January/February 2021 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 28, ISSUE 1 JANUARY/FEBRUARY 2021

Who Will Be Their Advocate? A Commentary on Facing Illness Alone. Page 22

President’s Message:

An Emergency Physician is NOT a Provider

From the Editor’s Desk:

A Test, a Shot, and a Prescription

AAEM21 Scientific Assembly Subcommittee:

AAEM21: Meet Me in St. Louis!

Young Physicians Section:

Finding Escapism and Mentorship in a Book Club

AAEM/RSA President’s

Addressing the Social and Structural Determinants of Health in Medical School and Residency Education

Table of Contents TM

Officers President Lisa A. Moreno, MD MS MSCR FIFEM President-Elect Jonathan S. Jones, MD Secretary-Treasurer Robert Frolichstein, MD Immediate Past President David A. Farcy, MD FCCM Past Presidents Council Representative Joseph Wood, MD JD Board of Directors L.E. Gomez, MD MBA Bobby Kapur, MD MPH CPE Bruce Lo, MD MBA RDMS Evie Marcolini, MD FCCM Sergey M. Motov, MD Terrence Mulligan, DO MPH Vicki Norton, MD Carol Pak-Teng, MD YPS Director Phillip Dixon, MD MPH AAEM/RSA President Haig Aintablian, MD Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD Editor, Common Sense Andy Mayer, MD Executive Director Missy Zagroba, CAE Executive Director Emeritus Kay Whalen, MBA CAE AAEM/RSA Executive Director Madeleine Hanan, MSM Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Alexandria Gregory, MD, Resident Editor Cassidy Davis, Managing Editor Articles appearing in Common Sense are intended for the individual use of AAEM members. Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA. Articles may not be duplicated or distributed without the explicit permission of AAEM. Permission is granted in some instances in the interest of public education. Requests for reprints should be directed to AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM is a non-profit, professional organization. Our mailing list is private.

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COMMONSENSE

Regular Features President’s Message: An Emergency Physician is NOT a Provider........................................................3 From the Editor’s Desk: A Test, a Shot, and a Prescription.....................................................................5 Letter to the Editor: Letter in response to the September/October 2020 “Dollars and Sense” article titled: Disability and Life…Another Option!............................................................................7 Foundation Donations.............................................................................................................................9 PAC Donations......................................................................................................................................10 LEAD-EM Donations.............................................................................................................................11 Upcoming Conferences ........................................................................................................................11 AAEM Position Statements...................................................................................................................12 AAEM/RSA President’s Message: Addressing the Social and Structural Determinants of Health in Medical School and Residency Education..................................................................45 AAEM/RSA Editor: How To Be a Great Senior Resident.......................................................................47 Medical Student Council President’s Message: Learning Virtually........................................................48 Resident Journal Review: Early Vasopressor Use in Septic Shock: What Do We Know?.....................52 Board of Directors Meeting Summary: November................................................................................57 Job Bank...............................................................................................................................................58 Special Articles Meet Me in St. Louis.............................................................................................................................18 SBO: Seize Back Onus – Focus on POCUS.........................................................................................20 Who Will Be Their Advocate? A Commentary on Facing Illness Alone.................................................22 Ethics: Questions..................................................................................................................................24 Operations Management: The Role of Ridesharing in Emergency Medicine........................................26 Wellness: Peer Coaching: A Strategy for Development and Wellbeing.................................................29 Critical Care Medicine: Intubating Asthma............................................................................................31 Women in EM: “Thank you, Dr. C:” The Stigma of the F-word (Fertility)...............................................35 Young Physicians: Finding Escapism and Mentorship in a Book Club..................................................39 Young Physicians: Biases in Emergency Medicine...............................................................................41 Updates and Announcements Updates from ABEM.............................................................................................................................15 AAEM21 Subcommittee: AAEM21 Meet Me in St. Louis!.....................................................................17 Emergency Ultrasound: Why an Ultrasound Fellowship Might Be Right for You...................................37 Young Physicians: VotER: Healthy Democracies Make Healthy Communities......................................42 Your Voice STILL Matters.....................................................................................................................49 AAEM/RSA Advocacy: Surprise Emergencies Shouldn’t Have to Result in Surprise Bills.....................50 Mission Statement

The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles: 1. Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine. 2. The practice of emergency medicine is best conducted by a specialist in emergency medicine. 3. A specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM). 4. The personal and professional welfare of the individual specialist in emergency medicine is a primary concern to the AAEM. 5. The Academy supports fair and equitable practice environments necessary to allow the specialist in emergency medicine to deliver the highest quality of patient care. Such an environment includes provisions for due process and the absence of restrictive covenants. 6. The Academy supports residency programs and graduate medical education, which are essential to the continued enrichment of emergency medicine and to ensure a high quallity of care for the patients. 7. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members. 8. The Academy supports the establishment and recognition of emergency medicine internationally as an independent specialty and is committed to its role in the advancement of emergency medicine worldwide.

Membership Information

Fellow and Full Voting Member (FAAEM): $525* (Must be ABEM or AOBEM certified, or have recertified for 25 years or more in EM or Pediatric EM) Associate: $150 (Limited to graduates of an ACGME or AOA approved emergency medicine program within their first year out of residency) or $250 (Limited to graduates of an ACGME or AOA approved emergency medicine program more than one year out of residency) Fellow-in-Training Member: $75 (Must be graduates of an ACGME or AOA approved emergency medicine program and be enrolled in a fellowship) Emeritus Member: $250 (Please visit www.aaem.org for special eligibility criteria) International Member: $150 (Non-voting status) Resident Member: $60 (voting in AAEM/RSA elections only) Transitional Member: $60 (voting in AAEM/RSA elections only) International Resident Member: $30 (voting in AAEM/RSA elections only) Student Member: $40 (voting in AAEM/RSA elections only) International Student Member: $30 (voting in AAEM/RSA elections only) Pay dues online at www.aaem.org or send check or money order to: AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM-1120-433

AAEM NEWS PRESIDENT’S MESSAGE

An Emergency Physician is NOT a Provider Lisa A. Moreno, MD MS MSCR FAAEM FIFEM — President, AAEM

I have had a real issue with this word almost since its introduction into medical vernacular. I often plagiarize a physician’s response I read sometime ago on social media, “Sorry, I never went to provider school. I went to medical school.” When I was a child, we used to respond to hurtful comments about our racial and ethnic backgrounds with a pithy jingle, “Sticks and stones may break my bones, but words can never hurt me.” How untrue this was then, and still is now. We have evolved as a society to the understanding that WORDS ARE POWERFUL, and what we call ourselves and each other, how we describe a given situation, very much matters and can very much hurt or help our interpersonal relationships. The word “provider” when used in reference to a health care professional has its origins with insurance companies and government agencies who seek to create in our patients the attitude that there is no difference among health care professionals, and so if they have seen a “provider,” they have received the highest level of care and their health concerns have been resolved and/or are being managed appropriately. The term gained popularity as it has been taken up by corporate medical groups with the same intended outcome. These “vendors” of medical care, as they call themselves, all can save lots and lots of money when patients are treated by “providers.” The problem is that all “providers” are NOT equal and that allowing, or leading patients to think so is dishonest and lacks integrity. AAEM’s mission statements stand clear that a board certified emergency physician is the only definition of a specialist in emergency medicine and that every patient in the world is entitled to this level of care when faced with a medical emergency. Our mission includes the support of EM residency training and CME, as well as the development of EM as a specialty world-wide. Our EM Workforce Committee, under the leadership of Dr. Marcolini and Dr. Vieth, has developed public statements based on hard facts to demonstrate that there is a difference and that it does matter.

I WILL NOT TOLERATE THE OBLITERATION OF THE INTEGRITY OF MY PROFESSION USING A WORD THAT SEEKS TO MAKE ME A GENERIC ENTITY.” The word “physician” is defined by the Oxford Dictionary as “a person qualified to practice medicine.” (italics mine)1 and the Merriam Webster dictionary defines it as “one educated, clinically experienced, and licensed to practice medicine.”2 Clinically experienced, qualified, and licensed to practice medicine is very different from clinically experienced, qualified, and licensed to practice physician assistance or any form of nursing. As the EM Workforce Committee points out, some nurse practitioners are entirely trained online, with no new clinical experience required to earn this advanced degree.

HAVE EVOLVED AS A SOCIETY TO THE UNDERSTANDINGWETHAT WORDS ARE POWERFUL, AND WHAT WE CALL OURSELVES AND EACH OTHER, HOW WE DESCRIBE A GIVEN SITUATION, VERY MUCH MATTERS AND CAN VERY MUCH HURT OR HELP OUR INTERPERSONAL RELATIONSHIPS.” The origin of the word “physician” comes from both French and Middle English, meaning “one who practices the science of healing.”. The linguist Janus Bahs Jacquet points out that a literal translation connotes “relating to that which is.”3 This derivation implies a grounding in truth, as we relate to our patients in the context in which they exist, making our responsibility for them far greater than a mere commitment to their chief complaint. Our Hippocratic Oath mandates that we live in purity and holiness.4 The Oath of the Hindu Physician, the Daily Prayer of Maimonides, and The Thousand Golden Remedies (China) all command the physician to be committed to truth and integrity in all aspects of his or her life.5 In the days in which Ibn Sina wrote the Canon of Medicine, physicians were required to pass examinations not only in the natural sciences and pharmacology, but also in religion, fine arts, law, philosophy, astrology, and mathematics. It was accepted that since the physician dispenses advice and treatment that impacts every aspect of a patient’s life, s/he must be a scholar and a person of wisdom to perform that role. And of note, female physicians were not a rarity in these Islamic medical universities.6 The Declaration of Geneva, developed after the horrific medical experimentation and abuses committed during the Second World War and to which I swore on my graduation day from medical school, states, “I solemnly pledge myself to consecrate my life to the service of humanity…The health of my patient will be my first consideration…I will maintain the utmost respect for human life…even under threat and I will not use

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AAEM NEWS PRESIDENT’S MESSAGE

my medical knowledge contrary to the laws of humanity…”7 These are not the obligations of a provider. Being a physician is not a job. This is a vocation. It is a profession in the least. It is an awesome thing to have a human being place his/her most precious gifts—life and body—into our care with complete and unwavering trust. And there are many of us today who still believe that we are accountable to the Creator of these lives and bodies for the manner in which we care for them. I am not now, never have been, and will never be a provider. I am called to be a physician. It is my privilege and my responsibility. It is one of the most important purposes of my life. I worked extremely hard to become a physician, and many others worked hard for me to become a physician, including but not limited to those who taught me and the family that sacrificed for my studies. And truthfully, I continue to work hard, and I continue to be taught and to learn, and my family continues to make sacrifices. I will not tolerate the obliteration of the integrity of my profession using a word that seeks to make me a generic entity. And I believe that every nurse, physician assistant, psychologist, midwife, plumber, electrician, pilot, teacher, priest, and rabbi should be PROUD of what they have chosen to do with their lives and should insist that they be called by the noble name of their profession. Because words matter, once we allow ourselves to be called “providers,” we will accept ourselves as providers, and we will indeed become providers. Medicine will become a job, and the biggest losers will be the patients whom we will no longer put first and no longer serve with integrity and dedication. We will no longer hold ourselves responsible for social injustice and political immorality. We will no longer feel responsible to educate our patients about gun violence, drug abuse, and respect for nutrition and preventive measures. Slowly, we may come to regard profit,

through put time, and billable services as more important than making the right diagnosis, ordering the necessary studies without regard for insurance status, delivering bad news with compassion, and taking the time to ensure that patients have a way to fill their prescriptions and a safe place to live. We will become part of the medical industrial complex, owned by the vendors of health care, providers for their profit-making industry. I will remain a physician, proud of the standards and the mission and vision of AAEM, proud to be part of an organization that upholds honesty and integrity. Thank you for being part of this with me.  References 1. www.dictionary.com 2. https://www.merriam-webster.com/dictionary/physician 3. http://ec2-23-21-117-9.compute-1.amazonaws.com/topics/body-brain/ segment/01/28/2011/science-diction-the-origin-of-physician.html 4. https://en.wikipedia.org/wiki/Hippocratic_Oath 5. Distributed to me at my graduation from medical school; copies available from me on request 6. The Physician by Noah Gordon is a historical novel that accurately describes medical training during what Europeans called the Dark Ages. This was a magnificent age of learning in the Middle East. As an aside, the movie of the same name does not do the book justice in my opinion. 7. https://www.wma.net/wp-content/uploads/2016/11/Decl-of-Geneva-v2006. pdf

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PHYSICIANEACHHASEMERGENCY TO DEVELOP THEIR

AAEM NEWS FROM THE EDITOR’S DESK

OWN STYLE AND SET OF COMMUNICATION SKILLS TO DEAL WITH THE DILEMMA BETWEEN PRACTICING EVIDENCE-BASED MEDICINE AND “GIVING THE CUSTOMER WHAT THEY WANT.”

Satisfaction feedback

A Test, a Shot, and a Prescription Andy Mayer, MD FAAEM — Editor, Common Sense

Each emergency physician needs to develop a strategy to deal with the numerous patient and personalty types which we can encounter in the average shift. There are of course the chronic pain patients, the worried mother, the anxious overly concerned son, the histrionic patient, the medically savvy (at least in their mind) patient, and this list goes on and on. Successfully dealing with each of these types of patients requires patience and interpersonal skills, which can be difficult to successfully master. Each of us has a weak point and a type of difficult patient, which is especially challenging for us to handle. All of us come to the practice of emergency medicine with a unique skill set and a set of biases due to past experiences. Learning a process which you can use to deal with our patients especially with the type of patient which you feel is “worst of the worst” is crucial for each of us. A failure or limited ability in mastering these skills needed to handle these patients can lead to significant frustration for the practicing emergency physician resulting in burnout. The problems related to dealing with these patients can come to the forefront when an individual emergency physician’s patient satisfaction scores are reported. Every emergency physician now has to deal with whatever patient satisfaction tool, which your hospital uses. There are some good reasons to try and measure

patient satisfaction and useful information can be obtained from them if the methodology allows for statistically significant results. Many of these survey tools do not offer such utility and simply meet the hospitals needed data requirements even if the data is worse than useless. Bad data drives bad results and conclusions, which can injure the parties involved. This fact is why these patient satisfaction tools often lead to significant deterioration in the satisfaction of the emergency physicians with their careers. This can lead to worsening of their wellness and their ability to provide empathetic and effective care to their patients. Physicians can develop unhealthy and wasteful practices as they develop their own unique method of dealing with these patients. I do not judge the tired emergency physician who towards the end of a long late shift, ends up bargaining with the manipulative patient who senses weakness in their quest for the narcotic du jour. Each of us has high and low points in our individual ability to remain strong and true to our principles. These incidents can be reflected directly in your hospital’s satisfaction tool. Many of these satisfaction surveying devices offer the patient the opportunity to write in comments. Reading all of these is one aspect of my role as a medical director. Certainly, there are many fine comments commending the wonderful and compassionate care, which the patients received, and everyone enjoys reading those. However, this same forum can

lead to offensive and soul-sucking experiences as the comments are turned into “incidents” by your quality department. These probably well intentioned quality and safety individuals want answers and solutions to every possible reported issue. They were not at the bedside at 2:00am but awoke fresh for their weekday shift to review what you did on the nights, weekends, and holidays while they were home with their families. Dealing with the often-ridiculous sounding complaints can be wellness killers for anyone involved. One of my least favorite aspects of being a medical director is having to share some of these patient satisfaction survey responses with my partners. Certainly, all emergency physicians can have a bad day or simply have a patient with whom they cannot connect with generating a complaint. We all on occasion receive valid negative comments associated with poor outcomes, delayed diagnosis, interpersonal interactions, etc. Using this feedback to learn and grow as a doctor can be a useful tool through which we can learn to become better physicians. However, many of us find that the criticism which we receive can really be unjustified particularly when it relates to not given pain medication, not treating a virus with an antibiotic, or otherwise trying to properly and cost-efficiently care for our patients. Taking the time required to reassure an anxious mother of a child with a bump on the head is a great example of this paradox. Using properly learned assessment techniques and our

>> COMMON SENSE JANUARY/FEBRUARY 2021

AAEM NEWS FROM THE EDITOR’S DESK

clinical experience we often and properly decide that the three-year-old should not have a head CT. Trying to relate this information and convincing someone else that your judgement and clinical decision making skills are accurate can be difficult. Taking the time needed to do this can be frustrating to all and lead to a poor patient satisfaction score and a withering of the involved physician’s spirit when they read the comment from this same mother that the “doctor didn’t do anything for us.” You know that you are right in that you properly did not expose the child to needless dangerous radiation, improved throughput in your department, saved resources and provided excellent and proper care. What is one to do? Learning to negotiate between doing what you know is right and “the customer is always right” mentality is one key to your professional contentment. Thirty years ago, when I finished my emergency medicine residency I entered a group which had an assortment of physicians. Most had been trained in other specialties and had “grandfathered” into emergency medicine and were board certified and were solid doctors. A couple of the older members who were founding members of the group had never bothered to go through the board certification process. These same more senior physicians clearly shied away from the sicker patients and wanted to focus on the easier “fast track” class of arrivals. This was okay with me as of course, I wanted to demonstrate my new emergency medicine training and enjoyed being able to see all of the sickest of the arrivals. As every young emergency physician should do, I watched the more senior members of my group and tried to learn from them. Working with physicians with decades of experience is a great way to see both good and bad techniques in dealing with patients. The senior physicians in my group seemed to be able to “satisfy” their patients despite the fact that many of their practice habits seemed to me to be wasteful and not science based. However, they seemed to understand patient satisfaction and how to make a satisfied customer much more than I did when I was handed my shiny new certificate denoting residency completion. They had developed their toolbox to make patients happy. Of course, I tried to use my training to practice quality evidence-based emergency medicine. I tried to explain that Amoxicillin does not cure viruses and that the Ottawa ankle rule allowed me to confidently say that the patient did not need an ankle X-ray. The old veterans would simply shake their head and smile and try to explain how to make patients happy. One of them quietly told me that if I followed a simple rule that life would be easier. I of course asked what was the rule as the insight and wisdom of someone who had been working for years in a busy suburban emergency department I assumed would be useful. I imagined that his advice would be on target and might be a game changer for me. He explained that if you simply did three things for every patient that they would be satisfied, believe that you cared about them and also believe that you wanted them to get better. These three things to do for every patient were “a test, a shot, and a prescription.” He asserted that if you provided these three things the patient seldom complained. Of course, I explained my shock that many patients did not need any of these and that his rule simply increased the cost of 6

COMMON SENSE JANUARY/FEBRUARY 2021

health care for limited if no benefit. He smiled and shook his head again telling me that I “would learn” about medicine. Certainly, physicians who practice this way significantly contributed to the explosive cost of health care in America. Sadly, these practices continue. Do any of you not hear from patients that the nurse practitioner who saw them at the local Urgent Care “always” gave them a flu test, a steroid shot, and a prescription for an antibiotic when they have a cold? Each emergency physician has to develop their own style and set of communication skills to deal with the dilemma between practicing evidence-based medicine and “giving the customer what they want.” This paradox is often at the root of many of our patient satisfaction issues and also our own personal wellness issues. Seeing excellent and caring physicians distraught about patient complaints when they believe they did the right thing for the patient by not giving them what they ask for is painful. We each need to develop the interpersonal skills to be able to navigate these treacherous waters. There is no single right answer or strategy which will work for everyone and this is why this issue is so difficult to master. Again, it is hard to judge too harshly a physician who “gave in” to a particular patient’s demand for a specific test, medication, or admission. The key is mastering a way to have the patient believe that you validated their need to come to the emergency department in the first place, that you took their complaint seriously, that you performed the necessary testing to support your expert opinion, and that you provided the best treatment for their problem. In a significant number of patient presentations all of these criteria can be accomplished by simply talking to a patient and not spending money on testing and medications. This of course is a real skill and also having the insight of knowing when to pick your battles is crucial. Consider watching other members of your group and also other physicians who come through your department as consultants. You can learn a great deal by watching the skills and techniques, which they use to satisfy their patients. You already know the physicians who the nurses want to work with and the patients want to see. You will quickly be able to see that some are popular with patients because they simply avoid all confrontation and do not fight doing tests, giving narcotics, or admitting problem patients. You will see others who practice excellent medicine but always seem to be generating complaints while actually being the better doctor. The key is to find the right approach between these two extremes which will work for you. Try and watch small interactions and see what methods you think might work for you and try them. The people who walk or roll into your emergency department are not just customers. They are our patients and we are their doctor. We cannot afford to lose this sacred relationship. Giving the patient what they want is not a good idea as it often is not the correct action. American health care costs are ridiculously high and ordering the tenth CT scan of the year for a headache patient or similar activity will only lead to a deeper hole of health care spending. Please work on your toolbox so you do not feel the need to waste money by giving every patient the abovementioned test, shot, and prescription. 

