July/August 2020 Common Sense

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 27, ISSUE 4 JULY/AUGUST 2020

AAEM Tales of COVID-19

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AEM sent a call out for stories March-May of 2020 so that you would have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you to all who submitted stories to share with other members so we can get through this crisis together. Please note that these stories were submitted months in advance of print of this issue. We acknowledge that much has and will continue to change with how we are dealing with COVID-19. Stories were up-to-date at the time they were submitted.

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President’s Message:

Doing the Right Thing

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From the Editor’s Desk:

Making a Difference

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AAEM/RSA President's Message:

Lend a Helping Hand.

Let’s Make EM More Inclusive.

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Young Physicians Section:

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YPS Photo Collage of Life during COVID-19

AAEM/RSA Editor:

Managing Stress during a Pandemic

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Table of Contents

COMMONSENSE

Regular Features 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 FAAEM 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 Adriana Coleska, 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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COMMON SENSE JULY/AUGUST 2020

President’s Message: Doing the Right Thing..................................................................................................................3 AAEM Member Bulletin..................................................................................................................................................4 From the Editor’s Desk: Making a Difference.................................................................................................................6 Dollars & Sense: Disability and Life…Another Option!...................................................................................................8 Foundation Donations..................................................................................................................................................10 PAC Donations.............................................................................................................................................................10 LEAD-EM Donations....................................................................................................................................................11 Upcoming Conferences ...............................................................................................................................................13 AAEM/RSA President’s Message: Lend a Helping Hand. Let’s Make EM More Inclusive............................................20 Resident Journal Review: Available Evidence Regarding Targeted Temperature Management (TTM)........................21 Medical Student Council President’s Message: 2020-2021 AAEM/RSA Medical Student Council Introduction...........25 AAEM/RSA Editor: Managing Stress during a Pandemic ............................................................................................41 Job Bank......................................................................................................................................................................62

Special Articles Wellness: Interruptions in the Emergency Department and the Myth of Multitasking...................................................15 Critical Care Medicine Section: What Is the Best Sedative Agent for NIV Intolerance?................................................17

AAEM Tales of COVID-19 Feature From the Editor’s Desk: The Moral Dilemma of COVID-19..........................................................................................28 Decision making: Combining the Emotion and Reason................................................................................................30 Operations Management: Crisis Management.............................................................................................................32 Wellness: Promoting Social Connection during COVID-19...........................................................................................34 Palliative Care: COVID-19 Pandemic Draws Palliative Care into the ED......................................................................36 Emergency Ultrasound Section: Ultrasound Education in the COVID-19 Era..............................................................37 Women in EM Section: Embracing Femininity in a Pandemic.......................................................................................38 Young Physicians Section: YPS Photo Collage of Life during COVID-19.....................................................................40 AAEM/RSA Wellness: A Medical Student/Paramedic’s Perspective on COVID-19.......................................................42 JAFERDs Can Do It.....................................................................................................................................................44 The Sun Is Rising.........................................................................................................................................................44 Is There Opportunity Amid a Pandemic?.....................................................................................................................45 The Role of Quarantined Medical Students.................................................................................................................46 One Month...................................................................................................................................................................47 Class of 2020: Match Day during a Pandemic.............................................................................................................50 The COVID-19 Experience Outside of the Epicenters.................................................................................................51 Dehumanized...............................................................................................................................................................54 COVID-19 Has Made Emergency Physicians the Default Leaders of Medicine...........................................................55 I’m Not Really a Hero...................................................................................................................................................56 The Reasoned Response to the PPE Debacle.............................................................................................................57 My Life was Turned Upside Down by a COVID-19 Antibody Test.................................................................................58 Should the 12-Hour Shift be of Historical Interest Only?..............................................................................................60 The Black Death..........................................................................................................................................................61 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) Affiliate Member: $365 (Non-voting status; must have been, but is no longer ABEM or AOBEM certified in 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-0320-464 AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

Doing the Right Thing

AAEM NEWS PRESIDENT’S MESSAGE

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM

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e are living in strange and complicated times. Our planet is home to 195 nations, 4,200 different religions and hundreds of political parties, all of which embrace different ethics, concepts of God, and philosophies of good and evil. What is common to all national constitutions, religions, and philosophies is the concept of loving our fellow humans as we love ourselves and treating others as we want to be treated. Everyone

that constant level of vigilance in order to stay alive in an environment in which YOU are a disposable commodity. Stop. Think about that. Now. As physicians, we are people with tremendous power. We are more educated, more financially secure, more respected, and more skilled than most other people in the world are. We have a platform, and we have the power to influence others. Power is the privilege to do the right thing.

Power is the privilege of giving a voice to those who do not have the education, the financial security, and the respect of society: the home-

THE ACADEMY HAS ITS ORIGINS IN DOING THE RIGHT THING, EVEN WHEN THE RIGHT THING IS THE HARDER THING TO DO, EVEN WHEN THE RIGHT THING IS THE LESS POPULAR THING TO DO. agrees that this is “the right thing to do.” Unfortunately, doing the right thing is very often not the easy thing. The easy thing is to say, “My way is the right way,” “One person can’t make a difference,” or “This is just the way things are.” Yet all of these easy answers have proven false repeatedly throughout history. “My way is the right way” leads to events like the Inquisition, the Holocaust, and the massacre of the Yazidi people. “One person can’t make a difference” denies the power of Mohandas Gandhi, Nelson Mandela and Cesar Chavez. “This is just the way things are” renders us impotent and helpless and, as Rev. Martin Niemoller famously said, if we stand for no one, no one will be left to stand for us.

We need to ask ourselves if the way that we are treating others is the way we want to be treated. Would I want my employer to tell me that I will no longer be on the schedule, have no right to know why, have no right to appeal the decision, and cannot seek other employment within 50 miles of the hospital?

Corporate medical groups do this to doctors every day when they demand that we waive our due process rights. Would I, as a heterosexual female, want to be told that I must identify myself as a male, answer to the name of “Ralph,” and use the men’s toilets in public buildings? This is what is done to our transgender patients in hospitals all over the world every day. Would I, as I prepare to go out jogging, want to need to know that there is a reasonable likelihood that I could be shot dead because I look like someone who might have done a robbery recently, or as I am out in my car that I could be told to lay on the ground while a police officer sworn to protect and defend me, presses his knee down on my neck until I am dead? This is the awareness that every Black man in America lives with, wakes up to, contemplates every time he leaves his home. I would ask each of us who is not that Black man to think about what it means to need to maintain

less, those who suffer from mental illness and substance addiction, the undocumented. As emergency physicians, we do this every day. As the American Academy of Emergency Medicine, we were founded on these principles. Our

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Would I want my employer to tell me that I will no longer be on the schedule, have no right to know why, have no right to appeal the decision, and cannot seek other employment within 50 miles of the hospital?

COMMON SENSE JULY/AUGUST 2020

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AAEM NEWS PRESIDENT’S MESSAGE

Unfortunately, doing the right thing is very often not the easy thing.

founding members broke away from a larger organization because they believed in the value of board certification, residency training, and the integrity of the specialty as not just a job that any doctor could do. The Academy has its origins in doing the right thing, even when the right thing is the harder thing to do, even when the right thing is the less popular thing to do. The Academy stands firmly on our principles because we believe that, as my grandfather told me, “Might does not make right.

Right makes right.” For every Goliath, a David stands firm and prevails.

Sometimes right does not prevail with the speed of David’s slingshot.

Sometimes, it’s more like the tortoise and the hare. We worked for decades to get a bill introduced in Congress to protect the due process rights of emergency physicians. Finally, due to our support and perseverance, Congressmen Roger Marshall, MD and Raul Ruiz, MD introduced H.R. 910, which will ensure due process rights for ER physicians that are employed by third-party contractors or physician staffing companies. We have worked for decades to protect the jobs of physicians who stand up for patient safety. We have worked to support the right of the physician

and not a lay corporation to make the decisions that impact patient care and affect patient outcomes. We have multiple cases in which we have succeeded through advocacy, advisement, amicus briefs, providing expert testimony, or assisting with legal fees, and we will persevere until every emergency physician can practice in a fair workplace.

We have worked to decrease the stigma of mental illness, to foster physician wellness, to insure that every patient has access to the care of a specialist in EM. We have created evidence-based best practice guidelines, championed women in emergency medicine, actively encouraged diversity, supported the right of patients to be treated by a physician led team in the ED. Most recently, we have joined with the Society for Academic Emergency Medicine to stand against the debilitating and fatal disease that is racism.

We do the right thing, even when it is the harder thing to do, even when it is the unpopular thing to do. It is really quite elegantly simple: We treat other people the way we want to be treated.

This is what the Academy has always done. This is what we will always do.

AAEM Antitrust Compliance Plan: As part of AAEM’s antitrust compliance plan, we invite all readers of Common Sense to report any AAEM publication or activity which may restrain trade or limit competition. You may confidentially file a report at info@aaem.org or by calling 800-884-AAEM.

AAEM NEWS

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 Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Dr. Moreno received the Section 2020 NMA Emergency Medicine Excellence in Service Award.

Haig Aintablian, MD ABEM appointed Dr. Aintablian to the Resident Ambassador Panel for its inaugural 2020-2022 term.

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COMMON SENSE JULY/AUGUST 2020

Terrence M. Mulligan, DO MPH FAAEM Dr. Mulligan was elected Vice President of IFEM.

Judith E. Tintinalli, MD MS FAAEM Dr. Tintinalli was awarded the Order of the IFEM (FIFEM).

Meet Your 2020-2021 AAEM Board of Directors AAEM is proud to welcome the newly elected board!

PRESIDENT

PRESIDENT-ELECT

SECRETARY-TREASURER

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM

Jonathan S. Jones, MD FAAEM

Robert Frolichstein, MD FAAEM

IMMEDIATE PAST PRESIDENT

PAST PRESIDENTS COUNCIL REPRESENTATIVE

AT-LARGE DIRECTOR

David A. Farcy, MD FAAEM FCCM

Joseph Wood, MD JD FAAEM

L.E. Gomez, MD MBA FAAEM

AT-LARGE DIRECTOR

AT-LARGE DIRECTOR

AT-LARGE DIRECTOR

Bobby Kapur, MD MPH CPE FAAEM

Bruce Lo, MD MBA FAAEM RDMS

Evie Marcolini, MD FAAEM FCCM

AT-LARGE DIRECTOR

AT-LARGE DIRECTOR

AT-LARGE DIRECTOR

Sergey M. Motov, MD FAAEM

Terrence Mulligan, DO MPH FAAEM

Vicki Norton, MD FAAEM

AT-LARGE DIRECTOR

YPS DIRECTOR

AAEM/RSA PRESIDENT

Carol Pak-Teng, MD FAAEM

Phillip Dixon, MD MPH

Haig Aintablian, MD

EDITOR, JEM EX-OFFICIO BOARD MEMBER

EDITOR, COMMON SENSE

Stephen R. Hayden, MD FAAEM

Andy Mayer, MD FAAEM

To contact the board of directors, email info@aaem.org.

COMMON SENSE JULY/AUGUST 2020

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AAEM NEWS FROM THE EDITOR’S DESK

This is why I want you to consider the idea of “Making a Difference” and that this phrase could have different meanings.

Making a Difference Andy Mayer, MD FAAEM — Editor, Common Sense

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et’s think back to when you opened that envelope and learned that you had been accepted iinto medical school. You dreamed of saving lives and helping people and making your mother proud. No matter where any of us ended up in our medical career, I think all of us at some point were idealistic and thought that we could “make a difference.” The typical path to becoming board certified in emergency medicine begins in grade school and progressed through a seemingly endless stream of pyramid schemes of advancement. At each step, you could look back at people left behind and feel relieved that you had reached that next ledge on the climb up the tall mountain which took us to the age of 30 or beyond to reach. Whether just finishing residency, or a grizzled old veteran, you can remember walking out onto the floor of your first shift as an actual emergency physician with the dueling feelings of sheer terror and incredible pride of having made it to the top of the mountain. You were finally the person who on your own could save lives, help people, and make the world a better place.

The first cracks I usually see are often expressed with negative comments about the quality and integrity of the patients during their shift.

Then of course, you picked up your first chart who was a patient with metastatic fibromyalgia with a completely positive review of symptoms and already threatening to complain if you do not admit them for their well-deserved dilaudid coma.

The shock and horror that the patients are not easier to manage when you are an attending and that you alone have to decide who stays and who goes hits you right in the face. I have seen this reaction many times over the years and have noticed a pattern in what I think of as the battle between idealism and acceptance and it often soon emerges. Most new attendings seem to do well when first out. They are excited to finally be getting a big paycheck and work more reasonable hours. There is occasionally the real save when a patient fibrillates in front of you and are shocked once back to a normal neurologically intact middle aged father with three teenagers. Who among us does not go home feeling better that night knowing that we actually did save a life just like you had always thought would happen numerous times a day. Your family might have also thought that your career would be like their favorite medical drama on television with an endless string of incredible lifesaving events on a daily basis. Their expectations of what your career would mean can also lead to this conflicted sense of our careers and what we actually do during our average work day. The shifts seem longer and the problem patients start to outweigh the saves. These new attending emergency physicians certainly don’t want to appear to be weak, slow, or lazy. They use their lifelong endurance skills which have been hard won and which helped them get there in the first place to mask the often-bitter turmoil inside their heads.

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The first cracks I usually see are often expressed with negative comments about the quality and integrity of the patients during their shift. We all know that we think that our hospital has the worst possible assortment of patients and think that our emergency department is the epicenter for the treatment of cyclic vomiting, fibromyalgia, migraine headache, low back pain, or whichever is your least favorite chief complaint which makes your grimace when you pick up the chart. I remember thinking about a year into my career that the belligerent drug seeking patient had actually come to the emergency department purposefully at 2:00am to torture me.

Learning that the patients usually have no intent to torture you, specifically, but rather are just trying to get what you want even if their methods are bizarre and sometimes cruel and manipulative. How many of you have sat worrying about a problem case you are working up, thinking of all the diagnoses which you as a young emergency physician do not want to miss. It is only on the fourth time you go into the room that it all becomes clear why the patient is even in your department when they ask for a work note for a week off.

This frustration can come to a head and if capped off with a bad early malpractice complaint can be fatal to a promising young career in emergency medicine. You probably know someone who started out strong to only end up after just a few years deciding that an urgent care or other venue for their career is right for them. Some of these young, well-trained, and caring physicians even leave medicine altogether.

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AAEM NEWS FROM THE EDITOR’S DESK

This is a real shame. I am not condemning these doctors or minimizing the stress and turmoil which led them to these difficult decisions. Some people did pick the wrong career and realized it too late. However, I think that these doctors did not fail, but that we as a profession and as a society have failed them.

Obviously, most young emergency physicians stay in emergency medicine and have to learn a method to deal with this internal paradox.

This is why I want you to consider the idea of “Making a Difference” and that this phrase could have different meanings. Obviously, it is important for us to feel like we are helping

Hopefully, you walk out the door at the end of your next shift and then smile to yourself that your shift is done, you did good work, and you can get on with the things which really bring a smile to your face.

the sick and dying in our careers. A sense of altruism and empathy for our patients is certainly a laudable and expected part of our professionalism. It is our core value which we need as a profession to hold sacred. However, I want you to try and see the other types of

differences which you make in other aspects of your life which are facilitated by your emergency medicine career. I ask you to try to use those positive results to help you build some armor for the trials and tribulations which you will face when you walk into the next weak and dizzy ninety something year old’s room. What can protect your well-being when explaining to the three 70 something children that you did not find a realistic solution as to why their ninety something year old mother is so weak and that no you cannot just admit her for her to build up her strength?

In the end, despite issues we have a great job, which is well-paid, and in which you can actually help people and save lives. For a moment, try to forget all of the other baggage related to CMGs, government regulation, EMTALA, midlevels, etc. Consider that you might use the positive aspects of our job to improve and balance the other aspects of your life. Making a good living and having a set schedule allows you to get home, hug your kids, have a hobby, exercise, fish, or whatever. Use the positive to create wellness in other aspects of your life which then can splash back onto your career.

In previous articles, I have encouraged all emergency physicians to have a non-clinical and usually unpaid or ill paid medically related activity. I use AAEM for this personal professionalism building activity, but I am also involved in hospital committees, etc. which allow me to feel like a doctor and a professional. It is great to think of yourself as a “doctor” and not a provider.

If you are not interested in this, maybe consider focusing on the joy which your emergency medicine career can shine onto your daily life.

Maybe you are an exercise junkie who enjoys the set schedule and can plan the long bike

rides, hiking trips, exercise classes, or whatever consumes your free time that a general surgeon in private practice might long for, but can never obtain. Maybe you and your significant other are travelers and you like the opportunity which your emergency medicine schedule allows for you to be off for frequent short or long trips which our internist friends long for in their dreams. It might be our salary which allows you to provide your children with a great education which will bring an increased sense of fulfilment into your life.

My point is that even if your professional and hard earned emergency medicine career is not bringing you the sense of self-actualization that you had hoped for, does not mean that it is necessarily a bad career. Even if you do not feel that your emergency medicine job is making you happy you can still take pride in and focus on providing excellent care while meeting all of the seemingly endless and mindless benchmarks or quality measures during your next shift. You can do so knowing that while at times tedious and frustrating, your job can provide you with the tools you can use to provide happiness for both you and your loved ones.

Hopefully, you walk out the door at the end of your next shift and then smile to yourself that your shift is done, you did good work, and you can get on with the things which really bring a smile to your face. Your emergency medicine career can make this possible. Making a difference to yourself and your loved ones may be the skill which will allow you to flourish in your career. Career longevity can be a real possibility while still being a doctor. Helping yourself might just be the tool you can use to better treat and care for your patients and really make a difference in your life and the lives of the ones you care about.

COMMON SENSE JULY/AUGUST 2020

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Disability and Life...Another Option!

AAEM NEWS DOLLARS & SENSE

Mark Borden, MD FAAEM

Many of you may remember Dr. Joel Schofer’s popular column Dollars and Sense. We are bringing this column back with Dr. Mark Borden as the new author! Dr. Borden will offer you frequent financial advice through this column. Check back each issue for a new topic of financial importance. View past articles from both Drs. Schofer and Borden here: www.aaem.org/resources/publications/common-sense/issues/dollars-and-sense.

— Andy Mayer, MD FAAEM, Editor, Common Sense

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As you know, insurance is a “gamble.”

oung doctors are the ripest of “low hanging fruit” for insurance sales agents. You will have, early in your training, friendly, affectionate, insurance sales people tracking you like a pack of slobbering hounds. They will play upon your insecurities, and be willing to sell you as much insurance as you are willing to buy. Should you buy it? Everyone will say “yes” if you ask them, but is that the right answer, or just the easy one?

I terminated my life and disability policies after 22/25 years and am offering the “counter point.”

I am likely the only one whose opinion you will read that has “nothing to gain” in this big money insurance world. I hunted around online for an argument against disability insurance and could not find one. The arguments for disability insurance sounded good to me 25 years ago, but they are not convincing now.

Life Insurance: It is generally agreed upon that a Term Life Insurance Policy is a good idea if you have people that depend upon you and that will be in a hard position if you are suddenly gone. While you are young, a term policy is not too expensive, and is certainly a good idea until the amount to be paid doesn’t seem important to you anymore. I dropped my life insurance a few years before I dropped my disability. I should have dropped it sooner. At that point, the benefit was no longer “a make or break” amount of money to me and my family. I suppose it is fairly easy to collect life insurance money when someone dies...though I can’t speak from experience! For the sake of the bereaved survivors, I hope it is easier than collecting disability benefits!

THE HOUSE (INSURANCE COMPANY) ALWAYS WINS.

As you know, insurance is a “gamble.” The house (insurance company) always wins. How big a “spread” is there between what we get and what we pay? The spread (insurance company profit) pays for billions of dollars in annual insurance advertising, billions of dollars in real estate for insurance company offices, and the wages of over two million insurance industry employees! Gambling at a casino results in a better return on investment (ROI) on average than buying insurance.

AS AN EMERGENCY PHYSICIAN, YOU WILL WANT TO INVEST IN A DIVERSE MANNER. Will buying disability insurance buy “peace of mind?” Peace of mind is important. As long as I had insurance, and never needed it, I had “peace of mind.” This peace lasted until I needed to file for disability. At that point, I came to realize that my Northwest Mutual Occupation Specific Policy for which I had paid hundreds of dollars each month for over 20 years, was very difficult to redeem, essentially impossible without legal help, and in fact, in the end, not worth the effort.

Additional Investment accounts are important, and having an advisor is a good plan, but WATCH THE PERCENTAGES AND FEES, AS THEY CAN SERIOUSLY ADD UP OVER TIME. 8

COMMON SENSE JULY/AUGUST 2020

In the ideal scenario, you buy a great (expensive) policy. A great policy is “Occupation Specific,” which means if you cannot practice emergency medicine, you are disabled and eligible for payment. Most “great” policies pay after an initial three-month period. You suffer an injury to your body or mind that prevents you from practicing, the payments start, you have time to heal and hopefully return to function. Your family is saved a financial crisis. Sounds great, but...

In actuality, here’s how it will probably go. You buy a “great” policy, paying monthly premiums of at least several hundred dollars for many years. As the years go by it gets more expensive, and becomes more restrictive, with small changes that you try to watch carefully. You are injured or very ill and not up to much of anything. The paperwork to file is long, complex, and very challenging. You won’t be speaking to the helpful salesperson, but rather to a claims person that specializes in NOT paying out money if at all possible. The person assigned to me could barely speak English, and had no

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AAEM NEWS DOLLARS & SENSE

medical knowledge whatsoever. She did understand, though, that every single form needed to be filled out completely before the claim could be considered. You will need to submit the last five years of your taxes, to prove you have been making a normal income as a physician, and to prove a substantial decrease in your income.

You will need to submit the medical records of physicians, both primary and specialists, certifying your disability. This may be harder if you have been “toughing it out” while asking your fellow doctors for advice. The diagnoses will be closely scrutinized and you will be considered, over a period of time, for percentages of disability. Remember, you may not be in the best condition to fight for justice at this point, and it will fall on your loved ones, and the attorneys they will almost certainly be required to hire.

The attorney will scrutinize your “great” policy very closely, and will find every weakness.

Hard Reality: Now picture this...Do you really want to be disabled? If you lose both legs, an arm and an eye you can still earn more by consulting online than your best disability policy will pay! Not only that, but you will feel useful and productive.

So what are the other options? First, what to do with the ~$300 a month you will save by not paying for disability insurance. You will want security with this money, so a good basic route to take is an investment account with dividends automatically re-invested. This will be an account you will not touch unless absolutely needed.

My investment broker did the calculations below. If you were to deposit a few hundred per month extra into this account initially, the numbers will be MUCH larger. Also, note that these numbers are very conservative. My own number, (what I would have now if I had chosen to invest in myself rather than in disability insurance) calculated in retrospect after paying the monthly fee for 25 years, was just over $400,000!! My own monthly fee ranged from $170 in the beginning, to $600 in the end.

Note that at 54 years of age my own policy had been trimmed to “maximum of three years benefit,” and was still a bit over $600 a month!

Had I become disabled my maximum total payout of the gradually trimmed and shrunken, but still expensive, policy would actually have been less than $300,000 dollars spread over three years!

