July/August 2022 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 29, ISSUE 4 JULY/AUGUST 2022

Politics Makes for Strange Bedfellows

Page 7

President’s Message:

Events

Legislators in the News:

Congressman Dr. Greg Murphy

Young Physicians Section:

Turning Foes to Friends: Establishing Collegiality in the ED?

AAEM/RSA President’s Message:

AAEM/RSA President Introduction

AAEM/RSA Editor’s Message:

AAEM/RSA Chair Introductory Letter

Table of Contents TM

Officers President Jonathan S. Jones, MD FAAEM President-Elect Robert Frolichstein, MD FAAEM Secretary-Treasurer L.E. Gomez, MD MBA FAAEM Immediate Past President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Past Presidents Council Representative William T. Durkin, Jr., MD MBA MAAEM FAAEM Board of Directors Kimberly M. Brown, MD MPH FAAEM Phillip A. Dixon, MD MBA MPH FAAEM CHCQMPHYADV Al O. Giwa, LLB MD MBA MBE FAAEM Robert P. Lam, MD FAAEM Bruce Lo, MD MBA RDMS FAAEM Vicki Norton, MD FAAEM Carol Pak-Teng, MD FAAEM Kraftin Schreyer, MD MBA FAAEM YPS Director Fred E. Kency, Jr., MD FAAEM AAEM/RSA President Leah Colucci, MD MS Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD FAAEM Editor, Common Sense Ex-Officio Board Member Andy Mayer, MD FAAEM Executive Director Missy Zagroba, CAE

COMMONSENSE

Regular Features

President’s Message: Events.......................................................................................................... 3 Editor’s Message: Politics Makes for Strange Bedfellows................................................................ 7 Letter to the Editor.......................................................................................................................... 9 Legislators in the News: Congressman Dr. Greg Murphy..............................................................14 Financial Wellness: A 5-part Series on Managing Money Wisely: Buying Happiness: Three Lessons for Physicians from the Literature on Happiness................................................16 Heart of a Doctor: Catch-22: A Story of the Impossible Choices Faced by Patients Battling Cancer.............................................................................................................18 Young Physicians Section: Turning Foes to Friends: Establishing Collegiality in the ED...............30 AAEM/RSA President’s Message: AAEM/RSA President Introduction..........................................34 AAEM/RSA Editor’s Message: AAEM/RSA Chair Introductory Letter............................................35 Medical Student Council Chair’s Message: Emergency Medicine Preference Signaling..............36 Foundation Contributions..............................................................................................................11 PAC Contributions..........................................................................................................................12 LEAD-EM Contributions.................................................................................................................13 Upcoming Conferences.................................................................................................................13 AAEM Job Bank..............................................................................................................................49

Featured Articles

Operations Management Committee: This Meeting Could Have Been an E-mail: How to Succeed in Managing Your Project.............................................................................................21 Palliative Care Committee: Oxygen is for the Weak.......................................................................23 Academic Affairs Committee: Five Rules for Emergency Medicine Interns...................................24 A Lament for Thucydides General................................................................................................25 Wellness Committee: A Renewed Mission.....................................................................................26 Women in Emergency Medicine Section: What Are You Saying “No to When You Continue to Work? (eh)..............................................................................................................................27 Emergency Ultrasound Section: 2022: The Year of the 1st AEMUS FPD Examination................29 AAEM-LG: AAEM-LG President’s Message to Hospitals, Physician Groups, and Locum Companies.................................................................................................................................32 Take Medicine Back: A New Emergency Medicine Application.......................................................37 Critical Care Medicine Section: Utilization of Arterial Lines in the Emergency Department..........40 Acute Airway Obstruction Due to COVID-19 Epiglottitis.............................................................42 AAEM/RSA Resident Journal Review: EDACS-ADP for Risk Stratification of Patients Presenting to the Emergency Department with Chest Pain.......................................................45

Executive Director Emeritus Kay Whalen, MBA CAE AAEM/RSA Executive Director Madeleine Hanan, MSM Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Alessandra Della Porta, MD, Resident Editor Stephanie Burmeister, MLIS, 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 JULY/AUGUST 2022

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, regardless of race, ethnicity, sexual identity or orientation, religion, age, socioeconomic or immigration status, physical or mental disability must have unencumbered access to quality emergency care. 2. The practice of emergency medicine is best conducted by a physician who is board certified or eligible by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM). 3. The Academy is committed to the personal and professional well-being of every emergency physician which must include fair and equitable practice environments and due process. 4. The Academy supports residency programs and graduate medical education free of harassment or discrimination, which are essential to the continued enrichment of emergency medicine, and to ensure a high quality of care for the patient. 5. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members. 6. 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, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM-0622-280

Events

AAEM PRESIDENT’S MESSAGE

Jonathan S. Jones, MD FAAEM

n my last article in Common Sense, I explained my goals for the Academy and my plans to accomplish them. And while I explained some of the things which I love about emergency medicine and some that I don’t, I didn’t really explain why I joined the Academy in the first place. Two recent, yet completely unrelated events reminded me why I joined and have motivated me to work even harder for the Academy.

Event #1: I was Fired Exactly one week after becoming President (and one day before my daughter’s birthday), I was fired by the CMG for which I primarily worked. My contract had a stipulation for termination without cause given 90 days’ notice. I was given that notice on May 4. I made sure to clarify if I was being fired with or without cause and it was communicated that it was without cause. I asked if there were any concerns or specific reasons I was being fired. Specifically, I asked if there were questions on my management of patients, if there was a threat of a lawsuit, if my quality or patient satisfaction metrics were subpar, if I was not seeing enough patients per hour or charting appropriately. I was told that it was none of these. It was simply “a staffing decision.” That decision was that the current 11:00am-9:00pm shift, no longer required a physician and it was being transitioned to be staffed by a non-physician practitioner (NPP). I then asked why specifically I was being terminated, given that two physicians working at that facility are not board certified. I was simply told, without further explanation, that it was for other reasons. I actually took that as a compliment. At first, I thought that I was being singled out, that this was a special case. But within seconds I realized that it was not a special case. In an odd way, I wish that I was special. I truly wish that the above is so odd and exceptional that everyone reading would be shocked that something like this could happen. Unfortunately, I know that that none

of the above is truly surprising. This is routine. Residency-trained, board certified, emergency physicians are being fired every day. We are being replaced by lesser qualified clinicians. And the decisions to do this are made by individuals with no medical training nor any ethical obligation to patients. Why? Well, for the same reason nearly everything is being replaced by inexpensive copies. Or actually, why there is a substitution or imitation version of nearly everything. I recently took a brief family vacation to Savannah, Georgia (which is a beautiful city by the way and one in which we may try to host a future meeting).

The point of my analogy is that I was informed about my options and I consented to purchase and wear inexpensive sandals. I was effectively provided with informed consent and freely made the choice which was best for me in that situation. Yet, for the infinitely more important decisions about our health, no such informed consent takes place. Neither the hospital nor the CMG has provided any notice or informational post to the patients about the impending changes to the quality and experience of those who will treat them in the emergency department. Nor have I seen any forms for patients to consent to receive care from clinicians not trained in emergency medicine.

I truly wish that [being fired] is so odd and exceptional that everyone reading would be shocked that something like this could happen. Unfortunately, I know that that none of [it] is truly surprising. This is routine.” We had arranged a boat rental to see some dolphins, explore a little, and enjoy quite time away from the city. I realized that I forgot to pack any sandals. Oops. Luckily, I found a very tacky beach store and was able to buy a pair of sandals for $9.99. They fit perfectly, were actually comfortable, and performed their job well. Seventy-two hours later, they were falling apart. I wasn’t upset in the least. I knew what I wanted and I knew what I had bought. I simply needed sandals for a boat and beach excursion. I had nice sandals at home. I didn’t need a replacement and I didn’t need any fashion sense. With full understanding of the situation, I purchased a pair of inexpensive sandals. I voluntarily entrusted my feet to this obviously inferior piece of footwear.

As we know, the root of this problem is multifaceted. First, especially in the emergency setting, patients are often critically ill, scared, desperate, or otherwise in need of immediate care. They are rightly more concerned that someone, some human being, is there for them. In their time of need, the credentials of this person are of secondary importance. Second, credentials can be misleading, sometimes purposefully so. What exactly is a “doctor?” Add to this the alternative boards as well as NPP “residencies” and it can even be unclear what “board certified” or “residency trained” means. Third, while all decisions about purchasing my sandals were completely within my control, very few decisions about receiving health care are within the patient’s

COMMON SENSE JULY/AUGUST 2022

AAEM PRESIDENT’S MESSAGE

[W]e need to clearly

define our allies…Our allies are all those trying to provide the best possible care to patients.” control. While this particular beach store did make the decision on what to stock, they clearly advertised the type of products they had and I made the decision on which store to use. However, while hospitals make the decision on which products to stock, i.e., which types of physicians or non-physicians to employ, they rarely advertise this. And worse, patients are often told which stores (hospitals) they may or may not use by their insurance companies. Finally, and most importantly, the product we provide is complex and literally life-saving. Yet, our skills are not acknowledged. Hospital and CMG executives are trained in business school and view the physician as any other commodity. And while it is true that every single employee is valuable, it is also time to stop being so politically correct and humble. Physicians are special. We are different. The entire organization revolves around the skills we possess and the care we provide. Above I named only four problems. There are many more. And while the solutions to the above problems are not easy to accomplish, they are actually simple. We need to educate patients. We need to ensure clarity about titles. We need to insist that hospitals and insurance companies clearly inform patients of the qualifications and expertise of those providing their care. Similarly, we need to ensure that hospitals and insurance companies understand the value that we provide. And yes, that does not only include the value to patient care, but also the value to the bottom line. I am grateful to past AAEM leaders, board members, committee members, and others 4

COMMON SENSE JULY/AUGUST 2022

who have worked on these issues. We have made tremendous progress but we are not nearly done. Only when patients begin to demand care from true specialists in emergency medicine will the current trend change.

As president, I am, and will continue to look for ways that we can educate the public about the qualities and qualifications which differentiate a Board-Certified Emergency Physician from everyone else. AAEM is already partnering with multiple organizations on this task and I will continue to explore new opportunities for collaboration. This includes seeking partnership with nurses, NPs, and PAs. I feel that nurse practitioners, PAs, and others play a vital role in providing patient care throughout the house of medicine. I personally know several whose presence in the emergency department only improves the overall care provided. In one of my previous roles, one of my most valued partners in the ED was a pharmacist. We physicians are not experts on everything. The ED pharmacist knows more about exactly which medications will interact with Paxlovid than I do. My NP colleague knows more about routine diabetes management (which many of my ED patients require) than I do. My ED nurse colleagues have specific knowledge and innumerable skills which I do not possess. On a recent night shift, we were woefully understaffed with nurses in the ED. This resulted in me performing some otherwise routine nursing tasks. It was horrible. I suffered. More importantly the patients suffered. Not that I didn’t already know it, but I cannot replace a nurse. I do not possess the specialized knowledge and skill set required. Likewise, a nurse cannot replace me unless of course some business person one thousand miles away says so. What I’m getting at is that we need to clearly define our allies. The NPP replacing me at this hospital is likely not my enemy. Most NPPs

with whom I’ve worked don’t actually want complete independent practice. Yet, they are being told by their professional organizations that they should seek this. They are told by hospital administrators and CMG regional directors that they are capable of this. They are told by their schools that despite the fact that they had to arrange all their own rotations and that none of their preceptors are actually vetted or reviewed, they are equal to a physician. Many if not most of you reading this message work with NPPs. Ask them if they are happy with the proliferation of NP schools with low standards, online-only instruction, loose accreditation, and preceptorships without any oversight. I have, and I’ve yet to meet one NPP who feels this is appropriate. I’ve even had one talk to me about the NP workforce issue and the fact that the supply of NPs now far exceeds the need and yet more NP programs are opening. Sound familiar? Are there unethical and dangerous NPs and PAs? Ones who purposefully confused patients about their training and qualifications? Ones who feel their education is truly equivalent to that of a physician? And ones who despise any type of collaboration? Yes, there most certainly are. These are dangerous individuals and they should be called out. However, this does not describe the typical NPP which I have met. Similarly, are there physicians who practice out of their scope in the ED? Are there BoardCertified Emergency Physicians who manage CMGs, sign sham agreements to “own” independent groups, and who dictate staffing levels without regard to patient safety? Yes, there are and they are dangerous individuals as well and should be called out. Our allies are all those trying to provide the best possible care to patients. Our enemies are those trying to confused and exploit patients. If the public at-large is to truly have informed consent about their medical treatment, it is going to take more than just our Academy. Therefore, similarly to partnering with organizations to educate the public about the qualities and qualifications of an ABEM or AOBEM Physician, I will work to partner

AAEM PRESIDENT’S MESSAGE

with non-physician allies who believe in our mission statement. In case you’re wondering, being fired has so far worked out rather well. I will now be working half-time at a more convenient hospital as well as doing Locums Tenens at a few locations in the state. (Do you know about the Academy’s own Locums Group, AAEMLG?) My schedule is better than it has been in years. It has also reminded me why I joined the Academy. I joined because bad actors are exploiting good doctors and endangering patients. Someone has to do something about this. That someone is the American Academy of Emergency Medicine.

Event #2: The Supreme Court did Some Stuff Multiple impactful decisions have recently been made by the Supreme Court. Nearly the entire country is talking. Some are happy, some are upset. The discussion about these momentous rulings also reminded me why I joined the Academy. I joined because I saw the Academy as an organization which could bring a diverse group of physicians together with one single focus—to improve the ability of emergency physicians to practice medicine. While I may personally have opinions on the Supreme Court decisions, none of that matters for the Academy.

The Academy should be a “safe space” and a place for us to share our opinions and have an opportunity for dialogue and to learn from one another. For the good of the Academy and for our profession, I don’t care if you are pro-life or pro-choice. I don’t care if you are an NRA member or an advocate to abolish the Second Amendment. I don’t care if you voted for Donald Trump, Joe Biden, or Jo Jorgensen (Who? Yeah, I’m not a fan of the two-party system). But I also don’t care if you love the two-party system. I care that you have dedicated your professional career to be exceptional in the practice of emergency medicine. If you want to practice medicine without interference from

corporate groups, then I care about you. If you are burned out and frustrated because of the limitations placed on your ability to practice medicine the way you see fit, then I care about you. For the Academy, I will be focused on what we do. Until I see AAEM Physicians Group vs. Envision Healthcare Corporation on the Supreme Court docket, then as far as the Academy is concerned, the Supreme Court doesn’t much affect us and I won’t let any ruling stop me from pursuing the goals that I have set for myself as President. Let’s stay focused, let’s find allies, let’s fight, and let’s win. Jonathan S. Jones, MD FAAEM

I joined because I saw the Academy as an organization which could bring a diverse group of physicians together with one single focus— to improve the ability of emergency physicians to practice medicine.”

Update on AAEM-PG vs Envision: Judge Denies Envision Healthcare’s Motion to Dismiss Lawsuit May 31, 2022

In January, Envision filed a motion to dismiss the complaint. On May 20, 2022, the Court met to hear the argument. We are excited to update you that the judge denied their motion to dismiss. This decision means that the Court has held that the allegations we make, if proven, are sufficient to sustain a violation of California law. It demonstrates our theory of the case is sound. The judge sustained the entire complaint with its many components, which you can read below. Know that this doesn’t mean we’ve won, and it doesn’t mean we will. This is however, the first step we needed to move forward to stop Envision’s corporate practice of medicine. Read the full Judge’s Order Denying the Motion to Dismiss here:

COMMON SENSE JULY/AUGUST 2022

The AAEM Foundation AAEM was established in 1993 to promote fair and equitable practice environments necessary to allow emergency physicians to deliver the highest quality of patient care. AAEM later established the AAEM Foundation to defend the rights of such care and the emergency physicians who provide it. Recently, AAEM-Physician Group, a subsidiary of the American Academy of Emergency Medicine (AAEM), filed suit in the Superior Court of California against Envision Healthcare Corporation to avoid a takeover of an emergency department contract that was held by and independent group. Issues at stake include lay influence over the patient-physician relationship, control of the fees charged, prohibited remuneration for referrals, and unfair restraint of the practice of a profession. Our specialty is in crisis. We cannot let these practices continue here and across the country.

AAEM is the only EM organization that speaks and acts against the harmful influences of the corporate practice of medicine.

Our Goal: How can you help? Join your colleagues and make a gift or a pledge today. Gifts at all levels can be paid in one year or pledged over two to five years. We encourage individuals, physician groups, and companies to help support the fight! $50,000+ Champion Circle $25,000 - $49,999 President’s Club $10,000 - $24,999 Advocate $5,000 - $9,999 Steward $2,500 - $4,999 Ambassador $1,000 - $2,499 Supporter Up to $1,000 Friend

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EDITOR’S MESSAGE

Politics Makes for Strange Bedfellows Andrew Mayer, MD FAAEM

n the past year, Common Sense has started a series of articles focusing on advocacy and politics. These have been a series of interviews of various political figures. These politicians have ranged from members of the U.S. Congress, state elected officials, to even an AAEM member who is running for the U.S. House of Representatives. The topics covered during these interviews try to emphasize health care related matters especially those which would be of interest to the membership of AAEM. The concept of this series is to help inform our members about political matters and advocacy efforts which impact our specialty. The hope is that more interest in the political realm can be generated within our membership so that AAEM’s lobbying and political efforts can blossom and become more impactful. This effort will also hopefully show that elected officials can be approachable and can be interested in the political concerns of the average emergency medicine specialist. These articles have generated some concerns by some of our members and I wanted as the editor to address these concerns with my opinion concerning this issue. Some members believe that it is improper to interview or interact with an elected official if some of these official’s opinions, actions, or statements are contrary to a member’s personal beliefs. Their opinion is that by interviewing these elected officials concerning health care that we somehow endorse or validate their opinion on other topics. Of course, speaking to someone who holds a stance on an issue which you personally strongly disagree with is difficult. However,

I would disagree that it is wrong to attempt to lobby an elected official about a piece of proposed legislation which you believe is important if that same official holds a totally polar opposite view on an unrelated issue. This dichotomy of opinions between citizens and their elected officials on different issues is unfortunately the typical situation in politics. This tension is especially stress provoking if an elected official holds the opposite stance on one of your core beliefs like abortion, immigration, gun control, etc. It is rare to find a politician whose policy stances totally or even partially align with your personal views. I do not feel that interacting with a politician concerning issues relevant to emergency medicine validates them on other issues. Please remember the phrase which you have probably heard that “politics makes for strange bedfellows.” This phrase has evolved from a quote from William Shakespeare’s “The Tempest.” He said “Misery acquaints a man with strange bedfellows.” Think about the quote and what it means. We are required to work with the team which we are given and not the team we dreamed of having when we start working on a project. I am a Winston Churchill fan. One of my favorite quotes by him was made in reference to complaints made by members of the British Parliament to his becoming an ally of Joseph Stalin during World War II. He said in the House of Commons ““If Hitler invaded Hell I would make at least a favorable reference to the Devil in the House of Commons.” Churchill believed that working with Stalin was the best way to beat Hitler despite his strong personal aversion to Stalin and his politics. I am not equating American politics to dealing with

“AMERICAN POLITICS HAVE BECOME VERY POLARIZED AND COMPROMISE AND HONEST DISCUSSION AND DEBATE HAS BEEN AN UNFORTUNATELY LESS FREQUENTLY USED TOOL FOR PROGRESS.” Stalin but the analogy I hope shows that we need to work with the tools which we are given. American politics have become very polarized and compromise and honest discussion and debate has been an unfortunately less frequently used tool for progress. In my opinion, our elected officials need to return to negotiation and compromise. I think that your duty as a citizen is to try and inform your elected legislator of your opinion and help guide them to what you think is the correct decision in their voting. Remember that there usually is another person trying to get them to take the opposite opinion from yours. I would hope that everyone would agree that our elected officials from any party or political perspective should carefully review and research any bill or legislative effort placed before them. They should make their own best-informed opinion on how they should vote. I personally do not feel that any elected official should blindly follow their political party’s instructions without the due diligence they owe to their constituents. With that being said, I

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EDITOR’S MESSAGE

think that interacting, interviewing, speaking to, or lobbying any elected official even those with whom you share little except that they happen to represent you is necessary and appropriate. Your legislators should know your opinion as a subject matter expert. Remember that you know more about emergency medicine and probably health care than they do. Your opinion regarding health care legislation is relevant to their deliberations. One of your best contributions to our specialty could be developing a personal relationship with a state or nationally elected official who could come to you for an opinion or for information germane to an issue placed before them. AAEM wants to emphasize our need as emergency medicine specialists to become involved and to lobby and advocate for our specific interests and issues. One thing which I have learned over the years is that physicians in general are typically apathetic at best and fatalistic at worst concerning the interaction between the American political system and their careers. The typical response has been inaction and neglect when faced with the complex and frustrating world which is our system of government. The percentage of American physicians who are actively involved is very small compared to lawyers and other professionals. The political prowess and strength of the various lobbying groups especially those who represent the insurance companies, nurse practitioners, and physician assistants should make us reflect on physician’s efforts for political activism. The percentage of emergency medicine specialists who donate money to political activities, write letters to their elected officials, or call legislators offices is shockingly small compared to

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other professions. The number of emergency physicians who will actually physically lobby at their state legislatures or in Washington could be considered to be embarrassing small. I understand that an emergency physician’s initial response to being asked to be involved in political matters is usually one of futility and inadequacy. Physicians like to be experts and to feel confident and competent with any activity in which they engage. Who are you to convince a state senator or a member of the U.S. Congress to support or oppose a bill? Physicians think that they have no training or abilities to lobby. This is simply another skill to learn and develop. I have had the opportunity to travel to Washington several times to advocate for AAEM. One quickly realizes how little our elected officials tend to know about any specific topic. The other realization is that although many can be personally charismatic or intelligent, there are many politicians who when you speak to them are frankly just seemingly an average human being with no magic skills or talents. They are continuously lobbied by a vast spectrum of interest groups about very complicated issues. They actually do care that one of their constituents feels passionately about a topic. Numbers do matter and the number of constituents who contact them is closely tallied and considered in their decision-making process. Certainly, you are not going to walk into an office or write an email and convince every official of their need to do

what you think is best. However, there are many professional lobbyists and other constituents who are actively trying to convince the elected official of the exact opposite opinion which you may hold dear to your heart. Our doing nothing simply dooms us to failure. If the only voice they hear expresses one opinion then they will usually listen to that opinion. AAEM is trying to represent and advocate for you as an emergency physician. This effort is not without its own difficulties and challenges. I hope this article helps explain the decision by Common Sense to interview politicians from a wide spectrum of the political realm. Reflect on this and decide if you agree or disagree or would suggest another approach. I would encourage you to write a letter to the editor expressing your opinion. Common Sense would like to develop a frank discussion within our specialty as to the best way to move forward in our advocacy efforts and would like to hear your opinion. Please consider becoming more politically active at a state or national level. You can make a difference but it does take effort!

