tag:blogger.com,1999:blog-14885701577879102772024-03-18T04:48:06.499-05:00AAEM Resident and Student Association AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.comBlogger460125tag:blogger.com,1999:blog-1488570157787910277.post-84762802433796046082021-06-30T13:58:00.004-05:002021-06-30T14:00:33.837-05:00EM/IM Combined Residency: What up with that?<div><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGlPJSvfmoOx1BLL4C7rh5ORxKMygoUFv0g9c7gLsJF3p2DtXhIXREW2P7swJSj5pC4psW7_b21A_pYjf4PyrL8zozPem69Tqj6VdFXu78uPbnVZbFSM90mnV2TfP-kLR-LkuZHFWeivcT/s2048/woman-medical-assistant-physician-skin-Pharmacy-technician-service-1605139-pxhere.com.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1367" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGlPJSvfmoOx1BLL4C7rh5ORxKMygoUFv0g9c7gLsJF3p2DtXhIXREW2P7swJSj5pC4psW7_b21A_pYjf4PyrL8zozPem69Tqj6VdFXu78uPbnVZbFSM90mnV2TfP-kLR-LkuZHFWeivcT/s320/woman-medical-assistant-physician-skin-Pharmacy-technician-service-1605139-pxhere.com.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: x-small;">Image credit: <i><a href="https://pxhere.com/en/photographer/3069707">secildegirmenciler</a></i></span></td></tr></tbody></table></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2Nmnv-6VaL9BmCtRmjCxIoXEIoJQpdGb4yu5MisRSIo258lr7lddpPQwQi6j7-9ZrC2_NIWUpBcdSkzTXDPS3jzE6HEspeuFDVXntVc3JNDkoyHOXAGdk1e7Kj0E2gQEwUZcmCp5fAkLs/s200/RSA+Peer+Reviewed+Logo.png" style="clear: right; display: inline; margin-bottom: 1em; margin-left: auto; margin-right: auto; text-align: center;"><span style="font-size: x-small;"><img border="0" data-original-height="85" data-original-width="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2Nmnv-6VaL9BmCtRmjCxIoXEIoJQpdGb4yu5MisRSIo258lr7lddpPQwQi6j7-9ZrC2_NIWUpBcdSkzTXDPS3jzE6HEspeuFDVXntVc3JNDkoyHOXAGdk1e7Kj0E2gQEwUZcmCp5fAkLs/s0/RSA+Peer+Reviewed+Logo.png" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="color: #cc0000; font-size: x-small;"><a href="http://aaemrsa.blogspot.com/2014/09/new-peer-review-system-for-original.html"><b>This post was peer reviewed. <br />Click to learn more. </b></a></span></td></tr></tbody></table><br /><div><b>Authors: </b>Kyla Rakoczy</div><div>MS-3, University of Miami Miller School of Medicine</div><div><br />Kasha Bornstein, MD, MPH <br />PGY-1, LSU New Orleans Internal Medicine/Emergency Medicine<br /><br />Choosing a specialty is one of the most daunting tasks of medical school. Pursuing an emergency medicine residency affords a fast-paced, often unpredictable environment with a diversity of patients unique to the specialty, while the life of an internist involves rounding, longitudinal patient care, and long contemplative sessions pertaining to pathophysiology and diagnosis. A combined Emergency Medicine (EM)/Internal Medicine (IM) residency program may allow for the best of both worlds. There are currently eleven, and soon to be twelve, programs that offer a combined five-year program. Required exposures in EM include experience performing invasive procedures, critical care experience, pediatric exposure, and emergency preparedness, while the IM aspect requires completion of rotations through IM subspecialties including oncology, cardiology, and infectious disease, with clinic opportunities in neurology, rheumatology, and endocrinology, as well as an additional four months dedicated specifically to pediatrics.[1] Graduates of the combined degree may choose to work solely in either field, enter a subspecialty, pursue additional fellowship experience in critical care, or engage in research.[2] The most popular fellowship pursued by combined training candidates is critical care (CC), and there are five all-inclusive combined EM/IM/CC programs in the United States. This path involves seventy-two months split between emergency medicine and internal medicine with additional experience in the critical care setting.[3] Upon completion of this challenging six-year period, residents are eligible for triple-board certification. Many triple-certified physicians choose to divide their time between the emergency department (ED) and intensive care unit (ICU) for extra variability in their careers, staying sharp in both the high acuity and physiological management of the most ill and complex patients.</div><div><br /><span><a name='more'></a></span><br />Board certification in EM and IM allows for the confidence to handle the high acuity of the ED while also developing sophisticated understanding of the pathophysiology of chronic conditions. In the United States, nearly half (45 percent) of all Americans suffer from at least one chronic disease, making the utility of a combined board certification easily apparent.[4] EM/IM doctors are well suited to manage “observation units” where patients whose conditions fall in between warranting inpatient care and outpatient follow-up are monitored for select intervals of time in a controlled setting just outside the ED. Veterans are a particularly needy population who frequently present with acute exacerbations of chronic disease. Working in rural and international settings offer the opportunity to gain unique cultural experiences and practice in providing high quality care in more austere environments. <br /><br />A fourth-year medical student rotation at a combined degree program is highly encouraged to bolster applications as spots are selective and highly competitive. Students pursuing a combined degree should be eager to apply both fields in their future career with a keen interest in research, scholarly endeavors at academic institutions, and a strong commitment to keeping up with changes in medical literature to manage both acute and chronic conditions. It is a common misconception that combined programs are preferred for learners desiring a slower paced emergency medicine education. Many who have completed the dual program themselves report that the training is far from slow-paced, however the challenge and clinical advantages of increased training and diversity of exposures is more than worth the extra time invested.[5] Dual-trained physicians are strong candidates for leadership positions including international clinic directors, program directors, and fellowship directors. Combined EM/IM doctors are lauded for their breadth of knowledge, commitment to upholding a high level of personal standard and patient care, and distinctive training to think like an internist and act with the speed and precision of an EM physician.<br /><br /><ol style="text-align: left;"><li>Martinez J. Emergency Medicine The Medical Student Survival Guide . https://www.emra.org/globalassets/emra/publications/books/emra-mssgonline-final.pdf.</li><li>ABEM. Guidelines for Combined Residency Training in Emergency Medicine and Internal Medicine.</li><li>Marcus D. Welcome to LIJ EM/IM and EM/IM+CC. EM Pulse</li><li>Raghupathi W, Raghupathi V. An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach to Public Health. International Journal of Environmental Research and Public Health. 2018; 15(3):431. https://doi.org/10.3390/ijerph15030431</li><li>Winters M. Combined Residency Programs in Emergency Medicine. The Journal of Emergency Medicine . Published online August 31, 2019.</li></ol></div><br />AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-74446439601663271292021-05-07T13:26:00.002-05:002021-05-07T13:26:22.722-05:00The Role of Ridesharing in Emergency Medicine<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitgM9MA67jFi45XM2ULtWYkypN3pq2F3QxYxi7M4W_9b3h6b1N8q1YQZjZiMuOJjH2UJv2SBEppCr41qxpCS6dpoGety_lUbjJXOIb6I4h8TY1K_L7CaFEoTBIviprDvVZHgwe2pnVFiOl/s2048/pexels-pavel-danilyuk-6754169.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1367" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitgM9MA67jFi45XM2ULtWYkypN3pq2F3QxYxi7M4W_9b3h6b1N8q1YQZjZiMuOJjH2UJv2SBEppCr41qxpCS6dpoGety_lUbjJXOIb6I4h8TY1K_L7CaFEoTBIviprDvVZHgwe2pnVFiOl/s320/pexels-pavel-danilyuk-6754169.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/search/ambulance/"><i>Pexels</i></a></td></tr></tbody></table><b>Authors:</b> Jennifer Rosenbaum, MD; Nicole V. Lucas, MD; and Kraftin E. Schreyer, MD CMQ FAAE<div>Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense/archived-issues/januaryfebruary-2021"><i>Common Sense</i></a><br />January/February 2021<br /><br />The advent and broad availability of ridesharing services, such as Lyft and Uber, are changing the way patients access medical services, and emergency departments (EDs) are taking notice. Health care providers are increasingly aware that patients’ social determinants greatly affect their clinical outcomes. One of these factors is access to transportation, and ridesharing might be part of the solution.<div><br /><div><br /><span><a name='more'></a></span><br />A 2013 review, published in the Journal of Community Health, reported that one in four lower-income patients missed or rescheduled medical appointments due to a lack of transportation.<sup>1</sup> Without appropriate outpatient care, those patients with worsening chronic medical conditions or new acute problems can lead to ED visits and hospitalizations. In fact, persons with unmet transportation needs are two times more likely to have multiple ED visits and inpatient visits.<sup>2</sup><br /><br />Ridesharing services may help with pre-hospital transportation by reducing unneeded transports by emergency medical services (EMS). Ambulances and EMS are a valuable community resource that are traditionally intended for the treatment and transport of critical patients. Yet, some articles estimate that 10% of EMS transports are “low acuity,” involving minor ailments like musculoskeletal injuries or mild upper respiratory infections.<sup>3</sup> That percentage can translate to millions of unneeded rides, given that in 2018, for example, there were over 30 million EMS transports in the U.S.<sup>4</sup> Interestingly, when surveyed, up to 60% of patients suggested they were willing to be transported by non-emergency vehicles to the ED if offered.<sup>5</sup> The cost of transport is also an issue. Seventy one percent of all ambulance rides involve surprise bills to the patient and on average, ambulance rides cost patients $450.<sup>6</sup> These numbers suggest that ridesharing services may be able to play a broader role in prehospital EMS transport availability and provide cost savings to both patients and the health care system.<br /><br />Patients without transportation to their discharge destination also contribute to ED crowding. Many patients are unable to find family or friends to pick them up, unable to use public transportation, or they may have received medications that make them unable to drive home independently. Although many patients are aware of ridesharing services, when surveyed, only 5% of patients planned to use these services post-discharge from the ED.<sup>7</sup> Psychiatric patients, in particular, are known to have lengthy disposition times while awaiting placement and transportation to a specialized psychiatric facility. Many barriers contribute to this long length of stay including type of insurance, insurance status, day of presentation to the ED, and medical transportation. In spite of these obstacles, EDs that use ridesharing services to transport voluntary psychiatric patients have shown shorter times to discharge.<sup>8</sup><br /><br />While some hospitals offer ride vouchers to defray costs of delayed discharge, health care organizations are now developing more consistent approaches to this issue. Ridesharing providers have rolled out new services to better integrate with medical care and health insurers. Uber recently partnered with Cerner, and Lyft recently paired with Epic, two of the largest electronic medical record (EMR) providers, to make it easier for hospitals to order rides for patients. These companies are increasingly finding that insurance payers, particularly Medicaid plans, are willing to cover the cost of their members’ rides. Not only could these services decrease missed appointments, but they could also be used in busy EDs to help patients get to their discharge destination in a more timely manner. The integration with EMRs also provides a better way for hospitals to collect data to determine the true impact of their transportation programs. <br /><br />The utilization of ridesharing and health care is still relatively new, but early programs suggest Uber and Lyft might decrease unnecessary ambulance utilization, improve ED throughput, and increase the patient show rate for outpatient and follow-up appointments. Overall, ridesharing has the potential to expand patient access to transportation and address a key social determinant of health.<br /><br /><b>References</b><br /><ol style="text-align: left;"><li>Syed ST, Gerber BS, Sharp LK. Traveling Towards Disease: Transportation Barriers to Health Care Access. Journal of Community Health. 2013;38(5):976-993. doi:10.1007/s10900-013-9681-1.<br /><br /></li><li>Coe EH, Cordina J, Parmar S. Insights from McKinsey's Consumer Social Determinants of Health Survey. McKinsey & Company. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/insights-from-the-mckinsey-2019-consumer-social-determinants-of-health-survey. Published March 1, 2020. Accessed October 21, 2020.<br /><br /></li><li>Iv AJB, Moscati R, Janicke D, Lerner EB, Seymour J, Olsson D. A Multisite Survey of Factors Contributing to Medically Unnecessary Ambulance Transports. Academic Emergency Medicine. 1996;3(11):1046-1050. doi:10.1111/j.1553-2712.1996.tb03352.x.<br /><br /></li><li>2020 National Emergency Medical Services Assessment. https://nasemso.org/wp-content/uploads/2020-National-EMS-Assessment_Reduced-File-Size.pdf. Published May 27, 2020. Accessed October 20, 2020.<br /><br /></li><li>Lam SH, Nakajima Y, Castillo EM, Brennan J, Vilke GM. Willingness to consider alternatives to ambulance use among adult emergency department patients. The American Journal of Emergency Medicine. 2020;38(5):1030-1033. doi:10.1016/j.ajem.2019.10.013.<br /><br /></li><li>Chhabra KR, Mcguire K, Sheetz KH, Scott JW, Nuliyalu U, Ryan AM. Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills. Health Affairs. 2020;39(5):777-782. doi:10.1377/hlthaff.2019.01484.<br /><br /></li><li>Tomar A, Ganesh S, Richards J. Transportation Preferences of Patients Discharged from the Emergency Department in the Era of Ridesharing Apps. Western Journal of Emergency Medicine. 2019;20(4):672-680. doi:10.5811/westjem.2019.5.42762.<br /><br /></li><li>Blome A, Rosenbaum J, Lucas N, Schreyer K. Ridesharing as an Alternative to Ambulance Transport for Voluntary Psychiatric Patients in the Emergency Department. WestJEM 213 May Issue Western Journal of Emergency Medicine. 2020;21(3). doi:10.5811/westjem.2020.2.45526.</li></ol></div></div></div>AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com1tag:blogger.com,1999:blog-1488570157787910277.post-34578560105491658842021-04-18T20:32:00.001-05:002021-04-18T20:32:55.596-05:00Chronic Pain and Addiction Patients Need Us Now More Than Ever<b><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkTQmW_piYQH_iIpd4wRT1ZvHud7sA2ew-tJ0XV4x2tPppApjKj-Uvg1YSLYOYz3Jg5sqFd34W1flIQyQbvRJ4SxwTElx1uq0vSqZNRlOSLGDEeWvNmUcsWczBoICqBGM-vbWlyyM7YqIQ/s2048/pexels-pietro-jeng-360622.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkTQmW_piYQH_iIpd4wRT1ZvHud7sA2ew-tJ0XV4x2tPppApjKj-Uvg1YSLYOYz3Jg5sqFd34W1flIQyQbvRJ4SxwTElx1uq0vSqZNRlOSLGDEeWvNmUcsWczBoICqBGM-vbWlyyM7YqIQ/s320/pexels-pietro-jeng-360622.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/photo/depth-photography-of-blue-and-white-medication-pill-360622/"><i>Pexels</i></a></td></tr></tbody></table>Author: </b>Shane A. Sobrio, MD<br />Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />March/April 2021<br /><br />Flashback to 2019. Hong Kong protests were raging on, the U.S. Women’s National Team won the world cup, Donald Trump was being impeached, and the health care battle continued to revolve around the opioid epidemic. It wasn’t necessarily easy, but it was familiar. Practices were being implemented to help prevent reckless opioid prescribing and increase availability of naloxone which, to an extent, were working. Flash forward to 2020, the year of the COVID-19 pandemic. Millions of people worldwide now dead from a novel respiratory virus and opioids are a distant memory, no longer causing the problems they used to, right? Unfortunately, not right at all.<div><br /><span><a name='more'></a></span> <br /><br />In 2018, drug overdose deaths dropped for the first time in 20 years. Nearly 47,000 people still died of opioid overdoses in the United States in 2018, but the slight down trending from the previous year began to create some level of optimism regarding the epidemic and its’ future. To put it lightly, 2020 has been a step in the wrong direction. People are losing their jobs, their social interactions, and their support systems. It is not surprising that tragedies such as overdoses, and suicides are up. Additionally, for patients with chronic pain, “elective” pain management procedures have been delayed or indefinitely cancelled, further exacerbating the suffering. <br /><br />While the COVID-19 pandemic is rightfully garnering most of our current attention due to the rapid spread and deadliness of the virus, data would suggest our diligence to the opioid epidemic has waned, creating a significant number of secondary COVID-19 casualties. A study published in JAMA in September 2020 showed that urine drug screens for opioids such as fentanyl and heroin nearly doubled in the first few months of the pandemic.1 While official 2020 drug overdose data is not yet published by the CDC, some early data suggested a 13% increase in drug overdose deaths during the pandemic, which translates to many thousands of lives. <br /><br />It is sometimes easy to forget that statistics represent human beings. People with loved ones, dreams, aspirations, etc. Unfortunately, when it comes to opioids and overdose deaths, those numbers have often been my family and friends. In fact, in 2019, one of those numbers was my older brother, who died at just 31 years old from an accidental overdose. He was the 4th family member or friend to pass at a young age from something similar. I can no longer afford to think of these statistics as numbers and must start finding ways to turn these tragedies into solutions. <br /><br />While the outlook may seem grim in some ways, there are certain reasons to be optimistic. Availability of lifesaving naloxone is at an all-time high. Awareness of the epidemic itself has been steadily increasing over the past few years as well. Most importantly, the opioid epidemic and the response needed to fight it adequately have garnered more congressional bipartisan support than almost any other political issue of our time. <br /><br />As emergency physicians, we have a difficult but privileged position in our society. We often see people at their lowest of low points. We give them naloxone during an overdose, we intervene when they are suicidal, and sometimes we simply provide an ear to listen when someone needs to be heard. I am as guilty as anyone when it comes to feeling frustrated after getting assigned another psychiatric patient or drug-seeking patient in the ER. However, I am using this worldwide disaster as an opportunity to address my biases and think about how I am contributing to the solutions instead of adding to the problem. I implore everyone reading this to spend that extra five minutes listening, provide that extra advice or encouragement; make that extra phone call. With emergency physicians leading the way, we will get through this opioid epidemic (and COVID-19 pandemic) together. <br /><b><br />References:</b><br /><ol style="text-align: left;"><li>https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html</li></ol><br /> </div>AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-79959217984501532942021-04-08T15:35:00.004-05:002021-04-08T15:35:51.564-05:00The Brink of Burnout<div><b><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWZTRyUFkBZhqBn2vw3iLAPZ5FCo5WzVCisEFuH79rebMuyjXebOwxsf_IGNp_fty0c3Cpuo6-pxlpjnn5h80MccY2xjQowcldU7r4Walj74nHp_ROI5vIYMWQ3qoMefGLDfwvN-J8NNWa/s2048/pexels-jonathan-borba-3279197.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="2048" data-original-width="1365" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWZTRyUFkBZhqBn2vw3iLAPZ5FCo5WzVCisEFuH79rebMuyjXebOwxsf_IGNp_fty0c3Cpuo6-pxlpjnn5h80MccY2xjQowcldU7r4Walj74nHp_ROI5vIYMWQ3qoMefGLDfwvN-J8NNWa/s320/pexels-jonathan-borba-3279197.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/photo/man-wearing-blue-scrub-suit-and-mask-sitting-on-bench-3279197/"><i>Pexels</i></a></td></tr></tbody></table>Author:</b> Ryan P. Gibney, MD</div><div>Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />March/April 2021<br /><br />It definitely felt different this new year. The normal buzz around town, packed stores, twinkling lights, and family gatherings uncharacteristically muted as compared to years past. I noticed a profound change in the hospital starting in mid-November: the winter chill was ever present in the air, while families prepped for the upcoming holidays in uncertainty. It started as a trickle three or four critically ill patient’s per day—COVID and others—but quickly became evident that the levee holding back the flood of patients was about to break. Over the course of two weeks, I saw the volume expand from a few sick COVID patients to every other patient coming in at the brink of complete respiratory failure, clinging to each breath, struggling to speak any words. Time and time again, I would ask a single family member to say their goodbyes while I prepared airway equipment and counseled families and patients that I was concerned and this may be the last time they speak to their loved ones. Tears and fear filling the eyes of patients and their family, quivering lips hidden behind flimsy masks, screaming, and hand holding had become the pre-intubation ritual I was now performing countless times per day. It is incredibly difficult. </div><div><br /><span><a name='more'></a></span><br />We are practicing medicine in unprecedented times, and as I near the completion of my training, I worry for what’s to come. California, where I train, feels like it’s about to burst. Occasionally, I hear the panic of higher ups as another tent is erected, or field hospital is installed in the parking lot, or a diversion suspension order is enacted. What are we going to do? What else can we do? We have already converted pediatric hospitals to accept adult patients, our backup docs are working full schedules, our nurses are working double time, the ED functions as an additional ICU, and we are stretched to our limits with no end in sight. The emotional toll that this is waging on many of us is very concerning. <br /><br />I feel that it’s important to be honest and vulnerable about my experience as I was totally blindsided by the feeling of burnout. I have always been resilient, and pride myself on being able to take everything in stride, and residency has been no different. I approached this journey with alacrity, humility, and perseverance. It has proven to be the most difficult, yet rewarding endeavor in my life. But, starting in April, there was a slow transition from a place of happiness, to one of uncertainty, then one of despair. <br /><br />Returning from a conference in New York in early March, I watched in sadness as the city began to buckle under the sheer volume of critically ill patients, and grew fearful that this was a preview of what was to come for all of us. I saw my first sick COVID patient a week later and was truly shaken at how a seemingly normal, healthy young woman could decompensate right in front of my eyes—65-58-49-35%. I went home that day and reflected on how frightening this was, and I was worried about myself and my loved ones. <br /><br />The shutdown in California began the following week, and my wife and I were now part-time teachers to our young daughter, all while trying to balance our work obligations. She worked in construction, so she had to go on job sites to coordinate, no one in masks, business as usual. I was concerned for her well-being and safety. I’m pretty sure she was downsized in April because of me and a letter she wrote about her concerns, especially since I would be on the COVID ICU and her coworkers had multiple comorbidities that made them high risk. We took it in stride and hoped for the best, but deep down I was worried. <br /><br />By the time summer hit, it seemed like everything was getting a little bit better. Slowly things started feeling more normal, restaurants had outdoor dining spaces, stores had toilet paper again, we had one or two quarantine families we would occasionally see to break the isolation of lockdown, and the hospital calmed down a bit. I wondered, “Had we done it, did we beat this?” A new challenge arose in August. My wife, a college educated professional with ample experience in different fields, had been looking for a job every day with no response—sometimes 50 applications per day. Unemployment funding ended in late July and suddenly our two-income household was cut nearly in half. We tore through our savings, delayed paying some bills and used credit cards for others. I searched tirelessly for moonlighting gigs, but none were to be had. By the time we got to Halloween, we were really struggling.<br /><br />I mention this because in retrospect it was a slow change that was occurring in me through little daily stresses that continued to pile up: financial, professional, physical, emotional. In early November, we started seeing more and more COVID cases. First, it was asymptomatic, younger patients but shortly it became the true surge we are seeing today. I remember seeing one or two, then four, then ten patients a shift that were critically ill. At first, it felt manageable, but quickly devolved into chaos and I found myself more hopeless about our current situation. I couldn’t help thinking about the loss of loved ones before the holidays, and the stress on the faces of everyone I work with, and the stress at home just trying to get by. It quickly became too much. I felt as if I was sinking farther and farther. I had never felt this way before, and it seemed like everything in my life was making it worse. I had reached the brink of burnout.<br /><br />Burnout has been an increasing topic of discussion for physicians over the past several years. Propelled by the loss of autonomy and an unnatural tethering to a computer and an EMR system, we have seen the rate of burnout approach nearly 50% of physicians, and signs of burnout have been seen in residents and medical students alike.1,2 The advent of this pandemic has turned the health care system upside down and it is more important than ever to recognize signs of burnout and intervene. It is well established that burnout leads to emotional exhaustion, depersonalization, patient safety issues, poor outcomes, lack of engagement, and more.2 Physician suicide rates, as well as the general public, have been rising at an alarming rate even more with the isolation of a pandemic.<br /><br />In speaking with attendings who have gone through similar experiences, we discussed how the number of sick patients that we see every day in the current pandemic drives us to impassivity. We don’t have time to process our emotions as we move from one terrible situation to the next, and it is taxing. How do we care for the sick and their families and still find time to care for ourselves and each other. Right now, more than ever, is the time to check in on each other. Many of our colleagues are struggling to keep it together from shift-to-shift, day-to-day. In our program, we are taking action to make sure that we are all okay together. My fellow chiefs and I have started doing chief check-ins with our classmates in addition to creating a virtual wellness event complete with painting and a homemade meal prep kit for all of us to hang out and share some time together. It’s small, but it’s something. <br /><br />In sharing this personal experience with others around me, and now on paper, it has been cathartic and I have refocused on the important things in my life and in my career. I never thought I’d be at this point and I was shocked at how slowly this transition occurs until one day you feel as if there is no going back. For me, recognition of what I was experiencing was the key to working through it, and the Maslach Burnout Inventory (MBI) is a well established tool for early recognition of burnout in addition to others.2 I hope that sharing this, will remind us all to look to each other for support, and remember that one of the most important lessons in life is, that when you’re overwhelmed, tired, struggling, ask for help. <br /><br /><b>References</b><br /><ol style="text-align: left;"><li>Hartzband, P., MD, & Groopman, J., MD. (2020, December 31). Physician Burnout, Interrupted: NEJM. Retrieved January 05, 2021, from https://www.nejm.org/doi/full/10.1056/NEJMp2003149<br /><br /></li><li>Singh, R., Volner, K., & Marlowe, D. (2020, November 15). Provider Burnout. Retrieved January 05, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK538330/<br /><br /></li><li>West, C. P., Dyrbye, L. N., & Shanfelt, T. D. (n.d.). Physician burnout: Contributors, consequences and solutions. Retrieved January 05, 2021, from https://pubmed.ncbi.nlm.nih.gov/29505159/</li></ol><br /></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-13017016005940555862021-04-01T22:43:00.001-05:002021-04-06T22:49:36.968-05:00Resident Journal Review: Massive Transfusion Protocols (MTPs) in Traumatic Hemorrhage<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji0aPYxNhLzQiyYPt7PsRJGZhTDa-ntDGAweJB1CQhMoUc2L0O939TPIBYiYKtz9wikLIPSWcNhizIXJIpLWDmMbn_J4NYrgUrPyiG4LlOFbFsi0fgjVZOc7S7huE06hJv5TEJ-B26MLyf/s1920/Resident+Journal+Review.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1084" data-original-width="1920" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji0aPYxNhLzQiyYPt7PsRJGZhTDa-ntDGAweJB1CQhMoUc2L0O939TPIBYiYKtz9wikLIPSWcNhizIXJIpLWDmMbn_J4NYrgUrPyiG4LlOFbFsi0fgjVZOc7S7huE06hJv5TEJ-B26MLyf/s320/Resident+Journal+Review.png" width="320" /></a></div><b>Authors: </b>Taylor M. Douglas, MD; Taylor Conrad, MD MS; Wesley Chan, MD; and Christianna Sim, MD MPH<br /><b>Editor:</b> Kelly Maurelus, MD FAAEM and Kami Hu, MD FAAEM<br /><br />Most, if not all, emergency medicine clinicians are familiar with massive transfusion protocols (MTP), which were developed to create a systematic method for the administration of large volume resuscitation for hemorrhagic shock. The evidence behind these protocols and how they were developed, however, are less well known. First seen in military trauma settings, MTPs have been translated to civilian patients with the supporting evidence to do so following behind their application.1 The American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) Massive Transfusion in Trauma Guidelines leave a good amount of flexibility for hospitals regarding transfusion protocols, focusing more on systems-level aspects of designing and implementing MTPs.2,3 Here we examine some of the evidence behind the various components of MTPs, specifically calcium and factor VIIa, and the ratios in which the main products of red blood cells, plasma, and platelets should be administered.