May/June 2021 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 28, ISSUE 3 MAY/JUNE 2021

HB 2622: An Interview

with Amish M. Shah, MD MPH FAAEM Page 9

President’s Message:

What Does Leadership Look Like? (Part 2)

From the Editor’s Desk:

Diversity of Priorities and Talents

AAEM News:

2021 AAEM Board of Directors Election Candidate Statements

AAEM News:

27th Annual Scientific Assembly (AAEM21) Feature

AAEM/RSA Editor’s Message

The “Privilege” of Working in the COVID ICU

Table of Contents

COMMONSENSE

Regular Features TM

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

COMMON SENSE MAY/JUNE 2021

President’s Message: What Does Leadership Look Like? (Part 2).............................................................................3 From the Editor’s Desk: Diversity of Priorities and Talents..........................................................................................6 Letter to the Editor: COVID Reimagined.....................................................................................................................8 Legislators in the News: HB 2622: An Interview with Amish M. Shah, MD MPH FAAEM...........................................9 Foundation Donations...............................................................................................................................................13 PAC Donations.........................................................................................................................................................13 LEAD-EM Donations................................................................................................................................................14 Upcoming Conferences ...........................................................................................................................................14 AAEM Chapter Division Updates: Florida Chapter Division Update: NPP Scope Creep...........................................61 AAEM Chapter Division Updates: California Chapter Division Update: CAL/AAEM Golden State Symposium........64 AAEM/RSA President: Passing the Baton: The Next Generation of AAEM/RSA.....................................................67 AAEM/RSA Editor: The “Privilege” of Working in the COVID ICU.............................................................................73 Resident Journal Review: Advances in the Use of Coronary Computed Tomographic Angiography in the Evaluation of Coronary Artery Disease in the Emergency Department...................................................74 Medical Student Council President’s Message: Thank You and Welcome the New 2021 MSC!...............................78 Job Bank...................................................................................................................................................................79

Special Articles 2021 AAEM Board of Directors Election Candidate Statements..............................................................................15 Careerealism: It’s Not Your Imagination: No Jobs Anywhere....................................................................................26 Just Another Overnight.............................................................................................................................................28 Traumatic Urinary Catheter Insertion: A Case Presentation.....................................................................................30 27th Annual Scientific Assembly (AAEM21) Feature................................................................................................31 Palliative Care: Hospital Associated Disability: Is Hospital Admission Really the Safest Disposition for Our Elderly Patients?....................................................................................................................................41 Palliative Care: A View from the Middle of My Mid-Career Fellowship......................................................................42 Social EM & Population Health: Social EM Spotlight: Dr. Kraftin Schreyer – An Emergency Department Based Hepatitis A Vaccination Program: A Merge of Social Emergency Medicine and Emergency Medicine Operations..........................................................................................................................................43 Diversity, Equity, and Inclusion: Next Generation Leadership: A Conversation About Equity and Inclusion..............45 Operations Management: Ops Series: Lean Six Sigma............................................................................................48 Women in EM: Why I Decided to participate in a COVID-19 Vaccine Trial – A Reminder that Diversity in Medicine Cannot be an After-Thought...........................................................................................................57 Young Physicians: Learning to Communicate in a Pandemic....................................................................................59 What Keeps Me Up at Night.....................................................................................................................................71

Updates and Announcements Updates from ABEM.................................................................................................................................................25 Speaker Development Group....................................................................................................................................38 International: A Lot to Learn from Our Colleagues from AAEM................................................................................47 Wellness: Bringing Wellness to Your Organization: Highlights from the AAEM Leadership Academy 2021..............50 Critical Care Medicine: Vents, Cardiac Events, and Aerosolized Contaminants: Performing CPR on Vented COVID-19 Patients................................................................................................................................53 Emergency Ultrasound: Emergency Ultrasound Billing Basics.................................................................................55

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-0321-450 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? (Part 2)

AAEM NEWS PRESIDENT’S MESSAGE

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

elcome to Part 2 of “What Does Leadership Look Like?” Part 1 (Common Sense 28:2, March/April issue) covered the first five of the qualities of a good leader that emerged from the discussions taking place during Leadership Academy. Today, we look at the other five. 1. Great leaders learn from great leaders. 2. Great leaders surround themselves with brilliant, trusted experts. Trust means not just that they know their stuff, but that they will tell you the truth and guide you with love and wisdom to do what is best for the organization. 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 make decisions, knowing that they will make enemies.

During a discussion, a few nights ago with Dr. Juan Nieto, Dr. Nieto commented to me that great leaders emerge in times of crisis. This reminded me of Dr. Amal Mattu’s talk, in which he told us that none of the U.S. presidents who held office during times when no war, no depression, no crisis existed have become renowned. Leadership emerges out of the need to make tough decisions. And tough decisions can make or break a leader. The famous physician, Maimonides, once said, “The risk of a wrong decision is preferable to the terror of indecision.” Yet how many people flounder in the waters of indecision, paralyzed by the need to “look good,” to not make a mistake, to please those around them. Madame C. J. Walker opened her factory to celebrate the beauty of the Black woman and to provide jobs for Black females at a salary that was four times that which they were earning as laundresses and domestic servants. Booker T. Washington told her she got it wrong; that the Black man needed to be lifted first. W. E. B. DuBois called her work magnificent. Did she make the right decision? Did Robert the Bruce make the right decision? King Edward thought not. Did President Abraham Lincoln make the right decision? Jefferson Davis thought not. Warriors coach Steve Kerr said in an interview with Sports Illustrated a few years ago that a leader needs to be prepared to be criticized. He explained that a coach needs to know each player

and what they need, what the team needs, what the owners expect, what the Association’s rules are, how the crew chief is likely to call a play, what the opposing team is likely to do, and what their coach is thinking. So, he said, you’re going to be criticized. With all those moving parts, someone is bound to call you wrong, to say you should have done better or different. “But they don’t see what we see; they’re not out there.” So you make the best decision you can, knowing what you know. You stand behind your decision, take the criticism, and keep it moving. As President Lincoln said, “You can’t please all of the people all of the time,” and if that’s what you’re trying to do, you’ll end up pleasing no one and being a mediocre leader.

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

I mentioned in my last column that three generations after we leave this life, no one will remember our names, but we can leave a legacy that will endure. Even when names are remembered, in the cases where professorships and chairs, buildings and wings of buildings, endowed foundations, and awards are named after people, we don’t usually know who those people were. What endures are the principals they embodied, the causes they supported, the good work that they did. Very few people know the name of Nellie Bly, but everyone has benefitted from the work that Bly did to catalyze the reform of psychiatric hospitals.1 Wise leaders like Bly’s editor, Joseph Pulitzer, who himself is the namesake of one of those eponymous awards, know that creating an

 The leader must weigh what is good for the indi-

vidual member (or a small group of members) against what is good for the organization and strike that elegant balance between the two.” COMMON SENSE MAY/JUNE 2021

AAEM NEWS PRESIDENT’S MESSAGE

environment where every member can achieve to their utmost ability creates an organization with impact. Vince Lombardi, who knew a lot about how teamwork makes the dream work, once said, “The achievements of an organization are the results of the combined effort of each individual.” It is not true that every individual must succeed if the organization is to succeed. We know that every organization has individuals who are members in name only. But it is true that every individual who puts out effort for the organization can improve its impact. The old Vidal Sassoon ads, which were punned on SNL for years, used to say, “If you look good, we look good.” The Emory University Department of Emergency Medicine is a great example of this axiom. This is a department that for years has had a culture of developing each of its members towards excellence in a niche area, understanding that the entire department benefits when people think of them when needing an expert in a particular area of emergency care, such as education or palliative care or toxicology. The American University of Beirut Department of Emergency Medicine is led in the same way. Dr. Eveline Hitti will send a young faculty member away to do a fellowship in an area that needs development in her department so that the department will grow in strength through growth in expertise. “An important part of leadership is being able to hold two things in your mind at once: Dealing with the reality, whatever it may be, and focus on hope for the future. Any leader helping an organization through challenges needs to be able to do both.”2 That balance is critical. It’s not about me; it’s about the organization. And to grow the organization, to create an organization that is legacy making, the leader needs to see where we are and what we need and have an eye to developing the future. The leader must weigh what is good for the individual member (or a small group of members) against what is good for the organization and strike that elegant balance between the two.

 Great leaders do not engage in personal attacks. Towards the end of a long and accomplished life, Benjamin Franklin stated, “Any fool can criticize, condemn, and complain- and most fools do.” Pointing a finger at others is a very easy thing to do, but it is not at all productive. No one is blameless when a problem exists. Both parties have contributed to the problem. But rather than seeking to apply blame, if our true goal is to resolve a problem, we need to look at the process that created the problem and suggest a way in which that process might be altered. Insightful historians rarely focus on the evil personal qualities of a dictator, but rather on the historical construct in which a dictator was able to rise to power, and the strategies he employed to stay in power. It’s the process that allows the problem to emerge. And the process is not always the “fault” of the person being blamed. The “smear campaigns” we see all too often in organizations are more appropriate to children in a playground calling out, “You said this,” “No, I didn’t,” and “You did this,” “Well, you did that.” Clearly nothing is getting accomplished here. Dr. Theodore Cherbuliez, one of my early mentors, used to say that the only things accomplished by personal attacks are alienation and fostering defensiveness. No one wins this game. As we discussed in last issue’s column, when you try to show strength by pushing someone else down, you lower yourself in the process. I make it a policy never to engage

COMMON SENSE MAY/JUNE 2021

 When you are the leader, you are re-

sponsible for everything. If you are responsible for everything, you are empowered to make things right.” in personal attacks and never to respond to them. I prefer Michelle Obama’s approach: “When they go low, we go high.” In her words, “When I say ‘go high,’ I’m not trying to win the argument. I’m trying to figure out how to understand you and how I can help you to understand me.”

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

“Passing the buck” was an old poker term that came to be used in international relations theory during the Second World War. According to Wikipedia, it “involves the tendency of nation-states to refuse to confront a growing threat in the hopes that another state will. The most notable example was the refusal of the United Kingdom, United States, France, or the Soviet Union to confront Nazi Germany effectively in the 1930s. With the Munich Agreement, France and the United Kingdom avoided armed confrontation with Germany, passing the buck to the Soviet Union, which then passed the buck back to the western powers by signing the Molotov–Ribbentrop Pact.” When he was elected President, Harry S. Truman was determined that such behavior would never occur again, and in 1959, he had a sign placed on his desk in the Oval Office reading, “The buck stops here.” Truman told the country that the President has to make the decisions and accept the ultimate responsibility for the decisions. I learned long ago that accepting responsibility creates endless opportunity. As I tell my medical students and residents, if something is the patient’s fault, or someone else’s fault, there is nothing we can do about it because we can’t control other people and we can’t change other people. But if something is our fault, we have the power to change it and get it right. When I began running my HIV testing program, I could not keep lab staff on the night schedule. I was frustrated and wanted to figure out what the lab supervisor was doing wrong, but then I remembered my own maxim: If I own the responsibility for the problem, I have the power to fix it. I asked the lab staff to tell me what I could do to ensure that we would have staff on the night shifts. They looked at each other, and then one of them said to me, “Well, Dr. Moreno, you pay fifty cents an hour less to your night technicians than anyone else in the city does, so no one wants to work here at night.” I increased the pay to match the city average and I never had an unfilled shift again. It was a powerful lesson. When you are the leader, you are responsible for everything. If you are responsible for everything, you are empowered to make things right. And when your team knows you take responsibility, they believe that you have their back, and they are empowered to focus all their energy on doing their very

AAEM NEWS PRESIDENT’S MESSAGE

best and not give any energy to worry about making mistakes. If they make a mistake, the leader knows it was inadvertent, will have their back, and work with them to fix things. This is precisely the reason that AAEM endorses due process. An employer that gives a physician due process is saying to that physician, “Do what is best for the patients. Take care of them. Don’t worry about retaliation for doing the right thing for the patients. If the administration has a complaint about you, we’ve got your back. You’ll have a right to defend yourself before a group of your peers.”

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

One of the many blessings of my professional life was having Dr. Peter DeBlieux as my mentor at LSU- New Orleans. Peter taught me more valuable things than I can ever recount, but one of the most valuable was his personal mantra Praise publicly, correct privately. When I was a medical student, I repeatedly witnessed attendings tell patients about the procedures they had done, when a resident had done the procedure while the attending was in the lounge. I saw Chairs put their names on papers that were written by their attendings. I saw CEOs tell Boards of Trustees about successful projects they had initiated which were really imitated by a Chair. But when something went wrong, it was immediately attributed to the person on the lower rung of the career ladder. We had an expression for that phenomenon: Shit runs downhill. But Dr. DeBlieux taught me that praise should run downhill, and shit should run uphill. It’s a beautiful thing to see the smiles on the faces and the gleams in the eyes of those who are praised for their accomplishments. And anyone smart enough to be a Chair or a Trustee is smart enough to know that if good stuff is being accomplished, there is a great leader at the helm. There is no need to seek praise when your team is doing well. Their excellence speaks for the work that you do, creating a culture of excellence where everyone can thrive. (See # 7: It’s about the organization first. If you look good, we all look good.)

I admit to using a lot of quotes from coaches. While I do love basketball, coaches of winning teams have a lot of wisdom to share about what makes a team succeed. Steve Kerr aptly describes the ideal leader: “They have this amazing combination of total belief in themselves and their ability and talent yet have a genuine modesty and awareness of how lucky they are.” At AAEM, we know how lucky we are to serve the membership of the EM organization that embodies integrity, honesty, doing the right thing, and going high when they go low. It is an honor and a privilege to watch the next group of great leaders coming up in AAEM/RSA, YPS, and our Leadership Academy. You are the future of emergency medicine. We hope to serve you well so that you will be well prepared to take us into the future.

Foot Notes 1. In 1887, Elizabeth Jane Cochran, pen name Nellie Bly, was a newspaper reporter for the New York World who feigned mental illness and was confined to the Women’s Lunatic Asylum on Blackwell’s Island in New York City. Ten days later, Bly’s editor, Joseph Pulitzer, arranged her release by exposing the ploy. Bly went on to write a book, Ten Days in a Mad House, and to write several news articles that exposed the barbaric treatment of psychiatric patients and the use of these facilities to warehouse marginalized women. Bly’s work resulted in the reform of the mental health treatment system in the United States. 2. Alan Mulally, an aerospace engineer who served as CEO of Ford Motor Company.

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.

Cast Your Ballot in the AAEM Board of Directors Election

2021 AAEM Election Cast Your Vote Online

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

and printed beginning on page 15 of this 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

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 COMMON SENSE MAY/JUNE 2021

AAEM NEWS FROM THE EDITOR’S DESK

MISSION STATEMENT

Diversity of Priorities and Talents Andy Mayer, MD FAAEM — Editor, Common Sense

his last year will be one of those times long from now that you will tell your grandchildren stories about and reflect on the trials and tribulations, which you have faced. I suspect this will be similar to our elders reminiscing about the Great Depression, Pearl Harbor, the Kennedy Assassination, or similar epic type events from our communal past. The turmoil related to COVID, George Floyd, and the 2020 election will probably stand out in our minds forever. On a professional level in regards to emergency medicine, COVID will certainly stand out in our collective memory as one of the great tests of our medical infrastructure and the abilities and fortitude of each doctor on the frontlines of the pandemic. The events of the last year will probably also go down for other significant reasons and will have long-lasting effects on our profession. The expansion of the independent practice of NonPhysician Providers (NPPs) was accelerated by the pandemic. The expanded used of these same NPPs by corporate management groups as a cost cutting measure will probably be long remembered. The possible glut of new emergency medicine graduates that has been predicted for several years may be finally becoming a reality. The decrease in emergency department patient volumes at the same time of record numbers of new emergency medicine residency graduates may present a perfect storm for graduating residents trying to land their first job. Recent comments and articles related to the difficulty of new graduates finding jobs is troubling. Just read the January 4th Washington Post article entitled, Young ER doctors risk their lives on the pandemic’s front lines. But they struggle to find jobs and see if you are concerned for our young colleagues as they try and enter the job market many with large student loan debts. The reason I am discussing this is in regards to priorities onto which we as a profession need to place our focus on in the near future. Our collective prospects as a specialty are at stake and deciding where and how our efforts and energies should be prioritized is a question we must face in the short run. This is especially true as it relates to our organized emergency medicine societies. AAEM is no longer an upstart organization and is now over 25 years old. AAEM is also no longer a small group of vocal emergency physicians crying out in relation to board certification, the loss of independent practice, the dangers of corporate management groups, due process, and the other core issues, which prompted the founding of our organization. AAEM has developed into a broader and more mature organization and has attracted a broad group of emergency physicians who all recognize the necessity of our focus on these core values of AAEM. This same group also has, as they should, a broad spectrum of talents, interests, and priorities. We all come to emergency medicine with a different history. Each person has their own set of battle scars from their past and has a calling to try and make the world and our profession a better place.

COMMON SENSE MAY/JUNE 2021

• The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles: • Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine. • The practice of emergency medicine is best conducted by a specialist in emergency medicine. • 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). • The personal and professional welfare of the individual specialist in emergency medicine is a primary concern to the AAEM. • 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. • The Academy supports residency programs and graduate medical education, which are essential to the continued enrichment of emergency medicine, and to ensure a high quality of care for the patient. • The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members. • 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.

AAEM NEWS FROM THE EDITOR’S DESK

This leads to a discussion about priorities for AAEM. Let us all remember that AAEM has a set of core values as outlined in our Mission Statement. Please review them and believe that the board of directors believes in these and works for you and advocates for each of you holding the valves below to be our core mission. The values above are a good starting point and remain the focal point of the Academy’s advocacy and focus. However, I do not believe that they have to be our only focus and that our organization does not need to exclusively limit itself as we mature as an organization under the tent of organized medicine. The Academy now has among our membership a group of talented emergency physicians with a diversity of interests besides our founding principles. Our publication has been including articles from many of the newer sections, committees, and interest groups as each of these groups organize and mature within the Academy. I am proud to publish their articles, which can lead to a broadening of our understanding of the issues and concerns of groups within the emergency medicine community, which have not been the historic focus of our efforts. Our long-standing committees related to education, international emergency medicine, and academic affairs are now mature and our educational and international meetings are something that the Academy can look to with deep satisfaction. The Academy now also includes committees, sections, and interest groups focused on various clinical topics like ultrasound, critical care, pain and addiction,

clinical practice, EMS, geriatrics, observation medicine, palliative care, etc. The Academy has deepened our focus on our traditional core issues with committees related to emergency medicine workforce, government and national affairs, legal, operations management, employed physicians, etc. We have also been fortunate to have groups of talented emergency physicians interested in what could be considered newer interests including women in emergency medicine; diversity, equity, and inclusion; social emergency medicine; wellness, etc. These committees, sections, and interest groups each attract a subsection of our membership who has a particular interest in these particular issues.

point is that I do not believe that the Academy expanding into these areas diminishes our focus on our core values as expressed in the mission statement. Instead they show that we are able to include many points of view and a diversity of ideas and priorities without losing sight of the major threats to our profession as emergency physicians. Working in our committee structure has allowed our membership to meet and discuss issues which are important to them and work towards improving many aspects of our specialty. I ask you to consider that the cores values of our long-standing mission statement still ring true and remain AAEM’s main focus. Each individual member can also work on and

 Our professional society is showing maturity and is serving

as a platform for multiple points of view.”

I bring this up as the editor of Common Sense. I have received some comments related to the broadening of the Academy’s committee structure and their submissions to Common Sense. Some members have commented to me that these sections and articles, which they produce, are diluting the message and the focus which the Academy needs to focus upon. I would strongly disagree as AAEM has grown and developed and has room for a broadening of our perspectives and activities. Our professional society is showing maturity and is serving as a platform for multiple points of view. Each member does not and should not be expected to agree with all of these ideas. The

become dedicated to other priorities at the same time. You as an individual will not and should not have to agree with every committee objective or article which it produces. I ask you to become more involved if you have a different idea or priority. Emergency medicine is a big specialty with an incredible mix of extremely talented physicians and we should bring all of our interests and passions to the table in our ongoing effort to improve our specialty. Please contact the editor if you would like to express your opinion related to this topic. Frank and honest discussion of the issues which we face and how we respond to them is crucial.

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

Get Started!

www.aaem.org/get-involved

COMMON SENSE MAY/JUNE 2021

AAEM NEWS LETTER TO THE EDITOR

Letter to the Editor COVID Reimagined John V. Murray, MD FAAEM

As an ED physician in the current COVID pandemic, we are told that once you are vaccinated you should continue to social distance and wear masks. Even though we are told the present Pfizer and Moderna vaccines confer 95-97% immunity we should continue these measures as we may still be conduits to spread the virus to others not vaccinated. At the same time, we are worried about changes in the virus such as the UK and South African strains, which may decrease our immunity and again make us susceptible to re-infection. What we KNOW is that presently we are at least partially protected from infection from any strains if we have been vaccinated. By preventing re-exposure to these strains now, we are insuring that eventually when our immunity wanes we will be susceptible to these re-infections. Now is the time when we, who are vaccinated, and have adequate antibody levels to resist infection of the COVID-19, to not avoid but rather boost our response to new variants. Contrary to conventional wisdom, I would encourage those with full vaccinations to go out without masks and social distancing to be exposed to the new variants while we have full or at least partial protection from our vaccine. Perhaps then we could avoid a resurgence of a new strain in the future.

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

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 MAY/JUNE 2021

LEGISLATORS IN THE NEWS

HB 2622: An Interview with Amish M. Shah, MD MPH FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM – President, AAEM

r. Amish Shah is an emergency physician (EP) and an elected member of the Arizona House of Representatives. Dr. Shah graduated from Northwestern University with both his Bachelor’s and his Medical Doctorate degrees and went on to complete an MPH at University of California, Berkeley. He did his emergency medicine residency at Lincoln Medical and Mental Health Center in the Bronx and a fellowship in Sports Medicine at the University of Arizona, Tucson. His run for the Arizona State House grew out of concerns that arose from his experiences as a practicing EP, and his work in the legislature has focused on health and education. Most recently, Rep. Dr. Shah introduced HB 2622, which has been ratified by both Houses of the Arizona legislature and signed into law by Arizona Governor Doug Ducey. A copy of the bill and Rep. Dr. Shah’s bio sketch appear at the end of this article. I recently had the privilege of interviewing Dr. Shah on his groundbreaking, and AAEM hopes, precedent-setting, legislation.

LM: Dr. Shah, would you share the context and a summary of the substance of your recently passed bill, HB 2622? AS: Prior to my bill, Arizona had a law on the books to prevent retaliation by health care institutions against health care professionals, but that law was outdated. It was written in 2003, and since then, the marketplace has substantially changed. Now, the health care marketplace is, in many regions of the country, dominated by corporate medical groups (CMGs). Even in areas where the CMGs do not dominate the health care marketplace, they are nonetheless significantly impactful. As you know, Dr. Moreno, CMGs have contractual relationships with health care institutions and as part of these contracts, the CMG provides physician services, in some cases for more than just the ED. Those services might include radiology, anesthesiology, critical care, hospitalist services, and inpatient psychiatry, to name a few. If the health care institution has an issue with a physician, the institution does not have to fire the physician because they do not employ the physician. Instead, they voice their complaint to the CMG, which in turn, will terminate the physician or keep the physician off the schedule. Similarly, if a physician voices a concern about staffing, patient safety, or a particular policy of the CMG or the hospital that the physician believes is not in the best interest of patient care, the CMG can retaliate by terminating the physician or failing to put him or her on the schedule. HB 2622 says that neither the health care institution nor the CMG can retaliate. A retaliatory action is not limited to termination but includes any adverse action, including taking a physician off the schedule. This bill is inclusive of all health care professionals and is not limited to physicians. My goal was to empower all health care professionals to be able to act with integrity around issues of patient safety and excellence in patient care without fear of retaliation.

LM: What prompted you to write this bill? AS: Two things: First, a friend who is an EP was in the ED and noticed a patient safety concern: a non-medical person was watching the nursing station telemetry monitors. The EP went to the administration and expressed the above concerns. The hospital administrator then talked to the third-party staffing company and informed them that the hospital did not want that physician on the schedule anymore because that physician was “causing trouble.” The staffing company took the doctor off the schedule, and the physician contacted me to share the story. Then, you invited me to speak at AAEM Advocacy Day 2019 in Washington DC. You asked me to speak about the physician’s role in public policy making. While I was there, I learned a lot about the work that AAEM does to protect physicians who are unjustly terminated for speaking up about patient safety and workplace fairness. I met Dr. Wanda Cruz from Florida, who shared her story about being terminated after reporting to her hospital administration that inadequate physician staffing had contributed to long waiting times and a poor outcome for one of her patients. I realized that retaliation against health care personnel, specifically emergency physicians, was far more common than I had previously been aware of, and I decided to act. I put forth a bill that allows physicians to address patient safety concerns. It also brings awareness to the public that these practices are in place. In the case of my friend’s situation, how would a patient know that they were being monitored by a non-medical person who was not trained to read a cardiac monitor? There are certain things that only the physician working in the ED would be aware of. The bill empowers these physicians to speak up about situations that only they could possibly be aware of by virtue of their work and education. And as I said, this bill is for all physicians, not just EPs, and for all health care professionals. As we know well, situations may arise that only nurses, or only respiratory therapists may be aware, and that have the potential to endanger patients or negatively impact their care.

 My goal was to empower all health

care professionals to be able to act with integrity around issues of patient safety and excellence in patient care without fear of retaliation.” COMMON SENSE MAY/JUNE 2021

LEGISLATORS IN THE NEWS

 You have also reinforced my belief that physicians, and emergency physicians in particular, have a critical responsibility in advocating for the needs of our patients.”

AS: (Laughs) There is a lot of statecraft that goes into writing and introducing a bill. What good would a bill do for anyone if it has no possibility of being passed into law? So in most cases, you want the bill that you drop to be reasonable, to be introduced in a way that will not unnecessarily create opposition. You can’t alienate or antagonize others without cause. You have to realize that there are powerful lobbies out there. Most organizations have lobbyists, and they spend considerable time and money protecting their interests.

LM: I’m genuinely happy to hear that AAEM had a role in prompting you to create this bill. It is important to us that our work makes legislators aware of the problems that exist so that legislators can work with us to enhance patient safety and workplace fairness.

One of the things I do prior to introducing a bill is called “the stakeholder process.” The legislator needs to make phone calls and have meetings with any entity that is a stakeholder with regards to the issue that we are planning to legislate. It’s important to give everyone a chance to work on a mutual solution. This is what other legislators will expect to have happened. Next, I try to get their buy-in. In this case, I explained to them that penalizing someone who is essentially a whistleblower, someone who is speaking up for the protection of the patient population, is not a good look. They won’t look good in the public eye.

AS: I have always believed that physicians have a responsibility in influencing and creating health policy, and this was a great opportunity to demonstrate the importance of such a collaboration.

LM: So, talk to me a little bit about how exactly the process works. Now that the bill has been passed in Arizona, how would an Arizona physician go about registering a concern so that she would be protected by this new law? AS: To be protected by this law, the health care professional would make a report to the health care institution’s administration about the patient safety issue of concern. This law only protects you if you go to administration first. The new law says you have to give the institution an opportunity to respond and address the report. The law would not protect someone who posts a grievance directly onto social media or another public forum. Every institution must maintain a reporting system, and the health care professional has to use the institution’s reporting system.

LM: Okay, but what would happen if the health care professional went to a regulatory agency first, before they go to the hospital’s administration? Would they still be protected? AS: Well, there is already a process in place for that. Regulatory agencies have what are called “whistleblower” policies that allow for anonymous reporting by any concerned person. As legislators, we need to be aware of existing federal and state legislation and avoid duplication of existing laws. But we also look at existing laws and consider whether they need to be updated to respond to circumstances that have changed over time. This was the case with my bill.

