March/April 2020 by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 27, ISSUE 2 MARCH/APRIL 2020

Does AAEM Advocacy Resonate with Residents? Page 23

President’s Message:

It’s Enough...

From the Editor’s Desk:

A Thick Skin

2020 AAEM Board of Directors Election Candidate Statements

Young Physicians Section:

Tips for Advancing Your Practice in the New Year

AAEM/RSA Editor:

Own Your Worth

COMMONSENSE TM

Officers President David A. Farcy, MD FCCM President-Elect Lisa A. Moreno, MD MS MSCR FIFEM Secretary-Treasurer Jonathan S. Jones, MD Immediate Past President Mark Reiter, MD MBA Past Presidents Council Representative Howard Blumstein, MD Board of Directors Kevin Beier, MD Robert Frolichstein, MD L.E. Gomez, MD MBA Bobby Kapur, MD MPH CPE Evie Marcolini, MD FCCM Terrence Mulligan, DO MPH Carol Pak-Teng, MD Thomas Tobin, MD MBA YPS Director Phillip Dixon, MD MPH AAEM/RSA President Haig Aintablian, MD Editor, Common Sense Ex-Officio Board Member Andy Mayer, MD Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD Executive Director Kay Whalen, MBA CAE Associate Executive Director Missy Zagroba 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.

COMMON SENSE MARCH/APRIL 2020

Table of Contents Regular Features President’s Message: It’s Enough........................................................................................................3 AAEM Member Bulletin........................................................................................................................4 From the Editor’s Desk: A Thick Skin...................................................................................................6 Foundation Donations..........................................................................................................................8 PAC Donations.....................................................................................................................................8 LEAD-EM Donations............................................................................................................................9 Upcoming Conferences ....................................................................................................................10 AAEM/RSA Editor: Own Your Worth..................................................................................................45 Resident Journal Review: Assessing Fluid Responsiveness in the Emergency Department Part II...46 Medical Student Council President’s Message: Considerations for Your Social Media Presence......50 Job Bank............................................................................................................................................53 Special Articles EM Workforce: Does AAEM Advocacy Resonate with Residents?....................................................23 Operations Management: New Care Model Promotes Early Intervention for Psychiatric Emergencies ...........................................................................................................24 Wellness: On-Shift Eating and Drinking: A Simple Strategy on Addressing Physician Burnout.........32 Palliative Care Interest Group: Health Care Proxies, Living Wills, and POLST Forms, Oh My: Interpreting Advance Care Planning Documents.......................................................................34 Critical Care Medicine Section: Andexanet alfa.................................................................................36 Women in Emergency Medicine Section: Choosing Locums.............................................................39 Emergency Ultrasound Section: Is Emergency Physician-Performed Bedside Ultrasound Dangerous?.............................................................................................................41 Young Physicians Section: Tips for Advancing Your Practice in the New Year...................................43 AAEM/RSA Advocacy: Human Trafficking: Identification and Treatment Tools for the Emergency Physician....................................................................................................................................51 Updates and Announcements 2020 AAEM Board of Directors Election Candidate Statements.......................................................11 Farewell, My Love..............................................................................................................................21 UpToDate® Now Available to ConCert™ Exam Takers......................................................................22 Highlights for Scientific Assembly 2020.............................................................................................25 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, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

AAEM-0120-469

AAEM NEWS PRESIDENT’S MESSAGE

It’s Enough… David A. Farcy, MD FAAEM FCCM — President, AAEM

Leaders are made, they are not born. They are made by hard effort, which is the price which all of us must pay to achieve any goal that is worthwhile.” – Vince Lombardi We are living in these times Where the evil one has come to rob us blind, oh yeah yeah yeah Oh people, we must understand That it’s time to wake up and do what we can, oh yeah yeah yeah it’s enough. – Lenny Kravitz

My last president’s message will be a call to action.

In one of my past presidential messages I wrote: “When people are passionate about something, it drives them to become engaged, to learn, to educate, and to want everyone else to listen too. However, most often the reality is that we are “too busy” or have “no time” to take up just another concern in our already busy personal and professional lives. I am deeply passionate about the work AAEM is taking on and my wish is for all of our members to be passionate as well.” But today, it is not an option anymore to just be passionate, it is time to wake up! Time to set aside time for your future! For our patients! This issue was brought home to me last month as I was honored to be the Doctor of the Day in Tallahassee. This happened to be the day when the Florida legislature was considering the issue of granting APPs in Florida independent practice rights. Is it in our patients’ best interest to allow pharmacists and others to prescribe antibiotics? Physicians debate and complain to each other in-person and on social media, but I was the only emergency physician in Tallahassee that spoke to the legislature on this issue on that day. However, many APPs were present and spoke. We need more emergency physicians to be willing to inform legislators on the dangers to the public of allowing such independent practice. It is time to take action. Posting complaints on social media is not effective if that is the only action that we take. People post and repost, giving them a sense of accomplishment. But this is far from enough. Social media is a great platform to get an idea started but unless there is action behind

s, I write my last president’s message, I have been reflecting on the last 27 months. Thank you for the amazing opportunity you gave me to earn your trust and support. My last president’s message will be a call to action. Our specialty is under attack from every possible angle… insurance Today, I will make sure that I renewed my membership. companies, the threat of advanced practice provider (APP) independent practices, CMGs controlling our Today, I will encourage my colleagues to join AAEM. practice, congress “fixing” the balanced billing issue, etc.

Today, I am giving a shift a year to the Political Action

As a specialty, we need for all emergency physicians to get involved. I often hear: “Why should I join an AAEM Committee. Today, I will get involved and join a committee?” “Why should I write and visit my congressional representative?” “Why should I encourage others committee. Today is the day that I will contact my to join AAEM and get involved?” “Why should I donate to the AAEM PAC?” “I am content, I am happy where I representative. Today is the day that I will take action. am!” This is the “laissez-faire” attitude that got us where we are at today! Laissez-faire is a French noun meaning “attitude of letting things take their own course, without interfering” the words, nothing tangible is accomplished. Take, for instance, the Arab We allowed others to make decisions for us, we allowed others to be at Spring — a series of protests that spread across the Islamic world in 2010 the table making decisions for us—not just emergency physicians, but all in response to an oppressive regime, anti-government for democracy, physicians. freedom of election, human rights, economic freedom, to name a few. People used social media to voice their opinion and to show the rest of the world what was happening via social media. But, there would not have Let your words be followed by actions been an Arab Spring if people did not also take to the streets, and strike in that help bring about change. hope of affecting change. I am not calling for a revolution, but I am calling

COMMON SENSE MARCH/APRIL 2020

AAEM NEWS PRESIDENT’S MESSAGE

for action. Let your words be followed by actions that help bring about change. If your words are not followed by actions, there will be little impact. Patients will be lost in the shuffle and will suffer the complication of our broken system. Emergency physicians will be replaced by APPs and will take significant pay cuts. We will be signing thousands of charts for APPs. Pharmacists and any others who take a year or less course will be able to treat patients. Some doctors will not be able to pay their student loans and will be making more money driving for Uber/Lyft, like we are seeing in other countries. It is time to make an impact. It is time to say today is the day that I will not allow others to make decisions that affect my future. Today, I will make sure that I renewed my membership. Today, I will encourage my colleagues to join AAEM. Today, I am giving a shift a year to the Political Action Committee. Today, I will get involved and join a committee. Today is the day that I will contact my representative. Today is the day that I will take action.

The Academy is your academy. It is a platform for you to have a voice, learn, share, and create new ideas. The Academy stands for board certified emergency physician. Our shield is a symbol of protection and our torch is the light we cast on the specialty. Because we are the champion of the emergency physician.

Today is a new day.

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.

Introducing the AAEM Member Bulletin 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 AAEM NEWS

Member Bulletin

David DuBois, MD FAAEM FACEP FACEM Kia ora from New Zealand. Now a Fellow of the Australasian College for Emergency Medicine, equivalent to ABEM certified down under. No nights for attendings. 100% locums working at 15 NZ hospitals, 2 Australian hospitals, 2 Guam hospitals. Patients here are nice, say thank-you, and don’t ask for unnecessary narcotics.

COMMON SENSE MARCH/APRIL 2020

AAEM NEWS FROM THE EDITOR’S DESK

A Thick Skin Andy Mayer, MD FAAEM — Editor, Common Sense

n essential skill for the wellness of any emergency physician is the ability to cordially and professionally interact with the doctors in person or on the other end of the phone whom we contact for admissions, consults, and follow-up. This skill is difficult to teach, but is essential for success from both a professional standing and wellness point-of-view. Each hospital staff has difficult and sometimes nasty consultants. Sadly, this is part of the terrain of emergency medicine and each of us needs to develop a path and strategy to be able to interact with the most difficult of consultants.

YOUR ABILITY TO PREVENT NEGATIVE FEELINGS AFTER ONE OF THESE PAINFUL ENCOUNTERS WILL PLAY A SIGNIFICANT ROLE IN YOUR ABILITY TO HAVE A SUCCESSFUL CAREER AND IS A USEFUL MARKER FOR YOUR Like almost all emergency physicians, I enjoy reading Dr. Ed Leap’s column in Emergency Medicine News. I personally think he is able to LONGEVITY IN EMERGENCY MEDICINE. most closely articulate the trials and tribulations of the average “pit doc” in an entertaining way so that important issues can be reflected upon while still maintaining some humor. His November column, “The 26-Year Intern,” speaks to the issue of our professional interactions with our consultants in his usual insightful and humorous way, and I encourage you to read or reread it and think about what he is saying. Each of us can immediately identify with all of the scenarios he relates in his column. Your own response to each of these scenarios is tempered by the individuals involved and where you are in your emergency medicine career and your own level of wellness.

Personally, I am close to thirty years into my emergency medicine career, but can still easily relate to his 26-year intern idea when I speak to some fellow or new attending on the phone who does not know me and feels entitled to treat me like an intern. We all know attendings who seem to obtain pleasure by torturing the poor ER doc on the phone. What is one to do? Your ability to prevent negative feelings after one of these painful encounters will play a significant role in your ability to have a successful career and is a useful marker for your longevity in emergency medicine. How should we deal with these sometimes unpleasant, and at times demeaning, interactions? The title of this article reveals many emergency physicians’ main coping mechanism in this regard. A thick skin is a very useful tool. We all realize that many of our consultant’s angry or condescending statements really have nothing to do with us. These doctors are often just inappropriately directing their angry at us as a coping mechanism for their own frustration with what is going on in their own career or personal life. Maybe their dog died or simply the fact that they are a tired middleaged surgeon with five elective cases in the BECOMING FRIENDLY morning having to come in at 3:00am WITH THEM CAN LEAD TO for a less than pleasant case is simply MUTUAL RESPECT AND AN overwhelming them. Their sleep deprived fog when you wake them up INCREASED WILLINGNESS ON leads them to say things that are inapTHEIR PART TO HELP YOU IN propriate and simply stupid. We did not ask the uninsured chronic pain patient THE EMERGENCY DEPARTMENT to present to the ER at 2:00am. We WHEN YOU NEED IT. are not responsible for EMTALA, 6

COMMON SENSE MARCH/APRIL 2020

medical staff bylaws, weekend call, or the other myriads of aggravations which can be thrown at a physician who is on their third spouse and facing huge college tuition bills or whatever malfunction is derailing their life. The tired emergency physician seems to them to be a perfect target for their misguided rage. In these instances, having a “thick skin” is useful if you avoid internalizing this unjustified and misdirected anger. Taking those same negative feelings into your wellness bucket will eventually cause a leak. This of course is easier said than done and does not excuse the physician at the other end of the phone for their behavior. Individuals are responsible for their behavior and we need to do what we reasonably can do to correct this negative and wellness-killing behavior. Whether religious or not, the wisdom of the Serenity Prayer is something to consider. “Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” – Reinhold Niebuhr AMERICAN THEOLOGIAN

AAEM NEWS FROM THE EDITOR’S DESK

The idea of turning the other cheek, as it were, can certainly become wearisome and I suggest developing other tools to deal with these unpleasant interactions. One of the best tools which I have found is the simple ability to become an actual person to the other members of your medical staff instead of just another unknown ER doc on the other end of the phone. This is certainly a challenge for locum’s doctors who often do not stay long enough at any one location to build these interpersonal relationships. However, for the rest of us, you might consider making positive steps to building relationships even if right out of residency. There is a lot of low-hanging fruit in this regard if you are willing to make even a little effort. Consider taking a few minutes before, during, or after a shift and sitting in the doctor’s lounge, cafeteria, or any location where fellow members of the staff gather to strike up a conversation and get to know some of your consultants. It is much harder for almost everyone to be disrespectful to someone they consider a friend or a colleague instead of a stranger. Consider attending staff parties, staff meetings, medical society meetings, and other social functions and you might discover some of the reasons your consultants seem to be so difficult. These reasons are sometimes that the person is simply unhappy and usually have little to nothing to do with you. Becoming friendly with them can lead to mutual respect and an increased willingness on their part to help you in the emergency department when you need it. Another technique worth considering is a more direct discussion about these issues with a difficult consultant. A reality check for these difficult souls can be much more productive than you might think. I suggest you try and talk to your difficult consultants about some interaction which you witnessed instead of confronting them in the heat of battle. Taking them on the side when emotions are not high and talking about an interaction in which you were not personally involved more frequently leads, in my experience, to an “Oh, I didn’t realize” response from the difficult doctor. Confronting them when emotions are running high can lead to a throw down instead of a useful outcome.

It is certainly more productive in my opinion than sending it to whatever official medical staff “quality improvement” process your hospital has in place. An informal private discussion is more likely to produce a positive collegial response than a possibly punitive process. There are certainly situations when the formal process is vital and the only solution but consider the more collegial approach and you might be surprised. Certainly many of us, particularly more youthful emergency physicians, might consider calling the grizzled old general surgeon on the side to discuss a delicate topic beyond their comfort zone. However, I suggest you try it and might very well be positively surprised with the result. If you just cannot do it, consider asking your medical director or a more senior member of your group to do it for you. Being collegial and right is a quick way for you to earn the respect of the more senior members of your medical staff. I am a fan of Benjamin Franklin. His autobiography is one of my all-time favorite books. I have tried with varying success to take some of his advice. His tactic of asking an enemy for a favor had baffled me until I tried it. What might seem like a futile approach to improving a difficult professional interaction is now is accepted as the Ben Franklin effect. Wikipedia explains below: The Ben Franklin effect is a proposed psychological phenomenon: a person who has already performed a favor for another is more likely to do another favor for the other than if they had received a favor from that person. An explanation for this is cognitive dissonance. People reason that they help others because they like them, even if they do not, because their minds struggle to maintain logical consistency between their actions and

perceptions. You might consider trying this by asking one of the consultants you have the most trouble with for a favor. Of course, this seems hard but I have personally been pleasantly surprised with the results. This could simply be done by asking for their advice or counsel about a case or follow-up about a patient you cared for together. I would suggest going further whether it be advice about a school for your kids, an opinion about a neighborhood, or whatever. This makes your nemesis feel important and makes you a real person in their eyes. Almost certainly, the next time you wake them up, they will be much more polite and helpful. My personal best instance of this was when I asked a difficult general surgeon for help with a school project for my daughter. She and I went to his house and had a great interaction. Every call to him from then on started with him asking about my daughter. I was a person with a family. I ask you to think about these ideas and the many more which you can use in an effort to improve our professional interactions. Maybe your skin will not need to be as thick. This will make that skin more resilient when the next psych patient calls you names which cannot be mentioned or a surgery resident gives you a totally inappropriate response to a consult. Having a personal relationship with their staff or a hospital administrator or whomever will make the next call much easier.

THE BEN FRANKLIN EFFECT

COMMON SENSE MARCH/APRIL 2020

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 2-17-2020. 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 Mary Ann H. Trephan, MD FAAEM

Isaac A. Odudu, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM

Contributions $250-$499

Contributions $100-$249

Kevin Allen, MD FAAEM Justin P. Anderson, MD FAAEM Michael R. Burton, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM Jerris R. Hedges, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT Ron Koury, DO FAAEM Bryan K. Miksanek, MD FAAEM

Patrick A. Aguilera, MD FAAEM Peter G. Anderson, MD FAAEM Mark Avery Boney, MD FAAEM Anthony J. Callisto, MD FAAEM Paul W. Gabriel, MD FAAEM Thomas Isenovski, DO FAAEM John H. Kelsey, MD FAAEM Katrina Kissman, MD FAAEM Stephanie Kok, MD FAAEM Calvin C. Krom, III, DO FAAEM

Gregory S. McCarty, MD FAAEM Nevin G. McGinley, MD MBA FAAEM James Arnold Nichols, MD FAAEM Scott D. Reiter, MD FAAEM Jeffrey A. Rey, MD FAAEM Phillip L. Rice Jr., 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 Susan Socha, DO FAAEM Jalil A. Thurber, MD FAAEM Andy Walker, MD FAAEM

Joanne Williams, MD MAAEM FAAEM George Robert Woodward, DO FAAEM

Contributions up to $50 Sameer M. Alhamid Jr., MD FRCPC FACEP FAAEM Eike Blohm, MD FAAEM Patrick D. Cichon, MD JD MSE FAAEM Adriana M. Horner, MD Edgar A. Marin, MD Melissa Natale, MD FAAEM Joshua E. Novy, MD MBA Ramon J. Pabalan, MD FAAEM Louis L. Rolston-Cregler, MD 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 2-17-2020.

Contributions $500-$999 Michael R. Burton, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM David A. Farcy, MD FAAEM FCCM

Contributions $250-$499 Jerris R. Hedges, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM Ron Koury, DO FAAEM Bryan K. Miksanek, MD FAAEM Don L. Snyder, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM

Andy Walker, MD FAAEM

Contributions $100-$249 Kevin Allen, MD FAAEM Peter G. Anderson, MD FAAEM Justin P. Anderson, MD FAAEM Jonathan Balakumar, MD Scott Beaudoin, MD FAAEM Mark Avery Boney, MD FAAEM Anthony J. Callisto, MD FAAEM R. Lee Chilton, III, MD FAAEM Martinez E. Clement, MD FAAEM Jonethan P. DeLaughter, DO FAAEM

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 8

COMMON SENSE MARCH/APRIL 2020

John T. Downing, DO FAAEM Steven H. Gartzman, MD FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeffrey Gordon, MD MBA FAAEM Thomas Isenovski, DO FAAEM John H. Kelsey, MD FAAEM Gregory S. McCarty, MD FAAEM James Arnold Nichols, MD FAAEM Isaac A. Odudu, MD 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 Jalil A. Thurber, MD FAAEM

Contributions up to $50 Doug Benkelman, MD FAAEM James W. Hickerson, Jr., MD Julie A. Littwin, DO FAAEM Melissa Natale, MD FAAEM Joshua E. Novy, MD MBA Dion R. Samerson, MD FAAEM Linda Sanders, MD Marc D. Squillante, DO FAAEM

LEAD-EM Contributors – Thank You! The AAEM Institute for Leadership, Education & Advancement in the Development of Emergency Medicine, Inc. (LEADEM) 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. LEAD-EM would like to thank the individuals below who contributed from 1-1-2020 to 2-17-2020.

Contributions $500-$999

Contributions $100-$249

Contributions up to $50

David A. Farcy, MD FAAEM FCCM

Justin P. Anderson, MD FAAEM Laura J. Bontempo, MD MEd FAAEM R. Lee Chilton, III, MD FAAEM Sarah B. Dubbs, MD FAAEM Paul W. Gabriel, MD FAAEM Gus M. Garmel, MD FAAEM FACEP Edward T. Grove, MD FAAEM MSPH Regina Hammock, DO FAAEM William E. Hauter, MD FAAEM Gregory S. McCarty, MD FAAEM Valerie G. McLaughlin, MD FAAEM Marcus Obeius, DO FAAEM Jeffrey A. Rey, MD FAAEM Richard D. Shih, MD FAAEM

Daniel V. Girzadas Jr., MD RDMS FAAEM James W. Hickerson, Jr., MD Irving P. Huber, MD FAAEM James Arnold Nichols, MD FAAEM Joshua E. Novy, MD MBA Tracy R. Rahall, MD FAAEM Marc D. Squillante, DO FAAEM Michael E. Winters, MD MBA FAAEM Molly Wormley, MD

Contributions $250-$499 Mark Avery Boney, MD FAAEM Michael R. Burton, MD FAAEM Anthony J. Callisto, MD FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT Eric M. Sergienko, MD FAAEM Mark O. Simon, MD FAAEM William E. Swigart, MD FAAEM Chad Viscusi, MD FAAEM Kay Whalen, MBA CAE George Robert Woodward, DO FAAEM Missy Zagroba, CAE

2020 Board of Directors Election What Sets Us Apart: Our democratic election procedures are truly what make AAEM unique among professional medical associations. In AAEM, any individual Full Voting or Emeritus member can be nominated and elected to the Board of Directors. Cast your ballot and learn more at: www.aaem.org/about-us/leadership/elections

Vote Today!