<div><br /><span><a name='more'></a></span><br /><b>Question:</b><br /><ol style="text-align: left;"><li>What is the emerging evidence and possible role regarding inclusion of components such as calcium and factor VIIa in trauma MTPs?</li><li>What is the ideal blood component ratio for massive transfusion in traumatic hemorrhage?</li></ol><b>Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial. JAMA. 2015;313(5):471-82.</b><br /><br />Prior to this study, there was a lack of well-designed research to guide transfusions in severe trauma and other major bleeding. The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPRR) was the first large, multicenter randomized control trial to compare the effectiveness and safety of a 1:1:1 to 1:1:2 plasma:platelet:packed red blood cell transfusion ratio. The study was conducted at 12 level-I trauma centers in North America and included non-pregnant patients estimated to be at least 15 years of age or 50 kg or greater who met criteria predicting massive transfusion, who were then transported directly from injury site, in which transfusion of one unit of blood component occurred within one hour of arrival or during transport. The authors excluded those with devastating injuries (expected to die within one hour of admission), need for thoracotomy prior to receiving blood products, significant burns (>20% total body surface area), inhalation injuries, or receiving over five minutes of cardiopulmonary resuscitation prior to arrival or in the ED.<br /><br />The authors analyzed 11,185 patients for eligibility, 680 of which were included in the study and analysis (338 to the 1:1:1 group and 342 to the 1:1:2 group). Clinicians were blinded to treatment until delivery of blood products. There was no significant difference between groups in the primary outcome of all-cause mortality at 24 hours (12.7% in the 1:1:1 group vs. 17.0% in the 1:1:2 group; p=0.12) or at 30 days (22.4% vs. 26.1%, respectively, p=0.26). Exsanguination as the predominant cause of death within the first 24 hours was significantly lower, however, in the 1:1:1 group (9.2% vs. 14.6%, p=0.03). Patients in the 1:1:1 group also achieved anatomic hemostasis at higher rates (86.1% vs. 78.1%, p=0.006). There was no difference in the secondary outcomes of time to hemostasis, ventilator-free days, ICU-free days, disposition at 30 days, incidence of primary surgical procedures, and functional status at hospital discharge (measured as Glasgow Outcome Scale-Extended Score). The rate of adverse events including acute respiratory distress syndrome, multi-organ failure, venous thromboembolism, sepsis, and transfusion-related complications was high overall (89%) but did not significantly differ between the two groups. <br /><br />While there was no all-cause mortality benefit at 24 hours or 30 days, 1:1:1 transfusion ratios were associated with decreased death due to exsanguination and greater achievement of hemostasis. Trauma-related deaths generally occur within the first 2-3 hours after injury, leading to the concept of the so-called “Golden Hour” as a key period for life-saving interventions.4 Any potential benefit of a 1:1:1 strategy would theoretically have been more pertinent for this time frame, but at or beyond 24 hours these effects may have been diminished as many of the patients in the 1:1:2 group approached the cumulative ratio of 1:1:1 with the standard care provided after the initial randomized treatment was received. While this study was adequately powered to detect a mortality difference of 10% at 24 hours and 12% at 30 days, it could not detect any smaller benefits. While it would seem and the authors suggest that the 1:1:1 transfusion ratios are safe as compared to the 1:1:2, it should be mentioned that the study was not powered to assess for safety and thus may not be able to detect differences in rarer complications. <br /><br /><b>Cornelius B, Ferrell E, Kilgore P, et al. Incidence of hypocalcemia and role of calcium replacement in major trauma patients requiring operative intervention. AANA J. 2020;88(5):383-9.</b><br /><br />Hypocalcemia is a known complication of blood product transfusion related to the use of citrate, a calcium chelator, as a stored blood anticoagulant. Transfusion-related hypocalcemia has been previously associated with an increased risk of mortality.5 This study was a blinded retrospective analysis from a single level-I trauma center of all trauma activations within a 12-month period. The objectives of this study were to determine the incidence and rate of calcium replacement in major trauma patients requiring operative intervention, as well as to investigate the impact of hypocalcemia on the rate of transfusion and mortality. All patients >18 years of age who were stat trauma activations were enrolled. Patients were excluded if calcium was given prior to arrival, if they were pregnant, or if no operative intervention occurred within the first 24 hours. The patients were divided into 2 groups based on whether they received calcium replacement or not.<br /><br />A total of 638 activations were identified. One hundred and ninety-seven patient cases were analyzed with 80 patients receiving calcium and 117 patients not receiving calcium. The majority of patients were male, and blunt trauma was the most common mechanism. There was no difference between groups in the percentage of patients who had received any blood product, but the calcium repletion group contained a higher percentage of MTP activations compared to the no-repletion group (36.3% vs 15.3% respectively, p<0.05), translating to a higher average transfusion of RBCs (8.1 vs. 3.2, p<0.05), FFP (6.4 vs. 2.6, p<0.05), platelets (1.8 vs. 0.98, p<0.05), and cryoprecipitate (0.5 vs 0, p<0.05). There was significantly higher mortality in patients requiring MTP versus not (20.6% vs 6.8%, p<0.005), with a trend towards increased mortality associated with any transfusion requirement compared to none (13.0% vs 3.8%, p=0.051).<br /><br />While there was no difference across groups in initial ionized calcium level, there was a relatively high incidence of initial and intraoperative hypocalcemia and severe hypocalcemia (defined as a serum <8 mg/dL or ionized <0.9 mmol/L) in patients who required operative intervention. In patients receiving calcium supplementation, the study found no significant difference in mortality between patients who did or did not require MTP activation (31.8% vs 17.9%, p=0.145).<br /><br />The study has major limitations and the authors acknowledge them: its retrospective nature, the small sample size, the high number of exclusions. They note the lack of current evidence that trauma patients who arrive hypocalcemic have better outcomes after calcium replacement, pointing to the 31.8 versus 17.9% trend in mortality difference, but fail to discuss the potential implication that calcium repletion could possibly mitigate the mortality risk in patients requiring MTP. In truth, the limitations of this study do not allow definitive conclusions to be made and contributions to mortality from trauma severity, hypocalcemia, calcium supplementation, and transfusion cannot be elucidated. This points to the need for future studies; not only examining mortality alone but also to other end-point benefits to determine the role of calcium in MTP.<br /><br /><b>O’Keeffe T, Refaai M, Tchorz K, et al. A massive transfusion protocol to decrease blood component use and costs. Arch Surg. 2008;143(7):686-90. </b><br /><br />Other than the physiological effects of large-volume blood transfusion, the establishment of a massive transfusion protocol has other significant health systems and care delivery effects. The urban, level-1 trauma center at Parkland Hospital in Dallas, Texas evaluated blood product use, costs, delivery times, and outcomes following implementation of a massive transfusion protocol at their institution. Patients receiving massive transfusion for trauma were prospectively enrolled and compared to the retrospective cohort from one year prior to institution of the protocol. The historical patients' data was collected from a previously established trauma database and using blood bank records including all patients who received more than 10 units of packed RBCs within the first 24 hours. The MTP protocolized the type and number of blood products received based on number of “shipments” required. For example, the shipments included five units of PRBCS and two units of thawed plasma, with platelets added in the third shipment, and cryoprecipitate and recombinant factor VIIa (rFVIIa) added in the fourth.<br /><br />The pre- and post- MTP implementation groups were similar in patient demographics, injury severity scores, and reported initial blood pressures. Most notably, following establishment of an MTP, providers used significantly less blood products on average, including PRBCS (15.5 vs 11.8, p<0.001), plasma (8.7 vs. 5.7, p<0.02), and platelets (3.8 vs. 1.1, p<0.001). There was no difference in cryoprecipitate administration and higher rFVIIa post-MTP, which was specifically included in the protocol to increase its use. Accordingly, the costs to the blood bank and the overall hospital costs were $2,300 lower on average per patient following initiation of the protocol, despite the increased costs incurred by increasing rFVIIa use. Use of the MTP was associated with decreased time to blood delivery, with average initial time to first blood delivery of nine minutes. Subsequent blood delivery times were reduced in half (p<0.05). Mortality in the retrospective and prospective cohorts were similar, even after stratification by need for operative intervention, time from transfusion, and by injury severity score. There was no increase in thrombotic events associated with increased rFVIIa use.<br /><br />This study demonstrates that implementation of a well-designed blood delivery protocol for massive transfusion has many systems-based improvements, including reduced costs and more efficient use of limited resources. It is important to note that the institution is a well-established trauma center with significant experience in management of the exsanguinating trauma patient, and that this study took place prior to designation of the widely-accepted 1:1:1 transfusion ratio. As such, this implementation reflects the more efficient delivery of a service and care. These results may not be translatable in all scenarios, and this study was not powered to detect mortality, especially since trauma patients are incredibly heterogeneous in mechanism and salvageability varies greatly despite best efforts. Lastly, recombinant factor VIIA represented an increased expense after protocol implementation and although no change in adverse events were noted, this study is not the correct design to determine its utility.<br /><br /><b>McQuilten ZK, Crighton G, Engelbrecht S, et al. Transfusion interventions in critical bleeding requiring massive transfusion: A systematic review. Transfus Med Rev. 2015;29(2):127-37.</b><br /><br />The authors of this systematic review aimed to identify new data as well as remaining evidence gaps in the investigation into benefit of specific components for inclusion in massive transfusion protocols. The authors were able to identify 19 papers to include in qualitative analysis, however they were unable to perform any meta-analysis due to the heterogeneity of interventions in the studies identified. As we are addressing MTP for trauma other causes of hemorrhage will not be discussed here.<br /><br />Only three studies were found examining the component ratios and timing. Among these studies, none were powered to detect differences in mortality, but one noted greater plasma wastage with the fixed 1:1:1 ratio. In the discussion they look to the then-impending PROPPR trial (discussed above) to provide more robust data. On the topic of specific components in addition to RBCs and plasma, three systematic reviews were evaluated. Those looking at fibrinogen concentrate were only in bleeding elective surgical patients but showed no change in mortality or increase in thrombotic episodes. The meta-analysis looking at FFP identified plasma to RBC ratios >1:3 to be associated with reduced mortality, with the caveat that this data is low evidence as it was based on observational data. No quality studies on platelet, prothrombin complex concentrate transfusion, or cryoprecipitate for fibrinogen repletion were identified.<br /><br />The strongest evidence discussed is that regarding factor VIIa. The authors cited civilian trauma randomized controlled trials and systematic reviews, although these reviews included non-trauma patients. In the RCTs evaluating trauma patients, one demonstrated no difference in RBC transfusion regardless of trauma mechanism. Another, the CONTROL trial, was halted early due to high likelihood of futility and low mortality, although they did see a reduction in the number of units transfused in the factor VIIa arm.<br /><br />Overall, this review identifies the significant lapses in evidence for the details of massive transfusion protocols. While most large societies advocate for a protocol based, structured transfusion plan for life-threatening hemorrhage, the evidence for the specifics of these plans are lacking, specifically related to inclusion of adjunctive therapies that could potentially further decrease mortality and/or resource utilization.<br /><br /><b>Conclusion</b><br /><br />The above studies and others in the literature support the role of MTP to standardize blood administration and conserve resources in the care of the critically ill trauma patient. As mentioned, the guidelines from the American College of Surgeons are broad, but do support a red blood cell to plasma transfusion ratio between 1:1 and 1:2, as well as one pool of platelets for every six units of red blood cells. There is no sufficient data to contravene their statement against the routine use of recombinant factor VIIa in trauma, and further studies are needed to determine how important stringent calcium repletion is in the setting of major trauma and massive transfusion. <br /><br />Answers:<br /><ol style="text-align: left;"><li><b>What is the emerging evidence and possible role regarding inclusion of components such as calcium and factor VIIa in trauma MTPs?</b><br />Robust data on the optimal inclusion of calcium repletion in MTPs and use of adjuncts such as recombinant factor is lacking and requires further study.</li><li><b>What is the ideal blood component ratio for massive transfusion in traumatic hemorrhage?</b><br />A definitive ideal ratio of blood products requires further study but the best current evidence is for a 1:1:1 ratio of plasma:platelets:packed red blood cells, and is consistent with the American College of Surgeons Best Practice Guidelines for Massive Transfusion in Trauma.2</li></ol><br /><b>References</b><br /><ol style="text-align: left;"><li>Holcomb JB, Wade C, Michalek J, et al. Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients, Ann Surg. 248(3):447-58.<br /><br /></li><li>MASSIVE TRANSFUSION IN TRAUMA. ACS TQIP Best Practice Guidelines. https://www.facs.org/-/media/files/quality-programs/trauma/tqip/transfusion_guildelines.ashx?la=en. Published October 2014. Accessed January 5, 2021.<br /><br /></li><li>CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 376(9734):23-32.<br /><br /></li><li>Newgard CD, Schmicker RH, Hedges JR, et al. Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort. Ann Emerg Med. 2010;55(3):235-246.e4.<br /><br /></li><li>Giancarelli A, Birrer KL, Alban RF, et al. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016 May 1;202(1):182-7.</li></ol><br /> <span><!--more--></span></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-25217227153544186182021-03-26T22:35:00.041-05:002021-04-06T22:42:51.073-05:00 EM Away Rotations in a Pandemic<b><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRuuXpuoSwIHT3iJSFoKXojt2VosH-dwfizyhU7LJJnKTPsPhGSy44MuknBgPxg5hosLmUao4n6coERFq0fOxMHlaMGafgsXcQL_EuEpfuLU5YBIn1hIQgiBhyIMuBDwT7AodBnvsqnd90/s2048/pexels-thirdman-5327584.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRuuXpuoSwIHT3iJSFoKXojt2VosH-dwfizyhU7LJJnKTPsPhGSy44MuknBgPxg5hosLmUao4n6coERFq0fOxMHlaMGafgsXcQL_EuEpfuLU5YBIn1hIQgiBhyIMuBDwT7AodBnvsqnd90/s320/pexels-thirdman-5327584.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.pexels.com/search/doctors/">Pexels</a></i></td></tr></tbody></table>Author: </b>Lauren Lamparter – President, AAEM/RSA Medical Student Council<div>Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />March/April 2021<br /><br />For the third-year medical student, the emergency medicine residency application process starts with applying to away rotations. This year, uncertainty remains around the possibility of aways, but hopefully, as COVID-19 vaccines are distributed more widely, travel and away rotations can become possible. One of the past AAEM/RSA Medical Student Council Presidents, Dr. Michael Wilk, wrote an article, “Seven Tips for Selecting Your EM Away Rotations.” His advice remains true whether you are able to rotate only at your home EM rotation, participate in one of the new virtual EM electives, or travel and participate in an away. So, here are his seven points, with my updated insight and an eighth point, for approaching the EM away rotations in a pandemic world. <br /><br /></div><span><a name='more'></a></span><br /><b>First, apply for your rotations early.</b> Whether virtual or in person, the application process for away rotations is rolling, so the earlier your application is submitted, the greater chance for acceptance. Most programs rely on the VSAS application system, but some schools have their own or a supplemental application. If there is a particular program you would like to apply to, be sure to follow their website instructions closely. Additionally, almost all programs require vaccination titers, so check your records and update as needed to prevent any delays in acceptance. <br /><br /><b>Second, location, location, location.</b> If you know you would like to go to residency in a particular region of the country, this is where you should apply for away rotations. If you are unable to travel, there might be a program in this region offering a virtual rotation experience. These virtual rotations allow you to interact with a wide range of EM faculty, residents, and fellows and can give you a real glimpse into life at that program. <br /><br /><b>Third, academic vs. community vs. county. </b>One benefit of an away rotation is experiencing a type of hospital that is different from where you have done your medical school training. In an ideal world, your away rotations would allow you to experience and compare these hospital systems to assist in your decision of which residency program you would like to attend prior to the application season. <br /><br /><b>Fourth, three vs. four-year programs.</b> It is stated that the ideal EM residency length is 3.5 years, so programs have chosen either three- or four-year models. If a program is ACGME accredited, it will give you a good EM training regardless of the length of time. Ultimately, choose based on the programs you love, rather than the length of training. <br /><br /><b>Fifth, how many rotations should I do?</b> This past year, EM applicants were advised to do only one EM rotation to obtain one SLOE (standard letter of evaluation). If you are allowed to travel and do away rotations, the recommended amount is two, a rotation at your home program and one away. Some students choose to do more, but keep in mind how draining these rotations can be as you “audition” for an entire month. If in person rotations are still not allowed, some of the virtual rotations offered narrative letters of recommendation, which can also be included in your residency application. <br /><br /><b>Six, when should I actually rotate?</b> You should try to rotate early enough that your SLOE will be submitted prior to the submission of your residency application so that your file can be complete and ready for evaluation. It is also advised that you do an away rotation after completing your home program’s EM rotation, but this might not be possible. <br /><br /><b>Seven, have fun! </b>You have finally made it to the goal, EM! Be yourself and enjoy learning and experiencing emergency medicine. Get to know the residents and assess the environment to see if it is right for you. Even if the rotation is virtual, you will be able to meet potential future co-interns and gain insight into your future specialty. <br /><b><br />Lastly, eight, write down any memorable patient experiences or stories. </b>In just a few short months, you will be on the interview trail. What you experience at your home rotation, an away, or even a virtual rotation will become stories to answer residency interview questions. The more you record as you experience it, the better memory you will have of these moments. <br /><br />Good luck!<br /><br />Dr. Michael Wilk’s original article with his seven points and advice can be found on AAEM/RSA’s website: Seven Tips for Selecting Your EM Away Rotations. https://www.aaemrsa.org/get-involved/students/selecting-away-rotations.<br /><br />For more information and advice on the EM Clerkship, see also our AAEM/RSA podcast episode 76: Ask Me Anything: About the EM Clerkship. https://www.aaemrsa.org/get-involved/podcasts/episode-76 <br /><br /><span><!--more--></span>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-60703089558529781752021-03-04T18:59:00.002-06:002021-03-04T18:59:24.905-06:00Who Will Be Their Advocate? A Commentary on Facing Illness Alone.<div><b><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTvlv6pnSyXQDywpkLxVhyU0KsAOjU319DIfppe4yC0_WqS5q1QOvFxSzQdpnV_U6wS-1uQVYvE8FRjjj6J2g73RJcbJYEi87hnXPRIpSyDr0S8PsaJN8sWFZ1ZsjCtK4c94REqxiOa5l7/s2048/pexels-rodnae-productions-6129685.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTvlv6pnSyXQDywpkLxVhyU0KsAOjU319DIfppe4yC0_WqS5q1QOvFxSzQdpnV_U6wS-1uQVYvE8FRjjj6J2g73RJcbJYEi87hnXPRIpSyDr0S8PsaJN8sWFZ1ZsjCtK4c94REqxiOa5l7/s320/pexels-rodnae-productions-6129685.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/photo/man-in-blue-shirt-holding-woman-in-blue-dress-6129685/"><i>Pexels</i></a></td></tr></tbody></table>Author: </b>Jennifer Gemmill, MD FAAEM<br />Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />January/February 2021<br /><br /><div>I am a terrible patient. I will refuse medicines prescribed to me. I will pick up my heavy 2-year-old just hours after delivering my newborn while the L&D nurses give me the evil eye. I will remove my own loop recorder in my bathroom at home instead of having it taken out by my unknowing cardiologist (it’s amazing how useful leftover lidocaine and eyebrow tweezers can be). If you are my physician for any reason, I will be a handful. However, I will also be my strongest advocate.<br /><br /></div><span><a name='more'></a></span><div><br /></div><div>As a practicing emergency physician, I have the tools, knowledge, and experience to know what questions to ask as it pertains to my own personal care. I understand the risks of procedures, what complications to look for, and how to mentally and physically prepare for what a medicine or intervention will do to my body. Most of our patients do not possess these skills. They rely on us to appropriately explain what we’re doing to them and why. Our patients trust us to ensure their safety and we are tasked with making sure they understand the care we’re providing them. But what if they don’t? What if they are altered, unconscious, too sick to know what is happening to them? Who do we, as providers, turn to for consent or discussion of options, or basic medical information? Family. We rely on the patients’ family members to provide basic yet invaluable information about their history, their wishes, their clinical course when the patients cannot speak for themselves. We rely on family to help us convince the patient that the intervention we’re suggesting is needed, necessary. We rely on the family to help ensure that the patient takes their medicine, supports their smoking cessation, keeps wearing their oxygen masks, avoids eating hamburgers every day. Family support is crucial to medical practice and clinical improvement, both in the home and in the hospital. When faced with my first intubation as a patient, my mother sat at my bedside, grilling the anesthesiologist. She asked him questions that I frankly, despite my having intubated thousands of patients in my career, was just too nervous to ask. I knew everything that could go wrong. Knew exactly what would happen when he gave me the Versed then wheeled me to the OR. But in that moment, all I could think about was how hungry I was and whether or not he’d accidentally chip my tooth with the blade. I needed her there to help me be a regular patient, not a doctor. When the anesthesiologist left the room, she said to me, “I like him.” I immediately felt calmer. I took my Versed obediently then closed my eyes as they rolled me away.<br /><br />As COVID cases hit their first peak in my hometown, my administration chose to stop allowing visitors into the hospital, both in the ED and on the inpatient floors. I understood the logic of this choice at the time. Fewer people in the building meant fewer chances of accidental transmission and spread of the virus. What was unforeseen, however, was the dramatic impact that would have on our patients. I found myself working up many patients on which I had no information at all: no prior medical history, no knowledge of their primary physician, medication use, or allergies. This not only made my job even more difficult but it added time, extraneous testing, and additional cost to the patient’s visit. That’s to say nothing about the friction it caused for my front-end staff. Families being turned away, sometimes with the needed assistance of our security staff, upset that they could not stay with their spouse, their mother, their sister, or their helpless elderly relative. I watched a 65-year-old man with Alzheimer’s tear up because he couldn’t remember the name of his doctor and told me to ask his wife. I frantically resuscitated a man with hypotension and bradycardia for multiple hours with no effect, only to discover later that he had intentionally overdosed on his blood pressure meds. We were lucky that his spouse called us in the ED to read the suicide note. I cried over the phone with the daughter of a man brought in by EMS alive, only to “code” a short time later. I pronounced his time of death, then had to tell her she couldn’t see her father again because he died of COVID. There are few times in my career thus far that I’ve felt uncomfortable doing my job. This was one of those times. Not allowing this daughter to see her dead father felt wrong. Ethically, morally, and physically wrong. No one should have to say goodbye to their loved ones at the door and wonder if they will ever see them again.<br /><br />The Coronavirus pandemic has changed the way we practice medicine. It has changed the way we interact and socialize, at work and at home. COVID will continue to impact our lives inside and outside the hospital until we have a way to either prevent it, or eradicate it. But there are some things that no virus or other infectious disease will ever be able to change. And that is the strength that we pull from our family and friends in times of despair and joy. We need our families around us during this time, and so do our patients. As providers, we will continue to provide the best care within our capabilities, but we need the assistance and advocacy of our patient’s family and loved ones. We need to have them to be present, safely, at the bedside to speak for the patient when the patient cannot, to encourage the recovery of each patient and to support us as providers as we battle this disease and all the others.<br /><br />I am a terrible patient, but having my mom at the bedside makes be a better one. Family presence makes us stronger. Our patients need this extra strength.<br /></div><div><br /></div></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-45021311263408862292021-02-18T16:26:00.000-06:002021-02-18T16:26:09.016-06:00SBO: Seize Back Onus – Focus on POCUS. <b><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiI5284Oq5QXAQQvRgW7bVK0CnPafbGznpl_0Z5h9sO2SECULtkOqrCvTkmZuo8seGXejNGD3VXeuLDLqas3v1S6X_GJhNpnzGqNaGAk6sBtrCNNptRaVV6h9VmE47NmVowe_Vo6fI9-oX4/s2048/pexels-anna-shvets-4586987.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="2048" data-original-width="1365" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiI5284Oq5QXAQQvRgW7bVK0CnPafbGznpl_0Z5h9sO2SECULtkOqrCvTkmZuo8seGXejNGD3VXeuLDLqas3v1S6X_GJhNpnzGqNaGAk6sBtrCNNptRaVV6h9VmE47NmVowe_Vo6fI9-oX4/s320/pexels-anna-shvets-4586987.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.pexels.com/photo/person-in-white-scrub-suit-lying-on-hospital-bed-4586987/">Pexels</a></i></td></tr></tbody></table>Authors: </b>Ahmed Mamdouh Taha Mostafa, MD; Kevin C. Welch, DO; and Max Cooper, MD RDMS<div>Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />January/February 2021<br /><br /><b>Case</b><br />A 76-year-old female with a past medical history of hypertension, obstructive sleep apnea, diverticulitis, fibromyalgia, osteoarthritis, depression, and renal cell carcinoma status post remote nephrectomy who presented to our ED with four days of intermittent, diffuse, crampy abdominal pain associated with nausea and non-bloody, non-bilious emesis, hiccoughs, and inability to tolerate PO.<br /><br />On examination, vital signs were temperature of 98.3º F, pulse of 108 bpm, respiratory rate of 15, blood pressure 146/91 and oxygen saturation of 97% on room air. Significant findings on examination were mild, diffuse tenderness over the abdomen on palpation, which was soft, positive for bowel sounds on auscultation. Bedside ultrasound performed showed keyboard sign - plicae circularis on the interior aspect of the jejunal wall, “to-and-fro” motion, and dilated bowel loops raising suspicion for small bowel obstruction (SBO), which was confirmed by CT.