LM: There are those who would say that your bill does not go far enough. You protect health care professionals against retaliation, but you don’t, for example, spell out severe penalties for the institutions that do retaliate.

COMMON SENSE MAY/JUNE 2021

LM: So, did this get buy-in from the health care institutions? AS: Mostly yes. In undertaking the stakeholder process, you get the broader picture. Like I said, you want to craft a bill that will pass so that it can actually do some good for your constituents. So, I ask them outright, look, is this a bill that you would oppose, and if so, why? They responded that they were okay with the idea as long as I made a couple of technical changes to the bill language. The health care institutions didn’t want liability if a third-party did the firing on their own. So, I tweaked the bill to factor that in and avoid unintended consequences. I appreciated that they worked with me in good faith. With some bills, we won’t reach an agreement during the stakeholder process, and so then we would have to battle it out in committee and on the floor for the votes.

LM: And is this stakeholder process a mandatory process for lawmakers? AS: Involving all the stakeholders is doing due diligence. It’s not mandatory, but it is likely expected from fellow lawmakers.

LM: And once you have done your due diligence and gone through the stakeholder process, you craft your proposed legislation and then you introduce it? AS: You can, but as I said, you want a bill that has a high likelihood of being passed into law. So, you want to get other legislators to join as co-sponsors and you want to look for bi-partisan support. So, you approach your colleagues and you point out why the proposal is valuable to constituents, why it is necessary, why it will protect the public. And you let them know that it is not unnecessarily antagonistic to other stakeholders.

LEGISLATORS IN THE NEWS

LM: I never realized how complicated this process is! And it takes a lot of skill. One just imagines that if you’re doing the right thing, a bill should be passed, but there is clearly a lot more involved in creating a bill that WILL pass. And it seems clear to me now that there can be a lot of value in speaking to the stakeholders. I would not have thought about the liability that a health care institution may be at risk for, even if a third-party entity is retaliating against the physician who speaks up. AS: You learn a lot as a lawmaker, just as you learn a lot as a physician.

LM: Since we’re talking about learning, can you just walk us through the process for a bill to become a law? AS: Sure. After the stakeholder process, crafting the bill, getting cosponsors (including hopefully bi-partisan support), the bill goes to the committee of the relevant chamber. Once it passes committee, it is presented to the floor of the chamber in which it originated. After a vote in that chamber, then it moves to the appropriate committee of the other chamber, and then to the floor of that chamber. Finally, it goes to the Governor, who can either sign it into law or veto it. A veto by the governor can be overruled with a 2/3 vote of the legislators.

LM: I’ve learned a lot today, and this interview has reinforced my commitment to the mission of AAEM and our work to champion the EP so that the EP can do the right thing for the emergency patient. You have also reinforced my belief that physicians, and emergency physicians in particular, have a critical responsibility in advocating for the needs of our patients. I know this is part of what fueled your commitment to run for office. AS: Absolutely. The things I’ve learned practicing emergency medicine have only reinforced my personal commitment to improve the health of our patient population through education and legislation. It is an honor for me to serve my patients and my constituency both as an emergency physician and a lawmaker.

LM: Thank you for taking the time to meet with me today and to educate us on the complex process of creating legislation and the specifics of HB 2622. AAEM hopes that the protections afforded to health care professionals in Arizona will soon be extended to many other states in the nation, and even to the entire country as a federal law. I want to thank you for all that you do to serve the citizens of Arizona and your fellow physicians. We are proud to have you as a member of AAEM! AS: You’re very welcome. I’m proud to stand up for my profession and my specialty.

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

XIth Mediterranean Emergency Medicine Congress

#MEMC21

www.aaem.org/MEMC21 COMMON SENSE MAY/JUNE 2021

LEGISLATORS IN THE NEWS

House Engrossed nonretaliation policies; health care institutions

State of Arizona House of Representatives Fifty-fifth Legislature First Regular Session 2021

HOUSE BILL 2622 AN ACT AMENDING SECTION 36-450.02, ARIZONA REVISED STATUTES; RELATING TO HEALTH CARE INSTITUTIONS.

(TEXT OF BILL BEGINS ON NEXT PAGE)

H.B. 2622

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Be it enacted by the Legislature of the State of Arizona: Section 1. Section 36-450.02, Arizona Revised Statutes, is amended to read: 36-450.02. Nonretaliatory policy; definition A. Each health care institution THAT IS licensed pursuant to this chapter shall adopt a policy that prohibits retaliatory action against a health professional who in good faith: 1. Makes a report to the health care institution pursuant to the requirements of section 36-450.01. 2. Having provided the health care institution a reasonable opportunity to address the report, provides information to a private health care accreditation organization or governmental entity concerning the activity, policy or practice that was the subject of the report. B. A THIRD-PARTY CONTRACTOR OF A HEALTH CARE INSTITUTION MAY NOT TAKE RETALIATORY ACTION AS PROSCRIBED IN THIS SECTION. B. C. This section does not prohibit a health care institution THAT IS licensed pursuant to this chapter from taking action against a health professional for a purpose THAT IS not related to a report filed pursuant to section 36-450.01. C. D. Except as provided in section 23-1501, subsection A, paragraph 3, subdivisions (a) and (c), this section shall only be enforced ONLY through the provisions of this chapter. D. E. There shall be IS a rebuttable presumption that any termination or other adverse action that occurs more than one hundred eighty days SIX MONTHS after the date of a report made pursuant to either subsection A, paragraph 1 or 2 of this section is not a retaliatory action. F. FOR THE PURPOSES OF THIS SECTION, "THIRD-PARTY CONTRACTOR" MEANS AN ENTITY THAT CONTRACTS WITH A HEALTH CARE INSTITUTION TO PROVIDE HEALTH CARE SERVICES IN THE HEALTH CARE INSTITUTION BY CONTRACTING OR HIRING HEALTH PROFESSIONALS.

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COMMON SENSE MAY/JUNE 2021

AAEM Foundation Contributors – Thank You! Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 1-1-2021 to 4-1-2021. 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.

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COMMON SENSE MAY/JUNE 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 1-1-2021 to 4-1-2021.

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

AAEM Conferences 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

October 12, 2021 TAEM Virtual Residents’ Day and Annual Meeting Virtual www.aaem.org/education/events

Jointly Provided

October 26-30, 2021 Emergency Medicine Update Hot Topics Jointly provided by UC-Davis Health Maui, HI www.aaem.org/education/events

Re-Occurring Monthly Unmute Your Probe - Virtual Ultrasound Course Series Jointly provided by EUS-AAEM Virtual www.aaem.org/eus

September 29, 2021 AAEMLa Residents’ Day and Annual Meeting Jointly provided by AAEMLa Shreveport, LA and livestreamed locally in New Orleans and Baton Rouge www.aaem.org/aaemla

COMMON SENSE MAY/JUNE 2021

AAEM Recommended Conferences May 21-23, 2021 ACAIM Academic International Medicine Conference Virtual www.acaim.org/AIM-2021 8-12 June 2021 International Virtual Conference on Emergency Medicine (ICEM21) Virtual www.icem21.com

PLATFORM STATEMENTS

Dear AAEM Member, Enclosed are the candidate statements for the 2021 AAEM Board of Directors Election. As you are aware, the call for nominations was sent to all voting members. Those AAEM members who appear on the enclosed ballot have indicated their willingness to serve on the AAEM board. Statements from each of the candidates full listing of previous board service and awards, and AAEM activities dating back five years (2016 and greater) are on the following pages. Please review the enclosed information, then exercise your democratic right to vote for the representatives you would like to see serve as AAEM’s leaders. Remember, we have a one member, one vote system, so your voice counts. Please follow these instructions for casting your ballot in the 2021 election. If You Will Attend the Scientific Assembly: • We recommend that you do not complete your official ballot at this time. There will be a Candidates’ Forum held during the Scientific Assembly on June 22, 2021, 9:00am-9:45am, where you can hear the candidates respond to direct questions from the voting membership. You will be asked to submit your ballot online at the conclusion of that Forum. • If certain of your choices or unsure if you will attend the Forum, you may vote online at www.aaem.org/elections. Voting will remain open until June 22, 2021 at 11:59pm CT. If You Are Unable to Attend the Scientific Assembly: • You may complete your official ballot online at www.aaem.org/elections. Online voting will remain open until June 22, 2021 at 11:59pm CT. Balloting Procedure for 2021: • Voting ballots will only be available online. Please visit www.aaem.org/elections to cast your vote electronically. Thank you for your continued support of AAEM. Please call (800) 884-2236 with any questions you may have regarding the election procedure. Sincerely,

Missy Zagroba, CAE Executive Director

COMMON SENSE MAY/JUNE 2021

PLATFORM STATEMENTS

Phillip A. Dixon, MD MBA MPH FAAEM CHCQM-PHYADV CANDIDATE FOR AT-LARGE DIRECTOR Ohio State University Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; Jonathan S. Jones, MD FAAEM Membership: 2013-2021 Disclosure: Nothing to disclose at this time. AAEM Activities (past five years) AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors AAEM/RSA Advocacy Committee Chair AAEM/RSA Board of Directors AAEM/RSA Representative Council AAEM/RSA Legacy Assembly

AAEM Marketing & Membership Consultant Task Force Government and National Affairs Committee Member Mediterranean Emergency Medicine Congress Abstract Judge Social Media Committee Board Liaison Scientific Assembly Student Ambassador Mentor Young Physicians Section Board of Directors

Candidate Statement To the membership of AAEM, I would first like to thank you for the opportunity to serve as the AAEM YPS Director for the past 2 years. I am running for re-election to the board, but this time as an At-Large board member. It has been my honor to have represented the young physicians section and young physician as a whole on the board for the past 2 years. I’d like to think that I was able to bring unique perspectives to AAEM by being a recent residency graduate. I am asking for the opportunity to continue to serve on the board for AAEM, and to continue to advocate for emergency physicians and the unique challenges we face. My personal goal for 2021 is to use my role on the board to advocate for all physicians who have been impacted by COVID-19, particularly due to a depressed job market. Many EM physicians are having a hard time finding open positions in a depressed job market due to hours restrictions and staffing cuts. We also continue to see the number of EM residencies rise due to private equity and other for-profit systems. I believe in AAEM’s message and believe AAEM is a leader when it comes to these issues. It is my goal that we continue to fight for the every day emergency physician and continue to be the voice against the abuses against ourselves and our specialty. In terms of my personal background, I have tried to bring some additional knowledge and skill sets to the AAEM board, as I have a background in business and finance as I have received an MBA degree. I also am a board certified physician advisor and work in my hospital on billing and coding, as well as reimbursement from government and private payers. This past year, I have helped develop AAEM’s business plan for this current year and have worked on several task forces and committees. I have been involved with AAEM since my second year of residency. I was on the executive board of RSA as a resident and YPS board as a recent graduate. I believe in AAEM’s mission and values above all else. AAEM has a unique perspective on physician advocacy and fair practice, which speak to me as a clinician. AAEM is the premier EM physician organization and I am so proud to be a member of such a strong and dedicated organization. I will continue to be an active member in AAEM as long as I am an emergency physician. In terms of other roles I have, I am currently the Assistant Medical Director of the University Hospital at The Ohio State Wexner Medical Center in addition to the Program Director for the Physician Advisor and Peer to Peer program. I hope to be able to continue to serve on the AAEM board. I can’t thank the members of AAEM enough for everything it has done for me as a person, clinician, and leader in emergency medicine. Thank you.

COMMON SENSE MAY/JUNE 2021

PLATFORM STATEMENTS

Al O. Giwa, LLB MD MBA MBE FAAEM Mount Sinai – New York

CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; Jonathan S. Jones, MD FAAEM; LE Gomez, MD MBA FAAEM Membership: 2012-2021 Disclosure: Nothing to disclose at this time. AAEM Activities (past five years) Attended 2021 AAEM Leadership Academy Program Academic Affairs Committee Clinical Practice Committee International Committee

Legal Committee Ethics Committee Chair MEMC Abstract Reviewer Oral Board Review Course Examiner

Candidate Statement It would be an honor to serve on the BOD of AAEM. I graduated from the University of Ilorin with a law degree, studied Philosophy at Clark University, and attended Columbia University for medical school, with the original intent of becoming a bioethics professor. Along the way, I started and led several companies to include a healthcare, legal, and management consulting firm based in NYC. I obtained an MBA from GWU, and while faculty at the Icahn School of Medicine and as a member of the healthcare ethics consult service, I obtained a masters of science in bioethics from the combined Clarkson University/Icahn School of Medicine program. Like many of you, I joined AAEM (serving on the International and the Clinical Practice Committees) to become part of an organization that truly cared about all EPs. As a former attorney and member of the Legal Committee, I relish in being part of a group that advocates for all EPs and uses its influence to right some of the wrongs in our respective practices. To that end, I felt a moral pulse needed to be demonstrated by the organization, and I successfully lobbied for the creation of the first Ethics Committee, to which I have the honor of serving as its founding Chair. In that role, I have helped to create position statements and codes of ethics that will propel AAEM to the forefront of forward-thinking ethical organizations. I have leveraged my years as a leader, both as a civilian and in the military to educate current and future leaders on the role ethics plays in achieving leadership success. I was most recently an Associate Professor at the Icahn School of Medicine at Mount Sinai, but have taken a position leading COVID disaster response under FEMA’s auspices, given my unfortunate first-hand knowledge of the COVID crisis in New York and as an author of several papers on the disease. As a member of the military I am the Command Surgeon for the US Army Innovation Command and head of medical innovation, and have led and taught several units on the importance of ethical and equitable leadership and behavior; leading the Equal Opportunity Liaison role in my previous unit and teaching on Sexual Harassment/Assault Response and Prevention. I am currently preparing for a combat deployment in support of current US objectives. Having the diversity of thought from my legal, medical, business, ethics, and military backgrounds will provide a needed source of knowledge and experience to help better reflect the diverse membership of the Academy.

COMMON SENSE MAY/JUNE 2021

PLATFORM STATEMENTS

LE Gomez, MD MBA FAAEM

University of Maryland Charles Regional Medical Center

CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; Mark Reiter, MD MBA FAAEM Membership: 2006-2023 Disclosure: Nothing to disclose at this time. AAEM Activities (past five years) AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors AAEM Physician Group (AAEM-PG) Board of Directors Attended 2021 AAEM Leadership Academy Program Capital Region Chapter Division of AAEM (CR/AAEM) Board of Directors Chapter Division Committee

Social EM and Population Health Interest Group Board Liaison DEI Committee DEI Committee Board Liaison Government and National Affairs Committee MEMC Abstract Reviewer MEMC Speaker Scientific Assembly Speaker

Candidate Statement Dear AAEM Colleagues, It has been a humbling experience to serve our academy in defense of our specialty and the promotion of fair and equitable practice environments. As I asserted in my first candidate statement, without AAEM to protect the right of EM specialists to define and control our practice and advocate for its integrity, the best interests of our patients will be compromised. As large corporate groups continue to put profits before patients (or any of us), the expansion of services within our AAEM-PG and new AAEM Locums Group (LG) (both efforts I had the honor of contributing to) are essential in order to help change the landscape of our practice. I plan to increase the number of members that participate in the collective effort to push this agenda forward. With the help of exceptional colleagues on our board, we have taken action to defend our specialty in court, in the legislature and using hospital contracts to protect due process and protect independent groups. We are bringing forward concrete steps to increase diversity, equity and inclusion with real initiative to change the demographics and culture in our specialty society. Our goal is to ensure AAEM is a truly democratic and transparent organization committed to living up to our values and spreading that message worldwide. These are not just platitudes, but real programs you will see in effect at our upcoming Scientific Assembly in St. Louis this June. We are also looking at how we invest so that we put our money where our mouth is, to market our strengths and grow, and promote equity and inclusion using our financial power and influence. These are tangible efforts to address the crisis of violence, divisiveness and hatred that threatens to overtake all our democratic institutions and erode the social fabric that would threaten our specialty. As the ancient African proverb reminds us “if you want to go far, go together.” With your vote, I will continue to work to ensure that together, all of us at AAEM continue to walk the walk.

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PLATFORM STATEMENTS

David R. Hoyer, Jr., MD FAAEM First Choice ER

CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: Jonathan S. Jones, MD FAAEM; Robert McNamara, MD MAAEM FAAEM Membership: 1995-2021 Disclosure: Nothing to disclose at this time. AAEM Activities (past five years) Free Standing Emergency Centers Interest Group Wellness Committee Texas Chapter Division of AAEM (TAEM) Board of Directors Scientific Assembly Student Ambassador Mentor

Inter-American Emergency Medicine Conference Speaker MEMC Speaker Oral Board Review Examiner Mitchell Goldman Service Award

Candidate Statement My fellow AAEM members, I am running for the Board because we have a wellness crisis in emergency medicine! I have been a member of AAEM’s Wellness Committee since its inception. I am also a Founding Member of AAEM and a past Scientific Assembly invited speaker. My Restoring Wellness campaign has 3 planks: Restoring Due Process- we need to get the due process waivers that are ubiquitous in our contracts outlawed. There already exists federal legislation, the “ER Hero and Patient Safety Act”, to do just that. It was introduced in the last Congress as HR 6910, but was not pushed hard enough to receive a vote. I intend to get AAEM’s lobbyists to get the ER Hero Act introduced and pushed in the current Congress after getting it tweaked by AAEM’s lawyers to close a couple of loopholes. After all, we deserve due process just like all the other medical specialties! The rationale for due process waivers is no longer valid. The waivers made their appearance back when staffing companies were hiring doctors trained in other specialties and hospitals wanted the option to “unschedule” those who weren’t up to practicing emergency medicine. Now, of course, due process waivers are used for nefarious purposes like firing doctors who speak up about working conditions or who get a complaint an administrator deems problematic. Restoring Mental Health- burnout, depression and suicidality are rampant in medicine! Our suicide rate is twice the national average. Burnout percentage for emergency medicine is in the 50th percentile. Burnout tends to be systemic, with many solutions which should be encouraged. I have addressed depression in my publication “I Came Back from Depression, and So Can You”, which is online. Finally, we need to continue to encourage the Federation of State Medical Boards and its fifty members to continue to update licensing (when needed) to encourage physicians to get help without fear of stigmatization. Restoring respect and fairness- we all are very privileged to be in one of the finest professions in the world! Sadly, there are too many physicians, in particular those in positions of power such as medical directorships or contract holders, who are willing to throw colleagues “under the bus”. I understand the pressure to pay off the mortgage and fund your kids’ college. But at the end of your careers sitting on a bigger pile of money is going to be cold comfort if you abused your colleagues en route. To each AAEM member, I am asking for two things. First is your vote. Second is for your support to do what you can for my 3 planks. In particular, the ER Hero Act will need everyone to contact your legislators. There will be opposition from CMGs and their owners on Wall Street. But if we pull together we can get the ER Hero Act passed, which would go a long way toward restoring wellness in emergency medicine.

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PLATFORM STATEMENTS

Bobby Kapur, MD MPH CPE FAAEM Allegheny Health Network Emergency Medicine Management

CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: David A. Farcy, MD FAAEM FCCM Membership: 2012-2021 Disclosure: Nothing to disclose at this time. AAEM Activities (past five years) AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors Academic Affairs Committee Member Academic Affairs Committee Board Liaison ACCME Subcommittee Board Liaison Education Committee Board Liaison India Chapter Division of AAEM (AAEMi) Board Liaison

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

Candidate Statement For all of us, 2020 has been a transformational year. We have been impacted in ways both great and small. We have been held up as heroes while at the same time we have witnessed and experienced physical and mental strain. Through the uncertainty and chaos, we have supported one another. We have remained united as a specialty as members of AAEM. We fought for due process and the freedom to voice our observations and concerns from the frontlines. We advocated for protections while we risked exposures in our Emergency Departments, and we made unique advances in how we practiced medicine. As we emerge from this global pandemic, we need to reflect thoughtfully on the multiple ways this experience has shaped our specialty, and we need to determine what changes we want to embrace and what we need to prevent from ever happening again. As an emergency public health expert, I know AAEM and our members will be at the forefront of these critical decisions. It has been an enormous honor and privilege to serve on the AAEM Board for the past 4 years, and I ask for your support for a 3rd term. I have focused much of my efforts on education and our future emergency physicians during the past 2 terms on the Board: • • • • • •

Leading the establishment of our new Online CME and Virtual Learning Platform Working with the Academic Affairs Committee, Education committee, Scientific Assembly Subcommittee and ACCME Subcommittee Mentoring and leading the Student Ambassador program at Scientific Assembly Guiding the Residency Visits program Serving as the Pre-Congress Chair for the Mediterranean Emergency Medicine Conference for 2019 and 2021 Integrating of the American Academy for Emergency Medicine in India (AAEMi) within AAEM

In addition to the advocacy and resources we provide our members, I believe the legacy we leave through the mentoring and guidance of medical students, residents and young physicians will be one of the greatest impacts we have on current and future generations of Emergency Physicians. The coming few years will bring new challenges, and I am confident that together we will find the innovative solutions that will elevate high quality emergency care, establish rights and protections for our emergency physicians and support our future colleagues coming out of training. We have always been the courageous voice and the Champion of the Emergency Physician.

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PLATFORM STATEMENTS

Robert P. Lam, MD FAAEM EMS PC / University of Colorado

CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; Jonathan S. Jones, MD FAAEM; Loice A. Swisher, MD FAAEM Membership: 2002-2021 Disclosure: Nothing to disclose at this time. AAEM Activities (past five years) AAEM-PG Consultant Attended 2021 AAEM Leadership Academy Program 2021 AAEM Leadership Academy Program Speaker Wilderness Medicine Interest Group Social Media Committee Wellness Committee Chair Scientific Assembly Speaker

Scientific Assembly Diagnostic Case Competition Top Faculty Discussant MEMC Abstract Reviewer Oral Board Review Course Examiner Mitchell Goldman Service Award Leadership Academy Speaker

Candidate Statement Having been a member of AAEM since I was a resident, I have personally seen the value of AAEM and how it makes a difference for its members. I had the privilege of founding and serving as Chair of the AAEM Wellness Committee for the last six years. Serving as Chair allowed me to see how AAEM is truly the advocate for the personal and professional well-being of the individual emergency physician. I am very proud of the work that the Wellness Committee continues to do for our members. We advocate for well-being with positions that aim to reduce unnecessary tasks, speak out against interruptions in the workplace, create experiences that invite members into the community through Airway storytelling at Scientific Assembly, collaborate with the SAEM on a Wellness Consensus Conference and launch campaigns with every other EM organization to fight the crisis of physician suicide. In the same way that AAEM is an advocate, I strive to be an advocate for the individual emergency physician in the issues that I believe are most pressing to our specialty. The issues that concern me the most: the constant threat of the corporate practice of medicine, lack of due process, nonphysician scope of practice, lack of diversity and equity, the crisis of physician burnout are issues that I have passion for because of my personal experience in the practice of emergency medicine. My passion for advocacy led me to found and continue to lead physician well-being efforts for the region at my own health care system as Director of Physician Wellness. I will continue AAEM’s use of position statements that use our power as a specialty society speaking with one voice to tell the story of our colleagues that are being unjustly terminated without due process for advocating for our patients. I will collaborate with our colleagues in other professional societies towards our shared goals of promoting physician well-being and diversity, equity and inclusion. I will work with our government and national affairs committee to continue to support legislation like the the Dr. Lorna Breen Health Care Provider Protection Act. Finally, I will support the work of our EM workforce committee to continue to advocate for appropriate scope of practice for non-physicians through research and public outreach. If elected, I will continue to embrace my role of advocating for you in every way possible towards these issues that threaten our beloved specialty of Emergency Medicine.

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PLATFORM STATEMENTS

Carol Pak-Teng, MD FAAEM APA Physician Leaders

CANDIDATE FOR AT-LARGE DIRECTOR Nominated by: David A. Farcy, MD FAAEM FCCM; Evie Marcolini, MD FAAEM FACEP FCCM Membership: 2017-2027 Disclosure: ACEP Membership including: American Association of Women Emergency Physicians, Chair of Awards Committee for Diversity Inclusion & Health Equity Section, NJ ACEP Council member AAEM Activities (past five years) AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors Attended the 2021 AAEM Leadership Academy Program Ethics Committee Membership Committee

Wellness Committee Women in EM Section Liaison Emergency Ultrasound Section Board Liaison Marketing & Membership Consultant Task Force EDI Management Task Force New York Chapter Division of AAEM (NYAAEM)

Candidate Statement I am honored and proud to be nominated by Dr. Farcy and Dr. Marcolini for a second term to the Board. Simply said, AAEM has become my heart and soul. Its uncompromising values of transparency, democracy, and championing Emergency physician led patient care solidifies my passion and drive to this organization. It has been an incredibly tough year for EPs, to say the least. Our residents have entered the toughest job market in a generation; in parallel we are seeing our hours and salaries slashed while simultaneously putting our lives on the line and dealing with the burn of PTSD. Now more than ever, AAEM needs to advocate and emphasize to our members that we are there for them. It is also an opportune time to engage with our non-member colleagues, emphasize our mission statement, and bring them into our AAEM family. My efforts on the Board have centered on marketing and communications strategies to amplify our core values and messaging to our community. Being on the Board, I know that our leadership at every level is forging the steps to be the dominant voice to protect our profession. That said, we have more work ahead of us to build our voice more strategically and deliberately. The planning and execution of the work I have done on the Board will be my persistent focus. As a recent member to the board, I still have fresh enough eyes to view the organization holistically and drive the transformative changes we need to become the leading force protecting our specialty. Furthermore, I now have hands-on experience to navigate, communicate, and manage the next step in AAEM’s organizational growth. Some highlights of my time on the Board: hiring a marketing consultant for expert assessment of the member’s needs and how we can better represent our profession; serving as Board Liaison to two innovative cohorts within our Academy, the Women in EM Section and the Emergency Ultrasound Section; evaluating the organizational aspect of working with our Management company and how to better serve the membership with their partnership; lobbying efforts around Due Process, Surprise Billing, and Physician Mental Health Advocacy. Finally, I’m excited to expand the newly formed Ethics Committee to ensure we continue to uphold principles of fairness and advocacy in how we deliver patient care and how we operate as an organization. As an entrepreneur, I have learned how to be both agile and innovative. We have an opportunity to take AAEM to the next level. From the tragedy of the pandemic, we can emerge stronger and with more fortitude. If you would give me the honor of a second term, I will continue to push AAEM to be the innovative force on the National forefront. Thank you for your support and I look forward to serving you by hearing your voice.

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PLATFORM STATEMENTS

Fred E. Kency, Jr., MD FAAEM University of Mississippi Medical Director

CANDIDATE FOR YPS DIRECTOR Nominated by: Jonathan S. Jones, MD FAAEM; Cara Kanter, MD FAAEM Membership: 2015-2021 Disclosure: Mississippi ACEP State Councilor. AAEM Activities (past five years) YPS Board of Directors DEI Committee 2020 Scientific Assembly Abstract Reviewer

AAEM/RSA Board of Directors AAEM/RSA Education Committee AAEM/RSA Diversity & Inclusion Committee

Candidate Statement I, Fred Earl Kency Jr., MD have been an active and contributing member of AAEM for over six years. Since 2015 I was active in AAEM/RSA and AAEM. I have served in multiple roles such as on the Board for Young Physician’s Section AAEM, At-Large Board Member Resident Student Association AAEM, Vice Chair education committee Resident Student Association AAEM, and a number of other capacities. I lead the creation of the monthly social media publication “AAEM YPS Member Spotlight” that selects one member each month to showcase that member’s accomplishment to the entire Academy. The social media platform has been a great success and one of my most exciting accomplishments. I am a Veteran of the United States Navy where I served four years of Honorable active duty. That tour included the deployment and management of troops in Africa, Europe, and Guam. Currently I work both in Academic and Community Emergency Medicine in Jackson, MS where I have the honor to continue to serve my passion for the community as well as my passion to educate the next set of Emergency Medicine Leaders in Health Care.

