March/April Common Sense

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 29, ISSUE 2 MARCH/APRIL 2022

Lessons Learned in a Term of Presidency of AAEM

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From the Editor’s Desk:

You Are the Plaintiff

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Legislators in the News:

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An Interview with Congressman Dr. Michael Burgess (R-TX)

AAEM Board of Directors Election:

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Election: Candidate Platform Statements

Young Physicians Section:

Two Years Later

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AAEM/RSA President’s Message:

An Interview with Dr. Dinesh Palipana

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Table of Contents TM

Officers President Lisa A. Moreno, MD MS MSCR FIFEM President-Elect Jonathan S. Jones, MD Secretary-Treasurer Robert Frolichstein, MD Immediate Past President David A. Farcy, MD FCCM Past Presidents Council Representative William T. Durkin Jr., MD MBA Board of Directors Phillip Dixon, MD MPH Al O. Giwa, LLB MD MBA MBE L.E. Gomez, MD MBA Robert P. Lam, MD Bruce Lo, MD MBA RDMS Terrence Mulligan, DO MPH Vicki Norton, MD Carol Pak-Teng, MD YPS Director Fred E. Kency, JR., MD AAEM/RSA President Lauren Lamparter, MD Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD Editor, Common Sense Ex-Officio Board Member Andy Mayer, MD Executive Director Missy Zagroba, CAE Executive Director Emeritus Kay Whalen, MBA CAE AAEM/RSA Executive Director Madeleine Hanan, MSM Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Kasha Bornstein, MD MPH MSC Pharm EMT-P, 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.

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COMMONSENSE

Regular Features

President’s Message: Lessons Learned in a Term of Presidency of AAEM................................................ 3 From the Editor’s Desk: You Are the Plaintiff............................................................................................... 8 AAEM News: Letter to the Editor................................................................................................................. 11 Legislators in the News: An Interview with Congressman Dr. Michael Burgess (R-TX)............................. 12 Young Physicians Section: Two Years Later............................................................................................. 55 AAEM/RSA President’s Message: An Interview with Dr. Dinesh Palipana................................................. 62 Medical Student Council Chair’s Message: Lessons from a Month in Addiction Medicine for an EM-Mindset.................................................................................................................................. 65 Medical Student Council Chair’s Message: New Year Resolutions from a Rising Intern.......................... 66 Financial Wellness: A 5-Part Series on Managing Money Wisely: Make Your Money Grow: Best Practices in Investing...................................................................................................................... 31 Heart of a Doctor: Six Hour Sacrifice.......................................................................................................... 33 Foundation Contributors............................................................................................................................ 16 PAC Contributors......................................................................................................................................... 16 LEAD-EM Contributors............................................................................................................................... 17 Upcoming Conferences.............................................................................................................................. 17 Board of Directors Meeting Summary: February...................................................................................... 80 Job Bank...................................................................................................................................................... 82

Special Features

AAEM Board of Directors Election: Candidate Platform Statements........................................................ 18 AAEM22: Preview of the 28th Annual Scientific Assembly........................................................................... 36

Featured Articles

Academic Affairs: Spring.............................................................................................................................41 International Committee: International Health Pearl – Taliban Afghanistan Crisis......................................43 JEDI Section: Why AAEM’s Mission to Reflect Justice, Equity, Diversity, and Inclusion is More Than Just Words........................................................................................................................45 Opinion: How to Stand Up for Science and Fight Burnout...........................................................................48 Emergency Medical Services Section: AAEM Emergency Medical Services Section Letter to Membership........................................................................................................................................51 Critical Care Medicine Section: Critical Care Education: How Early is Too Early?.....................................53 Rural Medicine Interest Group: Mission Statement....................................................................................57 Opinion: Mask Mandates: The Evidence and the Law.................................................................................58 Women Physicians Day: ABEM Statement Recognizing Women in EM Leadership..................................60 Opinion: Why I No Longer Teach ATLS........................................................................................................61 Emergency Ultrasound Section: Does Ultrasound Guidance During Insertion of Central Venous Catheters Increase Risk of Infection?: A Review of Recommendations and What You Can Do to Reduce this Risk....................................................................................................67 Operations Management Committee: Observation Medicine – It’s Common Sense.................................70 AAEM/RSA Resident Journal Review: Efficacy of the HINTS Exam by Emergency Medicine Physicians...............................................................................................................................................74 ABEM News: ABEM Recognizes Physicians Achieving 30 Years of Board Certification..............................79

Mission Statement

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

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

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

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

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

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

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

Membership Information

Fellow and Full Voting Member (FAAEM): $525* (Must be ABEM or AOBEM certified, or have recertified for 25 years or more in EM or Pediatric EM) Associate: $150 (Limited to graduates of an ACGME or AOA approved emergency medicine program within their first year out of residency) or $250 (Limited to graduates of an ACGME or AOA approved emergency medicine program more than one year out of residency) Fellow-in-Training Member: $75 (Must be graduates of an ACGME or AOA approved emergency medicine program and be enrolled in a fellowship) Emeritus Member: $250 (Please visit www.aaem.org for special eligibility criteria) International Member: $150 (Non-voting status) Resident Member: $60 (voting in AAEM/RSA elections only) Transitional Member: $60 (voting in AAEM/RSA elections only) International Resident Member: $30 (voting in AAEM/RSA elections only) Student Member: $40 (voting in AAEM/RSA elections only) International Student Member: $30 (voting in AAEM/RSA elections only) Pay dues online at www.aaem.org or send check or money order to: AAEM-0622-070 AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

Lessons Learned in a Term of Presidency of AAEM

AAEM PRESIDENT’S MESSAGE

Lisa Moreno, MD MS MSCR FAAEM FIFEM

W

riting my last President’s Message is a bittersweet experience.

As I approach the end of my term, I realize that being the President of AAEM was in many ways exactly what I expected and, in many ways, not at all what I expected. I expected to work long and hard. I did not expect to contend with the novel Coronavirus and the difficulties and contentions that it brought with it. I expected to learn and grow, but I did not expect to learn and grow to the extent that I did. As a high school senior, we were asked to write an essay on the five people we would want to invite to dinner if we could spend the evening with anyone, living or dead. I chose Mohandas Gandhi, Jesus Christ, Eva Peron, Mohammed Ali, and Albert Einstein. My style of leadership, inquiry, and decision making has at various times been reflective of all the five people I was fascinated with as a high school senior and remain fascinated by today. I have striven to meld the wisdom of Tim Grover’s “Relentless” (and yes, I am a cleaner) with that of Jim Collins’ “Good to Great,” and Fisher and Ury’s “Getting to Yes.” But like all people privileged with the task of leadership, I have learned my own lessons, discovered what works for me. When you become the president of an organization, you are suddenly besieged with requests to tell others “How did you get there?” and “what makes a good leader?” The truth is some of it is the same for every good leader, but some of it works for some and not others. I will share what I have learned.

The door can only be opened by someone who is already in the room. The goals and aspirations of both academic and community physicians focus on achieving roles and titles that are held almost exclusively by white males.

Time and time again, networking and mentorship have been shown to be intrinsically valuable to both the achievement of these goals and the timing of their achievement. You can spend decades on the outside, pounding on and shouting through the door, or you can find

(or be blessed with) an ally who understands his privilege, chooses to use it for the development of others, and simply turns the knob, opens the door, escorts you in, and gently guides you through the maze until you achieve your own leadership. In my career, that person has unequivocally been Dr. Peter DeBlieux.

At AAEM, those people have been Drs. Mark Reiter, Kevin Rodgers, and David Farcy. In my JEDI work, that person has been Dr. Marcus Martin. If you are standing in the space of privilege, be that person. If you are standing outside the door, find that person. As people like Peter and Mark and Kevin and David and Marcus continue to do what they do, people who look like me are now in the room and at the table. Our job now is to be that person.

None of our jobs are done until every person in the universe finds themselves in an environment that allows them to reach their full potential and give all they have to the world. And if you are on the outside of the door, never forget this: it is not a favor we give you by letting you

the first time many of the facts that many of us have known all our lives, and one of these facts is that the composition of the physician team serving a community should look like that community. This makes for better outcomes for the community. Fortune 500 companies have quickly jumped on this train, recognizing the power of the BIPOC market as the population of Black and Brown people in the US steadily increases and as appreciation for the tremendous value of multi-culturalism becomes pretty much the norm. It is a source of great pride to me that my election to the Board seven years ago brought with it a trend of integration and multi-culturalism that has resulted in our current Board which is genuinely representative of the physicians practicing emergency medicine today, the trainees pursuing our specialty, and the patients who we serve. As part of my succession plan, I am working hard to ensure that the entire Board understands and appreciates the value that diversity brings to decision making and wise leadership. Studies show that

We must create the workplace environment where every emergency physician is empowered to give the best care to every patient every time. And we will.” in, it is an obligation we have to facilitate your gift and your obligation to the world, without which the world will be less.

The leadership should look like the membership. In 2003, with the publication of “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” the US Institute of Medicine officially acknowledged for

the younger generation of physicians and residents consider diversity the acceptable norm.

As government, public entities, private corporations, and educational institutions adopt policies that speak to their clear understanding of the value of diversity, and as governing bodies and judicial systems acknowledge that equity

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I have learned that the talent within AAEM is astronomical—the willingness to work for the good of our specialty is unparalleled.”

is the only way forward for a heterogeneous nation and a global society, organizations who maintain their status quo will quickly become irrelevant and be left behind.

It is essential to plan for succession and to prepare the next generation. AAEM has traditionally used the invitation-only Leadership Academy as a way of identifying and training the Academy’s future leaders. During my term, we have expanded Leadership Academy to include the AAEM/RSA Board as well as individuals identified by the Board and by Committee/Section/Chapter/IG Chairs. We have gone from an average of 25 members per Leadership Academy to 75. Akin to the concept of citizen soldiers, AAEM is fostering the concept of member leaders. If individuals seek to serve and are identified by their Chairs and Board as having leadership potential, we train you! Our training process has increased to a longitudinal program encompassing a year of touch back sessions addressing those issues identified by Academy trainees as essential for their growth and development as well as a paired mentorship for those desiring this. We have successfully developed a cohort of Board candidates and Committee/Section/Chapter/ IG Co- and Vice Chairs from our Leadership Academy attendees. Dr. Farcy put a process into place limiting Chair terms and setting up a Vice Chair system whereby Vice Chairs are mentored towards Chairship. In doing so, he created more opportunities for leadership, especially for our early and mid-career members.

Sections, such as Critical Care and Women, have developed formal mentorship programs, and others such as JEDI have deliberate and

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strategic informal mentorship programs. AAEM/ RSA and YPS have always held Board seats, always for the purpose of apprenticing leaders, and these programs have resulted in the robust linear growth of members towards Chairships and service on the Board. I am delighted to see the increase in the number of individuals running for the Board, and they represent individuals who were part of Leadership Academy or a mentorship program of AAEM. Just as I believe the Universe suffers if every person does not develop their full potential, so I believe that the Academy suffers if every member does not develop their full potential within AAEM. One of the perks of professional success is being able to choose who to mentor. If you are a leader, seek out motivated, ambitious people who are willing to work hard and coach them for leadership. If you are early in your career and you are motivated, ambitious, and willing to work hard, identify yourself to us. As Congresswoman Shirley Chisholm used to say, “If no one gives you a seat at the table, bring a folding chair.”

We need a succession plan to ensure that the Academy continues to thrive!

Put your money where your mouth is.

Actions speak louder than words. AAEM has long been the proponent of workplace fairness, physician leadership of our practices and our health care teams, due process, the absence of restrictive covenants, and the right of every patient with an emergency condition to be treated by a board certified emergency physician.

But the fact is that we have been both fiscally and practically conservative. We have tended to be parsimonious with our spending and overly concerned with not offending anyone.

Taking risks can be scary, but if you don’t stand for something, you stand for nothing, and if you don’t ask, the answer will always be no. Over the past few years, we have taken increased well thought out risks. We have put out position statements that are real statements taking real positions. And we have caught flack. But as we grow, we are realizing that it is more important to be on the side of right than to be popular.

Being the biggest does not make you the best.

Accordingly, we have stood up for the rights of doctors to speak out against policies that endanger patients. We have stood up for science when others have tried to make vaccines and face masks a statement of political affiliation or an issue of personal rights. We have stood up for the rights of patients to know who is treating them and what that professional’s training, education, and licensure are. We have stood up for patients’ right to be cared for by a physician-led team. We have stood up for the human right to be free from the abuses of power and authority.

Most recently, and probably most impactfully, we have risked all to stand up for the right of physicians to be the sole practitioners of medicine and for the right of patients to be treated not according to the fiscally motivated protocols of corporate medical groups (CMGs), but according to evidence based protocols developed by residency trained, board certified physicians.

AAEM is suing Envision for the illegal practice of medicine in the State of California. (For full details of our lawsuit see reference link.1 Note that the plaintiff of record in the case is AAEMPG, but that AAEM is paying all of the costs related to the lawsuit.) On behalf of AAEM, I have approached ACEP, CORD, SAEM, and the California Medical Association (CMA) and have asked them to: • File an amicus brief on our behalf • Make a public statement that they are opposed to the corporate practice of medicine and believe that a lay corporation practicing medicine is illegal and unsafe for patients • Give us money to support this lawsuit (the lawyers are charging us $2 million and they may charge more if the case goes to appeal) • That they put a link on their website allowing

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their members to donate to the AAEM Foundation to support the lawsuit.

I am awaiting responses from ACEP, SAEM, and CORD. Our attorneys believe that ACEP may file an amicus brief on our behalf and this would be a wonderful accomplishment and an outstanding example of how it is possible to collaborate on areas of mutual interest with mutual respect, while still disagreeing on other issues. CMA has met with our attorneys and expressed the intent to file an amicus brief.

By the time you read this, I will have set up meetings with other organizations impacted by the corporate practice of medicine, such as the AMA, anesthesia, critical care, trauma surgery, radiology, radiation oncology, and others. I am making them all aware that their responses to our asks will be made public. AAEM is putting our money where our mouth is and we are urging others to do so as well. President Abraham Lincoln said you can’t please all of the people all of the time. My dad used to say that if everyone likes you, you’ve never stood for anything worth standing for. So, AAEM is standing for integrity. We are doing not the popular thing, but the right thing. This is what integrity looks like. We cannot be bought. We cannot be silenced. We say we are the champion of the emergency physician. We must create the workplace environment where every emergency physician is empowered to give the best care to every patient every time. And we will.

Break down silos; provide resources.

Every six months during my presidency, I have met with the leadership of every Committee, Section, Interest Group, and Chapter. I have challenged them each to have three projects that they work on for each six month period.

I have learned that the talent within AAEM is astronomical—the willingness to work for the good of our specialty is unparalleled. The creativity is boundless. But I have also learned that often great minds do think alike, and more than one committee may work on the same thing. Through my meetings with all of them, I have been able to put them together to work on projects in which there are shared interests.

Often, a committee wants to do something, but doesn’t know how. Another committee may

have the expertise. Wellness wants to make a policy statement. CPC knows how, even though they lack expertise on wellness. Critical Care and Palliative Care have a shared interest in teaching community docs how to have end of life conversations with patients dying of COVID in the ED and their families. JEDI wanted to become a Section and Women in EM knew how to do this. A State Chapter wants to lobby regarding a particular issue and Government Affairs has experience with this. We are an organization of volunteers, and it is impossible for one member to know what each group is doing, but each group has a board liaison who knows what the group is doing, and the president has the responsibility to be aware of what all the groups are doing. I was empowered to put people together in a way that facilitates them doing the best work that they can do. I learned that while I don’t need to be an expert in every area of EM or about everything that AAEM is doing, a good leader knows what her people are doing and fosters the kind of collaboration that allows them to be the best that they can be and to accomplish all their goals. Getting to yes is where we need to be. I told many of the groups that for me “no” is never the answer.

Rather, the answer is either “yes” or “how can we make this happen?” When you lead an organization like AAEM, you quickly realize that the Committees, Sections, Chapters, and IGs know what they need, understand what is going on in their locales and/or their content

areas, and they know what they want to do.

Collaboratively, we can find the resources that they need to make that happen.

Communication is key. This maxim holds true in every area of leadership. Good communication helps break down silos, create awareness of the work that groups are doing and the resources that the organization has, but it also creates an atmosphere of sharing of ideas that allows us to grow as individuals and as an organization. In our personal lives, we have friends who like the things we like, who share our opinions and our lifestyles. In an organization, it is important to hear all voices. We need to hear from those who disagree with us. Those who agree with us likely have reviewed the same literature as we have and have come to similar conclusions through a similar deductive process. Those who disagree with us have something to teach us. They have likely looked at other literature from other sources, listened to other speakers, had other lived experiences, and can broaden the way we evaluate an issue, often modifying the conclusions we come to and the actions we take. Being challenged can be threatening and stressful, but it allows us to grow, being better informed and stronger.

Hearing all voices also supports our membership by creating an environment in which we all can feel validated and valued, allowing us to continue to give of our time and talents in a way

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Now, my job is making the dreams of others come true: mentoring, encouraging, empowering people to achieve their greatness and to embrace it so that they can give to the Universe all that they have to give.”

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that fosters the growth of the group and the growth of the individual. An important aspect of communication that I sometimes overlook is thanks and praise. I frequently reflect on how grateful I am for things that others have done for me, ideas they have shared with me, ways in which they have helped make AAEM successful. I think about it, and often even tell others how grateful I am for that person, but it is less often that I tell the person for whom I am grateful. My presidency has afforded me the opportunity to see firsthand the acts of quiet heroism and selflessness, the acts of generosity and compassion that our members give to one another, to the Academy and to the specialty. I have focused more on communicating my thanks and my praise to those who have been so good to me and to AAEM. I have reflected on how meaningful it is to me when my acts of courage or generosity or hard work are noticed, and I have learned to make it a point to thank and praise others. There is tremendous power in words. Many people have extolled the habit of ending the day by thinking of three things to be grateful for. I try to do this and to also think of three people for whom I was thankful that day—and to tell them so.

Surround yourself with experts, especially people who are experts in areas that you are not. Early in our careers, many of us make the mistake of assuming we are not ready to lead because we don’t know “everything.”

History bears out that the best leaders are the ones who surround themselves with experts.

Insecure leaders, believing that they should know it all, often develop a defensive posture that results in authoritarian leadership. Like the Red Queen in Wonderland, they decimate anyone who disagrees with them or demonstrates more knowledge than they have. One of the comforts and pleasures of my presidency has been the opportunity to have experts in ultrasound, EMS, pain management, and so many other fields there to guide me when I was required to make decisions in areas in which I am not an expert. Knowing where to find the answers often ensures success more firmly than attempting to know it all. Great leaders know who to trust. In our case, people who LOVE the Academy and want its best,

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people who are not out for themselves but are for the organization, and people who have established expertise in their fields. The Legal Committee was there for me when members were being unfairly treated by their employers.

The Ultrasound Section was there for me when ABEM asked me to help develop guidelines for the Focused Practice Designation (FPD) in Advanced EM Ultrasonography.

When the Arizona State House asked for support on the position of board-certified physician led pre-hospital care teams, EMSS came with me. As the All EM Committee on Recommendations for ACGME formats our recommendations, the Workforce and Academic Affairs Committees are reviewing documents with me. Those who are experts on locums work came to me to create the AAEM-LG. The Past Presidents Council provides wisdom when I need to know how things were done when similar situations arose in the past. The Pain and Addiction Committee came to me with the idea of collaboration between AAEM and the American Society of Regional Anesthesia and Pain Medicine. AAEM staff routinely gives me guidance on bylaws and procedures. Some of the greatest blessings of becoming a leader in emergency medicine have been the opportunity to learn about content areas in which I am not an expert and the opportunity to witness the willingness of others to advise, guide, and contribute to the overall success of the Academy. And it is liberating to realize that I will never be an expert in everything—and that I don’t need to be.

There is tremendous value in interorganizational collaboration. It helps that I have been friends with many of the leaders of our fellow EM organizations for many years, so there has been a natural tendency to collaborate and sense of ease when discussing areas where we disagree. Over the course of my years on the Board, I also have become friends with many of those leaders whom I did not know before and in many cases, they were not the people I imagined them to be, but much more open and interested in cooperative engagement. I have learned to find common ground, to proceed with mutual respect, and to agree to disagree in spaces where no common

ground exists. But, as previously stated, I have also learned to look with a fresh perspective at the positions of others and to give them space to share the information and the deductive process that led them to the position that they take. EM organizations in more than one country have the tradition of rivalry that is often unpleasant. I have learned from the grace demonstrated by President Nelson Mandela.

If anyone had a reason to feel resentful, President Mandela did. Twenty-seven years of his life were stolen from him, and yet when asked why he felt no animosity towards his persecutors, he replied, “Resentment is like drinking poison and then hoping it kills your enemy.”

Collaboration is far better than resentment, and inclusion is always better than exclusion.

Remain humble and have an attitude of service. Women and those under-represented in medicine tend towards imposter syndrome, never really feeling deserving of our achievements, no matter how hard we have worked for them. We tend to be plagued by Michelle Obama’s perennial question “Am I good enough?” Yet, at times, success can be intoxicating. And at times, the gravity of the decisions we make when we are in positions of leadership is overlooked and decisions can be made without adequate consideration. It is important to remember in any position of leadership that we are chosen to serve. To be in a position of service is a position of blessing and power. We are blessed to be able to give when so many are in the position of need. I have learned to be mindful that this is a position of obligation, one which I have taken on willingly, one which I chose, and hence my acts of service should always be a pleasure and a privilege. Being elected to serve means two things: that I was chosen because of the principles for which I stand and the values I embrace, and I was also chosen to represent the people who have chosen me. When a judgement call must be AAEM made, the membership is countingPlan: on me Antitrust Compliance to make that judgement with the integrity As part of AAEM’s antitrust compliance and values I represented when they plan,that we invite all readerstoofthem Common Sense to report any AAEM publication voted for me. And when a decision mustorbe activity may restrain trade oron limit made, thewhich membership is counting me to competition. You may confidentially file a make the decision that reflects their wishes report at info@aaem.org or by calling 800- and 884-AAEM.

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interests, which may not always be my own.

This is often a delicate balance, and there is no playbook for these situations. I have learned the value of Marvin Williams’ maxim that “There is no better test of a man’s integrity than his behavior when he is wrong,” and of President Truman’s model that “The buck stops here.”

Taking ownership of the errors that are made by me and by the organization have allowed me to grow as a leader and as a person. Doing our best does not always result in doing what is best, but there must be integrity and transparency in our behavior. Part of that humility is, as I said, knowing who to trust, surrounding ourselves with experts, and listening to them, then weighing their sometimes conflicting advice and deciding based on all considerations, and sometimes still being wrong. I have learned that most people know what is best for themselves, and that sometimes I must trust their judgement when they say they are not ready for a role I would like them to take on. I have also learned that self-doubt is a common denominator in the human experience, and

sometimes I must trust my judgement and provide the reassurance and encouragement and mentorship that others need to achieve their greatness. But I have learned that all this must be done with a spirit of humility and an attitude of gratitude for the privilege to serve.

Becoming the President of AAEM has been a dream come true for me. This is something that I wanted very much and that I achieved because others invested in me and mentored me and because the membership believed in me and the values that I bring to the practice of medicine and the education and training of our students and residents. I will be eternally grateful and always indebted to those who have paved the way for me, mentored me and trusted me to lead the best organization in emergency medicine. As I move on to my new job as a tenured professor and Associate Dean for Diversity at Brody School of Medicine at East Carolina University, my opportunities to serve will grow to encompass many residency programs, an entire medical school, and various pipeline programs that exist and that I will

develop. Now, my job is making the dreams of others come true: mentoring, encouraging, empowering people to achieve their greatness and to embrace it so that they can give to the Universe all that they have to give. As you have honored me with your trust, so I honor each of you in your unique greatness. Realize your greatness and grow into it. Serve and love. This is truly a life of privilege and blessings.