<br /><br /><span><a name='more'></a></span><div><br /></div>Laboratory investigations included: white blood cell count 18.3 10*3/uL, hemoglobin 15.7 g/dL, platelets 440,000 10*3/uL, sodium 134 mmol/L, potassium 3.8 mmol/L, chloride 83 mmol/L, bicarbonate 34 mmol/L, BUN 52 mg/dL, creatinine 3.3 mg/dL, glucose 139 mg/dL, lactic acid 1.8 mmol/L, alkaline phosphatase 126 U/L, AST 20 U/L, ALT 13 U/L, and total bilirubin 1.2 mg/dL.<br /><br />The patient was made NPO, treated with 1 liter of normal saline, morphine and ondansetron, a nasogastric tube was placed, and the surgical team was consulted. The patient was admitted for IV fluids and bowel rest. They were discharged after an uncomplicated hospital course following conservative management. <br /><br /><b>Discussion</b><br />Small bowel obstruction may account for 2% of all ED abdominal pain presentations and may contribute to 300,000 admissions in the United States annually with high rates of severe complications. It represents an important disease entity for consideration in patients with abdominal complaints. According to one study, the best predictors of SBO on history and physical examination were previous abdominal surgery, constipation, abnormal bowel sounds, and/or abdominal distention.1 CT is not only the gold standard for diagnosis of SBO but it also plays an important role in delineating the etiology and, therefore, in operative planning.2 However, it is important to note that there is a relationship between early diagnosis and the decreased requirement for surgical intervention.3 Despite this significance, CT is not always readily available in many settings such as low resource hospitals, multiple simultaneous high priority patients (e.g. CVA, trauma), technical difficulties (machine malfunction, difficult transport). That combined with the fact that multiple studies have reported that bedside ultrasound has comparable sensitivity and specificity to CT, point us to consider it as an important adjunct or alternative in the diagnosis of SBO.1,2,4-6 In addition to being a less costly, more rapid test, that providers can be easily trained in, ultrasound has not been associated with increased risk of cancer due to radiation. It also allows for serial examination to assess for resolution.6<br /><br />Signs of bowel obstruction on ultrasound include:<br /><ol style="text-align: left;"><li>Dilated bowel loops with most studies using >25 mm as the cut-off for diagnosis (Figures 1 and 2).</li><li>“Tanga” sign: free fluid between loops taking a "pointy" triangular appearance, hence the name after the bikini bottom.</li><li>‘To-and-fro’ motion: hyperechoic bowel contents moving back and forth within the bowel lumen.</li><li>“Keyboard” sign: visualization of the plicae circularis (Figure 3).</li></ol><b>References</b><br /><ol style="text-align: left;"><li>Taylor MR, Lalani N. Adult small bowel obstruction. Acad Emerg Med. 2013;20(6):528-544. doi:10.1111/acem.12150<br /><br /></li><li>Frasure SE, Hildreth AF, Seethala R, Kimberly HH. Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department. World J Emerg Med. 2018;9(4):267-271. doi:10.5847/wjem.j.1920-8642.2018.04.005<br /><br /></li><li>Bickell N, Federman A, Aufses A. Influence of time on risk of bowel resection in complete small bowel obstruction. J Am Coll Surg. 2005;201(6):847-854.<br /><br /></li><li>Jang T, Schindler D, Kaji A. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. 2011;28(8):676-678.<br /><br /></li><li>Unlüer E, Yavaşi O, Eroğlu O, Yilmaz C, Akarca F. Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction. Eur J Emerg Med. 2010;17(5):260-264.<br /><br /></li><li>Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR. Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis. Am J Emerg Med. 2018;36(2):234-242. doi:10.1016/j.ajem.2017.07.085</li></ol><br /><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgr3SI0ph8zCau0bmrrlLJUqosK7EfCHFff28gMyzgc-79bsMhpnaMuzJ8db_Wmzb_BJytRXQJ6zijOYycWb_mQvLgl0CdNouZBiOtkATjL7qQzgGvjoY6Uxou8pV1EZgGJ8GTbV-tR8imO/s960/Fig1.jpg" style="clear: left; margin-bottom: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="720" data-original-width="960" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgr3SI0ph8zCau0bmrrlLJUqosK7EfCHFff28gMyzgc-79bsMhpnaMuzJ8db_Wmzb_BJytRXQJ6zijOYycWb_mQvLgl0CdNouZBiOtkATjL7qQzgGvjoY6Uxou8pV1EZgGJ8GTbV-tR8imO/s320/Fig1.jpg" width="320" /></a><br /><b><br /></b><div><b>Figure 1:</b> Transverse view of dilated small bowel loop measuring 3.16 cm with thickened bowel wall (between crosshairs).<div><br /><div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIcEMBDBxNwPmiabMTzj5ytXbR97aUIPFIFN2li0_bk7hNMnDgfNo8QRBcqDCk8O9EbpVlkYMokvdEK_D3sTPrArzZvKibw9y2yQL9rI4yAypCA-tfgdZoMNf9rBBRahM-YiuPfWRO75YH/s960/Fig2.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="720" data-original-width="960" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIcEMBDBxNwPmiabMTzj5ytXbR97aUIPFIFN2li0_bk7hNMnDgfNo8QRBcqDCk8O9EbpVlkYMokvdEK_D3sTPrArzZvKibw9y2yQL9rI4yAypCA-tfgdZoMNf9rBBRahM-YiuPfWRO75YH/s320/Fig2.jpg" width="320" /></a><div class="separator" style="clear: both; text-align: left;"><b>Figure 2: </b>Longitudinal view of dilated small bowel loop measuring 3.02 cm with thickened bowel wall (between crosshairs).</div></div><div><b><br /></b></div><div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2wsbtokwi9vhD1zC6kVxbwD-5AT0nnm0N9Obuhi6kMwj-q-V6fEuEwd01kkte6R6njz0psqba7MmnUQuKt1k-YzTTRfNFLohr3UfiVztgUWMHJOfXIGa593mfQNSdTpx3YF1a4JuSaXQb/s960/Fig3.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="720" data-original-width="960" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2wsbtokwi9vhD1zC6kVxbwD-5AT0nnm0N9Obuhi6kMwj-q-V6fEuEwd01kkte6R6njz0psqba7MmnUQuKt1k-YzTTRfNFLohr3UfiVztgUWMHJOfXIGa593mfQNSdTpx3YF1a4JuSaXQb/s320/Fig3.jpg" width="320" /></a></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b><br /></b></div><div><b>Figure 3:</b> “Keyboard” sign - plicae circularis (arrows) on the interior aspect of the jejunal wall.</div></div></div></div><span></span><div><br /></div><span></span><div><br /></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-39292312056551095902021-02-04T17:04:00.002-06:002021-02-12T17:19:17.735-06:00How to Be a Great Senior Resident<b><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCQXgxUjtwKmV2eOn17Gcs-0_zgtKnr_9SOZtO4m6Ij87aUV-oBiMo2HRwS1zuKa2mQAsTCKCuWRF3QG35x-xZiZK6d6R-nE2V6QQRmNyHISJ1cGysj7tH7FicI6EWCsnmG83IF5uMK3GO/s2048/pexels-rodnae-productions-6129681.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCQXgxUjtwKmV2eOn17Gcs-0_zgtKnr_9SOZtO4m6Ij87aUV-oBiMo2HRwS1zuKa2mQAsTCKCuWRF3QG35x-xZiZK6d6R-nE2V6QQRmNyHISJ1cGysj7tH7FicI6EWCsnmG83IF5uMK3GO/s320/pexels-rodnae-productions-6129681.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/photo/man-in-white-scrub-suit-massaging-man-in-blue-scrub-suit-6129681/"><i>Pexels</i></a></td></tr></tbody></table>Author:</b> Alexandria Gregory, MD – AAEM/RSA Editor, Common Sense<div>Originally published: <i><a href="https://www.aaemrsa.org/get-involved/common-sense">Common Sense</a></i><br />January/February 2021</div><div><br />Four months after the beginning of second year, I still feel weird being called a “senior resident.” It feels like just yesterday I was the intern, lowest on the totem pole, learning to navigate the flow of patient care and the ED. I didn’t expect July 1st to feel any different than the days prior when I walked into my shift, but I was wrong. Suddenly, it felt as if my attendings trusted me more, and now there were more junior doctors seeking my advice regularly. I am lucky to be at an institution that encourages independence and leadership early on, so even at the beginning of PGY-2, we are working senior shifts and running critical care pod shifts, helping to supervise interns and medical students while in those roles. Even in just a few months, I have learned a lot about what makes for a great senior resident and the qualities I hope to emulate. A great senior resident:</div><div><br /></div><span><a name='more'></a></span><div><br /><ol style="text-align: left;"><li><b>Encourages questions:</b> It’s important to be open to any and all questions, whether they are about the electronic health record or where something is. This sets a tone of openness so that residents and students feel their senior is approachable, which becomes especially important if they have a sick patient or need to do something outside of their scope.<br /><br /></li><li><b>Encourages independent decision-making, but with appropriate back-up: </b>When junior residents or medical students ask for advice on patient care, allow them to explain their thought process, which will help them learn more than simply giving them the answer.<br /><br /></li><li><b>Meets people where they are: </b>This can be tough, but it is important to recognize. Not every learner will respond well to the same teaching technique. Additionally, the ED typically has a variety of rotators (junior EM residents, off-service residents, EM-bound students, and non-EM bound students). Assessing someone’s level of comfort in the ED is important so that you know how much guidance they require and what they hope to get out of their rotation.<br /><br /></li><li><b>Recognizes their own weaknesses:</b> As a senior resident, you’re still a learner yourself. Letting a junior resident know that you don’t know something establishes that it’s okay not to know everything and allows for an opportunity to show them how you seek out answers.<br /><br /></li><li><b>Finds learning opportunities in spare time: </b>While there usually isn’t a ton of downtime in the ED, a good senior resident takes even small opportunities for extra teaching. Putting someone on BiPAP? Take a second to ask if your student or junior resident understands the physiology behind its efficacy. If the ED does happen to be slow, offer to take a few minutes to teach about a topic of an intern’s or student’s choice.<br /><br /></li><li><b>Leads by example:</b> Don’t expect junior residents to do anything that you wouldn’t do yourself. Be cognizant of you how you communicate with consultants, nurses, etc., because students and other residents are watching you, whether you’re aware of it or not.<br /><br /></li><li><b>Understands how their role is different than the attending’s:</b> Being a senior resident allows for a different, unique role before becoming an attending. You are both a peer and a mentor simultaneously; try to embrace that by being open if junior residents approach you for advice they might not feel comfortable approaching an attending about.<br /><br /></li><li><b>Sees giving procedures to junior residents as an opportunity, rather than a loss:</b> In my program, we strive to have a culture that gets the interns involved in procedures early on. The balance between wanting to practice your own procedural skills and share with junior residents can be tricky, but it’s helpful to view supervising procedures as just as valuable as doing them yourself. For example, in supervising an intern‘s first ever few intubations, I learned a lot more about the mechanics of intubation as well as how to teach without jumping in and doing the procedure myself, which is its own skill. At the same time, don’t feel pressured to give up procedures every single time, especially ones you’re not comfortable with or haven’t done in a while—your education is important too.<br /><br /></li><li><b>Asks for feedback: </b>In addition to asking your attendings for feedback, it can also be useful to ask for feedback from junior residents or medical students so you can assess how you’re doing in the senior role. Even quick questions such as “Did that explanation make sense? Was that helpful?” can you give you ideas of how to improve<br /><br /></li><li><b>Recognizes that interns are in an especially unique and challenging position during COVID-19:</b> It isn’t easy to become a physician during a pandemic. Beyond the obvious challenge of entering a stressed hospital system and learning the foundations of medicine in a time where nothing is “normal,” there are other challenges to consider. It’s likely that your interns have not been able to be as social outside of the hospital both among their own classmates and the other classes in your residency. Didactics are probably Zoom-based, your program may have budget cuts, and policies may be changing almost daily. Keep this in mind when interacting with your interns, ask them how they’re doing, and let them know that you’re there to support them however needed.</li></ol></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-35808152649895712132021-01-21T21:07:00.000-06:002021-01-26T21:08:10.548-06:00Resident Journal Review: End-Tidal Carbon Dioxide Monitoring in Cardiopulmonary Resuscitation<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji0aPYxNhLzQiyYPt7PsRJGZhTDa-ntDGAweJB1CQhMoUc2L0O939TPIBYiYKtz9wikLIPSWcNhizIXJIpLWDmMbn_J4NYrgUrPyiG4LlOFbFsi0fgjVZOc7S7huE06hJv5TEJ-B26MLyf/s1920/Resident+Journal+Review.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1084" data-original-width="1920" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji0aPYxNhLzQiyYPt7PsRJGZhTDa-ntDGAweJB1CQhMoUc2L0O939TPIBYiYKtz9wikLIPSWcNhizIXJIpLWDmMbn_J4NYrgUrPyiG4LlOFbFsi0fgjVZOc7S7huE06hJv5TEJ-B26MLyf/s320/Resident+Journal+Review.png" width="320" /></a></div><b>Authors: </b>Christianna Sim, MD MPH; Taylor Conrad, MD MS; Taylor M. Douglas, MD; Wesley Chan, MD<div><b>Editors:</b> Kelly Maurelus, MD FAAEM and Kami Hu, MD FAAEM</div><div>Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />November/December 2020<br /><br /><b>Question: How can end-tidal carbon dioxide (ETCO2) monitoring guide our management of cardiac arrest?</b><br /><br />In 2010, the American Heart Association (AHA) revised the Advanced Cardiac Life Support (ACLS) guidelines to include the recommendation of using capnography to monitor end-tidal carbon dioxide (ETCO2) during cardiopulmonary resuscitation (CPR),<sup>1</sup> and has continued this recommendation to date. Measured ETCO2 during cardiac arrest is a measure of the cardiac output generated by chest compressions but is affected by various other factors including endotracheal tube complications, ventilation, and medications administered. These issues notwithstanding, studies supporting ETCO2 as a surrogate marker of cardiac output outside of cardiac arrest<sup>2,3</sup> indicate that ETCO2 could be a non-invasive, more readily available means of providing feedback in real time during resuscitation efforts. Previous studies have shown that low (<10 mmHg) ETCO2 values during resuscitation are predictive of mortality<sup>4,5,6</sup> and that initial, average, and final ETCO2 are higher in successfully resuscitated patients<sup>7,8</sup> and there is an emerging possibility that ETCO2 could possibly even predict survival to discharge.<sup>7,9</sup> Here we review some of the more recent literature regarding the use of ETCO2 during CPR and evidence on how it can guide resuscitation efforts. </div><div><br /></div><span><a name='more'></a></span><div><br /><br /><b>Sheak KR, Wiebe DJ, Leary M, et al. Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest. Resuscitation. 2015;89:149-154.</b><br /><br />Based on previous studies that suggested ETCO2 as an indicator of cardiac output,<sup>2,3</sup> Sheak et al. hypothesized that it may also reflect the quality of chest compressions (CC) during CPR, thus giving feedback on resuscitation efforts in real time. They specifically sought to investigate the relationship between ETCO2 and CC depth, CC rate, and ventilation rate in both in-hospital cardiac arrests (IHCA) and out-of-hospital cardiac arrests (OHCA). <br /><br />They conducted a prospective, multicenter study at hospital sites in the United States in which they were able to capture CPR-recording defibrillator and continuous side-stream CO2 data in patients with an advanced airway (endotracheal tube or laryngeal mask airway), regardless of the etiology of the cardiac arrest or initial rhythm, with at least two minutes of synchronized chest compressions and ETCO2 data. The data metrics were averaged over 15-second epochs. In total, their study included 583 cases, 227 (39%) IHCA and 356 (61%) OHCA. <br /><br />While chest compression rate did not significantly affect ETCO2, the depth of compressions was a significant predictor of ETCO2values independent of CC or ventilation rate. For every 10 mm increase in depth there was an associated increase in ETCO2 by an average of 1.4 mmHg (p <0.001), independent of CC rate (slow, medium, fast). Perhaps unsurprisingly, ventilation rate was inversely related to ETCO2 values. Every additional 10 breath per minute increase in rate lowered ETCO2 by an average of 3.0 mmHg (p <0.001). The overall case-averaged mean ETCO2 values in those with ROSC were higher compared to those who did not achieve ROSC (34.5 ± 4.5 vs 23.1 ± 12.9 mmHg, p <0.001). They also observed a similar relationship seen in regard to survival to hospital discharge (38.2 ±12.9 vs 26.1 ±15.2 mmHg, p <0.001). <br /><br />The authors found a significant relationship between CC depth and ETCO2 and performed a fairly robust assessment, albeit not without limitations. The inability to assess for the effect ventilatory volume, without which minute ventilation cannot be calculated, leaves a possible confounder of the relationship between CC depth with ETCO2. They list other confounders they were unable to measure, such as the administration of epinephrine, the cause of cardiac arrest, underlying metabolic rate, and any metabolic derangements during the arrest. Also, because they did not know the relationship between the onset of resuscitation and initiation of active recording, they were unable to see if the CC depth- ETCO2 relationship differed depending on the phase of cardiac arrest care. To further understand the influence of CPR performance on ETCO2, there must be further investigations on how this relationship may be affected by these other factors. The authors highlighted the wide variability of the relationship between CC depth and ETCO2 posing a challenge to its applicability to all resuscitation events. As such, despite seeing a clear relationship between CPR quality (as indicated by depth of compressions) and ETCO2, there is no clear benchmark that can be set based on this data alone and would require further evidence to set a specific ETCO2 to aim for during resuscitation efforts. <br /><br /><b>Pokorná M, Necas E, Kratochvíl J, et al. A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med. 2010;38(5):614-621.</b><br /><br />While an increase in partial pressure ETCO2 has been observed after ROSC in both experimental and clinical studies, Pokarnoa et al. set out to determine whether an increase in ETCO2 could be used as a reliable indicator of ROSC in their retrospective case-control study. They looked at two extremes of patients experiencing OHCA: those who had single uncomplicated ROSC followed by stable spontaneous circulation and those with no signs of ROSC who died at the scene. <br /><br />In total a group of 140 patients were included. ROSC was defined by the researchers as a palpable central pulse with an organized spontaneous ECG rhythm and measurable blood pressure. All patients were intubated in the field by either emergency medicine physicians or anesthesiologists who were part of the EMS personnel, and consistent lung ventilation was maintained for each patient by an automatic device. Patients were reviewed regardless of age, cardiac arrest etiology, first ECG rhythm pattern, or bystander BLS. Exclusion criteria included patients with either capno-sensor moisturization or contamination with blood as well as patients who received sodium bicarbonate. Thirty-two records were excluded from patients in whom ROSC was achieved but the ensuring spontaneous circulation was unstable and failed again or repeatedly, leaving 108 patients for analysis. ETCO2 values were continuously recorded from the time ACLS was administered to when either ACLS was discontinued or when ROSC was achieved. All ETCO2 records were analyzed in two minute intervals and compared with each other against an arbitrarily set of threshold values ranging from two to 20 mmHg. True positive was noted when an increase equaled or exceeded a particular threshold value and ROSC was achieved. Mean values and standard deviations were compared by a two-tailed paired t-test. <br /><br />Analysis of the ETCO2 recording showed a mean difference of ETCO2 before and after ROSC was 9.95 mmHg (95% CI 6.46 - 13.50 mmHg). Individual comparisons of ETCO2 readings before and after ROSC showed a significant value of p <0.0001. Notably, patients who were not successfully resuscitated had lower mean ETCO2 values for all time points compared to patients who achieved ROSC. For patients in whom ROSC was achieved, mean ETCO2 values were always higher after ROSC than before.<br /><br />The authors acknowledge their study examined two extreme situations: uncomplicated ROSC and no signs of ROSC at all. The study did not cover cases when circulation restarted immediately after defibrillation because these patients were not intubated. It is worth mentioning that the majority of the patients who achieved ROSC ultimately were in vegetative states. The authors concluded that ventilated patients undergoing ACLS in out of hospital cardiac arrest have an increase in ETCO2 of about 10 mmHg after ROSC is achieved. They also suggested the increase of ETCO2 could be a suitable moment for checking pulse versus the preselected two minute intervals. Further investigation is needed given small sample size and the two extreme patient populations investigated.<br /><br /><b>Lui CT, Poon KM, Tsui KL. Abrupt rise of end tidal carbon dioxide level was a specific but non-sensitive marker of return of spontaneous circulation in patients with out-of-hospital cardiac arrest. Resuscitation. 2016;104:53-58.</b><br /><br />Lui et al. sought to evaluate the diagnostic accuracy of an “abrupt and sustained increase” in ETCO2 to indicate ROSC in their cross-sectional prospective study. They looked at a relatively narrow population of adult patients in Hong Kong with non-traumatic OHCA who only received basic life support in the field prior to transport to one of two regional hospitals. All of the data used in the study was prospectively recorded and then later retrieved by researchers from a cardiac arrest registry as well as the electronic health record, except for presumed etiology of arrest, which was determined based on clinical history from the scene, subsequent diagnostic testing, and autopsy data.</div><div style="text-align: left;"><br />They documented any rise of ≥10 mmHg sustained for at least three minutes, specifically noting rises of ≥10 or 20 mmHg, or to the level of ≥40 mmHg. They performed subgroup analysis based on cardiac vs. non-cardiac arrest etiology as well as occurrence of re-arrest. Of the 548 patients fulfilling their inclusion criteria, 370 were excluded due to inadequate documentation of ETCO2 values; comparison analyses between the included and excluded groups demonstrated no difference in baseline characteristics or outcome measures. The only baseline characteristics significantly different within the included cohort were witnessed arrest and ETCO2 change during resuscitation. Within the included cohort, 34% of patients had ROSC achieved, which is relatively in line with the heterogeneous published data. For the four different parameters (rise of 10, rise of 20, rise of 10 to 40, rise of 20 to 40), they found poor sensitivities from 33% to 15%, worsening as the parameters became more restrictive, and excellent specificities from 97% to 99%. They also performed detailed statistical analysis to conclude there was a significant difference between the readings immediately pre-ROSC and post-ROSC. When performing their subgroup analysis based on arrest etiology, they concluded the rise in ETCO2 was higher in the non-cardiac group (17.5 mmHg in non-cardiac vs. 5 mmHg in cardiac) with improved sensitivity (45% in non-cardiac vs. 18% in cardiac).<br /><br />The authors do identify some major limitations to their study that serve as future areas for investigation. They did not control for other factors that can affect ETCO2 such as tidal volume, medications administered, or quality of compressions. Commonly used ACLS medications such as sodium bicarbonate and epinephrine are documented to alter ETCO2 levels and the interaction of these effects with these data is unknown.10,11 In addition, these conclusions may not be generalizable to IHCA patients, patients on ventilatory support or intubated at the time of arrest, and patients who receive ACLS care in the field prior to arrival at the hospital. This was a good first prospective study into the accuracy of changes in ETCO2 to indicate ROSC and supported existing data indicating an increase of 10 mmHg or greater is indicative of successful resuscitation.<br /><br /><b>Paiva EF, Paxton JH, O'Neil BJ. The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review. Resuscitation. 2018;123:1-7. </b><br /><br />As part of the 2015 international Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendation (CoSTR) process, this systematic review was performed with the intention to identify whether any level of ETCO2 measured during CPR correlates with return of spontaneous circulation (ROSC) or survival or survival to discharge, irrespective of cardiac arrest setting. This systematic review included existing studies up to December 13, 2016, and found only five studies that reported enough data allowing them to be used in a quantitative synthesis. Of those five studies, only one single study was able to be included in the relationship between ETCO2 and achievement of ROSC. Only one additional study was designed to study survival at discharge, despite two others being included in the analysis. All studies included were purely observational, with high risks of bias (high rates of convenience sampling, some with >14% having already achieved ROSC, or extremely small numbers of patients).<br /><br />For the outcome of return of spontaneous circulation, only one study by Ahrens et al. was included, thus no meta-analysis was actually performed. This showed correlation between initial ETCO2 of ≥ 10mmHg and ≥ 20mmHg and increased rates of ROSC (OR 11.41, 95% CI 1.44 - 90.17 and OR 13.82, 95% CI 3.5 - 53.37, respectively). Increased odds ratios of ROSC were also noted with ETCO2 ≥ 20mmHg for 20 minutes (OR 20, 95% CI 1.97 - 203.32). This study, however, noted that 14% of patients had already achieved ROSC at first measurement of ETCO2.<br /><br />For the outcome of survival to discharge, a few other studies were included in the meta-analysis, but the primary study that affected the outcomes was the same Ahrens study with weights of >90% in all analysis except one, the correlation between initial ETCO2 ≥10 mmHg in which that study still had a weight of 66%. The pooled odds ratio for survival to discharge for initial ETCO2 ≥10 mmHg was reported as 10.71 (95% CI 5.65 - 20.30). For initial ETCO2 ≥ 20 mmHg, increased odds of survival was noted with OR 12.24 (95% CI 5.13 to 29.22). Increased odds of survival was also reported with ETCO2 ≥10 mmHg and ≥20 mmHg with OR 181.57 (95% CI of 40.08 to 822.61) and OR 234 (95% CI of 19.48 to 2811.42), respectively.<br /><br />Although reported as a systematic review and meta-analysis, nearly all the results came from a single study by Ahrens et al., which reported rates of >14% ROSC having been achieved prior to measurements and that samples were taken conveniently. As such, the authors conclude that initial ETCO2 should not be used to reliably predict outcomes and should not be used for determination of continuation of resuscitation. They do suggest that late in resuscitation, higher levels of ETCO2 are correlated with increased rates of ROSC and survivability to discharge but based on the poor quality and number of studies available, this is not supported in the literature. Physiologically, it makes since higher ETCO2 levels would indicate improved likelihood of ROSC or survival, but there are large variables that could affect this measurement that are not taken into account in the current available literature (rates and quality of ventilation, timing of intubation, presence of ROSC initially, etc.). As such, it is more reasonable to conclude from this study that insufficient data and research exists to make a claim on the utility of ETCO2 on the guidance of further resuscitative efforts and cardiac arrest outcomes. <br /><br /><b>Conclusion</b><br /><br />The American Heart Association’s ACLS guidelines include monitoring ETCO2 as a surrogate marker of cardiac output to help guide resuscitation during cardiac arrest. This concept is appealing given the non-invasive nature and wide availability of ETCO2: real-time feedback during resuscitation, limiting chest compression interruptions, and the ability to decide when to terminate resuscitation efforts. Existing data indicates that, in ventilated patients with a definitive airway, persistent ETCO2 values <10 mmHg despite maximum efforts are predictive of unsuccessful resuscitation, and that higher ETCO2 values are associated with ROSC. It is difficult to create an absolute numeric guide, however, due to the wide variability and inconsistent evidence regarding thresholds, due to many existing variables that may affect ETCO2, especially in causes related to pulmonary function.12 We need further evidence to understand what cutoffs and thresholds to use and how certain variables might affect them. <br /><br /><b>Answer </b><br /><br />In the management of patients with cardiac arrest and a definitive airway, a persistent ETCO2 of <10 mmHg, despite maximal resuscitative efforts, is associated with lack of ROSC, while an abrupt increase in ETCO2 of 10 mmHg or greater may be reliably indicative of ROSC. It remains that existing studies do not clearly account for confounding variables to clearly define a threshold to be the single deciding factor as to whether to stop or continue ACLS. Similarly, depth of chest compressions is associated with ETCO2 levels, but there remains no set number or guide by which to adjust chest compressions during cardiac arrest. <br /><br /><b>References </b><br /><ol><li>Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [published correction appears in Circulation. 