AAEM NEWS LETTER TO THE EDITOR

Letter to the Editor Common Sense appreciates thoughtful comments and ideas. Dr. Bordon’s recent article concerning disability insurance has generated such a response from Dr. Flaxman. Sadly, medical education often produces young physicians who when completing residency are faced with much larger incomes and a new set of concerns for the financial security of their families. These same young physicians can be deluged with a plethora of advice of what to do to protect themselves and their families. This advice can be self-serving as many types of “financial experts” appear and make recommendations to sometimes unsuspecting physicians. This can lead to bad decisions, which can have serious long term financial implications. Dr. Bordon suggests a somewhat contrarian view in regards to insurance. His approach does require significant financial discipline and some would say an unacceptable risk to a young family. Common Sense hopes that you will consider both points of view and form your own informed opinion in this regard. —The Editor

LETTER TO THE EDITOR : Letter in response to the September/October 2020 “Dollars and Sense” article titled: Disability and Life…Another Option! Dear Editor, I read with concern Dr. Borden’s article, “Disability and Life…Another Option!” in the July/August 2020 edition. Dr. Borden’s unfortunate experience, apparently with a company known for their aggressive sales techniques, should not be a generalization of the value, for many, of disability insurance / income protection. Since the likelihood of becoming disabled increases with increasing age, some policies may become more expensive and pay out less over time, although that is an uncommon structure. It is the buyer’s choice how they choose to structure their policy and any insurance professional should be able to assist in determining the relative value of an increasing or level cost. It is a simple breakeven calculation. Dr. Borden’s difficulty in utilizing his policy when he became disabled is obviously concerning. A financial planner, some of whose clients will have experienced a disability, should have experience with various companies and recommend against inappropriately recalcitrant ones. Furthermore, companies can be researched in any number of ways, including looking up the company at the Better Business Bureau (www. bbb.org). Dr. Borden is correct in that if you do not buy disability insurance but instead invest the money, assuming you are never disabled, you will have more money. But the same argument could be made of a car. If you do not buy a car, or instead by a cheaper car, and invest the money saved, you will have more money in the end. But disability insurance is not an investment account. It is protection of the asset…you! Insurance is not, as Dr. Borden says, “gambling at a casino” but rather it is about spreading out low-probability, high-cost risk. It is not likely that a given emergency physician will become disabled at a specific time over a career, but some certainly will. For those that have, and are living on disability income, I suspect that they would have a very different perspective on the relative value of the premiums versus the benefits. If you are one of those unfortunate ones, who is going to maintain the household financial security while they are not working? Many EM physicians have non-working or much lower income spouses. How will they sustain the rent/mortgage, transportation, food, clothes, and all the daily expenses for the family? 25 years into a career, you may have well have enough savings to not require disability insurance and at that point, the value proposition may certainly be different than when you are a first year attending. But if you are injured one, five, or 10 years

In an effort to keep our members connected, Common Sense will begin a column of member updates submitted by our members. We ask you to submit brief updates related to your career. We will also publish the unfortunate news of the passing of current or former members. Visit the Common Sense website to learn more and submit your updates for publication! www.aaem.org/resources/publications/common-sense WestJEM Awards

2020 EMRA 25 under 45 Honorees

Congratulations to the below members who received recognition from WestJEM on for being a top board member of 2019-2020 Distinguished Reviewers of 2019-2020

Congratulations to the below members who received recognition for their contributions to EM as young physicians Ashely Alker, MD MSc Sandra Coker, MD Mohamed Hagahmed, MD Shuhan He, MD Danya Khoujah, MBBS MEHP FAAEM

Joshua Bucher, MD Annahieta Kalantari, DO Michael Owens, MD

James Paxton, MD Jonathan Weyand, MD

COMMON SENSE JANUARY/FEBRUARY 2021

AAEM NEWS LETTER TO THE EDITOR

into your career, it is unlikely you will have already saved enough money to be financially secure for life. That is what disability insurance is for. I would be interested in hearing from someone who had to file a claim early in their career. From Dr. Borden’s purely financial analysis, surely, the amount they received would be greater than the amount paid in. More importantly, they had income (likely significant and tax-free income) when they otherwise would have had none. There were many other points in the article to address: term life insurance, real estate investments, rental income, financial planners, investment fees, accountants, “own occupation” policies, and general financial planning. The basics are straightforward, but perhaps each should be addressed in their own column, or columns, rather than presenting them as alternatives to not obtaining disability insurance. Please, speak with your own team: financial planner, accountant, lawyer, or all of the above. If you do not have a team, start building one. How to build such a team is worth another column in and of itself. But talk to your team: if you cannot absorb the cost of having no income, then you have a need for disability insurance. — Alex Flaxman, MD MSE Fellow, Critical Care Medicine Rowan SOM/Jefferson Health/Our Lady of Lourdes Health System

RESPONSE: Letter in response to the September/October 2020 “Dollars and Sense” article titled: Disability and Life…Another Option! Dear Dr. Flaxman and Mr. Ruffing, Thank you for your response to my article, “Disability and Life…Another Option!” To answer the question as regards the quality of my policy, it was the best available at the time of my purchase. It was the number one ranked company. During the midst of my struggle with the company (I can’t risk stating their name since insurance companies are too huge and powerful to risk offending) I asked for a reference. I wanted to talk to an emergency physician that was receiving disability payments from them. I was desperate for hope, and concerned that there was really no way to get disability (short, possibly, of having no arms, no legs, combined with head injury). My response was; “No, I do not know of any emergency physician that is currently receiving payments.” I asked three people with the company, and one (adjuster) stated that there was an EP that was applying after a serious motor vehicle accident, that would “likely begin to receive payments soon.” Thousands of us paying for disability insurance, and NOT ONE OF US receiving payments. That was very disheartening. Would I/you have any recourse against the second strongest political lobby in America? They could spend more than my (city’s) entire net worth on lawyers against me and not even notice it. Though I don’t know the exact numbers, I am quite certain that over 99% of EPs would be better off using their money to create a liquid “rainy day account” than they would be after paying for disability insurance. If you missed my article, please read it and comment!  — Mark Borden, MD FAAEM

Submit a Letter to the Editor What stood out to you from this issue of Common Sense? Have a question, idea, or opinion? Andy Mayer, MD FAAEM, editor of Common Sense, welcomes your comments and suggestions. Submit a letter to the editor and continue the conversation.

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COMMON SENSE JANUARY/FEBRUARY 2021

AAEM Foundation Contributors – Thank You! Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 1-1-2020 to 12-1-2020. AAEM established its Foundation for the purposes of (1) studying and providing education relating to the access and availability of emergency medical care and (2) defending the rights of patients to receive such care and emergency physicians to provide such care. The latter purpose may include providing financial support for litigation to further these objectives. The Foundation will limit financial support to cases involving physician practice rights and cases involving a broad public interest. Contributions to the Foundation are tax deductible.

Contributions $500-$999

Peter G. Anderson, MD FAAEM Bryan K. Miksanek, MD FAAEM Molly O’Sullivan Jancis, MD FAAEM Andrew W. Phillips, MD MEd FAAEM Pamela A. Ross, MD FAAEM Mary Ann H. Trephan, MD FAAEM David Thomas Williams, MD FAAEM Harry Charles Wolf IV, MD FAAEM

Contributions $250-$499

Kevin Allen, MD FAAEM Justin P. Anderson, MD FAAEM Kevin Robert Brown, MD FAAEM Michael R. Burton, MD FAAEM Christopher Calvert, MD FAAEM Garrett Clanton II, MD FAAEM Walter M. D’Alonzo, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM Deborah D. Fletcher, MD FAAEM Kathleen Hayward, MD FAAEM Jerris R. Hedges, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT John H. Kelsey, MD FAAEM Stephanie Kok, MD FAAEM Ron Koury, DO FAAEM Bruce E. Lohman, MD FAAEM Noah A. Maddy, MD FAAEM Nishit Mehta, MD FAAEM Isaac A. Odudu, MD FAAEM Phillip L. Rice Jr., MD FAAEM James Francis Rowley III, MD FAAEM Keith D. Stamler, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM R. Keith Winkle, MD FAAEM Leonard A. Yontz, MD FAAEM

Contributions $100-$249

Eric Anderson, MD MBA FAAEM Kian J. Azimian, MD FAAEM Lydia L. Baltarowich, MD FAAEM FACMT Mark Avery Boney, MD FAAEM Mary Jane Brown, MD FAAEM Charles E. Cady, MD FAAEM FAEMS Anthony J. Callisto, MD FAAEM Rebecca K. Carney-Calisch, MD FAAEM David C. Crutchfield, MD FAAEM Michael T. Cudnik, MD FAAEM Robert J. Darzynkiewicz, MD FAAEM Jason W. David, MD Angel Feliciano, MD FAAEM Matthew K. Fischer, MD FAAEM Taylor G. Fletcher, MD FAAEM William T. Freeman, MD FAAEM Paul W. Gabriel, MD FAAEM Gary M. Gaddis, MD PhD FAAEM FIFEM Albert L. Gest, DO FAAEM Kathryn Getzewich, MD FAAEM Luis E. Gomez, MD MBA FAAEM Regina Hammock, DO FAAEM Neal Handly, MD FAAEM Dennis P. Hanlon, MD FAAEM William E. Hauter, MD FAAEM Jacob Hennings Jessica Herrera, MD FAAEM David Anthony Hnatow, MD FAAEM Jamey P. Hourigan, DO FAAEM, FACEP Kevin T. Jordan, MD FACEP FAAEM Lenard Kerr, DO FAAEM Katrina Kissman, MD FAAEM Hannah J. Kleiman, MD H. Samuel Ko, MD MBA FAAEM Stephen J. Koczirka Jr., MD FAAEM FACEP

Calvin C. Krom III, DO FAAEM Steven Kushner, MD FAAEM David W. Lawhorn, MD MAAEM FAAEM Rebecca Liggin, MD FAAP FAAEM FACEP Robert D. Londeree III, MD FAAEM William M. Maguire, MD FAAEM Andrew P. Mayer, MD FAAEM Gregory S. McCarty, MD FAAEM Nevin G. McGinley, MD MBA FAAEM Rick A. McPheeters, DO FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM James Arnold Nichols, MD FAAEM Patricia Phan, MD FAAEM Jobin J. Philip, MD Jeffery M. Pinnow, MD FAAEM FACEP Matthew C. Ponder, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE George J. Reimann, MD FAAEM Scott D. Reiter, MD FAAEM Jeffrey A. Rey, MD FAAEM Gregory L. Roslund, MD FAAEM Teresa M. Ross, MD FAAEM Nate T. Rudman, MD FAAEM Kraftin E. Schreyer, MD CMQ FAAEM H. Edward Seibert, MD FAAEM Eric M. Sergienko, MD FAAEM Sachin J. Shah, MD FAAEM Richard D. Shih, MD FAAEM Jonathan F. Shultz, MD FAAEM Douglas P. Slabaugh, DO FAAEM Susan Socha, DO FAAEM Rohan Somar, MD FAAEM Robert E. Stambaugh, MD FAAEM Christine Stehman, MD FAAEM David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM

Jalil A. Thurber, MD FAAEM Robert Boyd Tober, MD FAAEM Andy Walker, MD FAAEM Joanne Williams, MD MAAEM FAAEM Kary Wisniewski, MD FAAEM George Robert Woodward, DO FAAEM

Contributions up to $50

NanaEfua Afoh Manin, MD MPH Sameer M. Alhamid Jr., MD FRCPC FACEP FAAEM Robert Bassett, DO FAAEM James Butler, MD Jordan R. Chanler-Berat, MD FAAEM Patrick D. Cichon, MD JD MSE FAAEM Francis X. Del Vecchio, MD FAAEM Stuart M. Gaynes, MD FAAEM Jeremy A. Hall, MD FAAEM Virgle O. Herrin Jr., MD FAAEM Adriana M. Horner, MD Alex Kaplan, MD FAAEM Maja L. Lundborg-Gray, MD FAAEM Edgar A. Marin, MD Jennifer A. Martin, MD FAAEM Syed-Ghazanfar A. Naqvi, MD Melissa Natale, MD FAAEM Ramon J. Pabalan, MD FAAEM Jeremiah Phelps Veerendra Kumar Nanjundaiah Ramasamudra Louis L. Rolston-Cregler, MD FAAEM Gholamreza Sadeghipour Roodsari Jenna N. Santiago-Wickey, DO Sabrina J. Schmitz, MD FAAEM Edward P. Sloan, MD MPH FAAEM Yeshvant Talati, MD FAAEM Zachary Tebb, MD FAAEM Katherine F. Tyler

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There are over 40 ways to get involved with AAEM Dive deeper with AAEM by joining a committee, interest group, task force, section, or chapter division of AAEM. Network with peers from around the U.S. sharing your clinical and/or professional interests or meet-up on the local level with members in your state. Visit the AAEM website to browse the 40+ groups you can become a part of today.

Get Started!

www.aaem.org/get-involved COMMON SENSE JANUARY/FEBRUARY 2021

AAEM PAC Contributors – Thank You! AAEM PAC is the political action committee of the American Academy of Emergency Medicine. Through AAEM PAC, the Academy is able to support legislation and effect change on behalf of its members and with consideration to their unique concerns. Our dedicated efforts will help to improve the overall quality of health care in our country and to improve the lot of all emergency physicians. All contributions are voluntary and the suggested amount of contribution is only a suggestion. The amount given by the contributor, or the refusal to give, will not benefit or disadvantage the person being solicited. Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the different levels of contributions. The PAC would like to thank the individuals below who contributed from 1-1-2020 to 12-1-2020.

Contributions $1,000+

David A. Farcy, MD FAAEM FCCM

Contributions $500-$999

Peter G. Anderson, MD FAAEM Michael R. Burton, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM Steven H. Gartzman, MD FAAEM Bryan K. Miksanek, MD FAAEM Don L. Snyder, MD FAAEM

Contributions $250-$499

Mina Altwail, MD Jeffrey D. Anderson, MD FAAEM FACEP Eric W. Brader, MD FAAEM Kevin Robert Brown, MD FAAEM Garrett Clanton II, MD FAAEM Deborah D. Fletcher, MD FAAEM Robert Bruce Genzel, MD FAAEM Jerris R. Hedges, MD FAAEM David Anthony Hnatow, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM Robert Kogel, MD FAAEM Ron Koury, DO FAAEM Bruce E. Lohman, MD FAAEM Noah A. Maddy, MD FAAEM Nishit Mehta, MD FAAEM Vicki Norton, MD FAAEM James Francis Rowley III, MD FAAEM Shane R. Sergent, DO FAAEM Keith D. Stamler, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM Andy Walker, MD FAAEM

Contributions $100-$249

Kevin Allen, MD FAAEM Justin P. Anderson, MD FAAEM Jonathan Balakumar, MD Maxime J. Berube, MD Mark Avery Boney, MD FAAEM Anthony J. Callisto, MD FAAEM Rebecca K. Carney-Calisch, MD FAAEM R. Lee Chilton III, MD FAAEM Liza Chopra, MD FAAEM Jacob Tyler Clark, MD Martinez E. Clement, MD FAAEM Michael T. Cudnik, MD FAAEM Walter M. D’Alonzo, MD FAAEM Francis X. Del Vecchio, MD FAAEM Jonethan P. DeLaughter, DO FAAEM John T. Downing, DO FAAEM Stephanie Eden, MD FAAEM Matthew K. Fischer, MD FAAEM William T. Freeman, MD FAAEM Gary M. Gaddis, MD PhD FAAEM FIFEM Albert L. Gest, DO FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeffrey Gordon, MD MBA FAAEM Neena Gupta, MD FAAEM Gregory T. Hartt, MD, PHD FAAEM Thomas Heniff, MD FAAEM Jacob Hennings Jessica Herrera, MD FAAEM Alice Horrell, DO FAAEM Richard G. Houle, MD FAAEM Jamey P. Hourigan, DO FAAEM, FACEP David R. Hoyer Jr., MD FAAEM Mercy M. Hylton, MD FAAEM John H. Kelsey, MD FAAEM

Lenard Kerr, DO FAAEM Shireen Khan, MD Stephen J. Koczirka Jr., MD FAAEM FACEP Steven Kushner, MD FAAEM Michael Lajeunesse, MD Jessica Neidig Leffler, MD FAAEM Michael R. Magoon, MD FAAEM Kerry McCabe, MD FAAEM Gregory S. McCarty, MD FAAEM Wendi S. Miller, MD FAAEM James Arnold Nichols, MD FAAEM Gabriel Ochoa Isaac A. Odudu, MD FAAEM Ramon J. Pabalan, MD FAAEM John Petersen, MD FAAEM Patricia Phan, MD FAAEM Nicholas R. Reinhart, DO, FACEP, FAAEM Jeffrey A. Rey, MD FAAEM Jada Lane Roe, MD FAAEM Javier E. Rosario, MD FACEP FAAEM Gregory L. Roslund, MD FAAEM Nate T. Rudman, MD FAAEM H. Edward Seibert, MD FAAEM Brendan P. Sheridan, MD FAAEM Jonathan F. Shultz, MD FAAEM Rohan Somar, MD FAAEM David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM Thomas Jerome Sugarman, MD FAAEM FACEP Matthew Szymaszek, DO FAAEM Yeshvant Talati, MD FAAEM Jalil A. Thurber, MD FAAEM Robert Boyd Tober, MD FAAEM Matthew J. Vreeland, MD FAAEM

Coffee Talk

Brought to you by the AAEM/RSA Representative Council 10

COMMON SENSE JANUARY/FEBRUARY 2021

A Mentorship Opportunity

Sidney P. Williamson, MD FAAEM Regan Wylie, MD FAAEM

Contributions up to $50

Robert Bassett, DO FAAEM Doug Benkelman, MD FAAEM Matthew C. Bombard, DO FAAEM Jordan R. Chanler-Berat, MD FAAEM Allyson F. Coopersmith Stuart M. Gaynes, MD FAAEM Jeremy A. Hall, MD FAAEM Kathleen Hayward, MD FAAEM Virgle O. Herrin Jr., MD FAAEM James W. Hickerson Jr., MD Ryan Horton, MD FAAEM Stefan Jensen Alex Kaplan, MD FAAEM Alexis Koda, MD Julie A. Littwin, DO FAAEM Melissa Natale, MD FAAEM Lindsey C. Remme, DO FAAEM Dion R. Samerson, MD FAAEM Linda Sanders, MD Sabrina J. Schmitz, MD FAAEM Michael Sherman, MD Marc D. Squillante, DO FAAEM Camilla Sulak, MD Zachary Tebb, MD FAAEM Katherine F. Tyler Arlene M. Vernon, MD FAAEM FACEP D. Shannon Waters, MD FAAEM Colin A. West, MD FAAEM Michael S. Westrol, MD FAAEM Emily L. Wolff, MD FAAEM

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This mentorship fund was created to allow current medical students the opportunity to have a mentoring session with an emergency medicine resident over a lowstakes cup of coffee.

Apply Today!

LEAD-EM Contributors – Thank You! The AAEM Institute for Leadership, Education & Advancement in the Development of Emergency Medicine, Inc. (LEAD-EM) was established after the tragic and unexpected death of AAEM president, Dr. Kevin G. Rodgers. The Kevin G. Rodgers Fund and the Institute will LEAD-EM just like Dr. Rodgers did. The funds will support important projects such as development of leadership qualities, and clinical and operational knowledge of emergency physicians with a view toward improving and advancing the quality of medical care in emergency medicine, and public health, safety and well-being overall. LEADEM would like to thank the individuals below who contributed from 1-1-2020 to 12-1-2020.

Contributions $500-$999

Peter G. Anderson, MD FAAEM David A. Farcy, MD FAAEM FCCM Bruce M. Lo, MD MBA RDMS FAAEM R. Keith Winkle, MD FAAEM

Contributions $250-$499

Jeffrey D. Anderson, MD FAAEM FACEP Elizabeth S. Atkinson, MD FAAEM Maxime J. Berube, MD Mark Avery Boney, MD FAAEM Kevin Robert Brown, MD FAAEM Michael R. Burton, MD FAAEM Anthony J. Callisto, MD FAAEM Daniel F. Danzl, MD MAAEM FAAEM Eric D. Ferraris, MD FAAEM Richard G. Foutch, DO FAAEM William E. Franklin, DO FAAEM Robert A. Frolichstein, MD FAAEM Albert L. Gest, DO FAAEM Sarah Hemming-Meyer, DO FAAEM Kenneth Scott Hickey, MD FAAEM FACEP David Anthony Hnatow, MD FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT Bruce E. Lohman, MD FAAEM Eric D. Lucas, MD FAAEM Kevin C. Reed, MD FAAEM James Francis Rowley III, MD FAAEM Eric M. Sergienko, MD FAAEM Mark O. Simon, MD FAAEM Douglas P. Slabaugh, DO FAAEM William E. Swigart, MD FAAEM Kristina Noelle Tune, MD FAAEM Chad Viscusi, MD FAAEM Kay Whalen, MBA CAE George Robert Woodward, DO FAAEM

Zachary Worley, DO FAAEM Leonard A. Yontz, MD FAAEM Missy Zagroba, CAE Gregory S. Zahn, MD FAAEM

Contributions $100-$249 Justin P. Anderson, MD FAAEM Kian J. Azimian, MD FAAEM Dale S. Birenbaum, MD FAAEM Laura J. Bontempo, MD MEd FAAEM Mary Jane Brown, MD FAAEM Rebecca K. Carney-Calisch, MD FAAEM Karen Carothers, MD FAAEM R. Lee Chilton III, MD FAAEM William K. Clegg, MD FAAEM Michael T. Cudnik, MD FAAEM Daniel Elliott, MD FAAEM Matthew K. Fischer, MD FAAEM William T. Freeman, MD FAAEM Paul W. Gabriel, MD FAAEM Gary M. Gaddis, MD PhD FAAEM FIFEM Scott C. Gibson, MD FAAEM Edward T. Grove, MD FAAEM MSPH Regina Hammock, DO FAAEM William E. Hauter, MD FAAEM Kathleen Hayward, MD FAAEM Jacob Hennings Patrick Holland, MD FAAEM Jamey P. Hourigan, DO FAAEM, FACEP Mercy M. Hylton, MD FAAEM Stefan Jensen Kevin T. Jordan, MD FACEP FAAEM H. Samuel Ko, MD MBA FAAEM Stephen J. Koczirka Jr., MD FAAEM FACEP Alexis Koda, MD

Robert P. Lam, MD FAAEM Jessica Neidig Leffler, MD FAAEM Kari A. Lemme, MD FAAEM, FAAP Michael P. Lucarelli-Cowles Gerald E. Maloney Jr., DO FAAEM Andrew P. Mayer, MD FAAEM Kerry McCabe, MD FAAEM Gregory S. McCarty, MD FAAEM P. Daniel McConnell, MD FAAEM Valerie G. McLaughlin, MD FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Vicki Norton, MD FAAEM Marcus Obeius, DO FAAEM John O’Neill, FAAEM Laura Ortiz, FAAEM Patricia Phan, MD FAAEM Jeffrey A. Rey, MD FAAEM Michael S. Ritter, MD FAAEM Gregory L. Roslund, MD FAAEM Jason T. Schaffer, MD FAAEM Richard D. Shih, MD FAAEM Jennica Siddle, MD-MPH Rohan Somar, MD FAAEM Christine Stehman, MD FAAEM David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM Robert Boyd Tober, MD FAAEM Joanne Williams, MD MAAEM FAAEM Emily L. Wolff, MD FAAEM

Contributions up to $75

Benjamin J. Archer, MD Rithvik Balakrishnan Robert Bassett, DO FAAEM Jordan R. Chanler-Berat, MD FAAEM Allyson F. Coopersmith

Francis X. Del Vecchio, MD FAAEM Thomas G. Derenne Sean L. Finnerty, DO FAAEM Stuart M. Gaynes, MD FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeremy A. Hall, MD FAAEM Thomas Heniff, MD FAAEM James W. Hickerson Jr., MD Irving P. Huber, MD FAAEM Hamad Husainy, DO FAAEM Stacey M. Jolley, MD FAAEM Lenard Kerr, DO FAAEM Paul Danl Kivela, MD MBA FAAEM FACEP Emily R. Knoble, DO FAAEM Jinyue Li, MD FAAEM Terrence M. Mulligan, DO MPH FAAEM FIFEM James Arnold Nichols, MD FAAEM Alison Panosian, MD Scott Pasichow, MD Tracy R. Rahall, MD FAAEM Saba A. Rizvi, MD FAAEM Grigoriy Rozenfeld, DO JD FAAEM Joshua A. Sawyer, OMS IV, RN Sabrina J. Schmitz, MD FAAEM Girish Sethuraman, MD FAAEM Edward P. Sloan, MD MPH FAAEM Marc D. Squillante, DO FAAEM Yeshvant Talati, MD FAAEM Sarah Todd, MD MPH FAAEM Katherine F. Tyler Arlene M. Vernon, MD FAAEM FACEP Maura Walsh, MD Michael E. Winters, MD MBA FAAEM Molly Wormley, MD Andrew Yocum, MD FAAEM

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Upcoming Conferences: AAEM Directly, Jointly Provided, & Recommended AAEM is featuring the following upcoming conferences and activities for your consideration. For a complete listing of upcoming conferences and other meetings, please visit: www.aaem.org/education/aaem-recommended-conferences-and-activities.

