meetings and course workshops. At the conclusion of the ARMED courses, the scholarship winners are asked to share their experiences. We invite you to read their stories here.
Seeking Applications for AEM Decision Editors
Academic Emergency Medicine (AEM) is seeking applications from individuals interested in serving as a decision editor. AEM has a strong commitment to diversify journal leadership and is encouraging applications from women and those who are underrepresented in medicine. Qualifications include a published track record demonstrating topical expertise. The journal has a present need for expertise in systematic reviews and meta-analyses, prehospital emergency care, health disparities and social determinants of health, health services research, errors and quality in emergency care. The position is unpaid and requires attendance of at least one editorial board meeting per year. The term generally lasts for three years and
requires membership in SAEM. Interested individuals should send their curriculum vitae and a cover letter to AEMeditor@ saem.org. Deadline for submissions is September 15, 2021.
SAEM Guides & Toolkits Academic Career Guide
AEM and AEM E&T Want to Hear From You!
The editorial boards of Academic Emergency Medicine and Academic Emergency Medicine Education and Training are seeking input from SAEM members regarding their experiences with the journals. The results of the survey will help the editorial boards provide the best service possible for journal authors and readers. Please take a few minutes to respond to this short survey by September 7, 2021.
Call for Papers: AEM E&T 2021 Virtual Meeting Proceedings Issue!
AEM Education and Training (AEM E&T) invites submissions from SAEM academies, committees, and interest groups for a special issue of the journal that will publish in early 2022 and highlight the proceedings from the SAEM21 Virtual Meeting relevant to education and training. Details and submission instructions can be found online. Deadline is October 15, 2021.
The Quick Guide to Promotion For the Uninitiated
2020 Call for Reviewers: AEM Education and Training
If you are interested in advancing your career and becoming part of a network that will prove professionally valuable, consider applying to become a reviewer for Academic Emergency Medicine Education and Training (AEM E&T) journal. The benefits of being a reviewer for AEM E&T are many: connections with key figures in the specialty, advanced access to the most current literature and research results, development of critical thinking skills essential to your own research and writing, and more! Visit the webpage for application information and instructions.
Academic Promotion Toolkit
Immigration Advocacy Toolkit
COMMITTEE, ACADEMY, IG REPORTS SIMULATION ACADEMY We've Had a Busy Few Months! • Our new website has launched! • Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds), a FREE openaccess eBook containing sixteen cases to address critical pediatric topics for EM residents through simulation has been published. Download it here! • In conjunction with the CORD Simulation Community, we are excited to offer a simulation consulting service to help troubleshoot simulation education and curricular challenges. (For details, see below) For more Simulation Academy updates, including upcoming events, follow us on twitter: @SAEMSimAcademy
Introducing the Simulation Consult Service Educational Dilemmas
You are the director of simulation at a newly minted emergency medicine residency program. You have developed a longitudinal simulation curriculum for your residency program, but you wonder what other programs around the country are doing. You are the director of simulation for an established emergency medicine residency program. Your department chair approaches you because there have been multiple residents involved in central line safety issues in the past six months. You are the associate program director for an established emergency medicine residency program. You have a resident who is lagging his peers in the clinical setting. You would like to put together a remediation program with a simulation component.
Simulation is a powerful educational tool universally embraced across emergency medicine residency programs. Successful deployment of simulation curricula depends on a range of factors, including understanding the specific needs of the trainee, the available resources, and the learning environment at each program.
“Simulation educators are confronting new and evolving challenges as they strive to provide high-quality education to trainees, such as the need to evaluate trainees based upon competency-based milestones, demand for accountability and documented assessments, and rapid advances in simulation technology.” Simulation educators are confronting new and evolving challenges as they strive to provide high-quality education to trainees, such as the need to evaluate trainees based upon competency-based milestones, demand for accountability and documented assessments, and rapid advances in simulation technology. However, training programs vary widely in available faculty and simulation resources, and it is common for residency programs to have only a handful of simulation-trained educators practicing in relative isolation. As leaders in the SAEM Simulation Academy, we believe that all simulation educators benefit from a forum to share experiences, expertise, and ideas on how to approach common educational dilemmas. Increased collaboration results in increased professional engagement, augmented creativity, and improved outcomes for our trainees.