As an emergency physician that commuted by motorcycle, and broke/trained horses for a hobby during 20+ years of my practice, I had suffered numerous painful injuries. With two MCAs, and being thrown more than a dozen times, I never came close to three months of down time. Knowing I would receive no payment without continued work, I went to my shifts with complex, recently repaired lacerations (my residents at UCD will remember!), fresh fractures (including a very painful pelvis), broken ribs (x2) and other painful things we won’t mention, but which would never last the three Annual Contribution month minimum. $2,400.00 It will need to be a rather unusual injury. $2,400.00 Losing a leg won’t do it. Losing both $2,400.00 legs won’t do it. In those cases you will Annual Contribution

Years

Annual % Rate

10

7%

20

7%

30

7% Annual % Rate

Then, figure out how to pay it off fast. The only time it is worth assuming debt after your training is to “leverage” your purchasing power on an asset that will appreciate. I am talking real estate.

Check the tax laws...but as of now you can still deduct the mortgage (remove from your gross income to lower your tax amount and tax bracket) on your home, and you will NEED deductions.

As an emergency physician, you will want to invest in a diverse manner. Real estate is a required investment, and real estate ownership has done well for most people. Buying the smallest/ lowest priced house in an expensive neighborhood is a good place to start. As a physician, you will have the monthly income to make it bigger and nicer, and you will have good returns at sales time. If you live in an area where there is a good rental market (the rents you charge are higher than the mortgage you pay) having a few rentals is a good idea. You may enjoy being a landlord, or you may not. Either way it is an adventure, and in the end you have a stream of income. Passive (a relative concept) income is very nice.

Additional Investment accounts are important, and having an advisor is a good plan, but watch the percentages and fees, as they can seriously add up over time. An accountant has also been very important over the years, but is a bit less important now with the decrease in ability to itemize deduction under the 2018 tax law.

Most emergency physicians are a bit ADD (in a good way) and like to have a productive activity outside of work. Investing some of your Future time in creating a lifelong rewarding enInflation Value terprise is fun and worthwhile. Mine was/ 0% $35,480.64 is horses and farming. I enjoyed pruning 0% $105,276.42 and caring for plants between shifts, and have hundreds of productive fruit trees, 0% $242,575.30 now mature. These outside enterprises Inflation Future Value can act as a shelter for some of your ER 3% $29,772.45 money, but realize that this “shelter” is just another investment.

4% $73,351.74

adapt to practicing with a prosthesis or Years from a wheelchair, and do so within three 10 7% months (no payment). Losing one arm or $2,400.00 $2,400.00 20 7% most of your vision will make intubation $2,400.00 30 7% 3% $137,140.72 and suturing difficult, but you can still You have the choice. You can bet on the work in a multiple cover ED where your insurance company, or you can bet on This (your savings in lieu of having disability fellow doc can handle the procedures. Losing yourself. As a rational person you should clearly insurance) is real money, that will be yours, and the ability to work well at night won’t do it, (we know that the odds are massively in your favor if not open to dispute, limitations, or other interall will to variable extent after we hit 50) as you you bet on yourself. esting calculations. That is very different from can still get day shifts, somewhere, if you try You can see this topic, and others that you may your “potential disability benefits,” trust me. hard enough. A head injury could qualify, but if find interesting, on my medical website www. it is at all subtle, proving disability will be a long Other investments...unbiased advice from a medicalnetworkus.com. tough road, which will require your brain to be fellow EP: First, evaluate your debt and conworking 100%...see the problem? solidate it at the lowest possible interest rate.

COMMON SENSE JULY/AUGUST 2020

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AAEM Foundation Contributors – Thank You! Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 1-1-2020 to 6-15-2020.

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

Contributions $100-$249

Pamela A. Ross, MD FAAEM Mary Ann H. Trephan, MD FAAEM David Thomas Williams, MD FAAEM

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Mark Avery Boney, MD FAAEM Anthony J. Callisto, MD FAAEM David C. Crutchfield, MD FAAEM Jason W. David, MD Angel Feliciano, MD FAAEM Taylor G. Fletcher, MD FAAEM Paul W. Gabriel, MD FAAEM Kathryn Getzewich, MD FAAEM Regina Hammock, DO FAAEM Neal Handly, MD FAAEM Dennis P. Hanlon, MD FAAEM William E. Hauter, MD FAAEM Kathleen Hayward, MD FAAEM Jacob Hennings Jessica Herrera, MD FAAEM Thomas Isenovski, DO FAAEM Kevin T. Jordan, MD FACEP FAAEM John H. Kelsey, MD FAAEM Katrina Kissman, MD FAAEM Stephen J. Koczirka, Jr., MD FAAEM FACEP Benjamin Krater, DO FAAEM Calvin C. Krom, III, DO FAAEM

David W. Lawhorn, MD MAAEM FAAEM Gregory S. McCarty, MD FAAEM Nevin G. McGinley, MD MBA FAAEM Rick A. McPheeters, DO FAAEM James Arnold Nichols, MD FAAEM Patricia Phan, MD FAAEM Matthew C. Ponder, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Scott D. Reiter, MD FAAEM Jeffrey A. Rey, MD FAAEM Teresa M. Ross, MD 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 Robert E. Stambaugh, MD FAAEM David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM Jalil A. Thurber, MD FAAEM Andy Walker, MD FAAEM Joanne Williams, MD MAAEM FAAEM

Kary Wisniewski, MD FAAEM George Robert Woodward, DO FAAEM Leonard A. Yontz, MD 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 Patrick D. Cichon, MD JD MSE FAAEM Francis X. Del Vecchio, MD FAAEM Jeremy A. Hall, MD FAAEM Adriana M. Horner, MD Alex Kaplan, MD FAAEM Edgar A. Marin, MD Jennifer A. Martin, MD FAAEM Melissa Natale, MD FAAEM Ramon J. Pabalan, MD FAAEM Louis L. Rolston-Cregler, MD FAAEM Gholamreza Sadeghipour Roodsari Katherine F. Tyler Patricia L. VanDevander, MD MBA FAAEM

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

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

Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the different levels of contributions. The PAC would like to thank the individuals below who contributed from 1-1-2020 to 6-15-2020.

Contributions $1,000+

David A. Farcy, MD FAAEM FCCM

Contributions $500-$999

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Contributions $250-$499

Eric W. Brader, MD FAAEM Jerris R. Hedges, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM Ron Koury, DO FAAEM Bruce E. Lohman, MD FAAEM Bryan K. Miksanek, MD FAAEM Vicki Norton, MD FAAEM James Francis Rowley III, MD FAAEM Don L. Snyder, MD FAAEM Keith D. Stamler, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM Andy Walker, MD FAAEM

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COMMON SENSE JULY/AUGUST 2020

Contributions $100-$249

Kevin Allen, MD FAAEM Justin P. Anderson, MD FAAEM Peter G. Anderson, MD FAAEM Jonathan Balakumar, MD Maxime J. Berube, MD Mark Avery Boney, MD FAAEM Anthony J. Callisto, MD FAAEM R. Lee Chilton, III, MD FAAEM Liza Chopra, MD FAAEM Martinez E. Clement, MD FAAEM Walter M. D’Alonzo, MD FAAEM Francis X. Del Vecchio, MD FAAEM Jonethan P. DeLaughter, DO FAAEM John T. Downing, DO FAAEM Deborah D. Fletcher, MD FAAEM Steven H. Gartzman, MD FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeffrey Gordon, MD MBA FAAEM Gregory T. Hartt, MD, PHD FAAEM Jacob Hennings Jessica Herrera, MD FAAEM

Alice Horrell, DO FAAEM David R. Hoyer Jr., MD FAAEM Thomas Isenovski, DO FAAEM John H. Kelsey, MD FAAEM Shireen Khan, MD Stephen J. Koczirka, Jr., MD FAAEM FACEP Michael Lajeunesse, MD Jessica Neidig Leffler, MD FAAEM Gregory S. McCarty, MD FAAEM James Arnold Nichols, MD FAAEM Isaac A. Odudu, MD FAAEM Ramon J. Pabalan, 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 H. Edward Seibert, MD FAAEM Jonathan F. Shultz, MD FAAEM David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM

Jalil A. Thurber, MD FAAEM Matthew J. Vreeland, MD FAAEM

Contributions up to $50

Robert Bassett, DO FAAEM Doug Benkelman, MD FAAEM Jeremy A. Hall, MD FAAEM Kathleen Hayward, MD FAAEM James W. Hickerson, Jr., MD Ryan Horton, MD FAAEM Stefan Jensen Alex Kaplan, MD FAAEM Julie A. Littwin, DO FAAEM Melissa Natale, MD FAAEM Lindsey C. Remme, DO FAAEM Dion R. Samerson, MD FAAEM Linda Sanders, MD Michael Sherman, MD Marc D. Squillante, DO FAAEM Camilla Sulak, MD Katherine F. Tyler

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 6-15-2020.

Contributions $500-$999

David A. Farcy, MD FAAEM FCCM

Contributions $250-$499

Maxime J. Berube, MD Mark Avery Boney, MD FAAEM Michael R. Burton, MD FAAEM Anthony J. Callisto, MD FAAEM William E. Franklin, DO FAAEM Sarah Hemming-Meyer, DO FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT Bruce E. Lohman, 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 Chad Viscusi, MD FAAEM Kay Whalen, MBA CAE

R. Keith Winkle, MD FAAEM George Robert Woodward, DO FAAEM Missy Zagroba, CAE

Contributions $100-$249

Justin P. Anderson, MD FAAEM Dale S. Birenbaum, MD FAAEM Laura J. Bontempo, MD MEd FAAEM Karen Carothers, MD FAAEM R. Lee Chilton, III, MD FAAEM Paul W. Gabriel, MD FAAEM 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 Stefan Jensen

Kevin T. Jordan, MD FACEP FAAEM Stephen J. Koczirka, Jr., MD FAAEM FACEP Jessica Neidig Leffler, MD FAAEM Michael P. Lucarelli-Cowles Gerald E. Maloney Jr., DO FAAEM Gregory S. McCarty, MD FAAEM Valerie G. McLaughlin, MD FAAEM Marcus Obeius, DO FAAEM John O’Neill, FAAEM Patricia Phan, MD FAAEM Jeffrey A. Rey, MD FAAEM Jason T. Schaffer, MD FAAEM Richard D. Shih, MD FAAEM David R. Steinbruner, MD FAAEM Paul E. Stromberg, MD FAAEM

Contributions up to $50

Francis X. Del Vecchio, MD FAAEM Sean L. Finnerty, DO FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeremy A. Hall, MD FAAEM James W. Hickerson, Jr., MD Irving P. Huber, MD FAAEM Stacey M. Jolley, MD FAAEM Emily R. Knoble, DO FAAEM James Arnold Nichols, MD FAAEM Tracy R. Rahall, MD FAAEM Saba A. Rizvi, MD FAAEM Marc D. Squillante, DO FAAEM Katherine F. Tyler Maura Walsh, MD Michael E. Winters, MD MBA FAAEM Molly Wormley, MD Andrew Yocum, MD FAAEM

Robert Bassett, DO 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.

Check out the redesigned Common Sense online at:

www.aaem.org/resources/publications/common-sense

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Listen and Subscribe – AAEM Podcasts AAEM is pleased to introduce six podcast series for the benefit of our members. Each series focuses on a different area of interest to emergency physicians. The podcasts are available for download directly from the AAEM website, or accessible via iTunes and Google Podcasts. Subscribe for new episodes!

Legal and Policy Issues in Emergency Medicine

Emergency Medicine Operations Management

The Journal of Emergency Medicine Audio Summary

Hosted by: Larry Weiss, MD JD MAAEM FAAEM and Cedric Dark, MD MPH

Hosted by: Joseph Guarisco, MD FAAEM and Tom Scaletta, MD FAAEM

Hosted by: Matthew Kostura, MD FAAEM

In this podcast series, Larry Weiss, MD JD FAAEM, Joseph Wood, MD JD MAAEM FAAEM, and Cedric Dark, MD MPH, discuss timely advocacy issues for the emergency physician. Drs. Weiss and Wood are practicing emergency physicians, attorneys, and past-presidents of AAEM. Dr. Dark is Assistant Professor of Medicine at the Emergency Medicine Residency Program at Baylor College of Medicine and is the founder & executive editor of the Policy Prescriptions® blog. Join them each month as they discuss issues of importance to emergency physicians.

In this podcast series, Joseph Guarisco, MD FAAEM, ED Chair at Ochsner Hospital (New Orleans, LA), is joined by guests to discuss operations management issues for the emergency physician. Dr. Guarisco is the chair of the Operations Management Committee of the American Academy of Emergency Medicine (AAEM). Join him each month as he discusses issues of importance to emergency physicians.

Critical Care in Emergency Medicine Hosted by: David Farcy, MD FAAEM FCCM David Farcy, MD FAAEM FCCM, Chairman, Department of Emergency Medicine at Mount Sinai Medical in Miami Beach, Florida, speaks with national and international experts in the field of critical care in emergency medicine. Join us each month for insights on a timely topic of importance for emergency physicians.

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Emergency Medicine Breve Dulce Talks Breve Dulce (formerly known as the PK Talks), which is derived from breve et dulce – Latin for “short and sweet” are rapid-fire talks that cover a variety of important topics. The Breve format is a succinct, high-level overview in less than seven minutes (short) of EM pearls that you can immediately put to use in your everyday practice (sweet). These talks are from the American Academy of Emergency Medicine’s Annual Scientific Assemblies.

For more educational content, including video and slides, visit AAEM Online.

Monthly audio podcast summary of important articles from the Journal of Emergency Medicine, the official journal of the American Academy of Emergency Medicine (AAEM) and discussion of emergency medicine board review topics.

Women’s Wisdom: Our Journey in Emergency Medicine Hosted by: Adria Ottoboni, MD FAAEM and Faith C. Quenzer, DO Women’s Wisdom: Our Journey in Emergency Medicine is a podcast created by the AAEM Women in Emergency Medicine Section to highlight the journeys of prominent women emergency physicians. Join us every other month as we explore a new path and share our stories as women physicians.

Listen and subscribe www.aaem.org/resources/ publications/podcasts

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

September 10-11, 2020 ED Management Solutions: Principles and Practice Seattle, WA www.aaem.org/ed-management-solutions

October 7, 2020 AAEMLa Residents’ Day and Meeting Baton Rouge, LA www.aaem.org/get-involved/chapter-divisions/ aaemla/residents-day-and-meeting

September 25-27, 2020 The Difficult Airway Course: EmergencyTM New Orleans, LA www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency

Ongoing through November 23, 2020 Written Board Review Online www.aaem.org/written-board-review

November 3-7, 2020 Emergency Medicine Update Hot Topics 2020 (Jointly provided by UC Davis Health) Oahu, Hawaii ces.ucdavis.edu/confreg/?confid=1120

October 16-18, 2020 The Difficult Airway Course: EmergencyTM San Diego, CA www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency November 13-15, 2020 The Difficult Airway Course: EmergencyTM Nashville, TN www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency

AAEM Online New and Improved AAEM Online AAEM Online is not only getting a new look, but will be completely revamped to offer a much more robust online learning experience. The new AAEM Online will premiere this spring. The library will consist of AAEM19 and select AAEM20 content. AAEM20 content will be added on a rolling basis. Watch your weekly Insights newsletter for new content.

New Features: • CME now available for educational activities • Social Chat – network with your colleagues • FREE for AAEM and AAEM/RSA members • Accessible to non-members for $99/year Access AAEM Online at: www.aaem.org/aaem-online

Over

100 videos available!

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50 credits available!

Log-in and Start Watching Today!

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COMMON SENSE JULY/AUGUST 2020

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COMMITTEE REPORT WELLNESS

Interruptions in the Emergency Department and the Myth of Multitasking Andrew Grock, MD FAAEM (@AndyGrock) and Al’ai Alvarez, MD FAAEM (@alvarezzzy)

T

hink back to your last shift in the emergency department (ED). Likely, you were juggling and prioritizing the dozens of tasks that simultaneously needed doing — reading EKGs, ordering tests, evaluating the next pa-

Kahneman’s book, Thinking Fast and Slow.8 During high-stakes, high-pressure situations like donning and doffing during the COVID-19 pandemic, interruptions can also undermine physician safety—you forgot to actually check the seal of your respirator, the door was not completely closed, etc. In fact, face-to-face interruptions are the most common and disrupting form of interruptions.9 Now that we know interruptions lead to

and practice.

As we address interruptions, it is also important to learn how to create boundaries — for patient safety, as well as your sanity, wellbeing,12 and efficiency. Often, we struggle with creating boundaries because we tend to be kinder people, we want to please others, or we want to show others that we are capable of doing it all. The truth is, we can’t. We are, in fact, serially uni-tasking.13 To that end, being clear with our intentions is actually the kinder14 way of dealing with others. It avoids vague expectations on who is doing what. It creates accountability and a closed loop communication. Often, success and failure depend on effective communication.

Simply calling out interruptions as they happen

During high-stakes, high-pressure situations like donning and doffing during the COVID-19 pandemic, interruptions can also undermine physician safety… tient, answering consultant callbacks, all while a patient’s family waits to talk to you. During multiple high stakes encounters, were you, perhaps, interrupted once or twice...or more? Were they valuable interruptions such as a nurse notifying you of a decompensating patient? Or were they less valuable and perhaps not ideally timed? For example, I was once asked midintubation to change a stable patient’s chest x-ray order from a portable to PA/lateral.

Interruptions are rampant in healthcare and have been shown to contribute significantly to medical error.1 In the ED, evidence demonstrates that an interruption occurs about every six minutes2 and can congeal into multiple back-to-back interruptions.3 After interruptions, physicians often fail to return to the task at hand.4 These interruptions likely have a significant effect5 not just on the patients, but in the emotional and mental toll they take6 on physicians struggling to incorporate them into an often hectic work environment. And interruptions can be costly.5 As emergency physicians, we rely heavily on heuristics;7 interruptions in our train of thought has significant effects as highlighted in Daniel

errors, what can we do about them? Two studies successfully decreased interruption rates by giving nurses specific, recognizable external signs10 that they were preparing medications and thus should not be interrupted. The use of checklists11 have also been shown to effectively keep on task. We can also learn from the business world.9 Helpful strategies include the following: first is awareness.

Knowing that interruptions can be dangerous is key. Create a space for interruptions; this means creating space for nointerruptions4 including during teaching time, during sign-outs, during patient procedures, and especially during resuscitations. Discuss with key stakeholders the content and timing to minimize interruptions effect, and work on creating priorities specific to your workflow

cognitively reminds you that you are being interrupted and that you have to stay with your task at hand. This allows the interrupter the opportunity to escalate priorities versus return at a less impactful time.

As to the cost of interruptions, one

>>

We must appreciate the deleterious effects of interruptions, call it out whenever it is happening, and set boundaries and priorities.

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COMMITTE REPORT WELLNESS

Often, success and failure depend on effective communication.

recommendation to pick up on medical error is to create a cognitive pause while writing every discharge instruction. During this pause, review the chief complaint, the workup ordered and results, and the discharge plan specifics in order to ensure two key goals — all dangerous etiologies have been appropriately evaluated and the patient’s concerns have been appropriately addressed. This simple practice could potentially minimize errors such as missing critical results as well pending lab tests that make you and your patients vulnerable.

AAEM has issued a position statement to minimize interruptions in the ED: “by working on mitigating the timing and frequency of unnecessary interruptions, there will be marked improvement in work productivity, delivery of safe patient care, and overall well-being of clinical care teams in this dynamic work environment.”15 We pride ourselves with being able to task-switch fast and efficiently.16 This does not mean we should tolerate harmful interruptions. We must appreciate the deleterious effects of interruptions, call it out whenever it is happening, and set boundaries and priorities.

Only then are we able to truly focus on what is important--practicing safe, kind and sustainable medicine.

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References: 1. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System [Internet]. Washington (DC): National Academies Press (US); 2000 [cited 2019 Dec 25]. Available from: http://www.ncbi.nlm.nih. gov/books/NBK225182/ 2. Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med 2001;38(2):146–51.

3. Fong A, Ratwani RM. Understanding Emergency Medicine Physicians Multitasking Behaviors Around Interruptions. Acad Emerg Med [Internet] 2018 [cited 2019 Dec 25];25(10):1164–8. Available from: https:// onlinelibrary.wiley.com/doi/abs/10.1111/ acem.13496 4. Emergency Medicine: A Life of Interruption [Internet]. In Pract. 2017 [cited 2019 Dec 25];Available from: https://blogs.jwatch. org/frontlines-clinical-medicine/2017/10/17/ emergency-medicine-a-life-of-interruption/ 5. Rivera AJ, Karsh B-T. Interruptions and Distractions in Healthcare: Review and Reappraisal. Qual Saf Health Care [Internet] 2010 [cited 2019 Dec 25];19(4):304–12.

Available from: https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3007093/

6. Please Stop Interrupting Me! | Greater Good [Internet]. [cited 2019 Dec 25];Available from: https://greatergood.berkeley.edu/article/item/ please_stop_interrupting_me 7. Munasque A. ‘Thinking about Thinking:’ Heuristics and the Emergency Physician.

2009;2.

8. Daniel Kahneman: “Thinking, Fast and Slow” | Talks at Google [Internet]. [cited 2019 Dec 25]. Available from: https://www.youtube.com/ watch?v=CjVQJdIrDJ0 9. Interruptions at work are killing your focus, productivity, and motivation [Internet]. [cited 2019 Dec 25]; Available from: https://blog. rescuetime.com/interruptions-at-work/ 10. Pape TM. Applying airline safety practices to medication administration. Medsurg Nurs Off J Acad Med-Surg Nurses 2003;12(2):77–93; quiz 94.

11. Pape TM, Guerra DM, Muzquiz M, et al.

Innovative approaches to reducing nurses’ distractions during medication administration.

J Contin Educ Nurs 2005;36(3):108–16; quiz 141–2.

12. Why Caregivers Need Self-Compassion by Kristin Neff [Internet]. Self-Compassion. 2012 [cited 2019 Dec 25]; Available from: https:// self-compassion.org/why-caregivers-need-selfcompassion/ 13. Skaugset LM, Farrell S, Carney M, et al. Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine. Ann Emerg Med 2016;68(2):189–95.

14. Brown B. Clear is Kind. Unclear is Unkind.

[Internet]. Brené Brown. 2018 [cited 2019 Dec 25];Available from: https://brenebrown. com/blog/2018/10/15/clear-is-kind-unclear-isunkind/ 15. AAEM Position Statement on Interruptions in the Emergency Department [Internet].

AAEM - Am. Acad. Emerg. Med. [cited 2020 Apr 21];Available from: https://www.aaem.org/ resources/statements/position/interruptionsin-the-ed 16. Clyne B. Multitasking in Emergency Medicine.

Acad Emerg Med [Internet] 2012 [cited 2019 Dec 25];19(2):230–1. Available from: https:// onlinelibrary.wiley.com/doi/abs/10.1111/j.15532712.2011.01265.x

SECTION REPORT CRITICAL CARE MEDICINE

What Is the Best Sedative Agent for NIV Intolerance?

Yi Li, MD and Andrew W Phillips, MD MEd FAAEM

Introduction

R

espiratory failure is a common cause of emergency department (ED) presentation in both pediatric and adult patients.