“COMMON SENSE WOULD LIKE TO DEVELOP A FRANK DISCUSSION WITHIN OUR SPECIALTY AS TO THE BEST WAY TO MOVE FORWARD IN OUR ADVOCACY EFFORTS AND WOULD LIKE TO HEAR YOUR OPINION.”

LETTER TO THE EDITOR

Letter to the Editor

As an AAEM member and long-time reader of Common Sense, I was extremely disappointed to read “An Interview with Congressman Dr. Michael Burgess” by Dr. Lisa Moreno in the March/April 2022 issue of Common Sense. While I recognize that the content of the interview in question mostly focused on Dr. Burgess’s personal story and views on physician advocacy, I would strongly urge AAEM to consider the message that they are sending to their readers by giving a platform to a politician such as Dr. Burgess. Throughout his two-decade tenure as a Congressman, Dr. Burgess has consistently advocated for policies and positions that are not compatible with the values espoused by AAEM. Dr. Burgess has voted over fifty times to repeal the Affordable Care Act, which many of our patients rely on to afford the cost of the care we provide. He has even gone so far as to say that he believes that fewer people in this country should have health care coverage. Additionally, Dr. Burgess is a proud climate denier, opposes patients’ access to abortion, and was a strong supporter of former President Trump’s Muslim ban. Most concerningly, Dr. Burgess has demonstrated a startling disdain for the process of democratic governance itself with his propagation of unfounded election conspiracy theories and his attempts to prevent votes in other states from being counted. All of these positions seem to me to be in direct conflict with AAEM’s purported commitment to science, health care access, and diversity, equity, and inclusion. I understand that AAEM is a nonpartisan professional organization with members on both sides of political aisle, however, I must object to using this publication to promote a politician who does not represent our specialty nor the values of this organization. Seeing AAEM ally itself with leaders such as Congressman Burgess makes me significantly less likely to support political action by AAEM in the future. Respectfully, Brendan James Flanagan, MD

Go Green! Did you know you can read the full issue

of Common Sense online even before the print copy hits your mailbox? It’s true! To go paperless, please visit aaem.org/resources/publications/common-sense (or scan the QR code) and click on “Electronic Issue Only” to update your preferences.

COMMON SENSE JULY/AUGUST 2022

LETTER TO THE EDITOR

Letter to the Editor

A note from Dr. Gomez: I am responding primarily as a mentor to Jada Watts and myself and not on behalf of the AAEM Board or JEDI. Public discourse on race is challenging and, at times, emotionally charged, so let me begin by stating that I loved my white grandmother and black grandfather equally. The article referenced in Dr. Andy Walker’s letter to the editor is one I co-wrote with my mentee, Jada Watts, a second-year medical student at Howard University College of Medicine, an HBCU where I was formerly an associate professor. Disappointingly, it seems Dr. Walker disagrees that we all carry implicit biases or can improve our ability to live up to our AAEM Mission of reflecting justice and equity by being aware of our biases. It makes me wonder if he read the article critically or dismissed it based on the coincident skin color of its authors. It is clear he believes he’s being labeled a racist by its content and compares that to being called a pedophile. The article did neither of those, yet his letter to the editor reflects discomfort and defensiveness based on his self-perceived race. Our statement in the article that we all hold biases could not be clearer. It is almost as if Dr. Walker intends to foment divisiveness by distinguishing himself as “white” even though I never use the word white to refer to race or distinguish between myself and any other emergency physician based on the color of our skin. I hope this clears up his first question. At the top of our article, I state that we are all affected by falsehoods about what we are taught about the inferiority of POC and specify that “we are all aware race is a social construct and there is only one that should be relevant to emergency medicine specialists: the human race.” I leave it to readers to decide if Dr. Walker, who I have been on a first-name basis with along with the rest of our leadership team for years, is being pejorative by referring to us as “Watts and Gomez.” I know it’s common in the military when a superior is addressing an inferior, but Andy and I are contemporaries and with almost identical credentials and years in practice and so he must be aware we are at a minimum, equals, professionally speaking. As such, we both know how to access the reference section of an article to review evidence regarding content such as that “we hold these biases.” The word “we” refers to all of us, equally, Dr. Walker. As for Dr. Walker’s self-reported attitude and what he has seen in his career, I expect Jada will not be reassured by his comments, but rather, more concerned, given that her brother’s life was lost to gun violence and some of us have no idea what is like to suffer being discriminated against based on the color of our skin at any time let alone in such a critical and painful situation. In my 30-year career, I have seen and met emergency medicine specialists that are humbly compassionate regarding cultural competence and others that arrogantly believe they are doing minority patients a favor because they agree to take care of them at all. Our current AAEM BOD has updated our Mission Statement to reflect humility and pledge to ensure we are all committed to providing compassionate, equitable care to all our patients. ABEM is developing requirements for cultural competence in emergency care. ACEP and the AMA have policy statements that specifically assert sensitivity to racial bias in practice. Admitting our biases is not tantamount to an accusation, it is a humble admission of shortcomings we all are subject to, and Dr. Walker should rest assured that we have many friends and allies in this process, not only in AAEM but in the house of medicine, not only in our country but the entire world, regardless of the color of our skin. L.E. Gomez MD MBA FAAEM Editor’s Note: Dr. Gomez and Ms. Watts’ original article ran in the March/April issue of Common Sense (page 45). Dr. Walker’s Letter to the Editor ran in the May/June issue of Common Sense (page 8). Please visit aaem.org/resources/publications/common-sense.

Tell Us Your Opinion! The editors of Common Sense want to hear from you! What articles did you like or which ones, not so much? Submissions are open for future issues. Please visit aaem.org/resources/publications/common-sense or contact cseditor@aaem.org for more information. This is where your voice can be heard! 10

COMMON SENSE JULY/AUGUST 2022

AAEM Foundation Contributors – Thank You! 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. 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 1-1-22 to 6-15-22.

Contributions $1000 and above Anisha Malhotra, MD John V. Murray, MD FAAEM Nathan J. McNeil, MD FAAEM Peter G. Anderson, MD FAAEM

Peter B. Mishky, MD FAAEM Phillip L. Rice Jr., MD FAAEM Robert Hanrahan, MD Ron Koury, DO FAAEM Sahibzadah M. Ihsanullah, MD FAAEM

Contributions $500-$999

Contributions $100-$249

Bret M. Birrer, MD FAAEM David A. Farcy, MD MAAEM FAAEM FCCM David E. Ramos, MD FAAEM Kathleen P. Kelly, MD FAAEM Lillian Oshva, MD FAAEM Mark Reiter, MD MBA MAAEM FAAEM Philip Beattie, MD FAAEM Vladana Aleman

Contributions $250-$499 Alex Flaxman, MD MSE Algis J. Baliunas, MD FAAEM Allison Zanaboni, MD FAAEM Azalea Saemi, MD FAAEM Benjamin J. Ricke, MD FAAEM Bradley Judson, MD FAAEM Bruce E. Lohman, MD FAAEM Bryan K. Miksanek, MD FAAEM Charles Chris Mickelson, MD FAAEM David Thomas Williams, MD FAAEM Deborah D. Fletcher, MD FAAEM Domenic F. Coletta Jr., MD FAAEM Douglas W. McFarland, MD FAAEM Eric D. Lucas, MD FAAEM Eric W. Brader, MD FAAEM Frosso Adamakos, MD FACEP FAAEM John H. Kelsey, MD FAAEM John R. Matjucha, MD FAAEM Joseph W. Raziano, MD FAAEM Justin Barrett Williams, MD FAAEM Larry D. Weiss, MD JD MAAEM FAAEM Michael Luszczak, DO FAAEM

Allie Min, MD FAAEM Andy Walker, MD MAAEM Ann Loudermilk, MD FAAEM Anthony J. Callisto, MD FAAEM Anthony R. Rosania, III, MD FAAEM Arjun Banerjee, MD Brent R. King, MD FAAEM FACEP FAAP Brian R. Potts, MD MBA FAAEM Bryan Beaver, MD FAAEM Bunmi Olarewaju, DO FAAEM Carlos F. Garcia-Gubern, MD FAAEM Catherine V. Perry, MD FAAEM Chaiya Laoteppitaks, MD FAAEM Christopher F. Tana, FAAEM Clayton J. Overton III, MD MPH MSPH FAAEM Clayton Ludlow, DO FAAEM Dan M. Mayer, MD FAAEM Daniel S. Medina, DO Darin E. Neven, MD FAAEM David W. Kelton, MD FAAEM David W. Lawhorn, MD MAAEM Donald L. Slack, MD FAAEM Elizabeth C. Ritz, MD FAAEM Eric J. Muehlbauer, MJ, CAE Eric S. Kenley, MD FAAEM Floyd W. Hartsell, MD FAAEM Fred Earl Kency, Jr., MD FAAEM FACEP Gary M. Gaddis, MD PhD FAAEM FIFEM Gayle Galletta, MD FAAEM Heather M. Mezzadra, MD FAAEM Ian R. Symons, MD FAAEM Isaac A. Odudu, MD FAAEM

James A. Pfaff, MD FAAEM James G. Sowards, MD FAAEM James R. Gill, MD MBA FAAEM James Webley, MD FAAEM Jamie J. Adamski, DO FAAEM Jeffrey A. Rey, MD FAAEM Jeffrey John Glinski, MD FAAEM Jonathan S. Jones, MD FAAEM Jorge L. Infante, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Julianne Wysocki Broadwater, DO FAAEM Justin P. Anderson, MD FAAEM Karl A. Nibbelink, MD FAAEM Kathleen Hayward, MD FAAEM Kathryn Getzewich, MD FAAEM Kathryn Kirsch, MD, FAAEM Kevin S. Barlotta, MD FAAEM Kraftin E. Schreyer, MD MBA FAAEM Laura J. Bontempo, MD MEd FAAEM Leon Adelman, MD MBA FAAEM Marilyn R. Geninatti, MD FACC FAAEM CWSP Mark E. Zeitzer, MD FAAEM Mary Ann H. Trephan, MD FAAEM Mary Jane Brown, MD FAAEM Matthew B. Underwood, MD FAAEM Megan Algeo, MD FAAEM Merlin T. Curry, MD FAAEM Mike Lesniak Nancy Conroy, MD FAAEM Nicholas G. Ross, MD FAAEM Pamela A. Ross, MD FAAEM Patrick A. Aguilera, MD FAAEM Paul W. Gabriel, MD FAAEM Ramon J. Pabalan, MD FAAEM Robert Bruce Genzel, MD FAAEM Robert P. Lam, MD FAAEM Rose Valentine Goncalves, MD FAAEM Sabrina J. Schmitz, MD FAAEM

Sameer D. Mistry, MD CPE FAAEM Scott Plasner, DO FAAEM Shanna M. Calero, MD FAAEM Steven Schmidt Sundeep J. Ekbote, MD FAAEM Tara Shapiro, DO FAAEM Teresa M. Ross, MD FAAEM Terrence M. Mulligan, DO MPH FAAEM FACOEP FIFEM FACEP FNVSHA FFSEM HPF Valerie Hoerster, MD William K. Clegg, MD FAAEM William T. Freeman, MD FAAEM

Contributions up to $99 Alex Kaplan, MD FAAEM Andrea C. Santoyo Andrew DeVries Chris Hummel, MD FAAEM Evan T. Burdette, MS Ivan Novikov James Cirone, DO Jason D. May, MD FAAEM Jason Hine, MD FAAEM Joanne Williams, MD MAAEM FAAEM Julia Alegria Astudillo Kasey Gore Kennadie P. Campbell Peter M.C. DeBlieux, MD FAAEM Richard Scott Johnson, FAAEM Ron S. Fuerst, MD FAAEM Ruth P. Crider, MD FAAEM Sameer M. Alhamid Jr., MD FRCPC FACEP FAAEM Sierra Cloud Sumintra Wood, MD Theodore B. Olson II, DO Trecia Henriques, FAAEM

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

Submit a Letter to the Editor at:

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

COMMON SENSE JULY/AUGUST 2022

AAEM PAC Contributors – Thank You! AAEM PAC is the political action committee of the American Academy of Emergency Medicine. Through AAEM PAC, the Academy is able to support legislation and effect change on behalf of its members and with consideration to their unique concerns. Our dedicated efforts will help to improve the overall quality of health care in our country and to improve the lot of all emergency physicians. All contributions are voluntary and the suggested amount of contribution is only a suggestion. The amount given by the contributor, or the refusal to give, will not benefit or disadvantage the person being solicited. Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the different levels of contributions. The PAC would like to thank the individuals below who contributed from 1-1-22 to 6-15-22 (please note that any donations made during Scientific Assembly will not reflect until our next issue).

Contributions $500-$999 Andrew P. Mayer, MD FAAEM David A. Farcy, MD MAAEM FAAEM FCCM Robert A. Frolichstein, MD FAAEM S. Eliza Dunn, MD Scott K. Rineer, MD MPH FAAEM

Contributions $250-$499 Allison Zanaboni, MD FAAEM Brian J. Cutcliffe, MD FAAEM Bruce E. Lohman, MD FAAEM Charles Chris Mickelson, MD FAAEM Eric D. Lucas, MD FAAEM Eric W. Brader, MD FAAEM Garrett Sterling, MD FAAEM John R. Matjucha, MD FAAEM Joseph T. Bleier, MD FAAEM Kevin Allen, MD FAAEM Lisandro Irizarry, MD FAAEM Marianne Haughey, MD FAAEM Peter B. Mishky, MD FAAEM Ron Koury, DO FAAEM Sahibzadah M. Ihsanullah, MD FAAEM

William E. Franklin, DO, MBA, FAAEM William E. Hauter, MD FAAEM

Contributions $100-$249 Alberto R. Rivera, MD FACEP FAAEM Andrew Wilson Anthony J. Callisto, MD FAAEM Anthony R. Rosania, III, MD FAAEM Benson Yeh, MD FAAEM Brian Charity, DO FAAEM Brian D. Stogner Jr., FAAEM Brian R. Potts, MD MBA FAAEM Bryan K. Miksanek, MD FAAEM Catherine V. Perry, MD FAAEM Chaiya Laoteppitaks, MD FAAEM David Touchstone, MD FAAEM David W. Kelton, MD FAAEM Donald L. Slack, MD FAAEM Eric S. Kenley, MD FAAEM Floyd W. Hartsell, MD FAAEM Ian R. Symons, MD FAAEM J. David Gatz, MD FAAEM FACEP Jeffrey A. Rey, MD FAAEM Jeffrey Gordon, MD MBA FAAEM

Jeffrey J. Thompson, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Julianne Wysocki Broadwater, DO FAAEM Justin P. Anderson, MD FAAEM Karl A. Nibbelink, MD FAAEM Kathryn Getzewich, MD FAAEM Lauren P. Sokolsky, MD FAAEM Leah B. Colucci, MD MS Lillian Oshva, MD FAAEM Mark A. Newberry, DO FAAEM FACEP Matthew B. Underwood, MD FAAEM Matthew W. Turney, MD FAAEM Megan Long, MD FAAEM Michael R. Magoon, MD FAAEM Nate T. Rudman, MD FAAEM Patrick O’Toole III Paul E. Stromberg, MD FAAEM Penelope Goode, MD FAAEM Peter M.C. DeBlieux, MD FAAEM Philip Beattie, MD FAAEM Phillip L. Rice Jr., MD FAAEM Rebecca N. Mills, MD FAAEM Rhett W. Silver, MD FAAEM Robert Bruce Genzel, MD FAAEM

Know a medical student or EMIG with an outstanding record of service to EM? Recognize them by nominating them for an AAEM/RSA Award: National Medical Student of the Year Scholarship Award Regional Medical Student of the Year Scholarship Award

AAEM/RSA Awards Submit Your Nomination Today!

EMIG of the Year Award (International and Regional)

aaemrsa.org/about/awards 12

COMMON SENSE JULY/AUGUST 2022

Robert E. Stambaugh, MD FAAEM Ryan L. Tenzer, MD FAAEM Sameer D. Mistry, MD CPE FAAEM Sundeep J. Ekbote, MD FAAEM Thomas B. Ramirez, MD FAAEM Thomas Heniff, MD FAAEM Trisha Anest, MD FAAEM William T. Freeman, MD FAAEM

Contributions up to $99 Ann Loudermilk, MD FAAEM Anne M. LaHue Charles Spencer III, MD FAAEM Chelsea Rodenberg, FAAEM Chris Hummel, MD FAAEM D. Shannon Waters, MD FAAEM Heather Enomoto, FAAEM James P. Alva, MD FAAEM Marc D. Squillante, DO FAAEM Peter Stueve, DO Richard Burke Neville, MD FAAEM Richard Scott Johnson, FAAEM Ruth P. Crider, MD FAAEM William J. Taylor, MD

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. LEAD-EM would like to thank the individuals below who contributed from 1-1-22 to 6-15-22.

Contributions $1000 and above

Contributions $100-$249

Mercy M. Hylton, MD FAAEM

Ann Loudermilk, MD FAAEM Bobby Kapur, MD MPH CPE FAAEM Brian R. Potts, MD MBA FAAEM Carol Pak-Teng, MD FAAEM Christopher Kang, MD FAAEM Clayton Ludlow, DO FAAEM Cory Duncan, MD FAAEM FACEP Daniel Elliott, MD FAAEM David W. Kelton, MD FAAEM David W. Lawhorn, MD MAAEM Deborah Dean, MD FAAEM Eric S. Kenley, MD FAAEM Floyd W. Hartsell, MD FAAEM Frank L. Christopher, MD FAAEM Gary M. Gaddis, MD PhD FAAEM FIFEM Ian R. Symons, MD FAAEM

Contributions $500-$999 Mark Reiter, MD MBA MAAEM FAAEM

Contributions $250-$499 Anthony J. Callisto, MD FAAEM Daniel F. Danzl, MD MAAEM Domenic F. Coletta Jr., MD FAAEM Eric D. Lucas, MD FAAEM Eric W. Brader, MD FAAEM Fred Earl Kency, Jr., MD FAAEM FACEP Joseph T. Bleier, MD FAAEM Kathleen Hayward, MD FAAEM Michael R. Burton, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM William E. Hauter, MD FAAEM Zachary Worley, DO FAAEM

Jason Hine, MD FAAEM Jeffery M. Pinnow, MD FAAEM FACEP John R. Matjucha, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Lillian Oshva, MD FAAEM Lisandro Irizarry, MD FAAEM Marc D. Squillante, DO FAAEM Mark A. Foppe, DO FAAEM FACOEP Mark E. Zeitzer, MD FAAEM Megan Healy, MD FAAEM Melanie S. Heniff, MD JD FAAEM FAAP Melissa Ann Barton, MD FAAEM Michael C. Bond, MD FAAEM FACEP Nate T. Rudman, MD FAAEM Nimish Mehta, MD FAAEM Paul W. Gabriel, MD FAAEM Phillip L. Rice Jr., MD FAAEM Sabrina J. Schmitz, MD FAAEM

Sarah B. Dubbs, MD FAAEM Thomas R. Tobin, MD MBA FAAEM William T. Freeman, MD FAAEM

Contributions up to $99 Ana Maria Navio Serrano Sr., MD PhD Gerald E. Maloney Jr., DO FAAEM Jason D. May, MD FAAEM Marianne Haughey, MD FAAEM Nancy Conroy, MD FAAEM Peter Stueve, DO Robert W. Bankov, MD FAAEM FACEP Ruth P. Crider, MD FAAEM Stephanee J. Evers, MD FAAEM

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

AAEM Events

Recommended

21-24 September 2022 XIth Mediterranean Emergency Medicine Congress (St. Julian, Malta) aaem.org/memc21

September 9-11, 2022 The Difficult Airway Course: EmergencyTM (Nashville, TN) theairwaysite.com

September 14 and 15, November 30 and December 1, 2022 Virtual Oral Board Review Courses aaem.org/education/events/oral-boards

September 23-25, 2022 The Difficult Airway Course: EmergencyTM (Minneapolis, MN) theairwaysite.com

April 21-25, 2023 29th Annual Scientific Assembly (New Orleans, LA) aaem.org/aaem23

November 11-13, 2022 The Difficult Airway Course: EmergencyTM (San Diego, CA) theairwaysite.com

Jointly Provided Re-Occurring Monthly Unmute Your Probe: Virtual Ultrasound Course Series Jointly provided by EUS-AAEM aaem.org/eus July 27-29, 2022 Coalition for Physician Well-Being 10th Annual Conference (Denver, CO) Jointly provided by the Coalition for Physician Well-Being forphysicianwellbeing.org/ November 2-6, 2022 Emergency Medicine Update: Hot Topics (Waimea, HI) Jointly provided by UC Davis https://ces.ucdavis.edu/emh2022

COMMON SENSE JULY/AUGUST 2022

LEGISLATORS IN THE NEWS

Legislators in the News: Congressman Dr. Greg Murphy Lisa A. Moreno, MD MS MSCR FAAEM FIFEM, Immediate Past President

n this installment of Legislators in the News, we interview Dr. Greg Murphy (R) who represents the 3rd district of North Carolina.