References 1. https://www.aaem.org/current-news/aaem-pgfiles-suit-against-envision-healthcare-allegingthe-illegal-corporate-practice-of-medicine

AAEM Antitrust Compliance Plan: As part of AAEM’s antitrust compliance plan, we invite all readers of Common Sense to report any AAEM publication or activity which may restrain trade or limit competition. You may confidentially file a report at info@aaem.org or by calling 800-884-AAEM.

AAEM Members Order Your Swag Today! business.landsend.com/store/aaem COMMON SENSE MARCH/APRIL 2022

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EDITOR’S MESSAGE

You Are the Plaintiff Andy Mayer, MD FAAEM

T

he above may sound like an odd statement but it relates to a recent lawsuit filed by the AAEM Physician Group (AAEM-PG) against Envision.

A copy of this suit was printed in the last issue of Common Sense with an introduction by Dr. Robert McNamara. I would encourage you to read it despite the legal jargon and try and understand some of the issues involved. This lawsuit, if successfully litigated, could eventually benefit every emergency physician in America.

The prospect of turning back corporate management groups (CMGs) including the negative role played by private equity in the business of emergency medicine could receive a significant boost by this lawsuit. This is a case which I think is vital for you to know about and advocate for in as many ways as possible. The expanding role of CMGs in our financial and professional future aided by private equity groups affects each and every emergency physician in America. This includes everyone even if you are academic, military, VA, private, democratic, CMG, or whatever type of practice environment in which you work. AAEM has been seeking the right case for many years and this one, hopefully, is the “One.” Read the full filing

The fight to win this lawsuit will not be quick, easy or cheap.”

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AAEM has been seeking the right case for many years and this one, hopefully, is the ‘One.’” An AAEM press release announcing this suit states: The American Academy of Emergency Medicine Physician Group (AAEM-PG) filed suit in the Superior Court of California against Envision Healthcare Corporation. AAEM-PG is responding to the takeover of an emergency department contract at Placentia Linda Hospital, part of the Tenet system. AAEM-PG alleges that Envision, as a lay entity owned by the private equity firm Kravis, Kohlberg, and Roberts, is in violation of the CA prohibitions on lay ownership of medical practices as embodied in the Business and Professions Code §§ 2400 and 2052. Issues at stake include lay influence over the patient-physician relationship, as well as control of the fees charged, prohibited remuneration for referrals, and unfair restraint of the practice of a profession. AAEMPG and its parent organization, the American Academy of Emergency Medicine, believes this arrangement is not in the public interest.

AAEM has helped members and non-members alike through the years in many types of legal cases. AAEM has provided advice, letters of support, amicus briefs, and financial support in legal cases involving issues with CMGs, due process, and unlawful termination. AAEM has helped gain some significant success in many of these cases but has of yet been unable to find a case which could set precedent on the issue of the corporate practice of medicine because many of these suits are settled without a ruling on the core issues involved.

CMGs have huge teams of very smart and well paid lawyers who are willing to use their

seemingly bottomless resources to thwart any effort to limit the CMGs ability to make money.

They are smart and are willing to back down and settle when they are clearly in the wrong.

The CMGs do not want the real issues like the corporate practice of medicine to actually be litigated. The CMG will settle with the individual emergency physician or group which we are helping as long as an ironclad non-disclosure agreement is in place. These types of settlement help right the wrongs done to the individual emergency physician and AAEM is willing and able to help but no legal precedent is set and no definitive ruling on the real issues are obtained. Other emergency medicine organizations have refused to become involved in many of these matters for unclear reasons. These issues cut to the essence of the struggle faced by every emergency physician in practice today and which every current or future emergency medicine resident will have to face as they enter their careers. AAEM certainly does not agree with sitting on the sidelines and believes strongly that we all need to work together to fight for our specialty even if it includes dealing with lawyers and the courts.

The settlement issue in these cases has typically been that the individual emergency physician or group are involved in a dispute which directly and immediately impacts their lives. They are fighting for their careers and ability to support their families. The prospect of a lengthy and very expensive legal process is daunting, at best, and can very easily be seen as insurmountable. The obvious smart move for them as individuals is to take a favorable

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settlement even if it includes a non-disclosure clause. This helps them financially and personally but does not settle the bigger legal issues which need clarification and definitive legal rulings.

AAEM has been looking for the right case which could actually affect real change for emergency medicine. This new case by the AAEM-PG looks like it could be the one we were seeking. This hope is based on several factors. First, AAEM believes that they are correct that Envision is violating the corporate practice of medicine statutes in California and therefore should win.

Winning a case in as large a state as California would set a huge precedent that other physicians could use in their own fight in other states against the CMGs and hopefully throughout the rest of the country.

Second, this suit was brought directly by the AAEM-PG against Envision. There is no individual physician or group as the plaintiff. Having the AAEM-PG as the plaintiff means that no one will settle the suit when someone dangles cash with a non-disclosure. AAEM has no interest in settling and actually wants this suit to litigate itself until completion. This fact alone should scare Envision and the other CMGs to their core. This is a long and expensive process but a trial and a ruling are what is necessary to win on the merits of the case.

Third, the suit does not seek a penny in damages. The AAEM-PG simply wants a ruling on the merits of the case. This fact should startle and impress the court. There will be no pretrial settlement talks. This seems to be an ingenious legal strategy and reveals that the motives of AAEM are to help emergency physicians and our patients.

Finally, CMGS are moving into several other medical specialties including anesthesia, hospital medicine, radiology, critical care, and others.

Their appetite for expansion and profit should be alarming to all physicians and medical specialties. Everyone should have an interest in this case and support should be enthusiastic.

Hopefully, many other specialty societies will join us in this fight with amicus briefs and even financial support.

News about this suit is appearing in many general media sources and is also gaining significant interest in health care circles. Imagine as this suit proceeds, how private equity will view the security of the billions of dollars which they have invested in CMGs. Will they consider their investments to still be sound? Will these same corporate executives at private equity firms realize what their billions have actually purchased? Are their large and valuable assets in CMGs which could be sold off to salvage their investments? Where are the factories and inventories or valuable intellectual property usually associated with multibillion dollar companies? In the end, CMGs only actually own the ability to take money from the physician fees of those physicians who are directly dealing face to face with Covid, staffing shortages, boarding, and burnout while the shareholders are home safe and warm in their beds. Imagine if the CMGs no longer had a right to take away the income of individual emergency physicians to generate profits for their shareholders. The CMGs could simply disappear along with the billions of dollars which private equity groups have invested in them. This legal action as it moves forward could cause financial panic in these private equity circles.

The fight to win this lawsuit will not be quick, easy or cheap. Envision will hire swarms of expensive lawyers who will try to throw up roadblocks to delay or prevent a trial. One can only guess the number of depositions, briefs, and motions which will be used to drive up the expensive of litigating this to a favorable conclusion. Remember that every year they can delay a ruling is more time the CMGs can make money from the labor of emergency physicians.

The very reality of the difficulty of this effort is precisely why AAEM is perfectly suited to play the role of the plaintiff in this case. AAEM has always been the champion of the practicing emergency physician and has always been willing to stand up for you as an emergency physician. AAEM is committed to this fight and knows that this fight represents an existential threat for our organization. Envision could attempt to bankrupt the organization by trying to outspend our ability to pay legal bills. They have very deep pockets. This cannot be allowed to

happen. AAEM needs the support of everyone who agrees with the goal of this suit. The time to unite around a just and essential cause is NOW. This suit should UNITE our specialty no matter if you belong to AAEM, ACEP, CORD SAEM, or even none of these organizations. It does not matter if you agree or disagree with AAEM on any other issue. Every emergency medicine organization should rally their members and resources behind this effort. This is not a “private business matter” but a winnable legal action which could help our specialty prosper and benefit every emergency physician by helping put physicians back in charge of their business.

I ask each of you to consider what your role will be in this fight. You could just sit back with a fatalistic attitude and think it is not your fight or that you will just wait and see what happens.

Please chose a different path. I ask each of you to do three things in this cause. First, I ask each one of you to consider making a real financial investment in this effort. AAEM will need a war chest to display to Envision so they clearly understand emergency medicine’s commitment to improving their own future.

Show them that you will no longer be passive victims of CMGs. Second, please speak to or email every emergency physician you know and discuss this case. Make sure everyone knows about it and understands what a victory could mean for our specialty. This is not a time to be divided or territorial. All emergency physicians need to unite. Lastly, speak to your colleagues from other specialties who are also being targeted by private equity and make sure they know about this and ask them to get their specialty societies involved now so that we can show the CMGs that physicians have decided to UNITE and fight back. Please consider that this is the hill to fight on and join the effort now!

Remember that you really are the plaintiff in this case and if the AAEM-PG wins then you win.

Donate Now

COMMON SENSE MARCH/APRIL 2022

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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.

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The AAEM Foundation is a 501(c)(3) non-profit organization. EIN: 20-2080841 ACMS-0718-026

AAEM NEWS LETTER TO THE EDITOR

Letter to the Editor My compliments to Dr. Andy Mayer, editor of Common Sense, and to all who contributed to the Jan/Feb issue. It may well be the best issue I have ever read, and as a former editor of Common Sense, it pains me a bit to say that.

While several topics appear in the issue, a consistent theme is clear. From the President’s Message to the interviews of politicians and candidates for office, from Dr. McNamara’s report on the AAEM-PG v. Envision lawsuit to Dr. Jones’ report on the Kansas legal decision on the corporate practice of medicine, a strong picture emerges of AAEM’s dedication to protecting the doctor-patient relationship and emergency physicians from outside interference—and especially from interference by lay-owned corporations. From the time of its founding, AAEM has been alone in that fight, and ACEP’s continuing absence from the struggle is glaring. The Jan/Feb issue thus also does a great job of pointing out how different our Academy is from the College, and how important our Academy is to the health of our specialty.

As bad as corporate control of emergency medicine is now, it would have been this bad twenty years ago if not for AAEM. And if the AAEM-PG prevails in its lawsuit against Envision, our specialty might actually turn the tide and start retaking some of the ground we have lost over past decades. Imagine that: emergency physicians free to exercise their hard-won professional judgment as they think best for patients and treated fairly in the workplace while doing so!

The only thing I would add, left unmentioned in the Jan/Feb issue, is that lay-owned corporations are not the only threat to our professional autonomy as we try to do our best for patients. Government regulation is just as dangerous. While laymen driven purely by profit certainly damage the practice of emergency medicine, so do well-intentioned laymen in government, with their immense and seemingly limitless power. More often than not, the Law of Unintended Consequences rears its ugly head and makes their cure worse than the disease. The HITECH Act of 2009, which forced electronic medical records on health care long before the technology was ready, is a good example. We should be suspicious of any lay-controlled entity that wants to tell us how to do our job, not just corporations.

Andy Walker, MD MAAEM

In an effort to keep our members connected, Common Sense began a column of member updates submitted by our members. We ask you to submit brief updates related to your career.

We will also publish the unfortunate news of the passing of current or former members.

Visit the Common Sense website to learn more and submit your updates for publication! www.aaem.org/resources/publications/common-sense

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

Submit a letter to the editor and continue the conversation.

Submit a Letter to the Editor at:

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

COMMON SENSE MARCH/APRIL 2022

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LEGISLATORS IN THE NEWS

An Interview with Congressman Dr. Michael Burgess (R-TX) Lisa Moreno, MD MS MSCR FAAEM FIFEM — President, American Academy of Emergency Medicine

F

or this issue, it was my pleasure to interview Congressman Dr. Michael Burgess (R-TX), an obstetrician-gynecologist by training. Dr. Burgess’ bio follows.

LM: What factors contributed to your decision to run for public office?

MB: Actually, I never planned on this! I have always loved medicine. In my early 50s, like many doctors at that age, I began cutting down on practice. I was part of a group practice with six other physicians, and while I continued to take obstetrics call, I made the decision to have no OB patients of my own. I was very happy in the practice. In September 2001, I found myself in the operating room, doing a case with a urologist when the events of 9/11 started. The twin towers went down, and you know how that went: one tower is hit and you think it’s some horrible accident. The second tower is hit, and you know it’s terrorism. I immediately became concerned about my son, who was at the time in the Air Force and stationed in New Mexico. I was also concerned for a general surgery colleague who was in New York City at the time, taking a review course. When this surgeon came back, he told me about how the course was abruptly stopped, and the doctors were instructed to go to the lobby of the hotel.

Details of the attack shortly became available, and the doctors were informed that a bus would arrive to take volunteers to Ground Zero to attend to the wounded.

As I listened to my colleague speak, I had to honestly question whether I would have had the courage to get on that bus. At that point, I made myself a promise that “if a door opens, I will walk through it.”

When I am asked whether I prefer to be addressed as “Congressman” or “Doctor,” there’s no contest. I prefer to be called DOCTOR.”

Shortly thereafter I found out that Dick Army was going to retire. I asked myself, “Is this the door that has opened, and I am supposed to walk through it?” All over Texas, TV news anchors were asking, “Who is going to be next for the 26th District?” During this time, I often reflected on how my son was serving in the military, but what was I doing to serve the country. So, I went online and I learned that it’s actually very easy to register to run for Congress. The forms are not complicated to fill out, but to actually run? Well, it’s very difficult to actually run. In Texas,

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the winner must have 51% of the vote. I came in second in a race of several candidates so I had a four week run off with the number one candidate. Up until now, I had not had to restrict my medical practice. There was a three month wait for appointments with me, so I was continuing to honor the scheduled appointments. I easily won the primary since it was in a Republican District. Texas requires 90-day notice to patients before leaving a practice, so I sent a letter letting my patients know I was leaving the practice of medicine to serve in Congress. I expected them to continue their routine care with one of my partners, but almost all of them decided they wanted one last appointment with me. It was during these visits that I really became aware of the power that physicians have just in the care that we give patients every day. My patients share with me examples of how I had changed their lives. This wasn’t something I had previously thought about. It was a little like having your eulogy read and not having to die to hear it.

LM: It isn’t something we often think about, and yet we have this privilege of impacting people’s lives so profoundly. I remember being in Walmart and having a young woman run up to me and tell me that she thinks about me every day when she puts her makeup on because I had sewn a laceration of her face. “You promised me I’d barely have a scar, and you were right!” she told me.

But discussing the impact we have on patients, there are some very disturbing statistics related to our outcomes in OB/GYN. The US is arguably the richest nation in the world, and we spend more by far on health care per capita than any other nation, yet the US maternal mortality rate is 6.2 and the rates in PR and the US VI are 8.4 and 7.5. As an OB/ GYN, how do you make sense of this and what is the government's role in improving this critical metric?

MB: This is one of my major areas of focus. There are many OB health shortage areas in the United States. In 2018, I was the Chair of

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the Health Subcommittee of Energy and Commerce. Rep. Butler from Washington State had a bill that passed which outlined the structure on State Directed Maternal Mortality Review Committees. At that time, I recalled the maxim of an epidemiologist friend of mine, “A chance to measure is a chance to fix, but you can’t measure if people are afraid to tell you the truth.” So, we decided to keep trial lawyers out. This was not going to be an investigation.

We would try to drill down on what happened in cases of maternal mortality, and what went wrong is usually multifactorial. We have had two hearings on this, one when Republicans were in charge and one when Democrats were in charge. The first case was from a hospital in California. The woman died in the recovery room less than 12 hours after a Caesarian section. When I reviewed the deposition, it seemed to me that any number of people should have realized that the new mother needed to go back to the OR. There were so many indications that she was hemorrhaging from a laceration to the uterine artery. It was a tough case for me to read as an OB. I asked myself, “How do I write legislation that mandates that doctors do the right thing—the thing that any reasonable doctor would have done.”

The Joint Commission has a role to play here. When they do an accreditation, we’re all familiar with their citations for dust on a shelf. Why are they worried about that? OB units should be scrutinized. Anything that can happen that can be lethal, how is the hospital prepared to deal with this to prevent it from becoming lethal? Our country counts maternal mortality as anyone who dies within one year of giving birth.

This is not the same in other countries, where the time since delivery is shorter for a death to be considered a maternal mortality. But this is not an excuse. The numbers are still too high, and we can get it down. All the agencies need to work together. Fragmentation of care contributes to this. CMS might have a role in this, but here’s the bottom line: We have to care as doctors---I mean, we have to set the tone there. We need to make sure that we don’t get the “agency practice of medicine”—they don’t always know what’s best for patients.

How do I write legislation that mandates that doctors do the right thing—the thing that any reasonable doctor would have done.”

LM: Your comments are so in line with the AAEM philosophy that all health care teams need to be led by a board certified physician. We also believe that it all comes down to training, to being adequately prepared to deal with all the exigencies of your specialty through The second case was a Georgia patient who was herself a member of the the rigorous process of residency training and board certification. public health service. According to the deposition, she went home from an Midwives, nurse practitioners, and PAs all have a role in the health care team, but as you say, we physicians have to set the tone, we appointment, came back, presented to the Emergency Department, saw different care givers at different levels of expertise, and despite a diastolic have to set and maintain the standards. AAEM is also in alignment blood pressure of 118 mm/Hg, she was sent home to rest. Again, how can with your contention that we physicians, and not agencies and you legislate that doctors and other health care workers do the right thing? administrators, know what’s best for patients. Our education and training uniquely qualify us for that.

Honestly, I think it comes down to training. Many people believe that race and ethnicity are factors in maternal mortality, and while the statistics bear AAEM is also focused on the need for physician advocacy. As both that out, that’s not the way it has to be. I trained in Parkland. Parkland takes a legislator and a physician, you are uniquely qualified to identify care of the highest risk obstetrical patients: Black and Brown, uninsured or the most critical health related issues facing the nation currently.

Could you talk about that? underinsured, late to getting prenatal care, and yet Parkland has some of the best mortality statistics in the country. They have post-partum hemor- MB: PHYSICIAN WORK FORCE! Without a doubt, this is the biggest rhage crash carts all over the place. And they have strict protocols about issue. As we age out, younger doctors are leaving because it’s hard who does what. When a patient is crashing, everyone has a job to do, and work and doesn’t pay as well as other professions. At a meeting of the they do it simultaneously. And then they have a debriefing. We know that Congressional Doctors Caucus, the Surgeon General told us that he is even the best doctors have complications, but at Parkland, complications seeing significant physician burnout throughout the nation since the panhappen in a setting that is prepared to respond to the complications. demic, but I think burnout started long before this. Practicing physicians You can’t tell me that it can’t be done. If you can do it at one of the hospi- are constantly facing reimbursement issues, fee cuts by CMS, an aggretals where the highest risk OB patients in the nation are treated, you can gate of issues that make it difficult for doctors to feel that they are valued. do this anywhere. It comes down to training. It comes down to being Look what happened in the midst of the pandemic when physician emprepared for the complications.1 ployers said, “Hey hero, here’s your pay cut.”

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LEGISLATORS IN THE NEWS

Other major issues are physician mental health and physician opiate abuse and how we deal with this. We need to allow people to get the help they need without being penalized. Even medical students and young docs are experiencing so much pressure that fewer people are signing up to do the job.

Another issue: There are those that don’t care if the nation does not have enough physicians—just use MD extenders—but this is not acceptable.

We need to have physicians leading the team in order to insure patient safety.

I’m also concerned about the time it takes for knowledge translation from the lab to the bedside. I am introducing a bill called CARE FOR THE 21st CENTURY. We demonstrated our ability to do this with OPERATION WARP SPEED in development of the COVID vaccine. Traditionally, we have not paid attention to how is anyone going to be able to afford the things we are developing. Will patent rights and individual ownership rights be taken over? These issues can be disincentives to drug and clinical practice development. Look, it’s been 40 years since a sickle cell drug has been developed! It’s hard to believe that we have not seen improvement in something like sickle cell disease in so long. But if we hit a home run with some of these things, wow. But what if it’s so expensive that no one can afford the drug? And what is the cost of doing nothing for 40 years? What is the cost in human life, quality of life? Insulin is a prime example. The cost of the medication is so high! When we ask pharma why, they tell us that this is because the rebates they have to pay to the federal government are so high. Why shouldn’t the rebates be given to the patient? Our goal, after all, is create the situation in which the patient is taking their medication. So much of what we are doing is not logical, but the problem is multifactorial, so the answers will require collaboration between several entities.

LM: The Academy shares your concerns about the appropriate use of non-physician health care professionals, and we are firmly committed to the model of the physician led team to protect the safety of our patients. We’ve also been outspoken about the pay cuts and decreased work hours that so many corporate groups imposed on physicians who had given their all during the pandemic. Your comments really demonstrate how you combine your skills as a physician and as a legislator. What are the traits that made you a good physician that are now making you an effective legislator?

MB: Physicians are lifelong learners, having to sort through a huge volume of information and cull out what really matters. This is what you must do in Congress. Another trait of a good doctor and a good legislator is being a good listener. In both jobs, you need to understand what people are concerned about, what matters to them, what they are worrying about. Both physicians and legislators need to realize the tremendous impact that we have on people’s day to day lives. And physicians especially need to realize the power that we have. I recall how Ross Perot once told me that doctors have a lot of power. Perot said that if his staffer hands him a stack of letters and one is from his doctor, he opens

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that first. Physicians hold a position of huge respect in the population.

When I am asked whether I prefer to be addressed as “Congressman” or “Doctor,” there’s no contest. I prefer to be called DOCTOR. LM: Dr. Burgess, thank you so much for taking the time to talk with me today. Regardless of specialty, we physicians put patients first.

It was a pleasure to explore the issues that impact our patients’ daily lives, and AAEM looks forward to continuing our relationship with you to ensure the highest level of care for the nation.

References 1. The bolding in this paragraph is the author’s emphasis.

Congressman Dr. Michael Burgess Bio After spending nearly three decades practicing medicine in North Texas Dr. Michael Burgess has served the constituents of the 26th District since 2003 in the United States House of Representatives. He currently serves on the House Energy and Commerce Committee, House Rules Committee, and House Budget Committee.

As part of the 115th Congress, Dr. Burgess is the most senior medical doctor, on both sides of the aisle, currently serving in the House of Representatives. Because of his medical background, he has been a strong advocate for health care legislation aimed at reducing health care costs, improving choices, reforming liability laws to put the needs of patients first, and ensuring there are enough doctors in the public and private sector to care for America’s patients and veterans. He has voted to repeal the Affordable Care Act over 50 times, and has played an important role in bipartisan efforts to reform the Food and Drug Administration.

Ever since he came to Congress, Dr. Burgess has made repealing Medicare's Sustainable Growth Rate (SGR) formula a top priority. At the beginning of the 114th Congress, over 90 percent of both chambers of Congress supported the formula's repeal and it was signed into law. As one of the largest entitlement reforms in the past few decades, this landmark policy will ensure greater access and quality for seniors, more stable reimbursements for providers, and a more fiscally solvent Medicare system as a whole.

As a member of Congress representing one of the fastest growing areas of the country, transportation is also a top priority. In 2005, Dr. Burgess successfully amended the Highway Bill to include development credits, design-build, and environmental streamlining. During his time on Capitol Hill, he has worked to build, maintain, and improve the safety of our roads, bridges, air service, and transit in the North Texas region.

As a fiscal conservative, Dr. Burgess believes Americans deserve a federal government that is more efficient, more effective, less costly, and always transparent. He is a proponent of a flat tax and has introduced a flat tax bill every term he has served in Congress. He follows a strict adherence to the Constitution and opposes unnecessary expansion of the

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LEGISLATORS IN THE NEWS

federal government’s control over the personal freedoms of Americans.