AAEM Conferences

Jointly Provided

AAEM Recommended Conferences

June 20-24, 2021 27th Annual Scientific Assembly – AAEM21 St. Louis, MO www.aaem.org/AAEM21

Re-Occurring Monthly Unmute Your Probe – Virtual Ultrasound Course Series Virtual www.aaem.org/eus

February 5-19, 2021 2021 ACMT Total Tox Course Virtual www.acmt.net/cgi/page.cgi/_evtcal. html?evt=670

February 20, 2021 California EM Symposium, Sponsored by CAL/AAEM and AAEM/RSA – Virtual www.aaem.org/get-involved/chapter-divisions/ calaaem/symposium

February 18, 2021 Advances in Cancer ImmunotherapyTM – SITC Salt Lake City, UT www.sitcancer.org/education/aci

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

COMMON SENSE JANUARY/FEBRUARY 2021

AAEM NEWS

AAEM Position Statements

Updated Position Statement on Non-Physician Practitioners PAs and NPs form a valuable part of the emergency medical team when properly supervised by a board certified/eligible EP. All team members should be referenced by their important roles to recognize individual contributions & provide transparency to those who matter most: patients. The term “provider” in reference to any clinician is vague, inaccurate, and hinders a patient’s ability to make informed decisions. This is why we have updated our terminology in our statement. The American Academy of Emergency Medicine (AAEM) believes that emergency department (ED) patients should have timely and unencumbered access to the most appropriate care led by a board-certified emergency physician (ABEM or AOBEM). AAEM and AAEM/RSA oppose the expansion of scope of practice regulations at the state and federal level, and do not support the unsupervised or “independent practice” of nonphysician practitioners (NPPs). Properly trained NPPs may provide emergency medical care as members of an emergency department team and must be supervised by a physician who is board certified in emergency medicine. As a member of the emergency department team, an NPP must not replace an emergency physician, but rather must engage in patient care in a supervised role to improve patient care efficiency without compromising safety. The role of NPPs within the department must be defined by their clinical supervising physicians who must know the training of each NPP and be involved in the hiring and continued employment evaluations of each NPP as part of the emergency department team with the intent to ensure that NPPs are not put into patient care situations beyond their clinical training and experience. Collaborating physicians must be permitted adequate time to be directly involved in supervision of care. They must not be required to supervise more NPPs than is appropriate to provide safe patient care. Furthermore, supervision must not be in name only. Physicians are expected, and must be permitted, to be involved in meaningful and ongoing assessment of the NPPs’ work. Billing must reflect the involvement of the physician in the emergency visit. If the physician’s name is used for billing purposes, the physician’s involvement must add value to the patient visit. A physician must not be required to cosign the chart, nor should his/her name be invoked with regard to any patient unless he/she has been actively involved in that patient’s care.

COMMON SENSE JANUARY/FEBRUARY 2021

NPPs must not supervise emergency medicine residents, nor can they, nor their education be allowed to interfere with the education of, or clinical opportunities for, emergency medicine residents. Every practitioner in an ED has a moral duty to clearly inform the patient of his/her training and qualifications to provide emergency care. In the interest of transparency, NPPs must not be called “doctor” in the clinical setting. *This designation includes, but is not limited to the following practitioners: • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Acute Care Nurse Practitioner (ACNP) Adult Nurse Practitioner (ANP) Advanced Nurse Practitioner (APN) Advanced Physician Assistant (APA) Advanced Physician Assistant Certified (APA-C) Advanced Practice Registered Nurse (APRN) Advanced Registered Nurse Practitioner (ARNP) Certified Nurse Practitioner (CNP) Certified Registered Nurse Practitioner (CRNP) Clinical Nurse Specialist (CNS) Doctor of Medical Science (DMSc) Doctor of Nursing Practice (DNP) Doctor of Nursing Science (DNS, DNSc) Doctor of Pharmacy (PharmD) Doctor of Science (DSC) Doctor of Science in Nursing (DSN) Emergency Nurse Practitioner (ENP) Family Nurse Practitioner (FNP) Nurse Practitioner (NP) Nurse Practitioner Certified (NPC) Pediatric Clinical Nurse Specialist OR Psychiatric Clinical Nurse Specialist (PCNS) Pediatric Nurse Practitioner - Acute Care (PNP-AC) Pediatric Nurse Practitioner (PNP) Physician Assistant (PA) Physician Assistant Certified (PA-C) Registered Physician Assistant (RPA) Registered Physician Assistant Certified (RPA-C) Women’s Health Nurse Practitioner (WHNP)

Approved: 1/29/2019 Updated: 9/1/2020

AAEM NEWS

Updated Position Statement on Emergency Medicine Training Programs for Non-Physician Practitioners AAEM has updated our position statement on EM training programs for PAs and NPs to strengthen and clarify our message. We must be clear about the structure of a physician-led team and roles of the team members for the safety of our patients. The American Academy of Emergency Medicine (AAEM) and the AAEM Resident and Student Association (AAEM/RSA) are aware that academic and other emergency departments sponsor additional training for nonphysician practitioners (NPP), including physician assistants (PA) and nurse practitioners (NP). We believe the following is in the best interest of the patient and our specialty.

• Must be structured, intended and advertised as to prepare its participants to practice only as members of a physician-led team. • Must not interfere with the educational opportunities of emergency medicine residents and medical students. Potential detriment to resident and student education must be monitored in a comprehensive and meaningful way throughout the existence of the NPP program. • Must be initiated with the consultation and approval of the emergency medicine residents and physician faculty. Approved: February 26, 2020 Updated: September 1, 2020

Such programs: • Must be clear to the public by prohibiting the use of the following terms: doctor, intern, internship, resident, residency, fellow, and fellowship. The recommended term is postgraduate training program.

NEW Position Statement on the Term “Provider” We all undergo unique training to contribute to the medical team and need to be recognized for those roles. AAEM opposes the use of the term “provider” when referencing physicians, PAs, and NPs. Read the new position statement. The American Academy of Emergency Medicine (AAEM) recognizes and advocates for the patient’s right to know the credentials of all clinicians being trusted with his/her well-being. Studies repeatedly show that patients in the US healthcare system want to know these credentials and are confused when credentials are not clearly presented.1 More importantly, AAEM believes that credential transparency is a moral obligation. The term “provider” in reference to any clinician is vague, inaccurate, and hinders a patient’s ability to make informed decisions. The education, expertise, and roles of different clinicians vary greatly. The term “provider” removes the ability to distinguish the unique contribution of the physician in not only the clinical setting, but also for purposes of policy and research that directly impact patient care. Physicians complete more education and maintain higher standards than any other healthcare professionals,2 and patients rightfully hold higher expectations for physicians than for any other clinician. AAEM believes that the patient/physician relationship is like no other; physicians spend a decade or more studying to earn—and a lifetime to maintain—patients’ trust. Far from a service to a customer, it is a calling to place in first consideration the health and well-being of the patient, as stated in the Declaration of Geneva. The therapeutic relationship of physician to patient has not changed despite a rapidly evolving healthcare system.

Best practice calls for clearly informing patients and referring to each healthcare professional by his or her individual title to convey unique roles and responsibilities. The American Academy of Emergency Medicine opposes use of the term “provider” in reference to any healthcare clinician and joins the American Medical Association3 and the American Academy of Family Physicians4 in calling on employers, policymakers, healthcare personnel, researchers, and others to refer to clinicians by their individual, proper titles. References 1. American Medical Association. Truth in Advertising Survey Results. Accessed 29 August 2020. Available from: https://www.ama-assn.org/ sites/ama-assn.org/files/corp/media-browser/premium/arc/tia-survey_0. pdf. 2. American Board of Medical Specialties. What is ABMS Board Certification? Accessed 29 August 2020. Available from: https://www. abms.org/board-certification/. 3. American Medical Association. AMA Policy H405.968. 2019. Accessed 29 August 2020. Available from: https://www.ama-assn.org/system/ files/2019-04/a19-bot09.pdf. 4. American Academy of Family Physicians. Provider, Use of Term (Position Paper). 2018. Accessed 29 August 2020. Available from: https://www.aafp. org/about/policies/all/provider-term-position.html. Approved: 9/14/2020

COMMON SENSE JANUARY/FEBRUARY 2021

AAEM NEWS

AAEM Position Statement on Emergency Department Visitation Policies during the COVID-19 Pandemic As the COVID-19 pandemic continues, many EDs have instituted policies that limit or prevent family members and/or loved ones from visiting patients who are being treated for COVID-19. While the initial intent was to limit the exposure of visitors to the virus, the practice has instead led to arguments, despair, and friction between the visitors and the emergency department staff. From a patient perspective, experience has proven that the support of loved ones is crucial during the treatment process. Limiting a patient’s contact with their loved ones can also be detrimental to their recovery. With proper screening questions, temperature checks, and appropriate personal protective equipment usage, COVID patients can be allowed visitors at the bedside while still adhering to current CDC guidelines. As these guidelines change, so should the screening and selection of ED visitors.

Though we recognize the current concerns in regard to the available PPE for ED staff, we urge that PPE contingency plans include the availability of the PPE to ED visitors as well. AAEM requests that emergency department policies be modified to allow at least one visitor per patient during these difficult times. Each visitor should be provided with the requisite personal protective equipment appropriate for their circumstances, and in accordance with CDC guidelines. This compassionate visitor policy should be available for all patients during their ED course, and not just those at their end-of-life period.

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Approved: 12/11/2020

Unmute Your Probe VIRTUAL ULTRASOUND COURSE SERIES

AAEM-1220-387

Monthly Re-occurring Beginner and Advanced Webinars

Jointly provided by AAEM and the Emergency Ultrasound Section of AAEM (EUS-AAEM)

COMMON SENSE JANUARY/FEBRUARY 2021

ABEM NEWS

Updates from ABEM

ABEM Virtual Oral Exam Starting in December 2020 October 14, 2020

FAQs: www.abem.org/public/docs/default-source/policies-faqs/virtualoral-exam-faqs.pdf Review Types of Cases and Samples: www.abem.org/public/ become-certified/oral-exam/types-of-cases-and-samples ABEM will be offering a virtual Oral Exam in December 2020 to approximately 150-200 candidates, with larger administrations held throughout 2021. Candidates who were scheduled for the 2020 exams will be the first slated for the 2020-2021 administrations. Features of the virtual Oral Exam: • There will be no triple cases. • There will be six, 15-minute single cases, and one new case type called the structured interview, also 15 minutes.

• The eOral platform will not be used. Not using the eOral platform will allow us to launch the virtual exam more quickly. • Stimuli will be static images. • Total testing time will be less than three hours. • Content covered will be consistent with previous Oral Exams. • ABEM will hold informational webinars in November to provide more detail about the virtual Oral Exam. Additional information is available in these FAQs. If you have any questions, please call 517.332.4800, option 1, or email oralcertification@abem.org. Thank you for leaving one message when you contact ABEM; doing so will allow us to respond to all calls more quickly.

The Development of ABEM Continuing Certification: A Reason for Applause? Mary Nan S. Mallory, MD MBA — President, ABEM

October 28, 2020

development /dəˈveləpmənt/ • a specified state of growth or advancement • an event constituting a new stage in a changing situation The one constant to ABEM’s continuing certification process is that there have always been requirements to recertify. Initially, physicians could opt to take a high-stakes, written recertification exam or an oral exam to recertify. In 2004, the ConCert Exam and LLSA requirements were instituted, and in 2011, attestation to a Patient Care Practice Improvement (PI) activity and a Communication / Professionalism (CP) activity were required. As can be expected with any change, these modifications were not met with overwhelming applause. The institution of the LLSA requirement was initially seen as just “one more thing” that busy emergency physicians had to do. There were “too many articles and too many questions.” There was confusion about seemingly “burdensome” PI and CP attestations, with some thinking patient data needed to be submitted. And the high-stakes, high-stress ConCert Exam came with travel and preparation time and costs for the physician. ABEM listened and physicians’ comments prompted review and some adjustments. The number of LLSA articles and questions were reduced, and the activity eventually became one applauded by physicians. The CP attestation was dropped as not being relevant to practice in the emergency department. More recently, a summit of representatives of

all Emergency Medicine (EM) organizations was convened to discuss the ConCert Exam, followed by focus groups and surveys of all ABEMcertified physicians. That exploration ultimately led to the development of MyEMCert. Each change made by the Board has been made through the lens of whether it would improve the continuing certification process while still maintaining a high standard for certification. The recent changes to the process reflect that philosophy. MyEMCert is designed with the uniqueness of Emergency Medicine in mind and was informed by the preferences of ABEM-certified physicians. It removes the high-stakes, high-stress ConCert Exam as a requirement and replaces it with an open-book, online, personal for learning assessment that can be taken anytime, anywhere. Topic-specific modules are based on subjects that are clinically relevant to the practice of EM. Key advances facilitate learning and amplify medical discoveries so you can assess and use them to improve patient care. These are characteristics that incorporate physician needs, improvements to the process, and high standards. The establishment of a 5-year certification period has been made using the same criteria. During the exploration of the ConCert Exam, physicians mentioned that ten years between exams was probably too long. Emergency Medicine practice evolves at such a fast pace that such a space of time was too long to ensure physicians were keeping up to date with current changes. A 5-year certification cycle encourages ongoing engagement to stay current with key advances in the specialty and demonstrates to the public that we are all committed to doing so.

COMMON SENSE JANUARY/FEBRUARY 2021

ABEM NEWS

Practically speaking, the 5-year cycle won’t have much effect on most physicians’ certification activities. Over 80 percent of ABEM-certified physicians already complete the activities every five years that are required to be designated as “participating in continuing certification;” that is, 4 LLSAs and 1 IMP attestation, with the additional every-ten-year ConCert Exam requirement. In the new 5-year certification period, physicians will complete 4 MyEMCert modules and one IMP attestation every five years, with no ConCert requirement. The timing of the change was made to minimize the number of adjustments physicians would have to

Just as the practice of Emergency Medicine develops and evolves, ABEM’s certification processes have and will continue to develop and evolve over time. You may not applaud each change, at least not initially, but we hope you continue to make suggestions for how the Board might improve the continuing certification process while maintaining both fairness for all ABEM certified physicians and the highest standards for our specialty.

EUFAC Meets for the First Time

Exception for Resident Quarantine Extended

October 28, 2020

October 29, 2020

September 10-11 marked the inaugural meeting of Emergency Medicine Ultrasound Fellowship Accreditation Council (EUFAC), the organization that will approve training programs for the Focused Practice Designation in Advanced EM Ultrasonography. Council members received an orientation and reviewed the program requirements.

For the 2020-2021 academic year, the American Board of Emergency Medicine has temporarily reduced minimum training requirements required to be ABEM board eligible to accommodate any two-week period of quarantine without negatively affecting a resident’s board eligibility status. This temporary accommodation reduces this year’s minimum of successfully completed training time from 46 to 44 weeks. This temporary allowance for quarantine should be adequate for most quarantine situations without extending training. ABEM strongly supports nontraditional learning approaches during periods of quarantine. In cases that are not covered by the revised policy, please have your program director contact ABEM.

Council Members • • • • • • • • • • • •

make over time, and to allow those with certifications that expire as early as 2021 the ability to recertify using MyEMCert instead of ConCert.

John Bailitz, M.D. Creagh T. Boulger, M.D., Chair-Elect Katharine M. Burns, M.D. Kristin A. Carmody, M.D. Sara Damewood, M.D., Chair Joshua Guttman, M.D. Lawrence Haines, M.D. Teresa Liu, M.D. Melissa Myers, M.D. Robert J. Strony, D.O. Romolo Gaspari, M.D., Founding Director Sabine Gifford, CAE, Executive Director

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This allowance for a two-week quarantine period is in addition to ABEM’s recently approved Policy on Parental, Caregiver, and Medical Leave: www.abem.org/public/docs/default-source/policies-faqs/policy-on-parental-caregiver-and-medical-leave.pdf?sfvrsn=c892c2f4_4. If you have any questions, please email training@abem.org, or call 517.332.4800 option 3. 

COMMITTEE REPORT AAEM NEWS

AAEM21 SCIENTIFIC ASSEMBLY SUBCOMMITTEE

AAEM21: Meet Me in St. Louis! Laura Bontempo, MD MEd FAAEM; Jack C. Perkins, Jr. MD FAAEM; Julie Vieth, MBChB FAAEM; and George C. Willis, MD FAAEM

WHILE IT HAS BEEN CHAL-

The 27th Annual Scientific Assembly (AAEM21) in St. Louis, Missouri may have new dates yet is keeping tradition to being THE emergency medicine conference to attend this year. The Assembly will begin Sunday, June 20, 2021 at 12:45pm at the historic downtown St. Louis Union Station Hotel and conclude Wednesday, June 23, 2021 at noon. Post-conference courses will be available to enhance your skills and knowledge in resuscitation, ECG, ultrasound, LLSA, disaster casualty preparedness, and more! While it has been challenging to plan for AAEM21, we are confident that the educational offerings will be equal to or even exceed the quality that you have come to expect each year. If you have not yet attended a Scientific Assembly, we encourage you to plan to attend this year. We are looking to debut new learning formats and interactive educational sessions. Signature plenary sessions will feature many of the same global and national leaders in emergency medicine that are the hallmark centerpieces of our educational programming as well as some new and upcoming inspiring leaders. AAEM21 will feature plenary talks on critical care, cardiology, pediatrics, public health, and COVID-19, among others.

LENGING TO PLAN FOR AAEM21, WE ARE CONFIDENT THAT THE EDUCATIONAL OFFERINGS WILL BE EQUAL TO OR EVEN EXCEED THE QUALITY THAT YOU HAVE COME TO EXPECT EACH YEAR.”

THE ASSEMBLY WILL BEGIN

SUNDAY, JUNE 20, 2021 AT 12:45PM AT THE HISTORIC DOWNTOWN ST. LOUIS UNION STATION HOTEL AND CONCLUDE WEDNESDAY, JUNE 23, 2021 AT NOON.”

The ‘small group clinic’ has become such a large draw for attendees that we will be offering more opportunities to attend these sessions. Topics will range from emergency obstetrics to transvenous pacing, LVAD, ultrasound, and other engaging skills. These popular sessions will again be available for advance and onsite registration. We have also expanded the Breve Dulce sessions (7-minute high-yield lecture / 25 slides). These quick, education packed lectures will be showcased throughout the conference. Please mark your calendars now to ‘Meet me in St. Louis’ in June. Conference registration will open in the spring. Learn more at www.aaem.org/aaem21. 

27th Annual Scientific Assembly

AAEM21 #AAEM21

COMMON SENSE JANUARY/FEBRUARY 2021

AAEM NEWS

Meet Me in St. Louis! Gary M. Gaddis, MD PhD FAAEM FIFEM

ARE OUR NEW ST. LOUIS AQUARIUM AT UNION STATION AND THE ST. LOUIS WHEEL, ONSITE A LARGE FERRIS WHEEL FROM WHICH ONE CAN GAIN A COMMANDING VIEW OF THE CITY.”

On behalf of all AAEM members from Missouri, I write to persuade you to join us here in St. Louis for the 27th Annual AAEM Scientific Assembly, June 20-24, 2021. The COVID pandemic has led AAEM leadership to move the scheduled time from the original early March date and change to June. And, June will actually be a better time to come “Meet Me in St. Louie!” It is much warmer and greener in St. Louis in June than in March! I will not delve deeply into the scientific program, but of course, our Scientific Assembly is always “top-notch.” To travel here simply for the scientific content to be shared will alone be worth the trip. However, June is a great time to come to “The Lou.” The Metro’s Red Line connects directly to our Lambert/St. Louis International Airport by rail, so one need not rent a car or ride a taxi or Uber/Lyft. But, if one drives to St. Louis or rents a car, there are other interesting sites nearby. More on that, later. The Assembly will be headquartered at the Union Station on Market Street, just west of downtown. Onsite are our new St. Louis Aquarium at Union Station and the St. Louis Wheel, a large Ferris wheel from which one can gain a commanding view of the city. Just to the east is the City Walk, with several parks and their statues, upon many of which children can climb. There is also a large playground in City Walk. The parks in City Walk that adjoin Market Street lead directly to the Old Courthouse, a part (along with our famous Gateway Arch) of the Gateway Arch National Park. The Old Courthouse is not likely to be open in June, but it has historic significance. It is the site at which Dred Scott began to sue for his freedom. A statue commemorating Mr. Scott and his wife stands outside the Old Courthouse. Across a green expanse from the Old Courthouse and abutting the Mississippi River is our city’s best-known attraction, the Gateway Arch, completed in 1965. It still retains a stunning modernity of appearance. One can ride to the top of the arch in a specially-designed elevator car

COMMON SENSE JANUARY/FEBRUARY 2021

for an unmatched view of the city. Do note, these elevators are very small, so claustrophobics should just admire the Arch from the park below. And, the Arch does move perceptibly in high wind, when sensed from the inside (Remember, flexible structures bend, but rigid structures break!). Just below the Arch, a recently renovated museum documenting details of our nation’s westward expansion is worth a visit. To the west of Union Station are other great attractions. As I have noted, the Union Station sits on our city’s Metro train line. One can ride the Metro west to the Forest Park/DeBaliviere station, two blocks north of our historic Forest Park. Forest Park was the site of the 1904 World’s Fair, and some of the buildings constructed for that event still stand. Chief among these are the beautiful and unique “Jewel Box,” the Missouri History Museum (which always has interesting exhibits), and the St. Louis Art Museum, fronted by our statue of “Saint Louis,” whom you may also know as King Louis IX of France. (Louis XIV, he of the “après moi, le deluge”, was the one who had Versailles built; he came later). Also in Forest Park is our world-renowned St. Louis Zoo. Admission is free (but they do charge to park in their lots). There is a bus that travels to different points in the park and connects all of these sites. If you want to run all or part of a former Olympic marathon course, the 1904 Olympics were also in St. Louis, and the marathon route starts and ends at the track within the outdoor stadium at Washington University, just west of the park. The route is marked through the county. A large set of commemorative Olympic rings gives a “photo-op” at the northeast end of the stadium grounds. South of the mid-town, our city is also justifiably proud of its Botanical Garden. You may need a car or taxi to get there, unless you rent a bike (There are decent on-street bike lanes that make the trip safe, St. Louis is a very bike-friendly city). At the Botanical Garden, one can enjoy the Japanese Garden, complete with Koi fish to feed. At the other end of the Garden, one can see examples of the many food-yielding plants that grow in our temperate climate. There is the Climatron, a geodesic dome completed in 1960 and that looks to have been dropped in from the future. It has many tropical plants. Nearby, don’t miss “World’s Fair Donuts” at the corner of Vendeventer and Shaw.

AAEM NEWS

If one wishes to venture farther away and into St. Louis County, we have the Butterfly House in Creve Coeur, open year-round. Also not to be overlooked is Grant’s Farm (former home of former President Ulysses S. Grant, then purchased by the Busch family, and now a place to see the Clydesdales and many other animals) and enjoy a nice outdoor experience, in the southwest part of our metro. Finally, there is a big beer culture here. The Anheuser-Busch (AB) brewery is about a mile south of the Arch, and is open for free tours (and a free glass of the AB beer of your choice). But the brewing movement here is much bigger than AB. St. Louis is DEFINITELY a “beer town.” From the Barnes-Jewish Hospital at which I work, there are at least 8

breweries (if craft breweries and brewpubs are counted) within four miles. Chief among these are the Schlafly brewery (which has a nice restaurant) in Maplewood, and the Urban Chestnut Brewing Company (UCBC) in “The Grove.” Urban Chestnut has gifted brewers, and they have many interesting choices. Hopefully COVID will be a receding memory, because UCBC has a proper German-style “beer hall,” with long tables and excellent German-inspired “pub grub.” Some other notable local breweries include “Side Project,” “Four Hands,” and “Perennial.” I hope I have made St. Louis seem irresistible! “Meet me in St. Louie” in June of 2021! 

COMMON SENSE JANUARY/FEBRUARY 2021

AAEM NEWS

SBO: Seize Back Onus – Focus on POCUS Ahmed Mamdouh Taha Mostafa, MD; Kevin C. Welch, DO; and Max Cooper, MD RDMS

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.