The Simulation Consult Service
The Simulation Consult Service was developed as a collaboration between the SAEM Simulation Academy and the CORD Simulation Community of Practice. This service, which is free to members, provides solutions to common educational dilemmas faced by programs when designing and implementing simulation curriculum. We strive to provide a personalized approach to each educational dilemma, integrating best practices in healthcare simulation and medical education.
How It Works
The SAEM Simulation Academy welcomes new consults by e-mailing the Simulation
Consult Service leadership at simconsults@ saem.org. Once submitted, consults go to a team of simulation educators in the SAEM Simulation Academy, who systematically review each submission and provide feedback, ideas, and resources for taking the next step in curriculum innovation.
You reach out to the Simulation Consult Service to see how other established emergency medicine programs are incorporating simulation into residency education. SAEM Simulation Academy members put together an outline of common elements of longitudinal simulation programs at their training sites and provide targeted feedback on your curriculum plan. Central line training is a critical element of emergency medicine residency training. Multiple members of SAEM Simulation Academy have experience with central line training programs from their respective institutions, including strategies for monitoring trainee progress. These suggestions allow you to kickstart your own surveillance and remediation program. Simulation can be a valuable component of clinical remediation, as it allows development of clinical reasoning skills without additional patient risk. Members of SAEM Simulation Academy share examples of prior remediation programs at their residency programs, including outcomes and pitfalls encountered. You build upon their experiences to develop a customized remediation program for your at-risk trainee.
EVIDENCE-BASED HEALTHCARE & IMPLEMENTATION INTEREST GROUP New Award to Honor Dr. Rekesh Engineer The SAEM Evidence Based Healthcare & Implementation Interest Group has announced a new award named in honor of the late Rakesh Engineer, MD, who passed away in 2019. The Rakesh Engineer Award, to be presented for the first time at SAEM22 in New Orleans, is intended to highlight an implementation science abstract exemplifying his spirit.
About Dr. Engineer
As an emergency medicine clinical researcher, Dr. Engineer thrived at the interface of published evidence and pragmatic application at the bedside. At the time of his death, he was finalizing an implementation science presentation on rapid cardiac evaluation in the emergency department for SAEM19. Dr. Engineer earned both his BS and MD at The Ohio State University. After his internship at Barnes-Jewish Hospitals/Washington
University in St. Louis, Missouri, he trained in emergency medicine at Spectrum Health (Butterworth Hospital)/Michigan State University in Grand Rapids. Thereafter, he joined the Cleveland Clinic to be with his family, educate the next generation of emergency physicians, and launch his clinical research career. Dr. Engineer epitomized the vision of Implementation Science that “knowing is not enough…we must apply” and therefore this award will forever bear his name.
What is Implementation Science?
“Implementation Science” journal defines this as “the scientific study of methods to promote the uptake of research findings into routine healthcare in clinical, organizational, and policy contexts.” In other words, implementation science programs use the available evidence to achieve measurable improvements in the quality of clinical care. These improvements can occur via implementation, such as adding or improving a process which will improve care, or by de-implementation, which is removing a prior process that has since been shown to be ineffective or harmful to better align with the optimal care.
Starting at SAEM22, abstracts that are accepted for the SAEM Annual Meeting will be eligible for consideration of this award.
The abstract must center on a project or study that evaluates the implementation, or de-implementation, of a process that leads to an evidence-based improvement in patient care. Both implementation and clinical outcomes should be reported, with the focus being on the implementation. Quality improvement projects may be considered if they describe the implementation methods and address the effectiveness of the implementation protocol as well as the corresponding clinical outcomes. The abstracts will be scored in two phases using a modified RE-AIM (Reach, Effectiveness, Adoption, Implementation Consistency, Maintenance) approach. First, judges will score written abstracts on the reach, effectiveness, adoption, and maintenance. For the top three abstracts, the oral or poster presentation will be then judged live at the SAEM Annual Meeting focusing again on the reach, adoption, and evidence base behind the process change. From these scores, a final winner will be chosen and announced at the conclusion of the SAEM Annual Meeting.
How to Apply
Interested SAEM members can apply through the SAEM website starting in December 2021. Details will be announced later this fall.