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PLATFORM STATEMENTS

Brian Parker, MD MS FAAEM UT Health San Antonio

CANDIDATE FOR YPS DIRECTOR Nominated by: Self-nomination Membership: 2015-2021 Disclosure: Nothing to disclose at this time. AAEM Activities (past five years) Attended 2021 AAEM Leadership Academy Program Open Mic Competition 1st Place Winner

Scientific Assembly Speaker YPS Education Committee Member

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

COMMON SENSE MAY/JUNE 2021

ABEM NEWS

Kim M. Feldhaus, MD and Theodore J. Gaeta, DO MPH Elected to the ABEM Board of Directors The Board of Directors of the American Board of Emergency (ABEM) has elected two new members: Kim M. Feldhaus, MD and Theodore J. Gaeta, DO MPH. Dr. Feldhaus is an emergency physician practicing at Boulder Community Health in Boulder, Colorado, a community-based not-forprofit hospital. She also serves as the founding Medical Director of the Sexual Assault Nurse Examiner (SANE) program. Dr. Feldhaus has been an ABEM oral examiner since 2001 and an exam item writer since 2020. She completed Emergency Medicine residency training at Denver Health Medical Center. Dr. Gaeta is Vice Chairman for Academic Affairs and Program Director for the Department of Emergency Medicine at New York-Presbyterian Brooklyn Methodist Hospital. He also serves as the Chief Research Officer for the institution. Dr. Gaeta has been an ABEM oral examiner since 2002. He completed his Emergency Medicine residency training at Lincoln Medical and Mental Health Center in the Bronx, New York, and received his M.P.H. degree from Columbia University. Dr. Feldhaus and Dr. Gaeta will begin their terms on the Board of Directors in July 2021. The ABEM Board of Directors is comprised solely of volunteer directors: one public member director, with all other directors being board-certified, clinically active emergency physicians who actively participate in ABEM continuing certification, a process of continuous learning and periodic assessment.

2021 Recipients of ABEM 30-year Certificates Emergency Medicine was recognized as the 23rd medical specialty in 1979, and the American Board of Emergency Medicine (ABEM) administered the first certification examinations in 1980. ABEM recognizes physicians who, as of December 31, 2020, have marked 30 years of being board certified in Emergency Medicine with a special certificate. Because board certification is a voluntary process, this landmark accomplishment reflects a dedication to the specialty of Emergency Medicine, a commitment to continuous professional development, and the long-standing provision of compassionate, quality care to all patients. To maintain certification for 30 years, ABEM-certified physicians must participate in a program of continuous professional development and learning in the specialty. The ABEM continuing certification process consists of activities that assist certified physicians keep current with medical advances and provides opportunities for practice improvement. Physicians must also pass the ConCert Examination (a clinically focused, comprehensive examination) every ten years. ABEM salutes these physicians for their dedication to the specialty, their recognition of the value of board certification, and their commitment to caring for acutely ill and injured patients. ABEM-certified physicians are among the finest health care providers in the United States. Each of them exemplifies the ABEM mission, “To ensure the highest standards in the specialty of Emergency Medicine.” A list of the over 500 physicians who have reached this milestone is available here: www.abem.org/public/docs/default-source/default-document-library/30-year-certificate-receipients-2021_list.pdf.

AAEM Online New and Improved AAEM Online The new AAEM Online premiered in the spring of 2020. The library consists of AAEM19, select AAEM20, and other educational content. Watch your weekly Insights newsletter for new content. New Features: • CME now available for educational activities • FREE for AAEM and AAEM/RSA members • Accessible to non-members for $99/year Access AAEM Online at: www.aaem.org/aaem-online

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AAEM NEWS

Careerealism: It’s Not Your Imagination: No Jobs Anywhere Thomas L. Belanger, MD FAAEM

the employer. This also meant that I counted job listings for EDs, urgent care centers, medical spas, sports events, speaking engagements, and other similar listings (even though they may not all be considered equal by prospective applicants). I read every post from June 6, 2018, the group’s inception, to Dec. 14, 2020. It was a horribly depressing read, as you will see.

Table 3. Total EM Docs Jobs Posts by Type

hen I last applied for jobs before my family’s move to Texas at the end of 2014, all an emergency physician had to do was wait for the free steak dinner. I often joked to my family that you could be offered a job before a recruiter even knew your name.

Table 1. Job Listings over Time

Flash forward to the present, and suddenly it seems as if there are no jobs anywhere. Two often-cited factors are the use of advanced practice providers as cheaper labor and private equity encouraging an overproduction of residents. The COVID-19 pandemic may have exacerbated the problem. The reasons for this shift are important, but there is some debate over whether a problematic shift exists. The question then is: How has the market for emergency physicians changed?

Classifying Posts I used an unconventional data source for these data: the EM Docs Jobs Facebook group. This group started in mid-2018, and has about 7200 members who use it to post job listings and requests for employment. This appealed to me as a data source because it is an organic, honest dataset; the page contains information on both sides of the employment market, employers and employees; and there is a time-stamped electronic log of posts. I read each post and classified it as a job listing or a request for employment; other types were not included. Some posts were difficult to classify; as a general rule, I classified it as a request if it seemed the poster was trying to recruit employers. A post was classified as a job listing if somebody posted contact info for a paid job, even if the poster was not

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Table 2. Employment Requests over Time

Results Examining the posts over the life of the group, both job listings and requests show a numerical increase over time, likely due to increasing membership in the Facebook group and some seasonality. (Tables 1 and 2.) Transposing the two histograms paints a much clearer picture, however. (Table 3.)

AAEM NEWS CAREEREALISM: ITS NOT YOUR IMAGINATION: NO JOBS ANYWHERE

Table 4. Proportional Posting Types over Time

The job listings and requests seem to match up fairly nicely in mid-2018 through the first part of 2019, at which point a major change seemed to have occurred. After this point, growth in job requests far outpaced growth in job listings. Let’s view this another way, by the percentage of all posts by type for each month. (Table 4.)

Table 6. Resampling Distribution of Early Posts

No Surprise Membership in this group is not constant. As the number of members increases (as it has done over the years), one would expect that the number of posts for job listings and requests to increase. This is why the relative composition of the two is more important. The most likely explanation for the trends demonstrated clearly in the data is that there are now fewer available jobs per emergency physician. There are, of course, other possible scenarios. These data may simply represent a change in the use of the page; more people are using the page to seek jobs than candidates. The data may also reflect a change in recruiting methods away from social media, though this seems unlikely. It also seems unlikely that the data may be a reflection of job scarcity due to the COVID-19 pandemic because the shift toward more requests begins before the months of the pandemic.

Table 5. Ratio of Requests to Listings over Time

Earlier posts to this group were a mix of job listings and requests, but the page was about 90 percent requests for employment at the end of 2020. It is valid to ask if this trend could simply be statistical noise. To answer this, let’s first rephrase the post counts as ratios of requests-to-listings and fit a linear regression line that correlates this ratio to time. (Table 5.) Not only does our t-test show statistical significance (indicating an exceedingly low chance of finding the observed data in the case that there is no correlation between time and the given ratio, p=3.89e-07), but our 95% CI shows that we expect the ratio of requests to listings to increase anywhere from 1.06 to 2.04 year over year (with a ratio of 1.54 as the expected value from the regression). Finally, let’s compare the observed data from the group’s first year (September through November 2018) to the same monthly interval in 2020. Using resampling, we can see how likely it would be to observe the data in 2020 if there were no difference between the two periods. (Table 6.) The vertical line representing the percentage of requests in late 2020 does not even touch the resampling distribution. The chance of seeing the current distribution if, in fact, the trend is simply statistical noise is 4.209457410^{-9}.

Further analysis could certainly be done on the quality of job listings. From an unscientific appraisal, the quality of job listings seemed to have deteriorated over time, with employers being more difficult to contact, prices being lower, and true career-focused emergency medicine jobs being fewer and farther between. Considering which requests for employment appeared to be successful and their characteristics that made them so would be another potential area for future exploration. Unfortunately, I think these data will not surprise anybody. It is my hope, however, that they may give numbers and pictures to the disenfranchisement that many emergency physicians are feeling and begin to inspire solutions. All code was written in R and can be found, along with the data, at https://github.com/splatton/EMDOCSJobs. Tom Belanger, MD, Emergency Medicine News: March 2021 - Volume 43 - Issue 3 - p 6-7, 2021 Wolters Kluwer Health, Inc. ©2021 This article first appeared in Emergency Medicine News, and is reprinted with permission. www.em-news.com

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AAEM NEWS

 Somehow, this case had taken

us through a broad sampling of emergency medicine: psychiatry, social determinants of health, trauma and resuscitation, and toxicology and addiction medicine.”

Just Another Overnight Leslie Crosby, MD and Laura B. Roper, MD

t was mid-April 2020 in the peak of the COVID-19 pandemic when I had one of the more bizarre, but enlightening cases of our careers. Late in the evening during an overnight shift, I signed up for a middle-aged female patient with the chief complaint of “fall.” Vitals were normal from triage, and the patient ambulated without difficulty into her room. I walk into the room and I see a somewhat disheveled, thin older woman sitting in the bed, taking off her shoes. When I ask what brings her in, she tells me, “About eight hours ago, I was up on a ladder on my stairs putting up fairy lights when I fell down the stairs. I hurt my right hip and my chest.” She described falling from five feet up the ladder and down almost a whole flight of stairs and minimal improvement of pain with OTC Tylenol. Denies LOC, head impact, headache, neck pain, vision change, numbness, or weakness. She’s not on blood thinners. She endorsed pain in her right chest and right hip where she hit the stairs, but no shortness of breath, cough, back pain, or abdominal pain. “Don’t take this the wrong way, but, can I ask why didn’t you come to the ED earlier?” I queried. “I thought it would get better...?” replied the patient. Huh. That’s kinda weird. I note that the patient has a nervous affect, but I don’t think much of it. I perform a brief trauma exam and see she has a large bruise on her right upper chest that’s pretty tender. Her chest wall is stable and her breath sounds are equal, but I am concerned she may have a broken rib. Because she fell from so high up, I asked our nurse to throw on a C-collar as well. I walk back and present the case to my attending and chief of our department Dr. Rich Hamilton. “I think we need to make this a level II. The mechanism is really concerning to me since it sounds like she fell at least 10 feet in total. She looks pretty well otherwise, but I don’t want to miss something.” We walk back to the patient’s room and he agrees. Dr. Hamilton calls a trauma alert over the loudspeakers and the trauma team joins us in the trauma bay as we wheel in the patient.

She is NOT having it. She refuses to let us transfer her onto the trauma stretcher and starts to become agitated and combative with the nurses. We assure her that this is what we do with every patient when we are concerned they could have life-threatening injuries, and we do our best to preserve her dignity during the exposure portion of the assessment. The trauma team takes over. The more she speaks, the clearer it becomes that our patient lacks the capacity to refuse care. She is oriented to person, place, and time, but the rest of her thought content is not making any sense. There is definitely some tangential thought, with flight of ideas. She is given 2 mg midazolam and she becomes more cooperative with the assessment. The FAST exam is negative for effusion and pneumothorax. There aren’t any obvious fractures on the chest X-ray. The X-ray of the pelvis was negative for fractures... but positive for contrast in the bladder? The patient had said nothing to me about recent hospitalizations. The trauma team takes over, and my attending and I step out to put in some orders and sign out to the overnight attending. Dr. Pollianne Ward, the overnight attending watches as the patient is wheeled to CT. “I recognize her. Wasn’t she just in here?” she asked. I check the chart for other visits – none for a couple years. “No, it’s her!” she exclaimed. We review the chart of the patient Dr. Ward had seen earlier this week. The patient’s name and DOB were different, but the story was almost exactly the same. I was on shift when the patient was here and one of our chief residents, Dr. Laura Roper was taking care of her. At the previous visit, the timeline and details of the patient’s presentation did not necessitate immediate trauma team activation. However, CT scans were ordered which didn’t show any traumatic injury, but demonstrated the presence of IV contrast in the renal system. This meant that she had received scans at another institution within the past 24 hours – again, no

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AAEM NEWS JUST ANOTHER OVERNIGHT

record of visits to our system in that time. Our patient told us she had had a “swallow study” at a different hospital... on a Saturday... in the middle of the COVID-19 pandemic. This wasn’t adding up. By then, Dr. Roper’s patient had demanded large amounts of morphine, close to 1.5 mg/kg of morphine for a small thin woman. She “hated” her nurse and “loved” her resident... until the morphine wore off.

patient. Despite her numerous efforts to build a relationship and appropriately advocate for complete evaluation for suspected serious injury, she left feeling kicked in the gut. Even though the patient was showing some concerning behavior and we, of course, must give her the benefit of the doubt that it is coming from a place of real illness, our patient’s words still hurt.

When the trauma team recommended an MRI to better visualize structures obscured by the contrast, our patient refused the MRI, so we sent the MRI tech home. Of course, about 30 minutes after the tech had arrived home, the patient agreed to have the study... only if she would receive large amounts of anxiolytics. By the time she was due to go for the study, our patient refused the study a second time, telling Dr. Roper, “You don’t care about me, you’ve done nothing for me, you are the worst doctor, something must be going on because I am in so much pain!” The patient ended up leaving AMA without an MRI, refusing to sign the AMA form, and saying that the team “had done nothing for her” despite multiple reassessments and discussions and generous repeated doses of narcotics and anxiolytics.

Getting back to my current experience with this patient, the CT scans of head, neck, chest, abdomen, and pelvis were finally uploaded. Nada. Except for... a lot of old contrast in her bladder. Huh. That would be consistent with very recent scans.

I had overheard Dr. Roper field a few of these phone calls, amid a thousand of her other responsibilities. She tirelessly took each of our patient’s concerns seriously, and made every effort to accommodate her, despite the verbal abuse. Our patient had accused her of being a cruel person, a monster! Of course this wasn’t true. Dr. Roper was nothing but kind and generous to her. We wouldn’t do this job if we didn’t care a great deal about our patients. Dr. Roper left that shift traumatized and emotionally exhausted, even though she had obviously tried to do what was best for our

As I catch up on my documentation, Dr. Hamilton tells me he just spoke with the patient. In the privacy of the trauma bay, Dr. Hamilton confronted our patient about how she had been intentionally signing in with different names. She snapped back similar to before, saying Crozer was a horrible place and accusing us of being incompetent. Dr. Hamilton pulled up a chair, sat down, and asked, “What’s going on? Because none of this is making any sense.” “Don’t you get it? I am embarrassed and mortified to say this but I have a problem with narcotic addiction. I am covering up for my actions,” she confessed. Why didn’t she say so in the first place? “Would you like help? We can connect you with addiction assistance and behavioral health resources right now!” he offered. And she agreed to try going to rehab. I spoke with our patient myself. She seemed a bit shell-shocked from the whirlwind of events,

but was now completely lucid. It was like a switch was flipped. I guess there’s nothing like a trauma evaluation to help face your opioid dependence. I stepped out of the trauma bay, and I still felt pretty silly escalating the case to the trauma service. Dr. Ward assured me the case met our trauma criteria, that I had done the right thing. But regardless, I was amazed at the completely unexpected turn recent events had taken. Somehow, this case had taken us through a broad sampling of emergency medicine: psychiatry, social determinants of health, trauma and resuscitation, and toxicology and addiction medicine. I was reminded that the reasons our patients present to the ED are often multifaceted, and not at all limited to the boundaries of what we would encounter in an anatomy and physiology textbook. It is really difficult to take a step back from the labels our biases assign to patients, like “drugseeker” or “cannabinoid hyperemesis chronic abdominal pain” or “borderline,” and explore a broad differential of our patient’s complaints... especially when there are interpersonal challenges pulling at heartstrings. Despite all this, we have the incredible opportunity and responsibility to make a positive impact in these less clear-cut, but no less critical cases. I came away from this case humbled by the weird and wild world of EM, and the privilege to be a part of it. Fortunately, there was a hopeful ending. Our patient went to the crisis center. On the way out, our patient stopped by the charge nurse station and apologized to us. I was able to follow her case, and saw that she was engaging with treatment and opening up with her small group. We wish her the best for her recovery journey.

COMMON SENSE MAY/JUNE 2021

AAEM NEWS

Traumatic Urinary Catheter Insertion: A Case Presentation Jonathan M. Yaghoubian, MS DO and Jason Grabert, MD FACEP FAAEM

hief Complaint

Altered Mental Status & Gross Hematuria

HPI 83-year-old minimally verbal male presented with altered mental status and confusion. He was recently discharged from the emergency department (ED) after a fall and has been residing in a rehabilitation facility. The patient was found to be septic with positive blood cultures from the prior ED visit. A urinary catheter was placed in the ED. Gross hematuria was noted. The patient was subsequently admitted for further work-up and management of sepsis and hematuria.

Pertinent Physical Exam Well-developed, well-nourished, white male in no acute distress. Responded to painful stimuli only. Abdomen was soft, but bladder felt distended. Testes were descended without masses. Severe amount of scrotal and penile edema. No perineal crepitus noted. Urinary catheter was not draining. Gross hematuria was noted. Rectal examination revealed a large amount of stool in the rectal vault. Prostate was smooth. Good sphincter tones were noted.

Pertinent Laboratory Data Blood cultures grew gram positive cocci in clusters in 1 of 2 bottles. Urinalysis demonstrated red urine, bloody in appearance, large bilirubin, large blood, positive for nitrites, moderate leukocyte esterase, 50+ red blood cells, 50+ white blood cells.

Radiographic Images CT abdomen/pelvis without contrast was ordered to determine the source of hematuria.

Discussion The image above depicts a (1) traumatic urinary catheter insertion which is (2) not optimally placed. The catheter is inflated in the posterior urethra with the tip of the catheter in perineal fluid collection. There is free air noted in the perineum as well as the left buttocks. The free air and fluid collection are likely from the traumatic catheter insertion.

COMMON SENSE MAY/JUNE 2021

It seems that the catheter was placed in the ED and caused traumatic rupture of the urethra. Urology was consulted and the catheter was redirected into the bladder. The catheter needed to be in place for at least a month to allow for healing. The patient was at increased risk for Fournier’s gangrene and/or abscess formation as a result of this catheter insertion. With the recent availability of ultrasound in the ED, a point of care study can be performed by the ED physician to confirm placement of an urinarycatheter within the bladder. The provider should be able to readily visualize the balloon within the bladder.

Pearls 1. Care must be taken when inserting an urinarycatheter particularly in male, altered patients, as they are not able to convey discomfort as an alert and oriented patient. 2. When in doubt, confirmatory imaging, such as, point of care ultrasound or computed tomography may be used.

Disclaimer This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

One Scientific Assembly. Two Experiences.

#AAEM21

One Scientific Assembly. Two Experiences 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.

June 20-24, 2021 ST. LOUIS, MO

AAEM21

Attend In-Person or Virtually

AAEM will be following the current protocols as recommended by the Centers for Disease Control, City of St. Louis, and Hilton Hotels to ensure the safety of conference faculty, attendees, sponsors, and exhibitors.

Breve Dulce

These ever-popular “short and sweet” sessions are seven-minute overviews and 25 slides packed full of information! We listened to your feedback and there are more Breve Dulce sessions this year. Plan to catch a variety Breve Dulce topics at AAEM21 to round out your educational experience. Every 10 minutes there’s a new topic!

Five EM Docs Walk into a Shift Show Sunday, June 20, 2021 | 3:40pm-5:00pm Speakers from the AAEM Critical Care Medicine Section, Emergency Ultrasound Section, EMS Section, Women in EM Section, and Young Physicians Section walk you through a terrible case from ringdown to the dreaded transfer decision. Follow Dr. Molly Estes as she navigates through a bounce-back case, sharing her thought process, as she draws insight from all five sections to achieve that coveted save. Will she choose wisely? Will you? Disclaimer: Not your average lecture

Meeting of the Minds New at AAEM21! Join our plenary speakers as they debate the pros and cons of the latest practice-changing articles in pediatrics, public health, and critical care. Bring your questions for an audience Q&A with the experts.

Boost your CME by staying after AAEM21 and adding a postconference course.

COMMON SENSE MAY/JUNE 2021

One Scientific Assembly. Two Experiences.

#AAEM21

On Demand Sessions Select presentations will be available for on demand viewing in-person in St. Louis, online, and on the AAEM21 mobile app. Attendees can stream these lectures and earn CME anytime, anywhere throughout Scientific Assembly and after. Visit www.aaem.org/aaem21 for updates.

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

Competitions Plan to browse the poster displays or attend abstract presentations at AAEM21. The following competitions will be taking place during the conference. Learn more at www.aaem.org/aaem21/competitions.

Small Group Clinic

These sessions provide personal and hands-on education. At AAEM21 there are more options than ever before! 20 slots will be filled with advanced registration and10 slots will be available onsite on a first-come, first-served basis. These sessions are only available to in-person attendees.

Visit the Exhibit Hall to make new connections - Exhibiting and sponsorship opportunities available.

AAEM/RSA Resident Track at AAEM21

• AAEM and Journal of Emergency Medicine Resident and Student Research Competition • AAEM/RSA & Western Journal of Emergency Medicine Population Health Research Competition • Photo Competition • AAEM Young Physicians Section (YPS) Research Competition • Resident Breve Dulce Competition • Open Mic Competition – Onsite sign-ups available!

Relax & Recharge with Wellness Events Not only does AAEM21 offer enriching education, it is also a motivational retreat where you leave feeling a renewed passion for emergency medicine. Throughout the Assembly, stop by the Wellness Room for a sanctuary from the conference bustle. New this year: contribute to our AAEM21 puzzle. The AAEM Wellness Committee has also planned the following events to participate in for those attending in-person: F3 Wellness Meals, Early Risers Yoga, Airway at AAEM, and the Wellness Fun Run/Walk. Some events require pre-registration. Learn more at www.aaem.org/aaem21/wellness.

Residency to the Real World: The Missing Curriculum June 22, 2021 | 10:15am-5:50pm The AAEM21 AAEM/RSA Track – Residency to the Real World: The Missing Curriculum focuses on topics not typically covered in residency. The goal of the track is to prepare residents for their careers in emergency medicine by concentrating on topics such as interviewing, contract negotiation, health policy, ways to prevent burnout, and more.

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Take time to celebrate & recharge at social, DEI, and wellness events.

One Scientific Assembly. Two Experiences.

#AAEM21

Plenary Speakers MOIZ QURESHI, MD MBA COVID-19 Panel: Lessons Learned from the Pandemic Sunday, June 20, 2021 | 1:35pm-2:15pm

NADEEM U. QURESHI, MD FAAP FCCM COVID-19 Panel: Lessons Learned from the Pandemic Sunday, June 20, 2021 | 1:35pm-2:15pm

Network at Social Events Join AAEM for networking and other fun activities throughout the Assembly. Kick off AAEM21 at our Opening Reception. Enjoy light hors d’oeurves and drinks while networking with colleagues and exhibitors. Spend time with the Women in EM Section by attending their Luncheon and Coffee Meet-Up. Explore opportunities to get involved in AAEM with the Chapter Divisions & Sections Social. Attend Airway at AAEM for an evening which promises to showcase the great range of human experience — to enlighten minds, expose vulnerabilities, and quietly suggest ways to overcome the challenges we all face each day. Learn more at www.aaem.org/aaem21/socials.

Collaborate and network with colleagues from around the world.

Celebrate Diversity, Equity, and Inclusion New this year: AAEM21 will have specific outreach activities to focus on diversity, equity, and inclusion. Participate in the African American Outreach Program by bringing a Black non-member EM physician to attend the conference as your guest, with waived registration fees. Attend the DEI Reception at BBs Jazz, Blues, and Soups to celebrate the diversity of the Academy. And then conclude the Assembly by touring the Scott Joplin Historic Site. Learn more at www.aaem.org/aaem21/diversity.

SUSAN R. WILCOX, MD FAAEM COVID-19 Panel: Lessons Learned from the Pandemic Sunday, June 20, 2021 | 1:35pm-2:15pm

AL’AI ALVAREZ, MD FAAEM Overcoming Self-Judgment with Self-Compassion Sunday, June 20, 2021 | 2:25pm-3:10pm

ILENE CLAUDIUS, MD FAAEM FAAP FACEP Agitation in the Pediatric Emergency Department Monday, June 21, 2021 | 8:00am-8:45am

COREY M. SLOVIS, MD FAAEM FACP FACEP The Most Important EMS Articles of the Past 18 Months for Emergency Physicians Monday, June 21, 2021 | 11:15am-12:00pm MIMI LU, MD FAAEM What’s New in Pediatrics Monday, June 21, 2021 | 4:15pm-5:00pm

GLENN E. SINGLETON, MA Courageous Conversations About Race in Emergency Medicine Tuesday, June 22, 2021 | 1:30pm-2:30pm MICHAEL E. WINTERS, MD MBA FAAEM Recent Resus Articles You’ve Got to Know! Wednesday, June 23, 2021 | 8:00am-8:45am

AMAL MATTU, MD FAAEM Emergency Cardiology 2021: The Articles You’ve Got to Know! Wednesday, June 23, 2021 | 10:15am-11:00am COMMON SENSE MAY/JUNE 2021

One Scientific Assembly. Two Experiences.

#AAEM21

Keynote Speaker THEA L. JAMES, MD Tuesday, June 22, 2021 | 8:00am-8:45am The “Upstream” Transformation of Healthcare: Leveraging Emergency Medicine

Talk Description This keynote will present an imperative for shifting the healthcare paradigm through using upstream, root cause models of care. The speaker will highlight unique insights and opportunities for emergency medicine physicians in this evolving national transformation. Biography Thea James, MD, is Vice President of Mission and Associate Chief Medical Officer at Boston Medical Center. She is an Associate Professor of Emergency Medicine and Director of the Violence Intervention Advocacy Program at BMC. Dr. James is a founding member of the National Network of Hospital-Based Violence Intervention Advocacy Programs (NNHVIP). In 2011 she was appointed to Attorney General Eric Holder’s National Task Force on Children Exposed to Violence. As Vice President of Mission Dr. James works with caregivers throughout BMC. Additionally she has primary responsibility for coordinating and maximizing BMC’s

relationships and strategic alliances with a wide range of local, state and national organizations including community agencies, housing advocates, and others that partner with BMC to meet the full spectrum of patients needs. The goal is to foster innovative and effective new models of care that are essential for patients and communities to thrive. Integrating upstream interventions into BMC’s clinical care models are critical to achieve equity and health in the broadest sense. Dr. James served on the Massachusetts Board of Registration in Medicine 20092012, where she served as chair of the Licensing Committee. She is 2008 awardee of Boston Public Health Commission’s Mulligan Award for public service and a 2012 recipient of the Suffolk County District Attorney’s Role Model Award. She received The Boston Business Journal Healthcare Hero award in 2012 & 2015. She was 2014 recipient of the Schwartz Center Compassionate Care Award. The Boston Chamber of Commerce awarded Dr. James with the Pinnacle Award in 2015, which honors women in business and the

Visit the AAEM21 website for full educational details including session titles, speakers, and more! www.aaem.org/AAEM21

COMMON SENSE MAY/JUNE 2021

professions. Dr. James was awarded the 2019 Leadership in Medicine Award by the Massachusetts Public Health Association. Dr. James’ passion is in public health both domestically and globally. For many years she and colleagues partnered with local international partners in Haiti and Africa to conduct sustainable projects. She is a member of the Board of Directors of Equal Health. Equal Health works with local partners in Haiti to create strong, sustainable medical and nursing education systems. Dr. James served as a Supervising Medical Officer on the Boston Disaster Medical Assistance Team (MA-1 DMAT), under the Department of Health and Human Services. She has deployed to post 9/11 in NYC, Hurricane Katrina in New Orleans in 2005, Bam, Iran after the 2003 earthquake, and Port-Au-Prince Haiti after the earthquake of 2010. Dr. James traveled to Haiti with MA-1 DMAT one day after the 2010 earthquake. A graduate of Georgetown University School of Medicine, James trained in Emergency Medicine at Boston City Hospital, where she was a chief resident.