2011;123:e236].Circulation. 2010; 122(suppl 3):S729–67.<br /><br /></li><li>Jin X, Weil MH, Tang W, et al. End-tidal carbon dioxide as a noninvasive indicator of cardiac index during circulatory shock. Crit Care Med. 2000;28:2415-9.<br /><br /></li><li>Weil MH, Bisera J, Trevino RP, Rackow EC. Cardiac output and end-tidal carbon dioxide. Crit Care Med. 1985;13:907-9.<br /><br /></li><li>Sanders AB, Kern KB, Otto CW, et al. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation: a prognostic indicator for survival. JAMA. 1989; 262:1347–51.<br /><br /></li><li>Cantineau JP, Lambert Y, Merckx P, et al. End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole: a predictor of outcome. Crit Care Med. 1996; 24:791–6.<br /><br /></li><li>Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997; 337:301–6.<br /><br /></li><li>Grmec S, Klemen P. Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest? Eur J Emerg Med. 2001;8:263-9.<br /><br /></li><li>Kolar M, Krizmaric M, Klemen P, Grmec S. Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study. Crit Care. 2008;12(5):R115.<br /><br /></li><li>Ahrens T, Schallom L, Bettorf K, et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care. 2001; 10:391–8.<br /><br /></li><li>Vukmir RB, Bircher N, Safar P. Sodium bicarbonate in cardiac arrest: a reasppraisal. Am J Emerg Med. 1996;14:192–206.<br /><br /></li><li>Okamoto H, Hoka S, Kawasaki T, et al. Changes in end-tidal carbon dioxide tension following sodium bicarbonate administration: correlation with cardiac output and haemoglobin concentration. Acta Anaesthesiol Scand. 1995;39:79–84.<br /><br /></li><li>Heradstveit BE, Sunde K, Sunde GA, et al. Factors complicating interpretation of capnography during advanced life support in cardiac arrest - a clinical retrospective study in 575 patients. Resuscitation. 2012;83:813-8.</li></ol><br /></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-11363711417656107962021-01-14T13:51:00.001-06:002021-01-14T13:51:11.795-06:00Virtual Insanity: Adapting Curriculum to the Virtual Environment<b><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjH50F3wwxpCGSGY0OTI0xi6jHNMrKIDI5_puScCBvjmqZ2i3CsBG3cR1OSS_eBu4e6tPJkoP0pik7o4zIGhe0MUaalpFsqzPT7MkKzoVEnopWt28iCwrvwWOplIpoeqRbE2bt2Lwd7odhN/s2048/pexels-burst-545057.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjH50F3wwxpCGSGY0OTI0xi6jHNMrKIDI5_puScCBvjmqZ2i3CsBG3cR1OSS_eBu4e6tPJkoP0pik7o4zIGhe0MUaalpFsqzPT7MkKzoVEnopWt28iCwrvwWOplIpoeqRbE2bt2Lwd7odhN/s320/pexels-burst-545057.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/photo/silver-ipad-545057/"><i>Pexels</i></a></td></tr></tbody></table>Author:</b> Ryan Gibney, MD <br />AEM/RSA Editor<br />Originally published: <a href="https://www.blogger.com/blog/post/edit/8358325768652634807/6144530314069492969#"><i>Common Sense</i></a><br />November/December 2020<br /><br />The sun peaks over the bay, as the crispness evaporates from the morning air to greet, what — in any other normal time — would be the start of a new school year. The traditional morning routine of packing lunch, gathering supplies, and a haphazard scurry to the front door to make it to class on time, has all but disappeared. The start of a new school year as a parent has brought a new face to education across the board. In my home, we have set up a dedicated learning space for both my daughter and I, complete with paper, pens, computers, reference books, and any other tool that may be needed. As I watch my daughter dive into the realm digital learning, I wonder how this generation is going to adapt. How are they going to apply their knowledge? Is this the new norm for education (please, God I hope not)? More importantly, how will the lack of social interaction shape her future? It has been shown that peer education with regards to emotional resiliency, empathy, and problem solving, are attained through social interactions. I believe that the same is true in medical education. <p></p><span><a name='more'></a></span><br />At the same time my daughter embarked on another year in her quest for knowledge, so did a new class of medical students and residents across the nation. However, this time was starkly different from the years before — in-person activities and orientations, social gatherings with colleagues, family and friends, and the time-honored white coat ceremony were noticeably missing. As my colleague Dr. Alexandria Gregory mentioned in the May/June issue of Common Sense, the transition of Step 1 to pass/fail, the myriad of quality supplemental resources, and question of lecture based teaching’s utility, traditional medical education is rapidly evolving, and the advent of distance learning has introduced a new set of complex problems. What do we, as clinical educators, do to make these sessions valuable? How do we incorporate peer learning to hone intangible skills such as empathy? How do we make it better than before?<br /><br />Virtual learning can be challenging for even the most skilled clinical educators. The content must be clearly developed and delivered in a way that engages the learner and maintains the quality standards of medical education. Falling back into a purely lecture driven curriculum is an easy way to navigate the virtual realm, but offers little to the learner and has been proven ineffective time and time again. Hands on, group format is limited by many institutions mandated social distancing and distance learning policies. With a little bit of creativity and a bit more backend effort, educational interactions can be extremely effective, interactive, and fun within the virtual space. <br /><br /><b>Ways to Augment Your Virtual Learning Environment</b><br /><br />As an academic chief, the responsibility of curating our weekly conference content is no simple task. The addition of a predominantly virtual learning environment added unique challenges to development of quality content that engages the learner. Through the help of our educational fellows, we have been able to develop many interactive learning modules that translate very well to the virtual learning environment. Here are a few of those ideas. <br /><br />The flipped classroom model has long been a staple in MedEd, and works incredibly well in the virtual environment. The flipped classroom focuses on the individual learner gaining and applying new knowledge. Prior to the sessions material is distributed for learning and understanding via email or assigned reading. Within the digital session application of the new material can be done through case based learning, iRAT-gRAT model, or other TBL/PBL methods. There is little work that needs to be done to translate this to the virtual learning space making it an ideal methodology for quick content integration. <br /><br />Choose your own adventure is another method that can be a great addition to the virtual curriculum. This allows the learners to engage in breakout rooms and solve a series of problems and clinical scenarios, expanding on the team based and problem based learning approaches. Web-based platforms, such as Google Forms, can be used to develop logic based clinical games, taking advantage of the sections feature, allowing for variant pathways through clinical scenarios. Adding a theme based on the topic can augment the engagement. For example, a Zombie Apocalypse themed game on toxidromes, or a digital escape room can increase the challenge level. Integration of puzzles requiring application of clinical knowledge allows for stronger memory association and retention. These builds can be customized to fill any amount of time and there are many online resources and how-to videos for creation. Although these are incredibly engaging and can cover broad swaths of material, there are some considerations when building these. They can be very laborious, so it’s best to start small to get the hang of the logic flow — for example a 90 minute game can take upwards of 12-16 hours to build out the content. Once you have developed a good logic flow, you can readapt it to varied content. Secondly, the platform can become unstable when the logic of the form becomes too large—around 70-80 branch points can slow it down significantly. To circumvent this plan small or break it into two smaller branch forms that run in succession. Finally, this platform allows for integration of robust video and image content making the experience that much more engaging, however this can also contribute to slowing. Overall, this has been well received by learners and builders alike, and offers a change to the traditional learning platforms. <br /><br />Simulation has become an integral part of medical education as it allows for hands on application of clinical knowledge in low pressure, low stakes environments, focused on team-based learning in the patient care setting. This can be accomplished in a variety of ways digitally as well. Using the above described Google build out with sections tied to the user choices, provides a direct feedback component based on their choices. Integration of the image and video components can increase the reality of the simulation experience. Also, simulation can be facilitated by an operator through shared PowerPoint documents with hyperlinks that correlate to clinical decisions and physiologic changes. The key is to provide a similar experience to the in-person simulation environment, engaging learners of all levels, and providing integration of clinical decision making with focused learning objectives. There are excellent resources for sim cases such as EM Sim Cases, JetEM, and ACEP, to name a few. <br /><br />Integration of high quality asynchronous resources provides a way to focus on the learning and evaluation process, rather than creating anew. In medical education and emergency medicine there already exists a plethora of excellent resources, such as HIPPO-EM, EMRAP, ROSH, PEER, and others. Integrating these into the digital curriculum can allow for the content developers to focus more on application of these principles. The fact that most learners already use these resources independently, makes the transition and integration more palatable. <br /><br />How do you teach soft skills virtually? Many institutions have integrated empathy and communication curricula into their standards and goals. The challenge is that applying these principles virtually becomes difficult for several reasons—body language is often obscured, tonality doesn’t always translate across video conferencing, and there are a lot of distractions that often don’t exist in-person. Having a focused wellness portion of your virtual programming, where learners can gather to discuss relevant social topics, challenges they are currently facing, difficult clinical cases, and process groups can bring about a true human component to the virtual realm effectively. Expanding this beyond the virtual realm to the workroom, rounds, and other in-person settings can further emphasize these skills. <br /><br />The key to any virtual learning space is adaptability. The truth of the matter is that you will try many different approaches and some of them will just not work. Being flexible and ready to change at a moment’s notice is crucial to effectively delivering your content. Focusing on embracing the virtual environment and making it an enjoyable space for learning is critical for its success. We are truly living through an unprecedented time socially; however, there is real opportunity to innovate in education right now. These are only a few suggestions to augment the digital learning space, and I hope that provides some new ideas to improve the quality of education we provide to our learners.AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-58878133482363371232020-12-31T12:30:00.000-06:002020-12-31T12:33:38.365-06:00Top 10 Most Read Posts of 2020<div class="separator" style="clear: both; text-align: left;"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4cHjWLOSboyRy_MS9JbqHU7ts44vgcHVhvnzVOJWtu427GqhHupW1aqbg-7yx5TAl-pHKYN7TLrJIwRDN1-zl5sEINF6_fIFm-ywEk8YgdWDg9P267pMJtYx_89ceGw4AY4gVKbO9xzUl/s2048/pexels-anna-tarazevich-6027785.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4cHjWLOSboyRy_MS9JbqHU7ts44vgcHVhvnzVOJWtu427GqhHupW1aqbg-7yx5TAl-pHKYN7TLrJIwRDN1-zl5sEINF6_fIFm-ywEk8YgdWDg9P267pMJtYx_89ceGw4AY4gVKbO9xzUl/s320/pexels-anna-tarazevich-6027785.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/search/new%20year/"><i>Pexels</i></a></td></tr></tbody></table>As 2020 comes to an end, we look forward to recognizing the year’s top 10 articles! Join me in congratulating this amazing group of authors at all levels of training and from across the United States!</div><p>Additionally, I would like to thank each of the AAEM/RSA Modern Resident Blog authors, reviewers, mentors, and editorial staff members for their tireless contributions to the blog. Without all of them, the blog would not be what it is today. Thanks for a successful 2020!<br /><br />We are currently accepting articles for 2021 and are always looking for additional faculty mentors as well. Feel free to contact us at info@aaemrsa.org with questions.<br /><br />Sincerely,<br /><br />Alex Gregory, MD<br />Editor-in-Chief<br />AAEM/RSA Modern Resident Blog<br /></p><br /><a name='more'></a><br /><br /><b>Top 10 Most Read Posts of 2020</b><br /><br /><ol><li><span><u><b><a href="https://aaemrsa.blogspot.com/2020/07/should-st-elevation-in-lead-avr-with.html"><span style="color: #ec1c2d;">Should ST elevation in lead aVR with concern for acute coronary syndrome prompt emergent coronary angiography?</span></a><br /></b></u></span><span style="color: black;">Akilesh Honasoge, MD, Robert Brown, MD, Samantha Yarmis, MD, Mark Sutherland, MD, Megan Donohue, MD, Hannah Goldberg, MD</span><br style="color: black;" /><span style="color: black;">Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM<br /><br /></span></li><li><span><b><u><a href="https://aaemrsa.blogspot.com/2020/02/tranexamic-acid-txa-in-obstetric.html"><span style="color: #ec1c2d;">Tranexamic Acid (TXA) in Obstetric Hemorrhage</span></a><br /></u></b></span><span style="color: black;">Patrick Wallace, DO, MS</span><br style="color: black;" /><span style="color: black;">Emergency Medicine Resident, PGY-2</span><br style="color: black;" /><span style="color: black;">University Nevada Las Vegas</span><br style="color: black;" /><span style="color: black;">AAEM/RSA Publications and Social Media Committee, and AAEM/RSA Education Committee</span><br style="color: black;" /><br style="color: black;" /><span style="color: black;">Laurie Bezjian Wallace, DO</span><br style="color: black;" /><span style="color: black;">Family Medicine Resident, PGY-2</span><br style="color: black;" /><span style="color: black;">Mike O’Callaghan Military Medical Center<br /><br /></span></li><li><span><b><u><a href="https://aaemrsa.blogspot.com/2020/02/sex-sent-her-to-emergency-department.html"><span style="color: #ec1c2d;">Sex Sent Her to the Emergency Department: A Rare Case of Postcoital Hemoperitoneum</span></a><br /></u></b></span>Christina Schramm, MSIV Medical Student<br />St. George’s University School of Medicine<br />AAEM/RSA Social Media Committee<br /><br /></li><li><span><b><u><a href="https://aaemrsa.blogspot.com/2020/05/intractable-hiccups-presentation-of.html"><span style="color: #ec1c2d;">Intractable hiccups: a presentation of COVID-19</span></a><br /></u></b></span>Jaclyn H. 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Diagnosis is clinical and challenged by overlap with more superficial skin infections (i.e. cellulitis) and the need for thorough examination of the genital region. Imaging and laboratory analysis are not able to consistently rule out FG. While risk calculators exist, they are also limited in their utility for ruling out severity of illness. This brief article discusses use of the monocyte-lymphocyte ratio, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio; recently innovated, simple, and effective biomarkers for prognosticating NSTIs. </div><div><br /></div><span><a name='more'></a></span><div><br /></div><div><b>Introduction: </b><br />While cases of genital gangrene were documented as early as 980 CE, the condition we know today as FG was coined in the 1880’s by French venerologist, Jean Alfred Fournier.<sup>1</sup> His description of cases of life-threatening infections in the perineal, genital or perianal regions were thought to be idiopathic in previously healthy men. Today, the underlying etiology for patients presenting with genital gangrene can be identified a majority of the time.<sup>2</sup> A better understanding of the demographics of FG indicate that it can present in any sex and at any age. While uncommon—representing less than 0.02% of hospital admissions—FG is associated with significant morbidity, and mortality rates as high as 88% when not suspected and treated early. Rapid recognition and time to surgical intervention are the single greatest factors impacting survival.<sup>3-5</sup> Fournier gangrene is a type of necrotizing soft tissue infection, which can be categorized into four types based on the infectious organism involved and other features (Table 1).<div><br /> <span id="docs-internal-guid-79a1ef15-7fff-fe93-2541-8bf18a6b196c"><div align="left" dir="ltr" style="margin-left: -5.4pt;"><table style="border-collapse: collapse; border: none;"><colgroup><col width="108"></col><col width="228"></col><col width="288"></col></colgroup><tbody><tr style="height: 0pt;"><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">NSTI Type</td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Implicated organisms</td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Common associations</td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Type I</td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; vertical-align: middle;"><div style="text-align: center;"><br /></div><div style="text-align: center;"><i>Bacteroides fragilis</i></div><div style="text-align: center;"><i>Escherichia coli</i></div><div style="text-align: center;"><i>Klebsiella pneumonia</i></div><div style="text-align: center;"><i>Staphylococcus aureus</i></div><div style="text-align: center;"><i>Clostridium specie</i>s</div></td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Commensal flora of the GI/GU tract, mixed anerobic and anerobic bacteria<sup>6,7</sup></td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Type II</td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; vertical-align: middle;"><div style="text-align: center;"><i style="text-align: left;">Streptococcus pyogenes</i></div><i><div style="text-align: center;"><i>Group A streptococcus</i></div></i></td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Complicated by toxic shock syndrome in > 50% of cases<sup>8</sup></td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Type III</td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; vertical-align: middle;"><div style="text-align: center;"><i>Clostridium perfringens</i></div><div style="text-align: center;"><i>Aeromonas hydrophila</i></div><div style="text-align: center;"><i>Vibrio vulnificu</i>s</div></td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Marine related infections following traumatic injury<sup>9</sup></td></tr><tr style="height: 0pt;"><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Type IV</td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; vertical-align: middle;"><div style="text-align: center;"><i>Candida albicans</i></div><i><div style="text-align: center;"><i>Rhizopus microspores</i></div><div style="text-align: center;"><i>Lactobacillus gasseri</i></div></i></td><td style="border-bottom: solid #000000 0.5pt; border-color: rgb(0, 0, 0); border-left: solid #000000 0.5pt; border-right: solid #000000 0.5pt; border-style: solid; border-top: solid #000000 0.5pt; border-width: 0.5pt; overflow-wrap: break-word; overflow: hidden; padding: 0pt 5.4pt; text-align: center; vertical-align: middle;">Often in immunocompromised or following traumatic burns<sup>10,11</sup></td></tr></tbody></table></div>Table 1: Classification of necrotizing soft tissue infections<br /><br />FG is most common in patients with diminished host defenses, including diabetes mellitus, human immunodeficiency virus (HIV), immunosuppression, malignancy, and/or liver failure, as well as, those with a history of chronic alcohol use, but up to 30% of patients may have no other comorbidities.<sup>12,13</sup> Proximal risk factors for development of FG include trauma to the perineal area, including iatrogenic/procedural trauma or injection of drugs (cocaine, heroin, other injection drug use) into the surrounding vasculature.<sup>14,15</sup> Infections are often polymicrobial and a mixture of aerobes and anaerobic bacteria from the gastrointestinal tract, genitourinary tract or skin flora.<sup>16</sup> Up to 80% of cases of FG are polymicrobial and synergistic interactions between bacteria allow for rapid progression from cellulitis to critical ischemia to gangrene.<sup>6,13,17</sup><br /><br /><b>Challenges in Diagnosis:</b><br />The diagnosis of Fournier’s gangrene is clinical: There are no laboratory or imaging studies that can be used to definitively rule out disease. Diagnosis is often challenging, due to both the indolent course of some cases, and that deep infections can be severe despite minimal cutaneous findings. Onset of symptoms can vary widely, as some patients present from days to weeks, while others present with rapid progression to sepsis and multiorgan failure.<sup>18</sup> In patients presenting early, tenderness, erythema, or edema of the perineal area is common, and thorough physical exam of the genital region may be necessary to appreciate findings, especially in obese or obtunded patients.<sup>19</sup> More specific findings for FG, as opposed to cellulitis or other soft tissue infections, include crepitus upon palpation, bulla formation, putrid odor, purulent discharge and pain out of proportion to examination.<sup>20,21</sup> Imaging may be helpful in diagnosis or surgical planning but cannot rule out NSTI and may delay definitive surgical management. Conventional radiography may demonstrate presence of tissue emphysema but this finding has low sensitivity (49%) and may not be present in NSTI types II or IV that do not commonly contain clostridium species.<sup>22</sup> Computed tomography (CT) with IV contrast has a better sensitivity and specificity for NSTI, 88.5% and 93.3%, respectively, and findings include fluid collection, fat stranding and abscess.<sup>23-26</sup> While point-of-care ultrasound has a similar sensitivity and specificity to CT and the advantage of rapid nature of a bedside exam, CT is preferred if the patient is able due to ability to detect extent of necrosis and benefit potential benefit to surgical planning.<sup>22,27</sup><br /><br />Multiple risk calculators currently exist to aid in the clinical diagnosis of FG, relying primarily on vital signs and bloodwork to predict likelihood of FG, overall prognosis, or need for specific interventions. The sensitivity of these scores range, but they cannot exclude FG diagnosis and may have lower sensitivity when used for prediction in ED patient populations.<sup>28</sup> When specifically assessing mortality, the platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) are newer validated markers of physiologic stress that have been applied to a wide variety of inflammatory conditions.<sup>29</sup> In patients with FG, a PLR >140 and a NLR >8 have been associated with an 11.6 and 4.66-fold increased odds of mortality, respectively.<sup>30</sup> An <a href="https://www.mdcalc.com/neutrophil-lymphocyte-ratio-nlr-calculator">MDcalc assessment tool</a> exists for NLR, requiring the absolute (cells/μL) or % neutrophil and lymphocyte counts, and classifies patients based on physiologic stress levels, ranging from normal to severe.<sup>31</sup> Additionally, the monocyte-lymphocyte ratio (MLR) can be used to follow patients as higher MLR have been used to predict repeat surgical debridement.<sup>32</sup> Relying on easily and rapidly obtained information, these simple and low-cost tools may be particularly useful in low resource settings and in cases where time or severity of patient presentation does not permit additional workup.<br /><br /><b>Conclusion:</b><br />Positive outcomes in diagnosis and management of FG rely on rapid intervention as soon as it is suspected. A thorough physical exam, imaging, and laboratory studies can assist, but definitive diagnosis can only be made in the operating room. Newer validated scoring tools, such as the PLR, NLR, and MLR, may be some of the first results returned and offer faster risk stratification in FG, when time is of the essence. <br /><br /><b>References</b></span></div><div><span><br /><ol style="text-align: left;"><li><span>Short B. Fournier gangrene: an histori9]al reappraisal. Internal medicine journal. 2018;48(9):1157-1160.<br /><br /></span></li><li><span>Filippone LM. MD Diagnosis: Fournier's Gangrene, Emergency Medicine News: May 2005 - Volume 27 - Issue 5 - p 36.<br /><br /></span></li><li><span>Peetermans M, de Prost N, Eckmann C, Norrby-Teglund A, Skrede S, De Waele JJ. Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect. 2020;26(1):8-17.<br /><br /></span></li><li><span>Sugihara T, Yasunaga H, Horiguchi H, et al. 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Int J Surg Case Rep. 2019;62:65-68.<br /><br /></span></li><li><span>Mouraviev VB, Pautler SE, Hayman WP. Fournier's gangrene following penile self-injection with cocaine. Scand J Urol Nephrol. 2002;36(4):317-318.<br /><br /></span></li><li><span>Mishra SP, Singh S, Gupta SK. Necrotizing Soft Tissue Infections: Surgeon's Prospective. Int J Inflam. 2013;2013:609628.<br /><br /></span></li><li><span>Tang LM, Su YJ, Lai YC. The evaluation of microbiology and prognosis of fournier's gangrene in past five years. Springerplus. 2015;4:14.<br /><br /></span></li><li><span>Parry N. Fournier gangrene. Clin Case Rep. 2015;3(3):198-199.<br /><br /></span></li><li><span>Nigam V, Halim TA, Chhabra HS. Fournier's gangrene in a female with spinal cord injury: a case report. Spinal Cord. 2010;48(3):268-269.<br /><br /></span></li><li><span>Ferreira PC, Reis JC, Amarante JM, et al. Fournier's gangrene: a review of 43 reconstructive cases. Plast Reconstr Surg. 2007;119(1):175-184.<br /><br /></span></li><li><span>Torremade Barreda J, Millan Scheiding M, Suarez Fernandez C, et al. [Fournier gangrene. A retrospective study of 41 cases]. Cir Esp. 2010;87(4):218-223.<br /><br /></span></li><li><span>Wysoki MG, Santora TA, Shah RM, Friedman AC. Necrotizing fasciitis: CT characteristics. Radiology. 1997;203(3):859-863.<br /><br /></span></li><li><span>Cocanour CS, Chang P, Huston JM, et al. Management and Novel Adjuncts of Necrotizing Soft Tissue Infections. Surg Infect (Larchmt). 2017;18(3):250-272.<br /><br /></span></li><li><span>Levenson RB, Singh AK, Novelline RA. Fournier gangrene: role of imaging. Radiographics. 2008;28(2):519-528.<br /><br /></span></li><li><span>Rajan DK, Scharer KA. Radiology of Fournier's gangrene. AJR Am J Roentgenol. 1998;170(1):163-168.<br /><br /></span></li><li><span>Piedra T, Ruiz E, Gonzalez FJ, Arnaiz J, Lastra P, Lopez-Rasines G. Fournier's gangrene: a radiologic emergency. Abdom Imaging. 2006;31(4):500-502.<br /><br /></span></li><li><span>Castleberg E, Jenson N, Dinh VA. Diagnosis of necrotizing faciitis with bedside ultrasound: the STAFF Exam. West J Emerg Med. 2014;15(1):111-113.<br /><br /></span></li><li><span>Burner E, Henderson SO, Burke G, Nakashioya J, Hoffman JR. Inadequate Sensitivity of Laboratory Risk Indicator to Rule Out Necrotizing Fasciitis in the Emergency Department. West J Emerg Med. 2016;17(3):333-336.<br /><br /></span></li><li><span>Zahorec R. Ratio of neutrophil to lymphocyte counts--rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001;102(1):5-14.<br /><br /></span></li><li><span>Yim SU, Kim SW, Ahn JH, et al. Neutrophil to Lymphocyte and Platelet to Lymphocyte Ratios Are More Effective than the Fournier's Gangrene Severity Index for Predicting Poor Prognosis in Fournier's Gangrene. Surg Infect (Larchmt). 2016;17(2):217-223.<br /><br /></span></li><li><span>Zahorec R. Neutrophil-Lymphocyte Ratio (NLR) Calculator. Neutrophil-Lymphocyte Ratio (NLR) Calculator. Published 2020. Accessed.<br /><br /></span></li><li><span>Yíldírím A, Anuk T, Çığşar G. Clinical Value of the Monocyte-to-Lymphocyte Ratio for Determining Number of Debridements in Treatment of Fournier's Gangrene. Turkish Journal of Colorectal Disease. 2017;2017;27:43.</span></li></ol><div><br /></div><div><br /></div></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmHaI1sTJsXonk3vOuS8TnALbAFryrz4O-NME3dmx8JE8fmLnAVAm52Off8GCFDlYKpdvWCClaJl4O-axIRk5_ueQ_2IRty_IG_PMLRfq5MIeDfljhqLQidzOg6dcLVod6Pz2FpCk4vX5G/s1280/MRB.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="853" data-original-width="1280" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmHaI1sTJsXonk3vOuS8TnALbAFryrz4O-NME3dmx8JE8fmLnAVAm52Off8GCFDlYKpdvWCClaJl4O-axIRk5_ueQ_2IRty_IG_PMLRfq5MIeDfljhqLQidzOg6dcLVod6Pz2FpCk4vX5G/s320/MRB.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /></div></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-67978169569205826352020-12-01T16:46:00.001-06:002020-12-01T16:46:30.676-06:00Optimizing Medical Surge Capacity<div class="separator" style="clear: both; text-align: center;"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcqKZSYpNTgT9_oAh8Rm08DkfdPWvCbIExUmtbjm5l-UDb0-ZJEkCZni1JjQPYC7OOLgykzgopwGX7L-0xcqU1snRUBbCMBe9T3aDD6dFGMwSKgCxUgILOj6m7oDmSb77V45tgCEp_V2vY/s1024/170811-A-XN107-016.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><span style="color: black;"><img border="0" data-original-height="795" data-original-width="1024" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcqKZSYpNTgT9_oAh8Rm08DkfdPWvCbIExUmtbjm5l-UDb0-ZJEkCZni1JjQPYC7OOLgykzgopwGX7L-0xcqU1snRUBbCMBe9T3aDD6dFGMwSKgCxUgILOj6m7oDmSb77V45tgCEp_V2vY/s320/170811-A-XN107-016.jpg" width="320" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://media.defense.gov/2017/Aug/11/2001791733/-1/-1/0/170811-A-XN107-016.JPG"><i>U.S. Department of Defense</i></a><br /></td></tr></tbody></table><div style="text-align: start;"><br /></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="http://aaemrsa.blogspot.com/2014/09/new-peer-review-system-for-original.html" style="clear: left; display: inline; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="114" data-original-width="268" height="85" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizSaNQrkUm0KsK6Zo7FaalyKcOTPo3-YG8UkNG37NVM93sVBs1AeKatzun0fd5eZz9OK-gAkPNHM1uDCOMoOkbCINJRX_kJvaJXKOtzmimBgZTOxIp5a-6-gLZg2gRPZhHYnaQ2adkr_GV/w200-h85/PeerRev-FINAL.png" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><a href="http://aaemrsa.blogspot.com/2014/09/new-peer-review-system-for-original.html"><span style="color: #990000; font-size: x-small;"><b>This post was peer reviewed.