Instead, he believes in giving people more control over their lives and their money. Dr. Burgess is committed to reducing illegal immigration into our country and has taken action to ensure our borders are secure and our immigration laws are enforced. He strongly opposes any proposal to grant amnesty to illegal immigrants.

During his time on Capitol Hill, Dr. Burgess has earned a reputation as a problem-solver who seeks sensible solutions to the challenges Americans face and has received several awards including the Guardian of Small Business award by the National Federation of Independent Business (NFIB), the Spirit of Enterprise award by the U.S. Chamber of Commerce, and the Taxpayer Hero award from the Council for Citizens Against Government Waste, among others. In 2013, he was named to Modern Healthcare’s 50 Most Influential Physician Executives and Leaders.

Today, Dr. Burgess represents the majority of Denton County and parts of Tarrant County. He was raised in Denton and attended The Selwyn School, graduating in 1968 as valedictorian. In addition, he graduated with both an undergraduate and a master’s degree from North Texas State University, now the University of North Texas. He received his MD from the University of Texas Medical School in Houston, and completed his residency programs at Parkland Hospital in Dallas. He also received a master’s degree in Medical Management from the University of Texas at Dallas, and in May 2009 was awarded an honorary Doctorate of Public Service from the University of North Texas Health Sciences Center. Dr. Burgess and his wife, Laura, have been married for more than 40 years and have three children and two grandsons.

Build confidence with each case encounter! scan for more information

Oral Board Review Course 2022 Dates: May 4, May 5, Sep 14, Sep 15, Nov 30, Dec 1 www.aaem.org/education/events/oral-boards

COMMON SENSE MARCH/APRIL 2022

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AAEM Foundation Contributors – Thank You! Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 1-1-22 to 3-1-22.

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

Contributions $1000 and above

Contributions $100-$249

Anisha Malhotra, MD Nathan J. McNeil, MD FAAEM

Ann Loudermilk, MD FAAEM Anthony J. Callisto, MD FAAEM Brian R. Potts, MD MBA FAAEM Carlos F. Garcia-Gubern, MD FAAEM Chaiya Laoteppitaks, MD FAAEM Christopher F. Tana, FAAEM Clayton Ludlow, DO FAAEM Dan M. Mayer, MD FAAEM David W. Kelton, MD FAAEM David W. Lawhorn, MD MAAEM Deborah D. Fletcher, MD FAAEM Donald L. Slack, MD FAAEM Eric J. Muehlbauer, MJ, CAE Fred Earl Kency Jr., MD FAAEM FACEP

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

Contributions $250-$499 Azalea Saemi, MD FAAEM Bradley Judson, MD FAAEM Bryan K. Miksanek, MD FAAEM Charles Chris Mickelson, MD FAAEM Eric W. Brader, MD FAAEM Ron Koury, DO FAAEM Sahibzadah M. Ihsanullah, MD FAAEM

Ian R. Symons, MD FAAEM Jeffrey A. Rey, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Julianne Wysocki Broadwater, DO FAAEM Kathleen Hayward, MD FAAEM Mark E. Zeitzer, MD FAAEM Mike Lesniak Nicholas G. Ross, MD FAAEM Paul W. Gabriel, MD FAAEM Robert Bruce Genzel, MD FAAEM Sabrina J. Schmitz, MD FAAEM Shanna M. Calero, MD FAAEM Sundeep J. Ekbote, MD FAAEM

Andrea C. Santoyo Chris Hummel, MD FAAEM Evan T. Burdette, MS Ivan Novikov Jason D. May, MD FAAEM Jason Hine, MD FAAEM Joanne Williams, MD MAAEM FAAEM Julia Alegria Astudillo Kasey Gore Kennadie P. Campbell Ron S. Fuerst, MD FAAEM Sierra Cloud

Contributions up to $99 Alex Kaplan, MD FAAEM

AAEM PAC Contributors – Thank You! AAEM PAC is the political action committee of the American Academy of Emergency Medicine. Through AAEM PAC, the Academy is able to support legislation and effect change on behalf of its members and with consideration to their unique concerns. Our dedicated efforts will help to improve the overall quality of health care in our country and to improve the lot of all emergency physicians.

All contributions are voluntary and the suggested amount of contribution is only a suggestion. The amount given by the contributor, or the refusal to give, will not benefit or disadvantage the person being solicited.

Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the different levels of contributions. The PAC would like to thank the individuals below who contributed from 1-1-22 to 3-1-22.

Contributions $250-$499 Brian J. Cutcliffe, MD FAAEM Charles Chris Mickelson, MD FAAEM Eric W. Brader, 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 Bryan K. Miksanek, MD FAAEM David W. Kelton, MD FAAEM Donald L. Slack, MD FAAEM

Philip Beattie, MD FAAEM Trisha Anest, MD FAAEM Matthew W. Turney, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Thomas B. Ramirez, MD FAAEM Brian R. Potts, MD MBA FAAEM Anthony J. Callisto, MD FAAEM Brian D. Stogner, Jr., FAAEM Chaiya Laoteppitaks, MD FAAEM David Touchstone, MD FAAEM Ian R. Symons, MD FAAEM Jeffrey A. Rey, MD FAAEM Jeffrey J. Thompson, MD FAAEM

Julianne Wysocki Broadwater, DO FAAEM Kathryn Getzewich, MD FAAEM Lauren P. Sokolsky, MD FAAEM Michael R. Magoon, MD FAAEM Nate T. Rudman, MD FAAEM Penelope Goode, MD FAAEM Rebecca N. Mills, MD FAAEM Rhett W. Silver, MD FAAEM Robert Bruce Genzel, MD FAAEM Sundeep J. Ekbote, MD FAAEM Thomas Heniff, MD FAAEM

Contributions up to $99 Ann Loudermilk, MD FAAEM Charles Spencer III, MD FAAEM Chris Hummel, MD FAAEM Marc D. Squillante, DO FAAEM Marianne Haughey, MD FAAEM William J. Taylor, MD Richard Burke Neville, MD FAAEM Anne M. LaHue James P. Alva, MD FAAEM Peter Stueve, DO

Corrections After publication of the January/February Common Sense, Dr. Gillian Battino informed us that she is now running for State Treasurer of Wisconsin instead of running in for the US Senate for the State of Wisconsin.

To Our Readers: Due to supply chain issues, print issues of Common Sense may be delayed. New issues of Common Sense will be posted as soon as they are published here: www.aaem.org/resources/publications/common-sense

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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 3-1-22.

Contributions $2000 and above Mercy M. Hylton, MD FAAEM

Sahibzadah M. Ihsanullah, MD FAAEM William E. Hauter, MD FAAEM

Contributions $500-$999

Contributions $100-$249

Mark Reiter, MD MBA MAAEM FAAEM

Contributions $250-$499 Anthony J. Callisto, MD FAAEM Eric W. Brader, MD FAAEM Michael R. Burton, MD FAAEM

Ann Loudermilk, MD FAAEM Brian R. Potts, MD MBA FAAEM Clayton Ludlow, DO FAAEM Daniel Elliott, MD FAAEM David W. Kelton, MD FAAEM David W. Lawhorn, MD MAAEM

Fred Earl Kency Jr., MD FAAEM FACEP Ian R. Symons, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Kathleen Hayward, MD FAAEM Marc D. Squillante, DO FAAEM Mark E. Zeitzer, MD FAAEM Nate T. Rudman, MD FAAEM Paul W. Gabriel, MD FAAEM Sabrina J. Schmitz, MD FAAEM

Contributions up to $99 Ana Maria Navio Serrano Sr., MD PhD Jason D. May, MD FAAEM Marianne Haughey, MD FAAEM Peter Stueve, DO Robert W. Bankov, MD FAAEM FACEP 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: www.aaem.org/education/events

AAEM Events

Recommended

April 23-27,2022 AAEM’s 28th Annual Scientific Assembly (Baltimore, MD) https://www.aaem.org/aaem22

April 8-10,2022 The Difficult Airway Course: EmergencyTM (Boston, MA) www.theairwaysite.com

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

April 23,2022 Advances in Cancer ImmunotherapyTM: Immune Checkpoint Inhibitors (Virtual) https://www.sitcancer.org/education/aci/2021-2022/ immunecheckpointinhibitors

https://www.aaem.org/memc21

Jointly Provided Re-Occurring Monthly Unmute Your Probe: Virtual Ultrasound Course Series Jointly provided by EUS-AAEM www.aaem.org/eus May 27-28, 2022 10th Annual FLAAEM Scientific Assembly (Miami Beach, FL) Jointly provided by the Florida Chapter Division of AAEM https://www.aaem.org/get-involved/chapter-divisions/flaaem/ scientific-assembly July 27-29,2022 Coalition for Physician Well-Being 12th Annual Conference (Denver, CO) https://www.forphysicianwellbeing.org/

April 28,2022 Advances in Cancer ImmunotherapyTM: A Focus on Toxicity Management (Houston, TX and Virtual) https://www.sitcancer.org/education/aci/2021-2022/toxicityirae September 9-11,2022 The Difficult Airway Course: EmergencyTM (Nashville, TN) www.theairwaysite.com September 23-25,2022 The Difficult Airway Course: EmergencyTM (Minneapolis, MN) www.theairwaysite.com November 11-13,2022 The Difficult Airway Course: EmergencyTM (San Diego, CA) www.theairwaysite.com

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PLATFORM STATEMENTS

Dear AAEM Member, Enclosed are the candidate statements for the 2022 AAEM Board of Directors Election.

As you are aware, the call for nominations was sent to all voting members. Those AAEM members who appear on the enclosed ballot have indicated their willingness to serve on the AAEM board.

Statements from each of the candidates full listing of previous board service and awards as well as AAEM activities dating back five years (2017 and on) are on the following pages. Please review the enclosed information, then exercise your democratic right to vote for the representatives you would like to see serve as AAEM’s leaders. Remember, we have a one member, one vote system, so your voice counts. Please follow these instructions for casting your ballot in the 2022 election.

If You Will Attend the Scientific Assembly: • We recommend that you do not complete your official ballot at this time. There will be a Candidates’ Forum held during the Scientific Assembly on April 26, 2022, 9:00am-9:45am EST, where you can hear the candidates respond to direct questions from the voting membership. You will be asked to submit your ballot online at the conclusion of the Forum.

• If certain of your choices or unsure if you will attend the Forum, you may vote online at www.aaem.org/ elections. Voting will remain open until April 26, 2022 at 11:59pm CST. If You Are Unable to Attend the Scientific Assembly: • You may complete your official ballot online at www.aaem.org/elections. Online voting will remain open until April 26, 2022 at 11:59pm CST. Balloting Procedure for 2022: • Voting ballots will only be available online.

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

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

Sincerely,

Missy Zagroba, CAE Executive Director

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PLATFORM STATEMENTS

Robert Frolichstein, MD FAAEM CANDIDATE FOR PRESIDENT-ELECT Greater San Antonio Emergency Physicians Nominated by: Jonathan S. Jones, MD FAAEM; David A. Farcy, MD FAAEM FCCM; Mark Reiter, MD MBA MAAEM FAAEM Membership: 1998-2022 Disclosure: Clinical Board of Directors for Wellvana Health - San Antonio AAEM Activities (past five years) James Keaney Award Recipient AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors Geriatric Committee Board Liaison Membership Committee Board Liaison Emergency Medical Services Section Board Liaison

Independent Practice Support Committee Member EM Workforce Committee Member Palliative Care Committee Member Wilderness Medicine Committee Member Leadership Academy Attendee Texas Chapter Division Member and Board Liaison Common Sense Author

Candidate Statement for President-Elect It is often said that our healthcare system is horribly broken. I disagree. Let me explain. The core of the delivery of medical care is the patient-physician relationship. This is the interaction that drives everything. Every other piece of the “system” should support and enhance this relationship.

Unfortunately our “system” recognized this and instead of supporting it, the “system” uses that relationship for the benefit of each piece of the system rather than for the benefit of the patient. Pharma, PBMs, insurance companies, hospitals, management groups, everything it seems, recognizes that the patient-physician relationship drives revenue and everybody wants a piece of the action. Our system is not broken. It works incredibly well to do what it is designed to do - make money. The problem is that the systems should be designed to support the patient-physician relationship as the foremost goal and as a byproduct make some money - not the other way around.

I am running for President-Elect of AAEM not because I think I have all the answers and can fix everything, but because I believe that physician engagement in matters away from the bedside is crucial in improving our “system”. I have held this belief for many years and it drove me to become involved in AAEM and develop relationships to share ideas and thoughts. I was encouraged to run for the Board and have served on the Board for several years now, most recently as the Secretary-Treasurer. During that time I have been involved in many committees and projects. I could list them all but that would miss the point that it is not any one thing or even any big accomplishment that matter. What matters is that I am a community emergency physician that believes that we are at a consequential time for our specialty and profession and I am trying to positively impact the future of our specialty. I am a “pit doc” just like most of you. We all need to get out of our pit and help drive change. I believe that if physicians do nothing our beloved profession will continue to disintegrate. The future we want will require engagement from the vast majority of emergency physicians. My time on the board has shown me that we all come from many different backgrounds and face challenges; however, learning of the barriers underrepresented minorities face on a daily basis has been eye opening to me. I admit I still have more to learn, but I will actively seek to increase inclusivity of all emergency physicians. Passion, ideas, desire, sacrifice, and yes, even money will be needed. We all have ways to contribute. You need to be involved because it is time to “ask not what The Academy can do for you, rather what you can do for The Academy and Emergency Medicine.” I hope to work hard over the next several years to make it easier for each and everyone to be engaged in shaping the work of The Academy to benefit our specialty.

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PLATFORM STATEMENTS

L.E. Gomez, MD MBA FAAEM CANDIDATE FOR SECRETARY-TREASURER Johns Hopkins Bloomberg School of Public Health Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; David A. Farcy, MD FAAEM FCCM Membership: 2006-2023 Disclosure: Nothing to disclose AAEM Activities (past five years) AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors AAEM Physician Group (AAEM-PG) Board of Directors Capital Region Chapter Division of AAEM (CR/AAEM) Board of Directors DEI Committee Board Liaison Oral Board Review Course Subcommittee Board Liaison Social EM and Population Health Committee Board Liaison

State Chapter Division Committee Member Government and National Affairs Committee Member JEDI-AAEM Section Member MEMC Abstract Reviewer MEMC Speaker Scientific Assembly Speaker Leadership Academy Speaker Common Sense Author

Candidate Statement for Secretary-Treasurer Dear AAEM Colleagues, We are on a deliberate path to growth with a progressive agenda at our academy that not only defines the integrity of our specialty but will legally and otherwise protect the survival of fair and equitable emergency medicine practice environments. Leading our financial task force to responsible socially conscious investment has been a gratifying reminder that it takes work and guts to live up to our stated values of inclusion and informed, deliberate diversification of our resources. Corporations will continue to put profit before people, and our attention to the repercussion of our actions, not a narrow view of our fiduciary duty to the organization, will keep us the most progressive professional organization in emergency medicine. It is also an honor to serve as a mentor and faculty for our AAEM Leadership Academy, a testament to our commitment to diversity and inclusion, and a forum where allies of all backgrounds contribute to a broad agenda that includes equity in educational leadership on a national and international stage. Our AAEMPG and new AAEM Locums Group put us in a position to capitalize on new opportunities on the horizon that are a result of bold decision-making by our boards, on which I have the continued honor of serving. I plan to continue consistent and faithful participation in all meetings, conference calls, and pay careful attention to our budgets and financial reports, so that our collective effort to push our agenda, not backward as some might prefer, but forward.

We have a social crisis of divisiveness in our society reflected in our healthcare system and emergency medicine practices that threaten to overtake all our democratic principles. They also threaten our specialty and undervalue the vision of young members. With your vote, I intend to ensure we all continue to walk together not only to fulfill our mission but expand it to make us the largest, most diverse, as well as the best in our industry.

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PLATFORM STATEMENTS

Terrence Mulligan, DO MPH FAAEM FACOEP FIFEM FACEP FNVSHA FFSEM HPF CANDIDATE FOR SECRETARY-TREASURER University of Maryland School of Medicine Nominated by: Jonathan S. Jones, MD FAAEM; Mark Reiter, MD MBA MAAEM FAAEM; Robert Frolichstein, MD FAAEM Membership: 2009-2022 Disclosure: Vice President of the International Federation for Emergency Medicine (IFEM) AAEM Activities (past five years) International EM Leadership Award Recipient AAEM Board of Directors (three terms) AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors AAEM India (AAEMi) Vice President/Board of Directors Capital Region Chapter Division of AAEM (CR/AAEM) President/Board of Directors EM Workforce Committee Board Liaison International Committee Board Liaison International Committee Member International Conference Committee Member Government and National Affairs Committee Member Amin Kazzi International EM Leadership Award Recipient AAEM Board of Directors (three terms) AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors AAEM India (AAEMi) Vice President/Board of Directors Capital Region Chapter Division of AAEM (CR/AAEM) President/Board of Directors

EM Workforce Committee Board Liaison International Committee Board Liaison International Committee Member International Conference Committee Member Government and National Affairs Committee Member Social EM and Population Health Committee Member MEMC Exec Director/Co-director/Scientific Committee/ Preconference/Track Chair/Abstracts/Speaker AAEM Health Policy Symposium Director/Co-Director/Lecturer AAEM Health Advocacy Day participant IAEMC Scientific Committee/Preconference/Track Chair/Speaker AAEM Scientific Assembly Speaker Leadership Academy Attendee AAEM Oral Board Review Instructor AAEM Residency Visit Speaker Common Sense Author

Candidate Statement for Secretary-Treasurer I am running for the position of AAEM Secretary/Treasurer. As we enter the third year of the COVID pandemic, now more than ever before in the history of emergency medicine, AAEM, emergency physicians, and emergency medicine are facing existential challenges and opportunities that require experience, dedication, performance and hard work, and I believe my 25+ years of service to EM and 18+ to AAEM have prepared me well to serve AAEM in this important position.

Over the past 25 years as an emergency physician, I have extensive training, education Fellowships and experience in emergency medicine, business, public health, health policy, health economics, health law, EM administration and management, and sports medicine, and have served in multiple leadership positions in EM within AAEM and without. I have also served as Secretary/Treasurer of multiple local, national and global EM organizations in the past, including the Secretary/Treasurer of the IFEM, for the IFEM Foundation and the IFEM Institute, and am well trained and experienced in the financial, budgeting and planning aspects of this crucial position.

I have had the privilege of serving for the past 6 years for 3 terms on the AAEM as a member of the AAEM Board of Directors. I have been an active AAEM member since 2004, and have chaired, co-chaired, vice-chaired and been a member of multiple AAEM committees. I am also the President and Co-founder of the new AAEM Capital Region Chapter Division since 2020 - a new AAEM State/Regional chapter covering Maryland, Virginia and Washington DC - which will focus on State and regional EM issues and national EM, health policy, legislative and economic issues as well. I am also the Vice-President and co-founder of the AAEM Chapter for India for the past 5 years. Since being elected to the AAEM Board of Directors in 2016, I

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PLATFORM STATEMENTS

was the executive director and co-executive director of 2 highly successful MEMC conferences in Italy and in Portugal. I co-developed and participated in several AAEM Health Policy Symposia in Washington D.C.as preludes to our National Advocacy Days, and have continued to represent AAEM at multiple residency visits, in Washington DC to our National legislators, and to our many EM colleagues in the USA and around the world. I am currently the Vice President of the International Federation for Emergency Medicine (IFEM), representing 75+ EM organizations from 55+ countries, including AAEM. I am an Adjunct Professor in Emergency Medicine at the University of Maryland School of Medicine, and was the Director of our International Emergency Medicine program from 2011-2019. I am also a visiting professor in South Africa, India, and in China. I am double-residency/double-board-certified in Emergency Medicine and in Neuromusculoskeletal/Osteopathic Manipulative Medicine, and completed four subspecialty fellowships (International EM; Health Policy; EM Administration & Management; and Sports & Exercise Medicine). In May 2021 I graduated from Harvard Business School. I have an MPH in Epidemiology and Biostatistics, and an MS in Health Economics, Policy and Law (pending). I look forward to continuing to serve AAEM: the best organization in emergency medicine, the Champion of the Emergency Physician, and ask for your vote to serve as AAEM Secretary/Treasurer, and to remain a member of the AAEM Board of Directors.

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PLATFORM STATEMENTS

Heidi Best, MD FAAEM CANDIDATE FOR AT-LARGE BOARD MEMBER Emergency Physicians of Tidewater Nominated by: Self-nomination Membership: 2005-2024 Disclosure: Nothing to disclose AAEM Activities (past five years) Capital Region (CR/AAEM) Chapter Division Member Women in EM Section Member AAEM Emergency Medicine Workforce Committee Member Candidate Statement for At-Large Board Member Since becoming the president of an independent democratic EM group in 2018, the importance of advocacy for our specialty and within our specialty has been magnified. There are multiple threats to EM that need a committed and knowledgeable group like AAEM to tackle. I have a strong knowledge of the financial threats to EM including insurers trying to use surprise billing legislation to tank reimbursement and government payors (like that in my state of Virginia) utilizing automatic chart downcodes despite the clear violation of the prudent layperson standard. I am very much against the corporatization of EM and of medicine in general.

In the past 4 years as president of Emergency Physicians of Tidewater, I have modernized our practice, brought in valuable new administrative talent, and solidified camaraderie that had been waning just before my inauguration. I am expanding my reach through committee work in both ACEP and AAEM, as chair-elect in the Emergency Medicine Business Coalition, and as an upcoming lecturer at EDPMA. I am encouraged by the work that AAEM is doing and am proud to continue to support the organization. My CV is available as needed.

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PLATFORM STATEMENTS

Kimberly M. Brown, MD MPH FAAEM CANDIDATE FOR AT-LARGE BOARD MEMBER Baptist Memorial Hospital Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; David A. Farcy, MD FAAEM FCCM; Loice Swisher, MD MAAEM FAAEM Membership: 2013-2023 Disclosure: Nothing to disclose AAEM Activities (past five years) AAEM Education Committee Member AAEM/RSA Diversity & Inclusion Committee Member JEDI-AAEM Section and Work Group Lead YPS-AAEM Section Member

Women in EM Section Member Critical Care Medicine Section Member Emergency Ultrasound Section Member Common Sense Author

Candidate Statement for At-Large Board Member Thank you for considering me for the Board of Directors of the American Academy of Emergency Medicine. I would be honored to serve. I graduated from Fisk University in 2007 with a degree in Biology, then earned a Master of Public Health in Health Management and Policy from the University of Florida in 2010. After earning my medical degree from Ross University School of Medicine, I became a member of the inaugural class of emergency medicine residents at the University of Tennessee Health Science Center, in Memphis, Tennessee.

I joined AAEM while I was a third year medical student. Coming from a Caribbean medical school, AAEM was instrumental in helping me to match into my dream specialty: emergency medicine. As you may know, matching into emergency medicine as a US international medical graduate can be quite difficult. My AAEM membership became a powerful source of information for me to strengthen my application for residency and to connect with other like-minded students and attendings. In 2013, I attended the AAEM/RSA Midwest Medical Student Symposium, which was instrumental for me to match into my top choice program.

AAEM has been a constant presence in my career and has given me a plethora of tools to support me in becoming an emergency physician. As one of only two women and the only person of color in my residency class, I desired mentorship from other women physicians. While in residency, AAEM/ RSA bridged the gap and granted me a scholarship to attend FIX17 in New York City. It was there that I connected with other AAEM members and met several mentors.