Invasive ventilation is associated with multiple hemodynamic, infectious, and respiratory complications that require sedation and ICU admission. Noninvasive ventilation (NIV) provides respiratory support by applying positive pressure to conscious patients, often avoiding intubation.1 However, one of the risk factors for NIV failure is intolerance. It was reported that about 5% of patients on NIV experienced intolerance which is associated with higher rate of intubation and mortality.2 There are multiple factors that contribute to NIV intolerance, including the type and severity of respiratory failure, the underlying disease, interface (mask) tolerance, hemodynamic instability, neurological status deterioration, and poor patient–ventilator synchrony.3 A prospective, international, multicenter study showed that about 20% of patients received analgesic or sedative drugs during NIV.4 Sedation and analgesia can mitigate the effects of psychological stress and pain thus potentially improving NIV tolerance.

But data on sedative or analgesic agent use in NIV remains limited. Agent selection is really at the physician’s judgement.

Neurocognitive disorders such as developmental delay and delirium can present additional challenges in managing NIV tolerance as well.

In this article, we discuss a hypothetical case of a patient with concomitant neurodevelopment and respiratory distress requiring NIV, emphasizing pearls and pitfalls.

Case presentation A 24-year-old man with a history of autism and morbid obesity presented to the ED in

respiratory distress. His SpO2 was 85% on 6L NC so additional airway support was needed but he was unable to tolerate NRB or BiPAP due to agitation. He was given haloperidol 5mg IV and lorazepam 2mg IV with minimal improvement. During shift change he removed the mask, desaturated and suffered a hypoxic cardiac arrest.

What went wrong?

First, let us review the current sedative options and their evidence.

Opioids Summary: Opioid infusion seems to work but respiratory rate and mental status need to be carefully monitored. Buyer beware.

Opioids remain the mainstay of pharmacologic management of dyspnea that is refractory to disease-modifying treatment because of their ability to suppress respiratory drive.5 Opioids are commonly used in mechanically ventilated patients in the ICU and are one of the most commonly used sedative/analgesic drugs during NIV.4 The combined effects of analgesia and sedation make it easier for physicians to use them if the cause of NIV intolerance is unclear. However, respiratory depression and hemodynamic effects are less desirable in NIV, a modality that is dependent on respiratory drive.

Newer machines have backup ventilation, but it is not a consistently reliable feature. Several opioids were studied in the past to facilitate NIV tolerance, including morphine, fentanyl, remifentanil, and sufentanil.4 Intravenous morphine infusion was found to be effective in improving NIV compliance in acute pulmonary edema caused by heart failure.6 Two European studies found that remifentanil improved NIV tolerance safely in patients with respiratory failure.7,8 One study showed sufentanil helped induce awake sedation without significant adverse effects but did not comment on whether it improved NIV tolerance.9 There is currently no evidence suggesting fentanyl can improve NIV tolerance.

None of the studies went into detail about adverse effects.

Ketamine Summary: Limited evidence but theoretically a good choice. Patients should mentally travel to their happy places.

Ketamine, a phencyclidine derivative, acts as a dissociative agent primarily by blocking the N-methyl-D-aspartate (NMDA) receptor. It provides both analgesic and sedative effects and can provide amnesia depending on dosing. In contrast to opioids, ketamine preserves pharyngeal and laryngeal protective reflexes, lowers airway resistance, increases lung compliance, and is less likely to produce respiratory depression. Hemodynamically, ketamine results in increased heart rate and blood pressure due to its sympathomimetic effect which may provide additional advantage in managing respiratory failure patients with hypotension.10 Emergence reaction, however, may trigger anxiety if the patient is not mentally prepared when ketamine is administered. There are currently two available case reports discussing ketamine use during NIV - one in asthma exacerbation and another in acute decompensated heart failure.11,12 Currently there are no studies comparing ketamine with other sedatives.

Dexmedetomidine Summary: Theoretically and in-practice a good choice if the heart rate and blood pressure can tolerate it.

Dexmedetomidine acts as an Îą2 adrenoreceptor agonist with anxiolytic, sedative, and some analgesic effects. Like ketamine, dexmedetomidine does not cause respiratory depression. The main adverse effects of dexmedetomidine are bradycardia and hypotension, so it should be used cautiously in patients with hemodynamic instability. Multiple studies have demonstrated that dexmedetomidine can be used safely in pediatric respiratory failure patients to facilitate NIV tolerance.13-16 In adults, there are reports of successful use of dexmedetomidine to improve ventilator-patient

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synchronization among patients with acute respiratory failure.17-19 Compared to midazolam, dexmedetomidine seems to be superior in terms of maintaining sedation with fewer dose adjustments.20,21 In addition to common medical etiologies of respiratory failure, dexmedetomidine was also found to improve NIV tolerance in blunt chest trauma patients.22 One study failed to show improvement of NIV tolerance with dexmedetomidine, although the sample size was small (n=33) and both arms could receive midazolam and fentanyl, which probably negated the effects of dexmedetomidine.23 Overall, it seems that dexmedetomidine is safe and probably effective during NIV.

Antipsychotics Summary: Theoretically helpful but no evidence.

Antipsychotics are usually dopamine antagonists that are commonly used to treat agitation in the ICU and ED. Despite their potential (and likely frequent off-label use for NIV), currently there is no data evaluating whether

comorbidities, allergies, and the cause of NIV intolerance. The ideal agent should be able to improve NIV tolerance without further respiratory deterioration.

Case conclusion Is there a better sedation option than the B-52?

Probably ketamine or dexmedetomidine, but

Sedation and analgesia can mitigate the effects of psychological stress and pain thus potentially improving NIV tolerance.

Benzodiazepines Summary: Often used, barely studied. Get the endotracheal tube ready if adding to opioids.

Benzodiazepines are anxiolytics that bind to GABA receptors. Despite being the most used sedative/analgesic drugs during NIV (particularly midazolam),4 benzodiazepines do not have an analgesic effect and increase the risk of delirium. There is very limited data on benzodiazepine use during NIV to facilitate tolerance. One case report showed successful use of lorazepam in severe asthma exacerbation requiring NIV.24 It is unclear if the benefit of benzodiazepines outweighs the risks.

Benzodiazepines such as midazolam might be a good choice if the cause of NIV intolerance is clearly identified as anxiety and the patient’s respiratory status can be closely monitored.

Propofol Summary: Milk of amnesia is well known for hypotension and apnea; it requires very careful observation.

Propofol activates central GABA receptors and is an intravenous anesthetic that is commonly used for sedation of agitated adult ICU patients. Propofol is well known to cause hypotension and apnea. However, there are a few studies showing potential safe use of propofol in adult patients to facilitate NIV at very low infusion doses.25,26

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Several factors need to be considered in selecting the most appropriate sedative agent, including hemodynamic and respiratory status, comorbidities, allergies, and the cause of NIV intolerance. antipsychotics can improve NIV tolerance.

Theoretically they would slow psychomotor activity without reducing respiratory drive. Of note, antipsychotics can cause extrapyramidal effects which could potentially worsen NIV tolerance.

Combination of sedatives and analgesics Summary: Not a good idea.

Current available data suggest that single use of analgesic or sedative during NIV does not have an apparent effect on outcome. However, in a study comparing analgesic only, sedative only, and combined use during NIV, the combined had higher mortality.4 So, what is the best sedative agent?

The answer is there is no single sedative agent that is optimal for every patient.27 Several factors need to be considered in selecting the most appropriate sedative agent, including hemodynamic and respiratory status,

no matter which agent, an infusion rather than bolus injection. The combined use of haloperidol and lorazepam might be associated with increased mortality and there are no data supporting antipsychotic use to facilitate NIV. Given that the patient had been hemodynamically stable but with severe hypoxemia, efforts could have been made to achieve adequate sedation without compromising respiratory status.   References 1. Masip, J., et al., Indications and practical approach to noninvasive ventilation in acute heart failure. European Heart Journal, 2017.

39(1): p. 17-25.

2. Liu, J., et al., Noninvasive Ventilation Intolerance: Characteristics, Predictors, and Outcomes. Respir Care, 2016. 61(3): p. 27784.

3. Garofalo, E., et al., Recognizing, quantifying and managing patient-ventilator asynchrony in invasive and noninvasive ventilation. Expert Rev Respir Med, 2018. 12(7): p. 557-567.

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4. Muriel, A., et al., Impact of sedation and analgesia during noninvasive positive pressure ventilation on outcome: a marginal structural model causal analysis. Intensive Care Med, 2015. 41(9): p. 1586-600.

5. Campbell, M.L., Dyspnea. Critical Care Nursing Clinics, 2017. 29(4): p. 461-470.

6. Nakayama, M., A. Ishii, and Y. Yamane, [Novel strategy of noninvasive positive pressure ventilation by intravenous morphine hydrochloride infusion for acute cardiogenic pulmonary edema: two case reports]. J Cardiol, 2006. 48(2): p. 109-14.

7. Constantin, J.M., et al., Remifentanil-based sedation to treat noninvasive ventilation failure: a preliminary study. Intensive Care Med, 2007.

33(1): p. 82-7.

8. Rocco, M., et al., Rescue treatment for noninvasive ventilation failure due to interface intolerance with remifentanil analgosedation: a pilot study. Intensive Care Med, 2010. 36(12): p. 2060-5.

9. Conti, G., et al., Sedation with sufentanil in patients receiving pressure support ventilation has no effects on respiration: a pilot study. Can J Anaesth, 2004. 51(5): p. 494-9.

10. Erstad, B.L. and A.E. Patanwala, Ketamine for analgosedation in critically ill patients. J Crit Care, 2016. 35: p. 145-9.

11. Verma, A., et al., Ketamine Use allows Noninvasive Ventilation in Distressed Patients with Acute Decompensated Heart Failure.

Indian J Crit Care Med, 2019. 23(4): p. 191-192.

12. Kiureghian, E. and J.M. Kowalski, Intravenous ketamine to facilitate noninvasive ventilation in a patient with a severe asthma exacerbation.

Am J Emerg Med, 2015. 33(11): p. 1720.e1-2.

13. Shein, S.L., Dexmedetomidine During Noninvasive Ventilation: Different Acuity, Different Risks? Pediatr Crit Care Med, 2018.

19(4): p. 373-375.

14. Shutes, B.L., et al., Dexmedetomidine as Single Continuous Sedative During Noninvasive Ventilation: Typical Usage, Hemodynamic Effects, and Withdrawal.

Pediatr Crit Care Med, 2018. 19(4): p. 287297.

15. Venkatraman, R., et al., Dexmedetomidine for Sedation During Noninvasive Ventilation in Pediatric Patients. Pediatr Crit Care Med, 2017. 18(9): p. 831-837.

16. Piastra, M., et al., Dexmedetomidine is effective and safe during NIV in infants and young children with acute respiratory failure.

BMC Pediatr, 2018. 18(1): p. 282.

17. Demuro, J.P., M.N. Mongelli, and A.F. Hanna, Use of dexmedetomidine to facilitate noninvasive ventilation. Int J Crit Illn Inj Sci, 2013. 3(4): p. 274-5.

18. Takasaki, Y., T. Kido, and K. Semba, Dexmedetomidine facilitates induction of noninvasive positive pressure ventilation for acute respiratory failure in patients with severe asthma. J Anesth, 2009. 23(1): p. 147-50.

19. Akada, S., et al., The efficacy of dexmedetomidine in patients with noninvasive ventilation: a preliminary study. Anesth Analg, 2008. 107(1): p. 167-70.

20. Huang, Z., et al., Dexmedetomidine versus midazolam for the sedation of patients with noninvasive ventilation failure. Intern Med, 2012. 51(17): p. 2299-305.

21. Senoglu, N., et al., Sedation during noninvasive mechanical ventilation with dexmedetomidine or midazolam: A randomized, double-blind, prospective study. Curr Ther Res Clin Exp, 2010. 71(3): p. 141-53.

22. Deletombe, B., et al., Dexmedetomidine to facilitate noninvasive ventilation after blunt chest trauma: A randomised, double-blind, crossover, placebo-controlled pilot study.

Anaesth Crit Care Pain Med, 2019. 38(5): p.

477-483.

23. Devlin, J.W., et al., Efficacy and safety of early dexmedetomidine during noninvasive ventilation for patients with acute respiratory failure: a randomized, double-blind, placebocontrolled pilot study. Chest, 2014. 145(6): p.

1204-1212.

24. Cappiello, J.L. and M.B. Hocker, Noninvasive ventilation in severe acute asthma. Respir Care, 2014. 59(10): p. e149-52.

25. Clouzeau, B., et al., Fiberoptic bronchoscopy under noninvasive ventilation and propofol target-controlled infusion in hypoxemic patients. Intensive Care Med, 2011. 37(12): p.

1969-75.

26. Clouzeau, B., et al., Target-controlled infusion of propofol for sedation in patients with noninvasive ventilation failure due to low tolerance: a preliminary study. Intensive Care Med, 2010. 36(10): p. 1675-80.

27. Battistoni, I., et al., [Noninvasive ventilation and sedation: evidence and practical tools for its utilization]. G Ital Cardiol (Rome), 2017.

18(6): p. 513-518.

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 top-quality 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 mentor-mentee 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 COMMON SENSE JULY/AUGUST 2020

19

AAEM/RSA PRESIDENT'S MESSAGE

Lend a Helping Hand. Let’s Make EM More Inclusive.

Haig Aintablian, MD, AAEM/RSA President

I

t’s a very interesting time to be alive. 2020 has been the culmination of a few positives and many negatives. Global human suffering with COVID-19, the uninterrupted exposures of systemic racism through another unfortunate brutality – the death of George Floyd, and the global instabilities in job-security and the economy have made for a point in history that we’d all like to see ourselves grow to betterment from. AAEM and AAEM/RSA have been involved heavily on the political and educational front of many of these issues, from the protection of EM physicians during COVID-19, to the addressing of issues that medical students and residents are facing during this pandemic. Most importantly though, ever since our advent, we’ve been working to educate and advocate for more diversity and inclusion in emergency medicine – this has been critical now, just as it has been always.

Today, I want to highlight the importance of recognizing our duties as emergency medicine bound medical students and EM residents to each other. The house of medicine is and likely always will be structurally hierarchical. Every passing year, you grow in your knowledge and are granted more authority, both when it comes to patient care, but also in your own abilities to mentor, educate, and advocate for others in medicine. To stress: as we climb the ladder of medicine, we gain increasing ability to mentor and help those lower than us on this ladder of training. This hierarchy is riddled with flaws. I think, though, that when it comes to combating inequalities, it may be a blessing when used ubiquitously and the right way, and could be an understated tool in increasing diversity in medicine.

Making it through medical training is not easy. You know this, I know this, the people trying to enter medicine know this. But imagine how much more difficult it is for those from backgrounds that cannot possibly foster the resources needed to produce a medical student. Imagine the difficulties for those who come from low-income households, where striving for extracurricular activities must come second to striving for a warm meal, or for those whose name alone is a filter from entering the house of medicine. We have made strides to tackle these issues in medicine,

Today, I want to highlight the importance of recognizing our duties as emergency medicine bound medical students and EM residents to each other.

especially in emergency medicine, and have been successful in many ways, but there’s still room for improvement.

As we, ourselves find our way through the difficulties of medical training and learn how to cope and succeed in the house of medicine, we should be more eager to help those with diverse backgrounds trying to enter it. Mentorship like this should be a characteristic not only in emergency medicine, where comradery is often associated with our specialty, but also in medicine in general. In all aspects of society, diversity and inclusion are critical aspects to betterment. In the house of medicine, this couldn’t be more true. Each of our patients comes from a diverse background, and having a diverse background of physicians can help to combat biases and misunderstandings in all aspects of their care.

We are all blessed to have made it this far. Maybe a part of the solution of our lack of diversity in medicine is to help lend more hands to those needing them.

Most importantly though, ever since our advent, we’ve been working to educate and advocate for more diversity and inclusion in emergency medicine – this has been critical now, just as it has been always.

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AAEM/RSA RESIDENT JOURNAL REVIEW

Available Evidence Regarding Targeted Temperature Management (TTM) Rithvik Balakrishnan, MD; Taylor M. Douglas, MD; Taylor Conrad, MD MS; Theodore Segarra, MD; Christianna Sim, MD MPH Editors: Kelly Maurelus, MD FAAEM; Kami Hu, MD FAAEM

Introduction: The ability to obtain good neurological outcomes after cardiac arrest is often limited. Interventions during the acute phase of treatment post return of spontaneous circulation (ROSC) are therefore critical.1 The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. While the utility of therapeutic hypothermia for preservation of neurologic function post-cardiac arrest had been suggested in the early 1950s and 1960s,2-4 the studies were inconclusive, with high complication rates. It was not until the 1990s that studies showed possible benefits to mild hypothermia in animal models.5-10 The results of the 2002 trial by the Hypothermia after Cardiac Arrest Study Group were the basis for the inclusion of therapeutic hypothermia in the American Heart Association’s post-cardiac arrest care guidelines.11 Subsequent trials have assessed the difference between therapeutic hypothermia to 33 degrees Celsius (ºC) and “targeted temperature management” (TTM) aiming for 36ºC, the duration of TTM, the method used to achieve and maintain it, and whether TTM confers a similar neurological benefit for cardiac arrests secondary to non-shockable rhythms; some of these trials will be discussed below and will help us answer the question at hand.

Question: What is the current available evidence on: temperature degree, duration and method of cooling in TTM patients post cardiac arrest?

Nielsen N, Wetterslev J, Cronberg T et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. New Engl J Med. 2013;369(23):2197–2206. doi: 10.1056/NEJMoa1310519.

By the time of the study by Nielsen et al. therapeutic hypothermia was recommended in international resuscitation guidelines but questions still remained as to whether a specific temperature was superior to general temperature regulation. Previous research had shown that fever is associated with worse outcomes and in the Hypothermia after Cardiac Arrest Study Group trial many patients in the control group developed fever, potentially confounding the results.12 This international, randomized clinical trial took place in intensive care units (ICUs) in Europe and Australia and involved patients with out-ofhospital cardiac arrest of a presumed cardiac cause, irrespective of arrest rhythm, with a Glasgow Coma Scale (GCS) score of less than 8 after ROSC. Patients were also required to maintain spontaneous circulation for more than 20 minutes after resuscitation. The main exclusion criteria were time from ROSC to screening of more than four hours, unwitnessed arrest with asystole as initial rhythm, suspected or known

intracranial hemorrhage or stroke, or an initial core temperature of less than 30ºC. Enrollees were then assigned to either TTM of 33ºC or 36ºC for 36 hours. There was no blinding for the direct care providers, but neurologic prognostication was performed by blinded individuals. There was no standardization of cooling performed and gradual warming was performed after 28 hours. Fever control continued until 72 hours after the arrest in both groups. The primary outcome was death at the end of the trial with secondary outcomes of death at 180 days, and neurological outcome assessed by cerebral performance category and the Modified Rankin scale.

Of the 939 patients enrolled, the majority, approximately 80%, in each group had a shockable rhythm on initial assessment and 75% had bystander CPR performed. For both groups, mean time to basic life support was determined to be one-minute, advanced life support started at 10 minutes, and time to ROSC at 25 minutes. Rates of cardiovascular disease were high and approximately 40% of patients in both groups had an ST-segment elevation myocardial infarction. Both groups had similar initial neurological presentations with median GCS of 3. Intravascular cooling was performed in 24% of patients and surface cooling performed in the remaining 76%.

By the end of the trial, 50% of patients in the 33ºC group and 48% of patients in the 36ºC group had died. Neurological outcomes by both scales were similar between the groups. The authors also investigated harms in both groups and determined no significant difference in adverse events between both groups. These results suggest that targeting a lower temperature of 33ºC confers no additional benefit to targeting 36ºC. However, the decade since the original Hypothermia after Cardiac Arrest trial had seen significant advances in pre-hospital, emergency department, and critical care that may have contributed to these outcomes.

Additionally, the study leaves unanswered the question regarding the benefits of TTM in certain post cardiac arrest patients compared to noncooling interventions.

Kirkegaard H, Soreide E, de Haas, I et al. Targeted temperature management for 48 vs 24 hours and neurologic outcome after out-of-hospital cardiac arrest: A randomized clinical trial. JAMA. 2017;318(4):341–350. doi: 10.1001/ jama.2017.8978.

After guidelines began to recommend the use of TTM, many researchers began studying the various logistical aspects of cooling and rewarming.

Kirkegaard et al. sought to address the proper duration of hypothermia.

The authors cite neonatal protocols for 72 hours of cooling as possible evidence that longer cooling may have benefits. They therefore designed

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a multicenter, randomized, blinded-outcome-assessor trial to compare 24 hours to 48 hours at 33°C. It is not clear from their manuscript why they chose 33°C when they cite in their introduction that there was no difference between 33°C and 36°C in prior studies.

Power analysis led to the enrollment of 355 patients stratified by study site, age, and initial rhythm. Patients were included if their arrest was presumed to be of cardiac origin, either shockable or non-shockable rhythm. Randomization occurred within the first 23 hours after the target temperature had been reached. As they could not blind the treatment teams, they blinded the outcome assessors who collected the six month variables.

When analyzing admission data, there were no significant differences between the two groups, but interestingly the majority of both groups received bystander CPR (82% for the 24-hour group and 84% for the 48-hour group) and were found to have an initial shockable rhythm (86% for 24 and 91% for 48). During the study, it took the 24-hour group significantly longer than the 48-hour group to reach target temperature after ROSC (320 minutes vs. 281 min, p=0.01). More complications (such as severe arrhythmias and pneumonias) occurred in the 48-hour group and more patients had to be rewarmed ahead of schedule, both of which make sense as one would expect more difficulties when keeping patients cooler longer. There was no significant difference between groups with respect to percentage of patients with good functional status (69 vs. 64%, p=0.33) or mortality (27 vs. 34%, p=0.19) at six months. The 48-hour group had a significantly longer length of stay in the ICU and time on mechanical ventilation amongst survivors, both of which were expected since they were kept at target temperature for longer, requiring more resources.

When looking at this study population overall, the authors noted most patients received bystander CPR and were found to have an initial shockable rhythm, different from prior TTM studies. These differences may have contributed to increased survival overall, altering the power of the study as its sample size was calculated based on prior research. The authors note a sample of closer to 3,000 would be required to detect a difference based on the results of their study, which would be extremely difficult to accomplish. Therefore, whilst the authors state that there was no statistically significant evidence to support cooling for 48-hours, more research is required to validate the trial results and possibly to evaluate the rate of cooling as another variable affecting mortality.

De Fazio C, Skrifvars MB, Soreide E et al. Intravascular versus surface cooling for targeted temperature management after out-of-hospital cardiac arrest: An analysis of the TTH48 trial. Crit Care. 2019;23(1):1–9. doi: 10.1186/ s13054-019-2335-7.

As a follow-up to the study comparing 24-hour to 48-hour duration of TTM, coined the TTM48 trial, the authors reanalyzed the data to evaluate different methods of cooling. Their outcomes in this post-hoc analysis were cooling precision, survival, neurologic outcome (specifically poor

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neurologic outcome), and adverse events among survivors, of which only cooling precision was not a primary or secondary outcome in the original study. The two groups analyzed were those using intravascular catheters (IC) and those using surface cooling devices (SFC) to achieve target temperature.

Three hundred and fifty-two of the original cohort of 355 were included in this analysis, of which 218 were cooled by IC and 134 by SFC. Both groups were allowed to use infusion of cold intravenous fluids and there was no difference in overall percentage of patients who received cold IV fluids between groups. There was no significant difference in cooling method between original cohorts. Time to TTM was statistically significantly shorter in the IC group (2.2 vs. 4.2 hours; p<0.001) but they also started at a lower temperature (35.0 vs 35.5°C, p=0.02). There was less temperature variability in the IC group, however more time spent outside of goal temperature range and post-rewarming fever were also noted in this group.