Case 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. 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. 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,

Figure 1: Transverse view of dilated small bowel loop measuring 3.16 cm with thickened bowel wall (between crosshairs). 20

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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.

Discussion 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 

Signs of bowel obstruction on ultrasound include: 1. Dilated bowel loops with most studies using >25 mm as the cut-off for diagnosis (Figures 1 and 2). 2. “Tanga” sign: free fluid between loops taking a “pointy” triangular appearance, hence the name after the bikini bottom. 3. ‘To-and-fro’ motion: hyperechoic bowel contents moving back and forth within the bowel lumen. “Keyboard” sign: visualization of the plicae circularis (Figure 3).

Figure 2: Longitudinal view of dilated small bowel loop measuring 3.02 cm with thickened bowel wall (between crosshairs).

Figure 3: “Keyboard” sign - plicae circularis (arrows) on the interior aspect of the jejunal wall.

ABEM NEWS

References 1. Taylor MR, Lalani N. Adult small bowel obstruction. Acad Emerg Med. 2013;20(6):528-544. doi:10.1111/acem.12150 2. 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 3. 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.

4. 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. 5. 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. 6. 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

MEMC21 Malta 9-12 September 2021 St. Julian’s

XIth Mediterranean Emergency Medicine Congress

#MEMC21

www.aaem.org/MEMC21 COMMON SENSE JANUARY/FEBRUARY 2021

COMMITTEE REPORT ETHICS

Who Will Be Their Advocate? A Commentary on Facing Illness Alone. Jennifer Gemmill, MD FAAEM

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. 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

COMMON SENSE JANUARY/FEBRUARY 2021

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

 NO ONE SHOULD HAVE TO SAY GOODBYE TO THEIR LOVED ONES AT THE DOOR AND WONDER IF THEY WILL EVER SEE THEM AGAIN.”

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. 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

FAMILY SUPPORT IS CRUCIAL  TO MEDICAL PRACTICE AND CLINICAL IMPROVEMENT, BOTH IN THE HOME AND IN THE HOSPITAL.” 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.

COMMITEE REPORT ETHICS

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

OUR PATIENTS TRUST US TO ENSURE THEIR SAFETY  AND WE ARE TASKED WITH MAKING SURE THEY UNDERSTAND THE CARE WE’RE PROVIDING THEM”

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. 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. 

For more information, view the new AAEM position statement on emergency department visitation policies during the COVID-19 pandemic on page 14.

A Strong Voice Your concerns reach the ears of our leaders in Washington. AAEM actively works to ensure the needs of EPs are being addressed on the national and state levels. We offer support & legal assistance to members whose rights are threatened. The strength of the Academy is in your corner.

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Effective Advocacy For over 20 years we have been committed to your personal and professional well being. Our primary concern is supporting you: your practice rights, your autonomy, your relationship with your patients. That’s the AAEM difference.

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In addition to the Annual Scientific Assembly, AAEM offers educational opportunities online and in-person at our Oral Board Review, Written Board Review, and ED Management Solutions courses, as well as other regional courses and meetings.

Meaningful Connections

www.aaem.org/whyaaem

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AAEM is over 8,000 members strong and growing. We offer multiple ways for you to get involved with the topics that matter most to you through engaging committees & projects plus multiple ways to network with fellow members in the U.S. and around the globe.

C H A M P I O N O F T H E E M E R G E N C Y P H YS I C I A N

COMMON SENSE JANUARY/FEBRUARY 2021

COMMITTEE REPORT ETHICS

Questions Melissa Myers, MD FAAEM and Jennifer M. Gemmill, MD FAAEM

Can I come into my house through the front door today? If I hug my daughter before taking a shower will I expose her? Can I drink a coffee on shift, or is taking my mask off too much of a risk? It’s a thousand small decisions every day. A thousand chances to get it wrong, to make the wrong decision. We’re emergency physicians. We can deal with stress. EMS just pulled up with CPR in progress? That’s fine, no problem. Someone just ran in the front door, saying their child is in the car and isn’t breathing? We can deal with it. We can fix it. We have an algorithm for that, training for that. A way to deal with it. Some time in residency, someone taught you a mantra for stress. A post-shift routine. Deep breathing. Some way to deal with acute stress so that it doesn’t become overwhelming. Maybe you cry in the car on the way home – but by the time you get there, you feel better. These are the questions now. Who gets the last bed in the hospital? When I show up for work tomorrow, am I risking my family along with myself? The patient in room 10 is dying from COVID and his family needs to be there, but he isn’t allowed visitors. Or he’s allowed one, but all of his children want to be here. Do you have to choose? Do you have the right to choose? Ethical decisions we never imagined are a part of our every shift. Or maybe you did imagine choosing, but it was in the safe confines of an ethics class in medical school, not in the middle of a busy shift. Or it was on a humanitarian mission in a foreign country. It wasn’t your hometown with the tent out in front of the hospital with not enough equipment. These situations are now in front of you, on your shift. You don’t have answers for yourself or your patients.

 WE’RE EMERGENCY PHYSICIANS. WE CAN DEAL WITH STRESS.”

This is different. It doesn’t end when we get home. The questions at work bleed into our lives at home and our dreams at night. Maybe your spouse is worried because school just went virtual again. Maybe your usual method of destressing is to hit up an exercise class at the gym, but cases are rising in your area and classes are canceled. So now what? You’re back on shift in 12 hours. So is it another night in front of the TV? Drink another beer, or maybe two? How do we deal with the stress today? Tomorrow? Every day from now until sometime in the future when everything is better? I’m not writing this because I have the answer. I don’t. I don’t really think anyone does, or rather I think that we all have to find our own answer. Each decision feels so small, but together it’s a mountain and we’re constantly under threat of being buried underneath. Cases are rising again. 24

COMMON SENSE JANUARY/FEBRUARY 2021

 ETHICAL DECISIONS WE NEVER IMAGINED ARE A PART OF OUR EVERY SHIFT.”

It’s not going away. Some days it feels like hitting a wall, like it’s not possible to get out of bed and do it all again. Residency didn’t teach me how to deal with this chronic stress, this cloud following me around all day. What we need is a sweeping wind to blow this cloud away. But honestly, I don’t think this exists, I know I don’t hold it. What I do know is that we all have to find our own wind. For me it’s been running and weight lifting. Getting out of my head and into my body. And to be honest, there are days where it doesn’t matter how far I run or how much I lift, everything going on right now is too much to deal with. Maybe for you it’s getting more practice on your favorite video game, or learning to cook something new. Maybe this is the year you see a therapist. I did. It’s okay to need help. I’m writing this to tell you it’s okay to have “pandemic” days. It’s okay if you didn’t write those papers or learn French or learn how to sew or whatever your plan was in the beginning of the pandemic. It’s okay if your entire plan for the next month is to try really hard to show up to work on time and take care of your patients. It’s okay if you can’t go to work right now and you’re taking a break. It’s great if yesterday you worked out, cooked a healthy dinner and went to bed early, but today your only accomplishment is eating a bag of chips in bed. It’s okay. Or maybe it’s not okay. Maybe it’s time to accept that you are not entirely in control of every situation as you were trained to be. To be sad some of the time. Or angry. Or happy one minute and sad the next. To be missing the things you love that

COMMITEE REPORT ETHICS

 OUR JOB IS REALLY HARD RIGHT NOW. BE PROUD THAT YOU SHOWED UP TO DO YOUR JOB AND HAVE DONE YOUR BEST TO TAKE CARE OF YOUR PATIENTS.”

you’re unable to do right now. To not have the answer to all of the thousand questions that need to be answered every time you get out of bed. So when the questions feel overwhelming, this is my advice. It’s okay to be overwhelmed. It’s okay to say no. Find a way to cope, and be gentle with yourself when there are days that coping mechanism doesn’t work. Our job is really hard right now. Be proud that you showed up to do your

C l e Fe

en d fi n

job and have done your best to take care of your patients. You might not have all the answers right now, but you’re not alone. And that’s okay. What are your mechanisms for coping? Want to share your story with the EM Community? Follow this link to the AAEM site and tell us what you’re doing to make it through this pandemic. www.aaem.org/get-involved/committees/interest-groups/ palliative-care/covid-19-story-submissions The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense, or the U.S. Government. 

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COMMITTEE REPORT OPERATIONS MANAGEMENT

The Role of Ridesharing in Emergency Medicine Jennifer Rosenbaum, MD; Nicole V. Lucas, MD; and Kraftin E. Schreyer, MD CMQ FAAEM



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.” 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. 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.1 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.2 Ridesharing services may help with prehospital 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.3 That percentage can translate to millions of unneeded rides, given that in 2018, for example, there were

COMMON SENSE JANUARY/FEBRUARY 2021

over 30 million EMS transports in the U.S.4 Interestingly, when surveyed, up to 60% of patients suggested they were willing to be transported by non-emergency vehicles to the ED if offered.5 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 $450.6 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. 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.7 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.8 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

ONLY COULD THESE SERVICES DECREASE MISSED APPOINTMENTS, BUT THEYNOTCOULD ALSO BE USED IN BUSY EDS TO HELP PATIENTS GET TO THEIR DISCHARGE DESTINATION IN A MORE TIMELY MANNER.”

COMMITEE REPORT OPERATIONS MANAGEMENT

provides a better way for hospitals to collect data to determine the true impact of their transportation programs. 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.  References 1. 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. 2. 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-healthsurvey. Published March 1, 2020. Accessed October 21, 2020. 3. 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.

4. 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. 5. 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. 6. 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. 7. 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. 8. 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.

2021 Board of Directors Election Nominations What Sets Us Apart: Our democratic election procedures are truly what make AAEM unique among professional medical associations. In AAEM, any individual Full Voting or Emeritus member can be nominated and elected to the board of directors. Submit a nomination and learn more at: www.aaem.org/about-us/leadership/elections

2021 AAEM Awards Honor a friend or colleague for their exceptional work in EM and their dedication to AAEM. Submit a nomination and learn more at: www.aaem.org/about-us/our-values/awards

Nominations Deadline: March 21, 2021 — 11:59pm CT COMMON SENSE JANUARY/FEBRUARY 2021

COMMON SENSE JANUARY/FEBRUARY 2021

COMMITTEE REPORT WELLNESS

Peer Coaching: A Strategy for Development and Wellbeing Alice A. Min, MD FAAEM and Carol Pak-Teng, MD FAAEM

This year has been one of the toughest in most of our lifetimes, and it has many of us feeling stuck and isolated. Peer coaching can be a strategy to connect and find the momentum to keep moving forward. “A good coach will make his players see what they can be rather than what they are.” — Ara Parseghian, University of Notre Dame football head coach, 1964-1974 When you think of a coach, what comes to mind? Many of us probably think of athletes receiving instruction and training on how to improve their performance on the field or court. The discipline of education has long used coaching to enhance knowledge acquisition and utilization in the classroom for ongoing development of teachers. The emergence of coaching is also trending in medicine. Research shows that it can have a significant impact on clinical skills, teaching effectiveness, and wellbeing. Coaching is consistent with the premise of life-long learning, a well-established tenet of medical education. Dr. Atul Gawande wrote about his experience with coaching in his essay “Personal Best” in the New Yorker in 2011.1 We all must strive to remain open to learning new skills, acquiring new knowledge, and continuing to improve ourselves in the ever-changing and rapidly advancing world of medicine. We should first differentiate coaching from mentoring, the latter is likely a more familiar framework from our years of school and residency training. Mentorship is based on a long-term relationship in which advice is offered to help the mentee build their overall career, whereas coaching is a shortterm process framed around a specific skill or goal.2 Coaching is asking guiding questions, leading someone to come to their own development of a skill or strategy. It is not offering explicit advice. The intent is to help a coachee discover skills and resources they already possess and increase the utilization of them. Mentorship may incorporate a component of coaching, but coaching involves a unique skill set and focus. As a coach, one must encourage self-reflection, dialogue, and inquiry. Coaching can uncover who you are and how you operate with the intent of growth. Peer coaching is a distinctive type of coaching. In the field of education where it was initially assumed that knowledge transfer necessitated an expert, research has shown that teachers sharing aspects of their teaching with fellow teachers through peer-coaching led to the application of new skills more often and appropriately.3 This concept has been adopted in medicine as well. Peers are

at similar levels of knowledge and experience, therefore these relationships remove the hierarchy and power differentials that can hinder communication and trust. Peers learn from each other in a collaborative, non-threatening setting. Because this model is based on connections between people at similar stages in their careers, it is of particular importance to women and people of color who may not see representation in leadership roles.

IS ASKING GUIDINGCOACHING QUESTIONS, LEADING SOMEONE TO COME TO THEIR OWN DEVELOPMENT OF A SKILL OR STRATEGY.” Peer coaching promotes a reciprocal exchange of information and attitudes and also provides opportunity for modeling desired interpersonal behaviors. Additionally, peers tend to provide feedback on behaviors that may be unnoticed by superiors.4 There is less reliance on the coach’s expertise or a “mastermind” but rather on the collective expertise of both parties. First and foremost, peer coaching relationships must be formed on the foundation of mutual trust. There are five essentials to build on:3 1. Voluntary commitment to the relationship based on collaboration, not competition 2. Self-evaluation 3. Feedback

>> COMMON SENSE JANUARY/FEBRUARY 2021

COMMITEE REPORT WELLNESS

PEER COACHING PROMOTES A RECIPROCAL EXCHANGE OF INFORMATION AND ATTITUDES AND ALSO PROVIDES OPPORTUNITY FOR MODELING DESIRED INTERPERSONAL BEHAVIORS.”

4. Establishment of goals or preferred outcomes 5. Focus on one’s strengths and the amplification of capacity In regards to physician wellness, coaching has also been shown to have a significant impact. Improvements in retention, interpersonal relationships, job satisfaction, organizational commitment, ability to manage complexity, and communication skills have been documented in the literature.5 Coaching may help physicians access personal strengths and skills to handle stressors, reducing vulnerability to burnout and emotional exhaustion.5 The framework of coaching provides a structure for self-improvement that may be accessible even when the motivation for engagement is low. When presented with measurable, attainable goals and a finite time commitment, it may be easier for people who are feeling overwhelmed and burnt out to say yes. Bite-sized achievements and small wins along the way may enhance one’s ability to recover from a state of unwellness. Peer coaching normalizes challenges and emotions about work-related stresses. It can create an intentional community and build networks that we all need to succeed. In our current environment with the isolation that is required to stay safe for ourselves and our community, a more formal coaching relationship may provide a structure to maintain professional relationships and mutually benefit all parties.

So how do you set this up? There are innumerable areas one could benefit from coaching. Some examples that conform well to a coaching structure include: • Promotion and tenure • Negotiations about your workload and salary • How to pursue new career ventures like advocacy or entrepreneurship • Financial planning • Dealing with stress during a pandemic Of note, even within these topics, it is a good idea for each participant to narrow down the scope to a realistic, actionable goal.

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Building a relationship on mutual commitment and accountability is a prerequisite for a successful coaching outcome. Identify someone that may share your core values and interests. Main components of building the foundation to the relationship are:6 1. Aligning roles and process expectations a. Emphasize that this is a partnership and you are learning together. b. Self-directed learning is required and goals should be set by each as the coachee. 2. Establishing rapport a.There must be a commitment to developing the relationship and being vulnerable. b. It is important to maintain an equitable exchange of giving and receiving. 3. Cultivating trust and psychological safety a. Demonstrate commitment and empathy. b. Confidentiality should be explicit. Set a schedule for regular meetings at the onset of the relationship. Do NOT cancel even if you feel unprepared or that there isn’t anything to talk about. Important questions and issues may arise that are unplanned – showing up is the most important part. Three top tips from professional coaches are:7 1. Pause. Before your meeting, take time to reflect and bring yourself to the present moment. 2. Listen. Professional coaches say their first duty is to be a listener, then a question-asker, and lastly a speaker. 3. Know your role. As physicians, we are trained to advise. As a coach, you are there to support someone else’s self-discovery rather than offering suggestions and imposing our ideas. Coaching is a sustainable way to collaborate with colleagues on a deeper level. It allows the coach and coachee to process their thoughts openly, unpack emotions, and gain awareness. Peer coaching is a strategy for self-improvement, and at the same time, helping others discover their own paths to improvement.  References 1. Gawande, Atul. Personal Best. The New Yorker website. October 3, 2011. Accessed October 30, 2020. https://www.newyorker.com/magazine/2011/10/03/personal-best. 2. Marcdante K, Simpson D. Choosing When to Advise, Coach, or Mentor. J Grad Med Educ. 2018;10(2):227-228. doi:10.4300/JGME-D-18-00111.1 3. Schwellnus H, Carnahan H. Peer-coaching with health care professionals: what is the current status of the literature and what are the key components necessary in peer-coaching? A scoping review. Medical Teacher. 2014;36:38-46. 4. Cheng A, Grant V, Huffman J, Burgess G, Szyld D, Robinson T, Eppich W. Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs. Simul Healthc. 2017 Oct;12(5):319-325. 5. Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a Professional Coaching Intervention on the Well-being and Distress of Physicians: A Pilot Randomized Clinical Trial. JAMA Intern Med. 2019;179(10):1406–1414. doi:10.1001/jamainternmed.2019.2425 6. Beasley HL, Ghousseini HN, Wiegmann DA, Brys NA, Pavuluri Quamme SR, Greenberg CC. Strategies for Building Peer Surgical Coaching Relationships. JAMA Surg. 2017 Apr 19;152(4):e165540. 7. Dearmin, S. Physician coaching: A growing conversation. Wolters Kluwer Health website. Feb 12, 2020. Accessed October 30, 2020. https://www.wolterskluwer.com/en/expert-insights/physiciancoaching-a-growing-conversation 8. Jordan J, Dorfsman M, Wagner MJ, Wolf S. The Council of Emergency Medicine Residency Directors Academy for Scholarship Coaching Program: Addressing the Needs of Academic Emergency Medicine Educators. West J of Emerg Med. 2019;20(1):105-110.

Intubating Asthma

SECTON REPORT CRITICAL CARE MEDICINE

Charles J. Blevins, MD

If a room full of emergency medicine physicians was asked, “How would you manage a severe asthmatic?” There would be a plethora of responses. However, all would likely agree that intubation is a last resort; something only to be considered when all other treatment options have been exhausted. Acute asthma exacerbations account for nearly two million ED visits annually and about 4% of these patients require ICU admission. Approximately one-third of those ICU admissions—roughly 27,000 patients—will require mechanical ventilation. Despite the complexity of initial management, outcomes for this subset of patients are reassuring. Unlike most other conditions that require mechanical ventilation, survival rates for intubated asthmatic patients range between 80-100%, with the majority of studies showing mortality rate <10%.1,2 The scarcity, severity of illness, and reversibility of this condition dictate the routine rehearsal of management techniques, similar to procedures like pericardiocentesis or cricothyroidotomy. The initial management of severe status asthmaticus should include some or ALL of the treatments in Table 1.3,4 In addition, non-invasive ventilation (NIV), equally effective in lowering PaCO2 in patients with severe hypercapnia, may be trialed. Still, up to 17% of patients receiving NIV will ultimately require intubation.2 There exist countless algorithms for the management of the severe asthmatic; for the purposes of this discussion, we will skip straight to intubation. Indications for intubation in the severe asthmatic include cyanosis, partial pressure of oxygen (PaO2) less than 60 mmHg despite supplemental oxygen, bradycardia, persistent acidosis, altered or worsening level of consciousness, signs of exhaustion, paradoxical thoracoabdominal

motion, a silent chest, and respiratory arrest. Worsening hypercapnia is also a factor to consider. PaCO2 is expected to be low in a hyperventilating patient (<35 mmHg), and the presence of elevated or even normal PaCO2 should be concerning for impending respiratory collapse.1 However, a single result showing hypercapnia alone should not influence the decision for intubation.5

Preparation Intubating the severe asthmatic can be extremely challenging, as risks include hypoxemia, worsening bronchospasm, pulmonary aspiration, tension pneumothorax, dynamic hyperinflation, hypotension, dysrhythmias, and even seizures. When managing these patients, you are truly between “a rock and a hard place.” The respiratory acidosis created by increased dead space and hypoventilation will limit the functionality of both endogenous and exogenous catecholamines and can lead to cardiopulmonary collapse. Moreover, hyperinflation will decrease venous return, thus decreasing cardiac preload, which can also lead to arrest. A few pearls with regard to pre-intubation management are as follows: 1) maximize oxygenation early 2) consider pH 3) increase chance of first pass success 4) optimize induction, paralysis, and sedation. Preparation for intubation should begin the moment you consider the necessity of managing an airway. In this incredibly sick population, that thought process often begins upon their arrival to the ED. Given their level of respiratory distress, these patients often present to the ED already on non-rebreather masks by EMS. However, it is important to note that many NRB’s are not compatible with nebulized therapies, and the NRB is often replaced by a nebulizer mask. This is a reasonable practice, but one should consider adding supplemental nasal cannula oxygen or even

Table 12,3

Name

Dosing

Supplemental Oxygen

2-6 L/min; Consider higher rate nasal cannula plus Continuous; titrate oxygen saturation to 94-98% nebulized medications overtop via mask; may be difficult to give nebs via non-rebreather

Albuterol Nebulizer

2.5-20 mg/hour depending on formulary (no study suggests higher dosing improves outcome; no study suggests higher dosing increases adverse events)

Continuous preferred over intermittent dosing (at least for the first hour)

Ipratropium Nebulizer [Anti-cholinergic]

0.5 mg diluted in 2.5 mL of saline

Every 20 mins (up to 3 doses), then every 8 hours

IV Magnesium

2-4 mg IV

Over 10-20 mins to avoid flushing and hypotension; may help protect against tachyarrhythmias associated with other treatments; more beneficial in pediatric patients

IV Steroids

1-2 mg/kg IV methylprednisolone equivalent

Every 6-8 hours; mainly delayed effects via immune modulation

SC ß-Agonists

Terbutaline 0.25 mg SC

Once; Specific ß-2 agonist

Epinephrine 0.1-0.5 mg SC/IM

Once; Bridge to IV; ß-1 & ß-2

IV ß-Agonists

Epinephrine 1-4 mcg/min IV

Continuous

IV Ketamine

0.5-1 mg/kg dissociative dose

Once; can re-dose PRN

[ß-Agonist]

Frequency; Notes

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COMMITEE REPORT CRITICAL CARE MEDICINE

