March/April 2021 Common Sense

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 28, ISSUE 2 MARCH/APRIL 2021

Respect: A Driver of Empathy and Equity Page 13

President’s Message:

What Does Leadership Look Like?

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From the Editor’s Desk:

Could Things Be Any Worse?

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Scientific Assembly Subcommittee:

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Scientific Assembly (AAEM21) Highlights

Young Physicians Section:

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Communication in the Age of COVID-19

AAEM/RSA Editor’s Message

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The Brink of Burnout

Table of Contents TM

Officers President Lisa A. Moreno, MD MS MSCR FIFEM President-Elect Jonathan S. Jones, MD Secretary-Treasurer Robert Frolichstein, MD Immediate Past President David A. Farcy, MD FCCM Past Presidents Council Representative Joseph Wood, MD JD Board of Directors L.E. Gomez, MD MBA Bobby Kapur, MD MPH CPE Bruce Lo, MD MBA RDMS Evie Marcolini, MD FCCM Sergey M. Motov, MD Terrence Mulligan, DO MPH Vicki Norton, MD Carol Pak-Teng, MD YPS Director Phillip Dixon, MD MPH AAEM/RSA President Haig Aintablian, MD Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD Editor, Common Sense Andy Mayer, MD

COMMONSENSE

Regular Features President’s Message: What Does Leadership Look Like?......................................................................3 From the Editor’s Desk: Could Things Be Any Worse?...........................................................................6 Foundation Donations.............................................................................................................................8 PAC Donations........................................................................................................................................8 LEAD-EM Donations...............................................................................................................................9 Upcoming Conferences ........................................................................................................................10 AAEM/RSA Editor: The Brink of Burnout..............................................................................................32 Resident Journal Review: Massive Transfusion Protocols (MTPs) in Traumatic Hemorrhage...............35 Medical Student Council President’s Message: EM Away Rotations in a Pandemic.............................38 Board of Directors Meeting Summary: February..................................................................................42 Job Bank...............................................................................................................................................43 Special Articles Palliative Care: Agnes S. (1918-2020): Great Grandma........................................................................11 Social EM & Population Health: Respect: A Driver of Empathy and Equity..........................................13 Operations Management: Ops Series: Lean Six Sigma........................................................................17 Wellness: It’s Time to Take Care of Those Who Take Care of Us.........................................................19 Women in EM: I Was a Witness, and Now am Haunted by the Ghosts of Other Mothers’ Sons...........24 Young Physicians: Communication in the Age of COVID-19................................................................27 Young Physicians: Burnout in Emergency Medicine and How to Prevent It..........................................29 Mind Your Language: The Need for Precision in the Vernacular of Medicine........................................40 Updates and Announcements Updates from ABEM.............................................................................................................................10 Scientific Assembly Subcommittee: Scientific Assembly (AAEM21) Highlights.....................................15 Critical Care Medicine: We are Nebulizing What Now? Nebulizing Nitro: Therapies for PE iNO More Excuses for PE Therapy.................................................................................................................21 Emergency Ultrasound: Remote Tele-mentored Ultrasound: The Next Ultrasound Frontier..................22 AAEM/RSA Statement of Concern for Graduating EM Residents and the Current Job Market............31 Chronic Pain and Addiction Patients Need Us Now More Than Ever....................................................39

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

Our mailing list is private.

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COMMON SENSE MARCH/APRIL 2021

Mission Statement

The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles: 1. Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine.

2. The practice of emergency medicine is best conducted by a specialist in emergency medicine.

3. A specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).

4. The personal and professional welfare of the individual specialist in emergency medicine is a primary concern to the AAEM. 5. The Academy supports fair and equitable practice environments necessary to allow the specialist in emergency medicine to deliver the highest quality of patient care. Such an environment includes provisions for due process and the absence of restrictive covenants.

6. The Academy supports residency programs and graduate medical education, which are essential to the continued enrichment of emergency medicine and to ensure a high quallity of care for the patients.

7. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members.

8. The Academy supports the establishment and recognition of emergency medicine internationally as an independent specialty and is committed to its role in the advancement of emergency medicine worldwide.

Membership Information

Fellow and Full Voting Member (FAAEM): $525* (Must be ABEM or AOBEM certified, or have recertified for 25 years or more in EM or Pediatric EM) Associate: $150 (Limited to graduates of an ACGME or AOA approved emergency medicine program within their first year out of residency) or $250 (Limited to graduates of an ACGME or AOA approved emergency medicine program more than one year out of residency) Fellow-in-Training Member: $75 (Must be graduates of an ACGME or AOA approved emergency medicine program and be enrolled in a fellowship) Emeritus Member: $250 (Please visit www.aaem.org for special eligibility criteria) International Member: $150 (Non-voting status) Resident Member: $60 (voting in AAEM/RSA elections only) Transitional Member: $60 (voting in AAEM/RSA elections only) International Resident Member: $30 (voting in AAEM/RSA elections only) Student Member: $40 (voting in AAEM/RSA elections only) International Student Member: $30 (voting in AAEM/RSA elections only) Pay dues online at www.aaem.org or send check or money order to: AAEM-0121-147 AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

What Does Leadership Look Like?

AAEM NEWS PRESIDENT’S MESSAGE

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM – President, AAEM

(HINT: It looks like you…)

L

eadership Academy is a tradition at AAEM, and this year, we kicked it up a notch. Instead of the usual approximately 25 potential leaders identified by the board, we invited the Chairs and Vice Chairs of all the sections, committees, interest groups and chapter divisions, the boards of YPS and AAEM/RSA, and sought nominations from other AAEM leaders outside the board of directors. I am proud to announce that 92 of AAEM’s future leaders attended the Leadership Academy and the discussion was vibrant with the fresh ideas and concerns they brought. The Leadership Academy was taught by some of the top faculty in emergency medicine, and we plan to make the presentations available on AAEM Online. The most important thing to understand about leadership was said succinctly by Vince Lombardi: That great leaders are not born, they are made through a process of hard work and dedication. Through the challenges of 2020, we have globally expressed concern about the crisis in leadership, but the boon of the pandemic is that from this crisis have emerged unexpected heroes and leaders of integrity. In this and my next President’s Message, I will share some of

the wisdom that emerged from the Leadership Academy. And if you recognize the leader in yourself and were not invited to attend this year’s Leadership Academy, take the bold step, and contact me so that we can include you next year. A big part of being a great leader is stepping up.

1. Great leaders learn from great leaders.

2. Great leaders surround themselves with brilliant, trusted experts.

3. Great leaders listen to all voices.

4. Great leaders think about their legacy.

5. Great leaders recognize the responsibility to create other great leaders.

6. Great leaders make decisions, knowing that they will make enemies.

7. Great leaders know it’s about the organization first.

8. Great leaders do not engage in personal attacks.

9. Great leaders accept the ultimate responsibility for everything that happens in the organization.

10. Great leaders give responsibility for success to those around them.

 Great leaders learn from great leaders.

There are hundreds of books available about how to be a great leader but think about who the authors are. They may have made a tremendous amount of money for themselves and their cohorts. They may have taken a company out of obscurity. If, however, we consider

the leaders who have made a profound difference in the lives of others, the leaders whose names and philosophies are known decades and even centuries after their passing, you will not find a how to book writer among them.

They were too busy doing the right thing. These are the people you want to emulate and from whose wisdom you want to learn. As different as Dr. John Snow is from Mohandas Gandhi is from St. Catherine of Sienna is from Martin Luther King, they have so much in common.

They were passionate about doing the right thing, even when they were criticized, mocked, and sometimes hated. They persevered against astonishing odds. There was no “try” for them; only “do.” (Thank you, Yoda.) They put the wellbeing of others ahead of their own interests and were willing to sacrifice to make the lives of others better. They were willing to be unpopular.

They led by example. True greatness does not come from making a lot of money. True greatness comes from doing the right thing. Said St. Catherine of Sienna, “Be who you were created to be, and you will set the world on fire.” Think about who you were born to be and move forward to your greatness. Look at those who you admire and want to be like. Study their lives and policies, and don’t hesitate to ask for advice and mentorship. Most leaders derive pleasure from mentoring others and recognize their obligation to do so (see #5).

 Great leaders surround themselves with brilliant, trusted experts.

Now more than in any previous decade, it is impossible for anyone to be an expert on

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 Through the challenges of 2020, we have

globally expressed concern about the crisis in leadership, but the boon of the pandemic is that from this crisis have emerged unexpected heroes and leaders of integrity.”

COMMON SENSE MARCH/APRIL 2021

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AAEM NEWS PRESIDENT’S MESSAGE

everything, even within a specific field like medicine or even within the specialty of emergency medicine. Great leaders are humble; aware and not ashamed of not knowing it all. They ask for help and seek that help from proven experts. Moreover, those experts are not sycophants but rather truth tellers. Secretary of State Dr. Henry Kissinger, Prof. Arthur M. Schlesinger, Jr., and Mayor/Ambassador/Congressman Rev. Andrew Young are among the most notable expert advisors to Presidents, providing scholarly and objective advice through turbulent times. The ever-popular President Franklin D. Roosevelt relied heavily on his First Lady, Mrs. Eleanor Roosevelt, for her cognitive and emotional intelligence. Many believe his presidency would have been mediocre without Mrs. Roosevelt’s counsel. What stands out about these advisors is their willingness to speak the truth, to recognize that when someone you like does wrong, it is wrong, and when someone you do not like does something brilliant, it is brilliant. While mediocre leaders are threatened by those who do not agree with them, great leaders welcome someone telling them that they are wrong and presenting them with the opportunity to learn. Rawle Adkins said it well: “I don’t mind criticism because at the end of the day, I never have learned anything from a compliment.” A few years ago, Past President Mark Reiter and I were conversing about how much more enlightening it is to talk to someone who disagrees with you. People who agree with you tend to have considered the same facts that formed your opinion. People who disagree with us can teach us about facts and opinions we may never have heard before. “I never learned anything from any man who agreed with me.” (Author Robert A. Heinlein)

 Great leaders listen to all voices.

If we are to be truly enlightened, we must consider the perspectives of all stakeholders. While those who differ from us have much to teach us, as discussed above, it is also important that all members of the organization have an integral role in the life of the organization. DeNine J. Fleming, EdD, from the Office of Diversity, Equity, and Inclusion at the Medical University of South Carolina explains that, “Equity is inviting someone to the dance. Inclusion is inviting them to dance.” And when we genuinely invite someone to dance, we invite them to dance in their own way, and we invite them to show us how they dance and to then include us in their dance, sharing their perspective of life in a meaningful way and allowing us to be part of their life. First Lady Eleanor Roosevelt was genuinely skilled at inviting people to show her their lives and perspectives. In 1934, she insisted that her visit to Puerto Rico was not to be restricted to the military base. After viewing the devastation caused by two hurricanes, being driven over muddy dirt roads, and visiting the San Juan housing where the tuberculosis rate was five times that of the U.S. mainland, she told her husband that it was an outrage that any citizen of the United States should live in such conditions. She partnered with PR House of Representatives member the Hon. Maria Luisa Arcelay, a former high school teacher and small business owner, to substantially influence Roosevelt’s New Deal aid to the island for building roads and housing and developing education. Roosevelt appointee Governor

 A good leader recognizes that she herself is made

better by pulling others up with her. A great leader recognizes that she has an obligation to the organization and to the profession to create the great Winship was manleaders of the future.”

dated by the President to take on Rep. Arcelay as his advisor, and she compelled significant change to his previously colonialist policies. Create a council for yourself of individuals from diverse backgrounds who can provide advice and guidance as you move towards your leadership role. And remember to include those whose opinions, life experiences, and expertise differ from your own.

 Great leaders think about their legacy.

Make it your policy to leave everything you touch better than you found it.

While many people “fall into” a leadership position, great leaders consider what they want to accomplish when given an opportunity. Leadership is a privilege. We can all recall that childhood wish to be a king or a queen who can have anything they want and could boss other children around. All too soon comes the knowledge that monarchs are deposed, poisoned, locked in the Tower, and have their kingdoms invaded! But mature leadership is service and given that no one person has the time or resources to accomplish all things, a mature leader focusses on what their organization needs most, what they are skilled at doing, and what they are passionate about. Leadership gives us the privilege of a platform. People listen to us because we have a title or hold an office. With that privilege, comes responsibility. Reality is, three generations after we have left this world, no one will remember our names. Hopefully, we will leave a program, or a policy, or will have effected a change that will continue to benefit others. That is our immortality. What is your passion?

What would you do if there were no barriers; no obstacles that could not be overcome? What do you want to be remembered for? Think about the legacy you want to leave, and make it happen. “It always seems impossible…until it’s done.” (President Nelson Mandela)

 Great leaders recognize the responsibility to create other great leaders.

Booker T. Washington told us, “There are two ways of exerting one’s strength. One is to push down. The other is to pull up.” As we know from our gym workouts, when you push down, you yourself go lower, but when you pull up, you yourself rise. A good leader recognizes that she herself is made better by pulling others up with her. A great leader recognizes that she has an obligation to the organization and to the profession to create the great leaders of the future. We have heard many times that no one is indispensable. And while in early career, it is not a bad idea to make yourself hard to replace and thereby secure a sweet spot for mentorship and advancement, as we do advance in our careers, we

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AAEM NEWS PRESIDENT’S MESSAGE

recognize that we will someday want to retire or work far less than we do now, and we have a responsibility to leave the organization and the profession in the hands of well-trained and able leaders. I remember thanking Dr. Sarah Stahmer for mentoring me early in my career. “Oh, don’t kid yourself. None of us do this solely out of the goodness of our hearts. We do it because we enjoy it and it feels good,” was her reply.

I have never forgotten the graciousness of her statement, and when I progressed to the point in my career that allowed me to mentor, I realized how right she was. Mentoring is a real joy. Watching the look on the face of a learner when he “gets it” is priceless. Watching that learner pay it forward by teaching yet another learner is even more fulfilling. If you aspire to leadership in EM, know that those above you on the career ladder will welcome the opportunity to mentor you. We will find pleasure in your achievements. We will feel good about investing in the future of the Academy and of the profession. And we will realize that by pulling you up, we rise.

As I told the attendees at Leadership Academy, do not keep your dreams a secret. Don’t be shy about your aspirations. You are offering us the gift of your time and your talents, and we want the best, the most talented, the hardest working, and those with the most integrity to make their mark right here at AAEM. If you participated in the Leadership Academy, thank you. We look forward to reconnecting with you at the Touch Back Sessions. We look forward to mentoring you. If we missed you and you want to be a leader in AAEM and in our specialty, speak up, reach out, reach up, and become a leader! We want to see you shine!

Next issue: Great leadership characteristics 6-10 explored. 

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.

MEMC21 Malta 10-13 November 2021 St. Julian’s

XIth Mediterranean Emergency Medicine Congress

#MEMC21

www.aaem.org/MEMC21 COMMON SENSE MARCH/APRIL 2021

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AAEM NEWS FROM THE EDITOR’S DESK

Could Things Be Any Worse?

Andy Mayer, MD FAAEM — Editor, Common Sense

I

recently had a discussion with a group of emergency physicians from various parts of the country and from all sorts of practice types. I respect the opinions and the wealth of experience of this group and of course was also interested in their COVID-19 experiences both good and bad and how their practices had been impacted by the virus. Each of us has a story to tell about 2020 and most would like to hit replay if that were an option. Sadly, during the wide-ranging discussion I heard comments from two different senior and well respected individuals which really stuck out in my mind. Each of these comments made me pause and reflect on them and to try to make sense of how we as a profession have reached a point where these seasoned physician leaders would make these statements and what it means and more importantly what we as emergency physicians should do about it.

The first statement was, “I am just a tool of corporate medicine.” This comment struck me as I highly respect the individual who made it and it deeply upset me at first that he felt that way. I certainly understand why he had become discouraged and how he had come to his sad conclusion. Each of us have had our ups and downs and can make statements at low points which may not reflect our true beliefs or feelings. I did not take his comment as an admission of defeat, but probably more a reflection of a low point which we all can have when our wellness bucket needs refilling. Facing staffing shortages, sick providers, lack of adequate PPE, insufficient equipment, and no empty hospital beds, the strength can be sapped of even the best of us. However, more and more the practice of emergency medicine is adversely impacted by the strangling grip of the corporate practice of medicine and insurance companies.