Deadline to Cast Your Vote: April 22, 2020 — 11:59pm MST

Candidate Statements Now Available Online and in this Issue

Open Positions

• Review the candidate statements: Now available online and printed in this issue of Common Sense.

• President-Elect

• Join the Candidates’ Forum at the 26th Annual Scientific Assembly in Phoenix, AZ. Wednesday, April 22 from 9:00am-9:45am.

• At-Large Directors (3 positions) – Must be a Full Voting or Emeritus member to vote in the above positions

• Cast your vote: Vote online at www.aaem.org/elections - electronically onsite at Scientific Assembly or from home. To learn more visit the AAEM elections website.

www.aaem.org/elections

Sponsorship of WiEM Section Networking Luncheon Tickets

• Secretary-Treasurer

• Young Physicians Section (YPS) Director – Must be a YPS member

AAEM would like to recognize President, David A. Farcy, MD FAAEM FCCM, for his $1,000 sponsorship of the WiEM Networking Lunch at AAEM20. This sponsorship will allow 10 Resident and Student members to attend the luncheon for free.

COMMON SENSE MARCH/APRIL 2020

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 April 19-23, 2020 26th Annual Scientific Assembly – AAEM20 Phoenix, AZ www.aaem.org/AAEM20

AAEM Recommended Conferences

March 28-29, April 1-2, and April 25-26, 2020 Oral Board Review Course

March 14, 2020 Advances in Cancer ImmunotherapyTM – SITC Tucson, AZ www.sitcancer.org/education/aci

Jointly Provided May 22, 2020 TNAAEM 2020: Updates in Emergency Medicine Nashville, TN www.aaem.org/get-involved/chapter-divisions/ tnaaem/updates-in-em

n e! s-O ractic d n Ha ral P eO

May 22-23, 2020 9th Annual FLAAEM Scientific Assembly Miami Beach, FL www.aaem.org/flaaem/scientific-assembly

March 21, 2020 Advances in Cancer ImmunotherapyTM – SITC Tampa, FL www.sitcancer.org/education/aci

March 28, 2020 Advances in Cancer ImmunotherapyTM – SITC Seattle, WA www.sitcancer.org/education/aci April 3-5, 2020 The Difficult Airway Course: EmergencyTM Boston, MA www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency May 29-31, 2020 The Difficult Airway Course: EmergencyTM Seattle, WA www.theairwaysite.com/a-course/ the-difficult-airway-course-emergency

AMERICAN ACADEMY OF EMERGENCY MEDICINE

PEARLS of WISDOM

SPRING 2020

ORAL BOARD REVIEW COURSE We are committed to helping you feel prepared for your Oral Board examination - our course includes the same system that ABEM uses for the board exam. REGIST Practice hands-on with the eOral system including: ER T O D A • Dynamic vital signs Y! • An interactive, computerized interface • Digital images AAEM has been granted a sub-license for use of eOral software identical to that used for the ABEM Oral Certification Examination. Case content is entirely that of AAEM.

CHICAGO AND ORLANDO

Saturday & Sunday March 28-29, 2020

LAS VEGAS

Wednesday & Thursday April 1-2, 2020

DALLAS AND PHILADELPHIA

Saturday & Sunday April 25-26, 2020

Feel Confident on Exam Day - Prepare with the Experts WWW.AAEM.ORG/ORAL-BOARD-REVIEW 10

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Dear AAEM Member, Enclosed are the candidate statements for the 2020 AAEM board of directors election. As you are aware, the call for nominations was sent to all voting members. Those AAEM members who appear on the enclosed ballot have indicated their willingness to serve on the AAEM board. Statements from each of the candidates full listing of previous board service and awards, and AAEM activities dating back five years (2015 and greater) are on the following pages. Please review the enclosed information, then exercise your democratic right to vote for the representatives you would like to see serve as AAEM’s leaders. Remember, we have a one member, one vote system, so your voice counts. Please follow these instructions for casting your ballot in the 2020 election. If You Will Attend the Scientific Assembly: • We recommend that you do not complete your official ballot at this time. There will be a Candidates’ Forum held during the Scientific Assembly on April 22, 2020, 9:00am-9:45am, where you can hear the candidates respond to direct questions from the voting membership. You will be asked to submit your ballot online at the conclusion of that Forum. • If certain of your choices or unsure if you will attend the Forum, you may vote online at www.aaem.org/ elections. Voting will remain open until April 22, 2020 at 11:59pm MST. If You Are Unable to Attend the Scientific Assembly: • You may complete your official ballot online at www.aaem.org/elections. Online voting will remain open until April 22, 2020 at 11:59pm MST. Balloting Procedure for 2020:

• Voting ballots will only be available online.

Please visit www.aaem.org/elections to cast your vote electronically.

Thank you for your continued support of AAEM. Please call 800-884-2236 with any questions you may have regarding the election procedure. Sincerely,

Kay Whalen Executive Director

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Jonathan S. Jones, MD FAAEM CANDIDATE FOR PRESIDENT-ELECT Nominated by: David A. Farcy, MD FAAEM FCCM; Mark Reiter, MD MBA MAAEM FAAEM; Robert McNamara, MD MAAEM FAAEM Membership: 2009-2022 Disclosure: Nothing to disclose at this time. AAEM Board of Directors AAEM Secretary-Treasurer AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors AAEM/RSA Board Liaison AAEM/RSA Program Director of the Year Award Chapter Division Committee Member Common Sense Assistant Editor Content Management System Sub-Committee Member Education Committee Member EM Workforce Committee Member Mediterranean Emergency Medicine Congress Speaker

Mediterranean Emergency Medicine Congress Abstract Judge Oral Board Review Course Examiner Oral Board Review Course Sub-Committee Board Liaison Residency Visit Speaker Scientific Assembly Abstract Judge Scientific Assembly Planning Subcommittee Scientific Assembly Speaker Wellness Committee Board Liaison Written Board Review Course Subcommittee Board Liaison Young Physicians Section Mentoring Program Young Physicians Section Vice President

Emergency Medicine is wonderful, but we need to fight to ensure it stays that way. I ask for your vote to lead that fight. I am a community physician and AAEM Secretary-Treasurer. Having previously worked in academics as Professor and Residency Program Director, and having served AAEM as an At-large Director, YPS leader, and RSA liaison, I understand the challenges we face and will lead us to solutions. As President-Elect, I will focus on: 1. Due process: This must remain a major priority for the Academy. Ensuring adequate due process for EM specialists will help us battle every other challenge we face. Ensuring due process is ensuring the rights of the physician to practice and advocate. We don’t need to abandon our fight for due process, we need to win it! 2. Non-physician scope of practice: The ED is the most inappropriate place for non-physicians to practice unsupervised or minimally supervised. Intense training is required to provide expert care. We, residency-trained, board-certified emergency physicians have it. Non-physicians don’t. AAEM has led on this issue, but we can do more. There was recent discussion in the EM Workforce committee debating if AAEM should speak out on behalf of urgent care physicians (mostly family physicians) who were replaced by nurse-practitioners. Some in our organization felt that this didn’t impact us. I fought hard to ensure that we did speak out. An assault on physician-led care in any specialty is an assault on physician-led care in all specialties. I propose increasing resources for research, advocacy, and public outreach. 3. Empower our members: Academy members are intelligent and hard-working; however, the current committee-board structure is inefficient and stifling. Our current board manages too much and leads too little. This needs to change and will be my first priority as president-elect. Members must be empowered to do the work of the organization through autonomous leadership committee structures. I will ensure predictable resources for committees and foster a collaborative culture and open door policy to tell me what we need to do in service to our members. 4. Focus on what unites us: Regardless of gender, race, practice setting, age, or anything else, we are all EM physicians. While our different backgrounds strengthen us, we can’t let this distract us. Many issues important to AAEM are important to other EM organizations and other specialties. Many challenges in medicine will require collaborative action to solve. While we adamantly disagree on certain important issues, this should not stop us from working together on others. I will reach out to other organizations and find ways for productive collaboration while never compromising AAEM’s mission. I have worked for over a decade to help AAEM because I, an individual EM doctor, need AAEM’s help to continue doing the job that I love. For each issue discussed at board meetings, I always ask myself, “How would the average EM doctor want me to vote?” I ask for your vote for President-Elect so that this question continues to be asked in everything AAEM does.

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Bobby Kapur, MD MPH CPE FAAEM CANDIDATE FOR PRESIDENT-ELECT Nominated by: David A. Farcy, MD FAAEM FCCM; Mark Reiter, MD MBA MAAEM FAAEM; Brian Potts, MD MBA FAAEM Membership: 2012-2020 Disclosure: Board Member - National Association of Free and Charitable Clinics.

AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors Academic Affairs Committee Member Academic Affairs Committee Board Liaison ACCME Subcommittee Board Liaison Education Committee Board Liaison India Chapter Division of AAEM (AAEMi) Board Liaison

Inter-American Emergency Medicine Congress Speaker LMS Task Force Chair Mediterranean Emergency Medicine Congress PreCongress Chair Residency Visit Liaison Residency Visit Speaker Scientific Assembly Planning Subcomittee Board Liaison Scientific Assembly Student Ambassador Liaison

I have the privilege of serving on the AAEM board for my second term, and it has been a humbling and eye-opening experience that has deepened my understanding and my profound respect for the enormous impact we have upon our local communities. During this time, I have worked with many friends and colleagues from the Academy around the country to expand high quality Emergency care, to address the unique needs of Emergency Physicians and to advocate for students, residents and fellows who are the future of our specialty. At our 26th Scientific Assembly, I am asking for your support to serve as the next President-Elect of AAEM. As ABEM celebrates its 40th anniversary, AAEM is firmly entrenched as the “Champion of the Emergency Physician” and the Champion for Emergency Medicine delivered by board-certified Emergency Physicians. With our specialty beginning its next decade, Emergency Medicine is entering a new stage, maybe a new era, in medicine. We no longer are the small voice in the halls of medicine that accompany being a young specialty. Emergency Physicians are now the leading voices, often the most poignant and articulate voices, in healthcare policy and broader social issues. We are at the forefront on the discussions of injury prevention, responsible firearm policies, diversity in medicine, the opioid crisis, HIV screening and treatment, global health, physician wellness, due process, meaningful reimbursement practices, and much more. This list exceeds 35,000 because it includes the spirit and passion of each board certified Emergency Physician. I share with my residents that if an issue has substance and importance in America then it is coming through our doors and people want to know from Emergency Physicians what are our views and what are the solutions. We have Emergency Physicians in local/state/national government positions, in healthcare executive offices and non-profit leadership roles, and, most importantly, in the front lines of medicine. We share a collective pride when we look around and take a moment to absorb the tremendous influence our specialty is having within our country. And this is the platform that serves as the basis of Emergency Medicine’s next stage. As AAEM’s President, I will continue dedicating my time and efforts to advance AAEM’s mission and to promote policies and practices that support Emergency Physicians who provide high quality care and support the Emergency Physicians themselves. I will work to strengthen and expand AAEM’s capacity to Champion the issues our members speak about and tackle each and every day. I am proud of AAEM’s vast accomplishments and optimistic that our Academy will play an even greater role in the future to improve the lives of our patients and our colleagues. It is an honor to serve you on the AAEM Board, and I ask for your continued support as President-Elect.

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Robert A. Frolichstein, MD FAAEM CANDIDATE FOR SECRETARY-TREASURER Nominated by: David A. Farcy, MD FAAEM FCCM; Lisa Moreno, MD MS MSCR FAAEM FIFEM; Robert McNamara, MD MAAEM FAAEM Membership: 1998-2020 Disclosure: Nothing to disclose at this time. AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors EM Workforce Committee Member EMS Committee Board Liaison Geriatrics Interest Group Board Liaison

Independent Practice Support Committee Member James Keaney Award Mediterranean Emergency Medicine Congress Pre-Congress Faculty Membership Committee Board Liaison Palliative Care Interest Group Board Liaison Wilderness Medicine Interest Group Board Liaison

The Academy saved our independent, democratic group in San Antonio - GSEP. In short, without the involvement and the expertise of AAEM-PG our group would have ceased to exist and I would likely be an employee of a large contract management group (CMG). Instead we carved out a unique situation that allows us to continue to practice as a democratic group without any noticeable impact on our jobs and no negative impact on our group structure. I don’t know how long it will last. CMGs are powerful, albeit in my estimation, weakening, entities. I believe the pendulum will swing back from consolidation to more independent groups and GSEP will be well positioned. This situation has taught me much. I know more about average collections per RVU by payer, budgets, profit and loss statements, etc. than I ever wanted to know. I know more about how large CMGs and corporate hospital companies think and work than most emergency medicine physicians. I have been president of our group for about 9 years and watched us contract and then grow again to currently, a group with annual revenue close to $25 million that we distribute according to our democratically decided, equitable distribution plan. I am thankful we were able to remain independent and I would like to continue to repay the favor with continued service to the Academy and you, by taking the next step and joining the Executive Board as Secretary-Treasurer. I believe the knowledge I have gained as a community emergency physician with extensive business negotiations with CMGs and a corporate hospital makes me uniquely qualified to serve in this role. I love our group, GSEP, and their dedication and belief in the independent, democratic model. Everyone on our team sacrifices to be part of a group that we believe in and are proud to be part of. This attitude is what has allowed our group to succeed. It was present when I joined 17 years ago so I won’t take credit. I was able to nurture this attitude and protect it during some very tumultuous times. I want to do the same for the Academy. I am proud to be a leader in AAEM and am ready to work hard as we grow and advocate for emergency physicians and their patients.

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Bruce Lo, MD MBA RDMS FAAEM CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: Thomas R. Tobin, MD MBA FAAEM; Mark Reiter, MD MBA MAAEM FAAEM Membership: 2012-2021 Disclosure: Board Member - Virginia College of Emergency Physicians.

Open Mic Competition 1st Place Winner Mediterranean Emergency Medicine Congress Speaker Scientific Assembly Speaker It’s an honor to accept the nomination for the position of At-Large Board Member of the American Academy of Emergency Medicine. I currently serve as the chief of emergency medicine for Sentara Norfolk General Hospital, a community hospital that is also the primary teaching site for residents and students at Eastern Virginia Medical School (EVMS), for the past 12 years. I also belong to a private, democratic group for the past 15 years, one of only a few left in the state of Virginia. Like many, I have seen a number of changes in emergency medicine throughout the years and foresee a number of changes coming down the road. Unfortunately, many of them have had consequences that have not been favorable for the specialty of emergency medicine, and there are others that will pose a threat to our specialty and to the front line emergency physician. At the state level, I’ve been very active over the years tackling various issues that affect emergency physicians such as the opioid crisis, independent practice from NPs, and balance billing. I’ve helped implement the emergency department information exchange (EDie) in Virginia several years ago. I’ve also been active regarding patients in the emergency department needing psychiatric care and helped create the state’s psychiatric medical clearance document, with the goal of reducing unnecessary testing. I’m also a Professor in emergency medicine at EVMS and one of the assistant program directors for our emergency medicine residency program for the past 13 years. This has allowed me to work closely with residents and medical students, discussing the issues that will affect their careers. I believe it is critical that residents and medical students get an early exposure to the importance of getting involved in advocacy. As the world becomes more challenging, I believe it is now, more than ever, we need to be more proactive in shaping the future of emergency medicine. I believe that being on the board of AAEM will allow me this opportunity and I look forward serving the membership of AAEM.

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Martin Makela, MD FAAEM FACHE CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: David A. Farcy, MD FAAEM FCCM Membership: 2001-2003, 2005, 2011, 2017-2020 Disclosure: Nothing to disclose at this time.

Oral Board Review Course Examiner Recipient of Three Mitchell Goldman Service Awards The Opioid Crisis, the Mental Health Crisis, the Boarding Crisis, the ED Safety Crisis, the Patient Satisfaction Crisis, the Balanced Billing Crisis... Even for physicians who specialize in treating patients in crisis, these issues are more of a challenge than any of us would choose. AAEM is at the forefront of helping ED physicians deal with these crises and I ask for your vote to allow me to assist AAEM as we move forward. After residency many years ago I attended the AAEM Oral Board Review Course. There I realized that AAEM was the organization that understood my needs. I have volunteered and taught at the Oral Board Review course more than 15 times since then and continue to do so. I recommend that every AAEM member consider teaching at this course. I believe in AAEM and still believe AAEM stands for me. As a US Navy veteran, I bring twenty-five years of broad leadership experience with me to this position. Beginning my career as a Naval Flight Officer, Flight Instructor, and Flight Surgeon I learned leadership skills firsthand and was awarded the Navy Air Medal for flights over Iraq. As a Navy Emergency Physician, I was the Chair of an Emergency Department, the Medical Director of an EMS system, and was awarded the Bronze Star for my actions as the Officer in Charge of a Marine Shock Trauma Platoon in Fallujah, Iraq in 2007. I transition to the civilian world after retirement and have been on the faculty at the University of Washington and Harborview Medical Centers since 2010. I was selected as the Medical Director of the UWMC ED in 2011 where I remain to this day. In that time, we have created a Department of Emergency Medicine, started an Emergency Medicine Residency, joined three campuses, and survived a major ED reconstruction. Like you, I deal daily with the above listed crises that we are all facing. I am an active member of many of the committees addressing these issues of modern Emergency Medicine, including ED and Patient Safety, ED Throughput, ED Boarding, Quality and Core Measures, Diversity, and Credentialing. I am a TeamSTEPPS Master Trainer and a member of the Metropolitan Seattle Sickle Cell Task Force. I developed and manage an active outreach program within the local fraternity and sorority system where I have discussed the dangers of binge drinking with over 4000 students in the last 6 years. I recently received my X waiver and use it nearly every shift. I sit on the Executive Committee for Admissions of the School of Medicine, Chair the Medical Emergency Response Committee and am most proud of my election as the Medical Chief of Staff by my peers in 2017. I also became a Fellow with the American College of Healthcare Executives in 2017. Whether Navy or civilian, my career has been based on service, and I now seek to serve as the At Large member of the AAEM Board of Directors. I ask for your vote.

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Terry Mulligan, DO MPH FAAEM CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: David A. Farcy, MD FAAEM FCCM; Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; Mark Reiter, MD MBA MAAEM FAAEM Membership: 2009-2020 Disclosure: Secretary – International Federation for Emergency Medicine (IFEM). AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors Amin Kazzi International Emergency Medicine Leadership Award EM Workforce Committee Government and National Affairs Committee Board Liaison Government and National Affairs Committee Interim Chair Government and National Affairs Committee Member Health Policy in EM Policy Symposium Chair India Chapter Division of AAEM (AAEMi) Board of Directors International Committee Board Liaison International Committee Chair International Committee Co-Chair International Committee Member International Conference Committee Member

Inter-American Emergency Medicine Congress Speaker Mediterranean Emergency Medicine Congress Abstract Judge Mediterranean Emergency Medicine Congress Executive Committee Mediterranean Emergency Medicine Congress Pre-Congress Course Director Mediterranean Emergency Medicine Congress Pre-Congress Chair Mediterranean Emergency Medicine Congress Scientific Committee Mediterranean Emergency Medicine Congress Steering Committee Mediterranean Emergency Medicine Congress Speaker Mediterranean Emergency Medicine Congress Track Chair Oral Board Review Course Examiner Residency Visit Speaker Scientific Assembly Speaker WestJEM Editorial Board Young Physicians Section Mentor

I have been lucky to have been elected to the AAEM Board of Directors twice already (2016 and 2018), and I am enthusiastically running for a third term as a Member At-Large of the AAEM Board of Directors. I’ve been an active AAEM member since 2004, and have chaired, co-chaired, vice-chaired and been a member of multiple AAEM committees. Since being on the Board of Directors, I was the executive director, executive co-director, track chair and preconference course director at 3 highly successful MEMC conferences in Italy, Portugal and Croatia, and have been deeply involved in every MEMC since 2003. I also developed and ran the first one-day AAEM symposium on Health Policy in 2017 Washington D.C. as a prelude to our National Advocacy Day, and have co-directed and lectured at this every year since. I was instrumental in creating one of AAEM’s newest international chapters: AAEM India, and am the current Vice-President of this Chapter. I have continued to represent AAEM at multiple residency visits, in Washington D.C. to our National legislators, and to our many EM colleagues in the USA and internationally. I am an Adjunct Professor at the University of Maryland School of Medicine, and am a visiting professor in South Africa, in India, and in China. I am double-residency/double-boarded in EM and in Neuromusculoskeletal Medicine, have completed four subspecialty fellowships in International EM, in Health Policy, in EM Administration and Management, and in Sports and Exercise Medicine (Ireland), and have an MPH in Epidemiology and Biostatistics, and an MS in Health Economics, Policy and Law (Netherlands, pending). I look forward to continuing to serve AAEM: the best organization in emergency medicine, the Champion of the Emergency Physician, and ask for your vote to remain a Member At-Large of the AAEM Board of Directors.