One Scientific Assembly. Two Experiences.

AAEM21 Speakers Michael K. Abraham, MD FAAEM Jason Adler, MD FAAEM Afrah Abdul Wahid Ali, MBBS FAAEM Al’ai Alvarez, MD FAAEM Stephanie Angel, MD Zeki Atesli, MD Andrew M. Bazakis, MD FAAEM Neeharika Bhatnagar, MD Michael Billet, MD Ellen Binder, MD Laura J. Bontempo, MD MEd FAAEM Joelle Borhart, MD FAAEM FACEP Matthew P. Borloz, MD FAAEM William J. Brady, MD FAAEM Cortlyn Brown, MD Katharine Burns, MD FAAEM Christine Joyce Butts, MD FAAEM Elisabeth Calhoun, MD David J. Carlberg, MD FAAEM Christopher R. Carpenter, MD MSc FAAEM AGSF Wan-Tsu W. Chang, MD FAAEM Eric J. Chin, MD MBA FAAEM Ilene Claudius, MD FAAEM FAAP FACEP Jared L. Cohen, MD Christopher Colbert, DO FAAEM James AP Connolly, MBBS FRCS(Ed) FCEM Krishna Constantino, MD Matthew C. DeLaney, MD FAAEM Phillip Arthur Dixon, MD MBA MPH FAAEM CHCQM-PHYADV Sean P. Dyer, MD FAAEM Erick Eiting, MD MPH MMM FAAEM Brandon A. Elder, MD FAAEM Molly K. Estes, MD FAAEM FACEP Bryan Everitt, MD Cheyenne Falat, MD David A. Farcy, MD FAAEM FCCM Emily Fite, MD FAAEM Jessica Fleischer-Black, MD FAAEM Jessica K. Fujimoto, MD Manish Garg, MD FAAEM Harman S. Gill, MD FAAEM Stephanie Goike, MD FAAEM Michael Gottlieb, MD FAAEM John C. Greenwood, MD FAAEM Tanner G. Greiving, MD Marc M. Grossman, MD FAAEM Alexander Gwynne, DO Joshua Guttman, MD FRCPC FAAEM FACEP

#AAEM21

Marc M. Grossman, MD FAAEM Bryan D. Hayes, PharmD FAACT FASHP Megan Healy, MD FAAEM Jacob Hempstead, NREMT-P Stanley Hempstead Beatrice Hoffmann, MD PhD FAAEM Jerry S. Hu, DO, PharmD Kami M. Hu (Windsor), MD FAAEM FACEP Korin B. Hudson, MD FAAEM Ashley Iannantone Ashika Jain, MD FAAEM FACEP Rupal Jain, MD Thea L. James, MD Paul S. Jansson, MD MS Andrew S. Johnson, MD MPH FAAEM Jonathan S. Jones, MD FAAEM James K. Keaney, MD MAAEM FAAEM Danya Khoujah, MBBS MEHP FAAEM Patrick G. Kishi, MD Diana K. Ladkany, MD FAAEM Skyler A. Lentz, MD FAAEM Mitchell Li, MD FAAEM David B. Liss, MD FAAEM Bruce M. Lo, MD MBA RDMS FAAEM Jacob Loesche, MD Mimi Lu, MD FAAEM Amy Marks, MD Joseph P. Martinez, MD FAAEM Wayne A. Martini, MD Amal Mattu, MD FAAEM Colin G. McCloskey, MD FAAEM Robert M. McNamara, MD MAAEM FAAEM Alexandre F. Migala, DO FAAEM Siamak Moayedi, MD FAAEM Robert Mohr, MD Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Sergey M. Motov, MD FAAEM Mohamad A. Moussa, MD FAAEM Melissa Myers, MD FAAEM Anthony Netzel, DO Michael D. Owens, DO FAAEM Patricia D. Panakos, MD FAAEM Brian Parker, MD MS FAAEM Gregory Patek, MD OD FAAEM Jack C. Perkins Jr., MD FAAEM Andrew W. Phillips, MD MEd FAAEM Roberta J. Pritchard, MD Marco Propersi, DO FAAEM Moiz Qureshi, MD MBA Nadeem U. Qureshi, MD FAAP FCCM

Steven Radloff, MD Mark Reiter, MD MBA MAAEM FAAEM Salim R. Rezaie, MD FAAEM Andrew Rizzo, DO FAAEM Lauren S. Rosenblatt, MD Alexis Salerno, MD FAAEM Maura E. Sammon, MD FAAEM Kraftin E. Schreyer, MD CMQ FAAEM Sean E. Scott, MD Amish M. Shah, MD MPH FAAEM Richard D. Shih, MD FAAEM Michael E. Silverman, MD MBA FAAEM FACEP Glenn E. Singleton, MA Zachary M. Sletten, MD FAAEM Corey M. Slovis, MD FAAEM FACP FACEP Ryan Spangler, MD FAAEM Adam Spanier, MD Eric M. Steinberg, DO MEHP FAAEM Bryan Stenson, MD Kathleen M. Stephanos, MD FAAEM Loice A. Swisher, MD FAAEM Veronica T. Tucci, MD JD FAAEM Julie Vieth, MBChB FAAEM Elias E. Wan, MD FAAEM James Webley, MD FAAEM Anne Whitehead, MD FAAEM Susan R. Wilcox, MD FAAEM George C. Willis, MD FAAEM Michael E. Winters, MD MBA FAAEM Joseph P. Wood, MD JD MAAEM FAAEM Gregory P. Wu, MD FAAEM Allen Yee, MD FAAEM Scott Young, DO FAAEM Andrew Zabel, DO Bob Zemple IV, MD FAAEM Matthew D. Zuckerman, MD FAAEM Speakers subject to change.

Rising Star speakers are mentees in the AAEM Speaker Development Group. Each year, AAEM members have an opportunity to apply to this program to develop their public speaking skills with an expert AAEM speaker. This year’s Rising Stars are denoted by a star () on the program. The year-long mentoring process culminates with the mentee delivering their presentation at Scientific Assembly. Come and see these rising star speakers.

COMMON SENSE MAY/JUNE 2021

One Scientific Assembly. Two Experiences.

#AAEM21

Thanks to Our 2021 Industry Partners The AAEM extends its thanks and appreciation to the following industry partners who have funded activities at the 2021 AAEM Scientific Assembly. CHAMPION SPONSOR – $50,000+ SUPPORT LEVEL • Gilead Sciences GOLD SPONSOR – $20,000-$49,999 SUPPORT LEVEL • Abbott • Bayer SILVER SPONSOR – $5,000-$19,000 SUPPORT LEVEL • DemeTech Corperation • Gryphon Healthcare • Masimo Corporation IN-KIND SPONSOR • Butterfly Network • EMedHome • FUJIFILM/SonoSite • PEPID

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AAEM21 Exhibitors – Thank You Plan your visit to the exhibit hall in St. Louis to network with these exhibitors. • Abbott • ABEM • Bayer - Crop Science • Biodynamic Research Corporation • ConsensioHealth • DemeTech Corperation • DuvaSawko • Gilead Sciences • Gottlieb • Gryphon Healthcare • NeurOptics, Inc. • North American Rescue, LLC • Pepid, LLC • SmartPractice • WestJEM • ZOLL Data Systems • Zotec Partners More to come! Visit www.aaem.org/aaem21/exhibitors-and-sponsors for the most up-to-date list.

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COMMON SENSE MAY/JUNE 2021

COMMITTEE REPORT

SPEAKER DEVELOPMENT GROUP SUBCOMMITTEE

Speaker Development Group Kevin Reed, MD FAAEM – Chair, AAEM Speaker Development Group Subcommittee

ooking for a way to polish your speaking skills and break into the EM lecture circuit? Consider applying for the AAEM Speaker Development Group program. A wonderful opportunity afforded to AAEM members, this exciting program is now in its fourth year. The goal is simple: we want to help you become a confident and engaging speaker. No formal speaking experience or training is required. So how does it work? The Speaker Development Group program matches interested individuals with nationally recognized AAEM speakers. This relationship is mentee led – as one of our amazing mentors said, “If you want to get better at speaking, I’m here for you.” So...does the program really work? As the saying goes – the proof is in the pudding. We reached out to current and previous participants and asked them about their experience as part of the Speaker Development Group. Check out their comments on the next few pages. For more information on this program and for details on applying for the 2021-2022 class, please visit the AAEM Speaker Development Group website: www.aaem.org/education/speaker-development-group A formal application link will open this summer. Hoping to see some of you in next year’s group. Stay safe!

Testimonials from Previous Speaker Development Group Participants

Afrah Abdul Wahid Ali, MBBS FAAEM The AAEM Speaker Development group is a brilliant path for junior faculty to obtain an opportunity to be able to speak on a national platform. This group will help guide you to better understand what areas you need to improve on to become a stronger public speaker. It helped me to focus and narrow down my niche and understand the pathway of becoming a successful national speaker. I had a great time working with my mentor, Dr. Amal Mattu, attaining a great wealth of knowledge about engaging and interacting with my audience. One of my greatest takeaways was learning that a clear and concise message, paired with an empowering story, is the key to establishing a connection with your audience. It is important to have an impactful takeaway and center your conversation around it.

Andrew M. Bazakis, MD FAAEM The AAEM Speaker Development [Group] program an excellent opportunity regardless of how much experience one has to get expert coaching to bring ones speaking skills to the next level. My mentor was able to provide fresh perspective and helpful suggestions, especially as regards to being prepared for both of the virtual and in person platforms amidst the uncertainty of the current pandemic transition. She introduced me to the concept of a walk-up song and how to channel one’s inner “Tony Romo.” I would recommend this program to speakers of all levels of experience.

Gregory P. Wu, MD FAAEM I have been interested in speaking at the national level after being inspired the by the likes of Mike Winters, MD FAAEM. Imagine my surprise when I found out who my mentor would be! I have sincerely enjoyed my discussions with Mike, and being able to put into words what separates a good talk from a great one. Working with Mike Winters, MD FAAEM and Speaker Development [Group] pushes emerging speakers to be better, and to adapt new and modern practices, which are sorely needed in medical education. From medical school onward we see thousands of slideshows, and can see over the decades how one type of presentation has dominated. We intuitively tell stories, but after years of medical education we suppress that ability, whether by social cuing or being overtly told not do that. Yet to reach an audience, they must first want to know, and telling stories forms an immediate connection. Rediscovering this skill, I have a much better idea of how to use this in future talks. For those interested in taking their speaking skills to the next level I would advise to not hesitate and consider this program.

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COMMITTE REPORT SPEAKER DEVELOPMENT GROUP SUBCOMMITTEE



If after your lecture you asked somebody in an elevator what they learned, they should be able to recite your chosen takeaways. If they don’t, you did not succeed at the task at hand.” Robert P. Lam, MD FAAEM My experience with the Speaker Development Group significantly changed my confidence and effectiveness as a public speaker and educator. It was a privilege to have a nationally recognized speaker like Dr. Mike Winters as my speaking mentor and instructor. I worked with Dr. Winters to build a foundation of best practices on becoming an effective and impactful speaker. In particular, our sessions on slide design have impacted my approach to visual aides to this day. Receiving direct feedback after viewing recorded examples on my speaking performance was also immensely helpful to my development.

Demis N. Lipe, MD FAAEM AAEM’s Speaker Development Group was a great experience. I was paired with a wonderful mentor who helped me not only develop my lecture for the Scientific Assembly, but also gave me plenty of feedback during the process to develop me as a speaker. We had phone and email communications often and I felt like there was always a pearl I came away with. Part of the experience was reading a very insightful book about public speaking by Lily Walters (Secrets of Successful Speakers), which I found very helpful and highly recommend to all those who want to improve their speaking skills. I feel like I am a much-improved speaker due to the efforts of AAEM’s Speaker Development Group, and my wonderful mentor. I am less scattered and more confident. The process allowed me to sharpen the skills I already possessed and find new skills I did not know I had. I would recommend this program to those that wish to improve their speaking abilities (whether they have had previous public speaking engagements or not). I would do this all over again, if I could!

Andrew W. Phillips, MD MEd FAAEM

I would highly recommend anyone interested in improving your skills as a speaker to apply for the Speaker Development Group at AAEM. No matter what roles you serve in your job, improving your public speaking skills will make you a more effective leader, teacher and physician

The SDG is a phenomenal opportunity and helped me grow as a speaker in ways not otherwise possible because it provides the fine-tuning that eventually becomes necessary. We can watch lectures and read chapters on the fundamentals—few words on the slide, T pattern walking, etc—but the next step of customizing your style and delivery to the topics you often discuss and varying venues, the “pop” that really good speakers have, requires 1-on-1 help from someone who has perfected the art not just for himself or herself, but for others as well to help you find your best delivery style. THAT is what the SDG does, and it is very, very effective.

Kraftin E. Schreyer, MDCMQ FAAEM

Vonzella Bryant, MD FAAEM FACEP

I’m very thankful for the opportunity to participate in AAEM’s Speaker Development [Group]. The experience was not too time intensive, yet still provided tremendous value. I entered the program thinking I was a decent speaker, but had no idea how much I could improve upon! Through the program, I gained skills on all aspects of presenting, including slide development, presentation style and topic selection. I thought the program was so valuable that I try to mimic it in our residency curriculum and teach those same skills I learned to our residents.

I participated in the Speaker Development Group program last year because I knew that I wanted to start doing presentations at a national level. The program was excellent! I enjoyed reading the book, “Secrets of Successful Speakers: How You Can Motivate, Captivate, and Persuade” by Lilly Walters. I was matched with the great, Dr. Joe Lex, to be my mentor. He was very easy to talk to and flexible with our meetings over Skype (preZoom times during COVID). I told Dr. Lex that I didn’t really like the sound of my voice for presentations when we first spoke. Hearing Dr. Lex, this fantastic, engaging speaker, say that he thought my voice was “just fine” meant so much to me. Dr. Lex gave me a lot of great tips for enhancing my presentation for AAEM last year called, “Increasing Diversity in Emergency Medicine: From Pipelines to Faculty Retention.” It was crazy seeing my picture next to Dr. Amal Mattu on the email announcement! I had three national EM presentations and a panel with these fantastic, powerhouse EM women physicians last year! I would definitely recommend the Speaker Development Group to anyone who wants to learn how to be an engaging speaker.

One of the most significant lessons I learned was the role of storytelling in public speaking. Even when talking about highly technical or scientific material, storytelling is an effective tool to connect to your audience and create a lasting impact.

I would highly recommend the Speaker Development [Group] to anyone interested in improving their speaking skills. Just one word of advice – embrace being uncomfortable during this experience! It was tough (really tough) to watch myself speak (for one ‘homework’ assignment, I had to film myself giving a presentation), but that exercise provided me with a new perspective and allowed me to adjust my mannerisms and cadence to enhance the presentation. Since completing the program, I’ve had more opportunities to speak on the regional and national stages and am looking forward to speaking at AAEM 2021!

COMMON SENSE MAY/JUNE 2021

COMMITTE REPORT SPEAKER DEVELOPMENT GROUP SUBCOMMITTEE

Patricia De Melo Panakos,MD FAAEM The AAEM Speaker Development [Group] program is an incredible and unique opportunity to get one on one mentorship from some of the most recognized speakers in the field of emergency medicine. The program is laid out as a series of virtual sessions where your mentor will do a thorough review of everything that it takes to be a successful and captivating speaker. You will develop a lecture with their assistance as well as obtain specific constructive feedback on areas such as content, visual appearance of slides, verbal delivery and connection with the audience. This experience certainly improved my slides and made me a more effective speaker. However, my favorite part about the program was working with Dr. Winters. He is a gifted speaker and his personal experience is unparalleled. He specifically imparted on me the importance of having a limited number of key takeaways you want to leave the audience with. If after your lecture you asked somebody in an elevator what they learned, they should be able to recite your chosen takeaways. If they don’t, you did not succeed at the task at hand. This brief yet powerful pearl is just an example of the many lessons I gained from this program and how they have changed the way I develop and deliver lectures. I recommend this program to anyone who wants to improve their speaking skills and is looking to become a national speaker. It is such an invaluable experience that I am surprised is a FREE benefit for AAEM members. Don’t wait, apply today!

Matthew P. Borloz, MD FAAEM I thoroughly enjoyed my time in AAEM’s Speaker Development Group when I participated in 2017-2018. I was paired with Dr. Amal Mattu, who took a great deal of time providing feedback on my slides and content and gave me some recommendations for resources he had used in the past as he developed his speaking chops. The Speaker Development Group provides a fantastic opportunity to establish relationships and engage with some of the masters of education in our field. In addition to the feedback I received directly from my mentor, I also noticed that colleagues of mine were more open with their feedback, since they knew I was in a program directed specifically at improving my speaking skills. I would strongly encourage other AAEM members to consider applying to the program.

Marco Propersi, DO FAAEM When I was a resident, I had the privilege of attending a lecture where Dr. Joe Lex was presenting. I can remember vivid detail of his discussion on the state of evidence on TPA in stroke. Though, what I remember most is his stage presence and the way he nonverbally engaged our attention. I even tried to emulate it during my senior resident talk later that year. I could not have been more excited to be paired with Dr. Lex as a speaking mentor. Working one-on-one with someone with a tremendous breadth of speaking experience has far exceeded my expectations. The pandemic has forced medical educators to move to web-based platforms for conference, which created the opportunity for my mentor to 40

COMMON SENSE MAY/JUNE 2021

attend live lectures and provide feedback. There were more than a few silver nuggets. We identified my overuse of some word fillers, worked to slow my delivery, and improved slide design. Dr. Lex also gave me sound advice on where to look for new speaking opportunities and to consider options outside medicine. Dr. Lex is an amazing teacher and a better person. He has extended himself above and beyond expectations. He’s reviewed my slides, watched videos of my recorded lectures, reviewed podcast outlines, listened to podcasts, and attended live lectures to help me improve. I cannot say enough about Dr. Lex. I highly recommend the Speaker Development Group. All speaking is public speaking. Improving in public speaking will make you a better and more confident speaker, teacher, administrator, physician and the list goes on.

Matthew D. Zuckerman, MD FAAEM Everyone should apply for the Speaker Development [Group] program. I got matched with Joe Lex, MD MAAEM FAAEM who is always available and gives constructive advice on every aspect of my talks. So often we view speaking skills as innate talent, but after talking to several leaders I learned that it really takes consistent practice and a reflective approach. Joe encouraged me to speak as much as possible, but at the same time, he gave feedback on my visuals before a talk and my performance after. With each session, we’d discuss a different aspect of preparation, recommended resources, personal pitfalls. Additionally, having a professional speaking mentor keyed me in that this was important and worth the time. It let my department head know that I was someone with specialized skills. I became a resource within my department because, in very little time, I had put more energy and thoughtfulness into public speaking than many of my peers. If you have ever given a talk or anticipate giving a talk (which is probably everyone reading this) I encourage you to consider applying. I encourage participants to treat this like any other professional development activity, expect to put some time into it and have measurable goals. The biggest epiphany I had was that being a good speaker is like any other skill, some people start out ahead of others, but those who succeed view it as a challenge to be mastered. There are no shortcuts but there are plenty of people who don’t put in enough time, rush through at the last minute, and then end up moving on from their talk as soon as it’s over, promising to do better “next time.” The people who get better realize that they need to plan ahead and give the talk to other audiences before taking it on the road. The most gifted speakers review their recording and audience notes in order to get better and better. Working with Dr. Lex was incredible. A one-on-one session forces each person to be candid but supportive. I was able to give a few different versions of something and get real feedback about why one worked more than the other. We worked on clarity, storytelling, and even how to choose a topic. Decades of experience taught him how to approach any situation and saved me hours of work.

INTEREST GROUP REPORT PALLIATIVE CARE

Hospital Associated Disability: Is Hospital Admission Really the Safest Disposition for Our Elderly Patients? Diana Huynh, MD and Austin J. Causey, MD

re we helping our elderly patients who are “too unsafe for discharge” by keeping them in the hospital? Emergency medicine (EM) physicians know this dilemma all too well. Imagine the 90-year-old patient who presents from home after a neighbor calls 911. The patient arrives via EMS and explains that her neighbor was worried by the amount of time she was spending in the house. She says that after some discussion with her neighbor and EMS, she agreed to come to the ED for a “checkup.” The patient in your emergency department is frail and disheveled. She is ambulatory with a cane and lives alone. You complete a work up and find only that her urinalysis is equivocal for a UTI. You’re preparing to discharge the patient but worry, “is this frail and disheveled 90-yearold woman safe for discharge back to her home alone?” As EM physicians we have limited exposure to the patient experience after patients are admitted — hospitals can be dangerous places for the elderly. Hospital associated disability (HAD) is defined as loss of ability to complete one of the basic ADLs needed to live independently without assistance: bathing, dressing, toileting, eating, or transferring. Almost one third of hospitalized older adults are discharged with a new major functional disability.1 Nearly three in four elderly patients do not walk during their hospital stays.2 Older patients are also highly susceptible to delirium and it tends to persist for longer in the elderly. After leaving the hospital, geriatric populations have a 60-fold increase in their risk of developing more permanent disabilities3 and it is estimated only about one in three patients return to their pre-illness level of function.4 These are things to seriously consider when deciding whether to recommend hospital admission for elderly patients.

Of course HAD cannot be eliminated, especially for elderly patients that are admitted for catastrophic events such as stroke or myocardial infarction. Inpatient programs like acute care for elders (ACE) units and early mobility initiatives have been shown to reduce HAD,5 but perhaps as EM physicians, we can help prevent HAD by reducing “social” admissions. When deciding disposition for your elderly patients, be sure to involve them in medical decision making. Physicians are known to be less likely to involve older patients in medical decision making when compared with younger patients.6 If your patient has the ability to make an informed decision about whether or not they want to stay in the hospital, empower them to decide and create a plan that safely supports their decision.

Hospital associated disability (HAD) is defined as loss of ability to complete one of the basic ADLs needed to live independently without assistance: bathing, dressing, toileting, eating, or transferring.” References 1. Loyd, Christine, et al. “Prevalence of Hospital-Associated Disability in Older Adults: A MetaAnalysis.” Journal of the American Medical Directors Association, vol. 21, no. 4, 2020, doi:10.1016/j. jamda.2019.09.015. 2. Callen, Bonnie L, et al. “Frequency of Hallway Ambulation by Hospitalized Older Adults on Medical Units of an Academic Hospital.” Geriatric Nursing, vol. 25, no. 4, 2004, pp. 212–217., doi:10.1016/j. gerinurse.2004.06.016. 3. Reichardt, Lucienne A., et al. “Unravelling the Potential Mechanisms behind HospitalizationAssociated Disability in Older Patients; the Hospital-Associated Disability and Impact on Daily Life (Hospital-ADL) Cohort Study Protocol.” BMC Geriatrics, vol. 16, no. 1, 2016, doi:10.1186/s12877016-0232-3. 4. Boyd, Cynthia M., et al. “Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness.” Journal of the American Geriatrics Society, vol. 56, no. 12, 2008, pp. 2171–2179., doi:10.1111/j.1532-5415.2008.02023.x. 5. Ortiz-Alonso, Javier, et al. “Effect of a Simple Exercise Program on Hospitalization-Associated Disability in Older Patients: A Randomized Controlled Trial.” Journal of the American Medical Directors Association, vol. 21, no. 4, 2020, doi:10.1016/j.jamda.2019.11.027. 6. Ben-Harush A, Shiovitz-Ezra S, Doron I, et al. Ageism among physicians, nurses, and social workers: findings from a qualitative study. Eur J Ageing. 2017;14(1):39-48.

COMMON SENSE MAY/JUNE 2021

INTEREST GROUP REPORT PALLIATIVE CARE

A View from the Middle of My Mid-Career Fellowship Jessica Fleischer-Black, MD FAAEM

ince July 2020, I’ve been engaged as a kind of a guinea pig in a graduate medical education experiment. I am taking part in fellowship training in Hospice and Palliative Medicine at Mount Sinai Hospital on a part-time, competency-based basis. I have not stopped my work as an emergency medicine (EM) physician. I continue to work as a member of the EM faculty, with administrative and teaching responsibilities in this realm. One week a month, I learn, as a fellow, on service for palliative medicine consults. One afternoon a week, I go to the palliative medicine fellows didactics (virtually). In a few months, I will do some rotations in hospice and outpatient clinics, all the while continuing to do EM shifts, seeing patients, doing bedside teaching of residents, and giving lectures at EM conferences. My fellowship directors monitor my learning closely and will ensure that I achieve the competencies required for board certification. Then they will certify me to take the Hospice and Palliative Medicine subspecialty boards. I’ve been doing it all through the COVID pandemic, in PPE, while my kids are remote-learning, and my husband works from home. And it’s been fantastic. I am learning so much. Palliative medicine physicians have advanced communication skills that seemed magical to me only a few years ago. But they’re learnable skills and I’m learning them. I have gone from feeling burnout from EM to being reinvigorated in my practice and eager to integrate the two fields, bringing strengths from each to the other. My ability to manage pain and symptoms has improved. I have a new-found appreciation of the scourge of constipation. I am the go-to person in the ED for questions about hospice, legality of surrogate decision-makers, and what a palliative consult might contribute to the patient and family. It’s been hard. I’m busy. But it’s a good kind of busy, where I’m engaged more than I am frazzled. It’s an adjustment to being a learner. But it’s also nice not to be in charge for once. I’ve been close to a lot of death this year (as we all have). On the palliative care service, that death is still grieved, but it’s more expected, there’s some emotional cushion. I’m very fortunate that my hospital system had a well-established palliative medicine fellowship with innovative fellowship directors who were willing to try this experiment. My department at Mount Sinai has been amazingly supportive of this faculty development project. I’ve got a ways to go before I can practice palliative medicine on my own, but I’m full of ideas and coming up with more possible projects every day. I no longer feel like I might have to leave medicine. I have things to learn and things to teach. I’m still excited to talk to patients and help them and their families through difficult times, just like I was as a medical student. There are two other competency-based fellows at University of Pennsylvania (both from Internal Medicine) and another coming to Mount Sinai next year (Family Medicine). Also, there is a program at the University of Colorado part-time for two years and results in an MS in Palliative Medicine. I hope we’re the beginning of a movement. There will be so much need for these skills as the population ages. You may want to learn more about palliative care. There are great resources and courses out there to learn more without necessarily doing a full fellowship and getting board certified. Some are listed below. Come be part of the movement towards advancing palliative care in the emergency department.

COMMON SENSE MAY/JUNE 2021

List of Palliative Care Educational Resources for EM Docs Center to Advance Palliative Care Your hospital or hospital system may be a member, which entitles you to membership CME-granting modules on a wide variety of Palliative Care topics https://www.capc.org/ Vital Talk Focused on teaching communication skills (delivering bad news, etc.) CME-granting communication courses https://www.vitaltalk.org/ EPEC-EM Education in Palliative and End-of-life Care Based at Northwestern CME-granting course focused for EM docs https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine. html PCEP Palliative Care Education and Practice At Harvard. Much bigger time commitment (1 week + 6 mo project at home + 1week) https://pallcare.hms.harvard.edu/ Fast Facts Sign up and they will send a weekly article about a pall care topic. They also have an index or prior articles. Short. Easily digestible. From the University of Wisconsin. https://www.mypcnow.org/fast-facts/ Pallimed A medical blog. https://www.pallimed.org/ AAHPM American Academy of Hospice and Palliative Medicine http://aahpm.org/self-study/essentials

INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

Social EM Spotlight: Dr. Kraftin Schreyer

An Emergency Department Based Hepatitis A Vaccination Program: A Merge of Social Emergency Medicine and Emergency Medicine Operations Katie Y. Kwon, BS; Jennifer Rosenbaum, MD; Sara Urquhart, MA RN

r. Kraftin Schreyer is an emergency physician whose innate passion for emergency medicine and quality improvement have led her to become a pioneer in the emerging field of social emergency medicine (EM). Throughout her residency training, her aptitude for identifying and correcting system weaknesses and inefficiencies lead her to a career in operations and administration. She is now the Director of Clinical Operations at Episcopal Hospital and an Assistant Director of Clinical Operations at Temple University Hospital. She had a chance to sit down and talk about her groundbreaking work in addressing a Hepatitis A outbreak in the community.