There was no significant difference in mortality, neurologic outcome, or adverse event rates between groups. Consistent with this study, other studies on this subject have also noted that IC has less variability and better control of temperature than SFC, but without changes in clinical outcomes.13-15 One major flaw of this post-hoc analysis is that the authors of both studies state in the TTM48 manuscript that the power of the original study was not sufficient and a larger study is needed. Therefore, a secondary analysis of the data is unlikely to demonstrate any significant difference. Additionally, as the patients were not randomized based on their cooling method, there were many statistically significant differences in baseline characteristics as well as their performance findings during the study between groups that could affect the authors’ conclusions, hence a larger, properly randomized study is required to detect any significant differences that might exist.

Lascarrou J-B, Merdji H, Le Gouge A et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. New Engl J Med. 2019;381(24):2327– 2337. doi: 10.1056/NEJMoa1906661.

The HYPERION trial was an open-label randomized control trial that compared moderate therapeutic hypothermia (33°C for 24 hours) with targeted normothermia (37°C for 24 hours) for patients admitted to the ICU after ROSC from a cardiac arrest secondary to a non-shockable rhythm. The primary outcome was the 90-day Cerebral Performance Category score (CPC) ranging from 1 to 5, with a higher number indicating greater disability. Participants aged 18 years or older who had achieved ROSC after an in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) secondary to a non-shockable rhythm, and a Glasgow Coma Scale (GCS) of ≤8 at ICU admission (or if the patient was sedated, a GCS ≤ 8 prior to sedation) were included. Exclusion criteria included time from collapse to initiation of CPR of >10 minutes, CPR time of >60 minutes, hemodynamic instability requiring vasopressors

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(epinephrine or norepinephrine >1ug/kg body weight per minute), time from arrest to screening of >300 minutes, Childs-Pugh class C hepatic cirrhosis, moribund condition, pregnant or lactating mothers, status of being incarcerated or under guardianship, inclusion in another trial assessing neurological function post-cardiac arrest at 90 days, lack of health insurance, and next-of-kin decision not to participate. The trial was conducted in 25 ICUs in France between 2014 and 2018. Patients were randomized in a 1:1 ratio to either the hypothermia or normothermia groups.

For patients who were assigned to the hypothermia group, a core body temperature of 33°C (± 0.5°C) was induced and then maintained for 24 hours per each center’s protocol (internal or external cooling with or without a specific device), and then patients were rewarmed at a rate of 0.250.5°C to a goal of 36.5 or 37.5°C over 24 hours. Sedation was tapered after core temperature rose above 36°C. For patients assigned to the normothermia group, core body temperature was maintained at 37°C (± 0.5°C) for 48 hours according to each center’s standard protocol; patients were sedated only during their first 12 hours. The primary outcome of all surviving patients was assessed at 90 days and a CPC score of 1 (good cerebral performance or minor disability) or 2 (moderate disability) was defined as a favorable neurologic outcome. Secondary outcomes included mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS), infections, and hematologic adverse events. Due to French Law, informed consent was not required as both groups were considered to be receiving components of standard of care, though patients (or their representatives) had the opportunity to decline the usage of their data.

Five hundred and eighty one patients were included in the final analysis: 284 in the hypothermia group and 297 in the normothermia group. The baseline characteristics of the two groups were similar. Overall, 27% suffered from OHCA and 73% from IHCA. At the 90-day mark, 29 of the hypothermia patients demonstrated a CPC score of 1 or 2 compared to 17 for the normothermia group (10.2 vs. 5.7%). Secondary outcomes were similar between the two groups, including 90-day and ICU mortality, ICU LOS, and duration of mechanical ventilation among those who survived to ICU discharge or died in the ICU. This trial carried several limitations. Survivor neurologic outcome was assessed using a telephone rather than in-person assessment. There were a significant number of patients who were hyperthermic (temperature > 38°C) after the TTM period, and to avoid rebound hyperthermia, TTM was performed for 56 to 64 hours in the hypothermia group versus 48 hours in the normothermia group. Patients with missing data (one in the hypothermia group and two in the normothermia group) were assumed to have died. While this yields a total of only three patients with missing data, it carries significant ramifications as the trial had a fragility index of one. As such, while the HYPERION trial suggests a neurological benefit to TTM for non-shockable rhythms, further study is required for more concrete support.

Conclusion There has been a significant amount of research over the past twenty years regarding TTM after cardiac arrest. The most recently updated American Heart Association guidelines from 2015 are supportive of TTM between 32°C and 36°C;16 based on some of the studies stated above it is unclear whether the method or a longer duration of cooling confers statistically significant differences at this time; further clinical trials are needed to assess for optimal duration of TTM, modality of cooling, and which patient groups would have the best neurological outcomes using TTM. References 1. Arrich J, Holzer M, Havel C, Mullner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2012;9:CD004128-CD004128 2. Benson DW, Williams GR Jr, Spencer FC, Yates AJ. The use of hypothermia after cardiac arrest. Anesth Analg 1958;38:423-8.

3. Williams GR Jr, Spencer FC. The clinical use of hypothermia following cardiac arrest. Ann Surg 1959;148:462-8.

4. Ravitch MM, Lane R, Safar P, Steichen FM, Knowles P. Lightning stroke: report of a case with recovery after cardiac massage and prolonged artificial respiration. N Engl J Med 1961;264:36-8.

5. Leonov Y, Sterz F, Safar P, et al. Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs. J Cereb Blood Flow Metab 1990;10:57-70.

6. Sterz F, Safar P, Tisherman S, Radovsky A, Kuboyama K, Oku K. Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs. Crit Care Med 1991;19:379-89.

7. Weinrauch V, Safar P, Tisherman S, Kuboyama K, Radovsky A. Beneficial effect of mild hypothermia and detrimental effect of deep hypothermia after cardiac arrest in dogs. Stroke 1992;23:1454-62.

8. Kuboyama K, Safar P, Radovsky A, Tisherman SA, Stezoski SW, Alexander H. Delay in cooling negates the beneficial effect of mild resuscitative cerebral hypothermia after cardiac arrest in dogs: a prospective, randomized study. Crit Care Med 1993;21:1348-58.

9. Safar P, Xiao F, Radovsky A, et al. Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion.

Stroke 1996;27:105-13.

10. Busto R, Globus MY, Dietrich WD, Martinez E, Valdes I, Ginsberg MD. Effect of mild hypothermia on ischemia-induced release of neurotransmitters and free fatty acids in rat brain. Stroke 1989;20:904-10.

11. Peberdy MA, Callaway CW, Neumar RW, et al. Post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:Suppl 3:S768-S786[Erratum, Circulation 2011;123(6):e237, 124(15):e403.]

12. Zeiner A, Holzer M, Sterz F, et al. Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome. Arch Intern Med 2001;161:2007-2012 13. Hoedemaekers C, Ezzahti M, Gerritsen A, van der Hoeven J. Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients: a prospective intervention study. Crit Care.

2007;11:R91.

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14. Gillies MA, Pratt R, Whiteley C, et al. Therapeutic hypothermia after cardiac arrest: a retrospective comparison of surface and endovascular cooling techniques. Resuscitation. 2010;81:1117–22.

15. Glover GW, Thomas RM, Vamvakas G, et al. Intravascular versus surface cooling for targeted temperature management after out-of-hospital cardiac arrest - an analysis of the TTM trial data. Crit Care. 2016;20:1–10.

16. Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015 Nov 3. 132(18 suppl 2):S465-82.

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

XIth Mediterranean Emergency Medicine Congress

#MEMC21 24

COMMON SENSE JULY/AUGUST 2020

www.aaem.org/MEMC21

MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

2020-2021 AAEM/RSA Medical Student Council Introduction Lauren Lamparter, Medical Student Council President

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ello! My name is Lauren Lamparter, and I am so excited to be serving as this year’s AAEM/RSA Medical Student Council President.

First, I’d like to introduce myself. I am from Southern California, and I am a rising fourthyear medical student at Loyola’s Stritch School of Medicine. I fell in love with emergency medicine (EM) after I worked as an emergency department (ED) scribe and gained firsthand insight into the positives and negatives of EM as a specialty. Through my time at Loyola I have become very involved in AAEM/RSA from volunteering at our AAEM/RSA Midwest

WE HOPE TO SHOW STUDENTS HOW BEING A MEMBER OF AAEM/RSA WOULD BE A BENEFIT TO THEM AND THEIR FUTURE CAREERS IN EM THROUGH OUR AVENUES OF EDUCATION, ADVOCACY, WELLNESS, AND MORE. Medical Student Symposium, to serving on the planning committee, to being able to serve as the Midwestern Representative on the AAEM/ RSA Medical Student Council this past year.

The values of this organization and the way it passionately pursues the best interest of the emergency physician is why I am incredibly grateful and excited to be serving again in a leadership role.

This past year our Medical Student Council has been working on increasing membership and inclusivity by finding avenues for medical students to maximize utilization of our resources.

We are proud of all of the opportunities that AAEM/RSA provides whether that is with the committees that allow us to gain experience in our professional interests, scholarships aimed at increasing diversity in our field, or educational resources such as podcasts and presentations. We aimed to streamline

our advertising of these opportunities with limited and concise emails that could be passed on to Emergency Medicine Interest Groups (EMIGs). For medical student symposia, we scripted documents that would act as a supplemental resource for students interested in starting up their own conferences or strengthening existing conferences. I would like to thank all of the 2019-2020 board for all of the work they did to build upon the strengths of AAEM/RSA. This year, we have a strong Medical Student Council in our returning Vice President Leah Colucci (University of Miami Miller School of Medicine), the four Regional Representatives Joshua Sawyer (Alabama College of Osteopathic Medicine), Daniel Walsh (Loyola University Stritch School of Medicine), Brianna Beaver (Western University of Health Sciences College of Osteopathic Medicine of the Pacific), and Brian Redmond (University of Rochester School of Medicine), and our International Ex-officio representative Bruno Perthus (University of Queensland – Ochsner Clinical School). For more information about the board’s interests and hobbies check out the AAEM/RSA leadership webpage: www.aaemrsa.org/about/leadership#msc

We are excited to continue the work of the board before us, and our goals for this year are to invest deeper into the regional Emergency Medicine Interest Groups and continue to reach out to students to increase membership in AAEM/RSA. We hope to show students how being a member of AAEM/RSA would be a benefit to them and their future careers in EM through our avenues of education, advocawcy, wellness, and more. For these goals and so much more, we look forward to serving you this coming year. We are enthusiastic and grateful for the opportunity to represent the interest of medical students. Please do not hesitate to reach out with any suggestions, concerns or questions. On behalf of the medical student council, we look forward to working with you in this coming year!

We are proud of all of the opportunities that AAEM/RSA provides whether that is with the committees that allow us to gain experience in our professional interests, scholarships aimed at increasing diversity in our field, or educational I WOULD LIKE TO THANK ALL OF THE resources such as podcasts 2019-2020 BOARD FOR ALL OF THE and presentations.

WORK THEY DID TO BUILD UPON THE STRENGTHS OF AAEM/RSA.

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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 26

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 JULY/AUGUST 2020

AAEM Tales of COVID-19

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AEM sent a call out for stories March-May of 2020 so that you would have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you to all who submitted stories to share with other members so we can get through this crisis together. Please note that these stories were submitted months in advance of print of this issue. We acknowledge that much has and will continue to change with how we are dealing with COVID-19. Stories were up-to-date at the time they were submitted.â&#x20AC;&#x2030;â&#x20AC;&#x2030;

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Tales of COVID-19

AAEM NEWS FROM THE EDITOR’S DESK

The Moral Dilemma of COVID-19 Andy Mayer, MD FAAEM — Editor, Common Sense

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ertainly, there is only one issue which is dominating all thoughts, prayers, and efforts on our planet right now and it is COVID-19.

Hopefully where you are, your life and practice will only be incredibly inconvenienced and that your family, your community, and your hospital will be spared the worst of this pandemic. Many areas may be relatively spared by early social distancing and the shutdown of many aspects of daily life which until last month we took for granted. This crisis has brought to the forefront many ethical and moral dilemmas which our society and world need to face with open eyes and minds. Our medical capabilities in our modern prosperous society are currently been taxed past the breaking point in the hotspots of the COVID-19 pandemic. We need as a profession and as a society to consider the correct response to the complex and difficult decisions which physicians on the frontlines are now making or may eventually be facing where conditions are worse. Even if we manage to make it through this pandemic without running out of ventilators and do not lose too many talented and selfless healthcare professionals there may be a next time.

Sadly, I work in one of the initial hotspots of New Orleans. The citywide healthcare system became inundated within days.

The whole medical community has come together to try and work through the new complex daily challenges which we are required to meet each and every day. The process, which we worked out the day before, can be quickly scrapped or modified as we learn or try new things. The idea that a new disease can come out of seemingly nowhere and challenge every treatment concept we have is a humbling experience.

When you realize that we truly are wandering in the desert when it comes to what is the best course of action for the dying patient is front of you, it is terrifying but also enlightening. How far are we really removed from the “plaque doctor” of old?

Many of us have quickly been through the protocols of early intubation, late intubation, prone ventilation, CPAP, BiPAP, non-rebreather masks, no non-rebreather masks, viral filters, or whatever in an attempt to figure a path forward. Just walk through an ICU of any COVID filled hospital and you quickly see the reality of this pandemic and the current limitations of the available treatments. The prospect of throwing away much of what we thought we knew in regards to treating critically ill patients can make one question much of what we thought were sound and scientifically based principles. Listening to the various experts proposing yet another way to do things differently for this novel disease is fascinating as the medical community having to throw out, at least partially, our “evidence-based” mindset.

Consider the ethical dilemma of trying a novel ARDS protocol or giving a medicine normally used for malaria or lupus with known serious side effects on only anecdotal evidence. Certainly, the intention of using

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Just walk through an ICU of any COVID filled hospital and you quickly see the reality of this pandemic and the current limitations of the available treatments.

these techniques or medications by physicians in the trenches seeing their ICU and emergency departments filled with patients struggling to breath and dying all around them is noble and in the finest traditions of medicine. The usual treatments and protocols which we have all learned to use are not working and in an act of desperation a dedicated and caring physician who is putting their very own life on the line is attempting to save the patient in front of them.

However, there will always be critics and naysayers who will demand to see the evidence and the trial, which shows the safety and efficacy of what is proposed. Many of these ideas will fail and patients will continue to die. I fear the personal consequences for these innovative physicians down the road when the tired old pundits and plaintiff attorneys come out to denounce the medical experimentation, which went on while they were safely home in self isolation. I certainly think that sovereign immunity should be granted to all physicians in this crisis to allay any fears of later recrimination after the dust settles. AAEM has sent letters to all of the governors of our states asking for relief from the fear of medical

Tales of COVID-19

AAEM NEWS FROM THE EDITOR’S DESK

Working together as a profession can help us all deal with the stress and uncertainty of our new reality.

malpractice liability during this crisis. Will it be fair to pass judgment on the actions of these same doctors who literally placed themselves in danger to treat these patients knowing that our treatments were untested and were driven by their professionalism and compassion to try novel treatment options, which may or may not work?

I certainly know what I believe, but more and more I feel like I am a plaque doctor of old.

Dealing with a novel disease which is cutting a swathe thorough my community is humbling to say the least. Our emergency department early in the pandemic tried new methods to try and depressurize the department and hospital.

Trying to keep a COVID-free area became almost impossible as despite a patient’s chief complaint, in the end everything became COVID. We started seeing patients via Zoom while they were in triage to help start workups and triage to see who needed the next available bed while preserving our limited personal protection equipment supplies and to try and limit exposure to the providers. The fire marshal allowed us to put army type cots along a long hallway outside of the waiting room to see patients when there was no other available space. The scene was surreal walking past six

ambulance stretchers waiting on the wall to see people in pediatric area, which we had also cannibalized for sick adults. I never would have thought that I would order so many ferritin or LDH levels in my career.

The potential of the need to ration care when your department seems to be drowning in COVID can become a pressing thought. This is especially true when your local nursing homes become infested with the virus. At one point, we would have nursing homes calling and stating they were sending five patients at a time. Who to see first? Who would get the bed? Would we have enough ventilators? Who to put on hydroxychloroquine? The crucial question, sadly on the initial presentation on some of these patients, is quickly reviewing the code status and immediately trying to call families to discuss treatment options. On some days, it seemed that our number one consulting service was palliative care. Hopefully this time is past for my emergency department, but please think about these questions now before you are doing this in a time of crisis. Please consider beefing up your medical ethics committee. There was a good article in JAMA related to this issue of the potential liability of the rationing of care (jamanetwork.com/journals/jama/fullarticle/2764239).

The reality of the shortage of personal protective equipment (PPE) is another moral dilemma. Can you expect any worker in the hospital from an emergency physician to the poor housekeeper dutifully deep cleaning the COVID rooms to enter these contaminated rooms without proper safety equipment? Can we judge them if they are too scared to work?

Should only staff less than sixty who do not have significant comorbidities be asked to see these patients? Should older staff members with these comorbidities be asked not to place themselves at risk? Should pregnant staff members be excused from direct patient care?

The questions can be endless and I think the answers will also be drastically different depending on your hospital and your perspective.

My hospital was spared the worst of this PPE shortage, except for the fact we were given one N95 mask and told we needed to use it for five days and to wipe off the gowns and reuse

them. I am thinking of having my first N95 mask bronzed to have as a memento of this pandemic. Luckily, one of my partners “knew a guy” who owned a contracting company and gave us a small supply of nicer masks, which seemed to fit better. Our hospital system seemed to work miracles and we were able to obtain real respirator masks relatively quickly compared to the stories out of New York.

The other remarkable fact about these COVID profession is truly on the frontlines of a real pandemic and that our work entails real risk makes me feel two paradoxical emotions. One is pride that we are professionals who have taken an oath and are dedicated to trying to save the lives of at times an overwhelming number of critically ill patients with the realization that we are putting ourselves and our coworkers at a potential real personal risk.

The conflicting emotion is a sense of humility and insignificance that in our advanced and modern medical system we can be seemingly vanquished by a tiny piece of RNA. Please reflect on these issues even if you have not been required to face them, as the moral and ethical issues related to COVID are real and significant. Hopefully this pandemic is a generational one, but we can never be sure and should be prepared. I would ask you to consider sharing your thoughts on these or any other COVID issues. Working together as a profession can help us all deal with the stress and uncertainty of our new reality.

The potential of the need to ration care when your department seems to be drowning in COVID can become a pressing thought.

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Tales of COVID-19

Decision Making: Combining the Emotion and Reason Robert Frolichstein, MD FAAEM

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We are faced with the rapid spread of a new disease that has devastating consequences.

e are living in unprecedented times.

Times filled with emotion and very little hard science. We are faced with the rapid spread of a new disease that has devastating consequences. The rapid spread is overwhelming our system that is designed for a steady state. Periodically, we are faced with events that overwhelm our system, mass shootings is a prime example. The duration of those events is measured in hours. We are currently faced with an event that will be measured in weeks and months. The illness is particularly devastating to physicians because of lack of treatment and sporadic failure of it to respond as expected to supportive care.

Mix into that the uncertainty surrounding how the disease is spread. We have not experienced an event with this much uncertainty and emotion in our lifetimes.

All physicians are leaders. We are leaders of the care team at the bedside. Many are leaders within our groups, hospitals and other organizations. As leaders faced with uncertainty and emotion, we are called upon to make good decisions even in times like these. Especially in times like these. We make decisions and form opinions based on what we know or can infer (rational) and what we feel (emotion), a process called affective decision-making (ADM) — not effective, though affective decisions are likely to be the most effective. Many of you are familiar

Kirk usually made better decisions because he recognized and allowed emotions to influence but not dominate his decision-making. It is crucial during these times that physicians form opinions and make decisions based on a balance of the rational and the emotional.

ADM is especially difficult because of the imbalance between emotion and rationality we are experiencing daily. There is not much universally accepted science to help us form the rational portion of our decisionmaking. However, our education has trained us as scientists and thinkers.

Faced with uncertainty about a disease process we are uniquely trained to fall back upon our knowledge of physiology, biochemistry, pathology, and the like to help us form our rational approach.

Physicians are the only members of the team that are trained to do this. We must embrace this and lead the way.

We need to take time to wrestle with both the

emotional and rational aspects of the opinions we form and decisions we make every day.

with the concept of thinking fast and thinking slow by Kahneman (Kahneman, Daniel. Thinking, Fast And Slow. New York : Farrar, Straus And Giroux, 2011.) As clinicians much of what we do is “thinking fast” and we must force ourselves to “think slow” as a means of supporting our “thinking fast” conclusion. Affective decision-making is a “thinking slow” process that is very difficult. To make affective decisions, we must be able to recognize emotions in our self and understand that emotions are influencing our opinions and decisions. We must balance this with the rational influences to our decisions.

Fans of the show Star Trek will recall that Spock made all his decisions based on reason as he was devoid of emotion. Fans also will recall that

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Just as we are hamstrung by the dearth of evidence upon which we can form the rational portion of decisionmaking and opinion forming, we are hampered in dealing with the emotional aspect. One of the techniques leaders use to allow emotions to guide but not unduly influence formation of opinions and decisions is to manage those emotions. People manage emotions in individual and varied ways. Talking about and expressing those emotions is frequently present in many of those techniques. This is especially hard in this time of physical distancing as we are not able to gather together and express those emotions and sympathize with one another. We want to be a calming influence on our families and friends that we dearly love so often don’t even turn to them to let our emotions out. When emotions remain pent up inside they more likely to unduly influence our decision-making. Physician leaders must recognize this and

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DECISION MAKING: COMBINING THE EMOTION AND REASON

find ways to manage our emotions or at least realize they may be having an undue influence in our decision making.

Affective decision-making is crucial for each and every physician to understand and practice and never more so than during this journey through COVID-19. Engage in “thinking slow.” We need to take time to wrestle with both the emotional and rational aspects of the opinions we form and decisions we make every day. Consider the idea that opinions formed with an undue influence of emotion should not be shared widely

AAEM COVID-19 RESPONSE

on social media as it may serve only to fuel the emotion rather than foster productive dialogue. Our ability to make excellent affective decisions is crucial and will cause us to be viewed not only as “heroes” but as leaders.

This article was first published by KevinMD.com and is reprinted with permissions. ©2020 KevinMD.com www.kevinmd.com/blog/2020/04/combining-emotion-and-reason-indecision-making.html

AAEM POSITION STATEMENTS • 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 Self-Supplied PPE (3/23/2020) • AAEM Position Statement on Protections for Emergency Medicine Physicians during COVID-19 (3/20/2020) To read each statement, visit: www.aaem.org/resources/statements/position

JOINT STATEMENTS • 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 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 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 • 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

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Tales of COVID-19

COMMITTEE REPORT OPERATIONS MANAGEMENT

Crisis Management Kelly Holz, MD

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rises faced by EDs can be short-term, as in the event of a major accident or weatherrelated emergency, or long-term, as in a pandemic. In all cases, the role of operations management simultaneously becomes more critically important and less rigorously defined. This paradox is created by the need for polices and guidelines to be evaluated, adjusted, created, discarded, and re-instated in response to new information as it becomes available in a rapidly changing environment.

Overseeing the implementation and monitoring of these actions should be an incident command system. A coordinated and streamlined hospital incident command system is essential for effective response and management of emergency operations.

