May/June 2020 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 27, ISSUE 3 MAY/JUNE 2020

Physician Wellness: Just a Dream without Due Process

Page 19

President’s Message:

Steadfast in the Midst of Uncertainty

From the Editor’s Desk:

The Moral Dilemma of COVID-19

Young Physicians Section:

The Quest for Better Sleep

AAEM/RSA President's Message:

It's Time We Taught Leadership in Medical School

AAEM/RSA Editor:

The Changing Landscape of Pre-clinical Medical Education

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, CAE AAEM/RSA Executive Director Madeleine Hanan, MSM Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Adriana Coleska, MD, Resident Editor Cassidy Davis, Managing Editor Articles appearing in Common Sense are intended for the individual use of AAEM members. Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA. Articles may not be duplicated or distributed without the explicit permission of AAEM. Permission is granted in some instances in the interest of public education. Requests for reprints should be directed to AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM is a non-profit, professional organization. Our mailing list is private.

COMMON SENSE MAY/JUNE 2020

Table of Contents Table of Contents Regular Features President’s Message: Steadfast in the Midst of Uncertainty.................................................................................. 3 AAEM Member Bulletin.......................................................................................................................................... 4 From the Editor’s Desk: The Moral Dilemma of COVID-19.................................................................................... 5 Foundation Donations............................................................................................................................................ 7 PAC Donations....................................................................................................................................................... 7 LEAD-EM Donations.............................................................................................................................................. 8 AAEM COVID-19 Response................................................................................................................................... 8 Upcoming Conferences ....................................................................................................................................... 10 AAEM/RSA President’s Message: It’s Time We Taught Leadership in Medical School........................................ 29 AAEM/RSA Editor: The Changing Landscape of Pre-clinical Medical Education................................................. 32 Resident Journal Review: Should ST Elevation in Lead aVR with Concern for Acute Coronary Syndrome Prompt Emergent Coronary Angiography?.................................................................................................... 34 Medical Student Council President’s Message: Medical Student Experiences with Ethical and Legal Cases...... 40 Job Bank.............................................................................................................................................................. 46

Special Articles Thank You............................................................................................................................................................ 12 Your Palpitations are Giving Me Palpitations: How Point of Care Ultrasound Aides in an Initial Thyroid Storm Diagnosis............................................................................................................................... 13 Operations Management: Promoting Staff and Patient Safety Through the Creation of an Emergency Department Patient and Visitor Code of Conduct....................................................................... 17 Wellness: Physician Wellness: Just a Dream without Due Process...................................................................... 19 Critical Care Medicine Section: Critical Care Hacks: Accidental Hypothermia..................................................... 23 Women in Emergency Medicine Section: Women’s Perspectives on Dual-EM Physician Couples....................... 24 Emergency Ultrasound Section: 5 Steps to Ensure that You Have a High Quality Ultrasound Program............... 26 Young Physicians Section: The Quest for Better Sleep........................................................................................ 28 AAEM/RSA Advocacy: Emergency Medicine on the Frontline: Workplace Violence in the Healthcare Setting......................................................................................................................................... 42 AAEM/RSA Advocacy: “Where are the Physicians on This?” A Call for Physician Advocacy on Healthcare Violence......................................................................................................................................................... 44 Updates and Announcements ABEM News......................................................................................................................................................... 16 Critical Care Medicine Section: The Greatest Resource You’ve Never Heard Of................................................. 22 AAEM/RSA News: Joint Statement Opposing Expanding Graduate Medical Education Funding to Nurse Practitioners and Physician Assistants............................................................................................ 30 AAEM/RSA 2020-2021 Leadership...................................................................................................................... 39 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-0320-464

Steadfast in the Midst of Uncertainty

AAEM NEWS PRESIDENT’S MESSAGE

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM – President, AAEM (2020-2022)

hings just don’t feel the same. I would like developing eight policy statements on physician rights. We have asked to say that it’s the excitement of stepping every other emergency medicine society to sign on to these stateup to my role as the first female President ments and have been joined by the American Academy of Emergency of AAEM, and indeed, that is exciting. But this Medicine Resident and Student Association (AAEM/RSA), the Society is not the kind of party a Latinx family from the for Academic Emergency Medicine (SAEM), and the American College South Bronx would be having when their mama of Osteopathic Emergency Physicians (ACOEP). Board members have becomes President. No, the social distancing, answered the call for interviews to elucidate the conditions under which the cancellation of Scientific Assembly, not being able to thank you in we are working and to clarify our position on pertinent issues: person for the confidence you have placed in me, not having physical • South Florida Sun Sentinel – Dr. David Farcy – South Florida hospicontact with my family, not having my house full of medical students tals preparing for potential cases of coronavirus and residents, not having big, loud, happy dinner parties when I’m not • Univision – Dr. David Farcy – Coronavirus travelling, not visiting residency programs to talk about AAEM—that’s • CalMatters – Dr. David Farcy – Facing doctor shortage, will California what feels so different. Without a doubt, these are unprecedented give nurse practitioners more authority to treat patients? times. With uncertainty, we seek that which is familiar, and we depend • AP – Drs. David Farcy & Mark Reiter – PPE shortage during COVIDon that which is reli19 pandemic Your Board is elected able. The Academy is • AP – Dr. Mark Reiter – Triaging in hospitals overwhelmed by COVIDdemocratically: one what it always has been: 19 patients member, one vote. And we the Champion of the • NPR – Dr. Lisa Moreno – Termination due to use of personal PPE are our members: working Emergency Physician, during COVID-19 emergency physicians. the uncompromising • EM News – Drs. Lisa Moreno and Robert McNamara – Termination proponent of workplace of Dr. Lin fairness, a consistent voice for the emergency patient, reliably put• Fox News – Dr. Lisa Moreno – Ventilator shortage during coronavirus ting patient before profit. Like our members, your Board is at work, crisis forcing doctors to decide who lives or dies caring for COVID-19 patients. We understand the conditions that you • E.W. Scripps Company – Dr. Lisa Moreno – If states’ should have are working in, because we work in those same conditions. Unlike the additional efforts in place to track the number of cases of medical corporate executives who run the CMGs, AAEM board members are on professionals contracting COVID-19 the frontlines, working with inadequate personal protective equipment, • The Wall Street Journal – Dr. Jonathon Jones – Research on striving to understand the novel aspects of unprecedented levels of TeamHealth hypoxia, determining the best time to intubate and the best settings for • The New Republic – Dr. Lisa Moreno – Early intubation of COVID-19 patients whose lungs remain highly compliant. We know what it is like patients >> to have to deny a family the right to be at a dying patient’s bedside. We know what it’s like to ponder ventilator rationing. Your Board is elected democratically: one member, one The only thing that has changed is that vote. And we are our members: working emergency we are working harder to serve you physicians. better at a time when you are working The Academy is taking dozens of calls each week harder to serve our patients better. from physicians who have been threatened with termination for speaking out about unfair and unsafe work conditions. The Legal Committee has formed a task force to respond to these calls individually and to provide resources and referrals. We are tracking the types of concerns expressed by members and non-members alike, so that we can represent the needs of emergency physicians. We listen when members report pay cuts and work hour modifications about which they were never consulted, decisions in which they played no part. Throughout the COVID pandemic, I have called for multiple ad hoc meetings of the Board to address emergent concerns of members, and we have responded to your concerns by COMMON SENSE MAY/JUNE 2020

AAEM NEWS PRESIDENT’S MESSAGE

We continue to be the Champion of the Emergency Physician, the voice for our patients and to work alongside you in the emergency departments. In addition, I asked the Government Affairs Committee to form a COVID19 Response Task Force under the leadership of Dr. Andy Walker. The Task Force created the letters that AAEM sent to President Donald Trump, the leaders of the House and Senate, and the Governors of all 50 states requesting that sovereign immunity be extended to us by raising the standard to prevail in a malpractice suit from ordinary negligence to gross negligence/willful misconduct, or both during COVID-19. We signed on to the American Medical Association’s letter to Secretary Azar requesting emergency funding for physicians under the CARES Act. The EM Work Force Committee and the Past Presidents Council then worked under Dr. McNamara’s leadership to write a letter of clarification to Sec. Azar taking the positon that this money should go to the DOCTORS and not to the CMGs or hospital groups who contract with doctors. We signed on to the Society for Academic Emergency Medicine’s letter to the public, urging social distancing and other safe practices during the pandemic. Dr. Farcy and I worked with AAEM staff to create a resources page for the website, which is constantly being updated so that you can find what you need to treat and test your patients, get help with transportation and housing, and the most recent guidelines from government agencies. Through our partnership with the American College of Medical Toxicology, we are bringing our members and the physician community updates on epicenter cities, best practices in PPE use, and conversations about emerging treatment strategies for a disease that is like no other we have

ever treated. Dr. Farcy and I were both featured speakers in this series. A newly formed AAEM/RSA task force led by Dr. Haig Aintablian is working on language for proposed legislation to forgive medical school loans for residents and attendings who are serving during the pandemic. Dr. Antoine Kazzi is working with Past Presidents Council to create a task force to propose the government create a Fallen Heroes fund for physicians who contract COVID and for the families of physicians who die as a result of occupational exposure. Nothing is different about the Academy. The only thing that has changed is that we are working harder to serve you better at a time when you are working harder to serve our patients better. We continue to be the Champion of the Emergency Physician, the voice for our patients and to work alongside you in the emergency departments. Well, another thing that has changed is your President. I am beyond proud that the Academy continues to champion diversity and to insure that AAEM looks more and more like America’s emergency physicians. I am beyond proud that you have elected me to represent AAEM as your President. I commit to serve you to the very best of my ability, to represent you well, and to be available and responsive to your needs always. I commit to stand on the shoulders of the giants who came before me to ensure that AAEM retains our proud heritage as what it always has been: the Champion of the Emergency Physician, the uncompromising proponent of workplace fairness, a consistent voice for the emergency patient, reliably putting patient before profit. In the midst of uncertainty, you can depend on AAEM.

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

For this issue of Common Sense we want to acknowledge each one of our amazing AAEM members. You all have been serving the frontlines during this fight against the COVID-19 pandemic and have not wavered. All of you have worked hard to protect your patients and communities, sacrificing your own health and well-being. It is unfortunately also possible that we may have lost some by this time as well. So this Member Bulletin, is for each and every one of you. THANK YOU! 4

COMMON SENSE MAY/JUNE 2020

AAEM NEWS FROM THE EDITOR’S DESK

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

ertainly, there is only one issue which is dominating all thoughts, prayers, and efforts on our planet right now and it is COVID-19. Hopefully where you are, your life and practice will only be incredibly inconvenienced and that your family, your community, and your hospital will be spared the worst of this pandemic. Many areas may be relatively spared by early social distancing and the shutdown of many aspects of daily life which until last month we took for granted. This crisis has brought to the forefront many ethical and moral dilemmas which our society and world need to face with open eyes and minds. Our medical capabilities in our modern prosperous society are currently been taxed past the breaking point in the hotspots of the COVID-19 pandemic. We need as a profession and as a society to consider the correct response to the complex and difficult decisions which physicians on the frontlines are now making or may eventually be facing where conditions are worse. Even if we manage to make it through this pandemic without running out of ventilators and do not lose too many talented and selfless healthcare professionals there may be a next time. Sadly, I work in one of the initial hotspots of New Orleans. The citywide healthcare system became inundated within days. The whole medical community has come together to try and work through the new complex daily challenges which we are required to meet each and every day. The process, which we worked out the day before, can be quickly scrapped or modified as we learn or try new things. The idea that a new disease can come out of seemingly nowhere and challenge every treatment concept we have is a humbling experience. When you realize that we truly are wandering in the desert when it comes to what is the best course of action for the dying patient is front of you, it is terrifying but also enlightening. How far are we really removed from the “plaque doctor” of old? Many of us have quickly been through the protocols of early intubation, late intubation, prone ventilation, CPAP, BiPAP, non-rebreather masks, no non-rebreather masks, viral filters, or whatever in an attempt to figure a path forward. Just walk through an ICU of any COVID filled hospital and you quickly see the reality of this pandemic and the current limitations of the available treatments. The prospect of throwing away much of what we thought we knew in regards to treating critically ill patients can make one question much of what we thought were sound and scientifically based principles. Listening to the various experts proposing yet another way to do things differently for this novel disease is fascinating as the medical community having to throw out, at least partially, our “evidence-based” mindset. Consider the ethical dilemma of trying a novel ARDS protocol or giving a medicine normally used for malaria or lupus with known serious side effects on only anecdotal evidence. Certainly, the intention of using

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

these techniques or medications by physicians in the trenches seeing their ICU and emergency departments filled with patients struggling to breath and dying all around them is noble and in the finest traditions of medicine. The usual treatments and protocols which we have all learned to use are not working and in an act of desperation a dedicated and caring physician who is putting their very own life on the line is attempting to save the patient in front of them. However, there will always be critics and naysayers who will demand to see the evidence and the trial, which shows the safety and efficacy of what is proposed. Many of these ideas will fail and patients will continue to die. I fear the personal consequences for these innovative physicians down the road when the tired old pundits and plaintiff attorneys come out to denounce the medical experimentation, which went on while they were safely home in self isolation. I certainly think that sovereign immunity should be granted to all physicians in this crisis to allay any fears of later recrimination after the dust settles. AAEM has sent letters to all of the governors of our states asking for relief from the fear of medical

>> COMMON SENSE MAY/JUNE 2020

AAEM NEWS FROM THE EDITOR’S DESK

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

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

I certainly know what I believe, but more and more I feel like I am a plaque doctor of old. Dealing with a novel disease which is cutting a swathe thorough my community is humbling to say the least. Our emergency department early in the pandemic tried new methods to try and depressurize the department and hospital. Trying to keep a COVID-free area became almost impossible as despite a patient’s chief complaint, in the end everything became COVID. We started seeing patients via Zoom while they were in triage to help start workups and triage to see who needed the next available bed while preserving our limited personal protection equipment supplies and to try and limit exposure to the providers. The fire marshal allowed us to put army type cots along a long hallway outside of the waiting room to see patients when there was no other available space. The scene was surreal walking past six

The reality of the shortage of personal protective equipment (PPE) is another moral dilemma. Can you expect any worker in the hospital from an emergency physician to the poor housekeeper dutifully deep cleaning the COVID rooms to enter these contaminated rooms without proper safety equipment? Can we judge them if they are too scared to work? Should only staff less than sixty who do not have significant comorbidities be asked to see these patients? Should older staff members with these comorbidities be asked not to place themselves at risk? Should pregnant staff members be excused from direct patient care? The questions can be endless and I think the answers will also be drastically different depending on your hospital and your perspective. My hospital was spared the worst of this PPE shortage, except for the fact we were given one N95 mask and told we needed to use it for

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

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

COMMON SENSE MAY/JUNE 2020

five days and to wipe off the gowns and reuse them. I am thinking of having my first N95 mask bronzed to have as a memento of this pandemic. Luckily, one of my partners “knew a guy” who owned a contracting company and gave us a small supply of nicer masks, which seemed to fit better. Our hospital system seemed to work miracles and we were able to obtain real respirator masks relatively quickly compared to the stories out of New York. The other remarkable fact about these COVID profession is truly on the frontlines of a real pandemic and that our work entails real risk makes me feel two paradoxical emotions. One is pride that we are professionals who have taken an oath and are dedicated to trying to save the lives of at times an overwhelming number of critically ill patients with the realization that we are putting ourselves and our coworkers at a potential real personal risk. The conflicting emotion is a sense of humility and insignificance that in our advanced and modern medical system we can be seemingly vanquished by a tiny piece of RNA. Please reflect on these issues even if you have not been required to face them, as the moral and ethical issues related to COVID are real and significant. Hopefully this pandemic is a generational one, but we can never be sure and should be prepared. I would ask you to consider sharing your thoughts on these or any other COVID issues. Working together as a profession can help us all deal with the stress and uncertainty of our new reality.

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

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 4-1-2020. AAEM established its Foundation for the purposes of (1) studying and providing education relating to the access and availability of emergency medical care and (2) defending the rights of patients to receive such care and emergency physicians to provide such care. The latter purpose may include providing financial support for litigation to further these objectives. The Foundation will limit financial support to cases involving physician practice rights and cases involving a broad public interest. Contributions to the Foundation are tax deductible.