COVID-19 has caused many of us to face up to the broad range of challenges, which the modern practice of emergency medicine has produced. Each of us has had our own COVID-19 saga, which is a combination of our work, home, and family experiences. We have all had to deal with the social isolation from our family and friends even if your medical COVID-19 experience has not been bad. Some of us faced the initial wave of COVID-19 while others were sitting in empty emergency departments worried about their jobs and salary. Each of us know excellent emergency physicians who have had their hours or salary cut during the pandemic. The corporate management groups have been able to use COVID-19 as a tool in their profit motive to displace board certified emergency physicians. Some of us have faced specific individual threats and termination when advocating for adequate PPE and other COVID-19 related issues. Many are facing later, sometimes overwhelming, waves of patients without the ability to pull in staff from other areas of the country or to have nurses leaving your hospital to seek the premium travel nursing dollar. How many of you are being replaced by lower cost midlevels now during this crisis with the excuse of lower volumes and the need to cut “costs?”

up on medicine’s flagship organization and regularly attends meeting and advocates for issues which impact all emergency physicians.

However, what he said was the second comment of the night which really struck me and led to the title of this article. He said, “Could things be any worse, even if the AMA didn’t exist?” Think about that sentiment for a minute from someone who has stayed in the fight and dedicated much of his free time to advocate for you within the AMA. Remember that this huge body is supposed to represent and advocate for all of us against the many threats and changes which each and every physician in America now faces. This physician commented that during meetings which set policy and advocacy goals that he reflected while looking around the room. He questioned if the physicians in the room really represented the interests of American physicians or rather the corporate and business interests of the organizations of which they belonged. Even if this is true I would ask whose fault is this? Did the average physician fail to advocate for themselves?

Most physicians spend little or no time in the political or organized medicine world. Most physicians I know have a fatalistic view of the future of the practice of medicine in America. Asking them to become involved by joining an organization let alone writing their

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The other comment made was related to the failure of organized medicine to meet the challenges, which have changed the practice of medicine over the past few decades. A senior leader of our specialty was talking about his work within the American Medical Association (AMA). Many physicians have become disillusioned with the AMA over the years, including myself. He has not given

 However, more and more the practice of emergency medicine is

adversely impacted by the strangling grip of the corporate practice of medicine and insurance companies.” >>

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COMMON SENSE MARCH/APRIL 2021

AAEM NEWS FROM THE EDITOR’S DESK

 My point is not to make

you more pessimistic about the future, but to emphasize the need for your personal increased interest and efforts right now if we can hope to have an impact on the future of emergency medicine.” congressperson or actually lobbying receives a blank and distant stare of non-committal.

Talk to any lawyer whose lobbying and fund raising efforts dwarf medicine’s efforts and hear their point of view. Lawyers look at physicians in shock and bemusement in regards to our feeble lobbying efforts compared to the plaintiffs’ attorney and other attorney groups.

Lawyers are not surprised to what has happened to us as we have stood idly by and let medicine become dominated by corporations, insurance companies, etc.

Nurse practitioners and physician assistant lobbying efforts often dwarf organized medicine’s efforts especially in state legislators where the

battle of scope of practice is rapidly being lost.

Their efforts, especially during COVID-19, are being sold as a way to improve access to care for your patients by allowing “unencumbered” rights of practice for all types on non-physicians. Just look at one statement which can be quickly found on an internet search from the American Association of Nurse Anesthetists which states “Removing Physician Supervision is the Right Thing for our Patients.” What do you think our anesthesia colleagues think about this when they reflect on the time they took to go to medical school and complete a residency?

Other midlevel groups continue to push the envelope and will use us to train them before our utility is no longer desired when we become the expendable “high cost problem” in the budget. I suggest you look up the Yale New Haven Hospital Emergency Medicine AAP Residency Program. It proudly suggests that it is an “18-month postgraduate training program designed to train PAs and NPs in the skills and knowledge required to evaluate and treat the full spectrum of patients seen in the emergency department.” Will for example Doctors of Nursing Practice who complete this “residency” not be able to state without hesitation that they are residency trained emergency doctors?

My point is not to make you more pessimistic about the future, but to emphasize the need for your personal increased interest and efforts right now if we can hope to have an impact on the future of emergency medicine. I make this

recommendation to the full spectrum of our emergency medicine community from medical students, residents, young attendings, to our senior leaders. Thinking that you are young and too busy to be involved is short sighted. In a few years, many of the core value issues related to the corporate practice of medicine, due process, scope of practice, or you name it, may be decided. Younger physicians do not have time to wait, especially with the huge increase in the number of emergency medicine residencies and the surge of midlevels entering the market.

Our older emergency medicine colleagues also have an obligation to the young to do what they can instead of thinking that the time for them is drawing to a close and that they are just trying to hold out until retirement. Letting an unseen hand direct our future is just asking for trouble.

Even with our most committed efforts, we as a profession will not win all of the battles, but by throwing in the towel without any effort, will be rewarded with predictable results. Will you look back later in your career and regret not making every effort to protect our profession?

We do not need to play the role of helpless victims in this fight. Physicians are still respected, especially on a local and state level. There is power in numbers and commitment. COVID-19 may be providing the catalyst we need for the house of emergency medicine to stand up and be heard from your state house to Washington.

So, the answer is yes, it could be worse and we need to do what we can to prevent that from happening. 

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

Submit a letter to the editor and continue the conversation.

Submit a Letter to the Editor at:

www.aaem.org/resources/publications/common-sense/ letters-to-the-editor

COMMON SENSE MARCH/APRIL 2021

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AAEM Foundation Contributors – Thank You! Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 12-1-2020 to 2-1-2021.

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

David A. Farcy, MD FAAEM FCCM Bobby Kapur, MD MPH CPE FAAEM Bruce M. Lo, MD MBA RDMS FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM

Contributions $250-$499

Dale S. Birenbaum, MD FAAEM Anthony J. Callisto, MD FAAEM Frank L. Christopher, MD FAAEM Andrew P. Mayer, MD FAAEM Andrew J. McCanna, MD FAAEM Carol Pak-Teng, MD FAAEM Thomas R. Tobin, MD MBA FAAEM

Molly Wormley, MD Emily Yu, MD FAAEM

Contributions $100-$249

Leonardo L. Alonso, DO FAAEM David Baumgartner, MD MBA FAAEM Mary Jane Brown, MD FAAEM Evan A. English, MD FAAEM Robert E. Gruner, MD FAAEM Regina Hammock, DO FAAEM Kailyn Kahre-Sights, MD FAAEM Christopher Kang, MD FAAEM John C. Kaufman, MD FAAEM Kathleen P. Kelly, MD FAAEM Ann Loudermilk, MD FAAEM

Gerald E. Maloney Jr., DO FAAEM David P. Mason, MD FAAEM FACEP Vicki Norton, MD FAAEM Travis Omura, MD FAAEM Brian R. Potts, MD MBA FAAEM Debra S. Rusk, MD FAAEM David T. Schwartz, MD FAAEM Hemali Shah, MD FAAEM Joanne Williams, MD MAAEM FAAEM Michael E. Winters, MD MBA FAAEM Marc B. Ydenberg, MD FAAEM

Contributions up to $75

Robert W. Bankov, MD FAAEM FACEP Bryan Beaver, MD FAAEM

Benjamin P. Davis, MD FAAEM FACEP Thomas G. Derenne Joseph Flynn, DO FAAEM Edward T. Grove, MD FAAEM MSPH William R. Hinckley, MD CMTE FAAEM Pamela J. Krol, MD FAAEM R. Sean Lenahan, MD FAAEM Elizabeth A. Moy, MD FAAEM Terrence M. Mulligan, DO MPH FAAEM FIFEM Ivan M. Santos, MD Edward P. Sloan, MD MPH FAAEM Joshua J. Solano, MD FAAEM George Robert Woodward, DO FAAEM

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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 12-1-2020 to 2-1-2021.

Contributions $1,000+

Mark S. Penner, DO FAAEM

Contributions $500-$999

William T. Durkin Jr., MD MBA MAAEM FAAEM David A. Farcy, MD FAAEM FCCM Damian Liebhardt, DO FAAEM FAWM

Contributions $250-$499

Brett Bechtel, MD FAAEM Edgar McPherson, MD FAAEM

Contributions $100-$249

Leonardo L. Alonso, DO FAAEM

Terence J. Alost, MD MBA FAAEM Justin P. Anderson, MD FAAEM Kevin S. Barlotta, MD FAAEM David Baumgartner, MD MBA FAAEM Elizabeth Bockewitz, MD FAAEM Anthony J. Callisto, MD FAAEM Benjamin P. Davis, MD FAAEM FACEP Deborah D. Fletcher, MD FAAEM Paul W. Gabriel, MD FAAEM Felipe H. Grimaldo, Jr., MD FAAEM Robert E. Gruner, MD FAAEM Jaime Harper Stefan Jensen Heath A. Jolliff, DO FAAEM

Kathleen P. Kelly, MD FAAEM Ron Koury, DO FAAEM Scott P. Marquis, MD FAAEM Andrew P. Mayer, MD FAAEM Travis Omura, MD FAAEM Brian R. Potts, MD MBA FAAEM Teresa M. Ross, MD FAAEM Linda Sanders, MD David T. Schwartz, MD FAAEM Christopher H. Stahmer, MD FAAEM Jeffrey J. Thompson, MD FAAEM Thomas R. Tobin, MD MBA FAAEM Marc B. Ydenberg, MD FAAEM

Contributions up to $50

Alexei Adan, MD Michael A. Cecilia, DO Timothy J. Durkin, DO FAAEM CAQSM Anthony J. Hackett, MD FAAEM Ryan Horton, MD FAAEM R. Sean Lenahan, MD FAAEM Ann Loudermilk, MD FAAEM Elizabeth A. Moy, MD FAAEM Joshua J. Solano, MD FAAEM James Webley, MD FAAEM

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

Visit the AAEM website to browse the 40+ groups you can become a part of today.

Get Started!

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COMMON SENSE MARCH/APRIL 2021

LEAD-EM Contributors – Thank You! The AAEM Institute for Leadership, Education & Advancement in the Development of Emergency Medicine, Inc. (LEAD-EM) was established after the tragic and unexpected death of AAEM president, Dr. Kevin G. Rodgers.

The Kevin G. Rodgers Fund and the Institute will LEAD-EM just like Dr. Rodgers did. The funds will support important projects such as development of leadership qualities, and clinical and operational knowledge of emergency physicians with a view toward improving and advancing the quality of medical care in emergency medicine, and public health, safety and well-being overall. LEADEM would like to thank the individuals below who contributed from 12-1-2020 to 2-1-2021.

Contributions $500-$999

David A. Farcy, MD FAAEM FCCM Bobby Kapur, MD MPH CPE FAAEM Bruce M. Lo, MD MBA RDMS FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM

Contributions $250-$499

Dale S. Birenbaum, MD FAAEM Anthony J. Callisto, MD FAAEM Frank L. Christopher, MD FAAEM Andrew P. Mayer, MD FAAEM Andrew J. McCanna, MD FAAEM Carol Pak-Teng, MD FAAEM Thomas R. Tobin, MD MBA FAAEM

Molly Wormley, MD Emily Yu, MD FAAEM

Contributions $100-$249

Leonardo L. Alonso, DO FAAEM David Baumgartner, MD MBA FAAEM Mary Jane Brown, MD FAAEM Evan A. English, MD FAAEM Robert E. Gruner, MD FAAEM Regina Hammock, DO FAAEM Kailyn Kahre-Sights, MD FAAEM Christopher Kang, MD FAAEM John C. Kaufman, MD FAAEM Kathleen P. Kelly, MD FAAEM Ann Loudermilk, MD FAAEM

Gerald E. Maloney Jr., DO FAAEM David P. Mason, MD FAAEM FACEP Vicki Norton, MD FAAEM Travis Omura, MD FAAEM Brian R. Potts, MD MBA FAAEM Debra S. Rusk, MD FAAEM David T. Schwartz, MD FAAEM Hemali Shah, MD FAAEM Joanne Williams, MD MAAEM FAAEM Michael E. Winters, MD MBA FAAEM Marc B. Ydenberg, MD FAAEM

Contributions up to $75

Robert W. Bankov, MD FAAEM FACEP Bryan Beaver, MD FAAEM

Benjamin P. Davis, MD FAAEM FACEP Thomas G. Derenne Joseph Flynn, DO FAAEM Edward T. Grove, MD FAAEM MSPH William R. Hinckley, MD CMTE FAAEM Pamela J. Krol, MD FAAEM R. Sean Lenahan, MD FAAEM Elizabeth A. Moy, MD FAAEM Terrence M. Mulligan, DO MPH FAAEM FIFEM Ivan M. Santos, MD Edward P. Sloan, MD MPH FAAEM Joshua J. Solano, MD FAAEM George Robert Woodward, DO FAAEM



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

AAEM Conferences April 17, 2021 Virtual Oral Board Review Course Virtual www.aaem.org/oral-board-review April 18, 2021 Virtual Oral Board Review Course Virtual www.aaem.org/oral-board-review May 4, 2021 Virtual Oral Board Review Course Virtual www.aaem.org/oral-board-review May 5, 2021 Virtual Oral Board Review Course Virtual www.aaem.org/oral-board-review June 20-24, 2021 27th Annual Scientific Assembly – AAEM21 St. Louis, MO or Virtual www.aaem.org/AAEM21

10-13 November 2021 XIth Mediterranean Emergency Medicine Congress – MEMC21 St. Julian’s, Malta www.aaem.org/MEMC21

Jointly Provided Re-Occurring Monthly Unmute Your Probe – Virtual Ultrasound Course Series Virtual www.aaem.org/eus March 24, 2021 DVAAEM Residents’ Day and Annual Meeting Virtual www.aaem.org/dvaaem

AAEM Recommended Conferences April 8, 2021 Advances in Cancer ImmunotherapyTM – SITC Portland, OR www.sitcancer.org/education/aci April 27, 2021 Advances in Cancer ImmunotherapyTM – SITC Charlottesville, VA www.sitcancer.org/education/aci April 29, 2021 Advances in Cancer ImmunotherapyTM – SITC New Brunswick, NJ www.sitcancer.org/education/aci May 1, 2021 Advances in Cancer ImmunotherapyTM – SITC Detriot, MI www.sitcancer.org/education/aci May 6, 2021 Advances in Cancer ImmunotherapyTM – SITC Los Angeles, CA www.sitcancer.org/education/aci

COMMON SENSE MARCH/APRIL 2021

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ABEM NEWS

ABEM Committed to Maintaining Certification Standards

February 8, 2021 The American Board of Emergency Medicine (ABEM) understands that this past year was particularly challenging for emergency physicians, especially early career physicians. Every physician member of the ABEM Board of Directors is clinically active and understands the disruptions caused by the COVID-19 pandemic. The disruptions affecting our specialty have also affected ABEM certification.

At the onset of the pandemic, ABEM took quick action to protect certification and board eligibility, including extending board eligibility for physicians whose initial certification was delayed due to COVID. The closing of Pearson VUE testing centers and the elimination of large gatherings created major disruptions to certification, including cancellations of the ABEM Oral Certification Examinations. Both examiners and candidates supported the cancellations as being a responsible action to take in 2020.

Consequently, ABEM pivoted to a new Oral Exam process and began testing in the virtual environment. ABEM administered the first virtual Oral Exam in December 2020 and will be administering three additional exams in early 2021. ABEM expects to examine a record number of candidates this year, administering the Oral Exam to most, if not all, physicians seeking certification in 2021.

It is true that we are in the midst of unprecedented circumstances, but despite this situation, ABEM expects to have a solution to remedy delays in certification by the end of 2021. While notice for some exams has been shorter than ideal, ABEM is working diligently to improve the

process. The pandemic has created scheduling challenges for everyone involved, including the nearly 500 ABEM oral examiners, all of whom are clinically active emergency physicians themselves.

Since its inception, the purpose of ABEM certification has been to independently and validly verify a physician’s competencies that have been acquired during residency training. That verification must be fair, valid, reliable, and nationally based rather than on local or regional practice variations. Over the years, ABEM has published significant data that support the validity of the Oral Exam. Eliminating the Oral Exam would diminish the rigor of ABEM certification and reduce the distinction between ABEM-certified physicians and other physicians and providers of emergency care. The stakes for the public and our profession are too high to not maintain this differentiation.

The ABEM Board of Directors is committed to providing physicians passing the 2019 and 2020 Qualifying Exams the opportunity to become certified in 2021. We will communicate about these efforts in as timely a manner as possible.

The past year has taxed our community in unprecedented ways. I am grateful for your service and proud of our Emergency Medicine community. I am confident there are brighter days ahead.

Sincerely, Mary Nan Mallory, MD MBA President 

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 premiered in the spring of 2020.

The library consists of AAEM19 and select AAEM20 content. 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 10

COMMON SENSE MARCH/APRIL 2021

Over

180 videos available!

Over

75 credits available!

Log-in and Start Watching Today!

www.aaem.org/aaem-online

INTEREST GROUP REPORT PALLIATIVE CARE

Agnes S. (1918-2020): Great Grandma Mary Jane Brown, MD FAAEM

A

ccording to a 2018 study, over 90% of Americans prefer to die at home, but two thirds of seniors over 65 end up dying in a health care setting.