ACADEMIC ANNOUNCEMENTS Dr. Ronny Otero Named Vice Chair for Clinical Operations
Dr. Greg Jay Awarded an Endowed Professorship
Ronny M. Otero, MD, MSHA, has been appointed vice chair for clinical operations, Medical College of Wisconsin (MCW) Department of Emergency Medicine. Dr. Otero will will assume this newly created senior leadership role on November 1, 2021; he will provide oversight, direction, and leadership for Dr. Ronny M. Otero the operations of all clinical practices of the MCW Department of Emergency Medicine. In addition, he will lead and mentor site medical directors across eight clinical practice locations in the Froedtert & the Medical College of Wisconsin health network. Dr. Otero is the former director of emergency medicine at Henry Ford Medical Center – Sterling Heights, MI.
Gregory Jay, MD, PhD, has been appointed to hold the John and Mary Panton and Emergency Medicine Professorship in Translational Sciences at Brown University. Dr. Jay is a professor of orthopaedics, professor of emergency medicine, and professor of engineering at Brown University in the Dr. Gregory Jay department of emergency medicine and division of engineering. Through his work leading the Musculoskeletal Trauma Lab, his many publications and patents, and his role as a scientific cofounder of the startup company Lμbris, LLC, Greg seeks to improve the care of emergency medicine patients and works to develop treatments for unmet medical needs. He has played a leading role in developing research at UEMF/Brown EM, Lifespan, and for SAEM in New England.
Dr. Deborah Levine Promoted to Associate Professor of Clinical Emergency Medicine Deborah Levine, MD, has been promoted to the rank of associate professor of clinical emergency medicine at NewYorkPresbyterian/Weill Cornell Medicine. Dr. Levine joined NewYork-Presbyterian/Weill Cornell Medicine in February 2020 as a research faculty in the division of pediatric Dr. Deborah Levine emergency medicine, departments of emergency medicine and pediatrics. She recently received funding through the President’s Council of Cornell Women Affinito-Stewart Grant and is currently leading a multicenter research consortium based in the New York metropolitan area to develop a predictive model for COVID-19related multisystem inflammatory syndrome in children (MIS-C). Dr. Levine is a cofounder of the New York Society of Pediatric Emergency Medicine and a research scholar with the Academic Pediatric Association.
Dr. Kaushal Shah Appointed Assistant Dean of Academic Advising Kaushal Shah, MD, is the new assistant dean of academic advising at Weill Cornell Medical College. Dr. Shah is responsible for the development and ongoing management of academic advisors for all medical students and for restructuring the current career and academic advising model, in collaboration Dr. Kaushal Shah with clinical departments and with other education deans. Dr. Shah joined the emergency department at Weill Cornell Medicine in 2018 as the vice chair of education, a role he will continue to hold. He also holds the rank of assistant professor of clinical emergency medicine.
Drs. Gerardo and Vissoci Receive NIH Funding to Study Snakebite Charles Gerardo, MD, chief, division of emergency medicine and professor of surgery at Duke School of Medicine, along with his colleague Joao Vissoci, PhD, received an NIH Fogarty International Center R21 grant to study snakebite in the Brazilian Amazon. Snakebite is a neglected tropical disease Dr. Charles Gerardo that affects 2.7 million people, mostly in low resource areas, with up to138,000 deaths, and 400,000 permanent disabilities annually. This proposal will develop and evaluate an innovative multi-modal intervention to improve care, including decentralized antivenom distribution among the existing community health care network in the Brazilian Amazon.
Dr. Angela Lumba-Brown Appointed Associate Vice Chair Angela Lumba-Brown, MD, has been appointed associate vice chair of Stanford Emergency Medicine. Dr. Lumba-Brown is also an associate professor of emergency medicine and, by courtesy, of pediatrics and neurosurgery at Stanford. She sits on the Board of Scientific Counselors for the Centers Dr. Angela Lumba-Brown for Disease Control’s National Center for Injury Prevention and Control and is an appointee to the Pac-12 Brain Trauma Task Force, guiding research and policy in athletes with head injury. Dr. Lumba-Brown is the codirector of the Stanford Brain Performance Center.
Dr. Charles Wira Elected Chair of AHA/ASA Stroke Council Committee
Dr. Charles Wira
Dr. Sheikh Promoted to Associate Professor of EM
Charles Wira, MD, assistant professor of emergency medicine, Yale Department of Emergency Medicine, was recently elected to be chair of the Emergency Neurovascular Care Committee of the AHA/ASA Stroke Council. He also serves as a member of the Stroke Council Leadership Committee and is on the program committee for the International Stroke Conference.