How has your background in emergency department (ED) administration and quality improvement helped you to spearhead social EM initiatives? After residency, I invested time in learning about change management and completed a Certification in Medical Quality, both of which are very important concepts for any initiative to be successful. You have to understand what it takes to get people to buy in, gain support, and sustain the initiative. Then, you need a plan to monitor it. To see what kind of impact you’re having, you have to choose the correct metrics to evaluate the state before and after the intervention, and to assess your performance, so you can continuously try to improve and build upon what you’ve done.

You designed a project to administer Hepatitis A vaccines in your community to stop an outbreak. What prompted this idea? We started seeing an uptick in ED patients with acute hepatitis and that was not the norm for us. At the same time, the news and public health department reported that there was a local Hepatitis A outbreak. It occurred to us that we administer other vaccines like rabies and tetanus in the ED, so why couldn’t we provide a Hepatitis A vaccine? We knew that the Hepatitis A vaccine is supposed to be a two-shot series, much

like the COVID vaccine, but the difference is that the first dose of the Hepatitis A vaccine is very effective, and the second dose is really just a small improvement upon that. Early on, we made the decision to not give a second vaccine because it was logistically too challenging to ensure that patients would follow up. The first step was laying the groundwork and getting the appropriate parties involved.

It occurred to us that we administer other  vaccines like rabies and tetanus in the ED, so why couldn’t we provide a Hepatitis A vaccine?“ Who were the key stakeholders and how did you engage them? We knew the first step was getting the vaccines supplied, so our first stakeholder was the Philadelphia Department of Public Health (PDPH). Luckily, PDPH was willing to donate the vaccines, which kept the cost of the program at a minimum. We also had to coordinate with PDPH to ensure that we had a consistent vaccine supply. The next phase was to figure out what requirements were needed for storage, which led us to a partnership with our pharmacy to find a large enough storage space. Because of the strict temperature monitoring required for storage, we also had to get the IT team involved to install a new continuous temperature monitoring system that could transmit data to PDPH. Other key stakeholder groups were nurses, who ultimately administered the vaccines, physicians, who signed the orders, and finally, patients, who had to understand the need for the vaccine.

How did you implement the vaccine administration in the ED? How was the project was perceived by hospital administrators, other ED physicians and nurses? To get buy in from the staff, we had to make sure that we had what we call “innovators” and “early adopters,” who were champions of this process from all groups. We made an effort to educate the ED staff on the importance of this initiative not only because there was an outbreak, but also because it was here in [our community]. The other important piece was to make sure that we didn’t complicate any existing processes. To keep it as simple as possible, we worked with the [electronic medical

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INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

While some people might not consider vaccination an “emergency,” in the setting of a public health outbreak, we felt that it merited an ED visit, and also demonstrated community awareness and acceptance of the program.” What were the benefits to the program? Did the project save money for the hospital, insurance company, provider group, or patients?

record] team to incorporate a screening question into triage. Nurses were already screening for HIV and Hepatitis C in triage, so we added, “Would you like to get vaccinated for Hepatitis A today?” If the patient said yes, then nursing would click a box that generated an order. When the provider picked up the patient to care for them, they would get a notification that the order had been placed and would just have to sign off on it.

We didn’t perform a detailed cost analysis on this particular project, but we did look at admissions before and after the vaccination program and there was a decrease in admissions for acute hepatitis. Because PDPH supplied the vaccines at no cost, the hospital saved costs. The only actual inherent cost was the labor that went into administering the vaccine. More important than cost was the benefit of public perception, specifically engagement with the community. While that’s a metric that’s very difficult to quantify, we got the sense that patients were very happy with this program. We had people that were coming in just for the Hepatitis A vaccine, perhaps because they didn’t have access to it any other way. While some people might not consider vaccination an “emergency,” in the setting of a public health outbreak, we felt that it merited an ED visit, and also demonstrated community awareness and acceptance of the program.

Did you experience any barriers to implementation and how did you overcome them?

If you were to re-design the project, what would you do differently or the same?

Yes, we did. The biggest one was the unexpected need for continuous temperature monitoring. Once we rolled out the program, though, there was very little pushback. Admittedly, we didn’t monitor the program too closely in the beginning. Rather, we let it ride to see over time how the process would improve, and we understood that there was going to be some inherent variation as people got used to it. With very little influence from us after going live, the vaccination numbers really took off. In fact, we had given out several hundred vaccines in just a few months. I think a lot of the program success was due to the work we put on the front end to get people to buy in and understand the “why” behind it, and also the effort to make it integrated into our existing workflow.

I wish I had known about some of the hurdles earlier on. Had we anticipated the difficulties with the temperature regulation, we may have been able to plan more up front. That could have been identified through a more detailed stakeholder analysis, to really understand what each party needed in order for the program to proceed. Overall, this program was very successful and a good example of a socially focus ed initiative. We identified the appropriate stakeholders and were in contact with hospital administration throughout the process. We had metrics that we could evaluate before and after the intervention to see if we had an impact. This is something I’m very proud of, very thankful to be involved in, and very happy that our department was able to do it.

COMMON SENSE MAY/JUNE 2021

COMMITTEE REPORT

DIVERSITY, EQUITY, AND INCLUSION

Next Generation Leadership: A Conversation About Equity and Inclusion Paul L. Petersen, MD FAAEM and Italo Brown, MPH MD

f you have thumbed through Emergency Medicine News on the counter of your emergency department during the last year, you cannot help but notice the eyeopening and informative articles by Italo Brown, MPH MD. Dr. Brown recently finished his Social Emergency Medicine Fellowship and is now Clinical Assistant Professor of Emergency Medicine at Stanford University Hospital. He is Co-Vice Chair of the Diversity, Equity, and Inclusion (DEI) Committee of the American Academy of Emergency Medicine (AAEM). The son of a firefighter in Sacramento, CA, Dr. Brown (Morehouse College ’06, Boston University ’08, Meharry Medical College ’15) completed his residency at the Jacobi/ Montefiore Emergency Medicine Residency Program of the Albert Einstein College of Medicine, where he served as Chief Resident. He splashed onto the national media scene with a highly popular and entertaining GQ web series installment on The Breakdown, where he humorously dissected inaccurately portrayed injuries in popular movies such as Scarface, Titanic, and Kill Bill 2. It went viral. After residency, he set his sights on Social Emergency Medicine at Stanford. His work includes an innovative pipeline leveraging the cultural capital of barbershops (Trust Research Access Prevention (TRAP) Medicine) for wellness and to encourage African American teenagers to pursue medicine. Throughout his career, Dr. Brown has been at the frontlines of social medicine and health equity. He is a former board member of the Tennessee Health Care Campaign, an organization that spearheads statewide advocacy efforts in support of the Affordable Care Act and Medicare/ Medicaid reform. In 2017, the National Minority Quality Forum named Dr. Brown among the 40 Under 40 Leaders in Minority Health. He is an avid writer and has contributed to The

Washington Post, JAMA, ABC News medical unit and The Root. Dr. Brown has been named Health Equity and Social Justice Curriculum lead for the Stanford School of Medicine and is tasked with integrating diversity, equity, and inclusive content into the medical curriculum. Recently, the DEI Committee leadership of the AAEM put together a list of questions for Dr. Brown. QUESTION: Why did you choose medicine as a career, and what influenced that choice? DR. BROWN: I knew from an early age that I wanted to be in medicine, to provide care to people. The major influence came at Morehouse College, where I shadowed a physician and witnessed health inequity. It created a desire in me to pursue both public health and medicine. QUESTION: Before you went to medical school, what were your greatest challenges and how did you overcome them? DR. BROWN: To be frank, I had confidence issues and academic hurdles after high school. I had difficulty performing well on tests, and thus had test anxiety. There were some failures and rejections, and I was quite hard on myself for those. It took time to rebuild my confidence, better understand how I learn, and forgive myself for not being perfect. Core to this rebuilding of confidence was support from others and my belief that I would be the type of physician who would resonate with patients who face health inequity. QUESTION: You mentioned support from others. Did you have mentors along the way? DR. BROWN: Most definitely — I had both near-peer and senior mentors, and friends, who were invaluable and to whom I am incredibly grateful. Ngina Lythcott, the Associate Dean for students at the Boston University School of Public Health, was the first person at

to encourage our advocacy  Wearmneed to use objective data to show that diversity, equity, and inclusion programs result in improved public health and thus are integral to the success of emergency medicine.” Boston University to make a significant investment in me. She taught me how to study, set a sleep schedule and carve out sufficient time to tackle tasks effectively. Dr. Alden Landry helped me enormously throughout medical school and was instrumental in my getting a residency. Dr. Aleron Kong talked me through each step of medical school residency and my early fellowship/young attending life. In addition, friends who were pursuing medicine (such as Marcus Emebo and Michael Adams) constantly shared their knowledge, insight and experience. This helped me be a better applicant and perform better in interviews and on exams. QUESTION: What were the greatest challenges on your path from medical school to residency? DR. BROWN: The path from medical school to residency is difficult for everyone, and it was difficult for me. I believe that the usual challenges were heightened because I graduated from Meharry Medical College, an HBCU. For example, many people I encountered didn’t know what or where Meharry was. There was an incorrect perception that because Meharry didn’t have an emergency medicine program, the school was behind the curve. So, I felt that I had to work harder to prove that I was as competent and capable as graduates of other schools.

COMMON SENSE MAY/JUNE 2021

It was as though I was two people listening to this: One was a panicked son, and the other was an emergency physician, picking up all the small things that the ER doctors are saying and doing, taking some comfort from understanding what they were doing. But it was late and, as hard as I tried, I could not book an immediate flight out of New York. I was destroyed, because I couldn’t get back home…I could not use my knowledge and skills and training to talk my dad through what happened and what was going to come next. So, yes, it was a very tough day.

valued through adequate funding. Training for this must be compensated at the same level as other areas of emergency medicine. Second, training (such as implicit-bias training, microaggression training, and training to understand and deconstruct privilege) must be developed and implemented at all levels of emergency medicine. Third, education curricula generally must be overhauled so that the pipeline includes equity education much earlier. Fourth, community-based programs must be implemented. Underserved community members should be involved. Fifth, the specialty must officially recognize racism in emergency medicine as a public health crisis.

QUESTION: As a child, my parents and grandparents reinforced the belief that Black people had to be twice as good to receive half as much. Do you share this belief?

QUESTION: Recently, some institutions have begun to cancel diversity, equity, and inclusion programs. What can we do to combat this? How can institutions make these initiatives sustainable?

DR. BROWN: I do share this belief. People of color are taught it early in life. That it must be taught makes me incredibly sad. But it does have to be taught, because we can’t take the risk that it isn’t true.

DR. BROWN: We need to encourage our advocacy arm to use objective data to show that diversity, equity, and inclusion programs result in improved public health and thus are integral to the success of emergency medicine. And we need to demonstrate that offering these programs attracts today’s students, who value and seek out institutions that have them. Institutions need to embrace and lead the trend in medicine towards diversity, equity, and inclusion, particularly at the level of those entering medicine. This will attract the kind of medical students we want in emergency medicine: folks who are self-starters, critical thinkers, problemsolvers, and doers; folks who focus on more than just preparing for a board exam or getting a job. We need medical students, indeed all emergency physicians, to understand the social underpinnings of medicine to ensure equitable outcomes for the patients they see. In terms of sustainability, we need to ensure that we encourage dialogue, including, for example, by pairing students and residents with mentors who have seen it, done it, and lived it. I believe that equity and social justice education in medicine aligns with the reason that people are drawn to this profession in the first place: the desire to help people. Change is not going to happen overnight, but I am hopeful that ultimately, we will make it happen and get it right. If any group of people can do it, emergency physicians can. We are built for this.

COMMITTEE REPORT DIVERSITY, EQUITY, AND INCLUSION

QUESTION: Can you talk about your podcast for GQ, which I understand went viral, amassing more than three million views in less than one week? DR. BROWN: I did an installment for GQ’s web series “The Breakdown,” in which I commented on the portrayal of injuries in movies, such as Scarface and Titanic, among others. GQ had other Black men in the series, but I think I was the first Black doctor. It was a lot of fun and I am blessed that it was so popular. QUESTION: Can you describe your work at Stanford in social emergency medicine and your efforts to advance people of color in medicine? DR. BROWN: Initially, I came to Stanford on a fellowship focusing on social emergency medicine, which examines health disparity issues in emergency departments. Stanford welcomed me with open arms, and I was able to explore social determinants of health, health equity and strategies to reduce or eliminate health inequity. My efforts to advance people of color in medicine have been amplified at Stanford, where folks think about ways to structure the work, create data, and drive results and interventions, eventually sharing those with the broader research and medical community. Collaborating in this way has been a game changer. The emergence of both COVID-19 and the current social justice climate has made these explorations and collaborations particularly vital. QUESTION: Can you describe the hardest day of your life? DR. BROWN: That is tough. The hardest day of my life was probably when my mother passed, a few years ago. I had been Chief Resident for less than a month at the Jacobi/ Montefiore Emergency Medicine Residency Program of the Albert Einstein College of Medicine where I trained. I received a frantic phone call from my dad, who had been a firefighter for 30 years…he had taken my mom to the hospital — she had been coughing up some blood — telling me that my mom wasn’t breathing and that she wasn’t awake. I could hear the physician in the background trying to tell my dad that she needed to be intubated and that she needed to have CPR performed. 46

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QUESTION: Wanda Sykes called on white people to “step up” and challenge systemic racism. She stated: “White people you have to fix your problem…we [people of color] are not the problem…the only way racism will stop is when white people tell white people to stop being racist.” What are your thoughts on this assessment? DR. BROWN: There is truth in this. There must be conversations amongst white people, about equity, with and without people of color in the room. But they also must act. For example, minorities are typically burdened with extra responsibilities, without compensation, in the name of efforts to achieve diversity…the so-called “minority tax”. So, yes, I agree that white people need to step up and participate in equity education. QUESTION: How can physician allies of people of color help change the disparities in emergency medicine? What do you consider the top five actions they can take to effect change? DR. BROWN: First, initiatives to eliminate disparities in emergency medicine must be

A Lot to Learn from Our Colleagues from AAEM

COMMITTEE REPORT INTERNATIONAL

Nino Butskhrikidze, MD

am writing this article as a representative of the Georgian Emergency Medicine Physician Association (GEMPA), an organization I co-founded in 2010. I have had the pleasure of coordinating international relationships since then.

assists our association by providing  AAEM new and comprehensive information.”

The development of emergency medicine in Georgia started in 2005. In 2013, emergency medicine was announced as an independent specialty with a three-year residency program. One year later, the scope of practice for emergency medicine physicians was set. It was the first time since the Soviet period that a new medical specialty was adopted in our country.

To further intensive collaboration with AAEM, I was awarded the AAEM International Scholarship in 2018 to attend the Annual Scientific Assembly in Las Vegas. It was my first experience attending such a large and exciting conference in the U.S. Attendance at this conference was important for several reasons:

The development of emergency medicine in Georgia was initiated by the collaboration of Kipshidze Central University Hospital, Emory University School of Medicine, and the Ministry of Health of Georgia with support from USAID and donors. Step-by-step, emergency medicine departments became more of a reality not only for acute care hospitals, but also for freestanding emergency facilities in the high mountain regions. It clearly shows advantages in terms of patient flow and acute patients’ care. The philosophy of emergency medicine shows clear advantages in terms of the management patient flow and the care of acute patients.

• I acquired newly updated, comprehensive clinical information (especially in the management of septic patients or suspected sepsis cases, new treatment guidelines, and the role of ED in improving patient outcomes). • I saw approaches in the management of emergency departments as an entire system and how to better coordinate activities with other departments. • I learned how to effectively conduct the large conferences and make them clinically fascinating for attendees. • I was able to expand relationships with our American colleagues from AAEM and draft new projects.

Despite the short history of emergency medicine in Georgia, we strive to keep abreast of international trends and innovations in this field of medicine. This is evidenced by our active participation in international conferences and workshops, establishing close contacts with international organizations including AAEM, IFEM, MEMC, EuSEM, and the Polish Society of Emergency Medicine as well as other regional societies.

Step-by-step, emergency medicine departments  became more of a reality not only for acute care hospitals, but also for freestanding emergency facilities in the high mountain regions.” Special emphasis is placed on effective cooperation with AAEM, one of the leading organizations in emergency medicine. Representatives of this organization are actively involved in the events held in Georgia. With their active support, we have organized several summer workshops dedicated to different clinical topics. In 2016, the first international conference in emergency medicine in Georgia was conducted. AAEM assists our association by providing new and comprehensive information. This organization also allows us to participate in international conferences, to share our experiences with our colleagues from other countries, and to discuss the current challenges.

Shortly after the conference, a new workshop was proposed, and topics were selected. However, the plan could not be implemented because of the COVID-19 pandemic. Currently, we are working on organizing an extended regional conference in the summer of 2021 in Tbilisi. We hope to conduct joint scientific projects as well, including research and training. A lot is already done, but it is not enough. There is always something to improve and collaboration with organizations such as AAEM, who always gives the right direction for further improvement.

COMMON SENSE MAY/JUNE 2021

COMMITTEE REPORT

OPERATIONS MANAGEMENT

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

elcome back to part two of the Ops Series on Lean Six Sigma! This issue, we’re taking a deep dive into Six Sigma, discussing other process improvement tools used in both lean and Six Sigma, and summarizing the intersection between the two performance improvement methodologies.

What is Six Sigma? Six Sigma is a performance improvement methodology that uses both qualitative and quantitative tools to improve processes through a reduction in variation and removal of defects. The concepts behind Six Sigma can be traced as far back as the late 1700s, when the normal curve was introduced by Carl Friedrich Gauss. Then, around 1920, Walter Shewhart demonstrated that the point at which a process required correction fell three sigma (aka standard deviations) from the mean on a normal curve. The term “Six Sigma” was coined by Bill Smith, an engineer for Motorola, and has come to be synonymous with process improvement through reduction in defects and variation. Statistically, six-sigma signifies that a process is so invariable, only 3.4 defects are generated per one million process runs. Visually, this translates to a very, very narrow bell curve. Six Sigma has been used in the emergency department to reduce wait times and overcrowding, improve patient turnaround times, and increase revenue.

What is a defect? In Six Sigma, a defect is a failure of a process or product. Defects are a key part of the Six Sigma methodology, because the existence of a defect indicates a problem that needs to be solved.

COMMON SENSE MAY/JUNE 2021

How does Six Sigma achieve reductions in variation and defects? Six Sigma is notoriously statistically rigorous. The approach used in Six Sigma is known as DMAIC: Define, Measure, Analyze, Improve, Control. Different performance improvement tools can be used for each step in the DMAIC process. Define: The first step is to define the problem that will be the focus of the Six Sigma improvement. Problems can be identified using a value stream map (remember that from part I?) and feedback from those involved with the process and/or customers of the end product. Defining the problem is more than just giving it a name – it involves the creation of a project charter that outlines the scope of the project and provides clear direction for future steps. Process Improvement tool: 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. Both value-added and non-value-added steps are then identified and the time for each is totaled. Measure: Once the problem has been defined, the process itself must be measured. Baseline data should be collected on the capability of the process (how well the process performs as it should) and the frequency and magnitude of problems within the process. These measurements provide reference data on variation and defects within the process. Process Improvement tool: Pareto chart A pareto chart is an ordered bar chart with a superimposed line graph that is used to identify the “vital few,” which are the 20% of causes that lead to 80% of the consequences. On a pareto chart, the ordered bars represent the frequency of contributing factors, and the line represents the cumulative percentage of those factors.

 Six Sigma has been used in the emergency department

to reduce wait times and overcrowding, improve patient turnaround times, and increase revenue.”

COMMITTEE REPORT OPERATIONS MANAGEMENT

Analyze: Defects and variation must next be analyzed, to determine the underlying causes of each. Unless the true root cause of variability or a defect is identified, further work cannot be done to correct future iterations of the process. Process Improvement tools: Root Cause Analysis, Failure Mode, and Effect Analysis Root cause analyses are reactionary tools used to break down processes into the most basic components and identify those that contributed to an adverse outcome. In contrast, failure mode and effect analyses are prospective tools used to identify potential failure points in a process that has yet to be implemented. Improve: Process performance is improved by addressing and eliminating the root causes of defects and variation. During the improvement phase, process changes are piloted, and data is collected to ensure change is being made in the process and outcomes. Process Improvement tool: Kaizen Event A Kaizen event is a brief, focused, performance improvement cycle that evaluates for rapid change. Both strong leadership and adequate planning are required for a successful Kaizen event. Control: The final phase focuses on sustainability of the process improvements. Both a plan for monitoring the process and a plan for responding to slippage should be created. Process Improvement tools: Control Chart, Quality Control Plan Control charts are line graphs that assess process variation over time, with respect to upper and lower control limits. Quality control plans are outlined in one or more documents, and specify each aspect of the control process, including objectives, allocation of responsibilities and resources, standards to be applied, measurement definitions, auditing tools, and procedures for change and modification.

What is Lean Six Sigma? Lean Six Sigma is a powerful combination of the two performance improvement methodologies, lean and Six Sigma. In addition to reducing waste, defects, and variability in a process, Lean Six Sigma provides a framework for performance optimization. By employing complementary process improvement tools used in both Lean and Six Sigma, the combination of the two methodologies has been shown to be the optimal way of improving process effectiveness and efficiency. Lean Six Sigma has been used to improve patient flow in many emergency departments around the world. Hopefully the basic knowledge shared in this brief introductory series can pave the way for you to do the same!

 By employing complementary

process improvement tools used in both Lean and Six Sigma, the combination of the two methodologies has been shown to be the optimal way of improving process effectiveness and efficiency.”

References 1. Furterer, S. Applying lean six sigma methods to reduce length of stay in a hospital’s emergency department. Qual Engin. 2018. https://doi.org/10.1080/08982112.2018.146 4657 2. Hall J, Scott T. Lean Six Sigma: A Beginner’s Guide to Understanding and Practicing Lean Six Sigma. 2016. 3. Hussein, NA, Abdelmaguid TF, Tawfik BS, Ahmed NGS. Mitigating overcrowding in emergency departments using six sigma and simulation: a case study in Egypt. Oper Res Healthcare. 2017. https://doi.org/10.1016/j. orhc.2017.06.003 4. Maniago E, Ardolic B, Peana J. ED Patient Flow: Utilizing the Six Sigma Approach to Reduce Emergency Department Overcrowding. Annals Emerg Med. 2005. https://doi. org/10.1016/j.annemergmed.2005.06.034 5. Tuttle, Kevin. Improving ED Wait Times at North Shore University Hospital. 2003. https://www.isixsigma.com/new-to-six-sigma/ dmaic/improving-ed-wait-times-north-shoreuniversity-hospital/

COMMON SENSE MAY/JUNE 2021

COMMITTEE REPORT WELLNESS

Bringing Wellness to Your Organization: Highlights from the AAEM Leadership Academy 2021 Robert Lam, MD, FAAEM @Doclam01 | Al’ai Alvarez, MD FAAEM @alvarezzzy

urnout remains at critical levels for physicians on the 2021 Medscape Physician Burnout and Suicide Report.1 With over 12,000 physicians participating in the survey, 42% of physicians reported that they experienced burnout. Consistent with prior reports, most of the top drivers of burnout were related to the work environment’s external factors. This includes bureaucratic tasks, lack of respect from administrators, colleagues, and staff, lack of autonomy, and the burden and complexity of the EHR. In a series of Common Sense articles last year, we introduced Shapiro’s Wellness Hierarchy as a roadmap for organizations to promote wellbeing.2–6 Utilizing Maslow’s Hierarchy of Needs, the Wellness Hierarchy is a framework for solutions to restoring well-being based on physicians’ thwarted needs. We introduced this model at the AAEM 2021 Leadership Academy with crowdsourced solutions solicited from the Academy’s leaders. We present ways to optimize each level of the Wellness Hierarchy to consider implementing in your organization.

Basics Physical Health • Advocate for eating and drinking at your workstation. Utilize the clarified JCAHO and OSHA statements as well as evidence that physicians become dehydrated on shift. Ensure easy access to ice, water, and cups.7 • Provide easy access to healthy food, and provide time to eat it. • Create a system to provide on-shift breaks, ideally allowing for at least 45 minutes to attend to personal needs such as meals, biobreaks, and even calling family or friends as needed. Outside of physicians, this break time is below the national standards. • Provide a dedicated lactation room instead of using the supply closet or the bathroom. • Ensure close by and clean bathrooms. • Consider limiting nights for our senior colleagues. Create a night float differential to support those who want to work nights. • Provide ways for new parents to schedule time with their new child. Check out this work by fellow AAEM colleague, Dr. June Gordon.8 • Ensure adequate time to rest in between shifts. Mental Health • Participate in National Physician Suicide Awareness Day. AAEM has partnered with every significant EM organization to raise awareness on the silent epidemic of at least 400 physicians dying of suicide each year.

• Provide protected time to meet with mental health counselors. This should be protected from repercussions for asking for help and is especially important for EM resident physicians. • Make counseling and mental health well-being programs opt-OUT rather than opt-IN. • Combat loneliness and isolation with platforms for information communication. • Create a process to provide time to contemplate/cope after a challenging patient encounter.

Safety Job Security • Due process. If you do not have due process, you cannot focus and advocate for what is best for your patient.3,10,11 • Provide paid leave for COVID+ physicians and sick leave in general, not just “move those shifts around.” • Promote democratic, independent practices with an emphasis on autonomy. Physical Safety • Create a campaign for a violence-free ED. We must advocate for No Silence on ED violence.12,13 • Provide adequate PPE to protect my family and myself. • Ensure a safe workplace with security guards who can effectively intervene when needed. • Create policies with zero tolerance for verbal and physical abuse from ER patients.

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Patient Safety • Ensure adequate staffing in the ED, and more importantly, adequate staffing on the floors, to prevent access blocks and back-up/borders in the ED. End the hospital practice of using the ED as an overflow valve for an understaffed, mismanaged hospital system. It’s not ED boarding. It’s hospital boarding.14

Respect and Autonomy Respect for Emergency Physicians • Create a surge plan to minimize hospital boarding. Again, this is not just an ED problem.14 • Create metrics to follow and minimize pajama time with the EHR.15 • Ensure equity in vaccinations. • Minimize interruptions.2 • Ensure fair compensation for ED physicians concerning the value that we provide to society at-large. • Ensure metrics on productivity are fair and balanced for quality and excellent patient care. Diversity, Equity, and Inclusion • Ensure efforts to advance diversity, equity, and inclusion. • Create a policy to ensure respect and safety from harassment (microaggressions and bias). • Create transparency and equity in compensation and promotion (gender blind salary). • Provide training and awareness to address and confront microaggressions from colleagues and patients.

Appreciation

Tokens of Gratitude • Coffee and donuts! Provide sincere thank you notes to the team, thanking them for their hard work and dedication. • Cookies, brownies, head coverings, eye pillows filled with rice, handwritten thank you notes written by my kids with crayons and markers, saying thank you. • Provide colorful trauma shears over the holidays. People love useful swag! • Midnight buffet to include all staff, including radiology techs.

Heal Patients and Contribute: Fulfillment/Professional Satisfaction Alignment with Personal Values and Meaning16 • Create programming to enhance connecting with patients (Metrics). • Doctor-patient relation (back to bedside). • Relationship-centered care (respecting the role of physicians in the physician-patient interaction). Strive for Contentment and Replenishing Your Energy • Pursue avocation activities and hobbies. • Laugh exercises with the team. Laughter yoga! While there is no one-size-fits-all solution to creating a department full of professionally fulfilled emergency physicians, we encourage you to utilize the above examples to pilot with your group. Designing a system that promotes joy and respect at work will optimize physician well-being and work-life integration. Although we know that burnout is a complex problem, even during a pandemic, with all of the challenges we face as the front lines of health care, we have an opportunity to continue to take care of each other. Which of these solutions will you try to bring wellness to your organization?