<br />Click to learn more.</b></span></a></td></tr></tbody></table><div style="clear: left; display: inline; margin-bottom: 1em; margin-right: 1em; text-align: start;"><a href="http://aaemrsa.blogspot.com/2014/09/new-peer-review-system-for-original.html" style="clear: left; display: inline; margin-bottom: 1em; margin-right: 1em;"></a></div></div><div><br /></div><b>Authors:</b> Mary Unanyan, OMS-I <br />Gregory Jasani, MD; AAEM/RSA Secretary Treasurer<br /><br />The coronavirus pandemic has caused many to wonder whether our nation’s healthcare system can properly treat all of the projected critically ill patients. Experts worry that the sudden increase in sick patients may overwhelm existing healthcare resources. One way to determine how well hospitals are able to respond to this pandemic is to look at the “surge capacity” of the health system. <br /><br />Medical surge capacity is a measure of the ability of a health system to manage care for a sudden increased volume of patients beyond the normal operating capacity.<sup>1</sup> <div> <br /><span><a name='more'></a></span><br />Surge capacity involves managing supply and demand—particularly, how to cope with a mismatch in resources and need. Factors that impact surge capacity are often thought of as the “4 S’s.”<sup>2</sup> The 4 S’s are: <br /><ol style="text-align: left;"><li>Staff: Having enough trained personnel to manage an influx of patients<br /><br />Personnel would include all staff—physicians (MD/DO), physician assistants, nurses, technicians, administrators, housekeeping, etc. Each member plays a vital role in the ability of a hospital or healthcare system to efficiently operate.<br /><br /></li><li>Supplies: Having enough supplies and equipment to properly treat patients<br /><br />Supplies include durable equipment, such as cardiac monitors, intravenous (IV) pumps, ventilators, wheelchairs, and beds, as well as consumable supplies, such as medications, intravenous fluids, syringes, sutures, and personal protective equipment.<br /><br /></li><li>Structure: Having enough physical space to accommodate these patients<br /><br />Hospitals are the most common referred to “structure,” where surge plans can modify traditionally non-medical areas (waiting room, hallways, etc.) into temporary treatment areas. Additionally, there are ideas to create new patient treatment areas outside of hospitals if necessary—for example, utilizing local convention centers, trailers, and/or other public health facilities.<sup>3</sup><br /><br /></li><li>Systems: Having policies and procedures in place to allow for the rapid expansion in clinical care provided to accommodate the surge<br /><br />Well thought-out policies and procedures enable normal systems to translate smoothly into “surge” protocol to ensure an efficient and sustainable clinical response. </li></ol><div>In order to properly respond to an influx of patients, all four factors must be optimized. For example, having adequate supplies in stock would be meaningless without the proper number of trained staff to utilize them. During the coronavirus pandemic, we have seen healthcare systems struggle with all aspects of surge capacity. Lack of adequate personal protective equipment and ventilators is a supply issue. Asking for retired physicians to rejoin the workforce is an attempt to increase staffing numbers.<sup>4</sup> Hospitals are converting many spaces into non-traditional intensive care units (ICUs) to try and create more structure.<sup>5</sup> Many health systems have also had to make changes to their policies (systems) to accommodate the new realities of providing care during the pandemic.<br /><br />Surge capacity is an important concept for us as emergency medicine physicians as we are often the first ones to receive these patients. Most emergency departments (EDs) already have disaster plans outlining how they will respond to a sudden influx of critically ill patients. Yet, we must also be cognizant that the surge preparedness of other units will affect the ability of the ED to operate efficiently. If other floors cannot accommodate a surge of critically ill patients, this will trickle down and negatively impact the ED's operations. For example, if the medicine service cannot accept an additional influx of patients, then those patients will not be able to leave the ED. If those patients cannot leave and remain in the ED beds, then this will cause a backup and decrease the department's ability to triage and care for the influx of new patients.<br /><br />As emergency medicine physicians, we must take an active role in preparing our hospitals for a surge in critically ill patients. The coronavirus pandemic will one day be behind us, we must remember the valuable lessons that it taught us about our healthcare system’s room for improvement. One way to improve our response is to optimize surge capacity so that when the next disaster hits, we can provide the best care possible to our patients. <br /><b><br />References</b><br /><ol style="text-align: left;"><li>U.S. Department of Health and Human Services. What is medical surge? Updated February 14, 2012. Accessed April 6, 2020.<br /><br /></li><li>Phillips, S. Current status of surge research. Acad Emerg Med. 2006;13(11): 1103-1108. doi:10.1197/j.aem.2006.07.007<br /><br /></li><li>Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3):253‐261.<br /><br /></li><li>Farrell C. COVID-19 draws retired doctors back to work. PBS News Hour website. March 30, 2020. Accessed April 8, 2020.<br /><br /></li><li>Condon A, Vaidya A, Paavola A. New York City’s public health system to convert all facilities into ICUs + 20 other updates from the 6 hardest hit states. Becker’s Hospital Review website. April 2, 2020. Accessed April 10, 2020. </li></ol></div></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-10379254674819043202020-11-23T14:02:00.004-06:002020-11-23T14:05:01.487-06:00The Gender Gap in Medical Leadership: Glass Ceiling, Domestic Tethers, or Both?<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6ybGaP5VPtXHrV0MrgzJEHlXKgdSXA3s7KHy8O29ovGO23KfabrPmj2f_osQzDbEQMcyNB872OuPuNY8B9NubNwnwyZg3HmIy7NR2tu-yx67l5wwQ_WkDmvXBDmoYJdXeiWZB9J_y2sxI/s2048/pexels-tim-mossholder-1722196.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6ybGaP5VPtXHrV0MrgzJEHlXKgdSXA3s7KHy8O29ovGO23KfabrPmj2f_osQzDbEQMcyNB872OuPuNY8B9NubNwnwyZg3HmIy7NR2tu-yx67l5wwQ_WkDmvXBDmoYJdXeiWZB9J_y2sxI/s320/pexels-tim-mossholder-1722196.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.pexels.com/photo/male-and-female-signage-on-wall-1722196/">Pexels</a></i></td></tr></tbody></table><b>Authors:</b> Eveline Hitti, MD MBA FAAEM<div>Lisa A. Moreno, MD MS MSCR FAAEM FIFEM <div>Originally published: <i><a href="https://issuu.com/aaeminfo/docs/mayjun_2017_common_sense_-_web?e=11123710/49736441">Common Sense</a></i><br />May/June 2017<br /><div><br />The number of women enrolled in medical schools has risen from less than 25% in the 1970s to over 47% today.<sup>1,2</sup> In spite of this, we continue to see striking under-representation of women in leadership positions in academic medicine, professional organizations, and health services in general. Women comprise only 38% of full-time faculty, 21% of full professors, and 30% of new tenures in academic medicine. Only 18% of hospital CEOs are women, and the percentage of female department chairs and deans at US medical schools remains low, at 15% and 16% respectively.<sup>2,3</sup> This leadership gap is not unique to medicine. It mirrors trends in law, where women continue to constitute a disproportionate minority of partners within firms; and business, where women are less likely than men to hold corporate executive positions. In the past this discrepancy could be explained by a higher percentage of male medical and professional school graduates. Yet today, when the percentage of females in medical school, law school, and business school equals or exceeds the percentage of males, a significant leadership gap persists. <br /><br /><span><a name='more'></a></span><br /><br />Much of the literature on the leadership gap has focused on the seemingly impenetrable “glass ceiling” effect of institutional culture and structure, which prevents women from advancing to senior positions. The glass ceiling is supported by conscious and unconscious gender stereotypes and biases, lack of policies that support work-life balance, lack of mentors or role models for women interested in high-level career advancement, and a paucity of networks that can open doors to women.<sup>3</sup> Sheryl Sandberg’s recent book, <i>Lean In</i>, focused attention on the individual factors that hinder the advancement of women and has challenged women to overcome their own low expectations and self-defeating behaviors. But are these institutional and individual challenges the main road blocks for women? Are education programs so egalitarian in their policies and cultures that women succeed at the training phase of their careers but fall out in the employment phase, or is there another factor at play?<br /><br />A closer look at the issue of gender equity at home might begin to explain some of the disparities at work. Women continue to shoulder the lion’s share of unpaid domestic work, be it household chores or parenting responsibilities, even in countries where they constitute more than half the workforce. In Australia, women spend twice as much time as men on child-care and unpaid household work.<sup>4</sup> In the U.S., where women constitute 50% of the labor force, they spend an average of 40 hours a week — the equivalent of a second full time job — performing domestic work in the home. Although U.S. fathers have certainly increased their domestic workload over the past 40 years, on a weekly basis it remains half a mother's.<sup>5</sup> Disparities in household responsibilities have historically been explained by economic calculations, but this doesn't necessarily hold in medicine, where the earning potential of both women and men is high. Yet studies on domestic responsibilities have found the same pattern of gender inequity in physician domestic partnerships as in the general population. Shollen et al. report that, despite spending equal hours at work, female academic medical faculty spent substantially more time per week on domestic work than their male colleagues (31 hours vs 19).<sup>6</sup> Jolly et al. found that among high-achieving young physician researchers who were married or partnered, women spent 8.5 hours more per week on domestic activities.<sup>7</sup> Even within specialties notorious for poor work-life balance such as surgery, where average working hours per week are around 60, conflicts between work and personal demands were resolved in favor of the female surgeon’s work only 59% of the time, compared to 87.3% of the time for male surgeons.<br /><br />The implications of such domestic inequities on the career advancement of women are significant. Over two-thirds of high-achieving women decrease their work schedules during their careers, and approximately one third take extended leave from their jobs. In a study of Spanish physicians Ariizabalga found that, after completing their specialty training, women held more than twice the number of part-time medical positions as men. Consequently, while their male colleagues were applying for promotions, female physicians with similar years of professional experience had not yet moved into full-time positions.<sup>8</sup> While approximately half the graduating medical students in the U.S. are women, only 38% of full-time faculty positions are held by women and the departure of women from full-time academia is disproportionately higher than that of men.<sup>2</sup> In the UK's National Health Service, 63% of women work part-time compared to 8% of men.<sup>9</sup> While these flexible tracks may help women remain in the workforce during the demanding child-rearing years, getting off track can be detrimental to career advancement and promotion, especially in comparison to men who usually start and remain in full-time service.<sup>3,10</sup><br /><br />Women who remain in full-time employment are not immune to the impact of domestic tethers on career advancement. Family responsibilities compete with work responsibilities in the lives of female physicians far more frequently than in the lives of their male colleagues. A large cross-sectional survey of U.S. surgeons found that female surgeons were five times more likely to care for a child home from school than male surgeons. In addition, they more often subjugated their career for their spouse's/partner’s when work-life conflicts arose and were more likely to report that their commitment to their children deterred their career advancement. Another study that looked at gender differences in the domestic and parenting work of high-achieving young physician researchers found that women spent more time on household work and less time on research than their male colleagues, suggesting that when home responsibilities compete with research responsibilities, the research productivity of women is more likely to be impacted.<sup>7</sup> The gender disparity in the burden of domestic work inevitably places women at a disadvantage compared to men, who are more at liberty to invest additional time in work and who experience fewer work-life disruptions.<br /><br />The impact of these disparities stretches beyond productivity and work time. In a qualitative study exploring under-representation of women in leadership positions, one male study participant described his advantage over women: “I could at any time turn up to a meeting on a weeknight. I could be away overnight. I could do what I have to do to be noticed and available.”<sup>1</sup> A woman's more restricted ability to attend off-hour meetings and other functions may exclude her from opportunities and from the notice of those who have the power to advance her career. And the restricted mobility of women, who are more likely to be in two-career relationships, can also limit opportunities and advancement options. In a study exploring barriers to leave, female faculty eligible for leave took fewer and shorter sabbaticals.<sup>11</sup> In a survey of health care executives, less than 60% of women reported a willingness to move in pursuit of career advancement compared to more than 75% of men.<sup>3</sup><br /><br />Understanding the impact of domestic tethers should not belittle the daunting barrier of the glass ceiling. Even in specialties such as pediatrics and ob-gyn, where women are an overwhelming majority, only 20% and 22% of department chairs are female. This indicates the enduring strength of cultural and structural barriers. At the same time, understanding that equity at work cannot be achieved without equity at home is critical to the advancement of female professionals. Our culture must set an expectation of equitably allocated responsibilities between partners at home, and institutions need to make success possible for both men and women with significant family responsibilities by investing in on-site child care, fitting meetings and development opportunities into regular work hours, and introducing parental leave policies that recognize men as equal partners at home and women as equal partners at work. <br /><br /><b>References</b><br /><ol style="text-align: left;"><li>Bismark M, Morris J, Thomas L, Loh E, Phelps G, Dickinson H. Reasons and remedies for under-representation of women in medical leadership roles: a qualitative study from Australia. BMJ Open. 2015;5(11):e009384.<br /><br /></li><li>Lautenberger D, Dandar V, Raezer C, Sloane R. The State of Women in Academic Medicine. The Pipeline and Pathways to Leadership. Wahington, DC: 2014.<br /><br /></li><li>Chisholm-Burns MA, Spivey CA, Hagemann T, Josephson MA. Women in leadership and the bewildering glass ceiling. Am J Health Syst Pharm. 2017;74(5):312-24.<br /><br /></li><li>Trends in Household Work. Australian Bureau of Statistics, 2009.<br /><br /></li><li>Bianchi SM, Sayer LC, Milkie MA, Robinson JP. Housework: Who Did, Does or Will Do It, and How Much Does It Matter? Soc Forces. 2012;91(1):55-63. http://workplaceflexibility.org/images/uploads/program_papers/bianchi_-_family_change_and_time_allocation_in_american_families.pdf<br /><br /></li><li>Shollen SL, Bland CJ, Finstad DA, Taylor AL. Organizational climate and family life: how these factors affect the status of women faculty at one medical school. Acad Med. 2009;84(1):87-94.<br /><br /></li><li>Jolly S, Griffith KA, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers. Ann Intern Med. 2014;160(5):344-53.<br /><br /></li><li>Arrizabalaga P, Abellana R, Viñas O, Merino A, Ascaso C. Gender inequalities in the medical profession: are there still barriers to women physicians in the 21st century? Gac Sanit. 2014;28(5):363-8.<br /><br /></li><li>Svirko E, Goldacre MJ, Lambert T. Career choices of the United Kingdom medical graduates of 2005, 2008 and 2009: questionnaire surveys. Med Teach. 2013;35(5):365-75.<br /><br /></li><li>Grisso JA, Hansen L, Zelling I, Bickel J, Eisenberg JM. Parental leave policies for faculty in U.S. medical schools. Ann Intern Med. 1991;114(1):43-5.<br /><br /></li><li>Smith D, Spronken-Smith D, Stringer R, Wilson CA. Gender, Academic careers and the sabbatical: A New Zealand case study. Higher Education Research and Development. 2015;35(3).</li></ol></div></div></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-11797985748319251642020-11-15T17:32:00.001-06:002020-11-15T17:32:29.268-06:00 From Chaos to Clarity: Leadership in the Resuscitation Bay<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_Cm-P6jpPCC-bZKBuGOeGJceNs-BLakIMwFM-49Am1p_zSfvqxviPv_JvekSje6FU6e1fKF8c5ce3i2w2OSKTqBflcgHVK7d1HyrBAI1F2gVwuz6MPebjeaaYdsjttVc9UwmNkez8clw8/s2048/pexels-karolina-grabowska-4021779.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_Cm-P6jpPCC-bZKBuGOeGJceNs-BLakIMwFM-49Am1p_zSfvqxviPv_JvekSje6FU6e1fKF8c5ce3i2w2OSKTqBflcgHVK7d1HyrBAI1F2gVwuz6MPebjeaaYdsjttVc9UwmNkez8clw8/s320/pexels-karolina-grabowska-4021779.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.pexels.com/photo/crop-doctor-with-stethoscope-in-hospital-4021779/">Pexels</a></i></td></tr></tbody></table><b>Author:</b> Mary Haas, MD<br />Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />November/December 2016<br /><br />You are managing a busy emergency department, when you hear via the overhead paging system that a new patient has arrived in your resuscitation bay. You scurry from the farthest corner of your department, where you were evaluating a patient with multiple chronic medical problems and multiple complaints. As you book it to the resuscitation bay, you carry the weight of several sick patients you are managing and the knowledge of several on stretchers waiting to be seen, not to mention the full waiting room. You arrive at the resuscitation bay, where a group of people are bustling around as if a storm is about to hit. You see the ambulance pull up to the doorway with lights flashing. In this moment, as leader of the resuscitation, you have the responsibility to transform chaos into clarity.<br /><br /><span><a name='more'></a></span><br />As I transition into my senior year of residency, this common scenario challenges me to reflect on and improve my leadership and communication skills. What makes a physician a good leader in the resuscitation bay?<br /><br />Be calm. <br /><br />Watching the physicians I most respect and admire in the resuscitation bay, I’ve realized the number one characteristic of an excellent leader is the ability to remain calm. The leader’s attitude and demeanor set the tone for the entire room, and a composed demeanor calms the environment and allows the leader to maintain control of the situation. Remaining calm eases the surge of adrenaline that accompanies the management of a crashing patient, allows one to think clearly and see the big picture, and leads to a safer and better resuscitation.<br /><br />Along these lines, employing “noise discipline” to keep the room quiet will improve the team’s overall ability to focus and communicate. A resuscitation often attracts a crowd; as team leader it is important to ensure that only those who are actively participating in the care of the patient and contributing to the work of the team remain present.<br /><br />Brief the team. <br /><br />Having a few minutes after the notification of a critically ill patient's impending arrival, to gather the team and get everyone on the same page, is an opportunity to be seized. This precious time can have a hugely positive impact on the flow and success of a resuscitation. Take this time to introduce all members of the team; clearly delineate roles; prepare for procedures by having the necessary equipment handy; and create a shared mental model of the patient’s current status, plan, and anticipated disposition. This time also allows the team to ask questions. It is during this time that I reiterate to my team that we will maintain a calm and quiet environment.<br /><br />Be clear and decisive. <br /><br />The team leader’s role is to step back and monitor the “big picture,” to ensure the appropriate order of interventions and their correct completion. To be an effective leader, it is critical that the physician is clear and decisive when communicating orders to the team. This is where closed loop communication comes into play, allowing the sender to know that the request has been heard and the receiver to clarify and confirm. When asking that something be done, make direct eye contact, state the name of the person you talking to, and be as specific as possible. For instance: “Jim, please place a second large-bore IV” is better than “can someone place a second IV?” Also, when requesting that a medication be administered, make sure to clarify the dosage and route. For instance: “Karen, please give 1 gram of calcium chloride via the femoral line?”<br /><br />Debrief. <br /><br />After every resuscitation, make an effort to gather your team and debrief. What went well? What could have gone better? This may only take a few minutes of your time, but will bring you closer with your team and improve future resuscitations. It will also help you grow as a leader and show your team that you care about their feedback. Debriefing can also help the group cope with a difficult outcome.<br /><br />Ultimately, the best way to improve one’s leadership skills in the resuscitation bay is to practice, reflect, and seek feedback. Observing my role models run resuscitations has also helped me to identify and mimic behaviors that lead to better team dynamics and better patient care. For many of us, it was the challenge of caring for the critically ill patient that drew us to emergency medicine. Mastering these skills helps us find satisfaction and meaning in our work.AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-10045821062966834002020-11-08T18:43:00.005-06:002020-11-09T18:58:53.838-06:00Meditation in Medicine<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmT13jXCUvt9mvHHxgV8YWWOilPlCClN6PLHqDqE3_RoBXDLEOIJAZjAus8-cSlPui486XQ5c6ZnECu9KaBKhRM2XktKkiKtkRCgndENleSW0DUvHO_oDqlkfHQHomASjeAQNFuhAB8jhD/s2048/pexels-andrea-piacquadio-3772612.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmT13jXCUvt9mvHHxgV8YWWOilPlCClN6PLHqDqE3_RoBXDLEOIJAZjAus8-cSlPui486XQ5c6ZnECu9KaBKhRM2XktKkiKtkRCgndENleSW0DUvHO_oDqlkfHQHomASjeAQNFuhAB8jhD/s320/pexels-andrea-piacquadio-3772612.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.pexels.com/photo/woman-meditating-in-bedroom-3772612/"><span style="color: #cc0000;">Pexels</span></a></i><br /></td></tr></tbody></table><b>Author: </b>Puja Gopal, MD<br />University of Illinois College of Medicine<br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2Nmnv-6VaL9BmCtRmjCxIoXEIoJQpdGb4yu5MisRSIo258lr7lddpPQwQi6j7-9ZrC2_NIWUpBcdSkzTXDPS3jzE6HEspeuFDVXntVc3JNDkoyHOXAGdk1e7Kj0E2gQEwUZcmCp5fAkLs/s200/RSA+Peer+Reviewed+Logo.png" style="clear: right; display: inline; margin-bottom: 1em; margin-left: auto; margin-right: auto; padding: 1em 0px; text-align: center;"><img alt="" border="0" data-original-height="85" data-original-width="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2Nmnv-6VaL9BmCtRmjCxIoXEIoJQpdGb4yu5MisRSIo258lr7lddpPQwQi6j7-9ZrC2_NIWUpBcdSkzTXDPS3jzE6HEspeuFDVXntVc3JNDkoyHOXAGdk1e7Kj0E2gQEwUZcmCp5fAkLs/s200/RSA+Peer+Reviewed+Logo.png" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><a href="http://aaemrsa.blogspot.com/2014/09/new-peer-review-system-for-original.html"><span style="color: #cc0000;"><b>This post was peer reviewed. <br />Click to learn more.</b></span></a><br /></td></tr></tbody></table><br />Recently when watching the evening news, I came across an interesting segment focusing on how teaching meditation in middle and high schools in San Francisco has led to many positive measurable changes. School officials have noted better attendance, better academic performance, and at least a 75 percent decrease in suspensions over a period of four years.<br /><br />Meditation and relaxation techniques have garnered a lot of attention lately and have become the focus of much research. A brief literature overview on the potential impact meditation can have, especially in the field of emergency medicine, follows below. For emergency physicians, who operate in high-stress environments; attend to multiple tasks, often simultaneously; and must manage 'the busy pit', overall wellness becomes especially important. Wellness is reflected in one's even mindedness and control during high stress situations such as coding patients; one’s focus and concentration during shifts of high volume; and one’s resiliency, especially after bad outcomes. Stress reduction techniques are thus essential to maintain wellness and happiness and avoid burn-out.<br /><br /><span><a name='more'></a></span><br /><div> An article published in the American Journal of Hypertension found that transcendental meditation, the simple act of sitting down with the eyes closed for 20 minutes, can help decrease rates of heart attacks and strokes by about 40% in high risk patients.<sup>2</sup> Similarly, in another study published in Psychiatry Research: Neuroimaging, researchers reported changes in brain gray matter density in those who meditated. Participants underwent an 8-week mindfulness based stress reduction program and had MRIs done both before and after the program. The meditation group had an increase in gray matter concentration in the hippocampus - an area of the brain involved in learning, memory, and empathy.<sup>3</sup> For emergency physicians, this improved physical health, stress reduction and neural processing may lead to multiple dividends including improved patient care, better productivity and increased satisfaction.<br /><br />Meditation can also help with mood and prevent burnout. In a study published by JAMA, primary care physicians underwent an 8 week course on mindfulness meditation and self awareness exercises and were found to experience significant benefits, including improvements in feelings of burnout and emotional exhaustion, personal accomplishment, empathy and mood disturbances.<sup>4</sup><br /><br />The ability to be 'in the zone' improves focus and concentration as well as work output. Try to be the calmest person in the room regardless of what is going on. Carve out a few minutes, which can be as little as 5-10 minutes, in your day to mediate. First find a comfortable position - you can be sitting on a chair, but keep your spine straight. Close your eyes and focus just on your breathing and allow yourself to relax in the present moment. Even if your mind drifts, return to focusing on your breathing. Meditation is an art, and with time and practice it will become easier and lead to great benefits.<br /><br /><b>References<br /></b><ol style="text-align: left;"><li>San Francisco schools transformed by the power of meditation. NBC News. http://www.nbcnews.com/nightly-news/san-francisco-schools-transformed-power-meditation-n276301. Accessed December 30, 2014.<br /><br /></li><li>Schneider R, Alexander C, Staggers F, et al. A randomized controlled trial of stress reduction in African Americans treated for hypertension for over one year. American Journal of Hypertension. 2005; 18(1): 88-98. doi: 10.1016/j.amjhyper.2004.08.027<br /><br /></li><li>Holzel B, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging. 2010; 191(1): 36-43. doi: 10.1016/j.pscychresns.2010.08.006<br /><br /></li><li>Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy and attitudes among primary care physicians. JAMA. 2009; 302(12): 1284-93. doi: 10.1001/jama.2009.1384</li></ol></div>AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-14810050351311746122020-11-01T13:43:00.005-06:002020-11-03T14:08:35.290-06:00The Open Door<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7L34BgaszM657yrKEau4KxpioBuPYIZNKuWOV8jO69RFN7Vrdz1wO2SF-NV2LmkwdWDypMtaLcnRly1sQXeQwpQDGoGAt4WQCdaehjL4MPQefhJ5IrkbQD-Do2lLGTWbKLvFBVeb0BIMi/s2048/pexels-sharon-mccutcheon-3859982.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7L34BgaszM657yrKEau4KxpioBuPYIZNKuWOV8jO69RFN7Vrdz1wO2SF-NV2LmkwdWDypMtaLcnRly1sQXeQwpQDGoGAt4WQCdaehjL4MPQefhJ5IrkbQD-Do2lLGTWbKLvFBVeb0BIMi/s320/pexels-sharon-mccutcheon-3859982.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.pexels.com/photo/cold-snow-love-art-3859982/">Pexels</a></i><br /></td></tr></tbody></table><b>Author:</b> Lauren Lamparter – Medical Student Council President<div>Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />September/October 2020<br /><br />One of the reasons I am drawn to and pursuing a career in emergency medicine is its open-door policy — all are welcome, regardless of their ability to pay, the color of their skin, their legal status, or their sexual orientation. The emergency department (ED) is open 24-hours a day, seven days a week, 365 days a year to serve those in need, no matter their ailment or chief complaint. It is a place where there should be no discrimination based on race, religion, insurance status, or gender. All are welcome and will be taken care of with the priority of receiving the best care we can possibly give. I aspire to be an emergency medicine physician so I too can be a champion of health for all; someone who can set aside my implicit biases and provide for a fellow human who is in need of help. </div><div><br /></div><span><a name='more'></a></span><div><br />Throughout this year, the many inequalities ingrained into our societal practices, culture, and policy have become even more apparent. The global pandemic has highlighted health care inequalities across cultural divides right at home, in our neighborhoods, and across the globe. The health disparities and social structures preventing some people the privilege of social distancing or being able to work from home has led to a disproportionate amount of deaths in minority groups and those of lower socioeconomic status. The system is broken and places limits on the value of a human life, and this pandemic has only highlighted the innate disparities in access to care of our health care system. The ED and its open door has remained the safety net for many patients who lack basic, primary preventative health care. Unfortunately, many of these patients often arrive too late in their disease course to actually help preserve their lives.