LM: Dr. Murphy, thank you for taking the time to interview with me today and to share your perspectives on politics and medicine with the members of the American Academy of Emergency Medicine. Our members take advocacy very seriously, and they always are interested in knowing what prompted a physician Member of Congress to change your focus of service from the practice of medicine to elected political office. GM: I was the Chief of Staff at Vidant Medical Center in Greenville, North Carolina from 2013-2015 when a member of the North Carolina House of Representatives resigned. I was asked by the hospital board if I would consider that office, and I said no. The North Carolina State Medical Society pointed out that there were no physicians in the General Assembly, and so there was no one to represent our perspective and no one who could represent the patients’ perspective with a physician’s understanding of the issues. In fact, at that time, the head of the Health Policy Committee was a bail bondsman. My Catholic guilt took over (he smiles) and I accepted an appointment to that position. I served in the State House from 2015-2019. During that time, I was responsible for introducing the “Stop Act” and the “Hope Act,” both addressing the opioid epidemic. During this time, I continued to practice Urology. Then, Congressman Walter Jones developed kidney failure and ultimately succumbed to ALS. I was urged to run for Congress. Twenty six people ran. There were four elections over 24 months. I was elected. And I am the only physician Member of Congress (MOC) who still sees patients and operates. I would rather be called “Doctor” than “Congressman.” (Author’s note: Readers of this column will recognize a trend here. Dr. Murphy is far from the first physician MOC who has made this statement.) And along the way, I have continued to do mission work. Of course, this was impossible once COVID started, but I had already been doing mission work for 35 years. My wife is a nurse. We have been to India and met Mother Teresa and worked in her hospitals and have been to Swaziland and other countries of East Africa. I’ve been to Nicaragua about 30 times. I took a mission from Greenville to Haiti in 2010. In Congress, I have had two committee assignments to Education and Labor. I have served on the Veterans Affairs Committee. I am now on the Ways and Means Committee, serving on the Health Subcommittee which covers the Centers for Medicare and Medicaid. Sometimes Members wait years or even decades to get on these Committees. Sometimes, you just have good luck and it works out that a physician can serve on a health related committee. LM: What are the skills that made you a great physician that you are also using to be an outstanding legislator? 14

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GM: Well, despite what they say, creativity is not the highest form of intellect. Perception and empathy are the things that make you a good doctor and those serve well for the politician also. Perception is key in understanding your opponents in the legislature. Being an educator is a key component of being a doctor, and I find it a key component of being a legislator as well—especially as a physician-legislator. LM: As an elected official who is also a physician what do you perceive as the most critical health care issues facing America today? GM: Affordability, accessibility, and technology. In America, we have the best health system in the world in many ways, and in many ways, it’s also the worst system. Sometimes, the patient just fails to take advantage of the care that’s available for them. Other times, it’s the insurance companies that get in the way. Patients can have insurance, but still not have accessibility. The hoops that doctors have to go through to get approval for a procedure that we know our patient needs are unacceptable. Insurance companies are in business to make money, and they drive up the cost of health care. Doctors know what their patients need. And, of course, right now, we are facing physician shortages, especially in the rural areas. We see this in my state. And it is going to get worse. LM: How can the government address these issues and improve the health care of the nation? GM: Let’s look at affordability. First, Obama Care caused prices to skyrocket. We need a decrease in regulation in the health care industry. We could start by cutting administrators by at least one third. They are not contributing anything to health care, and they are driving costs up. Drug pricing is another area we need to address. The pharmaceutical companies are the ones who are benefiting from the high prices that patients are paying for drugs. Managers also take up a lot of the health care budget. And then, we need to look at the cost of malpractice insurance. This gets passed on to the patient. Our nation needs tort reform. North Carolina did a great job with this in 2011. Accessibility: There are too many doctors practicing in urban areas. We need to use specific measures to attract physicians to rural areas. One way would be to increase GME funding for rural health programs. Another would be to recruit medical students from rural areas. Many of these individuals are committed to the communities they grew up in. The lifestyle is familiar to them, and they often want to go back and serve in their own or similar communities. These are specific interventions that could work. Technology: We could take a lesson from other industrialized nations who ration care. What I mean by this is that palliative care discussions need to

LEGISLATORS IN THE NEWS

begin in young adulthood, when people are healthy and can make measured and rational decisions about the kind of end of life care that they would like, the quality of life that they want at the end of life. The time to have that discussion is not when someone is 82 years old and very sick, when they can’t participate in decision making and their family feels guilty about limiting care. LM: What do you say to those who feel that loan forgiveness should not exist for physicians since physicians are highly paid? GM: That is preposterous, and you can quote me on that. What we need to look at is the free flow of money from the federal government. Universities know they can charge high tuitions because they know the federal government will give them money. They need to have some skin in the game so that they can think about what they teach. The critical problem is with the undergraduate curriculum. Students accumulate debt that they can’t pay back because they majored in something that will never facilitate employment. But on the medical school level, as I said, we need to create an incentive for physicians to

Biography of Dr. Greg Murphy Dr. Greg Murphy, originally from Raleigh, graduated magna cum laude from Davidson College in 1985. He then attended UNC School of Medicine graduating with Honors and a member of AOA. After completing his surgical residency in Urology and Renal Transplantation at the University of Kentucky in Lexington, he and his wife, Wendy, settled in Greenville, NC to begin his practice. He has been active in his community working with his church and other groups doing outreach and helping those in need. Murphy was formerly President of Eastern Urological Associates in Greenville and Affiliate Professor of Surgery and Chief of the Division of Urology at the ECU School of Medicine. He recently served as Davidson College’s Alumni President and was on its Board of Trustees. Outside of work he has demonstrated a desire to help those less fortunate. He has traveled extensively for the last 35 years to Third World Countries including India, several parts of Africa, Nicaragua, and Haiti as a Medical Missionary. Prior to entering politics Murphy’s, professional career had been primarily one of clinical practice and administrative leadership positions. His surgical practice site is Vidant Medical Center, a 1,000-bed level 1 Trauma Center, which serves 29 eastern NC counties. He served for three years as Chief of Staff of the Medical Center. He previously served on the Board of the NC Urological Association, on the Board of Directors of the South Eastern Section of the American Urological Association,and on the Executive Board of the Judicial and Ethics Committee for the American Urological Association as well as on the By-Laws Committee.

work in rural areas. GME funding for this is critical. Hospitals also need to cut costs. There is far too much money being spent on administration and management, which adds nothing to patient care and does not improve outcomes. There are going to have to be changes in CMS regulations as well. Much of my committee work is going to focus on this. It is ridiculous that CMS adds more and more regulations every year, and yet they fail to rescind regulations that have become obsolete or are countermanded by the new regulations. Over regulation just makes the work of being a doctor more arduous and has nothing to do with better patient care. LM: Dr. Murphy, AAEM thanks you for taking the time to talk with me today and sharing your own experiences and impressions as a physician in Congress. Editor’s Note: All opinions and positions expressed by Common Sense interviewees are their own and are not representative of the opinions and positions of AAEM.

He is a member in good standing of the North Carolina Institute of Medicine. He is the only actively practicing physician in Congress seeing patients a few days a month still. Dr. Murphy was recruited to serve in the North Carolina House of Representatives and did so from 2015 to 2019. During his second term in the General Assembly, he was asked to serve as Senior Chair of Health Policy and Chair of Health and Human Services Appropriations. While he was successful in getting a variety of legislative items passed, his greatest focus was on helping reduce the tragic impacts of the Opioid Epidemic. Dr. Murphy built strong bipartisan support and was the Primary Sponsor of both the STOP Act and the HOPE Act, North Carolina’s two main legislative initiatives to combat the Opioid Crisis. He also led efforts to combat waste, fraud and abuse in the state’s Medicaid system which saved the state hundreds of millions of dollars during his tenure. Dr. Murphy ran in North Carolina’s Third Congressional District special election in 2019 to replace Congressman Walter B. Jones, Jr, who passed away in office after serving eastern North Carolinians for more than 22 years. Murphy was officially sworn into the U.S. House of Representatives on September 15, 2019. He now serves on the Ways and Means Committee, and is a member of the Health and Oversight Subcommittees. As the only practicing surgeon in Congress, Murphy is also a Vice-Chair of the House Republican Doctors Caucus and has been a prolific publisher of medical information during the COVID 19 pandemic. He is currently working with local stakeholders to help develop a 100 year plan for Eastern NC to adapt to waterway challenges in the marine environment. COMMON SENSE JULY/AUGUST 2022

FINANCIAL WELLNESS: A 5-PART SERIES ON MANAGING MONEY WISELY

Buying Happiness: Three Lessons for Physicians from the Literature on Happiness James M. Dahle, MD FACEP FAAEM

here is scientific, peer-reviewed literature on all kinds of subjects. One of the most interesting subjects out there to study is how to be happy. Academics have been studying this for decades and the conclusions they have reached have important applications in your personal financial planning. In this column, we’ll examine three lessons from the happiness literature that you can apply in your financial life.

#1 The Relationship of Happiness to Income Many people have heard the statistic that additional income beyond $75,000 per year does not increase your happiness. If you go back to the primary literature, you will find that is not entirely true for three reasons. First, that number was not indexed to inflation. It is probably now in the low $100,000 range. Second, that number was not adjusted for high cost of living areas. It simply takes more income to have the same life in San Francisco as in Indianapolis. Third, the relationship between additional income and additional happiness was not flat after that $75,000 mark, it simply changed to a much lower slope. Making $200,000 a year does make you happier than making $100,000 a year, but not by nearly as much as increasing your income from $50,000 to $100,000. There are still two important personal finance lessons to take from these studies. The first is that when you have a low to middle class income, additional income can really have a dramatic effect on life satisfaction. Thus, you should do all you can at those income levels to boost your income. You can also help friends, family, and others at lower income levels to increase their income and financial resources through giving, mentorship, and job creation knowing there will be a lot of bang for your buck. The second lesson is that happiness continues to rise with additional income, but not nearly at the same rate. Thus, you should do what you can to increase your income, so long as what you have to do to increase that income does not make you noticeably less happy. If raising your income from $350,000 to $400,000 means asking for a raise, hiring a scribe, or lobbying for a more efficient electronic medical record, that’s probably a good thing. If it means working three additional night shifts every month, that may not be worth it.

#2 Spend Your Money on Experiences with Those You Care About There are a lot of ways to spend money. You can buy homes, automobiles, jewelry, clothes, handbags, airplanes, boats, and snowmobiles. You can pay for someone else to do your chores such as home cleaning, snow removal, and lawn care. You can pay for experiences such as

“The additional bump in happiness that comes from buying a new thing of any kind fades just as quickly as that new car smell.”

European vacations, bottle service, heli-skiing, or eating out. Different people have different values, but as a general rule, the happiness literature is very clear on where you should spend your money in order to get the largest increase in happiness. You should spend your money on shared experiences with people that you care about such as friends, family, or a romantic partner. The additional bump in happiness that comes from buying a new thing of any kind fades just as quickly as that new car smell. But an experience helps build relationships and provides great memories, both of which contribute to long-term happiness. So instead of buying that BMW, consider taking your family to Paris, Costa Rica, and your local National Park this year.

#3 Giving Money Makes You Happier You would think that since additional income makes you happier, giving that income away to someone else would make you less happy, but that is not what the data suggests. In fact, charitable giving can make you

COMMON SENSE JULY/AUGUST 2022

FINANCIAL WELLNESS: A 5-PART SERIES ON MANAGING MONEY WISELY

even happier than doubling your income. Thus, every person at any level of income or assets should find a way to give something away to others, including high quality charities, each year. Giving more frequently increases happiness. So although it takes more work to give something each month than a larger amount once a year, it is likely worth considering for the happiness benefit alone. Even better, you do not need to give very much money in order to get that happiness boost. Giving even a tiny percentage of your income will make you happier. Giving anonymously without any public recognition increases happiness even more. Using a Donor Advised Fund is a particularly powerful way to give anonymously to registered charities since it ensures the charities you give to will not spend any of your donated money lobbying you for additional donations, since they have no idea who you are. We all seek happiness in this life and paying attention to the scientific literature on happiness can help shape your personal finance plan in a way to maximize that happiness. Boost income, purchase experiences with people you care about, and give money away in order to increase your satisfaction with life.

“You would think that since additional income makes you happier, giving that income away to someone else would make you less happy, but that is not what the data suggests.”

James M. Dahle, MD FAAEM FACEP is a practicing emergency physician and the founder of “The White Coat Investor,” the most widely-read physician specific financial website in the world, a best-selling author, and a popular podcaster.

Join or Renew Today! aaemrsa.org/membership

COMMON SENSE JULY/AUGUST 2022

Catch-22: A Story of the Impossible Choices Faced by Patients Battling Cancer

HEART OF A DOCTOR

Pavitra Krishnamani, MD MS

“40

-something year old woman, history of metastatic breast cancer, now with pneumoperitoneum likely secondary to hollow viscus perforation. Surgery consulted, dispo based on recs.” The patient was uneventfully signed out to me that night. I knew I was in for a long shift, but the ED looked relatively quiet. My patients were “tucked away” nicely, which means they were waiting for scan results or recommendations from consultants. I signed up to see some of the new folks waiting for a doctor to evaluate them. After I spoke with one of them, Surgery caught me in the hallway.

She lay there, breathing hard and inhaling oxygen from a nasal cannula, clearly in pain from the inflammation and buildup of air in her abdomen. Her belly looked swollen against her thin frame, physically making it difficult for her to take a deep breath. She had a wet cloth laying on her forehead to make her more comfortable. Swaddled in blankets, she looked over at me. “Fine, thank you,” she responded.

“Hey, that patient, she’s palliative,” they said. I looked at them, thumbing through the mental notes I had made about the patients signed out to me.

Ms. Calo had kind eyes—the kind that had lovingly raised two children, protecting them from the evils of the world for as long as she could. One of them sat by her side quietly and solemnly, understanding entirely well how his mother was faring and trying with every fiber of his being to stay calm so he could be there for her through her ordeal.

“The one with pneumoperitoneum?” I asked, using the medical term for ‘air in the belly.’

I sat by her bedside. “I heard the surgeons had a chance to speak with you,” I started.

“Yeah, it was a tough call because of her underlying condition, but we offered her surgery for the pneumoperitoneum and she declined. She wants to stay comfortable through the end and I agree with her decision, the risks of surgery are quite high,” he explained.

“Yes, yes,” she responded.

I sighed. Given her medical history, it made sense that she would decline the surgery, especially with the risks involved with operating on her. “Okay,” I said. “I’ll check in with her and get our internists involved.” I walked over to her room to introduce myself. “Hi there, Ms. Calo,” I said, “I’m Dr. Pavitra, I’m your previous doctor’s relief for the night. How are you feeling?” Ms. Calo looked exhausted, her skin and eyes yellowed with jaundice. Her cancer had spread everywhere — most notably to her liver, where it had wreaked havoc. The yellowing of her

skin was from high levels of bilirubin streaming through her blood, depositing in her skin and mucous membranes.

COMMON SENSE JULY/AUGUST 2022

“And I heard that you didn’t wish to have surgery to close the hole in your digestive tract that is leaking air into your belly, is that right?” “No, I don’t want,” she responded. “Okay. If you’d like, we can get your pain under control, get you upstairs, and make sure you are comfortable then. Is that alright?” I asked. “Yes, it’s alright,” she said. Ms. Calo could only speak in discrete phrases—long conversations were taxing. I looked over at her son, who silently held his mother’s hand. “What questions can I answer about everything that is happening—I know it can be overwhelming…” I started. “Nothing,” Ms. Calo noted. Her son acknowledged her response.

After a pause, I thanked them and excused myself. Ms. Calo had already heard about her prognosis from the surgeons. I didn’t want to harp on it in what may be the final days of her life. As I got ready to reach out to the Medicine team, the nurse walked past me. “Hey, did you speak with them?” she asked. “Yeah, Surgery spoke with them too and said they wanted palliative care. She declined surgery when we spoke just now as well,” I said. The nurse looked at me quizzically. “I don’t think her son knows how serious her situation is,” she started. “What do you mean?” “I mean, he’s been saying she can be upstairs for a week to see if she will heal and then they can decide about the surgery.” “But, she’s probably not even going to make it through the week with her condition. Surgery told me she understood the risks of declining the operation…” “I don’t know, I just know that she’s still full code in the chart,” the nurse said, referring to the fact that Ms. Calo’s records still indicated that she would want ever life-saving measure taken if her health were to decline. Worried about the conversation, I confirmed with Surgery that the discussion had been comprehensive and that the patient understood the options available to her as well as the risks and benefits of each option before making a decision. They re-emphasized that the patient preferred palliative or end-of-life care. I stepped back into the patient’s room. “Ms. Calo, I’m back!” I said. She turned her head a bit to see me. “Hello!” she exclaimed back. “I just wanted to ask a couple of more questions,” I started, sitting back down on the stool near the bed. I looked at the dying woman

“Nothing a physician, nothing a nurse, nothing a healer, or a human being, or the cutting-edge technology we have today could do would give her a better chance of being alive.”

HEART OF A DOCTOR

in front of me and was reminded profoundly that this, my first end-of-life care conversations, may very well be one of the last conversations she would have in her life. As my hand rested on her thin bony shoulder, it surprised me that this woman, so much younger than my own mother, could have such a slight frame. In that moment, as she turned to look at me and her son turned his gaze downward quietly, I noticed just how young her son was. He had to be around my age, still learning to be an adult yet saddled with the immense responsibility of caring for a terminally ill loved one. I thought about just how typical their family must have been before hearing the news of her cancer. I didn’t know anymore how to have this conversation with Ms. Calo. Discussing end-of-life care with a patient and their family is both an art and a science. Medical school taught me the science, but nothing truly prepares anyone to tackle the art. Nothing prepares anyone to be the sole physician in that room sitting by a critically ill patient discussing what they will want when faced with, not a remote possibility, but rather an overwhelming probability of quickly impending death. How, I wondered, could I ask a dying woman what she would want if she died sooner than she had ever anticipated? And, how could I do that with overhead alerts calling me to other patients who were rushed in with gunshot wounds and heart attacks? Though Ms. Calo was critically ill, she was relatively stable compared to the patients announced overhead, who required my emergent and immediate attention. Ms. Calo too, however, deserved my undivided attention. It struck me just how challenging it would be to have this conversation in a busy emergency department in what may be the last few days of Ms. Calo’s life. After all, the woman in front of me had two very undesirable paths ahead of her from a medical standpoint—

She could be DNR/DNI and pursue palliative care options towards the end of her life. This essentially meant that she would forego any heroic life-preserving measures in the event that her heart or breathing stopped. It also meant that she would receive pain medication in the mere days of life she may have left. OR— She could pursue surgery. As the only definitive way of addressing her pneumoperitoneum, this option could potentially preserve Ms. Calo’s life past this particular medical event. However, given her baseline state of health, it also meant taking an enormous risk that could rob her of any meaningful life that very night if the surgery did not go as planned. If Ms. Calo refused surgery, any heroic life-saving measures would likely be futile, with a chance that they may leave her unconscious but alive on machines that she may never come off of. It was a Catch-22 no one anticipates when they visit the emergency department for abdominal pain. “Ms. Calo,” I started, “thank you again for taking the time to speak with me. I know a lot has happened since you came into the emergency department today, and I understand that this is a very difficult experience. But I want to make sure that we are honoring your wishes as we help you through it.”

“Okay…” “Your condition here, the air in your belly,” I started, “can you tell me more about your understanding of it?” Ms. Calo verbalized a crystal clear understanding of her condition before I explained to her that surgery would possibly alleviate the problem, but also pose its own set of risks. “What’s the alternative?” her son asked. “Well, the alternative is making sure your mother is comfortable through this experience. Though it’s a possibility, these holes don’t often close by themselves,” I turned to Ms. Calo, “In the event that any bacteria got out of your bowels, where the hole is, they can cause inflammation or infection, which can be a painful experience and lead to problems with the function of other organs in your body. We can treat the infection and help address any pain you may have with pain medication.” Ms. Calo’s son looked at her, verbalizing what I had danced around. “There are two options, Ma, the surgery, which you may not wake up from, but which could help you live a bit longer, or probably dying comfortably with pain medication, but being alive for a few more days.” “I know,” Ms. Calo paused, “I don’t know. I need time,” she finished, asking for the one thing she did not have much of.

COMMON SENSE JULY/AUGUST 2022

HEART OF A DOCTOR

I nodded my head. “I understand,” I said, “There are a few other things we should discuss though.” “Okay,” she said. “Sometimes, when a person is very sick, there is a risk of them feeling worse,” I took a deep breath, “If they start to feel worse, something bad could happen to their heart or their breathing, and if that were to happen, we have some ways of helping them if they would like.” I paused and Ms. Calo nodded in acknowledgement. “We can try CPR to try and bring back a person’s heartbeat and we can use a breathing tube that is attached to a machine that can breathe for a person. People are not conscious when we do those things, which is we try not to wait for people to get that sick to discuss those options.” Ms. Calo was still, her eyes closing from fatigue. “Ms. Calo?” I tapped her on the shoulder and she opened her eyes slowly again, “Are you understanding some of the things we can do when people get really sick? “Yes,” she said. “Some people want us to do all of those things and others do not—they say ‘just let me go if I go.’ I’m hoping to get a better idea of whether you would want us to do those things for you or not if you were to get sicker.” Ms. Calo closed her eyes again and was silent. Her son squeezed her hand. “Ma, she’s asking if you want them to put a tube in you and hook you up to a breathing machine if you need it to stay alive.” I jumped in, “I just want to clarify that if that were you happen, you likely wouldn’t be able to interact with anyone while on the breathing machine and there is no guarantee that you would be able to stay alive after we take you off of it.”