Design a Culture of Gratitude • Practice gratitude. You are more likely to see positive things around you. • Show appreciation for contributing time and talents, especially during this challenging pandemic. • Promote a daily practice of appreciation/ Heal Patients and Contribute: My institution is in alignment with my values and helps me recognition. towards professional fulfillment. My institution actively promotes my doctor patient relationship as paramount to • Recognize great care with “Save of the the success for our organization and my own fulfillment as a healer of my patients. Month” awards.4 • Create a “shoutout” board and a gratiAppreciation: My institution regularly shows appreciation for my service and talents. My tude board for staff, including clerks institution recognizes my accomplishments and supports my professional development. and housekeeping staff. • Thank your team at the end of Respect: My hospital listens to my expertise and addresses my concerns to the extent that they are your shift. able to. My institution has robust surge planning and actively addresses EM boarding. • Nominate staff for awards.

Safety: I have access to adequate PPE to protect my health and the health of my family, I have due process with job security when I advocate for my patients. My workplace is supports safety and minimizes risk of violence.

Basics: I can hydrate and have easy access to healthy foods. I have access to support my mental health and am not punished for treating mental illness.

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COMMITTEE REPORT WELLNESS

References 1. “Death by 1000 Cuts”: Medscape National Physician Burnout & Suicide Report 2021 [Internet]. Medscape. [cited 2021 Feb 22];Available from: https://www.medscape.com/slideshow/2021-lifestyle-burnout-6013456 2. Grock A, Alvarez A. Interruptions in the Emergency Department and the Myth of Multitasking. Common Sense AAEM - Am Acad Emerg Med [Internet] 2020;(July/August). Available from: https://issuu.com/aaeminfo/ docs/cs20_julyaug_for_web/14 3. Healy M, Alvarez A, Min A. Physician Wellness: Just a Dream without Due Process. Common Sense AAEM - Am Acad Emerg Med [Internet] 2020;(May/June). Available from: https://issuu.com/aaeminfo/docs/ cs20_mayjune_for_web 4. Alvarez A. Gratitude and Appreciation Amidst Chaos and Uncertainty: Awaken Humanity at Work. Common Sense AAEM - Am Acad Emerg Med [Internet] 2020;(September/October). Available from: https://issuu. com/aaeminfo/docs/c20_sepoct_for_web/s/11003502 5. Alvarez A. On-Shift Eating and Drinking: A Simple Strategy on Addressing Physician Burnout. Common Sense AAEM - Am Acad Emerg Med [Internet] 2020;(March/April). Available from: https://www.aaem.org/ UserFiles/file/Wellness.pdf 6. Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P. Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level. Am J Med [Internet] 2018 [cited 2019 Apr 21];Available from: https://linkinghub.elsevier.com/retrieve/pii/ S0002934318311550 7. Eating and Drinking in the Emergency Department [Internet]. American College of Emergency Physicians; 02/19. Available from: https:// www.acep.org/globalassets/sites/acep/media/life-as-a-physician/ eatinginedfaq19.pdf 8. The Birth of a Return to work Policy for New Resident Parents in Emergency Medicine - Gordon - 2019 - Academic Emergency Medicine Wiley Online Library [Internet]. [cited 2021 Feb 22];Available from: https:// onlinelibrary.wiley.com/doi/full/10.1111/acem.13684

9. Position Statement on Inquiries about Diagnosis and Treatment of Mental Disorders in Connection with Professional Licensing and Credentialing [Internet]. AAEM - Am. Acad. Emerg. Med. [cited 2021 Feb 22];Available from: https://www.aaem.org/resources/statements/position/positionstatement-on-inquiries-about-diagnosis-and-treatment-of-mentaldisorders-in-connection-with-professional-licensing-and-credentialing 10. AAEM Position Statement on the Firing of Dr. Ming Lin by TeamHealth and PeaceHealth St. Joseph Medical Center [Internet]. AAEM - Am. Acad. Emerg. Med. [cited 2021 Feb 22];Available from: https://www.aaem. org/resources/statements/position/firing-of-dr-ming-lin 11. The Impact of Due Process and Disruptions on Emergency Medicine Education in the United States - PubMed [Internet]. [cited 2021 Feb 22];Available from: https://pubmed.ncbi.nlm.nih.gov/31999245/ 12. Workplace Violence Prevention in Health Care - Regulatory Requirements [Internet]. [cited 2021 Feb 22];Available from: https://www.dir.ca.gov/dosh/ Workplace-Violence.html 13. California Violence Prevention Law Sets New Standard for Nation | 201801-04 | AHC Media - Continuing Medical Education Publishing [Internet]. [cited 2021 Feb 22];Available from: https://www.reliasmedia.com/ articles/142025-california-violence-prevention-law-sets-new-standard-fornation 14. AAEM Position Statement on ED Boarding [Internet]. AAEM - Am. Acad. Emerg. Med. [cited 2021 Feb 22];Available from: https://www.aaem.org/ resources/statements/position/position-statement-on-ed-boarding 15. 3 strategies that cut down on physician “pajama time” | American Medical Association [Internet]. [cited 2021 Feb 22];Available from: https://www. ama-assn.org/practice-management/sustainability/3-strategies-cut-downphysician-pajama-time 16. Mary Jane Brown, Coldebella L. Connecting to Purpose and Restoring Meaning. Common Sense AAEM - Am Acad Emerg Med [Internet] 2019;(May/June). Available from: https://www.aaem.org/UserFiles/file/ CS_MayJun19_Wellness.pdf

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 MAY/JUNE 2021

SECTON REPORT CRITICAL CARE MEDICINE

Vents, Cardiac Events, and Aerosolized Contaminants: Performing CPR on Vented COVID-19 Patients Kerolos Abadeer, DO and Christopher Perry, MD Editor: Alex Flaxman, MD MSE – RowanSOM/Jefferson Health/Virtua-Our Lady of Lourdes Medical Critical Care Fellowship Program

full year has now passed since COVID-19 first hit the U.S., yet we still face many of the same daunting challenges in caring for those affected who are critically ill. Such challenges encompass not only providing the best care for the patient, but also to ensuring the safety of staff members. Evidence during the first SARS-CoV epidemic suggested a consistent association between pathogen transmission and what was referred to as “aerosol generating procedures.”1 Such procedures allow air current to move across the surface of a film of liquid (mainly respiratory in source) generating aerosolized contaminants, with the particle size inversely proportional to the velocity (smaller viral particles vs larger bacterial cells).2,3

has dramatically changed theCOVID-19 practice of emergency medicine and critical care in many ways, not just in how we deliver care but also in how we ensure our personal safety during acute resuscitation.” Performing cardiopulmonary resuscitation (CPR) represents one such procedure,1,4 leading to potentially dangerous exposure for physicians and staff when a COVID-19 patient goes into cardiac arrest. This danger is multiplied by the fact that CPR is often performed by a team of practitioners all in close proximity to the patient and under intense emotional stress. Any means, therefore, of minimizing aerosolization during CPR has the potential to reduce risks to staff members. In the past, performing CPR on ventilated patients generally involved disconnecting the

patient from the ventilator and performing bag-mask-ventilation while chest compressions were being performed. In doing so, appropriate minute ventilation could be ensured without concerns of high-pressure limits or false triggers preventing the ventilator from delivering breaths to the patient. Given the concerns of danger to staff members, however, guidelines published by the American Heart Association have now recommended against this practice for COVID-19 patients, urging practitioners instead to “consider leaving the patient on a mechanical ventilator with a HEPA filter to maintain a closed circuit and to reduce aerosolization.”5 The efficacy of this approach has been supported in a Brazilian study performed during the pandemic.6 In this study, minute ventilation, airway peak pressures, and tidal volumes (VT) on three modes [volume control (VCV), pressure control (PCV) and pressure-regulated volume control (PRVC)] were evaluated using an intubated and mechanically ventilated CPR manikin. Ventilators were set to mimic recommended parameters for bag valve mask ventilation during CPR: PEEP of zero, respiratory rate of 10 breaths/min, FiO2 100%, and an inspiratory time of one second. During VCV and PRVC modes VT was set to 600 mL, while the PCV mode targeted inspiratory pressure was set to 16 cm H2O (adjusted to achieve 600 mL VT prior to compressions). Importantly, trigger thresholds were set to their least sensitive value (-20 cm H2O) to prevent false triggering and the peak pressure alarm was set to the maximum possible value (120 cm H2O) to maintain VT. Despite increased peak airway pressures in all three modes and a small reduction in VT in the pressure limited modes, none of the ventilation modes resulted in clinically prohibitive pressures and all delivered volumes acceptable by current standards. The data indicated that maintenance of mechanical ventilation during CPR can be done safely while still delivering appropriate minute ventilation to the patient. Recommended settings appear in table.1 Table 1: Recommended ventilation settings during cardiopulmonary resuscitation (Least sensible value) Trigger Pressure -20cm H2O (Max possible value) Peak Pressure alarm 120cm H2O PEEP RR FiO2 Inspiratory time per cycle

0 cm H2O 10 breaths/min 1.0 1s

VCV & PRVC modes PCV mode

TV = 600mL Inspiratory Pressure = 16cm H2O (Targeted to achieve TV = 600mL)

Ventilation settings set to mimic recommended parameters for bag-valve-mask ventilation during CPR

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SECTION REPORT CRITICAL CARE MEDICINE

COVID-19 has dramatically changed the practice of emergency medicine and critical care in many ways, not just in how we deliver care but also in how we ensure our personal safety during acute resuscitation. Maintaining an intubated patient on the ventilator while performing CPR is one such way in which we have the potential to minimize exposure to aerosolized virus while still ensuring the best possible care for our critically-ill COVID-19 patients.

References: 1. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. PMID: 22563403; PMCID: PMC3338532. 2. Morawska L, Johnson GR, Ristovski ZD, et al Size distribution and sites of origin of droplets expelled from the human respiratory tract during expiratory activities. J Aerosol Sci. 2009;40(3):256-259. 3. Thomas RJ. Particle size and pathogenicity in the respiratory tract. Virulence. 2013 Nov 15; 4(8): 847–858.

4. Liu W, Tang F, Fang L-Q, De Vlas SJ, Ma H-J, et al. (2009) Risk factors for SARS infection among hospital healthcare workers in Beijing: A case control study. Trop Med Int Health 14: 52–59. 5. Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, Berg RA, Bradley SM, Brooks SC, Cheng A, Escobedo M, Flores GE, Girotra S, Hsu A, Kamath-Rayne BD, Lee HC, Lehotsky RE, Mancini ME, Merchant RM, Nadkarni VM, Panchal AR, Peberdy MAR, Raymond TT, Walsh B, Wang DS, Zelop CM, Topjian AA; American Heart Association ECC Interim COVID Guidance Authors. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The GuidelinesResuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. 2020 Jun 23;141(25):e933-e943. doi: 10.1161/ CIRCULATIONAHA.120.047463. Epub 2020 Apr 9. PMID: 32270695; PMCID: PMC7302067. 6. Neumann LBA, Jardim-Neto AC, da Mota-Ribeiro GC. Empirical evidence for safety of mechanical ventilation during simulated cardiopulmonary resuscitation on a physical model. MedRxiv. 2020. [Preprint]. DOI: 10.1101/2019.12.11.12345678

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

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

Critical Care Hacks

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

COMMON SENSE MAY/JUNE 2021

Mentoring Program

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

COVID-19 Resources

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

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

Critical Care Salons

Join CCMS for our regularly programmed Critical Care Salons. Topics vary, but the theme for 2021 is: Do you really do that? How?

CCMS Newsletter

Catch up with CCMS. Read the first few issues of our quarterly newsletter. Check your subscription settings in your AAEM Members Center to ensure you receive these.

SECTON REPORT EMERGENCY ULTRASOUND

Emergency Ultrasound Billing Basics Allison Zanaboni, MD FAAEM

oint-of-care ultrasound (POCUS) is a valuable clinical tool for diagnostic evaluation and procedural guidance in the ED. It has long been realized that POCUS adds value to care of the ED patient by improving accuracy and efficiency, decreasing procedural complications, and reducing length of stay and cost while providing improved patient satisfaction.1,2,3 Since 2012, POCUS has been a required milestone competency for emergency medicine residents according to the Accreditation Council for Graduate Medical Education (ACGME). Opportunities for those who did not train with POCUS continue to expand through various continuing education offerings, including hands-on courses such as those offered at the Scientific Assembly and virtual courses like the EUS-AAEM Unmute Your Probe virtual series. This has contributed to POCUS playing an ever-growing role in daily practice for an expanding number of physicians. These factors have contributed to wide acquisition of ultrasound machines in both academic and community EDs across the country, but revenue capture for studies performed has lagged behind.

Billing for POCUS studies is a viable way to generate revenue for a department and, even with modest ultrasound use, can generate a return on investment in a less than five years.4,5 While a sustainable ultrasound program does require investment in a leader to coordinate and oversee quality assurance, equipment, image storage, and interdepartmental relationships, appropriate image acquisition and documentation falls on each physician to ensure the service being provided can be coded and billed properly. Similar to other procedures performed in the ED, POCUS exams are billable procedures, each designated by a specific Current Procedural Terminology (CPT) code and associated with a reimbursement value that varies based on payer and hospital or group contracts. For a study to be eligible to be billed, it does have to meet guidelines for diagnostic imaging set out by the Centers for Medicare and Medicaid Services (CMS), which include retaining retrievable images and providing appropriate documentation of the study.6 While CMS does not specify which images need to be stored to a departmental archive, representative still images or videos of relevant structures or findings is generally recommended.2

The documentation components required for ultrasound billing can be thought of as the 5Ws: Who, When, Why, What, and Where. Who:

Who is performing and interpreting the study This element is important for identifying who the study is being billed under.

Documentation of POCUS exams should ideally be performed contemporaneously.

When: Date and time the study is performed Why:

What:

Indication for the study The importance of this component of documentation should not be underestimated. Many payers will only reimburse clinically indicated exams, thus a relevant indication must be documented, such as “shortness of breath” as an indication for performing a thoracic ultrasound. Scope of the study, initial vs repeat exam, structures viewed, findings, and clinical interpretation This is the most robust component of documentation and the most important for conveying clinical information. The “what” should specify if the study was an initial exam or a repeat exam. A repeat study can be billed so long as there is an appropriate indication for the reevaluation, such as repeat FAST exam in a trauma patient who has become hypotensive. Documentation should also include if the study was a limited or complete evaluation, with the vast majority of emergency department studies being limited in nature, focusing on answering the clinical question(s) rather than surveying an entire region as is commonly performed with radiology performed scans. Documentation should also outline what structures were evaluated, any positive or negative findings, and a clinical interpretation of the findings.

Where: Image archive location

Including documentation that an image was stored is important. Failure to store or document storage of an image may result in denial of payment.

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SECTION REPORT EMERGENCY ULTRASOUND

Similar documentation requirements exist for billing ultrasound guided procedures. A representative image can be obtained before, during or after a procedure and a procedure note specifying that ultrasound guidance was employed is required. Certain procedures such as arthrocentesis and paracentesis have a combined CPT codes that includes the ultrasound imaging code and the surgical procedural code in a single code.7 Other procedures, such as pericardiocentesis and abscess drainage, are coded and billed separately.7 In such instances three distinct CPT codes can be billed, i.e. 76882 soft tissue ultrasound of the extremity, 76942 ultrasound guided abscess drainage, 10060 incision and drainage of an abscess. Performing a bedside ultrasound and neither saving images nor documenting findings leads to a “phantom scan.” 6 Phantom scans are problematic as they cannot be billed, reviewed for quality assurance, or made available to other providers. A similar mistake occurs when a study is documented but no images are stored. While the documentation will convey important information gained from the study, these are considered “blind” studies that are not available for quality assurance review and cannot be billed.6 Appropriate image storage and documentation of bedside ultrasound studies is not only important for billing but is also part of good patient care. It allows for written communication of findings between providers

and across practice settings, it can serve as an important comparator for future clinical reference, and adds to medical decision making. These factors make investing in image storage and instituting standardized documentation practices across ED providers a worthy endeavor.

References 1. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749–757. doi: 10.1056/nejmra0909487. 2. American College of Emergency Physicians. Ultrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine. 2016: Emergency Ultrasound Section. https://www.acep.org/Clinical— Practice-Management/Ultrasound/#sm.0001wi32c84dcew4yrs2erxapx6h1. 3. Howard ZD, Noble VE, Marill KA, Sajed D, Rodrigues M, Bertuzzi B, Liteplo AS. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014 Jan;46(1):46-53. doi: 10.1016/j.jemermed.2013.05.044. 4. Adhikari S, Amini R, Stolz L, et al. Implementation of a novel point-of-care ultrasound billing and reimbursement program: fiscal impact. Am J Emerg Med. 2014;32(6):592–595. doi: 10.1016/j.ajem.2014.02.051 5. Soremekun OA, Noble VE, Liteplo AS, et al. Financial impact of emergency department ultrasound. Acad Emerg Med. 2009 Jul;16(7):674-80. doi: 10.1111/j.1553-2712.2009.00447 6. Hughes D, Corrado M, Mynatt I et al. Billing I-AIM: a novel framework for ultrasound billing. Ultrasound J. 2020 Dec; 12: 8. doi: 10.1186/s13089-0200157-0 7. 2020 ACEP EUS Coding and Reimbursement Update. ACEP.

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Why I Decided to participate in a COVID-19 Vaccine Trial – A Reminder that Diversity in Medicine Cannot be an After-Thought Tessa Haspil-Corgan, MD FACEP FAAEM

This work reminds me daily of why I went into medicine: my ability to ease a patient’s nerves by walking them through a diagnosis in their native tongue or even by sharing their racial and ethnic background.”

highlighted byThetheinequities COVID-19 pandemic must not be forgotten; we must remain vigilant and remember that the importance of diversity and access in the medical community extends beyond the news cycle.”

he COVID-19 vaccine is here, providing us with a glimmer of hope, but this provides hope for only one pandemic. In the battle against deeply rooted racism, COVID-19 has reminded us that medicine is not immune. Despite the over 44.5 million Americans who have received at least one dose, many in the Black community are still hesitant to receive the vaccine.1 Reports indicate that Black Americans are vaccinated at a lower rate than white Americans, nation-wide.2 Skepticism about the vaccine remains palpable and is the reason why as a Black physician I made the decision to participate in the Pfizer COVID19 trial. As an Assistant Professor of Medicine at Florida International University, I have spent the past few months teaching medical students over Zoom and practicing as one of the attending physicians in our Neighborhood Health Education Learning Program (NHELP®). This program provides a proactive step towards administering accessible primary care in underserved communities. This work reminds me daily of why I went into medicine: my ability to ease a patient’s nerves by walking them through a diagnosis in their native tongue or even by sharing their racial and ethnic background. The power of these connections is all too often undervalued in medicine. Likewise, I fear that their significance is underestimated in the rollout of the vaccine. Many of my patients of color just do not trust the vaccine. The skepticism has roots in centuries of unethical and harmful medical experimentation on Black Americans. The fear is not irrational but rather a reminder that medicine has repeatedly failed underrepresented people. A recent article in the New England Journal of Medicine indicated that, “although Black people make up 13% of the U.S. population, they account for 21% of deaths from COVID-19 but only 3% of enrollees in vaccine trials.”3 As a result of these concerning disparities, presidents of four Historically Black Colleges and Universities stated earlier this year that, “Black doctors are the best way to build trust in our communities. But they need help. Without significant participation in clinical trials, there will be no proof that our patients should trust the vaccine.”4 Conversations concerning diversity and equity in these trials ensued, with health care workers and officials pushing for not only greater participation in the trials from communities of color, but also clear procedures that would enhance trust, such as providing access to health care for participants and pushing for rigorous informed consent processes. Yet, despite the prevalence of these conversations in the development of the vaccine, I still encounter patients that are adamantly against the vaccine. This opposition exists despite the grief that weighs on each of us who are members of the communities most devastatingly hit by COVID-19. Our conversations are laden with longstanding grief – a grief tied to how structural racism and medicine have intersected for centuries predating the arrival of COVID-19.

>> COMMON SENSE MAY/JUNE 2021

SECTION REPORT WOMEN IN EMERGENCY MEDICINE

The clinician in me wants to look at the data – examine the efficacy rates, detail the steps involved in Emergency Use Authorizations, and explain the science behind the vaccine to my patients. I want to use science to encourage my patients’ trust in vaccination. However, I know simply explaining the science cannot automatically heal generations of heartbreak, trauma, and distrust. I am not naive enough to believe that my decision to be one of the 40,000 people in the Pfizer trial will resolve this crisis of confidence. I DO believe that my decision and my willingness to be vocal about it CAN have an impact. We hear most frequently from clinicians, CEOs and public health officials, all of whom, despite their expertise, were not the ones who decided to take an experimental drug. The decision to participate in a trial is personal. I did so because as a Black physician, I do not want my advocacy for the vaccine to be lip service. I have felt the waves that the pandemic has sent through the system as a whole; highlighting inequities that have rocked each of us to our core. Yet the vaccine roll-out reminds me that I am only one person. There are limits to how many people I can reach with my voice, heart, and education to have a frank conversation about their justified fears concerning the vaccine. The frustration that comes with navigating the medical community throughout the COVID-19 pandemic as a Black physician is a reminder that diversity in medicine is often treated as an

of efforts such as the NHELP® program that seek to redistribute resources and provide care to under resourced communities.

afterthought. We aim to treat the symptoms but not the root cause. Diversity and inclusion efforts, such as those implemented in the vaccine trials only after the urging of Black physicians, are merely Band-Aids on a festering wound. As a mentor to many BIPOC pre-med students and as a professor who focuses on the social determinants of health, I cannot overstate the importance of a more inclusive medical field. The inequities highlighted by the COVID-19 pandemic must not be forgotten; we must remain vigilant and remember that the importance of diversity and access in the medical community extends beyond the news cycle. Logically the question becomes how do we begin to change a field that has continually failed Black and Brown communities? Mentorship is key as demonstrated by the work of Dr. Dale Okorodudu, MD, who founded Black Men in Whites Coats. Good mentorship can go a long way to diversifying the medical community. It is clear that diversity in medicine has positive impacts on providing quality patient care and ensuring that underserved populations have access to such care. Mentorship is a necessity, but the burden cannot all fall on Black physicians who represent 5% of physicians in the U.S. We need the medical community to dedicate resources to ensure that young students in our public-school systems have access to quality STEM education, to prioritize holistic evaluations of students that recognize longstanding inequities in admissions, to require courses and fund research that focuses on social inequities, and to broaden the scope

As a physician, I believe in the good that medicine can and does bring to our society. However, medicine is not absolved from its role in perpetuating racial health disparities. COVID-19 is a reminder that we need to be more proactive in redesigning our health systems to account for centuries of racialized violence, oppression, and inequity. Let us extend the conversation beyond mentorship and tackle this issue from all angles, from future physician education to socially inclusive medical practices and research.

References 1. https://www.bloomberg.com/graphics/covidvaccine-tracker-global-distribution/ 2. https://www.nbcnews.com/health/health-news/ black-americans-are-getting-vaccinated-lowerrates-white-americans-n1254433 3. Tuskegee Study - Timeline - CDC - NCHHSTP. (2020, March 02). Retrieved from https://www. cdc.gov/tuskegee/timeline.htm 4. Warren, R. C., Forrow, L., Hodge Sr., D., & Truog, R. (2020, December 10). Trustworthiness before Trust - Covid-19 Vaccine Trials and the Black Community: NEJM. Retrieved from https://www.nejm.org/ doi/full/10.1056/NEJMp2030033 5. Frederick WAI, Montgomery Rice V, Carlisle DM, Hildreth JEK. We need to recruit more Black Americans in vaccine trials. New York Times. September 11, 2020 (https://www. nytimes.com/2020/09/11/opinion/vaccinetesting-black-americans.html).

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.

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

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

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

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

History of Present Illness

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

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

References 1. 2.

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

Now available!

Learning to Communicate in a Pandemic

SECTON REPORT YOUNG PHYSICIANS

Jessica Fujimoto, MD

he transition from resident physician to attending physician is full of challenges: fighting imposter syndrome, learning to work in a new hospital system, and finding one’s voice as a new leader. During the SARS-CoV2 pandemic, young physicians have the added task of doing all of this while donning PAPRs, P100 respirators, or N95s to protect themselves. Though interpersonal communication is a skill that physicians start to build in residency, communicating while wearing a mask is an entirely new skill. Masks cover mouths and noses, taking away our primary means of nonverbal communication. They muffle voices, particularly at higher pitches, which hinders our ability to communicate verbally. Interpersonal communication is a critical part of our job – a key component of both the physician-patient relationship and health care team dynamics; thus, poor communication is a threat to patient care and patient safety.

Speak up. Optimizing verbal communication can help compensate for the impairment of nonverbal communication caused by mask wearing. • When in doubt, speak up! Masks muffle voices, particularly at higher frequency. • Always introduce yourself, including your role. It is challenging for patients and staff to distinguish each other when everyone is wearing gowns, bouffants, goggles, face shields, and masks. • Use names as much as possible when addressing others. This decreases reliance on eye contact, which is difficult to determine when wearing PPE. • Communicate nonverbal information verbally. For example, tell your patient “I’m smiling back at you” since they are unable to see your expression under your mask. • Invite questions and check for understanding to maintain open lines of communication.

As with other challenges, we can begin by learning from those with different experiences than our own. Surgeons effectively communicate and lead teams in the OR while wearing a mask by keeping clear and open channels of communication. Muslim women who wear niqab are able to convey emotions by varying voice pitch and tone. People with congenital prosopagnosia use nonverbal cues such as gait and hand gestures to interpret sentiments of their communication partners. Additional review of current literature reveals the following recommendations for overcoming the challenge of communicating while wearing masks: Acknowledge the challenge. It is important to first recognize the communication challenges that come with mask wearing. • Verbally name the communication challenges presented by mask wearing. This helps team members and patients get on the same page and adjust communication styles. • Departments or hospitals should provide education about the challenges of interpersonal communication in masks. • Consider discussing strategies with speech language therapists, who can be a helpful resource given their experience with patients rehabilitating from aphasias and facial nerve palsies. Set the stage. Time spent preparing the environment for an exchange can pay dividends. • Reduce background noise by discussing communication goals with the team, and by minimizing the number of people and equipment in the room. • Perform a team huddle when high stress, complex patient encounters are expected (e.g. cardiac arrest). The huddle allows the leader to convey a medical management plan in addition to a communication plan. It also allows team members to familiarize themselves with each other’s roles. • When possible, reduce obstructions of visual fields in order to optimize viewing of each other’s nonverbal cues.

Interpersonal communication is a  critical part of our job – a key component

of both the physician-patient relationship and health care team dynamics; thus, poor communication is a threat to patient care and patient safety.”

COMMON SENSE MAY/JUNE 2021

SECTION REPORT YOUNG PHYSICIANS

challenges, we can begin by learning from As with other those with different experiences than our own.”

Talk with your hands. The lower ½ to ⅔ of our faces are responsible for the majority of facial expression, so it is important to utilize other means of nonverbal communication when wearing a mask. • Utilize your upper face to convey emotion, particularly your eyes and eyebrows. • Communicate with hand gestures, changing head orientation, and body language. • When possible, use visual aids like whiteboards. Working as a young emergency medicine physician is a tough job. Now that we have the added challenge of communicating while wearing masks, it is important that we learn new skills to improve the way we communicate with our patients and team.