Contributions $500-$999

Keith D. Stamler, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM

Mary Ann H. Trephan, MD FAAEM David Thomas Williams, MD FAAEM

Contributions $100-$249

Contributions $250-$499 Kevin Allen, MD FAAEM Justin P. Anderson, MD FAAEM Michael R. Burton, MD FAAEM Walter M. D'Alonzo, 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 Isaac A. Odudu, MD FAAEM James Francis Rowley III, 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 Gary M. Gaddis, MD PhD FAAEM FIFEM Kathleen Hayward, MD FAAEM Jacob Hennings Thomas Isenovski, DO FAAEM John H. Kelsey, MD FAAEM Katrina Kissman, MD FAAEM Stephen J. Koczirka, Jr., MD FAAEM FACEP Stephanie Kok, MD FAAEM

Calvin C. Krom, III, DO FAAEM Gregory S. McCarty, MD FAAEM James Arnold Nichols, MD FAAEM Patricia Phan, 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 James Butler, MD Patrick D. Cichon, MD JD MSE FAAEM Adriana M. Horner, MD Edgar A. Marin, MD Jennifer A. Martin, MD FAAEM Nevin G. McGinley, MD MBA FAAEM Melissa Natale, MD FAAEM Joshua E. Novy, MD MBA Ramon J. Pabalan, MD FAAEM Veerendra Kumar Nanjundaiah Ramasamudra George J. Reimann, 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 4-1-2020.

Contributions $500-$999

Contributions $100-$249

Michael R. Burton, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM David A. Farcy, MD FAAEM FCCM

Kevin Allen, MD FAAEM Justin P. Anderson, MD FAAEM Peter G. 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 Walter M. D'Alonzo, MD FAAEM Jonethan P. DeLaughter, DO FAAEM John T. Downing, DO FAAEM Steven H. Gartzman, MD FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM Jeffrey Gordon, MD MBA FAAEM Jacob Hennings

Contributions $250-$499 Eric W. Brader, MD FAAEM Jerris R. Hedges, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM Ron Koury, DO FAAEM Bryan K. Miksanek, MD FAAEM James Francis Rowley III, MD FAAEM Don L. Snyder, MD FAAEM Keith D. Stamler, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM Andy Walker, MD FAAEM

Alice Horrell, DO Thomas Isenovski, DO FAAEM John H. Kelsey, MD FAAEM Stephen J. Koczirka, Jr., MD FAAEM FACEP Jessica Neidig Leffler, MD FAAEM Gregory S. McCarty, MD FAAEM James Arnold Nichols, MD FAAEM Isaac A. Odudu, MD FAAEM Patricia Phan, 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 Kathleen Hayward, MD FAAEM James W. Hickerson, Jr., MD Stefan Jensen Julie A. Littwin, DO FAAEM Melissa Natale, MD FAAEM Joshua E. Novy, MD MBA Lindsey C. Remme, DO FAAEM Dion R. Samerson, MD FAAEM Linda Sanders, MD Michael Sherman, MD Marc D. Squillante, DO FAAEM

COMMON SENSE MAY/JUNE 2020

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 4-1-2020.

Contributions $500-$999 David A. Farcy, MD FAAEM FCCM

George Robert Woodward, DO FAAEM Missy Zagroba, CAE

Contributions $250-$499

Contributions $100-$249

Mark Avery Boney, MD FAAEM Michael R. Burton, MD FAAEM Anthony J. Callisto, MD FAAEM Sarah Hemming-Meyer, DO FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT James Francis Rowley III, MD FAAEM Eric M. Sergienko, MD FAAEM Mark O. Simon, MD FAAEM William E. Swigart, MD FAAEM Chad Viscusi, MD FAAEM Kay Whalen, MBA CAE

Justin P. Anderson, MD FAAEM Laura J. Bontempo, MD MEd FAAEM Karen Carothers, MD FAAEM R. Lee Chilton, III, MD FAAEM Sarah B. Dubbs, MD FAAEM Paul W. Gabriel, MD FAAEM Gus M. Garmel, MD FAAEM FACEP Scott C. Gibson, MD FAAEM Edward T. Grove, MD FAAEM MSPH Regina Hammock, DO FAAEM William E. Hauter, MD FAAEM

AAEM COVID-19 RESPONSE

Kathleen Hayward, MD FAAEM Jacob Hennings Patrick Holland, MD FAAEM Stefan Jensen Stephen J. Koczirka, Jr., MD FAAEM FACEP Jessica Neidig Leffler, MD FAAEM Gerald E. Maloney Jr., DO FAAEM Gregory S. McCarty, MD FAAEM Valerie G. McLaughlin, MD FAAEM Marcus Obeius, DO FAAEM Patricia Phan, MD FAAEM Jeffrey A. Rey, MD FAAEM Richard D. Shih, MD FAAEM

Contributions up to $50 Sean L. Finnerty, DO FAAEM Daniel V. Girzadas Jr., MD RDMS FAAEM James W. Hickerson, Jr., MD Irving P. Huber, MD FAAEM Emily R. Knoble, DO FAAEM James Arnold Nichols, MD FAAEM Joshua E. Novy, MD MBA Tracy R. Rahall, MD FAAEM Saba A. Rizvi, MD FAAEM Marc D. Squillante, DO FAAEM Michael E. Winters, MD MBA FAAEM Molly Wormley, MD

AAEM POSITION STATEMENTS • AAEM Position Statement on the Firing of Dr. Ming Lin by TeamHealth and PeaceHealth St. Joseph Medical Center (3/28/2020) • AAEM Position Statement on Ensuring that Frontline Personnel Can Provide for their Families (3/23/2020) • AAEM Position Statement Advocating for Immunity From Malpractice Litigation During the COVID-19 Pandemic (3/23/2020) • AAEM Position Statement on Use of Self-Supplied PPE (3/23/2020) • AAEM Position Statement on Protections for Emergency Medicine Physicians during COVID-19 (3/20/2020) To read each statement, visit: www.aaem.org/resources/statements/position JOINT STATEMENTS • AAEM Signs on to Joint Letter to Congress Urging further Protections for Healthcare Workers during COVID-19 (4/15/2020) • AAEM Signs on to Joint Letter to HHS: Emergency Funding for Physicians through the CARES Act (PDF) (4/7/2020) • Solidarity of Purpose to Confront COVID-19 (PDF) (3/23/2020) To read each statement, visit: www.aaem.org/resources/statements/joint-endorsed LETTERS SENT • Letter to All 50 Governors Calling for Immunity from Malpractice during COVID-19 • Letter to President Donald J. Trump Calling for Immunity from Malpractice during COVID-19 • Letter to Congress for Further Financial Support during COVID-19 To read each letter, visit: www.aaem.org/current-news

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

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

Legal and Policy Issues in Emergency Medicine

Emergency Medicine Operations Management

The Journal of Emergency Medicine Audio Summary

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

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

Hosted by: Matthew Kostura, MD FAAEM

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

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

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

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

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

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

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

COMMON SENSE MAY/JUNE 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 September 10-11, 2020 ED Management Solutions: Principles and Practice Seattle, WA www.aaem.org/ed-management-solutions August 29-30, 2020 Oral Board Review Course Chicago, IL and Orlando, FL www.aaem.org/oral-board-review September 12-13, 2020 Oral Board Review Course Dallas, TX and Philadelphia, PA www.aaem.org/oral-board-review September 15-18, 2020 Written Board Review Course Orlando, FL www.aaem.org/written-board-review

AAEM Recommended Conferences

September 30-October 1, 2020 Oral Board Review Course Las Vegas, NV www.aaem.org/oral-board-review

Jointly Provided

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

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

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

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

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

AAEM Online New and Improved AAEM Online AAEM Online is not only getting a new look, but will be completely revamped to offer a much more robust online learning experience. The new AAEM Online will premiere this spring. The library will consist of AAEM19 and select AAEM20 content. AAEM20 content will be added on a rolling basis. Watch your weekly Insights newsletter for new content. New Features: • CME now available for educational activities • Social Chat – network with your colleagues • FREE for AAEM and AAEM/RSA members • Accessible to non-members for $99/year Access AAEM Online at: www.aaem.org/aaem-online

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AAEM NEWS

Thank You Leonard Dunikoski, DO

here is a room. Inside the room is an old man. Wisened, distilled by the years. He made it through the war, and the next war, and the war after that. He even fought in them. He’s survived to the far edge of 80, keenly alert with full command of his mental faculties. Fit, tough, and yet kindhearted with a small smile as I delivered the news. Your wife, I said, has suffered an injury. Ah, there it is. He knows. Having held that smile lightly as I entered the room, I watched his face flicker, then hold. Putting on the face of the optimist, even though he was there when it happened. He was witness to the chaos. He had taken his wife to a late lunch. “She’s one of a kind,” he had told me with surety. Still using the present tense. Although he knew. We all knew. The strength of their love in their life was implicit in the way he spoke of her. She was his harmony and it showed in his steadiness, his carefully chosen words, his warmth.

The lunch was not memorable but his wife made it shine. They had talked, they had laughed about the neighbors, and then he had began the drive home. He was careful, he said, because of his age. There was a motor vehicle collision. Clinically, we term it the MVC but that strips it of the careless evil that it was. Well, it was probably my fault, he said, eyes turning down. Incorrect. He had been crossing the intersection, with appropriate speed, with the flow of traffic and with the light. The cocaine fueled women with unrestrained toddlers in the back of her SUV drove into the side of his car. She was driving across the intersection, running a red light. Why? I had asked her. (You see, I treated her too.) She didn’t know. And didn’t care. The old man knew. He knew it was the end for his wife, the woman he had been married to for over 60 years. He had seen the intrusion into his vehicle and seen the paramedic carry his wife away, a marionette dancing to CPR and forced to rhythm with epinephrine. Your wife, I said, has suffered an injury. Thank you, he said, I appreciate everything you have done for her. There it was. The finality. I watched his eyes break in pain while he held the smile for me. Unwavering.

Clinically, we term it the MVC but that strips it of the careless evil that it was. Thank you, he said, I APPRECIATE everything you have done for her.

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Your Palpitations are Giving Me Palpitations: How Point of Care Ultrasound Aides in an Initial Thyroid Storm Diagnosis

AAEM NEWS

Morgan Ritz, MD; Julia Todd, DO; Max Cooper, MD

bstract

Thyroid storm is a rare condition that can cause respiratory and cardiovascular collapse. Although about half of all presentations of the disease encompass an initial history of hyperthyroidism or an inciting event, it can be diagnosed by an initial presentation in the emergency department with the aid of point of care ultrasound (POCUS).1 In this case report we review the appropriate steps for initial evaluation, suspected etiologies, and emergent initial treatment in patients who present in thyroid storm and how ultrasound imaging guided us to a thyroid storm diagnosis.

Introduction We present a case of thyroid storm as the initial presentation of hyperthyroid disease in the emergency department. Although hyperthyroidism can be diagnosed based on emergent thyroid storm signs and symptoms, we present here how thyroid storm can cause respiratory and cardiovascular collapse even without a previous diagnostic etiology or inciting factor and how point of care ultrasound (POCUS) imaging guided the course to this diagnosis. Ultrasonography is increasing in utilization in emergency settings, but it is most useful for procedures and undifferentiated patients, especially for patients who go on to fail physician interventions. Thyroid storm or thyrotoxic crisis is an endocrinological emergency that is caused by extremely elevated concentrations of circulating thyroid hormones. Thyroid storm is commonly seen in patients with underlying or undiagnosed Graveâ&#x20AC;&#x2122;s disease.2 All of the major organs can be affected by secreted thyroid hormone. Significant elevations of this hormone lead to organ decompensation represented by fever, sweating, high output cardiac failure, pulmonary edema, hepatic congestion, and even delirium.

Figure 1: Left: Bedside ultrasound showing thyroid goiter with arrow indicating thyroid. Right: B lines (arrow) over the right lung base indicative of pulmonary edema using Sonosite X-porte with high-frequency linear probe 13-6 MHz L25 and phased array probe 5-1 MHz P21.

primary care doctor, she had a heart rate greater than 170 on electrocardiogram, and was sent to the emergency department for evaluation. She reports that her symptoms worsened with exertion but denied chest pain, nausea, vomiting, fever, or chills. She did not admit to any leg swelling, personal or family history of deep vein thrombosis, pulmonary embolism, or other associated symptoms. She had no significant past medical or surgical history.

Case Report A 32-year-old, otherwise healthy female, presented to the ED from her primary care office with complaints of cough, shortness of breath, and tachycardia that had been progressively worsening over the past six months. On initial presentation to her

Figure 2: Electrocardiogram showing atrial fibrillation with rapid ventricular response

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AAEM NEWS

Table 1: Burch-Wartofsky Scoring

Thermoregulatory Dysfunction

Score

Cardiovascular Dysfunction

37.2-37.7 C

Tachycardia (beats per minute)

37.8-38.2 C

99-109

38.3-38.8 C

110-119

38.9-39.3 C

120-129

39.4-39.9 C

130-139

>40.0 C

>140

Central Nervous System

Score

Congestive Heart Failure

Score

Agitation

Pedal Edema

Delirium/ Psychosis/ Lethargy

Bibasal Rales

Seizure/ Coma

Pulmonary Edema

GI- Hepatic Dysfunction

Score

Atrial Fibrillation Present

Diarrhea, Nausea/ Vomiting, Abdominal Pains

Precipitant History Present

Severe Jaundice

Upon arrival to the ED, the patient looked uncomfortable and slightly diaphoretic with an increased heart and respiratory rate but without signs of tremor or hyperthermia. Her abdomen was non-tender and non-distended. She had a heart rate of 175 beats per minute with an initial electrocardiogram showing narrow complex tachycardia concerning for supraventricular tachycardia. She was given 6 mg of adenosine followed by 12 mg of adenosine without improvement of her tachycardia. Her heart rate was still greater than 160 beats per minute with her blood pressures ranging from 140s-150s/80s-90s mmHg and no noted respiratory distress. A 10 mg bolus of diltiazem was then attempted without any improvement in vital signs. Next, 0.5 mg of propranolol was given without significant improvement. As the repeat electrocardiogram showed atrial fibrillation with rapid ventricular response, a 150 mg amiodarone bolus was administered without improvement. POCUS showed a nontender thyroid goiter and pleural effusions with a visually decreased left ventricular ejection fraction. The thyroid stimulating horm one level result was 0 milli-international units per liter and a Burch-Wartofsky Score was calculated at 55 (25 points for heart rate, 15 points for pulmonary edema, 10 points for atrial fibrillation, and five points for temperature). Esmolol, methimazole, and hydrocortisone were then given. The patient started to have respiratory distress secondary to worsening pulmonary edema and was eventually placed on bilevel positive airway pressure (BiPAP) in the emergency department prior to her intensive care unit (ICU) admission. During her ICU stay she received a formal echocardiogram which showed a left ventricular ejection fraction of 30%. Eventually, the patient was discharged from the hospital after a prolonged stay with an improved ejection fraction of 55%.

Discussion Thyroid storm is a life-threatening condition where blood pressure, heart rate, and temperature can soar to dangerously high levels. Thyroid storm typically presents after an acute physiologic stressor such as surgery, trauma, infection or acute iodine load in those with well-established

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Score

hyperthyroidism.3-6 This case presentation is an example of a common, potentially life-threatening condition with a common sign - tachycardia seen in the ED. This patient had no past medical history and presented with six months of shortness of breath, cough, and palpitations. These types of critical patients who are refractory to treatment are excellent candidates for POCUS in the emergency room in order to help narrow the differential and highlight further issues that could be causing the patientâ&#x20AC;&#x2122;s presentation. POCUS in these patients commonly includes thyroid size and vascularity, cardiac echo to investigate heart failure, and lung to evaluate for edema. Patients with suspected thyroid storm need a detailed medical history, medication reconciliation, and history of present illness to try and identify

Patients with SUSPECTED THYROID STORM need a detailed medical history, medication reconciliation, and history of present illness to try and identify a trigger.

AAEM NEWS

n this case report we review the appropriate steps for initial evaluation, suspected etiologies, and emergent initial treatment in patients who present in thyroid storm and HOW ULTRASOUND IMAGING GUIDED US TO A THYROID STORM DIAGNOSIS.

a trigger. This patient was unremarkable in all of these categories. Cardiovascular symptoms in many patients include tachycardia, cardiac arrhythmia, hypotension, and de novo congestive heart failure which may even lead to death from cardiovascular collapse. Other symptoms can include hyperpyrexia up to 104-106°F, agitation, anxiety, delirium, stupor, and even coma.7-8

Thyroid storm can also mimic sepsis so it is not only important to have a correct diagnosis but to start treatment as soon as possible. The first step is to block the production and synthesis of thyroid hormone with methimazole or propylthiouracil. Propylthiouracil is the preferred agent as it is safe in pregnancy and has a dual function of blocking peripheral conversion. The second step is to block release of thyroid hormones with iodine or lithium. The third step is to block the sympathetic outflow most commonly with propranolol, however caution should be used with patients with symptomatic congestive heart failure. For this reason, some physicians prefer esmolol as it is more titrateable. The fourth and final step is to block the peripheral conversion of T4 to T3 with either propylthiouracil, glucocorticoids, or propranolol. Ultimately, symptomatic treatment with cooling techniques and intravenous fluids may also be required.9

Questions & Take-aways What do we already know about this clinical entity? Thyrotoxicosis or thyroid storm is a well-established endocrinological emergency.