COMMON SENSE JULY/AUGUST 2022

The seconds that Ms. Calo spent thinking about her decision were excruciating. “Yes,” she finally said. “Yes…?” I paused to clarify. “Yes, I want the machines. Do everything.” “Okay, Ms. Calo,” I paused. “But can you tell me more about why you would like the machines, but not the surgery?” Ms. Calo looked appropriately distressed about the decisions she was having to make. “I want to be alive,” she finally said. I looked at her cachectic body, turning yellow from the metastases to her liver, swelling up from the air and cancer in her belly, and I understood. Ms. Calo had a greater chance of being alive tomorrow if she didn’t do the surgery tonight. And though she had a more certain chance of dying in a week without a successful operation, her surgery was far from being a guaranteed success. Ms. Calo wanted to be resuscitated and be on machines if that’s what it took for her to be alive because that’s all she wanted. That’s all she must wanted since her diagnosis, through multiple rounds of chemotherapy, and the radiation therapy she was scheduled to have earlier that very day. Yet, even if Ms. Calo were to survive any of the options she was having to choose between, her health would likely deteriorate until the cancer or another medical complication took her life. Ms. Calo wanted to be alive, but her body was just not giving her that option. Ms. Calo wanted to be alive, but nothing we could do at this time would help her accomplish that. Nothing a physician, nothing a nurse, nothing a healer, or a human being, or the cutting-edge technology we have today could do would give her a better chance of being alive.

I remember that sobering moment of realization with such clarity. Her heart rate elevated, her O2 saturation stable at 95% as she breathed in what she hoped would be life-restoring oxygen. Her eyes pleading for the impossible as she looked me with such a deep sense of sadness and disillusionment. Those eyes that lovingly raised the son who was by her side now showed me they knew she was not going to be around to see the type of man he becomes. I sat with her for as long as I possibly could. I let my attending physician know it may be a while and my other patients would have to wait a bit longer. I was thankful it was a slow night and that I was only interrupted twice during our conversation. And when I finally got home after the night was over, I sat in the driver’s seat of my car outside of my apartment, leaned my head back against the headrest, closed my eyes against the sunlight that had peaked over the horizon, and finally let free the tears that had been forming behind my eyelids throughout my thirteen hours at the hospital. I found out later in the week that Ms. Calo had died just four days after our conversation. She was one of the first patients with cancer I had the privilege of caring for during residency and, years later, she remains a transformational icon in my life, inspiring my interest in oncologic emergency medicine and my decision to pursue a fellowship in the subspecialty this year. She will never get a chance to read this, but I hope she knew that she was loved during her visit to our emergency department. And, even though there wasn’t a thing I could do about it, I hope Ms. Calo knew just how much her resident physician wanted her to be alive too.

OPERATIONS MANAGEMENT COMMITTEE

This Meeting Could Have Been an E-mail: How to Succeed in Managing Your Project Erin Muckey, MD MBA, Akiva Dym, MD, and Anthony Rosania, MD MHA

e’ve all been there. We’ve all had one of “those” meetings. They come in several flavors: The ‘this meeting could have been an email’ meeting. The ‘Groundhog Day’ meeting. The ‘flight of ideas,’ but in reality, a ‘no next steps’ meeting…

On the other hand, we have all experienced a project that never fully launches because organizing over email is also full of roadblocks. Most of us would agree that there is a value in the collaboration, idea generation, and organizational management that comes from gathering stakeholders together in real time. But how do we capitalize on that benefit while effectively managing a project with a diverse group of very busy stakeholders who all have other competing interests for their time? To put it in other words, how do we consistently achieve this ambitious goal and ultimately develop a “unicorn” of meetings?

of the project’s key stakeholders to ensure that everyone is on the same page for the upcoming discussion.

Meeting organization and structure. The first step in any successful meeting begins upfront, with the design of the meeting itself. The goal is to pull off that white buffalo of meetings: one that is both high-yield and highly efficient. One of the keys to unlocking such meetings begins prior to the day of the meeting. Consider ahead of time what the desired goals of the meeting are and setting an outlined agenda to help you ensure a productive and focused meeting. Ideally, distribute the agenda to all participants the day before. This allows for the development of a shared mental model before the meeting even begins. If the topic is expected to be sensitive or controversial, it may be helpful to consider a ‘pre-meeting’ with some

“The goal is to pull off that white buffalo of meetings: one that is both high-yield and highly efficient.”

The next step is to focus on the management and flow of the meeting itself. Set clear expectations at the beginning of every meeting about the goals of the meeting and what you and your team hope to accomplish at the end of it. This allows everyone to begin the meeting with the same end goal in mind. The agenda will be very helpful with this part, as it will serve as a clear roadmap for the goals of each meeting. Remember that sometimes less is more. Don’t fall into the trap of trying to accomplish too much with each meeting. Often, a clear, focused agenda can lead to deeper discussion and more productive outcomes. It can also be helpful to level set early with the team on what the scope of the meeting is and what the scope of the meeting is not. This will help reduce tangential or unproductive discussions which may not align with the current meeting’s focus. Even the best planned meetings can at times have a mind of their own and take on a new direction. Sometimes, these tangents may be productive, other times they are not and detract from the original intent of the meeting. In particular, meetings related to process improvement can derail into a session with attendees voicing complaints or concerns about the current state. It is critical to have a plan to guide the meeting back on track with a thoughtful and diplomatic approach. Reminding the team of the focused agenda and offering to table the other concerns for an upcoming meeting, can help bring the focus back to the original goals.

Maintaining Momentum Once you’ve had your perfect meeting, it is now important to capitalize on that momentum and avoid the dreaded ‘Groundhog Day’ phenomenon—where you return to the follow-up meeting and feel like you are repeating the exact same thing as before, with nothing having changed or been accomplished. Without a concerted effort

>> COMMON SENSE JULY/AUGUST 2022

OPERATIONS MANAGEMENT COMMITTEE

to promote and maintain momentum, even the best of projects with good intentions can stall or fail. Before each meeting ends, develop action items for the group. It can be helpful to identify these tasks in real time during the meeting itself so that there is a sense of responsibility and accountability to the group. In particular, assign tasks to specific individuals or small groups, and set a target goal date for each next step. Develop your individual style for organizing the outcomes and planned follow-ups from the meeting. One such option is to maintain a spreadsheet with a row for each agenda item. There can be a column for the individual(s) assigned, goal date for next steps, and current status. After each meeting, send out the action items with a very clear subject line so that you can refer to (and reforward) this e-mail to ensure accountability in advance of future meetings. Prioritizing goals is also critical in order to maintain momentum. Focusing on too many initiatives at once can often dilute and distract from the main goal. Assign lower priority items to a formal ‘parking lot’ which can be re-visited at a later time or future meeting. By formally

outlining this list, you can continue to acknowledge good ideas without distracting from the high priority goals or the project’s next steps.

for future projects with similar participants who will now see you as an effective, team-focused leader who is worth supporting.

Lastly, it is important to remember that projects are generally more successful with delegation. However, part of this is also understanding that not everyone who is assigned a task will complete it the way you would have. Part of empowering others includes avoiding micromanaging each individual step in the process.

If all these steps seem like extra work, it’s because they are. However, it is a much more effective use of the entire teams’ time, and will yield more effective results. Overall, the keys to effective project management include prioritization, communication, and accountability. While this is something we all expect from our teams, it is important as a leader ourselves to reflect these principles and walk the walk to build a genuine culture.

Feedback and Messaging Understanding the response to a new initiative is key in targeting messaging and anticipating roadblocks. Be intentional about getting buy in—especially from the person completing the action items. As a project progresses, elicit individual feedback from those not directly involved to anticipate the general response and get a temperature check on progress and overall direction of the workstream. Lastly, as you are nearing the end of your project, develop the plan for communicating the change or efforts. This process should be multimodal and iterative. Make sure to celebrate wins and delegate success/kudos to key contributors, this will reinforce team ownership, and set the stage

“If all these steps seem like extra work, it’s because they are.”

Whether you’re considering specializing in emergency medicine (EM) or you’re preparing to apply for an EM residency, the AAEM/RSA Medical Student Symposia are for you! This is YOUR time to focus on creating your plan for the rest of med school and learn about different EM residency programs. Upcoming Symposium: Southeast Medical Student Symposium | September 10, 2022 Midwest Medical Student Symposium | September 17, 2022 Northeast Medical Student Symposium | Date Coming Soon! M1s-M4s | Free for AAEM/RSA Student Members | Register Now!

COMMON SENSE JULY/AUGUST 2022

PALLIATIVE CARE COMMITTEE

Oxygen is for the Weak Robyn Hitchcock, MD FAAEM

hen I started my day shift on a busy Sunday, the night doctor signed out a 100-year-old woman whose chief complaint was “low oxygen level.” She actually had no chief complaints at all, but the care facility she lives at couldn't get her oxygen level up so they sent her in for evaluation. She was on 100% non-rebreather and her oxygen level was reading barely 80% on her saturation monitor. She looked great and was not in any distress so we thought perhaps the reading wasn't accurate because she had poor circulation. So I ordered a blood gas to determine her real levels. When it came back her real oxygen saturation was 80% with a PO2 of 40. Those numbers were real. She did have a subtle pneumonia on chest x-ray so I thought we had something we could treat. She made it clear from the outset that she didn't want to be there—the facility basically forced her to come in. She didn't want to be hospitalized or in the ICU and she certainly did not want any kind of ventilator treatment. I tried to approach her about one of the kinds of mask ventilation or high flow and she adamantly refused that too. "I'm 100 years old, it’s okay if I die," she kept saying. Eventually we took off the monitor because she made it clear she didn't want any intervention and the recurrent alarm was driving all of us, but especially me, crazy. I tried to reach her family to get them involved with the conversation but we were only able to leave messages. She was completely lucid and could make her own decisions, but out of courtesy it's always good to have the family on board with these difficult moments. Then I tried to get a hold of hospice on call so I could send her home with hospice, but her facility does their own hospice and they don't have an agreement with the local hospice so that failed too. This was a critical access hospital, so there was no palliative care team available for consultation. Eventually I was able to reach the medical director on call who was able to put forth a palliative care plan, and stop the facility from doing vital signs. A little while later she took off her oxygen. "If I'm going to die anyway, I don't want to die wearing this rotten stuff." We did not recheck her oxygen level. She remained completely lucid, and left the ED smiling in a wheelchair. With a PO2 of 40 on a non-rebreather I don't even want to think about what her room air saturations were. The hypoxemia did not take the smile off of her face when she left having gotten her way.

“Take that end of life care. I laugh at your dependency on oxidative phosphorylation.” She didn't say it out loud but I could see it all over her face. "Oxygen is for the weak. I reject your stinking oxygen and your whole hospital philosophy. Take that end of life care. I laugh at your dependency on oxidative phosphorylation." Another doctor might have approached it differently. Maybe they would have tried to bully her into staying in the hospital or at least going home on oxygen. Maybe they would have waited for the family to see if they could talk her into more aggressive care. I chose to respect her spirit, her spunk, and her very clearly stated end of life wishes. She was a total badass. And she was determined to finish her life on her terms. Oxygen is for the weak, ask Grandma. Dr. Hitchcock blogs about rural, emergency, and travel medicine at stethoscopesuitcasemd.wordpress.com.

COMMON SENSE JULY/AUGUST 2022

ACADEMIC AFFAIRS COMMITTEE

Five Rules for Emergency Medicine Interns Mary Claire O’Brien, MD FAAEM

uckle up, faculty, it’s July! (Again.)

It’s GAME TIME, interns. Pay attention. Here are five “Rules for Emergency Medicine Interns.”

    

There are no stupid questions. Ask!

Rule #4: If someone is rude to you, tell me.

If you don’t know what to do, ask.

The emergency department is a healing environment. It is also a learning environment. We treat everyone with respect. We do not tolerate abusive behavior. If someone is rude to you, whether it is a colleague, a consultant, a patient, or a family member—you tell me.

If someone is rude to you, tell me.

I will take care of it. I have your back. You be polite too.

If the patient is sick, come get me. It’s your job to check “it.”

FEEDBACK IS LOVE!

Rule 1: If the patient is sick, come get me. Turn right around, come out of the room, don’t even stop ask the patient’s name. Come get me! When you find me, don’t say, “Um, Dr. O’Brien, if you have a minute, could I talk to you about a patient?” Don’t stand there waiting patiently while I am speaking to someone. Interrupt me! Say, “Dr. O’Brien! I need you RIGHT NOW!” If we go into the room together and the patient doesn’t seem as sick to me as they did to you—that’s ok. You will learn with time how to tell who is sick. If you think the patient is sick, come get me.

Rule #2: It’s your job to check “it.” “It” is anything and everything related to your patients. Why did the nursing home send them in? What did EMS say? What was the point-of-care glucose? Did you review the medication list? Have the nurses started that IV? Did the pain medicine help? What did the family say? What’s the hemoglobin? Is the chest X-ray back yet? What’s taking so long for the head CT?! Why is the ambulance transport delayed? Did that consult resident call you back? It’s your job to know “it” about your patients before I do. If I know the answers before you do, I win! You lose. They are your patients. It’s your job to check “it.”

Rule #3: If you don’t know what to do, ask.

COMMON SENSE JULY/AUGUST 2022

Rule #5: Last rule: Feedback is love. Doctor, how you get from July 1st this year to June 30th three years from now involves a lot of feedback. I get paid to criticize you, and you get paid to listen to it. If I didn’t criticize you it would mean I didn’t care about you. I care about you! I have faith in your ability to do better. Prepare to be criticized.

Feedback is love!

A Lament for Thucydides General Leonard Dunikoski, DO FAAEM

note to the reader: This piece was written with consideration of the current state of our specialty and is loosely based on Thucydides' Melian Dialogue. Crude realism encouraged by corporate influence in our specialty seemed ideologically opposed to our mission and training. Like the Melians in the original manuscript, there is an unequal power dynamic between corporate medicine and small group practice and I hope to highlight the similarities between the situation between the Greek city states then and our emergency medicine practice now. A version of the original Melian dialogue can be found at mtholyoke.edu/acad/intrel/melian.htm.

After much consideration by the board, it was determined that bids would be entertained for staffing the emergency department at Thucydides General. Representatives from the incumbent local group and the national staffing group argued their cases before the board. First spoke Dr. Athenos on behalf of the national corporate group: “Our appeal is simple and straightforward. We can maximize profits, minimize hospital risk, and do so in a manner that results in satisfied patients.” To which Dr. Melos of the local democratic group replied: “Of course your strategy has outward appeal, but there is a hidden cost. To the first point, profits come from patients. Patients who should be an end in themselves, not the means to a successful business model. To the second point, risk is inherent to our specialty. To the third point, satisfaction is a poor measure of success. Is not our mandate the identification and treatment of disease?” Dr. Athenos: “Surely you cannot ignore the fundamental nature of our work. We are a service industry, providing necessary skills and expertise to those who seek our care. I would not criticize you for idealism nor would I presume your ignorance. Supplies are finite as are the hours allotted to our physicians. Our work is transactional. We simply assure that we, and our hospital partners, are appropriately compensated for the work that we do.” Dr. Melos: “And in doing so, consign your physicians to the damnation of metrics and your patients to the hell of balanced billing. We are not ignorant of the economy of health care. We strike a better balance between the industry and the provision of care.” Dr. Athenos: “Without standards, how could we measure? What you would decry as evil is a necessary mechanism for improvement. We would extend to you a simple offer—join us and become of the future of medicine.”

Dr. Melos: “An offer made under threat to our livelihood. What a bleak future you offer, of machine men and clockwork minds, of calculations of care. It seems that you have set aside humanism for profit. What of the art of our craft? We would name you fee splitters, a corruption spreading within the house of medicine.” Dr. Athenos: “Our legal team would debate that.” Dr. Melos: “Their fees paid in the sweat of physicians.” Dr. Athenos: “Yet your partners take distributions from the earnings of the group. Democratic? Our groups are the same by action if not name. We simply differ in scale. Your appeals to higher abstractions will fall on deaf ears here. Can you measure a quanta of beneficence? An iota of justice? Corporatism is drawn to like and we offer a logic proven by numbers.” Dr. Melos: “It is just that same scale that leads to hazard. Medicine is the personal, not the abstract. We deal in lives, not dollars. You accuse us of hypocrisy and we accuse you of perfidy.” Dr. Athenos: “Might makes right and woe to the vanquished.” Thus it came to pass that the board signed the national group for the emergency department at Thucydides General. Metrics demanded excellent care and surveys documented its delivery. And staff continued to care for patients despite challenges old and new.

“It seems that you have set aside humanism for profit. What of the art of our craft?” COMMON SENSE JULY/AUGUST 2022

WELLNESS COMMITTEE

A Renewed Mission Alice Min Simpkins, MD FAAEM* and Al’ai Alvarez, MD FAAEM†

ecently, the AAEM Mission statement was modified to include the following (emphasis below are author’s):

The Wellness Committee is so appreciative to the Board for acknowledging the impact of well-being on productivity, sustainability, and a sense of fulfillment in our careers. The values embodied in the AAEM Mission Statement reflect the hierarchy of needs that impact our professional and personal well-being. This modified-Maslow hierarchy aimed to capture physician needs has helped guide the Wellness Committee and informed all of our endeavors. As we look to the future with the renewed Mission of AAEM, the Wellness Committee is committed to pursuing and continuing initiatives that impact the well-being of AAEM members to address the diversity of needs and challenges we face and to work across the intersections that influence our sense of purpose and meaning in our work. We are always open to new ideas, innovative and creative pursuits, collaborations across AAEM, and new membership in our committee. Once again, we thank the Board for their commitment and support of the work to continually focus on and improve the well-being of our physicians. *Chair, AAEM Wellness Committee, Assistant Dean, Career Development, Office of Faculty Affairs, Professor, Emergency Medicine University of Arizona College of Medicine - Tucson @allieminMD

† 4. The Academy supports residency programs and graduate medical Vice-Chair, AAEM Wellness Committee, Director of Well-Being and education free of harassment or discrimination, which are essential Co-Chair of the Human Potential Team, Clinically Associate Professor, to the continued enrichment of emergency medicine, and to ensure a Emergency Medicine - Stanford University School of Medicine @alvarezhigh quality of care for the patient. zzy 5. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members. 6. The Academy supports the establishment and recognition of emergency medicine internationally as an independent specialty and is Heal Patients and Contribute: My institution is in alignment with my values and helps me committed to its role in the advancement of towards professional fulfillment. My institution actively promotes my doctor patient relationship as paramount to the success for our organization and my own fulfillment as a healer of my patients. emergency medicine worldwide.

Appreciation: My institution regularly shows appreciation for my service and talents. My institution recognizes my accomplishments and supports my professional development.

Respect: My hospital listens to my expertise and addresses my concerns to the extent that they are able to. My institution has robust surge planning and actively addresses EM boarding.

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.

COMMON SENSE JULY/AUGUST 2022

WOMEN IN EMERGENCY MEDICINE SECTION

What Are You Saying “No” to When You Continue to Work? (eh) Marianne Haughey, MD FAAEM

was an eager, front-of-the-class, hand-waving-inthe-air type of student. I brought that same energy to residency and early attending hood. If there was an extra project, or extra hours to work to “help the team out,” I was your girl. Therefore, I signed up for many projects, many committees, and many extra hours. Then I had children. When I had a daughter, she was a tangible and vocal reminder that if I said yes to an additional hour of work, I was saying “no” to an hour with this adorable creature, who was also completely dependent on me and my husband. She helped me to clarify my priorities. There were absolutely some projects and committees and hours that were worth saying “yes” to, and therefore (by extension) giving up time with my daughter, but the benefits needed to be clear. That benefit might be pay, or fulfilling a desire and interest I had, or connecting to others with similar interests in order to build something together. There were other things, however, that had consumed my time that were not worth being prioritized over time with my daughter (and later also my son). I worked to identify and diplomatically shed many of those less desirable (to me) responsibilities, keeping an account of what made sense for me to take on and what did not. And when new opportunities came along, I always then considered whether they were worth saying “no” to my children. Many tasks made the cut, but some clearly did not. This priority setting allowed me to prune away things I did not enjoy as much and grow my career into something that included the things that provided personal satisfaction and joy. If there were educational talks to give for the residents, or mentoring sessions with medical students, or sessions with educators learning how to be a better teacher, I was in and excited. If there were meetings about ED metrics, algorithms for faster processing patients through the ED, or other department wide administration tasks I was happy to leave those meetings to others. These choices have resulted in my career in EM medical student and residency education. My son and daughter are no longer infants. In fact, they aren’t even teenagers. They are now 24 and 22. I am lucky in that by prioritizing them, I developed relationships with both of them, alone and together, that we enjoy, and clearly, they are my life’s greatest accomplishment. But I also worked many, many hours to hone and practice my profession in the more than two decades they have been alive. I love my work, I love figuring out the puzzles of clinical presentations, I love talking to people and meeting so many new people as patients a day, I love the teaching that comes with my job as an associate residency program director and professor. I love the excitement of the ED and the true sense that I “help people” every day. I have joined many committees and even led some of them. I have taught nationally and internationally. I have received

respect and support and praise in my role. I have mentored many and have come to enjoy friendships with many mentees over the years. Emergency medicine feels like the best adventure out there, but it is one with a priceless ticket to ride. One must keep up with the craft to practice it well. Last summer, during the annual intern retreat with the education faculty and the interns, one of my fellow APDs mentioned casually he would like to retire at 55. As I was 55 at the time, I challenged him and asked if he was calling me old? He edited his comment, saying he would like to “have the option of retiring at 55.” Well, that made it sound more palatable. And made me consider—did I have the option? I looked over the numbers of my husband and I and realized it was not impossible. So that then raised another point. Would I want to retire? Wow. That was a question. I have worked for pay since I was 16. My immigrant grandparents and my first-generation parents had instilled a very strong work ethic. I had recently shifted to a job I was completely enjoying, with a wonderfully supportive group. I had cut my commute time to 10 minutes from an hour. I was working with friends I had known for more than 25 years. I was having even more fun than before when at work. So, on a daily basis I want to go to work. I realize though, the essential question about choosing work is the same as it was when I was younger and raising my children. It is just less clear. When I choose to say “yes” to continuing to work, I am saying “no” to something or someone. It is just much less clear who or what that “no” is directed at. My children are now adults. Although we enjoy each other they don’t need me. My husband, after 17 years at home with the kids as a stay-at-home dad, returned to work outside the home in an elementary school. He has a mission and enjoys impacting young lives, so he does not need me home daily. My parents have needs, but they know I enjoy my work and they would never want me to stop to care for them.