My continued devotion to AAEM comes from completing residency and now working as a community physician in Memphis. The Academy’s principal belief that all patients who seek emergency care should be seen by a specialist in emergency medicine is one that I hold dear. Memphis had been deficient in the number of emergency medicine-trained physicians for decades until my emergency program began at the University of Tennessee Health Science Center. I continue to work and live in Memphis in order to continue providing the highest level of emergency care that the local community deserves.

I currently serve the Academy in various roles, including as a Virtual Oral Board Examiner, a judge for student oral presentations during the Scientific Assembly, and as an active member of the Women in EM, Young Physicians, and JEDI sections. It would be a distinct honor to serve this organization on the Board of Directors, just as the American Academy of Emergency Medicine has served me throughout my career.

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PLATFORM STATEMENTS

Meredith Hall, MD FAAEM CANDIDATE FOR AT-LARGE BOARD MEMBER University Medical Center New Orleans Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Membership: 2000-2022 Disclosure: Nothing to disclose AAEM Activities (past five years) Louisiana Chapter Division Board of Directors Oral Board Review Course Examiner State Chapter Division Committee Member Women in EM Section Member Leadership Academy Attendee Candidate Statement for At-Large Board Member I was very excited to hear of the open positions available on the AAEM 2022 Board of Directors. During the month after Hurricane Katrina, I was in the process of preparing for my Oral Boards while cleaning up after devastating loss. I wanted to postpone my boards, but decided instead to attend an Oral Board Review Course held by AAEM. The mock examiners at that course were some of the original and “famous” faces of AAEM. They not only superbly prepared me for my boards, but they also supported me in what I was facing outside of Emergency Medicine at the time. Because of that support, I vowed to give back to AAEM. I have been an AAEM Oral Board Examiner over the years at multiple sites as well as virtually. I have served as a Director-at-Large on the Louisiana Chapter Board of AAEM and, most recently, completed my term as President of the AAEM-Louisiana Chapter.

Our chapter accomplishments include a statewide residency day, expanding our chapter, including students on our board, and a most recent successful advocation AGAINST a bill in our State legislature for Free practice authority in rural areas for APP’s. I have also supported several residents in abstract submissions for AAEM Scientific Assembly. I believe in the concept of “champion of the Emergency Physician” and am dedicated to the core values of AAEM. I feel being elected as an At-Large member on the AAEM22 National Board will afford me the opportunity of my promise to continue to give back to AAEM.

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PLATFORM STATEMENTS

Bruce Lo, MD MBA RDMS FAAEM CANDIDATE FOR AT-LARGE BOARD MEMBER Emergency Physicians of Tidewater/Eastern Virginia Medical School Nominated by: Jonathan S. Jones, MD FAAEM Membership: 2012-2022 Disclosure: Nothing to disclose AAEM Activities (past five years) AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors Capital Region (CR/AAEM) Chapter Division Board of Directors Academic Affairs Committee Member Operations Management Committee Member

Operations Management Committee Board Liaison MEMC Speaker Scientific Assembly Speaker ED Management Solutions Speaker and Planner ED Operations Certificate Course Planner Leadership Academy Attendee

Candidate Statement for At-Large Board Member It’s an honor to accept the nomination for the position of At-Large Board Member of the American Academy of Emergency Medicine. I currently serve as the chief of emergency medicine for Sentara Norfolk General hospital, a community hospital that is also the primary teaching site for resident and student at Eastern Virginia Medical School (EVMS) for the past 14 years. I also am fortunate enough to belong to a private, democratic group for the past 17 years, one of the only few remaining in the state of Virginia.

Unfortunately, over the past 2 years, we continue to be challenged with the COVID pandemic. It has shown us the challenges and fragility of the health care systems we work in and exacerbate the many issues we face in emergency medicine.

We also saw more evidence showing the danger we are facing in the hyper growth of emergency medicine residencies as the job market for not only new graduates become more restrictive, but also the downward pressure on current emergency physicians with an oversupply that benefits employers. Emergency Physicians are also continuing to be challenged by the consolidation of emergency medicine employers and the constant push by NPPs for independent practice.

It’s simply not enough to be called “heroes” in these turbulent times while expected to do more with less. We need to continue to focus on the individual emergency physicians especially regarding due process. This is where AAEM can continue to excel - representing the individual emergency physician.

I’m proud to have served on the board these past 2 years and believe we have accomplished important things, from supporting emergency physicians who faced injustice by speaking out of concern for the safety of staff during the pandemic to the recent lawsuit enforcing the corporate practice of medicine. As the pandemic continues to challenge us all, I believe it is now, more than ever, that we need to be even more proactive in shaping the future of emergency medicine. If given the opportunity, I look forward continuing to serve the membership of AAEM.

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PLATFORM STATEMENTS

Vicki Norton, MD FAAEM CANDIDATE FOR AT-LARGE BOARD MEMBER Boca Raton Regional Hospital Nominated by: Jonathan S. Jones, MD FAAEM; David A. Farcy, MD FAAEM FCCM; Mark Reiter, MD MBA MAAEM FAAEM Membership: 2007-2024 Disclosure: Nothing to disclose AAEM Activities (past five years) James Keaney Award Recipient AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors Florida (FLAAEM) Chapter Division Board of Directors and Past President Membership Committee Member State Chapter Division Committee Member and Board Liaison

Women in EM Section Council and Board Liaison JEDI-AAEM Section Member YPS-AAEM Section Member Health Policy in EM Symposium Speaker MEMC Speaker Scientific Assembly Speaker Common Sense Author

Candidate Statement for At-Large Board Member As a member of AAEM for the last 15 years, I am honored to be nominated for re-election to the Board of Directors. I am thankful for the opportunity to serve on the Board the past two years, and I continue to be passionate about the ideals and values of our organization. Every patient deserves to see a board-certified emergency physician; and every emergency physician deserves a fair, safe, and equitable practice setting. I will continue to fight the outside interests that threaten our specialty: the corporate practice of medicine and private equity control, the lack of due process for physicians, and the interference in the doctor-patient relationship.

The past two years I have served on the AAEM Board, we have made great strides toward these goals. One of our recent board decisions was to move forward with a lawsuit against Envision for the corporate practice of medicine (CPOM) in California. This case can be an example to other states to enforce their corporate practice of medicine laws and for other states to institute these laws in the future. This unanimous board decision to pursue the lawsuit was a momentous step forward in our fight against the corporate control of EPs. Additionally, I personally spearheaded a way for all of us to stay on top of new legislation and to communicate directly with lawmakers. With the launch of AAEM’s Action Center, using a software called Quorum, members can “Take Action Now” with just the click of a button to email, call, or tweet at legislators. We can craft alerts to members and have them engage in campaigns important to emergency medicine on a state and/or federal level. Emergency physicians are amazing patient and community advocates and that should not cease when they go home after a shift.

I have been an advocate for emergency medicine, inside and outside of AAEM, and will continue to be in the future. I previously served as the President of the Florida Chapter of AAEM and as the chair of the Women in Emergency Medicine committee and oversaw the committee’s transition to a formal section. This year I have been active in my state and county medical societies and served as a delegate to the annual Florida Medical Association meeting over the summer. I personally authored and advocated for 4 resolutions and had my resolution on billing transparency passed by the House of Delegates. I was also involved in the formation of Take EM Back, an advocacy group which has grown to a multi-specialty movement to fight the private equity infiltration of healthcare.

Another goal of mine is to restore due process for emergency physicians. At the AAEM Health Policy in Emergency Medicine Symposium in October, I spoke to legislators about this issue and encouraged their support of a national due process bill. Many emergency physicians sign away their due process rights in their employment contracts without realizing it. These rights are supposed to be guaranteed by medical staff bylaws, but corporate groups often take advantage of the employment contract to have EPs waive these rights. The fear of termination without due process leads to a learned helplessness and the loss of patient advocacy. AAEM has worked closely with legislators to help guarantee that due process rights cannot be waived by a third-party contract with a bipartisan, bicameral bill to be introduced this year.

Our duty as physicians is to help our patients: to be their advocates, to be their safety net when they need it most. But who will protect us, while we are in the trenches? Who will take a stand and keep fighting for physicians? I will. I will be the advocate for Emergency Medicine physicians everywhere. I ask that you vote for me to continue to serve on the AAEM Board. Thank you for this opportunity.

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PLATFORM STATEMENTS

Eugene Saltzberg, MD FAAEM CANDIDATE FOR AT-LARGE BOARD MEMBER North Chicago Federal Healthcare Facility Nominated by: Self nomination Membership: 1995-2022 Disclosure: Nothing to disclose AAEM Activities (past five years) Great Lakes (GLAAEM) Chapter Division Member Ethics Committee Member Wellness Committee Member Government and National Affairs Committee Member Candidate Statement for At-Large Board Member Founding member, now Emeritus. Have worked in private practice of EM, Contract group of EM, Salaried group of EM, VA-DOD practice of EM, current academic appointment to a medical school in Dept. of Emergency Medicine, have had supervisory role over “mid-level” EM “practitioners.” Have extensive knowledge of each of these employed situations. Belief that patient care must drive the EM workforce of EM. Have experience and knowledge to enhance the knowledge of the membership of AAEM in their choice of work situations.

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PLATFORM STATEMENTS

Kraftin Schreyer, MD MBA FAAEM CANDIDATE FOR AT-LARGE BOARD MEMBER Temple University Hospital Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; Anthony Rosania, MD FAAEM Membership: 2010-2022 Disclosure: Nothing to disclose AAEM Activities (past five years) Open Mic Competition Award Winner AAEM Physician Group Consultant Operations Management Committee Chair Speaker Development Group Member Delaware Valley (DVAAEM) Chapter Division Member YPS-AAEM Section Member Women in EM Section Member and Leadership Work Group Lead

Scientific Assembly Speaker Scientific Assembly Abstract Reviewer ED Management Solutions Speaker and Planner ED Operations Certificate Course Planner Leadership Academy Attendee Common Sense Author MEMC Speaker

Candidate Statement for At-Large Board Member To be honest, I wasn’t expecting this nomination, but I am very honored to receive it. I’m so thankful for the chance to be a part of the AAEM board, and for everyone I’ve had the opportunity to work with through AAEM thus far.

My involvement in AAEM started under the mentorship of Dr. McNamara, when I did my residency training at Temple University Hospital in Philadelphia. Since first participating with DVAAEM, over the past several years, I’ve found my home within the organization in both the Operations Management Committee and Women in Emergency Medicine Section. Both of these venues have enabled me to hone my own leadership skills while simultaneously enhancing skills of others and access to leadership opportunities. As the head of the Leadership Working Group within WiEM, I’ve had the opportunity to promote and recognize women within the organization, and look forward to future opportunities to continue to do so. As chair of the Operations Management Committee, I’ve been fortunate to be involved with AAEM’s operations courses, EDMS and EDOCC, notably as the most junior and only female instructor.

I continue to practice emergency medicine at Temple, and, as a physician at an academic institution, I am also passionate about resident and student education and the training of the future generations. Through WiEM and OMC, we’ve begun to develop mentoring programs and centralized repositories of educational materials, which I plan to expand. It is so important to engage trainees, not only about the core foundations of emergency medicine, but how to best thrive in the current environment.

Now, perhaps more so than ever, emergency medicine is challenged. Challenged with COVID surges, staffing shortages, limited capacity, and internal and external threats to physician independence and wellness. As an operations leader, my goal is to fix the broken system within which we all work.

I’ve worked tirelessly to do this within my department, hospital, and health system. At each step, I’ve realized the need to drive change from the next higher level. I can confidently say that I’m ready to drive needed change on the national level, and I know that AAEM is the organization through which that can be achieved. I’d be honored to have a part in what is to come as a member of the AAEM board.

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PLATFORM STATEMENTS

41301A45-9F26-43A9-A4A8-8054EF13D421 - Fred Kency.jpeg

https://drive.google.com/file/d/1jrW23UG3mnhPmEiljraY1X8pPWQY...

Fred E. Kency, Jr., MD FAAEM CANDIDATE FOR YPS DIRECTOR University of Mississippi Medical Center Nominated by: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM; Jonathan S. Jones, MD FAAEM Membership: 2015-2022 Disclosure: Mississippi ACEP State Councilor

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AAEM Activities (past five years) AAEM Board of Directors AAEM Foundation Board of Directors AAEM LEAD-EM Board of Directors AAEM/RSA Board of Directors AAEM/RSA Education Committee AAEM/RSA Diversity & Inclusion Committee 2/15/2022, 5:15 PM

YPS-AAEM Council JEDI-AAEM Section Member and Work Group Lead Women in EM Section Member Scientific Assembly Abstract Reviewer Oral Board Review Course Examiner Common Sense Author

Candidate Statement for YPS Director Fred Earl Kency Jr, MD, FAAEM FACEP is a board-certified emergency physician and a native of Jackson, Mississippi who is passionate about men’s health. He received his Bachelor’s of Science in Biology from Alcorn State University and his Doctorate of Medicine from the University of South Alabama College of Medicine in Mobile, Alabama. Dr. Kency proudly served in the United States Navy for four years, and was deployed to Africa and Europe, prior to his honorable discharge. He returned home to Jackson, MS to complete his emergency medicine residency at the University of Mississippi Medical Center.

Dr. Kency has been a member of AAEM since 2015. He has served in many leadership roles to include AAEM’s Resident and Student Association (RSA) Board of Directors, AAEM’s Young physician Section (YPS) council member, and most recently elected as AAEM YPS Director. He has served on a host of committees within AAEM/RSA and YPS. Dr. Kency wants to continue his leadership in AAEM with another term as YPS Director to continue to move the young physicians in the section forward with headship training, financial awareness training, and continuing to be an advocate for Justice, Equity, Diversity, and Inclusion.

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

Make Your Money Grow: Best Practices in Investing James M. Dahle, MD FACEP FAAEM

I

nvesting is simply delaying spending in hopes of being able to spend or give even more money away later, and is an important part of reaching any serious financial goal. One cannot invest what one does not have, so the first part of investing is simply saving. You save money any time you spend less than you earn and the truth is that the vast majority of people, including physicians, spend more money than they should. The average American savings rate has varied widely over the last few decades. It was over 10% until the mid-80s, but subsequently has been in the 7% range, with one brief dip under 3%. While temporarily higher during the COVID pandemic while travel and spending has been particularly difficult, it has been returning to historical ranges as the pandemic wanes. Physicians are likely no different. Annual surveys by Medscape show 60% of doctors are saving less than $3,000 per month.

Given the average annual physician income of $275,000, that means well over half of doctors have a savings rate under 13%.

How much should doctors be saving? If they run the numbers with any sort of reasonable assumptions, most doctors will arrive at a necessary savings rate of around 20% of gross income, and that’s just for retirement. Any money that goes toward extra debt payments, college savings, a second home, or a sports car is in addition to that.

The best place to start any endeavor is at the beginning, and when it comes to building wealth, the beginning is figuring out where you are at. Check your financial records. Add up all of your financial assets.

Include the value of your house and anything that can readily be priced and sold such as vehicles. Then pour a stiff drink and add up all of your debts. Subtract the debts from the assets and that will give you your net worth. Now, calculate your savings rate for the last year. Just focus on retirement for now. Determine how much you made (the easy way is to look at the total income line from your tax return). Add up how much you saved for retirement and divide it by your total income. Was it more than 20%? Less than 20%? Much less than 20%? If so, it is likely time to get really serious about financial planning, including a written spending plan or budget.

Now that you know where you are at, consider where you want to be.

The biggest mistake investors make is that they don’t have any sort of written goals, nor a plan to reach them. Investing is all about reaching your goals. If you don’t know where the finish line is, how will you know when you reach it or how much effort you need to put toward arriving there?

Once you have a goal and a general idea of how much money you need to put toward it each year, consider what accounts there are available to

assist you in reaching that goal. The US government actually wants you to save for your retirement and has heavily incentivized you to do so by providing substantial tax breaks to investors. Some of the greatest tax breaks available to physicians include tax-protected retirement accounts such as 401(k)s, 403(b)s, 457(b)s, SEP-IRAs, Roth IRAs, profit-sharing plans, and cash balance plans. If you are employed, become an expert in the plans provided by your employer. If you are an independent contractor, you have more control but also more responsibility in this regard.

You will need to set up your own retirement account, usually in the form of an individual 401(k). If you need to save more for retirement than will fit into retirement accounts, you can always save an unlimited amount in a simple taxable account, sometimes referred to as a non-qualified or brokerage account. There are still tax benefits available such as lower qualified dividend or long-term capital gains tax rates or the ability to use depreciation to offset income from the investment.

Once you know how much to save and where you are going to save it, the next step is to choose the types of investments that you will invest in.

The mix of these types of investments is known as an asset allocation.

Diversification, not putting all of your eggs in one basket, is the guiding principle here. While you will almost certainly need to take substantial risk to meet your goals, do not take more than you need to and certainly avoid risks that are unlikely to provide sufficient reward for the risk taken.

Most portfolios are dominated by three asset classes, or types of investments—stocks, bonds, and real estate. More exotic asset classes, ranging from commodities to precious metals to cryptocurrencies can be added in small quantities if desired. Even within the big three categories, there are an infinite number of subclasses that can be used. The key is to maintain broad diversification, take on an adequate amount of risk but not too much, and to stick to your reasonable, long term plan even when the talking heads on TV and even your own stomach are making you

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By their very nature, people are disposed to make all kinds of behavioral errors that lead to poor investment returns.”

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

You save money any time you spend less than you earn and the truth is that the vast majority of people, including physicians, spend more money than they should.”

worry about that money during the next economic downturn. If you are like most investors, you will find that the majority of your portfolio will need to be invested in risky assets like stocks and real estate in order to reach your financial goals. Investing only in safe asset classes, such as bonds, will require you to save much more than 20% of your gross income for retirement. However, bonds and other safe asset classes will moderate the volatility of the portfolio and make it much easier to stay the course in a market downturn.

Once you have decided on your asset allocation, it is time to choose investments. Most retirement investors lean toward mutual funds, where they can pool their money together with other investors to benefit from professional management, economies of scale, broad diversification, and easy liquidity. The academic literature is very clear that mutual funds that try to match the market rather than beat it usually have higher long-term returns, especially after tax. These mutual funds are known as low cost index funds, and an investor need invest in nothing else in order to be successful. Index funds are available for stocks, bonds, and even real estate.

Unfortunately, many times the investor matters more than the investment. By their very nature, people are disposed to make all kinds of behavioral errors that lead to poor investment returns.

These include trying to time the market, panic selling at market bottoms, picking individual stocks, and chasing performance with the latest hot asset class, whether it be tech stocks, gold, or Bitcoin.

Staying the course with your reasonable long-term plan is actually far more important, and perhaps far more difficult, than coming up with the plan in the first place.

Investing is an important aspect of your financial plan. The sooner you get a plan in place, the easier it will be to reach your goals.

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.1 1. https://www.whitecoatinvestor.com/

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HEART OF A DOCTOR

Six Hour Sacrifice Pavitra Parimala Krishnamani, MD MS

“Y

ou gotta make your night shifts count,” Dr. Nguyen once said to me, “Don’t you know, for every switch you make between days and nights and vice versa, you sacrifice about six hours of your life.” It was a statistic that my attending physician invented at three o’clock in the morning on a shift we had together at my local children’s hospital. We laughed it off, staying positive throughout our shift, but his statistic was based on real-world data. Individuals working night shifts are at an increased risk of obesity, heart disease, cancer, and a loss in their quality and quantity of life. How much? Well, that we don’t know quite yet.

‘Six hours,’ I thought to myself as I drove back home afterwards, ‘That’s significant given the number of times I’ve switched between days and nights in residency alone.’ The fact that working nights had risks associated with it was never lost on me, but the quantification of those risks seemed oddly profound that morning as I drove back to my home and family. Working at a children’s hospital on my pediatric emergency medicine month had me wondering if I had just missed out on six more hours I could have spent with my future children in my golden years, or six more hours I could have spent holding my future grandchildren.

I shook off the conjecture before falling asleep that day. Little did I know that the following night, I’d be reminded what those six hours were worth.

When I got back to work that night, I saw a lot of toddlers with colds, some kids with stomach upsets who had been waiting since earlier in the day to be evaluated by a physician, and one Lia Raman who never thought she would be in the hospital that night. Rather, Lia Raman and her parents would have preferred to be anywhere else.

Working at a children’s hospital…had me wondering if I had just missed out on six more hours I could have spent with my future children in my golden years, or six more hours I could have spent holding my future grandchildren.”

Lia, barely into elementary school, had struggled with an aggressive type of brain cancer since she was a toddler. Her parents celebrated with her when she went into remission and held her in their arms as their hearts collectively broke when her cancer came back a little over a year before that night. Lia Raman looked like any other small child: thin spindly legs, soft dark hair in a bowl cut, small hands grasping up for her mother as she tried to cope with her distress.

“She was just her usual self yesterday; we had family over for the holiday and she was showing them her new dances and songs. Then, tonight, she woke up, suddenly held her head in her hands and told me, ‘Mumma, it hurts,’” Mrs. Raman said to me and the rest of Lia’s medical team. She looked lost as she continued, “Then, she started vomiting, and we knew something was wrong.”

Lia lay there, barely responding to our questions and commands, a far cry from the person her mother described she had been just hours ago. Only Mrs. Raman, dutifully standing by Lia’s bedside holding her hand and softly brushing her hair, could elicit a response from the visibly uncomfortable child who had just been rushed into our emergency department.

To receive treatment for her brain cancer, Lia had a small device placed into her ventricles. The device, called an Ommaya reservoir, tracks back up through the skull, allowing for the delivery of chemotherapeutic medications. Though its access point located underneath the scalp normally feels like a soft bleb, Lia’s felt like a hard marble of fluid bulging out of her skull.

Looking through her chart, it was obvious that the tumors in her brain and spinal cord were plenty and quickly increasing in size and number.

Most concerning was the possibility that a new tumor or growing one could have blocked off the flow of fluid through Lia’s ventricles, leading to increased pressure inside her skull. Certainly, that would explain the bulge we felt on Lia’s head. It also meant that Lia could be very close to experiencing a cerebral herniation and the life-threatening complications that would accompany it.

Lia responded less and less after a few minutes with us and her heart rate started slowly decreasing. Her blood pressure, on the other hand, increased. My attending physician, fellow and I all agreed that these were early signs of a cerebral herniation and that it would best to protect her ability to breathe with an intubation while we coordinated the rest of her care. We explained the procedure to Mrs. and Mr. Raman and prepared ourselves.

“You’re up for this intubation, ready?” my attending physician asked rhetorically.

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HEART OF A DOCTOR

“Me?” I hadn’t expected to be given the opportunity to intubate a child while working alongside a pediatric emergency medicine fellow. “Are you sure? You know that I’ve never intubated a kid before, right?” I quietly inquired.

“Always a first time, I’ll walk you through it. You’ll be using a Miller for the procedure though,” she said.

“Are you sure?” I confirmed with my attending physician, “I usually use a Mac.” Reviewing my experiences using a Miller in prior simulation sessions, I placed the straight metal blade next to a near unconscious Lia Raman.

“Yes, you can do it, it’s just like you’ve practiced throughout medical school and residency,” my attending physician encouraged, sensing my hesitation.

It wasn’t. It was nothing like my experience in the many simulation sessions I had throughout medical school and residency, where the plastic dummy in front of me didn’t have a life to lose. That night, Lia lay helpless in front of me, her parents’ eyes trained on me as they held on to one other in what can only be described as a significantly devastating moment in their lives. I looked over at both Mrs. and Mr. Raman, whose hopeful eyes followed me as I pulled together my materials and put on an aura of confidence. That night, their child’s ability to stay alive, if even just for another six hours, depended on how safely I would be able to intubate her.

“78% oxygen saturation,” my fellow yelled out, getting ready to place her finger on Lia’s pulse. We were running out of time.