The time to consider fulfilling this desire often arises in our clinical setting, the emergency department.

As emergency physicians in 2021, we need to talk to our elderly patients about end-of-life care. My strong belief in this commitment to our patients comes from my family’s recent experience with the death of my mother-in-law, Agnes. The following is my own personal family story about hospice, a story about emergency physicians providing palliative and hospice care, and finally a call to action detailing how we provide palliative and hospice care in our emergency departments during the new year.

Agnes, my mother-in-law, died at 102 in November of 2020. She was born in a small rural community west of St. Louis in May 1918 during the Spanish flu pandemic. She was the youngest of nine children. She had outlived all of her brothers and sisters. Her vitality, humility, and generosity were always manifest. She loved all of her children, grandchildren, and great grandchildren; she was MOM, GMA, and GIGI to our family.

My sisters-in-law gave her 24/7 care for nearly 10 years after a fall which resulted in a hip fracture and subsequent hip replacement. By March of 2020, I feared my mother-in-law would be isolated and have little contact with family if admitted to a hospital or skilled facility given her physical decline and frailty.

Thankfully, hospice was consulted around the same time and so began an end-of-life experience navigated cautiously at home 45 miles from where she was born. The experience was highly regarded by my sistersin-law. The support from nurses, health care aides, social workers, was gratefully appreciated. “She got good care,” “[The intense comfort measures and support through the final] six months of mom’s life was fantastic” my sisters-in-law were pleased to report. I was relieved and thankful for the experience. My family felt informed and in control; they were supported by hospice as family caregivers.

When my family reflects on the home support my mother in law received, they realize more knowledge and information are needed by patients and their families about what palliative care and hospice can offer. Hospice did not make my mother-in-law a hostage, and her intense comfort care was not limited by an advanced directive or the “DNR” order. They felt empowered and relieved by the efforts made in response to their concerns for their mother and my dear mother-in-law.

The following is my own personal family story about hospice, a story about emergency physicians providing palliative and hospice care, and finally a call to action detailing how we provide palliative and hospice care in our emergency departments during the new year.”

So, let us continue with a look at our story as emergency physicians in 2021. Our experiences vary but barriers to making early referrals to palliative medicine remain constant. Among these barriers may be our fears: what do I say? How much time will this take? Others may be uncertain about when the palliative service will be available to see the patient.

Certainly, the limited availability of palliative consultants to the ED is a challenge as very few departments have ED-embedded palliative medicine or access to an emergency and palliative trained physician. The COVID-19 pandemic has added additional barriers dealing with prognostication challenges in those with chronic conditions affecting the heart or lungs, or cultural and racial disparities including social determinants of health.1 In 2021, let’s change our STORY and overcome these barriers. As EM physicians, let’s demystify and destigmatize palliative care implementation in the ED.2 As we confront this pandemic, let’s take advantage of the opportunity to focus on life giving, life changing, or life improving interventions.

As we distance ourselves from the binary mindset of “everything done” or “nothing,” we offer ourselves and those we care for more options.

What are the goals for the patient? Life prolonging? Limited intervention or comfort care? What helps most is planning, preparing, and practicing for the goals of care discussion.

>>

let’s take advantage of the opportunity to focus on  As we confront this pandemic, life giving, life changing, or life improving interventions.”

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INTEREST GROUP REPORT PALLIATIVE CARE

• Plan for the conversation by practicing and pre-procedural planning • Prepare for an invitational approach and be open: what do you know, what is your understanding? Be willing to listen with soft eyes and ears.

• Practice being present with empathy and compassion so necessary for aligning with the patient and family to build trust and respect.

We overcome our fears and reticence through practice and simulation discussing withdrawal or withholding non-beneficial life/medical interventions. These discussions may be emotionally laboring and mentally stressful for us as clinicians, but the benefit to an aunt, a grandparent, or mother-in-law cannot be ignored.

In hopes of respecting life and the sacred ground, that encompasses a patient’s last months or weeks it is important for us to provide opportunities for patients and families to express their wishes. We can promote and foster the connection to hospice by focusing on patient dignity, with goals to seek permission to engage the patient and family, so that we may partner to alleviate suffering, provide quality patient centered living and dying.

As health care leaders, let us advocate for and demonstrate patient centered assessments guided by patients and family wishes. Continually, let us advocate for the wide availability of palliative care interventions. We may enhance workflow and care delivery in the emergency department, with timely referrals for palliative and hospice support. As we broaden emergency disposition with early palliative care referrals,2 let’s also consider accelerating direct ED to hospice connection by engaging case managers. We can build electronic order sets to trigger and facilitate referrals. Let’s participate in sectional interest groups in your health care systems and within AAEM.3

Palliative care initiated early offers patients and their families invaluable support. Be proactive and create paths to assist patients in gaining knowledge or access to palliative support and hospice. At this pivotal moment as physicians, we hold a unique presence in our systems and departments. Let us educate ourselves and let us offer prompt palliative care to patients who would benefit. Please set your intention to provide this desired care.

Resources • • • •

APPS: Vital Talk. Palliative Care fast facts Blogs: Geri Pal Nov 5, 2020 Center to Advance Palliative Care Common Sense articles since 2018, with recent Nov/Dec Create a LIFEMAP for Goals of Care discussion Austin Causey, MD • Palliative Care Interest Group View all of the resources and more on the Palliative Care Interest Group website: www.aaem.org/get-involved/committees/interest-groups/ palliative-care  References 1. Chidiac,C. Feuer,D. The need for early referral to palliative care for Black, Asian, and minority ethnic groups in Covid-19 pandemic: Findings from a service evaluation. Palliative Medicine 2020, vol 34(9) 1241-1248.DOI: 10.1177/0269216320946688 2. Wang DH. Beyond Code Status: Palliative Care Begins in the Emergency Department. Ann Emerg Med. 2017 Apr;69(4) 437-443. doi:10.1016/j. annemergmed.2016.10.027. Epub 2017 Jan 26. PMID: 28131488 3. George N, Bowman J, Aaronson E, Ouchi K. Past, present and future of palliative care in emergency medicine in the USA. Acute Med Surg. 2020 Mar 18;7(1):e497. doi: 10.1002/ams2.497. PMID: 32395248; PMCID:

Board of Directors Election Opens April 1, 2021

2021 AAEM Election Cast Your Vote Online

• Review the candidate statements: Available online April 1, 2021

and will be printed in the May/June issue of Common Sense.

• Join the Candidates’ Forum at the 27th Annual Scientific Assembly

in St. Louis, MO. Tuesday, June 22, 2021 from 9:00am-9:45am.

• Cast your vote: Vote online at www.aaem.org/elections onsite at

Scientific Assembly or from home. To learn more visit the AAEM elections website.

www.aaem.org/elections Voting closes: June 22, 2021 at 11:59pm CT 12

COMMON SENSE MARCH/APRIL 2021

Open Positions • At-Large Directors (5 positions) – Must be a Full Voting or Emeritus member • Young Physicians Section (YPS) Director – Must be a YPS member

INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

Respect: A Driver of Empathy and Equity Shanna S. Strauss, MSc MS4; Megan Healy, MD FAAEM; and Sara Urquhart, MA RN

the main social determinants of our patients’ health outcomes, especially those drivers that impact the most marginalized patients.

I

n 1967, Arethra Franklin created “Respect,” a song that not only stayed at the top of the charts for months, but also became a civil rights anthem (Brown, 2018). Respect was central to creating equality in the 1960s and it is just as important today as we strive to create health equity for our patients. This important end cannot be achieved without fair work environments for clinicians.

In many ways, we have seen how public admiration doesn’t translate to workplace respect. On one hand physicians are admired as health care heroes by the public, on the other hand some are also being retaliated against for speaking out about lack of PPE during a pandemic (Carville et al., 2020). Physicians are not immune to the experiences of dehumanization, devaluation, and exploitation in the workplace. These are commonly experienced as unfair employment contracts, punitive policies, and incentives that drive us away from the bedside and our patients.

Many of our patients experience the direct effects of criminalized poverty (Yungman, 2019) and institutionalized classism (Scambler, 2019). These social factors are foundational to the health inequities contributing to our patients presenting illness. To compound the problem, most medical centers do not have robust systems in place to address issues like homelessness, food insecurity, and violence.

At minimum, emergency physicians need to be empowered to speak out about issues that impact patient safety. Work environments that lack transparency, threaten physician autonomy, or place profit above patient care are unsafe. In challenging work environments like these, physicians face substantial barriers to providing equitable care.

We must also recognize that our patients experience independent hardships when they seek treatment in the emergency department. Just as

Is there a connection between the systems eroding the physician-patient relationship and our patients’ health outcomes?

• Hostile work environments contribute to burnout and high physician attrition rates (NunezSmith et al., 2009).

• Physician attrition affects patient care. Not only does it limit clinical research but it also sequesters funds for hiring that could be invested in employee satisfaction and patient outcomes (Meurer et al., 2013).

• Burnout is not only expensive for physicians and employers; it is also contributing to the significant rise in physician suicide. “Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs” (Stehman et al., 2019).

• As physicians become more burned out, their self-reported empathy levels decline (Wolfshohl et al., 2019).

In the pioneering article “Reframing Clinician Distress,” (Dean et al., 2019) the authors argued that moral injury lies at the heart of physician burnout. Moral injury “describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.” Medicine at large is ill equipped to address

we AAEM members scrutinize the systems and cultures that threaten our ability to practice good medicine, we must also turn a critical eye to the systems and culture that disempower our patients. Part of the answer to addressing these inequities lies in the same core value: respect. Often patient mistreatment is institutionalized and disproportionately affects patients based on their socioeconomic status, their racial categorization, sexual identity, mental health conditions, and/or addiction. We

 Physicians are

not immune to the experiences of dehumanization, devaluation, and exploitation in the workplace.”

>>

COMMON SENSE MARCH/APRIL 2021

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INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

must look beyond individual patient encounters to the systems, policies and incentives that propagate injustice.

Stigma is one byproduct of medical culture we must closely examine. It is particularly challenging to prevent the stigmatization of people who experience social factors with chronic and less visible stressors. For example, when a patient is obese because they are underemployed and living in a food desert they cannot afford or access unprocessed foods. Too often, this obese patient is stigmatized by their weight, as their weight becomes an easy means of judging their value. The patient becomes the object of blame, rather than the system that failed them. Research has shown negative provider attitudes impact quality of care and outcomes for obese patients (Phelan et al., 2015).

Likewise, when we see patients who are unemployed presenting with mental health crises, how often are we attributing their unemployment to their mental health instead of their crisis as a result of unfair employment practices? This will be increasingly important to recognize as we continue to address the downstream impact of the pandemic.

“Unemployment has been linked with a number of psychological disorders, particularly anxiety, depression, and substance abuse; dangerous behaviors including suicide and violence toward family members or others also correlate with unemployment. These associations hold true not only in surveys of those already unemployed but also in studies that follow one or several individuals with no psychological difficulties into a period of unemployment.”

(LexisNexis, 2009 There are similar impacts on psychological health in the underemployed (LaMontagne, 2017).

46% of Americans are experiencing underemployment (PayScale, 2018). At the end of 2020 the United States unemployment rate was at 6.7 percent (Bureau of Labor Statistics, U.S. Department of Labor, 2020). These two statistics highlight that unemployment doesn’t quite capture all of the stressors our patients face.

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COMMON SENSE MARCH/APRIL 2021

We do not need to live our patients’ experiences to be able to express empathy. We as physicians inherently understand the importance of respect and feel the repercussions when it is lacking. When we are able to find solidarity with our patients, it connects us to our common humanity.

Simple actions rooted in respect move us closer to empathy and equity in healthcare.

When we recognize where we are attributing blame or reinforcing the stigmatization of our patients because of their social factors, we are taking steps towards ending healthcare disparities. When we advocate for our own fair workplace environments, we are taking steps towards increasing our agency. Our ability to advocate for patients is central to addressing health care disparities. By uplifting our patients’ voices and valuing their lived experiences as important contributors to their health, we strengthen our platform for creating better health outcomes. There is hope in respect.

Through solidarity and respect, we increase our power to implement solutions.  References 1. Brown, D. L. (2018, August 16). How Aretha Franklin’s ‘Respect’ became an anthem for civil rights and feminism. The Washington Post.

Retrieved December 26, 2020, from https:// www.washingtonpost.com/news/retropolis/ wp/2018/08/14/how-aretha-franklins-respectbecame-an-anthem-for-civil-rights-andfeminism/ 2. Bureau of Labor Statistics, U.S. Department of Labor. (2020, December 4). THEEMPLOYMENTSITUATION — NOVEMBER 2020. News Release, USDL-202184, 1-42. https://www.bls.gov/news.release/ pdf/empsit.pdf 3. Carville, O., Court, E., & Brown, K. (2020, March 31). Hospitals Tell Doctors They’ll Be Fired If They Speak Out About Lack of Gear. Bloomberg. Retrieved December 26, 2020, from https://www.bloomberg.com/news/ articles/2020-03-31/hospitals-tell-doctors-theyll-be-fired-if-they-talk-to-press 4. Dean, W., Talbot, S., & Dean, A. (2019, September). Reframing Clinician Distress: Moral Injury Not Burnout. Federal Practitioner, 36(9), 400-402. PubMed. https://www.ncbi.nlm. nih.gov/pmc/articles/PMC6752815/

5. LaMontagne, M. A. (2017). Underemployment and mental health: comparing fixed-effects and random-effects regression approaches in an Australian working population cohort. Occupational and Environmental Medicine, 74, 344-350. https://oem.bmj.com/ content/74/5/344 6. LexisNexis. (2009, June 25). Workers’ Compensation: The Psychological Impact of Unemployment. LexisNexis Occupational Injury & Illness. https://www.lexisnexis.com/ legalnewsroom/workers-compensation/b/ workers-compensation-law-blog/posts/thepsychological-impact-of-unemployment 7. Meurer, W., Sozener, C., Xu, Z., Frederiksen, S., Kade, A., Olgren, M., Vieder, S., Kalbfleish, J., & Scott, P. (2013). The Impact of Emergency Physician Turnover on Planning for Prospective Clinical Trials (14th ed., Vol. 1). West J Emerg Med. 10.5811/ westjem.2011.8.6798 8. Nunez-Smith, M., Pilgrim, N., Wynia, M., Sesai, M., Bright, C., Krumholz, H., & Bradley, E. (2009, November 19). Health care workplace discrimination and physician turnover. J Natl Med Assoc, 101(12), 1274–1282. PubMed. 10.1016/s00279684(15)31139-1 9. PayScale. (2018). The Underemployment Big Picture. PayScale. https://www.payscale.com/ data-packages/underemployment/ 10. Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & Van Ryn, M. (2015, April). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev, 16(4), 319-326.

PubMed. 10.1111/obr.12266 11. Scambler, G. (2019, July 05). Sociology, Social Class, Health Inequalities, and the Avoidance of “Classism”. Frontiers in Sociology, 4, 56.

10.3389/fsoc.2019.00056 12. Stehman, C. R., Testo, Z., Gershaw, R. S., & Kellogg, A. R. (2019, April 23). Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. West J Emerg Med, 20(3), 485–494. PubMed. 10.5811/ westjem.2019.4.40970 13. Wolfshohl, J. A., Bradley, K., Bell, C., Bell, S., Hodges, C., Knowles, H., Chaudhari, B. R., Kirby, R., Kline, J. A., & Wang, H. (2019, July 11). Association Between Empathy and Burnout Among Emergency Medicine Physicians. J Clin Med Res, 11(7), 532-538.

PubMed. 10.14740/jocmr3878 14. Yungman, J. (2019, January/February). The Criminalization of Poverty. GPSolo, 36(1). https://www.americanbar.org/groups/gpsolo/ publications/gp_solo/2019/january-february/ criminalization-poverty/

COMMITTEE REPORT AAEM NEWS

SCIENTIFIC ASSEMBLY SUBCOMMITTEE

Scientific Assembly (AAEM21) Highlights

Laura J. Bontempo, MD MEd FAAEM; Jack C. Perkins, Jr., MD FAAEM; Julie Vieth, MBChB FAAEM; and George C. Willis, MD FAAEM — Co-Chairs, Scientific Assembly Subcommittee

“O

ne Scientific Assembly. Two Experiences.” is both the theme and the goal of this year’s Scientific Assembly. We are looking forward to hosting AAEM21 in St. Louis and understand that there may be travel policies and other reasons that prevent some from joining us in-person on June 20-24, 2021. In order to accommodate all of our members during this pandemic, we will be adjusting the conference to allow participants and speakers to attend in-person or virtually. For those attending in-person, we have been working with the hotel to ensure that the Assembly will be a safe, accessible, and highly productive experience for all. For those attending virtually, we will work to ensure that you don’t miss out on the premier educational content you have come to expect.