COMMON SENSE JULY/AUGUST 2022

WOMEN IN EMERGENCY MEDICINE

“When I had a daughter, she was a tangible and vocal reminder that if I said yes to an additional hour of work, I was saying “no” to an hour with this adorable creature.” Both my parents retired at about 55. They are now 80. Their health is declining rapidly over the last four years, but for 20 years they had time together to travel and enjoy each other that they did not have the resources to do as young parents of three children in four years. They built another stage of their life together—one not based on paying bills and discussing the “work” of couple hood and raising a family but one based on adventure and building fun and laughing together. If they had each worked an additional decade, they would have missed that time building more of their lives together. Daily work in EM does consume my time. Essentially, I am saying “no” to me to have more unstructured time when I continue to be on the schedule. I am saying “no” to what would fill that time. What do I enjoy that I don’t do as much as I would like to do now? I love to read, I love writing,

I really enjoy getting fit, and especially swimming. I love my husband and enjoy spending time with him just “being.” I would like to raise a puppy from puppy hood. That is a fairly short list. I can and do incorporate many of these things into my current life. It is challenging, though, to think of what I am saying “no” to as it requires creativity in thinking how would I spend my time if not filled with the fun (and challenges) of work. I am extremely lucky as I look at the world to realize I truly love my job. Not everyone has that. But what other fun things can I fill my time with? Before I had an infant who personified what I was choosing when I chose work. Now, with the choice less concrete, I have to consider what my needs and desires are once again and make the decision to say yes or no to employment conscious. What are you saying “no” to when you choose work?

Build confidence with each case encounter! scan for more information

Oral Board Review Course 2022 Dates: Sep 14, Sep 15, Nov 30, Dec 1 www.aaem.org/education/events/oral-boards

COMMON SENSE JULY/AUGUST 2022

EMERGENCY ULTRASOUND SECTION

2022: The Year of the 1st AEMUS FPD Examination Alexis Salerno, MD FPD-AEMUS FAAEM

inally, after years of development, the first Advanced EM Ultrasonography (AEMUS) Focused Practice Designation (FPD) examination was held March 7-11, 2022. FPD, which is approved by the American Board of Medical Specialties, “recognizes physicians who devote a substantial portion of their practice to a specific area of a specialty.” This designation recognizes emergency physicians with expertise in emergency ultrasound beyond the requirements for American Board of Emergency Medicine (ABEM) certification. There are currently three pathways to be eligible to take the FPD examination. The first is a training pathway through an Emergency Ultrasound Fellowship Accreditation Council (EUFAC) accredited AEMUS fellowship. The second pathway is through training-plus-practice, for physicians who have completed a non-accredited ultrasound fellowship. The third pathway is a practice-only pathway for physicians who have demonstrated significant involvement in AEMUS but perhaps trained prior to the establishment of ultrasound fellowships. The FPD designation is only available to physicians who are certified by ABEM. The AEMUS-FPD examination was written by an elected group of ultrasound experts who were required to complete an accredited item writing training course. The exam questions were discussed amongst the group and 100 multiple choice questions were chosen for the examination. These questions included a mixture of text only and text with ultrasound images or clips. The exam questions were based on specific content which is listed on the ABEM website. The content included not only advanced ultrasound image knowledge but also questions on physics, administration, education, and research skills. Some of the

comments from this year’s test takers stated that some of the quality of images could be better. However, the examination writers wanted the images to be represented of real life, and, let’s face it, in real life we are not always going to be able to obtain “textbook” worthy ultrasound images.

after the examination with 75% of those who took the examination passing. For those who have passed the exam, the AEMUS Exam Committee is currently developing continuing educational activities directly related to advanced ultrasound to keep physicians up to date.

To obtain a passing score, a Modified Angoff method was used. In this method an independent panel was created to recommend a passing score to the AEMUS exam committee who then recommended the passing score to ABEM. The independent panel was a diverse group of clinically active physicians who are knowledgeable in AEMUS, i.e. eligible for the examination but who chose not to take the exam during the first cohort. The panelist evaluated each test question to assess how the standard test taker would perform. The exam was taken multiple times and each exam question was rated and discussed by the group. The group then endorsed a passing score. For the 2022 AEMUS FPD examination, ABEM set a passing score of 54 out of 76 questions scored. Results were released prior to 90 days

The next AEMUS Exam will be in 2024 and will continue to be administered in even-numbered years. Ultrasound fellows graduating from a non-EUFAC accredited fellowship before June 30th, 2024 will be eligible to take the examination through the training plus practice pathway. If you took the FPD exam in 2022 and did not pass, you can sign up to take the test again in 2022 with a pre-approved application. If you are looking for resources to study for the 2024 AEMUS FPD examination, check out AAEM’s Unmute Your Probe lecture series as well as resources from other national organizations.

COMMON SENSE JULY/AUGUST 2022

YOUNG PHYSICIANS SECTION

Turning Foes to Friends: Establishing Collegiality in the ED Alan Sazama, MD FAAEM

opefully you’ve had the opportunity to see the fantastic sequel to “Top Gun” by now, but let’s flash back to the original 1986 hit movie. Tom Cruise’s Maverick faces off in flight training with Val Kilmer’s Iceman. The two open the movie as intense adversaries but end the movie as lifelong friends. Many of you are celebrating the end of your long medical training this summer and starting a new job. Some of you will continue at hospitals you trained at, giving you the advantage of being already familiar with many of the consulting services. Some, however, will find themselves starting off with a new roster of colleagues at a different hospital. The 24/7 nature of the emergency department leads to us calling on our new colleagues at inopportune times such as nights, weekends, and holidays. This can lead to an Iceman/Maverick adversarial start to these relationships. Let’s look at some practical tips to turn our colleagues in the hospital from foes to friends.

Be an excellent emergency physician Residency uniquely prepares yo zu to practice medicine independently. It’s important, however, to always continue learning. Sitting now on a medical school admissions committee, I frequently hear premedical students talk about how the prospect of being a lifelong learner excites them. Now that you’ve reached the end of your training journey, don’t forget this! In your first couple of years out of residency, you’ll find the experience of independent practice an effective but sometimes cruel teacher. Use these first years of transition to become excellent at your craft. This excellence will breed respect amongst the other specialties in the hospital. While they may not be

thrilled to receive a call from the ED at 3 a.m., they’ll know if it is coming from you, it is indeed important and that a patient will need their expertise. Even if they persist being adversarial, you’ll know that you are providing the best care for your patients.

Collaborate Recently, I had the pleasure of taking care of a pleasant lady who unfortunately had a massive GI bleed. I met with the hospitalist outside the patient’s room, and together we discussed her care plan at the bedside and took turns calling the GI consultant who was reluctant to come in. We started massive transfusion protocol and eventually involved interventional radiology to embolize one of her gastric arteries that was actively bleeding. The next day, when I admitted a different patient, the hospitalist came down, and we discussed the previous night’s patient. Our collaborative decision making had led to a positive outcome for our mutual patient. This case helped develop a mutual trust and even friendship between me and the hospitalist. It’s important to remember in our sometimes-broken health care system that we are really all on the same team, uniting to help patients in need. Collaboration with other specialties can be a rewarding experience and certainly benefits our patients.

Humanize Much has been written about burnout in emergency medicine, but it is important to remember that this isn’t an emergency medicine problem but a medicine-at-large problem. It can be easy to get frustrated when the consultant is not being as helpful as we think they should be. It can be even easier to be rude back over the phone or in person when they question your expertise. We may not be thinking about what they might be going through currently. It can be hard to know if the surgeon who is barking at you on the phone just got done telling a family that their loved one didn’t survive surgery, or if a hospitalist is on their eighth straight admit and is getting paged and interrupted constantly as they’re trying to take care of these patients. The cliché here is “walk a mile in their shoes.” Now, none of this changes the fact that a job needs to be done. Regardless of personal feelings, patients need to be taken care of. However, humanizing our consultants can be an important step towards building collegiality. Giving grace to rude or disagreeable consultants can be one of the more challenging aspects of our field yet, if done correctly, can have tremendous payoff.

“For every Maverick and Iceman success story of turning foes into friends, there are some Batman and Joker relationships that stay foes forever.”

COMMON SENSE JULY/AUGUST 2022

YOUNG PHYSICIANS SECTION

Hang out!

“It’s important to remember in our sometimes-broken health care system that we are really all on the same team, uniting to help patients in need.”

AAEM

While it might be wishful thinking to imagine all the hospital’s doctors coming together and being the best of friends, there certainly is room for developing relationships outside of work. Find common interests with other doctors. As an example, I love golfing and have formed a golf group with some of my ED colleagues, nurses, surgeons, and hospitalists. We enjoy each other’s company outside the hospital walls allowing us to be more collegial within its walls. This further emphasizes the previous point about humanizing each other. Conversation and laughs over 18 holes of golf can build relationships that leads to better teamwork during intense trauma team activations. Maybe this bond happens over similar family situations, kids, spouses, or other hobbies. Try to find common ground with specialists and look to develop relationships with them outside of work. For every Maverick and Iceman success story of turning foes into friends, there are some Batman and Joker relationships that stay foes forever. Some consultants will always be prickly to us in the emergency department. This is where it’s of the utmost importance to always keep patient care a priority. Do what is best for the patient always, regardless of the unpleasant conversations that may result. Residency training has probably taught you to have a thick skin. I believe if you apply the above principles, there is a good chance you may be high-fiving consultants like Maverick and Iceman in no time, albeit maybe not on an aircraft carrier. Remember, we are all on the same team! Now, where are my aviators?

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COMMON SENSE JULY/AUGUST 2022

AAEM-LG

AAEM-LG President’s Message to Hospitals, Physician Groups, and Locum Companies Rob Mohr, MD

ear Hospitals, Physician groups, and Locum Companies,

So much has changed in the last year! Locum Tenens is stronger than it has ever been. Clients who made cuts to survive the pandemic are now short staffed. Hospital systems are stretched thin. Reimbursement rates are higher than they have ever been and Locum Tenens is back as a superb way to practice medicine. As of this writing there are locums jobs across the country in every region. What hasn’t changed is that as physicians we don’t know if we are being treated fairly. On the other side of the table, there is still the problem of locum companies and hospitals not being able to find enough quality physicians available to work. What is left is a situation of mutual distrust where neither party comes out ahead. Enter the American Academy of Emergency Medicine Locum Group (AAEM-LG). We exist because we feel that matching a physician with a job should be conducted better than a used car deal. I, as the AAEM-LG Board of Directors President, know that through honest transparent conversation all parties can work together and win. Welcome to what I hope is a referendum on how locum tenens is conducted. We are different! From the way we were founded to the way we conduct business we aren’t “just another locums staffing company.” Our zero dollar diminishing buyout for qualified clients is just the first example. AAEM-LG wants to change the face of locum tenens industry wide by setting the example of what a good company looks like. There is never a question of “who is making what.” With our Locums Transparency Sheet your docs come in with full knowledge of the work environment, the pay,

the benefits, and the responsibilities before ever signing a contract. The end result is they come in ready to work and ready to face the challenges of your department. Finding a quality physician can be daunting. It’s frustrating to sort through vaguely worded CVs and discern who is qualified and who isn’t. Furthermore just because a doctor checks the boxes on paper doesn’t mean they are going to show up ready to move your department forward. This is why the AAEM-Locums Group wants to work with industry to ensure that qualified doctors that understand the importance of team dynamics are put forward. We strive to internally vet and maintain high quality physicians that you are proud to have in your department. When adverse outcomes occur we want to partner with you to ensure that the patient, the physician, and the hospital’s interests are fairly represented and that process improvement and quality control occurs. We feel that by disclosing margins both parties actually come out ahead since clients and physicians know and can trust that opportunities are truly represented fairly. This puts morally forward companies ahead and discourages companies that rely on exploitative practices thereby tipping the scales towards those who are conducting honest business. AAEM-LG strives to change the marketplace for Locum Tenens by attaining market share and influencing the way business is conducted. We will show that transparency, ethical integrity and competency are the only way to ensure that patients, hospitals and physicians win. Very Respectfully, Rob Mohr, MD President AAEM-LG

AAEM-LG facilitates fair and transparent relationships between high-quality, board-certified emergency physicians and hospitals and independent emergency medicine staffing groups. Learn More: aaemlocumgroup.com in Partnership With:

Providing You With Top-Tier Emergency Physicians

COMMON SENSE JULY/AUGUST 2022

AAEM/RSA PRESIDENT’S MESSAGE

AAEM/RSA President Introduction Leah Colucci, MD MS

y name is Leah Colucci and I wanted to dedicate my first AAEM/RSA President’s corner of Common Sense introducing myself and my board as we take on the task of running AAEM/RSA!

I am a PGY-1 at Yale New Haven Hospital. I come from the great state of Florida and spent my undergrad, medical school, and masters at The University of Miami. (It is all about the []_[]!) I double majored in Neuroscience and Marine Biology. My family still calls me Mermaid. I am the only child of two emergency medicine nurses. My mom climbed in leadership at her institution and became the CNO of a rural hospital whose ED is staffed by a rare democratic group. I firsthand saw and heard the struggles of life in the ED and swore I would not be going into emergency medicine. However, I quickly fell in love with the unique ability we have as EM physicians to meet people on the worst day of their life and make a positive impact. After years of resisting, I found there was no other specialty that would be as fulfilling and I committed myself with eyes wide open.

“We need to take our privilege and work on what is broken in our system, not accept the status quo.” I joined AAEM, because I passionately believe everyone deserves access to a board-certified emergency medicine physician when they present to an ED. I don’t believe that just because you live in a rural community, or because you are a vulnerable member of society that you are forced to be seen by an NPP. Our specialty is dedicated to anyone, anything, anytime, and that should include anywhere in our country—not anywhere that doesn’t have independent practice. I also believe COVID highlighted how CMGs and private equity can take advantage of our care. AAEM has been the organization ringing the alarm bells for years. I don’t want our amazing residents to enter our incredible specialty with learned helplessness. We are physicians, we have overcome every obstacle thrown are way to become elite members of society. We need to take our privilege and work on what is broken in our system, not accept the status quo. I hope to give residents a voice and empower the best and brightest to enter our specialty and make a difference.

COMMON SENSE JULY/AUGUST 2022

These passions and opinions I am bringing into my presidency. I look forward to working with the rest of my board: Vice President: Corey McNeilly, MD, University of Tennessee- Murfreesboro/Nashville

Past-President: Lauren Lamparter, MD, University of Illinois Chicago

Secretary/Treasurer: Anantha Singarajah, DO, Eisenhower Medical Center

Advocacy Liaison: Andrew Langille, DO, University of Tennessee-Murfreesboro/Nashville

Wellness Liaison: Nahal Nikroo, MD, Nuvance Health/Vassar Brothers Medical Center

International Liaison: Donna Okoli, MD, Advocate Christ Medical Center

Publications and Social Media Liaison: Kaitlin Parks, DO, Washington University in St. Louis

Chapter Division & Section Liaison: Heather Renfro, MD, University of Chicago

Education Liaison: Loren Touma, DO, Jefferson Northeast Medical

Student Representative: Mary Unanyan, Western University of Health Sciences College of Osteopathic Medicine of the Pacific

AAEM/RSA EDITOR’S MESSAGE

AAEM/RSA Chair Introductory Letter Alessandra Della Porta, MD

ello! My name is Alessandra Della Porta and I am excited to introduce myself as the 2022-2023 Chair of AAEM/RSA’s Publications and Social Media Committee. I would like to take this space to introduce you to who I am, my goals for the year, and to thank the outgoing Chair, Dr. Kasha Bornstein, for their service to the committee, and instrumental role in shaping the position for years to come. I am a born and raised Floridian and I attended the University of Florida and the University of Miami for my undergraduate and doctoral studies, respectively. Prior to medical school, I worked as an EMT which was my introduction to emergency medicine. However, it was my time in Miami that shaped what I believe is the call of all emergency physicians, to bear witness to the inequality in society and do our best to mitigate it within the walls of our health care systems. I am incredibly passionate about social emergency medicine and the future of its integration into all facets of emergency care, and I know this will be reflected in my Editor’s messages over the next year. My other professional passions include medical education, specifically FOAMed (free open-access medical education). Through mentorship, I was introduced to the power of FOAMed early in my graduate studies and I believe emergency medicine has capitalized on the opportunity to learn in real time from nontraditional sources. I have recently left the sunshine state, moving to Ohio, and have started my residency in emergency medicine at the University of Cincinnati Medical Center. Personally, I am a novice potter and an avid thrifter, and it is common for me to spend a weekend afternoon perusing the aisles of my local second-hand shops.

Over the next year, I would love to use my role on the Social Media and Publications Committee to amplify the reach of the RSA, but also individual student and resident voices. Through the social media branch of this position, I am looking forward to coordinating with the other committees to assist them in marketing and sharing of their well-planned and impactful events. Please be on the lookout for introductions to each committee and a bit about what they have planned for their terms this year. Secondly, with the publications branch of my position I am excited to bring my passion for medical education through contributions to the Common Sense AAEM publication and Modern Resident blog, and showing RSA members the utility and accessibility of FOAMed resources. Finally, I want to acknowledge the work of the past committee chair, Dr. Kasha Bornstein, for their work over the last year. Given our shared passion for social justice and equity, their support of both novice and experienced writers looking to contribute in this arena is something to be acknowledged and celebrated. I look forward to connecting with medical students, fellow residents, and mentors over the next year! Alessandra Della Porta, MD Chair, AAEM/RSA Publications & Social Media Committee Resident, Emergency Medicine University of Cincinnati Medical Center Pronouns: she/her/hers

Over the next year, I would love to use my role on the Social Media and Publications Committee to amplify the reach of the RSA, but also individual student and resident voices.” COMMON SENSE JULY/AUGUST 2022

MEDICAL STUDENT COUNCIL CHAIR’S MESSAGE

Emergency Medicine Preference Signaling Mary Unanyan, OMSIII

mergency Medicine (EM) will be participating in Preference/Program Signaling (PS) via the ERAS Supplemental Application in the upcoming 2022-2023 residency application cycle. However, EM will participate only in the Program Signaling portion of the supplemental application; applicants will not need to fill out the Past Experiences or Geographical Preferences and these sections will not be visible to EM programs. More detailed information regarding the mechanics of PS can be found in the ERAS Supplemental Application Guide.1 Additionally, there is a PS Applicant/Advisor Supplement Guide posted on the Council of Residency Directors (CORD) in EM website.2 This guide was constructed and reviewed by multiple national EM organizations, program directors, and residency applicants.

may be given to applicants who signaled that program over a similar applicant who did not. There is no mechanism for programs to tell which applicants are not participating versus those who are but did not send them a signal. This was intentionally done to prevent programs from holding a bias against applicants who did not signal them. It is important to note that how a program interprets a “lack of signal” is subject to the discretion of each individual program.

What is Preference/Program Signaling (PS)? PS will allow EM applicants to send up to five “signals” to residency programs that they are most interested in. Signals can be sent beginning on August 1st and can be edited up until you officially submit your selections, with a deadline of September 16th. PS aims to help applicants increase their chances at their most interested programs as well as help programs focus their holistic review on applicants who are genuinely interested in their program.

Do I have to participate in PS? PS is optional for both programs and applicants; however, applicants who opt out may be at a theoretical disadvantage as interviews

COMMON SENSE JULY/AUGUST 2022

Which programs should I signal? PS is new to the residency application process and, thus, there is not yet robust data on how to best assign signals. Applicants should spend time researching programs and reflecting on their priorities during their initial application. While there will be time to reflect more deeply during the interview and ranking stages, there will not be a post-interview round of PS. Ultimately, the strategy for PS will vary from applicant to applicant. It is strongly recommended that applicants work with their medical school and EM advisors on how to best allocate their

signals. The PS guide on CORD lists a few examples as well as resources an applicant can use to determine how to best use their signals.

How do I start thinking about PS? One suggested strategy is to begin with creating a list of your top residency programs. Remove your home program or program(s) where you rotated. Use online resources (e.g. EMRA Match, Texas Star, AAMC Residency Explorer Tool) and program websites to determine your competitiveness. Consider removing programs where you do not match their demographics of current residents. If you still have more than five programs on your list, consider how competitive each program is versus each other. Signals will likely hold more value at less competitive programs as the more competitive program may receive a significant amount of signals thus decreasing their value. An applicant can choose to signal more competitive programs, but consider not using all five signals on competitive programs to maximize the value of your tokens. More detailed information and frequently asked questions can be found in the ERAS supplemental application instructions as well as in the PS Applicant/Advisor Supplement Guide posted on the CORD website.

References 1. https://students-residents.aamc.org/ media/12326/download?attachment 2. https://www.cordem.org/globalassets/files/emps-applicant_advisor-guide.pdf

TAKE MEDICINE BACK

A New Emergency Medicine Application Tom Belanger, MD FAAEM and Mitch Li, MD FAAEM

he Problem

There is significant concern about corporate consolidation in emergency medicine—both ACEP1 and AAEM2 have expressed their concern in recent position statements. These concerns occur within a broader national concern over consolidation; many emergency physicians, prompted by Take Medicine Back—including representation from both AAEM and ACEP—recently lent their voices to a DOJ and FTC Request for Information on Merger Enforcement,3 in both anonymous statements virtual appearances.4 While market consolidation harms workers through regional monopsonies, another potential factor affecting labor market power is information asymmetry—a reference to the idea that employers, especially large ones, will often have more information on a labor market than employees.5 A less competitive labor market stifles wage growth and reduces the quality of the product delivered. Improving access to information—thereby reducing information asymmetry—is one important way to fight back against an increasingly consolidated market, thereby improving conditions for workers and consumers—in this case, doctors and patients.