AAEM

References 1. Carbon C-C. Wearing Face Masks Strongly Confuses Counterparts in Reading Emotions. Frontiers in Psychology. 2020;11. doi:10.3389/ fpsyg.2020.566886 2. Ellis R, Hay-David A, Brennan P. Operating during the COVID-19 pandemic: How to reduce medical error. British Journal of Oral and Maxillofacial Surgery. 2020;58(5):577-580. doi:10.1016/j. bjoms.2020.04.002 3. Hampton T, Crunkhorn R, Lowe N, et al. The negative impact of wearing personal protective equipment on communication during coronavirus disease 2019. The Journal of Laryngology & Otology. 2020;134(7):577581. doi:10.1017/s0022215120001437 4. Marler H, Ditton A. “Im smiling back at you”: Exploring the impact of mask wearing on communication in healthcare. International Journal of Language & Communication Disorders. 2020;56(1):205-214. doi:10.1111/1460-6984.12578 5. Mheidly N, Fares MY, Zalzale H, Fares J. Effect of Face Masks on Interpersonal Communication During the COVID-19 Pandemic. Frontiers in Public Health. 2020;8. doi:10.3389/fpubh.2020.582191

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he Florida Chapter Division of AAEM (FLAAEM) has been having a busy year. Despite having to cancel our annual Florida Scientific Assembly last May due to COVID, we are planning to have a Scientific Assembly in Miami this fall. We also recently hosted a virtual Town Hall on March 20, 2021 to update our members on all our goings-on and give some CME. The chapter division has also been involved in legislative advocacy and working with the Florida Medical Association and Florida Osteopathic Medical Association in order to ensure patient safety and fair working conditions for physicians in the state. FLAAEM obtained a specialty society delegate seat on the FMA Specialty Society Section in 2019, an important step to voicing the concerns of emergency physicians in the state. One of the current issues affecting EM physicians is non-physicians gaining independent practice in Florida. This topic has loomed large this past year.

advocated against passing thisFLAAEM legislation due to concerns for

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https://nursing.vanderbilt.edu/msn/pmhnp/pmhnp_curriculum.php

Last March of 2020 with the COVID-19 pandemic just beginning, physicians and patients in Florida faced this all too-familiar issue. Florida House Bill 607 regarding direct care workers was passed with an amendment allowing for Advanced Practice Registered Nurses (APRNs) to practice without physician supervision or even a collaborative agreement. Despite opposition from numerous physician groups, Governor Ron Desantis signed the bill into law. Florida statute 464.01231 now allows an APRN with an active, unrestricted Florida

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patient safety and the subsequent quality of medical care.”

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acknowledges that NPPs are an important part  Everyone of the care team, but at the same time, they cannot be

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replacements for physicians.” Psychiatry Training PSYCHIATRY

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Step 2 U.S. Medical Licensing Exam (17 Hour Test)

Medical Ethics Psychopathology Neuroscience Renal System Cardiopulmonary Musculoskeletal Gross Anatomy Pathology Immunology Pharmacology Microbiology Genetics Cell Biology Biochemistry

Psychiatrist Training

Prerequisite: 4Year Premedical Bachelor’s Degree

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Year 6

Year 7

MD/DO: 8 PMHNP: 2

Year 8

17,000

Years of graduate education Hours of clinical training

600

Years of graduate education Hours of clinical shadowing

@drseanwilkes @drseanwilkes

https://nursing.vanderbilt.edu/msn/pmhnp/pmhnp_curriculum.php

MD/DO Awarded Residency

MCAT Exam

4 Year Premed 7.5 Hour Exam College Degree 4 Year NCLEX Nursing Exam for RN College Degree 26 Hour Exam

Medical School Part 1

Medical Licensing Exam Step 1

2 Years Classroom

8Hour Exam

NP School 1.52 Years 5001000 Clinical Hours

Nurse Practitioner Certification Exam

DNP Degree Administrative (No Clinical Training)

3.54 Hour Exam

Medical School Part 2 2 Years Clinical 5,000 Clinical Hours

Medical Licensing Exam Step 2

Intern Year 3,000 Clinical Hours

Medical Licensing Exam

26 Years Clinical Training

Step 3

6,000 to 18,000 Hours

16Hour 2Day Exam

Specialty Medical Board Exam 1+ Day Exam

With patient encounters

MD/DO Awarded Residency

MCAT Exam

4 Year Premed 7.5 Hour Exam College Degree 4 Year NCLEX Nursing Exam for RN College Degree 26 Hour Exam

Medical School Part 1

Medical Licensing Exam Step 1

2 Years Classroom

8Hour Exam

NP School

Nurse Practitioner Certification Exam

1.52 Years 5001000 Clinical Hours DNP Degree Administrative (No Clinical Training)

3.54 Hour Exam

Medical School Part 2 2 Years Clinical 5,000 Clinical Hours

Or Further Subspecialty Training (3,000 to 9,000 Hours)

With case simulations

17Hour 2Day Exam

Independent Practice Of Medicine

Medical Licensing Exam Step 2 17Hour 2Day Exam With patient encounters

Intern Year 3,000 Clinical Hours

Medical Licensing Exam

26 Years Clinical Training

Step 3

6,000 to 18,000 Hours

16Hour 2Day Exam With case simulations

Specialty Medical Board Exam 1+ Day Exam

Independent Practice Of Medicine Or Further Subspecialty Training (3,000 to 9,000 Hours)

license, 3000 clinical practice hours, three hours of recent pharmacology training, and minimal malpractice coverage to practice primary care independently. The law was enacted intending to increase patient access to primary care: in this case, defined as family practice, internal medicine, and pediatrics. FLAAEM advocated against passing this legislation due to concerns for patient safety and the subsequent quality of medical care. The mission and values of AAEM support this stance. As the position statement2 published by the Academy on January 29, 2019 states: “AAEM believes that emergency department (ED) patients should have timely and unencumbered access to the most appropriate care led by a board certified emergency physician (ABEM or AOBEM). AAEM and AAEM/RSA oppose the expansion of scope of practice regulations at the state and federal level, and do not support the unsupervised or “independent practice” of non-physician practitioners (NPPs).” Everyone acknowledges that NPPs are an important part of the care team, but at the same time, they cannot be replacements for physicians. Local lobbying efforts in Florida fell short against the powerful NP lobby in combating this scope expansion. Members’ call to action and grassroots lobbying from FLAAEM, state medical societies (FMA/FOMA), and organizations such as Physicians for Patient Protection (PPP), were unable to stop the passage of HB 607. Unfortunately for the state of Florida and its patients, the “scope creep” and insidious objectives of the NPP lobbies don’t stop there. At the first meeting of the Council of APRN Autonomous Practice formed in the wake of HB 607, a member argued in favor of sovereign immunity for APRNs.3 This luckily is not within the Council’s authority to grant, as it would mean NPs with a fraction of the training of doctors would be free from malpractice suits when they inevitably harm a patient. The

>> 62

COMMON SENSE MAY/JUNE 2021

AAEM CHAPTER DIVISION UPDATES FLAAEM

Florida Board of Nursing was also given authority to adopt rules to define exactly what primary care is. This past fall during the Board’s discussion of the definition, nurse specialty groups fought to include psychiatric and aesthetic nurses among those granted autonomous practice.4 Physician groups objected that those are distinct specialties under the practice of medicine. The original intent of the legislation was to increase patient access to primary care. To consider those specialties as primary care would be contradictory to that.

WHAT IT TAKES TO MAKE A

DOCTOR The Educational Differences between Medical Doctors and Nurse Practitioners

CERTIFICATION BY UNIT REQUIREMENT

Even without accounting for

NP School

residency, which is an additional 3-7 years of training, physicians who just graduated medical

Medical School

237 0

school had to take nearly 5x the

100 150 Units

200

250

In recent developments, the push for scope expansion continues and FLAAEM is committed to continuing to advocate for patient safety concerns. New bills introduced this session,5 HB 111 and SB 424, would legislate that APRNs can practice unsupervised in any specialty area of medicine they see fit. Again, this would contravene the original intent of the law. Physician assistants (PAs) have jumped on the bandwagon with their own legislation. HB 431 and SB 894 would allow for PAs to practice independently, without any physician supervision requirements, contrary to their very profession’s name.

programs of their same degree.

CLINICAL HOURS REQUIRED FOR CERTIFICATION

600

Medical School

6,000

16,000

Physician (3 year residency)

advocate for patient safety concerns.”

compared to NPs.

*Example programs are listed that state their specific unit requirements for graduation. These sources closely resemble other

In recent developments, the push for scope expansion continues and FLAAEM is committed to continuing to

amount of units for their degree

(not including residency)

1 ,2

5,000

10,000

15,000

20,000

Clinical Hours

While some nurse practitioner degrees can be completed 100% online in as little as 5 years including college, physicians must complete at least 11 years and more than 16,000 hours of hands-on training before treating patients independently.

An NP has less than 4% of the clinical hour training of an MD/DO (with the 4

minimum 3 years residency training).

A medical student, who is not allowed to treat a patient independently, would have undergone nearly 5x the amount of unit requirements and 10x the amount of clinical training that a fully licensed NP has.

With the vast amount of education, training, and clinical hours required to produce a single physician (the most of any healthcare team member), physicians can rely on a much larger breadth of knowledge in each of the medical decisions they make. This is why we at AAEM/RSA believe that all healthcare team members, including nurse practitioners, should be under the supervision of a physician in order to ensure the safety and proper health care of our patients.

#ASKTOSEEYOURPHYSICIAN 1.https://www.samuelmerritt.edu/nursing/fnp_nursing/curriculum 2.http://med.stanford.edu/md/mdhandbook/section-4-curriculum-overview.html 3.https://tafp.org/media/default/downloads/advocacy/scope-education.pdf 4.https://www.tafp.org/Media/Default/Downloads/advocacy/scope-ramas.pdf

Despite the dire outlook, the way forward is through educating the public and our lawmakers. Many do not see scope expansion as a negative, but in fact, see the increased access to care as a positive. It is up to us to reach out to legislators on a state level and inform them of the differences in training and education (see the graphics below). We at FLAAEM are continuing to advocate for a safe healthcare system for our patients and hope that our members will continue to support and join us in this endeavor.

References 1. Florida Statute 0464.0123: Autonomous practice by an advanced practice registered nurse http://www.leg.state.fl.us/statutes/index.cfm?App_ mode=Display_Statute&Search_String=&URL=0400-0499/0464/ Sections/0464.0123.html 2. AAEM Updated Position statement on Non-Physician Practitioners https://www.aaem.org/resources/statements/position/updated-advancedpractice-providers 3. Thomas, Mary Esq. Rule-making rules in Florida Physicians should Watch. https://www.flmedical.org/florida/Florida_Public/Docs/Legis/RulemakingMoves-in-Floridapdf?fbclid=IwAR1o2lMVQL6QKF7Sim0cfCqaVWsec0gIC hM4v5MFxXWDmY3qGdlDpWzxwYE, FMA News 9/3/2020 4. Florida Regulatory Update. Florida Medical Magazine Fall 2020. P. 19-22 5. Thomas, Mary Esq. 2021 Scope-of-Practice Legislation Preview https:// www.flmedical.org/florida/Florida_Public/Docs/Legis/2021-Scope-ofPractice-Legislation.pdf, FMA News 2/24/2021

COMMON SENSE MAY/JUNE 2021

CHAPTER DIVISION UPDATE CAL/AAEM

CAL/AAEM Golden State Symposium Emily Rose, MD FAAEM FAAP

AEM members, on behalf of CAL/AAEM, I am thrilled to invite you to participate in a complementary CME activity (worth 5.5 AMA PRA Category 1 CreditsTM). The CAL/AAEM Golden State Symposium is available here: https://online.aaem.org/course/view. php?id=270&pageid=1828. We have an all-star speaker line up with topics important to today’s practice of EM. The CAL/AAEM Golden State Symposium delivers high yield, quality CME that both inspires and informs with practical pearls for your next shift. With a powerhouse faculty line up, these talks will make you smarter, more efficient purpose-driven, and more effective.

Dan Dworkis, MD (emergencymind.com) gives practical insights on maximizing our mental capacity and performance under stress. Amy Faith Ho, MD (amyfaithho.com) gives practical advice on how to navigate social media and have an effective presence as a medical professional. The legendary Stuart Swadron, MD FAAEM gives insights on the important clinical decision point—is this a STEMI or no STEMI? Mary Cheffers, MD (who works at the busiest stroke receiving hospital in California) gives practical bedside management pearls and updates on the rapid evaluation and treatment of acute stroke patients.

The keynote features AAEM President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM who details healthcare disparities in the time of the COVID-19 pandemic and our role and responsibilities to our most vulnerable patients.

Effective communication skills are essential for success, both personally and professionally. Gus Garmel, MD FAAEM FACEP details communication pearls gained through his years of experience and mentorship to ensure our effectiveness.

Jennifer Kanapicki-Comer, MD FAAEM (CAL/AAEM President), highlights the important history of AAEM and the important activities of our chapter division.

Emily Rose, MD FAAP FAAEM FACEP highlights key issues in the diagnosis and management of COVID-19 and MIS-C in kids.

Sanjay Arora, MD FAAEM and Michael Menchine, MD MPH FAAEM (of the Emergency Medical Abstracts) highlight some important practicechanging papers including d-dimer cut-offs, TXA use in ICH, the Roc versus Sux debate, and return to play after a concussion.

CAL/AAEM

Electrolyte emergencies are life-threatening and can have many atypical presentations. Anneli von Reinhart, MD will detail specific emergencies and how to most effectively treat these emergencies.

the issue California

Golden State Symposium Virtual Event

COMMON SENSE MAY/JUNE 2021

CHAPTER DIVISION REPORT CAL/AAEM

Here are some of the highlights and important take home pearls from the day: • The COVID-19 pandemic has disproportionally impacted our country’s most vulnerable populations in incidence, complications, and death rate. • Rocuronium may be preferred in a hemodynamically compromised patient. • Earlier return to activity may be beneficial in concussion. • Increasing the d-dimer threshold (to 1000 ng/mL) in low risk patients may decrease imaging without increasing risk. • Review your professionalism contract clause with your medical group and hospital and how it applies to your social media presence. • AAEM advocates for fair and equitable practice environments for the emergency physician including physician ownership and the right to due process. • Clinical symptoms of a large vessel occlusion in acute stroke include: aphasia, gaze deviation, or neglect. These symptoms are potentially an indication for mechanical thrombectomy. • A STEMI is a complete vessel occlusion while a NONSTEMI is an incomplete occlusion. The clinical picture should significantly impact your decision to activate the cath lab or administer thrombolytics. • deWinters T waves and post-arrest are two clinical indications for a Code STEMI. • Mental visualization of procedures and resuscitations can improve performance.

• Less than 1% of children with acute SARS-CoV2 infection require ICU admission. • MIS-C is a rare but serious post-infectious sequelae that presents with fever, abdominal pain, and with two general phenotypes: 1) Kawasakilike or 2) multi-organ involvement commonly with cardiac involvement. Treatment is extrapolated from KD treatment. Cardiac function typically improves with treatment but long term outcomes are unknown. • Communication is a critical skill which enhances the patient care experience, improves outcomes, and reduces risk management events. Excellent communication requires practice, intentionality, and feedback. Effective communication is vital when disclosing medical errors, delivering bad news, during handoffs, and with conflicts. • In his classic book Nonverbal Communication (1972), Mehrabian described the 7-38-55% rule in which 7% of personal communication involves spoken words, 38% is voice and tone, and 55% is through body language. Communicating empathy is an important skill that can be learned and body language is part of that communication. • Hyperkalemia is the deadliest of all electrolyte emergencies. Nebulized albuterol, IV calcium (if QRS is wide) and IV insulin/dextrose “buy time” by shifting K+. 5 units of insulin is effective and safer than 10 units (particularly in renal failure). Hemodialysis or working kidneys are the only way to really solve the problem of hyperkalemia by removing potassium from the circulation. Sodium polystyrene and patiromer (Kayexalate and Veltassa) prevent GI absorption of K+ and are not effective in emergencies.

These great pearls and more were discussed during this high yield symposium. Check it out for some CME credit!

Attend Social, DEI, and Wellness Events at AAEM21! SUNDAY, JUNE 20, 2021

WEDNESDAY, JUNE 23, 2021

• Opening Reception | 5:45pm-6:45pm • DEI Reception at BBs Jazz, Blues, and Soups | 8:30pm-9:30pm

• Women in EM Coffee Meet-Up | 7:00am • Scott Joplin Historic Site Tour | 12:30pm-3:00pm

MONDAY, JUNE 21, 2021

• • • •

• Early Risers Yoga | 6:30am-7:30am • AAEM/RSA & YPS Social | 6:00pm-7:00pm • Airway at AAEM Storytelling | 7:00pm-9:30pm

ONGOING African American Outreach Program Wellness Room AAEM21 Wellness Puzzle F3 Wellness Meals - Food, Friendship, and Fun

TUESDAY, JUNE 22, 2021 • Wellness Fun Run/Walk | 6:30am-7:55am • Women in EM Networking Lunch | 12:05pm-1:30pm • Chapter Divisions & Sections Social | 7:00pm-8:30pm

Take time to celebrate and recharge at social, DEI, and wellness events.

Learn more at www.aaem.org/aaem21 COMMON SENSE MAY/JUNE 2021

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

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

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

FOR MORE INFORMATION PLEASE CONTACT:

Heather Peffley, PHR FASPR at: hpeffley@pennstatehealth.psu.edu 66

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 MAY/JUNE 2021

AAEM/RSA PRESIDENT’S MESSAGE

Passing the Baton: The Next Generation of AAEM/RSA Haig Aintablian, MD

ll good things must come to an end, but in this case I’m reflecting on the ellipses in front of AAEM/ RSA as we continue to fight the good fight of putting our emergency medicine physicians-in-training at the forefront of our advocacy. It’s a broken record cliché now, 2020 was an unprecedented year. Emergency physicians have never seen this level of uncertainty in not only our daily lives as we battle COVID surges, but also in the prospect of potentially not finding jobs after we graduate residency. My focus over the last two years of my presidency has been to show who and what AAEM/RSA is and does for emergency medicine residents and students through advocacy. I hope that I have done that, and can say that I am most proud of my colleagues on the Board of Directors, the Medical Student Council, and all of our members for listening and participating in our cries for protections, fairness, equity, and due process for EM physician trainees. Together, we campaigned to educate fellow physicians and our patients about so many different advocacy issues, from NPP scope of practice battles to the over expansion of residency programs by corporate interests. Here are just a few of the position statements and advocacy efforts we led over the last two years: AAEM/RSA is poised to continue this marathon of advocating for residents and students in emergency medicine, and educating them on their practice rights and the business of EM. I’m excited to pass the baton to Lauren Lamparter, MD, our current Medical Student Council President, as she steps into her intern year and the AAEM/RSA President role. I am proud of the diversity of people and opinions of our organization, our strong values, and our commitment to fighting the good fight. I can’t wait to see what AAEM/RSA does next as I continue as Immediate Past President. Welcome to the 2021-2022 AAEM/RSA Board of Directors!

WHAT IT TAKES TO MAKE A

DOCTOR The Educational Differences between Medical Doctors and Nurse Practitioners

CERTIFICATION BY UNIT REQUIREMENT

Even without accounting for

NP School

residency, which is an additional 3-7 years of training, physicians who just graduated medical

Medical School

237 0

school had to take nearly 5x the amount of units for their degree

(not including residency)

1 ,2

100 150 Units

200

250

compared to NPs.

*Example programs are listed that state their specific unit requirements for graduation. These sources closely resemble other programs of their same degree.

CLINICAL HOURS REQUIRED FOR CERTIFICATION

600

Medical School

6,000

16,000

Physician (3 year residency)

5,000

10,000

15,000

20,000

Clinical Hours

An NP has less than 4% of the clinical hour training of an MD/DO (with the 4

minimum 3 years residency training).

COMMON SENSE MAY/JUNE 2021

AAEM/RSA PRESIDENT’S MESSAGE

AAEM/RSA Position Statement on Medical Student Education and Residency Applications during the COVID-19 Pandemic AAEM/RSA Position Statement on COMLEX Level 2-PE AAEM/RSA supports the equality and safety of all medical  students, and we believe that accredited medical schools should be given the final authority in evaluating the clinical skills of their future physician graduates.”

AAEM/RSA exists to support all emergency medicine  residents and medical students. We understand the severity of this pandemic and the major impact it has on medical student education. We will continue to advocate for a dynamic response to emergency medicine education during this time and encourage flexibility from program directors during this unprecedented residency application season.”

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

AAEM/RSA Position Statement on Occupational English Test Taking these facts into account, AAEM/RSA does not support  the mistreatment of IMG candidates who have already proved their English-proficiency through a US undergraduate degree, a medical school curriculum taught in English, or through their performance of two years of clinical rotations in US hospitals. While we are aware that the current state of affairs may prevent any significant changes to this portion of the ECFMG accreditation process for the current application cycle, we believe that changes to the OET requirement should be addressed for the following Match if the Step 2CS exam continues to be suspended.”

AAEM/RSA Position Statement on the Protection of Residents and Medical Students during the COVID-19 Pandemic AAEM/RSA exists to support all emergency medi cine residents and medical students. We understand the severity of this pandemic and will continue to fight relentlessly to represent the safety and protection of our members both on The Hill and in the hospital.”

AAEM and AAEM/RSA Position Statement on Emergency Medicine Training Programs for Physician Assistants (PAs) and Nurse Practitioners (NPs) The American Academy of Emergency Medicine (AAEM) and  the AAEM Resident and Student Association (AAEM/RSA) are aware that academic and other emergency departments sponsor additional training for non-physician practitioners (NPP), including physician assistants (PA) and nurse practitioners (NP). We believe the following is in the best interest of the patient and our specialty.”

Position Statement on the Independent Practice of NonPhysicians and Trainee Oversight AAEM/RSA supports the AAEM updated position statement on  Advanced Practice Providers. AAEM/RSA believes that the only appropriate preparation and qualification for the independent practice of emergency medicine is through completion of an ACGME or AOA accredited residency training program with subsequent board certification by the American Board of Emergency Medicine (ABEM) or American Osteopathic Board of Emergency Medicine (AOBEM).”

COMMON SENSE MAY/JUNE 2021

AAEM/RSA PRESIDENT’S MESSAGE

AAEM/RSA Board of Directors 2021-2022 PRESIDENT

Lauren Lamparter, MD

VICE PRESIDENT

SECRETARY-TREASURER

Ryan DesCamp, MD MPH

Corey McNeilly, MD

University of Chicago

University of Illinois

University of Tennessee Nashville

IMMEDIATE PAST PRESIDENT

AT-LARGE BOARD MEMBER

Haig Aintablian, MD

Megan Daniels, MD MS

UCLA - Olive View

Temple University

Nahal Nikroo, MD

AT-LARGE BOARD MEMBER

Alexandra Reed, DO

Loren Touma, DO MS

Anika Turkiewicz, MD

Jefferson Health Northeast

Temple University

AT-LARGE BOARD MEMBER

MEDICAL STUDENT COUNCIL PRESIDENT

Jordan Vaughn, MD

Healthquest – Vassar Brothers Medical Center

Ashley Iannantone, MA

Louisiana State University New Orleans

Loyola Stritch School of Medicine

AAEM21 AAEM/RSA Track Tuesday, June 22, 2021

NEW: Resident Breve Dulce Competition AAEM/RSA is excited to bring resident members a new Breve Dulce competition! The theme of this competition is “My First Solo Shifts.”

Learn more at: www.aaem.org/aaem21/attendees/residents COMMON SENSE MAY/JUNE 2021

COMMON SENSE MAY/JUNE 2021

What Keeps Me Up at Night

AAEM/RSA NEWS

Elizabeth Dalchand, MD

ow lucky are we that we hardly know our patients? And I mean really know them. In my busy shift with dozens of patients waiting to be seen within a 9-hour period, there’s no way I care to ask, “what’s your favorite food?” We often go into a patient’s room for a maximum of 15 minutes to get a short history of why they came into the hospital and a physical exam, and the rest of our time is spent on the computers ordering labs and exams. It’s not that emergency physicians have no desire to know their patients on a personal level, but the quick pace of the emergency department naturally lends itself to our curtness. We have so many patients to see that our time is filled with busy work where going to take a bathroom break feels like a luxury. The brevity in which we know each patient definitely affects how we see and view our patients, whether intentional or not. Sometimes I find myself sneakily rolling my eyes when the patient goes off in a diatribe about their grandkids when all I want to do is remove myself from the room and order their labs so they can either go home or get admitted to the hospital.

patients that morning. Four patients for a 12hour shift. I had no idea what I would do with this exuberant amount of free time after rounding. Maybe this was the day I got lunch, or took a nice afternoon stroll downstairs to get coffee. The possibilities were endless.

But I found myself spending time with Mr. Fred. Mr. Fred was a former smoker and came in for shortness of breath due to COVID. It wasn’t long before he was placed on the BIPAP machine, but his oxygen saturations were still hovering in the mid-80s. He was adamant that he wanted to continue BIPAP for as long as possible because we all knew that once he was intubated it would be difficult to get him off of the ventilator. In my head, I thought this was silly. If he was in the emergency department I wouldn’t really give a second thought to intubating. Partially because of my naivety and partially because I wanted to have another intubation in my book. And in my head, I thought that everyone gets off of the ventilator. Ha.

 The brevity in which we know each patient definitely affects how we see and view our patients, whether intentional or not.”

Being in an environment where there is simply no time to waste, it is no surprise that I persuaded myself that there is simply no time to feel, either. But then I was placed on the ICU floors. COVID ICU. When I arrived to the COVID ICU, almost everyone on the floor was intubated and sedated, or on a BIPAP machine slowly chipping away at what would become the inevitable. There were multiple residents, so I only received four

I sat down with him one morning after rounding because I was trying to find some way to waste time in this eerily gloomy ICU. Through muffled noises from his BIPAP machine I learned about his wife and daughter. I learned what he liked to watch on TV and what his last meal was. I learned that all he wanted to do is see his wife and get out of the COVID ICU so he could spend time with her. I learned he was a person and not a chief complaint. Every day I sat with him and video chatted with his wife. Every day I was in close contact with his family members

giving them updates multiple times a day. I knew him more personally than I did any other patient in my two years as a resident. And the extenuating circumstances of him being COVID positive didn’t dissuade me against my better judgement from spending multiple hours in his room. One day he wasn’t doing so well. I saw that his oxygen saturation started to drop precipitously, now in the 70s, and we had to intubate soon. During the last few moments prior to intubating, I rapidly dialed his wife and daughter so he could video chat with him before he would be completely sedated and intubated. I saw tears streaming down his face as he knew what was coming next. I saw his wife and daughter shed tears and whisper, “I love you,” already somewhat defeated. My face started to feel like it was on fire underneath my N95 mask and my chest was heavy. Tears flowed down and soaked my surgical mask realizing that this could be it; this may be the last time he ever speaks to his loved ones. This might be the last time he’s awake. And yes, I’ve heard stories of people spending time with patients and realizing that they’re people – of course they are. But it doesn’t register when you’re working in a busy emergency department. We’re protected by the limits of

COMMON SENSE MAY/JUNE 2021

AAEM/RSA NEWS

 As much as I enjoyed my short-lived time with Mr. Fred,

the heartache and mental capacity it took to process his untimely clinical deterioration overwhelms my thoughts.”

our time to fully register the disheartening fact that once we admit our patients, we know very little of the burdensome course of events that occur later. Our connections are severed once the admit to hospital order goes in.