What is the major learning point? The case highlights the signs and symptoms of thyrotoxicosis, the appropriate first line diagnostic and therapeutic approach, and a strategy to help identify the underlying pathology using POCUS. How might this improve emergency medicine practice? This report seeks to reinforce the diagnostic and therapeutic approach to treating patients with thyrotoxicosis in the ED and the possible utilization of POCUS in these cases.

Conclusion In the ED, thyroid storm is an uncommon, however well known, diagnosis that warrants immediate attention and a keen eye to separate it from its more common counterpart sepsis. This case of thyroid storm in a patient with no known hyperthyroidism highlights the myriad of etiologies that need to be considered when approaching a patient with septic like complaints and how POCUS can aid in diagnosis. Here we have highlighted the appropriate history, physical exam, imaging modalities, and therapies that emergency physicians should be familiar with in order to manage patients with thyroid storm and to consider the use of POCUS. References: 1. Swee D, Chng C, Lim A. Clinical Characteristics and Outcome of Thyroid Storm: A Case Series and Review of Neuropsychiatric Derangements in Thyrotoxicosis. Endocr Prac. 2015;21(2):182-189. 2. Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010;1(3):139-145 3. Sarlis NJ, Gourgiotis L. Thyroid emergencies. Rev Endocr Metab Disord 2003;4:129. 4. Akamizu T, Satoh T, Isozaki O, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012;22:661. 5. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid Storm. Endocrinol Metab Clin North Am. 1993 Jun; 22(2):263-77. 6. Akamizu T. Thyroid Storm: A Japanese Perspective. Thyroid 2018;28:32. 7. Swee du S, Chng CL, Lim A. Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis. Endocr Pract 2015;21:182. 8. Angell TE, Lechner MG, Nguyen CT, et al. Clinical features and hospital outcomes in thyroid storm: a retrospective cohort study. J Clin Endocrinol Metab 2015;100:451. 9. Ngo SY, Chew HC. When the storm passes unnoticed--a case series of thyroid storm. Resuscitation 2007;73:485.

What makes this presentation of the disease reportable? This report shows how thyrotoxicosis or thyroid storm can present in the ED de novo without a previous diagnosis of hyperthyroidism and how POCUS can help solidify the diagnosis.

COMMON SENSE MAY/JUNE 2020

ABEM NEWS

2020 Recipients of ABEM 30-year Certificates

ABEM Board of Directors Elects Three New Members, Including First Public Member

East Lansing, MI (February 20, 2020) — Emergency Medicine was recognized as the 23rd medical specialty in 1979, and the American Board of Emergency Medicine (ABEM) administered the first certification examinations in 1980. ABEM recognizes physicians who, as of December 31, 2019, have marked 30 years of being board certified in Emergency Medicine with a special certificate. Because board certification is a voluntary process, this landmark accomplishment reflects a dedication to the specialty of Emergency Medicine, a commitment to continuous professional development, and the long-standing provision of compassionate, quality care to all patients.

East Lansing, MI (February 25, 2020) — The Board of Directors of the American Board of Emergency (ABEM) recently elected three new members: James D. Barry, MD, and Suzanne R. White, MD, as physician directors, and Hala Durrah, MTA, as its first public member director. Dr. Barry was nominated by the American Medical Association, and Dr. White from the Emergency Medicine community-at-large.

To maintain certification for 30 years, ABEMcertified physicians must participate in a program of continuous professional development and learning in the specialty. The ABEM continuing certification process consists of activities that assist certified physicians keep current with medical advances and provides opportunities for practice improvement. Physicians must also pass the ConCert Examination (a clinically focused, comprehensive examination) every ten years. ABEM salutes these physicians for their dedication to the specialty, their recognition of the value of board certification, and their commitment to caring for acutely ill and injured patients. ABEM-certified physicians are among the finest health care providers in the United States. Each of them exemplifies the ABEM mission, “To ensure the highest standards in the specialty of Emergency Medicine.” A list of the over 660 physicians who have reached this milestone is available here: vhttps://www.abem.org/public/docs/defaultsource/general/news/30-year-certificate-list-forweb.pdf.

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Dr. Barry is a Clinical Professor in the Department of Emergency Medicine at University of California, Irvine. He also is Assistant Chief of Emergency Medicine, Section of Emergency Medicine, Department of Internal Medicine at the Long Beach VA Medical Center. He has been an ABEM oral examiner since 2012. Dr. Barry completed his Emergency Medicine residency training at San Antonio Uniformed Services Health Education Consortium (Brooke Army Medical Center & Wilford Hall Air Force Medical Center). Dr. White is Professor of Emergency Medicine and Pediatrics at Wayne State University and Chief Medical Advisor for the City of Detroit. She practices clinically at the John D. Dingell VA Medical Center in Detroit. She has volunteered for ABEM in a number of capacities since 1999, including as an oral examiner, member and chair of the Medical Toxicology Subboard, and MyEMCert test question writer. She completed her residency training at Detroit Receiving Hospital, Wayne State University. Ms. Durrah was elected as the Board’s first public member director. She is a national speaker, patient/family-centered care consultant and advocate. She serves on a number of national committees, including the American Academy of Pediatrics Family Partnerships Network Executive Committee, the CMS Executive Leadership Council of the Strategic Innovation Engine, the Patient-Centered Primary Care Collaborative Care Delivery and Integration Cabinet. Ms. Durrah earned a Bachelor’s degree in International Affairs and Master’s degree in Tourism Administration, both from George Washington University in Washington, D.C. Dr. Barry and Dr. White will begin their terms as ABEM directors at the close of the summer Board meeting. Ms. Durrah’s term as the first public member director is effective April 1, 2020. The ABEM Board of Directors is comprised solely of volunteer directors: one public member director, with all other directors being board-certified, clinically active emergency physicians who are currently participating in the ABEM continuing certification process, a program of continuous learning and periodic assessment.

COMMITTEE REPORT OPERATIONS MANAGEMENT

Promoting Staff and Patient Safety Through the Creation of an Emergency Department Patient and Visitor Code of Conduct Jonathan D. Sonis, MD MHCM; Elizabeth S. Temin, MD; Andrea Blome, MD; and Kraftin E. Schreyer, MD CMQ FAAEM

hile a simple document certainly does not solve the problem of workplace violence, a Patient and Visitor Code of Conduct serves several purposes...

Everyone who works in EM is proud to treat our patients, their visitors, and each other with respect and dignity.

Violence against emergency medicine (EM) providers has been increasing at an alarming rate. The CDC defines workplace violence as, “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.”1 The Joint Commission highlighted workplace violence as a particular concern for healthcare workers, especially those in emergency settings, in a Sentinel Event Report in 2018.2 That same year, an ACEP survey found that 69% of EM physicians reported an increase in workplace violence over the preceding five years, and that 38% of EM physicians reported having been victims of violence in the emergency department (ED) within the past year, which was a 10% increase compared to a similar survey done in 2005. The survey also found that 97% of the assailants were patients.3 Physical assaults and other behaviors like swearing, yelling, or using derogatory or threatening language that would never be accepted in any other workplace are often tolerated in the ED and treated as “business as usual.” However, workplace violence negatively impacts the physical and mental wellness of providers and the care of all ED patients, by increasing emotional trauma, reducing staff productivity, and extending wait times.2,4 The emotional impact on staff leads to job dissatisfaction and fear, which in turn leads to increasing burnout and high turnover rates.2,5 Through disruption and interruption, workplace violence can additionally negatively impact quality and safety of care, by contributing to medical errors and adverse events. Furthermore, it likely contributes to increasing cost of care.6

While a simple document certainly does not solve the problem of workplace violence, A PATIENT AND VISITOR CODE OF CONDUCT SERVES SEVERAL PURPOSES... COMMON SENSE MAY/JUNE 2020

COMMITTEE REPORT OPERATIONS MANAGEMENT

It is imperative that ED leadership acknowledge and respond to this threat to the safety of their staff and workplace.7 While many EDs have responded to this increase in violence by increasing security, another tactic is to create Codes of Conduct for ED patients and visitors.8 These documents, which should be vetted by departmental, security, and legal leadership, as well as patient advocates, if available, can be posted throughout the ED and made available in laminated form to be presented to patients or visitors when warranted. It is important to note that Codes of Conduct do not supersede EMTALA. While a simple document certainly does not solve the problem of workplace violence, a Patient and Visitor Code of Conduct serves several purposes, including: • Reminding patients and family members that inappropriate behavior is unacceptable in the ED • Comforting our patient population at large that the ED will not tolerate inappropriate behavior • Empowering and protecting staff Everyone who works in EM is proud to treat our patients, their visitors, and each other with respect and dignity. An ED Code of Conduct will remind all staff that the same should be expected from our patients and visitors. Pairing the Code of Conduct with a distilled, ED-specific Patient Bill of Rights can promote balance. Together, these documents can foster patient and visitor comfort and staff safety, furthering an environment in which optimal healing can occur.

EVERYONE WHO WORKS IN EM is proud to treat our patients, their visitors, and each other with respect and dignity.

References: 1. CDC - NIOSH Publications and Products - Violence in the Workplace (96100). https://www.cdc.gov/niosh/docs/96-100/risk.html. Published October 1, 2018. Accessed February 28, 2020. 2. sea_59_workplace_violence_4_13_18_final.pdf. https://www. jointcommission.org/-/media/documents/office-quality-and-patient-safety/ sea_59_workplace_violence_4_13_18_final.pdf?db=web&hash=9E6592 37DBAF28F07982817322B99FFB. Accessed February 28, 2020. 3. American College of Emergency Physicians. https://www.acep.org/ administration/violence-in-the-emergency-department-resources-for-asafer-workplace/. Accessed February 28, 2020. 4. Sachdeva S, Jamshed N, Aggarwal P, Kashyap SR. Perception of workplace violence in the emergency department. J Emerg Trauma Shock. 2019;12(3):179. doi:10.4103/JETS.JETS_81_18 5. Morken T, Johansen IH. Safety measures to prevent workplace violence in emergency primary care centres–a cross-sectional study. BMC Health Serv Res. 2013;13(1):384. doi:10.1186/1472-6963-13-384

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6. Sentinel Event Alert 40 Behaviors that undermine a culture of safety. https://www.jointcommission.org/resources/patient-safety-topics/sentinelevent/Sentinel Event Alert Newsletters/Sentinel Event Alert Issue 40 Behaviors that undermine a culture of safety. Accessed February 28, 2020. 7. Sentinel Event Alert 57 The essential role of leadership in developing a safety culture. https://www.jointcommission.org/resources/patient-safetytopics/sentinel-event/Sentinel Event Alert Newsletters/Sentinel Event Alert 57 The essential role of leadership in developing a safety culture. Accessed February 28, 2020. 8. mha-developing-healthcare-safety-violence-prevention-programs-inhospitals.pdf. https://www.aha.org/system/files/media/file/2019/08/mhadeveloping-healthcare-safety-violence-prevention-programs-in-hospitals. pdf. Accessed February 28, 2020.

COMMITTEE REPORT WELLNESS

Physician Wellness: Just a Dream without Due Process Megan Healy, MD FAAEM; Al’ai Alvarez, MD FAAEM; and Alice Min, MD FAAEM

he culture of medicine is increasingly recognizing physician wellbeing as essential to any quality medical practice. However, due process continues to be threatened in emergency medicine (EM) and wellness cannot exist without due process. At its core, physician well-being is dependent upon meaning, autonomy and control over one’s own work environment. No physician can possibly attain these prerequisites if they have waived their rights to due process. As emergency physicians (EPs), we witness the effects of social determinants of health and challenges in access to care, while being simultaneously tasked to see as many patients as possible in universally crowded emergency departments (EDs) in under-resourced settings. According to the Institute for Healthcare Improvement’s Triple Aim, we are charged to provide cost-effective, efficient care and improve the health of the patient and the community.1 Many of us chose EM because we want to advocate for change, improve the health and wellbeing of our communities, and address health disparities. Many factors impact physician wellness, including time at the bedside and perceived ability to make an impact for individual patients.

No physician can possibly attain these prerequisites if they have waived their rights to due process. Unfortunately, despite our best efforts, our work may conflict with the expectations from senior leaders in the hospital or healthcare organizations. We are increasingly beholden to metrics such as door to provider time, turnaround time, return visits, and more. These metrics do not always align with optimal patient care. Physicians are mainly incentivized via relative value units (RVUs), and the EP’s ability to advocate for patients may be in conflict with throughput metrics designed to increase these units. In an increasingly efficiency-focused and metric-driven environment, we need to be especially leery of contracts that include due process waivers. Due process protects EPs who may be advocating patient safety or providing value for patients in a way that is not reflected in these metrics, who in turn, may find themselves in conflict with managers and/or hospital leadership. This problem has the potential to be exacerbated when corporations managing ED contracts are also beholden to shareholders and need to prove their value—mainly through increased volume and RVUs. Perhaps this is one reason why the American Medical Association cautions that physicians should consider the potential impact of corporate investor partnerships on physician and practice employee satisfaction and future physician recruitment.2

Imagine you’re an independent contractor (IC) with the expectation of seeing well above two patients per hour, disposition them appropriately, chart well to maximize billing, sign charts from midlevel providers for patients you haven’t even seen, along with many other responsibilities. Imagine you missed a subtle EKG finding, or a patient complained because they have been waiting longer while you were resuscitating in a single coverage setting. Imagine you are told you cannot admit a patient because they are heavy ED utilizers and that they do not have insurance. In the midst of the COVID-19 pandemic, reports of physicians in the frontlines infected with the virus after providing care for their patients were forced to use their own vacation time to recover and self-quarantine.3 Imagine then that as an IC, your medical director can fire you without due process because you signed a contract allowing that to happen. Here’s an example of such language from a corporate management group contract with its physician independent contractor relinquishing due process: (g) Company in its sole discretion determines that Contractor is committing, or has committed during the term hereof, unfair and/or unethical practices, or practices which are or could be harmful to patients, or in violation of law … (o) Inadequate or unsatisfactory quality of medical practice or performance of professional medical services of Contractor in the sole discretion of the Company Due process waivers are commonplace. Is there language in your contract that relinquishes your right for due process as above? Lack of due process in hospitals and contract management group (CMG) settings affect EPs, and many jobs have been lost without recourse because of these waivers in physician contracts. In addition to impact on practicing EPs, we need to be aware of how a metric-driven environment impacts the training environment for our residents. The AAMC task force Sponsoring Institution 2025 identified corporatization as one of the three major forces shaping the future of healthcare, and as a result graduate medical education (GME). The task force report concluded that “in 2025 almost all newly graduated residents and fellows will enter practice under the employment of large corporate systems” and went on to identify a need for changes to the GME model to ensure acquisition of skills necessary for practicing in this environment.4 This is concerning considering the data linking type of practice environment to physician well-being. A 2013 AMA-RAND study on professional satisfaction found that physicians in physician-owned practices

>> COMMON SENSE MAY/JUNE 2020

COMMITTEE REPORT WELLNESS

were more satisfied than physicians in other ownership models (hospital or corporate ownership). In addition, work controls and ability to be part of strategic decision making mediated the effect of practice ownership on overall professional satisfaction.5 Hospital Corporation of America (HCA), the nation’s largest for-profit hospital chain, currently operates the largest GME network in the U.S. with its 230 training programs. HCA programs are focused on attaining the unique needs of the future corporate-employed physicians. The opening slide of HCA’s GME Resident Guide highlights their “unique emphasis on the individual resident’s performance.” The VP goes on to explain that “we work on competencies that a physician will face once he or she enters practice, such as core measures and patient satisfaction”.6 What impact will a focus on these measures have for EPs in training?

Many of us chose EM because we want to advocate for change, improve the health and wellbeing of our communities, and address health disparities. In addition to advocating for patients, EPs should be able to advocate for residents and other learners in the setting of a training program to ensure educational objectives are met without threat to their livelihood. We have seen residency programs dismantled secondary to changes in ED contract management such as the case in Summa Akron Ohio. A recent publication from the Council of Residency Directors in EM (CORD) Due Process Task Force outlines several initiatives that may anticipate and prevent disruptive changes in the setting of an EM training program.7 Until recommendations like these are more broadly implemented, we will continue to see the disruption that occurs without safeguards in place. It is clear that as stewards of patient safety and health, we must be protected in our duty to advocate for our patient’s best interest despite conflict with other stakeholders’ priorities. We must also be protected when we advocate for the rights and safety of our trainees and other members of our team. Our institutions are striving for the Quadruple Aim, which includes physician well-being.8 The AMA, ACEP, AAEM, and others have continued to affirm the need for due process protections for physicians, recognizing its critical link to satisfaction. Most important in addressing physician burnout is addressing the larger systems issues that contribute to physicians’ perceived loss of autonomy, meaning, and control. Dismantling the systems barriers that threaten the physician-patient relationship is key to building a cadre of fulfilled, well physicians, who can in turn care better for our patients. Due process is a linchpin in this important mission.