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Vicki Norton, MD FAAEM CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: David A. Farcy, MD FAAEM FCCM; Loice Swisher, MD FAAEM; Robert McNamara, MD MAAEM FAAEM Membership: 2007-2021 Disclosure: Nothing to disclose at this time.

Florida Chapter Division of AAEM (FLAAEM) Board of Directors Florida Chapter Division of AAEM (FLAAEM) Board President Mediterranean Emergency Medicine Congress Speaker

Membership Committee Member State Chapter Division Committee Member Women in EM Committee/Section Chair Women in EM Committee/Section Member

It is an honor to be nominated for the position of At-Large Board Member of AAEM. As an active member of AAEM for more than a decade, I am passionate about the ideals and values of our organization. I believe every emergency patient deserves to see a board certified specialist in Emergency Medicine and every physician deserves a fair, safe, and equitable practice setting. I will not sit by and allow outside interests threaten to take over our specialty. I want to work towards a safe environment for patients and physicians, due process for physicians, and the preservation of the independent doctor-patient relationship. My first job out of residency, I signed on with a contract management group (CMG). They had recently acquired the ED contract at the hospital where I was originally offered a position with an independent group. If I declined the job at that time, I faced being unemployed and saddled with all my medical school debt and a new mortgage. And thus, began my exposure to corporate medicine. When I didn’t agree with blindly signing mid-level charts, I was threatened and labeled as a “disruptive physician.” When I saw a colleague fired without cause (but really because he was similarly “disruptive”), I had to silently cover his shifts. This experience validated all my concerns about corporate interference in medicine and became my call to action to do more for our profession. As the past President of the Florida Chapter of AAEM, I have seen the effects of corporate medicine on my colleagues and patients in the state. Florida is often ground zero for questionable practices by CMGs. I have witnessed colleagues put the best interests of their patients first, only to get fired, be blacklisted, and be written off the schedule; shockingly, they were even accused of trying to interfere with the CMG’s contract. These “companies” do not care about patient safety or our medical licenses. Their only concern is profit and no one can threaten their bottom line. AAEM has long held that this type of interference in medicine should not be allowed. AAEM’s values also include equitable conditions for physicians and I believe a part of this relates to gender equity, of which I am a strong proponent. As the Chair of the Women in EM (WiEM) committee for the previous two years, I have lead our efforts to advance women in Emergency Medicine and I am now overseeing the committee’s transition into a formal section of AAEM. I will continue to promote women in AAEM through award nominations, recognizing their achievements, and encouraging them to take leadership roles in their professional communities. As physicians, our duty is to our patients: to be their advocates, to be their safety net for when they need it most. But who will protect us while we are in the trenches? I will. I will be your advocate and the advocate for Emergency Medicine physicians everywhere. I ask that you vote for me to join the AAEM Board.

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Phillip A. Dixon, MD MBA MPH FAAEM CHCQM-PHYADV CANDIDATE FOR YPS DIRECTOR Nominated by: Self-nomination Membership: 2013-2020 Disclosure: Nothing to disclose at this time.

AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors AAEM/RSA Advocacy Committee Chair AAEM/RSA Board of Directors AAEM/RSA Representative Council

AAEM/RSA Legacy Assembly Government and National Affairs Committee Member Mediterranean Emergency Medicine Congress Abstract Judge Social Media Committee Board Liaison Scientific Assembly Student Ambassador Mentor Young Physicians Section Board of Directors

I am applying for the Young Physician Section Director of the American Academy of Emergency Medicine. I very much appreciate the opportunity and consideration to continue my involvement in this tremendous organization. I have served as the YPS Director for the past year and would like to continue to serve in this capacity. Previously, I have also served on both the RSA board as a resident, as well as the YPS board after residency. My interests in emergency medicine include administration/operations, patient and physician advocacy, and health policy. I have recently completed my MBA at The Ohio State University and am currently serving as the Assistant Medical Director while being on faculty there. Among the many initiatives that AAEM participates in, the most important to me has been the advocacy efforts. I am proud to have participated in AAEM’s Advocacy Day and feel AAEM provides an integral and highly valued voice for emergency physicians. AAEM’s strong support for the emergency medicine physician is second to none and is ultimately why I want to continue to participate in this organization. AAEM’s advocacy efforts focus on combating unsafe work environments that unfortunately many emergency medicine physicians face on a daily basis. Overcrowding and understaffing are all too common. Another related topic is the issue of due process rights; where emergency physicians are oftentimes influenced to waive these rights and subsequently can be terminated easily. Due process is integral to practicing emergency medicine and something I believe in strongly. AAEM also supports the existence and proliferation of democratic groups. I am applying for this position in order to continue my involvement with AAEM and participate in its important advocacy efforts. I believe emergency medicine plays a unique role in the community as it functions as not only guaranteed care in case of emergency, but it also functions as a safety net for the most underserved and vulnerable patients. Unlike most other specialties, we as emergency medicine physicians do not chose our patients or their financial circumstances and the medical services we provide and the patient’s insurance status or ability to pay are not connected at all whatsoever. We need to protect our specialty and the physicians that practice this amazing specialty. AAEM champions those who serve our most vulnerable patients and I would be proud to continue my service in AAEM.

COMMON SENSE MARCH/APRIL 2020

PLATFORM STATEMENTS

Brian Parker, MD MS FAAEM CANDIDATE FOR YPS DIRECTOR Nominated by: Self-nomination Membership: 2015-2020 Disclosure: Nothing to disclose at this time.

Open Mic Competition 1st Place Winner Scientific Assembly Speaker YPS Education Committee Member Over the past several years, I have served on the YPS education committee, presented several posters at our scientific assembly, spoken at the scientific assembly in the Breve Dulce area, as well as winning the Open Mic competition last year. Joining the board at AAEM would represent an amazing opportunity to continue to advocate for new attendings and residents. Each one of us experienced tremendous growth and change during our residencies and the first several years after. The YPS section has been designed to assist in making that transition, and I would like to make sure their voice is continued to be heard at the board. I currently serve as core faculty at a county training program, and I get to see what struggles the residents are facing in their training, and how the current healthcare environment affects our most at risk populations. As the next generation of learners begin to graduate medical school and enter our residencies, we need to ensure they have access to the highest quality education and career opportunities that are available to them. The YPS section already offers CV reviewing and several podcasts for them, however, I believe this is the time to investigate if there is more that the academy could support. Our hospital is the only one in Texas that has all third year medical students rotate through the department, which means we have contact with greater than 220 third year students, in addition to the fourth year students completing their electives here, this experience allows mentorship and opportunities to help mold our current crop of learners, to better understand how they are seeking career advice and what their career goals are focused on. As a board member I would make it my goal to ensure that AAEM is the organization residents turn to first when looking for career advice, and realize that our academy will continue to fight to ensure every patient seen in the emergency department will be evaluated and treated by a board certified emergency physician. I would love the chance to give back to the organization that has given me so much during my career; I see the benefit that AAEM can provide residents and early career physicians, and I want to continue to improve on them.

COMMON SENSE MARCH/APRIL 2020

Farewell, My Love

AAEM NEWS

Domenic F. Coletta, Jr., MD FAAEM

ear Emergency Medicine,

Thank you. You saved my life. I’m not being dramatic here – well, maybe just a little – but it’s true. I don’t know what I would have done these past 35 years if it wasn’t for you. Perhaps I would have played in the NBA (if only I wasn’t 5’ 6”) or lead guitar in a rock band (if only I had an ounce of musical talent). No, there’s no doubt in my mind, you were the one for me – which is why my decision to leave you in January of 2020 has been so bitter-sweet for me. But like a prize fighter who has reached his zenith, I want to go out “on top.” I don’t want to be “that doc” who the ER nurses, though they still love him, secretly feel a tad less confident in because his skills are a tad less proficient. More importantly, I NEVER want to be in a situation where someone’s life is in my hands, and those hands are shaking, or a crucial decision needs to be made, and my 65-year-old brain is failing me. So, back to our love affair, EM. Do you remember how it began? I’m not sure I ever told you this part, but it almost never happened. It was some time during my sophomore year at Penn when I chanced upon a production by a small theater group, The Mask and Wig Club. Within minutes I was mesmerized, entertained, and hooked (please don’t be jealous, EM). So, my plan was to change my major from pre-med to theater the first thing in the morning, after I called Dad, of course. It would be a risk, but love conquers uncertainty…doesn’t it? You see, EM, unlike so many physicians I know - my older brother Tony for one - I was never really sure that a career in health care was the right thing for me. I chose pre-med at Penn because, well, at 18 years old and ready to party my ass off, I just didn’t consider what other options were out there. But now, I knew where I was headed - BROADWAY! Or, was Hollywood my destiny? Sure, there was a chance I’d fail, but love conquers failure…doesn’t it? Dad didn’t seem to think so.

OUR FIRST COUPLE OF YEARS WERE A BIT “ROCKY,” LIKE MANY RELATIONSHIPS CAN BE, AS I FOUND MYSELF PETRIFIED WITH THE RESPONSIBILITY OF SAVING LIVES IN THE HECTIC EMERGENCY DEPARTMENT OF JOHNS HOPKINS HOSPITAL.

I’LL MISS YOU SO MUCH, EM. FAREWELL, MY LOVE.

My father, a renowned Philadelphia pathologist, shared with me his perspective on my newfound revelation to pursue a life in performing arts instead of medicine. I can’t recall his exact words, but certain phrases like “starving and penniless,” “one in a million chance,” and “waiting tables the rest of your miserable life” tend to protrude from my memory banks. How ironic, EM, that in his cold and dream squelching way, my dad played a key role in our ultimate love affair which was still a few years away. I resumed my half-hearted pre-med studies while I concentrated on the important aspects of my college experience – rugby, beer, and women. Needless to say, my first attempt at the medical school admission process was not a successful one. I guess that “D” in organic chemistry was an omen. But, upon obtaining a Master’s Degree at Drexel University and improving my MCAT scores enough to get accepted, I found myself, in the fall of 1978, matriculating at Hahnemann Medical College – still no more sure about my future as a doctor than I was the night of that fateful conversation with Dad. But, with big brother Tony as a role model and a core of fantastic classmates and comrades, I began to like (as a friend, EM – it wasn’t true love like ours, I promise) the feeling, or should I say the essence of what it was to be a

physician. The next crossroad in this journey of uncertainty and doubt came in year three when young doctors-in-training need to declare the specialty they intend to choose before that inevitable day known as the “Residency Match.” Oh shit!!!! “Well” I thought, “let me see….” I kinda liked the OR, but no way did I want to be a surgeon. I definitely loved kids, but no way did I want to be a pediatrician. I really enjoyed delivering babies, but no way did I …etc., etc., etc. The one field I knew I detested was internal medicine but, realistically, I figured a year of IM wouldn’t hurt and, perhaps, my true love would find me. Thankfully, you did my dear EM. It was now 1982 and a relatively new medical specialty with relatively few residency programs was out there, flirting with folks like me who saw something sexy and intriguing in it. You caught my eye, EM, and I never looked at or yearned for another. Our first couple of years were a bit “rocky,” like many relationships can be, as I found myself petrified with the responsibility of saving lives in the hectic emergency department of Johns Hopkins Hospital. But, with the guidance of my attendings – Gabe, Keith, Chris, and Ed, to name a few, and the camaraderie of my fellow residents, our love affair flourished.

>> COMMON SENSE MARCH/APRIL 2020

AAEM NEWS

Thanks to you, I even found my OTHER true love (again, please don’t be jealous) when I came across the prettiest ER nurse in all of Baltimore and married her (Annette) in the spring of 1986. We moved to the South Jersey shore area where I became a founding partner of Cape Emergency Physicians, one of the longest running single hospital democratic ED groups in the state, possibly the entire country. What a ride it’s been! You gave me laughter - like the time I was spraying Ethyl Chloride on a man’s pilonidal abscess as I prepared to incise and drain it, not realizing the chemical agent was dripping onto his scrotum. He jumped off that stretcher so fast and proceeded to run through the ED screaming “my nuts are on fire.” You gave me

tears - like the night we coded that 8-year-old lifeless girl who had been in the ED the day before with a mild case of flu. I will never forget that scene and so many other ones through the years – both joyous when a life was saved and devastating when one was lost – that generated such intense emotions for me and my ED family. You allowed me the flexibility to take on other endeavors such as Ringside Medicine, Urgentcare and multiple positions of medical staff leadership at my hospital. And, as your parting gift to me, you gave me extreme pride as I watched my son, Michael, complete his ER residency this past July. Even though you put some restraints on me – working shifts on weekends and holidays when everyone else in the world was off, going for 10

ABEM NEWS

UpToDate® Now Available to ConCert™ Exam Takers Beginning with the spring 2020 administration, Wolters Kluwer’s online, evidence-based clinical decision support resource, UpToDate, will be available to physicians during the ConCert Examination. UpToDate will be a click away while answering questions during the test. You can visit their website and take a tutorial (https://www.uptodate.com/home/uptodate-user-academy-abem-exam).

New Opportunity! Combined Subspecialty Training in Addiction Medicine and Medical Toxicology ABEM is expanding career opportunities for emergency physicians. Combined subspecialty training in Addiction Medicine and Medical Toxicology has been approved by ABEM and the American Board of Preventive Medicine (ABPM). Normally, an Addiction Medicine fellowship is one year in length and a Medical Toxicology fellowship is two years; however, the combined fellowship training requires just twoand-a-half years of training, decreasing training time by six months. Program guidelines and application are available on the ABEM website (https://www.abem.org/public/for-program-directors/combinedtraining-programs). The application must be submitted to both ABEM and ABPM.

COMMON SENSE MARCH/APRIL 2020

hours straight without eating (or peeing), dealing with the occasional “unsavory” character whose violent outbursts while intoxicated or in a state of psychosis makes one wonder if they truly appreciate your efforts to assure their medical well-being – I have always loved you, EM. And, in some ways, with each and every shift I did over these past three decades, I feel like I got to fulfill my desire to be in theater – with the ER as my stage, the staff as my fellow performers and my patients as the audience I genuinely loved to care for. I soon will take my final bow (night shift on New Year’s Eve!) and embark on my new life as a retired senior citizen which, I hope, will include lots of golf, travel, and family time. I’ll miss you so much, EM. Farewell, my love.

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.

COMMITTEE REPORT EM WORKFORCE

Does AAEM Advocacy Resonate with Residents? Jonathan S. Jones, MD FAAEM

he Academy recently released a position statement on the replacement of physicians by non-physician providers at urgent care centers in the Edwards-Elmhurst health system. There was some healthy internal debate within the Academy and within the EM Workforce Committee about whether AAEM should speak out about this situation given that it involved urgent care centers as opposed to emergency departments. Do employment decisions at urgent care centers impact EM physicians? Could we have any actual influence over the decision? Do our members care about this? Are there more important things on which to focus?

• Well I suppose I would be happier if physicians weren’t replaced by non-physicians, but we’re still working on that.

Ultimately, the Academy decided that this situation was important to us and we published a statement on December 3, 2019 (https://www. aaem.org/current-news/edward-elmhurst-health). Separately, on December 5, I was visiting the Kingman Regional Medical Center EM Residency Program in Kingman, AZ as part of the Academy’s commitment to visit as many EM residency programs as possible to explain the Academy and mission to residents. I often start my discussion by asking the audience what they know about AAEM. The first response was something along the lines of, “Didn’t AAEM just do something about doctor’s getting replaced by NPs?” I couldn’t have been happier. (Well I suppose I would be happier if physicians weren’t replaced by non-physicians, but we’re still working on that.) While we have a template for residency presentations, I didn’t really use it at all. What followed was instead, an open, informative, sometimes scary, sometimes inspiring conversation between me, an AAEM representative, and a room full of eager and excited EM residents. It was great. While our statement on the Edwards-Elmhurst situation may not change the decision that organization has made, it absolutely helped inform residents and Academy members. I am fairly certain that it added a few members to our Academy and even more certain that these members will be engaged and contribute to the future of emergency medicine. For that, I want to thank the EM Workforce Committee members and particularly Evie Marcolini and Julie Vieth for their leadership. Job well done.

Statement of the American Academy of Emergency Medicine (AAEM) on the Edward-Elmhurst Health Firing of Physicians and Replacement with Non-Physician Providers The American Academy of Emergency Medicine is expressing it concerns over the recent firing of 15 physicians from the urgent care centers operated by Edward-Elmhurst Health in Chicago. The Academy represents board-certified emergency physicians, some of whom practice in urgent care settings, and most of whom receive patients sent from urgent care centers when their medical condition requires a higher level of care. Urgent care centers, while created to serve lower acuity patients, do in fact see a significant number of patients who have serious medical problems. It is well known that even a routine complaint such as a headache may be the harbinger of a life-threatening illness. We therefore are concerned by the report that these physicians were fired in a cost-cutting move by Edward-Elmhurst Health. The AAEM believes that the skills and training of non-physician clinicians requires that they function as part of a physician-led team with immediate, onsite, physician supervision. The AAEM asks that the decision to replace physicians with NPs and PAs be reconsidered. The community served must be informed and deserves a chance to be heard on the removal of these physicians. There are better ways to cut costs of health care delivery than removing the most qualified person who cares for the patient. Approved: December 3, 2019

COMMON SENSE MARCH/APRIL 2020

COMMITTEE REPORT OPERATIONS MANAGEMENT

New Care Model Promotes Early Intervention for Psychiatric Emergencies Seth Thomas, MD and Gregg Miller, MD FAAEM

re patients with substance abuse and mental health complaints waiting too long for care in your emergency department (ED)? If so, you’re not alone. The average behavioral health patient now spends 11.5 hours in the ED.1 The practice of holding patients waiting for consults and admissions creates congestion, drives up costs, and delays care for all patients. To address this, we have developed an integrated model of acute psychiatric care that’s improving throughput and patient outomes in multiple EDs. Here’s how it works and how you can apply its principles to your own department.

Why Behavioral Health Patients Wait One of the biggest challenges providers face when treating behavioral health patients in the ED is providing differentiated care. For example, a patient with chest pain is risk-assessed based on their history, physical, and selected testing and then they are treated accordingly. By contrast, every mental health and substance abuse patient tends to be placed into the same proverbial diagnostic bucket. Few standardized tools exist to help us assess and treat behavioral health patients in the same manner we do for medical patients. As a result, the majority of behavioral health patients wait for psychiatry consults or crisis worker evaluations regardless of their complaint.

The EPI Solution Solutions like telepsychiatry, consult liaison services, and crisis stabilization units all benefit patients with mental health needs. But these require resources and take time to implement. We need additional solutions that can be rolled out now to manage mental health patients. One solution that addresses these problems is what we call Emergency Psychiatry Intervention (EPI). EPI applies the same concepts we use for all other ED patients to patients with mental health needs: stratification by acuity, split flow streaming with an emphasis on early discharge for low-acuity patients, and early medical intervention for high acuity patients. EPI empowers ED care teams through clinical education, best-practice implementation, and leadership training. It provides teams with pathways to assess risk and provide early intervention. This includes identifying and stabilizing low- to moderate-risk patients, who, in many cases, can be safely discharged from the ED. Ultimately, EPI empowers the ED team to own more of the care of our behavioral health patients. The EPI model has many benefits. Behavioral health patients receive early and appropriate treatment. Providers and staff feel more satisfied in their roles knowing they have the tools to help. The process reduces

COMMON SENSE MARCH/APRIL 2020

wait times and delays for all patients, improving outcomes and satisfaction. And finally, the process saves hospitals money and resources by improving throughput and freeing psychiatric consultants to focus where they are truly needed.