2021 Highlights Include: • An expanded number of Breve Dulce talks (short 7-minute | 20-slide presentations) • Multiple offerings addressing physician wellness and burnout avoidance • *New* Meeting of the Minds literature review & open forum • COVID-19 pandemic updates and lessons learned • Literature reviews of the most influential articles of the year • Multiple hands-on Small Group Clinics • New voices in emergency medicine mixed in with the premier educators our field • Post-conference sessions addressing resuscitation, ECGs, ultrasound, the LLSA, and more.

Visit www.aaem.org/aaem21 to register now and reserve your hotel guest room. Learn more about the speakers, daily schedules, networking events, committee meetings, competitions, and more through the website. >> 27th Annual Scientific Assembly

AAEM21 #AAEM21

COMMON SENSE MARCH/APRIL 2021

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COMMITTEE REPORT AAEM21 SCIENTIFIC ASSEMBLY SUBCOMMITTEE

Invite your colleagues and join us in-person or virtually! There will certainly be many stories to share and lots of catching up to be done. Stay safe.

Breve Dulce Planning Work Group Laura J. Bontempo, MD MEd FAAEM - Chair David J. Carlberg, MD FAAEM Sarah B. Dubbs, MD FAAEM Rupal Jain, MD Patricia De Melo Panakos, MD FAAEM Kathleen M. Stephanos, MD FAAEM Matthew D. Zuckerman, MD FAAEM

Scientific Assembly Planning Subcommittee Laura J. Bontempo, MD MEd FAAEM - Co-Chair Sara Bradley, MD - AAEM/RSA Track Joelle Borhart, MD FAAEM - Advisor David Carlberg, MD FAAEM - Education Committee Vice Chair Christopher Colbert, DO FAAEM Christopher Doty, MD MAAEM FAAEM - Advisor Molly Estes, MD FAAEM David A. Farcy, MD FAAEM FCCM - AAEM Board Liaison David Fine, MD - AAEM/RSA Track Harman S. Gill, MD FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM - AAEM President Siamak Moayedi, MD FAAEM Jack Perkins, Jr., MD FAAEM - Co-Chair Kevin Reed, MD FAAEM - Advisor Teresa Ross, MD FAAEM - Education Committee Chair Julie Vieth, MBChB FAAEM - Co-Chair George C. Willis, MD FAAEM - Co-Chair R. Gentry Wilkerson, MD FAAEM - Advisor 16

COMMON SENSE MARCH/APRIL 2021

The American Academy of Emergency Medicine’s 27th Annual Scientific Assembly is proudly the premier clinical conference in emergency medicine. The Scientific Assembly will begin in the afternoon on Sunday, June 20 and end on Wednesday, June 23 at noon. Post-conference courses will begin Wednesday, June 23 in the afternoon through Thursday evening, June 24, 2021. 

COMMITTEE REPORT

OPERATIONS MANAGEMENT

Ops Series: Lean Six Sigma Kraftin E. Schreyer, MD CMQ FAAEM

T

his is the first installment of a two-part series on lean six sigma, a performance improvement methodology that combines two schools of thought: lean and six sigma. Performance improvement (PI) is crucial to operations management in an emergency department (ED), but can be more widely applied. This introductory series aims to provide an overview of the basics of lean six sigma and some PI tools.

What is lean thinking?

Lean thinking is a philosophy that is focused on continuous improvement and eliminating waste. With its roots in the Toyota Production system, lean thinking is traditionally thought of as being a business philosophy, but is also very applicable to health care. In fact, lean thinking has been implemented successfully in EDs worldwide, and studies have shown that using lean methodologies has led to improved efficiency, higher quality patient care, and improved patient satisfaction.

Where is the waste?

Although some wastes can easily be identified, others are less obvious. In traditional lean thinking, there are seven different types of wastes: defects, waiting, inventory, transport, motion, overproduction, and overprocessing. In more recent years, an eighth waste, skill, has been identified. Each type of waste is unique, and each can be found in an ED. 1.

Defects – Quite simply, defects are products that do not meet quality standards. To correct defects, additional resources, which can be time, money, personnel, or equipment, are required. In the ED, defects are synonymous with low-quality patient care, and include incorrect diagnoses, iatrogenic injuries, and poor patient satisfaction.

2. Waiting – Waiting is the time that passes while a previous step in a process is being completed, or before the next step in a process has begun. It is typically indicative of flawed design processes. Waiting is perhaps the most common and well-understood waste in an ED. Patients can experience waiting at any point in their care process: arrival, triage, provider evaluation, diagnostic evaluation, treatment, and disposition. But, in addition to patients, providers can wait, too, for results, or other personnel. Furthermore, equipment can also wait, as it sits idle while patients are undergoing other parts of their care.

>>

 Waste, according to lean thinking, is anything and everything that does not add value.”

What is waste?

To get lean, one must get rid of waste. Waste, according to lean thinking, is anything and everything that does not add value. Value, in medicine, is determined by our patients, who are seeking the service we provide, which is patient care. Value-added activities affect or change the service in demand. Non-valueadded activities, in contrast, do not forward progress towards the ultimate goal. Nonvalue activities, according to lean thinking, are waste, and should be removed from a process. While completely eradicating waste from any system, including an ED, is impossible, waste can be reduced.

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COMMITTEE REPORT OPERATIONS MANAGEMENT

3. Inventory – Inventory waste results when supply exceeds demand. While it can seem that excess supply is beneficial, it actually leads to misallocated capital and space, and can contribute to increased damage to necessary inventory and delayed discovery of defects. In the ED, one form of inventory waste is excessive medical supplies, which create crowded supply rooms, overflowing room carts, and jam-packed cabinets, and make it difficult to find necessary equipment in a timely manner. As another example, when more medications are ordered and stocked than used, some expire, and are no longer of use to patients.

4. Transport – Transport waste is unnecessary movement of tools, inventory, equipment, or products. It often reflects poorly designed systems, and can lead to damaged products and increased costs. In an ED setting, excess transport can be seen in medications needing to be moved from one area of the department to another, and in the need to send equipment to other areas of a hospital to be sterilized.

5. Motion – Like transport waste, motion waste is unnecessary movement, but in contrast, motion waste involves unnecessary movement of people. Motion waste results from a disorganized workplace and poor ergonomics. The most common form of waste in the ED is excess walking done by personnel, who must take a circuitous path to complete a task. This can lead to damage to people, aka exhaustion.

6. Overproduction – When a product is produced before it is required, it is considered overproduced. Overproduction leads to high storage costs, hidden defects, and a non-linear process.

It can occur in any workflow in which there is a bottleneck, and tends to happen behind a bottleneck step. An example in the ED would be mismatched staffing models. Employing peak staffing during non-peak volume hours is a waste of provider supply.

7. Overprocessing – The most effective processes are those that are linear and able to be done with minimal variation. Processes that have more steps than necessary, or for which there are multiple versions, are overprocessing waste. In the ED, this is very commonly seen in the electronic medical record, in which there are often multiple ways to order the same medication or document the same findings.

8. Skill – This most recently identified waste represents under-utilized talent. Everyone in the ED has a skillset, and if those skills are not optimized, then waste is generated. This waste can be the result of assigning tasks to the wrong people, a lack of teamwork, or a lack of communication.

Each of the different types of waste can be identified using a tool known as a value stream map.

A value stream map is a visual display of all steps in a specific process and how they relate to the final product. For each step in the process, time, materials, and information are quantified. Valueadded steps are then identified, and value-added time is totaled. The same is done for non-valueadded steps and time. Actions can then be taken to reduce waste and increase the percentage of value-added time in each process. As more processes are modified to have higher percent of value-added steps, the ED becomes leaner.

Up Next In the next issue, look for Part II of this series, which will dive into six sigma, and other tools for continuous improvement. 

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 In fact, lean thinking has been

implemented successfully in EDs worldwide, and studies have shown that using lean methodologies has led to improved efficiency, higher quality patient care, and improved patient satisfaction.”

References 1. Chan H, Lo S, Lee L, et al. Lean techniques for the improvement of patients’ flow in emergency department. World J Emerg Med. 2014;5(1):24-28. doi:10.5847/wjem.j.is sn.1920-8642.2014.01.004 2. Chase D. Applying Lean to Hospital Emergency Rooms. Personal Interview.

Kettering Global. 30 Jan 2018. https://online. kettering.edu/news/2018/01/30/applying-leanhospital-emergency-rooms 3. Hall J, Scott T. Lean Six Sigma: A Beginner’s Guide to Understanding and Practicing Lean Six Sigma. 2016.

4. Holden RJ. Lean Thinking in Emergency Departments: A Critical Review. Ann Emerg Med. 2020. https://doi.org/10.1016/j. annemergmed.2010.08.001 5. Improta, G., Romano, M., Di Cicco, M.V. et al. Lean thinking to improve emergency depa rtment throughput at AORN Cardarelli hospital. BMC Health Serv Res 18, 914 (2018). https://doi.org/10.1186/s12913-018-3654-0 6. McGee-Abe J. The 8 Deadly Lean Wastes.

Process Excellence Network. 12 Aug 2015. https://www.processexcellencenetwork.com/ business-transformation/articles/the-8-deadlylean-wastes-downtime 7. Roseke B, Peng P, Leave A. Steps to Powerful Value Stream Mapping. Project Engineer. 9 Oct 2019. https://www.projectengineer.net/ steps-to-powerful-value-stream-mapping/ 8. Skhmot, N. The 8 Wastes of Lean. The Lean Way Blog. 5 Aug 2017. https://theleanway.net/ The-8-Wastes-of-Lean

It’s Time to Take Care of Those Who Take Care of Us

COMMITTEE REPORT WELLNESS

Robert Lam, MD FAAEM

T

he physician burnout crisis has only been exacerbated by the COVID-19 pandemic. The pandemic revealed the vulnerabilities of our health care institutions to meet even the basic needs of emergency physicians and their patients. Many emergency physicians were unable to secure adequate PPE to protect themselves, their families and their patients.1 Countless health care workers contracted COVID-19. Some became critically ill and tragically, some died.2 Thwarted basic needs, moral injury from working in a chronically overwhelmed safety net stretched to the breaking point, and challenges to mental well-being created disillusionment and contributed to the already widespread crisis of clinician burnout.

In times of crisis, we need to have our basic needs of safety and protection addressed at a minimum. In fact, we need to address all of Maslow’s hierarchy of needs to promote wellbeing. A framework to prioritize and address thwarted needs can be found in the wellness hierarchy created by Shaprio et all.3 The wellness hierarchy provides a road map that includes where to begin to address unmet needs. An institution supported well-being program is also needed to carry out an effective response to physician distress.

been subject to meaningless unachievable metrics, thankless unpaid tasks that do not improve patient care5 and have become saddled with an EHR that has the effect of removing us from patient contact and turning us into highly paid clerks.6 At the center of the burnout crisis and the net effect of the dysfunctional work environment is the removal of physicians from the doctor patient relationship. The diminishment of doctor patient relationships has eroded our sense of purpose and many of the rewards of our work.

Emergency physicians have always done the work of caring for our communities during normal times as well as during times of crisis.

COVID-19 revealed the inadequate response to meet the basic needs of safety and personal protection. Hospitals filled beyond capacity with the overflow of patients inevitably ending up in the emergency department, amplifying the moral injury of caring for patients with inadequate resources. The seeds of cynicism and disillusionment are fueled when these thwarted needs continue through the first and then the second peaks of the pandemic.

The price of burnout on physicians and to health care systems is high. Burnt out physicians leave the institution they work for at rates of 3-4 times compared to their peers.

Financially, it costs between 3-5 times a physician’s annual salary7 to replace one physician that leaves in lost revenue, ramp up costs, and recruiting. Institutions literally have millions of reasons to support the retainment of their physicians. Physicians that are burnt out have higher rates of error8 and lower patient satisfaction scores.9 Burnt out physicians also have lower productivity10 all of these factors affect the bottom line for institutions. Tragically, an argument can be made that burn out is related directly to the epidemic of physician suicide.

Physicians currently have the higher risk of suicide of any profession11,12 with rates so staggering that we likely all know a colleague that has died by suicide.

In every crisis, there is also an opportunity. For the first time in recent memory, emergency physicians are viewed by the public with the respect that was long overdue. Although many may find the title of “hero” uncomfortable, the work done by our specialty is truly heroic.

Pushing past the fear of a lethal illness and putting our own health at risk truly is what heroes do. In much the same way that we have rebounded from wars and disasters with improved systems, we have an opportunity to ride the wave of public support for health care workers into real systems change.

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Heal Patients and Contribute: My institution is in alignment with my values and helps me

towards professional fulfillment. My institution actively promotes my doctor patient relationship as paramount to Physician burnout exists because of a dysfuncthe success for our organization and my own fulfillment as a healer of my patients. tional work environment. For decades, we have struggled with inadequate hospital staffing reAppreciation: My institution regularly shows appreciation for my service and talents. My sulting in chronic ED boarding with the effect institution recognizes my accomplishments and supports my professional development. of creating a moral injury of working with inadequate resources to provide the care we desire for our patients. The culture Respect: My hospital listens to my expertise and addresses my concerns to the extent that they are created by the relentless pursuit of able to. My institution has robust surge planning and actively addresses EM boarding. lower cost, yet increasingly efficient health care with high patient Safety: I have access to adequate PPE to protect my health and the health of my family, I have due process with satisfaction places physicians job security when I advocate for my patients. My workplace is supports safety and minimizes risk of violence. in an unwinnable scenario further diminishing sense of accomplishment at Basics: I can hydrate and have easy access to healthy foods. I have access to support my mental health and am not work.4 Physicians have punished for treating mental illness.

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COMMITTEE REPORT WELLNESS

Over the past year, the Wellness Committee has written articles taking a deep dive into each level of the wellness hierarchy of needs. Using this same model and adapted from this study from Shanafelt et all,13 here is what institutions should do right now to support emergency physicians during the pandemic: • Basics: Ensure the basic needs of physicians are met. That includes provisions that allow physicians to stay well hydrated, adequately fed and allow for their basic physiological needs to be met.14 • Safety: Provide confidential support for treatment of mental health strain of caring for critically ill patients during a pandemic and put programs in place to lower the risk of PTSD for the caring experience.15,16 • Safety: Provide adequate personal protection and minimize conditions that physicians might contract COVID-19.

• Respect: Listen to and respect the challenges and expertise of emergency physicians working in extraordinary circumstances and address their concerns to the extent that organizations and leaders are able.

• Respect: Work to redesign the surge plan to take into account once in a career events but also everyday staffing challenges that result in chronic ED boarding.

• Respect: Don’t silence the voices of physicians. Physicians advocating for patient and health care workers safety need due process and a safe place for their concerns to be addressed through hospital leadership.17 • Appreciation: Recognize good work and show appreciation to health care teams particularly in a time where physicians are putting their own health at risk to care for others.

• Heal Patients and Contribute: Empower physicians to contribute to process improvements that results in better patient care and continuous improvement of the health care delivery.

• Create or strengthen a well-being infrastructure to effectively and sustainably continue to meet the needs of emergency physicians towards professional fulfillment.

Organizations should prioritize organizing and engaging this infrastructure at the highest level of leadership in order to achieve the goals of professional fulfillment, engagement and returning joy to practice.

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7. Shanafelt, Tait, Joel Goh, and Christine Sinsky.

Taking care of those who take care of us re“The business case for investing in physician quires us to transform this crisis into a system well-being.” JAMA internal medicine 177.12 that takes better care of all physicians. Health (2017): 1826-1832. care systems like Stanford and Christiana Care 8. Tawfik, Daniel S., et al. “Physician burnout, were ready to meet this challenge with a robust well-being, and work unit safety grades in response because of the well-being infrastrucrelationship to reported medical errors.” Mayo ture already in place. Will you use this moment Clinic Proceedings. Vol. 93. No. 11. Elsevier, to advocate for a robust wellness infrastructure 2018. in your health care system? The stakes are 9. Panagioti, Maria, et al. “Association between physician burnout and patient safety, high and there is no better time than the presprofessionalism, and patient satisfaction: a ent moment to ensure that our current and systematic review and meta-analysis.” JAMA future colleagues will continue to be cared for internal medicine 178.10 (2018): 1317-1331. and supported in the way they deserve. 

10. Dewa, Carolyn S., et al. “How does burnout affect physician productivity? A systematic References literature review.” BMC health services research 1. Bobrow, Bentley J., Micah J. Panczyk, and 14.1 (2014): 325.

Normandy W. Villa. “Emergency medicine: 11. Sargent, Douglas A., et al. “Preventing physician the finest hour in our time.” Journal of the suicide: the role of family, colleagues, and American College of Emergency Physicians organized medicine.” JAMA237.2 (1977): 143Open (2020).Rodriguez, Robert M., et al.

145.