In addition to advocating for patients, EPs should be able to advocate for residents and other learners in the setting of a training program to ensure educational objectives are met without threat to their livelihood. 20

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References: 1. The IHI Triple Aim | IHI - Institute for Healthcare Improvement [Internet]. [cited 2020 Mar 3];Available from: 2. Report 11 of the Council on Medical Service (A-19:) Corporate Investors. American Medical Association 2019. 3. Shugerman E. Sick Doctors Are Being Forced to Use Vacation Time if They Get Coronavirus [Internet]. Dly. Beast. 2020 [cited 2020 Mar 23]; Available from: https://www.thedailybeast.com/sick-doctors-arebeing-forced-to-use-vacation-time-if-they-get-coronavirus 4. Duval JF, Opas LM, Nasca TJ, Johnson PF, Weiss KB. Report of the SI2025 Task Force. J Grad Med Educ. 2017;9(6 Suppl):11–57. doi: 5. Friedberg, Mark W., Peggy G. Chen, Kristin R. Van Busum, Frances Aunon, Chau Pham, John P. Caloyeras, Soeren Mattke, Emma Pitchforth, Denise D. Quigley, Robert H. Brook, F. Jay Crosson, and Michael Tutty. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation, 2013. 6. \2019 GME Resident Fellow Manual - HCA Healthcare. 7. Alvarez A, Messman A, Platt M, Healy M, Josephson E, London S, Char D. The Impact of Due Process and Disruptions on Emergency Medicine Education in the United States. West J Emerg Med. 2020;1–5. doi: 8. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med;12(6):573576. doi:

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

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

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

FOR MORE INFORMATION PLEASE CONTACT:

Heather Peffley, PHR FASPR at: hpeffley@pennstatehealth.psu.edu Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

SECTION REPORT CRITICAL CARE MEDICINE

The AAEM Critical Care Section: The Greatest Resource You’ve Never Heard Of Andrew Phillips, MD MEd FAAEM, Chair and Ashika Jain, MD FAAEM, Immediate Past Chair

mergency medicine IS critical care. There isn’t a magical central line fairy or intubation genie for us. Patients arrive derailing and we *often* get them at least back on the tracks even while having very little idea what sent them off the tracks to begin with. It is a unique skillset. But the ICU is different because so much of it is the long-term approach, the 4th-line agent, etc. Here is where AAEM-CCMS is so important: it’s a group of emergency physicians (EPs) with an interest in critical care and some EPs who loved rounding so much they signed up for 1-2 more years of it in the ICU. But this group is about where the rubber meets the road, the needs of the EP in the pit with the critically ill patient. Whether a resource is prepared by an EP with a special interest in critical care or an EP intensivist, the major objective for the AAEM Critical Care Medicine Section is that it’s written by an EP, for an EP. Take the article in the last issue of Common Sense, for example, on whether andexanet alfa should really be adopted as strongly and quickly as some say. Should you really give it to your bleeding patients on apixaban? It’s a medication for a critical problem seen in the ED more often than we wish and it’s from AAEM-CCMS. Read the andexanet alfa article: https://www.aaem.org/get-involved/ sections/ccms/resources/common-sense Then, there are the Critical Care Hacks. We have all figured out some little work-around that makes it easier to take care of critically ill patients. The Critical Care Hacks videos demonstrate some MacGyvering our colleagues have shared to improve your and your patient’s day. Each hack comes with a tidbit education piece relevant to the hack, so you can quickly catch up on classifications of hypothermia as you rewarm your icicle of a patient. Have a knack for the hack? https://www.aaem.org/get-involved/sections/ ccms/resources/hacks Did you catch the last AAEM Critical Care podcast where Dr. Farcy, AAEM Past President, speaks with Tiffany Osborne, Professor of Surgery and Emergency Medicine Acute and Critical Care Surgery at the Washington University School of Medicine in St. Louis, about the Surviving Sepsis Campaign (SSC) Hour-1 Bundle? What is the goal BP for a patient with an acute subarachnoid hemorrhage? Did the patient decompensate after intubation? Are you struggling with the 1-hour sepsis bundle? Did you know you can use an ultrasound to assess fluid status? These are some of the topics covered in the long standing AAEM Critical Care podcast.

COMMON SENSE MAY/JUNE 2020

Listen here: https://www.aaem.org/resources/publications/podcasts/ critical-care-in-emergency-medicine Posting for the first time this year is the new Mentorship Program for residents/students and attendings. Whether your interests are research, clinical applications, or fellowship or whether you are a junior faculty member or a seasoned pro, there’s a good match for a mentee or mentor for you in AAEM. We recognize that we all need mentorship at different stages in our career. AAEM-CCMS wants to support both mentees and mentors to foster these dialogues. Learn more: https://www.aaem. org/get-involved/sections/ccms/ resources/mentorship-program Finally, whether you are interested in sharing your critical care knowledge on a public stage or if you are looking for a critical care speaker for your institution’s educational programming, the new CCMS Speakers Bureau is a place to check for the latest additions. All members of CCMS are invited to participate. We ask for a short sample of your speaking abilities so that anyone looking for a speaker can see how great you are.

But this group is about where the rubber meets the road, the needs of the EP in the pit with the critically ill patient. What sets us apart from all of the other critical care sections is that our mission is to support ALL emergency physicians who are interested in critical care, because we understand that the emergency department IS critical care.

Along those lines, we have opened our section meeting to new speakers to give Breve Talks. We want to give our novice speakers a platform to grow. Plus these talks can be used for submission to the Speakers Bureau. Learn more: https://www.aaem.org/get-involved/sections/ccms/ resources/speakers-bureau Involvement in the Critical Care Medicine Section does not require a critical care fellowship; in fact most members are not fellowship trained. What sets us apart from all of the other critical care sections is that our mission is to support ALL emergency physicians who are interested in critical care, because we understand that the emergency department IS critical care.

SECTION REPORT CRITICAL CARE MEDICINE

Critical Care Hacks Cheyenne Snavely, MD and Ashika Jain, MD FAAEM

COMMON SENSE MAY/JUNE 2020

SECTION REPORT WOMEN IN EMERGENCY MEDICINE

Women’s Perspectives on Dual-EM Physician Couples Megan Mandile

nvisioning and planning out any career can be daunting. Doing so for two emergency medicine (EM) careers simultaneously can have even more challenges. Nevertheless, this is the situation my significant other and I found ourselves in. Having participated in the current match as a couple in EM, we definitely experienced times of uncertainty. Did we make a difficult situation that much more complicated? We also experienced times where being a couple worked to our advantage. We each had someone in our corner who understood how crazy this process can get. With the majority of the match process behind me, I have turned my

attention to the future. I was fortunate to find that there were more than enough women who had been in my shoes before, eager to share their experience. I was able to speak with five female EM physicians: Drs. Lisa Leuchten, Jillian Moretto, Alexandra Reens, Danielle Turrin, and Smeeta Verma who are all in dual-EM physician couples. They each differ in their stage of career

COMMON SENSE MAY/JUNE 2020

and life, from Dr. Moretto, a resident without any children, to Dr. Verma, who has been in practice for over 20 years and has two children. They also met their partners at different points in their career. I learned important perspectives from each of them. The greatest benefit which a dual career EM couple can look forward to is being able to communicate with ease. The bottom line is you will have a partner that just “gets it.” EM can be draining and at times distressing. And so, Dr. Turrin says having someone who “speaks your

a little chaos and with getting creative.” They all seemed to follow a similar formula: request time off for the important things, become flexible with holiday celebration dates, and revel in the random weekdays off. Finding a supportive residency program or hospital system was something they all highlighted as critical. It can really make a difference when it comes to balancing family life and work. Childcare was another important topic for these women. EM has made huge progress in this domain. There was a time, during which Dr.

The greatest benefit which a dual career EM couple can look forward to is being able to communicate with ease. language” is a significant plus. Frustrations and victories will be heard by someone that has had a similar experience and truly empathizes. Being able to bounce ideas off of one another is something Dr. Verma points out as a benefit to her and her husband’s administrative roles. For others, having someone that can sense your need to communicate about anything but medicine is also a major benefit. Whatever their communication needs, the women all appreciated having a partner that shares in their experiences so intimately. When it comes to scheduling, it’s unlikely that either partner will have any semblance of a traditional 9-to-5. Working nights while the other works days is, at times, a reality of the job. Yet, they all find solutions to “make it work.” Dr. Reens remarks that if you are going into EM then you are likely “comfortable with

Verma recalls being told that maternity leave was simply unavailable to her, having to use sick days instead. The other women, having had their children more recently, view EM today as a very supportive and understanding specialty. Some specific challenges remain; getting a babysitter that can come at 5:00am one day and 11:00pm the next is not easy. Alternating schedules and hiring nannies/au pairs were all solutions the women recommended. Other challenges, like pumping breast milk during a shift, required a good amount of support from the department. Dr. Reens stressed the importance of remembering that a career which is “bad for a mother” is also “bad for a father.” Things like paternity leave was something the women proposed as a way the specialty can take a more family-oriented approach. Overall, there is still progress to be made, but EM seems to be heading in the right direction.

SECTION REPORT WOMEN IN EMERGENCY MEDICINE

everyone is working together and bringing one another upward. Critical evaluation, however, is at times necessary. According to Dr. Verma, what’s important is that you don’t bring that dynamic home. Keeping in mind that at times EM can still feel like a boys club, the women tended to agree that being in a junior position relative to their partner, although frustrating at times, was something that pushed them to be better.

There will be

sacrifices, but in the end with a little creativity and dedication, this partnership can be remarkably beneficial for both. With an emphasis on teamwork and bringing each other up for the benefit of the patient, EM gives couples the opportunity to have healthy senior/junior dynamics. Dr. Moretto, currently one year behind her significant other in residency, says that in the ED, these dynamics just don’t matter as much. It matters more that

Join an AAEM Section

For those hesitant to align their career so closely with a significant other, the women all highlighted how truly diverse the specialty is. EM is not a “one size fits all” career. Some chose fellowships while others jumped right in to clinical work. Some went after large academic centers with administrative or education roles while others pursued community hospitals with limited resources. When asked about this topic, Dr. Leuchten advises to focus mainly on yourself during residency. It is your time to develop and

grow, even if there is someone going for the ride alongside you. All in all, EM seems to leave enough space for developing a unique identity, even for a couple. Above all, this endeavor showed me that there is a community of women out there eager to help one another. I am grateful for the time these women took out of their already hectic schedules to speak with me. These conversations reassured me that emergency medicine is not only an amazing specialty for individuals but is also well-suited for a couple. I wish anyone about to embark on the journey with a partner the best of luck. Dr. Turrin quoted her father in saying, approach everything, from your partner to yourself, with “patience and tolerance.” There will be sacrifices, but in the end with a little creativity and dedication, this partnership can be remarkably beneficial for both.

Sections of AAEM give members the opportunity to get more involved in AAEM in an area that they are especially interested in. Sections all have their own bylaws and members pay dues to be a part of the section. See below for more information regarding the different AAEM sections that you can join. Critical Care Medicine Section Critical care is an ever revolving field with major advances, and the goals for this section are to keep you up-to-date by writing guidelines or position statements, networking, developing a job database, and providing mentorship. The Critical Care Medicine Section (CCMS-AAEM) aims to engage your clinical interests. Emergency Medical Services Section We are excited to announce the new Emergency Medical Services Section of the American Academy of Emergency Medicine (EMSS-AAEM)! Our section is founded to foster the professional development of its members and to educate them regarding emergency medical services. Emergency Ultrasound Section We are excited to announce the new Emergency Ultrasound Section of the American Academy of Emergency Medicine (EUS-AAEM)! Our section is founded to foster the professional development of its members and to educate them regarding point of care ultrasound. Women in Emergency Medicine Section The Women in Emergency Medicine Section (WiEMS-AAEM) is constituted with a vision of equity for AAEM women in emergency medicine and a purpose to champion the recruitment, retention, and advancement of women in emergency medicine through the pillars of advocacy, leadership, and education. Young Physicians Section AAEM Young Physicians Section (YPS-AAEM) membership is open to all emergency medicine residency-trained Fellow-in-Training, Associate or Full Voting members of the American Academy of Emergency Medicine who are within the first five years of professional practice after residency or fellowship training.

Learn more at: www.aaem.org/get-involved/sections COMMON SENSE MAY/JUNE 2020

SECTION REPORT EMERGENCY ULTRASOUND

5 Steps to Ensure that You Have a High Quality Ultrasound Program Alexis Salerno, MD FAAEM

s your department ultrasound machine in the corner of the room collecting dust or is your department missing out on reimbursement for point of care studies? Now is the time to resuscitate your ED ultrasound program. The increasing use of POCUS among different specialties is leading to increased scrutiny by regulatory agencies on the policies and procedures regarding its use. Most recently, The Joint Commission has listed POCUS as a top medical technological hazard. Although we may disagree with this stance, now is the time to make sure that your group has a high quality ultrasound program.1 Five steps to jump-start your ED ultrasound program are (1) having an ultrasound leader, (2) having the right equipment for your department, (3) having educational opportunities for your group, (4) having a data archiving system, and (5) having a qualitative assessment process. Let’s delve more into these five topics.

protocol when the machine malfunctions? Does your hospital have a biomedical department, or do you need to repair the machine yourself?

Leadership

A lot of times nice machines are bought by the department and sit in the corner of the ED and are never used because staff are not educated or do not feel comfortable with the ultrasound machine. It is important for the US leader to work with the department to make sure group members have educational workshops. These workshops can even be extended to your nursing staff to teach peripheral ultrasound guided IV access. Some group members may know how to perform the ultrasound exams but may be “wary” of using the department’s ultrasound machine because it is not a machine they trained with previously. To help group members familiarize themselves with the knobology of your machine you can print a quick access information sheet and attach it to the back of the ultrasound machine. This sheet can include information such as how to start, save or end a study.

John Maxwell wrote “a leader is one who knows the way, goes the way, and shows the way.” One of the most important aspects of an ultrasound program is to have an established ultrasound leader. Ultrasound leaders should be the individual(s) in your department whom you can come to with questions about how to perform a certain study or to take a second look at an ultrasound image. The ultrasound leader should also act as the bridge between the group, hospital administration and the ultrasound manufacturer. They will work with hospital administration to ensure that group members are credentialed and that there is agreement between other departments that use ultrasound, such as radiology or cardiology. They will also be the ones to work with the ultrasound manufactures to purchase equipment and to make sure that group members have ultrasound supplies available to them on shift.

Equipment In the ED, it is important to shop for the ultrasound machine that is right for your group. For example, does your group only use ultrasound for IV insertion? If this is the case, you may want a more simplified system. This is in contrast to the group that is performing advanced calculations and may want advanced cardiac and vascular packages installed on their ultrasound machine. Additionally, when looking at the equipment you need to be aware of machine maintenance to prolong your purchase. It is important to understand your machine’s warranty and service contract because this can vary with purchases. Furthermore, you want to learn how to care for your machine such as identifying which solution is best to clean your ultrasound probes. Another question to address is what happens when your ultrasound machine malfunctions? We all dread the day when the ultrasound machine stops working, and an error box pops up. What is your department’s

COMMON SENSE MAY/JUNE 2020

Lastly, when thinking about the equipment you also need to have protocols in place for cleaning the ultrasound probes. Over the last year, you may have seen many conversations about what probe cover to use when placing ultrasound guided peripheral IVs.2 ACEP has written a policy on this, but ultimately your department will need to have a protocol created in discussion with your infectious control team.3 Other probes require high-level disinfection such as transvaginal and transesophageal probes. Again, protocols vary by individual department — some EDs have the ability to clean the probe in their department while others require the probe to be sent to central sterilization. All that matters is that your group has a standardized plan.

Education and Privileging

Once staff are educated, they will need to have clinical ultrasound privileges granted by the hospital. This process usually includes documentation of a certain number of examinations performed by the group member and is usually dictated by hospital credentialing. As a framework, the 2016 ACEP Emergency Ultrasound guidelines suggest 25-50 reviewed examinations for each core application.