If not already established, an ad hoc command group should promptly be formed with the inclusion of representatives from To successfully navigate these crises, priority hospital administration, opmust be given to large-scale preparation for a challenges enerations management, comlengthy disaster response, not micromanaging Transparent communication is countered to date munication, medical personal daily affairs. This requires a degree of flexibility particularly crucial in establishing or expected in the from key specialties, human and discipline in making high-level decisions trust in the leadership, especially near future. During resources, nursing adminin a setting of uncertainty with incomplete or in times of pandemic when fears of times of emergency, istration, infection control, absent information. The operations team must personal safety and wellbeing are timely and relevant, respiratory therapy, security, be able to identify and manage uncertainties, heightened. but perhaps inpharmacy, engineering, and and be comfortable in their inability to predict complete updates cleaning and waste managethe future. Decision-making and communication are more useful than waiting for fully finalized ment. A similar command structure should be cannot be delayed in search of perfection in the plans.

Employees should be encouraged to be set up within the ED, with divisions to manage imperfect environment of a disaster. flexible and understanding as the operational key issues including communication, staffing, staff adjusts protocols and operations as often In light of these unsafety, logistics, finance, as needed in response to the evolving crisis. certainties, there are and wellness.

Additionally, relevant information should be guidelines on creating To successfully navigate these crises, Clear, accurate, and an effective disaster priority must be given to large-scale timely communication is relayed to the local media, both to provide reassurance to the community as well as to ensure response plan. Per preparation for a lengthy disaster important to ensure safe that the public has up-to-date guidelines on the World Health response, not micromanaging daily and informed decision when to seek emergency treatment.

Organizationâ&#x20AC;&#x2122;s hospital affairs. making and effective emergency response Transparent communication is particularly cooperation between checklist, the critical actions that should be crucial in establishing trust in the leadership, these key policy makers. Protocol updates and prioritized to support an effective and safe diespecially in times of pandemic when fears of revisions should be concise, and distributed in saster response include: personal safety and wellbeing are heightened. a manner that is easily and quickly accessible Protecting staff and creating a safe working 1) continuity of essential services; by all stakeholders, such as recurring huddles environment is paramount. Personal protective 2) well-coordinated implementation of hospital and emails, webinars, or a centralized reposiequipment (PPE) in line with national policy operations at every level; tory of information. Situational updates to staff and health authority guidelines should be made 3) clear and accurate internal and external should be made available as the crisis evolves, available and easily accessible to staff, prioricommunication; and should include an evaluation of the curtizing those most at risk if it is limited. Efforts 4) swift adaptation to increased demands; rent status of disaster response, guidelines should be made to centralize and conserve 5) the effective use of scarce resources; and on clinical practices, availability and limitations 6) a safe environment for health-care workers.

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on supplies or resources, and successes and

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COMMITTEE REPORT: COMBINING THE EMOTION AND REASON

PPE, and educate on and supervise appropriate use of PPE. Contrary to the traditional team approach in the ED, the number of team members participating in assessments and resuscitations may need to be limited during a crisis, to conserve PPE and reduce exposure.

A clear sick-leave policy for staff with confirmed or suspected cases should be established early, including guidelines for return to work.

Testing and vaccination of staff should also be implemented as applicable and appropriate.

for allocation of scarce resources, including access to testing, admission, and life support, should be created in advance, formally sanctioned by the hospital administration and ethics committee, and continually reevaluated as the situation develops.

Special attention should also be paid to wellness, with easily accessible and relevant resources provided to all staff. Efforts should be made to recognize how different staff members may cope with a crisis, and to identify those most at risk of burnout. Operational leaders must take care to not overlook themselves or neglect the emotional and physical toll crisis management can take on the individual and on the team.

Control of the vector in the hospital and ED is key to reducing morbidity and mortality of patients and staff alike, including limiting ports of entry, controlling and limiting visitor access, screening all patients for symptoms, and isolating symptomatic patients as soon as possible.

Calculating the maximum surge capacity of a healthcare system is a crucial step in establishing safe and rapid adaptation to increased demands. While sudden-onset disasters mandate an immediate, large-scale need of resources for a finite amount of time, a pandemic can often be expected to have a much more protracted course. Surge capacity should be identified by evaluation of available physical space and beds, healthcare workers and support staff, medications, and other critical care resources and supplies. Non-essential procedures and patient encounters should be canceled or delayed, with redistribution of clinical space, supplies, and staff to fulfill the demands of the disaster response. In the ED, existing treatment spaces or non-patient care areas may need to be modified or repurposed, and non-ED staff may be utilized in non-traditional roles. Plans

Successfully navigating crises is highly dependent on the pre-existing state of the organization and the social capital operational leaders possess. Without a reservoir of trust, well-developed leadership skills, and knowledge of each team member’s strengths and weaknesses, operational leaders will lack the foundation needed to survive a crisis and ready preparedness for the next.

Special thanks to the members of the Operations Management Committee who contributed to this article by sharing their experiences managing the COVID-19 pandemic crisis.

References: • World Health Organization. Hospital emergency response checklist: an all-hazards tool for hospital administrators and emergency managers. Geneva: WHO, 2011

• World Health Organization. Hospital preparedness checklist for pandemic influenza: focus on pandemic (H1N1). Geneva, WHO, 2009.

• US Department of Health and Human Services. Pandemic Influenza Plan https://www.cdc.gov/flu/pandemic-resources/ pdf/pan-flu-report-2017v2.pdf. Accessed April 19, 2020.

• Centers for Disease Control and Prevention.

Coronavirus Disease 2019 (COVID-19).

Infection control. Reviewed April 13, 2020. https://www.cdc.gov/coronavirus/2019-ncov/ infection-control/index.html. Accessed April 19, 2020.

• Chopra V, Toner E, Waldhorn R, et al. How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19). Ann Intern Med. 2020. doi: https://doi.org/10.7326/M20-0907 • Toner E, Waldhorn R. What US Hospitals Should Do Now to Prepare for a COVID-19 Pandemic. Clinicians’ Biosecurity News, Johns Hopkins Bloomberg School of Public Health Center for Health Security. February 27, 2020. https://www.centerforhealthsecurity.org/ cbn/2020/cbnreport-02272020.html • Hougaard, R, Carter, J. Perfectionism Will Slow You Down in a Crisis. Harvard Business Review.

• April 16, 2020. https://hbr.org/2020/04/ perfectionism-will-slow-you-down-in-a-crisis • McNulty, E, Marcus, L. Are You Leading Through the Crisis … or Managing the Response? Harvard Business Review. March 25, 2020. https://hbr.org/2020/03/are-youleading-through-the-crisis-or-managing-theresponse • Argenti, P. Communicating Through the Coronavirus Crisis. Harvard Business Review.

March 13, 2020. https://hbr.org/2020/03/ communicating-through-the-coronavirus-crisis

Access Your Member Benefits Get Started!

Visit the redesigned website: www.aaem.org/membership/benefits Our academic and career-based benefits range from discounts on AAEM educational meetings to free and discounted publications and other resources.

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Tales of COVID-19

COMMITTEE REPORT WELLNESS

Promoting Social Connection during COVID-19 Al’ai Alvarez, MD FAAEM; Dr. Aneesha Dhargalkar, MD FAAEM; Carole Levy, MD MPH FAAEM; and Robert Lam, MD FAAEM

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he COVID-19 pandemic has led to the implementation of social distancing, which has led to a decreased patient volume from non-COVID-19 related complaints. Along with canceled hospital elective surgeries and other major sources of revenue for the hospital, many emergency departments (ED) across the country, outside of New York City, the major hub of the pandemic in the United States, have implemented reduced staffing.

Furthermore, some physicians are not working due to increased health risks, adding to the decreasing frequency of clinicians interacting with each other at work. We simply are not seeing each other in person as much as we used to. In-person department meetings have also been rapidly converted into remote meetings, further exacerbating this loss of physical

Reinforce Purpose and Meaning

contact among clinicians in the workplace.

With all the emotions that come with dealing with this global pandemic – fear, anxiety, grief, frustrations, and a clear sense of lack of control – physical distancing and the feelings of isolation add to the moral distress that clinicians experience.

Left unaddressed, the literature suggests loneliness and isolation in medicine lead to decreased productivity, burnout, depression, and other mental health disorders, physician suicide and is even a risk factor for death.1-5 Loneliness and social network size have even been linked

• Celebrate together with colleagues when COVID patients recover and when they are discharged from the hospital.

to immune response as well as greater psychological stress, poorer sleep, and elevations in circulating levels of cortisol.6 A promising study of isolated senior citizens demonstrated that the use of SkypeTM for video chat had half the probability of depressive symptoms.7 Another study showed that an emotional connectedness similarly to in-person interactions could be achieved with video chat.8 In the time of social distancing, embracing technology as a tool to use with traditional strategies may promote teamwork, build community, and optimize use of positive psychology to enhance social connection.

We propose the following ways of combating isolation during the physical distancing restrictions of the COVID-19 pandemic:

• Utilize journaling. Keep a log of • Be detectives for random acts of each shift along with the thoughts kindness. Pause and recognize and emotions of the day. whenever you see goodness happening around you.

Support and Improve Clinician Team • Send funny memes or words of encouragement. Be careful about patient information when messaging a group via a personal mobile. ContextTM is a HIPAA compliant app that you can use via cell phone or computer for chats.

• Virtual cocktail hours can be beneficial for those who normally enjoy reveling in a postwork beverage with their friend or coworkers.

• Playing online games as a group can be a nice way to socialize from a distance.

Host an online game night, dance party, or escape room experience.

– Jackbox (www.jackboxgames.com) has a variety of games and you can make a trivia quiz for the group.

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– Crowd Purr (www.crowdpurr.com/livecrowd-trivia.html) – Mario Kart tour can be played multiplayer (mariokarttour.com/en-US).

– Animal Crossing can be played multiplayer (www.nintendo.com/games/detail/ animal-crossing-new-horizons-switch).

• Lead with optimism.

– As physicians, we are the team leader and we set the tone for the work environment. How we show up for work ultimately affects how the day will go for the entire team. Inspire.

• Lead with appreciation and gratitude.

– Highlight aspects of our work so that you

can show appreciation and gratitude to your team and your leaders.

• Continue to celebrate life events and other things that reinforce the cohesiveness of the team.

• Make time for a formal or informal debrief at the end of each shift.

– Check-in with your colleagues.

– Consider using a modified three good things platform.

– Focus on the positive things that happened during the shift.

• Send postcards. There’s something uplifting about receiving a personal note from someone in the mail.

Tales of COVID-19 COMMITTEE REPORT: WELLNESS

Encourage Connection to our Shared Humanity • Create a wall of post-it notes or memes in the break room or office space with encouraging messages or funny memes.

• Post notes of encouragement from the community.

• Bring in photos from home to post on the walls of the break room or office of the family, including fur babies. Include pictures from past social events.

• Pin photos of yourself to your PPE suit to humanize you to your staff and patients.

• Exercise and encourage self-compassion – treat yourself like you would treat a treasured friend.

• Do the 36 Questions with friends.

– ggia.berkeley.edu/practice/36_questions_for_increasing_closeness – With a group, have each friend respond to the question, then go on to the next one.

Personal Improvement / Professional Development • Start a book club to create a shared narrative. Make it an excuse to meet monthly.

• Start a virtual journal club or work on ABEM MOC articles together • Create an online band; rehearse songs together. Here’s a beautiful example from Italy – www.vox.com/culture/2020/3/13/21179293/coronavirus-italycovid19-music-balconies-sing.

Resources

Helping Others Has a Double Beneficial Effect Reaching out to others right now will not only help others but it helps the helper: Helping others increases happiness and our own well-being.

• Give blood if you are able. Convalescent plasma programs for clinicians that recover from COVID-19 can be a life-saving gift.

• Be a battle buddy. A battle buddy is a fellow peer and colleague. The goal is to have two clinicians partner together to support one another.

– www.peerrxmed.com • Organize a PPE drive. Here is an example of medical students participating in #PPEdrive.

• www.twitter.com/SU_FightCOVID/ status/1244653024200384512?s=20 Our work in the ED, and medicine, in general, can be isolating with or without the COVID19 pandemic. With social distancing, we can continue to physically isolate ourselves, while maintaining social connections. You can start now. Take a moment to reach out to someone.

Go ahead. Text a friend and share a moment of gratitude.

• University of Washington Department of Science of Social Connection depts.washington.edu/ uwcssc/content/staying-connected-duringcovid-19 Articles – Staying connected — at a distance (University of Washington News) www.washington.edu/ news/2020/03/12/staying-connected-at-adistance – Why You Shouldn’t Give Up on Virtual Happy Hours (Seattle Met) www.seattlemet.com/ coronavirus/2020/04/why-you-shouldn-t-giveup-on-virtual-happy-hours

• AMA – Peer Support Program Strives to Ease Distress during Pandemic American Medical Association, April 14, 2020 www.ama-assn.org/practice-management/ physician-health/peer-support-programstrives-ease-distressduring-pandemic – 5 Resources Built to Provide Emotional Support In Times of Crisis www.ama-assn.org/practice-management/ physician-health/5-resources-built-provideemotional-support-times-crisis • Peer Support – PeerRxMed - Free peer to peer program for physicians and others working in health care to provide support, connection, and encouragement. www.peerrxmed.com

References: • Heinrich, Liesl M., and Eleonora Gullone. “The clinical significance of loneliness: A literature review.” Clinical psychology review 26.6 (2006): 695-718.

• Cacioppo, John T., et al. “Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses.”

Psychology and aging 21.1 (2006): 140 • Stravynski, Ariel, and Richard Boyer.

“Loneliness in relation to suicide ideation and parasuicide: A population-wide study.” Suicide and life-threatening behavior 31.1 (2001): 32-40.

• Seppala, Emma, and Marissa King. “Burnout at work isn’t just about exhaustion. It’s also about loneliness.” Harvard Business Review 29 (2017).

• Holt-Lunstad, Julianne, et al. “Loneliness and social isolation as risk factors for mortality: a meta-analytic review.” Perspectives on psychological science 10.2 (2015): 227-237.

• Pressman, Sarah D., et al. “Loneliness, social network size, and immune response to influenza vaccination in college freshmen.”

Health Psychology 24.3 (2005): 297.

• Teo, Alan R., Sheila Markwardt, and Ladson Hinton. “Using Skype to beat the blues: Longitudinal data from a national representative sample.” The American Journal of Geriatric Psychiatry 27.3 (2019): 254-262.

• Sherman, Lauren E., Minas Michikyan, and Patricia M. Greenfield. “The effects of text, audio, video, and in-person communication on bonding between friends.” Cyberpsychology: Journal of psychosocial research on cyberspace 7.2 (2013).

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Tales of COVID-19

INTEREST GROUP REPORT PALLIATIVE CARE

COVID-19 Pandemic Draws Palliative Care into the ED Jessica Fleischer-Black, MD FAAEM

I

work in an ED in New York City. As of this writing, NYC has been the hardest hit of the U.S. cities during the COVID-19 pandemic. In some ways, it was inevitable. The city has over eight million residents and is one of the densest areas in the U.S. We use public transportation, gather for entertainment and dining, and have three international airports.

I have worked as the palliative care liaison for my department for several years. We are fortunate to have both a palliative care service and a hospice floor. A palliative care fellow is on call for our hospital 24 hours a day. Still, bringing palliative to the ED on a timeline that worked for the ED was often a challenge. If we called overnight, they would see the patient first thing

in the morning. If a patient was actively dying, they would provide recommendations for symptom management over the phone. Occasionally, they would be willing to talk with the family over the phone to help clarify goals of care.

Sometimes, the pager didn’t get answered.

Still, it was much more than other hospitals had access to.

As the number of COVID-19 cases across New York City soared, the palliative care team in our hospital system recognized the exponential 36

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need for their services. Some hospitals in the system had no palliative care presence at all.

Some of them, like our hospital, had a service, but that service was likely to be overwhelmed.

Furthermore, there was concern from the beginning that we might run out of ventilators.

While ED and ICU doctors strategized how to use one ventilator on two patients, the palliative care team considered how best to keep those patients who didn’t want extraordinary measures from getting on ventilators in the first place. How could we start having these conversations sooner, in the beginning of a patient’s hospital stay?

The Palliative Care Department at the main academic center put together a list of communication tips that was widely disseminated but quickly learned that the ED needed more.

Shortly thereafter, they established a 24-hour hotline connecting to palliative care-trained attendings and fellows who could have the conversation with the patient, family or health care proxy. As the volume of COVID-19 patients in the EDs increased, though, the calls dropped off. It wasn’t that there wasn’t a need — it was that with the surge of COVID-19 patients, the ED providers didn’t even have time to make the phone call to the 24-hour line. They needed more help. They needed someone on site.

At the same time that the EDs were overwhelmed, some of the hospital system’s services had less to do.

Elective surgeries and clinics were cancelled.

There were doctors who wanted to help. In my ED, we used ophthalmology residents to act as palliative care “runners,” serving as in situ palliative care extenders. They would see a patient, determine the decision-makers, get health care proxy paperwork filled out, talk with the family, and connect with the 24-hour line if it was felt that the goals of care were unclear. They also set up iPads for video calls because patients

weren’t allowed to have visitors. They helped patients and families connect at an incredibly disconnected time.

Redeploying these residents served so many purposes: ED physicians got onsite support, palliative care physicians got connected, and ophthalmology residents got an opportunity to connect to patients and families on a less clinical, more human, level.

How could we start having these conversations sooner, in the beginning of a patient’s hospital stay?

By performing these primary palliative care tasks, these residents provided valuable, patient-centered care during a challenging time.

It gave them the opportunity to help during a crisis that they might have otherwise had to sit out. As the volume of COVID-19 patients is waning, plans are being made to re-open clinics and restart surgeries. The residents will go back to their surgical subspecialty training. I will remember how helpful having someone dedicated to primary palliative care in the ED was during the crisis. Their training, done over video, was not difficult and could be recorded and used during another surge of patients. I strongly recommend that this model be considered in EDs that find themselves in similar situations in the future. For more details about the implementation of the 24-hour hotline, see catalyst.nejm.org/doi/full/10.1056/ CAT.20.0204.

Tales of COVID-19

SECTION REPORT EMERGENCY ULTRASOUND

Ultrasound Education in the COVID-19 Era Melissa Myers, MD FAAEM and Alexis Salerno, MD FAAEM

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edical education, including instruction in point-of-care ultrasound (POCUS), has been severely disrupted by the COVID-19 pandemic. Many of those in ultrasound education rely heavily on in-person, hands-on instruction and have had to completely change their approach in response to the need for social distancing. Programs across the country are adapting and adopting new forms of ultrasound education using alternative platforms.

Ultrasound education is an essential part of emergency medicine (EM) residency training. Most programs rely on structured ultrasound rotations involving hands-on teaching and feedback on clinical scans.1 For example, at the San Antonio Military Medical Center interns go through a month-long rotation with either fellow or faculty feedback on training scans as well as weekly Quality Assurance sessions. Many programs also include a competency assessment either during intern year or prior to graduation. This ensures that graduates finish residency with confidence in their POCUS skills.2 Teaching a procedure through a virtual platform requires an innovative approach. An instructor attempting to provide traditional instruction might need two or more cameras to show surface anatomy and the ultrasound screen. This can be difficult if the instructor is alone or if the cameras are not available. Fortunately, there are multiple other options available.

Ultrasound board cases translate well to a virtual format and can provide good practice. Many ultrasound program directors have archives of pathologic images that can be used for this purpose. Other images and cases are available for educational use through online resources such as the POCUS Atlas.3 Cases can be presented in an ABEM oral format.

Alternatively, learners can each take turns interpreting images. An element of feedback can be incorporated by including recent images and discussing the quality of images.

Teaching a procedure through a virtual platform requires an innovative approach.

Traditional lectures can be translated to a virtual format as well. Many platforms have a chat function where the audience can post their questions.

Programs such as Poll Everywhere™ allow for polling of the audience during the lecture to increase audience engagement. Lectures are also available from previous national conferences, including AAEM. AAEM Online is available through your AAEM membership.

Over the next several months, lectures which would have been presented at

the 2020 AAEM Scientific Assembly will be available through this portal.

This is an opportune time to conduct a virtual journal club. Consider sending out two to three articles for students to read prior to a set meeting time and organize a journal club debate. The students split into two groups and argue for or against a statement such as “POCUS use for the evaluation of an abscess.” Prior to the meeting, have the groups decide amongst themselves their main points and the evidence to back up their standpoint. This format encourages the learners to read the articles in depth and encourages discussion. Alternatively, consider a journal club scavenger hunt. Break the students into small groups and write a short list of searches that you want the students to find prior to the meeting time. For example, “find an article which shows that EM performed TVUS decreases ED visit time.” Depending on how big your group is you may want the students to find everything or one topic on the list. During the meeting have the students perform a short summary and analysis of the articles they found.

Regardless of the approach, the next few months will require us to use new and innovative teaching methods for teaching what is ultimately a procedural skill. Making full use of online platforms will allow those in ultrasound education to continue to train EM fellows and residents to the full extent of our abilities during this challenging time.

The views expressed herein are those of the authors and do not reflect the official policy or position of the 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.

References: 1. Amini, R., Adhikari, S., & Fiorello, A. (2014). Ultrasound competency assessment in emergency medicine residency programs. Academic Emergency Medicine, 21(7), 799-801.

2. Ahern, M., Mallin, M. P., Weitzel, S., Madsen, T., & Hunt, P. (2010).

Variability in ultrasound education among emergency medicine residencies. Western Journal of Emergency Medicine, 11(4), 314.

3. http://www.thepocusatlas.com/

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Tales of COVID-19

SECTION REPORT WOMEN IN EMERGENCY MEDICINE

Embracing Femininity in a Pandemic Lauren Maloney, MD NRP FP-C NCEE

W

hen I became an EMT in 2007, I could count on one hand the female paramedics I knew from working in the emergency room (ER) of a community hospital across the street from my high school. Female psych patient transports required a female provider in back, and because of how few women in EMS there were, some days the same paramedic would reappear half a dozen times. Those women were total badasses in my mind – they held their own, were wicked smart, quick with a joke, and could literally pull their own weight.

Later on in college as an 18-year-old female paramedic student in New York City, I quickly realized how naïve I was to the prevailing EMS culture.

I was told by a preceptor that “women are supposed to be nurses, and men are supposed to be paramedics, so you might as well just quit medic school right now.” I had a signet ring worn by three generations of women in my family resized to fit on my pinky, as wearing it on my ring finger attracted attention from men who believed I was married and therefore more desirable. I learned how to weightlift so my partners wouldn’t be averse to working with a woman in the pre-powerlift stretcher era. I took up reading automotive magazines and watching local sports so I could make conversation across the daily gender and generational gaps. Most of all, I learned to show no emotion, even after a patient attempted to stab me with a knife enroute to the hospital one afternoon.

I continued to work as a paramedic, graduated as one of the few women in my biomedical engineering class, was accepted to medical school, and spent hundreds of hours becoming a state and nationally certified EMS educator. I earned my flight paramedic board certification which allowed me to take a highly coveted position as a critical care transport paramedic, and went on to become a resident emergency physician, still working shifts as a paramedic until I was granted my own medical license.

As I finish an EMS fellowship and become an EMS Medical Director, I feel like I am finally in a position that I feel safe enough – respected enough – to show others that it’s okay to not be okay. That it takes more far courage to say, “I need help” than “Yeah, I’m fine.” To say we need a safety net for rough calls and to diffuse the cumulative occupational stress we endure.