EPI in Action Four EDs in the Chicago-based AMITA Health system, which were seeing high volumes of behavioral health patients, participated in the launch of EPI in late 2018. In particular, the ED team at AMITA Health Saint Joseph Hospital was facing a number of challenges, including turnover in the hospital’s inpatient behavioral health unit. They needed resource-neutral solutions that could be fully implemented within the ED. To this end, they decided to focus on developing a risk-stratification process, creating discharge resources, and promoting earlier administration of oral second-generation antipsychotic medications to treat agitation, which are less sedating than older antipsychotics, and therefore, less likely to prolong patients’ ED stays. After undergoing EPI training and implementing the toolkit, AMITA Saint Joseph reduced ED length of stay for low-risk patients by 38% and medium-risk patients by 20%. What’s more, none of the discharged patients “bounced back” unexpectedly.1 Three other hospitals saw similar results. The ED at AMITA Health Saint Francis Hospital cut their length of stay for discharged behavioral health patients in half, from 300 minutes to 150.1 Together, the four participating hospitals reduced their average wait times for this population by an impressive 43 minutes.1

Pathway to Differentiated Care In order to successfully differentiate behavioral care in the ED, departments need a few key elements in place. First, it’s crucial to get buy-in from everyone involved in patient care. Providing differentiated care requires emergency physicians and nurses to take true ownership of behavioral health patients rather than waiting for a psychiatrist or crisis worker to make decisions. This may require a significant cultural shift in your department. Second, prioritize education. Physicians and staff are more likely to assist patients when they are confident in their ability to help. Essential topics to cover include risk assessment, de-escalation, and clinical management. Third, create clinical pathways for behavioral health patients with different levels of need. Low-risk patients can often be stabilized in the ED and safely discharged for outpatient follow-up. However, some patients will need access to telepsychiatry, crisis stabilization, or inpatient care, so map out how and when you will transition them to these services. We are happy to discuss our experiences if you’re interested. Please email us at Seth.Thomas@vituity.com and Gregg.Miller@vituity.com.

OPERATIONS MANAGEMENT

About the Authors Seth Thomas, MD is Director of Quality and Performance at Vituity. In addition, Dr. Thomas is an emergency medicine physician practicing at Mercy San Juan Medical Center. Dr. Thomas earned his medical degree from Albany Medical College and completed his emergency medicine residency at Loma Linda University Medical Center. He has been with Vituity since 2009.

Gregg Miller, MD FAAEM is Chief Medical Officer for Vituity. He is an emergency medicine physician practicing at Swedish Edmonds Hospital. He earned his medical degree from UCSF and completed emergency medicine residency at Harbor UCLA. References: 1. 1 Thomas S. Closing the Gap on Psychiatric Care in the Emergency Department (webinar). Posted July 31, 2019. https://www.youtube.com/ watch?v=GcOWbYIQbUs&feature=youtu.be

HIGHLIGHTS FOR SCIENTIFIC ASSEMBLY 2020 AAEM20: This year’s theme is “All Voices Heard.” This means that whether you are a physician, a patient, or the public, your voice is important and is heard. As physicians we need to be stronger advocates for our patients, the public, and each other. At AAEM, we hear you.

PHYSICIANS We’ve heard what you have said about past conferences, and have made changes to AAEM20 programming to accommodate your requests. This year you will see: More Breve Dulce talks – The afternoon of Tuesday, April 21st will be dedicated primarily to Breve Dulce talks located in a larger room with minimal other tracks running concurrently and will continue through Wednesday and Thursday. Thursday, April 23rd will be dedicated to one room only plenary and Breve Dulce talks. Up-to-date literature discussions – New this year will be a literature review panel: “Meeting of the Minds” session where panels of experts will discuss recent controversial medical literature. More Small Group Clinics – Small Group Clinics are back, and this year there are more than ever. Fewer tracks – Past Scientific Assemblies have been chock full of education, and we heard that there were too many session choices and that physicians felt like they were missing out. This year we still have a ton of great education, and you won’t have to worry about missing anything. More advocacy-related talks – Not only did we add more advocacy talks to programming this year, we also moved the Health Policy in Emergency Medicine (HPEM) Symposium to a pre-conference course so you can kick-off AAEM20 by learning how to use your voice to advocate at the local and national levels. New voices – You wanted to hear new voices from rising stars in emergency medicine so this year we invited new voices and faces to speak while maintaining the expert education of seasoned favorites you’ve come to expect from AAEM. View our full speaker list here. We’ve also heard what you have said about the practice and business of EM and have specific talks that address your concerns:

• The Influx of Advanced Practice Providers: What is the Role of the Emergency Physician? Julie Vieth, MBChB FAAEM Monday, April 20, 2020 | 4:10pm-4:30pm (Phoenix A) This lecture will provide an overview of the scope of this issue, including training requirements for APP; discussion of several recent issues highlighted in the national press when APPs practice unsupervised and present options for utilizing a physician team-led approach in the treatment of our patients in the ED. • The Existential Threat to EM Right Now: If We Don’t Take Control, Someone Else Will Jason Adler, MD FAAEM Wednesday, April 22, 2020|11:45am-12:05pm (Camelback AB) This talk will explore three merging phenomenons, reduction in public reimbursement, reduction in private reimbursement, and an expanding labor force, that together could threaten the economic health of our community. Potential solutions will be discussed. • Emergency Medicine at the Precipice Richard M. Pescatore II, DO FAAEM Wednesday, April 22, 2020 | 2:30pm-2:50pm (Phoenix DE) This lecture will discuss the evolution of EM from presence only for life- and limb-threatening disease toward our role as “availabilists” simultaneously the front line and the safety net for healthcare. The speaker will beat back on the over-consulting and under-treating culture driven by medicolegal fear and CMG influence. • How to Get Involved in Advocacy Amish Mahendra Shah, MD FAAEM Wednesday, April 22, 2020 | 5:20pm-5:40pm (Camelback AB) Arizona State Congressman and emergency physician Dr. Amish Shah shares practical tips and advice on how to get involved in advocacy at the state and local level, and how to get other physicians to get involved. • The Joint Commission as Complicit in the Opioid Crisis Talcott Franklin Thursday, April 23, 2020 | 11:40am-12:00pm (Phoenix DE) Attend the final AAEM Scientific Assembly 2020 presentation by plaintiffs’ attorney Tal Franklin, who represents four West Virginia cities pursuing civil litigation against TJC for its culpability in causing and worsening the opiate epidemic in those cities. COMMON SENSE MARCH/APRIL 2020

PATIENTS

PUBLIC

We’ve heard our patients and this year our patient panel will be returning along with other patient-focused sessions. Be sure to attend:

We’ve heard the public and the public wants social change. The public voice will be represented by our Keynote speaker, Thea James, MD as well as in other sessions which address topics such as #ThisIsOurLane and Social EM:

• Beyond He Said/She Said Maite A. Huis in ‘t Veld, MD FAAEM Wednesday, April 22, 2020 | 1:30pm-1:50pm (Phoenix DE) Transgender patients face many health disparities and complications, yet they often fear coming to the ED because of previous negative experiences. This lecture focuses on how to best interact with this patient population. • Patient Satisfaction in EM Gus M. Garmel, MD FAAEM FACEP Wednesday, April 22, 2020 | 1:30pm-1:50pm (Ahwatukee A) This lecture is focused on literature, evidence, and anecdotes to teach and improve patient satisfaction for EPs, RNs, faculty, and residents. • Sickle Cell Patient Panel Jack C. Perkins Jr., MD FAAEM Wednesday, April 22, 2020 | 4:20pm-5:10pm (Phoenix DE) Come experience a truly unique learning format where the patient is the educator. We will have three patients with sickle cell disease along with their hematologist to provide their perspective on optimal care of the patient with sickle cell disease in the emergency department. In this session, moderated by two EM physicians with an interest in SCD, the patients will discuss their experiences with life-threatening sickle cell disease complications as well as barriers to care that they have encountered in the ED. Your perspective on ‘optimal care’ of sickle cell disease will be challenged when hearing from the patients themselves.

• Keynote: The “Upstream” Transformation of Healthcare: Leveraging Emergency Medicine Thea L. James, MD Wednesday, April 22, 2020 | 8:15am-9:00am (Phoenix DE) Population health disparities are a downstream effect of upstream causes. Using case examples, Dr. James will describe how emergency medicine can be leveraged to address the root causes of high cost and poor patient outcomes. • Our Lane: The Critical Role of Emergency Physicians in Advancing Public Health Joneigh S. Khaldun, MD MPH FAAEM Tuesday, April 21, 2020 | 10:15am-11:00am (Phoenix DE) Most of us went into medicine because we genuinely want to help people. While our individual reach may be limited, there are still things we as physicians can do to broadly improve the health of our patient population. • Social Emergency Medicine: “Not My Job” Doesn’t Cut It in 2020 Megan Healy, MD FAAEM Tuesday, April 21, 2020 | 9:30am-9:40am (Phoenix DE) This talk introduces the emerging field of social emergency medicine and describes why the ED is the perfect setting for population health and social determinants innovation. This is a paradigm-shifting talk meant to challenge the notion that social issues are “not our job” to address in the ED.

26TH ANNUAL SCIENTIFIC ASSEMBLY Boost your CME by kicking off AAEM20 with a pre-conference course.

Visit the Exhibit Hall to make new connections.

COMMON SENSE MARCH/APRIL 2020

APRIL 19-23, 2020 SHERATON PHOENIX DOWNTOWN

PHOENIX, AZ #AAEM20

www.aaem.org/AAEM20

THANKS TO OUR 2020 INDUSTRY PARTNERS AAEM extends its thanks and appreciation to the following industry partners who have funded activities at the 2020 AAEM Scientific Assembly.

AAEM20 EXHIBITORS – THANK YOU Plan your visit to the exhibit hall in Phoenix to network with these exhibitors. EXHIBITOR

BOOTH

Bayer - Crop Science

225

Biodynamic Research Corporation

100

$50,000+ SUPPORT LEVEL

BMS/Pfizer, Inc

302

Bayer - Crop Science

Brault Practice Solutions

207

Change Healthcare

216

Clozex Medical

213

$20,000 - $49,999 SUPPORT LEVEL Abbott Point of Care Inc

DuvaSawko

203

EM Coach

209

• Non-CME Educational Program

Fisher & Paykel Healthcare, Inc

312

AAEM Physician Group

Intelligent Ultrasound North America

204

• Lanyards • Coffee Breaks

KPG Provider Services

316

Locums United, Inc.

109

LocumTenens.com

117

LogixHealth

103

Luttner Financial Group

215

• USAAEM Unrestricted Educational Grant - Disaster Medicine Familiarization Preconference Course

Martin Gottlieb & Associates

212

Medlytix

202

UP TO $4,999 SUPPORT LEVEL

Mercy

304

Cambridge University Press

Nabriva Therapeutics

113

• Exhibit Hall Box Lunch Sponsorship • Non-CME Educational Program • Twitter Monitor

$5,000 - $19,999 SUPPORT LEVEL

Brault • Mobile App

Masimo Corporation

• Registration Bag Inserts

DuvaSawko

Pepid, LLC

206/208

R1 RCM

214

Shift Administrators, LLC

217

The Dental Box

205

Vituity

VEP Healthcare

308

• Registration Bag Inserts

Vituity

221

Zerowet, Inc

314

Zotec Partners 120

120

• Pedometers

iSimulate • Unrestricted Educational Grant

IN-KIND SUPPORT

Butterfly Network • Use of (5) Butterfly Ultra Sound Machines

FUJIFILM/SonoSite • Use of (13) Ultrasound Machines and Probes

More to come! Visit www.aaem.org/aaem20/exhibitors-and-sponsors for the most up-to-date list.

Intelligent Ultrasound • Use of (2) Simulators

COMMON SENSE MARCH/APRIL 2020

CHECK OUT THESE MOC RELATED SESSIONS AT AAEM20 View the full program and all topics covered at AAEM20 on the website: www.aaem.org/aaem20/program

CARDIOVASCULAR

MEDICOLEGAL

Wednesday, April 22

Monday, April 20

• (326) Basic Echo | Melissa Myers, MD FAAEM • (327) Caring for the Heart Transplant Patient in the ED | Samantha Wood, MD FAAEM • (328) Ventricular Storm: What to Do When Electricity Isn’t Enough | Christopher San Miguel, MD FAAEM • (328) Managing Exercise Associated Heat Illness | Korin B. Hudson, MD FAAEM • (328) Pressure Pushing Down on Me: The Sonographic Assessment of Pericardial Effusions | Mark Magee, MD FAAEM • (331) Transvenous Pacer | Siamak Moayedi, MD FAAEM

• (115) Collision Course: Medicine and the Law | Diana Nordlund, DO JD FAAEM FACEP • (117) Telemedicine Legal Pitfalls | Ethan Andrew Booker, MD FAAEM

Thursday, April 23

• (265) Meet the PRES: Posterior Reversible Encephalopathy Syndrome in Your ED | Bradley E. Barth, MD FAAEM • (265) Does Anyone Deserve Platelets with Intracerebral Hemorrhage? | Karen Greenberg, DO FAAEM FACOEP • (265) Slow Down to Speed Up | Evie G. Marcolini, MD FAAEM FACEP FCCM

• (405) Be Still My Beating Heart: Recognizing and Using Cardiac Standstill | Melissa Myers, MD FAAEM • (405) PE in Pregnancy: Navigating the Minefield | Joelle Borhart, MD FAAEM FACEP • (405) Spontaneous Coronary Artery Dissection: An Overview of an Underrecognized Disease | Patricia De Melo Panakos, MD FAAEM • (Plenary) Emergency Cardiology 2020: The Articles You’ve Got to Know! | Amal Mattu, MD FAAEM

INFECTIOUS DISEASE Monday, April 20

• (Plenary) Are Bugs Going to Win the War? - Update on Infectious Disease | Peter M.C. DeBlieux, MD FAAEM • (115) The Febrile Infant | Ilene Claudius, MD FAAEM FAAP FACEP Tuesday, April 21

• (290) DIY: Peritonsillar Abscess Management | Laura J. Bontempo, MD MEd FAAEM Wednesday, April 22

• (318) Fever, Shock & Serositis | Manu Ayyan, MD FACEE • (327) The Five Most Common and Serious Mistakes Made in Care of the Septic Patient | Jack C. Perkins Jr., MD FAAEM Thursday, April 23

• (405) Finer Points in Febrile Neutropenia | Sarah B. Dubbs, MD FAAEM

Wednesday, April 22

• (334) Medicolegal Pitfalls | Matthew C. DeLaney, MD FAAEM

NEUROLOGY Monday, April 20

• (118) Large Vessel Occlusion: What You Need to Know | Michael E. Silverman, MD FACP FAAEM Tuesday, April 21

Wednesday, April 22

• (333) More Than Just Drunk - Wernick’s Encephalopathy in the ED | Jason Hine, MD FAAEM • (333) Are You Performing GCS Correctly? | Wan-Tsu W. Chang, MD FAAEM

PAIN MANAGEMENT/OPIOIDS Monday, April 20

• (116) Building a Successful ED Buprenorphine Program: Step by Step – the Hard Lessons Learned | Eric M. Ketcham, MD FAAEM FASAM Tuesday, April 21

• (270) Small Group Clinic: Upper Extremity US Guided Nerve Block | Michael Gottlieb, MD FAAEM RDMS • (295) Small Group Clinic: Lower Extremity US Guided Nerve Blocks | Michael Gottlieb, MD FAAEM RDMS Wednesday, April 22

• (315) Opioid Stewardship 2.0: From Quantity to Quality and Beyond | Sergey M. Motov, MD FAAEM • (318) Headache Regional Anesthesia | Michael Shalaby, MD • (325) Top Myths and Truths About ED Suboxone | Matthew D. Zuckerman, MD FAAEM Thursday, April 23

• (415) Trigger Point Injections | Zachary Repanshek, MD FAAEM

COMMON SENSE MARCH/APRIL 2020

PEDIATRICS

PLENARY SPEAKERS

Monday, April 20

• (115) The Febrile Infant | Ilene Claudius, MD FAAEM FAAP FACEP Tuesday, April 21

• (Plenary) Vision 20/20: Updates in Pediatric EM | Mimi Lu, MD FAAEM • (210) Pediatric Gynecology | Ilene Claudius, MD FAAEM FAAP FACEP • (210) Literature Review Panel: Pediatrics/Public Health | Joneigh S. Khaldun, MD MPH FAAEM; and Mimi Lu, MD FAAEM

Peter M.C. DeBlieux, MD FAAEM

Are Bugs Going to Win the War? Update on Infectious Disease Monday, April 20, 2020 | 1:35pm-2:15pm

Corey M. Slovis, MD FAAEM FACP FACEP

Recent Practice Changing Articles in Prehospital Resuscitation Monday, April 20, 2020 | 2:25pm-3:10pm

Wednesday, April 22

• (333) The Precipitous Delivery: Essential Tasks for Newborn Resuscitation | Daphne M. Morrison Ponce, MD FAAEM

Mimi Lu, MD FAAEM

Thursday, April 23

Tuesday, April 21, 2020 | 8:00am-8:45am

Vision 20/20: Updates in Pediatric EM

• (415) Help, My Child is Bleeding!: Tips and Tricks for Managing the Pediatric Upper GI Bleed | Kathleen M. Stephanos, MD FAAEM

RISK MANAGEMENT/PATIENT SAFETY

Joneigh S. Khaldun, MD MPH FAAEM

Tuesday, April 21

• (265) Documenting the Space Between the Exam and Diagnosis Line: Rapid Fire Pearls You’ve Got to Know | Jason Adler, MD FAAEM Wednesday, April 22

• (333) Resisting the EASY Button: Why It’s Probably Not a UTI in Your Geriatric Patient | Danya Khoujah, MBBS FAAEM • (334) Medicolegal Pitfalls | Matthew C. DeLaney, MD FAAEM

TRAUMA

Our Lane: The Critical Role of Emergency Physicians in Advancing Public Health Tuesday, April 21, 2020 | 10:15am-11:00am

Haney Mallemat, MD FAAEM Critical Care in Review

Tuesday, April 21, 2020 | 4:05pm-4:50pm

Michael L. Epter, DO FAAEM

Wednesday, April 22

• (318) Junctional Hemorrhage | Elizabeth M. Mannion, MD FAAEM • (333) Managing the Hanging Victim | Manish Garg, MD FAAEM

The ABC Algorithm: Why C Should ALWAYS Come First - At the Bedside and in Life Thursday, April 23, 2020 | 8:00am-8:45am

Thursday, April 23

• (405) Trauma-Informed Care for Violently Injured Patients | Kyle R. Fischer, MD MPH FAAEM

Amal Mattu, MD FAAEM

Emergency Cardiology 2020: The Articles You’ve Got to Know! Thursday, April 23, 2020 | 10:15am-11:00am

Share in cutting-edge education and hear from new voices in EM.