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AS WITH ALL CRITICAL CARE MEDICINE, NUANCE LOOMS LARGE; YET, WE WILL ATTEMPT TO GIVE INSIGHT INTO THE MOST ACCEPTED RECOMMENDATIONS.” high-flow nasal cannula oxygen in conjunction with this nebulized mask. In the event of worsening status, pre-oxygenation will be key to a safe intubation and simultaneous use of NC or HFNC oxygen affords this preparation.4 Many of these patients will be physiologically hyperinflated and can demonstrate signs of early obstructive shock triggered by decreased venous return leading to decreased cardiac output. Additionally, they will often have severe respiratory acidosis. A common pressor like epinephrine, although part of the multi-modal treatment approach will have limited effect in an environment below a pH of 7.15-7.20. Thus, a pressor like vasopressin can be employed, as its action is not dependent on pH. Similarly, one could also consider pre-intubation dosing of an alkalinizing agent, like sodium bicarbonate in setting of severe acidosis. The efficacy of sodium bicarbonate administration is debated, and is thought to be limited in severe respiratory acidosis as the CO2 produced readily crosses cell membranes, potentially leading to further decrease of intracellular pH.2 This needs to be investigated further and, in the interim, administration in the face of severe acidemia is logical: acceleration of normal compensatory mechanisms (think renal production of bicarbonate), reduced respiratory drive (correcting the acidemia that further worsens tachypnea), and avoidance of worsening acidemia (preventing cardiac dysrhythmias, multiorgan failure).5 As with all critically ill intubations, it goes without saying that the rate of first pass success is directly correlated to decreased adverse events.6 As such, the person intubating should be the physician with the most airway management experience. These airways should be planned with appropriate adjuncts as clinically indicated, including but not limited to video laryngoscopy, bougie, and supra-glottic devices like the LMA. Additionally, consider using the largest endotracheal tube (ETT) indicated for your patient. A larger ETT will reduce airflow resistance, facilitating ventilation, and will also aide in post-intubation procedures, like bronchoscopy. For most adults, an 8.0 ETT is appropriate (even 8.5 or 9.0 in taller patients).1 Lastly, remember that ventilator desynchrony and agitation will lead to higher peak pressures and volumes, increasing the risk of complications from hyperinflation. Deep sedation and paralysis are necessary at the initial phase of invasive ventilation given the marked activation of central respiratory drive by necessary management techniques of this condition; namely forced hypoventilation and hypercapnia.3 When selecting the appropriate induction agent for intubation, consensus recommendation includes ketamine or propofol, as both have bronchodilator properties. However, vasodilatory effects of propofol combined

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with blunting of sympathetic drive make it less desirable than ketamine, and it should be used with caution in these patients. If ketamine is not available, consider etomidate. Etomidate, although lacking bronchodilator properties, possesses favorable cardiovascular hemodynamic properties.1 Paralysis should be employed as part of the intubation strategy from the beginning, when the clinical scenario allows. Specifically, non-depolarizing agents like rocuronium are preferred as they will provide 30-60 minutes of paralysis, allowing for post-intubation monitoring and optimization as discussed below. If the airway is deemed difficult, or there is concern about failure, succinylcholine, a faster acting and cleared agent could be considered. After successful intubation, longer acting agents like vecuronium, rocuronium, or cis-atracurium can be utilized. When given, intermittent boluses are preferred to continuous infusion to allow for serial assessments and lessen risks of myopathy associated with prolonged paralysis.2 Although many of these patients exhibit significant improvement in first 24-48 hours on the ventilator, deep sedation is still recommended in the initial phase of mechanical ventilation, with a goal Richmond AgitationSedation Scale (RASS) score of -4 to -5.3 Sedation agents should be selected carefully to avoid residual sedation effects that may prolong time on the ventilator. A combination of propofol and fentanyl is preferred to benzodiazepines and ketamine. Propofol, unlike benzodiazepines, has bronchodilator properties and allows for quick awakening.2 Ketamine, although a recommended induction agent, is not recommended for longterm or continuous sedation.3

Initial Ventilator Settings Many resources and podcasts have discussed this topic in the past few years, and there is a great deal of debate in the literature about ventilator management in these critically ill patients. As with all critical care medicine, nuance looms large; yet, we will attempt to give insight into the most accepted recommendations. In mechanical ventilation, there are two main modes, pressure control and volume control. Although there has been no overall outcome difference demonstrated between volume control and pressure control modes,1 volume control modes are often preferred in the severe asthmatic. Pressure control does have the advantage of achieving better control over alveolar pressure, limiting risks of barotrauma, but this comes at the expense of losing control over tidal volume, further worsening ventilation.5 Conversely, volume control allows for control of tidal volume, and simultaneously allows for monitoring of peak inspiratory pressure (PIP) and plateau pressure (Pplat).1 Additionally, volume control modes also allow for titration of how quickly a breath is delivered (inspiratory time, or “the slope”), unlike pressure control modes that are built to allow for patients to control their length of breath.7 All of these factors contribute to the recommendation for volume control modes in the severe asthmatic.

COMMITEE REPORT CRITICAL CARE MEDICINE

Tidal volume (TV) is more straightforward. We are accustomed to lung protective ventilation volumes of 6-8 cc/kg, as seen in ARDS, however, this is less of a concern in the asthmatic population, and a reasonable TV of 7-9 cc/kg is suggested. For most adults this is a TV of about 450500 cc. An oxygen saturation greater than 94% should be the oxygenation goal of the severe asthmatic; with an ideal range of 94-98%.3 Rarely will a pure asthmatic require significant FiO2 to achieve this goal, and a reasonable number should be FiO2 around 40%. However, one would not be wrong to start the ventilator at 100% FiO2 and titrate down as tolerated; this depends on pre-oxygenation and post-intubation status. Respiratory rate is arguably the most important parameter in intubated asthmatics. Status asthmaticus is a disease of obstruction, air trapping, and impaired ventilation. The main goal of intubation, in addition to alleviating fatigue and hypoxemia, is to control ventilation, and the respiratory rate is key. Not allowing for adequate expiratory time will result in “air trapping,” also known as “breath-stacking” (Figure 1). This hyperinflation leads to decreased ventilation and increased risk of pneumothorax and arrest, among other complications.1 A good place to start for RR is between 6 and 12 breaths per minute. Once set, it is necessary to monitor to the flow curve on the ventilator you are using (middle image in Figure 1). If the exhalation curve is not returning to baseline after a breath, then the respiratory rate should be reduced; as this is the definition of air trapping, breath stacking or auto-PEEP. Further monitoring parameters, PIP and Pplat will be discussed below.

More complex is the discussion of positive end expiratory pressure. In mechanical ventilation there are two forms or PEEP, intrinsic positive end-expiratory pressure (PEEPi) and extrinsic positive end-expiratory pressure (PEEPe). PEEPi (intrinsic), also known as “auto-PEEP” is the pressure generated by hyperinflation or inadequate exhalation as described above: “air trapping” or “breath-stacking.” This is in contrast to PEEPe which is the pressure maintained by the ventilator at end-expiration, serving to maintain recruitment of alveoli. In asthmatics, PEEPe has been shown to reduce mechanical work of breathing and improve respiratory effort, lung mechanics, ventilator triggering sensitivity, ventilation/ perfusion mismatch, and gas exchange. However, for this discussion, we will assume that the patient is fully paralyzed and sedated. Thus, there is no benefit with regard to work of breathing by the addition of PEEPe since patient effort is not a variable. Moreover, the addition of PEEPe may actually worsen gas trapping, thus forming the recommendation to set PEEPe at zero in these patients.1 Current practice favors lowering PEEPe, but until further research provides more definitive answer, consider raising PEEPe for those patients in whom lowering PEEPe does not help. In summary, the following initial ventilator settings can be considered when intubating the severe asthmatic: • Mode: Volume Assist Control • Tidal Volume: 7-9 cc/kg • Respiratory Rate: 6-12 breaths/minute; start at 10 and adjust based on flow curve analysis • Inspiratory Flow Rate: 60-80 LPM (set high in asthmatics) • FiO2: start at 100% and titrate down for oxygen saturation 94-98% (expect to settle between 40-50%) • PEEP: 0-3 cm H2O; start with 0 and adjust based on flow curve analysis, if this fails, consider raising PEEPe to help open airways • Peak Pressure Alarm: set high to assure ventilator breath delivery

Ventilator Adjustments

Another parameter used to maximize exhalation time is the maximum inspiratory flow rate. Most ventilators have a maximum available peak inspiratory flow rate of 60-80 LPM. Choose 80 LPM to start, or have the respiratory therapist set the maximum allowed on your ventilator model. In a volume control mode, setting a higher inspiratory flow rate will decrease the inspiratory time to achieve the set volume, and thus increase/ maximize the time for exhalation.7 Additionally, shorten the ratio of inspiration to exhalation time (I:E ratio) to 1:3 or 1:4 to maximize exhalation time.

Once the patient is intubated, frequent reassessment of ventilator mechanics and compliance is crucial. This is not the typical patient that can be left to “settle out” and reassessed in 20-30 minutes. The main complications in this patient population stem from hyperinflation. Dynamic hyperinflation begins when a reduction in expiratory flow results in incomplete exhalation of the delivered tidal volume. With subsequent breaths, lung volumes increase, leading to higher elastic recoil pressure and larger airway diameter. Multiple methods have been described to quantify hyperinflation, but the easiest method for the bedside clinician is measuring plateau pressure (Pplat) and peak inspiratory pressure (PIP) during volume-controlled ventilation.2 Pplat represents the average end-inspiratory alveolar pressure. In intubated asthmatic patients, the average Pplat is 24-26 cm H2O. Given that the majority of patients with asthma have near-normal respiratory system compliance, Pplat is primarily influenced by the degree of

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COMMITEE REPORT CRITICAL CARE MEDICINE

hyperventilation.2 The majority of published algorithms suggest an acceptable upper limit for Pplat of 30 cm H2O. Even extremely high PIPs will not result in injury to alveoli (barotrauma) as long as Pplat is maintained less than 30 cm H2O.1 To measure Pplat, press the inspiratory pause button and hold it until the ventilator gives you a number. If Pplat is less than 30, the set RR is satisfactory, however, if it is greater than 30, you should decrease the RR.7 Consideration of PIP can provide insight into ventilator compliance for further optimization. When ventilating the severe asthmatic, it is expected to have severely elevated PIPs, sometimes as high as 60-80 cm H2O. However, recall that asthma is a disease of medium-sized airways. These constrict, limiting air flow to and from the distal airways, so the alveoli never “see” the high PIP. However, many ventilators have default upper pressure limits around 40 cm H2O. In this example, the ventilator would cease further flow when the pressure of 40 cm H2O is reached, significantly limiting ventilation and worsening the patient’s respiratory status. Thus, it is critical to set the upper pressure limit on the ventilator above the patient’s average PIP, keeping in mind that PIP alone does not result in barotrauma.1



INTUBATING THE SEVERE ASTHMATIC CAN BE EXTREMELY CHALLENGING, AS RISKS INCLUDE HYPOXEMIA, WORSENING BRONCHOSPASM, PULMONARY ASPIRATION, TENSION PNEUMOTHORAX, DYNAMIC HYPERINFLATION, HYPOTENSION, DYSRHYTHMIAS, AND EVEN SEIZURES.”

Next Steps after Intubation In patients with severe asthma, the vicious cycle of airflow obstruction, air trapping, and impaired ventilation leads to hypercapnia; the average PCO2 in these patients is 68 mmHg and the average pH is 7.18.2 The solution to hypercapnia in normal patients would be to increase ventilation by increasing the respiratory rate, as described by the alveolar ventilation equation. However, increased respiratory rate is not an option in the mechanically ventilated severe asthmatic. Thus a strategy of permissive hypercapnia can be employed; provided the pH be corrected and

be maintained above 7.2. Additionally, there must be no evidence of increased intracranial pressure.1 Provided these conditions are met, intubated patients can tolerate high PCO2 (>40 mmHg) and low pH (<7.4) for many days until the lungs improve.4 Similarly, it is important to note that status asthmaticus will eventually resolve, but this may take as long as a few days. Once intubated continue to aggressively treat the underlying etiology by employing the multimodal approach discussed in Table 1. The ETT should be used as a conduit for continued ß-agonists. While intubation is the highest level of intervention that can be offered in the majority of emergency departments in the US today, there are many other interventions available in the ICU including inhaled anesthetics, bronchoscopy, and even extracorporeal membrane oxygenation (ECMO). However, many academic/larger centers continue to push the boundaries of ED care algorithms, and we will undoubtedly see the expansion of (ECMO) as a treatment option for these patients in the future.  References 1. Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. J Intensive Care Med. 2018 Sep;33(9):491-501. doi: 10.1177/0885066617740079. Epub 2017 Nov 5. PMID: 29105540. 2. Leatherman J. Mechanical ventilation for severe asthma. Chest. 2015 Jun;147(6):1671-1680. doi: 10.1378/chest.14-1733. PMID: 26033128. 3. Le Conte, P., Terzi, N., Mortamet, G. et al. Management of severe asthma exacerbation: guidelines from the Société Française de Médecine d’Urgence, the Société de Réanimation de Langue Française and the French Group for Pediatric Intensive Care and Emergencies. Ann. Intensive Care 9, 115 (2019). https://doi.org/10.1186/s13613-019-0584-x 4. Herbert, Mel, and Stuart Swadron. “The ‘Crashing’ Asthmatic.” EMRAP: C3. Aug. 2016. 5. Farkas, Josh. “Asthma.” EMCrit Project, 28 January. 2017, emcrit.org/ibcc/ asthma/. 6. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013 Jan;20(1):71-8. doi: 10.1111/ acem.12055. PMID: 23574475; PMCID: PMC4530518. 7. Weingart, Scott, and Rob Orman. “Intubated Asthmatic.” EMRAP: Critical Care Mailbag. June 2016.

CCMS Resources Join the Critical Care Medicine Section of AAEM and benefit from the below resources.

Critical Care Speakers Exchange

This member benefit is a resource for conference organizers to recruit topquality speakers in critical care medicine. All speakers must be members of the Critical Care Medicine Section of AAEM. Join today!

Mentoring Program

In addition to the traditional mentormentee relationship, CCMS offers several opportunities for mentors and mentees to create something together. Apply today to become a mentor or mentee!

Critical Care Hacks

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

COVID-19 Resources

The CCMS Council has created and gathered resources specific to helping members during the COVID-19 pandemic. Join our listerv to connect.

Learn more: www.aaem.org/get-involved/sections/ccms/resources 34

COMMON SENSE JANUARY/FEBRUARY 2021

SECTON REPORT WOMEN IN EM

“Thank you, Dr. C:” The Stigma of the F-word (Fertility) Maria L. Sturchler, MD EdD

Emergency medicine is a field full of individuals looking to meet the needs of their communities and most needy patients. The characteristic dedication, work ethic, and self-sacrificing nature of most EPs sometimes leads to selfneglect, and all too often, a failure to reflect periodically on the state of our own lives. As we rush from patient to patient, shift to shift, year to year, we can find that more time has passed than we imagined. Sometimes the changes that occur without our noting can be significant, particularly for female EPs. During the start of my intern year, I was laser-focused on my residency training. My husband and I were finally together after four long-distance years, I had matched at my top choice program, and I was living in a lovely, vibrant city. In my mind, all I had to focus on was becoming the best physician I could be. The learning curve was steep, but I was graced with plenty of attendings who loved to work with residents. Not only did they help me hone my clinical knowledge, but frequently they also took time to learn about me as a person. A few even dared to offer advice from time to time. One shift in particular stands out in my mind; it was a day during which I was working with one of the most admired physicians in our city’s safety net hospital. It was a busy shift, but we had worked several together already that month and thus he knew a little bit about me. He knew I was a latecomer to medicine after having been a teacher, that we both shared a passion for endurance sports, and had similar value systems. I was always a bit intimidated, albeit inspired, on shifts with him because he is one of the most efficient but thorough EPs I have ever worked with. He is clinically brilliant with a fabulous bedside manner to boot. For some reason, that day we started talking about family. He has a large family, and asked about my plans for children. I was never shy about admitting that I wished for several children, and was honest in telling him this. I dreamed of a loud, boisterous house with my children and their friends gathered in my kitchen or playing in the yard, I found myself telling him. As a former educator, I have a deep respect for and love of children, and I think he perceived this in me during our previous conversations.

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MOST PEOPLE FEEL THAT FERTILITY IS A TOPIC THAT IS TABOO, AN UNSPEAKABLE “F-WORD,” PARTICULARLY AMONG COLLEAGUES.”

“Well, Maria, what are you waiting for?” he pressed. I was somewhat taken aback by this comment, but it was appreciated. Out came the excuses I had been practicing for the past 10 years: I need to finish my training. I need to pay off some debt. I need to travel a little bit more. I want to buy a house first. After all, my husband and I had just started living together full-time; what was the rush, I thought? “You might be surprised that it is harder than you think to get pregnant. Just give it some thought... that’s my two cents’ worth.” Needless to say, I went home and mulled over this commentary. I ruminated, digested and felt these words impossibly folding and twisting in my mind over several weeks. Finally, I summoned the courage to tell my husband about this conversation and ask his thoughts about the idea of

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MY PGY-2 YEAR WAS OFF TO A GREAT START, WITH EXCEPTION OF MY PERSONAL BIOLOGY.” moving up our family planning timeline. It prompted some thinking on both of our parts, and we ultimately decided that we should start trying to conceive at the tail end of the academic year, just so I had a little bit more time to find closure for my harbored excuses. Spring turned into summer, and summer to fall, and in exchange for my sunny optimism, I had five negative pregnancy tests. My PGY-2 year was off to a great start, with exception of my personal biology. In my frustration, I divulged to one of my closest mentors that I was struggling to conceive. She suggested using ovulation kits, so I stocked up and pressed onward. Three more failures came my way and I could not shake a deep, unsettling feeling in my gut. Was something wrong with me? With my partner? Was having children just not in the cards for me? We sought out help from a specialist, trying fertility drugs along with IUI (intrauterine insemination) to no avail for three more cycles. All my life I had expected pregnancy to occur for me without difficulty, and avoided becoming pregnant like it was the plague. Now here I was,

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staring down IVF, the “worst case scenario” I mentioned to my husband when our fertility journey began over a year prior. The loss of control was overwhelming, not to mention the price tag.

Most people feel that fertility is a topic that is taboo, an unspeakable “Fword,” particularly among colleagues. Luckily for me, I was able to train under several attending physicians who were brave enough to broach this topic with candor and grace. I firmly believe they saved my life; not in the way one would think of typically, but they forced me to come to terms with a key facet of what I wanted in life before it was too late.

We applied for a personal loan, and meanwhile I scoured online forums, message groups, read our local infertility specialists’ statistics online, and finally asked my husband to accompany me to our first appointment for IVF consultation. Long story short, there were several more complications and quite the rollercoaster ride along the road to pregnancy, but ultimately I write this while feeling my 35-week-old daughter kicking away in my womb as we await her birthday.

Thank you, Dr. C, for being selfless enough, even while working a busy ED shift, to look out for my best interests both in and out of the hospital. You have made all the difference. 

Join the WiEM Section The Women in Emergency Medicine (WiEM) Section is constituted with a vision of equity for AAEM women in emergency medicine and a purpose to champion the recruitment, retention, and advancement of women in emergency medicine through the pillars of advocacy, leadership, and education. The AAEM Women in Emergency Medicine Section membership is free for AAEM and AAEM/RSA members.

WiEM Mentorship Program The WiEM Section provides education that builds mentoring systems for female medical students and emergency physicians at different stages of their careers, whether in an academic or community setting. Apply today to be successfully matched with a mentor/mentee.

Learn more at:

www.aaem.org/wiems

AAEM Online Flinging a Spotted Arm Joshua Mirkin, MD; Daniel Simpson, DO; Erica Harris, MD

The patient’s rash, in the setting of HIV, was immediately suspicious for secondary syphilis. In the morning, the patient’s RPR and FTA-ABS were positive. The patient had no recollection of a chancre and thought he had the pictured rash for a long time. Infectious disease saw the patient in the morning and felt this was residual hyperpigmentation from a previous rash associated with secondary syphilis. Because the rash was no longer pink or violaceous, typical of secondary syphilis, he was deemed to currently not be infectious. Because the patient did not know when he was infected or started having the rash, he was treated as late latent syphilis with 3 weekly doses of penicillin G benzathine.

CC: shortness of breath 48-year-old man history of hypertension and HIV, unknown CD4 count, brought in by EMS for shortness of breath. Patient states that he became short of breath just prior to arrival. Patient is awake and alert, but confused and has difficulty answering many questions. As an IV is being placed, the patient apologizes that his arm keeps on moving. He states that he is short of breath because he has not been able to stop his arm from moving for 3 hours.

Physical Exam

Women in EM Section Poster Pearls www.aaem.org/aaem-online 36

COMMON SENSE JANUARY/FEBRUARY 2021

Because of the patient’s unmanaged HIV and syphilis, we had a broad differential for the cause of the patient’s hemiballismus. The patient denied any personal or family history of epilepsy. Because of his history of HIV we considered the possibility of seizures caused by an intracranial infection such as, toxoplasma, cryptococcus, and herpes encephalitis. Other potential causes included CNS lymphoma and progressive multifocal leukoencephalopathy. We also considered that the patient’s altered mental status and involuntary motions could be due to neurosyphilis.

Vitals: BP 114/71 HR 92 RR 20 T 36.9C General: oriented to person and place, NAD CV: nl s1s2, RRR, no MRG Resp: tachypneic, CTAB Abd: SNDNT Neuro: intermittent flinging of right upper extremity, CN II-XII intact, normal strength and sensation.

Labs POC Glucose >600 VBG pH 7.60, pCO2 21, HCO3 20.6, BE 1.0 CBC: WBC 5.21, Hgb 12.9, Hct 40.5, Plt 41 BMP: Na 116, K 4.1, Cl 78, CO2 19, BUN 14, Cr 0.8, Glu 1,397 Osmolality 327

Questions 1. What is the differential diagnosis of the rash? 2. Why is the patient flinging his right arm?

Answers 1. Secondary syphilis, pityriasis rosea, lichen planus, guttate psoriasis, rocky mountain spotted fever 2. The patient was clinically diagnosed with hyperglycemic hemiballismus syndrome, but we were suspicious for partial seizures.

Department of Emergency Medicine Albert Einstein Medical Center Philadelphia, PA Case Discussion

History of Present Illness

Pearls • Patients with fading or hyperpigmentation after the rash of secondary syphilis may need a longer course of treatment (3 doses versus 1 dose of penicillin G benzathine) than those with an active, violaceous rash. • Keep a wide differential for those with syphilis or HIV and neurological symptoms.

Early in the ED course, the patient was newly diagnosed with diabetes and found to be in a hyperosmolar hyperglycemic state. The patient’s mental status and hemiballismus improved with IV hydration. CT of his head was unremarkable. At the time of admission, he was fully oriented and hemiballismus had ceased. When the patient was signed out to the ICU, we discussed that if the patient continued to have hemiballismus, change in mental status, or seizure-like activity, the above differential should be explored. Ultimately, none of these symptoms returned and he was clinically diagnosed with hyperglycemic hemiballismus syndrome. If an MRI is done there is often hyperintensity of the contralateral basal ganglia, most commonly of the putamen.

References 1. 2.

Cosentino C, et al. Hemichorea/Hemiballism Associated with Hyperglycemia: Report of 20 Cases. Tremor Other Hyperkinet Mov (NY). 2016;6:402. Published 2016 Jul 19. Tintinalli, J.E., Stapczynski, J.S., Ma, O.J. et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. McGraw-Hill Education, New York, NY; 2015.

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SECTON REPORT EMERGENCY ULTRASOUND

Why an Ultrasound Fellowship Might Be Right for You Joshua Guttman, MD FAAEM FACEP FRCPC and Lekha A. Shah, MD

The COVID-19 pandemic in combination with the reduced demand for emergency medicine attendings and greater supply of EM residency graduates exacerbates the difficulty of obtaining a desirable position. Finding an emergency medicine position in your chosen location was once a virtual guarantee. But it has become increasingly difficult for some EM graduates to find a satisfactory position these days. Completing a fellowship gives you expertise beyond that of a general EM graduate. ED directors and chairs are more likely to hire a fellowship graduate and preferentially retain those graduates in the event of a layoff if your fellowship background provides value to the ED.