Dr. Sophia Sheikh
Dr. Alvarez Named Director of Wellbeing and Director of EM Wellness Fellowship
Dr. Baruch Fertel Promoted to Associate Professor of Emergency Medicine
Dr. Baruch S. Fertel
Sophia Sheikh, MD, has been promoted to associate professor of emergency medicine at the University of Florida College of Medicine– Jacksonville. Fellowship trained in clinical toxicology, Dr. Sheikh’s research interest is in improving patient safety and education for pain management in acute care settings.
Baruch S. Fertel, MD, MPA, has been promoted to the rank of associate professor of emergency medicine at Lerner College of Medicine of Case Western Reserve University. Dr. Fertel is director of operations for the Emergency Services Institute at Cleveland Clinic as well as associate chief quality officer– regulatory affairs for the Cleveland Clinic Health System.
Dr. Sanjey Gupta Promoted to Professor of EM Sanjey Gupta, MD has been promoted to professor of emergency medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Dr. Gupta is the chair of emergency medicine at South Shore University Hospital, a member hospital of Northwell Health. He is a wilderness Dr. Sanjey Gupta medicine educator and a fellow of the Academy of Wilderness Medicine.
Al’ai Alvarez, MD, clinical assistant professor for Stanford School of Medicine Department of Emergency Medicine has been named director of wellbeing and director of the emergency medicine wellness fellowship. Previously, Dr. Alvarez served as an associate residency program director. Dr. Alvarez Dr. Al’ai Alvarez serves as the cochair of Stanford’s WellMD's Physician Wellness Forum, cochair of the Council of EM Residency Directors Wellness Leadership MiniFellowship, and cochairs the largest national diversity mentoring program through a joint ACEP-EMRA initiative. Dr. Alvarez received the 2020 SAEM Academy for Diversity and Inclusion in Emergency Medicine (ADIEM) Outstanding Academician Award.
Dr. Mark Conroy Promoted to Associate Professor–Clinical Mark Conroy, MD, has been promoted to associate professor-clinical at The Ohio State University Wexner Medical Center where he is also an assistant professor of emergency medicine and sports medicine Dr. Mark Conroy
SUBMIT YOUR ANNOUNCEMENT! The SAEM Pulse Academic Announcements section publishes academic appointments, promotions, retirements, grant awards, research announcements, published papers, etc. Send your content (50-75 words max) to email@example.com. The next content deadline is October 1, 2021 for the November/December 2021 issue. 67
NOW HIRING POST YOUR OPEN JOBS IN FRONT OF OUR QUALIFIED CANDIDATES! Accepting ads for our “Now Hiring” section! Deadline for the next issue of SAEM Pulse is October 1. For specs and pricing, visit the SAEM Pulse advertising webpage.
CLIMATE CHANGE. OUR WORLD IN CHANGE.
BE THE CHANGE.
As we envision the world after COVID-19, we have a once-in-a-generation opportunity to reinvigorate our communities, institutions, and the trajectory of future public health crises — including that from a rapidly changing climate.
CLIMATE & HEALTH SCIENCE POLICY FELLOWSHIP
Become an expert clinical voice schooled in the science, facile with health policy, and a confident, connected advocate for the most complex health policy challenges of our time. Fellows have the chance to work with federal agency organizations and non-profits:
For more information, and to apply, please go to bit.ly/NCHSPF
Clinical and Translation Science Fellowship Transforming clinical emergency medicine! www.umassmed.edu/emed/fellowship Contact: Jean Baril at 508-421-1750 Email: Jean.Baril@umassmed.edu
• Launch your career in research that directly impacts health systems, clinicians, and patients • Develop research skills essential to studying the translation of evidence based practices into routine care in emergency settings • Earn your Masters of Science in Clinical Investigation • Work with internationally recognized EM translation and implementation science mentors
Envision Physician Services is currently seeking emergency physicians who want to make a larger impact on healthcare. With various leadership and clinical positions available at highly desirable academic facilities across the nation, we can help you find the perfect fit.
Featured Positions Director of Education Osceola Regional Medical Center Orlando, Florida
Associate Residency Program Director Aventura Hospital and Medical Center Miami, Florida
Director of Simulation Osceola Regional Medical Center Orlando, Florida
Talk with us at ACEP: Booth #2400
Ready to learn more?
Contact our experienced recruiters today!