COMMON SENSE MARCH/APRIL 2020

AAEM20 SPEAKERS Jason Adler, MD FAAEM Haig Aintablian, MD Abena O. Akomeah, MD Afrah Abdul Wahid Ali, MBBS Zeki Atesli, MD Manu Ayyan, MD FACEE Crystal Bae, MD Jeffery A. Baker, MD FAAEM Jessica Barlow, MD Bradley E. Barth, MD FAAEM Kersti Bellardi, MS Rahul Bhat, MD FAAEM Michael Billet, MD Michael C. Bond, MD FAAEM FACEP Laura J. Bontempo, MD MEd FAAEM Ethan Andrew Booker, MD FAAEM Joelle Borhart, MD FAAEM FACEP Matthew P. Borloz, MD FAAEM William J. Brady, MD FAAEM Vonzella A. Bryant, MD FAAEM Katharine Burns, MD FAAEM Joseph S. Bushra, MD FAAEM Christine Joyce Butts, MD FAAEM David J. Carlberg, MD FAAEM Kiersten L. Carter, MD FAAEM Wan-Tsu W. Chang, MD FAAEM Eric J. Chin, MD MBA FAAEM Mark Chottiner, MD Victor M. Cisneros, MD MPH Ilene Claudius, MD FAAEM FAAP FACEP Jared L. Cohen, MD Adriana Coleska, MD James AP Connolly, MBBS FRCS(Ed) FCEM Krishna Constantino, MD Juliette Conte, MD Kyle S. Couperus, MD FAAEM Katrina D’Amore, DO MPH Peter M.C. DeBlieux, MD FAAEM Matthew C. DeLaney, MD FAAEM Matthew DeStefano, DO Halil Dogan, PhD MD Christopher I. Doty, MD FAAEM Sarah B. Dubbs, MD FAAEM Florence MV Dupriez, MD Erick Eiting, MD MPH MMM FAAEM Brandon A. Elder, MD FAAEM Michael L. Epter, DO FAAEM David A. Farcy, MD FAAEM FCCM David F. Fine Kyle R. Fischer, MD MPH FAAEM Jessica Fleischer-Black, MD FAAEM Talcott J. Franklin, MA JD Gary M. Gaddis, MD PhD FAAEM FIFEM Rajat Gangahar, MBBS FRCS(Ed) FCEM Manish Garg, MD FAAEM Gus M. Garmel, MD FAAEM FACEP Paul Geukens, MD Harman S. Gill, MD FAAEM Jacob K. Goertz, MD FAAEM L.E. Gomez, MD MBA FAAEM Alexandra June Gordon, MD Michael Gottlieb, MD FAAEM RDMS Karen Greenberg, DO FAAEM FACOEP John C. Greenwood, FAAEM Andrew Grock, MD FAAEM Joshua Guttman, MD FAAEM Gregory R. Hand, MD Stephen R. Hayden, MD FAAEM Bryan D. Hayes, PharmD FAACT FASHP Megan Healy, MD FAAEM Jacob Hempstead, NREMT-P Stanley Hempstead Jason Hine, MD FAAEM Beatrice Hoffmann, MD PhD FAAEM Aleta Hong, MD Kami M. Hu (Windsor), MD FAAEM Korin B. Hudson, MD FAAEM Maite A. Huis in ‘t Veld, MD FAAEM Ashika Jain, MD FAAEM FACEP Rupal Jain, MD Thea L. James, MD Paul S. Jansson, MD Gregory Jasani, MD Kristine Jeffers, MD Jonathan S. Jones, MD FAAEM Andrea L. Kaelin, MD FAAEM Jennifer Kanapicki Comer, MD FAAEM Eric M. Ketcham, MD MBA FAAEM FASAM

COMMON SENSE MARCH/APRIL 2020

KEYNOTE SPEAKER Joneigh S. Khaldun, MD MPH FAAEM Danya Khoujah, MBBS FAAEM Robert P. Lam, MD FAAEM Michael J. Lambert, MD FAAEM RDMS Tracy Leigh LeGros, MD PhD FAAEM Skyler A. Lentz, MD FAAEM Michael D. Levine, MD FAAEM Judy Lin, MD FAAEM Demis N. Lipe, MD FAAEM Joshua Lowe, MD Mimi Lu, MD FAAEM Mark Magee, MD FAAEM Haney Mallemat, MD FAAEM Elizabeth M. Mannion, MD FAAEM Evie G. Marcolini, MD FAAEM FACEP FCCM Amal Mattu, MD FAAEM Colin G. McCloskey, MD FAAEM Nevin G. McGinley, MD MBA FAAEM Alexandre F. Migala, DO FAAEM Carl E. Mitchell, MD FAAEM Siamak Moayedi, MD FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Daphne M. Morrison Ponce, MD FAAEM Sergey M. Motov, MD FAAEM Melissa Myers, MD FAAEM Anthony Netzel, DO Diana Nordlund, DO JD FAAEM FACEP Carol Pak-Teng, MD FAAEM Patricia D. Panakos, MD FAAEM Brian Parker, MD MS FAAEM Gregory Patek, MD OD FAAEM Alec Pawlukiewicz, MD Jack C. Perkins Jr., MD FAAEM Richard M. Pescatore II, DO FAAEM Andrew W. Phillips, MD MEd FAAEM Elizabeth Pontius, MD FAAEM RDMS Marco Propersi, DO Kevin C. Reed, MD FAAEM Mark Reiter, MD MBA MAAEM FAAEM Jennifer Repanshek, MD FAAEM Zachary Repanshek, MD FAAEM Salim R. Rezaie, MD FAAEM Andrew Rizzo, DO FAAEM Mounica D. Robinson, MD Shana EN Ross, DO Alexis Salerno, MD FAAEM Christopher San Miguel, MD FAAEM Douglas Schiller, DO FAAEM Amish Mahendra Shah, MD MPH FAAEM Michael Shalaby, MD Richard D. Shih, MD FAAEM Michael E. Silverman, MD FAAEM FACP Zachary M. Sletten, MD FAAEM Corey M. Slovis, MD FAAEM FACP FACEP Randy Sorge, MD Ryan Spangler, MD FAAEM Adam Spanier, MD Gabriel Stahl, MD MPH Eric M. Steinberg, DO MEHP FAAEM Kathleen M. Stephanos, MD FAAEM Jeffrey R. Stowell, MD FAAEM Reuben J. Strayer, MD FRCP FAAEM FACEP Matthew J. Stull, MD FAAEM Loice A. Swisher, MD FAAEM Elizabeth B. Takacs, MD Michael E. Takacs, MD MS FAAEM Semhar Z. Tewelde, MD FAAEM Celine Thum, MD FAAEM Joseph R. Twanmoh, MD MBA FAAEM Atilla B. Uner, MD MPH FAAEM FAEMS Julie Vieth, MBChB FAAEM Andy Walker, MD FAAEM Brett Walters, MD Susan R. Wilcox, MD FAAEM R. Gentry Wilkerson, MD FAAEM George C. Willis, MD FAAEM Michael E. Winters, MD MBA FAAEM Joseph P. Wood, MD JD MAAEM FAAEM Samantha Wood, MD FAAEM Allen Yee, MD FAAEM Yonatan Yohannes, MD FAAEM Allison Zanaboni, MD FAAEM Bob Zemple IV, MD FAAEM Matthew D. Zuckerman, MD FAAEM Speakers subject to change

Thea L. James, MD

Wednesday, April 22 | 8:15am-9:00am

The “Upstream” Transformation of Healthcare: Leveraging Emergency Medicine Talk Description This keynote will present an imperative for shifting the healthcare paradigm through using upstream, root cause models of care. The speaker will highlight unique insights and opportunities for emergency medicine physicians in this evolving national transformation. Biography Thea James, MD, is Vice President of Mission and Associate Chief Medical Officer at Boston Medical Center. She is an Associate Professor of Emergency Medicine and Director of the Violence Intervention Advocacy Program at BMC. Dr. James is a founding member of the National Network of Hospital-Based Violence Intervention Advocacy Programs (NNHVIP). In 2011 she was appointed to Attorney General Eric Holder’s National Task Force on Children Exposed to Violence. As Vice President of Mission Dr. James works with caregivers throughout BMC. Additionally she has primary responsibility for coordinating and maximizing BMC’s relationships and strategic alliances with a wide range of local, state and national organizations including community agencies, housing advocates, and others that partner with BMC to meet the full spectrum of patients needs. The goal is to foster innovative and effective new models of care that are essential for patients and communities to thrive. Integrating upstream interventions into BMC’s clinical care models are critical to achieve equity and health in the broadest sense. Dr. James served on the Massachusetts Board of Registration in Medicine 2009-2012, where she served as chair of the Licensing Committee. She is 2008 awardee of Boston Public Health Commission’s Mulligan Award for public service and a 2012 recipient of the Suffolk County District Attorney’s Role Model Award. She received The Boston Business Journal Healthcare Hero award in 2012 & 2015. She was 2014 recipient of the Schwartz Center Compassionate Care Award. The Boston Chamber of Commerce awarded Dr. James with the Pinnacle Award in 2015, which honors women in business and the professions. Dr. James was awarded the 2019 Leadership in Medicine Award by the Massachusetts Public Health Association. Dr. James’ passion is in public health both domestically and globally. For many years she and colleagues partnered with local international partners in Haiti and Africa to conduct sustainable projects. She is a member of the Board of Directors of Equal Health. Equal Health works with local partners in Haiti to create strong, sustainable medical and nursing education systems. Dr. James served as a Supervising Medical Officer on the Boston Disaster Medical Assistance Team (MA-1 DMAT), under the Department of Health and Human Services. She has deployed to post 9/11 in NYC, Hurricane Katrina in New Orleans in 2005, Bam, Iran after the 2003 earthquake, and Port-Au-Prince Haiti after the earthquake of 2010. Dr. James traveled to Haiti with MA-1 DMAT one day after the 2010 earthquake. A graduate of Georgetown University School of Medicine, James trained in Emergency Medicine at Boston City Hospital, where she was a chief resident. Visit the AAEM20 website for full educational details including session titles, speakers, and more!

www.aaem.org/AAEM20

BREVE DULCE These ever-popular “short and sweet” sessions last just seven minutes and have 25 slides. We listened to your feedback and at AAEM20, most Breve Dulce sessions will be held in a larger room.

JOIN US IN PHOENIX!

LITERATURE REVIEW AND EXPERT ANALYSIS – MEETING OF THE MINDS New at AAEM20! Join our plenary speakers as they delve deep into the latest practice-changing articles in pediatrics, public health, and critical care. Bring your questions for an audience Q&A with the experts.

Collaborate and network with colleagues from around the world.

SMALL GROUP CLINIC These sessions provide personal and hands-on education. At AAEM20 there are more options than ever before! 20 slots will be filled with advanced registration and10 slots will be available onsite on a first-come, first-served basis.

Design your own schedule – AAEM20 offers topics for all interests.

COMPETITIONS The AAEM/JEM, WestJEM, and the YPS Competitions invite attendees to be a part of the audience. The Open Mic Competition is open to participants as well as observers. Learn more at www.aaem.org/AAEM20/ competitions.

Earn FREE CME – AAEM20 is free for members

AAEM20 COMPETITIONS

(with a refundable deposit).

Plan to browse the poster displays or attend abstract presentations at AAEM20. The following competitions will be taking place during the conference. Learn more at www.aaem.org/aaem20/competitions. • AAEM and Journal of Emergency Medicine Resident and Student Research Competition • AAEM/RSA & Western Journal of Emergency Medicine Population Health Research Competition • Photo Competition • AAEM Young Physicians Section (YPS) Poster Competition • Open Mic Competition – Onsite sign-ups available!

RELAX & RECHARGE AAEM20 offers opportunities to socialize, network and recharge with your EM colleagues. Join us for Opening Reception in the Exhibit Hall on Monday evening, April 20, 2020 from 5:45pm-6:45pm. AAEM20 will again offer additional social events as well as wellness events to make our conference both an enriching educational experience as well as a motivational retreat where you leave feeling a renewed passion for emergency medicine. Expect to see some of your favorite wellness and social events again, as well as the return of the Women in Emergency Medicine Luncheon. Stay tuned for more information.

Take time to recharge at social and wellness events.

www.aaem.org/AAEM20

COMMON SENSE MARCH/APRIL 2020

On-Shift Eating and Drinking: A Simple Strategy on Addressing Physician Burnout

COMMITTEE REPORT WELLNESS

Al’ai Alvarez, MD FACEP FAAEM | @alvarezzzy

or the longest time, health care workers including physicians were not allowed to eat and drink in the emergency department (ED) effectively due to strict interpretations of regulations from the Occupational Safety and Health Administration (OSHA) and The Joint Commission 1,2 (TJC). The American College of Emergency Physicians (ACEP) clarified this with the TJC earlier in 2019, finally allowing for ED physicians to attend to one of our basic physiological needs while on shift – that of being able to eat and drink. However, despite this provision, why is it that many of us ED physicians are still not taking this opportunity to take care of ourselves while at work? From the perspective of Maslow’s hierarchy of needs, before we can achieve self-actualization, our basic physiological needs must be met.3 Over the next several Common Sense issues, the AAEM Wellness Committee will highlight each of the key factors of each levels of the physician wellness hierarchy modeled after Maslow’s hierarchy of needs.4 Who would have thought that eating and drinking in the ED is actually a path towards professional fulfillment and happiness? If not for happiness, could it be that by simply allowing ourselves to take a break and snack or eat lunch during a shift, we may become more efficient? Many states require lunch and rest breaks on shift, all of which excludes ED

physicians.5,6 Why is it that on an 8-12 hour long shift, we often deprive ourselves opportunities to recharge and nurture ourselves? It’s as if it has been ingrained in us that as physicians we are better than everyone else. That we don’t need to eat or drink or use the bathroom. Sadly, many of us do this on a daily basis. And for what? To be more efficient? Because our patients need us? Because there’s simply no time? Most, if not all of us, can attest to this practice of martyrdom starting way before we even became ED physicians. These acts of self-sacrifices were common as we tried to get into medical school, while we were in medical school, and definitely during residency. Perhaps this is why Maslow’s hierarchy of needs are now being considered as a model to address residency burnout, as well.7 In order for us to focus on self-actualization and professional fulfillment, we must understand how attending to our basic physiological needs towards improved mental and physical health, including provisions for food, shelter, sleep, and clothing matter. Similar to the airline analogy, “In case of emergency … If you are traveling with a minor, please put on your own mask before helping the minor,” we must also learn to apply this self-preservation to our daily practice. We must learn to take care of our needs first in order to maximize the impact of our expertise in the ED. “But I just don’t have the time to eat!”

In order for us to focus on selfactualization and professional fulfillment, we must understand how attending to our basic physiological needs towards improved mental and physical health,

including provisions for food, shelter, sleep, and clothing matter.

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As ED physicians, we are experts in understanding the value of time. Many of our metrics hinges on turnaround times, and we have learned to adapt to this environment. It is with this keen understanding of the scarcity of time that we can be creative in maximizing efficiency in time to include taking into account our basic needs in order to prevent personal burnout. TJC understands this now.8 According to a 2019 Medscape survey, emergency physicians rank one of the lowest in “how happy” we are at work, with 48% of our colleagues experience burnout.9 Picking up that next patient without pausing for a break, no matter how quick that respite is, may prevent you from optimizing yourself to your best potential. There is a dwindling return on investment as we fatigue over the course of our shift.10 Not only does hunger affect efficiency, it also can also affect patient then it may no longer safety.11 Hunger also afbe perceived as a fects our mood and how we react to stress, and weakness to provide in turn, may affect our care for ourselves. levels of professionalism and collegiality.11–14

WELLNESS

If everyone is doing it,

Working in the ED is hard in-and-of itself. We now have better systems in place to allow us to address hunger in the ED. If you are in hospital or departmental leadership, consider providing easy access to food and drinks while on shift such as a stocked refrigerator. Gathering around food may even help promote belongingness in the ED. Create a culture where it is okay for physicians to eat meals and attend to other “bio breaks.” Plus, when we take this into consideration, we are more likely to plan healthier meal options instead of eating junk food and simply over caffeinating ourselves on-shift, which later have negative downstream effects on our health including our sleep and weight. And, on an individual basis, please do take a break while you are on shift. If everyone is doing it, then it may no longer be perceived as a weakness to provide care for ourselves. While food and drinking in the ED alone will not fix the epidemic of physician burnout amongst our EM colleagues, it is one of the basic things that is within our control. As we strive to achieve balance in our practice, we hope that you would consider taking a pause during your shift and practice self-care through nourishing yourself. It’s now “allowed.” So, before you take on that next task, ask yourself if it can wait and allow yourself to take care of yourself just as you would want your family members, your colleagues, your patients to care for themselves.

References: 1. The Joint Commission Clarifies that Physicians Can Eat and Drink in ED Workspaces [Internet]. ACEP Now. [cited 2019 Dec 29];Available from: https://www.acepnow.com/article/the-joint-commission-clarifies-thatphysicians-can-eat-and-drink-in-ed-workspaces/ 2. Taking food and drink away from doctors and nurses is just cruel [Internet]. KevinMD.com. 2019 [cited 2019 Dec 29];Available from: https://www.kevinmd.com/blog/2019/12/taking-food-and-drink-away-fromdoctors-and-nurses-is-just-cruel.html 3. McLeod S. Maslow’s hierarchy of needs. [Internet]. Simply Psychol. 2018 [cited 2019 Dec 29];Available from: https://www.simplypsychology.org/ maslow.html 4. Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P. Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level. Am J Med [Internet] 2018 [cited 2019 Apr 21];Available from: https://linkinghub.elsevier.com/retrieve/pii/ S0002934318311550 5. Employee Lunch Break Laws | OSHA Education Center [Internet]. [cited 2019 Dec 29];Available from: https://www.oshaeducationcenter.com/ articles/employee-lunch-breaks/ 6. Minimum Length of Meal Period Required under State Law for Adult Employees in Private Sector 1 | U.S. Department of Labor [Internet]. [cited 2020 Jan 2];Available from: https://www.dol.gov/agencies/whd/ state/meal-breaks 7. Hale AJ, Ricotta DN, Freed J, Smith CC, Huang GC. Adapting Maslow’s Hierarchy of Needs as a Framework for Resident Wellness. Teach Learn Med 2019;31(1):109–18. 8. The Joint Commission Perspectives. Jt Comm Perspect [Internet] 2019 [cited 2020 Jan 2];39(3). Available from: https://www.jcrinc.com/the-jointcommission-perspectives/ 9. Medscape Emergency Medicine Physician Lifestyle, Happiness & Burnout Report 2019 [Internet]. Medscape. [cited 2019 Dec 29];Available from: //www.medscape.com/slideshow/2019-lifestyle-emergencymedicine-6011112 10. Patterson PD, Buysse DJ, Weaver MD, et al. Real-Time Fatigue Reduction in Emergency Care Clinicians: The SleepTrackTXT Randomized Trial. Am J Ind Med [Internet] 2015 [cited 2019 Dec 29];58(10):1098–113. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4573891/ 11. Your decisions are what you eat [Internet]. [cited 2019 Dec 29];Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674453/ 12. MacCormack JK, Lindquist KA. Feeling hangry? When hunger is conceptualized as emotion. Emot Wash DC 2019;19(2):301–19. 13. Horman T, Fernandes MF, Zhou Y, Fuller B, Tigert M, Leri F. An exploration of the aversive properties of 2-deoxy-D-glucose in rats. Psychopharmacology (Berl) [Internet] 2018 [cited 2019 Dec 29];235(10):3055–63. Available from: https://doi.org/10.1007/s00213018-4998-1 14. Dyrbye LN, West CP, Hunderfund AL, et al. Relationship Between Burnout, Professional Behaviors, and Cost-Conscious Attitudes Among US Physicians. J Gen Intern Med [Internet] 2019 [cited 2020 Jan 2];Available from: https://doi.org/10.1007/s11606-019-05376-x

COMMON SENSE MARCH/APRIL 2020

INTEREST GROUP REPORT PALLIATIVE CARE

Health Care Proxies, Living Wills, and POLST Forms, Oh My: Interpreting Advance Care Planning Documents Jessica Fleischer-Black, MD FAAEM; Erika Blaikie, MD; and Kelsie Phelan, MD

here are two categories of advance care plans: medical orders and legal documents. POLST forms and advance directives are both types of advance care plans and serve different functions. A Health Care Proxy is a named individual who can make medical decisions for a patient when they become incapable of making decisions for themselves. Any of these can help an emergency physician to determine how best to help a patient in extremis and help to provide care consistent with a patient’s care goals. An important caveat to this discussion is that knowing your individual state laws is critical to interpreting advance care planning documents. To get information regarding state-specific advance directives visit https://www.nhpco.org/patients-andcaregivers/advance-care-planning/advance-directives/downloading-yourstates-advance-directive The POLST* (Physician Orders for Life Sustaining Treatment) form is a medical order. This is the only type of advance care planning document that falls under this category. A POLST form is not appropriate for all patients – it addresses a set number of limited medical treatments and is designed for patients with life-limiting illness or frailty at the end of life. It serves as medical orders for a physician or emergency services to follow in the event of an emergency. It addresses whether or not a patient wants CPR attempted, full treatment, selective treatment, or comfort-focused treatment. The form briefly elaborates on these treatment options, giving examples of each. It also addresses the question of whether or not a patient would want medically assisted nutrition. It is signed by the patient or patient representative and a health care provider. It goes into effect only if the patient does not have decision-making capacity. * also called MOLST (depending on what state you live in - Medical Orders for Life Sustaining Treatment) Let’s take the example of Mr. L who is an 86-year-old gentleman with multiple comorbidities. One day he collapses at home. His wife, Mrs. L is frightened and calls EMS. When EMS arrives ready to perform CPR,

COMMON SENSE MARCH/APRIL 2020

they find a POLST form on the refrigerator which clearly explains that Mr. L does not want CPR. EMS explains to Mrs. L that Mr. L has no pulse and that they will honor his wishes by not performing CPR. Mr. L is declared dead at the scene without transport to the hospital. The other type of advance care planning document is an advance directive. In contrast to a POLST form which is designed for certain populations, all adults should have an advance directive. An advance directive is a legal document. This gets a little complicated as an advance directive is called different things in different states. A living will is a type of advance directive in which patients indicate the types of life-prolonging medical care they would want if they became terminally ill, permanently unconscious, or in a vegetative state and unable to make their own decisions. A durable power of attorney for health care is another type of advance

If a patient does not have an advance directive indicating a decision-maker, the chain of surrogacy is as follows: legal guardian > spouse > adult children > parent > adult sibling > any adult relative > close friend.

directive that appoints a surrogate decision maker should the patient no longer have the capacity to make medical decisions. The surrogate’s decision making power is only invoked if the patient does not have decision making capacity. Advance directives can also provide insight into what the patient would or would not want for medical treatment. Unfortunately, it is often vague and left open to interpretation of the medical team to determine what should be done in the context of the patient’s illness, prognosis, and guidelines in the advance directive, along with his or her surrogate. In the emergency department, it’s very important to make sure that you’re talking to the right person. If a patient does not have an advance directive indicating a decision-maker, the chain of surrogacy is as follows: legal guardian > spouse > adult children > parent > adult sibling > any adult relative > close friend. If the chain of

PALLIATIVE CARE

surrogacy reaches adult children or adult siblings, remember that if a patient has multiple children (or adult siblings) they share equal decision making power. Let’s review advance directives with a sample case. Ms. J is a 76-yearold woman who was in an unexpected accident that left her in a coma. She has a living sister with whom she is not close. When it comes time to make decisions about her medical care, Ms. J’s advance directive names her close friend, Ms. R as her surrogate. Ms. R knows Ms. J well and Ms. J chose her as a health care proxy because she felt that she would be able to speak on her behalf and ensure she receives the interventions she would have wanted.