Data Archiving If you are using your ultrasound studies for medical decision making or reimbursement, it is important to save your images. Eventually the ultrasound machine’s storage will fill and the files will need to be either uploaded to cloud storage or downloaded to an external hard drive. If the files are downloaded to an external hard drive, the images should be in DICOM format because it adds an extra level of security as only certain programs can open the image. Additionally, the external hard drive should be password protected. >>

SECTION REPORT EMERGENCY ULTRASOUND

Five steps to jump-start your ED ultrasound program are (1) having an ultrasound leader, (2) having the right equipment for your department, (3) having educational opportunities for your group, (4) having a data archiving system, and

POINT OF CARE ULTRASOUND

is a wonderful tool that physicians can use to diagnose emergent medical conditions at the bedside.

(5) having a qualitative assessment process.

When documenting your ultrasound exam, make sure to write an informative image report to help consultants understand what you saw. The goal would be to have the ultrasound images and videos connect to the electronic medical record, but this is not always easy. One workaround may be to print images and have the images scanned into the chart. Another idea is to take photos without medical information on your phone and if your electronic medical records allow you can upload them to your patient’s chart.

Qualitative Assessment Now that you have a budding ultrasound program, it is important to have a quality assurance (QA) process in place. QA helps to maintain the quality of ultrasound studies performed by your group. It is a chance to give feedback to group members about the quality of their study images or reads. Review group member images and comment on the proper depth, gain, and scanning mode. Focus on making sure that group members are measuring distances, such as biparietal diameter, correctly. Reviewing studies is not only important to group members but also to patients. Sometimes while performing QA, you may identify an incidental finding and it is important to contact patients about this finding for further outpatient workup. Point of Care Ultrasound is a wonderful tool that physicians can use to diagnose emergent medical conditions at the bedside. It is very important to make sure that your emergency department has a high quality ultrasound program. Ensure that your ultrasound program has a leader to communicate between the group and hospital administration, equipment that meets the group’s needs, opportunities for education, a data archiving system, and a process of quality assurance. If you are interested in ultrasound topics and want to read more, check out the POCUS Report on the AAEM-EUS website. If you have any ideas or suggestions for articles related to ultrasound administration please email the POCUS Report at info@aaem.org.

References: 1. Castro G. Top 10 Health Technology Hazards for 2020. The Joint Commission. https://www.jointcommission.org/en/resources/news-andmultimedia/blogs/dateline-tjc/2020/01/top-10-health-technology-hazardsfor-2020/. Accessed February 27, 2020. 2. Mirsch D, Lewiss R, Au A. Ultrasound guided peripheral IV: It’s time to clean up our act. ALiEM. https://www.aliem.com/ultrasound-guidedperiphal-iv-time-to-clean-up-our-act/. Published September 11, 2018. Accessed February 27, 2020. 3. Guideline for Ultrasound Transducer Cleaning and Disinfection. Ann Emerg Med. 2018 Oct;72(4):e45-e47. 4. Emergency Ultrasound Imaging Criteria Compendium. Ann Emerg Med. 2016 Jul;68(1):e11-48

COMMON SENSE MAY/JUNE 2020

The Quest for Better Sleep

SECTON REPORT YOUNG PHYSICIANS

Danielle Goodrich, MD FAAEM — Chair, YPS

egardless of the stage in your training or career you are in, you will most certainly have experienced the sleep-disrupting effects of switching between day and night shifts. Shift work sleep disorder, a circadian rhythm disturbance resulting in insomnia or excessive sleepiness, can affect up to one-fifth of shift workers. In our efforts to ensure that patients have the proper access to medical care at all times, shift work has regrettably also been associated with numerous health consequences for health care workers. Shift workers have an increased risk of obesity, hypertension, and type 2 diabetes, as well as an increased risk of cardiovascular disease, stroke, and even certain types of cancer. In the short term, shift work can also lead to impaired neurocognitive abilities, increasing the risk of motor vehicle accidents on the way home from a shift. Although many emergency departments seek to ameliorate some of these effects with specific shift progression or the hiring of nocturnists, most still require at least some switching between your sleep/wake cycles. While you may not have control over your schedule, thankfully there are a few things that you can do to promote good sleep and good health.

Light

Sleep Hygiene

Anchor Sleep

The light/dark cycle is a strong circadian regulator. Light triggers the pathways that ultimately lead to the suppression of melatonin, signaling to your internal clock that it is daytime and time to rise. Therefore, light exposure in the workplace, especially bright light for even brief periods of time (eg 15 minutes), can improve your alertness and performance. And conversely, during the daytime, light avoidance such as wearing dark glasses, installing blackout curtains, or using a sleep mask has been shown to enhance sleep.

Sleep quality is essential. Improved sleep quality can reduce the harmful health consequences associated with sleep deprivation. Start by designing your bedroom environment to be conducive to quality sleep. Your bedroom should be dark, quiet, and cool. Easy solutions are to invest in fans or air conditioners. Avoid alcohol, nicotine, and caffeine as you near bedtime. While some use alcohol to get to sleep, alcohol actually decreases the proportion of REM sleep and leads to greater sleep fragmentation.

Anchor sleep is a period of at least 4 hours during which one sleeps on both work and nonwork days. This allows some sleep to always overlap and therefore, your circadian rhythm can be stabilized and minimally disrupted. While napping does not fully negate fatigue, napping before a night shift is a form of anchor sleep and can positively impact performance. If you are able, strategic napping during a shift can increase alertness and reduce fatigue as well. Additionally, a quick nap before driving home after an overnight shift can increase alertness and avoid potential motor vehicle accidents.

While you may not have control over your schedule, thankfully there are a few things that you can do to promote good sleep and good health. 28

Improved sleep quality can reduce the harmful health consequences associated with sleep deprivation.

COMMON SENSE MAY/JUNE 2020

References 1. Ferguson, Brian A., et al. “Remember the Drive Home? An Assessment of Emergency Providers’ Sleep Deficit.” Emergency Medicine International, vol. 2018, 2018, pp. 1–4. 2. Whitehead, Dennis C, et al. “A Rational Approach to Shift Work in Emergency Medicine.” Annals of Emergency Medicine, vol. 21, no. 10, 1992, pp. 1250–1258. 3. Wickwire, Emerson M., et al. “Shift Work and Shift Work Sleep Disorder.” Chest, vol. 151, no. 5, May 2017, pp. 1156–1172.

AAEM/RSA PRESIDENT’S MESSAGE

It’s Time We Taught Leadership in Medical School Haig Aintablian, MD — AAEM/RSA President

valued my inter-professional team building classes while I was a medical student. I thought they added an additional glimpse into the workings of other professions - something that taught me a lot about the utility of each member of the healthcare team. But I remember one quality being distinctly abolished from any discussion while we had our interprofessional sessions - the notion of the physician as the leader.

But as a good medical student, we were taught that “professionalism” meant bowing down to the claims of your team members and not rocking the boat. The leader of the team, it seemed, was definitely not allowed to be the physician. The culture I felt back then (not too long ago) and the one I see being forced on medical students now is to “find your role” in the healthcare team. Find your role? Hint med students: it is as the team leader. Medical schools should not devalue, the not only historic, but absolutely necessary position of a physician at the top of the healthcare team. Physicians in training should not be taught how to find their role in the healthcare team, but reinforced that they are to lead it. I believe that part of the reason why we have so many scope of practice battles in medicine is because we have lost our quality as leaders in it. We have lost the ability to stand up for ourselves and call out injustices and wild claims of equivalency by other professions.

I recall my classmates one time visibly frustrated that our physician assistant (PA) colleagues would minimize our education during one of the sessions. I heard the often used “we learn everything you do, in half the time” myself. That wasn’t true, I thought. I studied in the library with PAs. Some of my closest friends were PA students. They did not study to the depth that we did. They did not learn the inner workings of the human body to the degree that we did. Their tests were not nearly as difficult as ours were.

Physicians in training should not be taught how to find their role in the healthcare team, but reinforced that they are to lead it.

I believe that part of the reason why we have so many scope of practice battles in medicine is because we have lost our quality as leaders in it. For medical schools, the fiduciary duty is not only to produce the best patient advocates and most knowledgeable clinicians, but above all, to produce the next generation of team leaders. Why have our academic institutions succumbed to the “be a good team player” attitude instead of endorsing the ideal of “being a good team leader?” At the end of the day, the next generation of medical students is waking up. They are understanding scope of practice issues and the injustices of our current medical climate. They know the vast differences in training between their education and that of midlevel and other “providers.” They see the devaluation of their medical degrees, the stealing of medical training terminology (resident, residency, and even doctor) by other professions and they are not having it. If we really want the next generation of successful physicians, we must start by allowing them to accept, value, and embrace their role as the healthcare team leader.

COMMON SENSE MAY/JUNE 2020

AAEM/RSA NEWS

Joint Statement Opposing Expanding Graduate Medical Education Funding to Nurse Practitioners and Physician Assistants

Haig Aintablian, MDa; Gabriel Stahl, MDb; Gregory Jasani, MDb; Hannah R. Hughes, MD, MBAc; Allison Beaulieu, MDd; Nehal Naik, MDe; Christina Hornack, DOf American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA), President American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA), Member-at-Large c Emergency Medicine Residents’ Association, President d Council of Residency Directors in Emergency Medicine, Resident Member-at-Large e Society for Academic Emergency Medicine Residents and Medical Students, President f American College of Osteopathic Emergency Physicians Resident Student Organization (ACOEP-RSO), President a b

STATEMENT:

On December 18th, the Government Accountability Office (GAO) released a report considering the expansion of federal General Medical Education (GME) funding to include nurse-practitioners (NPs) and physician assistants (PAs).1 All Emergency Medicine Resident Organizations and Students (AEROS) opposes the expansion of GME funding to include non-physician practitioners (NPP). The report was created to consider the utilization of NPPs as an avenue to mitigate the anticipated primary care physician shortage as outlined by the Health Resources and Services Administration (HRSA) in 2016.2

hile NPP programs experience rapid expansion, the US physician pipeline faces persistent shortages. Any expansion of GME must prioritize the physician shortage. There has been an increase in medical school enrollment (allopathic and osteopathic) by an average of 4% from 2005-2018 which far outpaces the 1% annual increase in residency positions per year since the Balanced Budget Act (BBA) was passed in 1997.3,4 The BBA was created to avoid what was thought to be an impending physician surplus at the time. Based on the HRSA report from 2016, the surplus will never come to fruition. The restricted supply of GME positions results in medical students who are unmatched to GME training, delaying their entry into the physician workforce, and further exacerbating the physician shortage. While the physician shortage is growing, NPP programs have no limitation on training positions. According to the Health Resources and Services Association report from 2016, NPs and PAs are growing at a rate that will result in a 74% and 61% surplus by 2025 respectively.2 Even with the projected surplus, NPPs receive $41 million in annual funding from the Centers for Medicare & Medicaid Services (CMS).1 The stark contrast in proliferation of new NPPs to new

physicians based on the current funding model, further supports the argument against the expansion of funding for NPP education. GME funds a well-developed and consistent model physician training. GME funding of NPP programs would fund an unstandardized curriculum with highly variable cost of training. Medical students accrue roughly 6,000 clinical hours in addition to the thousands of hours dedicated to independent study and lecture.5 Furthermore, prior to receiving funding from GME, physicians have completed three United States Medical Licensing Exams with a fourth to be completed in clinical training. Once residency begins, physicians take part in a time-tested model of training with predictable budgets. The varied training pathways of NPPs and lack of formal clinical training requirements results in “limited and incomplete” estimates of NPP training, as stated in the GAO report.1 The GAO previously recommended that the Department of Health and Human Services (HHS) develop a comprehensive plan to address the physician shortage and noted the vast disparity in GME funding between rural and urban communities.6,7 In response, HHS has included efforts to redistribute physicians from densely populated areas to rural communities using multiple incentives, including distribution of CMS funds.8 Of

While the physician shortage is growing, NPP programs have no limitation on training positions. 30

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AAEM/RSA NEWS

note, GAO addressed the use of non-physician practitioners to improve access to healthcare in rural areas. However, according to the Agency for Healthcare Research and Quality (AHRQ), NPPs remain far more concentrated in urban areas.9 With such measures already presented for federal funding to address the physician shortage and geographic distribution, expanding GME funds to include NPPs only poses additional planning and costs without guaranteeing improving access and quality of primary care. AEROS steadfastly opposes the expansion of GME funding to NPPs. GME funding of NPP training would lead to poorly vetted expenditures that would divert funds away from the unsolved physician shortage. To address the unsolved physician shortage, as well as access to high quality and compassionate care, we need to focus our time and resources on training the next generation of physicians.

GME funding of NPP training would lead to poorly vetted expenditures that would divert funds away from the unsolved physician shortage.

References: • Government Accountability Office, Views on Expanding Medicare Graduate Medical Education Funding to Nurse Practitioners and Physician Assistants. (GAO Publication No. 20-162). Washington, D.C.: U.S. Government Printing Office.: December 2019. • Health Resources and Services Administration, National and Regional Projections of Supply and Demand for Primary Care Practitioners: 20132025 (Rockville, Md.: November 2016). • AAMC: Results of the 2018 Medical School Enrollment Survey . AAMC. 2018, http://www.aamc.org/system/files/2019-08/results-2018-medicalschool-enrollment• Survey.pdf. Accessed January 2020. • United States. Congress. House. Committee on the Budget. Balanced Budget Act Of 1997 : Report of the Committee on the Budget, House of Representatives, to Accompany H.R. 2015, a Bill to Provide for Reconciliation Pursuant to Subsections (b)(1) and (c) of Section 105 of the Concurrent Resolution on the Budget for Fiscal Year 1998, Together with Additional and Minority Views. Washington :U.S. G.P.O., 1997. • Coalition PC. Compare the Education Gaps Between Primary Care Physicians and Nurse Practitioners. Texas Academy of Family Physicians website. tafp. org/Media/Default/Downloads/advocacy/scope-education. pdf. Accessed January 2020. • US Government Accountability Office. Health care workforce: comprehensive planning by HHS needed to meet national needs. December 11, 2015. http://www.gao.gov/products/GAO-16-17. Accessed January 20, 2020. • US Department of Health and Human Services. HHS Strategic Plan FY 2018-2022 [Internet]. Washington (DC): US Department of Health and Human Services.: 2018 • Government Accountability Office, PHYSICIAN WORKFORCE: Locations and Types of Graduate Training Were Largely Unchanged, and Federal Efforts May Not Be Sufficient to Meet Needs. (GAO Publication No. 17411). Washington, D.C.: U.S. Government Printing Office.: May 2017. • Primary Care Workforce Facts and Stats. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www. ahrq.gov/research/findings/factsheets/primary/pcworkforce/index.html. Accessed January 2020.

COMMON SENSE MAY/JUNE 2020

The Changing Landscape of Pre-clinical Medical Education

AAEM/RSA EDITOR’S MESSAGE

Alexandria Gregory, MD

n mid-February, the National Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB) announced that the United States Medical Licensing Examination (USMLE) Step 1 scoring would be changed to pass/fail as early as 2022.1 Many rejoiced about the potential for residency programs to emphasize other parts of applications rather than a test that does not evaluate the most clinically-relevant medical knowledge, while others expressed concern about the logistics of the decision and whether it would truly have its intended effect. Regardless of where you stand on the issue, it is important to recognize the implication this has regarding how preclinical education may change in upcoming years in medical schools across the country. Separate from the debate of Step 1 scoring, preclinical medical education has been evolving quickly, particularly over the last decade. In 2018, 108 medical schools used pass/fail grading. This is up from 87 in 2014, while only 24 schools still used letter or numerical grades.2 This trend was driven largely by a call to improve student wellness and was strongly supported by the American Medical Association (AMA) who published an official resolution in 2012.3 Other reasons cited for the proposed change were increased student collaboration, more time for extracurricular activities, and lack of evidence to show negative effects on Step 1 and 2 scores.

across the country. Almost all students are familiar with First Aid, SketchyMedical, Pathoma, and a few other core Step 1 resources. Sketchy and Pathoma, specifically, consist of videos to convey the important pathology, pharmacology, and microbiology concepts necessary for Step 1. This raises the question about the utility of in-class lectures, especially ones that do not “teach to the test.” If students are by-and-large relying on the same five-or-so resources for their preclinical education, while also skipping the lectures provided by their schools, what is the value of the education provided by their schools (and at a much greater cost)?

The migration to pass/fail, in conjunction with increased use of technology, has already impacted how schools and outside stakeholders approach preclinical education. Many schools have reduced attendance requirements, allowing students to study on their own schedules and using their own techniques. Lectures are often recorded, allowing students to pause or speed up the lectures at their discretion. Concurrently, the emphasis on Step 1 has resulted in the standardization of resources

This is not to say schools should discard their curricula in favor of standardized outlines and recorded videos. On the contrary, changing Step 1 to pass/fail can help facilitate medical schools regaining control of preclinical medical education. First, however, several questions must be addressed:

The migration to pass/fail, in conjunction with increased use of technology, has already impacted how schools and outside stakeholders approach pre-clinical education.