Penn State Health Emergency Medicine About Us: Penn State Health is a multi-hospital health system serving patients and communities across 29 counties in central Pennsylvania. The system includes Penn State Health Milton S. Hershey Medical Center, Penn State Children’s Hospital, and Penn State Cancer Institute based in Hershey, PA; Penn State Health Holy Spirit Medical Center in Camp Hill, PA; Penn State Health St. Joseph Medical Center in Reading, PA; and more than 2,300 physicians and direct care providers at more than 125 medical office locations. Additionally, the system jointly operates various health care providers, including Penn State JOIN OUR TEAM Health Rehabilitation Hospital, Hershey Outpatient Surgery Center, Hershey Endoscopy Center, Horizon Home Healthcare and Pennsylvania Psychiatric Institute. EMERGENCY MEDICINE OPPORTUNITIES In December 2017, Penn State Health partnered with Highmark Health to facilitate creation of a value-based, AVAILABLE community care network in the region. Penn State Health shares an integrated strategic plan and operations with Penn State College of Medicine, the university’s medical school. We foster a collaborative environment rich with diversity, share a passion for patient care, and have a space for those who share our spark of innovative research interests. Our health system is expanding and we have opportunities in both an academic hospital as well community hospital settings.
Benefit highlights include: • Competitive salary with sign-on bonus • Comprehensive benefits and retirement package • Relocation assistance & CME allowance • Attractive neighborhoods in scenic Central Pennsylvania
FOR MORE INFORMATION PLEASE CONTACT: Heather Peffley, PHR CPRP - Penn State Health Physician Recruiter
Penn State Health is fundamentally committed to the diversity of our faculty and staff. We believe diversity is unapologetically expressing itself through every person’s perspectives and lived experiences. We are an equal opportunity and affirmative action employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.
UNIVERSITY OF WISCONSIN EMERGENCY MEDICINE
F E LL O W SHIPS ACADEMIC EMERGENCY MEDICINE FELLOWSHIP POSITIONS AVAILABLE Continue your academic training at the University of Wisconsin School of Medicine and Public Health, a recognized international, national, and statewide leader in medical education, research, and service. The BerbeeWalsh Department of Emergency Medicine located in Madison, Wisconsin's isthmus capital and second largest city, sponsors several fellowships for graduating residents. Our primary ED at UW Health's flagship hospital: #1 hospital in Wisconsin for the last nine years ACS-certified, Level 1 adult and pediatric trauma and burn center One of only 25 U.S. hospitals named to Newsweek’s “Top 100 Global” list
University Hospital ED: 75,000+ patient visits annually
ACCREDITED EMS FELLOWSHIP
Our program trains physicians in medical direction for ground and air transport, disaster preparedness, event medicine, tactical EMS, QA/QI, prehospital research, and EMS education. The fellowship is flexible to allow time to explore individual interests and scholarship. Graduates are fully prepared to sit for their ABEM EMS board certification exam and to provide exceptional medical direction to prehospital emergency care agencies with advanced competencies in EMS operations, administration, and clinical care. Learn more online at emed.wisc.edu/ems-fellowship.
RESEARCH FELLOWSHIP Two-year SAEM-certified SAEM-certified research research fellowship fellowship trains physicians to become Two-year independent investigators and nationally recognized leaders in emergency medicine research, capable of conducting externally-funded clinical or health services research. At the end of the program, fellows will have completed a Master of Science in Clinical Investigation (MSCI) degree and will be wellprepared to obtain a federal career development award. The UW Department of Emergency Medicine is a recognized leader in our specialty, ranking among the top academic departments of emergency medicine for NIH research funding. Fellows are able to leverage the tremendous resources across the UW-Madison campus as well as its collaborative, interdisciplinary spirit, which promotes connectedness across an extensive network of research programs. Learn more at emed.wisc.edu/research.
SIMULATION FELLOWSHIP One-year simulation simulation fellowship One-year fellowship develops physician skills in the creation and execution of simulation-based learning experiences, including in curriculum development, underlying theory, research, and debriefing/technical skills. Our program offers extensive interdisciplinary teaching and learning opportunities, inclusive of subspecialty areas such as out-of-hospital EMS and Med Flight. Fellows receive ample support for education, such as attending the Harvard Comprehensive Instructor Course and national Simulation/EM conferences. Fellows also have access to a newly renovated clinical simulation facility with knowledgeable simulation educators. The 7,500 sq. ft. facility houses state-ofthe-art resources, including high fidelity manikins, wet labs, task/virtual reality simulators, advanced audio-visual capture and playback system, and a virtual environment simulation cave. Learn more at go.wisc.edu/sim-fellowship.