“Academic Emergency Medicine Physicians’ 12. Feist, Jennifer B., J. Corey Feist, and Anxiety Levels, Stressors, and Potential Stress Pamela Cipriano. “Stigma Compounds the Mitigation Measures During the Acceleration Consequences of Clinician Burnout During Phase of the COVID‐19 Pandemic.”

COVID-19: A Call to Action to Break the Culture Academic Emergency Medicine 27.8 (2020): of Silence.” NAM Perspectives (2020).

700-707.

13. Shanafelt, Tait, Jonathan Ripp, and Mickey 2. Erdem, Hakan, and Daniel R. Lucey. “Health Trockel. “Understanding and addressing sources Care Worker Infections and Deaths due to of anxiety among health care professionals COVID-9: A Survey from 37 Nations and a during the COVID-19 pandemic.” Jama 323.21 Call for WHO to Post National Data on their (2020): 2133-2134.

Website.” International Journal of Infectious 14. https://www.acep.org/globalassets/sites/acep/ Diseases (2020). media/life-as-a-physician/eatinginedfaq19.pdf 3. Shapiro, Daniel E., et al. “Beyond burnout: 15. https://www.aaem.org/resources/statements/ a physician wellness hierarchy designed to position/position-statement-on-inquiries-aboutprioritize interventions at the systems level.” diagnosis-and-treatment-of-mental-disordersThe American journal of medicine 132.5 in-connection-with-professional-licensing-and(2019): 556-563. credentialing 4. Bodenheimer, Thomas, and Christine Sinsky.

16. American College of Emergency Physicians.

“From triple to quadruple aim: care of the 2020. Joint Statement: Supporting Clinician patient requires care of the provider.” The Health in the Post-COVID Pandemic Era. Annals of Family Medicine 12.6 (2014): 573Available at: https://www.acep.org/globalassets/ 576. new-pdfs/ac_stmt_jsmh_physicians-mh_06202.

5. https://www.aaem.org/resources/statements/ pdf position/aaem-endorses-the-acp-policy17. https://www.aaem.org/resources/statements/ recommendations-on-reducing-administrativeposition/firing-of-dr-ming-lin tasks 6. Sinsky, Christine, et al. “Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.” Annals of internal medicine 165.11 (2016): 753-760.

SECTON REPORT CRITICAL CARE MEDICINE

We are Nebulizing What Now? Nebulizing Nitro: Therapies for PE iNO More Excuses for PE Therapy Mark Ramzy, DO EMT-P

W

ith the rising number of COVID-19 cases nationally and the limited number of available ICU beds, emergency physicians should expect to see a greater number of critically ill patients boarding in their departments. The following case is not only more than likely to happen, it already IS happening in emergency departments across the nation: A 34-year-old male named Darrell presents with significant shortness of breath and tachypnea. He was brought in for evaluation after being found minimally responsive by his girlfriend. She states that he has had a progressively worse cough and was in quarantine after he tested positive for COVID-19. He is currently tachycardic, hypoxic, confused, and has bilateral pulmonary infiltrates on his chest X-ray. Darrell is ultimately intubated for airway protection; however, there are no ICU beds and so he remains in the ED joining the list of many other patients in line for a bed. Several hours pass and the respiratory therapist informs you that Darrell is becoming increasingly more hypoxic despite increases in lung protective ventilation strategies and increases in PEEP. Bedside echo shows evidence of right-heart strain and he has remained persistently tachycardic. Now what?

Given Darrell’s hypercoagulable state secondary to COVID-19, pulmonary embolism should be at the top of your differential. The literature is fraught with stories of these patients receiving Tissue plasminogen activator (tPA) and having successful outcomes.1-3 Pharmacy informs you that given the high demand, there will be a bit of a delay in getting tPA started. Meanwhile, Darrell continues to remain hypoxic. Upon reevaluation, he’s been getting more hypotensive with escalating vasopressor requirements. Instead of waiting for him to further deteriorate and imminent code, consider the early use of inhaled pulmonary vasodilators such as nebulized nitroglycerin.

Darrell’s body is responding to COVID and his PE by releasing inflammatory mediators that cause pulmonary vasoconstriction. Inhaled nitric oxide (iNO) as a vasodilatory has been studied in patients with PE and improved hemodynamics.4 When metabolized, nitroglycerin eventually yields that very same nitric oxide. Furthermore, the therapy can be targeted to the pulmonary vasculature by nebulizing it. So how is it actually done?

Most studies recommend a dose of 2.5 - 5 µg/kg/min, which equates to about 5 mg over 15 minutes. There are no studies on inhaled nitroglycerin directly for this indication but there are prior studies in pulmonary hypertension/cardiac surgery. More commonly used agents are iNO and epoprostenol but may not be readily available or available to the ED at all because of cost, need for specialized nebulization equipment, and other factors.

Many institutions carry nitroglycerin in 200 or 400 µg/mL which means 6 or 12 mL should be administered over 15 minutes. This can be connected to the ventilator circuit the same way other nebulizers are given to critically ill intubated patients. In non-intubated patients, it’s important to remember that oxygen delivery should not exceed 6-8 L in order to appropriately nebulize any medication. Lastly, inhaled nitroglycerin’s duration is only 20-30 minutes and thus should serve as a bridge to more definitive therapy such as tPA or continuous iNO.

 Instead of waiting for him to further deteriorate and imminent code, consider the early use of inhaled pulmonary vasodilators such as nebulized nitroglycerin.”

As emergency physicians, we excel in troubleshooting problems and improvising treatments with little to no resources. When considering pulmonary vasodilators for unstable PE don’t settle for the extensive list of excuses: “Too expensive,” “takes too long to set up,” “we don’t have it in the ED,” etc. Inhaled nitroglycerin is a cheap, quick, and effective therapeutic option in these patients, the only difficulty is actually thinking of it in the moment.  References: 1. Goyal A, et al. Successful use of tPA for thrombolysis in COVID related ARDS: a case series. J Thromb Thrombolysis. 2020 Jul 2; PMID: 32617806 2. Wang J, et al. Tissue plasminogen activator (tPA) treatment for COVID-19 associated acute respiratory distress syndrome (ARDS): A case series. J Thromb Haemost. 2020 Jul. PMID: 32267998 3. Poor HD, et al. COVID-19 critical illness pathophysiology driven by diffuse pulmonary thrombi and pulmonary endothelial dysfunction responsive to thrombolysis. Clin Transl Med. 2020 May 13. PMID: 32508062 4. Kline JA, et al. Inhaled nitric oxide to treat intermediate risk pulmonary embolism: A multicenter randomized controlled trial. Nitric Oxide. 2019 Mar 1; PMID: 30633959 5. Farkas, J. Pulmcrit- Nebulized Nitroglycerin: The Stealth Pulmonary Vasodilator Hiding Under Your Nose? Dec 2019. EMCrit Project. Available here

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SECTON REPORT EMERGENCY ULTRASOUND

Remote Tele-mentored Ultrasound: The Next Ultrasound Frontier Alexis Salerno, MD FAAEM

D

o you have point-ofcare ultrasound (POCUS) training but at times you still would like an expert consultant to look over the images? Are your resources constrained and you do not have 24/7 staff with POCUS knowledge? Well then remote tele-mentored ultrasound (RTMUS) may be of interest to you and your group.

Tele-ultrasound involves the transmission of ultrasound (US) images from one location to another for interpretation. Image transmission can occur asynchronously, i.e., a sonographer performs an US study and then transmits the images to an expert for review. This is typical of classic radiological US examinations.

Images can also be transmitted synchronously, so that a non-expert sonographer performing an US study on a patient can receive feedback in real-time from an expert on how to optimize the images and interpret them.1 This method of transmission is often used with POCUS and is increasing in use due to technological advances.

Much of the prior literature on RTMUS describes the use of the Focused Assessment with Sonography for Trauma (FAST) exam.2 For

example, one pilot study described the use of RTMUS for FAST exam during trauma activations at a community hospital outside of Banff National Park.3 Physicians at the tertiary hospital were able to guide local providers through the FAST exam and were involved early in the care of patients who may be transferred to their hospital. In another study, paramedics performed the FAST examination through telemedicine.4 The authors found that paramedics with minimal US training could be guided through a FAST exam in less than five minutes.

There is also evidence to support that RTMUS can be expanded to virtually any POCUS exam including cardiac, thoracic and renal US. One study described the use of RTMUS to evaluate left ventricular function, right ventricular function and to evaluate for pathology such as pericardial effusion.5 They compared the images and interpretation of RTMUS as compared to traditional POCUS and found the exams to be concordant 80-100% of the time.

Over the past year, the use of RTMUS has expanded not only because the technology for video conferencing has advanced, but also because of the large amounts of patients who require high levels of isolation due to COVID-19.

In these situations, RTMUS can help decrease the number of providers contacting these

 Over the past year, the use of

RTMUS has expanded not only because the technology for video conferencing has advanced, but also because of the large amounts of patients who require high levels of isolation due to COVID-19.”

patients and help with resource constraints.6 For example, one team member may be in the room examining the patient and performing the US. On the outside of the room, a supervising physician can see the US images in real time and ask the one team member to obtain other US views.

As with any technological advancement, RTMUS requires a large amount of preparation prior to implementation. At present, there are four integral parts to having a successful RTMUS program: The first part is an US operator at bedside who can perform images. Studies have shown that very little education and practice is needed to obtain US images. There have been feasibility studies published showing that medical students, nurses, and even non-medical personnel with little training can obtain the images needed for experts to interpret.7 The second part is a functioning US machine.

Many providers in remote areas are finding that handheld US can be helpful in these situations.

However, it is important to decide if the image quality is good enough for what you wish to accomplish. If you are using telemedicine as a way to teach US, then you may be willing to compromise on image quality rather than if you are using the US images to make a medical decision.

The third part is a technological platform than can provide active communication between the sonographer and US expert with simultaneous transmission of US images and probe location on the patient. Historically, this has been the limiting factor for RTMUS as many of these platforms can be expensive. However, as videoconferencing has increased in prevalence, the price of these platforms has decreased. Many of the US vendors are now offering their own tele-ultrasound solutions such as Philips and Clarius.

The fourth part is an expert US consultant who can interpret the images for real-time interpretation and be able to instruct

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SECTION REPORT EMERGENCY ULTRASOUND

the sonographer on improving their image. Many emergency physicians graduate with advanced US skills or have completed a fellowship. This would be a perfect way for emergency physicians to expand their US knowledge to other specialties who are just beginning to learn US skills.

4.

In 2020, we saw the rise of telemedicine to bridge the medicine gap due to COVID-19. In 2021, we may see the rise of tele-ultrasound as technological platforms have advanced and US devices have become more compact with improved image display. 

5.

References

1.

Ferreira AC, O’Mahony E, Oliani AH, Araujo Júnior E, da Silva Costa F. Teleultrasound: historical perspective and clinical application. Int J Telemed Appl. 2015;2015:306259. doi: 10.1155/2015/306259.

2. Salerno A, Tupchong K, Verceles AC, McCurdy MT. Point-of-Care Teleultrasound: A Systematic Review. Telemed J E Health. 2020 Nov;26(11):1314-1321. doi: 10.1089/tmj.2019.0177.

3. Dyer D, Cusden J, Turner C, Boyd J, Hall R, Lautner D, Hamilton DR, Shepherd L, Dunham M, Bigras A, Bigras G, McBeth P, Kirkpatrick AW. The clinical and technical evaluation of a remote

6.

7.

telementored telesonography system during the acute resuscitation and transfer of the injured patient. J Trauma. 2008 Dec;65(6):120916. doi: 10.1097/TA.0b013e3181878052.

Boniface KS, Shokoohi H, Smith ER, Scantlebury K. Teleultrasound and paramedics: real-time remote physician guidance of the Focused Assessment With Sonography for Trauma examination. Am J Emerg Med. 2011 Jun;29(5):477-81. doi: 10.1016/j. ajem.2009.12.001.

Olivieri PP, Verceles AC, Hurley JM, Zubrow MT, Jeudy J, McCurdy MT. A Pilot Study of Ultrasonography-Naïve Operators’ Ability to Use Tele-Ultrasonography to Assess the Heart and Lung. J Intensive Care Med. 2020 Jul;35(7):672-678. doi: 10.1177/0885066618777187.

Salerno A, Kuhn D, El Sibai R, Levine AR, McCurdy MT. RealTime Remote Tele-Mentored Echocardiography: A Systematic Review. Medicina (Kaunas). 2020 Dec 2;56(12):668. doi: 10.3390/ medicina56120668.

Robertson TE, Levine AR, Verceles AC, et al. Remote tele-mentored ultrasound for non-physician learners using FaceTime: A feasibility study in a low-income country. J Crit Care 2017;40:145–148

Unmute Your Probe VIRTUAL ULTRASOUND COURSE SERIES

AAEM-1220-387

Monthly Re-occurring Beginner and Advanced Webinars

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

REGISTER TODAY www.aaem.org/eus

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

Learn more about EUS-AAEM and join the section at www.aaem.org/eus COMMON SENSE MARCH/APRIL 2021

23

SECTON REPORT WOMEN IN EMERGENCY MEDCINE

I Was a Witness, and Now am Haunted by the Ghosts of Other Mothers’ Sons Marianne Haughey, MD FAAEM

I

haven’t seen someone with a gun injury in more than a year, and I feel guilty.

My career path began in an urban ED, near where I grew up. The implications of poverty, illicit drug use, housing challenges, a hard to navigate education system, poor access to care (especially psychiatric care and drug rehabilitation programs) were inherent in every patient encounter I had during the nearly three decades I served in the neighborhoods I trained and had grown up in. I worked in two separate level one trauma centers that were less than three miles apart, yet each had plenty of penetrating trauma business.

front doorThetoEDtheis thehospital; it is also the front door to the public health challenges of the local community.”

Emergency medicine is a very in-your-face specialty. Often fearful, and overwhelmed, our patients may not always present their best selves as they often are having a terrible day. And often we are the people who have to break the bad news that their day has gotten even worse.

The bad news comes in many forms. We tell patients they need to stay in the hospital. We tell people they have cancer. We share that women are pregnant when they would rather not be, or that the desired pregnancy carried for months no longer has a heartbeat. We share with people that they have had a heart attack, a stroke, diabetes, or a new spot on their chest X-ray. None of these are easy conversations to have, and many are tragic, but the conversations that haunt me are the ones I had not with patients, but instead with the families of young victims of gun and knife violence. Mostly young men of color, in their teens or early 20s, nearly invisible ghosts exiting this earth in vast numbers.

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On November 7, 2018, the National Rifle Association posted a tweet asking for doctors to “stay in their lane” after a position paper published by the American College of Physicians suggested approaching gun violence as a public health issue, rather than merely a political one.1 I read the tweet by the NRA after working an overnight and in my anger tweeted back: “I see no one from the @nra next to me in the trauma bay as I have cared for victims of gun violence for the past 25 years, THAT must be MY lane. COME INTO MY LANE. Tell one mother her child is dead with me, then we can talk.” Let me point out I am not a Twitter star—I have fewer than 300 followers. So, I was shocked when I awoke to find that my tweet had been seen more than 65,000 times.2 I was angry when I wrote that tweet. But I truly cannot count how many times in my career I have had to share the news of a loved one’s death or grievous injury from a bullet, and the resulting sorrow is overwhelming.

It haunts me that as I write this, on only the FOURTH day of January 2021 in the middle of a pandemic, there have already been 395 deaths attributed to gunshots in the United states this year.3 In four days. Just four days. It is terrifying to me to imagine where that number will be when this is published in May. A year ago, I changed jobs. I now work at a level two trauma center. Still a busy ED. Still with a large residency. Still within the same city. But the immediately surrounding area is middle class rather than poor, with better schools, more accessible medical care, and people overall live in a safer environment. I have seen no gunshots in over a year since I have switched. There still is some gun violence in the area, but it goes to the level one center a couple miles away.

I have been relieved of the associated burden of being present and witness to such trauma over and over. Of telling mother, father, siblings of each patient who dies or is injured what has happened. I sleep better.

The shock and horror of such a constant exposure to the fallout of gun injuries and violence I think eroded some piece of me that is now growing again. I have, of course, shared horrible news with patients and families over the last year, but the pure senselessness that I attach to deaths from gun violence isn’t there. The tragedy of the lost lives of these (mostly) young men each time felt like such a failure to me. We as a society had failed them. All of the pieces of what could help them and their families be successful were not aligned for them to be able to climb those steps. Systemic racism should be listed as a major contributing factor on their death certificates.

So many in the U.S. do not have the window I did into violence. I had thought it would be present in any EM job that I would ever have, and here I have discovered that isn’t so. I also am left reflecting on how the trauma of this exposure to the patients and their families primarily, but

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SECTION REPORT WOMEN IN EMERGENCY MEDICINE

 The shock and horror of such a constant exposure to the fallout

of gun injuries and violence I think eroded some piece of me that is now growing again.” also to those of us who care for them persists yet is limited to the few people who have a window into that environment. The compassion drain from this moral injury takes some of our most hopeful and earnest young doctors and makes them enormously jaded. Physicians cannot fix this on their own; they need politicians and voters to make it work.