<br /><br />Moreover, the death of George Floyd and so many other innocent Black people such as Breonna Taylor and Rayshard Brooks, have highlighted the racial injustices and inequalities pervasive in our society. Discrimination by race devalues human life and communicates to people that just because of the color of their skin, they are not welcome. Across the country, physicians, medical students, and other health care workers have been standing in solidarity with silent reflection over the eight minutes and 45 seconds it took to murder George Floyd. The goal was and is to raise awareness for administration and leadership both in medicine and more broadly across the country to critically examine our own racist history, lack of diversity in leadership, and promotion of policies that will work toward greater racial equality. While this article will be published long after our expressions of unity and solidarity, we cannot return to complacency in regard to racial inequality. We have to start somewhere and as future physicians, medical students have the ability to create a shift in our thinking now to promote equality for all humans alike. All humans are equal members of American society and are entitled to justice. Human life is worth saving, Black lives are worth saving. <br /><br />Even as the doors of the ED remain open to all, emergency medicine physicians, residents, and medical students need to be aware of their unintentional biases and how this can affect patient care. Many studies have examined bias and shown that disparities exist within the ED, including differences in pain management, triage assessment accuracy, wait times, and resource utilization. I personally was raised with “white privilege,” and I am aware of the assumptions I have made in falsely believing it was better to be “color blind” as a method of seeking equality. I am working to educate myself and my colleagues on the importance of understanding both the differences and similarities we, as racially diverse persons, bring to society as a whole. As we interact with an extremely diverse population and our innate decisions often determine life and death, emergency medicine physicians must stand in that gap and be the difference makers. We stand at the open door, so we must be the first to work toward active change in our mindsets as we pursue justice in both medicine and humanism.</div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-64288311144519491892020-10-23T14:25:00.001-05:002020-10-27T15:21:07.522-05:00Human Trafficking: A Review for Health Care Providers <table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDnBnHXvQQOIzvsS7-KObMXsyhxFQJ9i3bKFzkxC7POhxNkwk5EEzRui3peOuK_1-OZu7wM5atnMAtuxHx9VpdqjFOP7VltApOfrUqzY2lHmNIbT2FDCMrIDQi47OqB4BeOwRjIj_3PDh4/s2048/pexels-travis-saylor-951408.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDnBnHXvQQOIzvsS7-KObMXsyhxFQJ9i3bKFzkxC7POhxNkwk5EEzRui3peOuK_1-OZu7wM5atnMAtuxHx9VpdqjFOP7VltApOfrUqzY2lHmNIbT2FDCMrIDQi47OqB4BeOwRjIj_3PDh4/w320-h213/pexels-travis-saylor-951408.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.pexels.com/photo/cyclone-fence-in-shallow-photography-951408/">Pexels</a></i></td></tr></tbody></table><b>Authors:</b> Nicole E. McAmis; Angela C. Mirabella; Elizabeth M. McCarthy; Cara A. Cama, MBA; and Frank H. Netter, MD <br />Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />September/October 2020<div><b><br /></b></div><div><b>Background </b><br />The U.S. Department of State defines human trafficking in The Trafficking Victims Protection Act of 2000 as: <br /><div><ul><li>Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age; or</li><li>The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.<sup>1</sup></li></ul><b><div><span><a name='more'></a></span><span></span><b><br /></b></div><div><b><br /></b></div>Introduction </b><br />Human trafficking is a violation of human rights and a global pandemic. Health care providers are often the first group of professionals to interact with victims of human trafficking with over 88% of victims seeking medical care in a variety of health care settings.<sup>2,3</sup> These health care professionals provide not only medical care for various concerns, but also emotional and psychological support. <br /><br />Medical complaints can include infectious diseases, physical violence, sexual abuse, pelvic pain, hazardous working conditions, unintended pregnancies, abortions, malnutrition, dental disease, anxiety, chronic pain, posttraumatic stress disorder (PTSD), depression, substance use disorders, suicidal ideations, or suicide attempt.<sup>4</sup> Unfortunately, many health care providers lack the knowledge and tools needed to recognize these victims. In this post, we will dive into some basic information that all health care providers need to identify victims of human trafficking. <br /><b><br />Risk Factors<sup>5</sup> </b><br /><ul style="text-align: left;"><li>Poverty</li><li>Racial/ethnic minority status</li><li>Marginalized individuals: LGBTQ, runaway youth, Native Americans, indigenous people</li><li>Rural location</li><li>Lack of education</li><li>Disability</li><li>Inadequate family support and protection</li><li>Migration</li></ul><b>Red Flags + Indicators<sup>6</sup> </b><br /><ul style="text-align: left;"><li>Someone else is speaking for the patient and refuses to let the patient have privacy</li><li>Exhibits fear, anxiety, or tension</li><li>Reluctant to explain his/her injuries or shared a scripted/inconsistent history</li><li>Tattoos or other forms of branding are visible</li><li>Reports an unusually high number of sexual partners, STDs, pregnancies, miscarriages, or terminations</li><li>Uses language [or slang] common in the commercial sex industry</li></ul><b>Appropriate Questions + Screening Tools<sup>6,7</sup> </b><br /><ul style="text-align: left;"><li>What are your working or living conditions like?</li><li>Have you ever been deprived of food, water, sleep, or medical care?</li><li>Can you leave your job or situation if you want?</li><li>Can you come and go as you please?</li><li>Who is the person who came with you today? Can you tell me about them?</li><li>Have you ever been threatened or intimidated? </li><li>Has anyone threatened to hurt you or your family if you leave? </li><li>Do you have a debt to someone you cannot pay off? </li><li>Is someone holding your identification documents (passport, visa, driver’s license)? </li><li>Did you ever feel pressured to do something that you didn’t want to do or felt uncomfortable doing? </li><li>Have you ever been told to have sex with people you don't want to have sex with?</li><li>Have you been forced to engage in sexual acts for money or favors? </li><li>Does anyone take all or part of the money you earn? </li><li>Do you have to meet a quota of money each night before you return home?</li></ul><div class="BCX0 SCXW166597272" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; margin: 0px; padding: 0px; user-select: text;"><b>When Approaching Questions </b><br /><ul style="text-align: left;"><li>Conduct the assessment in a comfortable, private location with a social worker or advocate present whenever possible</li><li>Conduct the interview in the potential victim’s native language and use a professional, neutral interpreter if needed</li><li>Ask others present to leave for the interview and examination </li><li>Use an approachable tone, demeanor, and body language that remains neutral and is non-judgmental</li><li>Refrain from taking notes while in the room to promote active listening </li><li>Assure confidentiality, unless the situation invokes state mandatory reporting laws (i.e. persons in grave danger, minors under the age of 18 years, or persons with disabilities)</li><li>Victims may find it easier to speak with a provider who is of the same sex, ethnicity, or age range </li><li>Reference existing institutional protocols for victims of abuse</li><li>Before you begin, do a safety check: </li><ul><li>Is it safe for you to talk with me right now? </li><li>Do you feel safe right now? </li><li>Do you feel like you are in any kind of danger for speaking with me?</li></ul></ul></div><b>Next Steps </b><br />After addressing the immediate needs of your patient and obtaining informed consent, consider calling the National Human Trafficking Resource Center (NHTRC) hotline at 1-888-373-7888.<sup>8</sup> The NHTRC can help assess the current level of danger, provide further recommendations, identify local resources, and potentially involve law enforcement. In situations of life-threatening danger, follow your institutional policies for reporting to law enforcement. <br /><br />Some items to consider include: <br /><ul style="text-align: left;"><li>Presence of the trafficker in patient room, waiting room, or home </li><li>Potential that calling the hotline may put the patient or the patient’s family in danger </li><li>Age of patient</li></ul>It is vital that you help the patient memorize the phone number, so they can call 1-888-373-7888 or text HELP or INFO to BeFree (233733) at a later time. Please avoid giving the patient physical materials including written notes or brochures that could place them at increased risk if detected. <br /><br /><b>Closing </b><br />Health care providers are in a unique and powerful position to serve as the first responders for victims of human trafficking. We hope this article has provided you with some tips and tools to utilize in your practice and profession. <br /><br />Many health care professionals have shared concerns about the lack of quality training available on this topic. As such, we sought to identify the self-reported knowledge level of providers on the global issue of human trafficking. Please keep an eye out for the results of our study in a future publication. <div class="BCX0 SCXW166597272" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; font-family: "Arial Narrow", "Arial Narrow_MSFontService", sans-serif; font-size: 14.6667px; margin: 0px; padding: 0px; user-select: text;"><div class="OutlineElement Ltr BCX0 SCXW166597272" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; clear: both; cursor: text; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;"><p class="Paragraph BCX0 SCXW166597272" paraeid="{8ab6f851-b2e1-467d-9e88-318fb5281b91}{92}" paraid="1530533058" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; margin: 0px; overflow-wrap: break-word; padding: 0px; user-select: text; vertical-align: baseline;"><span class="TextRun BCX0 SCXW166597272" data-contrast="none" face=""Arial Narrow", "Arial Narrow_EmbeddedFont", "Arial Narrow_MSFontService", sans-serif" lang="EN-US" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-kerning: none; font-size: 11pt; font-variant-ligatures: none; line-height: 18.3458px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-US"><span class="NormalTextRun BCX0 SCXW166597272" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: inherit; margin: 0px; padding: 0px; user-select: text;"></span></span><span class="EOP BCX0 SCXW166597272" data-ccp-props="{}" face=""Arial Narrow", "Arial Narrow_EmbeddedFont", "Arial Narrow_MSFontService", sans-serif" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-size: 11pt; line-height: 18.3458px; margin: 0px; padding: 0px; user-select: text;"> </span></p></div></div><b>References: </b><ol style="text-align: left;"><li>U.S. Department of State. Trafficking in Persons Report June 2019. Available at: <a href="https://www.state.gov/wp-content/uploads/2019/06/2019-Trafficking-in-Persons-Report.pdf">https://www.state.gov/wp-content/uploads/2019/06/2019-Trafficking-in-Persons-Report.pdf</a>. Accessed May 2020.</li><li>Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):36-49.</li><li>Isaac R, Solak J, Giardino AP. Health Care Providers' Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene. Journal of Applied Research on Children: Informing Policy for Children at Risk. 2011;2(1).</li><li>Lederer, Laura. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Health care Facilities. Annals of Health Law. 2014;23(61).</li><li>Zimmerman C, Yun K, Shvab I, et al. The health risks and consequences of trafficking in women and adolescents. Findings from a European study. London: London School of Hygiene & Tropical Medicine (LSHTM). 2003.</li><li>Chohaney ML. Minor and Adult Domestic Sex Trafficking Risk Factors in Ohio. Journal of the Society for Social Work and Research. 2016;7(1):117-141.</li><li>National Human Trafficking Resource Center. Identifying Victims of Human Trafficking: What to Look for in a Health care Setting. Available at: <a href="https://humantraffickinghotline.org/sites/default/files/What%20to%20Look%20for%20during%20a%20Medical%20Exam%20-%20FINAL%20-%202-16-16_0.pdf">https://humantraffickinghotline.org/sites/default/files/What%20to%20Look%20for%20during%20a%20Medical%20Exam%20-%20FINAL%20-%202-16-16_0.pdf</a>. Accessed May 2020.</li><li>National Human Trafficking Resource Center. Comprehensive Human Trafficking Assessment. Available at: <a href="https://humantraffickinghotline.org/sites/default/files/Comprehensive%20Trafficking%20Assessment.pdf">https://humantraffickinghotline.org/sites/default/files/Comprehensive%20Trafficking%20Assessment.pdf</a>. Accessed May 2020.</li><li>National Human Trafficking Hotline. Available at: <a href="https://humantraffickinghotline.org/">https://humantraffickinghotline.org</a>. Accessed May 2020.</li></ol> </div></div>AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-72891091280897723162020-10-16T17:21:00.001-05:002020-10-16T17:21:23.433-05:00When Do Things in Medicine Start to Become Common Knowledge?<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh62HY98EM7XTDVI3aWXitFNfWSLySRdTbbKcOve7tFUkM-gzSJ9IEODRn9V1IlnGwZmxPGFNTJOVNVjLO9EofV3V5Dij-QeIulbY3WCpR7hkM4dIHXQSIBw38ovrjkMLr8-2EG7ints40N/s2048/pexels-kaboompics-com-6078.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh62HY98EM7XTDVI3aWXitFNfWSLySRdTbbKcOve7tFUkM-gzSJ9IEODRn9V1IlnGwZmxPGFNTJOVNVjLO9EofV3V5Dij-QeIulbY3WCpR7hkM4dIHXQSIBw38ovrjkMLr8-2EG7ints40N/s320/pexels-kaboompics-com-6078.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/photo/repairing-a-car-6078/"><i>Pexels</i></a><br /></td></tr></tbody></table><b>Author:</b> Shaughnelene D. Smith, BSc (Hons); Eddie K. Maybury, BSc<br /><div>Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a></div><div>September/October 2020</div><div><br /></div>Several weeks ago, I finished my first year of medical school and began the arborous drive from Kansas City, Missouri, to California for a summer research position. When I was just six minutes away from my destination, my car of 21 years decided to break down. It is important to note that I am studying in the United States as an international student from Canada, and despite growing up as a neighbor from the north, much of the U.S. and its various systems are foreign to me. <br /><br />As midnight approached and the smoke started billowing out of the front bonnet, I found myself pulling off to the side of the road in a city unfamiliar to myself. I quickly took all the essential paperwork from my vehicle – F1-student visa, passport, insurance papers – and found a rock a safe distance away, where I proceeded to call my parents and quickly realized how clueless I was in navigating what to do next.<div><br /><span><a name='more'></a></span><div><br /><br />The following day, in the early hours of the morning, a tow truck transported my car to the nearest dealership, where the diagnosis was made that I had injured the radiator driving through an extreme heatwave. The vehicle's internal damage wasn't worth the cost of repairs, and so began the days of paperwork and arduous tasks to find a new car. Much of this headache included learning about the processes trying to purchase a vehicle as an international student, surrender my Canadian license plate, change insurance companies, and finding a way to scrap an unwanted foreign car with an odometer tainted in kilometers rather than miles.<br /><br />What is considered common sense to someone from the United States is not what is considered to be general knowledge to someone international. Having to explain why I did not have a social security number and uncovering the process to obtain one proved to require more effort than some of my classes in medical school. I had to do the research not only for myself but also for those attempting to help me. In uncharted territory, stuck in an endless feedback loop of frustrating conversations, I couldn't help but think of the ironic similarity to the U.S. healthcare system. <br /><br />If I had an accident and end up in the emergency room, I wouldn't even know what would be considered good practice. Do I have to pay before you treat me? Yes, I have insurance, but what does that mean? Am I supposed to learn about this in medical school, or does it come naturally over the years as you spend time in a hospital? When do these essential details become common sense as I continue on the trajectory from student to doctor?<br /><br />As I advance in my medical training, I have good faith that I will slowly learn these various processes; however, I often question how disorientating this might seem to a patient unfamiliar with a country's medical system. How often do they experience distress and uncertainty due to a lack of knowledge that others have subconsciously acquired by growing up within the U.S.? It was reported in 2018 that more than 44.7 million immigrants lived in the United States.1 Although I am not an immigrant per se, I would speculate that this would indicate that there is a sizable population just as lost and confused as myself when it comes to navigating these systems both within and outside of healthcare. My car experience taught me that despite English being my first language, being well educated, and growing up in a country that is arguably culturally similar to the United States, I still had an element of vulnerability. Most of the newly-discovered tasks I encountered seemed like a different language and left me feeling like I didn't have full control of my situation. Taking into consideration a patient's perspective, I can only begin to imagine how troubling this must be, especially when we start to consider differences in language, cultural, and past experience regarding medical care. <br /><br />We are taught as medical students not to use medical jargon when communicating with standardized patients. This rule is implemented so that we don't overwhelm the patient with words that they may not understand; however, I never considered that even if everything was explained in lay terminology, the process may still not be intuitive. As physicians, we need to consider this as a part of our efforts better to improve immigrant status as a social determinant of health. It has long been established that immigrants have higher morbidity and mortality rates than their non-immigrant counterparts. These poorer health outcomes can be attributed to various factors such as lower English proficiency, socioeconomic status, marginalization, and inferior treatment on behalf of the practicing healthcare personnel.2<br /><br />It is often overlooked that navigating a system unfamiliar to oneself can be intimidating, and this can be a deterrent when seeking treatment, leading to less access to care. This experience has taught me the need to be respectful, patient, and empathetic with our communication as a healthcare team because what may be common knowledge to one person isn't necessarily common knowledge to another.<br /><br /><b>References</b><br /><br /><ol style="text-align: left;"><li>Batalova J, Blizzard B, Bolter J. Frequently Requested Statistics on Immigrants and Immigration in the United States [Internet]. The Online Journal of the Migration Policy Institute. 2020. Available from: https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states<br /><br /></li><li>Derose KP, Escarce JJ, Lurie N. Immigrants And Health Care: Sources Of Vulnerability. Health Aff (Millwood). 2007 Sep;26(5):1258–68.</li></ol><br /></div></div>AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-20795491971307728992020-10-01T19:34:00.004-05:002020-10-01T19:35:29.219-05:00 “Zooming” into a New Era of Clinical Education<div class="separator" style="clear: both; text-align: left;"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://www.pexels.com/photo/people-on-a-video-call-4226122/" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="2048" data-original-width="1365" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKUAoYJc79N5P_k1y5QohMPOENbmUnxJ2KKxfl_aOvYQ84SaX9fmTvwZUj0XF6DgjQtOMBUCljD-2gnhZxUaR-fs4MemriK4S1ThC2iDs0Filq_9btTNfsz8pDF8usAnAyyCIOEDiOaxF_/w266-h400/pexels-anna-shvets-4226122.jpg" width="266" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.pexels.com/photo/people-on-a-video-call-4226122/">Pexels</a></i></td></tr></tbody></table><b>Author:</b> Alexandria Gregory, MD </div>Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />September/October 2020<br /><br />If your residency is like most programs, your pre-COVID didactics likely consisted of several hours of in-person conference once a week. That common, traditional way of learning has been turned upside down with the need for social distancing, and most programs have transitioned to virtual conferences. As the reality of COVID persists, it is important to continuously evaluate the effectiveness of virtual learning. Furthermore, in planning for a post-COVID era, it will be beneficial to determine whether virtual learning remains a valid, effective teaching technique despite being able to meet in-person.<br /><br />To understand how virtual learning affects curriculum design, it is important to start by breaking down what, in general, emergency medicine residency curriculum looks like. Most programs include the following in some fashion: <div><br /></div><div><br /></div><div><br /></div><div><br /><ul style="text-align: left;"><li>Core Topics</li><li>Small-Group Sessions/Problem-Based learning</li><li>Electrocardiogram (EKG)/Radiology Interpretation</li><li>Morbidity and Mortality/Case Presentations</li><li>Journal Club</li><li>Ultrasound</li><li>Grand Rounds</li><li>Simulation/Procedure Lab</li><li>Oral Board Review</li><li>Asynchronous Learning</li></ul><div><br /></div><span><a name='more'></a></span><div><br /></div><div>With a few exceptions, the majority of these can easily be done virtually. Core topics and grand rounds can be covered with slide-sharing. EKG and radiology interpretation can also be done with slide-sharing and participation from the audience using the chat or audio functions. Small-group/problem-based learning sessions, and even oral board review, can be done using Zoom’s “breakout rooms” feature. Asynchronous learning, of course, remains unaffected. Simulation and procedure labs present the biggest challenge. </div><br />Of course, just because something can be done does not mean it should be done. Certainly, there are downsides of virtual learning. One of the underrated features of weekly in-person conference is the social interaction. Lectures are a time for residents to come together and interact informally outside of their shifts, which is especially true if lecture begins with breakfast or ends with lunch. Post-lecture Zoom hangouts, which some programs have tried, will never have quite the same effect. On a more practical level, accessibility, or lack thereof, poses a huge issue for virtual learning in general. Not everyone has access to the internet or computers, and even those that do may have difficulty learning new systems. During lecture itself, participation may not come as easily as it would during an in-person lecture. It can be an added challenge for lecturers to sit in a room and talk, seemingly to themselves, without real-time feedback from the audience. However, it can be argued that in-person lectures do not necessarily mean automatic audience participation and pose similar issues, and that in fact, use of the chat function actually allows for more discussion than would be possible in person because there is no need to interrupt the lecturer while participants add their thoughts and questions. Lastly, virtual lectures do not offer a suitable substitute for hands-on learning that is crucial for procedures and sim lab.<br /><br />At the same time, however, virtual lectures do offer things that in-person lectures do not. First, they allow residents time to get things done—such as cooking, cleaning, and laundry—while also participating in lecture. Especially for residents with busy schedules, that extra time is crucial and much-appreciated. Similarly, lecturers and residents alike can be more easily available for the scheduled time when they do not have to factor in things like transportation time or childcare, which may actually encourage more participation in lectures overall. For those who still cannot make it to lecture, Zoom lectures are easier to record than in-person ones for those wishing to watch later. <br /><br />Another significant advantage of virtual lectures is the ability to connect residents across the country through national live lectures. Academic Life in Emergency Medicine (ALiEM) Connect, a multiple-part live conference brought residents together nationwide from over sixty programs to learn from various experts in the field, such as Michelle Lin and Salim Rezaie. The series has been able to offer concise, focused talks that also foster group discussion through the use of Slack channels. Similarly, it is much easier to get experts to give lectures to a given program when they can do so from their own home or institution, rather than having to travel. <br /><br />While there are certainly drawbacks to virtual learning, it is worth considering as an increasingly valid teaching technique, even when in-person lectures are again possible. The best scenario may be a hybrid model. For instance, in-person lectures could be replaced by virtual ones once a month, allowing residents a day to learn “conveniently” from home, while also recognizing the value of in-person lectures for activities such as sim lab and other interactive sessions. Regardless of the way lectures are presented, quality education relies on the both the learner and educator to be invested. Ultimately, we are being forced to re-examine the way we teach and the way we learn to foster that investment, which makes this time a pivotal moment in medical education.<br /><br /> </div>AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-40383704535311686452020-09-17T10:54:00.002-05:002020-09-22T11:22:51.300-05:00Resident Journal Review: Do Adjunctive Therapies Beyond Infection Control and Appropriate Fluid Resuscitation Change Outcomes in Sepsis and Septic Shock? <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGYoGI5_P_cZVIa8v-nFQ-R3mSEBR2QSDTeoeEgajpVeouvpUIeGV1nVJVLnqkYs2lzADIbLJo5xdlqcw5XyEeByaqhRdpkmwWKae1LZo-WrcCLjoL9Z2u_lw_br9cUg4eSfW3bA3D1rKK/s1600/Resident+Journal+Review.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="903" data-original-width="1600" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGYoGI5_P_cZVIa8v-nFQ-R3mSEBR2QSDTeoeEgajpVeouvpUIeGV1nVJVLnqkYs2lzADIbLJo5xdlqcw5XyEeByaqhRdpkmwWKae1LZo-WrcCLjoL9Z2u_lw_br9cUg4eSfW3bA3D1rKK/s320/Resident+Journal+Review.png" width="320" /></a></div><b>Authors:</b> Jordan Parker MD; Sharleen Yuan, MA MD PhD; Megan Donohue, MD; Robert Brown, MD; Mark Sutherland, MD; Hannah Goldberg, MD; Akilesh Honasoge, MD<br />Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM<br />Originally published: <a href="https://www.aaemrsa.org/get-involved/common-sense"><i>Common Sense</i></a><br />September/October 2020<br /><br /><b>Introduction</b><br />Septic shock is an illness with complex pathophysiology and few available therapies, beyond infection control and appropriate fluid resuscitation, to reverse the disease state. It is one of the most prevalent and lethal disease states that a physician may manage, with 1.7 million cases of sepsis in the United States per year and a reported mortality rate of up to 34%.<sup>1,2</sup> The pathogenesis of septic shock is thought to be driven by a dysregulated host response<sup>3</sup> with the role of adjunctive therapies being to assist in reversing this dysregulated response. Treatments that have more recently been a hot topic of debate include vitamin C, corticosteroids and thiamine. Vitamin C (ascorbic acid) a role in numerous physiologic processes including endothelial permeability, micro and macrovascular function, cellular apoptosis, immune system function and endogenous catecholamines.<sup>4</sup> Studies have shown that vitamin C deficiency is present in critically ill patients,<sup>4</sup> and its role in these essential functions is the basis for its use as a potential treatment in septic shock. Thiamine also plays a role in key metabolic processes, including cellular energy production and generation of cellular antioxidants, and thiamine deficiency has been well-documented in sepsis, with observational studies indicating a signal for improved outcomes with supplementation.<sup>4</sup> Steroids have been used in refractory septic shock for almost the past two decades<sup>5</sup> but the recent rationale for its use includes its synergism with vitamin C. Glucocorticoids may be able to increase the activity of vitamin C by increasing expression of the transporter involved in its uptake into cells, sodium-vitamin C transporter (SVCT2).