What can schools offer that standardized Step 1 resources and recorded lectures do not? If Step 1 does not optimally cover material that makes for good doctors (cited by those who proposed changing the test to pass/fail), which material should schools focus on? How can the curriculum be transformed so as to maximize learner engagement, especially when traditional medical school lectures have, arguably, failed at this? Already medical schools have begun to address some of these questions. One way this has been done is by introducing problem-based learning (PBL). PBL encourages learners, often in small groups, to become

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more actively involved in learning and collaborate with one another, often while applying basic science concepts to more clinically relevant material.4 Though this style of learning certainly does not fit all learning styles, it is a good way to encourage active learning and is reflective of how material is learned during the clinical years, thus offering a good introduction to an important method for learning medicine. Another potential way to adapt preclinical education to the learning styles of the current generation is the incorporation of free open access medical education (FOAM). FOAM consists of visual and auditory resources such as podcasts, blogs, and videos that allow for knowledge sharing, often with more up-to-date information than textbooks and in-person lectures due to the quicker distribution of online resources.5 Certainly FOAM presents its own issues (particularly how to assess which resources can be trusted), but it is also an example of how to adapt medical education to millennial learners. FOAM has been embraced by emergency medicine, with other specialties following suit, and has been successfully incorporated into many residency programs’ curriculum, so the possibility of expanding FOAM to the preclinical years as a supplement to other educational tools is not far-fetched. While these issues exist separately from Step 1, they are now more relevant than ever, as making Step 1 pass/fail eliminates the need to emphasize only the material on the test and only in a way that drives students to aim for high Step scores at the expense of other important lessons. Regardless of how you feel about Step 1 scoring, the impact on preclinical education cannot be ignored. In light of this change, medical schools should start re-evaluating their preclinical curricula now to prepare for a world without Step 1 scores.

Many rejoiced about the potential for residency programs to emphasize other parts of applications rather than a test that does not evaluate the most clinically-relevant medical knowledge, while others expressed concern about the logistics of the decision and whether it would truly have its intended effect.

References: 1. United States Medical Licensing Exam. Change to pass/fail score reporting for Step 1. https://www.usmle.org/incus/#decision. Accessed February 15, 2020. 2. Murphy B. How do medical schools use pass-fail grading? American Medical Association. https://www.ama-assn.org/residents-students/ preparing-medical-school/how-do-medical-schools-use-pass-fail-grading. Published January 9, 2020. Accessed February 15, 2020. 3. American Medical Association. Supporting two-interval grading systems of medical education H295.866. Published 2012. Last Modified 2019. 4. Chang B. Problem-based learning in medical school: A student’s perspective. Ann Med Surg (Lond). 2016 Dec;12: 88-9. 5. Otterness K. Incorporating FOAM into medical student and resident education. Clin Exp Emerg Med. 2017 Jun; 4(2): 119-20.

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Ultrasound in the Emergency Department Navigating Your Career Path Post-Residency Crowding in Emergency Departments Myths, Bias, and Lies My Medical School Taught Me COMMON SENSE MAY/JUNE 2020

AAEM/RSA RESIDENT JOURNAL REVIEW

Should ST Elevation in Lead aVR with Concern for Acute Coronary Syndrome Prompt Emergent Coronary Angiography? Akilesh Honasoge, MD, Robert Brown, MD, Samantha Yarmis, MD, Mark Sutherland, MD, Megan Donohue, MD, Hannah Goldberg, MD Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM

Introduction: Emergent management of traditional ST elevation myocardial infarction (STEMI) has been well defined over the past few decades, including fibrinolytic therapy and/or emergent coronary angiography with percutaneous intervention (PCI) when able.1 There has not been, however, a clear consensus on acute management of ST elevation (STE) in lead aVR. When examined in isolation, STE in aVR carries a broad differential including, but not limited to, myopericarditis, massive pulmonary embolism, global ischemia from hemorrhagic shock, left ventricular hypertrophy, left bundle branch block (LBBB), thoracic aortic dissection, and left main coronary artery (LMCA) disease.2 However, when a patient’s clinical history and presentation is concerning for acute coronary syndrome (ACS), what is the most appropriate emergent intervention? The most recent update to the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guideline on STEMI management was in 2013 and was the first American guideline to include mention of STE in lead aVR as a concern. The statement is rather broad, however, stating “multilead ST depression with coexistent ST elevation in lead aVR has been described in patients with left main or proximal left anterior descending artery occlusion.”1 The 2017 European Society of Cardiology (ESC) guidelines make the stronger assertion that ST depression greater than 1 mm in 8 or more surface leads coupled with STE in aVR and/or V1 “suggests multivessel ischemia or left main coronary artery obstruction.”3 The guidelines go on to recommend that ongoing symptoms of myocardial ischemia with this atypical sign should prompt primary PCI similar to patients with a LBBB meeting Sgarbossa’s criteria, but these recommendations have not reached widespread adoption in the United States. The following studies look at the outcomes of coronary angiography with STE in aVR to answer the following question: Question: What are the coronary angiogram findings and clinical outcomes of coronary angiography associated with ST elevation in aVR?

Harhash AA, Huang JJ, Reddy S, et al. aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion. Am J Med 2019;132(5):622-630. The investigators sought to clarify the incidence of acute coronary thrombus versus severe nonocclusive multivessel disease in patients presenting with ST elevation in aVR and multi-lead ST depression (STE-aVR). They reasoned that a high incidence of acute coronary occlusion would support the 2013 ACCF/AHA recommendation for emergent coronary reperfusion within 90 minutes of identification of these EKG findings.

COMMON SENSE MAY/JUNE 2020

They performed a retrospective analysis of four years of STEMI team activations for emergent cardiac catheterization at University of Arizona’s two academic hospitals. Two blinded cardiologists retrospectively reviewed all ECGs originally determined to be STEMI and based on which the catheterization lab was activated. A separate, blinded interventional cardiologist then reviewed the coronary angiograms to determine incidence of acute coronary artery occlusion requiring intervention. The authors looked at secondary outcomes which included a comparison of presentations in cardiac arrest, survival to discharge, and the presence of severe coronary artery disease (defined as greater than 70% stenosis) without occlusion. Data was presented as means with standard deviations for normally distributed continuous variables or as median values with interquartile ranges for skewed data. Of 854 consecutive patients for which a STEMI team was activated, 847 had ECGs available and 99 (12%) were determined to have STEaVR. Of these patients, 63 of the 99 had STE in leads other than aVR, most predominantly V1, but none had STE in two or more contiguous leads which would have met traditional STEMI criteria. Of the 99 patients, 79 underwent emergent coronary angiography with eight of these (10%) having evidence of an acute thrombotic coronary occlusion thought to be a culprit lesion, 47 (59%) having evidence of severe coronary artery disease (45% of which was 3-vessel), 13 (16%) having mild-moderate disease and 19 (24%) having angiographically normal coronaries. Twenty-nine patients had in-hospital PCI and seven patients underwent in-hospital coronary artery bypass grafting (CABG). Of the eight patients who had an acute coronary thrombus, none involved the LMCA or LAD. The overall mortality rate of patients with STE-aVR was 31%, with the highest mortality rate among the patients who presented in cardiac arrest (67% vs 11% of those who did not present in arrest, p<0.001). The in-hospital outcomes of these 99 patients revealed a relatively sick population, with 47% requiring mechanical ventilation (19% in the nonarrest population) and 15% developing cardiogenic shock. Comparison of mortality made by randomly selecting 190 other non-aVR STEMI cases, from the same period, were found to have an in-hospital mortality rate of 6.2%. The authors conclude that the incidence of disease requiring

AAEM/RSA RESIDENT JOURNAL REVIEW

emergent intervention is low in the STE-aVR population, but 20 of the study group participants, arguably some of the sicker patients, did not undergo coronary angiography, potentially underestimating the actual incidence of acute coronary thrombosis. The authors compare the STEaVR and non-aVR STEMI group mortality without other comparisons of illness severity, and do not confirm the actual incidence of acute thrombotic occlusion in the non-aVR group. There is no report for the specific incidence of PCI or CABG for the patients with STE-aVR and severe disease. The study suffers from a low number of ECGs with STE-aVR and is confounded by the presence other ST segment elevations in the study group. The authors suggest that STE in aVR is a poor predictor for the need for revascularization yet a predictor of increased mortality. Due to the limited size of the study, however, no definitive conclusions can be reached from these data.

Kosuge M, Kimura K, Ishikawa T, et al. Combined Prognostic Utility of ST segment in Lead aVR and Troponin T on Admission in Non-ST-Segment Elevation Acute Coronary Syndromes. Am J Cardiol 2006;97:334-9. This study looked at a composite 90-day outcome with the goal of establishing an early risk stratification system for patients using the presence of STE in aVR and laboratory testing including troponin T (a group defined by this study as an NSTEMI group). The study was a retrospective cohort study that examined patients admitted to a single coronary care unit in Japan between 2001 and 2004. Patients were included if they had typical cardiac chest discomfort lasting at least 5 minutes within the 48 hours prior to hospital admission. Other inclusion criteria included an ECG on arrival and angiography during admission. Exclusion criteria

included preexisting LBBB, RBBB, left ventricular hypertrophy (LVH), ventricular pacing, STE in leads other than aVR, Q wave MI on admission, or recent PCI within six months. All patients were followed for 90 days after admission. A total of 333 patients were included in the study; 69% were male, and the mean age was 67 years. Of the included patients, a total of 78 patients (23%) had a history of revascularization, 66 patients (20%) having had prior PCI and 21 patients (6.3%) having had prior CABG. There were 115 patients (35%) with a history of diabetes mellitus, and 213 patients (64%) with a history of hypertension. A single cardiologist who was blinded to other data evaluated admission ECGs. STE was defined as ≥0.5 mm in any lead. A troponin T ≥0.1 ng/ ml was defined as positive. Cardiac catheterizations were performed at a median of three days after admission. A single cardiologist who was blinded to other data evaluated angiograms. Clinically significant stenosis was defined as stenosis of ≥50% in the LMCA or ≥75% in ≥1 major epicardial vessel or its main branches. The primary end-point of this study was a composite of death, myocardial infarction or reinfarction, or urgent revascularization within 90 days. Overall, 90 of the 333 (27%) patients had STE in aVR. On admission, when compared with patients without, patients with STE in aVR had a significantly higher CRP (0.838 vs 0.474, p=0.04), CK-MB (19 vs 13, p<0.01), and more often had a positive troponin T (52% vs 26%, p<0.01). Patients with STE in aVR were significantly more likely to have LMCA disease (12% vs 0.4%, p<0.01) or composite LMCA/3-vessel disease (51% vs 7%, p<0.01), with a higher rate of in-hospital PCI or CABG (87%

Congratulations 2020 AAEM/RSA Award Winners Congratulations to our 2020 AAEM/RSA award winners! These awards will be presented in-person at AAEM21 March 6-10, 2021 in St. Louis, MO. Kevin G. Rodgers Program Director of the Year Award This award recognizes an EM program director who has made an outstanding contribution to the field of emergency medicine and AAEM. 2020 Award Recipient: Scott Young, DO FAAEM Program Coordinator of the Year Award This award recognizes an EM program coordinator who has made an outstanding contribution to the field of emergency medicine and AAEM. 2020 Award Recipient: Norma Franco Committee Member of the Year Award This award recognizes AAEM/RSA committee members who have made noteworthy contributions to their committee(s). 2020 Award Recipients: Gregory Jasani, MD and Nahal G. Nikroo, MD

Learn more at: www.aaemrsa.org/about/values/awards COMMON SENSE MAY/JUNE 2020

AAEM/RSA RESIDENT JOURNAL REVIEW

vs 59%, p<0.01). The composite 90-day outcome of death, myocardial infarction/reinfarction, or urgent revascularization occurred more frequently in the STE in aVR group (40% vs 6%, p<0.01). Most importantly, a multivariate analysis demonstrated that ST segment elevation in aVR and a positive troponin T were the only statistically significant independent predictors of death or MI at 90 days (p=0.03 and p=0.04, respectively). The other variables examined such as age, gender, prior MI, prior revascularization, Killip class, coronary risk factors, systolic blood pressure, heart rate, CRP, CK-MB, and non-aVR ST segment depression, did not show statistical significance as predictors for the composite outcome.

In a single center retrospective observational study, the authors screened 286 consecutive post-arrest patients in whom ROSC had been achieved, looking at the 111 patients with a presumed cardiac cause of arrest who also then underwent coronary angiography. After excluding patients with post-ROSC ECG findings of STEMI, LBB, or LVH, a total of 74 patients were included in the study. The study investigators measured ST elevation immediately after and within a few hours of ROSC and compared them in patients with and without lesions on post-arrest angiography. ST elevation was considered significant if >0.5 mm, and coronary artery stenosis of 50% or greater was considered clinically significant.

Further subgroup analysis found a stepwise increase in the rate of the composite 90-day outcome with either STE in aVR, a positive troponin, or both. Rates of this 90-day outcome were 4% (- STE in aVR, - troponin), 13% (- STE in aVR, + troponin), 33% (+ STE in aVR, - troponin), and 47% (+ STE in aVR, + troponin). The authors conclude that both ST elevation in aVR and elevated troponin are independent predictors of adverse outcomes and that the combination of both provides a stronger predictor of adverse outcomes than either one alone. They note that left main or triple vessel disease can cause the ST segment vector to be directed to the right, leading to ST elevation in aVR and providing an explanation for why this specific ECG finding is indicative of extensive myocardial ischemia.

Of the 74 patients, 85% were male, 88% had a witnessed arrest, and 73% of patients had an initial rhythm of ventricular tachycardia or ventricular fibrillation. The median time to ROSC was 13 minutes. Coronary angiography was performed within 24 hours in 50% of these patients. The initial ECG was obtained within 10 minutes of ROSC with the early follow-up ECG acquired at a median time of 137 minutes post-ROSC. Angiography found acute culprit lesions in 20 patients (27%), stable coronary artery disease in 23 patients (31%), and 31 patients (42%) had no significant coronary stenosis. PCI with intervention was performed on 28 patients (38%) during their hospitalization, while two patients (3%) underwent CABG.

There are several limitations to this study. The study was a retrospective analysis of patients admitted to a single medical center. In addition, 10 of the 343 patients were lost to follow up and excluded from analysis. While the study provides some useful information in the patient population included, there were several subpopulations that were excluded, namely those with common preexisting ECG abnormalities such as LBBB, RBBB, and left ventricular hypertrophy, potentially limiting the generalizability of the studyâ&#x20AC;&#x2122;s findings in these subpopulations.

Yamamoto M, Witsch T, Kubota S, Hara H, Hiroi Y. Diagnostic value of lead aVR in electrocardiography for identifying acute coronary lesions in patients with out-of-hospital cardiac arrest. Resuscitation 2019;142:97-103. These authors looked to retrospectively evaluate the outcomes of cardiac catheterization in post-cardiac arrest patients without traditional STEMI criteria but demonstrating ST elevation in lead aVR after return of spontaneous circulation (ROSC). Both the 2013 ACCF/AHA guidelines and the 2017 ESC guidelines provide a class 1B recommendation for emergent PCI in a post-ROSC patient with a traditional STEMI, especially with a prearrest clinical course suggestive of a primary cardiac cause or an initial rhythm of ventricular fibrillation or ventricular tachycardia.i,iii Emergency physicians in recent years may be trending towards a more aggressive approach to post-ROSC patients with STE in aVR and widespread ST depressions, despite these patients not meeting traditional STEMI criteria, perhaps looking towards the 2017 ESC guidelines as more up-to-date guidance.

The authors found that STE in aVR immediately post-ROSC was not predictive of the presence of a culprit lesion. The authors did find, however, that patients with acute culprit lesions on angiography were significantly less likely to have a decrease in the degree of aVR ST elevation on their repeat ECG, compared to those without (0.1 mm versus 0.5 mm, respectively, p=0.01). Patients with a culprit lesion also trended towards having more leads with ST depression (5 vs 2 leads on initial EKG, 4 vs 0 leads on follow-up EKG) although this result was not statistically significant. Interestingly, patients treated with epinephrine prior to the initial ECG had statistically higher STE in aVR (0.8 mm vs 0.2 mm, p<0.001). No difference was found between other medications given. Patients with STE in aVR â&#x2030;Ľ0.5 mm on the early follow up ECG also had a significantly higher incidence of 3-vessel coronary artery disease (67% vs 21%, p<0.001), chronic total occlusion (50% vs 7.1%, p<0.001), as well as higher SYNTAX scores for coronary complexity (34% vs 0%, p<0.001). The authors found that STE in aVR on follow-up EKG had an independent odds ratio of 4.41 (95% CI: 1.12-17.4) for predicting acute coronary lesions post-cardiac arrest. Although this study did not find immediate STE in aVR post-ROSC to be diagnostically useful, persistent aVR elevation on repeat ECG may indicate a higher likelihood of culprit coronary lesion. Limitations of this study include a small sample size and a male-dominated patient population with a large portion of the initially-screened patients excluded from final analysis. While it should certainly not be the sole factor in the decision to pursue coronary angiography, patients with continued ST elevation in aVR on a subsequent ECG one to two hours after ROSC should be strongly considered for urgent cardiac catheterization.