This winter I teamed up with a paramedic supervisor and we began to craft a program called the EMS Code Lavender. Code Lavender started in a Hawaiian hospital1 as a way for healthcare providers to recognize and begin to heal from traumatic situations and unexpected deaths.

During a Code Lavender, a multidisciplinary team meets staff real-time, and while the team composition varies across institutions, all utilize some 38

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sort of lavender aromatherapy for the sense of calm and tranquility it’s believed to bring. To overcome operational challenges unique to EMS, we framed it in two parts: a consistent way to recognize and reach out to staff after acute events and a long-term wellness initiative. We formulated a set of initial criteria for notifying the Code Lavender Team about a call and hoped by making it analogous to using criteria to call a major trauma code, the program would be less threatening and remove the sense of “tattling” on each other. A webpage was created so that all the wellness and mental health resources already available to staff, though rarely known about, were in one location. We printed stickers with a QR code that links to the page for providers to put on the back of their ID badge.

Finally, we created a Google Voice number for notifications to go to. We planned to screen the notifications to determine if it was appropriate to reach out to providers via text or phone call, or if a Code Lavender needed to be activated for an immediate in-person response. Our grand plans involved rolling the program out in May during a series of departmentwide training days.

IF THERE EVER WAS A TIME TO HOPEFULLY GET BUY IN ABOUT ACKNOWLEDGING AND EMBRACING MENTAL HEALTH, SURELY IT WOULD BE DURING A PANDEMIC WITH NO REALISTIC END IN SIGHT.

Then COVID-19 hit, blowing our seemingly brilliant plans right out of the water. Within a week, we realized we were soon-becoming an epicenter in the COVID-19 outbreak. If there ever was a time to hopefully get buy in about acknowledging and embracing mental health, surely it would be during a pandemic with no realistic end in sight. We sent out an email explaining the program to staff, hurriedly gave out the stickers, and made the notification line live within several days. Much of the medical response to COVID-19 has evolved on a daily basis, the EMS Code Lavender response has evolved as well. In addition to maintaining daily peer contact with providers who are quarantined, we gathered items for care packages and purple teddy bears to give to those under strict isolation precautions. We started weekly happy hours via Zoom as a way for folks to laugh and breath together while enjoying a seltzer or adult beverage of their choice.We bought a supply of chalk for the therapeutic graffiti of EMS bay sidewalks to create visual reminders of the love, community, and gratitude that surrounds us.

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Tales of COVID-19

SECTION REPORT WOMEN IN EMERGENCY MEDICINE

I would like to believe that on some level, helping to spearhead this effort as a woman has made it more inviting and warmer. Channeling what I hope someday to be maternal love, to make it non-threatening and genuine. I admittedly have paused before I hit send on emails to the EMS staff, cringing, wondering about if what I’m writing is too “personal”, or “touchy-feely” or “emotional”. Then I think, so what if it is? Since when did saying, “I care about you as a fellow human” become taboo? I have endured what EMS is like without feelings and femininity, and I know that

my EMS reality right now, even in the midst of the worst medical nightmare of my lifetime, is something I am so very proud of.

References: 1. Karlamangla S. As health workers deal with mass shootings and fires, more hospitals are looking to help them cope. Los Angeles Times. 01/02/2018, 2018. https://www.latimes.com/local/california/la-me-ln-code-compassion20180102-htmlstory.html

SINCE WHEN DID SAYING, “I CARE ABOUT YOU AS A FELLOW HUMAN” BECOME TABOO?

27th Annual Scientific Assembly

SAVE THE DATE March 6-10, 2021 St. Louis Union Station

AAEM21 St. Louis, MO

www.aaem.org/AAEM21 #AAEM21

COMMON SENSE JULY/AUGUST 2020

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Tales of COVID-19

YPS Photo Collage of Life during COVID-19

SECTON REPORT YOUNG PHYSICIANS

Danielle Goodrich, MD FAAEM

T

o help showcase what we are going through during the COVID-19 pandemic, we requested YPS members submit photo representations of their lives during COVID-19. Please explore this photo collage from your Young Physicians Section.

Kimberly M. Brown, MD MPH FAAEM

Molly K. Estes, MD FAAEM Danielle E. Goodrich, MD FAAEM

Fred Earl Kency, Jr., MD FAAEM

Cara Kanter, MD FAAEM

Priya J. Ghelani, DO FAAEM

Becca Link, MD FAAEM Sara A. Misthal, MD FAAEM Matthew C. Bombard, DO FAAEM Kraftin E. Schreyer, MD CMQ FAAEM

Daniel J. Migliaccio, MD Mitchell Louis Judge Li, MD FAAEM

Maninder Singh, MD and Residents at Jacobi Medical Center

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Taylor Nichols, MD

Daphne M. Morrison Ponce, MD FAAEM

Greg Wanner, DO FAAEM

Tales of COVID-19

AAEM/RSA EDITOR’S MESSAGE

Managing Stress during a Pandemic Adriana Coleska, MD

W

hether it’s taking care of COVID+ patients in the emergency department (ED) or dealing with the social consequences, COVID-19 has greatly affected our lives. Our workdays are filled with terrified and sick patients, whose management is complicated by our continued lack of understanding of the viral pathogenesis and treatment options. But worst of all, when we finally get to leave the ED, we cannot go home and see our friends to debrief the hard day, spend time with our families, get a supportive hug, or go out and dance the stress away, even if only for a few hours. For those of you graduating this year like I am, social distancing also means no graduation party, no class photo, and no nights spent bonding with your co-residents before you all move across the country.

Despite the hardship that we endure due to the social distancing mandates, we as emergency physicians are the ones that understand the need for these measures the most. It is because of this that I wanted to share with you a few things that have helped me stay sane during this very isolating and uncertain time.

1. Use your time on a shift for social interaction As essential workers we have the privilege to continue going to work. For us residents, this also means that we can continue spending time with our friends. Use your downtime on shift to check in on each other, tell jokes, and take wellness walks. When calling a consultant feel free to ask them how they’re doing and check in to see what’s new in their life. Your time at work can be very stressful so make sure that you capitalize on the break from social distancing.

2. Virtual games and conversations are your friends Whether you prefer Zoom, Facetime, WhatsApp or Skype, set up virtual hangouts as much as you can. Though not as good as the real thing, a virtual happy hour or Jack-inthe-Box game night will successfully raise your spirits.

3. Get to know your co-residents While zoom conference and FaceTime conversations have become the new norm in keeping us connected, our residency has thought of other ways to keep us entertained. One such way has been our GroupMe Truth or Dare game, through which I’ve gotten to know my residents on a deeper level and have been blown away by their creativity. I can’t wait for our future virtual trivia night.

4. Take advantage of frontline worker specials Businesses around the country have been amazing at showing their support. Do yourself a favor and use some of these amazing deals. Get a subscription to a relaxation and mindfulness app to help you cope with the stress, sign up for free workout classes and sweat the frustration out of you, or summon the power of retail therapy. Pick one or all, but make sure that you prioritize your happiness.

5. Ask for help You know yourself best, and only you can tell if you are feeling overwhelmed. Please don’t hesitate to reach out to friends, family, or any of the confidential counseling services for help.

COVID-19 has been hard on all of us physically and emotionally. It is okay to be angry and upset by what this virus has taken from us. Know that you’re not alone and that there are many ways that we can get through this together.

And to all of you residents graduating this year: Congratulations, WE DID IT!!!

Please don’t hesitate to reach out to friends, family, or any of the confidential counseling services for help.

IT IS OKAY TO BE ANGRY AND UPSET BY WHAT THIS VIRUS HAS TAKEN FROM US

For those of you graduating this year like I am, social distancing also means no graduation party, no class photo, and no nights spent bonding with your co-residents before you all move across the country.

COMMON SENSE JULY/AUGUST 2020

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Tales of COVID-19

AAEM/RSA COMMITTEE REPORT WELLNESS

A Medical Student/Paramedic’s Perspective on COVID-19 Matthew Carvey

M

edic-1 is responding to an assault in a rural location.

Dispatch notifies EMS that the patient has a fever and was put on mandatory self-isolation for 14 days.

On arrival, EMS dons a sterile cap, goggles, an N95 mask, face shield, gown, and gloves.

The patient, belligerent and intoxicated on alcohol and psilocybin, yells at EMS ‘I have the COVID!’. She rushes EMS, removes the practitioners mask, and coughs in his face.

Police arrest the woman under the Mental Health Act, and EMS transports, only for her to spit and verbally abuse them the entire length of transport. EMS unloads the patient and awaits triage. After handing over care, EMS doffs all used PPE, and don’s new equipment to thoroughly clean the ambulance. One of the practitioner’s displays signs of COVID-19 three days later. This article is a medical student/ paramedic’s perspective on COVID-19.

The COVID-19 pandemic has united the medical community – physicians, nurses, researchers, respiratory therapy, EMS, housekeeping staff, and medical students – in the singular purpose of containing the virus. With this comradery comes shared challenges, such as fear of contracting the virus, overwhelming PPE shortages, and frontline staff burnout. Because of these concerns facing society, a unique population of medical students are continuing

To prevent viral spread, EMS protocols now necessitate strict decontamination of ambulances and aircraft, a requirement prior to becoming available for service.

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school online while simultaneously responding to nationwide callings to assist with surge capacity in their previous professions. Being on the leading edge of the frontlines, EMS practitioners are particularly challenged by these three aforementioned crises.

The shortage of PPE leads to unintentional exposure to COVID-19, causing all practitioners to enter precarious situations, triggering delays in patient care.

Contraction of the virus is on the minds of all health care professionals during this pandemic. With additional decontamination procedures, creation of COVID-19 protocols, and rapid modification to practice guidelines puts pressure on EMS to comply and care for patients. The reliability of screening questionnaires has also been problematic, with certain patient populations “lying” about recent travel or signs/symptoms of COVID-19 to receive care, further increasing the risk of under-protected EMS personnel. There are multiple explanations for why these issues have arisen, but the result is the same – EMS is unnecessarily vulnerable to COVID-19 when patients are inappropriately cleared. To prevent viral spread, EMS protocols now necessitate strict decontamination of ambulances and aircraft, a requirement prior to becoming available for service. This process can take hours from donning and doffing PPE, to wiping/spraying the ambulance/aircraft and ensuring all linen is disposed of appropriately, only to repeat this whole ordeal after transporting the next patient who is displaying signs of influenza-like-illness. Treatments such as nebulization of medication and intubation have also been replaced by “diesel” – a prehospital term for “scoop and run” – due to the potential risk for droplet contact, reducing possible early reversal of disorders such as COPD and respiratory arrest.

The need to protect against the virus creates a catch-22 in the delivery of prehospital care: delay patient care for proper PPE precautions or delay proper precautions to avoid interruptions in patient care.

The shortage of PPE leads to unintentional exposure to COVID19, causing all practitioners to enter precarious situations, triggering delays in patient care. From the perspective of the patient, those in cardiac arrest from the latter stages of COVID-19, or what we’re presuming was caused by COVID-19, are now down for additional time-dependant minutes as EMS dons all available PPE prior to entering ANY cardiac arrest situation. This precaution is necessary, but may be contributing to further deaths from a lack of early chest compressions and advanced cardiac life support. As PPE continues to be rapidly consumed, the inability to care for patients in the same capacity as done pre-COVID-19 will have dire consequences for patients and practitioners.

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Tales of COVID-19

COMMITTEE REPORT WELLNESS

The unsung nature of EMS is a primary reason many individuals enter this profession, not requiring praise or reward, but solely to be the primary caregiver during what is usually the worst day of a patient’s life.

Finally, the increase in patient fatalities is leading to a “pandemic within a pandemic” in the form of frontline health care staff burnout.

Emergency medicine (EM) staff are particularly vulnerable, as in EM no patient, regardless of disposition, is rejected from medical care.

COVID-19 has not only accelerated provider burnout, but also contributed to other mental health syndromes, such as acute stress disorder. The wide range of patient presentations

AAEM

EMS witnesses with COVID-19, fluctuating from fevers, and myalgias to chest pain, and cardiac arrest, makes this virus exceptionally hard diagnostically. The increased overall death toll to which this disease has contributed exacerbates the disastrous mental stress on EMS. The number of cardiac arrests has drastically risen each tour, an outcome not just unique to pre-hospital care, but also hospitals. Transportation of artificially ventilated patients, only to know the ventilator will be removed to assist those who require it more at the receiving facility is making interfacility transfers, relatively low stress calls pre-COVID-19, emotional minefields. The tendency of EMS practitioners to suppress their emotions in these circumstances – often a necessary coping mechanism of the job – could lead to disastrous mental health consequences post-pandemic.

The unsung nature of EMS is a primary reason many individuals enter this profession, not requiring praise or reward, but solely to be the primary caregiver during what is usually the worst day of a patient’s life. Is the martyr nature of EM worth the potential chance of contracting COVID-19?

Everyone in EM has weighed this risk, putting their lives on the line to care for those affected by this pandemic. Does the community understand the danger practitioners are putting themselves in everyday? Poor compliance with public health guidelines that have been recommended, which does not seem to be driven by malice for health care workers, but by a shift in societal rules to include enforcement of self-isolation and social distancing, causes the population to become agitated and instigate scenarios such as the vignette described above. Until this pandemic produces not just a “flattened curve”, but a society that heeds the advice of public health experts and frontline staffs’ cries for compliance, we the frontline staff will continue to put our lives on the line to care for a population that pushes against the ideals we see necessary to end this pandemic and return to “normalcy”. Because of the duty we feel to care for others, no matter how great the personal risk, we will always be there, 24/7/365.

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Tales of COVID-19

JAFERDs Can Do It Elizabeth Paterek, MD FAAEM

I

t is the calm before the storm where I practice in Philadelphia (at least it is at the time I’m writing this). New York and Northern New Jersey are already struggling and I fear what’s coming next. We are poised to fight a war without adequate protection or support nationally. I want to believe that we can do it..

The Sun Is Rising Monica Anita Gupta

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he sun is rising with each shivering step I take.

It’s still dark out, but I see pink creeping into the blue: spring pastels to match the canary yellow gowns inside.

Cotton candy dreams. A veneer of peace.

A flock of birds welcomes it in, nibbling, eager for a taste of life, thirsty for the warmth of sun.

Show me how you fly, you birds.

How, on little nibbles, you get by, consuming little, yet soaring long and wide and far and singing, enthused about the dawn you’re bringing, with faith in the power of the morning sun.

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Tales of COVID-19

Is There Opportunity Amid this Pandemic?

Robert Frolichstein, MD FAAEM

“It was the best of times, it was the worst of times,”

Heroism happens because, for the most part, each of us feels that we are called to this profession rather than it just being a job.

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e are living in unprecedented times that will be pivotal for our beloved profession. In the Dickens novel, A Tale of Two Cities, quoted above, the period of time in which the story was set was pivotal in the evolution of society and politics. Our current times may provide the setting that allows physicians to regain independence from the medical industrial complex that is the current state of the delivery of healthcare in the U.S. We know that we have a vital perspective in determining how healthcare should be delivered to the American people.

We have limited ability to use our knowledge to influence the vehicle that delivers healthcare to the population. For many years, perhaps decades, physicians have been a cog in the money-making machine that is the U.S. healthcare system. A vital cog that has been carefully and systematically undermined such that our past role as leaders is only rarely and sporadically apparent. We know this and feel it every day. Its symptom is burnout. Is that because our leadership is spurned or because we failed to demonstrate skillful leadership? Both?

The current pandemic is highlighting our diminished position within the greedy medical industrial complex and perhaps exposing a fragment of why this has happened and suggests a path forward.

As is typically the case, we have seen numerous examples of the heroism of physicians throughout this pandemic. Heroism happens because, for the most part, each of us feels that we are called to this profession rather than it just being a job. That is admirable and inspiring. It is the single greatest hope for the future of our profession. It is why we will get through this pandemic.

Our position of being able to incorporate both the emotion and the reason into decisions, makes us uniquely qualified to be leaders of the “system.”

I suggest to you that the single biggest reason we feel that we have been diminished to the role of a cog in the machine is because the “system” figured out how to make money from our interaction with the patient. I suggest to you a small, but unimportant reason is because, as a whole, we are viewed by “management,” in general, as lacking skill in making affective decisions. We are often seen as the physicians crying out with emotion for change. Too often, that is viewed as an irrational response — “you don’t understand the business.” Those that do not have the emotional connection to patients that we have are limited in their ability to incorporate those emotions into their affective decision making. We have to understand that limitation and advocate for change with that in mind. Our position of being able to incorporate both the emotion and the reason into decisions, makes us uniquely qualified to be leaders of the “system.”

These are the “worst of times” for healthcare in my lifetime. There will be lasting changes to our system. Physicians need to embrace this period as a time that we can be viewed not only as “heroes,” but as leaders. If we all practice affective decision making we can, and will, change the future. A future where physicians are respected not only for their role at the bedside and as money making cogs in the machine but also for their role in redesigning a system to deliver healthcare to the public that places the patient-physician relationship at the center. Imagine such a system.

A system only designed to support the needs of the patient and the physician taking care of that patient. Gone would be the debates over balance billing, due process, proper integration of NPs and PAs into the team, insurance premiums and all the rest. This is our chance to look back on this pandemic and see that it was ironically the event that led, at last, to the “best of times.”

This article was first published by KevinMD.com and is reprinted with permissions. ©2020 KevinMD.com www.kevinmd.com/blog/2020/05/is-there-opportunity-for-physicians-in-the-pandemic.html COMMON SENSE JULY/AUGUST 2020

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Tales of COVID-19

The Role of Quarantined Medical Students Jason Wang, MBS

I

had the opportunity to recently travel to Eagle Butte, SD to work with the Indian Health Services Hospital on the Cheyenne River reservation. With limited resources and providers, I was given the opportunity to work closely with patients as a third-year medical student.

My attending physician entrusted me with the responsibilities of an intern, inputting orders and creating treatment plans. As a student, I learned the necessity of calling down to the laboratory when I added another request after initial blood collection. I researched society guidelines to learn proper antibiotic dosages.

It was a great opportunity to be thrust onto the forefront of emergency medicine, seeing patients, seeing results in real-time, and making clinical decisions accordingly.

Watching my colleagues and peers being thrust onto the frontlines in New York, Washington, and California, I am both envious and nervous.

This experience also proved to be quite nerve-wracking. On my first day in the ED, I was uncertain that I had put in all the correct orders, constantly double-checking my orders and plans with my attending. I poured over and reread the same articles multiple times to make sure I had memorized the correct duration of treatment for otitis media versus streptococcus pharyngitis. Falling asleep at night became more difficult, as I ruminated about each day’s decisions and whether I had mistakenly over- or under-diagnosed my patients. Fortunately, I was never tasked with the most complicated patients, but I couldn’t shake the worry.

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Now, as hospitals are starting to call students back to help, I am hopeful that we will help with this pandemic and hopeful that those who aren’t returning to rotations will be spending this time getting the training to be even more effective once we finally get back into the emergency room.

Watching my colleagues and peers being thrust onto the frontlines in New York, Washington, and California, I am both envious and nervous.

I trust that our academic preparation and clinical training. I know that we are capable of seeing patients and understanding what diseases may be afflicting them. However, I still worry that we are being thrust into positions for which we may not be ready. What happens if we overreact and place a patient under droplet precautions and unnecessarily waste PPE? What if we don’t recognize a PUI and expose healthcare professionals to the disease?

Our hospitals, and more specifically our emergency rooms, are being overwhelmed. As our healthcare professionals are drowning in this COVID-19 pandemic, I want students to step up to the calling that drew them into healthcare.

I also want to caution against reaching out to whatever resources are available, especially if they can be harmful to the system. I know that we are capable, but there is definite training that we will need in order to contribute to emergency rooms. I’m disappointed that clinical rotations were suspended. Even though this was necessary to redirect personnel to direct healthcare, it unintentionally interrupted our training. This lapse has left medical students scrambling to catch up. We have missed a critical opportunity to train medical students in proper triaging skills, or as scribes for overburdened resident and attending physicians. Now, as hospitals are starting to call students back to help, I am hopeful that we will help with this pandemic and hopeful that those who aren’t returning to rotations will be spending this time getting the training to be even more effective once we finally get back into the emergency room.

Tales of COVID-19

One Month Stephanie Benjamin, MA MD

FEBRUARY 29, 2020 Happy Leap Day! Sitting in my backyard, listening to the birds and the wind chimes, pushing aside my ever-growing concerns about COVID-19. I checked my old journals but apparently didn’t write anything on the last leap day. Makes sense – 4 years ago I was in the midst of my intern year of my EM residency. But now, I’m more than halfway through my EMS fellowship, casually house hunting, and chats with my hubby have recently revolved around starting a family.

MARCH 1, 2020 About to head into a nightshift. One of several emails today noted that our N95 masks are now under lock and key behind the nursing station. So many sick people. Washing my hands a lot. Hoping to not get sick…

MARCH 6, 2020 Planted our summer garden! The usual array of squash, tomatoes, eggplants, potatoes and peppers are in, as well as a variety of herbs.

MARCH 9, 2020 People are panicked and freaking out, spreading rumors and gossip on social media. Seems like everyone is worried, but no one is staying home. I can’t stay home, I need (and want) to keep working, but other than my ED shifts, I’m not leaving my house.

I don’t want to contribute to the societal burden. Told my 70-year-old parents (who live in Manhattan), and my sister (who has 4 small kids) to hunker down.

MARCH 11, 2020 Trying to order COVID testing is a mess.

“Infection control” (not infectious disease, to be clear: infection control folks are NOT doctors) implemented a password restriction on obtaining tests. The password is only given if they (again, NOT doctors) approve the test.

One of my patients arrived in respiratory

distress, and met all the high-risk criteria and classic symptoms, except for recent travel to China or Italy. Infection control declined my test request. ALL requests for testing last night were declined. A co-worker hacked the system and we covertly ordered the tests anyway. It’s insane. People are going to die as a result of the ineptitude.

MARCH 12, 2020 Between not being able to test patients, the projected number of millions infected and dying, and seeing the empty grocery store shelves, my morning began with a panic attack. I stress-cleaned the house within an inch of its life. Then I moved on to stresscooking. I made stir-fry with a mix of homegrown and store-bought veggies. I’m calmer now, but still worried about my parents.

protocols, and contributing my medical opinion on topics ranging from neb treatments to paramedicine to PPE. I can fight now. I’m not helpless anymore, yet at the same time, I feel as if I’m a pawn being shuffled around at the whim of our psychotic government. Deep breath. It’s been an emotional few days and now it’s late. I should go to bed. Need to be ready for more meetings and more bad news tomorrow.

MARCH 16, 2020

The constant emails and texts and online meetings are a continual source of stress.

Probably should avoid social media for a while, at least until I calm down, and probably after that, too. Reminding myself that there’s nothing else I can do helps. We have plenty of food and water and toiletries and entertainment. But my mind keeps wondering if I’ll get sick. Or my family. Or my husband. It feels as if the world is pressing in on me.

All the bars will close indefinitely at midnight.

And no dining-in anymore. At all. How surreal. What a simple thing – going out to eat. I wonder the next time we’ll eat at a restaurant.

Months? Years? And I leaned that my city currently has a three week supply of masks.

Seems like we’ll run out right at the peak of things. Well, who knows when the peak will be. Everything is speculative. Perhaps people will stay home, and we won’t have a peak? Ha. Yeah right. In the meantime, I’ll keep working on protocols/policies for the county and the city and doing whatever else is needed from me. This is my job. I’m here to help.