And with that I feel lucky. Don’t get me wrong, I love interacting with my patients in the emergency department and for the time I do know them I will always proceed with medical care with their best interests at heart. But I can cope quicker with death and go about my day faster when I don’t know them. When I don’t realize that their imminent death means leaving a family behind. Yes, it seems selfish, but it’s true. We’re often taught in medical school to establish a great relationship with the patient, but that’s almost nearly impossible in emergency medicine since we don’t have the luxury to spend

hours at the bedside or follow up on a monthly basis. In the time frame that we see patients with a critical illness, fostering a relationship isn’t as much of a priority as is grabbing a central line kit or preparing for an intubation. Sometimes it’s impossible to do that when a patient is having a cardiac arrest right in front of you and death just becomes another number in the system. As much as I enjoyed my short-lived time with Mr. Fred, the heartache and mental capacity it took to process his untimely clinical deterioration overwhelms my thoughts. A question I am sure most emergency physicians receive is: How do you deal with this every day? When you see traumatic medical cases on a daily basis, there will always be a level of desentization that physicians feel from years of being in practice. However, we are still human. We are humans that have to experience loss and pain on a daily basis, but we learn to re-focus on our successes and better days in order to stay emotionally stable. The unfortunate truth is that even with the best medical care out there, we can’t save everyone. And it’s difficult. And it keeps most of us up at night. But the days where you saved someone from a pneumothorax or sutured a gaping wound is what makes it all worth it. That is the light at the end of the tunnel.

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!

COMMON SENSE MAY/JUNE 2021

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

AAEM/RSA EDITOR’S MESSAGE

 However, seeing another person die every day,

regardless of how comfortable they were, was an ever-present painful reminder that there was, in reality, very little we could do with the modern medicine we’ve committed our lives to studying.”

The “Privilege” of Working in the COVID ICU Alexandria Gregory, MD

had a difficult time deciding what to name this piece. In some ways, I hate to look at COVID with any positivity, and honestly, my time as a resident in the COVID ICU was the worst thing I’ve ever done. On the flip side, looking back to how I felt early in the pandemic, I signed up for this, right? I signed up to take care of people at their sickest and most vulnerable. I signed up for the long hours, nights, and weekends. I signed up understanding that medicine would often come first. I signed up to be on the frontlines, even if a pandemic happened to fall right in the middle of residency. But I didn’t sign up for the daily self-doubt and soul-searching, the never-ending phone calls to family members trying to make them understand just how sick their loved ones were despite them not being able to see them, the seemingly constant death certificates. In the moment, I was beaten down and angry nearly constantly. And while it’s important to allow for those negative emotions, the only way to move on is to “make lemonade,” so to speak. To do that, I’m choosing to look at my time in the COVID ICU as a privilege—the privilege of taking care of some of the sickest patients medicine has ever seen, the privilege of being a lifeline between them and their loved ones, and the privilege of working alongside other physicians, nurses, respiratory therapists, and countless others trying to do the best we could in one of the most difficult situations. In the time since I worked in the COVID ICU, I’ve thought a lot about how the experience has changed me as a physician. One of my patients died every single day. Luckily, the overwhelming majority of those were made Comfort Measures Only prior to dying, so that they could do so in

comfort and with dignity. However, seeing another person die every day, regardless of how comfortable they were, was an ever-present painful reminder that there was, in reality, very little we could do with the modern medicine we’ve committed our lives to studying. Of course, I’m not naïve; I recognize the limits of critical care and understand that dying is not the worst thing that can happen to someone in the ICU. But this was different. In a way, we’re shielded in the emergency department. We’re able to stabilize many of the people who come in extremely ill and get them to the ICU. Mentally, this has always been a shield from the reality of the poor prognosis up there. It also provides a shield from having to have difficult conversations with the patient’s family. Admittedly, we cannot always know a patient’s trajectory based on the limited time we are taking care of them, but I wonder if I’ve used this to be as vague as possible with family to shield myself from a difficult conversation. I left the COVID ICU worried that I would never be the same physician I was before that experience. And while that’s true, I’m choosing to see that as a good thing. I’ve started having earlier prognostic discussions with patients and their families. Sure, I’ve had to reframe those discussions to allow for more uncertainty, but when I explain to a family member that I’m choosing to be honest and open up front so that they aren’t blindsided later on, I’m almost always met with appreciation. I spend more time having such discussions or even just providing updates because I have a greater understanding of how difficult it is to not be with a loved one when they are sick and vulnerable. I’m hoping that these changes will help me become a better physician, and if that’s the case, working in the COVID ICU would have been the greatest privilege of all.

 But I didn’t sign up for the daily self-doubt and soul-searching, the never-ending phone calls to

family members trying to make them understand just how sick their loved ones were despite them not being able to see them, the seemingly constant death certificates." COMMON SENSE MAY/JUNE 2021

AAEM/RSA RESIDENT JOURNAL REVIEW

Advances in the Use of Coronary Computed Tomographic Angiography in the Evaluation of Coronary Artery Disease in the Emergency Department Christine Carter, MD; John Harringa, MD; Zachary Wynne, MD; and Akilesh Honasoge, MD Editors: Kami M. Hu, MD FAAEM FACEP; and Kelly Maurelus, MD FAAEM

linical Question:

Is there a way to improve the performance of standard coronary computed tomographic angiography (CCTA) in ruling out clinically significant coronary ischemia as the cause of chest pain in the emergency department?

Introduction: Compared to other non-invasive coronary imaging modalities, CCTA has consistently shown higher sensitivity and negative predictive value in determining the presence of coronary stenosis,1-3 even supporting its use in the evaluation of low-risk chest pain presenting to the emergency department (ED).4,5 Fractional flow reserve (FFR) has traditionally been performed during invasive coronary angiography (ICA) by inserting a wire across a stenotic vessel to calculate pressure differences caused by vessel narrowing as a marker of flow limitation – thus risk stratifying need for further intervention. Advances in computational fluid dynamics have allowed for noninvasive CT-derived FFR (FFRCT) assessment,6 but whether this adds to the ED evaluation of chest pain is unclear.

Koo BK, Andrejs E, Doh JH, et al. Diagnosis of ischemiacausing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW. J Am Coll Cardiol. 2011;58(19):1989-97. doi: 10.1016/j.jacc.2011.06.066. This landmark study set out to evaluate the diagnostic performance of a novel noninvasive method of calculating FFR by using computational fluid dynamics to determine lesion-specific ischemia on CCTA, comparing it to the gold standard of invasive FFR measured during ICA. The study included patients from four different facilities in Seoul, Korea, Riga, Latvia, Goyang, Korea, and Palo Alto, California. Included patients were ≥18 years of age with CCTA findings of ≥50% stenosis in a major coronary artery ≥2.0 mm diameter and planned ICA with FFR. Notable exclusion criteria included noncardiac illness with life expectancy <2 years, pregnancy, iodinated contrast allergy, serum creatinine ≥ 1.7 mg/ dl, significant arrhythmia, heart rate ≥100 beats/min, systolic blood pressure ≤90 mmHg, contraindication to beta-blockers, nitroglycerin, or adenosine, prior coronary artery bypass grafting (CABG), Canadian Cardiovascular Society class IV angina or non-evaluable CCTA as determined by the CTA core laboratory.

A total of 103 patients were included, all of whom underwent both CCTA and ICA with FFR. All patients received metoprolol to reach a heart rate <65 beats/min and 0.2 mg sublingual nitroglycerin immediately before acquiring CCTA. Images were obtained of coronary vessels, left ventricle and proximal ascending aorta. 3-dimensional image analysis was performed in a blinded fashion. Coronary segments with densities > 1 mm2 were considered to meet criteria for atherosclerosis. Lesion-related luminal diameter stenosis was quantified as none (0%), mild (1-49%), moderate (50-69%) or severe (≥70%). Diagnosis of obstructive coronary artery disease was based on the presence of ≥50% or ≥70% stenosis depending on the vessel. ICA and FFR were done per normal standards, with a FFR ≤0.80 considered diagnostic for ischemia. FFRCT was calculated using reconstructed CCTA images to obtain values for coronary flow, resistance and pressure. As with invasive FFR, FFRCT ≤0.80 was considered diagnostic for stenosis-related ischemia. Compared to CCTA alone, FFRCT performed similarly with respect to sensitivity, negative predictive value (NPV), and negative likelihood ratio (NLR) for the diagnosis of lesion-specific ischemia. FFRCT, however, also had statistically significant improvements in accuracy, specificity, positive predictive value (PPV) and positive likelihood ratio (PLR). Additionally, FFRCT showed good correlation to FFR with Spearman’s rank correlation = 0.717, p<0.0001; Pearson’s correlation coefficient = 0.678, p<0.0001. At the per-vessel level there was slight underestimation by FFRCT as compared to measured FFR (mean difference 0.022 ± 0.116, p<0.016), with similar values and no systematic differences at the perpatient level (mean difference 0.019 ± 0.128, p<0.131). Limitations of this study include a smaller study size, which limited the power of per-patient performance of FFRCT vs CCTA; the study was adequately powered, however, for per-vessel calculations. Another limitation is that all of the study subjects had clinical indications for ICA, exposing the study to selection bias and limiting the ability to assess the diagnostic performance of FFRCT in consecutive all-comer patients undergoing CCTA. Lastly, patients with prior CABG were excluded from this study, precluding performance evaluation in this high-risk population. Overall, this study demonstrated that FFRCT correlated well with invasive FFR and provided increased diagnostic accuracy of lesion-specific ischemia and lower false positives when compared to CCTA alone.

Coenen A, Lubbers MM, Kurata A, et al. Fractional flow reserve computed from noninvasive CT angiography data: diagnostic performance of an on-site clinician-operated computational fluid dynamics algorithm. Radiology. 2015 Mar;274(3):674-83. doi: 10.1148/radiol.14140992.

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In this study, Coenen et al. looked to validate a new computational algorithm which could perform calculations both quickly and locally in the same hospital while maintaining the diagnostic potential of the results. In a single center retrospective observational study, they looked to compare CCTA and computationally derived FFR with invasive coronary angiography and invasively-measured FFR. They included 122 consecutive patients with known or suspected CAD between 2007 and 2013 who had a CCTA performed based on clinical factors and an invasive angiogram with invasive FFR performed within 50 days of the CCTA. They excluded patients with prior CABG, PCI of the vessel of interest, or a cardiac event between the two imaging methods. In total, 106 total patients were included with 189 unique vessels analyzed. Baseline characteristics of the population included an average age of 61.4 ± 9.2 years and a largely male population (77%). Most of the patients had hypertension (59%), dyslipidemia (59%), and almost half had a family history of CAD (48%). A total of 14 patients had a history of MI with 11 patients with prior PCI, but not in the vessel considered for this study. Patients were routinely given sublingual nitroglycerin prior to the studies, with beta blockers used in those with a fast heart rate. The median time between CTA and invasive measurements was 16 days. Anatomic stenosis > 50% and FFR < 0.80 was considered significant as defined in previous studies. A total of 42.3% of vessels were found to have hemodynamically significant stenosis by invasive FFR, the gold standard test for this study. Anatomic CCTA characterized 70.4% of vessels as significant stenosis while invasive anatomic angiography characterized 46.0% of vessels as such. This led to a sensitivity and specificity of CCTA for hemodynamically significant stenosis of 81.3% and 37.6%, respectively, compared to the sensitivity and specificity of invasive ICA, 73.8% and 74.3%, respectively. Computational FFR using this new locally processed and faster algorithm had the same sensitivity as CCTA with improved specificity (65.1%). Furthermore, increasing the FFR cutoff for significance from 0.80 to 0.82 improved the sensitivity to 90% but did not alter the specificity (similar at 64%). Computational time ranged from 30 minutes to 2 hours, a significant improvement on prior outsourced computational methods. Finally, the overall correlation between computational FFR and invasive FFR was moderate to good with a Pearson correlation coefficient of 0.59. This study largely served as evidence that computational FFR can reliably be performed locally and efficiently in a hospital without having the wait long hours and high costs associated with prior outsourced serverbased computation of FFR. It also further validated the growing evidence for use of computational FFR as a reliable metric for the prediction of functionally significant coronary artery disease. A few major limitations of this study include the predominantly male patient population, and the exclusion of vessels with prior PCI, extremely high coronary calcium scores, and the patients with acute cardiac events.

Chinnaiyan KM, Safian RD, Gallagher ML, et al. Clinical Use of CT-Derived Fractional Flow Reserve in the Emergency Department. JACC Cardiovasc Imaging. 2020;13(2 Pt 1):45261. doi: 10.1016/j.jcmg.2019.05.025. In clearly minimal or severe atherosclerosis, CCTA can safely expedite disposition either to ED discharge or admission for planned ICA. Patients with intermediate (50-70%) stenosis, calcifications impairing study quality, or complex plaque morphology are not as reliably risk-stratified, however, leading to additional invasive testing and increased cost. To evaluate the utility of FFRCT in patients with acute chest pain (ACP), Chinnaiyan et al. performed a retrospective analysis of prospectively enrolled institutional CCTA registry. They sought to evaluate the feasibility, clinical outcomes, and costs associated with the use of FFRCT in patients experiencing ACP and undergoing CCTA. Inclusion criteria were the presence of ACP, no known history of coronary artery disease (CAD), and presence of stenosis >25% on CCTA. Patients were excluded if they had a heart rate >100 bpm, renal insufficiency, or other contraindication to iodinated contrast. Patients received beta blockers to target a heart rate <60 bpm, as well as 0.8 mg sublingual nitroglycerin prior to CCTA. In the original registry, patients were selected for CCTA if they had no clinical evidence of acute coronary syndrome by electrocardiogram or cardiac biomarkers. Only a subset of those patients undergoing CCTA also underwent FFRCT, which was pursued by recommendation from the physician interpreting the CCTA on the basis of discovering: 1) coronary stenosis >50%, 2) dense coronary calcification obscuring the lumen, or 3) high-risk plaque features in coronary stenoses <50%. The authors established CCTA and FFRCT groups for comparison by looking at all those undergoing FFRCT and identifying a CCTA group with similar degree of stenosis, indicating a likely attempt at propensitymatching the cohorts, though the statistical details of this effort were not elaborated upon. Patients were followed for 90 days after index scan. Specifically, safety was defined as absence of death, nonfatal MI, and unplanned revascularization therapy in patients with negative FFRCT. A total of 327 patients were referred to FFRCT, with 24 excluded due to either normal or occluded arteries and six excluded due to insufficient study quality, leading to inclusion of 297 patients compared to 258 in the CCTA arm. Arms were well matched for age, sex, hypertension, hyperlipidemia, smoking, and familial history of early CAD, although a significantly higher portion of typical angina was seen in the CCTA group (11% vs. 2%, p<0.001). There was no statistically significant difference in 90-day major adverse cardiac events (MACE) between CCTA and FFRCT groups (4.3 vs 2.7%, p=0.31). In the CCTA group there was one death, three myocardial infarctions (MI), and six patients with unexpected percutaneous coronary intervention (PCI), five of whom were found to have severe disease on coronary angiography despite CCTA results indicating only 26-50% stenosis. There were four late unexpected

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AAEM/RSA RESIDENT JOURNAL REVIEW

revascularizations in the FFRCT-negative group (FFR >0.80), with no death or MI. When confirmed by findings on ICA, nonobstructive CAD was higher in those with negative FFRCT (56.5%) compared with those with positive FFRCT (8%) or CCTA alone (22.9%) (p<0.001). Costs were lower in the negative FFRCT group compared to positive FFRCT, and compared to the CCTA-only group for stenoses >50%, with no difference between groups in hospitalization or subsequent ED visits, and no increase in ED length of stay. There were some limitations. This was a prospective trial based on an institutional coronary CTA registry which limits generalizability to an all-comers approach. Moreover, the decision of who underwent FFRCT was a function of the previous trial, and not established a priori, possibly introducing unclear bias into the results. The authors indicated patients with similar stenoses on CCTA were selected for matching but did not elaborate on the statistical method of choosing these patients, a possible source of bias. Patients with ACS as determined by ECG or cardiac biomarker abnormalities were excluded, limiting the evaluation of CCTA and FFRCT accuracy and utility in this patient population. Within every stenosis category negative FFRCT was associated with higher rates of nonobstructive CAD on ICA compared with negative FFRCT or CCTA, indicating a possibly higher sensitivity for hemodynamically-significant disease. The authors conclude that deferral of revascularization is safe with negative FFRCT on the basis of lower obstructive disease on invasive angiography. We agree that this study serves as an important proof-of-concept and that prospective studies of FFRCT-guided triage algorithms in the ED are warranted.

Shiono Y, Matsuo H, Kawasaki T, et al. Clinical Impact of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve on Japanese Population in the ADVANCE Registry. Circ J. 2019;83(6):1293-1301. Doi: 10.1253/circj.CJ-18-1269. The ADVANCE registry (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) is an international prospective registry of individuals with at least 30% coronary stenosis on CCTA who undergo FFRCT. This retrospective secondary analysis of the ADVANCE registry evaluated 1,758 Japanese patients with FFRCT data to determine the effect of adding FFRCT data on treatment strategy allocation and association with 90-day MACE. An initial management plan of optimal medical therapy, percutaneous coronary intervention (PCI), or CABG was determined by site investigators based on initial CCTA imaging results. FFRCT data was then provided and used by the investigators to guide their management plan. The same CCTA and FFRCT data were also sent to a blinded independent laboratory where subject management plans were made in the same stepwise fashion. Primary endpoints included rate of reclassification in management plan with the addition of FFRCT data, incidence of ICA without obstructive CAD (<50% stenosis), surgical and percutaneous revascularization rates, and 90-day survival free from MACE.

COMMON SENSE MAY/JUNE 2021

The study population had a Diamond-Forrester pretest probability for obstructive CAD of 55%. CCTA found ≥50% stenosis in 77.9% of subjects, and >70% stenosis in 46.9% of patients, with multivessel disease in 33.7%. A majority of patients (71%) had FFRCT-positive lesions; the left anterior descending artery (LAD) more frequently had anatomically severe and physiologically significant stenoses compared to the left circumflex or right coronary artery. Addition of FFRCT data led to reclassification in patient treatment strategy in 55.8% and 56.9% of cases by the site investigators and independent laboratory analysis, respectively. The majority of reclassifications were de-escalations to optimal medical therapy (58.5%) as opposed to selection of PCI (22.1%) or CABG (2.5%). Only 22.6% of FFRCT-negative patients received invasive coronary angiography as opposed to 61.7% of FFRCT-positive patients. There was a trend toward a higher rate of 90-day MACE in the FFRCT-positive group compared to the FFRCT-negative group (five vs. zero, respectively). The five events in the FFRCT-positive group included two hospitalizations for acute coronary syndrome and three deaths. This study again demonstrated the importance of augmenting anatomic evaluation with physiologic assessment. The addition of FFR data allowed the reclassification of many anatomically concerning lesions as physiologically less concerning, leading to a reduction in unnecessary invasive testing, as supported by the zero MACE event rate in the FFRCTnegative group. It is important to note that because this study was a sub-analysis of the ADVANCE registry, statistical significance was not achieved. However, these trends follow those seen in the full prospective analysis of the ADVANCE registry which was appropriately powered for statistical significance. Additionally, while the MACE rate at 90 days is certainly relevant in the acute setting, further study with more longitudinal follow-up would be ideal to further assess the potential benefits of FFRCT use.

Patel MR, Nørgaard BL, Fairbairn TA, et al. 1-Year Impact on Medical Practice and Clinical Outcomes of FFRCT: The ADVANCE Registry. JACC Cardiovasc Imaging. 2020;13(1 Pt 1):97-105. doi:10.1016/j.jcmg.2019.03.003. An observational study using patients from the ADVANCE registry was used to determine 1-year clinical events for patients who underwent evaluation of their chest pain via CCTA and FFRCT if indicated. Data for 5,083 patients undergoing CCTA with FFRCT from 38 international sites were reviewed for treatment plans and 1-year clinical outcomes including MACE (ACS, MI, and death). Of the 5,083 patients, 190 did not have FFRCT after CCTA and 156 had FFRCT unable to be analyzed. Approximately 5.5% of patients were lost to follow up. The total number of patients who had CCTA followed by positive versus negative FFRCT was 2,860 and 1,428 patients, respectively. 1-year clinical data was reviewed for the patients with CCTA followed by FFRCT. Major adverse cardiac events occurred in 55 patients, 43 in those with positive FFRCT and 12 in those with negative FFRCT (RR 1.91, 95% CI:

AAEM/RSA RESIDENT JOURNAL REVIEW

0.96-3.43). Time to first event occurred more often in patients with positive FFRCT versus those with negative FFRCT. At 1-year, only 0.19% of patients with FFRCT >0.80 had an MI and none died from cardiovascular related death. Additional 1-year data was collected on those with positive FFRCT; analysis demonstrated increasing rates of MACE with decreasing FFRCT, with the highest rates in patients with FFRCT <0.71. Limitations of this study include those listed previously, and that the data was collected from a registry, which is inherently subject to referral bias. Additionally, because it is an observational review of a registry instead a randomized study, treatment recommendations are unable to be made.

Conclusion The primary advantage of adding FFRCT to CCTA is the decreased need for additional and/or more invasive diagnostics for anatomically higher-grade stenoses that do not significantly limit perfusion. The benefit of this advantage to the evaluation of chest pain in the ED remains unclear. As in previous CCTA-only studies,4,5 rates of major adverse cardiac events seen in the ADVANCE registry were low overall, limiting the real-word utility of a diagnostic test whose purpose is to rule out adverse events, and the addition of FFRCT did not greatly improve sensitivity for hemodynamically-significant stenoses over CCTA alone. The avoidance of unnecessary admission and/or invasive cardiac angiography and decreased overall costs remain attractive and could potentially balance the reservations regarding the use of ionizing radiation.

References 1. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52(21):1724-32. doi: 10.1016/j. jacc.2008.07.031 2. Hulten E, Pickett C, Bittencourt MS, et al. Meta-analysis of coronary CT angiography in the emergency department. Eur Heart J Cardiovasc Imaging. 2013;14(6):607. doi: 10.1093/ehjci/jet027 3. Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol. 2009;53:1642-50. 4. Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes; the ACRIN trial. New Engl J Med. 2012;366(15):1393-403. 5. Hoffman U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. ROMICAT-II. New Engl J Med. 2012;367(4):299-308. 6. Taylor CA, Fonte TA, Min JK. Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: scientific basis. J Am Coll Cardiol. 2013;61(22):2233-41. doi: 10.1016/j.jacc.2012.11.083.

Answer For those who already choose to utilize CCTA in low-risk chest pain, FFRCT seems to be a good addition, but the current data on FFRCT is not enough to mandate significant change in clinical practice at this time for emergency medicine physicians.

AAEM21 OPPORTUNITIES FOR RESIDENTS AND STUDENTS LEARN MORE AT www.aaem.org/aaem21/attendees/residents

AND www.aaem.org/aaem21/attendees/students AAEM21 is the ideal conference for residents and students to attend. With specialized sessions and content tailored to you, there are valuable opportunities to take advantage of every day of the assembly.

COMMON SENSE MAY/JUNE 2021

MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

Thank You and Welcome the New 2021 MSC! Lauren Lamparter – 2020-2021 Medical Student Council President

ello everyone! I wanted to use this space to thank you for a great year of medical student involvement in AAEM/RSA. It has been an honor serving as your Medical Student Council (MSC) President for this past year, and I am excited to introduce to you the new MSC President, Ashley Iannantone! Ashley is a rising M4 at Loyola Stritch School of Medicine, and she has been involved in the EMIG leadership at Stritch. Her passion for emergency medicine has been clear since day one, and I know she will bring excellent leadership to the MSC this coming year. This year, the MSC strove to increase our available content for medical students. While the COVID-19 pandemic limited most of our regular activities, we were able to jump headfirst into virtual programming which enabled us to reach many more medical students across the U.S. and abroad. We established

our Medical Student Monday webinar series to provide high yield, relevant content for medical students about applying to EM and how to succeed in the field. We were able to run four virtual, regional symposia to connect medical students to EM programs and provide high quality education about the field of EM. We worked to increase membership and inclusivity in our organization by advocating for and seeking to make our resources ever more available. We are so proud of all we have been able to accomplish alongside the AAEM/RSA Board of Directors, despite a very difficult year for everyone in the medical field and in our specialty specifically. I am looking forward to next year’s board continuing on these efforts, and we have a strong Medical Student Council for 2021-2022. Vice President Bryan Redmond (University of Rochester School of Medicine), who has served as Northeastern Representative for the past two years, will bring his past experience to strengthen the council. The regional

representatives will bring fresh leadership to the student council: Western Representative, Kersti Bellardi (Western University of Health Sciences College of Osteopathic Medicine of the Pacific), Midwest Representative, Robert G. Canning, Jr., JD MBA (Loyola Stritch School of Medicine), Southeastern Representative, Joseph Dodd (University of Mississippi Medical Center), and Northeast representative, Joanna Cho (University of Rochester School of Medicine and Dentistry), and International Ex-officio Representative Ava Omidvar (St. George’s University). For more information about the council’s interests and hobbies check out this AAEM/RSA leadership webpage: www.aaemrsa.org/about/leadership#msc. Another great year is ahead, medical students, keep your eyes open for medical student regional symposia, get involved with a committee, and tune in to Medical Student Monday webinars!

AAEM/RSA Medical Student Council 2021-2022 PRESIDENT

Ashley Iannantone, MA Loyola Stritch School of Medicine

MIDWEST REGIONAL REPRESENTATIVE

SOUTHERN REGIONAL REPRESENTATIVE

Robert (Rob) Canning, Jr., JD MBA

Joseph (JoJo) Dodd, MSc

NORTHEASTERN REGIONAL REPRESENTATIVE

WESTERN REGIONAL REPRESENTATIVE

Joanna Cho, BA

Kersti Bellardi, MSc

Loyola Stritch School of Medicine VICE PRESIDENT

Bryan Redmond

University of Rochester School of Medicine & Dentistry

 We are so proud of all we have been able to accomplish with the

AAEM/RSA Board of Directors, despite a very difficult year for everyone in the medical field and in our specialty specifically.”

COMMON SENSE MAY/JUNE 2021

University of Mississippi Medical Center

Western University of Health Sciences College of Osteopathic Medicine of the Pacific EX-OFFICIO INTERNATIONAL REPRESENTATIVE

Ava Omidvar, , MPH FP-C St. George’s University

COMMONSENSE

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

June 20-24, 2021 ST. LOUIS, MO

AAEM21

Attend In-Person or Virtually

May/June 2021 Common Sense

Articles inside

Resident Journal Review: Advances in the Use of Coronary Computed Tomographic Angiography in the Evaluation of Coronary Artery Disease in the Emergency Department

AAEM/RSA Editor: The “Privilege” of Working in the COVID ICU

What Keeps Me Up at Night

AAEM/RSA President: Passing the Baton: The Next Generation of AAEM/RSA

Critical Care Medicine: Vents, Cardiac Events, and Aerosolized Contaminants: Performing CPR on Vented COVID-19 Patients

Wellness: Bringing Wellness to Your Organization: Highlights from the AAEM Leadership Academy 2021

Operations Management: Ops Series: Lean Six Sigma

International: A Lot to Learn from Our Colleagues from AAEM

AAEM Chapter Division Updates: California Chapter Division Update: CAL/AAEM Golden State Symposium

Diversity, Equity, and Inclusion: Next Generation Leadership: A Conversation About Equity and Inclusion

Women in EM: Why I Decided to participate in a COVID-19 Vaccine Trial – A Reminder that Diversity in Medicine Cannot be an After-Thought

Young Physicians: Learning to Communicate in a Pandemic

Social EM & Population Health: Social EM Spotlight: Dr. Kraftin Schreyer – An Emergency Department Based Hepatitis A Vaccination Program: A Merge of Social Emergency Medicine and Emergency Medicine Operations

Palliative Care: A View from the Middle of My Mid-Career Fellowship

Palliative Care: Hospital Associated Disability: Is Hospital Admission Really the Safest Disposition for Our Elderly Patients?

Speaker Development Group

27th Annual Scientific Assembly (AAEM21) Feature

Traumatic Urinary Catheter Insertion: A Case Presentation

Just Another Overnight

Careerealism: It’s Not Your Imagination: No Jobs Anywhere

2021 AAEM Board of Directors Election Candidate Statements

From the Editor’s Desk: Diversity of Priorities and Talents

President’s Message: What Does Leadership Look Like? (Part 2

Legislators in the News: HB 2622: An Interview with Amish M. Shah, MD MPH FAAEM

Letter to the Editor: COVID Reimagined