“Good view, keep your view,” my attending physician encouraged. I reached back for the endotracheal tube, quickly glanced over at it to turn it right side up myself, and dove through the vocal cords with it before Lia’s oxygen saturation dipped any lower. The respiratory therapist swiftly attached a silicone bag onto the tube and started squeezing it to give Lia some breaths. We knew the breathing tube was in the right place, but Lia’s vital signs would take a moment to catch up.

My breaths sounded heavy under my mask, my face felt warm, every second that went by came with a pounding in my chest that I somehow felt resonating in my ears. “Come on, oxygen,” I whispered to myself as I held on to the breathing tube tightly and watched Lia’s vital signs on her monitor. Lia’s parents seemed to sense that the numbers on that screen were important and that those numbers had the entire medical team on edge. As Lia’s oxygen saturation rose, our collective stress levels diminished.

That night, [Lia’s parents] had courageously placed their daughter’s future in the hands of her medical team, just to have more time with her.”

I stood at the head of the bed at two o’clock in the morning, watching Lia and her vital signs closely as we gave her the usual cocktail of pre-intubation medications. Lia’s parents watched as I tried to get a good view of their child’s vocal cords. In mere seconds, Lia’s oxygen saturation had dropped into the low 90s and then into the 80s. My attending physician stood next to me as I struggled to find Lia’s larynx and hold my apprehension at bay amidst the pressure I felt. After what felt like a century, I caught a view of Lia’s elusive vocal cords and asked for the breathing tube, which our respiratory therapist handed to me upside down.

“Would you turn it right side up, please,” I said, handing it back.

Her oxygen saturation was at 92% when the respiratory therapist physically pried my hand off the endotracheal tube to secure it in place.

She flashed me a smile under her mask “Sorry about the mix-up, I was still getting accustomed to the equipment,” she said sheepishly.

I nodded and smiled back, knowing full well how great she was at her job. “No worries,” I wanted to say, “We got the tube in.” But my words were gone, muted by the adrenaline still coursing through my veins. Of the three ‘Fs’ in a classic stress response, “fight, flight, or freeze,” my body had decided to freeze.

I hadn’t realized how stiff I had become in the moments it took for Lia’s oxygen saturation to recover. Those moments felt like eons and every hair in my body remained standing at attention, as if ready to rush into battle. In those moments, I had imagined the worst-case scenario of Lia coding—imagined having to perform CPR on her, imagined her parents’ horrified expressions as we swept them out of the room with an explanation as to what happened, imagined their anguish. I released those thoughts along with the breath I had been holding in all along.

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HEART OF A DOCTOR

“You did great,” my attending physician said, placing a slight hand on my back. I was momentarily startled.

“Really? That was terrifying,” I whispered to her, barely able to speak.

“It wasn’t easy, and you got it in pretty quickly on the first attempt. That’s just how it feels the first time around.”

I nodded, pulling much needed strength into my own vocal cords before debriefing with Lia’s parents about the procedure. As I left the medical resuscitation room, I thought about how harrowing it was to intubate a child I had just met, and how harrowing it must have been for Lia’s parents to see their baby intubated by a physician they had just met. That night, they had courageously placed their daughter’s future in the hands of her medical team, just to have more time with her.

Emergency physicians are here for our communities twenty-four hours a day, seven days a week. We’re here every Christmas a father falls off his ladder while installing lights on the tree outside his home and every night a child wakes up vomiting or unable to breathe. All we ask for in return is kindness, patience, and a system that is as committed to caring for our patients as we are. Dr. Nguyen may be right—it’s possible that I had lost six hours of my life, maybe even twelve, on that string of night shifts.

But, on my drive home after meeting Lia and her family, I wasn’t thinking of the hours of my future I had sacrificed. I was thinking of the hours of future that Lia now had to spend with her loving family.

28 TH ANNUAL SCIENTIFIC ASSEMBLY SEE YOU IN BALTIMORE - APRIL 23-27, 2022 aaem.org/aaem22 COMMON SENSE MARCH/APRIL 2022

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PREVIEW OF THE 28 TH ANNUAL SCIENTIFIC ASSEMBLY WELCOME TO BALTIMORE! On behalf of the Scientific Planning Subcommittee of the American Academy of Emergency Medicine, we are looking forward to welcoming you to the AAEM 2022 Scientific Assembly and to Baltimore, Maryland. This event is one of the most anticipated academic conferences of the year, with a focus on cutting edge clinical medicine as well as practical application to patient care.

The Scientific Assembly will take an innovative and practical look at various topics within emergency medicine that are shaping our field of practice.

We are excited to provide the opportunity to expand the conversation on the topics of toxicology, cardiology, critical care, infectious disease, and many more. By combining discussion from leading scholars with innovative medical nuances, we hope to provide a resource to enhance the understanding of our beloved specialty. Additionally, special attention has been dedicated to ensure that participants’ health and safety are maintained throughout this phenomenal conference.

The planning committee has invested significant time and thought to ensure that every participant has an educational, enjoyable, and safe experience in Baltimore. We look forward to sharing these amazing topics and engaging presenters with you.

We look forward to seeing you in Baltimore!

CO-CHAIR

CO-CHAIR

VICE CHAIR

Laura J. Bontempo, MD MEd FAAEM

George C. Willis, MD FAAEM

Christopher Colbert, DO FAAEM

KEYNOTE ADDRESS: OUR PATIENTS, OUR SPECIALTY: AAEM-PG VERSUS ENVISION AND THE FUTURE OF EM Tuesday, April 26, 2022 | 1:30pm – 2:15pm The AAEM suit against Envision (EmCare) is a momentous event for our specialty and our patients. AAEM is asking the courts to invalidate the contractual scheme used by Envision to skirt the patient protections inherent to the prohibition on the corporate practice of medicine.

ROBERT M. MCNAMARA, MD MAAEM FAAEM

MARK REITER, MD MBA MAAEM FAAEM

AAEM has filed suits in the past against corporate interests with favorable results, but this litigation is significantly different. Join Dr. Robert McNamara and Dr. Mark Reiter as they break down what the lawsuit means for emergency physicians and our patients. This will be an enormous undertaking, but this is the hill we must fight on for the soul of our specialty. The future of EM is at stake – are you ready to join the battle?

VISIT THE AAEM22 WEBSITE FOR FULL EDUCATIONAL DETAILS INCLUDING SESSION TITLES, SPEAKERS, AND MORE! WWW.AAEM.ORG/AAEM22

SIX EM DOCS WALK INTO A SHIFT SHOW Sunday, April 24, 2022 | 3:40pm - 5:30pm Speakers from the AAEM Critical Care Medicine Section, EMS Section, Emergency Ultrasound Section, Justice, Equity, Diversity and Inclusion Section, Women in EM Section, and Young Physicians Section walk you through a series of patient encounters during a natural disaster. Follow Dr. Molly Estes as she treats multiple patients in the wake of a hurricane, sharing her thought process, as she draws insight from all six sections to manage the storm after the storm. Can she keep a level head and save these patients? Could you?

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COMMON SENSE MARCH/APRIL 2022

BREVE DULCE These ever-popular “short and sweet” sessions are seven-minute overviews with 25 slides packed full of information! Plan to catch a variety of Breve Dulce topics at AAEM22 to round out your educational experience. Every 10 minutes there’s a new topic!

MEETING OF THE MINDS Watch as prominent EM practitioners debate the pros and cons of the latest practice-changing articles in critical care and medical ethics.

Bring your questions for an audience Q&A with the experts.

COMPETITIONS Plan to browse the poster displays or attend abstract presentations at AAEM22. The following competitions will be taking place during the conference.

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

Learn more at www.aaem.org/aaem22/program/competitions

SMALL GROUP CLINIC TAKE TIME TO CELEBRATE AND RECHARGE AT SOCIAL, JEDI, AND WELLNESS EVENTS THROUGHOUT AAEM22.

These sessions provide personal and hands-on education. At AAEM22 25 slots will be filled with advanced registration and 5 slots will be available on a first-come, first served-basis. These sessions are only available to in-person attendees.

RELAX & RECHARGE WITH WELLNESS EVENTS Not only does AAEM22 offer enriching education, it is also a motivational retreat where you leave feeling a renewed passion for emergency medicine. Throughout the Assembly, stop by the Wellness Room for a sanctuary from the conference bustle. New this year: Book Exchange in the Wellness Room. The AAEM Wellness Committee has also planned the following events to participate in: F3 Wellness Meals, Early Risers Yoga, Airway at AAEM, Wellness Paint’n Sip, and New Attendee Reception. Some events require pre-registration.

Learn more at https://www.aaem.org/aaem22/program/networking-events

AAEM/RSA RESIDENT TRACK AT AAEM22 RESIDENCY TO THE REAL WORLD: THE MISSING CURRICULUM April 26, 2022 | 10:15am - 6:15pm The AAEM/RSA Resident Track programming is selected by residents for residents. The goal of the track is to prepare residents for their careers in emergency medicine by concentrating on topics such as career success, clinical topics, and social detriments of health. The session concludes with the AAEM/RSA Breve Dulce Competition, featuring five resident presentations on the theme of “Great Catch: A difficult diagnosis,” a challenging presentation, or a nearmiss that might change the way that way you approach that topic.

NETWORK AT SOCIAL EVENTS Join AAEM for networking and other fun activities throughout the Assembly. Kick off AAEM22 at our Opening Reception enjoy light hors d’oeurves and drinks while networking with colleagues and exhibitors, then join JEDI for an offsite reception. Spend time with the Women in EM Section at their Networking Lunch. Explore opportunities to get involved in AAEM with the Chapter Divisions and Sections Social. Attend Airway at AAEM for an evening which promises to showcase the great range of human experience—to enlighten minds, expose vulnerabilities, and quietly suggest ways to overcome the challenges we all face each day.

Learn more at www.aaem.org/aaem22/program/networking-events COMMON SENSE MARCH/APRIL 2022

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PREVIEW OF THE 28 TH ANNUAL SCIENTIFIC ASSEMBLY PLENARY SPEAKERS PANEL: JUSTICE, EQUITY, DIVERSITY & INCLUSION: THE WAY FORWARD

PEM LITERATURE UPDATE Monday, April 25, 2022 | 4:15pm – 5:00pm

Sunday, April 24, 2022 | 1:40pm – 2:25pm Ilene Claudius, MD FAAEM Al’ai Alvarez, MD FAAEM FACEP

Cortlyn Brown, MD FAAEM

Mimi Lu, MD FAAEM

HEMORRHAGE CONTROL Tuesday, April 26, 2022 | 1:30pm – 2:15pm Italo M. Brown, MD MPH Deborah M. Stein, MD MPH David Davidson, BA MEd

SICKLE CELL PATIENT PANEL Wednesday, April 27, 2022 | 8:00am – 8:45am

Joanne Williams, MD MAAEM FAAEM

Isaiah Dudley

THE ROLE OF ULTRASOUND IN RESUSCITATION Sunday, April 24, 2022 | 2:25pm – 3:10pm

Tenesha Dudley

Haney Mallemat, MD FAAEM Joshua Morales, MD

RECENT RESUSCITATION ARTICLES YOU’VE GOT TO KNOW! Monday, April 25, 2022 | 8:00am – 8:45am

Jack Perkins, MD FAAEM

Michael Winters, MD MBA FAAEM Kenya Thompson

RECENT IMPORTANT ARTICLES FOR EMS PHYSICIANS AND THE ED TOO Monday, April 25, 2022 | 10:45am – 11:30am

EMERGENCY CARDIOLOGY 2022: THE ARTICLES YOU’VE GOT TO KNOW! Wednesday, April 27, 2022 | 10:30am – 11:15am

Corey M. Slovis, MD FAAEM Amal Mattu, MD FAAEM 38

COMMON SENSE MARCH/APRIL 2022

AAEM22 SPEAKERS Michael K. Abraham, MD FAAEM Frosso Adamakos, MD FACEP FAAEM Jason Adler, MD FAAEM Haig Aintablian, MD Leen Alblaihed, MBBS MHA FAAEM Afrah A. Ali, MBBS FAAEM Al'ai Alvarez, MD FAAEM FACEP Zeki Atesli, MD Chelsea Ausman, MD Jerome Balbin, MD FAAEM Stacey Barnes, DO FACEP FACOEP FAAEM Rahul G. Bhat, MD FAAEM Neha Bhatnagar, MD Michael Billet, MD FAAEM Jim Blakeman Eliot Blum, MD FAAEM Laura J. Bontempo, MD MEd FAAEM Joelle C. Borhart, MD FAAEM Molly Boyd, MD * William J. Brady, MD FAAEM Andrea Brault, MD MMM FACEP Daniel Brillhart, MD FAAEM Cortlyn Brown, MD FAAEM Italo M. Brown, MD MPH Josh Bukowski, MD FAAEM Katharine Burns, MD FAAEM Kenneth H. Butler, DO FACEP Christine Butts, MD FAAEM Elisabeth Calhoun, MD MPH FAAEM David J. Carlberg, MD FAAEM Matthew Carvey, MD EMT-P FP-C Wan-Tsu W. Chang, MD FAAEM Eric Chin, MD MBA FAAEM Ilene Claudius, MD FAAEM Christopher Colbert, DO FAAEM Wesley Oliver Cook Neil K. Dasgupta, MD FAAEM FACEP * Suchismita Datta, MD FAAEM Peter DeBlieux, MD FAAEM Matthew DeLaney, MD FAAEM Pierre G. Detiege, MD FAAEM Dolly-Davis Dollberg Tina Doshi, MD MHS Christopher I. Doty, MD MAAEM FAAEM FACEP Isaiah Dudley Tenesha Dudley Luke Duncan, MD Erick Eiting, MD FAAEM Jessica Eker, MD

Brandon A. Elder, MD FAAEM FAWM Molly K. Estes, MD FAAEM FACEP Bryan Everitt, MD NRP Cheyenne Falat, MD Cayla Fappiano, MD David Fernandez, MD Jessica Fleischer-Black, MD FAAEM Gus M. Garmel, MD FAAEM FACEP J. David Gatz, MD FAAEM Sean P. Geary, MD FAAEM Harman S. Gill, MD FAAEM Jim Gill, MD MBA FAAEM FACEP * Daniel B. Gingold, MD MPH FAAEM Jacob K. Goertz, MD FAAEM June Gordon, MD FAAEM Michael Gottlieb, MD FAAEM Karen Greenberg, DO FACOEP FAAEM FAHA John C. Greenwood, MD FAAEM Kimberly Groen, DO MPH Joshua Guttman, MD FRCPC FAAEM Bryan D. Hayes, PharmD FAACT FASHP Michael Hayoun, MD MPhil FAAEM Megan Healy, MD FAAEM Melanie Heniff, MD JD FAAEM Matthew Hessel, MD FAAEM Jason Hine, MD FAAEM Matthew B. Hoekstra Beatrice Hoffmann, MD PhD FAAEM Kami M. Hu Windsor, MD FAAEM FACEP Korin B. Hudson, MD FAAEM FACEP Maite Huis in 't Veld, MD FAAEM Meghan M. Hurley, MD Mercy M. Hylton, MD MBA FAAEM* Ashley Iannantone, MA Ryan C. Jacobsen, MD FAAEM FACEP FAEMS Rashmi A. Jadhav, MD Ashika Jain, MD FAAEM FACEP RDMS Paul S. Jansson, MD MS FAAEM Kristine Jeffers, MD FAAEM Jonathan S. Jones, MD FAAEM Andrea L. Kaelin, MD FAAEM RDMS Jeremy M. Kaswer, MD Danya Khoujah, MBBS MEHP FAAEM Patrick G. Kishi, MD FAAEM Adeola Kosoko, MD FAAEM FAAP Andrew J. Kuschnerait, MD Diana Ladkany, MD FAAEM

Michelle Lall, MD FAAEM Michael J. Lambert, MD RDMS FAAEM Lauren Lamparter, MD Rachel Le, MD Scott J. Leuchten, DO FAAEM * Jason J. Lewis, MD FAAEM Mimi Lu, MD FAAEM Joshua Lynch, DO FAAEM FACEP Haney Mallemat, MD FAAEM Wayne A. Martini, MD Amal Mattu, MD FAAEM Joel A. Miller, MD FAAEM Siamak Moayedi, MD FAAEM Joel Moll, MD FAAEM Malia J. Moore, MD FAAEM Joshua Morales, MD Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Landon Mueller, MD FAAEM Neeraja Murali, DO MPH FAAEM FACEP * Lauren T. Murphy, MD FAAEM * Melissa Myers, MD FAAEM Robert K. Needleman, MD FAAEM Mark A. Newberry, DO FAAEM FACEP Craig Nowadly, MD Ava Omidvar, MPH FP-C Jessica Palmer, MD Brian Parker, MD MS FAAEM Daven Patel, MD MPH Jack Perkins, MD FAAEM Andrew Phillips, MD MEd FAAEM Gregory M. Polites, MD FAAEM Elizabeth Pontius, MD FAAEM Marco E. Propersi, DO FAAEM Michael Pulia, MD MS FAAEM Renato Rapada, DO Mark Reiter, MD MBA MAAEM FAAEM Jennifer Repanshek, MD FAAEM Zachary Repanshek, MD FAAEM Rebekah Riordan, MD Lauren S. Rosenblatt, MD Rebecca J. Rubenstein, MD Alexis Salerno, MD FAAEM Nima Sarani, MD FAAEM

Alan J. Sazama, MD FAAEM Kraftin E. Schreyer, MD MBA FAAEM Alexander Sheng, MD FAAEM Joseph Shiber, MD FAAEM FACP FCCM FNCS Richard D. Shih, MD FAAEM Mari Siegel, MD FAAEM FACEP Zachary J. Sletten, MD FAAEM Corey M. Slovis, MD FAAEM HS Smith Dmitri Souza, MD PhD FASA Ryan Spangler, MD FAAEM Deborah M. Stein, MD MPH Eric Steinberg, DO MEHP FAAEM Bryan Stenson, MD Kathleen Stephanos, MD FAAEM Sean Stuart, DO FAAEM FACEP FAWM Tina W. Sundaram, MD MS FAAEM Mark Sutherland, MD FAAEM Loice A. Swisher, MD MAAEM FAAEM Lloyd Tannenbaum, MD FAAEM William G. TenBrink Jr, MD FAAEM Kenya Thompson Loren Touma, DO MS Joseph R. Twanmoh, MD MBA FAAEM Emilee Venn, DVM MS DACVECC Julie T. Vieth, MD FAAEM Elias Wan, MD FAAEM James Webley, MD FAAEM Benjamin White, MD FAAEM Anne Whitehead, MD FAAEM FACEP Dominic M. Williams, DO Joanne Williams, MD MAAEM FAAEM George Willis, MD FAAEM Michael Winters, MD MBA FAAEM Matthew L. Wong, MD MPH FAAEM Gregory Wu, MD FAAEM Allison Zanaboni, MD FAAEM Robert Zemple, MD MBA FAAEM Matthew Zuckerman, MD FAAEM Speakers subject to change. * Speaker Development Group mentee

COLLABORATE AND NETWORK WITH COLLEAGUES FROM AROUND THE WORLD.

COMMON SENSE MARCH/APRIL 2022

39

PREVIEW OF THE 28 TH ANNUAL SCIENTIFIC ASSEMBLY

THANKS TO OUR 2022 INDUSTRY PARTNERS AAEM extends its thanks and appreciation to the following industry partners who have funded activities at the 2022 AAEM Scientific Assembly.

CHAMPION SPONSOR – $50,000+ SUPPORT LEVEL • Bayer Crop Science GOLD SPONSOR – $20,000-$49,999 SUPPORT LEVEL • Abbott Point of Care • Gilead Sciences IN-KIND SPONSOR • EchoNous, Inc. • EMedHome • FUJIFILM/SonoSite • Gaumard • Green Cloud Apparel • Intelligent Ultrasound • Karl Storz Endoscopy - America, Inc. • University of Maryland School of Medicine Department of Emergency Medicine • Verathon

AAEM22 EXHIBITORS – THANK YOU Plan your visit to the exhibit hall in Baltimore to network with these exhibitors: • • • •

Abbott Point of Care • Emergency Care Partners ABEM • ER Doc Finance AMBOSS • First Responder Network Authority (FirstNet) American Society of Regional Anesthesia • Fisher & Paykel Healthcare, Inc. and Pain Medicine (ASRA) • Gilead Sciences • Bayer Crop Science • GSK • Biodynamic Research Corporation • Hippo Education Inc. • BrainScope • IntuiTap Medical • Brault Practice Solutions • LogixHealth • C2Dx • NeurOptics, Inc. • Change Healthcare • Patient First • EchoNous, Inc. • PEPID, LLC Please visit https://www.aaem.org/aaem22/exhibitors-sponsors for the most up-to-date list.

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• • • • • • • • • • •

PracticeMatch Praxi Management Premier Physician Staffing R1 RCM Spectral MD The Dental Box Vapotherm Inc. Ventra Health Vituity WestJEM Zerowet, Inc

Spring

ACADEMIC AFFAIRS COMMITTEE

Mary Claire O’Brien, MD FAAEM

“Do they know?” I asked one of the paramedics.

“No,” he said. “They don’t.”

Doctors have memory aides to use for how to break bad news—mnemonics, acronyms, little lists devised to help us remember what to say. I can never remember the mnemonics. I always think: there will be so many questions…

Questions. That’s my reminder. Who, what, when, where, [pause], why, how?

S

prng in Winston-Salem is glorious to behold.

Tiny white snowdrops are the first to appear, then gold and amethyst crocuses, proud trumpeting yellow daffodils, and a dazzling rainbow of tulips.

Pansies that have been sleeping in beds of licorice mulch shrug off their thin blanket of snow, rub their faces in the brisk rain, and wake up. The redbud trees comes alive with delicate purple blossoms. Bradford pear trees, then magnolias. Star magnolias with delicate white flowers against dark gray bark. Saucer magnolias—Mulan Trees—enormous pale pink blossoms that look like hands folded upright in prayer. Cherry trees: weeping, Black, and laurel. Exuberant dogwoods. A few deep heady breaths of wisteria… and summer is here.

It was drizzly on that beautiful Sunday morning in spring many years ago when a 16-year-old driver lost control of her car and slid over an embankment, flipping upside down into a teeming creek. Her 8-year old-brother managed to scramble out a back window unhurt. The girl was unconscious, buckled fast in her seatbelt. She drowned. Medics found her pulseless but it was too awful to give up on that child at the scene.

They did CPR and came lights and sirens to the ED. She was dead.

I pronounced her.

The nurses put her soggy church clothes in a brown paper bag for the medical examiner, as required by law. They lifted her chin and straightened her arms. They tucked warm white blankets around her. They tilted up the head of the stretcher so that it would look like she was sleeping.

She wasn’t sleeping—she was dead. And I had to tell her mother.

Everyone was assembled in the waiting room—her mother, her little brother wrapped in a blanket, her aunts and uncles, a few neighbors, her grandmother, and their pastor.

I choked with rage. WHAT KIND OF GOD allows a beautiful young girl to drown on a Sunday morning in the BEAUTIFUL SPRING OF HER LIFE while she was driving her little brother to church?! It was impossible to comprehend.

Who are the people in the family room? I introduce myself and offer my hand. I make eye contact with each person and acknowledge their relationship. Without asking directly, I am trying to identify the closest member of kin. I sit down.

When your [husband/wife/mom/dad/daughter/son/sister/brother/friend] got here…] I start. I explain what things were like when the patient first arrived. They were lethargic, they were seizing, they had no heartbeat.

Then, where things went after that. We gave them medicine, we did CPR, we did a CT scan, we gave them blood, we put them on a breathing machine.

Then, a pause.

The emergency department visit is their story, not yours.”