MARCH 14, 2020

MARCH 17, 2020

MARCH 13, 2020

The situation continues to evolve (unravel, devolve, dissolve?) into chaos. We’re still limited in the amount of testing we’re allowed to do. I’ve had over 100 emails today about COVID and am trying not to spend my day on the news.

MARCH 15, 2020 9/11 and Katrina put me on the path to disaster medicine. In the past, I couldn’t do anything. I was helpless. Now, I’m an EM/ EMS physician. I’m writing and reviewing

Things are changing rapidly. Time to read a bit (American Gods, by Neil Gaiman). I’ve taken to avoiding social media before bed.

Any wonderful news or any terrible news makes me cry. A cartoon of superheroes looking at an ED doc and saying, “Welcome to the Club,” triggered the waterworks. The Spanish citizens who cheered from their balconies as medical staff returned home from a shift unleashed the dam as well. So far I’m keeping my shit together at work. >> COMMON SENSE JULY/AUGUST 2020

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Tales of COVID-19

ONE MONTH

MARCH 18, 2020

MARCH 23, 2020

We had a St. Patrick’s Day online happy hour with our friends last night. Seems like everyone around the country is having similar experiences with anxiety and fear and frustration, but seeing their faces and hearing their voices was a needed reminder that I’m not alone.

Work is terrifying. I wonder if anyone else feels his or her pulse quicken or anxiety flare when donning PPE. I felt the panic. I faced it. I cared for my patients. I don’t see how it’s possible not to get sick. Even with all the hand washing and hand sanitizing and whatnot. We all work in such close quarters.

MARCH 19, 2020 The deluge is coming. I can feel it. People are on spring break, ignoring social distancing, spreading it around. People are going to die. A lot of them. A million? Less? More?

My own odds: almost certain to get infected, unlikely to die. Maybe I already had it and am fine. Need to pace myself at work, not burn out. Need to be ready for the long haul. It feels like I’m in a movie, one where a small group knows what lies ahead, and everyone else in society is voluntarily/volitionally clueless. And then all hell breaks loose. We’re at that point. All hell is about to break loose.

MARCH 20, 2020 Watching The Lord of the Rings. Needed an epic, courageous tale of heroes across the realms banding together, a reminder of hope in dark times, and the triumph of good over evil. I lost it when Pippin said, “I don’t want to be in a battle, but waiting on the edge of one I can’t escape is even worse.”

MARCH 21, 2020 The thought of starting a family has slipped out of our reach. We can’t. Not now. I worry everyday about my friends that are currently pregnant. I’ve accepted who I am and what my response will be. I will work. I’ve already picked up extra shifts, and signed up to be available for backup for when others cannot work. I will accept the consequences, even if that means getting sick – though of course I will do everything possible to protect myself.

I can fight now. I’m not helpless anymore, yet at the same time, I feel as if I’m a pawn being shuffled around at the whim of our psychotic government.

MARCH 24, 2020 (Remote) meetings all day. All. Day. All about COVID-19. Hospital, regional, city, county, state, and national meetings. As the EMS fellow I’m invited to join all of them, which means I learn all the concerns that everyone has about everything related to this pandemic, from limited PPE to hacking ventilator tubing to keeping EMS safe to nursing homes and prison outbreaks, to the homeless to the lack of any convincing evidence for any effective treatment. The tsunami is about to hit. I hope we’re ready.

MARCH 25, 2020 I range between feeling okay, and abject panic. Yesterday was a rough day. Today so far is better, but if I think too much about the lack of ventilators and the exponential number of cases then I’m sure I’ll panic again. For now, staying home (as usual), and then off to another ED shift tonight.

MARCH 26, 2020 Home from another shift, freshly showered, and disinfected. The skin on my hands, especially my right hand, is cracked and red

I should be okay, right?

And perhaps this will all be under control by the summer. Or by next spring. Or perhaps by the next Leap Day. 48

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and burning from all the hand sanitizer. The respiratory cases are increasing. Had a tricky case with one of my interns and even though we stabilized the patient, I’m still rethinking every order and every medication we gave, trying to make sure I didn’t miss something.

The admitting physician commented something to the effect that it probably doesn’t matter what we did, because if the patient

ends up being COVID positive, they will probably die anyway. Ouch. That doesn’t mean we don’t try! It’s 2:30am, time for bed. I’m hoping to fall asleep and not dream/nightmare about work. Again.

MARCH 26, 2020 Trying to remember what life was like before COVID. I had recently accepted an EM/EMS faculty position at my University. I had been writing and publishing a ton. My husband and I were planning a trip to Italy. My husband and I were planning to start a family. My whole family, all in NY, was planning to visit us here in California.

I’m scraping the barrel for silver linings: We planted a large garden, which is minimizing my husband’s trips to the grocery store.

Our recipes have become more creative as ingredients run out. The dogs love that we’re home more. I talk to my family a lot on FaceTime, and so far everyone is still healthy.

I thank them every day for heeding my warnings to self-quarantine before NY turned into the cesspool that it is today.

MARCH 27, 2020 PPE is spread thin. I have a single N95 per shift, but way more than 1 potential COVID patient per shift these days. The healthcare system is on the brink of collapse. Perhaps in NY it already has collapsed. Same with the economy. The government is still working >>

Tales of COVID-19

ONE MONTH

MARCH 29, 2020

against us. My friends and colleagues are getting sick. More every day. Young people are dying. A cardiology fellow died. Someone like me, right on the cusp of completing a dozen years of medical training, dead. I lost it.

Sitting in my backyard, listening to the birds and the wind rustling the leaves. It’s been a month. Everything’s changed. One day my hubby and I will revisit our plans to buy a home and start a family.

Not anytime soon. My anxiety still occasionally peaks, but overall has numbed to a dull ache. I’d write more but I have to get ready for my next shift. I’ll keep working until I get sick. Until I can’t. And when I get better, I’ll go back to work and keep at it. I’m assuming I’ll recover. I should be okay, right? And perhaps this will all be under control by the summer. Or by next spring. Or perhaps by the next Leap Day.

MARCH 28, 2020 Going to work feels like playing Russian roulette. I updated my will. Well, technically I didn’t update it, I wrote one. I never had one before. I’m 36-years-old. Having to write a will when you’re still paying off student loans seems unfair, even absurd. I suppose a lot of this is, though. And so much of it was preventable. So much. Help us.

Please. Stay home.

Join an AAEM Section

Sections of AAEM give members the opportunity to get more involved in AAEM in an area that they are especially interested in. Sections all have their own bylaws and members pay dues to be a part of the section. See below for more information regarding the different AAEM sections that you can join.

Critical Care Medicine Section Critical care is an ever revolving field with major advances, and the goals for this section are to keep you up-to-date by writing guidelines or position statements, networking, developing a job database, and providing mentorship. The Critical Care Medicine Section (CCMS-AAEM) aims to engage your clinical interests.

Emergency Medical Services Section We are excited to announce the new Emergency Medical Services Section of the American Academy of Emergency Medicine (EMSS-AAEM)! Our section is founded to foster the professional development of its members and to educate them regarding emergency medical services.

Emergency Ultrasound Section We are excited to announce the new Emergency Ultrasound Section of the American Academy of Emergency Medicine (EUS-AAEM)! Our section is founded to foster the professional development of its members and to educate them regarding point of care ultrasound.

Women in Emergency Medicine Section The Women in Emergency Medicine Section (WiEMS-AAEM) 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.

Young Physicians Section AAEM Young Physicians Section (YPS-AAEM) membership is open to all emergency medicine residency-trained Fellow-in-Training, Associate or Full Voting members of the American Academy of Emergency Medicine who are within the first five years of professional practice after residency or fellowship training.

Learn more at: www.aaem.org/get-involved/sections

COMMON SENSE JULY/AUGUST 2020

49

Tales of COVID-19

Class of 2020: Match Day during a Pandemic Gloria Felix

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opened my email on March 20, 2020 at 11:59 am: I matched into emergency medicine, at a program that serves my community and one where I used to volunteer when I was a teen. After years of living away from home, I get to come back!! I was overwhelmed with nerves, happiness, and joy.

At 12:15pm, I hear the familiar ringtone from my computer, time for our virtual match day party! My fellow 4th years shared our new destinations and jumped for joy for one another. For the past four years we’ve been each other’s support system, we’ve laughed together, studied together, cried together, and here we are – the day we’ve been dreaming of has arrived. We finally did it! We are going to be physicians serving communities all over the country. We laughed, shared silly stories and jokes with liners of “remember that time” or “O man I never thought I’d make it past class…” but here we are. We made it! After rounds of laughs and trips down memory lane we said our “see you later and stay safe everyone” farewells and signed off.

The screen shifted to black, I sat in front of my computer, and suddenly once the adrenaline started to wear off, I started to feel reality set in. I was going to be an emergency medicine intern at the epicenter of the pandemic. I began to feel fear. Will I be able to keep up? Will I know what to do when a family member sees MD on my ID badge and is asking for help? Will I get I was going to be an my family members sick when emergency medicine I come home? Suddenly the intern at the epicenter excitement and joy I felt was of the pandemic. I overshadowed by fear. A list of began to feel fear. what if scenarios one after the other were playing in my mind on repeat.

I muted the fear, at least for that day, and tried to focus on spending time with my sister and nieces who I hadn’t seen for months. I sat around the table with them as we cut the fluorescent pink match day cake they had bought for me. My niece continued to sing a happy “match day” song on repeat and for a moment my doubts were silenced.

I woke up the next morning and I felt different. My world had changed overnight. I was no longer waiting for where I would be spending the next four years.

I already knew. My contract offer was signed and emailed. My new EM family welcomed me and the intern group chat was already booming with funny

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emojis and excitement for meeting each other. I started to feel the familiar mixture of excitement and fear.

We finally did it!

We are going to be physicians serving communities all over the country.

I reached out to my fellow 4th years and future co-interns and asked, “is it me or are you guys feeling kind of scared?”

We all were prepared for the traditional novice feeling of moving from medical student to doctor. We’ve been reassured about it being completely normal and everyone feels that way, but no one would have imagined that the class of 2020 would have to be prepared for being novices in what has been compared to be a warzone, a fight against time, and an uphill battle to find resources to keep patients alive.

My worries were not just my own.

My fellow 4th years shared the same concerns, my co-interns flooded the chat with words of encouragement and funny videos to ease the seriousness we are facing, and mentors began to share that although they felt immense joy for me, they also felt concern and wished me to be safe.

In sharing my fears, I began to feel less afraid. I am not alone in being scared. I am not alone in wanting to help but not being sure how to do so.

To my fellow 4th years who are entering or have already entered the frontlines of this pandemic, you’re not alone. The class of 2020 is resilient and we will make it through this together. Our voices and sharing our stories make us stronger and empower us during these uncertain times.

The class of 2020 is resilient and we will make it through this together.

I congratulate all of the incoming interns and seniors who will soon be attendings for your accomplishments. It is a crazy time to join the emergency medicine family, but we are in this together!

Stay safe, stay resilient.

Tales of COVID-19

The COVID-19 Experience Outside of the Epicenters Robyn Hitchcock, MD FAAEM

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e’ve all read the heartbreaking stories of what’s going on in the epi centers in New York City, the Seattle area, Detroit, etc. Clinicians drowning in their work. Typical ICU care turned on its head because standard management of respiratory failure isn’t working. One day we’re told if they start to crump intubate early because using BiPAP and even nebulizers spreads and aerosolizes the virus putting everyone in the department at risk. The next day they’re telling us don’t intubate until very very late because even ventilating them puts them at risk. Then we’re told use higher lung volumes than you think and less peep and then the next day they switch it. Wait, now we need to try prone ventilation and even rolling your patient regularly to expand and drain different parts of the lung.

Nobody really knows how to manage this because it’s not playing by any typical rules.

Everyone’s trying to figure out how to split one ventilator to be able to vent from two to four people because there’s such a shortage.

Anesthesia societies and pulmonary societies are coming out against this practice but some places have no choice. Human rights groups are up in arms because some facilities and states with shortages are making age cut-offs, or not treating the mentally retarded as aggressively to save a vent for perhaps a college professor instead. We are hearing tearful pleas from nurses that are working in intensive care with staffing ratios that are inconceivable: 19 patients to one ICU nurse with no relief because their colleagues are getting sick or refusing to come to work because of the dangerous staffing ratios. Orthopedic surgeons, dermatologists, and ophthalmologists who have had their clinics closed are retraining for ICU and ER care to help their overwhelmed colleagues.

These are the stories that most people are seeing and read about every day for the past month and more since this COVID pandemic has become real.

But this is not the experience for most of the healthcare workers in this country, and at this time I am working primarily at places that have not yet peaked their use of resources.

Right now I’m at a hybrid freestanding ER / urgent care facility in the southwest. Our usual complaint is volume. This facility was designed to see about 75 people a day and over the holidays we were seeing upwards of 150 to 200 and experiencing 5-hour waits routinely, etc. It was exhausting and frustrating for all of us. Things seemed to be settling down in January and February to a reasonable number to handle, typically between in the 120 to 140 a day range sometimes less. Then COVID-19 happened. In early March the very few patients we had coming through, we were able to put in our one negative pressure room, and have full PPE available for staff. I don’t think we had a test yet on site at that point, and we had to call the department of health to even get approval for the very few tests that were available.

just coming around to that on April 11th. The facility I’m working at which is always drowning in people, is barely seeing half of their previous volumes. That’s good and it means people are staying home like they’re supposed to.

Unfortunately, the side effect of that is we’re seeing heart attacks stay home and not get intervention until it’s too late. I’ve seen abdominal pain stay home and progress from simple diverticulitis, which we can treat with antibiotics, to bowel perforation which needs surgery, a drain, and sometimes a colostomy. There are many, many people that come in with very minor symptoms like a runny nose, watery eyes, mild GI symptoms. The more we read about COVID the more we realize it can present with just about anything. So anyone with shortness of breath and cough, or a fever and just about any other symptom is “rule out COVID.” Many of these we are trying to see in the car and then our outdoor tent to avoid bringing them in to avoid exposing both our patients and our staff.

If their vitals are normal and lungs are clear we

Unfortunately, the side effect of that is we’re seeing heart attacks stay home and not get intervention until it’s too late.

In the interim I left to go back home and go to Stanford trying to get a loved one operated on which got canceled because of the pandemic.

During this time I fortunately missed when one of these facilities was designated the local testing site and things were pretty chaotic for a while. They moved the elective testing site to a park outside of town so this site is now just seeing sick people again.

I returned to work April 8th. This is right around the time when the New York and California sites were starting to peak and finally flattening their curves, But the smaller communities with delayed onset of symptoms had often not even closed their federal facilities and parks, and certainly were nowhere near their peak. Many states issued a stay home order by mid-March but this state was

will generally test them and send them on their way. If they’re sick enough to need more evaluation we bring them into the tent and if they’re really sick we bring them inside.

Again, most of these are going to test COVID negative and you know it, except when they don’t. So you have to don full PPE, we are given one N95 mask and face shield to reuse for the entire day. And then we’re even saving those at home at the end of the day in case they run out or in case our health system figures out how to reprocess them for reuse.

We are also assigned one surgical mask a day, which we are supposed to wear all day long. This is actually our more important mask to protect our patients and each other.

And it’s the most exhausting one to wear. I’m

>> COMMON SENSE JULY/AUGUST 2020

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Tales of COVID-19

The COVID-19 Experience Outside of the Epicenters

claustrophobic and struggle with wearing a mask at all for more than a few minutes. The N95 mask makes me absolutely feel like I can’t breathe so I’m stuck with a surgical mask most of the time and just switch to the N95 when I

wears a mask and could be infecting me as I walk into any room. I have to assume I’m an asymptomatic carrier. So I’ve made myself into a leper. At my travel assignment, I will not allow housekeeping in my room until I leave to mini-

I feel more connected than ever to my ED colleagues as we get through our shifts and try and keep our spirits up, together. go in a patient room with suggestive symptoms or known COVID. It used to take a week to get the test back, now we’re seeing them generally in 24 to 48 hours, but it’s still not enough time for those of us on the frontlines to rule in or rule out needing PPE. It is really hard to maintain super caution in a high level of suspicion when you know what you’re dealing with is mostly not COVID. The rest of the time I am wearing a simple surgical mask which offers me little or no protection, but will protect my patients and coworkers at least somewhat if I’m an asymptomatic carrier. It would be ideal if they would do the same but some people (co-workers) keep taking their masks off. I would also prefer we mask every patient that came in the door for the same reason, but apparently we don’t have enough to do that so we’re only masking people with symptoms. Well, that works until it doesn’t.

People are thanking us for what we’re doing.

We’re just going to work. At these facilities, the acuity isn’t very high and we’re not seeing very sick COVID patients. At least not often.

We’re still at least two weeks away from our projected peak in New Mexico. People keep buying us food: lunches from local restaurants roll in with thank you notes. It feels somewhat disingenuous to accept this gift because really we’re working less than we typically do with the volumes being lower and all that. So add guilt to the table as well.

But the human fallout of this experience is very real. I’m extremely careful with hand washing and PPE, but not every one of my patients

mize their exposure. I am obsessive with the six foot social distance compliance. I wear a mask whenever I leave my room to protect others. I won’t go in an elevator if somebody else is in it.

I move into clumps of weeds on a walking path to make sure I’m not exposing anyone going for a walk, etc. etc. It’s exhausting. I feel like I’m walking poison and must stay away from other people. This is not a pleasant feeling.

And what’s happening at work? Right now the facility I work at is actually pretty slow with low volume. We have a little too much time to spin and talk about the what ifs. Healthcare workers are being laid off all over the country. NOT just at elective facilities like eye clinics, low acuity doctors offices, outpatient surgery or procedure centers, dermatology and aesthetics, physiatrists and physical therapy, etc. Even ER nurses, yes ER nurses and doctors are being furloughed and/or asked to be take mandatory pay cuts because the volume is down. Much to my surprise many people (patients) actually are trying to stay home as much as they can. So not only are we putting ourselves at risk everyday by going to work, we’re being offered less work. Or less pay to do the same or both. Many are being forced to take less hours than they are contracted for or mandatory pay cuts. And it is strictly forbidden to travel to the areas that need help because then that puts you at risk and you would have to have a two-week quarantine before returning to work which would then put you in violation of your contract.

I understand the hospital administrations have to keep their patient population safe but the catch-22 of so many healthcare workers out of work, yet so many systems desperately needing help and the one not able to go to the other makes my soul cringe. Maybe one good thing that could come out of this, since all of the hard hit areas are offering fast track to licenses, which usually take 6 months or more, would be centralized licensing. The medical licensing community will realize we actually all have the same training and if you are licensed in one state you should be able to be licensed in any state. Medical licensing should be a national thing. It’s ridiculous to have to redo this process for every state you work in, and maybe there will be a push for this to happen but honestly I wouldn’t count on it. It would make too much sense.

I’m lucky so far that many of the facilities that I work at are single coverage, smallish places.

You can’t really have less than one doctor on at a time. So far I’ve had all the shifts I need. Right now the places I’m working at haven’t surged and the volumes are down. I haven’t gotten sick and I haven’t brought the virus home to people I care about. Yet.

>>

I understand the hospital administrations have to keep their patient population safe but the catch-22 of so many healthcare workers out of work, yet so many systems desperately needing help and the one not able to go to the other makes my soul cringe.

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Tales of COVID-19

The COVID-19 Experience Outside of the Epicenters

There’s a lot of talk of reopening the country, And the significant economic fallout of staying home and having things locked down. I wonder how we’re going to measure the toll that this virus is taking on all of us. The covered presentations, hospitalizations, and I see you length of stay as well as deaths are actually fairly easy to measure. But how do you measure everybody with chest pain that stays home or a heart attack that dies at home because they were afraid to come in? How do you measure the abdominal pains that turn into perforation or death because they didn’t come in? For the first time, I’m really understanding why people with what we consider to be minor or non-emergent problems need to feel that it’s safe for them to come in to the emergency department and not be ridiculed… That’s the only way we can

ensure that the really sick people come. But they’re not coming or they’re not coming until it’s late. COPD exacerbations almost always have to be admitted or intubated because they delay presentations so long. Many systems have gotten telemedicine up and running or are managing more patients remotely. I hope that’s a change that sticks.

It’s way too early to be able to quantify the fallout from this pandemic, so right now we’re all just logging through the best that we can. I actually feel fortunate that I have a job that I can (and need to) go to outside the home. Nobody knows how long this will last. University of Washington cautiously is suggesting mid-May might be a good time to open the country back up. There are increasing protests about the

stay home and social distancing orders. We’re seeing some countries that locked down illness right away like Singapore have huge spikes when they started opening things up again, but we don’t seem to be learning from it.

So I go to work. I wash my hands. I wear a mask, and when indicated full PPE. And just try to take things one day at a time and not think too hard about the what ifs. I truly do feel fortunate to still have full-time employment when so many people are out of work and so many things are closing. Times like these define us.

Will it tear us apart, or bring us closer? I feel more connected than ever to my ED colleagues as we get through our shifts and try and keep our spirits up, together.

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

COMMON SENSE JULY/AUGUST 2020

53

Tales of COVID-19

Dehumanized Puja Singh

T

hey asked me, “How does the current pandemic situation make you feel as a future emergency medicine doctor taken out of your clinical rotations?” Dehumanized.

Anxious. Heartbroken. Anxious about the upcoming residency application cycle, anxious about whether I will be able to do audition rotations at the prestigious institutions I have imagined myself going to for the past three years. Anxious about whether I can take Step 2 in time. But more than this, I feel as though our humanity has been snatched away. My mother,

an internist in NYC and a single mom, has been isolated in her room, forced to stay away from my ten-year-old brother because she has been taking care of others’ loved ones. Dehumanized because when we got notice of my maternal grandmother, my Nani, passing away in California I had to stay away from my mom and could not go home to see her in order to abide by proper quarantine guidelines. Dehumanized because when we traveled to California to complete the last rites and rituals for my Nani, we were encaged by N95s. As we bid farewell to our grandmother, our hands could not touch her cold and limp body because of the gloves

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that lay in between us. Dehumanized because as we cried and grieved, we could not wipe each other’s tears away and hug one another, since we were all that we had left. We were all that we had left; and yet we were still so far from one another. Finally, 14 days after my Nani passed, I hugged my mother, I wiped my aunt’s tears away as they fogged her glasses, I brushed my little cousin’s hair as she sat in front of the mirror and cried, I rubbed my uncles back as he sobbed into his palms, and I squeezed my brother’s hand as he watched my mother’s heart break into a million pieces. I cried alone.

Four weeks ago, when I was pulled from my OB/GYN rotation, little did I know that this life changing event would happen in the midst of this global pandemic. My grandmother was my entire life – she raised me for 10 years by herself with no help whatsoever. She was a mother to me when my own mother couldn’t be after the death of my father, an internal medicine resident himself. She was my rock, my person, and now because of this pandemic I could never say goodbye to her the way I had imagined. I was never ready for this day; yet now there were a million barriers to what I had always wished I could do.

We aren’t sure why she passed away, but I was sure that I wanted to help lighten the suffering of other families experiencing similar pain.

They asked me, “How does the current pandemic situation make you feel as a future emergency medicine doctor taken out of your clinical rotations?”

Dehumanized. Anxious.