It can be difficult for emergency physicians to hold back from resuscitation. We’re trained to save lives. But we have all had cases where we’ve wondered if our life-saving interventions truly were in the best interests of the patient. Family members are often too distraught to make a measured decision. Advance care planning documents can help reassure the physician and the team that the medical care is in line with what the patient would have wanted. References: 1. www.polst.org 2. https://www.nhpco.org/patients-and-caregivers/advance-care-planning/ advance-directives/downloading-your-states-advance-directive 3. https://www.aha.org/system/files/2018-01/putitinwriting.pdf

NTE A R A U

G PASS

ORLANDO, FL ORLANDO, FL

SEPTEMBER 15-18, 2020 SEPTEMBER 15-18, 2020 EMBASSY SUITES ORLANDO EMBASSY SUITES ORLANDO LAKE BUENA VISTA

LAKE BUENA VISTA

Written Board Review Course Unmatched preparation for the Qualifying and ConCertTM Exams

COURSE HIGHLIGHTS

• • • • • •

Up to 27 hours of intense review of EM board materials Instruction from top educators in emergency medicine Comprehensive, timely material Content tailored to you – one-on-one discussion with the instructors Bonus materials – detailed study guide and test-taking skill strategies AAEM has over 15 years of experience in Written Board preparation www.aaem.org/written-board-review COMMON SENSE MARCH/APRIL 2020

SECTION REPORT CRITICAL CARE MEDICINE

Andexanet alfa Craig Hertz, DO FAAEM; Iosif Davidov, MD, PGY-2; and Dorjan Pantic, MD, PGY-6

s our populations age, incurring increases in cardiovascular and neoplastic disease, the use of anticoagulants is bound to rise. Over the past decade there has been a shift from vitamin K antagonists to more targeted anticoagulants, specifically factor Xa inhibitors (Xa inhibitors). Reasons behind this shift are numerable, with reduced potential for major bleeding being one. Despite the reduced bleeding risk, patients on Xa inhibitors who develop major bleeding require mitigation and anticoagulation reversal, previously accomplished with entities such as Prothrombin Complex Concentrates (4-factor (4F PCC), 3-factor, Activated or Inactivated). Now Coagulation Factor Xa (Recombinant), Inactivated-zhzo, or andexanet alfa, appears on the scene as an alternative under accelerated FDA approval.1 Andexanet alfa – approved in 2018 – is a Xa specific decoy molecule for patients afflicted by “life-threatening or uncontrolled bleeding” who are taking rivaroxaban or apixaban2 and was approved under the Accelerated Approval Requirements by the Federal Drug Administration in accordance with rules for an unmet need in medical therapy/treatment.1,3

an 85% improvement6 in hemostatic efficacy.4,7 The impact of this effect was immediate – less than four minutes – and lasted up to four hours.4 The half-life of rivaroxaban and apixaban is 9-12 hours8,9 with previous therapy for major bleeding being 4F PCC, possibly adjunct agents (i.e. tranexamic acid) and give it time, thus a four hour window of improved hemostatic efficacy and reduced bleeding risk provides the bridge clinical practitioners and patients have been looking for. Though no current study has compared the efficacy of andexanet alfa to 4F PCC, we can infer the potential benefit of andexanet alfa over 4F PCC from andexanet alfa’s 85% hemostatic efficacy6 of bleeding risk in gastrointestinal (GI) bleeding and 80% hemostatic efficacy10 in intracranial hemorrhage (ICH) volume expansion.4,7 Mortality within a PCC study population study (70.4% ICH predominance) was higher at 32% compared to andexanet alfa (43% ICH predominance) mortality of 14% at 30 days.4,7,11 Furthermore, a study using similar criteria to the ANNEXA-4 group, for evaluation of PCC was deemed 69.1% effective in hemostasis compared to andexanet alfa 82% hemostatic efficacy.4,7,11

Taking the above data in to account, several review articles on treatment of hemorrhage for patients taking rivaroxaban or apixaban have added • We must be stewards andexanet alfa into the recomfor our patients who mended repertoire. August 2019, may only read or hear Emergency Medicine Practice about some new “FDA” The Andexanet alfa, a Novel lists “Coagulation factor Xa medication. Andexanet Antidote to the Anticoagulation (recombinant), inactivatedalfa is a ~$50,000 per high Effects of Factor Xa Inhibitors zhzo” as “first line” treatment dose medication which (ANNEXA) studies (ANNEXAin their flow to reverse Xa temporarily reduces R[ivaroxaban], ANNEXAinhibitor hemorrhages.12 The inhibition of Xa levels in A[pixaban]) and most recently CHEST journal, September patients on rivaroxaban or ANNEX-4,4 paved the way for 2019 suggest andexanet alfa apixaban. accelerated approval and rapid for reversal of major hemoracceptance as the primary therarhage, as does the Emergency peutic agent for patients with lifeMedicine and Cardiac Research and threatening bleeding on rivaroxaban or Education Group.13,14 Desai, et al., in apixaban. As with any new agent, there are Hospital Practice, July 2019 offer andexant pros and cons. alfa as the primary reversal agent for “major or life-threatening” bleeding or “need for emergency Pro surgery/procedure.”15 The andexanet alfa molecule is currently the only medication that acts Putting it all together, biochemically and – by surrogacy – clinically, as a decoy for Xa inhibitors rivaroxaban and apixaban.5 Once bound, patients with major or life-threatening hemorrhage on rivaroxaban or the ANNEXA-4 study demonstrated a 92% reduction in anti-factor Xa apixaban, there is a reasonable argument andexanet alfa is the treatment activity levels in patients on rivaroxaban or apixaban. Patients suffering of choice to reduce the risk of further bleeding and improve hemostatic from gastrointestinal bleeding (26% of study population) demonstrated efficacy.

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CRITICAL CARE MEDICINE

Con

Industry sponsorship aside, the ANNEXA-4 study provided us 249 patients in which only an efficacy arm was evaluated (60 GI Bleed, 168 ICH, 21 Other)—no control arm.7 We concede the biochemical findings are impressive, though the use of a laboratory value as a surrogate for clinical improvement is inherently limited and potentially flawed. Furthermore, the primary endpoint in ANNEXA-4 changed to include laboratory value reduction as a second primary endpoint, with the original single primary endpoint of hemostatic efficacy “only tested if a change in anti-f[actor]Xa active was first demonstrated.”7 Therefore, could this additional primary endpoint reduce hemostatic efficacy testing – i.e. reduced denominator – skewing the hemostatic efficacy findings and artificially inflate improvements? In short, we have no evidence that andexanet alfa improves morbidity, mortality, or that it does so better than the current treatment(s), such as 4F PCC. Although the current studies have not directly compared efficacy of 4F PCC versus andexanet alfa, we can pull upon the body of PCC literature and modestly say even PCC does not demonstrate the rapid, almost complete reversal of abnormal biochemical laboratory values.11 If we are to use a biochemical test as surrogacy for clinical outcomes, how should we address the ~24% of patients being excluded – despite meeting bleeding criteria – due to their anti-factor Xa levels being “too low?”4, 7 While intuitively these patients would unlikely benefit – biochemically – from andexanet alfa, the exclusion of these patients yields a different population than we would encounter clinically. Furthermore, this exclusion, without demonstrating hemostatic efficacy and/or clinical improvement, raises concern for selection bias and whether or not such clinical end-points are achievable. Andexanet alfa’s function is based on its decoy receptor property with limited duration- 4 hours- and concerns of rebound Xa levels after infusion.4,7 Andexanet alfa also not eliminate Xa inhibitors in plasma—that is to say, the decoy binding is temporary and later releases the Xa inhibitors.4, 7 Based on the decoy properties, andexanet alfa is being touted as a reversal agent; while not untrue in a strict sense, it should be made clear andexanet alfa does not definitively remove the Xa inhibitors – unlike idarucizumab the reversal agent for dabigatran, which permanently binds dabigatran. In contrast, PCC functions as a “replacement agent” by providing clotting factors involved in the clotting cascade, (i.e. factors X,IX, VII,II ), thus, allowing a dose-dependent circumvention of the inhibited Xa. Factor X’s half-life of 24-48 hours provides a longer duration of action comparted to andexanet alfa16 (4 hours). Baugh, et al., provides an excellent discussion on this topic, suggesting 4F PCC as first-line when andexanet alfa is not available.17 At current it would appear andexanet alfa is a reversal agent of biochemical markers though is yet to be a proven one of active bleeding, a more clinically relevant end point. The FDA reiterated this: “This approval requires you to study the biological product further, to verify and describe its clinical benefit, where there is uncertainty as to the relation of the surrogate endpoint to clinical benefit…”1 Furthermore, Ryan Radecki in “Disutility, Thy Name is ANEXXA-4” quotes the ANEXXA-4 study:

“Reduction in anti–factor Xa activity was not predictive of hemostatic efficacy overall but was modestly predictive in patients with intracranial hemorrhage.”4,8 It should not go without mention andexanet alfa is associated with thrombosis of 10% within 30 days. This is a factor to consider when giving andexanet alfa in patients with unclear morbidity and potentially long-term mortality as a result of associated thrombotic risk. Thrombosis primarily occurred in patients in which anticoagulation was not restarted “immediately,”4,7 though the thrombotic culprit remains unclear, and 10% appears unexpectedly high.

As our populations age, incurring increases in cardiovascular and neoplastic disease, the use of anticoagulants is bound to rise. Peled, H., et al., in a response to Lip, G., et al., in CHEST, suggested “The cost-benefit analysis of available treatments is critical in any health-care ecosystem. For patients who truly present with life-threatening non-vitamin K antagonist oral anticoagulant-associated bleeding, we felt the opportunity to save more lives warrants preference of specific reversal agents over PCCs”.19 Thus, we must address the ~$50,00020 gorilla in the room… the approximate cost per patient who requires the high dose (800mg) andexanet alfa rather than the low dose 400mg.21 Even with the Center for Medicare & Medicaid services offering a reimbursement program up to ~$18,20022 there is still a substantial cost burden to healthcare facilities and potentially patients. Haque, et. al., provides us an interesting perspective regarding the cost effectiveness of andexanet alfa, suggesting it is more cost-effective for GI bleeding than ICH by a factor of ~5 ($40,718 GI bleed v $211,056 ICH; cost-effectiveness ratio- andexanet alfa v standard of care).23 Their work further expands the need for clinically relevant outcomes and comparative studies to current standards of care, especially considering Deitelzweig et al’s work suggesting the economic burden for “mean total all-cause healthcare cost” for ICH was ~$90,000.24 As evidence-based quality is at the forefront of healthcare, we must be aware of the cost burden to patients, caregivers, and communities. What about the review articles suggesting use of andexanet alfa as the reversal agent of choice for life-threatening or major bleeding? Diving into them, take for example, Maher, et al., in Emergency Medicine Practice,13 despite listing andexanet alfa as “first line” it is followed by stating it is “Class IV” evidence- defined as “indeterminate.”25 Baugh, et al’s, Annals of Emergency Medicine expert panel publication recommends andexanet alfa, unless it is unavailable, or replacement of factors is felt warranted rather than reversal (i.e. dosing of andexanet alfa)- it should also be clear “the expert panel meeting was convened with funds from unrestricted educational grants from Portola Pharmaceuticals and Boehringer Ingelheim.”17 Furthermore, several of these articles conflict one another and/or FDA sentiments, suggesting andexanet alfa for reversal in patients who need “emergency surgery/procedure.”15 Only the National Institute for Health and Care Excellence (N.I.C.E) is slated to have a viewpoint in 2020,26 other guideline agencies such as Cochrane and Emergency Care Research Institute (ECRI) had no information about andexanet alfa during the time of this writing.

>> COMMON SENSE MARCH/APRIL 2020

In an aim to improve the value of care: Value=Quality/Cost, driven by evidencebased practices, we cannot say that andexanet alfa has proven to improve value or quality, although it does increase cost. The lacking support for clinical improvements, with none due for another 4-10 years, is concerning when it comes to the rapid assimilation into articles suggesting andexanet alfa as “first line” therapy – more concerning when various articles continue to only site one another, and consensus guidelines are industry sponsored. Based on the above, there is a reasonable argument andexanet alfa is not actually the treatment of choice to improve the value of care in major bleeding for patients on rivaroxaban or apixaban.

CRITICAL CARE MEDICINE

Let’s Be Real We agree new medications, needed medications, and medications which can impact lives require a more streamlined approval, implementation, and reimbursement process. We caution clinical, administrative, and policy groups in rapid adoption, when the downstream impact is not fully elucidated. There are already over a hundred articles on andexanet alfa – including this one – which continually cite, sponsor, and quote one another. While several more clinical trials – randomized double blinded, comparison, etc. – are pending for andexanet alfa, none of these (at current) are due for completion until the mid-2020’s. Using surrogate markers for clinical outcomes can be a stretch (i.e. pro-brain natriuretic peptide, D-dimer, troponins); we know this; we live this. We must be stewards for our patients who may only read or hear about some new “FDA” medication. Andexanet alfa is a ~$50,000 per high dose medication which temporarily reduces inhibition of Xa levels in patients on rivaroxaban or apixaban. Based on the published literature this is all we can conclude. What has been extrapolated is: andexanet alfa is a medication which reverses Xa inhibitors and stops life-threatening bleeding. While it may or may not be true, we must be cognizant of the all the variables that play into providing cost effect, evidence based, patient partnered, quality care. References: 1. Accelerate Approval: BL 125586/0. U.S. Food and Drug Administration, FDA. May 3, 2018 2. ANDEXXA® Prescribing Information. Revised 12/2018 Rivaroxaban and apixaban are the only two Xa inhibitors thus far tested 3. FDA Accelerated Approval: “Qualifying Criteria: Treats a serious condition that generally provides a meaningful advantage over available therapies. Features: Can approve on the basis of a surrogate or intermediate endpoint that is reasonably likely to predict a clinical benefit.” https://www. fda.gov/patients/fast-track-breakthrough-therapy-accelerated-approvalpriority-review/accelerated-approval 4. Connolly, S.J., et al. Full Study Report of Andexanet alfa for Bleeding Associated with Factor Xa Inhibitors. New England Journal of Medicine, 380 (14): 2/7/2019; Updated Apr 18, 2019 5. It may bind others- edoxaban or betrixaban- to date, published studies and approval is based on apixaban and rivaroxaban 6. Not requiring further transfusion of blood products or <20% decrease in hemoglobin/hematocrit as compared to baseline over 12 hours; See footnote- 4,7 7. Connolly, S.J., et al. Full Study Report of Andexanet alfa for Bleeding Associated with Factor Xa Inhibitors. New England Journal of Medicine, 380 (14): 2/7/2019; Updated Apr 18, 2019- supplemental 38

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8. Lexicomp, apixaban. Accessed 8/20/2019 http://online.lexi.com/lco/action/ search;jsessionid=084e4e198ff1e22a25b 5bc132499?origin=api&t= globalid&q=512790&nq=true 9. Lexicomp, rivaroxaban. Accessed 8/20/2019: http://online.lexi.com/lco/action/search?q=rivaroxaban&t=name&va=rivaroxaban 10. 85% efficacy in preventing more than 20% decrease in corrected hemoglobin and hematocrit at 12 hours, 80% efficacy 35% increase in intracranial hemorrhage volume expansion- see footnote 7 11. Majeed, A., et al. Management of rivaroxaban- or apixaban- associated major bleeding with prothrombin complex concentrates: a cohort study. Blood. 130(15): 10/12/2017. Pg 1706-1712 12. Maher, P., et al. Emergency Department Management of Patients Taking Director Oral Anticoagulant Agents. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. 21(8); 8/2019 13. Rali, R., et al. Direct-Acting Oral Anticoagulants in Critically Ill. Chest Journal. 156(3): 9/2019. Pg 604-618 14. Fermann, G., et al. Management of Life-Threatening Bleeding in the Anticoagulated Patient in the Emergency Setting and the Impact of ANNEXA-4 on the Treatment of Patients Taking Factor Xa Inhibitors. Emergency Medicine Cardiac Research and Education Group. 8/2019 15. Desai, N., et al. Reversal Agents for Direct Oral Anticoagulants: Considerations for Hospital Physicians and Intensivists. Hospital Practice. 7/2019 16. Lexicomp, Prothrombin Complex Concentrate (Human) [(Factors II, VII, IX, X), Protein C, and Protein S]. Accessed 1/12/2020. http://online.lexi.com/lco/action/doc/retrieve/docid/ patch_f/1034779?cesid=4hRVhUoEBY5&searchUrl=%2Flco%2Faction %2Fsearch%3Fq%3Dkcentra%26t%3Dname%26va%3Dkcentra 17. Baugh, C., et al. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Annals of Emergency Medicine. 0(0). Published online 11/2019 18. Radeck, Ryan. Disutility, Thy Name is ANEXXA-4; updated 2/7/2019 https://www.emlitofnote.com/?p=4384 19. Peled, H., et al. Response- Prothrombin Complex Concentrate or Coagulation Factor Xa (Recombinant), Inactivated-zhzo. CHEST Journal. 155(6): 6/2019. pg 1308 20. Extracted from Analy$ource 11.12.2019 21. High dose indications: Patient on Apixaban at >5mg or unknown dose, < 8 hours from last dose; Rivaroxaban >10mg or unknown dose, < 8 hours from last dose. Low dose: Apixaban ≤ 5 mg, ≥ 8 hours from last dose; Rivaroxaban ≤ 10mg, ≥ 8 hours from last dose. Lexicomp: Factor Xa (recombinant), Inactivated-zhzo. Accessed 1/12/2020. http://online. lexi.com/lco/action/doc/retrieve/docid/essential_ashp/6671728#dosageadmin-nested 22. https://www.andexxa.com/ordering#reimbursement. Accessed 12.26.2019 23. Haque, M., et al. Beginning to Understand the Cost-effectiveness of Andexxa. Georgetown Medical Review. 3(1). 2019 24. Deitelzweig, S., et al. Incremental economic burden associated with major bleeding among atrial fibrillation patietns treated with factor Xa inhibitors. Journal of Medical Economics. 20(12): 8/2017. Pg 1217-1223 25. See f.n. 13: Indeterminate: Continuing area of research; No recommendations until further researching: Evidence not available; Higher studies in progress; Results inconsistent, contradictory; Results not compelling 26. NICE Guidance. Andexanet alfa for Reversing Anticoagulation [ID1101]. Expected 6/2020. https://www.nice.org.uk/guidance/indevelopment/gidta10440

SECTION REPORT WOMEN IN EMERGENCY MEDICINE

Choosing Locums Robyn Hitchcock, MD FAAEM

or the first time in years I had the brain space to begin the process of wondering what I wanted, and was at a complete loss.