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WHILE EDS MIGHT HAVE A “POCUS CHAMPION” FILL THAT ROLE, AN ED DIRECTOR MAY RATHER HIRE QUALIFIED FELLOWSHIPTRAINED EPS THAT HAVE COMPLETED FORMAL US TRAINING RATHER THAN A GENERAL EP WHO HAS TO FIGURE OUT THESE ANSWERS IN REAL-TIME.” ED ultrasound fellowships have enjoyed a steady increase in popularity over the past two decades. The first fellowship was founded in 1994; in 2020, there were 135 fellowship programs accepting 212 fellows. While there are many fantastic fellowship opportunities through emergency medicine, the breadth of an ultrasound fellowship makes it a great choice for those with a wide range of intended practice. The use of POCUS is generally popular among emergency physicians (EPs), especially among those trained in its use during residency. Most emergency physicians recognize the value of this tool for both diagnostic and procedural performance. The ability to quickly “look inside” a patient to answer a focused clinical question

expedites care without subjecting them to ionizing radiation or expensive comprehensive imaging. With POCUS, you no longer need to wonder whether a patient has a pericardial effusion based on EKG, physical exam and X-ray; you can simply know the answer in mere seconds. For this reason, virtually all EDs have POCUS machines in the clinical area. For EPs interested in an academic career with a focus on education, ultrasound fellowships provide significant opportunities to hone teaching skills. POCUS is popular with all levels of learners who are keenly receptive to ultrasound teaching. All POCUS fellowships provide the opportunity to improve bedside teaching skills and deliver formal didactics (e.g., lectures, workshops, curriculum development, etc.). All EM residencies have a mandatory POCUS rotation that necessitates teaching by POCUS experts. These experts are generally given protected time as faculty. For POCUS faculty looking to advance beyond resident education, an ultrasound fellowship graduate may easily transition to become a POCUS educational lead for a medical school and other clinical departments (e.g., critical care, hospitalist, primary care, etc.). Some graduates have chosen to transition to roles within residency leadership (e.g. program director). Even those who simply prefer to teach a variety of learners (from first year medical students to seasoned faculty) benefit from POCUS education. There will be a role for you at an academic program.

manufacturers, these companies provide grants and equipment for research purposes. As a fellowship-trained POCUS expert, you would be an instinctive choice for developers to assist with product development. While research experience in ultrasound fellowships varies, all fellowships require mentored scholarly work.

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FOR EPS INTERESTED IN AN ACADEMIC CAREER WITH A FOCUS ON EDUCATION, ULTRASOUND FELLOWSHIPS PROVIDE SIGNIFICANT OPPORTUNITIES TO HONE TEACHING SKILLS.” For those interested in community emergency medicine or administration, there is ample opportunity to lead an ultrasound program. The goals for a community EM group is usually to credential the group for POCUS, improve patient safety, and provide ongoing quality assurance. Revenue generation from POCUS studies is a key driver for these EDs. Community EDs hire ultrasound fellowshiptrained EPs to fill this role, often giving paid administrative time for those tasks. Some community health systems additionally hire

For EPs interested in an academic career in research, POCUS provides unlimited scope since novel POCUS applications are constantly emerging. Some widely used POCUS applications require a stronger body of evidence to validate their current usage. Aside from diagnostic accuracy, POCUS provides other benefits to ED flow – reduced length of stay, time to diagnosis and cost savings. As artificial intelligence (AI) becomes more common, private companies are looking to integrate AI with POCUS. They need POCUS researchers to provide feedback as they refine their products for the market. Along with ultrasound COMMON SENSE JANUARY/FEBRUARY 2021

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system-wide POCUS directors with significant allotted time for ultrasound tasks. This administrative role helps mitigate the risk of burnout, which is prevalent in community EPs. POCUS fellowships provide focused education on billing, quality assurance, credentialing, and machine selection. While EDs might have a “POCUS champion” fill that role, an ED director may rather hire qualified fellowship-trained EPs that have completed formal US training rather than a general EP who has to figure out these answers in real-time. Beyond the ED, becoming a POCUS lead creates connections across multiple specialties within the hospital. Other specialties recognize EM as the leader in POCUS and welcome EP assistance as they develop their own POCUS policies and education. Ultrasound fellowships have occasionally been criticized for not being accredited. Fortunately, this is changing. As was discussed in a previous issue of Common Sense, the American Board of Emergency Medicine

(ABEM) is starting a focused practice designation (FPD) in Advanced Emergency Medicine Ultrasonography (AEMUS). To this end, ABEM has spearheaded the creation of the Emergency Medicine Ultrasound Fellowship Accreditation Council (EUFAC), which is accrediting fellowships which adhere to rigorous standards in fellow education. While all EM fellowships provide wonderful opportunities, we believe that ultrasound fellowships, in particular, are suited to a broad range of EM graduates looking for varied practice opportunities, whether in academic or community EM. We urge you to consider a fellowship to increase your employability, job security, and long-term career satisfaction in EM. Joshua Guttman, MD FAAEM is the emergency ultrasound fellowship director at the Emory University Department of Emergency Medicine. Lekha Shah, MD is the pediatric emergency medicine ultrasound fellowship. 

Join the Emergency Ultrasound Section of AAEM (EUS-AAEM) THE EUS MISSION IS TO FOSTER PROFESSIONAL DEVELOPMENT AND EDUCATE MEMBERS ON POINT OF CARE ULTRASOUND.

EUS-AAEM POCUS Report We are proud to publish the POCUS Report, our e-newsletter with original contributions from many of our members. We encourage all members to submit for future editions. Topics include but are not limited to educational, community focus, interesting cases, resident and student section, and adventures abroad. Catch up on issues and submit an article at: www.aaem.org/get-involved/sections/eus/newsletter

Learn more about EUS-AAEM and join the section at www.aaem.org/eus

COMMON SENSE JANUARY/FEBRUARY 2021

SECTON REPORT YOUNG PHYSICIANS

Finding Escapism and Mentorship in a Book Club Alexandra Reed, DO; Cara Kanter, MD FAAEM – President, YPS; Jefferson Health Northeast, Emergency Medicine

Wellness has gained traction in the academic world not only as a concept, but as a necessity to physician mental health and well-being. Many emergency departments have found their stride in promoting wellness through activities, events and lectures over the past few years. Our residency program had an annual retreat in the form of a rafting trip to which both residents and attendings counted down the days. However, the ripple effects of the COVID-19 pandemic know no bounds, and one of the inevitable changes was a loss of traditional gatherings—a loss of wellness retreats and activities, and even the solidarity of weekly in-person conference. Struck with the question of what to do and how to adapt, it became clear that creating connection in this time was of paramount importance. While residency has always been challenging, wellness is arguably more important now than ever. The initial phases of quarantine resulted in a universal turn towards individualistic activities and newfound hobbies that could be completed at home (bread baking anyone?). Many turned towards reading not only as a hobby, but as a form of escapism during days when the outside world felt foreign and uninviting. Amongst the many reclaimed hobbies, reading specifically has

BOOK CLUB PROVIDED A REDIRECTION AWAY FROM STRESS, ISOLATION AND FEAR TOWARDS CONVERSATION, COMMUNITY, AND ENGAGEMENT.” been noted to be crucial as an activity for physician wellness as it forces the reader to slow down in contrast to the pace of working in the hospital.1 While there is a place for independence in wellness, enhancing social support systems is also a vital component to physician and resident well-being.2 We were struck with the realization that a healthy dose of escapism might actually be ideal in this time and could additionally be done in community— thus the idea for a Women’s Book Club for formed. Three contemporary books by female authors were presented and voted on by those interested, which was a large majority of female attendings and residents in the emergency medicine program at Jefferson Health Northeast in Philadelphia. Kim Liggett’s “The Grace Year” was chosen and all participants were given two months to read the book.3 In the weeks leading up to the book club meeting there was excited conversation in the ED at shift change between female residents and attendings working their way through the book. Rather than discussing COVID case trends or whether someone would embark on the adventure that HOWEVER, THE RIPPLE EFFECTS OF THE COVID-19 PANDEMIC KNOW is indoor dining, we were discussing the follies of a fictional teenNO BOUNDS, AND ONE OF THE INEVITABLE CHANGES WAS A LOSS OF TRAage girl, debating her decisions, and discussing what we might do DITIONAL GATHERINGS—A LOSS OF WELLNESS RETREATS AND ACTIVITIES, if put in her preposterous circumstances. When asked about their dream form of wellness, a committee of 29 residents stated their top priorities included camaraderie and mentorship.4 Mentorship can take many traditional and professional forms, but can also be fostered in the setting of a pandemic-induced book club. No one in the health care community has

AND EVEN THE SOLIDARITY OF WEEKLY IN-PERSON CONFERENCE.”

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been spared from the stressors of this year, and coming together puts that into direct view. On the night of book club, a quorum of attendings and residents gathered on the host’s back deck, with another cohort tuning in from home via zoom. Over wine and s’mores we expressed our thoughts about the book and about the world. Through the starting point of a dystopian novel, as a group we were able to discuss shared experiences as women and as physicians. Book club provided a redirection away from stress, isolation and fear towards conversation, community and engagement. It served as an exercise in imagination, a muscle which has been underused by many of us for months. That same night we all marked our calendars for the next meeting, and we laughed as we proposed what book to read next and mused on what hors d’oeuvres to prepare. Emergency physicians have dedicated innumerable hours to medicine, and especially during this unprecedented pandemic, we have worked under unimaginable circumstances and been pushed to the limits of emotional and mental stress. Our normal world and structure has changed, but our priorities should not. There is opportunity for novel versions of community, and mentorship that is much needed in this time, but there is also opportunity for something simple— sitting around a campfire and discussing a good book. 

AAEM

References 1. Hategan, Ana, et al. Humanism and Resilience in Residency Training: a Guide to Physician Wellness. Springer, 2020. 2. Brower, Kirk J. & Riba, Michelle B. “Work Associated Trauma.” Physician Mental Health and Well-Being: Research and Practice. Springer, 2017. 3. Liggett, K. (2019). The Grace Year. New York, NY: Wednesday Books. 4. Timothy J. Daskivich, Dinchen A. Jardine, Jennifer Tseng, Ricardo Correa, Brian C. Stagg, Kristin M. Jacob, and Jared L. Harwood (2015) Promotion of Wellness and Mental Health Awareness Among Physicians in Training: Perspective of a National, Multispecialty Panel of Residents and Fellows. Journal of Graduate Medical Education: March 2015, Vol. 7, No. 1, pp. 143-147.

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BIASES UNFORTUNATELY ARE A NORMAL PART OF THE HUMAN CONDITION AND NEARLY EVERY PHYSICIAN IS IMPACTED BY COGNITIVE BIASES.”

THE FIRST STEP IN REDUCTION OF COGNITIVE BIASES IS BY INCREASING OUR AWARENESS OF THEM AND WE HOPEFULLY CAN IMPROVE PATIENT OUTCOMES AND ALSO GROW AS PHYSICIANS.“

Biases in Emergency Medicine Shana EN Ross, DO

“Remember that patient from last week?” are some of the most dreaded words emergency medicine physicians hear. Given the nature of EM with unfamiliar patients who present undifferentiated medical complaints while under time constraints and seeing multiple other patients with frequent interruptions, we are bound to make mistakes, often due to our biases. During residency, your attending was always there to check your biases and ensure you provided optimal care. However, once you are graduated and practicing solo, being aware of your cognitive biases is imperative to your growth as a physician and for patient safety. Cognitive biases are described as flaws in cognition, or systematic distortions, that alter reality.1 Biases unfortunately are a normal part of the human condition and nearly every physician is impacted by cognitive biases. Myriad biases have been described in the literature, and the majority of biases physicians make is with diagnostic accuracy.2 A meta-analysis by Saposnik et al. identified that framing effect and overconfidence biases, or blind-spot bias are the most prevalent biases among physicians, while confirmation and anchoring biases are also common.2 Blind-spot Bias

Being able to recognize others biases while overestimating one’s abilities and not being cognizant of one’s own biases

Framing Effect Bias

Opinions and decisions based on influences of the words, context, positive/negative connotations

Confirmation Bias

Interpreting the data and information to support one’s preexisting beliefs and ignoring the evidence that refutes it

Anchoring Bias

Relying too heavily on the first piece of information given and refuting to readjust beliefs after receiving new information

Biases do not occur due to lack of knowledge, and the same goes for most medical errors.3 Understanding our cognitive biases are the first step in preventing them from impacting our medical-decision making in a negative way. Studies show that mid-carren EM physicians have more awareness of blind-spot bias, likely due to education and experience.4 Hansen3 describes four methods to reduce cognitive biases in emergency medicine: 1. Checklists: Through checklists attention is forced in certain areas that may be overlooked otherwise 2. Forcing Functions: Forcing functions are “if this, then that” scenarios, that encourage systematic approach such as applying the HEART score before discharging a patient with chest pain 3. Biostatistical Knowledge: Understanding prevalence of diseases and statistical knowledge will assist physicians from disregarding a diagnosis 4. Transition into Type 2, or, Slow Thinking: This allows for exploration of other options or potential diagnosis vs type one which is reflexive and based on heuristics The first step in reduction of cognitive biases is by increasing our awareness of them and we hopefully can improve patient outcomes and also grow as physicians.  References 1. Haselton MG, Nettle D, Andrews PW. The evolution 3. Hansen K. Cognitive bias in emergency medicine. Emerg Med Australas. 2020 Oct;32(5):852-855. doi: of cognitive bias. In: Buss DM, ed. The Handbook of 10.1111/1742-6723.13622. Epub 2020 Sep 9. PMID: Evolutionary Psychology. Hoboken, NJ: John Wiley & 32902161 Sons, 2005; 724–46. 4. Pines JM, Strong A. Cognitive Biases in 2. Saposnik G, Redelmeier D, Ruff CC, Tobler PN. Emergency Physicians: A Pilot Study. J Emerg Cognitive biases associated with medical decisions: Med. 2019;57(2):168-172. doi:10.1016/j. a systematic review. BMC Med Inform Decis Mak. jemermed.2019.03.048 2016;16(1):138. Published 2016 Nov 3. doi:10.1186/ s12911-016-0377-1 COMMON SENSE JANUARY/FEBRUARY 2021

SECTON REPORT YOUNG PHYSICIANS

VotER: Healthy Democracies Make Healthy Communities TaReva Warrick-Stone, DO and Peter Puthenveetil, MD FAAEM

Like many, I am encouraged by the shift among emergency physicians toward exploring our role in addressing social determinants of health. The power of these societal factors is enormous compared to health care’s capacity to counteract them. Yet, interest among emergency medicine providers is resulting in community partnerships that are improving the lives of some of our most vulnerable patients. In April 2020, though still in COVID survival-mode, I began to wonder how I could get involved in addressing some of the failures that underpin our health system and were leading to the pandemic’s disproportionate impact on black, brown, and low-income communities.1 My search led me to VotER and its healthy democracy kit.

change in strategy and the healthy democracy kit was born – a red, white, and blue lanyard and badge-backer with a QR code for patients to scan. This decentralized VotER framework empowered health care providers to have brief, nonpartisan conversations with patients to encourage them to be politically engaged and to vote safely by mail.

THROUGH THE EFFORTS OF HEALTH CARE PROVIDERS AND MEDICAL STUDENTS ACROSS THE STATE, WE HELPED 4,881 PEOPLE REGISTER TO VOTE AND ENGAGED 9,805.”

In June, myself and three others were invited to meet with Dr. Martin and his community organizers. The four of us – attending, fellow, resident, and medical student – met our guide in community organizing, a law student focused on civil rights and policy. Together we set out to grow the VotER effort in Pennsylvania. Using the framework of Harvard’s Marshall Ganz, our strategy was relational community organizing, a methodology that was new and inspiring to all of us. Our aim was to build a network of health care professionals registering new voters. We learned to tell our story, a public narrative. “Organizers work through narrative to deepen people’s understanding of their values, their capacity to share them, and to draw upon them for the courage to act.”4 This helped me approach my residency program with a goal to mobilize the feelings of urgency, anger, and empathy among my colleagues, and to challenge feelings of apathy, fear, and isolation all too typical of our times.

VotER was started at Massachusetts General by emergency physician Alister Martin. Dr. Martin observed that those who are more likely to present as low acuity patients in the emergency department are also more likely to be unregistered to vote – young adults, people of lower socioeconomic status, and people of color. He wanted to invite patients to be civically engaged because so much of the health care system and our health care experiences are determined by the policies of our elected officials.2 Initially, iPad-based kiosks and posters in waiting areas offered patients a convenient, nonpartisan opportunity for voter registration.3 The arrival of COVID-19 necessitated a

In approaching my residency program for support, I was fortunate that the attending in the organizing group also works in my hospital system. I also found that one of my co-residents had already requested a healthy democracy kit and begun to get posters approved to hang in the emergency department. Our program director was receptive, as was the chair of the

COMMON SENSE JANUARY/FEBRUARY 2021

DR. MARTIN OBSERVED THAT THOSE WHO ARE MORE LIKELY TO PRESENT AS LOW ACUITY PATIENTS IN THE EMERGENCY DEPARTMENT ARE ALSO MORE LIKELY TO BE UNREGISTERED TO VOTE – YOUNG ADULTS, PEOPLE OF LOWER SOCIOECONOMIC STATUS, AND PEOPLE OF COLOR.” department. Both advocated on our behalf to hospital leadership that the VotER initiative is in line with the hospital’s value to improve the lives of our patients. Aspiring to an American democracy that is inclusive of all and empowering patients to participate in shaping public policy through civic engagement is essential to eliminating health disparities and holding our government accountable.5 Legally speaking, the VotER platform simply serves as a prompt for patients to register themselves to vote. It does not involve medical providers actively registering patients. Even if it were interpreted as such, the American Hospital Association’s legal team has stated that nonprofit hospitals are permitted to conduct nonpartisan voter registration activities.6

SECTION REPORT YOUNG PHYSICIANS

With the support of the hospital, emergency department, and residency leadership, I ordered more kits and prepared presentations for resident conferences. My co-resident crafted a staff message and hung our VotER posters. We eventually created a group of 15 residents and attendings committed to speaking with our patients about voting. Obviously, it is not appropriate to speak to all patients about voting, some are critically ill or altered, and some shifts are just too busy. But on manageable shifts for low acuity patients, I found the experience uplifting. After collecting the initial clinical information for their visit, or when returning with results and to discuss disposition, I would ask about the patients’ voting status and express my concern that they have a plan to vote safely. The conversation usually took 1-2 minutes, and most of my patients were already registered to vote. I offered my VotER badge with its QR code to those who were not registered, had recently changed their address, or wanted to request a mail-in ballot. All these patients expressed appreciation at the end of our conversation.

HEALTHY DEMOCRACIES MAKE HEALTHY COMMUNITIES.” Our group met monthly on-line to check in, reflect on challenging conversations, discuss ideas, and offer each other support. We also participated in virtual statewide meetings where VotER organizing groups around Pennsylvania joined to share experiences and develop collective momentum. Through the efforts of health care providers and medical students across the state, we helped 4,881 people register to vote and engaged 9,805.7 The total is, in fact, much higher as not all the patients we interacted with needed to scan the badge, but they still benefited from knowing that their health care providers valued their civic participation. While some may say it is not the role of emergency departments or physicians to address the social determinants of health, there is no doubt that circumstances outside health care nurture or impair health. “When the fabric of communities upon which health depends is torn, then healers are called to mend it.”8 Healthy democracies make healthy

communities. I think we can agree that we want our patients to invest in their own health and wellbeing. So just as we might counsel them to stop smoking, exercise, and wear helmets, we must also encourage patients to vote, because without claiming their role in our democracy, they will never achieve true health equity. Nonpartisan voter registration through platforms like VotER can help us heal the communities we serve.  References

1. Centers for Disease Control and Prevention. (2020, Aug 18). COVID-19 Hospitalization and Death by Race/Ethnicity. Retrieved from Centers for Disease Control and Prevention: https://www.cdc. gov/coronavirus/2019-ncov/covid-data/investigations-discovery/ hospitalization-death-by-race-ethnicity.html 2. VotER. (2020, Oct 28). VotER. Retrieved from VotER: https://vot-er. org/ 3. Kusner, J., Dean, L., & Martin, A. (2020, June 24). Emergency Departments Can Help Get Patients Registered to Vote. ACEP Now, 39(6), pp. 1-2. Retrieved from https://www.acepnow.com/article/ emergency-departments-can-help-get-patients-registered-to-vote/ 4. Ganz, M. (2017). Organizing Notes: “What is organizing?”. Organizing: People, Power, Change. Cambridge, Massachusetts, United States of America: Harvard University Kennedy School of Government. 5. New England Journal of Medicine. (2020). Dying in a Leadership Vacuum. New England Journal of Medicine, 383(15), 1479-1480. Retrieved from https://doi.org/10.1056/NEJMe2029812 6. American Hospital Association. (2020, Oct 28). We Care... We Vote. Retrieved from Tools & Resources: https://wecarewevote.aha.org/ we-care-we-vote-tools-resources 7. VotER. (2020, Oct 28). VotER. Retrieved from VotER: https://vot-er. org/ 8. Berwick, D. (2020, June 12). The Moral Determinants of Health. Journal of the American Medical Association, 324(3), 225226. Retrieved from https://jamanetwork.com/journals/jama/ fullarticle/2767353

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

It’s a challenging time for emergency physicians AAEM recognizes that and were doing something about it. • We’ve continued to fight for your due process rights — AAEM worked closely with the sponsors of newly introduced legislation. • We’ve had your back during COVID-19 — Read our position statements and letters to government officials advocating for you during this pandemic. • We protect your practice rights — We’re actively working to address APP independent practice to create a balanced workforce through both position and policy statements. • We’re advocating for a solid future for our specialty - we’re working with the newly formed EM Workforce Committee for a future with a balanced work force.

• We’re committed to diversity, equity, and inclusion – The AAEM Diversity, Equity, and Inclusion Committee is working hard to bring members resources and awareness, including statement on the Death of George Floyd and the Statement Against Federal Regulation. • We joined the clear message being sent that #ThisIsOurLane. We are the front line providers, and we will be at the forefront of the solution, which is why we signed on to support AFFIRM.

Learn more at www.aaem.org/whyaaem Join/renew today: www.aaem.org/membership COMMON SENSE JANUARY/FEBRUARY 2021

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FDA-Approved Immunotherapy Treatments LIVE VIRTUAL PROGRAMS Please join us for one of the programs scheduled below! • Atlanta – Jan. 23, 2021 • Salt Lake City – Feb. 18, 2021 Please visit sitcancer.org/aci for more information and to view added dates for 2021.

WHY ATTEND? • Earn CME, CPE and CNE credits and MOC points • Attend for FREE if you are a healthcare professional, student, patient or patient advocate • Hear from and network with local experts in tumor immunology and cancer immunotherapy • Attend from the comfort of your home/workspace, and logon when it fits your schedule.

ACI PROGRAM TAKEAWAYS

ACCREDITATION INFORMATION

ACIs are presented by local authorities in tumor immunology and cancer immunotherapy and cover the following topics: • Treating patients with FDA-approved immunotherapies • Interpreting new clinical data supporting the use of checkpoint inhibitors, • CAR T therapies, cytokines, oncolytic viruses and vaccines • Identifying and managing irAEs • Employing strategies to overcome operational and reimbursement barriers to incorporating immunotherapy into your practice • Applying foundational knowledge for clinical implementation of SITC’s Cancer Immunotherapy Guidelines • Anticipating forthcoming immunotherapy trends/treatments/ trials and how they impact your patients and practices • Recognizing common and uncommon toxicities in immunotherapy patients and provide solutions/adjustments in treatment to address them

AMA Credit Designation These activities have been approved for AMA PRA Category 1 Credit(s)™. Pharmacist Credit Designation These activities are eligible for ACPE credit, see final CPE activity announcement for specific details. Nursing Credit Designation These activities are eligible for ANCC contact hours, see final CNE activity announcement for specific details.