Our Application In order to place as much information as possible into the hands of doctors, we built an application (https://www.takemedicineback.org/emrating) that collects anonymous EM (emergency medicine) employer reviews and processes these results for analysis. The application is entirely free to use—both for leaving a review and reading current reviews. The application is also completely anonymous— it does not track IP addresses and uses no user identification in order to protect potential reviewers. It is not operated for profit.

Reviewers will answer a series of questions specifically tailored to employment in EM; they also have the ability to enter free text. Questions are specific to either attendings or residents. Reviewers are able to search for current employers or residencies and add their own if a new entry is needed. Viewers may view results and filter by employer (or residency) and/or by employer type (or residency employment model). A Net Promoter Score is calculated where enough data is available. Basic sentiment analysis is used to turn free text comments (not visible) into a sentiment score to allow users to get a softer “feel” for an employer. Finally, the information is incorporated into a Google Data Studio report which allows users to view geographical information and sort and filter data based on collected features; for instance, a resident could create a map of residencies operated by democratic groups, hospital employees, or contract management groups—or any combination of the three.

Results Using data from the 199 reviews entered when this data was pulled (2022-06-01), we can begin to see some emerging trends. First, the vast majority of the reviewers so far are attendings—190 versus 9 residents. Of these, a few employment types dominate the reviews.

>> COMMON SENSE JULY/AUGUST 2022

TAKE MEDICINE BACK: A NEW EMERGENCY MEDICINE APPLICATION

Most reviews appear limited to four types of employers: contract management groups, democratic groups, hospital employees, and academic institutions. Even without performing a deep analysis of the various employer types, it is clear, among respondents, contract management groups are viewed very unfavorably compared to over employers. However, this is a very rough summary of the data; the application itself gives a much more granular breakdown of the data.

Summary We would like to encourage all emergency physicians—residents and attendings alike—to review their own employers. The more data we begin to share freely, the greater chance we have of overcoming our own informational disadvantage against an increasingly consolidated market. Not only is it our duty to hold our employers accountable, but creating information for another emergency physician to use may someday change where they work, where they live—maybe even the course of their lives. When making such important decisions, we all deserve access to the best information available.

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COMMON SENSE JULY/AUGUST 2022

References 1. https://www.acep.org/administration/physician-autonomy/acep-statementon-private-equity-and-corporate-investment-in-emergency-medicine/ 2. https://www.aaem.org/resources/statements/position/state-of-em 3. https://www.ftc.gov/policy/studies/submit-comment-merger-enforcementrequest-information 4. https://www.acep.org/federal-advocacy/workforce-issues/impacted-by-emconsolidation-tell-the-federal-government/ 5. https://home.treasury.gov/system/files/136/State-of-Labor-MarketCompetition-2022.pdf

Not only is it our duty to hold our employers accountable, but creating information for another emergency physician to use may someday change where they work, where they live— maybe even the course of their lives.”

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COMMON SENSE JULY/AUGUST 2022

CRITICAL CARE MEDICINE SECTION

Utilization of Arterial Lines in the Emergency Department Alex Yang, MD* and Elias Wan, MD FAAEM†

onitoring and early goal-directed therapy when utilized for the critically ill patient in the emergency department has shown to reduce mortality. The placement of an arterial cannula into the radial, brachial, femoral, or dorsalis pedis artery allows for continuous and accurate monitoring of arterial blood pressure and can provide vital information that can affect the management of critical patients in the emergency department.1

The arterial pressure waveform Once in the artery, the arterial cannula is connected to a calibrated transducer that converts pressure readings to electrical signals that show up on the monitor as a waveform (Figure 1). The waveform consists of two phases—the systolic and diastolic—separated by the dicrotic notch. The systolic phase consists of the systolic upstroke which is initiated by the opening of the aortic valve, the peak systolic pressure, and the systolic decline. The diastolic phase consists of the dicrotic notch and the diastolic runoff. The dicrotic notch, which may represent the closure of the aortic valve, interrupts the arterial runoff phase with a small peak as the forward flow of blood is reflected upon the closed valve. The waveform then terminates with the diastolic runoff where the lowest point is marked by the minimum diastolic pressure.2

emergency department.3 A landmark study by Lehman et al. in the Beth Israel Deaconess Medical Center compared over 27,0000 simultaneously obtained blood pressure measurements in ICU patients and found that despite having similar mean arterial pressures (MAP), non-invasive systolic pressure readings (NIBP) were less sensitive in hypotensive patients compared to invasive measurements (IABP).4 A recent study also demonstrated that patients with hypotensive shock who were either on vasopressin or had elevated lactic acid of 4 millimole per liter (mmol/L) demonstrated clinically relevant MAP difference between IABP and NIBP.13 While MAP is the measurement of choice in the management of hypotensive patients on pressors, there are several populations of patients who require accurate continuous monitoring of systolic and mean arterial pressures, especially diseases with hypertensive emergency, which often can have more than >10mmHg difference between IABP and NIBP. Moreover, up to 30% can have clinically relevant differences that need intervention.14 These populations include patients with strict blood pressure goals such as patients with aortic dissections, spontaneous intracranial hemorrhages, and left ventricular assist devices (LVAD). Current guidelines recommend a strict blood pressure goal of 100-120 mmHg for patients with aortic dissections to limit the shearing forces on the initial aortic flap.5 Similarly, patients with spontaneous intracerebral hemorrhages have a strict goal of lower to 130-150 mmHg to minimize hemorrhage while also maintaining appropriate perfusion.6 Lastly, LVAD patients have a strict MAP goal of 70-80 mmHg to optimize cardiac support which is not measurable by traditional blood pressure cuffs due to the absence of pulsatile arterial flow.7

Pulse monitoring

Figure 1: The Arterial waveform Legend: A) Aortic valve opens B) Systolic upstroke C) Peak systolic pressure D) Systolic decline E) Aortic valve closes F) Dicrotic notch G) Diastolic runoff H) Minimum diastolic pressure

Blood pressure monitoring Accurate monitoring of blood pressure in critically ill patients was the primary indication in 41% of arterial lines placed in one pediatric

COMMON SENSE JULY/AUGUST 2022

Invasive monitoring is also necessary to monitor pulsatility. This is particularly useful in the peri-arrest patient, and patients receiving extracorporeal membrane oxygenation (ECMO). In the peri-arrest patient, pulses are often soft and difficult to palpate and can determine whether the patient has a shockable rhythm.8 Monitoring pulsatility is also useful in ECMO patients to assess cardiac function. These patients tend to have abnormal pulses due to the collision between the pulsatile antegrade flow of blood from the heart and the continuous retrograde flow of blood supplied by ECMO. Using invasive monitoring, left ventricular function can be estimated based on whether the pulse is absent, decreased, or increased. Absent or decreased pulsatility in ECMO patients tend to suggest decreased left ventricular stroke volume and therefore decreased cardiac function, while increased pulsatility suggests myocardial recovery.9 Routinely, in peripheral cannulated Veno-Arterial ECMO setting the preferred site would be right radial as this would reflect the most distal sampling of oxygen delivery.

CRITICAL CARE MEDICINE SECTION

Analysis of waveform morphology

Conclusion

The morphology of the arterial pressure waveform can offer useful information regarding the undifferentiated hypotensive patient. The slope of the waveform represents a change in pressure over time. The slope of the systolic upstroke has been postulated to reflect left ventricular contractility. Steeper systolic slopes suggest stronger cardiac contractility while shallower slopes suggest weaker contractility. This change in the systolic slope has been shown to play a role in the titration of inotropes. In contrast to the slope of the systolic upstroke, the slope of the diastolic runoff has been postulated to reflect systemic vascular resistance (SVR), with a steeper runoff indicating lower SVR. Estimation of SVR may provide crucial information to determine the etiology for shock in the acute setting. Low SVR may suggest distributive shock, which is managed with pressors, while high SVR may suggest hypovolemic, cardiogenic, or obstructive shock which might be better managed with fluids.10

The arterial catheter for hemodynamic monitoring is underutilized in the emergency department for the management of critically ill patients. In addition to providing a continuous and accurate measurement of arterial pressure, the arterial waveform can provide information on pulsatility, contractility, SVR and PPV. This information can guide fluid resuscitation and direct the early use of inotropes and vasopressors in critically ill patients in the emergency department.

Directing fluid resuscitation Dynamic changes in the arterial waveform can also be utilized to direct fluid resuscitation in the emergency department. In intubated patients on mechanical ventilation, measurement of dynamic variables such as pulse-pressure variability (PPV) can predict with a high degree of accuracy those patients who would benefit from fluid resuscitation. The reason is because PPV is a dynamic marker of the patient’s position on the frank-starling curve. With inspiration, the negative intrathoracic pressure increases LV preload and therefore increases the cardiac output, while the opposite occurs with expiration. Therefore, hypotensive patients with increased PPV are likely to respond to volume expansion since they reside along the leftward end of the Frank-Starling curve, while those with decreased PPV reside further right along the curve and are more likely to benefit from inotropic agents and/or vasopressors.11

Potential challenges and limitations Invasive monitoring of blood pressure in the emergency department poses several potential challenges and has its own limitations. One factor to consider is that the morphology of the arterial waveform is site dependent. Central sites such as the femoral artery tend to have a lower systolic pressure and a higher diastolic pressure—and therefore, a narrower pulse pressure—when compared to peripheral sites such as the radial artery.2 This variance should be considered when placement of an arterial line is contraindicated at a site due to infection, trauma, or lack of collateral circulation. Additionally, there is a risk of complications including thrombosis, hemorrhage, ischemia, or infection. Sepsis secondary to radial arterial lines is however very rare (0.3%).12 Lastly, setting up and maintaining an arterial line in the emergency department may be dependent on the department resources. Training nurses to set up the equipment, troubleshoot the device for accuracy, and maintain its patency may be more difficult in resource-poor institutions.

References *Department of Emergency Medicine. Maimonides Medical Center, Brooklyn † Department of Surgery, Critical Care and Emergency Medicine. Maimonides Medical Center, Brooklyn NY 1. Andrews, F. J., and J. P. Nolan. "Critical care in the emergency department: monitoring the critically ill patient." Emergency medicine journal 23.7 (2006): 561-564. 2. Esper, Stephen A., and Michael R. Pinsky. "Arterial waveform analysis." Best Practice & Research Clinical Anaesthesiology 28.4 (2014): 363-380. 3. Saladino, Richard, David Bachman, and Gary Fleisher. "Arterial access in the pediatric emergency department." Annals of emergency medicine 19.4 (1990): 382-385. 4. Li-wei, H. Lehman, et al. "Methods of blood pressure measurement in the ICU." Critical care medicine 41.1 (2013): 34. 5. Ruszala, Michael W et al. “Use of arterial catheters in the management of acute aortic dissection.” Air medical journal vol. 33,6 (2014): 326-30. doi:10.1016/j.amj.2014.06.001 6. Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC 3rd, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS; American Heart Association/ American Stroke Association. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 May 17:101161STR0000000000000407. doi: 10.1161/ STR.0000000000000407. Epub ahead of print. PMID: 35579034. 7. Castagna, Francesco et al. “The Unique Blood Pressures and Pulsatility of LVAD Patients: Current Challenges and Future Opportunities.” Current hypertension reports vol. 19,10 85. 18 Oct. 2017, doi:10.1007/s11906017-0782-6 8. Tibballs, James, and Philip Russell. "Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest." Resuscitation 80.1 (2009): 61-64. 9. Su, Ying, et al. "Hemodynamic monitoring in patients with venoarterial extracorporeal membrane oxygenation." Annals of Translational Medicine 8.12 (2020). 10. Saugel, Bernd, et al. "Cardiac output estimation using pulse wave analysis—physiology, algorithms, and technologies: a narrative review." British journal of anaesthesia 126.1 (2021): 67-76. Continue reading on page 44

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Acute Airway Obstruction Due to COVID-19 Epiglottitis Tiffany Truong, MD

bstract

Patients with COVID-19 have the broadest range of presentations, from asymptomatic to severe respiratory distress and even cardiac arrest. We report a case of epiglottitis associated with SARS-CoV-2 infection with rapid progression to complete airway obstruction requiring cricothyroidotomy in the emergency department. The potential for SARS-CoV-2 to cause epiglottitis highlights the need for added vigilance in assessing the upper airway in patients with COVID-19 symptoms and providing precautions for immediate return for those who develop worsening throat pain, hoarseness, drooling, or stridor.

(0.15 ng/mL). Chest radiograph showed mild basilar atelectasis and contrast-enhanced computed tomography of the neck showed marked hyperemia and edema of the epiglottis and supraglottic structures (Figure 1).

Introduction Coronavirus disease 19 (COVID-19), an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily manifests with fever and respiratory symptoms of cough and shortness of breath. Recent studies have shown that the clinical manifestations of COVID-19 are highly variable and can include gastrointestinal, neurological, and less commonly dermatologic symptoms.1 The severity of disease is also profoundly variable and can range from asymptomatic infection to respiratory failure. Epiglottitis, most commonly due to infectious etiologies, has rarely been described in association with COVID-19.4-12 Here, we report a unique presentation of COVID-19, manifesting initially as acute severe epiglottitis with rapid progression to complete airway obstruction requiring emergent cricothyroidotomy in the emergency department (ED).

Case presentation A 42-year-old female with a history of sickle cell disease and adenoidectomy presented to the ED with a two-day history of sore throat, odynophagia, and loss of voice which had rapidly worsened over the previous two hours. Her temperature was 36.8’C, blood pressure was 147/83, heart rate was 117, respiratory rate was 22, and oxygen saturation was 97% on room air. She was in distress, sitting upright in bed, drooling, and unable to speak. Physical exam was additionally significant for mild uvular edema, mild cervical lymphadenopathy, and submandibular fullness with lungs clear to auscultation. Her BMI was 29.4. Video laryngoscopy under ketamine sedation revealed markedly edematous and friable epiglottis and surrounding supraglottic structures with the vocal cords partially visible. Gentle attempts at intubation using video laryngoscopy followed by an attempt with a bougie resulted in bleeding, worsening edema, and complete airway obstruction. An emergent cricothyroidotomy was performed in the ED and the patient was admitted to the intensive care unit. Laboratory data was significant for leukocytosis (22.9 x 109/L), anemia (6.9 g/dL), and minimally elevated procalcitonin

Figure 1. Computed tomography of the neck with intravenous contrast enhancement, sagittal view, demonstrating complete absence of an airway; presence of endotracheal tube entering the trachea at the level of the cricothyroid cartilage (arrows); with gastric tube (G) and hyoid bone (H) additionally identified.

Nasopharyngeal swab tested positive for SARS-CoV-2 by reverse-transcription polymerase reaction (RT-PCR). Subsequent studies showed no additional pathogens to present and included PCR for Adenovirus, common human Coronaviruses, Influenza A, Influenza B, Parainfluenza 1-4, RSV, Metapneumovirus, Rhinovirus/Enterovirus, Chlamydia pneumoniae, and Mycoplasma pneumoniae. Cultures of the blood and sputum and Bordatella pertussis antibodies were also negative. The patient was treated with dexamethasone, remdesivir, ampicillin-sulbactam, vancomycin, and levofloxacin. On hospital day two, a chest x-ray demonstrated worsening infiltrates and baracitinib was added. On hospital day four, she underwent a red blood cell exchange transfusion for acute chest syndrome. On hospital day seven, repeat video laryngoscopy showed improved yet remaining epiglottitis (Figure 2). An orotracheal tube was advanced over a fiberoptic bronchoscope into the trachea and her cricothyroidotomy tube was removed. She was extubated on hospital day nine and was discharged home on hospital day 17 fully recovered.

Discussion Acute epiglottitis (also known as supraglottitis) was previously most commonly caused by the bacteria Haemophilus influenzae and was historically a pediatric disease prior to the introduction of the Hemophilus influenzae type b vaccine. Acute epiglottitis is now more common in the adult population and differs from that in children in being typically a less severe non-bacteremic infection that has a longer duration of symptoms,

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ACUTE AIRWAY OBSTRUCTION DUE TO COVID-19 EPIGLOTTITIS

References:

Figure 2. Resolving epiglottic edema and arytenoid cartilage on day seven.

with a predominant complaint of sore throat. Additional symptoms may include odynophagia, fever, shortness of breath, hoarseness, muffled voice, drooling and stridor.13-14 Risk factors for epiglottitis in adults include advanced age, male sex, obesity, preexisting epiglottic cyst, and impaired immune system from pre-existing conditions including sickle cell disease.15-16 This case report presents a rare case of severe and rapidly progressive epiglottitis and airway obstruction caused by SARS-CoV-2 infection requiring emergent cricothyroidotomy in the emergency department. Without other pathogens identified, we propose COVID-19 to have been the sole infectious cause of our patient’s severe epiglottitis. To our knowledge this case report represents the 10th reported case of epiglottitis caused by SARS-CoV-2 infection.4-12 Patients’ age in the reports ranged from 29 to 68 years and 70% were men. As with our patient, six of the other nine patients in case reports suffered airway obstruction and all but one required a surgical airway. With our case included, 70% of those with COVID-19 related epiglottitis required airway intervention, a rate alarmingly higher than the 10.9% reported in the pre-COVID, post-H influenza vaccine, era.17 Genomic sequencing was not available at the time of manuscript preparation, but Omicron (B.1.1.529) was suspected to be the SARS-CoV-2 variant affecting our patients based on a high community prevalence of 95%. Symptoms reported by patients suffering from the Omicron variant vary from other variants such as Delta with sore throat being the most common symptom in Omicron patients18 compared to cough in those with Delta.19 The significance of higher rates of throat pain in patients with COVID-19 and the potential impact on rates of epiglottitis is yet to be determined. With epiglottitis becoming a more recognized presentation of COVID-19, we suggest added vigilance in assessing patients with COVID-19-like symptoms who present with severe throat pain in the ED. This case also highlights the need for emergency physicians to encourage COVID-19 patients to be immediately re-evaluated if their sore throat becomes severe or progressed to hoarseness, drooling, or stridor.

1. da Rosa Mesquita, R., Francelino Silva Junior, L. C., Santos Santana, F. M., Farias de Oliveira, T., Campos Alcântara, R., Monteiro Arnozo, G., Rodrigues da Silva Filho, E., Galdino Dos Santos, A. G., Oliveira da Cunha, E. J., Salgueiro de Aquino, S. H., & Freire de Souza, C. D. (2021). Clinical manifestations of COVID-19 in the general population: systematic review. Wiener klinische Wochenschrift, 133(7-8), 377–382. https://doi. org/10.1007/s00508-020-01760-4 2. Guldfred, L. A., Lyhne, D., & Becker, B. C. (2008). Acute epiglottitis: epidemiology, clinical presentation, management and outcome. The Journal of laryngology and otology, 122(8), 818–823. https://doi. org/10.1017/S0022215107000473 3. Frantz, T. D., & Rasgon, B. M. (1993). Acute epiglottitis: changing epidemiologic patterns. Otolaryngology--head and neck surgery : official journal of American Academy of OtolaryngologyHead and Neck Surgery, 109(3 Pt 1), 457–460. https://doi. org/10.1177/019459989310900311 4. Smith, C., Mobarakai, O., Sahra, S., Twito, J., & Mobarakai, N. (2021). Case report: Epiglottitis in the setting of COVID-19. IDCases, 24, e01116. https://doi.org/10.1016/j.idcr.2021.e01116 5. Iwamoto, S., Sato, M. P., Hoshi, Y., Otsuki, N., & Doi, K. (2021). COVID-19 presenting as acute epiglottitis: A case report and literature review. Auris, nasus, larynx, S0385-8146(21)00283-2. Advance online publication. https://doi.org/10.1016/j.anl.2021.12.007 6. Fondaw, A., Arshad, M., Batool, S., Robinson, B., & Patel, T. (2020). COVID-19 infection presenting with acute epiglottitis. Journal of surgical case reports, 2020(9), rjaa280. https://doi.org/10.1093/jscr/rjaa280 7. Renner, A., Lamminmäki, S., Ilmarinen, T., Khawaja, T., & Paajanen, J. (2021). Acute epiglottitis after COVID-19 infection. Clinical case reports, 9(7), e04419. https://doi.org/10.1002/ccr3.4419 8. Gezer, B., Karabagli, H., Sahinoglu, M., & Karagoz, A. S. (2022). Acute epiglottitis is a rare clinical presentation of coronavirus disease 2019: a case report. Infectious diseases (London, England), 54(4), 308–310. https://doi.org/10.1080/23744235.2021.2014560 9. Cordial, P., Le, T., & Neuenschwander, J. (2022). Acute epiglottitis in a COVID-19 positive patient. The American journal of emergency medicine, 51, 427.e1–427.e2. https://doi.org/10.1016/j.ajem.2021.06.077 10. Emberey, J., Velala, S. S., Marshall, B., Hassan, A., Meghjee, S. P., Malik, M. J., & Hussain, M. (2021). Acute Epiglottitis Due to COVID-19 Infection. European journal of case reports in internal medicine, 8(3), 002280. https://doi.org/10.12890/2021_002280 11. Alqaisi S, Almomani A, Alwakeel M, Akbik B. (2021). Epiglottitis case report: a unique presentation of COVID-19 infection. Crit Care Med. https://doi: 10.1097/01.ccm.0000726844.46189.61 12. Sahril, S., Narayanan, M. S., & Mohamad, I. (2021). Managing supraglottitis in the COVID-19 era. Visual journal of emergency medicine, 24, 101092. https://doi.org/10.1016/j.visj.2021.101092 13. McVernon, J., Slack, M. P., & Ramsay, M. E. (2006). Changes in the epidemiology of epiglottitis following introduction of Haemophilus influenzae type b (Hib) conjugate vaccines in England: a comparison of two data sources. Epidemiology and infection, 134(3), 570–572. https:// doi.org/10.1017/S0950268805005546

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14. Orhan, İ., Aydın, S., & Karlıdağ, T. (2015). Infectious and Noninfectious Causes of Epiglottitis in Adults, Review of 24 Patients. Turkish archives of otorhinolaryngology, 53(1), 10–14. https://doi.org/10.5152/tao.2015.718 15. Tsai, Y. T., Huang, E. I., Chang, G. H., Tsai, M. S., Hsu, C. M., Yang, Y. H., Lin, M. H., Liu, C. Y., & Li, H. Y. (2018). Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based casecontrol study. PloS one, 13(6), e0199036. https://doi.org/10.1371/journal. pone.0199036 16. Ochocinski, D., Dalal, M., Black, L. V., Carr, S., Lew, J., Sullivan, K., & Kissoon, N. (2020). Life-Threatening Infectious Complications in Sickle Cell Disease: A Concise Narrative Review. Frontiers in pediatrics, 8, 38. https://doi.org/10.3389/fped.2020.00038 17. Sideris, A., Holmes, T. R., Cumming, B., & Havas, T. (2020). A systematic review and meta-analysis of predictors of airway intervention in adult epiglottitis. The Laryngoscope, 130(2), 465–473. https://doi.org/10.1002/ lary.28076

18. Kim, M. K., Lee, B., Choi, Y. Y., Um, J., Lee, K. S., Sung, H. K., Kim, Y., Park, J. S., Lee, M., Jang, H. C., Bang, J. H., Chung, K. H., & Jeon, J. (2022). Clinical Characteristics of 40 Patients Infected With the SARS-CoV-2 Omicron Variant in Korea. Journal of Korean medical science, 37(3), e31. https://doi.org/10.3346/jkms.2022.37.e31 19. Jang, T. Y., Wang, H. H., Huang, C. F., Dai, C. Y., Huang, J. F., Chuang, W. L., Kuo, C. Y., & Yu, M. L. (2022). Clinical characteristics and treatment outcomes of SARS-CoV-2 delta variant outbreak, Pingtung, Taiwan, June 2021. Journal of the Formosan Medical Association = Taiwan yi zhi, S0929-6646(22)00008-0. Advance online publication. https://doi. org/10.1016/j.jfma.2022.01.008

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11. Marik, Paul E., et al. "Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature." Critical care medicine 37.9 (2009): 2642-2647. 12. O’Horo, John C., et al. "Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis." Critical care medicine 42.6 (2014): 1334-1339. 13. Keville MP, Gelmann D, Hollis G, Beher R, Raffman A, Tanveer S, Jones K, Parker BM, Haase DJ, Tran QK. Arterial or cuff pressure: Clinical predictors among patients in shock in a critical care resuscitation unit. Am J Emerg Med. 2021 Aug;46:109-115. doi: 10.1016/j.ajem.2021.03.012. Epub 2021 Mar 9. PMID: 33744746.