<sup>4</sup> In return, vitamin C, as an antioxidant, may be able to facilitate the binding of glucocorticoids to their receptor, a coupling impeded by oxidizing molecules. We will review several of the high-profile trials that have attempted to elucidate the effectiveness of utilizing corticosteroids, vitamin C, and thiamine in the management of patients with sepsis and septic shock.<div><br /><span><a name='more'></a></span><br /><b>Questions </b><br /><ol><li>Does the treatment of sepsis with a combination of vitamin C, thiamine, and hydrocortisone improve outcomes in septic shock?<br /><br /></li><li>Should steroids be used in patients with septic shock?</li></ol><b>Marik P, Khangoora V, Rivera R, et al. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-38.</b><br /><br />This retrospective before-and-after study was conducted at a single-center tertiary care referral hospital in the U.S. All patients >18 years of age with primary diagnosis of severe sepsis or septic shock and procalcitonin >2 ng/ml were enrolled. Patients were excluded if pregnant or had limitations of care. The treatment group received hydrocortisone 50mg every 6 hours for 7 days, IV vitamin C 1.5g every 6 hours for 4 days, and IV thiamine 200mg every 12 hours for 4 days. All treatments were given for the assigned time frame or until ICU discharge, whichever came first. In the control group, patients treated for severe sepsis or septic shock in the year prior to the initiation of triple therapy, hydrocortisone was used at the discretion of the intensive care unit (ICU) attending. All patients otherwise received standard treatment including broad-spectrum antibiotics, conservative fluid and vasopressor strategies, lung-protective ventilation, and appropriate prophylaxis. The primary outcome was hospital survival. Secondary outcomes included duration of vasopressor therapy, requirement for renal replacement therapy, ICU length of stay, and change in serum procalcitonin and sequential organ failure assessment (SOFA) score. <br /><br />A total of 47 patients were enrolled in each arm of the study. No significant differences in baseline characteristics were reported between the two groups, though it is worth noting that p-values are not presented to support this conclusion. Hospital mortality in the treatment group was 8.5% compared to 40.4% in control group (p<0.001). Discriminant logistic analysis identified three independent predictors of mortality: APACHE IV score, need for mechanical ventilation and the vitamin C protocol (p<0.001). Three secondary outcomes were also statistically significant: duration of vasopressor therapy (18.3 h vs 54.9 h in the treatment vs control group, respectively, p<0.001), procalcitonin clearance (6.4% vs 33.9%, p<0.001), and change in SOFA score (4.8 versus 0.9, p<0.001).<br /><br />These findings are impressive but exceed expected improvement and should be interpreted cautiously. Marik et al. appropriately acknowledge several major limitations to this study, including small sample size, single-center design and non-concurrent enrollment of control and treatment groups. For these reasons, it is imperative the results of this study are reproducible in a large randomized controlled trial before HAT (hydrocortisone, ascorbic acid, thiamine) therapy is accepted as standard treatment.<br /><br /><b>Fowler AA 3rd, Truwit JD, Hite RD, et al. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients with Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322(13):1261-1270. [published correction appears in JAMA. 2020 Jan 28;323(4):379].</b><br /><br />The CITRIS-ALI Trial was a randomized, placebo-controlled, double-blinded study that was conducted in seven medical ICUs. Patients were included if they required mechanical ventilation, met criteria for acute respiratory distress syndrome (ARDS), and had a suspected or proven infection with two of four sepsis inflammatory response syndrome (SIRS) criteria, all with a 24-hour period. A total number of 167 patients were enrolled, the 84 in the treatment arm receiving 50 mg/kg of vitamin C in 5% dextrose in water (D5W) every 6 hours for 96 hours, and the 83 in the placebo arm receiving only 5% D5W every 6 hours for 96 hours. <br /><br />While the trial was negative for its primary endpoints – a change in the modified SOFA (Sequential Organ Failure Assessment) score at 96 hours, and improvement in CRP or thrombomodulin levels within 168 hours – there were some secondary endpoints that reached significance. There was a reduction in 28-day mortality from 46.3% to 29.8% (p = 0.03) in the vitamin C group, an increase in ICU-free days from 7.7 to 10.7 (p = .03), and an increase in transfer out of the ICU by hour 168 from 12.5% to 25% of patients (p = .03). <br /><br />Although the mortality and ICU length of stay benefits may seem compelling, there are several issues that may potentially limit the validity of the results. A large portion of screened patients (86.5%) were excluded, and the resulting sample size was perhaps too small to detect differences in primary outcomes. Reconciling a lack of difference in mSOFA scores with an improvement in mortality may be feasible if one considers survivorship bias: the sicker mSOFA scores died with the patients who did not survive. Quite appropriately, the authors point out that 46 secondary endpoints were evaluated, and a correction for multiple comparisons was not conducted, and acknowledge that these secondary results should be viewed as exploratory.<br /><br />As with many bleeding-edge therapies, how practitioners view this trial will likely depend on their pre-existing beliefs. Proponents will likely point to the positive secondary outcomes of CITRIS-ALI as evidence that vitamin C improves outcomes or fall back on the argument that vitamin C is more effective when administered early in the course of sepsis, rather than after the patient has developed full-blown ARDS. On the other hand, nonbelievers are likely to point out that this was a negative trial, and it is certainly difficult to support the administration of vitamin C in septic ARDS based on this paper. <br /><br /><b>Fujii T, Luethi N, Young P, et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock. JAMA. 2020;323(5):423-43
.<br /></b><br />This was a prospective, open-label, randomized controlled trial taking place across 10 ICUs in Australia, New Zealand, and Brazil. Patients were adults with presumed or confirmed infection, increase in SOFA score of at least 2 points, lactate > 2 mmol/L, and vasopressor requirement > 2 hours, enrolled within 24 hours of septic shock diagnosis. The intervention arm received 1.5g of IV ascorbate every 6 hours, 50mg IV hydrocortisone every 6 hours, and 200mg IV thiamine every 12 hours. The control arm received 50mg IV hydrocortisone every 6 hours and thiamine at the discretion of the intensivist. Treatment continued for 10 days or until the subjects maintained a MAP 65 mmHg or greater for 4 hours without the need for vasopressors. <br /><br />The primary outcome was the cumulative time alive and free of vasopressors (for at least four hours) at day 7 after randomization. Predetermined secondary outcomes were mortality at 28 and 90 days, ICU and hospital mortality, 28-day cumulative vasopressor-free days, 28-day cumulative ventilator-free days, 28-day renal replacement therapy-free days, 28-day ICU-free days, hospital length of stay, and change in the SOFA score by day 3.<br /><br />A total of 211 patients were included in the study: 107 in the intervention arm and 104 in the control arm. The intervention arm had lower baseline APACHE III scores but similar comorbidities, rates of mechanical ventilation and renal replacement therapy, and causes of sepsis. There was no significant difference in the primary outcome between groups (p = 0.83). There were no significant differences in the secondary outcomes between the groups with the exception of improved SOFA score at 3 days in the intervention arm (p = 0.02) a finding which must be interpreted with caution given it was applied only to patients who were in the ICU on day 3, removing from question both those who improved and left the unit and those who died within 3 days. <br /><br />Though open label, the introduction of systematic performance bias may be less likely given the scale of the study, with more than 100 attending physician and intensive care fellows. The goal and achieved mean arterial pressures (MAPs) were not provided; these could affect vasopressor use. All patients received antibiotics prior to enrollment, but the time to initial antibiotic was not recorded. <br /><br /><b>Keh D, Trips E, Marx G, et al. Effect of hydrocortisone on development of shock among patients with severe sepsis: the HYPRESS randomized clinical trial. JAMA. 2016:316(17);1775-85.<br /></b><br />The HYPRESS trial was a multicenter, placebo-controlled, double-blinded study examining the utility of hydrocortisone in preventing progression to septic shock. It included adult patients in ICUs, intermediate care units (IMCs), and community hospitals who had evidence of infection, at least 2 SIRS criteria and evidence of organ dysfunction present for < 48 hours. Exclusion criteria included septic shock (hypotension greater than 4 hours despite adequate fluid resuscitation), hydrocortisone or mannitol hypersensitivity, and history of glucocorticoid use with need for continuation of therapy. The treatment group received hydrocortisone as a dose of 50mg followed by a 24-hour infusion of 200mg for 5 days that was then tapered to 100mg on days 6 and 7, 50mg on days 8 and 9, and 25mg on days 10 and 11. The placebo group was given mannitol instead. The primary end point was the occurrence of septic shock within 14 days. Secondary end points included time to septic shock development, death, ICU and hospital mortality, vital status at days 28, 90, and 180, ICU and hospital LOS, SOFA score, duration of mechanical ventilation, renal replacement therapy requirement, and various prespecified adverse events.<br /><br />A total of 380 patients were randomized, 190 to each group. There was no difference between groups in the primary outcome, and there were no significant differences in any of the secondary end points except more hyperglycemia (9.4% difference, p= 0.009) and less delirium (13.3% difference, p=0.01) in the hydrocortisone group. <br /><br />Limitations include possibly missing patients who quickly developed septic shock and were therefore excluded, and the possibility that hydrocortisone may be more effective in patients who are more severely ill. The major limitation, however, is that the study population’s lower-than-anticipated incidence of septic shock (23% vs the expected 40%) resulted in an underpowering of the trial and inconclusive results.<br /><br /><b>Venkatesh B, Finfer S, Cohen J, et al. Adjunctive glucocorticoid therapy in patients with septic shock. New Engl J Med. 2018;378(9):797-808.</b><br /><br />The ADRENAL Trial was an investigator-initiated, international, pragmatic, double-blind, parallel-group, randomized, controlled trial that compared IV infusions of hydrocortisone with matched placebo in adult patients with septic shock on vasopressors who were undergoing mechanical ventilation in an ICU. Patients in the experimental arm of the study were given an intravenous infusion of hydrocortisone at a fixed dose of 200 mg per day. Both experimental and control groups were well matched with respect to age, sex, site of infection, and type of ICU. The primary outcome of the study was all-cause mortality at 90 days. Secondary outcomes included 28-day mortality, time to shock resolution, ICU and hospital length of stay (LOS), mechanical ventilation and renal replacement therapy requirement and duration, incidence of subsequent bacteremia/fungemia, and blood transfusion requirement.<br /><br />A total of 3658 patients were enrolled: 1832 patients randomized to the hydrocortisone group and 1826 to the control group. At 90 days, there was no significant difference in mortality [27.9% vs 28.8%, (odds ratio, 0.95; 95% confidence interval [CI], 0.82 to 1.10; P=0.50)]. The treatment group had faster shock resolution [3 vs 4 days (hazard ratio [HR] 1.32, 95% CI 1.23-1.41)], more ventilator-free days [6 vs 7 days (HR 1.13, 95% CI 1.05-1.22, p<0.001)], and a shorter ICU LOS [(10 vs 12 days (HR 1.14, 95% CI 1.06-1.23, p<0.001)]. Also, fewer patients in the treatment group received a blood transfusion (37.0% vs. 41.7%; odds ratio, 0.82; 95% CI, 0.72 to 0.94; P=0.004), without a significant between-group difference in mean total volume of blood transfused when examining all patients who received transfusions. There were more adverse events (hyperglycemia, hypernatremia, encephalopathy, myopathy, etcetera) in the hydrocortisone group (1.1 vs 0.3%, p=0.009).<br /><br />Investigators did not clarify if additional sepsis management was appropriate (i.e., correct antibiotics, appropriate fluid resuscitation), so the potential for confounding remains. They excluded patients who received etomidate, a medication that remains widely used for rapid sequence induction, which limits generalizability of the results, and did not assess for actual adrenal insufficiency. Finally, it remains unclear whether continuous infusion of hydrocortisone is less beneficial than bolus dosing due to slower drug delivery.<br /><br />Ultimately, the ADRENAL Trial seems to indicate that infusions of hydrocortisone did not improve 90-day mortality in septic shock. It does support consistent findings of earlier shock resolution and ventilator weaning, and in general is unlikely that this paper will change independent physicians’ practice given its limitations, which could be argued for or against its validity.<br /><b><br />Annane D, Renault A, Brun-Buisson C, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. New Engl J Med. 2018;378(9): 809-18.</b><br /><br />The AProCCHSS trial (Activated Protein C and Corticosteroids for Human Septic Shock), so named because it was initially designed as a 2x2 factorial study investigating hydrocortisone plus fludrocortisone versus droctrecogin alfa versus placebo, was continued as a multicenter randomized controlled trial without droctrecogin after it was pulled from the market.<br /><br />A total of 1241 patients were enrolled from 34 different centers, with randomization occurring in a permuted block of eight patients. Major inclusion criteria included an indisputable or probable diagnosis of septic shock, a SOFA score of at least 3-4 in at least two different organs, and a vasopressor requirement for at least 6 hours at a dose of at least 0.25 micrograms per kg per minute (mcg/kg/min) of norepinephrine (or equivalent-dose alternative vasopressor). Major exclusion criteria included presence of septic shock for >24 hours since transfer to the ICU, a high risk of bleeding, pregnancy/lactation, or prior treatment with corticosteroids.<br /><br />The treatment group received hydrocortisone 50 mg every 6 hours and fludrocortisone 50 mcg daily for 7 days without taper, while the placebo group received mannitol and microcrystalline cellulose. In addition, attempts were made to harmonize non-experimental interventions between centers including anti-infective treatments, hemodynamic and respiratory management, blood glucose control, and neuromuscular blockade use. A steering committee also judged the adequacy of the anti-infective coverage which was found to be similarly adequate in both the treatment and placebo group (96.9% vs 96.2%).<br /><br />Patient characteristics were similar between both intervention and placebo groups including an average age of 66 years and male predominance (65.5% vs 67.7%. The majority were admitted as an escalation from the medical wards with pulmonary and urinary infections being the most common. Norepinephrine was the most common vasopressor used. The primary outcome was 90-day all-cause mortality which was found to be significantly lower in the steroid group [43.0% vs 49.1%; RR (relative risk) 0.88 (95% CI 0.78 – 0.99, p=0.03)]. The steroid group also had a decrease in both death from any cause at ICU (35.4% vs 41.0%, p=0.04) and death by day 180 (46.6% vs 52.5%, p=0.04, with significantly more vasopressor-free days through day 28 (17 vs 15 days , p<0.001). With the exception of increased hyperglycemia incidence in the treatment group, rates of adverse events (serious bleeding, superinfections, neurologic sequelae) were similar.<br /><br />The authors argue two significant differences between the steroid trials that have shown mortality benefit and those that did not: (1) the use of the mineralocorticoid fludrocortisone, which may have contributed to intravascular volume expansion, and (2) the requirement for at least 6 hours of vasopressor therapy, likely selecting for sicker patients who do not improve with the standard 6-hour Surviving Sepsis Campaign bundle of care. They argue that the inclusion and exclusion criteria for this study select for a sicker patient population with worse illness severity scores, which makes them an ideal group for adjunctive therapies. With the confidence interval for mortality reduction approaching 1.0, the benefit should be considered potential and needs replication in additional studies.<br /><br /><b>Discussion</b><br />The Marik trial was certainly attention-grabbing and left many feeling hopeful that an effective therapy for septic shock with significant mortality benefit had been discovered, despite its various limitations. The CITRIS-ALI trial showed no benefit in the non-patient-oriented primary outcome of reduction in SOFA scores, CRP or thrombomodulin. Its 28-day mortality benefit, as a secondary outcome in a study that did not adjust for multiple comparisons, can be nothing more than hypothesis-generating. The VITAMINS trial showed no benefit to adding vitamin C and thiamine to the widely-used hydrocortisone. Ongoing studies including VICTAS (vitamin C, Thiamine, and Steroids in Sepsis),6 ACTS (Ascorbic acid, Corticosteroids, and Thiamine in Sepsis)7 and others will be needed before the universal use of vitamin C, thiamine and corticosteroids is implemented in patients with septic shock.<br /><br />The controversy regarding the use of steroids has been ongoing for over a decade. Both Annane’s APROCCHSS trial and his trial in 2002 showed a mortality benefit to hydrocortisone and fludrocortisone,12 while the results of the ADRENAL trial mirror those of the CORTICUS trial: no difference in mortality with faster shock resolution.8 It is important to note that the APROCCHSS trial did have patients with higher overall mortality than the ADRENAL and CORTICUS trials, suggesting that the benefit from steroids may only be seen in the sickest of patients. What is most consistent is that several of these studies have demonstrated faster shock resolution, ventilator weaning, and/or shortened ICU LOS, with slight increase in hypernatremia and hyperglycemia. While steroids for all septic patients does not seem supported, in a patient who is critically ill and not responding to antibiotics, appropriate fluids, and high-dose and/or multiple vasopressors, it seems reasonable to add steroid therapy to ongoing life-saving efforts.<br /><br /><b>Answers </b><br /><ol><li>Existing evidence does not clearly support improved clinical outcomes with the combination of vitamin C, thiamine, and hydrocortisone in septic shock.<br /><br /></li><li>For septic shock refractory to standard therapies, steroids hasten shock resolution and are probably worth initiating, but their effect on mortality remains unclear.</li></ol><b>References</b><br /><ol style="text-align: left;"><li>Rhee C, Dantes R, Epstein L, et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA. 2017;318(13):1241-9.<br /><br /></li><li>Hatfield K, Dantes R, Baggs J, et al. Assessing Variability in Hospital-Level Mortality Among U.S. Medicare Beneficiaries With Hospitalizations for Severe Sepsis and Septic Shock. Crit Care Med. 2018; 46(11):1753-60.<br /><br /></li><li>Angus D, van der Poll T. Severe Sepsis and Septic Shock. New Engl J Med. 2013;369(9):840-51.<br /><br /></li><li>Moskowitz A, Andersen L, Huang D, et al. Ascorbic acid, corticosteroids, and thiamine in sepsis: a review of the biologic rationale and the present state of clinical evaluation. Critical Care. 2018;22(1): 283.<br /><br /></li><li>Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288(7):862871.<br /><br /></li><li>Hager D, Hooper M, Bernard G, et al. The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) Protocol: A prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial. Trials. 2019. doi: 10.1186/s13063-019-3254-2.<br /><br /></li><li>Moskowitz A, Yankama T, Andersen LW, et al. Ascorbic Acid, Corticosteroids and Thiamine in Sepsis (ACTS) protocol and statistical analysis plan: a prospective, multicentre, double-blind, randomised, placebo-controlled clinical trial. BMJ Open. 2019;9(12):e034406. doi:10.1136/bmjopen-2019-034406.<br /><br /></li><li>Sprung CL, Annane D, Keh D, et al. Hydrocortisone Therapy for Patients with Septic Shock. New Engl J Med. 2008;358(2):111-24.</li></ol></div>AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-53002456092349741262020-09-04T10:44:00.000-05:002020-09-04T10:44:18.189-05:00A Medical Student/Paramedic's Perspective on COVID-19<b><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimBcPWHVHxqwOdNg3MsFZAgiQ4JXT3OPpKQrqvX0uHJdosd0oVa5jtDDwLtM6jaAyu2ho7KXPbqPE7xKTph1tUICJh9NBtWfxXnNTpxA1aZnijke47b9enXPTclYmfoHdXOGUM66AipX-E/s2048/pexels-ian-panelo-3584101.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1365" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimBcPWHVHxqwOdNg3MsFZAgiQ4JXT3OPpKQrqvX0uHJdosd0oVa5jtDDwLtM6jaAyu2ho7KXPbqPE7xKTph1tUICJh9NBtWfxXnNTpxA1aZnijke47b9enXPTclYmfoHdXOGUM66AipX-E/s320/pexels-ian-panelo-3584101.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <a href="https://www.pexels.com/photo/photo-of-ambulance-parked-in-parking-lot-3584101/"><i>Pexels</i></a><br /></td></tr></tbody></table>Author: </b>Matthew Carvey <br /><div>Originally published: <i><a href="https://www.aaemrsa.org/get-involved/common-sense">Common Sense</a></i></div><div>July/August 2020</div><br />Medic-1 is responding to an assault in a rural location. Dispatch notifies EMS that the patient has a fever and was put on mandatory self-isolation for 14 days. On arrival, EMS dons a sterile cap, goggles, an N95 mask, face shield, gown, and gloves. The patient, belligerent and intoxicated on alcohol and psilocybin, yells at EMS ‘I have the COVID!’. She rushes EMS, removes the practitioners mask, and coughs in his face. Police arrest the woman under the Mental Health Act, and EMS transports, only for her to spit and verbally abuse them the entire length of transport. EMS unloads the patient and awaits triage. After handing over care, EMS doffs all used PPE, and don’s new equipment to thoroughly clean the ambulance. One of the practitioner’s displays signs of COVID-19 three days later. This article is a medical student/paramedic’s perspective on COVID-19.<div><br /></div><span><a name='more'></a></span><div><br /><br />The COVID-19 pandemic has united the medical community – physicians, nurses, researchers, respiratory therapy, EMS, housekeeping staff, and medical students – in the singular purpose of containing the virus. With this comradery comes shared challenges, such as fear of contracting the virus, overwhelming PPE shortages, and frontline staff burnout. Because of these concerns facing society, a unique population of medical students are continuing school online while simultaneously responding to nation-wide callings to assist with surge capacity in their previous professions. Being on the leading edge of the frontlines, EMS practitioners are particularly challenged by these three aforementioned crises.<br /><br />Contraction of the virus is on the minds of all health care professionals during this pandemic. With additional decontamination procedures, creation of COVID-19 protocols, and rapid modification to practice guidelines puts pressure on EMS to comply and care for patients. The reliability of screening questionnaires has also been problematic, with certain patient populations “lying” about recent travel or signs/symptoms of COVID-19 to receive care, further increasing the risk of under-protected EMS personnel. There are multiple explanations for why these issues have arisen, but the result is the same – EMS is unnecessarily vulnerable to COVID-19 when patients are inappropriately cleared. To prevent viral spread, EMS protocols now necessitate strict decontamination of ambulances and aircraft, a requirement prior to becoming available for service. This process can take hours from donning and doffing PPE, to wiping/spraying the ambulance/aircraft and ensuring all linen is disposed of appropriately, only to repeat this whole ordeal after transporting the next patient who is displaying signs of influenza-like-illness. Treatments such as nebulization of medication and intubation have also been replaced by “diesel” – a prehospital term for “scoop and run” – due to the potential risk for droplet contact, reducing possible early reversal of disorders such as COPD and respiratory arrest. The need to protect against the virus creates a catch-22 in the delivery of prehospital care: delay patient care for proper PPE precautions or delay proper precautions to avoid interruptions in patient care.<br /><br />The shortage of PPE leads to unintentional exposure to COVID-19, causing all practitioners to enter precarious situations, triggering delays in patient care. From the perspective of the patient, those in cardiac arrest from the latter stages of COVID-19, or what we’re presuming was caused by COVID-19, are now down for additional time-dependant minutes as EMS dons all available PPE prior to entering ANY cardiac arrest situation. This precaution is necessary, but may be contributing to further deaths from a lack of early chest compressions and advanced cardiac life support. As PPE continues to be rapidly consumed, the inability to care for patients in the same capacity as done pre-COVID-19 will have dire consequences for patients and practitioners.<br /><br />Finally, the increase in patient fatalities is leading to a “pandemic within a pandemic” in the form of frontline health care staff burnout. Emergency medicine (EM) staff are particularly vulnerable, as in EM no patient, regardless of disposition, is rejected from medical care. COVID-19 has not only accelerated provider burnout, but also contributed to other mental health syndromes, such as acute stress disorder. The wide range of patient presentations EMS witnesses with COVID-19, fluctuating from fevers, and myalgias to chest pain, and cardiac arrest, makes this virus exceptionally hard diagnostically. The increased overall death toll to which this disease has contributed exacerbates the disastrous mental stress on EMS. The number of cardiac arrests has drastically risen each tour, an outcome not just unique to pre-hospital care, but also hospitals. Transportation of artificially ventilated patients, only to know the ventilator will be removed to assist those who require it more at the receiving facility is making interfacility transfers, relatively low stress calls pre-COVID-19, emotional minefields. The tendency of EMS practitioners to suppress their emotions in these circumstances – often a necessary coping mechanism of the job – could lead to disastrous mental health consequences post-pandemic.<br /><br />The unsung nature of EMS is a primary reason many individuals enter this profession, not requiring praise or reward, but solely to be the primary caregiver during what is usually the worst day of a patient’s life. Is the martyr nature of EM worth the potential chance of contracting COVID-19? Everyone in EM has weighed this risk, putting their lives on the line to care for those affected by this pandemic. Does the community understand the danger practitioners are putting themselves in everyday? Poor compliance with public health guidelines that have been recommended, which does not seem to be driven by malice for health care workers, but by a shift in societal rules to include enforcement of self-isolation and social distancing, causes the population to become agitated and instigate scenarios such as the vignette described above. Until this pandemic produces not just a “flattened curve”, but a society that heeds the advice of public health experts and frontline staffs’ cries for compliance, we the frontline staff will continue to put our lives on the line to care for a population that pushes against the ideals we see necessary to end this pandemic and return to “normalcy”. Because of the duty we feel to care for others, no matter how great the personal risk, we will always be there, 24/7/365.<br /></div>AAEM/RSAhttp://www.blogger.com/profile/17872881550986350855noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-63162192748457555312020-08-27T19:07:00.000-05:002020-09-02T19:21:03.423-05:00Resident Journal Review: Available Evidence Regarding Targeted Temperature Management (TTM)<b><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji0aPYxNhLzQiyYPt7PsRJGZhTDa-ntDGAweJB1CQhMoUc2L0O939TPIBYiYKtz9wikLIPSWcNhizIXJIpLWDmMbn_J4NYrgUrPyiG4LlOFbFsi0fgjVZOc7S7huE06hJv5TEJ-B26MLyf/s1920/Resident+Journal+Review.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1084" data-original-width="1920" height="230" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji0aPYxNhLzQiyYPt7PsRJGZhTDa-ntDGAweJB1CQhMoUc2L0O939TPIBYiYKtz9wikLIPSWcNhizIXJIpLWDmMbn_J4NYrgUrPyiG4LlOFbFsi0fgjVZOc7S7huE06hJv5TEJ-B26MLyf/w410-h230/Resident+Journal+Review.png" width="410" /></a></div>Authors:</b> Rithvik Balakrishnan MD; Taylor M. Douglas, MD; Taylor Conrad, MD, MS; Theodore Segarra, MD; Christianna Sim, MD, MPH<br />Editors: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM<br />Originally published:<i> <a href="https://www.aaemrsa.org/get-involved/common-sense">Common Sense</a></i><br />July/August 2020<br /><br /><b>Introduction</b><br />The ability to obtain good neurological outcomes after cardiac arrest is often limited. Interventions during the acute phase of treatment post return of spontaneous circulation (ROSC) are therefore critical.<sup>1</sup> The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. While the utility of therapeutic hypothermia for preservation of neurologic function post-cardiac arrest had been suggested in the early 1950s and 1960s, <sup>2-4</sup> the studies were inconclusive, with high complication rates. It was not until the 1990s that studies showed possible benefits to mild hypothermia in animal models. <sup>5-10</sup> The results of the 2002 trial by the Hypothermia after Cardiac Arrest Study Group were the basis for the inclusion of therapeutic hypothermia in the American Heart Association’s post-cardiac arrest care guidelines.