For full accreditation information and to register for these events, please visit:

sitcancer.org/aci

+The 2020–2021 ACI series is jointly provided by Postgraduate Institute for Medicine and the Society for Immunotherapy of Cancer in collaboration with the American Academy of Emergency Medicine and the Association of Community Cancer Centers and the Hematology/Oncology Pharmacy Association. +The 2020–2021 Advances in Cancer Immunotherapy™ educational series is supported, in part, by independent medical education grants from Amgen, AstraZeneca Pharmaceuticals LP, Bristol Myers Squibb, Exelixis, Inc. and Merck & Co., Inc. 44

COMMON SENSE JANUARY/FEBRUARY 2021 SITC-1220-149

AAEM/RSA PRESIDENT'S MESSAGE

Addressing the Social and Structural Determinants of Health in Medical School and Residency Education Jennifer Rosenbaum, MD – Vice President, AAEM/RSA

In light of the ongoing COVID-19 pandemic and increased focus on social justice, physicians are more aware that patients’ social determinants effect their health. These times are also highlighting how the structural determinants, which include government process and economic and social policies, are effecting their patients. As the safety net of the health care system, emergency physicians have the privilege of taking care of any patient that walks through the door. We are often the frontline providers for underserved populations and we bear witness to the societal patterns of health inequity. Despite our advanced training, health care disparities persist. Social emergency medicine is an emerging branch of emergency medicine that investigates the interplay of the social determinants of health (SDH) and emergency medical care. As emergency medicine adapts to meet the needs of our patients, it is essential that social and structural determinants of health are incorporated into medical school and residency education.

medical schools varies. In 2019, when surveyed, medical schools were nearly split down the middle about whether the teaching of SDH was a low priority or a high priority.3 If the population’s health is to be improved, and if disparities in outcomes are to be reduced, medical schools and residencies must do a better job of incorporating the SDH into their curriculum.

Medical School Curriculum

Recently, many medical schools have developed creative ways to integrate public health into their coursework. During the preclinical years some medical schools have developed seminars and didactics on cultural competency, reformatted Objective Standardized Clinical Examinations (OSCEs) with cases highlighting the SDH, created a service-learning curriculum, or attempted to teach the SDH at the bedside through an emergency medicine clerkship.4 Creating a curriculum that emphasizes SDH is important, but some of these interventions have been critiqued for being flawed. A positive experience requires a considerable Medical education in the 20th ceninvestment of time and planning AS THE SAFETY NET OF THE HEALTH CARE tury was largely influenced by the on the part of academic instituSYSTEM, EMERGENCY PHYSICIANS HAVE THE Flexner Report, which called upon tions and faculty. For example, American medical schools to enact PRIVILEGE OF TAKING CARE OF ANY PATIENT THAT if service learning is not well higher admission and graduation WALKS THROUGH THE DOOR.” coordinated, it places burdens standards.1 It established the bioon community partners. Cultural medical model as the gold standard competency education has been integral in drawing attention to health of medical training and challenged U.S. medical schools to become more inequities, but it has also been criticized for being reductionist. It often inacademic. In response, medical schools redesigned their curricula to volves teaching homogenized ideas of culture that may overstate cultural focus on training physicians to practice using the scientific method and or racial differences and unintendedly reinforce stereotypes. Medical engage in original research. The Flexner Report was integral in creating educators must continue to re-examine their SDH curriculum to make standards for academic rigor. However, it is also contributed to racial sure its intentions are being met. bias in medicine and is partially responsible for the disproportionally low number of diverse physicians in the workforce today.2 Most Black mediResidency Curriculum cal schools in the early 20th century did not have the resources necesSeveral residency programs have SDH “tracks” for interested EM physisary to implement the standards that Flexner called for, and consequently cians in training. These may allow residents to focus on scholarly projwere shut down. In the 100 years since the Flexner Report, the Beyond ects and advanced professional development. However, to really narrow the Flexner Alliance (BFA) was created to address the disparities that the gap between health care and the community, it is important that all still exist today. The BFA’s mission is to promote social mission in health residents have this type of formal education. Emergency medical educaprofessional’s education. tors are uniquely positioned to incorporate structural competencies into Despite great strides in public health throughout the 20th century, historiresidency education. Emerging frameworks of structural competency call cally public health courses took a backseat to core basic science and for physicians to recognize that health outcomes are shaped by complex, clinical courses. Even presently, the extent to which SDH are taught by

COMMON SENSE JANUARY/FEBRUARY 2021

AAEM/RSA PRESIDENT’S MESSAGE

IF THE POPULATION’S HEALTH IS TO BE IMPROVED, AND IF DISPARITIES IN OUTCOMES ARE TO BE REDUCED, MEDICAL SCHOOLS AND RESIDENCIES MUST DO A BETTER JOB OF INCORPORATING THE SDH INTO THEIR CURRICULUM.” interrelated structural forces. One group of educators provided their framework for incorporating structural competencies into emergency residency education.5 They highlight that it is critical to develop community partners with organizations in your area. These might include free clinics, shelters, food banks, substance use disorder clinics, domestic violence resource centers, and many more. Some EM residencies introduce their residents to these organizations during their orientation period. Curriculum can also be routinely integrated into resident conference sessions and journal clubs by choosing topics, speakers, and articles centered on the voices of patients and community organizations.6,7

Beyond Residency For residents who seek a career dedicated to understanding and intervening on the social origins of health and disease, there are now fellowships available in population health and social EM. For others not seeking a fellowship, there are plenty of ways to get involved. Making connections with community partners, learning from social workers, and taking time to ask patients about their SDH are easy tasks that can be done on your next shift. By doing these things, you might be setting an example for a newer learner. Medical education must also continue to diversify with initiatives led by persons that represent the communities they serve. By emphasizing diversity in medicine and the importance of the social determinants of health throughout a medical career, we will be graduating a cohort of clinically well-trained physicians who are better equipped to restore the health of underserved populations. 

References 1. Page D, Baranchuk A. The Flexner report: 100 years later. International Journal of Medical Education. 2010;1:74-75. doi:10.5116/ijme.4cb4.85c8. 2. Hlavinka E. Racial Bias in Flexner Report Permeates Medical Education Today. Medical News and Free CME Online. https://www.medpagetoday. com/publichealthpolicy/medicaleducation/87171. Published June 18, 2020. Accessed November 9, 2020. 3. Lewis JH, Lage OG, Grant BK, et al. [Full text] Addressing the Social Determinants of Health in Undergraduate Medical: AMEP. Advances in Medical Education and Practice. https://www.dovepress.com/ addressing-the-social-determinants-of-health-in-undergraduate-medical-peer-reviewed-fulltext-article-AMEP. Published May 22, 2020. Accessed November 5, 2020. 4. Moffett SE, Shahidi H, Sule H, Lamba S. Social Determinants of Health Curriculum Integrated Into a Core Emergency Medicine Clerkship. MedEdPORTAL. 2019;15(1). doi:10.15766/mep_2374-8265.10789. 5. Salhi BA, Tsai JW, Druck J, Ward‐Gaines J, White MH, Lopez BL. Toward Structural Competency in Emergency Medical Education. AEM Education and Training. 2019;4(S1). doi:10.1002/aet2.10416. 6. Porter S. Residency Curriculum Hits Mark on Social Determinants. https:// www.aafp.org/news/education-professional-development/20190322sdohre sidency.html. Published March 22, 2019. Accessed November 5, 2020. 7. Axelson DJ, Stull MJ, Coates WC. Social Determinants of Health: A Missing Link in Emergency Medicine Training. AEM Education and Training. 2017;2(1):66-68. doi:10.1002/aet2.10056.

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Featured podcasts: K is for Komfort: Ketamine for Pain Patient Callbacks Experiences for Women of Color in the Emergency Department Choose Compassion: How We Can Provide Better Care For Our Most Vulnerable Patients Easing the Transition to Attending This podcast series presents emergency medicine leaders speaking with residents and students to share their knowledge on a variety of topics. Don’t miss an episode - subscribe today! 46

COMMON SENSE JANUARY/FEBRUARY 2021

Ultrasound in the Emergency Department Navigating Your Career Path Post-Residency Crowding in Emergency Departments Myths, Bias, and Lies My Medical School Taught Me

AAEM/RSA EDITORS MESSAGE

How To Be a Great Senior Resident Alexandria Gregory, MD – AAEM/RSA Editor, Common Sense

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:

NOT EVERY LEARNER WILL RESPOND WELL TO THE SAME TEACHING TECHNIQUE.”

1. Encourages questions: 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. 2. Encourages independent decision-making, but with appropriate back-up: 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. 3. Meets people where they are: 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. 4. Recognizes their own weaknesses: 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. 5. Finds learning opportunities in spare time: 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. 6. Leads by example: 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. 7. Understands how their role is different than the attending’s: 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. 8. Sees giving procedures to junior residents as an opportunity, rather than a loss: 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. 9. Asks for feedback: 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. 10. Recognizes that interns are in an especially unique and challenging position during COVID-19: 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.  COMMON SENSE JANUARY/FEBRUARY 2021

MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

Learning Virtually Lauren Lamparter – President, AAEM/RSA Medical Student Council

As stay at home orders took place and group sizes were limited, learning became virtual. Medical school classes moved to the live-online format for lectures, small group discussions, case presentations, and skills labs. The first two years of medical school are taught mainly in lecture format, and already many students opt to listen to recorded versions from home. Therefore, moving lecture content online was not too drastic of a change for students. However, medical education is a largely hands-on experience, and we rely heavily on our senses of sight, touch, sound, and smell to discern a diagnosis. Can this be replicated in a virtual setting? What impact will this loss of in-person practical application and group collaboration have on future physicians?

In a post-COVID world, virtual learning may very well move to the forefront of the educational experience. It is therefore important that we attempt to understand the ways we can better prioritize learning and engagement while on screen, and research must be done to see how the practical side of medical education has been affected by the loss of in-person instruction. I believe we will continue to see a lasting impact of this sudden virtual reality on the medical field for many years to come. If virtual learning limits the provision of adequate medical skills, this will prove to be a great disservice for future patients. All in all, practical training, such as the physician residency, is key to solidify the established knowledge, whether undergraduate medical education is obtained virtually or in-person. 

IT IS THEREFORE IMPORTANT THAT WE ATTEMPT TO UNDERSTAND THE WAYS WE CAN BETTER PRIORITIZE LEARNING AND ENGAGEMENT WHILE ON SCREEN, AND RESEARCH MUST BE DONE TO SEE HOW THE PRACTICAL SIDE OF MEDICAL EDUCATION HAS BEEN AFFECTED BY THE LOSS OF INPERSON INSTRUCTION.” Medical students and residents have to learn to prioritize studying for prolonged periods of time, and there is proven data to show that technology can enhance engagement with medical school material.1 However, there is very limited data to convey the degree to which non-lecture material is learned virtually. One study looking at a virtual compared to in-person microbiology lab (from pre-COVID times) found that students preferred a combination of in-person and virtual experiences, with those fully virtual students expressing that they did not feel as prepared for the exam content.2 Another study performed a meta-analysis of the existing research for virtual compared to in-person medical education and found no significant difference in test scores after both methods of education; declaring that both virtual and in-person teaching methods are effective.3 This supports what we have known to be true, students can learn well from virtual lectures, but it again left us short on the hands-on application of said knowledge. Unfortunately, passing a multiple-choice exam does not ensure the student will become a skilled clinician.

COMMON SENSE JANUARY/FEBRUARY 2021

References 1. Preeti Sandhu & Maisie de Wolf (2020) The impact of COVID-19 on the undergraduate medical curriculum, Medical Education Online, 25:1, DOI: 10.1080/10872981.2020.1764740 2. Ross M. Brockman, John M. Taylor, Larry W. Segars, Veronica Selke & Tracey A. H. Taylor (2020) Student perceptions of online and in-person microbiology laboratory experiences in undergraduate medical education, Medical Education Online, 25:1, DOI: 10.1080/10872981.2019.1710324 3. Pei L, Wu H. Does online learning work better than offline learning in undergraduate medical education? A systematic review and meta-analysis. Med Educ Online. 2019 Dec;24(1):1666538. doi: 10.1080/10872981.2019.1666538. PMID: 31526248; PMCID: PMC6758693.

AAEM/RSA NEWS

OUR MEDICAL EXPERTISE AND ABILITY TO SPEAK TO THE PERSONAL, HUMAN ASPECT OF THESE ISSUES IS A RARE COMBINATION THAT MAKES OUR VOICES INCREDIBLY UNIQUE.”

Your Voice STILL Matters Gregory Jasani, MD

Amazingly, the 2020 Presidential election is behind us. Whether your preferred candidate won or not, many of us will likely be thankful that our news programs and television ads will no longer be consumed by the campaign. As the election fades from the public discourse, it may be tempting to disengage from discussions about issues facing this nation. We must not let this happen. As physicians, we must continue to be involved in these conversations. This election cast a spotlight on many of the consequential issues facing this nation: racial inequality, the pandemic response, and the future of the Supreme Court to name a few. The candidates staked out their positions on the issues, and many of us used our votes to signal our support of these views. Yet these issues will outlast this election. The election of one candidate or party over another will not bring sudden fixes to these issues. Crafting and implementing policy is a much more nuanced and lengthy process than making campaign speeches. As our leaders transition from campaigning to governing, we need to make our voices heard and contribute to actively shaping the policies. As emergency medicine physicians, we have an invaluable perspective to lend to these discussions. Every day, we interact with some of the most vulnerable members of society. We have seen the devastating effects of food and housing insecurity, untreated mental illness, addiction,

and even systemic racism on our patients. Many of our patients are not in a position to advocate for themselves – but we are. We can speak to their condition and, unfortunately, can bear witness to their suffering. Continuing to be engaged on these issues is one of the most important ways that we can advocate for our patients. There are many ways we can participate in these conversations. Obviously, working directly with elected officials on policy is one of the most direct methods. Officials may seek your input on certain policy directives, or ask for advice on crafting legislation. Similarly, many nonprofit and advocacy organizations may seek out your expertise as they make their pitches to officials. Working with elected officials and advocacy organizations is a great way to use your expertise to help shape policy. There are also many ways that you yourself can make your voice heard, even if you are not working with elected officials or a group. The COVID19 pandemic has caused many physicians to become actively engaged with various forms of media. Whether it’s television, radio, podcasts, or even writing op-eds, making your voice heard on a media platform is an excellent way to add your voice to a debate. Similarly, many politicians, even after the election, will hold town halls with their constituents to stay engaged. Going to these events to interact with your politicians is another way to contribute your expertise to a discussion of policy. The election may be over, but the issues it highlighted will persist for years, if not decades to come. Our medical expertise and ability to speak to the personal, human aspect of these issues is a rare combination that makes our voices incredibly unique. We can take an active role in shaping these issues. Our continued involvement on these topics at the local, state, and even federal level is one of the best ways we can advocate for our patients. 

AS OUR LEADERS TRANSITION FROM CAMPAIGNING TO GOVERNING, WE NEED TO MAKE OUR VOICES HEARD AND CONTRIBUTE TO ACTIVELY SHAPING THE POLICIES.”.

COMMON SENSE JANUARY/FEBRUARY 2021

AAEM/RSA COMMITTEE REPORT ADVOCACY

Surprise Emergencies Shouldn’t Have to Result in Surprise Bills Maryam Hockley, MD MPH and Kersti Bellardi

The Emergency Medical Treatment and Active Labor Act (EMTALA) became federal law in 1986. It was designed to guarantee access to life-saving medical care in emergencies regardless of a patient’s insurance status or ability to pay for such care.1 It is illegal under EMTALA for physicians to warn a patient that a particular hospital or physician group is out-of-network prior to providing care, as this is seen as an attempt to coerce patients into leaving without receiving appropriate care. EMTALA provides America’s medical safety net, but has never been funded by the federal government (even partially), resulting in an average of $140,000 per year in non-reimbursed or “charity” care being donated by every emergency physician in the country.1 Patients should not have to worry about hefty unexpected bills after an ED visit but many, even those visiting an in-network hospital, still receive a surprise bill after the fact. Here is a scenario to illustrate how this happens. One evening, Mr. Blud Claught’s wife called 911 after noticing that her husband’s speech was becoming incomprehensible. The left side of his face was drooping and he couldn’t hold up his left arm. The ambulance arrived shortly afterward and took him to the nearest ED. Once there, he was given tissue plasminogen activator (tPA) within two hours of symptom onset. Thankfully, he made a full recovery, but what Mr. and Mrs. Claught didn’t know was that, while the hospital was in-network, the emergency physician was out-of-network. Despite thinking they had done the right thing to avoid out of network charges this lovely couple was hit with extensive out-of-pocket expenses. A reasonable person might ask why did this happen? It is not always possible for a patient to know

COMMON SENSE JANUARY/FEBRUARY 2021

which hospitals and physician groups are in-network. Emergency physicians believe patients shouldn’t have to be concerned about that factor in a crisis, but thanks to the insurance industry the reality is much different. Many patients fear accessing care due to cost and don’t know how to find the lowest priced option. To make matters worse, many insurance companies often do not make current or accurate information available to patients regarding which physicians are in- or out-of-network. Additionally, depending on the nature of the emergency and which emergency department is closest, the patient may have no say in the matter.

fully cover emergency medical visits. This is unacceptable. Although insurers pretend to lobby for capping OON fees as a means of protecting patients, their real concern is lining their own pockets by enlarging their profit margins. It is important that we educate the public

 EMERGENCY PHYSICIANS BELIEVE PATIENTS SHOULDN’T HAVE TO

BE CONCERNED ABOUT THAT FACTOR IN A CRISIS, BUT THANKS TO THE INSURANCE INDUSTRY THE REALITY IS MUCH DIFFERENT.”

In a 2011 survey of 7,812 patients, 4% (250) of respondents reported needing involuntary care with an out-of-network (OON) physician. Involuntary care was defined as either (1) due to a medical emergency, (2) the physician’s OON status was unknown at the time of care, or (3) an attempt was made to find an innetwork physician in the hospital but none were available. Of those 250 patients who received involuntary OON care, 58% resulted in further inpatient care incurring additional costs for specialists and the hospitalization. Furthermore, 68% of these in-patients originated from a medical emergency and 31% reported that the OON status of their care was unknown at the time.2 These distinctions are key because, for many patients, even though premiums have skyrocketed in recent years, benefits rarely

and our legislators on protecting our patients’ and nation’s medical safety net rather than the insurance industry, which is already one of the richest and most powerful corporate groups in America. Surprise billing happens in two stages: 1. First, insurers use differential cost-sharing to push patients towards in-network rather than out-of-network hospitals and physicians,3 because in-network providers have agreed to deeply discounted fees and this drastically reduces the insurer’s costs. Under a typical PPO plan, an in-network facility will bill the patient 20% of the total cost while an out-of-network provider will bill the patient 40%, with the rest billed to

AAEM/RSA COMMITTEE REPORT ADVOCACY

the insurer. Patients with HMO plans may be required by the insurer to pay the entire cost of services at an out-of-network facility. 2. Next comes “balance billing,” when the patient receives a bill for the difference between what the insurance company paid and the total fee (the balance of the bill for all services rendered).3 To eliminate balance billing altogether, insurers should pay for OON emergency care at the usual and customary rate, as defined by a fair, accurate, independent database such as FAIR Health. Patients themselves should not have to pay more for OON care than innetwork care, especially in an emergency. An additional layer of complexity in the emergency department, as seen with Mr. Blud Claught, is the fact that many emergency physicians are not hospital employees, but are employed by local, independent, physician-owned medical groups or large, publicly traded staffing corporations. That means that even if the hospital is in-network, the emergency physician may not be (along with other specialists such as radiologists, for example). Because insurers know emergency physicians are bound by EMTALA, they have little incentive to negotiate in good faith and almost always offer less than the fair-market payment rates needed to staff EDs with board certified emergency physicians 24/7/365. Insurance companies have powerful incentives to keep physicians OON, because the narrower the network is, the more costs they can shift onto patients and the higher their profit margins will be. Emergency physicians want to be in-network because of lower overhead costs, less hassle, more rapid and reliable

 PATIENTS SHOULD NOT HAVE TO WORRY ABOUT HEFTY UNEXPECTED BILLS

AFTER AN ED VISIT BUT MANY, EVEN THOSE VISITING AN IN-NETWORK HOSPITAL, STILL RECEIVE A SURPRISE BILL AFTER THE FACT.”

payment, happier patients, and happier hospital administrators,4 but insurers must offer fair contract terms to make that possible. Surprise and balance billing are issues that have been at the forefront of the EM community’s advocacy efforts for years now. As emergency physicians, we need to be a big part of the affordability conversation. Not only are our patients in danger financially, as medical bills are listed as the number one cause for filing for bankruptcy in the U.S.,5 they are struggling to navigate a health care system that is stacked against them during some of the most terrifying and vulnerable times of their lives. As current and future emergency medicine physicians, we call for education and legislation that: 1. Encourages insurance companies to negotiate in good faith and offer fair compensation rates for being in-network. In specific practical terms, that means requiring insurers to pay out-of-network emergency physicians at no lower than the 80th percentile of the usual and customary fee as defined by the FAIR Health database. 2. Protects patients by capping out-of-pocket bills at the in-network rate (or eliminates out-of-pocket bills entirely for emergency care), as long as the insurer pays the outof-network emergency physician no less than the FAIR Health 80th percentile of the usual and customary fee.

3. Addresses the fact that smaller, physicianowned groups almost always prefer to be in-network while big, publicly traded staffing corporations are the ones that adopt staying out-of-network as a business strategy4. It’s time we reframe this conversation by holding large corporations accountable for covering the cost of patients’ emergency care from the first dollar.  References 1. Kane CK. Physician marketplace report – the impact of EMTALA on physician practices. The Center for Health Policy Research, American Medical Association; Feb 2003. 2. Kyanko, K.A., Curry, L.A., Busch, S.H. (2012). Out of Network Physicians: How Prevalent Are Involuntary Use and Cost Transparency? Health Services Research, 48(3),1154-1172. https://doi.org/10.1111/1475-6773.12007 3. Pollitz, K., Rae, M., Claxton, G., Cox, C., Levitt, L. (2020). An examination of surprise medical bills and proposals to protect consumers from them. Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/brief/ an-examination-of-surprise-medical-bills-andproposals-to-protect-consumers-from-them-3/ 4. A Resource for Emergency Physicians on Balance Billing, Out-of-Network Fees, and Surprise Bills. The Independent Practice Support Committee, American Academy of Emergency Medicine. 5. Shrime, M.G., Weinstein, M.C., Hammitt, J.K., Cohen, J.L., Salomon, J.A. (2018). Trading Bankruptcy for Health: A Discrete-Choice Experiment. Value in Health, 21(1),95-104. https://doi.org/10.1016/j.jval.2017.07.006

AAEM/RSA DIVERSITY & INCLUSION

FOR RESIDENCY APPLICATIONS

www.aaemrsa.org/get-involved/committees/diversity-inclusion

COMMON SENSE JANUARY/FEBRUARY 2021

AAEM/RSA RESIDENT JOURNAL REVIEW

Early Vasopressor Use in Septic Shock: What Do We Know? John Harringa, MD; Zachary Wynne, MD; Akilesh Honasoge, MD; and Samantha Yarmis, MD Editors: Kami M. Hu, MD FAAEM FACEP and Kelly Maurelus MD FAAEM

Clinical Questions 1. How do outcomes compare when vasopressors are administered earlier in the course of septic shock? 2. Are rates of adverse events such as acute kidney injury, new-onset arrhythmia, or pulmonary edema higher when vasopressors are administered earlier?