14. Raffman A, Shah U, Barr JF, Hassan S, Azike LU, Tanveer S, Bracklow S, Parker B, Haase DJ, Tran QK. Predictors of clinically relevant differences between noninvasive versus arterial blood pressure. Am J Emerg Med. 2021 May;43:170-174. doi: 10.1016/j.ajem.2020.02.044. Epub 2020 Feb 24. PMID: 32169387. 15. Figure 1: The Arterial waveform 16. Legend: A) Aortic valve opens B) Systolic upstroke C) Peak systolic pressure D) Systolic decline E) Aortic valve closes F) Dicrotic notch G) Diastolic runoff H) Minimum diastolic pressure

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RESIDENT JOURNAL REVIEW

EDACS-ADP for Risk Stratification of Patients Presenting to the Emergency Department with Chest Pain Jordan Parker, MD, Zachary Wynne, MD, Zachary Rogers, MD, Cody Couperus, MD, Jonathan Hurst, MD, and John Harringa, MD Editors: Kami M. Hu, MD FAAEM FACEP and Kelly Maurelus, MD FAAEM FACEP

Question: Can the EDACS-ADP be used to safely determine which patients presenting to the ED with chest pain can be discharged? Introduction Chest pain is the second most common complaint for patients presenting to the emergency department and accounts for over several million visits per year.1 A presenting symptom for both benign and life-threatening etiologies, chest pain or discomfort is the most common presenting symptom for acute coronary syndrome (ACS).2 Various chest pain scoring tools have been developed over the years: ADAPT, HEART, TIMI, Vancouver Chest Pain Rule, and others.3-5 Many of these scoring tools have been combined with serial troponins and EKG to develop accelerated diagnostic pathways (ADP). The widely-used HEART score utilizes history, ECG, age, risk factors and troponin to risk-stratify patients in terms of likelihood of major adverse cardiac events (MACE) in the next 30 days (MACE-30). External validation studies have found that the HEART score classifies 28-46% of patients presenting to the emergency department as low-risk, with a MACE-30 of 0-1.7%, increasing early ED discharges by 21%.4,6 The acceptable miss rate for ED chest pain ADPs has been a topic of ongoing discussion, with a general consensus that the optimal ADP would provide a miss rate of 1% or less while still allowing a large portion of patients to be classified as low-risk and able to be discharged.7 One of the more recent diagnostic tools that has gained popularity is the Emergency Department Assessment of Chest Pain Score accelerated diagnostic protocol (EDACS-ADP). EDACS uses age, risk factors, sex, and clinical features (diaphoresis, radiation, pain with inspiration or palpation) to determine a weighted score. Age is stratified into 10 groups with increasing score as age increases. Patients with either known coronary artery disease (CAD) or ≥3 risk factors (family history of early CAD, dyslipidemia, hypertension, smoking, or diabetes) also receive an additional allocation of points. One unique feature of this scoring system is that it utilizes pain on inspiration or with palpation to reduce the score since these have been shown to be negative predictors for ACS. When utilizing the EDACS-ADP a score of less than 16, negative 0- and 2-hour troponins and an ECG with no evidence of new ischemia classifies a patient as low-risk for MACE-30 and makes them eligible for early discharge from the ED.8 With the prominent and very encouraging results of the derivation and validation study, there have been numerous additional studies adding data to the EDACS-ADP literature.

Than M, Pickering J, Aldous S, et al. Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice. Ann Emerg Med. 2016; 68(1): 93-102. This study was a single-center, pragmatic, randomized clinical trial out of New Zealand that evaluated the effectiveness of the EDACS-ADP compared to the Accelerated Diagnostic protocol to Assess Patients with chest pain symptoms using contemporary Troponins Accelerated Diagnostic Pathway (ADAPT-ADP) in appropriately risk-stratifying patients with symptoms concerning for myocardial infarction. Exclusion criteria included diagnosis of acute ST-elevation myocardial infarction (STEMI) on arrival, proven noncardiac etiology for their symptoms, and existing admission requirement regardless of cardiac work up. Patients were randomized to either the EDACS-ADP or ADAPT-ADP pathways, both of which included an ECG and high-sensitivity cardiac troponin (hs-cTn) measured on arrival and hour 2. Based on the results of their respective clinical pathway, patients were stratified into “low risk” and “not low risk” groups. Low risk patients were discharged home while “not low risk” groups were admitted for further observation. The primary outcome was the percentage able to be discharged from the ED within six hours without MACE by 30 days. A total of 560 patients underwent randomization, 279 in each arm. Data were examined using an intention-to-treat analysis. A total of 66 patients had a MACE within 30 days, none of which occurred in “low-risk” patients. The EDACS-ADP group classified more patients as low risk compared to the ADAPT-ACS group (47.7% versus 32.3%, difference 15.4%, 95%CI 7.0% to 23.8%). This was adjusted to 41.6% vs 30.5% after reclassification of patients that had the presence of predetermined clinical red flags. There was no difference in number of patients successfully discharged within six hours between the two groups (32.3% versus 34.4%, respectively). There are several limitations to this trial. A single-center study out of New Zealand, this trial used a pragmatic design, as treating clinicians were able to change selection criteria and interventions throughout the course of the trial when deemed necessary. These factors may compromise the generalizability of the study results. Additionally, the center had previously incorporated the ADAPT-ADP into clinical practice, so clinicians were already familiar with the pathway. Although the EDACS-ADP identified a significantly larger number of patients as low-risk and safe for early discharge, the clinicians did not discharge them any earlier compared to the ADAPT-ADP arm, possibly due to less clinician comfortability and trust in the new pathway—a potential source of bias.

COMMON SENSE JULY/AUGUST 2022

AAEM/RSA RESIDENT JOURNAL REVIEW

Flaws D, Than M, Scheuermeyer F, et al. External Validation of the Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Pathway (EDACS-ADP). Emergency Medicine Journal. 2016; 33:618-25. The investigators in this study retrospectively applied the EDACS-ADP to a prospective cohort of 763 patients presenting with chest pain to a single hospital in Vancouver, Canada between June 2000 and January 2003 in an attempt at external validation of the decision rule. To be eligible for this study, patients had to have anterior or lateral chest pain. Exclusion criteria were age <25 years old, clear traumatic or noncardiac etiology of chest pain as evidenced by radiographic evaluation, a terminal illness, difficulty with communication, no fixed address or telephone number, and prior enrollment in the study within the last 30 days. The primary outcome was MACE during the initial hospital visit or within 30 days of initial presentation. All data from the initial patient presentation was collected by a research assistant with the treating clinicians blinded to both the collected data and 30-day outcomes. ECG interpretations were made by the emergency department staff and categorized as either “no new ischemia” or “demonstrating evidence of new ischemia.” If no prior ECG was found, any findings were assumed to be new. Any patient with an unstable presentation (chest discomfort thought to be cardiac in etiology in an ongoing or crescendo pattern or concerning abnormal vital signs) was automatically classified as high risk. Immediate and 30-day MACE was retrospectively collected by a separate group of researchers blinded to the initial evaluation. Conditions classified as MACE included both non-ST and ST-elevation myocardial infarctions, emergent cardiac revascularization, cardiovascular death, cardiac arrest, cardiogenic shock, or high atrioventricular block. If there was a case of an unclear MACE, the event was independently reviewed and determined by a cardiologist blinded to the predictions of the EDACS-ADP scoring. In total, 819 patients were determined to be eligible for this study. Of that group, 37 were excluded, and 19 were lost to follow up. None of the 19 patients lost to follow up were found to return to any local emergency department and none were listed in the death registry. Of the remaining 763 individuals included in the study, 79 patients 10.4% experienced a MACE at 30-days, 76 (10%) suffering an acute myocardial infarction (AMI) during their initial admission, and three with events by 30 days. The EDACS-ADP classified 317 patients (41.6%) as “low risk,” none of whom experienced MACE in the following 30 days, ultimately resulting in a sensitivity and negative predictive value (NPV) of 100% for the EDACS-ADP. The authors concluded that the EDACS-ADP demonstrated remarkable sensitivity and NPV for MACE-30, allowing for safe ED discharge of a large number of patients. Limitations of this study include its retrospective nature, as this cohort of patient data was collected prior to the initial EDACS-ADP derivation study. Of note, the troponin assays used during the dates of this study were not the high-sensitivity troponins of today. Interestingly, the majority of MACE occurred during the initial visit with only three occurring in 30-day follow up. This unusually low number of 46

COMMON SENSE JULY/AUGUST 2022

30-day events may raise reproducibility concerns for the incredibly high sensitivity and specificity found in this study. Finally, the inclusion requirement of only anterior or lateral chest pain limits the ability to generalize the excellent NPV of EDACS-ADP found in this study to other potential anginal equivalents such as abdominal pain, dyspnea, near-syncope, or malaise.

Stopyra J, Miller C, Hiestand B, et al. Performance of the EDACS-accelerated Diagnostic Pathway in a Cohort of US Patients with Acute Chest Pain. Critical Pathways in Cardiology. 2015; 14(4):134-8. While the EDACS-ADP had been derived and internally validated in Australasia, external validation in a North American population was needed. Stopyra et al. performed a secondary analysis validation study using the original data from the Heart Pathway randomized controlled trial, evaluating a cohort of 282 ED patients from various communities in North Carolina who were evaluated for low-risk chest pain with electrocardiography and troponins. Each patient’s EDACS score was calculated and used to determine its performance in predicting MACE, the actual rate of which was determined in the original study by phone interview at 30 days. There was an overall MACE-30 of 6% (17/282). Retrospectively-applied EDACS-ACP classified 188 patients (66.7%) as low-risk, with 1.1% MACE-30 (12/188). EDACS-ADP was 88.2% (95% CI 63.6-98.5%) sensitive for MACE with a negative predictive value (NPV) of 98.9% (CI 96.299.9%). The study group concluded that the EDACS-ADP had neither sufficient sensitivity nor NPV (>99% to achieve a MACE miss rate of less than 1%). Limitations of this study include its less rigorous nature as a secondary data analysis and its 3.5% attrition. The United States population for the HEART score derivation was very different from the Australasian population used for EDACS study including rates of revascularization, which may affect patients’ basic risk classification, as EDACS assigns four points for prior percutaneous coronary intervention. Finally, the troponin timing for EDACS is zero and two hours, slightly different from the zero and three hours obtained for the HEART score. Overall, this study showed EDACS-ADP had a sensitivity and NPV lower than those determined in the original validation studies and recommended further analyses prior to implementation in clinical practice.

Shin Y, Ahn S, Kim Y, et al. External validation of the emergency department assessment of chest pain score accelerate diagnostic pathway (EDACS-ADP). American Journal of Emergency Medicine. 2020; 38:2264-70. As another EDACS-ADP validation effort, this study out of Korea retrospectively applied the EDACS-ACP score to ED patients presenting with chest pain or suspected ACS who also underwent coronary computed tomographic angiography (cCTA) and serial troponins. The primary outcome was MACE-30 in patients classified as low risk by EDACS-ADP.

AAEM/RSA RESIDENT JOURNAL REVIEW

The requirement for cCTA was used to specifically identify patients in whom ACS was a diagnostic consideration during their ED visit, as the investigators wished to capture those patients with a broader range of chief complaints (such as epigastric, neck, jaw, or arm pain) beyond “chest pain.” When variables of the score or occurrence of MACE were not documented, they were considered absent. Ultimately, 221 of the 1273 (17.3%) patients suffered a MACE. There was a 1.1% (5/448) MACE-30 in the 35.2% (448/1273) of patients deemed low-risk by EDACS-ADP, yielding a sensitivity of 97.7% (95% CI 94.8-99.3) and a NPV of 98.9% (95% CI 97.4-99.5). While the performance of EDACS-ADP is impressive in this trial, the authors point out that a 1.1% MACE-30 in patients stratified as low-risk is above the acceptable threshold (<0.5-1%) found in existing surveys of ED physicians. They felt the decreased percentage of patients classified as low-risk (35.2%) in this study compared to previous trials (40-60%) may have been due to the requirement for cCTA as this may have excluded a number of low-risk patients able to be included in the study and potentially included more inherently at-risk patients, if the treating providers at that time felt that a cCTA was necessary. This potentially-biased sampling of total low-risk patients may also be a reason for the higher MACE-30 in this trial (17.3% versus 6-15.5%) and lower NPV performance by EDACS-ACP. Of note, applying this study’s data to MACE-30 incidences of 15.5% (highest observed), 10.8% (midpoint), and 6% (lowest observed) equates to NPVs of 99%, 99.3%, and 99.7%, theoretical MACE-30 miss rates of 1.0%, 0.7%, or 0.3%, which would fall within the acceptable miss rate for most ED physicians.

Mark D, Huang J, Chettipally U, et al. Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department. Journal of the American College of Cardiology, 2018; 71(6). 606-616. The EDACS, simplified EDACS, and modified HEART score all use elevated cardiac troponin I (cTnI) as an independent non-low risk factor. The 99th percentile for cTnI, 0.04 ng/mL, is commonly used as the cutoff designation for abnormal, while the limit of quantitation for the cTnI assays is 0.02 ng/mL. The authors hypothesized that using this lower cTnI cutoff would identify a subgroup of patients previously considered low-risk patients who had clinically-meaningful risk of MACE. This study was a retrospective chart review of patients being evaluated in the ED at one of 21 Kaiser Permanente Northern California Health System hospitals between January 2013 and December 2015. Patients were included if they were ≥18 years of age, underwent cTnI testing during the visit, and had chest pain/discomfort as either a chief complaint or ICD-coded diagnosis. For patients with multiple visits in the study period, only the index visit was considered. Exclusion criteria included cTnI elevation, MACE diagnosis in the ED or in the 30 days prior, alternative chest pain diagnosis during visit, or lack of active health plan membership during the allotted time period. If a clinical decision score element was not identified in clinical notes, then it was considered absent. The generated risk scores were classified as either low risk or non-low

risk. Measures of agreement were reported comparing the generated values and those calculated from 450 manually reviewed charts. The primary outcome of MACE at 60 days (MACE-60) was measured based on ICD codes or death events identified within databases either internal or external to the study hospitals. To evaluate the effect of a lower cTnI cutoff, each risk score was reclassified with a cTnI cutoff of <0.02 ng/ mL. Patients were considered correctly reclassified from low-risk to nonlow-risk if the primary outcome of MACE-60 occurred. “Reclassification yield” was defined as the percent of correctly reclassified patients, with a threshold of 1% for clinically significant reclassification yield based on previously described methods.1 Of approximately 3.3 million ED encounters during the study period, 118,822 patients met criteria for inclusion. The mean age was 59 years, with a slight female majority (57.3%). MACE-60 was identified in 1.9%. The percentage of patients classified as low-risk by EDACS, simplified EDACS, and modified HEART score with the standard cTnI cutoff was 66.5%, 52.3%, and 56.2% respectively, and 60.6%, 48.1%, and 51.8% with a cTnI cutoff <0.02 ng/mL. Reclassification yield was above the estimated threshold of clinical significance for all scores (3.4%-3.9%). The NPV for MACE-60 ranged from 99.19% to 99.32% (p = 0.0012) across scores. Unweighted kappa values indicated near perfect agreement between generated and manually calculated binary risk classifications (0.94-0.99). This study had multiple limitations, mostly stemming from the retrospective chart review design. Lack of documentation undoubtedly fails to guarantee absence of the symptom or risk factor, and imputation of unidentified variables as absent yields estimates of NPV that are conservative and may underestimate the tests’ capabilities. All patients with measured cTnI were considered for inclusion, but cTnI measurement alone does not necessarily indicate a clinical suspicion for ACS at the time of care and risks selection bias by introducing more inherently low-risk patients into the cohort; the investigators limited inclusion for analysis to those receiving at least two cTnIs during their ED visit in an attempt to mitigate this issue. It is worth noting that all of the scores performed well using the standard cTnI cutoffs with NPVs >99%—corresponding to an accepted miss rate of <1%—for MACE-60. While the use of a lower cutoff further increased the NPVs for all scores, it did so at the cost of falsely reclassifying thousands of patients who did not go on to experience MACE-60. In practice, this could result in a high number of unnecessary admissions with the accompanying resource utilization, cost, and potential risks of additional downstream testing or unnecessary procedures. Of the scores evaluated, EDACS identified the most patients as low risk (60%) while maintaining a NPV of >99% for MACE-60. This study provides evidence that a lower cTnI cutoff increases the clinically meaningful diagnostic yield of the EDACS, simplified EDACS, and modified HEART score.

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AAEM/RSA RESIDENT JOURNAL REVIEW

Conclusion The original studies performed by Than et al. in the EDACS derivation and validation studies found a NPV of 100% for MACE-30 with roughly 40% to 50% of patients classified as low-risk and eligible for discharge. The decision rule performed similarly in several follow-up studies, with an NPV close to or greater than 99%, and an ability to discharge more patients than other clinical decision rules as low-risk. A 2021 systematic review and meta-analysis found that overall 55% of patients were classified as low-risk and eligible for early discharge, with only 0.54% of the low-risk group having a 30-day MACE, with a pooled sensitivity of 96.1%.9 Further studies prospectively comparing the EDACS-ADP to the HEART pathway and other chest pain diagnostic tools in larger populations will be helpful.

Answer: The evidence provided via existing studies is sufficient to feel confident that the EDACS-ADP can be utilized to identify patients with chest pain who are low risk for subsequent 30-day MACE and can be safely discharged. References: 1. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_ tables-508.pdf. 2. DeVon H, Mirzaei S, Zegre-Hemsey J. Typical and Atypical Symptoms of Acute Coronary Syndrome: Time to Retire the Terms?. Journal of the American Heart Association, 2020; 9(7). doi: 10.1161/JAHA.119.015539

3. Than M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker. Journal of the American College of Cardiology, 2012;59: 2091-2098. 4. Six AJ, Cullen L, Backus BE, et al. The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013; 12: 121-126 5. Scheuermeyer FX, Wong H, Yu E, et al. Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain. CJEM. 2014; 16: 106-119. 6. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: Identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes, 2015; 8(2): 195-203. 7. Than M, Herbert M, Flaws D. What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the emergency department? A clinical survey. Int J Cardiol. 2013;166.752-4. 8. Than M, Flaws D, Sanders S, et al. Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emergency Medicine Australasia, 2014; 26: 34-44 9. Boyle R, Brody R. The Diagnostic Accuracy of the Emergency Department Assessment of Chest Pain (EDACS) Score: A Systematic Review and Meta-analysis. Annals of Emergency Medicine, 2021; 77(4): 433-441.

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COMMON SENSE JULY/AUGUST 2022

AAEM Job Bank Service

Promote Your Open Position

To place an ad in the Job Bank: Equitable positions consistent with the Mission Statement of the American Academy of Emergency Medicine and absent of restrictive covenants, will be published (upon approval). All ads run for a six month period or until canceled and will appear in the AAEM member magazine Common Sense and online. For pricing and more information visit www.aaem.org/membership/benefits/ job-bank.

Positions Available For further information on a particular listing, please use the contact information listed. Section I: Positions in full compliance with AAEM’s job bank advertising criteria, meaning the practice is wholly-owned by its physicians, with no lay shareholders; the practice is equitable and democratic; due process is guaranteed after a probationary period of no more than one year; there are no post-employment restrictive covenants; and board certified emergency physicians are treated equally, whether they achieved ABEM/AOBEM/RCPSC certification via residency training or the practice track. Section II: Positions that cannot be in full compliance with AAEM’s job bank criteria, because they are employee positions with hospitals or medical schools and the practice is not owned by its emergency physicians. Thus there may not be financial transparency or political equity.