<sup>11</sup> Subsequent trials have assessed the difference between therapeutic hypothermia to 33 degrees Celsius (ºC) and “targeted temperature management” (TTM) aiming for 36ºC, the duration of TTM, the method used to achieve and maintain it, and whether TTM confers a similar neurological benefit for cardiac arrests secondary to non-shockable rhythms; some of these trials will be discussed below and will help us answer the question at hand.<div><br /></div><span><a name='more'></a></span><div><br /><br /><b>Question: </b>What is the current available evidence on: temperature degree, duration and method of cooling in TTM patients post cardiac arrest?<br /><br /><b>Nielsen N, Wetterslev J, Cronberg T et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. New Engl J Med. 2013;369(23):2197–2206. doi: 10.1056/NEJMoa1310519.</b><br /><br />By the time of the study by Nielsen et al. therapeutic hypothermia was recommended in international resuscitation guidelines but questions still remained as to whether a specific temperature was superior to general temperature regulation. Previous research had shown that fever is associated with worse outcomes and in the Hypothermia after Cardiac Arrest Study Group trial many patients in the control group developed fever, potentially confounding the results.<sup>12</sup><br /><br />This international, randomized clinical trial took place in intensive care units (ICUs) in Europe and Australia and involved patients with out-of-hospital cardiac arrest of a presumed cardiac cause, irrespective of arrest rhythm, with a Glasgow Coma Scale (GCS) score of less than 8 after ROSC. Patients were also required to maintain spontaneous circulation for more than 20 minutes after resuscitation. The main exclusion criteria were time from ROSC to screening of more than four hours, unwitnessed arrest with asystole as initial rhythm, suspected or known intracranial hemorrhage or stroke, or an initial core temperature of less than 30ºC. Enrollees were then assigned to either TTM of 33ºC or 36ºC for 36 hours. There was no blinding for the direct care providers, but neurologic prognostication was performed by blinded individuals. There was no standardization of cooling performed and gradual warming was performed after 28 hours. Fever control continued until 72 hours after the arrest in both groups. The primary outcome was death at the end of the trial with secondary outcomes of death at 180 days, and neurological outcome assessed by cerebral performance category and the Modified Rankin scale.<br /><br />Of the 939 patients enrolled, the majority, approximately 80%, in each group had a shockable rhythm on initial assessment and 75% had bystander CPR performed. For both groups, mean time to basic life support was determined to be one-minute, advanced life support started at 10 minutes, and time to ROSC at 25 minutes. Rates of cardiovascular disease were high and approximately 40% of patients in both groups had an ST-segment elevation myocardial infarction. Both groups had similar initial neurological presentations with median GCS of 3. Intravascular cooling was performed in 24% of patients and surface cooling performed in the remaining 76%.<br /><br />By the end of the trial, 50% of patients in the 33ºC group and 48% of patients in the 36ºC group had died. Neurological outcomes by both scales were similar between the groups. The authors also investigated harms in both groups and determined no significant difference in adverse events between both groups. These results suggest that targeting a lower temperature of 33ºC confers no additional benefit to targeting 36ºC. However, the decade since the original Hypothermia after Cardiac Arrest trial had seen significant advances in pre-hospital, emergency department, and critical care that may have contributed to these outcomes. Additionally, the study leaves unanswered the question regarding the benefits of TTM in certain post cardiac arrest patients compared to non-cooling interventions.<br /><br /><b>Kirkegaard H, Soreide E, de Haas, I et al. Targeted temperature management for 48 vs 24 hours and neurologic outcome after out-of-hospital cardiac arrest: A randomized clinical trial. JAMA. 2017;318(4):341–350. doi: 10.1001/jama.2017.8978.</b><br /><br />After guidelines began to recommend the use of TTM, many researchers began studying the various logistical aspects of cooling and rewarming. Kirkegaard et al. sought to address the proper duration of hypothermia. The authors cite neonatal protocols for 72 hours of cooling as possible evidence that longer cooling may have benefits. They therefore designed a multicenter, randomized, blinded-outcome-assessor trial to compare 24 hours to 48 hours at 33°C. It is not clear from their manuscript why they chose 33°C when they cite in their introduction that there was no difference between 33°C and 36°C in prior studies.<br /><br />Power analysis led to the enrollment of 355 patients stratified by study site, age, and initial rhythm. Patients were included if their arrest was presumed to be of cardiac origin, either shockable or non-shockable rhythm. Randomization occurred within the first 23 hours after the target temperature had been reached. As they could not blind the treatment teams, they blinded the outcome assessors who collected the six month variables. <br /><br />When analyzing admission data, there were no significant differences between the two groups, but interestingly the majority of both groups received bystander CPR (82% for the 24-hour group and 84% for the 48-hour group) and were found to have an initial shockable rhythm (86% for 24 and 91% for 48). During the study, it took the 24-hour group significantly longer than the 48-hour group to reach target temperature after ROSC (320 minutes vs. 281 min, p=0.01). More complications (such as severe arrhythmias and pneumonias) occurred in the 48-hour group and more patients had to be rewarmed ahead of schedule, both of which make sense as one would expect more difficulties when keeping patients cooler longer. There was no significant difference between groups with respect to percentage of patients with good functional status (69 vs. 64%, p=0.33) or mortality (27 vs. 34%, p=0.19) at six months. The 48-hour group had a significantly longer length of stay in the ICU and time on mechanical ventilation amongst survivors, both of which were expected since they were kept at target temperature for longer, requiring more resources. <br /><br />When looking at this study population overall, the authors noted most patients received bystander CPR and were found to have an initial shockable rhythm, different from prior TTM studies. These differences may have contributed to increased survival overall, altering the power of the study as its sample size was calculated based on prior research. The authors note a sample of closer to 3,000 would be required to detect a difference based on the results of their study, which would be extremely difficult to accomplish. Therefore, whilst the authors state that there was no statistically significant evidence to support cooling for 48-hours, more research is required to validate the trial results and possibly to evaluate the rate of cooling as another variable affecting mortality. <br /><br /><b>De Fazio C, Skrifvars MB, Soreide E et al. Intravascular versus surface cooling for targeted temperature management after out-of-hospital cardiac arrest: An analysis of the TTH48 trial. Crit Care. 2019;23(1):1–9. doi: 10.1186/s13054-019-2335-7.</b><br /><br />As a follow-up to the study comparing 24-hour to 48-hour duration of TTM, coined the TTM48 trial, the authors reanalyzed the data to evaluate different methods of cooling. Their outcomes in this post-hoc analysis were cooling precision, survival, neurologic outcome (specifically poor neurologic outcome), and adverse events among survivors, of which only cooling precision was not a primary or secondary outcome in the original study. The two groups analyzed were those using intravascular catheters (IC) and those using surface cooling devices (SFC) to achieve target temperature. <br /><br />Three hundred and fifty-two of the original cohort of 355 were included in this analysis, of which 218 were cooled by IC and 134 by SFC. Both groups were allowed to use infusion of cold intravenous fluids and there was no difference in overall percentage of patients who received cold IV fluids between groups. There was no significant difference in cooling method between original cohorts. Time to TTM was statistically significantly shorter in the IC group (2.2 vs. 4.2 hours; p<0.001) but they also started at a lower temperature (35.0 vs 35.5°C, p=0.02). There was less temperature variability in the IC group, however more time spent outside of goal temperature range and post-rewarming fever were also noted in this group. <br /><br />There was no significant difference in mortality, neurologic outcome, or adverse event rates between groups. Consistent with this study, other studies on this subject have also noted that IC has less variability and better control of temperature than SFC, but without changes in clinical outcomes.<sup>13-15</sup> One major flaw of this post-hoc analysis is that the authors of both studies state in the TTM48 manuscript that the power of the original study was not sufficient and a larger study is needed. Therefore, a secondary analysis of the data is unlikely to demonstrate any significant difference. Additionally, as the patients were not randomized based on their cooling method, there were many statistically significant differences in baseline characteristics as well as their performance findings during the study between groups that could affect the authors’ conclusions, hence a larger, properly randomized study is required to detect any significant differences that might exist.<br /><br /><b>Lascarrou J-B, Merdji H, Le Gouge A et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. New Engl J Med. 2019;381(24):2327–2337. doi: 10.1056/NEJMoa1906661.<br /><br /></b>The HYPERION trial was an open-label randomized control trial that compared moderate therapeutic hypothermia (33°C for 24 hours) with targeted normothermia (37°C for 24 hours) for patients admitted to the ICU after ROSC from a cardiac arrest secondary to a non-shockable rhythm. The primary outcome was the 90-day Cerebral Performance Category score (CPC) ranging from 1 to 5, with a higher number indicating greater disability. Participants aged 18 years or older who had achieved ROSC after an in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) secondary to a non-shockable rhythm, and a Glasgow Coma Scale (GCS) of ≤8 at ICU admission (or if the patient was sedated, a GCS ≤ 8 prior to sedation) were included. Exclusion criteria included time from collapse to initiation of CPR of >10 minutes, CPR time of >60 minutes, hemodynamic instability requiring vasopressors (epinephrine or norepinephrine >1ug/kg body weight per minute), time from arrest to screening of >300 minutes, Childs-Pugh class C hepatic cirrhosis, moribund condition, pregnant or lactating mothers, status of being incarcerated or under guardianship, inclusion in another trial assessing neurological function post-cardiac arrest at 90 days, lack of health insurance, and next-of-kin decision not to participate. The trial was conducted in 25 ICUs in France between 2014 and 2018. Patients were randomized in a 1:1 ratio to either the hypothermia or normothermia groups.<br /><br />For patients who were assigned to the hypothermia group, a core body temperature of 33°C (± 0.5°C) was induced and then maintained for 24 hours per each center’s protocol (internal or external cooling with or without a specific device), and then patients were rewarmed at a rate of 0.25-0.5°C to a goal of 36.5 or 37.5°C over 24 hours. Sedation was tapered after core temperature rose above 36°C. For patients assigned to the normothermia group, core body temperature was maintained at 37°C (± 0.5°C) for 48 hours according to each center’s standard protocol; patients were sedated only during their first 12 hours. The primary outcome of all surviving patients was assessed at 90 days and a CPC score of 1 (good cerebral performance or minor disability) or 2 (moderate disability) was defined as a favorable neurologic outcome. Secondary outcomes included mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS), infections, and hematologic adverse events. Due to French Law, informed consent was not required as both groups were considered to be receiving components of standard of care, though patients (or their representatives) had the opportunity to decline the usage of their data. <br /><br />Five hundred and eighty one patients were included in the final analysis: 284 in the hypothermia group and 297 in the normothermia group. The baseline characteristics of the two groups were similar. Overall, 27% suffered from OHCA and 73% from IHCA.<br /><br />At the 90-day mark, 29 of the hypothermia patients demonstrated a CPC score of 1 or 2 compared to 17 for the normothermia group (10.2 vs. 5.7%). Secondary outcomes were similar between the two groups, including 90-day and ICU mortality, ICU LOS, and duration of mechanical ventilation among those who survived to ICU discharge or died in the ICU.<br /><br />This trial carried several limitations. Survivor neurologic outcome was assessed using a telephone rather than in-person assessment. There were a significant number of patients who were hyperthermic (temperature > 38°C) after the TTM period, and to avoid rebound hyperthermia, TTM was performed for 56 to 64 hours in the hypothermia group versus 48 hours in the normothermia group. Patients with missing data (one in the hypothermia group and two in the normothermia group) were assumed to have died. While this yields a total of only three patients with missing data, it carries significant ramifications as the trial had a fragility index of one. As such, while the HYPERION trial suggests a neurological benefit to TTM for non-shockable rhythms, further study is required for more concrete support.<br /><br /><b>Conclusion</b><br />There has been a significant amount of research over the past twenty years regarding TTM after cardiac arrest. The most recently updated American Heart Association guidelines from 2015 are supportive of TTM between 32°C and 36°C;16 based on some of the studies stated above it is unclear whether the method or a longer duration of cooling confers statistically significant differences at this time; further clinical trials are needed to assess for optimal duration of TTM, modality of cooling, and which patient groups would have the best neurological outcomes using TTM. <br /><br /><b>References</b><br /><br />1. Arrich J, Holzer M, Havel C, Mullner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2012;9:CD004128-CD004128<br /><br />2. Benson DW, Williams GR Jr, Spencer FC, Yates AJ. The use of hypothermia after cardiac arrest. Anesth Analg 1958;38:423-8. <br /><br />3. Williams GR Jr, Spencer FC. The clinical use of hypothermia following cardiac arrest. Ann Surg 1959;148:462-8.<br /><br />4. Ravitch MM, Lane R, Safar P, Steichen FM, Knowles P. Lightning stroke: report of a case with recovery after cardiac massage and prolonged artificial respiration. N Engl J Med 1961;264:36-8. <br /><br />5. Leonov Y, Sterz F, Safar P, et al. Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs. J Cereb Blood Flow Metab 1990;10:57-70. <br /><br />6. Sterz F, Safar P, Tisherman S, Radovsky A, Kuboyama K, Oku K. Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs. Crit Care Med 1991;19:379-89. <br /><br />7. Weinrauch V, Safar P, Tisherman S, Kuboyama K, Radovsky A. Beneficial effect of mild hypothermia and detrimental effect of deep hypothermia after cardiac arrest in dogs. Stroke 1992;23:1454-62. <br /><br />8. Kuboyama K, Safar P, Radovsky A, Tisherman SA, Stezoski SW, Alexander H. Delay in cooling negates the beneficial effect of mild resuscitative cerebral hypothermia after cardiac arrest in dogs: a prospective, randomized study. Crit Care Med 1993;21:1348-58. <br /><br />9. Safar P, Xiao F, Radovsky A, et al. Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion. Stroke 1996;27:105-13.<br /><br />10. Busto R, Globus MY, Dietrich WD, Martinez E, Valdes I, Ginsberg MD. Effect of mild hypothermia on ischemia-induced release of neurotransmitters and free fatty acids in rat brain. Stroke 1989;20:904-10.<br /><br />11. Peberdy MA, Callaway CW, Neumar RW, et al. Post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation2010;122:Suppl 3:S768-S786[Erratum, Circulation 2011;123(6):e237, 124(15):e403.]<br /><br />12. Zeiner A, Holzer M, Sterz F, et al. Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome. Arch Intern Med 2001;161:2007-2012<br /><br />13. Hoedemaekers C, Ezzahti M, Gerritsen A, van der Hoeven J. Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients: a prospective intervention study. Crit Care. 2007;11:R91.<br /><br />14. Gillies MA, Pratt R, Whiteley C, et al. Therapeutic hypothermia after cardiac arrest: a retrospective comparison of surface and endovascular cooling techniques. Resuscitation. 2010;81:1117–22.<br /><br />15. Glover GW, Thomas RM, Vamvakas G, et al. Intravascular versus surface cooling for targeted temperature management after out-of-hospital cardiac arrest - an analysis of the TTM trial data. Crit Care. 2016;20:1–10.<br /><br />16. Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015 Nov 3. 132(18 suppl 2):S465-82.<div><br /></div><div></div></div>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0tag:blogger.com,1999:blog-1488570157787910277.post-16967169854550071962020-08-20T15:50:00.000-05:002020-08-24T16:29:22.254-05:00New Florida Law Requiring Written Consent for Pelvic Exams: Stumbling Towards Trauma-Informed Care<div class="separator" style="clear: both; text-align: left;"><span><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; font-weight: bold;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjzE29Cf5Z4qJRzOmh_WFXTFW-wdnb6qzIMku3vQCgykyas_k-CU-l4WjxL4QJnSAjRkHTghynksEWa9HEcIRabpsW-PPlIuOWx-YUSAXNbLLWd_6oJJdTjR5RDtcqDkvecUkqhRugqU_Yd/s800/27014511240_418ae35e68_c.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="600" data-original-width="800" height="307" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjzE29Cf5Z4qJRzOmh_WFXTFW-wdnb6qzIMku3vQCgykyas_k-CU-l4WjxL4QJnSAjRkHTghynksEWa9HEcIRabpsW-PPlIuOWx-YUSAXNbLLWd_6oJJdTjR5RDtcqDkvecUkqhRugqU_Yd/w410-h307/27014511240_418ae35e68_c.jpg" width="410" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Image credit: <i><a href="https://www.flickr.com/photos/141290938@N03/27014511240" target="_blank">Flickr</a></i></td></tr></tbody></table><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8Hm1X2R73LKK5Tl2wb4aOog5twOvMHRgGW0nxukPNdzEqEBNvAte-Yj4BIlLenTbhPKLkzH5Eo0lJWx3HRky5GWFCn4JbG7RZl4TNBN_BVRQE6OzDfEWxXdstWHASBCREFmYLmystivZC/s268/RSA+Peer+Reviewed+Logo.png" imageanchor="1" style="font-weight: 400; margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="114" data-original-width="268" height="71" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8Hm1X2R73LKK5Tl2wb4aOog5twOvMHRgGW0nxukPNdzEqEBNvAte-Yj4BIlLenTbhPKLkzH5Eo0lJWx3HRky5GWFCn4JbG7RZl4TNBN_BVRQE6OzDfEWxXdstWHASBCREFmYLmystivZC/w170-h71/RSA+Peer+Reviewed+Logo.png" width="170" /></a><br /><b style="font-weight: bold;">Authors:</b>Emily Lara S. Dawra, BS, MSII</span></div>University of Miami Miller School of Medicine MD Program<br />AAEM/RSA Member<br /><br />Kasha Bornstein, MSc Pharm, EMT-P, MSIV<br />University of Miami Miller School of Medicine MD/MPH Program<br />AAEM/RSA Modern Resident Blog Copy Editor<br /><br /><br /><div><b>Introduction</b><br />On June 18, 2020, Florida Governor Rick DeSantis approved Florida Senate Bill 698, which strictly prohibited and criminalized the non-emergent use of pelvic examinations without written consent of either the patient or legal guardian.<sup>1</sup> The new measure has particular implications for the flow of operations in emergency departments across Florida, as the requirements are a potential source of confusion, additional legal jeopardy, and increased bureaucratic workload. Effective as of July 1, 2020, this legislation has already garnered strong reactions from medical professionals, including the American College of Obstetrics and Gynecology, who believe this serves a “gross intrusion in the patient-physician relationship,” and whose statement is further endorsed by the Florida Medical Association.<sup>2,3</sup> This article describes and expands on the spoken concerns surrounding this bill as they may apply to the emergency clinician. </div><div><br /></div><span><a name='more'></a></span><div><br /><br /><b>Background</b><br />The original portion of Senate Bill 698 pertaining to pelvic exams was filed under Senate Bill 1470 (since withdrawn), and was modeled after California’s 2003 Senate Bill AB-663 that protects unconscious, female-assigned patients from receiving medically unnecessary pelvic exams.<sup>3,4</sup> Senate Bill AB-663 was written to address concerns regarding medical students performing pelvic exams without prior patient consent on patients who are under general anesthesia (such as during a surgical procedure) in order to gain a better understanding of the gynecologic pathology. At this time, nine other states have similar bills to California’s enacted, including Virginia (2007), Oregon (2011), Hawaii (2012), Iowa (2017), Illinois (2018), Utah (2019), New York (2019), Maryland (2019), and Delaware (2019).<sup>5</sup> Although the American College of Obstetricians and Gynecologists endorsed the national need for prior consent in these scenarios beginning in 2011, this consent had not been legally required in most states.<sup>6,7</sup> Consequently, many patients would awaken from anesthesia to learn that this exam had been performed on them without their permission.<sup>8,9</sup> With the knowledge we have today on the importance of trauma-informed care (TIC)–that is, the need to recognize the potential previous sexual traumas of our patients and prevent re-traumatization while under our care – we must act to better protect our patients. The original Florida Senate Bill 698 was aimed at doing just that.<br /><br />However, the more general verbiage in the final, approved version of Florida’s bill, which was modified and then authorized without medical association guidance, created more broad-sweeping effects than originally intended. The term “female” was removed, and the definition of pelvis was expanded to include the rectum, thus modifying the affected patient population. Furthermore, the language around consent timing and frequency remains unclear. With the addition of criminalization, prosecution, and possible revocation of medical licenses for anyone who fails to abide by this law, emergency medical providers must now take additional precaution in everyday scenarios, some of which are listed below.<br /><br /><b>Consequences for Emergency Physicians</b><br />Written consent may now be required for patients of all genders, including nonbinary, cisgender, and transgender female and male patients for:<br /><ul style="text-align: left;"><li>Internal <i>and</i> external pelvic exams</li><li>Rectal exams, including those assessing for tone after initial trauma assessment</li><li>Rectal temperatures of infants</li><li>Pelvic exams to diagnose sexually transmitted infections,</li><li>Pelvic exams via sonography, including those for pregnancy</li><li>Each exam. There is no blanket consent (even for multiple exams during one visit).<sup>3</sup></li><li>Each person assessing the patient, student or doctor. They each must be listed on the consent form.</li><li>Catheter sample collections</li><li>Foley insertions</li></ul>The few exceptions are:<br /><ul style="text-align: left;"><li>Court-ordered examinations for the collection of evidence,</li><li>Emergent situations where an exam is necessary to “avert a serious risk of imminent substantial and irreversible physical impairment of a major bodily function of the patient.[1]”</li></ul>Failure to comply could result in federal disciplinary action against one’s license.<br /><br /><b>A Step Forward Towards Trauma-informed Care</b><br />While Senate Bill 698 is an imperfect step towards building a culture of consent in medicine, the controversy around it highlights an area of growth in medical education and care. TIC has gained recognition over the past three decades in the fields of psychology and social work, and more recently has entered into frameworks for improving medical care, particularly for survivors of sexual violence. In “Trauma-Informed Care: What it is, and Why it’s important,” Dr. Monique Tello writes that:<br /><br /><div style="text-align: left;"><i>“A medical office or hospital can be a terrifying experience for someone who has experienced trauma, particularly for childhood sexual abuse survivors. The perceived power differential, being asked to remove clothing, and having invasive testing can remind someone of prior episodes of abuse. This can lead to anxiety about medical visits, flashbacks during the visit, or avoidance of medical care.”</i>[10]</div><br />Principles of TIC guide clinicians to recognize and consider the pervasiveness of trauma — including harms perpetrated in the course of medical care—and tasks them with promoting environments of consent, healing, and recovery, rather than practices that may re-traumatize survivors. These principles include safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment of voice and choice, and emphasizing humility around cultural, historical, gender, race, and sexuality issues.<sup>1</sup> Mandating a consent form such as Senate Bill 698 requires only superficially addressing one component of TIC, which calls for a change in organizational culture with emphasis placed on understanding, respecting, and appropriately responding to the effects that trauma can have at all levels.[12]<br /><br />Integration of TIC into a medical setting such as the emergency department can include early and respectful trauma screening for all patients when possible, establishment of a social work and mental health service-based internal trauma team on-site to allow for rapid connection to further appropriate care, introductory training for all staff and clinicians, and development of an administrative commitment to integrating a trauma informed institutional culture.<sup>13</sup> California is once again leading the way with this initiative, with Medi-Cal requiring providers to undergo TIC training and paying those providers who then screen their patients for trauma (effective January 2020).<sup>11</sup> It is evident that the United States is beginning to shift towards TIC, and it is necessary that we model our laws under this framework.<br /><br /><b>Conclusion</b><br />While the original form of Senate Bill 698 was undoubtedly a well-intentioned motion towards trauma-informed care, the current form is precipitously vague. For the time being, this move forward towards TIC is certainly a positive; however, we will hopefully see a version of this measure that can be more easily integrated into medical infrastructure in the future. Medical schools and emergency medicine residencies can take steps to integrate trauma-informed care into their curricula. <br /><br />A template consent form from the Florida Medical Association can be found <a href="https://www.flmedical.org/florida/Florida_Public/Docs/Legis/Pelvic-Consent-Form.pdf" target="_blank">here</a>.<br /><b><br />References</b><br /><ol style="text-align: left;"><li>Book L, Stewart L. Senate Bill 698 (2020) - The Florida Senate. Flsenate.gov. https://www.flsenate.gov/Session/Bill/2020/698/. Published 2020. Accessed July 13, 2020.</li><li>Phipps M, Benrubi G. ACOG Statement on New Florida Law Requiring Written Consent for Pelvic Examinations. Acog.org. https://www.acog.org/news/news-releases/2020/06/acog-statement-on-newflorida-law-requiring-written-consent-for-pelvic-examinations. Published 2020. Accessed July 13, 2020.</li><li>Scott J. Analysis Of Florida’s New Law Regarding Pelvic Examinations. Florida Medical Association; 2020:1-2. https://www.flmedical.org/florida/Florida_Public/Docs/Legis/Legal-Update-Summary-Update-SB-698.pdf. Accessed July 13, 2020.</li><li>California Senate Bill AB 663. Vol 2281.http://www.leginfo.ca.gov/pub/0304/statute/ch_0601-0650/ch_644_st_2003_ab_663; 2020.</li><li>Chong A, Monzel A, Hubaishy J, Costella K. Unauthorized Pelvic Exams: Public Engagement Initiative—The Epstein Health Law and Policy Program. The Epstein Health Law and Policy Program. https://www.epsteinprogram.com/pelvic-exams. Published 2020. Accessed July 13, 2020.</li><li>American College of Obstetricians and Gynecologists. Committee on Education. Committee opinion no. 500: Professional responsibilities in obstetric-gynecologic medical education and training. Obstet Gynecol. 2011;118(2 Pt 1):400-4.</li><li>Hammoud M, Spector-Bagdady K, OʼReilly M, Major C, Baecher-Lind L. Consent for the pelvic examination under anesthesia by medical students. Obstetrics & Gynecology. 2019;134(6):1303-1307. doi:10.1097/aog.0000000000003560</li><li>Hsieh P. Pelvic Exams On Anesthetized Women Without Consent: A Troubling And Outdated Practice. Forbes. https://www.forbes.com/sites/paulhsieh/2018/05/14/pelvic-exams-on-anesthetized-womenwithout- consent-a-troubling-and-outdated-practice/#6636449d7846. Published 2020. Accessed July 13, 2020.</li><li>Goldberg E. “She Didn’t Want a Pelvic Exam. She Received One Anyway.” Nytimes.com. https://www.nytimes.com/2020/02/17/health/pelvic-medical-exam-unconscious.html. Published 2020. Accessed July 13, 2020.</li><li>Tello M. Trauma-informed care: What it is, and why it’s important. In: Harvard Health Blog 2018.</li><li>Trauma Informed Care. https://www.dhcs.ca.gov/provgovpart/Pages/TraumaCare.aspx. Published 2020. Accessed July 13, 2020.</li><li>Substance Abuse and Mental Health Services Administration. (2014). Concept of Trauma and Guidance for a Trauma-Informed Care Approach. In. U.S. Department of Health and Human Services.</li><li>Corbin TJ, Rich JA, Bloom SL, Delgado D, Rich LJ, Wilson AS. Developing a trauma-informed, emergency department-based intervention for victims of urban violence. J Trauma Dissociation. 2011;12(5):510-525.</li><li>Harris M, Fallot RD. Trauma-informed inpatient services. New Dir Ment Health Serv. 2001(89):33-46.</li></ol></div><span></span>AAEM Resident and Student Associationhttp://www.blogger.com/profile/13038672826661225850noreply@blogger.com0