I hope in my heart that this does not need to occur with gun violence.

Unfortunately, the populations affected, inner city (mostly) youth and gun owners who commit suicide by gunshot, are each segregated in their own ways, and their witnesses are therefore limited.

Selfishly, I now sleep better as I no longer treat the victims of our society’s neglect-borne violence. But I bore heart-wrenching daily witness to The ED is the front door to the hospital; it is also the front door to the public health challenges of the local community. I understand from some it for nearly three decades, and I feel guilty, as a member of this society that has not addressed this dysfunction and cured the massive public of my colleagues that the faces of gun violence haunting them are different, reflecting the rural depressed suicide patient. In my new position, health crisis that is right under—some of our—noses.  I am relieved to have decreased my exposure, but I know the violence References continues and has even grown.4 I understand better now why the whole country is not as angry about this as I am, as they may not see it at all. It 1. Butkus R, Doherty R, Bornstein SS. Reducing firearm injuries and deaths in the United States: A position paper from the American College of is one of those things that probably doesn’t feel real to you unless you or Physicians.

Annals of Emergency Medicine. 2018: 169(10):704-707 a loved one is impacted.

2. Haag M. Doctors Revolt After N.R.A. Tells Them to ‘Stay in Their

It reminds me that many did not believe, and still do not believe, that Lane’ on Gun Policy. New York Times. 11.13.2018 https://www.nytimes. com/2018/11/13/us/nra-stay-in-your-lane-doctors.html accessed 1/4/2021 COVID-19 is real. There were so many statements and arguments about the science of this pandemic. Being in New York, I was on the first wave 3. https://www.gunviolencearchive.org/ accessed 1/4/2021 of EM docs hit, and early on saw those affected directly. It was very real 4. Watkis A. Violent Year in New York and Across U.S. as Pandemic Fuels Crime Spike. NYT. December 29, 2020. https://www.nytimes. to me. Yet, until this contagion spread, and frankly, those across the com/2020/12/29/nyregion/nyc-2020-crime-covid.html accessed 1/4/2021 country started having someone they knew either ill or killed by this infection, it felt unreal to many in our country. Now, with the spread there are more believers.

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

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

CC: shortness of breath 48-year-old man history of hypertension and HIV, unknown CD4 count, brought in by EMS for shortness of breath. Patient states that he became short of breath just prior to arrival. Patient is awake and alert, but confused and has difficulty answering many questions.

As an IV is being placed, the patient apologizes that his arm keeps on moving. He states that he is short of breath because he has not been able to stop his arm from moving for 3 hours.

Physical Exam

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

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

Labs

Women in EM Section Poster Pearls

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

Questions 1. What is the differential diagnosis of the rash?

2. Why is the patient flinging his right arm?

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

www.aaem.org/aaem-online The Women in EM section of AAEM is pleased to announce the inauguration of Poster Pearls. These brief CME videos will feature section members’ accepted work from the yearly AAEM Photo Competition. Our hope is to use these high yield images to further medical knowledge outside by interviewing section authors.

Presentations will focus on images from the AAEM Photo Competition with discussion of diagnosis and treatment. Our first session will feature Dr. Alex Reed from Jefferson Health Northeast in Philadelphia.

This session will be the presentation of a patient with an “Abnormal

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

History of Present Illness

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

• Keep a wide differential for those with syphilis or HIV and neurological symptoms.

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

References 1.

2.

Cosentino C, et al. Hemichorea/Hemiballism Associated with Hyperglycemia: Report of 20 Cases. Tremor Other Hyperkinet Mov (NY). 2016;6:402. Published 2016 Jul 19.

Tintinalli, J.E., Stapczynski, J.S., Ma, O.J. et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. McGraw-Hill Education, New York, NY; 2015.

Now available!

Abdomen.” We will focus on ultrasound imaging to diagnose pneumoperitoneum and the ultrasound finding of the Enhanced Peritoneal Stripe Sign (EPSS). This is an excellent discussion of how ultrasound can be utilized for making a critical diagnosis in the ED. Our second session is with medical student, Lavinia Turian from Oregon Health & Science University. We will review a case of accidental hydrogen peroxide ingestion and its complications. After viewing each video, members will be eligible for 0.25 hours CME credit.

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SECTON REPORT YOUNG PHYSCIANS

Communication in the Age of COVID-19 Reed Wise, MS and Danielle Goodrich, MD FAAEM FACEP

C

 Armed with the skills to

communicate effectively with our patients, the work becomes a little bit easier and infinitely more rewarding for our patients as well as ourselves.”

ommunication between physicians and patients is essential. How we convey information to our patients is equally important to how we receive information from them, and both are critical to the outcome of the encounter. Barriers that can hinder the effectiveness of our communication have become inescapable in today’s pandemic health care landscape; we often trade in person communication with telemedicine and must cover our open and welcoming facial expressions with a mask and face shield. On top of these challenges, increased patient loads mean we have even less time to spend with individual patients. As the pandemic persists, these changes to health care may remain indefinitely, and it is important that we understand how to adapt our communication skills to the circumstances currently at hand.

During this pandemic, many of our hospitals have been inundated with patients and there is immense pressure to conduct a quick and efficient interview. Research has shown that physicians, on average, interrupt their patients within eleven seconds of the start of a patient encounter.1 While this may allow us to ask the questions we want answered, it does not give our patients the space to share their stories the way they need to be heard. Allowing our patients the time and space to open the interaction on their terms can be key to improved patient outcomes and satisfaction, especially during this pandemic where a safe space to share concerns may be even more valuable. Armed with the skills to communicate effectively with our patients, the work becomes a little bit easier and infinitely more rewarding for our patients as well as ourselves.

In a recent article by Back et al, they present a map and emphasize points to aid clinicians in communicating during a pandemic.2 The article highlights prioritization of the patient’s feelings (even more so than the actual information regarding their diagnosis), management of information volume, and respect for patient autonomy with regard to their values and beliefs surrounding treatment. It must be noted that even in time of pandemic, the respect for patient autonomy must be upheld by the triage and group health measures mandated by governments and hospital policy, until such decisions begin to harm others. Helping our patients becomes infinitely harder when they do not feel like they are being listened to and being heard.

Alternatively: when patients feel that they are being listened to and valued, effectively caring for them becomes that much easier.

 Now, more than ever,

we must ensure that our kindness shows through the digital and physical barriers of our visits.”

In their 2020 article, Zulman et al recommend five implementable practices to aid in connecting with patients: intentional preparedness, active listening, prioritization of patient’s expressed needs, connection with the patient’s holistic story, and appropriate response to patient’s emotions. Active listening is vital to a successful encounter and can be done despite the limitations of our personal protective equipment. It is not enough to just listen, the patient must also feel that they are your sole priority at that moment. Try the simple act of an intentional pause before entering the patient room to aid in being present mentally and physically throughout the encounter. This pause could take the form of intentional handwashing, purposeful breaths, or any other brief, yet mindful action that serves as a personalized practice. In addition to preparing to fully engage in active listening,

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 Since masks are an

a mindful moment has also been shown to improve physician well-being, as well as, aid in coping with difficult patient encounters. This pause is also a good opportunity to recognize that the impulse to interrupt our patients and ask questions can be combated, allowing our patients to fully express their concerns.

additional barrier to nonverbal communication, it is even more important to pay careful attention to emotional cues such as changes in tone, expression, and body language. “

Additionally, effective active listening is dependent on eliminating interruptions and by actively using silence to listen without interruption. Keep in mind that silence at the right time can be just as important as a properly timed response to a patient query. Furthermore, nonverbal language is crucial to making a patient feel comfortable. One of the easiest ways to make a patient feel comfortable is to sit down at the level of the patient to avoid ‘talking down’ to patients. While responses to many nonverbal cues will vary based on cultural differences, sitting down and maintaining an open body posture have both been shown to positively impact multiple levels of the encounter including effectiveness of information gathering, interpersonal trust, and the overall patient satisfaction with the encounter. Since masks are an additional barrier to nonverbal communication, it is even more important to pay careful attention to emotional cues such as changes in tone, expression, and body language.

Practicing evidence-based medicine and exercising compassion with our patients is the best combination to ensure a successful patient interaction. Now, more than ever, we must ensure that our kindness shows through the digital and physical barriers of our visits. Patients are visiting our hospitals and clinics in a period of exquisite vulnerability, and it is our responsibility to ensure they know and feel that they are our first and only priority during their interaction. Quite simply, the community needs compassionate doctors — we must lead the charge to reinforce the importance of simple connection with our patients. Communication with our patients is key, and it could be the very thing that saves a life. 

AAEM

References 1. Zulman DM, Haverfield MC, Shaw JG, et al. Practices to Foster Physician Presence and Connection with Patients in the Clinical Encounter. JAMA. 2020;323(1):70-81.

2. Back, A., Tulsky, J. A., & Arnold, R. M. (2020).

Communication Skills in the Age of COVID-19. Annals of Internal Medicine, 172(11), 759-760.

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MENTORING PROGRAM

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Burnout in Emergency Medicine and How to Prevent It

SECTON REPORT YOUNG PHYSICIANS

Alveena Dawood, MD

T

he term “burnout” is becoming increasingly more common in medicine over the past several years. As medical care continues to become more complex, a significant portion of that burden begins to fall on physicians, especially the physicians on the front lines. Taking care of medically complex patients, charting in electronic medical records in real time, satisfying metrics, meeting the needs of family members, working under resource-scarce environments, and trying to meet patient satisfaction goals are just a few reasons why burnout is high in emergency medicine. These pressures in medicine can be immense.

This past year has brought on even more unique challenges. Struggling with the COVID-19 pandemic has further stretched emergency medicine physicians. Historically in medicine, admitting to feeling “stressed out” or “overwhelmed’ has been viewed as a sign of weakness. This has propagated a malignant culture where physicians overwork themselves in fear of being inadequate, and subsequently, end up hurting themselves. It is time for that to change. It has been increasingly apparent that in order to properly care for patients, we must also care for ourselves.

Study after study continues to find emergency medicine as the highest ranked specialty for physician burnout. The fast pace, high acuity, the constant unknown, high volumes with often low resources all contribute to the immense difficulty of this specialty. Shanefelt et al. found emergency medicine in their 2012 study to rank highest in physician burn out rates at 65%, 10% greater than the next specialty (general internal medicine).4 Medscape releases an annual survey of physician burnout rates since 2013, and it has shown a gradual rise in physician reported burnout rates year after year. Most recent data showed that as high as 44% of physician reported feeling burnt out.3 This is alarming.

Physician burnout can lead to multiple consequences. When physicians start feeling burnt out, it can start off by affecting their clinical practice i.e. losing empathy for patients, making medical errors, and not being able to connect with patients the way you once did. This ultimately leads to patient dissatisfaction as well as patient harm.

Furthermore, not only is clinical practice affected, your personal life suffers too. Relationships, friendships, and your personal well-being are all at stake. Physicians often turn to substance abuse, suffer from depression, leave the profession they once loved, or sadly turn to suicide. The general public is often surprised to hear when a young physician has committed suicide since doctors are generally held to a high standard in society. How can someone who has devoted their life to saving the lives of others take their own? It is mostly due to a complex and broken system; however, we as physicians can take steps to save ourselves, and in turn, our patients.

Wellness in emergency medicine is, plain and simple, extremely important. In order to take care of your patients well, you have to take care of yourself first.

1. Start off by making time for yourself. It can be easy to fall into the same mundane routine of work and home. Make sure to schedule time every day, even if just 30 minutes, to do something you enjoy. Read books, take time to exercise, hike, yoga, go out with friends, cook, anything to destress from daily life. Take off time to go on trips with friends and decompress from medicine.

2. Find a good support network; whether a group of individuals at work or friends from another time in your life. It is important to be able to talk to someone about difficult cases you have had at work.

3. Get involved in a project that excites you. Whether it is work related or completely unrelated to medicine, have a task that you can look forward to working on.

4. Sleep hygiene can also be difficult to achieve in the field of emergency medicine. However, it remains just as important so you don’t fall victim to the challenges of sleep deprivation. Use the usual sleep hygiene techniques; no caffeine or alcohol prior to a good night’s rest. After overnight shift, sleep in a dark and quiet room or use ear plugs, white noise machines, and blackout curtains if possible. Try suggesting circadian rhythm schedules if your group does not already employ them. Schedule naps during the day to catch up on your sleep debt, especially before your overnight shifts.

5. If you find yourself struggling with work and life balance, and none of these previous techniques seem to be helping you, reach out. Talk to your director or seek out any wellness resources your hospital and/or group may offer. Seek professional help if you find yourself continuing to struggle. It is not a sign of weakness, but rather strength to admit when you know that you need help. 

 Study after study

continues to find emergency medicine as the highest ranked specialty for physician burnout.”

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References 1. Chen, P. (2012, August 23). The Widespread Problem of Doctor Burnout. The New York Times.

2. Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress. Ann Emerg Med. 2017 Dec;70(6):884-890. doi: 10.1016/j. annemergmed.2017.03.018. Epub 2017 Apr 29. PMID: 28460863.

3. Peckham C. Medscape National Physician Burnout & Depression Report 2019. Medscape. 2019. Available at: https://www.medscape.com/ slideshow/2019-lifestyle-burnout-depression-6011056#2.

4. Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1377–1385. doi:10.1001/ archinternmed.2012.3199 5. Shanafelt TD. Enhancing Meaning in Work: A Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care. JAMA. 2009;302(12):1338–1340. doi:10.1001/jama.2009.1385

l e e F

t n e fid

Con

OW

and simple, extremely important. In order to take care of your patients well, you have to take care of yourself first.”

6. Stehman CR, Testo Z, Gershaw RS, Kellogg AR. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I [published correction appears in West J Emerg Med. 2019 Aug 21;20(5):840841]. West J Emerg Med. 2019;20(3):485-494. doi:10.5811/ westjem.2019.4.40970

AMERICAN ACADEMY OF EMERGENCY MEDICINE

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COMMON SENSE MARCH/APRIL 2021

AAEM/RSA NEWS

AAEM/RSA Statement of Concern for Graduating EM Residents and the Current Job Market

T

he American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA) is gravely concerned that graduating resident physicians are having significant difficulty in finding adequate jobs due to the current job market.

We believe that COVID has unearthed a very concerning combination of issues including:

• Dramatic overproduction of residents by Contract Management Group (CMG) run residencies.

• The inappropriate overuse of NPs and PAs practicing beyond their training in roles that should be filled by highly trained board certified emergency physicians.

• The significant conflict of influence of CMGs in our specialty societies, which prohibits physicians from advocating for themselves on these topics.

AAEM/RSA is fearful that this dramatic decline in job opportunities will result in increased medical student caution and avoidance in choosing emergency medicine as a specialty and will ultimately result in under-filling of residency spots in the 2022 Match. We advise all senior residents to vocalize their concerns to their specialty societies and advise their programs to do the same.  Approved: 1/27/2021

AAEM/RSA Podcasts – Subscribe Today!

Featured podcasts:

This podcast series presents emergency medicine leaders speaking with residents and students to share their knowledge on a variety of topics.

Don’t miss an episode - subscribe today!

TOPICS INCLUDE:

Experiences of Women of Color in the Emergency Department Parts 1 & 2 Understanding Your Compensation: Metrics, RVUs and the Evolving Economics of EM Ask Me Anything Series Including: – Subspecialties in EM – The EM Interview – The EM Clerkship AAEM/RSA East Coast Program Director Panel State of Shock - Managing Refractory Shock Like a Rock Star Applying EM in the Time of COVID-19: Program Director Q&A Becoming a Leader Point of Care Resiliency Pearls & Pitfalls for New Graduates

COMMON SENSE MARCH/APRIL 2021

31

The Brink of Burnout

AAEM/RSA EDITOR’S MESSAGE

Ryan P. Gibney, MD

I

t definitely felt different this new year. The normal buzz around town, packed stores, twinkling lights, and family gatherings uncharacteristically muted as compared to years past. I noticed a profound change in the hospital starting in mid-November: the winter chill was ever present in the air, while families prepped for the upcoming holidays in uncertainty.

It started as a trickle three or four critically ill patient’s per day—COVID and others—but quickly became evident that the levee holding back the flood of patients was about to break. Over the course of two weeks, I saw the volume expand from a few sick COVID patients to every other patient coming in at the brink of complete respiratory failure, clinging to each breath, struggling to speak any words. Time and time again, I would ask a single family member to say their goodbyes while I prepared airway equipment and counseled families and patients that I was concerned and this may be the last time they speak to their loved ones. Tears and fear filling the eyes of patients and their family, quivering lips hidden behind flimsy masks, screaming, and hand holding had become the pre-intubation ritual I was now performing countless times per day. It is incredibly difficult.