Heartbroken. Anxious

Before my Nani’s passing, I had spoken to her about my idea of recruiting fellow medical students to conduct family phone calls to update them of their loved one’s status in the hospital since hospital visitation had been halted. She absolutely loved the idea! Since then, I have worked alongside my colleagues to develop an initiative to do this at our hospital and we have now called over forty families for COVID and non-COVID patients. The joy and happiness that this has brought me and my classmates, and hopefully the families with whom we have spoken, is a feeling that is unimaginable! To be able to make even a small difference in someone’s life when I, myself, am grieving is somehow healing me. Is this selfish? Or is this selfless?

My heart will never be put fully back together from the loss I have suffered, but it is somehow, just a little bit full and warm. Bliss. Gratitude.

Human.

To be able to make even a small difference in someone’s life when I, myself, am grieving is somehow healing me.

Tales of COVID-19

COVID-19 Has Made Emergency Physicians the Default Leaders of Medicine Mohamad Moussa, MD FAAEM

As many suggestions came through on COVID-19 patient care, the decisiveness of EPs remained keen and directed towards doing what is right for their patients.

T

he emergency physician (EP) was flung into the spotlight during this COVID-19 pandemic. Every single day since early March 2020 we have seen our EP colleagues on news channels and websites of all kinds talking about COVID-19. Their calm and collected mannerisms on screens all over the country and world gave people the insight of what an EP is willing to do to help their patients—essentially risk their life for the life of another. What was so inspiring was the homogenous message that all EPs gave their communities no matter what part of the country or world they were in. They served as ambassadors of global health to teach and reinforce proper hand hygiene, social distancing, and stay at home measures. This was all in the background of extreme uncertainty about disease spread and treatment. The ability to lead in such a challenging environment and maintain composure for our patients sets us up as the lead doctors across the globe. And because of this unconditional care in this novel pandemic, that is why I say EPs are the new leaders in Medicine.

I say, EPs are the new leaders of medicine because of our practical nature. People understand EPs because we speak in their terms. No big medical terminology laced with the most recent literature. Rather, we use plain, basic language like stay at home, wear a mask, use social distancing, follow national and state COVID-19 protocols.

After all, this is what EPs have been doing for years. We are the blue-collar physicians of our day and we do everything we can to blend in with our community. Many times, you cannot differentiate a patient checking in from an EP walking through for a shift in the main entrance lobby. EPs swimmingly shift between complicated Level One MVC trauma resuscitations and simple sore throat patients and carry on with their day. All the while, taking a bite from a peanut butter and jelly sandwich they packed from home. This versatility of an EP is what also made them shine as physician leaders in this relentless COVID-19 pandemic.

I say, EPs are the new leaders of medicine because we keep the calm in chaos. COVID19 has brought nothing but uncertainty, anxiety, doubt, fear, and death. While hospital administrators, infection control personnel, and infectious disease physicians developed untested protocols, EPs were still covering the emergency department seamlessly in the midst of constant emergency department zoning changes. The EPs applied what they have learned all along in their training which was to adapt to whatever comes their way. The fluttering that now exists between intubating early

or not, anticoagulating or not, and pronating or not did not deter the EPs from doing what was right for their patients in that moment. As many suggestions came through on COVID-19 patient care, the decisiveness of EPs remained keen and directed towards doing what is right for their patients.

I say, EPs are the new leaders of medicine because they make an immediate impact.

Patients and family members see the lifesaving heroics that are made in the emergency department the minute they arrive. The eye contact from the EP to the patient’s family member about how serious the situation is forever memorable. There is no setting up appointments for another later visit, no blood draws without immediate results, and no insurance checks before a CT or MRI needs to be done.

Patients feel the presence and advocacy of the EPs more than any other physician. Similarly, in front of the news cameras, EwPs give calm and hope to people in their homes. We lead by example. We lead by our recycled N95 facial bruises. We lead by our worn and torn gowns and gloves. We lead from the very uncertain frontlines. And that is okay with us.

We lead by example. We lead by our recycled N95 facial bruises. We lead by our worn and torn gowns and gloves. We lead from the very uncertain frontlines.

COMMON SENSE JULY/AUGUST 2020

55

Tales of COVID-19

I’m Not Really a Hero Gregory Jasani, MD

W

hen I lived in Washington, DC, I would occasionally travel to Reagan National Airport to welcome Honor Flights to our nation’s capital. Honor Flight is a program dedicated to transporting military veterans to see the memorials of the wars they fought in, at no cost to the veterans. Anyone who has witnessed these events can tell you that they are filled with cheering crowds and lots of flags. It truly is a sight to behold, and it is a fitting tribute to those brave men and women. They are true heroes. Yet, the veterans I met always insisted that they did not deserve the title of hero. “I’m not a hero,” I heard far more times than I can count. I never could understand how they could feel that way.

I understand it now. I am an emergency medicine physician working during the coronavirus pandemic. To many, that makes me a hero. I have been truly touched by the outpouring of support from my friends, family, and even strangers. It has helped enormously during this challenging time. However, let me be clear, I do not consider myself a hero.

To me, a hero is someone who does something to benefit other people, despite the possibility of immense personal risk. Though COVID-19 is a serious disease, I am in my 20s and in good health. While I could get infected with coronavirus, I know my chances of succumbing to it are fairly low. I am also fortunate enough to work at a hospital that has provided us with adequate PPE. My wife even works in the same hospital as I do, so I do not have the added burden of wondering if I’m endangering her health. For me, the risk I have faced during this pandemic has been minimal.

Many health care workers are not as lucky as I am. Some have continued to work despite being at higher risk due to their age or their underlying health problems. Some work at institutions that face shortages of vital PPE. Some have had to sequester themselves away from their families

These are the true heroes of this pandemic. Their sacrifice required courage beyond measure, and they exemplify the very best of the healthcare field.

However, let me be clear, I do not consider myself a hero.

for long periods of time, just to keep their loved ones safe.

Some have even made the ultimate sacrifice and lost their lives during this pandemic. They strove to preserve the lives of others even at the cost of their own. These are the true heroes of this pandemic. Their sacrifice required courage beyond measure, and they exemplify the very best of the healthcare field. They should be held up for generations to come as the ideal of heroism that we should all aspire to.

I will always have the pride of knowing that I was a doctor during a difficult and perilous time. But I am not a hero. I am just doing my job. It is the same job I did before the pandemic, and I will continue to do it after COVID-19 has faded from the public mind. Many healthcare workers are being asked to face much higher risks and make greater sacrifices than I am. They are the heroes that we should honor and remember.

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Tales of COVID-19

The Reasoned Response to the PPE Debacle Robert Frolichstein, MD FAAEM

There is no surplus in the system.

That was the mistake. supply and that we can do it better? Or should we do our part to raise awareness, coordinate donations and then rely on the hospitals and organizations to manage the supply?

T

he lack of adequate supplies of PPE is deplorable, inconceivable.

This has been made abundantly clear through both social media and traditional media. Post after post on various social media outlets have exposed the appalling shortages and at times blame and attack those that are obliged to provide us the PPE. Those posts, in part, have spurned movements among non-medical personnel to donate and make masks. Heartwarming, and it feels good to have widespread sympathy with our plight.

Thinking rationally, it is unlikely that those actions will solve this problem on a widespread scale. Hospitals and other organizations have entire teams of experts that deal with supply chains daily. Terrible mistakes were made with horrific consequences. The mistakes were in the design of the system. The process of just-in-time ordering from group purchasing organizations is designed from a financial perspective. It makes perfect sense to those making the decisions.

We use X amount of PPE every week (the burn rate) and if the supply of PPE matches the burn rate there is no warehousing and warehouse management needed and thus costs per unit of PPE go down. Now, faced with a burn rate of many multiples of X the supply chain can not meet the demand. This process is reproduced all the way back to the manufacturing and importing of PPE. There is no surplus in the system. That was the mistake. Based on affective decision making principles should we conclude that these organizations are now incapable of ramping up acquisition and maximizing

So a strategy to conserve equipment and protect us must be developed based on reason balanced with the fear of becoming ill.

Again, the lack of PPE is appalling. We are asked, expected, to care for patients in uncertain times with what is felt to be inadequate protection. The lack of equipment should be made known to industry and to the public to pressure industry leaders to ramp up supply. That has happened. The time for changing the system to prevent this from occurring again is in the future. Now it is the time to step back and balance the emotion with the reason. Will continuing to emotionally appeal for more PPE or attack the organizations whose duty it is to supply it help?

Rationally, does it make sense that our hospitals and supply chains do not want us to have the necessary PPE? Is it more likely that the conservation strategies (which emotionally seem ridiculous) are necessary to prevent running out of supplies completely? Using the affective decision-making model let us ask — how much more does an N95 mask protect us than does a surgical mask and contact precautions? The answer is incredibly complex and depends upon so many variables including droplet size, chances of infection after exposure to an unknown amount of viral particles, air currents in the room, time in the room - the list goes on and on. My job as a scientist and a leader is to postulate that an N95 mask reduces my chance of becoming ill more than a surgical mask, but likely by a very small amount. So we must weigh this slight increase in benefit with the desire (emotion) to eliminate all risk while understanding the supply chain issues. So a strategy to conserve equipment and protect us must be developed based on reason balanced with the fear of becoming ill.

My job as a physician leader is to form my opinion about PPE based on a balance of emotion and what is rational. This is perhaps the most difficult decision we will make because the emotion is so strong as we literally put our lives on the line. We have done a fantastic job of raising awareness of the issue of inadequate PPE. It has primed the system to now obtain as much PPE as possible. It will soon be time to start having rational conversations when emotion is lower about how to prevent this scenario in the future.

This article was first published by KevinMD.com and is reprinted with permissions. ©2020 KevinMD.com www.kevinmd.com/blog/2020/05/a-reasoned-response-to-the-ppedebacle.html

COMMON SENSE JULY/AUGUST 2020

57

Tales of COVID-19

My Life was Turned Upside Down by a COVID-19 Antibody Test Matthew C. Holden, MD

*As information about COVID-19 testing is rapidly evolving, please excuse data that may not be most up to date at the time of this publication.

I

signed in for my shift at the freestanding emergency room I work at and found that in addition to answering the COVID-19 check in questions and getting my temperature taken I would also be getting a finger stick COVID-19 antibody test. I felt fine, had not been ill and had no known recent exposure to a coronavirus

tract secretions. They have more recently also been found in feces and sperm. There are multiple ways of obtaining specimen. The most common method involves inserting a nasal swab deep into the nasopharynx and preserving in either a dry or liquid medium. Turnaround times are variable. Some tests take as little as

This would make my life as an emergency physician much easier since I could then evaluate and treat patients who may have COVID-19 without worrying if I was going to become infected. patient. I had no cough, sore throat, runny nose, headache, diarrhea, shortness of breath, or body aches. My sense of taste and smell were intact. These questions covered most of the current known symptomatology of the pandemic COVID-19 virus. I knew that there was considerable debate regarding the accuracy of antibody testing and how it should be used but I expected to get a negative antibody test.

The two-part test would look for IgM antibodies that develop in the first 7-14 days of the infection. IgG antibodies begin to develop 14 days and peak between 21 and 28 days. They represent the antibodies of the recovery phase of the infection and remain elevated for weeks to months and possibly years. It is unknown whether IgG levels represent immunity to the COVID-19 virus.

Our current best test for active infection is not antibody testing but by real time reverse transcriptase polymerase chain reaction (PCR) test. PCR testing, although not perfect, is what we use to tell us who is infected now. It is the best screening test to help us with contact tracing and quarantine and treatment recommendations. This test identifies viral RNA beginning on or around day one of clinical illness but can remain positive, from current data, for weeks to months even without symptoms. COVID-19 viral RNA are found in nasal, oral or pulmonary

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15 minutes while others may take up to a week.

PCR antigen testing is considered the gold standard for diagnostic purposes even though they have variable specificities and sensitivities. Some may only have 80-85% specificity. Sensitivity and false negative rates are also variable due to variable viral loads at different stages of illness, inadequate specimen collection, or problems with transport media or the lab testing itself.

The goal of antibody testing is to tell us what proportion of the population may have been infected and may possibly be immune to COVID-19 in hopes of reopening America safely, but experience thus far has been inconsistent and unreliable. It is not a good test to identify whether someone is acutely infected.

By the time IgG and IgM antibody levels are detected, viral levels may already be decreasing or cleared from the system. As of April 21, the FDA had approved four antibody tests. These

are all enzyme linked immunosorbent assay (ELISA) tests which can identify whether antibodies are present. The FDA had also allowed at least 50 non approved, mostly lateral flow immunodiffusion tests to be marketed. These are point-of-care tests that are supposed to be done on site in doctorsâ&#x20AC;&#x2122; offices or labs but are also sold online for home use similar to point of care pregnancy tests. They utilize small plastic cartridges where a drop of blood or serum is applied to one end, followed by a reagent that mixes with the blood sample and then diffuses up a strip of paper. Antibodies collect along

lines as antibodies are deposited and provide a colorimetric reading when positive. A final control line validates the test. Many of the nonapproved tests have 20-30% or less sensitivity, limiting their utility. Some of the best tests still have limited specificities. A positive IgM (acute phase) with a negative IgG (recovering phase) should lead to a patient getting a PCR antigen test to see if they have acute COVID1-9. A positive IgM and positive IgG may represent recovery from COVID-19 if it they are true positives, but they still do not rule out the presence of an active viral infection. One danger is that people with false positives may let down their

I saw how hard it would be to safely quarantine in the same house with someone infected with COVID-19.

>>

Tales of COVID-19 My Life was Turned Upside Down by a COVID-19 Antibody Test

guard and stop avoiding possible exposure and then actually contract COVID-19. Negative IgM antibody test results suggest absence of active illness but it may actually be negative because the patient is in the early and most infectious stage of infection before they start producing a measurable number of antibodies. Again, only PCR testing may provide an answer.

So, I got my finger stick antibody test at the ER and it was positive for IgM. I discussed the findings with my medical director, and he recommended I get a nasal swab PCR antigen study to send out to a lab. He suggested that even though I had no symptoms that I get another doctor to cover the rest of my shift and go home early to await final PCR test results in 2-3 days. I had very mixed emotions. First, I was excited to think that I may have an asymptomatic case of COVID-19. This would make my life as an emergency physician much easier since I could then evaluate and treat patients who may have COVID-19 without worrying

reactive but false positive test. She had a sinus infection and a sore throat for a couple of weeks and had only recently started some antibiotics when it would not go away. To help resolve the dilemma I was able to bring home an antibody test and give her the finger stick test. If she tested positive we could both relax. I presented the test to her as soon as I got home in hopes of being able to avoid a long explanation about possible bad news.

“Good news,” I said. “I got one of those antibody tests for you.”

Then the test was negative, and the questions started. Why did I test positive? What if I have it? How can she remain safe?What does the antibody test mean? Can I get a repeat test somewhere else? Can I go get a nasal swab PCR test with instant results now? How long will we have to wait until we get the test results back from the lab? Can I call the ER tomorrow to see if the results are back and call every day until the results are back? I tried to put myself in her place and be patient and answer every question, every time she asked, in detail. I wore a mask and maintained a healthy separation. I slept in a spare bedroom and tried to stay in a different part of the house. I saw how hard it would be to safely quarantine in the same house with someone infected with COVID-19.

As the weekend went on and I continued to feel healthy, I became less hopeful that I had an asymptomatic case. I became more confident that I had a false positive although nothing on the test kit instructions explained what that might be in my case. It was a long, tense weekend. She worried that she might develop COVID-19. I worried about how she might do if she got it. I called for results on Sunday. They were not back. On Monday I got the results phone call from the ER. It was negative. I told my wife I wanted a big hug and a kiss. She said no tongue.

We were back to our normal routines in the COVID-19 era.

It was a long, tense weekend. She worried that she might develop COVID-19. I worried about how she might do if she got it. if I was going to become infected. And I wouldn’t have to worry about catching the illness through exposure in the community. This is where we all hope to be in a couple of years as the illness spreads through the population and we eventually get immunized with a vaccine. Just maybe I was very very lucky. But I was also apprehensive that if I went home to quarantine with my wife that I might give her a COVID-19 infection that might make her very ill. Another possibility was that I had caught another common cold coronavirus infection from her that was giving me a cross

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COMMON SENSE JULY/AUGUST 2020

59

Tales of COVID-19

Should the 12-Hour Shift be of Historical Interest Only?

David P. Lisbon, MD FACEP

I

listened with sadness and despair as reports of the death of Dr. Lorna M. Been were broadcast. There were a series of interviews with her heartbroken family. The one that sticks with me was that of her sister. I felt she was most able to convey the sense of fatigue and exhaustion that Dr. Breen felt. In her interview she said, “She had 12 hour shifts.”

clear to me. First, humans are not nocturnal, being your best at 4:00am is just not likely.

Second, when I think of the close calls with cognitive, diagnostic, or procedural error, they almost uniformly occurred between 3:00am and 7:00am. Third, the recovery time needed after a string of 12-hour ED shifts in a modern busy ED is at least 24 hours.

In my practice life, I’ve worked both 12 and eight-hour shifts. My first position after residency was one where I contracted to work 12, 12-hour shifts. I trained in a residency program that had eight-hour shifts; I made the adjustment. At the time, my community ED saw 27,000 patients a year, we admitted about 21%, and we were a Level II trauma center.

The year was 1995 and I was 25 years younger, the internet was dial -up, there were no cell phone cameras and Tintinalli was soft-cover and could be read twice in residency!

I had the great honor to be the founding program director for the emergency medicine residency at the University Kansas School of Medicine. I served for 10 years.

I used to joke with my residents that I was open to a discussion about any and everything; except, the implementation of 12-hour shifts. I know that the 12-hour shift has its allure in that one works less shifts a month. I am also aware that very low volume emergency departments might have a logistical need to staff with 12-hour or longer shifts.

As time passed, patient volume, patient acuity, patient admissions, patient psychosocial issues, and my age all increased. As my children later reminded me; I sometimes struggled to not doze off as I read bedtime stories over the years. As I look back and consider the moment we’re in now, a few other things are

Shift length should be evaluated carefully for its effects on ED physicians.

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Notwithstanding the aforementioned realities, I still believe shifts shorter than 12 hours should be our future. My conversations with colleagues and observations over the years lead me to believe that once an ED gets to 40,000 visits and an admit rate of 25%, the 12-hour shift needs to be rethought. Shift length should be evaluated carefully for its effects on ED physicians.

Certainly, a number of operational variables can be considered; staffing matrices, trauma center status, chest, and stroke center designation etc., but cognitive and physical workload over a distinct timespan at some point become germane.

I used to joke with my residents that I was open to a discussion about any and everything; except, the implementation of 12-hour shifts.

As a frontline response to COVID-19, emergency medicine has and will endure a lot. The 12-hour shift had a place when our mission was perhaps more limited, before medical treatments and medical complexity shifted into high gear and before the pathogenic devastation of the coronavirus struck like a tidal wave.

When considering coronavirus one might even ask what degree of concentrated time exposure becomes hazardous?

All of us on the frontlines of healthcare, like Dr. Breen will aim to bring the best of ourselves to each shift. It might be time to ask if it is fair and just to expect that best self to be present at hour 11 and 30 minutes into a 12-hour shift.

Tales of COVID-19

The Black Death Jeff Wade, MD FAAEM

“The Black Death, also known as the Great Plague or the Plague, or less commonly the Black Plague, was one of the most devastating pandemics in human history, resulting in the deaths of an estimated 75 to 200 million people in Eurasia and peaking in Europe from 1347 to 1351.”

That day I decided to change my major to microbiology and my goal to med school.

-Wikipedia definition

T

he plague has been a huge thing in my life. My third year of college I was still pre-veterinary, but starting to be ready to change. I was working for a vet and he wasn’t seemingly happy at his job, and from what I could see the job wasn’t happiness inducing. People call pediatrics and geriatrics, veterinary medicine. Your patients at either extreme of the lifespan are not able to talk to you and tell you what is wrong, nor understand why you are hurting them. And worse, they can have parents/ adult children/owners who can be at either extreme: overly helicopter-y and in-your-face about everything or abusive/neglectful assholes. That’s a pretty good argument against veterinary medicine, peds, or geriatrics in my book (literally in my book). And I had just finished a test in my agribusiness/pre-vet major. The test question was: ‘You have just inherited a large quantity of money. You decide to use this money to open a pig farm (EXACTLY what I would do conveniently enough). Please describe in detail how you would setup the farm with room for breeding, food storage, waste disposal, etc.’ Nice.

Then I had my first microbiology class. The teacher read a case report from the Centers for Disease Control’s Morbidity & Mortality Weekly Report (CDC MMWR), a sampling of trending infection or toxic events.

The case he read was about a case of modern-day plague. It still exists today, but as people became more used to it after the Black Death & just people’s and bacterial evolution, it is rare and almost only associated with desert rodent exposure anymore.

He described how the bacteria literally fill the blood vessels. And how from getting sick to dying can be as fast as a day or less. They can get the black swollen lymph nodes in the groin & armpits called buboes. This is where the terms Black Death and Bubonic Plague come from. He also talked about how sometimes it can spread to the lungs and become much more easily spread by coughing instead of requiring rat fleas, the typical way of transmission.

This came at THE right time for me. That day I decided to change my major to microbiology and my goal to med school. And I made the right choice. People are much better conversationalists and by virtue of that, much more interesting to work with than animals. As long as you see non-demented/drunk/high adults or older children, you don’t have to torture things that don’t at least understand the reason for the torture. And the adult children/parents/owners issue doesn’t come up.

Since then I have had an interest in the plague. It literally changed the face of Europe. Before the Black Death, Europe was feudal, where the

majority of people were essentially the property of the local lord. The tremendous social change initiated by the plague (and other historical trends at the same time), got rid of the feudal system in all but Russia within a 100 years or so. This freeing of the individuals to live where and how they wanted and general mobilization of society was one of the biggest contributors to the Renaissance and modernity in general.

I have found and read several books that deal with the plague since then.

One of the best is by the French Nobel winner Camus and called The Plague. It describes a fictionalized version of one of the last modern widespread outbreaks of the plague in North Africa, where Camus was born and grew up. It is a riveting account that includes all the standard stuff you see in an outbreak: dead rats, buboes, mass graves. However, Camus was an Existentialist, meaning he was interested in how people should act in a world where there is not necessarily a God. So the book is also about more than just the rats, it focuses on a group of accidental friends who band together to deal with the situation. Everyone has a crisis of conscience, even the priest. Quite a great book, one of my alltime favorites.

Another is A Journal of the Plague Year by Daniel DeFoe, the writer of Robinson Crusoe. It is about the 1666 London Plague. He was born not long after the plague, so was able to draw on survivors and recent records. It is a purely journalistic account of the plague and gets into the reactions to and management of this overwhelming event. It’s a nice book if you are interested in the plague.

Much later, I found out that Oxford University has summer school for adults who can afford to study in Oxford. We made plans to do that a few years ago after visiting Oxford. When we looked online at the available courses, the one that jumped out at me, was called The Plague. Of course, I took that one. I brought a fake concert T-shirt that I have had for years. It looks like your standard black long-sleeved concert shirt. Except on the front, it has a picture of a rat surrounded by flies and ‘Black Death European Tour 1347-51.’ The back has the ‘concert’ locations. While there, we learned tons about the plague and its societal aftereffects. As this was right after the big Ebola outbreak, it was even more topical. ANY disease, from Ebola to the plague or even the common flu, can mutate overnite and turn drastically more severe and/or more contagious.

We live in a world where when, not if, the next big epidemic comes up, it will be spread worldwide within days.

Get your flu and other shots. And be afraid. Be not so very afraid…

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