Learn more online at emed.wisc.edu/fellowships
One-year ACGME-accredited One-year ACGME-accreditedEMS EMSfellowship fellowship combines ground, aeromedical and tactical EMS exposure with administrative, leadership, and research activities, including utilization of two dedicated physician response vehicles for on-scene field experience and the ability to train with our world-class helicopter EMS unit.
Emergency Medicine Residency Program Director Penn State Health Milton S. Hershey Medical Center is seeking an Emergency Medicine Residency Program Director to join our exceptional academic team located in Hershey, PA. This is an excellent opportunity to join an outstanding academic program with a national reputation and inpact the lives of our future Emergency Medicine physicians. What We’re Offering: • Competitive salary and benefits • Sign-On Bonus • Relocation Assistance • Leadership for Emergency Medicine Residency Program • Comprehensive benefit and retirement options
FOR MORE INFORMATION PLEASE CONTACT:
Heather Pefﬂey, PHR CPRP Physician Recruiter Penn State Health
Email: firstname.lastname@example.org Website: careers.pennstatehealth.org
What We’re Seeking: • MD, DO, or foreign equivalent • BC/BE by ABEM or ABOEM • Leadership experience • Outstanding patient care qualities • Ability to work collaboratively within a diverse academic and clinical environment
What the Area Offers: Located in a safe family-friendly setting, Hershey, PA, our local neighborhoods boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Known as the home of the Hershey chocolate bar, Hershey’s community is rich in history and offers an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC.
Penn State Health is fundamentally committed to the diversity of our faculty and staff. We believe diversity is unapologetically expressing itself through every person's perspectives and lived experiences. We are an equal opportunity and affirmative action employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.
NEW CAREER OPPORTUNITIES IN ACADEMIC MEDICINE
We’re focused on shaping the future of emergency medicine and we need strong Academic Physicians to lead-the-way. Join the team at one of our academic medical centers across the nation!
Join our team
teamhealth.com/join or call 877.650.1218
DEPARTMENT OF EMERGENCY MEDICINE MASSACHUSETTS GENERAL HOSPITAL A Major Teaching Affiliate of Harvard Medical School
The Department of Emergency Medicine at Massachusetts General Hospital is seeking candidates for academic faculty positions. Candidates must have a commitment to excellence in clinical care and teaching; academic appointment will be at Harvard Medical School at the instructor, assistant professor or associate professor level. MGH is the home of the 4-year MGH/BWH Harvard Affiliated Emergency Medicine Residency Program. The ED at MGH is a high volume, high acuity level 1 trauma and burn center caring for approximately 114,000 adult and pediatric patients annually. The successful candidate will join a faculty of 62 academic emergency physicians in a department with active research and teaching programs as well as fellowship programs in administration, research, medical simulation, ultrasonography, medical education, geriatrics, wilderness medicine, and disaster medicine. Inquiries should be accompanied by a curriculum vitae and may submitted by email (Brown.email@example.com) to: David F. M. Brown, MD FACEP MGH Trustees Professor & Chair Department of Emergency Medicine Austen110 Massachusetts General Hospital Boston, Massachusetts 02114 Massachusetts General Hospital is an equal opportunity/affirmative action employer.
Employers, are your recruiting efforts effective? Specific targeted career websites, like EM Job Link, deliver the most highly qualified talent and have the best return on investment. Our candidates are made up of the specific professionals you want to reach. If you want the best and brightest candidates, you need to go where they job search – EM Job Link. Along with posting your jobs in front of qualified candidates at EM Job Link, you can search our resume bank for talent as well. Post today or speak to an expert who can help create a customized recruiting solution to get you great candidates.
WORLD’S LARGEST AND MOST PRESTIGIOUS EMERGENCY MEDICINE CONFERENCE Approved for AMA PRA Category 1 Credit ™
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Emergency medicine’s largest and most prestigious educational conference offering the latest in EM education from pre-conference courses, 300+ in-person courses, 60+ at-home courses, to hands-on skills labs, ACEP21 has it all!
Courses Labs Exhibits Parties Networking Events And More... Your health and safety are important to us. During the conference we will be following strict adherence to COVID-19 safety protocols and procedures during all ACEP21 official events