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Lee GK, Hsieh YP, Hsu SW, et al. Value of ST-segment change in lead aVR in diagnosing left main disease in NonST-elevation acute coronary syndrome-A meta-analysis. Ann Noninvasive Electrocardiol. 2019;24(6):e12692. This meta-analysis sought to use existing data to define an odds ratio of left main coronary artery (LMCA) disease based on ST deviations in lead aVR, noting that although multiple prior studies had contended that STE in lead aVR was suggestive of LMCA disease, the results across available studies were inconsistent. The authors performed a wide literature search for articles through October 22, 2018 using multiple online databases including PubMed, Web of Science, Cochrane Library, MEDLINE, and China National Knowledge Infrastructure (CNKI). Search keywords included “aVR,” “aVR lead,” “ST,” “non‐ST‐segment elevation,” “myocardial infarction,” and “left main.” The authors initially identified 676 potentially relevant published articles. After removing duplicate articles as well as excluding articles that provided only prediction of clinical prognosis, only ECG analysis, case reports/conference abstracts, or were irrelevant, they were left with 175 articles. Of those 175 articles, 148 were excluded due to being gray literature, a duplicated or overlapping report, or providing insufficient data. Of note, 28 of these articles were excluded because they “had no left main coronary artery lesion or LMCA total occlusion” noted on search. After these exclusions a final 27 articles were included for analysis, for a total of 7,870 cases with STE in lead aVR <0.05 mV and 2,582 cases with STE ≥0.05 mV. Nine of the articles also further defined outcomes between STE in aVR and LMCA disease with 4,426 patients subdivided into STE <0.05 mV (none), STE 0.05-0.1 mV (minor STE), and STE ≥0.1mV (overt STE). For each study they collected data on rates of acute myocardial infarction, severity of STE in aVR, and angiography results to be included in the final meta-analysis. Odds ratio was determined using the Z test. Two models for dichotomous outcomes were used, the random‐effects model (using DerSimonian and Laird’s method) and the fixed‐effects model (using Mantel‐Haenszel’s method). Heterogeneity was also calculated, and studies were weighted based on their Newcastle‐Ottawa score. Finally, a sensitivity analysis was conducted and demonstrated that the overall result was not influenced by a single study. The pooled results of these studies showed that STE in aVR ≥0.05 mV (both minor and overt STE) was associated with a higher incidence of myocardial infarction (OR 3.12, 95% CI: 1.73-5.62) and LMCA disease compared to no STE (OR 6.64, 95% CI 4.80-9.17). The degree of STE in aVR was associated with the prevalence of LMCA disease; the pooled odds ratio for minor STE compared to no STE was 2.57 (95% CI: 1.973.36), and for overt STE was 6.17 (95% CI: 4.31-8.84). Overall, the prevalence of LMCA disease was 12% (95% CI: 8%-16%), with a higher prevalence in either minor or overt STE (26%, 95% CI: 18%-34%) than the no STE group (5%, 95% CI: 3%-7%).

This meta-analysis, the largest aggregation of these data to date, found a statistically significant association between STE in aVR and the presence of LMCA disease. It is a major limitation, however, that 28 articles were excluded because they had either “no left main coronary artery lesion or LMCA total occlusion.” As with all meta-analyses, it is possible that studies arriving at negative conclusions were performed and not ultimately reported, and while the authors tried to mitigate its effects using a random-effects model, there was significant heterogeneity between studies. Overall, this paper points to a strong correlation between ST elevation in lead aVR and LMCA disease but does not provide guidance on the urgency with which these patients should undergo coronary angiography.

Discussion: The literature demonstrates that with respect to coronary artery disease, patients with ST-segment elevation in lead aVR are at an overall higher risk for more severe disease. They may have higher rates of LMCA and triple-vessel disease4-7 as well as poorer outcomes, including a higher inhospital mortality rate,5-8 worse composite 90-day outcomes,5 and worse cardiac function.7 Current existing literature does not, however, provide clear guidance on the acuity with which these patients should undergo coronary angiography. It can be argued that, as with STEMI, the goal of emergent angiography and PCI is rapid revascularization of perfusionstarved myocardium. Although limited by size, the study by Harhash et al. finds a rate of acute thrombotic coronary occlusion of about 10% in these patients, none involving the LMCA or LAD.4 Yamamoto et al. propose that for out-of-hospital cardiac arrest patients with STE in aVR, the persistence of this finding a few hours after ROSC is suggestive of a culprit lesion that may benefit from acute intervention.6 It could be argued that emergent angiography and revascularization may improve patients’ clinical outcomes even without an acute culprit lesion. There is no data to help answer the latter question in this specific patient population. It is worth noting that the severity of STE in aVR and the number of concurrent ST segment depressions appear to correlate in a stepwise fashion with the incidence and severity of underlying coronary artery disease. These findings together could be used to risk-stratify patients from the Emergency Department to help determine the urgency with which should undergo coronary angiography. Overall, the best approach is likely a multidisciplinary conversation between the emergency physician and the cardiology consultant with the mutual understanding that these patients are high risk regardless of the approach taken. Question: What are the coronary angiogram findings and clinical outcomes of coronary angiography associated with ST elevation in aVR?

Answer: When seen in acute coronary syndrome with elevated cardiac markers, ST-segment elevation in lead aVR with multi-lead ST depression portends a high risk of left main or multivessel coronary disease and worsened inhospital and 90-day outcomes. The limited data appears to show a direct

>> COMMON SENSE MAY/JUNE 2020

AAEM/RSA RESIDENT JOURNAL REVIEW

correlation between amount of STE and disease. The scarce data available on emergent angiography of these patients does not show a clear benefit for all-comers to the ED with chest pain and STE in aVR. It seems prudent that emergency physicians base their decision to activate the catheterization lab on the patient’s presentation, history, cardiology consultation, troponin, persistent STE in aVR after ROSC, or has uncontrolled anginal chest pain despite aggressive management (similar to patients with NSTEMI). References: 1. O’gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-425. 2. Lipinski MJ, Mattu A, Brady WJ. Evolving Electrocardiographic Indications for Emergent Reperfusion. Cardiol Clin. 2018;36(1):13-26. 3. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177.

4. Lee GK, Hsieh YP, Hsu SW, Lan SJ, Soni K. Value of ST-segment change in lead aVR in diagnosing left main disease in Non-ST-elevation acute coronary syndrome-A meta-analysis. Ann Noninvasive Electrocardiol. 2019;24(6):e12692. 5. Harhash AA, Huang JJ, Reddy S, et al. aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion. Am J Med. 2019;132(5):622-630. 6. Kosuge M, Kimura K, Ishikawa T, et al. Combined Prognostic Utility of ST segment in Lead aVR and Troponin T on Admission in Non-ST-Segment Elevation Acute Coronary Syndromes. Am J Cardiol 2006;97:334-339 7. Yamamoto M, Witsch T, Kubota S, Hara H, Hiroi Y. Diagnostic value of lead aVR in electrocardiography for identifying acute coronary lesions in patients with out-of-hospital cardiac arrest. Resuscitation. 2019;142:97103. 8. Barrabes et al. Prognostic Value of Lead aVR in Patients with a First Non-ST-Segment Elevation Acute Myocardial Infarction. Circulation 2003; 108: 814-819.

Join an AAEM/RSA Committee!

Apply Today: www.aaemrsa.org/get-involved/committees

Wellness Committee

Committee members will focus on resident and student wellness initiatives including taking on new initiatives like creating a wellness curriculum and identifying the unwell resident and/or student. Committee members will act as liaisons to the AAEM Wellness Committee in helping to plan activities for the annual Scientific Assembly that enhance their vision of making Scientific Assembly a rejuvenating wellness experience for EM physicians, residents, and students.

Advocacy Committee

Committee members staff three sub-committees, focusing on patient advocacy, resident advocacy and political advocacy both at the state and national levels. Your activities include developing policy statements, outreaching to AAEM/RSA members about critical issues in emergency medicine, and collaborating with the AAEM Government Affairs Committee.

*New* Membership & Awards Committee

The Membership & Awards Committee will focus specifically on the needs of membership by brainstorming recruitment and retainment strategies. This new committee would also be responsible for selecting award recipients for the current AAEM/RSA awards (Kevin G. Rodgers Program Director of the Year Award, Program Coordinator of the Year Award, Committee Member of the Year Award(s), and EMIG of the Year Award), and for recommending the creation of new awards to the board of directors as a means to recognize the ongoing work of AAEM/RSA member.

Publications and Social Media Committee

The Social Media Committee members will contribute to the development and content of RSA’s four primary media outlets: the RSA Blog Modern Resident, the AAEM/RSA website, Facebook and Twitter. The committee also oversees development and revisions of AAEM/ RSA’s multiple publications including clinical handbooks and board review materials. You will have numerous opportunities to edit, pubDiversity & Inclusion Committee lish, and act as peer-reviewers, as well as work from the ground-up Committee members will work with the AAEM Diversity and Inclusion in developing AAEM/RSA’s expansion to electronic publications. Committee outreach to underserved medical schools, and create resources for minority residents and students in emergency medicine. Education Committee Committee members plan and organize the resident educational International Subcommittee track at the AAEM Scientific Assembly, which will be held April The International Committee will have the opportunity to contribute 19-23, 2020 in Phoenix, AZ. You will also assist with the medical to international medicine projects and resource development that are student symposia that occur around the country. helpful and beneficial to students and residents. 38

COMMON SENSE MAY/JUNE 2020

AAEM/RSA Board of Directors 2020-2021 PRESIDENT:

AT-LARGE DIRECTORS:

Gabriel Stahl, MD MPH

Haig Aintablian, MD UCLA Medical Center – Olive View

Ryan DesCamp, MD MPH

Brookdale University Hospital

VICE PRESIDENT:

David Fine, M4

Jennifer Rosenbaum, MD

Temple University Hospital

Temple University

Medical College of Wisconsin

SECRETARY-TREASURER:

Ryan Gibney, MD,

Jordan Vaughn, MD

Joshua Elliott Novy, MD MBA MS

University of California – Irvine

Louisiana State University Health Science Center New Orleans

University of Chicago

Zucker School of Medicine at Hofstra/Northwell Southside Hospital

Anika Turkiewicz, MD

IMMEDIATE PAST PRESIDENT:

Moiz Qureshi, MD MBA Harvard Beth Israel Deaconess Medical Center Medical Center

AAEM/RSA Medical Student Council 2020-2021 MEDICAL STUDENT COUNCIL PRESIDENT

REGIONAL REPRESENTATIVE – MIDWEST

REGIONAL REPRESENTATIVE – WEST

Lauren Lamparte

Dan Walsh

Brianna Beaver

Loyola University Stritch School of Medicine

Western University of Health Sciences College of Osteopathic Medicine of the Pacific

VICE PRESIDENT

REGIONAL REPRESENTATIVE – SOUTH

REGIONAL REPRESENTATIVE – NORTHEAST

Joshua Sawyer

Bryan Redmond, PhD

Alabama College of Osteopathic Medicine

University of Rochester School of Medicine & Dentistry

Leah Colucci University of Miami – Miller School of Medicine

INTERNATIONAL EX-OFFICIO MEMBER

Bruno Perthus

University of Queensland – Ochsner Clinical Schoolmi – Miller School of Medicine

COMMON SENSE MAY/JUNE 2020

MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

Medical Student Experiences with Ethical and Legal Cases David Fine — Medical Student Council President

he purpose of medical education is to train future providers to be prepared for the multitude of patients, presentations, and complications that they might face in their future careers. Ethical and legal dilemmas are incredibly complicated and vary based on where you practice, so they are often less discussed than our essential medical fundamentals. Being somewhat familiar with common problems, however, is relevant not only to your future career but your rotations as well. I aim to share a few of the complex situations that I faced, which may apply to your rotations in the emergency department or on the floors.

In mid-February, the National Board of Medical Examiners (NBME) and Federation of State thical and legal dilemmas are incredibly complicated and vary based on where you practice, so they are often less discussed than our essential medical fundamentals.

Dilemma 1: A patient who was frustrated with long wait times starts the patient interview by stating that they are recording the conversation. Legally, most states fall under the cover of single-party jurisdictions where only one party in the recording needs to assent (in this case the patient recording the conversation). In California, Florida, Illinois, Maryland, Massachusetts, Michigan, Montana, New Hampshire, Oregon, Pennsylvania, and Washington both parties must assent to the recording.4 Hospital policies and guidelines can also help clarify these confrontational situations. Context is everything, and some patients may want to record conversations so that they may refer to them in the future rather than relying on memory. The issue arises when this action makes somebody uncomfortable and, particularly, when this begins to affect patient care. In this situation, the patient was first asked why they were recording the conversation. They vocalized that they wanted to prevent being taken advantage of as they have in prior encounters with medical providers. The physician assented to the recording and asked the resident to pick up a different patient.

Context is everything, and some patients may want to record conversations so that they may refer to them in the future rather than relying on memory. Dilemma 2: A patient is brought to the ED after overdosing on an unknown substance. The contact information of the substance provider is available but patient is altered and unable to approve disclosure. This is another fairly straightforward dilemma in the sense that the urge is to reach out to someone who may be able to quickly identify the culprit substance. The issue is that the patient is altered and unable/unwilling to provide consent to disclose information about their hospitalization. HIPAA exceptions include court orders, public health organization requests, cases of neglect/abuse, cases of organ donation, and the threat to themselves or public safety.3 In the balance of patient privacy and patient

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well-being this is a situation where we must be more reliant on physical exams, a solid understanding of toxidromes, and laboratory testing.

Dilemma 3: An inebriated patient is brought in by the police after an MVC and is refusing care. HIPPA prohibits the release of information without consent, which includes law officials (aside from the exceptions above). A conflict can arise where they may not be able to differentiate questioning for the purposes of law enforcement vs. health care. A study evaluating patient perspectives on Philadelphia police transporting trauma victims showed that some patients appreciated the expedited transport to the hospital while others felt that police questioning was an added stressor that disrupted essential medical interventions.2 Police presence is often unavoidable, but steps should be taken that allow patients to feel safe and build the physician-patient relationship. Furthermore, you should assess the necessity of testing. Having a drug screen, for example, can quantitate levels of drugs in the patient’s system. This could help estimate the time that the drug will be in their system, but clinically may not be relevant. Capacity to refuse treatment won’t be determined by a blood alcohol level, but rather their mental status assessment. In determining capacity, you should consider the patient’s ability to communicate a choice, understand the risks and benefits, and use reasoning to arrive at their choice.1 This patient remained in a C-collar until they were no longer clinically inebriated. They were then cleared of spinal precautions after fulfilling the NEXUS criteria and discharged without imaging.

Knowing your state and hospital policies can go a long way in building comfort while handling these situations.

MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

The common goals of all three cases are to understand patient perspectives and deescalate conflicts. Knowing your state and hospital policies can go a long way in building comfort while handling these situations. Learning from your experiences and the experiences of others is another great way to supplement your medical school education. References: 1. Colwell, Christopher. “Know When Uncooperative Patients Can Refuse Care and Transport.” Journal of Emergency Medical Services, vol. 41, no. 8, 1 Aug. 2016, www.jems.com/2016/08/01/know-whenuncooperative-patients-can-refuse-care-and-transport/.

2. Jacoby, Sara F. “When Health Care And Law Enforcement Intersect In Trauma Care, What Rules Apply?” Health Affairs, 1 Oct. 2018, www. healthaffairs.org/do/10.1377/hblog20180926.69826/full/. 3. Raines, Rebeccah Therkelson. “Evaluating the Inebriated: An Analysis of the HIPAA Privacy Rule and Its Implications for Intoxicated Patients in Hospital Emergency Departments.” University of Dayton Law Review, vol. 40, no. 3, 2016, pp. 479–498. 4. Saleh, Naveed. “What to Do If Your Patient Is Recording You.” MDLinx, 22 May 2019, www.mdlinx.com/internal-medicine/article/3723.