“I’m afraid I have very difficult news.” I brace myself to say the “D” word. “I’m so terribly sorry,” I say. “She died.”

No medical jargon. No euphemisms. “She died.” You have to say it.

Sometimes the wheels come off. The mother screams and it hits you like lightening. The aunts wail, grabbing one another’s hands, rocking on their plastic seats. An uncle bangs the plaster wall with his heavy fists, cursing and pounding, rattling the cheap emotionally neutral landscape print hanging there above the mother. A neighbor might throw a chair. And sometimes, someone in the family falls to the ground, shaking uncontrollably—not a seizure, but to everyone there assembled it looks like one—a shocking, horrible, physical outpouring of grief.

You sit there, letting it wash over you like battery acid. You try not to cry.

Why did it happen, they will want to know.

“I don’t know,” I mumble. Sometimes it’s a heart attack or a burst aneurysm, and you can offer this, “I’m sure when he slumped over that was the last thing he knew. I’m sure it was quick. I’m sure he didn’t suffer.”

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Finally. This is how the body will look. ‘I’ll go in with you. I’ll help you.”

“Yes.”

What questions do you have for me? Here is the telephone number for Decedent Affairs. This is Diane, our Patient Family Coordinator. She will explain what you need to do. We will help you. It is always awful.

“Welcome your loving servant home, Lord. Help us, Lord, to bear the agony of this separation. Give us strength to wait upon her Lord, just as we wait upon You. Carry us, until we see You, and until we see her again in Glory.”

This Sunday morning in spring, this family was quiet. They silently put their heads in their hands. They covered their eyes. They wept.

“Do you want to see her?” I asked, when the news was done. “You don’t have to. But I’ll go with you, if you do.”

They all wanted to come, first the patient’s mother with her own sisters, then the rest of the family, then the neighbors and the pastor. They made a circle around the bed. I always touch the dead person in front of the family. I smoothed the girl’s hair and turned to leave the room.

“Let us pray,” said the pastor. The people in the room extended their hands to one another, leaning in around the dead girl’s body. They bowed their heads and waited.

My own hand was already on the doorknob. Something stopped me.

She wasn’t sleeping—she was dead. And I had to tell her mother.”

“May I stay?” I asked. They were strangers with a different faith tradition.

Without looking up, they opened their circle and took my hands.

“Lord,” the pastor began. “Oh Lord, hear the cries of your people. We are hurting, Lord, we are suffering. Lord, we are broken. If ever before we needed you, we need you now.”

“Yes, Lord,” they murmured.

“Lift up this mother, Lord, lift up this boy, her son, and lift up this family. Lift up your church community. Lord, we beseech you. We need you, Lord.

Help us today and this week and ever after. We’re gonna need your help, Lord.”

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Silently, they wept, swaying together like fragile trees in a violent storm, and the very strength of their pastor’s words kept them from uprooting and crashing to the ground. I had a daughter the age of the dead girl and my heart was breaking for them.

“Bless this doctor, Lord, these nurses, this hospital. Bless them, Lord. We thank you for their skill and for their compassion, Lord, for what they have given to your servant and to all her family. Bless them, Lord. Give them strength to continue their important work.”

The strangers on either side of me squeezed my hands.

“Amen,” they whispered.

A friend asked me once: Does your faith enter into your practice of medicine?

This is an important question. Yes and no, is the answer.

We have to be careful. You can’t impose your beliefs, whatever they are—or your lack of them—on people who are sick or on families who have had a sudden loss. The emergency department visit is their story, not yours.

But I say this: whether or not you believe in God, in the emergency department you will be a witness to unbelievable Grace. You will SEE, and you will BELIEVE, in Grace.

AAEM/RSA INTERNATIONAL COMMITTEE

International Health Pearl – Taliban Afghanistan Crisis

Jasmin Custodio, MS, Tracie Dang, MS4, Ava Omidvar, MS3 MPH FP-C, and Matt Carvey, MD EMT-P FP-C

I

nternational Health Pearls, a new project by the AAEM/RSA International Committee, introduces and highlights the ongoing foci in global health, while simultaneously raising awareness for certain international crises that may impact health care from a universal perspective.

Who are the Taliban?

Predominantly Pashtun, the Taliban, are an Islamic fundamentalist group that returned to power in Afghanistan in 2021 after waging a 20-year insurgency.1 The Taliban’s lead council, the Rahbari Shura, makes all decisions regarding political and military affairs of the Emirate.1

What is the Taliban’s role in Afghanistan?

Soviet influences left Afghanistan in 1992, giving rise to the Taliban’s rule and promising a restoration of order.2 In 1997, the Taliban gained control over most of the country and imposed their rule, which ultimately restricted women’s rights.2 After September 11, 2001, a US-led military invasion targeted the Taliban and Al-Qaida, forcing the Taliban to retreat and relinquish their grip over Afghanistan.2 In 2006, US and NATO forces supported Afghani defenses against the Taliban as they started to re-emerge.2 During May of 2021, the Taliban began usurping power over vast areas and by August, they seized control of key cities and provinces. This rise led to a seize on the capital, ultimately falling under Taliban control.2

What does their battle look like now?

Taliban officials insisted they only aim to implement an "Islamic government" and will not pose a threat to any other country.3 Many are concerned for women's uncertain future in their freedom to work, gain an education, dress as they choose, access health care, or leave their home without a chaperone.3 Women’s rights within the country have already been curtailed since the Taliban came into power in August. North American and European countries also fear the country would once again become a training ground for terrorism.3,4

What are the health concerns?

Due to restrictions placed on women during Taliban rule, Afghanistan faces an increased risk of overall decline in women’s health. Restrictions to women’s lives allowed only female health workers to examine them, limiting their access to quality health services. Women are more reluctant to seek health care, driving more women to give birth at home without prenatal or reproductive care.

As a country with one of the highest rates of maternal deaths in the world, Afghanistan currently has 638 deaths per 100,000 live births and the number is more likely to increase with current circumstances.4 Political unrest and a growing humanitarian crisis in Afghanistan pose a major threat to the country’s crumbling health care system. With reduced numbers of health care workers, minimal personal protective equipment, hospital closures, low COVID testing and vaccination rates, and rising COVID cases, Afghanistan faces great danger in terms of fighting COVID.5 Increased risk of polio and measles outbreaks are also worrisome, as both are endemic to Afghanistan.6

What is being done now?

The UN stated it is releasing $45 million from the Central Emergency Response Fund to “help prevent Afghanistan’s health care system from collapsing.”6 The UN set goals for 2030 which include reducing global maternal mortality to <70 deaths per 100,000 live births.4 The UN and the Taliban have both agreed to campaign for increased measles and COVID vaccinations, as well as polio eradication to prevent future outbreaks of preventable diseases.7

Impacts on health care in the region.

Many international donors suspended aid to Afghanistan, which decreased financial support to humanitarian projects in a country that is heavily dependent on international aid and funding. Reduced donations to Afghanistan’s largest health project, Sehatmandi, left health facilities without medications, medical supplies, fuel, and salaries for medical workers.6 As a result, health care access in Afghanistan is even more limited with fewer resources.

Afghan refugees and the impact on US health care.

Primary care clinicians are now faced with diseases afflicting the refugees that are uncommon in the US, such as TB, leishmaniosis, malaria, polio, and measles.8 Of the refugees who arrived in the US, 40% are children with an increased risk of malnutrition. With the relocation of many Afghani families, these diseases are introduced in non-endemic areas around the country, including areas with less access to health care.9 This introduction of people and pathogens requires further monitoring.

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AAEM/RSA INTERNATIONAL COMMITTEE

What aid is being provided to refugees?

Organizations are housing the 125,000 Afghan refugees who came to the US without prearranged accommodation. Many of these people have limited contacts within the US and had even less time to reach out before the Taliban reclaimed power. Upon their arrival, the Red Cross assisted with temporary housing, food, supplies, and equipment until they were flown to military bases across the country. Once the vetting process was completed, families were resettled into housing and supported through their transition.

Due to restrictions placed on women during Taliban rule, Afghanistan faces an increased risk of overall decline in women’s health.”

What are some ways to help?

Volunteers can become mentors to adults and children through their transition process in the Maryland and Virginia area. The organization is looking for volunteers to help with immigration and employment assistance and with their youth programs that are available to the Afghani children. For more information visit: https://lssnca.org/take_action/volunteer/volunteer-opportunities.html.

Help Afghans Now is a database of all the organizations that are assisting the Afghan refugees with resettlement. The website provides people with the opportunity to find ways to help the Afghani people in their country and community. For more information visit: https://www. helpafghansnow.info/i-want-to-help/.

Amnesty International has created a page to allow Americans to help refugees based on their location, availability, and preferred method of volunteering (online or within the community). Many services that are being rendered require language and administrative work. For more information visit: https://longertable.amnestyusa.org/.

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Islamic Relief USA is an NGO that focuses on providing goods, services, and support to refugees worldwide, but specifically from Islamic countries. They have assisted in the support of Afghanis, and accept donations, career and volunteer opportunities, and provide internships to those interested in helping their cause. For more information visit: https://irusa.org/.

The IRC specializes in assisting those trapped in humanitarian crises in conflict zones. They are accepting volunteers, donations, and people looking to advance their careers in relief efforts. For more information visit: https://www.rescue.org/.

The Red Cross and Crescent has posted an article about how they assisted in the repatriation of Afghani refugees in the US. Within the article, they provide links to contact loved ones who may have been separated during the evacuation, volunteer opportunities, and requests for donations to continue their efforts. For more information visit: https://www.redcross.org/about-us/news-andevents/news/2021/afghanistan-how-the-red-cross-and-red-crescent-are-helping.html.

The AFG Diaspora Hub is an organization within the DC metro area that has been assisting the Afghani people since they arrived in the US. They have provided access to goods and services to assist them in the resettlement process. They are currently looking for monetary, vehicle, and furniture donations to make some of their living spaces more comfortable. For more information visit: https://www.afgdiasporahub.com/resources-outside-afg.

Women for Afghan Women is an NGO that provides support services to Afghani women worldwide. They have created a living document that lists ways to help with translating, immigration processing, rehoming, and other support services for the Afghani refugees who were evacuated.

For more information visit: https://bit.ly/3iUsWIP

References 1. Maizland, L. (2021, September). What is the Taliban? Council on Foreign Relations. Retrieved November 12, 2021, from https://www.cfr.org/backgrounder/taliban-afghanistan.

2. Bloch, H. (2021, August 31). A look at Afghanistan's 40 years of crisis - from the Soviet War to Taliban recapture. NPR. Retrieved November 12, 2021, from https://www.npr. org/2021/08/19/1028472005/afghanistan-conflict-timeline.

3. BBC. (2021, August 30). Taliban are back - what next for Afghanistan? BBC News. Retrieved November 12, 2021, from https://www.bbc.com/news/world-asia-49192495.

4. Qaderi, S., Ahmadi, A., & Lucero-Prisno III, D. E. (2021, September 21). Afghanistan: Taliban's return Imperils Maternal Health. Nature News. Retrieved November 7, 2021, from https://www.nature.com/ articles/d41586-021-02551-1.

5. Essar, M.Y., Hasan, M.M., Islam, Z. et al. COVID-19 and multiple crises in Afghanistan: an urgent battle. Confl Health 15, 70 (2021). https://doi.org/10.1186/s13031-021-00406-0.

6. Goel, S. (2021, September 24). Afghanistan's health-care system is 'on the brink of collapse,' who warns. CNBC. Retrieved November 7, 2021, from http://www.cnbc.com/2021/09/24/afghanistanshealth-care-system-is-on-the-brink-of-collapse-who.html.

7. United Nations. (2021, October 18). Taliban backs who polio vaccination campaign across Afghanistan next month | | UN news. United Nations. Retrieved November 7, 2021, from https://news. un.org/en/story/2021/10/1103322.

8. Centers for Disease Control and Prevention. (2021, September 14). Han archive - 00452. Centers for Disease Control and Prevention. Retrieved November 7, 2021, from https://emergency.cdc.gov/ han/2021/han00452.asp.

9. Operation allies welcome completes vaccination campaign for measles and varicella for Afghan evacuees. Department of Homeland Security. (2021, October 4). Retrieved November 7, 2021, from https://www.dhs.gov/news/2021/10/04/operation-allies-welcome-completes-vaccination-campaignmeasles-and-varicella-afghan.

JUSTICE, EQUITY, DIVERSITY, AND INCLUSION SECTION

Why AAEM’s Mission to Reflect Justice, Equity, Diversity, and Inclusion is More Than Just Words Jada Watts, M2 and L.E. Gomez, MD MBA FAAEM

B

y now, the most “un-woke” among us are tired of hearing about implicit bias.

You know, the connection mental representations of objects or concepts we all access like our computers access RAM. Like the short-hand fight or flight response to a bear or a lion, or anything we sense may be threatening. It’s a phenomenon emergency physicians need pay particular attention to as we are masters of immediate data gathering for prompt diagnoses. Our mentors often warn us against the medicolegal risks of too fast decision-making.

Well, perhaps we should consider that health inequities can be perpetuated by our brainwashed tendencies.

There is no doubt we hold these biases. If you doubt it, you can test yourself using the now famous Harvard IAT test and in 10-15 minutes see how fast you will show we are all frail with regard to holding biases, particularly when considering our propensity to believe in such false-hoods as the inherent inferiority and threat of people with brown skin. Yes, I am going to avoid use of race here as 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. According to my pre-eminently qualified HBCU mentee from Howard University College of Medicine: Anti-racism in medicine is the action to combat biases, improve social inequities, and protect marginalized populations in the workplace.

Addressing and acknowledging these barriers in the hospital is the first step towards fostering a healthier environment for providers to practice medicine. In a study investigating the prevalence of mistreatment amongst EM Residents, 67.5% reported that they had experienced some type of racial discrimination. The mental burden of dealing with racism is enough alone but coupled with the added pressures of being a resident doctor in the medical field, it is an extremely large load to carry. I worry about the mental warfare of minority doctors who experience this. This number came as no surprise to me but I hope this serves as a wake-up call to those who have the privilege of not being subjected to such prejudices.

What the future Dr. Jada Watts is alluding to here is something called allostatic load. Let’s take a not so brief detour into the physiology behind the disease and take a closer look at why it would tax future colleagues like Jada to a greater extent than some of her non-HBCU peers and why they are at lower risk for more than an inconvenience they are better able to endure.

Homeostasis vs. Allostasis We take for granted that homeostasis, our normal state of equilibrium, allows our bodies to remain at or near a steady state of function despite constant changes in our external environments. As humans, we routinely experience challenges which, when minor, such as someone accidentally cutting us off in the supermarket aisle startles us, but even if we get slightly annoyed, we recover rapidly, responding unconsciously to the unintended act. There’s that moment of heart racing but no harm done and we move on. But what happens when we suspect it was not an accident. Health psychologists are now recognizing there are adaptive stress responses and that mild to moderate stress, is not bad. The negative of lasting impact arise when our response to perceived threats are both disproportionate, sustained, and maladaptive.1 To understand why stress has varying effect on different people, let’s start with how we respond to any perceived threats in general. Typically, we process information through those oldest and most familiar parts of our brain, the brain stem and thalamus. We take in raw visual, nasal, auditory, and tactile sensory information and only later send it to the cerebral cortex for processing. The process is fast, but the pathway works best for situations when we don’t interpret an immediate threat to our existence. The problem comes when our perception is that stimulus represents a critical threat and requires an immediate response that can’t await higher order mental processes. In those cases, an emergency mechanism takes over and the information bypasses the cortex, goes directly to the amygdala, where the autonomic process or so-called ‘amygdala hijack’ of the brain takes over.

We all know why this response evolved.

Our genetic predecessors were selected out for and evolved the “fight, flight, or freeze response” (FFF) to escape life-threatening events, such as encountering a predator during a hunt for food. Once the threat

>>

If we are committed to representing the population, we must be more intentional in attracting EM residents who are representative of the population we are serving.”

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JUSTICE, EQUITY, DIVERSITY, AND INCLUSION SECTION

resolved, we rested and our bodies recovered and return to normal function through a process called allostasis, which is also adaptive.2 So emergency states (which ER docs are, and to a lesser extent future doctors, constantly exposed to) trigger the emotional core of the brain, the amygdala, whenever the fear response sets off an emotional explosion that bypasses the thalamus and goes directly to the hypothalamus causing the pituitary to activate the adrenals to pump outbursts of cortisol and adrenaline (like when an ER contract is up for renewal and the hospital administration takes bids on who will control our paychecks).

This results in a physical and emotional response to escape an acute threat. We all know the drill—heart rate and blood pressure shoot up, blood flows to our brain and muscles preferentially, pupils dilate, blood clots faster, muscles tense, blood shunts away from skin and internal organs, liver converts glycogen to glucose, added to by free fatty acids that supply more fuel for quick energy, breathing becomes fast and shallow, hands get cold and hypersensitive, palms get sweaty, legs and arms shake, tunnel vision develops as our pupils dilate and focus on the central field of vision along with loss of peripheral vision, and diminished focus on details in facial expressions. Furthermore, high levels of cortisol short-circuit the hippocampus making it difficult to form memories and allow learning only to be more sensitive to similar events in the future.

Once the threat was past (back then in prehistoric times) we rested and recovered. Still good, we’re alive, right? Perhaps even a bit stronger as a result.3 Well isn’t the stress of modern work or training and work environments toxic to all of us? The short answer is yes, but some of us are at even higher risk. Why?

Acute vs. Chronic Stress The sum total of these stressors is referred to as the allostatic load.

But while stressors range from mild to severe, they can also range from acute to chronic and can trigger maladaptive or dysfunctional long-term responses. It turns out our brains and bodies are vulnerable to misinterpretation of the degree of threat in our modern worlds and the response is often inappropriately triggered. In turn, the pathology of chronic stress daily, weekly, and yearly basis over decades leads to dangerous physiological effects. Sustained stress that begins with an alarm clock in the morning, continues with commuter traffic, unwelcome interactions at work, challenging relationship interactions with family and friends resulting in similar amygdale hijack, no longer adaptive response to threats but rather sustained allostatic load with no provisions made for periods of recovery (how often do medical students and ER attendings miss meals, take a coffee break, or even remember to go to the bathroom?). Instead, we turn to maladaptive responses that silently predispose us to atherosclerosis, diabetes, cardiovascular disease, depressed immune function, psychological ill health, depression, and premature death, including through suicidality. Can we stop calling it burnout, as if we were doing it to ourselves?

Resiliency and Recovery Resiliency, on the other hand, is the ability to withstand or recover from stressors. The cumulative allostatic load of all the adjustments any 46

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human must make to address all of it requires resiliency to counteract it. Resiliency, our ability to maintain health when taxed, should interrupt stress, and allow for rest and recovery and if resiliency is greater than allostatic load, we remain in relatively good health. Repeated stress unrelieved by a period of recovery, overwhelms resiliency and disease state prevails.4 You see, we humans are bio-psycho-social-spiritual beings and, ironically perhaps, we are fully integrated.

The mental burden of dealing with racism is enough alone but coupled with the added pressures of being a resident doctor in the medical field, it is an extremely large load to carry.”

Stress hormones have been measured to remain elevated for 18 minutes on average after a typical episode. If another stimulus stacks on top of last before recovery sustained levels lead to permanent disease and tissue remodeling. Question: how often micro and macro aggressions lead to sustained levels particularly when prior experience sensitizes victims to future events, and interfere with rest and sleep lead to depression, lead to maladaptive behavior such as self-medication. One way to avoid this adrenal fatigue is to build our own virtual and physical spaces to rest and recover. For example, you can breathe deeply, find allies to affirm our experiences, listen to music, exercise, eat well, and get outside. The differential treatment of the dark-skinned population of humans internationally has been front and center in the media relentlessly throughout the pandemic. It is evident these phenomena are extant throughout modern society and we have all been made aware.

Jada points out that “medicine is teeming with the same issues that affect our society. Whether inadvertently or purposefully, it is our responsibility to correct these biases before stepping into the hospital. Just as we are taught to cast a wide net for our differential diagnoses the same protocol should be followed for addressing these racial complexes.”

You probably already realized the mechanisms to counter-act the negative forces of chronic and critical stress fall into two major categories to promote healing and health: decreasing allostatic load or increasing resiliency. What about for those who have even less opportunity for recovery and resiliency owing to enduring increased exposure to stress and fewer avenues to recovery?

Allostatic Load and Racial Disparities It has been almost two decades since the Institutes of Health published their exhaustive study “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health” in March of 2002. Since then, several well-done

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JUSTICE, EQUITY, DIVERSITY, AND INCLUSION SECTION

studies have established the health disparities in cardiovascular disease and infant mortality persist after adjustment for socioeconomic status and health behaviors due to allostatic load and chronic life stressors.5 Most studies exist in psychology and sociology journals with a virtual alphabet soup of titles and degrees among researchers, the word racism was nearly absent over the past decade in Journal of the American Medical Association (JAMA) or New England Journal of Medicine (NEJM) until recently.6 Another study showed allostatic load was shown to be predictive of cardiovascular disease and all-cause mortality and correlated with poor health practices including decreased rates of exercise and social behavior such as smoking, alcohol, and rates of depression. The study concludes discrimination plays a critical role in explaining racial based health disparities.7 A large review and meta-analysis perspective was provided by a review showing ethnicity had a significant effect due to racism that included negative mental health effects on Asian American and Latino American participants. It also established a relationship between allostatic load and concomitant pathophysiological processes, diminished participation in healthy behaviors such as sleep and exercise, and an increase in alcohol consumption as coping mechanisms for stress. However, recently interest has grown in the issue, along with the call to action that has permeated all industries, let alone medicine. Among the more recent to gain attention specifically pertinent to emergency medicine is one addressing discrimination, abuse and harassment in EM Residencies in the US.8 According to Jada: While there has been a huge jump in programs creating diversity and inclusion initiatives, I sometimes question how much this has helped.

In addition, programs must also focus on the retention and support of students once they are admitted. The truth of the matter is that when I look around for potential residency opportunities, I still see entire cohorts with no person of color. If we are committed to representing the population, we must be more intentional in attracting EM residents who are representative of the population we are serving.”

Mitigating the Cost of Allostatic Load and Health Disparities It does not take much imagination to guess the potential cost to our health care system is astronomical. Can it be mitigated? What if we nurtured spiritual and psychosocial healing? Research already exists that suggests there is a protective role to positive racial identity and worldview in the association between racial discrimination and blood pressure. It is possible that racial and cultural identity may serve a protective function in young adult African Americans. Perhaps the approach can serve as a model for healing patients of all backgrounds and a significant reduction in health disparities that exceeds even consideration of the so-called social determinants of health.9 So how can emergency medicine specialists help? It goes beyond our treatment of patients to mentorship and guidance. As Jada describes:

At my current institution, I see the talent and drive of my fellow classmates. With that being said, I do not think the problem is a lack in the number of applicants, but I do think there can be more programs set in motion to better assist matriculation into both residency and medical school. Historically Black medical schools produce massive amounts of physicians who are underrepresented in medicine. None of these medical schools currently have EM residencies which could possibly put students at a disadvantage when compared to those at other institutions. This may result in a lack of exposure to EM for students who may not have been initially interested in the specialty.

I’d like to invite all of my colleagues, especially the gray hairs and, like myself, thinning haired, to think back to what it was like when we aspired to join the ranks of residency trained, boarded emergency physicians.

Now imagine if that was made many times harder by feeling misunderstood, judged, discriminated against, let alone harassed or marginated.