I enjoy seeing the commonalities of communities and how similar people and diseases are all over the country, yet enjoying the differences I experience from region to region. Nearly seven years ago after a surprise divorce (you know the drill, husband comes home after 16 years of marriage, announces “he’s not happy,” and leaves you and the kids for a much younger woman at the office…) I found myself thinking about what “I” wanted for the first time in many years. Life just seemed to be going at a frenetic pace and it was all I could do to keep my head above water. Then my marriage dissolved and I was in crisis management mode for both myself and the kids for some time. Eventually the fog cleared. I began to realize that being on my own was much better for both myself and the children than constantly being in an environment where a critical, unsupportive spouse/father was making the home an unhappy place. For the first time in years I had the brain space to begin the process of wondering what I wanted, and was at a complete loss. I found myself floating mentally back to my residency days, the last time I was a “me,” not a “we.” After completing my emergency medicine residency, I didn’t really know what kind of practice I wanted to have: big city or small town, academic or community medicine. I thought I would do locums for a while, try out some different practice models and see what I liked. After a one year locums stint in Hawaii, I took a job at a small freestanding facility in the Lake Tahoe area. There I met my husband, got married, and started down the family track. The locums plan was terminated. We moved around the country and we both changed jobs several times, but we seemed pretty settled in the small town in the northwest we had landed in. So after nine years in the same small town, the spark of an idea began to form. The children were in middle and high school, I would be an Empty Nester before long. Could I go back to my dream of all those years ago and do some locum tenens work? As it turns out, the answer is a resounding “yes.” My oldest two girls have actually been in college for several years. About a year and a half

ago there was a custody change, it was time for my youngest who was a boy to spend more time with his dad and for the first time I was able to carve out some blocks of time to work Locums in addition to my usual shifts at the hospital where I’d been working. Despite their promise of “we do the paperwork for you,” there is a lot that you need to do when you’re engaging in locums work. I found a facility in the Midwest that was an easy plane ride from my nearby airport and spent about one week a month there. It was a great income supplement and a good toe in the water for what it’s like to be the locums in the emergency department. My youngest graduated in June and now with three children in college I started full-time work this past summer sticking with the higher paying jobs for obvious reasons. It can be very hectic and the paperwork is never ending. You can spend months credentialing at a facility and by the time you get privileges they no longer need locums. This has happened to me several times. The frustrations of doing locums in my mind are really kind of offset by the experience. It’s fun working at a place and when administration tells you this is the way things are, being able to say that this is not the way they have to be. (For example, delays in ambulance transport limited equipment at small facilities etc.) You learn what typical is and what’s reasonable and what’s not. For the most part the nurses and support staff are glad you’re there and work hard. There isn’t nearly as much testing and torturing the new locums as I thought there would be. I’ve discovered I like traveling, but I don’t like long drives from the airport. Scribes make all the difference in the world for me, and having worked facilities with great scribe support, I think I’ll be reluctant to go back to doing every bit of my own charting.

I enjoy seeing the commonalities of communities and how similar people and diseases are all over the country, yet enjoying the differences I experience from region to region.

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WOMEN IN EMERGENCY MEDICINE

For the first time in years I had the brain space to begin the process of wondering what I wanted, and was at a complete loss.

One of the surprise benefits of locums is how inspiring it is to my children. They’re all in college and wondering what their next step is going to be. It’s a scary time. They tell me that seeing me embrace this adventure at this point in my life is inspiring to them. Instead of going home for Christmas, I’m actually flying them out to where I’m going to be traveling. I’ll have a couple of days off when we will all engage in some fun new adventures (like a hot air balloon ride around Christmas Eve) with them at a place they’ve never been to, create some great memories, and teach them without words that it’s never too late to change gears or embrace new adventures. So, at least for right now, I’m choosing to live a locum’s life. There’s no such thing as a perfect job. The decreased administrative headaches and requests to be on committees, participate in performance review, etc. are offset by the increased paperwork that’s always in process for the next job you’re working on. But it’s a great feeling providing care at facilities, most of them fairly small ones that are desperately in need. I enjoy seeing the commonalities of communities and how similar people and diseases are all over the country, yet enjoying the differences I experience from region to region. But most importantly, as a mom, I’m proud that me embarking on this adventure might help inspire my children to embrace their own adventures as they carve through early adulthood and beyond. You can read more from Dr. Hitchcock regarding locums work and travel in her blog by visiting www.stethoscopesuitcasemd.wordpress.com.

ATTEND WELLNESS AND SOCIAL EVENTS AT AAEM20! MONDAY, APRIL 20, 2020

WEDNESDAY, APRIL 22, 2020

• Opening Reception | 5:45pm-6:45pm

• Yoga for Early Risers | 6:30am-7:30am • Women in EM Networking Lunch | 12:05pm-1:30pm • DIVE into AAEM Chapter Division & Section Social Event | 6:00pm-7:30pm

TUESDAY, APRIL 21, 2020 • • • • •

Learn more at: www.aaem.org/AAEM20

COMMON SENSE MARCH/APRIL 2020

Take time to recharge at social and wellness events.

THURSDAY, APRIL 23, 2020 • Women in EM Coffee Meet-Up | 6:00am • AAEM Coffee Crawl | 7:00am

ONGOING • F3 Wellness Meals – Food, Friendship, and Fun • “The Oasis” Wellness Room

SECTION REPORT EMERGENCY ULTRASOUND

Is Emergency Physician-Performed Bedside Ultrasound Dangerous? Eric Chin, MD MBA FAAEM and Melissa Myers, MD FAAEM

“

…it will never come into general use notwithstanding its value. It is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble to both the patient and the practitioner; and because its hue and character are foreign and opposed to all our habits and associations. It is just not going to get used.” – Sir John Forbes, 19th-century Scottish physician Given its widespread use and acceptance in medical practice today, it is surprising that something as basic as a stethoscope still held controversy around its time of invention. Sir John Forbes, a Scottish physician, wrote of this discord when he translated a publication, “A Treatise on the Diseases of the Chest, in which they are described according to their Anatomical Characters, and their Diagnosis established on a new Principle by means of Acoustick Instruments,” by the inventor of the modern stethoscope, French physician Rene Laennec. These concerns echo those currently being applied to the exploding growth of point of care ultrasound (POCUS) today. There are some doubts concerning safety and the adequacy in training in POCUS, and many physicians feel that frankly, it’s not worth their effort. This viewpoint looks past three decades of research into POCUS demonstrating its efficacy, safety, its role in improving diagnostic accuracy and overall efficiency, and its ability to improve the practice of emergency physicians.1

During the 18th century, medicine emphasized the history of present illness disproportionately over what most would consider any type of physical examination by today’s standards. The introduction of the stethoscope was a revolution by popularizing a diagnostic approach of “looking, listening, tapping and rapping, even shaking the body to find out what was going on inside.”2 When used appropriately POCUS improves the bedside physical exam by adding the ability to truly see into the abdomen. It is intuitive that being able to see abdominal structures provides more answers to our clinical questions than palpation or auscultation alone. The desire to improve upon known limitations to the physical examination are demonstrated by the never-ending rise in advanced imaging utilization, such as computed tomography (CT), performed on a daily basis. Coincidentally, ultrasound can answer many of the same questions as CT without exposing patients to unnecessary ionizing radiation. Recent literature demonstrates the value of adding POCUS in the evaluation of emergency department patients. One of the first and most enduring examples of the utility of POCUS is in its use for the bedside evaluation of an abdominal aortic aneurysm (AAA). These patients are often critically ill and their survival depends on early diagnosis. Physical examination alone has an overall sensitivity of 68% and a specificity of 75% for aneurysms greater than 3cm. Compare that to ultrasound which has a sensitivity of 99% and a specificity of 98%. The utility of physical exam improves in patients with a smaller body habitus and larger aneurysms, but how often do we have the ideal patient? It puts patients at risk to ignore a tool which allows early and accurate diagnosis in the vast majority of patients.3-4

>> It is intuitive that being able to see abdominal structures provides more answers to our clinical questions than palpation or auscultation alone.

COMMON SENSE MARCH/APRIL 2020

Far more common than the patient with a rupturing AAA is the older patient presenting with undifferentiated shortness of breath. The definitive diagnosis is often difficult to obtain while the patient is in extremis or even during the ED portion of their evaluation. Physicians often resort to treating simultaneously for multiple possible diagnoses, such as congestive heart failure, chronic obstructive pulmonary disease, and pneumonia. While potentially effective, this may delay care and exposes patients to side effects from medications they may have never needed. POCUS increases diagnostic accuracy in patients presenting with dyspnea by allowing for bedside evaluation of left ventricular ejection fraction, consolidations, pulmonary edema, and right ventricular dilation.5 Furthermore, when compared to a chest x-ray, ultrasound has increased accuracy for conditions such as pulmonary edema and pneumothorax.6 POCUS can be performed immediately upon patient arrival and facilitate a diagnosis without the need to wait for lab results or radiology-performed imaging.

EMERGENCY ULTRASOUND

This is not to say that there are no pitfalls associated with the use of bedside ultrasound. Drs. Blanco and Volpicelli pointed out several technical errors in their 2016 article which could adversely affect patient care.7 They point out that incorrect interpretation of right ventricular size could incorrectly point an emergency physician away from a diagnosis of pulmonary embolism, or that over-reliance on gallbladder wall edema as a marker for cholecystitis could lead to an incorrect diagnosis. Their point is well made and their emphasis on physician education is paramount. The takeaway from this should not be that we should avoid these exams because we might misinterpret results – it is to provide the education and training needed for all of our colleagues to confidently and correctly incorporate ultrasound into their daily practice. We routinely intubate patients, a procedure that carries significant potential risk, but through structured training, such as is done during residency, we are able to reduce that risk to an acceptable level. POCUS should be no different. The Accreditation Council on Graduate Medical Education (ACGME) agrees that education in POCUS for emergency physicians is an essential part of residency training. The ACGME requires that graduating residents be competent in using ultrasound “...for the bedside diagnostic evaluation of emergency medical conditions and diagnoses, resuscitation of the acutely ill or injured patient, and procedural guidance” as well as requiring 150 scans to reach the graduating resident milestone.8 While recent graduates should feel confident with these exams based on residency training, the ultrasound section of AAEM has worked towards providing opportunities for attendings who graduated prior to the

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inclusion of POCUS into residency training to become familiar with these new techniques. Sir John Forbes quote regarding the advent of the stethoscope is often taken out of context. It should begin with “… I have no doubt whatever, from my own experience of its value, that it will be acknowledged to be one of the greatest discoveries in medicine by all those who are of a temper, and in circumstances, that will enable them to give it a fair trial.” It’s time to give POCUS a fair trial.1 The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense, or the U.S. Government. References: 1. Long, N. (2019, October 18). Funtabulously Frivolous Friday 298. Life in the Fast Lane. Retrieved from https://litfl.com. 2. The Guardian. 2016. Rene Laennec’s stethoscope: giving doctors a new way to listen to patients. [ONLINE] Available at: https://theguardian.com/ science/the-h-word/2016/feb/17/rene-laennec-stethoscope-a-new-way-oflistening-to-patients. [Accessed 21 January 2020]. 3. Fink, H. A., Lederle, F. A., Roth, C. S., Bowles, C. A., Nelson, D. B., & Haas, M. A. (2000). The accuracy of physical examination to detect abdominal aortic aneurysm. Archives of internal medicine, 160(6), 833-836. 4. Mehta, N., Rubano, E., Sinert, R., Caputo, W., Paladino, L., & Guy, A. (2011). Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing an Abdominal Aortic Aneurysm. Ultrasound in Medicine and Biology, 37(8), S113. 5. Mantuani, D., Frazee, B. W., Fahimi, J., & Nagdev, A. (2016). Point-of-care multi-organ ultrasound improves diagnostic accuracy in adults presenting to the emergency department with acute dyspnea. Western Journal of Emergency Medicine, 17(1), 46. 6. Xirouchaki, N., Magkanas, E., Vaporidi, K., Kondili, E., Plataki, M., Patrianakos, A., ... & Georgopoulos, D. (2011). Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive care medicine, 37(9), 1488. 7. Blanco, P., & Volpicelli, G. (2016). Common pitfalls in point-of-care ultrasound: a practical guide for emergency and critical care physicians. Critical ultrasound journal, 8(1), 15. 8. The American Council of Graduate Medical Education.(2015). The Emergency Medicine Milestone Project. Retrieved from https://www. acgme.org/Portals/0/PDFs/Milestonesd/EmergencyMedicineMilestones. pdf?ver=2015-11-06-120531-877.

SECTON REPORT YOUNG PHYSICIANS

Tips for Advancing Your Practice in the New Year Danielle Goodrich, MD FAAEM — President, YPS

ow that 2020 is off to a running start, it is time to set yourself up for success. While the winter months can be grueling, taking the time now to improve your practice and develop good habits will pay off for the rest of the year, and years to come. Better than joining a new gym that you’ll stop going to by the time summer rolls around, here are three ways to optimize your practice that will translate into a successful career and strong personal health.

The goal is to gain alternate views, expose yourself to different opportunities, and help you develop skills and knowledge to advance your career. Mentorship Mentorship is an important part of career development and is significant in all stages of your career. Both the mentor and mentee gain from the relationship in different ways.1 Take the time now to find a mentor, and if you do have one, set goals and expectations for the year to come. Don’t know where to start? A mentor may be a more senior physician in your department, but can also be from a different specialty or from an entirely different field. The goal is to gain alternate views, expose yourself to different opportunities, and help you develop skills and knowledge to advance your career. You can seek career guidance from your mentor, ask for help with professional development or personal and professional problem-solving, as well as utilize your mentor for support and advice. This isn’t just a placebo either; research shows that those that are part of a mentor/mentee relationship have more career satisfaction and productivity than those without one. Beneficial mentorship is an active process for both participants and it will be an investment of time and effort, but ultimately everyone involved will reap the benefits.

Education The medical field is constantly evolving. With our wide scope of practice, it is vital that we continue to learn and stay up-to-date as the literature changes and our knowledge of disease processes expands. After

residency, without dedicated conference time or education time in your schedule, it can be difficult to find opportunities to read between shifts, family time, and other activities. One solution is to utilize the free open access movement (FOAM), which has expanded the resources at our fingertips with high quality blogs and podcasts free to all. There are many resources available, so it is important to choose one that meets your educational needs and works with your study habits.2 Here are some highquality options to make sure you are accessing the best content. For those with especially hectic schedules, there are tons of great podcasts each featuring a variety of topics that can be listened to on the go or to enjoy during some down time. An easy trick is to keep your podcasts together with a podcast app that automatically downloads new episodes and keeps them organized in one central location. Also, stay current on the latest journal articles with apps such as QxMD that can give you access to journal articles that are specialty specific or subscribe to blogs that curate content for you and often they will send it straight to your inbox. Develop a system for lifelong learning and with the help of FOAM, you can find the resources that work for your learning style and educational needs.

Wellness Nearly half of all physicians report burnout, with emergency physicians reporting higher levels of burnout compared to other specialties.3 As emergency physicians, we often have high workloads, stressful work environments, and irregular sleep schedules – all while juggling personal responsibilities. Burnout affects everyone differently and at different times, but personal wellness should be on every physician’s mind. Burnout is defined as a syndrome characterized by high emotional exhaustion, depersonalization, and a low sense of personal accomplishments.4 Burnout not only has personal consequences for the physician, but it can adversely affect quality of care with studies showing increased risk for patient safety incidents, reduced patient satisfaction, and poorer communication between patients and physicians. While many different aspects of the health environment (health culture, health organizations, etc.) need to work together to develop integrated ways to prevent and reduce burnout, there are ways YOU can implement wellness measures in your life. Studies have found that resiliency, coping strategies, as well as, strong social support can be protective against burnout. Start 2020 by developing a work-life balance by scheduling regular physical activity and leisure hobbies into your daily routine.

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YOUNG PHYSICIANS

Develop a system for lifelong learning and with the help of FOAM, you can find the resources that work for your learning style and educational needs. Additionally, adequate nutrition keeps you sharp on the job; bring meals and nutritious snacks to work to keep you energized throughout your shift. Learn to recognize burnout in yourself and colleagues, do not hesitate to reach out to others for help, and begin to develop your own wellness practices. For more tips to enhance your career, follow us on Twitter @AAEMYPS.

AAEM

References: 1. Garmel, G. M. “Mentoring Medical Students in Academic Emergency Medicine.” Academic Emergency Medicine, vol. 11, no. 12, 2004, pp. 1351–1357. 2. Thoma, Brent et al. “Five Strategies to Effectively Use Online Resources in Emergency Medicine.” Annals of Emergency Medicine, vol 64, No. 4, 2014, pp 392-397. 3. Ross, Shana, et al. “Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs.” Annals of Emergency Medicine, vol. 70, no. 6, 2017, pp. 891-897. 4. National Academies of Sciences, Engineering, and Medicine 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. https://doi. org/10.17226/25521

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AAEM/RSA EDITOR’S MESSAGE

Own Your Worth Adriana Coleska, MD — AAEM/RSA Board of Directors

s emergency medicine (EM) physicians, we use humor as a way to cope with a difficult diagnosis, patient loss, or an uncomfortable consultant interaction. While those who have worked with me in the emergency department know that I thrive on a relaxed and joking environment to make the shifts go by, I want to shed light on a worrisome trend that I have noticed. I want to talk about the overuse of self-deprecating humor by physicians in our specialty. I have only been in the field of emergency medicine for 2.5 years, and I cannot count how many times I’ve heard my coresidents, friends in EM, even attendings end

a story or consultation with the phrase “but what do I know, I am just an emergency room doctor.” Some physicians have even gone so far as coining the term “JAFERD” (just another f****** emergency room doctor). Though jokes, even self-deprecating ones, can quickly diffuse a tense situation, my sense is that sometimes the “just an ER doc” phrase comes from a place of insecurity. I’ve witnessed residents and attendings give thorough explanations regarding their thought process and reason for a consult, only to end with the wobbly “but I’m not sure, I am only an ER doc.” Using this statement in a professional setting diminishes the validity of your question and possibly the consultant’s opinion of your clinical knowledge and reliability. Why use language that can negatively impact your intelligence? Have you ever heard a surgeon say “I am JUST a surgeon?” We all went to medical school and matched in a competitive

field, trust in your knowledge and hard work, be confident in your exam and thought process. We are not perfect. We are allowed to get things wrong; it’s hard to keep up with new literature and new protocols on all of medicine. But when speaking to a consultant who is questioning your management, don’t shy away and hide behind the phrase JAFERD. Explain to them where you are coming from and eagerly ask to be educated on the new literature that consultant is guiding their treatment off of. And while some may use JAFERD as an inside joke, when heard by outsiders the “just” portion of the phrase can be misconstrued as lacking confidence or as excusatory. I don’t expect this article to change everyone’s mind when it comes to using self-deprecating humor. My hope is that next time you consider making a statement calling yourself a JAFERD or “just an ED doc,” you make sure it is not to undermine your management or knowledge. And if you thrive on acronyms and phrases, consider using BAFERD (bad-a** f****** ER doc) instead, as that is more representative of a physician who saves lives daily.

Though jokes, even self-deprecating ones, can quickly diffuse a tense situation, my sense is that sometimes the “just an ER doc” phrase comes from a place of insecurity.