Introduction Sepsis is a complex disease state with multiple pathophysiological considerations. In particular, we know that hypotension in septic shock is due not only to hypovolemia in the setting of poor intake and insensible losses, but also profound vasoplegia related to widespread release of inflammatory mediators.1 While fluid administration alongside early antibiotics remains a mainstay of treatment in septic shock, as there is evidence that excess fluid is harmful,2-5 many clinicians have thus wondered if earlier administration of vasoactive medications may help to more comprehensively address the disease process. Several articles have explored this important question in recent years.

Permpikul C, Tongyoo S, Viarasilpa T, et al. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019;199(9):1097-1105. doi:10.1164/rccm.201806-1034OC A number of studies have explored the utility of early norepinephrine administration in septic shock, but most have been retrospective in nature. The CENSER investigators sought to address a paucity of prospective data regarding the efficacy of early norepinephrine administration in improving outcomes in septic shock by way of a single-center, randomized, double-blind placebo-controlled trial. Patients carrying a diagnosis of sepsis with hypotension were randomized to receive either norepinephrine or placebo in addition to standard care. Adults aged 18 or older presenting to the ED with a mean arterial pressure (MAP) <65 and infection as the suspected cause were eligible for enrollment, while those with septic shock for ≥1 hour prior to randomization, those with CVA, ACS, acute pulmonary edema, status asthmaticus, active arrythmias, active GI hemorrhage, pregnancy, seizure, drug overdose, burn injury, trauma, requirement of immediate surgery, or advanced-stage cancer were excluded. Both drug (norepinephrine in 5% dextrose) and placebo (5% dextrose) were administered at a fixed rate of 0.05 mcg/kg/min for 24 hours. If the hemodynamic goal of MAP ≥65 mmHg was not met after a 30 mL/ kg fluid bolus and study drug infusion, open-label vasopressors were permitted. Overall, 456 hypotensive patients were screened, and 320

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patients met inclusion criteria and were randomized. Ten patients revoked consent at a later time (seven and three in the study and control groups, respectively). The intention-to-treat principle was used in final analysis, and outcomes were assessed prospectively. Shock control was defined as MAP ≥65 mmHg with urine flow ≥0.5 ml/kg/hr for two consecutive hours or serum lactate decreased by ≥10% from baseline within 6 hours. Randomization was effective, with well-matched arms in terms of demographics and disease severity. There was no difference between groups in time from diagnosis to study intervention, nor in time to open label-NE use. With respect to the primary outcome, shock control was significantly improved in the early NE group (76.1 vs 48.4%, p<0.001) with a shorter median time to MAP goal (3:30 vs 4:45h:m, p<0.001). Mortality at 28 days trended towards a decrease in the intervention group but did not meet statistical significance (15.5% vs 21.9%, p=0.15). Open label NE was used in a higher proportion of control-group patients (80% vs 67.7%). Total volume of IV fluids administered and ICU admission rates were similar between groups, with subgroup analyses revealing significantly decreased rates of both cardiogenic pulmonary edema and newonset arrythmias in the early-NE group. Interestingly, though patients in the early NE group received higher median NE dosage during hours 2-5 after diagnosis, the overall NE dosage did not differ between groups at 6 hours. This study found that earlier administration of NE was associated with an increase in and more rapid achievement of shock control, but not 28-day mortality. The authors posited that the decrease in rate of cardiac arrhythmias may be related to improved cardiac output with decreased oxygen demand secondary to shorter shock duration. Despite these encouraging results the authors advised caution, noting that additional research is important prior to at-large adoption of this practice and that safety of early NE administration relative to lower incidence of congestive heart failure and new-onset arrhythmia awaits confirmation through future research. Study limitations include the limited generalizability of a single ED study population in Thailand, inadequate power to detect a mortality difference, and the inability to mask the effect of NE (i.e. rapid blood pressure increases in the experimental arm could have clued in physicians to the treatment arm). Of note, up to 20% of control-arm patients had similar increases. It remains that the results of this trial are encouraging with respect to early NE administration and warrant further prospective investigation.

Bai X, Yu W, Ji W, et al. Early versus delayed administration of norepinephrine in patients with septic shock. Crit Care Lond Engl. 2014;18(5):532.

AAEM/RSA RESIDENT JOURNAL REVIEW

Mortality and other negative outcomes in septic shock still remain relatively high despite the engraining of early fluid resuscitation and antimicrobial delivery as part of standard clinical practice. Surviving Sepsis Campaign guidelines focus on vasopressor administration only for refractory hypotension after fluid resuscitation.6 As timing to vasopressor initiation can be variable in clinical practice, this study looked to determine the frequency of delayed norepinephrine initiation and its effect on mortality in septic shock patients. This retrospective cohort study examined the outcomes of adult patients with septic shock admitted to two surgical ICUs in a Chinese tertiary care hospital. Surviving Sepsis Campaign guidelines were followed for initiation of fluid resuscitation, antimicrobials, and vasopressors. The primary outcome was 28-day mortality. Analysis was performed comparing early (receiving NE within two hours from onset of septic shock) and late (receiving NE > two hours after septic shock onset) NE groups as well as treating initial NE administration as a continuous variable for logistic regression. Overall, 241 patients with septic shock were identified and 213 were included in the study. The study population had an overall mortality of 37.6% at 28 days. The average time to initial norepinephrine administration for all patients was 3.1 +/- 2.5 hours. In comparing septic shock survivors to non-survivors, groups were well matched in demographics. The non-survivor group had higher average initial lactate and APACHE II scores while the survivor group had shorter time to initial NE and antimicrobial therapy administration, higher volumes of IV fluids administered within 6 hours but less at 24 hours, and less overall norepinephrine at 24 hours. The likelihood of death at 28 days was significantly higher in the late norepinephrine group compared to the early norepinephrine group (OR 1.86, 95% CI 1.04 – 3.34; p=0.035), with 29.1% versus 43.3% mortality in the early versus late NE groups, respectively. Each hour of delay was associated with a 20.4% increased probability of death (OR = 1.20, 95% CI 1.07 – 1.35; p=0.002). The early norepinephrine group received less intravenous fluids (6.2 ± 0.6 L vs. 6.9 ± 0.7 L, p <0.001) and norepinephrine over 24 hours (29.4 ± 9.7 mg vs. 32.8 ± 10.0 mg, p=0.013). The early norepinephrine group also had higher mean arterial pressures and lower lactates at hours two, four, six, and eight despite a higher initial lactate than compared to the late norepinephrine group (p<0.05). There was no significant difference in ICU days, time to antimicrobial initiation, or frequency of antibiotics or steroids. Independent risk factors for 28-day mortality in septic shock patients analyzed with multivariate regression included time to norepinephrine (OR 1.392, 95% CI 1.138 – 1.702; p=0.003), time to antimicrobial initiation (OR 1.330, 95% CI 1.067 – 1.659; p=0.011), serum lactate at onset (OR 1.770, 95% CI 1.174 – 2.537; p=0.005), and APACHE II score (OR 1.243, 95% CI 1.096 – 1.409; p<0.001). This study demonstrated a relationship between time to initial norepinephrine administration and mortality, with a mortality increase of 5.3% for every hour delay in NE administration. As this study was a

retrospective analysis, causation between norepinephrine timing and mortality could not be established. Additionally, this study focused on septic shock in surgical ICUs at one institution and therefore may not be generalizable to other ICU settings and would require further multiinstitutional analysis. Overall, early administration of norepinephrine was associated with decreased mortality in surgical ICU patients with septic shock, similar in effect to early initiation of antimicrobials.

Elbouhy MA, Soliman M, Gaber A, et al. Early Use of Norepinephrine Improves Survival in Septic Shock: Earlier than Early. Arch Med Res. 2019;50(6):325-32. doi:10.1016/j. arcmed.2019.10.003 Elbouhy et al. performed a single-center, randomized, controlled trial comparing immediate and delayed norepinephrine administration to ED patients with septic shock. The study’s primary outcome was in-hospital survival, with secondary outcomes that included time to MAP ≥65 mmHg, lactate clearance at 6 hours, and volume of fluid administered. Septic shock was defined as a positive quick Sepsis Related Organ Failure Assessment (qSOFA) score with hypotension and a lactate of >2 in the setting of suspected infection. Major exclusion criteria included an ICU length of stay less than 24 hours due to death or transfer, uncontrolled hemorrhage, left ventricular dysfunction, or age <18-years-old. The treatment group received simultaneous IV crystalloid bolus (target of 30 mL/kg) with norepinephrine started at 5 mcg/min through a peripheral IV. The control group received norepinephrine only after initial 30 mL/kg fluid bolus if MAP remained <65 mmHg. Of the initially randomized patients, 18 were excluded, 3 from the treatment group and 15 from the control group, leaving 101 patients for inclusion in the analysis. The groups were well-matched with respect to demographics and baseline clinical characteristics including initial MAP, heart rate, lactate levels and APACHE II scores. The average patient age was 63 years and 57.4% of patients were male. Chest infections were the overwhelmingly predominant culprit in the study population at 55.4%, with abdominal infections coming in second at 17.8%. The early norepinephrine group had an improved survival rate compared to the control group (71.9% vs 45.5%, p=0.007) with a shorter time to target MAP (2 vs 3 hours, p=0.003). The treatment group also had a lower repeat lactate six hours later (2 vs 2.9 mmol/L, p=0.037), with less fluid volume administered (25 vs 32.5 mL/kg, p=0.000). There was a trend towards decreased acute kidney injury (AKI) in the early norepinephrine group that did not reach statistical significance (42% vs 52%, p=0.3). Lower lactate levels, faster lactate clearance, and absence of AKI were each associated with survival regardless of treatment group. While these results are striking, the single-center nature of the study and the exclusion of patients with LV dysfunction may limit their generalizability. Possible influence due to lack of treatment team blinding must also be considered. A major limitation not addressed by the investigators was the

>> COMMON SENSE JANUARY/FEBRUARY 2021

AAEM/RSA RESIDENT JOURNAL REVIEW

exclusion of patients who died within 24 hours of ICU admission, which may limit ability to draw conclusions about early norepinephrine use in potentially the sickest patients and could certainly affect the primary outcome of in-hospital survival. Although a small trial, it is a randomized controlled trial providing further evidence that early use of vasopressors is associated with improved mortality and earlier successful resuscitation as indicated by laboratory and clinical markers, with less IV fluid required.

Colon Hidalgo D, Patel J, Masic D, et al. Delayed vasopressor initiation is associated with increased mortality in patients with septic shock. J Crit Care. 2020;55:145-148. doi:10.1016/j. jcrc.2019.11.004 This study was a retrospective cohort study conducted at a single academic medical center. The included population was patients admitted between January and July of 2017 with septic shock. The authors initially identified patients with shock by identifying patients for whom vasopressors were ordered; they subsequently reviewed the charts of those patients to identify adult patients who met criteria for septic shock per the Sepsis-3 definition.7 In total, 119 patients were included. Exclusion criteria included shock not due to sepsis, pregnancy, a set MAP goal >70 mm Hg, outside hospital transfers, vasopressor initiation in the OR, and planned withdrawal of care or death within 72 hours of vasopressor initiation. The variable of interest was timing from initial hypotension (defined as first MAP < 65 mm Hg) to initiation of vasopressors; patients were divided into those who received vasopressors in ≤6 hours versus > 6 hours. The primary outcome was 30-day mortality. Secondary outcomes were cumulative vasopressor dosing at 12, 24, and 72 hours, vasopressor-free hours at 72 hours, time to MAP ≥ 65 mm Hg, and ICU and hospital length of stay (LOS). Overall, 76 patients (63.9%) received vasopressors within 6 hours of hypotension onset. There was a higher 30-day mortality in patients receiving vasopressors after 6 hours than those who received them earlier (51.1 vs 25%, p<0.01). In subsequent multivariable analysis, the only other reported factor independently associated with increased 30-day mortality was the presence of cirrhosis. In terms of the secondary outcomes, patients who received early vasopressors had significantly more vasopressor-free hours at 72 hours (34.5 vs 13.1 h, p=0.03) and achieved a MAP >65 mmHg faster (1.5 vs 3 hours, p<0.01). Cumulative vasopressor dosing at 12, 24, and 72 hours did not differ significantly between the two groups, and there was no difference in ICU or hospital LOS. There were several limitations of this study. Beyond the usual limitations of single-center and retrospective studies, one major limitation is again the exclusion of patients who died (in this study within 72 hours rather than 24). The rationale for excluding these patients was provided as “an attempt to determine that mortality [was] due to vasopressor delay rather than the severity of sepsis.” However, this time cutoff is arbitrary, and the authors do not provide any evidence that it would achieve their stated aim. In addition, this clearly led to the exclusion of patients with more severe sepsis, and outcomes data for this group could be very valuable

COMMON SENSE JANUARY/FEBRUARY 2021

in determining appropriate timing for vasopressor initiation. An additional limitation is the division of patients into binary groups, i.e. those who received vasopressors within 6 hours and those who received them after 6 hours. Using time as a continuous variable could have potentially provided insight into an inflection point, if one exists, at which time mortality increases if vasopressors have not been started. It is worth noting, however, that a larger cohort would likely be needed to provide adequate power for such a study. Limitations aside, this study found a significantly higher 30-day mortality in patients who received vasopressors more than 6 hours after onset of hypotension. Further research is needed to elucidate the true optimal timing for initiation of vasopressors, but this study provides additional support that early vasopressor administration is beneficial.

Conclusions Multiple studies have demonstrated improved outcomes when vasopressors are administered earlier in the course of septic shock, including lactate clearance, time to MAP goal, decreased overall fluid volume administration, and in some cases, mortality. The studies reviewed included between 101 and 320 patients and by and large utilized rigorous methods, though the choice to exclude patients with more severe illness in mortality assessments is of unclear significance. The cutoff between “early” and “late” for most studies fell anywhere between 90 minutes and six hours. It is unclear if there is an inflection point on the care timeline before which vasopressors must be administered to derive the observed benefits. More prospective research is needed to clarify the role and benefits of early vasopressors, especially as compared to liberal fluid administration. The authors look forward to the results of the CLOVERS trial, which tries to address this question. One barrier to early administration of vasopressors is the notion that they must always be delivered through a central line. There has been disagreement in the literature as to the safety of peripheral vasopressor administration.8,9the need for a CVC for the management of septic shock has been questioned, and the risk of extravasation and incidence of severe injury when vasopressors are given via a peripheral venous line (PVL Suffice to say that additional research would be welcomed and this would make an interesting topic for a future review. When septic shock is recognized, in addition to IV fluids and antibiotics, vasopressors should be an early consideration.

Answers 1. Outcomes are improved when vasopressors are administered earlier in the course of septic shock, including mortality, lactate clearance, time to MAP goal, and decreased overall fluid volume administration. 2. Rates of AKI were similar between early and delayed administration groups. Pulmonary edema and new-onset arrhythmias were decreased in the study that reported these outcomes, which may be related to decreased fluid volumes administered and improved cardiac output. 

AAEM/RSA RESIDENT JOURNAL REVIEW

References 1. Burgdorff AM, Bucher M, Schumann J. Vasoplegia in patients with sepsis and septic shock: pathways and mechanisms. J Int Med Res. 2018;46(4):1303-10. 2. Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care. 2008;12(3):R74. 3. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-95. 4. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39(2):259-65. 5. van Mourik N, Geerts BF, Binnekade JM, et al. A Higher Fluid Balance in the Days After Septic Shock Reversal Is Associated With Increased Mortality: An Observational Cohort Study. Crit Care Explor. 2020;2(10):e0219.

6. Levy M, Evans L, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 Update, Crit Care Med. 2018;46(6):997-1000. 7. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. 8. Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med. 2019;34(1):26-33. 9. Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653.e9-653.e17.

AAEM POSITION STATEMENTS

AAEM COVID-19 RESPONSE

AAEM COVID-19 Resources Page In addition to the above statements, AAEM recognizes the need for resources and supplies, and it is our intent to assist in any way we can. We hope that the following list of resources can assist you in your work. You know better than others that this is a fluid situation, changing every few hours. We will attempt to continue to update our resources both here and on social media as the situation changes.

• AAEM Statement on the Death of Dr. Breen (5/1/2020) • AAEM Position Statement on Interruptions in the Emergency Department (4/19/2020) • AAEM Position Statement on the Firing of Dr. Ming Lin by TeamHealth and PeaceHealth St. Joseph Medical Center (3/28/2020) • AAEM Position Statement on Ensuring that Frontline Personnel Can Provide for their Families (3/23/2020) • AAEM Position Statement Advocating for Immunity From Malpractice Litigation During the COVID-19 Pandemic (3/23/2020) • AAEM Position Statement on Use of SelfSupplied PPE (3/23/2020) • AAEM Position Statement on Protections for Emergency Medicine Physicians during COVID19 (3/20/2020) To read each statement, visit: www.aaem.org/ resources/statements/position

JOINT STATEMENTS • Joint Statement on Excuses from Mask Compliance (7/28/2020) • Consensus Statement on the 2020-2021 Residency Application Process for US Medical Students Planning Careers in Emergency Medicine in the Main Residency Match (5/27/2020) • COMMB Joint Policy Statement on Pediatric Care in the Emergency Department (5/4/2020) • AAEM Statement on the Death of Dr. Breen (5/1/2020)

• AAEM-ACEP Joint Statement on Physician Misinformation (4/27/2020) • AAEM Signs on to Joint Letter to Congress Urging further Protections for Healthcare Workers during COVID-19 (4/15/2020) • AAEM Signs on to Joint Letter to HHS: Emergency Funding for Physicians through the CARES Act (PDF) (4/7/2020) • Solidarity of Purpose to Confront COVID-19 (PDF) (3/23/2020) To read each statement, visit: www.aaem.org/ resources/statements/joint-endorsed

LETTERS SENT • Joint Letter to Congress regarding Surprise Medical Billing in COVID-19 Relief Package (7/29/2020) • Joint Letter to CMS to Sunset Waivers When PHE Concludes (7/22/2020) • Joint Letter to Veterans Health Administration on CRNA Oversight (6/24/2020) • Joint Letter Urging Congress to Extend Eligibility for the PPP Loan Program (6/17/2020) • Joint Letter Encouraging the Passage of the Mainstreaming Addiction Treatment Act (6/1/2020) AAEM Signs on to AMA Letter: Coronavirus Provider Protection Act (6/9/2020) • Letter to All 50 Governors Calling for Immunity from Malpractice during COVID-19 • Letter to President Donald J. Trump Calling for Immunity from Malpractice during COVID-19 • Letter to Congress for Further Financial Support during COVID-19 To read each letter, visit: www.aaem.org/current-news

Access AAEM’s COVID-19 Resources webpage: www.aaem.org/current-news/covid-19-resources COMMON SENSE JANUARY/FEBRUARY 2021

Exciting opportunities at our growing organization • Adult and Pediatric Emergency Medicine Faculty positions • Medical Director • Vice Chair, Clinical Operations • Vice Chair, Research • Medical Student Clerkship Director

Penn State Health, Hershey PA, is expanding our health system. We offer multiple new positions for exceptional physicians eager to join our dynamic team of EM and PEM faculty treating patients at the only Level I Adult and Level I Pediatrics Trauma Center in Central Pennsylvania. What We’re Offering: • Salaries commensurate with qualifications • Sign-on Bonus • Relocation Assistance • Retirement options, Penn State University Tuition Discount, and so much more! What We’re Seeking: • Emergency Medicine trained physicians with additional training in any of the following: Toxicology, Ultrasound, Geriatric Medicine, Pediatric Emergency Medicine, Research • Completion of an accredited Residency Program. • BE/BC by ABEM or ABOEM

What the Area Offers: We welcome you to a community that emulates the values Milton Hershey instilled in a town that holds his name. Located in a safe family-friendly setting, Hershey, PA, our local neighborhoods boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Known as the home of the Hershey chocolate bar, Hershey’s community is rich in history and offers an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC.

FOR MORE INFORMATION PLEASE CONTACT:

Heather Peffley, PHR FASPR at: hpeffley@pennstatehealth.psu.edu 56

Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

COMMON SENSE JANUARY/FEBRUARY 2021

November Board of Directors Meeting Summary

The members of the AAEM Board of Directors met in New Orleans, LA on November 12, 2020 to discuss current and future activities. The members of the Board of Directors appreciate and value the work of AAEM committee, section, interest groups, and chapter division members and chairs as they strive toward the AAEM mission and to be the specialty

2021 Elected Board of Directors

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

Approvals

Miscellaneous

President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM provided further insights on her presidential activities, interviews, and other updates. Treasurer Robert Frolichstein, MD FAAEM reported on AAEM and AAEM subsidiaries financial performance and presented the 2021 Budget for approval. AAEM Lobbyist Matt Hoekstra provided a federal update.

A number of approvals took place during the meeting, including the appointment of the new AAEM-LG Board of Directors, updates to the AAEM Bylaws, and an updated clinical practice statement on Angioedema. The new Ethics Committee position statement was also approved. Several new podcast initiatives were presented and approved as well.

There were several board task forces formed to review current policies and ways to engage AAEM members in board activities. AAEM will be working with a marketing and communications consultant to assist in branding of AAEM and engagement of members.

What

When

Where

The next Board of Directors meeting

February 21, 2021

Miami, Florida

COMMON SENSE JANUARY/FEBRUARY 2021

COMMONSENSE

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

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

27th Annual Scientific Assembly

SAVE THE DATE June 20-24, 2021 Meet Me in St. Louis!

AAEM21 St. Louis, MO

January/February 2021 Common Sense

Articles inside

Resident Journal Review: Early Vasopressor Use in Septic Shock: What Do We Know?

AAEM/RSA Editor: How To Be a Great Senior Resident

AAEM/RSA President’s Message: Addressing the Social and Structural Determinants of Health in Medical School and Residency Education

AAEM/RSA Advocacy: Surprise Emergencies Shouldn’t Have to Result in Surprise Bills

Board of Directors Meeting Summary: November

Your Voice STILL Matters

Young Physicians: VotER: Healthy Democracies Make Healthy Communities

Young Physicians: Biases in Emergency Medicine

Young Physicians: Finding Escapism and Mentorship in a Book Club

Special Articles

Operations Management: The Role of Ridesharing in Emergency Medicine

Who Will Be Their Advocate? A Commentary on Facing Illness Alone

Emergency Ultrasound: Why an Ultrasound Fellowship Might Be Right for You

Critical Care Medicine: Intubating Asthma

Ethics: Questions

SBO: Seize Back Onus – Focus on POCUS

Wellness: Peer Coaching: A Strategy for Development and Wellbeing

AAEM21 Subcommittee: AAEM21 Meet Me in St. Louis

Updates and Announcements

PAC Donations

Letter to the Editor: Letter in response to the September/October 2020 “Dollars and Sense” article titled: Disability and Life…Another Option

AAEM Position Statements

Foundation Donations

From the Editor’s Desk: A Test, a Shot, and a Prescription

Regular Features