In Jada’s words: As a medical student, it is very intimidating to see pages of people who do not look like me. It makes me scared for the patients because if we are facing this type of discrimination at an administrative level, I worry about what they may experience on the other side. I remember how I felt when my brother was getting operated on due to a gunshot wound. Would they see him as a black “thug” or as the basketball standout, honors student that he was? Would that affect how hard they worked to resuscitate him? While I won’t ever know the answer to those questions, it made me realize how deadly racism can be when put in the setting of patient care. This further proves the importance and urgency for better practices to start regarding race in medicine.

Final piece of advice: do not be afraid to admit we have all been brainwashed to believe we are not all part of the same race. Go ahead and take the Harvard IAT and fearlessly accept we all hold implicit biases.10 Our Task Force on Mission and Vision is in the process of updating our philosophical compass to include our commitment to equitable emergency training, leadership, professionalism, and care delivery that considers and respects all our differences. We will all be made stronger and healthier working together to reduce our biases.

References 1. https://news.stanford.edu/2015/05/07/stress-embrace-mcgonigal-050715/ 2. https://pdfs.semanticscholar.org/c6c0/ dcc3ad330cf46f84fa5cabcacead7e3d4da3.pdf 3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579396/ 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5137920/ 5. http://www.nationalacademies.org/hmd/Reports/2002/Unequal-TreatmentConfronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx 6. https://www.ncbi.nlm.nih.gov/pubmed/22708252 7. https://www.ncbi.nlm.nih.gov/pubmed/27018723 8. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2783236 9. http://cds.web.unc.edu/files/2012/12/NeblettandCarter_2012.pdf 10. https://implicit.harvard.edu/implicit/

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OPINION

How to Stand Up for Science and Fight Burnout Gary M. Gaddis, MD PhD FAAEM FIFEM

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s I write this during the first week of February, the Omicron variant of the SARS-CoV-2 virus is still kicking us, taxing hospital capacities, and causing patients with so-called non-urgent procedure needs to endure forced delays of care.

Everyone seems to be wondering when this COVID-19 nightmare will end so that things can return to some semblance of “normal.” Many of our patients are registering their emotion of being “over it” by abandoning any pretense of trying to mask or social distance whether they are vaccinated or not. Such a cavalier approach is not open to us in our workplaces where we continue to deal with surly patients, avoidably crowded emergency departments and ED waiting rooms, and the ongoing need to continue wearing PPE. The nightmare of the pandemic and citizens’ non-heedful responses are combining to cause unprecedented burnout among health care personnel. Burnout is a consequence of moral injury and we have all been getting overdosed on that! We know that our nation’s highly suboptimal immunization rate and many of its citizens’ resistance to scientific measures to blunt the pandemic have been prolonging the avoidable pain, and these factors are causing a significant amount of that moral injury. Those health care workers who can leave their moral injuries behind have been departing from health care as part of a broader societal trend of workers departing the workforce in what has been called “the great resignation.” According to a February 1, 2022 “COVID-19 Update” video, the American Medical Association’s Board of Trustees President, Dr. Gerald Harmon, shared that an additional 20% of physicians and 40% of non-physician health care workers are contemplating leaving their careers within the next year. If that happens, we are all in deep trouble.

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Most of us would agree that one of the things that could help kill the nightmare and blunt the moral injuries leading to burnout quickly would be to persuade more of our still-unvaccinated patients to finally get their jabs and become a vaccinated part of the solution. They also should resume masking but more on that in a bit. To persuade those not yet vaccinated to get their jabs requires us to convince them of the science of the matter and the illogic of their contrarian anti-science positions.

The thing about science is that an anti-science faction has NOT always been a large part of America’s citizens. In the America of my youth, science was revered. I was born in 1957 and grew up enthralled by the Mercury, Gemini, and Apollo programs as did many of my classmates, and indeed, many of our fellow Americans. The space programs that resulted in our fulfillment of President John Kennedy’s vision, the outrageously optimistic proposal to land a man on the moon and return him safely to Earth before the decade of the 1960s ended, was the result of a national devotion to science and the benefits science could bring.

It is true that there were outliers, the kind of people who if they were alive today, would believe the baseless anti-science theories perpetrated by that great, nearly un-refereed “graffiti board” called the internet. But, those individuals were the minority and they didn’t have the ability to go online and quickly find numerous other like-minded people who were as misguided as they were, such that they could form an online community and come to believe that it was them who was normal and everyone else who was misguided.

As an example of what the some of the few who were overtly anti-science believed in the era of Apollo, one theory that gained traction in various parts of the country was the idea that fluoridation of drinking water, a step that helps dental health by decreasing dental caries, was

The outrageously optimistic proposal to land a man on the moon and return him safely to Earth before the decade of the 1960s ended, was the result of a national devotion to science and the benefits science could bring.”

The mobilization of science was the result of the kick in the pants America got in 1957 from the Soviet Union’s launch of the Sputnik satellite, followed by a national mission to leverage our society’s might in science, wealth, industrial capacity, and technology such that we would win the “space race” and beat the Soviets to the moon. It was rare to find anyone who would publicly declare as a bad idea the set of choices required to emphasize science and enable the moon missions.

actually a government plot to assist in gaining governmental control over our minds. This belief is about as sensible as the current and woefully misguided idea that the COVID-19 vaccine implants recipients with microchips, or the idea that more people have died from the COVID-19 vaccine than from the disease. In other words, those who reject scientific thought have always been among us and we can’t change that. But the internet sure makes it easier for these people to find each other and

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OPINION

create their own misguided communities, where it is them who come to believe that they are the normal ones.

Now, having stated the general problems of irrational beliefs being potentiated by the internet, the current general disrespect of science and scientific advice, the role of moral injury in “burnout,” the threat that a burnout-induced “great resignation” from health care careers which could accelerate and threaten the well-being of our nation and its people, and the expectation that most of us want things to “get better,” I will offer some ideas to counteract these forces.

Just as conventional military forces learn from experience which tactics worked and which failed in fighting an enemy, and just as the motivations of the enemy may not be apparent early in a conventional war, so it has been in our medical war against COVID.”

Here are six ideas for engaging the engageable. You may have others.

My ideas are constructs, based in stories. Humans are “hard-wired” to respond to stories and they respond much better to stories than to data.

The fact that you have read this far into my story reinforces the validity of my premise.

My stories are designed to engage those willing to engage with some ideas about science that they probably had not considered, toward trying to persuade them to change.

Useful change can help fight moral injury!

My first construct is “the fog of war,” to explain how health care authorities have proffered changing recommendations for the public as to how to respond to the COVID-19 threat. The fact that our health care authorities’ recommendations have changed as our experience with the virus has evolved is not a sign of incompetence or weakness. It is a consequence of what can be expected to happen as knowledge is gained. We are all engaged in a war, an anti-microbial war against a foe that has killed more than 3500 health care workers, among its nearly 900,000 American fatalities. Just as conventional military forces learn from experience which tactics worked and which failed in fighting an enemy, and just as the motivations of the enemy may not be apparent early in a conventional war, so it has been in

our medical war against COVID. You remember how it was in March of 2020—we were all in a “learn as you go” mode. We adopted measures that worked and abandoned practices that didn’t. Over time, we have dispelled a lot of this “fog of war” as we have learned much about our viral opponent. But, we still have some “fog.” The new Omicron variant may, or may not, be deterred by current vaccines and newer monoclonal antibody and oral antiviral medications, for instance. Our patients need to give our health care leaders a break. They can’t disseminate reliable guidelines until they have gained the necessary knowledge to enable those recommendations.

My second construct is “systems work best when fully engaged.” The everyday experience of any person includes exposure to multi-part systems where the whole is greater than the sum of the parts. An example is seat belts/shoulder harnesses plus air bags in motor vehicles. They work best when used together.

Those who don’t “buckle up” are more likely to die in crashes in which they are not employing all parts of a vehicle’s restraint system—sort of like those who won’t get vaccinated and/ or won’t wear masks are more likely to be

burdened or killed by COVID. Further, although there are those that argue against mask mandates because there is availability of a vaccine, no one of whom I am aware is advocating that we no longer need seat belts and shoulder harnesses because, after all, vehicles have air bags. It’s time to bring that logic regarding auto restraint systems into the public discussion of mask mandates. I get it that no one wants to have widespread business or school closures but it is the schools that won’t impose mask mandates that are more likely to be forced to return to virtual instruction, an outcome that few on either side of this debate wish to occur. The bottom line: masks and vaccines work best when enabled to work together!

My third construct is “location does not impact effectiveness, and thus I can prove you actually do believe masks work!” Despite widespread resistance on the part of the public and some politicians to mask mandates in public places, I have never heard advocacy for abandonment of mandatory masking in the operating theater or other similar locations in the medical care delivery system. The fact that no politician or science-detractor is advocating for optional masking in the operating room implies that they must believe masks help decrease disease transmission. So the argument against masks becomes not that they don’t work, but rather, that the detractors are just not used to wearing masks in public to fight COVID, and/or they simply find masks inconvenient or disagreeable.

My fourth construct is “your ‘liberty’ arguments are not persuasive.” Those who view mandatory masking as heavy-handed thefts of their liberty nonetheless do not protest other societal expectations that they fulfill, in a manner that inherently requires non-assertion of a liberty. Examples are numerous, including but not limited to the facts that no one is suddenly arguing that clothes should be optional in public, that shoes cannot be required to enter a

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OPINION

business, or that reasonable speed limits should be obeyed, especially in areas such as school zones.

There is great power in being a physician. Use it, and use it wisely.”

My fifth construct is “actually, warp speed isn’t speeding.” President Trump was wise to set processes into motion that have rapidly resulted in the useful vaccines that only a minority of his supporters have been willing to receive. (Actually, the Pfizer-BioNTech vaccine was developed by the Germans outside of “Warp Speed”).

However, the “warp” was only in the final step, the testing of the vaccine on willing subjects. The basic science upon which the vaccine was built includes tactics and ideas that have been known for up to two decades or more but it is unethical to deliberately infect study subjects with a potentially fatal illness. No IRB would approve such a trial so medical science had to wait until the onset of a pandemic to try out these new RNA vaccines. The vaccine was NOT rushed to development, it was only rushed to market.

My sixth and final construct is “so, you’re now my patient. What changed?” Rare is the anti-science, vaccine-renouncing, non-masking patient who will remain at home and die without at least seeing if perhaps the doctors and nurses at the hospital might be able to help them once they become significantly burdened by COVID-19. It is logical to wonder why they would suddenly believe in us and the measures we have to offer after resoundingly rejecting scientific wisdom until the present moment.

The thing is most patients still respect their doctor, even if they don’t respect science or “medical experts.” They rightfully believe that we will do our best to help them and that we will therefore deploy all of the scientific measures that are indicated.

Thus, the time of the patient encounter with those “doubting Thomas” patient whom we meet is the time to persuade them, one person at a time, that perhaps they might be well served by abandoning their recent, counterproductive beliefs and implement some useful actions. After all, the SARS-CoV-2 virus doesn’t care what its victims believe but it is influenced by what we as medical care professionals can do to attempt to blunt its impacts.

The take away is that by politely confronting and refuting recalcitrant patients’ misguided beliefs and behaviors, we gain the chance to see with our own eyes and with our own experiences that we can sometimes change the minds and beliefs of some of these people. And in changing their beliefs and attitudes, we gain an antidote to yet another episode of moral injury and fight our own tendencies to burn out.

There is great power in being a physician. Use it, and use it wisely. When you have the chance to try to make a “convert,” one person at a time, and persuade them to “get religion” as regards vaccines or masking to blunt the impact of COVID-19 disease, you get to use your inherent superpower and take the opportunity to at least try.

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

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AAEM Emergency Medical Services Section Letter to Membership

EMERGENCY MEDICAL SERVICES SECTION

C. J. Winckler, MD LP FAAEM

The work of EMS will only multiply in the complexity of calls and forward-thinking health care missions in the coming years.”

A

s an EMS physician and EMS medical director the question I dread the most is, “What is an EMS medical director?” If I’m giving my elevator speech, it generally starts and ends like this, “I write medical protocols for EMS, fire, and police.” Since I am talking to my colleagues, I appreciate the opportunity to explain what we EMS physicians do and how the American Academy of Emergency Medicine now has an EMS Section to support the mission of EMS physician clinical leadership.

Importantly, the clinical component of emergency medical services and the multiple non-traditional out of hospital patient care modalities deployed by EMS are ultimately the EMS physician’s responsibility.

AAEM has consistently stated that every health care team must be led by a board-certified physician. The AAEM EMS Section supports the model relationship EMS physicians have with all levels of prehospital providers.

This current model presents to the rest of health care the ideal that a physician led team in which every member is respected, valued, and heard. In this ideal model, physician medical directors routinely and regularly solicit information and recommendations from their non-physician colleagues, truly listen to them with the respect they deserve for the work they do and the expertise they have acquired, and formatively create policy and procedure based on this valuable input. All hospitals and clinical practices should look at how EMS functions and adjust their processes to reflect this respectful, successful practice which has proven to have maximum benefit for the patients it serves. The AAEM EMS Section will work to continue this successful model.

As EMS physicians, we are proud that the model of egalitarianism of the profession is how EMS medicine has always been practiced. It is organic for the physician’s involvement in EMS to include non-physician colleagues. Indeed, without emergency medical technicians, paramedics, and many of our other non-physician colleagues, the American EMS model would not work. Similarly, the emergency physician clinical leadership model of the emergency department would not work without the myriad non-physician medical colleagues serving patients in the hospital setting.

With over 800 board-certified EMS physicians in the United States, emergency medical services is the largest sub-specialty of emergency medicine. Emergency medical services’ roots go back to the Napoleonic Wars, where triage was a term used to sort those that have a chance at survival, and where Dr. Dominique Jean Larrey innovated prehospital care by bringing ‘flying ambulances’ to the battlefield to better care for casualties near the point of injury. To this day the basic tenets of EMS are the same: deliver those that are sick or injured to an emergency department while providing life-saving interventions. While that tenet remains, the entire field has gone through much evolution over the last few decades. For physicians, the pioneering change was recognition of the practice of EMS physician as medical director in the form of a sub-specialty board certification from the American Board of Emergency Medicine.

A recent example of this continued evolutionary progression is when the Health and Human Services Secretary made a historic announcement in a Washington, DC fire department station that a five-year pilot program, called “Emergency Triage, Treatment, and Transport (ET3),” would reimburse Medicare patient transport to destinations other than an emergency department. Previously, EMS would not be reimbursed for taking patients anywhere but a hospital. The ET3 pilot allows low risk patients to be transported directly to an urgent care center, clinic, or their physician’s office, and allows for an EMS clinician to be on scene with patient or via a telehealth platform and receive reimbursement for an evaluation. The ET3 concept, and similar programs in development, will require the EMS physician to be clinically responsible for another layer of clinical complexity in an already complex job.

Over the last decade, EMS mobile integrated health (MIH) has moved a not insignificant portion of EMS providers away from the base operating model of “you call, we haul” to a patient centered, multi-provider approach that focuses more on public health and harm reduction than performing life-saving interventions. This author’s primary EMS agency offers an MIH-led acute care station in Texas’ largest homeless shelter

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EMERGENCY MEDICAL SERVICES SECTION

staffed by paramedics on duty for 12 hours every night. This has reduced unnecessary 911 calls and provided continuity of care for that community’s most vulnerable patients. Another example of transitioning EMS care is when the author’s MIH team administered over 225,000 vaccines and monoclonal antibodies for San Antonio and the South Texas community.

Multi-team out of hospital targeted opioid reduction and medication assisted treatment programs are also found in many metropolitan EMS systems. Programs like this require involved medical direction. During this pandemic many EMS physicians have answered the call to duty by providing EMS medical direction and being the public health authority for their communities. EMS has become multi-faceted with the EMS physician ultimately responsible for these ever-changing aspects of out-of-hospital care.

As a new sub-specialty in the house of medicine, there are topics that EMS medical directors and EMS physicians are still developing such as

Indeed, without emergency medical technicians, paramedics, and many of our other non-physician colleagues, the American EMS model would not work.”

The work of EMS will only multiply in the complexity of calls and forward-thinking health care missions in the coming years.” job duties, due process, peer recognition, delegation of practice, reimbursement, disaster response, mass casualty roles, and many others.

We need to ensure that EMS physicians are not isolated from others in the specialty but are instead collaborative and supported through group practice and fellowship. Understanding the role of the EMS physician and how our influence can positively impact the delivery of prehospital patient care is foundational to building better systems of care within a community. This is where support from the AAEM EMS Section and the AAEM membership at large can truly improve EMS physician practice.

The American Academy of Emergency Medicine Emergency Medical Services Section welcomes the opportunity to contribute to the practice of EMS and medicine. As EMS physicians, we are proud EMS has been a democratic profession for many years. The work of EMS will only multiply in the complexity of calls and forward-thinking health care missions in the coming years. This means the EMS physician will need house of medicine support to continue the ideal of physician-led clinical care to manage the out of hospital patient in an ever-changing environment. By working with other professional organizations and advocating for protection of the independent practice of the EMS physician, AAEM EMS Section can help lead the way by defining the workforce, promoting physician-led teams, and improving out of hospital care.

Respectfully Submitted, C. J. Winckler, MD LP FAAEM, Chair AAEM EMS Section Brett Rosen, MD FAAEM, Past Chair AAEM EMS Section Bryan Everitt, MD LP FAAEM

Acknowledgments Craig Cooley, MD MPH EMT-P FAAEM FAEMS Stephen Harper, MD MPH FAAEM Rachel Ely, MD MPH FAAEM Lisa Moreno, MD MS MSCR FAAEM FIFEM

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CRITICAL CARE MEDICINE SECTION

Critical Care Education: How Early Is Too Early?

Ava Omidvar, MSIII MPH FP-C and Matthew Carvey, MD EMT-P FP-C Editor: Elias Wan, MD FAAEM

C

ritical care has a young history of serving the needs of the most complex patients. The first intensive care unit (ICU) was established in the United States in 1959.1,2 Critical care has now extended into additional medical domains, specifically neonatal, pediatric, neurological, surgical, cardiac, and trauma being among the few common examples.

This vast range of critical care specialization resulted in precision of care tailored to each individual patient suffering from a variety of ailments. Hospital systems have also started expanding ICUs to meet the demands fueled by the COVID-19 pandemic, bringing intensivists out of urban tertiary care facilities, and leading them directly to the communities, either physically or through telemedicine.3 Because of its complexity, critical care education is regularly taught later during medical training, often while in residency or fellowship. However, can these sophisticated concepts be broken down into digestible components and taught earlier to medical students and interns?

The stunning reality is that medical students have very limited exposure to intensive care medicine.4 As mentioned previously, this field is generally not accessible to a student until they decide to pursue a residency or fellowship, in which it is usually part of their standard curriculum.

However, the concepts of physiology, navigating ethical challenges, utilizing modern medical technology while understanding its limitations, eliciting our patients’ goals of care, and breaking down complex cases into workable parts are displayed daily on ICU rounds. These important concepts taught during an ICU rotation or by other methods may provide students with cognitive training and in-depth understanding to solutions for daily medical problems and tasks. It is difficult to gauge how much exposure to scientific knowledge a medical student requires to be successful in their future practice due to the limited research on this topic.

Current medical curricula have become so extensive and broad that

only individuals with an invested interest in critical care seek the opportunity to acquire the specialty specific knowledge and skillset. However, those individuals also risk losing insight to the depth and complexity of medicine as a whole if they focus only on specific critical care topics. Regardless, the standardized exposure to common treatments, concepts, procedures, and methodologies of intensive care may improve medical students’ critical thinking, decision-making, and overall confidence as they begin their careers.

Introduction to Critical Care and Anesthesia Course Syllabus Online Flipped-Classroom Lectures • Analgesics, Sedatives, and Paralytics • Arterial Blood Gas (ABG’s), Basic Chemistry Panel, and CBC Interpretation • Oxygen Therapy and Ventilation • Intra-aortic Balloon Pumps (IABP) and Extracorporeal Membrane Oxygenation (ECMO) and Central Line Insertion • Pediatric and Neonatal Critical Care • Hemodynamic and Intracranial Pressure Monitoring • Cardiac Pacing and Implantable Cardiac Devices • Fluid Therapy and Massive Transfusion • POCUS Course (Optional)

The delicate matter of introducing complex critiPractical Sessions at AAEM22: cal care aspects such as • Advanced Airway Management advanced resuscitation • Ventilator Management to learners with little or no foundation requires a stepwise approach, which builds on the fundamental anatomical and physiological concepts taught in medical school. The AAEM/RSA’s Introduction to Critical Care and Anesthesia (ICCA) course, targeting M3, M4, and PGY-1 residents, attempts to bridge this educational gap by utilizing the core axioms of the basic sciences and connecting this to the understanding of advanced topics, such as extracorporeal membrane oxygenation (ECMO), mechanical ventilation, and hemodynamic monitoring (see box). There is minimal data exploring the relevance of early critical care education for physicians-in-training. However, a similar notion was utilized in undergraduate nursing instruction where an “Integrated Nursing Care” module, which explored the early detection and acute management of the deteriorating patient, was incorporated into year three of their four-year program. It was found that the early introduction of managing deteriorating patients was essential to improve nurses’ competence and confidence when dealing with this patient population.5 Applying the notions found in this nursing care module may provide evidence for familiarizing medical students with critical care concepts.

The information can be presented as early as the basic science years of medical school through an incremental model, improving the students’

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[S]tandardized exposure to common treatments, concepts, procedures, and methodologies of intensive care may improve medical students’ critical thinking, decisionmaking, and overall confidence as they begin their careers.” practical understanding of these topics, especially when they inevitably must confront issues in practice.

Critical care is a vastly growing subspecialty of medicine that is in high demand nationwide. Medical students may benefit personally and professionally by having additional experiences in critical care prior to the start of residency or fellowship. Early exposure to intensive care medicine will solidify their ability to incorporate various aspects of medicine, hone their critical thought process, and further enhance their interpersonal skills, which are all crucial during residency, fellowship, or even in practice as a licensed physician. Additional investigations and curricula (such as the proposed course) should be explored in order to find the best educational plan that prepares our future physicians for the increased aging and dynamic world of tomorrow’s health care realm.

AAEM

References 1. Vincent JL. Critical care--where have we been and where are we going?. Crit Care. 2013;17:S2. doi.org/10.1186/cc11500 2. Weil MH, Tang W. From intensive care to critical care medicine: a historical perspective. Am J Respir Crit Care Med. 2011;183(11):1451-3. doi.org/10.1164/rccm.201008-1341OE 3. Deslich S, Coustasse A. Expanding technology in the ICU: the case for the utilization of telemedicine. Telemed J E Health. 2014;20(5):485-92. doi.org/10.1089/tmj.2013.0102 4. Al Ansari M, Al Bshabshe A, Al Otair H, et al. Knowledge and confidence of final-year medical students regarding critical care core-concepts, a comparison between problem-based learning and a traditional curriculum. J Med Educ Curric. 2021;8. doi. org/10.1177/2382120521999669 5. McGaughey J. Acute care teaching in the undergraduate nursing curriculum. Nurs Crit Care. 2009;14(1):11-16. doi.org/10.1111/j.14785153.2008.00303.x

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Two Years Later Priya Ghelani, DO FAAEM

T

hird and fourth years of medical school are often when medical students find their “calling.”

Many know instantly. I wish it had been that simple for me. I chose to pursue medicine years ago because I wanted to do primary care but quickly realized I was not quite cut out for clinic. I flirted with the idea of general surgery but was swiftly enticed by the words “work-life balance,” and briefly thought I would pursue critical care before I remembered how bored I felt with management, rather than diagnostics. Ultimately, I kept finding myself gravitating towards emergency medicine with the perfect blend of versatile cognitive and procedural skills.

There are plenty of pros to emergency medicine, the most obvious of which is that we get to make difficult diagnoses and save lives every day.