We are practicing medicine in unprecedented times, and as I near the completion of my training, I worry for what’s to come. California, where I train, feels like it’s about to burst. Occasionally, I hear the panic of higher ups as another tent is erected, or field hospital is installed in the parking lot, or a diversion suspension order is enacted. What are we going to do?

What else can we do? We have already converted pediatric hospitals to accept adult patients, our backup docs are working full schedules, our nurses are working double time, the ED functions as an additional ICU, and we are stretched to our limits with no end in sight. The emotional toll that this is waging on many of us is very concerning.

 How do we care for the sick and their

families and still find time to care for ourselves and each other.”

I feel that it’s important to be honest and vulnerable about my experience as I was totally blindsided by the feeling of burnout. I have always been resilient, and pride myself on being able to take everything in stride, and residency has been no different. I approached this journey with alacrity, humility, and perseverance. It has proven to be the most difficult, yet rewarding endeavor in my life. But, starting in April, there was a slow transition from a place of happiness, to one of uncertainty, then one of despair.

Returning from a conference in New York in early March, I watched in sadness as the city began to buckle under the sheer volume of critically

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COMMON SENSE MARCH/APRIL 2021

 I feel that it’s important to be honest and

vulnerable about my experience as I was totally blindsided by the feeling of burnout.”

ill patients, and grew fearful that this was a preview of what was to come for all of us. I saw my first sick COVID patient a week later and was truly shaken at how a seemingly normal, healthy young woman could decompensate right in front of my eyes—65-58-49-35%. I went home that day and reflected on how frightening this was, and I was worried about myself and my loved ones.

The shutdown in California began the following week, and my wife and I were now part-time teachers to our young daughter, all while trying to balance our work obligations. She worked in construction, so she had to go on job sites to coordinate, no one in masks, business as usual. I was concerned for her well-being and safety. I’m pretty sure she was downsized in April because of me and a letter she wrote about her concerns, especially since I would be on the COVID ICU and her coworkers had multiple comorbidities that made them high risk. We took it in stride and hoped for the best, but deep down I was worried.

By the time summer hit, it seemed like everything was getting a little bit better. Slowly things started feeling more normal, restaurants had outdoor dining spaces, stores had toilet paper again, we had one or two quarantine families we would occasionally see to break the isolation of lockdown, and the hospital calmed down a bit. I wondered, “Had we done it, did we beat this?” A new challenge arose in August. My wife, a college educated professional with ample experience in different fields, had been looking for a job every day with no response—sometimes 50 applications per day. Unemployment funding ended in late July and suddenly our two-income household was cut nearly in half. We tore through our savings, delayed paying some bills and used credit cards for others.

I searched tirelessly for moonlighting gigs, but none were to be had. By the time we got to Halloween, we were really struggling.

I mention this because in retrospect it was a slow change that was occurring in me through little daily stresses that continued to pile up: financial, professional, physical, emotional. In early November, we started seeing more and more COVID cases. First, it was asymptomatic, younger patients but shortly it became the true surge we are seeing today. I

>>

AAEM/RSA EDITOR’S MESSAGE

remember seeing one or two, then four, then ten patients a shift that were critically ill. At first, it felt manageable, but quickly devolved into chaos and I found myself more hopeless about our current situation. I couldn’t help thinking about the loss of loved ones before the holidays, and the stress on the faces of everyone I work with, and the stress at home just trying to get by. It quickly became too much. I felt as if I was sinking farther and farther. I had never felt this way before, and it seemed like everything in my life was making it worse. I had reached the brink of burnout.

Burnout has been an increasing topic of discussion for physicians over the past several years. Propelled by the loss of autonomy and an unnatural tethering to a computer and an EMR system, we have seen the rate of burnout approach nearly 50% of physicians, and signs

 Over the course of two weeks,

I saw the volume expand from a few sick COVID patients to every other patient coming in at the brink of complete respiratory failure, clinging to each breath, struggling to speak any words.”

of burnout have been seen in residents and medical students alike.1,2 The advent of this pandemic has turned the health care system upside down and it is more important than ever to recognize signs of burnout and intervene. It is well established that burnout leads to emotional exhaustion, depersonalization, patient safety issues, poor outcomes, lack of engagement, and more.2 Physician suicide rates, as well as the general public, have been rising at an alarming rate even more with the isolation of a pandemic.

In speaking with attendings who have gone through similar experiences, we discussed how the number of sick patients that we see every day in the current pandemic drives us to impassivity. We don’t have time to process our emotions as we move from one terrible situation to the next, and it is taxing. How do we care for the sick and their families and still find time to care for ourselves and each other. Right now, more than ever, is the time to check in on each other. Many of our colleagues are struggling to keep it together from shift-to-shift, day-to-day.

In our program, we are taking action to make sure that we are all okay together. My fellow chiefs and I have started doing chief check-ins with our classmates in addition to creating a virtual wellness event complete with painting and a homemade meal prep kit for all of us to hang out and share some time together. It’s small, but it’s something.

In sharing this personal experience with others around me, and now on paper, it has been cathartic and I have refocused on the important things in my life and in my career. I never thought I’d be at this point and I was shocked at how slowly this transition occurs until one day you feel as if there is no going back. For me, recognition of what I was experiencing was the key to working through it, and the Maslach Burnout Inventory (MBI) is a well established tool for early recognition of burnout in addition to others.2 I hope that sharing this, will remind us all to look to each other for support, and remember that one of the most important lessons in life is, that when you’re overwhelmed, tired, struggling, ask for help. 

References 1. Hartzband, P., MD, & Groopman, J., MD. (2020, December 31). Physician Burnout, Interrupted: NEJM. Retrieved January 05, 2021, from https://www.nejm.org/doi/ full/10.1056/NEJMp2003149 2. Singh, R., Volner, K., & Marlowe, D. (2020, November 15). Provider Burnout. Retrieved January 05, 2021, from https://www.ncbi.nlm. nih.gov/books/NBK538330/ 3. West, C. P., Dyrbye, L. N., & Shanfelt, T. D. (n.d.). Physician burnout: Contributors, consequences and solutions. Retrieved January 05, 2021, from https://pubmed.ncbi. nlm.nih.gov/29505159/

AAEM Wellness Resources AAEM recognizes the burnout that emergency physicians can feel. Our jobs are demanding under normal conditions, and COVID has just increased that demand and feeling of burnout. The AAEM Wellness Committee works on resources and efforts to decrease burnout and increase well-being. Examples of Wellness Committee projects include: • • • •

Wellness activities at the Annual Scientific Assembly AAEM Position Statement on Interruptions in the Emergency Department Suicide Prevention and Awareness Efforts Articles in the AAEM member magazine, Common Sense

To access these wellness resources, please visit: www.aaem.org/get-involved/committees/committee-groups/wellness

COMMON SENSE MARCH/APRIL 2021

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

AMA Credit Designation These activities have been approved for AMA PRA Category 1 Credit(s)™.

Pharmacist Credit Designation These activities are eligible for ACPE credit, see final CPE activity announcement for specific details.

Nursing Credit Designation These activities are eligible for ANCC contact hours, see final CNE activity announcement for specific details.

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

sitcancer.org/aci

+The 2020–2021 ACI series is jointly provided by Postgraduate Institute for Medicine and the Society for Immunotherapy of Cancer in collaboration with the American Academy of Emergency Medicine and the Association of Community Cancer Centers and the Hematology/Oncology Pharmacy Association. +The 2020–2021 Advances in Cancer Immunotherapy™ educational series is supported, in part, by independent medical education grants from Amgen, AstraZeneca Pharmaceuticals LP, Bristol Myers Squibb, Exelixis, Inc. and Merck & Co., Inc. 34

COMMON SENSE MARCH/APRIL 2021 SITC-0121-523

AAEM/RSA RESIDENT JOURNAL REVIEW

Massive Transfusion Protocols (MTPs) in Traumatic Hemorrhage Authors: Taylor M. Douglas, MD; Taylor Conrad, MD MS; Wesley Chan, MD; and Christianna Sim, MD MPH Editor: Kelly Maurelus, MD FAAEM and Kami Hu, MD FAAEM

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ost, if not all, emergency medicine clinicians are familiar with massive transfusion protocols (MTP), which were developed to create a systematic method for the administration of large volume resuscitation for hemorrhagic shock. The evidence behind these protocols and how they were developed, however, are less well known. First seen in military trauma settings, MTPs have been translated to civilian patients with the supporting evidence to do so following behind their application.1 The American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) Massive Transfusion in Trauma Guidelines leave a good amount of flexibility for hospitals regarding transfusion protocols, focusing more on systems-level aspects of designing and implementing MTPs.2,3 Here we examine some of the evidence behind the various components of MTPs, specifically calcium and factor VIIa, and the ratios in which the main products of red blood cells, plasma, and platelets should be administered.

Question: 1. What is the emerging evidence and possible role regarding inclusion of components such as calcium and factor VIIa in trauma MTPs? 2. What is the ideal blood component ratio for massive transfusion in traumatic hemorrhage?

Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial. JAMA. 2015;313(5):471-82.

Prior to this study, there was a lack of well-designed research to guide transfusions in severe trauma and other major bleeding. The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPRR) was the first large, multicenter randomized control trial to compare the effectiveness and safety of a 1:1:1 to 1:1:2 plasma:platelet:packed red blood cell transfusion ratio. The study was conducted at 12 level-I trauma centers in North America and included non-pregnant patients estimated to be at least 15 years of age or 50 kg or greater who met criteria predicting massive transfusion, who were then transported directly from injury site, in which transfusion of one unit of blood component occurred within one hour of arrival or during transport. The authors excluded those with devastating injuries (expected to die within one hour of admission), need for thoracotomy prior to receiving blood products, significant burns (>20% total body surface area), inhalation injuries, or receiving over five minutes of cardiopulmonary resuscitation prior to arrival or in the ED.

The authors analyzed 11,185 patients for eligibility, 680 of which were included in the study and analysis (338 to the 1:1:1 group and 342 to the 1:1:2 group). Clinicians were blinded to treatment until delivery of blood products. There was no significant difference between groups in the primary outcome of all-cause mortality at 24 hours (12.7% in the 1:1:1 group vs. 17.0% in the 1:1:2 group; p=0.12) or at 30 days (22.4% vs. 26.1%, respectively, p=0.26). Exsanguination as the predominant cause of death within the first 24 hours was significantly lower, however, in the 1:1:1 group (9.2% vs. 14.6%, p=0.03). Patients in the 1:1:1 group also achieved anatomic hemostasis at higher rates (86.1% vs. 78.1%, p=0.006). There was no difference in the secondary outcomes of time to hemostasis, ventilator-free days, ICU-free days, disposition at 30 days, incidence of primary surgical procedures, and functional status at hospital discharge (measured as Glasgow Outcome Scale-Extended Score). The rate of adverse events including acute respiratory distress syndrome, multi-organ failure, venous thromboembolism, sepsis, and transfusion-related complications was high overall (89%) but did not significantly differ between the two groups.

While there was no all-cause mortality benefit at 24 hours or 30 days, 1:1:1 transfusion ratios were associated with decreased death due to exsanguination and greater achievement of hemostasis. Trauma-related deaths generally occur within the first 2-3 hours after injury, leading to the concept of the so-called “Golden Hour” as a key period for life-saving interventions.4 Any potential benefit of a 1:1:1 strategy would theoretically have been more pertinent for this time frame, but at or beyond 24 hours these effects may have been diminished as many of the patients in the 1:1:2 group approached the cumulative ratio of 1:1:1 with the standard care provided after the initial randomized treatment was received. While this study was adequately powered to detect a mortality difference of 10% at 24 hours and 12% at 30 days, it could not detect any smaller benefits. While it would seem and the authors suggest that the 1:1:1 transfusion ratios are safe as compared to the 1:1:2, it should be mentioned that the study was not powered to assess for safety and thus may not be able to detect differences in rarer complications.

Cornelius B, Ferrell E, Kilgore P, et al. Incidence of hypocalcemia and role of calcium replacement in major trauma patients requiring operative intervention. AANA J. 2020;88(5):383-9.

Hypocalcemia is a known complication of blood product transfusion related to the use of citrate, a calcium chelator, as a stored blood anticoagulant. Transfusion-related hypocalcemia has been previously associated with an increased risk of mortality.5 This study was a blinded

>> COMMON SENSE MARCH/APRIL 2021

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AAEM/RSA RESIDENT JOURNAL REVIEW

retrospective analysis from a single level-I trauma center of all trauma activations within a 12-month period. The objectives of this study were to determine the incidence and rate of calcium replacement in major trauma patients requiring operative intervention, as well as to investigate the impact of hypocalcemia on the rate of transfusion and mortality. All patients >18 years of age who were stat trauma activations were enrolled. Patients were excluded if calcium was given prior to arrival, if they were pregnant, or if no operative intervention occurred within the first 24 hours. The patients were divided into two groups based on whether they received calcium replacement or not.

A total of 638 activations were identified. One hundred and ninety-seven patient cases were analyzed with 80 patients receiving calcium and 117 patients not receiving calcium. The majority of patients were male, and blunt trauma was the most common mechanism. There was no difference between groups in the percentage of patients who had received any blood product, but the calcium repletion group contained a higher percentage of MTP activations compared to the no-repletion group (36.3% vs 15.3% respectively, p<0.05), translating to a higher average transfusion of RBCs (8.1 vs. 3.2, p<0.05), FFP (6.4 vs. 2.6, p<0.05), platelets (1.8 vs. 0.98, p<0.05), and cryoprecipitate (0.5 vs 0, p<0.05).

There was significantly higher mortality in patients requiring MTP versus not (20.6% vs 6.8%, p<0.005), with a trend towards increased mortality associated with any transfusion requirement compared to none (13.0% vs 3.8%, p=0.051).

While there was no difference across groups in initial ionized calcium level, there was a relatively high incidence of initial and intraoperative hypocalcemia and severe hypocalcemia (defined as a serum <8 mg/dL or ionized <0.9 mmol/L) in patients who required operative intervention.

In patients receiving calcium supplementation, the study found no significant difference in mortality between patients who did or did not require MTP activation (31.8% vs 17.9%, p=0.145).

The study has major limitations and the authors acknowledge them: its retrospective nature, the small sample size, the high number of exclusions. They note the lack of current evidence that trauma patients who arrive hypocalcemic have better outcomes after calcium replacement, pointing to the 31.8 versus 17.9% trend in mortality difference, but fail to discuss the potential implication that calcium repletion could possibly mitigate the mortality risk in patients requiring MTP. In truth, the limitations of this study do not allow definitive conclusions to be made and contributions to mortality from trauma severity, hypocalcemia, calcium supplementation, and transfusion cannot be elucidated. This points to the need for future studies; not only examining mortality alone but also to other end-point benefits to determine the role of calcium in MTP.

O’Keeffe T, Refaai M, Tchorz K, et al. A massive transfusion protocol to decrease blood component use and costs. Arch Surg. 2008;143(7):686-90.

Other than the physiological effects of large-volume blood transfusion, the establishment of a massive transfusion protocol has other significant

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health systems and care delivery effects. The urban, level-1 trauma center at Parkland Hospital in Dallas, Texas evaluated blood product use, costs, delivery times, and outcomes following implementation of a massive transfusion protocol at their institution. Patients receiving massive transfusion for trauma were prospectively enrolled and compared to the retrospective cohort from one year prior to institution of the protocol.

The historical patients’ data was collected from a previously established trauma database and using blood bank records including all patients who received more than 10 units of packed RBCs within the first 24 hours.

The MTP protocolized the type and number of blood products received based on number of “shipments” required. For example, the shipments included five units of PRBCS and two units of thawed plasma, with platelets added in the third shipment, and cryoprecipitate and recombinant factor VIIa (rFVIIa) added in the fourth.

The pre- and post- MTP implementation groups were similar in patient demographics, injury severity scores, and reported initial blood pressures. Most notably, following establishment of an MTP, providers used significantly less blood products on average, including PRBCS (15.5 vs 11.8, p<0.001), plasma (8.7 vs. 5.7, p<0.02), and platelets (3.8 vs. 1.1, p<0.001). There was no difference in cryoprecipitate administration and higher rFVIIa post-MTP, which was specifically included in the protocol to increase its use. Accordingly, the costs to the blood bank and the overall hospital costs were $2,300 lower on average per patient following initiation of the protocol, despite the increased costs incurred by increasing rFVIIa use. Use of the MTP was associated with decreased time to blood delivery, with average initial time to first blood delivery of nine minutes.

Subsequent blood delivery times were reduced in half (p<0.05). Mortality in the retrospective and prospective cohorts were similar, even after stratification by need for operative intervention, time from transfusion, and by injury severity score. There was no increase in thrombotic events associated with increased rFVIIa use.