Congratulations 2020 AAEM Award Winners Congratulations to our 2020 AAEM award winners! These awards will be presented in-person at AAEM21 March 6-10, 2021 in St. Louis, MO. Master of AAEM This recognition of senior AAEM fellows shall be extended to those who demonstrated a long career of extraordinary: • Service to AAEM • Service as an exemplary clinician and/or teacher of emergency medicine • Service to emergency medicine in the area of research and/or published works • Service as a leader in the hospital, the community or organized medicine • Service in the areas of health policy and advocacy • Volunteerism or other activities or high honors that distinguished the physician as preeminent in the field of emergency medicine

2020 Award Recipient: Christopher I. Doty, MD MAAEM FAAEM

David K. Wagner Award As an organization, AAEM recognizes Dr. Wagner’s contributions to the specialty by offering an award named in his honor to individuals who have had a meaningful impact on the field of emergency medicine and who have contributed significantly to the promotion of AAEM’s goals and objectives. Dr. Wagner himself was given the first such award in 1995.

2020 Award Recipient: Peter G. Anderson, MD FAAEM Administrator of the Year Award This award is for an administrator deserving special recognition for their dedication to emergency medicine and patient care. 2020 Award Recipient: Peter M.C. DeBlieux, MD FAAEM Young Educator Award This award recognizes an AAEM member out of residency less than five years who has made an outstanding contribution to AAEM through work on educational programs.

James Keaney Leadership Award Named after the founder of AAEM, this award recognizes an individual 2020 Award Recipient: Molly K. Estes, MD FAAEM who has made an outstanding contribution to our organization. Nominees for this award must have 10 or more years’ experience in EM clinical prac- Joe Lex Educator of the Year Award This award recognizes an individual who has made an outstanding contritice and must be AAEM members. bution to AAEM through work on educational programs. Nominees must 2020 Award Recipient: Vicki Norton, MD FAAEM be AAEM members who have been out of their residency for more than Robert McNamara Award 5 years. This award recognizes an individual who has made an outstanding con2020 Award Recipient: Ziad N. Kazzi, MD FAAEM FACMT FAACT tribution to AAEM in the area of academic leadership. Nominees for this Amin Kazzi International Emergency Medicine Leadership Award award must have 10 or more years experience in an EM academic leadThe international leadership award recognizes an individual who has ership position and must be AAEM members. made an exceptional, longstanding, and profound leadership contribution 2020 Award Recipient: Michael L. Epter, DO FAAEM to the international development of EM or to the advancement of EM education worldwide.

Learn more at: www.aaem.org/awards

2020 Award Recipient: Haywood Hall, MD FIFEM Resident of the Year Award This award recognizes a resident member who has made an outstanding contribution to AAEM. Nominees for this award must be AAEM/RSA resident members and must be enrolled in an EM residency training program.

2020 Award Recipient: Haig Aintablian, MD COMMON SENSE MAY/JUNE 2020

AAEM/RSA COMMITTEE REPORT ADVOCACY

Emergency Medicine on the Frontline: Workplace Violence in the Healthcare Setting Erin Hartnett, BS BA and Gregory Jasani, MD

by police who are unscreened and violent or potentially violent. 29% of ealthcare workers are shootings in emergency departments have been perpetrated by individuaffected in the majority als in police custody and 8% of the time the gun was taken from the of cases of incidents police officer assigned to monitor the patient.6 WPV is not relegated to of workplace violence (WPV) those located in urban areas of low socioeconomic status as data has in the United States each year. shown that suburban departments are equally vulnerable.6 Unsurprisingly to those who work in emergency departments throughout the country, emergency medicine has one of the highest rates of WPV With this compelling data reflecting WPV trends in the past two decades, each year. A recent survey of emergency department staff showed that it is reasonable to question why more has not been done to address the 88% of staff in a Level 1 Trauma Center were exposed to WPV within the issue. One such reason is that WPV is underreported.6 If no one was last six months.2 Of assaults on healthcare workers recorded throughout hurt, an incident is often not seen as warranting a report. Lack of polithe country, 75% were aggravated assaults and 93% were due to a type cies or clear language related to WPV reporting in hospitals, as well as II physical or verbal assault, defined as there being a patient relationship employees not seeing a benefit to reporting, or fearing retribution due to between the perpetrator and the victim.6 Despite these rates of assault, a report being filed also factor in. In the era of “the customer is always shockingly 98% of respondents felt safe at work and 64% reported that right,” healthcare workers can often see patients as not responsible they felt that violence was an expected part of their job as a part of the emergency department.2 This was a constant theme across many inquiries into the perception of WPV in emergency Over the years, voices departments. Not only was WPV experienced at a higher have been raised against the level than almost all other healthcare settings but it was seen vulnerability of healthcare as a necessary part of the job—something that could not be providers to assault during avoided and something that they signed up for. This reflects sensationalist news cycles that the disturbing state of affairs when it comes to prevention do not lead to meaningful change of WPV in the emergency department setting. Emergency providers should not accept a higher level of risk of WPV compared to their counterparts in other specialties but the historical attitude of apathy and powerlessness to the epidemic of WPV is only serving to stall progress in finding solutions to this important problem. WPV results in increased missed workdays, burnout, job dissatisfaction, and decreased productivity, but it tends to only come to the forefront of the nation’s attention during shocking tragedies. Over the years, voices have been raised against the vulnerability of healthcare providers to assault during sensationalist news cycles that do not lead to meaningful change. In the past five years, we have seen healthcare workers gunned down in Chicago, Ohio, and Massachusetts to name a few.3,4,7 A survey of 154 hospital related shootings between 2000-2011 showed that the emergency department was the site of 29% of shootings, the most of any location, and that 20% of victims were hospital staff, 5% nurses, and 3% physicians.8 You may ask, why is the emergency department so vulnerable to these episodes of violence? It may stem from the fact that emergency departments run on high emotions and high stakes. Additionally, they are usually one of the most accessible places in a hospital, often with a door from the outside leading directly into the department. By contrast, to enter an operating room, a perpetrator would have to cover more ground to get to their destination. Emergency departments also tend to host a greater population of inmates or suspects brought in 42

COMMON SENSE MAY/JUNE 2020

for their actions when it comes to assault and may feel that an assault was due to negligence on their part.6 Additionally, as mentioned above, expecting violence as a part of the job greatly contributes to the discrepancy between events and event reporting. Data shows that only 30% of nurses and 26% of physicians report incidents of WPV.6 All these factors contribute to the fact that there is a lack of peer-reviewed research regarding impact of WPV and the effect of potential interventions to curb the rise of such incidents. Even when there are studies to this effect they often have no reliable evidence base for their interventions.6 Regarding current policies and interventions into WPV, positive results are often intermingled with setbacks or limitations. Metal detectors have often been touted as a potential solution to the risk of gun or knife violence in the emergency department, but despite studies showing that they led to a greater confiscation of weapons, WPV incidents did not decrease.6 Importantly, it should be noted that <1% of type II assaults in the hospital setting involve a deadly weapon.6 Metal detectors

AAEM/RSA COMMITTEE REPORT ADVOCACY

cannot prevent a provider If all the solutions from being punched, kicked, proposed thus far have bitten, or verbally abused. failed to achieve radical or Disappointingly, verbal promising improvements, abuse is in fact not quantiin what new direction does fied into WPV results by the research and policy change go Bureau of Labor Statistics, to make a difference? and this only serves to increase the discrepancy in accurate WPV reporting. Other proposed solutions have often followed a one-size-fits-all approach and this has proven over and over again to fail.6 The lack of consistency in wording and terminology between existing studies hinders progress as results cannot be widely cross compared to identify strengths and weaknesses.6 This is vital, as most interventions that have been tried have not led to a decrease in WPV and being unable to build on prior research is a waste of resources and precious time. Finally, on the legal side of the matter, laws with special protection for medical care providers in the emergency department have been passed in some states, including Colorado9, Delaware,10 and Idaho.11 However, the enforcement and wording of these laws are not uniform across the state or country, leading their effectiveness to be diminished.5,6 If all the solutions proposed thus far have failed to achieve radical or promising improvements, in what new direction does research and policy change go to make a difference? Firstly, the impact of WPV on emergency department healthcare workers cannot be ignored or underestimated. A qualitative study of WPV on affected healthcare works showed that differences in cognitive appraisal of WPV led to variability in coping strategies.12 Hospital policy cannot assume that each incident of WPV will affect each individual the same way. Care needs to be put into addressing each affected staff member’s personal needs after an event to decrease burnout, increase a sense of safety, and to mitigate the negative effects of WPV as much as possible. This is also why it is highly critical that verbal assault is not overlooked. Permitting verbal assault allows for the “broken windows” principle to take effect, where a low-level assault being permitting is conducive to a more violent episode in the future.6 Zero-tolerance needs to be the basis of any sound reporting strategy. Any and all WPV incidents must be reported, and there need to be clear policies regarding what constitutes WPV and how the reporting process functions, so that personal views cannot create discrepancies that make the policy ineffective. The expected increase in reporting that a zero-tolerance policy should have can allow for simple cautions, such as the flagging of charts of known violent individuals as is done in Veterans Affairs hospitals to measurable success, to be implemented on a larger scale across different institutions.6 Secondly, the creation of an individualized plan for each department incorporating supervisors, workers, and law

enforcement is critica.l6 Each unit has its own unique pattern of WPV and areas of concern so an open dialogue identifying areas that could be improved and what needs to be done to achieve a successful policy change has to occur. That is what can separate future research studies from the cookie-cutter solutions that have already been tried and failed. Overall, an effective WPV reduction policy needs to include policy updates, procedural enhancements, and education for staff and supervisors.1 Without each of these components, an intervention will not be successful. With 25% of emergency physicians and 82% of emergency nurses reporting physical assault in the workplace, this is a problem that can no longer be treated as a part of the job.6 Emergency healthcare providers deserve protection now. They cannot and will not wait much longer to be taken seriously when it comes to their safety and the safety of their patients.

Emergency healthcare providers deserve protection now.

References: 1. Adams, G. (2018) Evidence-Based Interventions to Address Workplace Violence in the Emergency Department. (Doctoral Dissertation). Available from ProQuest Dissertations and Theses database. (UMI No. 10844861) 2. Copeland, D., Henry M. (2017). Workplace Violence and Perceptions of Safety Among Emergency Department Staff Members. Journal of Trauma Nursing, 24(2). 3. Freyer, F. J., Kowalczyk, L., & Murphy, S. P. (2015, January 21). Surgeon slain, gunman found dead in day of crisis at Brigham - The Boston Globe. Retrieved from https://www.bostonglobe.com 4. Iannitelli, K. B. (2019). The Aftermath of the Shooting at Chicago’s Mercy Hospital. Emergency Medicine News, 41(1), 5–6. 5. Maguire, B. J., Omeara, P., Oneill, B. J., & Brightwell, R. (2017). Violence against emergency medical services personnel: A systematic review of the literature. American Journal of Industrial Medicine, 61(2), 167–180. 6. Phillips, J. P. (2016). Workplace Violence against Health Care Workers in the United States. New England Journal of Medicine, 375(7). 7. Rege, A. (2017, February 10). Hospital shootings: How common are they? 8 things to know. Retrieved from https://www.beckershospitalreview.com 8. Rege, A. (2018, November 21). 17 fatal hospital shootings since 2002. Retrieved from https://www.beckershospitalreview.com 9. See Colo. Rev. Stat. Ann. § 18-3-202 (West). 10. See Del. Code Ann. tit. 11, § 613 (West). 11. See Idaho Code Ann. § 18-915C (West) 12. Vrablik, M. C., Chipman, A. K., Rosenman, E. D., Simcox, N. J., Huynh, L., Moore, M., & Fernandez, R. (2019). Identification of processes that mediate the impact of workplace violence on emergency department healthcare workers in the USA: results from a qualitative study. BMJ Open, 9(8).

COMMON SENSE MAY/JUNE 2020

AAEM/RSA COMMITTEE REPORT ADVOCACY

“Where are the Physicians on This?” A Call for Physician Advocacy on Healthcare Violence Gregory Jasani, MD

ecently, I had the honor of meeting Congressman Joe Courtney in his office in Washington, DC to discuss a bill that he had introduced in the House, HR 1309: The Workplace Violence Prevention for Health Care and Social Services Workers Act.” If passed, this bill would direct the Occupational Safety and Health Administration (OSHA) to develop a standard on workplace violence pre-

Your advocacy today may make your workplace safer tomorrow.

vention for the healthcare field. It would also require all healthcare facilities to develop violence prevention plans in line with this new standard and to keep records of all incidents that occur in their facilities.1 This bill passed the House in November and is currently in the Senate.

a few days after our op-ed was published, a legislative assistant from Congressman Courtney’s office reached out to us. She informed us that Congressman Courtney had read our op-ed and wanted to meet with us to discuss our thoughts on his bill. We were completely shocked by this, but readily agreed. Unfortunately, my colleague could not attend due to work constraints so I attended the meeting on our behalf.

the physician community regarding this bill. In contrast to nursing groups, who have been very vocal on this issue, he found the silence from the physician community perplexing. He asked me, somewhat exasperatedly, “Where are the physicians on this?” I did not have a good answer for him.

Congressman Courtney was incredibly gracious. He and I spoke at length about the rampant levels of workplace violence in the healthcare field. I shared with him how, even though I am only a second year resident, I have been witness to countless incidents of violence in the emergency department where I work. Congressman Courtney, unfortunately, has heard similar stories from his wife, who is a nurse practitioner, and from his constituents. It was these alarming stories that prompted him to develop HR 1309. We ended our meeting by discussing his bill and how we believe it will stem some of the violence experienced in healthcare.

A colleague and I had written an op-ed in support of this bill that was published in the Violence has become ubiquitous in our field and something has to be Baltimore Sun in early January.2 As physicians, done to reverse this trend. we felt it was important to express our support of this legislation. We both view the levels of violence in the healthcare field to be wholly unacceptable and feel As physicians, we need to make our voices After leaving that this legislation heard on this issue. Workplace violence has Congressman is an important step become a grimly common occurrence in our As physicians, we need to make Courtney’s office, I in the right direction. profession. According to The Joint Commission, our voices heard on this issue. met with staff from To be completely hospital staff are confronting “steadily increasthe office of Senator honest, we did not ing rates of crime including violent crimes such Tammy Baldwin. think much would as assault, rape, and homicide.”3 Approximately Senator Baldwin is the sponsor of HR 1309 come from our op-ed; we did not think anyone 75% of all workplace violence incidents rein the Senate. Since the bill has not yet been outside of our friends and family would even ported to OHSA occurred in the healthcare presented in the Senate, Senator Baldwin’s read it. We shared our piece on Facebook and field and healthcare workers are over four times staff is still actively working to ensure its pasgot a few likes and messages of congratulamore likely to be victims of workplace violence sage. The staffer with whom I met expressed tions. That was all we thought was going to compared to every other profession (excluding his gratitude about the op-ed my colleague and come of our efforts. law enforcement).4 I had written. He told me that, prior to our op-ed >> We were both incredibly surprised when, being printed, he had not heard much from 44

COMMON SENSE MAY/JUNE 2020

AAEM/RSA COMMITTEE REPORT ADVOCACY

Despite these appalling numbers, there are very few legal protections for us in place. Only nine states currently require healthcare facilities to have proactive violence prevention strategies.4 Hospitals in the remaining forty-one states are under no mandate to have any type of policy in place. OSHA has produced a guideline to reduce the risk of workplace violence in healthcare, but it is purely advisory.4 Our silence on this issue is unacceptable. Violence has become ubiquitous in our field and something has to be done to reverse this trend. I truly believe that, while HR 1309 will likely not solve workplace violence in healthcare by itself, it is an important first step. To my fellow physicians, if you also support this

legislation, please be vocal in your support. If there is one thing that I learned from my experience of writing my op-ed, it is that our lawmakers value our perspective as physicians. I never imagined that my op-ed would make it to the halls of Congress or that I would be invited there myself. Your Senators are waiting to hear from you; please let them know how important this issue is to you. Your advocacy today may make your workplace safer tomorrow. References: 1. Congress.gov. HR 1309 – Workplace Violence Prevention for Health Care and Social Service Workers Act. https://www.congress.gov/ bill/116th-congress/house-bill/1309. Accessed February 27, 2020

2. Jasani G, Hussain A. The dangers of being a doctor: threatened by those who seek help. The Baltimore Sun. 2020 3. Preventing violence in the health care setting. The Joint Commission. Sentinel Event Alert 2010; 45: 1-3. 4. Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers. https://www.osha.gov/dsg/ hospitals/workplace_violence.html. Accessed February 26, 2020 5. ECRIInstitute. Violence in Healthcare Facilities. https://www.ecri.org/ components/HRC/Pages/SafSec3. aspx?PF=1%3Fsource=print. Accessed February 27, 2020

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May/June 2020 Common Sense

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May/June 2020 Common Sense

May/June 2020 Common Sense