>> COMMON SENSE MARCH/APRIL 2020

AAEM/RSA RESIDENT JOURNAL REVIEW

Assessing Fluid Responsiveness in the Emergency Department Part II Taylor Conrad, MD MS, Taylor M. Douglas MD, Ted Segarra, MD, Rithvik Balakrishnan MD, Christianna Sim, MD MPH Editor: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM

Clinical Question What methods are most effective at determining if a patient will be fluid responsive? The most recent Common Sense Resident Journal Review article looked at the utility of ultrasound to accurately assess fluid responsiveness in the Emergency Department (ED). In this article, we attempt to look at other modalities that ED physicians may use to quickly determine how patients with various etiologies of hypotension and shock respond to fluid. Initial intervention often involves a fluid bolus of varying amounts to determine if increasing preload can improve the patient’s hemodynamic status along the Frank-Starling curve.1,2 Other factors affect the patient’s hemodynamics, however, including systemic vascular resistance and the contractility of the myocardium. Vital signs and the rest of the physical exam are inadequate in determining response to fluid and persistent hypotension may represent alterations in these other factors.3 Invasive measurements of a patient’s hemodynamic status can be performed with insertion of Swan-Ganz catheter but its lack of proven benefit in the ED and associated potential complications has led to a decline in its use.5 As such, patients often receive varying amounts of fluid by ED providers, which often comprises a large amount of the initial resuscitation volume. As it has also been established that a positive fluid balance is associated with a variety of negative effects and worsened patient outcomes, identifying means to help avoid unnecessary fluid administration is crucial.2,6

Cherpanath TG, Hirsch A, Geerts BF, et al. Predicting Fluid Responsiveness by Passive Leg Raising: A Systematic Review and Meta-Analysis of 23 Clinical Trials. Crit Care Med. 2016; 44(5):981-91. The passive leg raise (PLR) has been proposed as an alternative to the traditional fluid challenge with a bolus of IV fluids. It involves straightening and lifting the lower limbs to an angle of 45 degrees, causing an increase in venous return with effects that last about one minute. Cherpanath et al. sought to evaluate the predictive value of PLR in various settings and patients to validate its use. They designed a meta-analysis to compare PLR to fluid challenge using variable outcome measures and measurement techniques, intending to evaluate not only PLR’s utility as a surrogate fluid challenge, but also its use in different clinical settings and across different patient groups. In compliance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, they reviewed the literature and identified 23 articles to include, totaling 1,034 fluid challenges. The variable practice settings included one obstetrics/anesthesia unit, one ED, and 21 intensive care units. The fluids used in the fluid challenge were mostly normal saline with some colloid and one gelatin. Regardless of

COMMON SENSE MARCH/APRIL 2020

fluid composition, the “gold standard” bolus to which PLR was compared was always 500 mL over 10 to 30 minutes. The outcome measures were divided into “flow” variables (cardiac index, cardiac output, stroke volume, and aortic blood flow) and “pressure” variables (pulse pressure). These measures could be evaluated using four different methods: transthoracic echocardiography, esophageal Doppler, pulse contour analysis, or bioreactance. Of note, most of these methods are not available in the ED. Many studies used multiple methods and/or outcome variables. Fluid responsiveness was defined as an increase of 10-15% in cardiac output or its direct derivatives depending on the study. PLR was found to have a pooled sensitivity of 86% (95% CI, 79–92) and a pooled specificity 92% (95% CI, 88–96) when compared to a fluid challenge. The pooling refers to using data from all four measurement methods. They also quote sensitivities and specificities for each individual method and cite no significant difference between the individual methods or the pooled numbers. They performed subgroup comparisons without finding any significant difference between the following groups: studies in France vs. not in France, old studies vs. recent studies, spontaneously breathing vs. mechanically ventilated patients, saline vs. other fluid types, and supine vs. semi-recumbent patients. In terms of the outcome measures, the “pressure” variable of pulse pressure was found to be inferior to all of the “flow” variables, all of which were found to be equivalent. The authors conclude that PLR, when interpreted using a “flow” outcome measure, is an acceptable surrogate fluid challenge. Their goal was to demonstrate this in various settings and patient populations. They do demonstrate it, but the variety of settings was not sufficient. The study authors mention specific situations in which the response to PLR may be confounded such as in patients on norepinephrine, on propofol, or with intra-abdominal hypertension, and emphasize the importance of avoiding pain during the PLR, as it can cause a sympathetic surge that would affect the interpretation. Overall, this paper supports the use of PLR as a surrogate fluid challenge, however its conclusion is strongest in the ICU population and may require further validation in other clinical settings.

Bentzer P, Griesdale DE, Boyd J, et al. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA. 2016;316(12):1298-1309. Bentzer et al. conducted a systematic literature review of all English language studies from 1966 to June 15, 2016 on MEDLINE and EMBASE and extracted data to calculate summary measures of the diagnostic accuracy of multiple methods to predict fluid responsiveness in ED or

RESIDENT JOURNAL REVIEW

ICU patients with refractory hypotension: physical exam findings, central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and dynamic measurements of changes in cardiac output in response to bedside maneuvers that transiently increase preload, such as PLR or positive pressure breaths. Initially, 651 studies were identified and screened. Only studies with over 20 patients were included. Each study was graded for quality as per the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Studies graded as level 1 to 3 were included, level 4 and 5 studies were excluded. The authors also excluded studies where the majority of patients had irreversible loss of brain function or major thoracic or cardiac surgery. Ultimately 50 studies, consisting of 2260 hemodynamically unstable patients, were included in the meta-analysis. The investigators extracted data directly from the articles and built a bivariate mixed-effects regression model to pool sensitivities and specificities, also addressing publication bias using the Deek’s test when diagnostic tests had 10 or more studies. Among the studies included, fluid responsiveness was defined as an increase in cardiac output of at least 10-15%. Cardiac output was measured by multiple means, primarily thermodilution using a Swan-Ganz catheter or by transthoracic echocardiography. The summary prevalence of fluid responsiveness was 50% (95% CI, 41-56%). There were two studies that assessed the accuracy of physical exam findings (e.g. dry mucous membranes, decreased skin turgor, increased capillary refill time,

tachycardia, jugular venous pressure, pulmonary auscultation, presence or absence of leg edema, ascites, pleural effusion) in predicting fluid responsiveness. Neither study showed these findings increased or decreased the likelihood of fluid responsiveness. The only static measure included was CVP as a measure of preload. In patients with a lower estimated preload as measured by CVP below the set threshold, there was a moderate likelihood of fluid responsiveness, while patients with CVP at or above the threshold had about half the likelihood of being fluid responsive. The dynamic measurements assessed included pulse pressure variation, stroke volume variation, and inferior vena cava distensibility with breaths as well as in response to passive leg raise. The authors’ summary findings suggest that physical exam findings do not help differentiate between patients who will or will not respond to fluids, CVP measurement is both invasive and inadequate, variable pulse pressure and IVC diameter can be moderately useful in ventilated patients, and that a change in cardiac output in response to passive leg raise is the most accurate predictor of fluid responsiveness in critically ill patients who have already received initial resuscitation. None of the measures, however, were helpful in ruling out fluid responsiveness7. There were many limitations to this study especially relating to its overall generalizability. A majority of the patients included in the studies had already received fluid prior to enrollment (at least 43 of 50 studies included) and many studies excluded patients with arrhythmias, pulmonary edema, significant valvular disease, right or left ventricular failure, and

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RESIDENT JOURNAL REVIEW

impaired oxygenation. Also, while a change in cardiac output in response to passive leg raise was the most accurate in predicting fluid responsiveness, many studies used methods other than the standard thermodilution via pulmonary artery catheter to define the response. While the authors tried to include higher quality studies by only including studies of level 1 to 3 by the QUADAS tool and excluding studies with sample sizes 20 or less, many of the studies were still quite small (mean sample size of 45 patients) and there were wide ranges of summary measures overall.

Conclusion While these studies demonstrate that progress has been made in the understanding of determining fluid responsiveness, they also underscore the lack of rigorous, well-validated research. The passive leg raise maneuver represents an alternative to a direct fluid challenge, but it has been less studied in the emergency department setting and it has been shown in the literature that many practitioners perform the maneuver incorrectly. The question then arises as to which method of determining a response to passive leg raise or direct fluid bolus is most accurate and effective. Direct measurement with thermodilution methods with a SwanGanz catheter represents a gold standard, while non-invasive methods such as transthoracic echocardiography, stroke volume variation, and pulse pressure variation do show promise but can vary with patient characteristics and different disease states. Bioimpedance monitors or other methods of performing the latter two measures are typically not performed in the ED.

Answer Direct fluid bolus or a passive leg raise with echocardiographic measurements of a change in cardiac output are the best literature-supported noninvasive means of determining general fluid responsiveness. The incorporation of additional methods (e.g. pulse pressure variation, stroke volume variation, carotid doppler, or cardiac output measurement with a Swan-Ganz catheter) may be utilized for more confident decisionmaking.â&#x20AC;&#x2030;â&#x20AC;&#x2030; References: 1. McDermid RC, Raghunathan K, Romanovsky A, Shaw AD, Bagshaw SM. Controversies in fluid therapy: Type, dose and toxicity. World J Crit Care Med. 2014;3(1):24-33. 2. Latham HE, Bengtson CD, Satterwhite L, et al. Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes. J Crit Care. 2017;42:42-46. 3. Bentzer P, Griesdale DE, Boyd J, MacLean K, Sirounis D, Ayas NT. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA. 2016;316(12):1298-1309. 4. Hadian M, Pinsky MR. Evidence-based review of the use of the pulmonary artery catheter: impact data and complications. Crit Care. 2006;10(Suppl 3):1-11. 5. Chatterjee K. The Swan-Ganz Catheters: Past, Present, and Future. Circulation. 2009;119(1):147-152. 6. Acheampong A, Vincent J-L. A positive fluid balance is an independent prognostic factor in patients with sepsis. Crit Care. 2015;19(1). 7. Li JJ, Hassel J, Gernsheimer J. Markers of fluid responsiveness in hemodynamically unstable patients. The NNT. https://www.thennt.com/ lr/markers-fluid-responsiveness-hemodynamically-unstable-patients/. Published 2019. Accessed.

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COMMON SENSE MARCH/APRIL 2020

{ Job Opportunities } Division Chief, Pediatric Emergency Medicine EMS Fellowship Director/EMS Medical Director Assistant Medical Director PEM/EM Core Faculty Vice Chair Research Emergency Medicine

What We’re Offering: • We’ll foster your passion for patient care and cultivate a collaborative environment rich with diversity • Salaries commensurate with qualifications • Sign-on bonus • Relocation assistance • Retirement options • Penn State University Tuition Discount • On-campus fitness center, daycare, credit union, and so much more! What We’re Seeking: • Experienced leaders with a passion to inspire a team • Ability to work collaboratively within diverse academic and clinical environments • Demonstrate a spark for innovation and research opportunities for Department • Completion of an accredited Emergency Medicine Residency Program • BE/BC by ABEM or ABOEM • Observation experience is a plus

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 ADDITIONAL INFORMATION PLEASE CONTACT: Susan B. Promes, Professor and Chair, Department of Emergency Medicine c/o Heather Peffley, Physician Recruiter, Penn State Health Milton S. Hershey Medical Center 500 University Drive, MC A595, P O Box 855, Hershey PA 17033 Email: hpeffley@pennstatehealth.psu.edu or apply online at: hmc.pennstatehealth.org/careers/physicians Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

Considerations for Your Social Media Presence David Fine — Medical Student Council President

hould you create a professional social media account? What are the benefits and risks associated with this commitment? When applying for medical school, residency, or jobs are people searching for you on the internet? How do HIPPA, professionalism, and unspoken rules factor into your social media presence? My search for information has shown that many people are asking the same questions. There are a plethora of different resources that can help you make informed decisions. The American Medical Student Association (AMSA) has created a set of 10 social media guidelines: be professional, be responsible, maintain separation, be transparent/use disclaimers, be respectful, follow copyright laws, avoid politics, protect client/patient information, comply with all legal restrictions and obligations, and be aware of risks to privacy and security (Keating 2016). These guidelines are vague, but this speaks to the potential for problems that you might face and the importance of thoughtful posting. Even on private accounts, posts that violate HIPAA and professionalism can result in punitive actions from your home institutions. There is often this discussion about ways that these forums can be negative, but there is a massive potential benefit that is much less often explained. The primary function of these sites is to connect people. In medicine this may be with other professionals or with patients. Emergency physicians do not have to worry about patients seeking them out based on their online profiles as one might do for a primary care physician or a specialist, but there are still ways to utilize social media in this field. The benefits of community outreach, education, and communication are self-evident as this new medium exists to disseminate information. Whether providing context to popularized health stories in the media or dispelling harmful medical myths there are various ways to interact with your community (Pho and Gray, 2013). These forums can also be used to connect to other professionals and supplement your knowledge with various sources of Free Open Access Medical education (FOAM). Benefits are individualized as people appreciate these tools for different reasons.

For medical students and others who are going through an application process, an AAMC article entitled “How Social Media Can Affect Your Application” discusses the relevance of your various accounts (‘Aspiring Docs’). In short, your social media presence is fair game and admission committees often look up applications. This can, however, work in your favor as an opportunity to share your interests, achievements, and experiences. You should maintain professionalism with these public accounts and make connections by joining groups, connecting with peers, and sharing content that is aligned with your interests. General tips from a variety of sources say delete pictures and posts that can be misconstrued, set accounts to private, and search for yourself online to see your electronic footprint. References: 1. ‘Aspring Docs.’ “How Social Media Can Affect Your Application.” Aamc. org, AAMC, students-residents.aamc.org/applying-medical-school/article/ how-social-media-can-affect-your-application/. 2. Keating, Jennifer. “Social Media Guidelines for Medical Students and Physicians.” AMSA, 16 Sept. 2016, www.amsa.org/2016/09/15/socialmedia-guidelines-medical-students-physicians/. 3. Pho, Kevin, and Susan Gay. Establishing, Managing, and Protecting Your Online Reputation: a Social Media Guide for

Even on private accounts, posts that violate HIPAA and professionalism can result in punitive actions from your home institutions.

COMMON SENSE MARCH/APRIL 2020

AAEM/RSA COMMITTEE REPORT ADVOCACY

Human Trafficking: Identification and Treatment Tools for the Emergency Physician Maryam Hockley, MD MPH; Erin Hartnett, BS BA; and Gregory Jasani, MD

uman trafficking (HT) affects over 21 million people worldwide¹, with 600,000-800,000 persons being trafficked annually across international borders, approximately half of whom are younger than 18 years old.² Closer to home, roughly 18,000-20,000 trafficking victims are brought into the United States every year, and this number does not count victims already within our borders.³ Its victims are not confined to a certain age, race, gender, sexual orientation, or socioeconomic level, and it is this level of pervasiveness that makes signs of HT difficult to identify. Vulnerable populations include those in the child welfare and juvenile justice systems, runaway and homeless youth, unaccompanied children, American Indians/Alaska Natives, migrant laborers including undocumented workers and temporary workers on visas, foreign national domestic workers in diplomatic homes, those with limited English proficiency and low literacy, disabled peoples, LGBTI, and those in court-ordered substance use programs.4 The International Labor Office estimates that 44% of all HT victims worldwide had migrated either within or across international borders prior to being put into forced labor.¹ The nature of human trafficking often leads to both physical and emotional harm for the victims, as it relies upon the coercion of a person into such an exploited role. As a result, an article by emDocs estimates that as many as 88% of victims will seek medical care during the time that they are being trafficked, oftentimes in an emergency department. However, their studies have also shown that as few as 5% of emergency medicine providers feel comfortable identifying and treating victims of HT.5 This unique encounter, however, offers emergency medicine physicians an invaluable opportunity to intervene

This unique encounter, however, offers emergency medicine physicians an invaluable opportunity to intervene in these victims’ lives. in these victims’ lives. Improving this statistic represents a crucial opportunity to increase awareness and understanding of the potential role we can play in these patients’ lives. As one of the primary contact persons for their health care, it is vitally important for emergency medicine physicians to identify those at a high risk for trafficking and understand the appropriate steps to take to intervene. Physicians Against the Trafficking of Humans (PATH), an organization within the American Medical Women’s Association (AMWA), offers a structured approach to identifying and caring for victims of trafficking called Stand Up to Sex Trafficking: Awareness, Implementation, and Networking (SUSTAIN).6 From this training, we learn that the first step is to pick up on subtle cues victims may give. Red flags during the history taking can include: high numbers of sexual partners, multiple sexually transmitted infections, prior abuse or self-harm, homelessness, or repeated ER visits with lack of follow-up. Physical exam findings can include: tattoos such as barcodes or other symbols of one’s ownership, scars, gynecologic injuries that seem out of proportion for age or medical history, and lack of prenatal care.² When in the room with your patient, be aware of their social history, including an unclear living situation as well as those that are in the room at the time of the encounter. Never assume an elder is their parent. Ask how they are related to the patient, and if a clear answer is not given, be on alert. Always ask everyone besides the patient to step out so you can speak to your patient privately. This can be a difficult part of the overall encounter, as this individual may insist on staying. Remind yourself that you are the physician and you can control the situation and realize that the patient should not be asked if they would like this person to stay as they will likely say yes out of fear of retribution. Once in a private setting, it is paramount to this conversation to allow the patient to feel like they have control and that their hospital room is a non-judgmental space. Questions to ask at this stage would be where they live and if they feel safe, and do they work and sleep in the same place. Administering a domestic violence screen would be appropriate, as well as asking outright if they have ever been forced to have sex in return for necessities for living. A crucial aspect to this very sensitive conversation is giving them the space to share as much or as little as they wish, and that includes asking probing questions like “Do you feel up to telling me what happened?” or “It would be helpful to us if you are willing to tell us what happened, but it is up to you and we understand if it is too difficult to talk about it,” as these statements shift the control back to the patient and reaffirms their autonomy.

>> COMMON SENSE MARCH/APRIL 2020

ADVOCACY

A 12-step approach provided by SUSTAIN6 for when you suspect a patient is being trafficked: 1. Get the patient alone and comfortable. Tell other parties that they need to step out of the room for your examination. 2. Disclose mandated reporting obligations. Let them know that what is discussed is subject to confidentiality, unless they disclose thoughts of self-harm or harming others, in which you legally must report this to law enforcement for both their safety and the safety of others. 3. Inquire about immediate needs and safety. Ask where they live and if they feel safe there. Assess if living and sleeping occur in the same place. 4. Ask only for need-to-know information without judgement. Ask probing questions only when necessary to understand their situation, but maintain their control and let them know they only have to share if they feel comfortable doing so. 5. Listen to body language, especially during the physical exam. Stop when they don’t feel comfortable, especially during a GYN exam. During a GYN exam, consider standing to the side of the patient when possible instead of between their legs, as this may make the exam less traumatizing for victims. 6. Ask the patient if they feel safe during the encounter. 7. Ask direct questions sensitively. Remind them that they have control. 8. Provide resources: a. HELP line: 888-3737-888. Tell them ways they can memorize this number or write it down/save it somewhere discreet, such as in the sole of their shoe or save it in their phone under a different name. 9. Obtain follow-up information. How can you reach them with test results? Ask for an email or two phone numbers for people important in their lives that both you and the patient can trust. a. Often, they will have phone numbers that change constantly, so a phone may or may not be the best method for contact. 10. Give them a follow-up appointment in written form. They can show this to their pimp or whoever is trafficking them as proof that they will need to return for a legitimate medical reason. Traffickers know that in order to be profitable this person needs to be in good health, so this will make face-to-face follow-up more likely. 11. Involve Social Work services. They can assist with providing resources and are invaluable to the holistic care of these patients. 12. For all patients under 18-years-old, disclosure and notification of law enforcement is mandatory. For adult victims, disclosure is their choice. Should they choose to report, ask them about how they would prefer to disclose their situation to the proper resources and authorities. Actively empowering victims in the process gives them back some control. Victims often lack control in their lives, so they may be more likely to choose to disclose if they feel they have some autonomy. Additionally, involving them in decisions important to them is a positive way to begin their journey out of “the life” should they choose to pursue that. 52

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Understanding what to look for in a patient encounter and how to address the situation with tact and careful assessment can help connect these patients to the proper resources necessary for their unique needs. Paramount to this approach is meeting them where they’re at and allowing them to have control of their lives when, for so long, they had none. Walking this path with them at their own pace and comfort level is one of the first steps to empowering them and ourselves to address this often-ignored epidemic. To learn more about what impact you can have on human trafficking, visit https://www.amwa-doc.org/path-events/ for upcoming SUSTAIN training events. References: 1. Profits and poverty: The economics of forced labor. Special Action Program to Combat Forced Labor. Fundamental Principles and Rights at Work Branch. International Labor Office. http://www.ilo.org/wcmsp5/ groups/public/---ed_norm/---declaration/documents/publication/ wcms_243027.pdf 2. Clawson, H.J., Dutch, N., Solomon, A., Grace, L.G. (2009). Human Trafficking Into and Within the United States: A Review of the Literature. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. a. https://aspe.hhs.gov/system/files/pdf/75891/index.pdf 3. U.S. Department of State. (2003). Trafficking Victims Protection Act of 2000: Trafficking in persons report. Washington, D.C. Office of the Under Secretary for Global Affairs. https://www.state.gov/documents/ organization/21555.pdf 4. U.S. Department of State. (2018). Trafficking Victims Protection Act of 2000: Trafficking in persons report. Washington, D.C. Office of the Under Secretary for Civilian Security, Democracy, and Human Rights. https:// www.state.gov/documents/organization/282798.pdf 5. Findlay S, Runde D, Buresh C. Human Trafficking in ED: Pearls and Pitfalls. Dec 2016. http://www.emdocs.net/human-trafficking-ed-pearlspitfalls/ 6. Stand Up to Sex Trafficking: Awareness, Implementation, and Networking (SUSTAIN) training provided by AMWA-PATH.

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

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