Complete a Job Bank registration form, along with the Criteria for Advertising Section, and submit payment. If you are an outside recruiting agent, the Job Bank Criteria for Advertising must be downloaded and completed by a representative from the recruiting hospital/group.

Section III: Positions that cannot be in full compliance with AAEM’s job bank criteria, because they are government or military employee positions. The practice is not owned by its emergency physicians, and there may not be financial transparency or political equity.

Direct all inquiries to: www.aaem.org/membership/benefits/job-bank or email info@aaem.org.

Section IV: Position listings that are independent contractor positions rather than owner-partner or employee positions.

SECTION I: POSITIONS RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK CRITERIA None Available at this time.

SECTION II: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are hospitals, non-profit or medical school employed positions.)

CALIFORNIA

EMERGENCY MEDICINE PHYSICIAN - San Francisco Bay Area; Contra Costa Regional Medical Center in Martinez, CA, is currently looking for a CA-licensed, BC/BE Emergency Medicine Physician for a full-time, benefited position or a 1099 contract position. The schedule is a mix of days and nights (always double coverage). Our Safety-Net hospital offers a 23-bed ER (17 monitored and 6 non-monitored) that sees over 35,000 patients per year. This an exceptional opportunity to join a supportive, close-knit, mission driven group to serve the community by providing quality care in our safety-net system. We offer flexibility in scheduling, a competitive compensation package and a collaborative environment of care. We are conveniently located in the East San Francisco Bay, with easy access to Lake Tahoe, San Francisco, the Napa Valley, the Sierra Foothills and all coastal areas. Fore more information about this unique opportunity, email your CV and cover letter to recruit@cchealth.org. (PA 1886) Email: recruit@cchealth.org Website: https://cchealth.org/medicalcenter/

CALIFORNIA

The Department of Emergency Medicine at Stanford University is seeking a Board-Certified Emergency Medicine physician to join the Department in the role of Medical Director of the Adult Emergency Department. The position includes a fulltime faculty appointment in the Clinician Educator Line. Rank will be determined by the qualifications and experience of the successful candidates. Applicants who meet criteria for the rank of Associate Professor or Professor are preferred. Stanford Emergency Medicine has a strong focus on precision emergency medicine - the use of information and technology to improve the care of individual patients and their communities. Key areas of focus include optimizing Access to Care, capitalizing on Technology and Digital Health Tools, Leveraging Human-Centered Data to Individualize Treatment Decisions, Advancing Population and Global Health, and Redesigning Medical Education. Of particular interest are Adult Medical Director candidates who have experience in health innovation and information technology to advance and optimize the delivery of emergency care. Clinical responsibilities will include patient care in the emergency department at Stanford Hospital, a world-renowned, academic medical center with approximately

90,000 adult Emergency Department visits annually. Our faculty consists of over 90 board-certified emergency physicians with broad scholarly interests and extramural funding. We sponsor 13 fellowship programs, a four-year residency program, required and advanced student clerkships, and several courses available to learners throughout our university. In the Medical Director role, the successful candidate will be an integral part of the Department leadership team as they will navigate a strong desire for emergency care services in our community in a new state of the art hospital and 66 bed Emergency Department with a Clinical Decision Unit. The Medical Director will work with the Vice Chair of Clinical Operations and Quality along with a team of Associate and Assistant Medical Directors and collaborate with hospital leadership to enhance clinical care. The successful candidate will represent Emergency Medicine within our interdisciplinary teams and to healthcare system leadership. Besides providing administrative and management experience in areas of ED operations, we are especially interested in EM physician leaders with specific expertise with: • Emergency Department clinical operations strategies • Optimizing patient flow • Clinical pathway design and implementation • Novel clinical decision support • Informatics and clinical data science • Process and quality improvement science • Digital Health/ Telemedicine • Health System Science education • Expertise in innovative emergency care delivery models Please submit a letter of interest, curriculum vitae, and the names of three references (PA 1878) Email: emedacademicaffairs@stanford.edu

CALIFORNIA

for the critically ill through education, scientific discovery, and patient-centered care. Our clinical practice includes attending in the medical-surgical ICUs and consulting on the care of critically ill patients in the ED during peak hours. We help supervise and mentor trainees in both the EM residency and the multiple CCM fellowship programs at Stanford. Our faculty are engaged in clinical research focused on transitions of care between the ED and ICU, and on early interventions for patients with pneumonia, sepsis, ARDS, and neurologic emergencies. Stanford Emergency Medicine has a strong focus on precision emergency medicine - the use of information and technology to improve the care of individual patients and their communities. Key areas of focus include optimizing Access to Care, capitalizing on Technology and Digital Health Tools, Leveraging Human-Centered Data to Individualize Treatment Decisions, Advancing Population and Global Health, and Redesigning Medical Education. The successful applicant must be board-certified in both emergency medicine and critical care medicine (through the internal medicine, anesthesia, or surgical critical care training pathways). The applicant must enjoy working with trainees at all levels, from medical students to residents to fellows. In addition, the applicant must have a proven track record of interprofessional collaboration with nursing and advanced practice colleagues. Applicants who have 2+ years practicing in an academic ICU environment, are actively engaged in research, or who have held leadership positions in the field of emergency critical care are preferred. Application Process: To apply, please submit a current CV, a 1-2 page candidate statement*, and the names and contact information of three references** to: Jennifer Wilson, MD, Director of Emergency Critical Care Program (jgwilson@ stanford.edu): Department of Emergency Medicine, Stanford University. Please enter “ECC application” in the subject line and cc Caitlin O’Brien (cobrien1@stanford.edu). *In the candidate statement, please include a section on patient care, education, scholarly work, and leadership experience that highlights how you can contribute to the program. ** References should include both EM and CCM providers who have current knowledge of the candidate through direct observation. Additional information may be requested. Deadline for Submission: Open Until Filled. (PA 1879) Email: emedacademicaffairs@stanford.edu

COMMON SENSE JULY/AUGUST 2022

SECTION II: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are hospitals, non-profit or medical school employed positions.)

CALIFORNIA

The Department of Emergency Medicine at Stanford University seeks a candidate who is board certified in both emergency medicine and critical care to join the Emergency Critical Care faculty. The position includes a full-time appointment at Stanford University in the Clinician Educator Line at the rank of Clinical Assistant or Clinical Associate Professor. Rank will be determined by the qualifications and experience of the successful candidate. Clinical responsibilities include patient care in both the medicalsurgical intensive care units and the emergency department of Stanford University Hospital, an academic medical center that is the main teaching hospital for the Stanford University School of Medicine. The Stanford Emergency Critical Care Program is a multidisciplinary initiative focused on improving outcomes for the critically ill through education, scientific discovery, and patient-centered care. Our clinical practice includes attending in the medical-surgical ICUs and consulting on the care of critically ill patients in the ED during peak hours. We help supervise and mentor trainees in both the EM residency and the multiple CCM fellowship programs at Stanford. Our faculty are engaged in clinical research focused on transitions of care between the ED and ICU, and on early interventions for patients with pneumonia, sepsis, ARDS, and neurologic emergencies. Stanford Emergency Medicine has a strong focus on precision emergency medicine - the use of information and technology to improve the care of individual patients and their communities. Key areas of focus include optimizing Access to Care, capitalizing on Technology and Digital Health Tools, Leveraging Human-Centered Data to Individualize Treatment Decisions, Advancing Population and Global Health, and Redesigning Medical Education. The successful applicant must be board-certified in both emergency medicine and critical care medicine (through the internal medicine, anesthesia, or surgical critical care training pathways). The applicant must enjoy working with trainees at all levels, from medical students to residents to fellows. In addition, the applicant must have a proven track record of interprofessional collaboration with nursing and advanced practice colleagues. Applicants who have 2+ years practicing in an academic ICU environment, are actively engaged in research, or who have held leadership positions in the field of emergency critical care are preferred. Application Process: To apply, please submit a current CV, a 1-2 page candidate statement*, and the names and contact information of three references** to: Jennifer Wilson, MD, Director of Emergency Critical Care Program (jgwilson@ stanford.edu): Department of Emergency Medicine, Stanford University. Please enter “ECC application” in the subject line and cc Caitlin O’Brien (cobrien1@stanford.edu). *In the candidate statement, please include a section on patient care, education, scholarly work, and leadership experience that highlights how you can contribute to the program. ** References should include both EM and CCM providers who have current knowledge of the candidate through direct observation. Additional information may be requested. Deadline for Submission: Open Until Filled. (PA 1880) Email: emedacademicaffairs@stanford.edu

CALIFORNIA

The Department of Emergency Medicine at Stanford University seeks board-certified academic faculty in Emergency Medicine to join at the Assistant Professor or Associate Professor level in the University Medical Line. The successful applicant must have an MD/DO with the requisite research training or extensive experience in research and must demonstrate a track record or the potential to obtain a track record of independently funded investigator-initiated research. The major criteria for appointment for faculty in the University Medical Line shall be excellence in the overall mix of clinical care, clinical teaching, scholarly activity that advances clinical medicine, and institutional service appropriate to the programmatic need the individual is expected to fulfill. Faculty rank will be determined by the qualifications and experience of the successful candidate. All areas of research relevant to Emergency Medicine are of interest, including but not limited to basic, translational, clinical research, technology development, big data science, epidemiology/statistics, informatics, health services, and health policy. Of particular interest are applicants whose research focus aligns with the departmental aim to advance the specialty through Precision Emergency Medicine - the use of information and technology to improve the care of individual patients and their communities. Key areas of focus include optimizing Access to Care, capitalizing on Technology and Digital Health Tools, Leveraging Human-Centered Data to Individualize Treatment Decisions, Advancing Population and Global Health, and Redesigning

COMMON SENSE JULY/AUGUST 2022

Medical Education. In addition to providing excellent care and teaching house staff and medical students, the new clinician scientist will focus on creating new knowledge, securing research funding, producing scholarly output, and engaging in the educational component of our program as it relates to research. He or she will also be expected to be a resource and mentor for more junior faculty, residents, and medical students. Clinical responsibilities will include patient care in the emergency department at Stanford Hospital, a world-renowned, academic medical center. Our faculty consists of over 90 board-certified emergency physicians with broad scholarly interests and extramural funding. We sponsor 13 fellowship programs, a four-year residency program, required and advanced student clerkships, and several courses available to learners throughout our university. Stanford is an equal employment opportunity and affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law. Stanford welcomes applications from all who would bring additional dimensions to the University’s research, teaching and clinical missions. The Department of Emergency Medicine, School of Medicine, and Stanford University value faculty who are committed to advancing diversity, equity, and inclusion. Candidates may optionally include as part of their research or teaching statement a brief discussion of how their work will further these ideals. Please submit a letter of interest, curriculum vitae, and the names of three references (PA 1881) Email: emedacademicaffairs@stanford.edu

CALIFORNIA

The Department of Emergency Medicine at Stanford University is seeking a Board-Certified Emergency Medicine physician to join the department in the role of Section Chief of Ultrasound. The position includes a full-time faculty appointment in the Clinician Educator Line. Rank will be determined by the qualifications and experience of the successful candidate. Applicants who meet criteria for the rank of Associate Professor or Professor are preferred. Stanford Emergency Medicine is dedicated to transforming healthcare for all by leading in the advancement of emergency medicine through innovation and scientific discovery. We have a strong focus on precision emergency medicine - the use of information and technology to improve the care of individual patients and their communities. Key areas of focus include optimizing access to care; capitalizing on technology and digital health tools; leveraging human-centered data to individualize treatment decisions; advancing population and global health; and redesigning medical education. Of particular interest are candidates who have experience in health innovation and information technology to advance and optimize the delivery of emergency care. The Section Chief of Ultrasound will serve as our departmental leader in ultrasound, supporting the operational, educational, and administrative missions, as well as interdepartmental point-of-care ultrasound (POCUS) projects, and research and scholarship in ultrasound to facilitate the ongoing academic productivity and success of our ultrasound section. In addition, this position will serve as Co-Director of the Stanford Hospital and Clinics POCUS enterprise initiative. Clinical responsibilities will include patient care in the emergency department at Stanford Hospital, a world-renowned, academic medical center with approximately 90,000 adult Emergency Department visits annually. Our faculty consists of over 100 board-certified emergency physicians with broad scholarly interests and extramural funding. We sponsor 13 fellowship programs, a four-year residency program, required and advanced student clerkships, and several courses available to learners throughout our university. Stanford is an equal employment opportunity and affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law. Stanford welcomes applications from all who would bring additional dimensions to the University’s research, teaching and clinical missions. The Department of Emergency Medicine, School of Medicine and Stanford University value faculty who are committed to advancing diversity, equity, and inclusion. Candidates may optionally include as part of their application a statement or a brief discussion of how their work will further these ideals. Please submit a letter of interest and curriculum vitae to: Jody Vogel, MD, MSc Vice Chair for Academic Affairs Email: emedacademicaffairs@stanford.edu (PA 1900) Website: http://www.emed.stanford.edu

INDIANA

The Indiana University School of Medicine (IUSM) Department of Emergency Medicine is seeking applications for Division Chief of Simulation. We are a statewide network of emergency departments striving to set new standards of training for medical students, residents, fellows, and pre-hospital providers while providing quality care for a diverse patient population. The vision of the department is to improve the health and well-being of every life entrusted to us. The Simulation Division within the Department of Emergency Medicine is in the second year of an ambitious five-year plan with the goal of becoming one of the top five simulation divisions in the United States. The work of the division is completed under the direction of the chief and five additional faculty members. Further, the division has a fellowship program. Fellows can develop expertise in the educational, administrative, and research aspects of simulation and receive the leadership training necessary to direct their own simulation program. Simulation training takes place at the 30,000 square foot Indiana University Health (IUH) Simulation Center at Fairbanks Hall, which is led by a member of the division. The fellowship program ranges from one to two years and accepts up to three fellows per year. While the division’s primary focus is emergency medicine, the team provides consultation and simulation tools for other specialties, such as surgery, pediatrics, anesthesia, and obstetrics, to train health care providers how to respond in high-intensity crisis situations. For the long term, however, the division expects to broaden its scope to any specialty or interprofessional group with an educational goal that is best served by immersive training. As the nation’s largest medical school, IUSM is committed to being an institution that not only reflects the diversity of the learners we teach and the patient populations we serve, but also pursues the values of diversity, equity and inclusion that inform academic excellence. We desire candidates who enhance our representational diversity, as well as those whose work contributes to equitable and inclusive learning and working environments for our students, staff, and faculty. IUSM strives to take an anti-racist stance, regularly evaluating and updating its policies, procedures, and practices to confer equitable opportunities for contribution and advancement for all members of our community. We invite individuals who will join us in our mission to advance racial equity to transform health and wellbeing for all throughout the state of Indiana. IUSM provides concierge and dual career services to assist new faculty with their personal or family’s relocation needs. Requirements Doctorate or Terminal Degree Required; Boardcertified MD or DO We are seeking someone who has at least five years of experience post-GME training, is well-established in medical simulation, and would qualify to be hired at the rank of associate or full professor. Individuals can apply to fill the division chief and fellowship director role or conduct a search for a fellowship director upon hire. https://indiana.peopleadmin.com/ postings/12748 (PA 1899) Email: kimgibso@iu.edu Website: https://medicine.iu.edu/emergency-medicine

NORTH CAROLINA

Due to our continued expansion and growth Wake Forest Emergency Providers seeks an emerging or established team leader to serve as Medical Director or Assistant Director. Our teams of exceptional patient-centered emergency physicians will be providing services in the Greater Charlotte region. We embrace diversity, equity, inclusion, and belonging principles into the foundation of our group and are intentionally looking for talented physicians who wish to join an inclusive team. We offer a unique employment model inclusive of comprehensive benefits, local influence on practice decisions, and a strong provider voice in care delivery creating a highly collaborative, collegial culture. (PA 1882) Email: michael.ginsberg@wakehealth.edu Website: http://www.wakehealth.edu

SECTION II: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA, CONTINUED (Below are hospitals, non-profit or medical school employed positions.)

NORTH CAROLINA

FACULTY LEADER, EMERGENCY MEDICINE DIVERSITY, EQUITY & INCLUSION Wake Forest School of Medicine’s Department of Emergency Medicine has a rare opportunity to join our academic faculty team in a leadership position with a scholarly focus on Emergency Medicine Diversity, Equity & Inclusion. This position will be an integral part of our ongoing EM departmental DEI initiatives and the successful candidate will take over leadership of our active DEI committee. There are additional opportunities to participate and lead new and ongoing initiatives throughout the medical school and health system impacting patient care across our learning healthcare system with Atrium Health. (PA 1889) Email: michael.ginsberg@wakehealth.edu

NORTH CAROLINA

Wake Forest School of Medicine has a rare opportunity to join our academic faculty team as a Clinical Assistant Professor dedicated to clinical teaching and patient care activities during overnight hours. This permanent nocturnist position will be responsible for excellent patient care, bedside teaching of residents and medical students, and participation in the teaching academic mission. A full clinical faculty appointment at the School of Medicine will align this position with opportunities for academic advancement. Our ED features a Level 1 trauma center, an accredited chest pain center, stroke center, a burn center and full subspecialty backup. (PA 1897) Email: michael.ginsberg@wakehealth.edu Website: https://school.wakehealth.edu/

NORTH CAROLINA

Duke Pediatrics is seeking an innovative physician leader to serve as Division Chief for Pediatric Emergency Medicine. Proven leadership and excellence in clinical care, education, scholarship, and administrative experience are required. Duke Children’s is ranked among the nation’s finest for pediatric care and the department is #1 in NIH funding for pediatric clinical science departments. The Greater Triangle area of Raleigh, Durham, Chapel Hill is culturally diverse, economically resilient and nationally recognized as a great place to live and work. Interested individuals should submit a statement of academic interest and curriculum vitae prior to May 27, 2022 to: http://www. practicematch.com/physicians/job-details.cfm/699090 (PA 1904) Email: debbie.hackney@duke.edu Website: https://pdc.dukehealth.org/

SECTION III: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are military/government employed positions.) None Available at this time.

SECTION IV: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are independent contractor positions.)

CALIFORNIA

The Monterey Bay Emergency Physicians are looking a stellar FP physician. We are a great, independent, single-hospital group looking for an intelligent, efficient, and excited provider to join us as we look to increase coverage in our Clinical Decision Unit. This is an exciting opportunity for a motivated provider to join a vibrant team that provides outstanding care. Our department is dedicated to excellence in patient care, supportive teamwork and professional growth. The CDU provider will be responsible for evaluating and treating patients who present to the ER and require short-term observation and care. This position is for scheduled shifts only, there is no on-call requirement. The provider will initiate and interpret diagnostic evaluation(s) as appropriate. Our hospital is truly a gem, perched above the Pacific Ocean. We have 250 beds, a full call panel, and a great nursing staff. Salary is competitive, shifts are equitable and scheduling is fair. (PA 1885) Email: kavitha.weaver@chomp.org

CALIFORNIA

Pacific Redwood Medical Group of Mendocino County, California is seeking a BC/BE Emergency Medicine Physician to join our stable, independent, democratic group. We currently staff all three emergency departments in our county and are looking for a new physician to join our team. We offer flexibility in scheduling, a competitive compensation package including health insurance, 401k contribution and a business expense reimbursement plan, in a collaborative environment of care. Mendocino County includes endless opportunities for hiking, biking, kayaking, camping, adventuring and more in our redwood forests, beaches and mountains. Come join us in Northern California! (PA 1894) Email: hr@prmg365.com

CALIFORNIA

Come live the SLO life! Central Coast Emergency Physicians is seeking to hire a full-time BC/BE emergency physician. We are a fully independent ER physician owned group staffing two local community emergency rooms in Paso Robles and San Luis Obispo. We have a healthy call panel, easy access to imaging and ancillary resources, and staff to the mindset of practicing in this speciality is a marathon and not a sprint. We do not staff any mid-levels. A full time position involves at least 100 hours/month and includes full benefits, paid CME and vacation, malpractice and disability coverage, as well as living in one of the state’s most beautiful places! (PA 1896) Email: bcknox@gmail.com Website: https://ccepslo.com/

OREGON

Emergency Specialists of Oregon (ESO) is recruiting both Full Time and Part Time Emergency Medicine (BC) Physicians to join our independent, democratic group. ESO practices at Providence Newberg Medical Center, a community hospital located in Newberg, Oregon (~25 miles SW of Portland). We have approximately 24,000 annual visits, excellent hospitalist and specialist support, and are part of a regional health system, allowing for expedited transfers and consults. We have 32 hours of Physician coverage, augmented with additional hours of APP coverage. ESO offers competitive pay and independent contractor status. Newberg is nestled in Oregon wine country, with easy access to a wide range of outdoor and cultural pursuits. Commuting to the hospital from Portland and its surrounding suburbs is common. Contact: Tom Johnson, MD; esomedicaldirector@gmail.com. Please include CV and interest statement. (PA 1888) Email: esomedicaldirector@gmail.com

WASHINGTON

North Sound Emergency Medicine, a well-established, large democratic provider group in Everett, Washington, is looking for an EM residency-trained BC/BE physician. This is a tremendous opportunity to join an exceptional team of clinicians who are dedicated to excellence, providing evidence-based patient care in a supportive environment, while offering opportunities for professional growth, education, and development. Our practice site has a very stable contract and sees more than 80,000 patients annually in a state-of-the-art 79-bed ED: the largest and busiest ED in the state of Washington and one of the busiest in the nation. One of the most desirable places to live, the greater Seattle area offers an abundance of recreational activities from scuba diving and skiing to backpacking the Pacific Crest Trail, professional sports teams, and a myriad of cultural amenities, ranging from opera and ballet to museums and theater. (PA 1903) Email: cmgilliland@northsoundem.com Website: http://www.northsoundem.com

COMMON SENSE JULY/AUGUST 2022

COMMONSENSE

PRSRT STD U.S. POSTAGE

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

PAID MILWAUKEE, WI PERMIT NO. 0188

MEMC22 Malta 21-24 September 2022 St. Julian’s

XIth Mediterranean Emergency Medicine Congress

#MEMC22