This study demonstrates that implementation of a well-designed blood delivery protocol for massive transfusion has many systems-based improvements, including reduced costs and more efficient use of limited resources. It is important to note that the institution is a well-established trauma center with significant experience in management of the exsanguinating trauma patient, and that this study took place prior to designation of the widely-accepted 1:1:1 transfusion ratio. As such, this implementation reflects the more efficient delivery of a service and care.

These results may not be translatable in all scenarios, and this study was not powered to detect mortality, especially since trauma patients are incredibly heterogeneous in mechanism and salvageability varies greatly despite best efforts. Lastly, recombinant factor VIIA represented an increased expense after protocol implementation and although no change in adverse events were noted, this study is not the correct design to determine its utility.

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AAEM/RSA RESIDENT JOURNAL REVIEW

McQuilten ZK, Crighton G, Engelbrecht S, et al. Transfusion interventions in critical bleeding requiring massive transfusion: A systematic review. Transfus Med Rev. 2015;29(2):127-37.

The authors of this systematic review aimed to identify new data as well as remaining evidence gaps in the investigation into benefit of specific components for inclusion in massive transfusion protocols. The authors were able to identify 19 papers to include in qualitative analysis, however they were unable to perform any meta-analysis due to the heterogeneity of interventions in the studies identified. As we are addressing MTP for trauma other causes of hemorrhage will not be discussed here.

Only three studies were found examining the component ratios and timing. Among these studies, none were powered to detect differences in mortality, but one noted greater plasma wastage with the fixed 1:1:1 ratio.

In the discussion they look to the then-impending PROPPR trial (discussed above) to provide more robust data. On the topic of specific components in addition to RBCs and plasma, three systematic reviews were evaluated. Those looking at fibrinogen concentrate were only in bleeding elective surgical patients but showed no change in mortality or increase in thrombotic episodes. The meta-analysis looking at FFP identified plasma to RBC ratios >1:3 to be associated with reduced mortality, with the caveat that this data is low evidence as it was based on observational data. No quality studies on platelet, prothrombin complex concentrate transfusion, or cryoprecipitate for fibrinogen repletion were identified.

The strongest evidence discussed is that regarding factor VIIa. The authors cited civilian trauma randomized controlled trials and systematic reviews, although these reviews included non-trauma patients. In the RCTs evaluating trauma patients, one demonstrated no difference in RBC transfusion regardless of trauma mechanism. Another, the CONTROL trial, was halted early due to high likelihood of futility and low mortality, although they did see a reduction in the number of units transfused in the factor VIIa arm.

Overall, this review identifies the significant lapses in evidence for the details of massive transfusion protocols. While most large societies advocate for a protocol based, structured transfusion plan for life-threatening hemorrhage, the evidence for the specifics of these plans are lacking, specifically related to inclusion of adjunctive therapies that could potentially further decrease mortality and/or resource utilization.

Conclusion The above studies and others in the literature support the role of MTP to standardize blood administration and conserve resources in the care of the critically ill trauma patient. As mentioned, the guidelines from the American College of Surgeons are broad, but do support a red blood cell to plasma transfusion ratio between 1:1 and 1:2, as well as one pool of platelets for every six units of red blood cells. There is no sufficient data to contravene their statement against the routine use of recombinant factor VIIa in trauma, and further studies are needed to determine how important stringent calcium repletion is in the setting of major trauma and massive transfusion.

Answers: 1. What is the emerging evidence and possible role regarding inclusion of components such as calcium and factor VIIa in trauma MTPs? Robust data on the optimal inclusion of calcium repletion in MTPs and use of adjuncts such as recombinant factor is lacking and requires further study.

2. What is the ideal blood component ratio for massive transfusion in traumatic hemorrhage?

A definitive ideal ratio of blood products requires further study but the best current evidence is for a 1:1:1 ratio of plasma:platelets:packed red blood cells, and is consistent with the American College of Surgeons Best Practice Guidelines for Massive Transfusion in Trauma.2  References 1. Holcomb JB, Wade C, Michalek J, et al. Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients, Ann Surg. 248(3):447-58.

2. MASSIVE TRANSFUSION IN TRAUMA. ACS TQIP Best Practice Guidelines. https://www.facs.org/-/media/files/quality-programs/trauma/ tqip/transfusion_guildelines.ashx?la=en. Published October 2014.

Accessed January 5, 2021.

3. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 376(9734):23-32.

4. Newgard CD, Schmicker RH, Hedges JR, et al. Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort. Ann Emerg Med. 2010;55(3):235-246.e4.

5. Giancarelli A, Birrer KL, Alban RF, et al. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016 May 1;202(1):182-7.

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MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

EM Away Rotations in a Pandemic Lauren Lamparter – President, AAEM/RSA Medical Student Council

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or the third-year medical student, the emergency medicine residency application process starts with applying to away rotations. This year, uncertainty remains around the possibility of aways, but hopefully, as COVID-19 vaccines are distributed more widely, travel and away rotations can become possible. One of the past AAEM/RSA Medical Student Council Presidents, Dr. Michael Wilk, wrote an article, “Seven Tips for Selecting Your EM Away Rotations.” His advice remains true whether you are able to rotate only at your home EM rotation, participate in one of the new virtual EM electives, or travel and participate in an away. So, here are his seven points, with my updated insight and an eighth point, for approaching the EM away rotations in a pandemic world.

First, apply for your rotations early. Whether virtual or in person, the application process for away rotations is rolling, so the earlier your application is submitted, the greater chance for acceptance. Most programs rely on the VSAS application system, but some schools have their own or a supplemental application. If there is a particular program you would like to apply to, be sure to follow their website instructions closely.

Additionally, almost all programs require vaccination titers, so check your records and update as needed to prevent any delays in acceptance.

Second, location, location, location. If you know you would like to go to residency in a particular region of the country, this is where you should apply for away rotations. If you are unable to travel, there might be a program in this region offering a virtual rotation experience. These virtual rotations allow you to interact with a wide range of EM faculty, residents, and fellows and can give you a real glimpse into life at that program.

Third, academic vs. community vs. county. One benefit of an away rotation is experiencing a type of hospital that is different from where you have done your medical school training. In an ideal world, your away rotations would allow you to experience and compare these hospital systems to assist in your decision of which residency program you would like to attend prior to the application season.

choose  Ultimately, based on the programs you love, rather than the length of training.”

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Fourth, three vs. four-year programs. It is stated that the ideal EM residency length is 3.5 years, so programs have chosen either three- or fouryear models. If a program is ACGME accredited, it will give you a good EM training regardless of the length of time. Ultimately, choose based on the programs you love, rather than the length of training.

Fifth, how many rotations should I do? This past year, EM applicants were advised to do only one EM rotation to obtain one SLOE (standard letter of evaluation). If you are allowed to travel and do away rotations, the recommended amount is two, a rotation at your home program and one away. Some students choose to do more, but keep in mind how draining these rotations can be as you “audition” for an entire month. If in person rotations are still not allowed, some of the virtual rotations offered narrative letters of recommendation, which can also be included in your residency application.

 Even if the rotation is virtual, you will be able

to meet potential future co-interns and gain insight into your future specialty.”

Six, when should I actually rotate? You should try to rotate early enough that your SLOE will be submitted prior to the submission of your residency application so that your file can be complete and ready for evaluation. It is also advised that you do an away rotation after completing your home program’s EM rotation, but this might not be possible.

Seven, have fun! You have finally made it to the goal, EM! Be yourself and enjoy learning and experiencing emergency medicine. Get to know the residents and assess the environment to see if it is right for you.

Even if the rotation is virtual, you will be able to meet potential future cointerns and gain insight into your future specialty.

Lastly, eight, write down any memorable patient experiences or stories. In just a few short months, you will be on the interview trail. What you experience at your home rotation, an away, or even a virtual rotation will become stories to answer residency interview questions. The more you record as you experience it, the better memory you will have of these moments.

Good luck!

Dr. Michael Wilk’s original article with his seven points and advice can be found on AAEM/RSA’s website: Seven Tips for Selecting Your EM Away Rotations. https://www.aaemrsa.org/get-involved/students/ selecting-away-rotations.

For more information and advice on the EM Clerkship, see also our AAEM/RSA podcast episode 76: Ask Me Anything: About the EM Clerkship. https://www.aaemrsa.org/get-involved/podcasts/episode-76 

Chronic Pain and Addiction Patients Need Us Now More Than Ever

AAEM/RSA NEWS

Shane A. Sobrio, MD

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lashback to 2019. Hong Kong protests were raging on, the U.S. Women’s National Team won the world cup, Donald Trump was being impeached, and the health care battle continued to revolve around the opioid epidemic. It wasn’t necessarily easy, but it was familiar. Practices were being implemented to help prevent reckless opioid prescribing and increase availability of naloxone which, to an extent, were working. Flash forward to 2020, the year of the COVID-19 pandemic. Millions of people worldwide now dead from a novel respiratory virus and opioids are a distant memory, no longer causing the problems they used to, right? Unfortunately, not right at all.

In 2018, drug overdose deaths dropped for the first time in 20 years. Nearly 47,000 people still died of opioid overdoses in the United States in 2018, but the slight down trending from the previous year began to create some level of optimism regarding the epidemic and its’ future. To put it lightly, 2020 has been a step in the wrong direction. People are losing their jobs, their social interactions, and their support systems. It is not surprising that tragedies such as overdoses, and suicides are up. Additionally, for patients with chronic pain, “elective” pain management procedures have been delayed or indefinitely cancelled, further exacerbating the suffering.

 In fact, in 2019, one of

those numbers was my older brother, who died at just 31 years old from an accidental overdose.”

While the COVID-19 pandemic is rightfully garnering most of our current attention due to the rapid spread and deadliness of the virus, data would suggest our diligence to the opioid epidemic has waned, creating a significant number of secondary COVID-19 casualties. A study published in JAMA in September 2020 showed that urine drug screens for opioids such as fentanyl and heroin nearly doubled in the first few months of the pandemic. While official 2020 drug overdose data is not yet published by the CDC, some early data suggested a 13% increase in drug overdose deaths during the pandemic, which translates to many thousands of lives.

It is sometimes easy to forget that statistics represent human beings. People with loved ones, dreams, aspirations, etc. Unfortunately, when it comes to opioids and overdose deaths, those numbers have often been my family and friends. In fact, in 2019, one of those numbers was my older brother, who died at just 31 years old from an accidental overdose. He was the 4th family member or friend to pass at a young age from something similar. I can no longer afford to think of these statistics as numbers and must start finding ways to turn these tragedies into solutions.

While the outlook may seem grim in some ways, there are certain reasons to be optimistic. Availability of lifesaving naloxone is at an all-time high. Awareness of the epidemic itself has been steadily increasing over the past few years as well. Most importantly, the opioid epidemic and the response needed to fight it adequately have garnered more congressional bipartisan support than almost any other political issue of our time.

 I can no longer afford to

think of these statistics as numbers and must start finding ways to turn these tragedies into solutions.”

As emergency physicians, we have a difficult but privileged position in our society. We often see people at their lowest of low points. We give them naloxone during an overdose, we intervene when they are suicidal, and sometimes we simply provide an ear to listen when someone needs to be heard. I am as guilty as anyone when it comes to feeling frustrated after getting assigned another psychiatric patient or drug-seeking patient in the ER. However, I am using this worldwide disaster as an opportunity to address my biases and think about how I am contributing to the solutions instead of adding to the problem. I implore everyone reading this to spend that extra five minutes listening, provide that extra advice or encouragement; make that extra phone call. With emergency physicians leading the way, we will get through this opioid epidemic (and COVID-19 pandemic) together. 

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Mind Your Language: The Need for Precision in the Vernacular of Medicine

AAEM/RSA NEWS

Richard J. Cunningham, MD

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’m sure many of us during our long and arduous training have been told we have a true “doctor’s handwriting” when others catch a glimpse of our rushed and indecipherable script. While the electronic medical record has made the notoriously illegible penmanship of physicians less relevant than in years past, I ponder why what we write has not received as much scrutiny as how we write it.

 To call us ‘providers’ also blurs the distinction

between physicians and other health care professionals.”

From our early years memorizing the mind-numbing details of the electron transport train and Krebs cycle to the many hours reviewing signs, symptoms, and differentials, the humanities have often suffered at the expense of medical education and the way doctors distort, contort, and at times abuse the English language is perhaps the best example of this.

“To endorse” is defined by the American Heritage dictionary as, “To express approval of or give support to, especially by public statement.”

If so, why would any patient ever “endorse nausea and vomiting?” Yet, many of my colleagues use this word daily when relaying that a patient replies in the affirmative to a myriad of questions; “The patient endorses chest pain, headache, history of hypertension, drug use, etc.” (I myself was at one time guilty of the exact same transgression).

That is just the tip of the iceberg. “Room air” is redundant as the FiO2 inside or outside a room is exactly the same. I’ve been reprimanded on ICU rounds for presenting: “Cardiovascularly, the patient is hemodynamically stable.” Cardiovascularly? What Frankenstein have I created?

Though I often employ the old adage “the patient is a poor historian”

myself, let’s not forget that a historian is a compiler or writer of a chronicle. Does that make us the poor historians? Finally, I’m sure we all as emergency physicians can agree that the emergency department was never just an “emergency room.”

I personally find some of the ways we physicians bend and twist our malleable language as infinitely charming. “Bolus” is not a verb, but the phrase “Bolus ‘em with X, Y, Z!” rolls off the tongue like no other. I enjoy saying, “He’s satting in the 80s” the same way I enjoy casually replying, “I’m doing pretty good.” I know both are wrong, but some of the fun of language comes from its flexibility. Though grammatically abhorrent, colloquially these loose applications of the rules of English bind us together and make a heavy job a little lighter.

One misapplication of the English language in medicine however, has come from outside our own. The term “Provider” has insidiously crept into the mainstream language of health care. Invented by bureaucrats, applied by administrators, and passively accepted by many, the term implies that we as physicians “provide” our patients a service. If so, does that make a patient the consumer? Or, perhaps worse, a customer? At a particular community hospital I spend time at in my residency, the screensaver on every computer lists the non-profit health systems company values, among them is “customer-obsessed.” Medicine may indeed be at times more art than science, but should it be a business?

 Cardiovascularly? What Frankenstein

have I created?”

To call us “providers” also blurs the distinction between physicians and other health care professionals. While I personally know and enjoy working with many non-physician practitioners, to label us all as “providers” implies a false-equivalency and ignores the vast gap in education and training between us. Language matters. To ignore such is to ignore reality.  References 1. https://www.ahdictionary.com/word/search.html?q=endorse 2. https://www.aaemrsa.org/current-news/infographic-what-it-takes-to-makea-doctor

PROVIDER 40

COMMON SENSE MARCH/APRIL 2021

 Medicine may indeed be at times

more art than science, but should it be a business?”

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.

COMMON SENSE MARCH/APRIL 2021

41

February Board of Directors Meeting Summary

The members of the AAEM Board of Directors met in-person and virtually on February 22, 2021 to discuss current and future activities.

The members of the Board of Directors appreciate and value the work of AAEM committee, section, interest groups, and chapter division members and chairs as they strive toward the AAEM mission and to be the specialty society of emergency medicine. Over the course of the meeting, a number

2021 Elected Board of Directors

of significant decisions and actions were made. Here are the highlights:

42

Presentations

Approvals

Miscellaneous

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

AAEM-PG President Mark Reiter, MD MBA MAAEM FAAEM reported on the activities of AAEM-PG. In addition, the Board Liaisons provided update reports on behalf of the Diversity, Equity, and Inclusion Committee; Emergency Medical Services Section (EMSS); Oral Board Review Course Subcommittee; Emergency Ultrasound Section; Legal Committee; and the Young Physicians Section (YPS).

A number of approvals took place during the meeting, including transitioning the Geriatric Interest Group to a committee; a joint recommendation statement from the Palliative Care IG, Ethics Committee, and Geriatric IG on navigating the moral dilemmas during the COVID pandemic; implementing software that will allow committees, IG, sections, and chapter divisions to have online communities for ease of communication; and a 12-month certification course on ED Operations and Management.

AAEM will be engaging an outside firm to help distribute a membership survey and the AAEM Board of Directors announced that AAEM21 will have a virtual option, members will have the option to attend in-person and/or virtually.

COMMON SENSE MARCH/APRIL 2021

What

When

Where

The next Board of Directors meeting

June 19, 2021

St. Louis, MO (onsite at AAEM21)

COMMONSENSE

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

ONE SCIENTIFIC ASSEMBLY. TWO EXPERIENCES. 27th Annual Scientific Assembly

June 20-24, 2021 ST. LOUIS, MO

AAEM21

Attend In-Person or Virtually

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