To be perfectly honest however, there are plenty of cons to our field as well. Shift work is not easy. Nights, weekends, and holidays affect our

Despite repetition, it often feels like some things only seem to get harder, rather than easier, every passing day.” family and social lives. The lack of adequate public health infrastructure has progressively weighed down our emergency departments, with no end in sight. The inability to own our own practice makes us dependent on sometime arbitrary rules made by hospital administrators incentivized by profit margins, and excludes us from profit-sharing models our other colleagues in other specialties have the opportunity to benefit from.

Making high stakes decisions regularly contributes to the escalating rate of burnout among emergency physicians as studies continue to remind us. Despite all of this, in the chaos of the ER, there are moments every day that serve as a reminder as to why I was drawn to the field as a young medical student. We are privileged to care for patients from all walks of life, from the undomiciled to the most affluent, during a time of vulnerability and need. Not having to worry about payment plans or insurance, but rather focusing on and addressing their emergent and immediate needs in a rapidly changing healthcare world which appears to be becoming more transactional in nature every day feels truly liberating.

Pulseless, torsades, apneic, VT, penetrating trauma—these are words we hear every day and have seconds to act on to actually save lives. From initiating ECMO to troubleshooting LVADs, to pushing TPA, to managing a septic neonate, our ability to manage complexity never fails to humble me. Patients are far from algorithmic, and they present far from the way our textbooks read. We frequently arrive at convoluted diagnoses, from the dizzy patient who ends up being a submassive PE, to the vomiting patient we choose to give contrast to despite their renal function who ends up being a basilar stroke. A dissection flap, an intramural thrombus around a leaky aorta, or a large right heart on ultrasound clues us into why our patient is in extremis, and from there we act as conductors in an orchestra, with no room for error, working as swiftly as we can to save their life. There is a constant flux of emotions throughout a shift, from the hypoxic bloody airway that is rapidly converted to a cricothyroidotomy, a child struck by a drunk driver who arrives in severe hemorrhagic shock, a pregnant woman who tries to drive off a highway to commit suicide. “I’m so sorry, but it appears you have cancer which has spread to your lungs and brain” is a painful thing to say to a patient in the emergency room who you met a couple hours ago and likely will never see again. So is “I’m so sorry, sir, but your father is dead.” Despite repetition, it often feels like some things only seem to get harder, rather than easier, every passing day.

I’m often asked how I would describe being an emergency physician during the pandemic. It is two years later and I’m still not sure how to respond. I was in New York City when the pandemic first took hold in America and previously wrote about how that experience forever changed my perspective of the word “hero.”1 While we continue with the peaks and troughs of the virus, it remains an easy topic of discussion.

What is the ER like right now? Are you seeing a lot of patients with coronavirus? How busy is it? Is it true, what they are saying in the news, about the ER being overwhelmed and full of sick patients?

In early 2020 at the height of the pandemic, I pondered about it all. I thought about my own mortality, my nuclear family, and what my role would be during the pandemic. When they said we didn’t have any personal protective equipment, I wondered if we were also ill-fated, and curiously wondered what my own short-lived legacy could possibly be.

When they said we have too many admit holds in the department and asked us to see patients in the waiting room, I wondered what our future as a specialty looked like. And when they said we had severe nursing shortages and we cared for patients as best as we could in the waiting room, I wondered how any of this was ever our patients’ fault (or, might I dare say, our own). My own family members passed away due to COVID-related complications this past year and I struggled to maintain optimism despite it all. >> COMMON SENSE MARCH/APRIL 2022

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Patients are far from algorithmic, and they present far from the way our textbooks read.”

It is two years later and how things have changed. Today we have a vaccine thanks to so many courageous scientists and researchers who have pushed the boundaries of medicine. Yes, we work in a broken health care system, full of daily challenges, but I’m grateful that we continue to have personal protective equipment, a safe and effective vaccine, and clinical data guiding our management strategies. When I reflect on the past two years, despite the obstacles I faced, personally and professionally, I can’t help but be optimistic about our future and be grateful for our profession.

Despite what felt like insurmountable odds at times, I couldn’t have imagined being on the sidelines during the past two years. We all know it, and

feel it, when walking into work every day—emergency medicine docs are incredible at their core. There is something beautiful about being able to do it all, while having the opportunity to serve humanity in a time of need, and it strikes every chord. Health care is changing. Our specialty is adapting to this rapidly evolving world. Our future will continue to serve us challenges, big and small, every day, but we’ll be ready for them. We survived a pandemic. We can survive anything.

References 1. https://issuu.com/aaeminfo/docs/cs20_novdec_v7_for_web/36

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Use MyAAEM to collaborate with peers & stay up to date with the latest events and announcements.

Scan this code or visit: aaem.org/membership/myaaem

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RURAL MEDICINE INTEREST GROUP

Rural Medicine Interest Group

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ission

The Rural Medicine Interest Group will give doctors working in small community and critical access hospitals the opportunity to interact, network, and support each other. This will be a forum to discuss some of the challenges unique to hospitals with limited resources and share solutions.

Who We Are Doctors from small hospitals and hospital systems often feel overlooked in larger forums. We are typically in single coverage systems or sometimes single coverage with a mid-level. We are never working with another emergency medicine colleague other than briefly at the time of shift change. We are seldom supported, validated, or reinforced by any colleagues. We seldom get any feedback other than the occasional chart review. We rarely interact with other physicians other than at national meetings and at those times we can feel very intimidated. It's difficult in a small town practice to keep current with constantly evolving practice.

When attending large meetings, it's obvious we'll never get kudos or awards.

We're not residency directors or research leaders. Other than a rare case write up it would be unlikely for us to ever be able to publish or present anything. We'll never be seen as masters of anything. We typically don't have enough connections to lead a committee, be considered for a board position, or any significant leadership role. So it's easy to feel marginalized and/or invisible. My hope is that this forum will be an opportunity for community emergency physicians, which, at the end of the day is why our specialty exists, to share our joys and challenges and feel like our concerns matter. Our career path matters. And we belong at these conferences as much as anybody from a prestigious academic institution.

AAEM supports the practicing emergency physician. Let's form this interest group and see if people are interested in participating and helping AAEM serve this under-appreciated and unacknowledged but very important physician cohort.

[W]e belong at these conferences as much as anybody from a prestigious academic institution.”

To learn more and to join visit: aaem.org/get-involved/interst-groups

Leadership Chair: Robyn Hitchcock, MD FAAEM Board Liaison: Robert P. Lam, MD FAAEM

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OPINION

Mask Mandates: The Evidence and the Law Gary M. Gaddis, MD PhD

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ise leaders of numerous Missouri school systems have recently implemented sensible mask mandates for students, faculty, and staff to protect them from the Omicron surge of COVID-19 and to help keep schools open. Unfortunately, Missouri’s Attorney General (AG) Eric Schmitt has just unilaterally and unwisely escalated an avoidable conflict by filing restraining orders to stop implementation of these mask mandates. Mr. Schmitt also recently sued to prevent numerous school systems from mandating masking, characterizing these actions as illegal institutions of health policies.

I will present my qualifications, then discuss Missouri statutes and medical evidence, to suggest that AG Schmitt’s most recent actions constitute criminal behavior, the crime of assault.

First, my qualifications. I understand medical evidence. I’m an emergency physician who recently retired from full-time practice at the Washington University School of Medicine, practicing at Barnes-Jewish and BarnesJewish West County Hospitals, while also teaching residents and students. I’ve spent nearly three decades as a full-time faculty member of a medical school, chiefly at the University of Missouri-Kansas City (UMKC) School of Medicine. My professional actions have been guided by medical evidence, including teaching it and implementing it. Presently, I’m a Teaching Professor of Biomedical and Health Informatics at UMKC. I’m also the Immediate Past Chair of the Governing Council of the Academic Physicians Section of the American Medical Association.

Second, Missouri statutes are clear. Missouri Statute 565.054 states, “A person commits the offense of assault in the third degree (a “Class E” felony) if he or she knowingly causes physical injury to another person.”1 Missouri Statute 565.056 defines that assault in the fourth degree (a “Class A” misdemeanor) has occurred when (3) The person purposely places another person in apprehension of immediate physical injury; or (4) The person recklessly engages in conduct which creates a substantial risk of death or serious physical injury to another person.”2 Importantly, to qualify as a fourth-degree assault, an act need not cause injury. Under the statute, the act needs only to cause a reasonable fear of physical injury, or substantial risk of death.

Third, the evidence. Reasonable people cannot dispute that COVID-19 causes death, and death is the worst possible “physical injury.” As of February 1, the Centers for Disease Control (CDC) stated that 881,887 Americans have died of COVID-19.3 That death toll includes at least 1262 educators and school personnel, 429 being active teachers.4 Also, as of January 26, 2022, 603 children aged 5-18 had died of COVID-19.5 In fairness, it’s unknowable how many of these deaths were school-acquired. However, students, and especially older school personnel, can

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Mask mandates can also decrease the probability that a school or school system must revert to virtual instruction, an outcome we all want!” reasonably fear that an avoidable school-acquired case of COVID-19 could cause them to die. Further, there is the injury known as “Long COVID” among the unlucky minority who develop prolonged severe symptoms.

CDC data unambiguously express that masks help decrease COVID-19 transmission, thus blunting the likelihood of school-based outbreaks.6 Schools with mask mandates have been less likely to require temporary suspension of in-person education due to COVID.7 Thus, mask mandates can also decrease the probability that a school or school system must revert to virtual instruction, an outcome we all want!

To summarize, laws and the evidence are clear. A mere credible threat, without a violent act, can construe an assault. And by acting to prevent masking, the statutory language supports that AG Schmitt has caused credible fears of injury, harm, and risk of death. Therefore, AG Schmitt has already committed fourth degree assault. Once educators or students develop an avoidable case of COVID-19, his actions may become third degree assault. And consider, even students, educators, and staff who chose masking voluntarily in the absence of a mandate would have less protections than if all people in the building were masked.

The next logical step is for school superintendents or school boards that have chosen to act responsibly by enacting sensible mask mandates, to persuade their city’s or county’s prosecuting attorney to criminally charge AG Schmitt with assault. Maybe that will finally persuade him to abandon his fourth degree assault criminal behavior, his being an agent promoting actions causing reasonable fears of threatened or actual illness and death in our state. Such charges also would help keep Missouri students and teachers safely in class, where they belong.

The opinions expressed in this opinion are my own and do not represent an official stance of any school of medicine.

>>

OPINION

The author, Gary M. Gaddis, MD PhD, is a resident of University City, a physician board-certified by the American Board of Emergency Medicine, and a recently-retired faculty member of the Washington University in St Louis School of Medicine. (I included bio-relevant data within the text because I believe it is important toward establishing my credentials.)

References: 1. Revisor of Missouri. Title XXXVIII Crimes and Punishment; Peace Officers and Public Defenders. Chapter 565. http://www.revisor.mo.gov/ main/OneSection.aspx?section=565.054 Accessed February 1, 2022 2. Revisor of Missouri: Title XXXVIII Crimes and Punishment; Peace Officers and Public Defenders. Chapter 565. https://revisor.mo.gov/main/ OneSection.aspx?section=565.056 Accessed February 1, 2022 3. Centers for Disease Control. COVID-19 Data Tracker. https://covid.cdc. gov/covid-data-tracker/#datatracker-home Accessed February 1, 2022

4. Education Week. Educators we have lost to the COVID virus. https:// www.edweek.org/teaching-learning/educators-weve-lost-to-thecoronavirus/2020/04 Updated January 25, 2022. Accessed February 1, 2022 5. Centers for Disease Control. Provisional COVID-19 Deaths. Focus on Ages 0-18 Years. https://data.cdc.gov/NCHS/Provisional-COVID-19Deaths-Focus-on-Ages-0-18-Yea/nr4s-juj3 Updated January 26, 2022.

Accessed February 1, 2022 6. Centers for Disease Control. Science Briefs. Community Use of Masks to Control the Spread of SARS-CoV-2. https://www.cdc.gov/ coronavirus/2019-ncov/science/science-briefs/masking-science-sarscov2.html Updated December 6, 2021. Accessed February 1, 2022 7. Sparks SD. CDC: COVID Outbreaks Far Higher at Schools without Mask Mandates. Education Week September 24, 2021. https://www.edweek. org/leadership/cdc-covid-outbreaks-far-higher-at-schools-without-maskmandates/2021/09 Accessed February 1, 2022.

Announcing New AAEM Interest Groups!

Interest Groups are established by the president and/or Executive Committee as a group of AAEM members who have a common interest that impacts both the Academy and emergency medicine as a specialty not covered by either a committee or task force.

We are pleased to announce the launch of two new AAEM Interest Groups:

AAEM Rural Medicine Interest Group AAEM Simulation Interest Group All AAEM Members can sign up to participate!

aaem.org/get-involved/interest-groups

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WOMEN PHYSICIANS DAY

ABEM Statement Recognizing Women in EM Leadership

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ow more than ever, emergency medicine is proud to have an ever-growing number of women in leadership positions in health care and the specialty. This representation provides important perspectives to emergency medicine. A diversity of ideas leads to better-informed decision making, and a diversity of physicians allows us to better serve the communities in which we work.

This year marks a momentous milestone for emergency medicine when most major organizations that serve the specialty’s community are led by women.

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM, is Professor of Emergency Medicine, Director of Research and Director of Diversity for the Section of Emergency Medicine at Louisiana State University Health Sciences Center-New Orleans. She serves as Director of the Latino Scholars Program for the School of Medicine and Regional Faculty Advisor for the Southwestern Region of the Latino Medical Student Association. Dr. Moreno is the first woman President of the American Academy of Emergency Medicine (AAEM). During her years serving on the AAEM Board of Directors, she has focused on the development of women and underrepresented minorities in leadership positions. She holds degrees in Medicine and Clinical Research and is a National Institutes of Health Research Scholar. She is the founder of the Academy for Diversity and Inclusion in Emergency Medicine (ADIEM), an academy of the Society of Academic Emergency Medicine (SAEM).

Her multiple awards include the SAEM Martin Leadership Award, Alpha Omega Alpha Medical Professionalism Award, Council of Residency Directors in Emergency Medicine Distinguished Educator Award, the ADIEM Outstanding Academician Award, Association of American

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On this Women Physicians Day, we recognize not only the many current leaders in the field, but all those who preceded us, who led the way, who provided us guidance. We will endeavor to follow their footsteps, encourage and mentor another generation of women physicians to enter emergency medicine, and contribute to the advancement of the specialty.

Scan the QR code below to learn more about these incredible women and the work they have achieved:

Medical Colleges (AAMC) Healthcare Executive Diversity & Inclusion Certificate, and the Order of the International Federation of Emergency Medicine. The recipient of many research grants, Dr. Moreno has over 500 academic presentations, 45 publications, six book chapters, and two authored textbooks Diversity and Inclusion in Quality Patient Care, and Your Story, Our Story: A Case Compendium of Diversity and Inclusion in Quality Patient Care. Her research interests include HIV, violence prevention and treatment, diversity, and health care disparities.

Lauren Lamparter, MD, is a first-year Emergency Medicine resident at the University of Illinois Chicago. She was born and raised in Southern California, attended Westmont College, and graduated from Loyola’s Stritch School of Medicine.

Dr. Lamparter has pursued leadership roles within emergency medicine since early in medical school and was the recipient of AAEM/RSA’s National Medical Student of the Year award. Her passions include mentorship, education, and social emergency medicine.

Outside of the ED she enjoys exploring Chicago’s food and entertainment scene with her residency family.

OPINION

Why I No Longer Teach ATLS Michael LeWitt, MD MPH

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everal years into my nearly 40 years of emergency medicine practice, I took an ATLS provider, and then an ATLS instructor course. Since 1984, I had taught in over 120 courses, mostly in and around Philadelphia, but, thanks to an enthusiastic ED physician I met initially on a List-Serv, also several times in Wales, where I met a large number of enthusiastic ED and other physicians who made teaching an otherwise standard course quite interesting.

Come the pandemic, I taught my first ATLS Zoom course in March 2020 for a program where I had taught over half of all my courses, and planned to teach at several more throughout that year. Unfortunately, in June, the parent organization decided to stop all teaching programs at this facility, and most of the staff was let go.

Two of the people I had worked with, extensively, landed at another hospital where the following year they instituted a training program and were initiating their ATLS courses with an instructor course in August 2021. I was one of the three physician instructors who would supervise the course, along with an educator. I was reluctant to spend time indoors in any venue, much less one where close contact, speaking, and interacting might be necessary, but because of assurances from my friends, I agreed.

The course description said mask wearing was mandatory and described the usual Covid-19 precautions. When I arrived at the facility where the course was to be taught, I checked in on the ground floor where my temperature was checked and I was offered a paper mask to supplement my cloth mask. I then proceeded to the site where the teaching was to occur.

When I got there, I entered the room and found that the educator was not wearing a mask. I asked him to put one on but he insisted it wasn’t necessary. I again asked and he refused. I saw one of my colleagues and mentioned to her that the educator was

refusing to wear a mask and asked her if she wanted to walk out if he still refused. She concurred. I then approached the educator and stated that if he refused to mask, I would leave, and the course would have to be cancelled. He finally put a mask on, but incorrectly, and I advised him that if he didn’t know how to wear one correctly, I would show him. He walked away and I shouted after him “You are a f***ing educator, how about if you educate yourself?” I also spoke with the administrative people to get their support but was told that they couldn’t do anything as the educator was also their boss.

The course proceeded without further incident but afterwards I wrote a summary of the events to everyone at the American College of Surgeons about the event, and encouraged the course administrators at the national level to again require mask wearing.

I didn’t hear anything for a month but when I did, it was to reprimand me for being a disruptive influence, rather than focusing on the serious issue of violating the local health rules, hospital requirements, and course requirements of mask wearing specifically, and providing a safe teaching environment in general.

I realize that big institutions move slowly but somehow, 18 months into the pandemic, enforcing what seems to be a simple public health measure seems to be too much to expect. Consequently, I decided that I am the dinosaur and the time has come to give up teaching since none of the courses being offered locally are Zoom based. Too bad, I enjoyed teaching.

I was a founding member of AAEM until my retirement from practice in 2015 and was the initial sponsor of what was the Joe Lex (now Educator of the Year) Award, as well as a long-time oral board instructor (25 courses), and member of the education committee,

I realize that big institutions move slowly but somehow, 18 months into the pandemic, enforcing what seems to be a simple public health measure seems to be too much to expect.”

Michael LeWitt, MD MPH (formerly, FAAEM)

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AAEM/RSA PRESIDENT’S MESSAGE

An Interview with Dr. Dinesh Palipana Lauren Lamparter, MD

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had the pleasure of being introduced to Dr. Dinesh Palipana when he spoke at a conference at my residency program, University of Illinois, Chicago. Dr. Palipana is a senior emergency medicine resident at the busiest ED in Queensland, Australia, and he was recently recognized as the 2021 Queensland Australian of the year. He is well deserving of this title, as he is an incredible advocate for disability equity and inclusion, and particularly doctors with disabilities.

Dr. Palipana sustained a spinal cord injury that left him paralyzed while he was attending medical school. He underwent intense rehabilitation and with immense strength, was able to become the first quadriplegic intern in Australia when he started residency. He is now in his final year of EM residency. I had the great privilege of being able to interview him about his career and life, and I am happy to share a portion of that interview with you today.

LL: Dr. Palipana, thank you so much for agreeing to speak with me!

Your story is so powerful, and you have overcome so much to be an emergency medicine physician. Tell me more about why medicine remained your career goal after your injury.

DP: I did not start my career wanting to be a doctor. When I finished school, I went to law school. However, during law school, I experienced depression, and I became very affected by mental health. I discovered medicine by going to see my own doctor, and through that experience, I got to know the power of medicine because I came out of depression and my entire world changed. I thought it was amazing that we have the opportunity to change people’s worlds, as mine was, so that is why I got into medicine.

As to why EM, I think more than anything there is a real opportunity to make a difference in someone’s life at the sharp end of medicine.

Before the car accident, I had an introductory lecture to EM from an EM physician who specialized in emergency response services. I remember watching his lecture and thinking this guy is really cool because he has the ability to save someone’s life at a really tough time. When the car accident happened, I was paralyzed, and as I was lifted into the ambulance I looked up and there was that same doctor! It was so wild! We connected for a moment, and I said I remember the lecture you gave us.

I was freaking out because I had become paralyzed, and in that moment, I think he taught me probably the single most important lesson about medicine. Today I don’t remember what he did for me, what drugs he gave, or what procedures he did. But, I remember what he did for me in that he made me feel safe and told me that I’d be okay and that I was in good hands. He told me I’d find a way to become a doctor because that was something I was really worried about because I was still a medical student then.

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I thought it was amazing that we have the opportunity to change people’s worlds, as mine was, so that is why I got into medicine.”

I think that is the opportunity we have in emergency medicine, we encounter people when they are going through the shock of their life, and in addition to the technical skills that we can use, there is also that really deeply human aspect where a person is so vulnerable and in a really dark time, we have the opportunity to make them feel safe and bring light to that situation. So that to me is the essence of emergency medicine and why I had to be an EM doctor.

LL: What was the biggest barrier you faced in pursuing emergency medicine because of your spinal cord injury?

DP: You know, here is the funny thing. When I was going back to medical school, a lot of people told me I wouldn’t become a doctor. How would I examine a patient? How would I do a ward round? How would I do these activities that a doctor needs to do? I have found ways to do what I need to do, and with each rotation, I was able to win over the supervisors. But the supervisor for emergency medicine was completely different, when I met her, she said “we can’t wait to have you, and we will make it work.”

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AAEM/RSA PRESIDENT’S MESSAGE

All the EM physicians I have met have really encouraged me and they’ve made me feel like anything is possible. I think it is because they are problem solvers and they are not people that get stuck on limitations, but they’d rather think about the opportunities. So actually, in EM I’ve had the least barriers and the most opportunities and support.

LL: I love that, we have such a special field!

DP: Yes, I love it too, we absolutely do.

LL: One of the reasons I was so interested in interviewing you is the focus you have on advocating for inclusion in medicine. AAEM/RSA prioritizes advocacy for our EM residents, students and patients.

How has your pursuit of EM changed the field for doctors with disabilities?

DP: I think if you can have a doctor with a spinal cord injury work in Australia’s biggest ED, that sets an example for the rest of medicine. If you can say this guy gets around doing it, there is no reason we cannot be more inclusive in other areas of medicine, in EM, and in the public.

I think the other really cool thing has been the people without disabilities who advocated for me. One EM physician offered part of her salary so I could have an opportunity to train and to get the hospital to take a chance on me. She didn’t have a disability, she didn’t have a wheelchair, but she was an ally. It is not just about doctors with disabilities, it is about being an advocate for others because they were an advocate for me. If we can do this in medicine, we can have outflow into other professions. In medicine, we have the ability to be thought leaders, and the public listens to what we say on certain topics, so we have the responsibility to be advocates.

LL: How can EM residents be better allies and advocates for our colleagues with disabilities?

DP: I love that question. It really starts with one person and that one person has a snowball effect. My mom has this saying that “by helping one person you might not change the world, but you will change the world for them.” They can go on to become an agent of change as well, so it just starts with listening to that one person and asking them how you can help. Doing that for the one is a powerful thing.

There is a SMACC talk by Cliff Reid about what a hero is, and he defines heroes as “people who will do something for others without any expectation of personal gain, while weathering personal risk, and having a strong moral compass.” I think we just have to be heroes for others because a lot of time there is personal and professional risk to advocacy, but we need to overcome that fear. If your moral compass is strong, you will always do the right things for others. So above everything we have to keep that in mind. That is the most important thing we can do for our colleagues with disabilities.

LL: What are you most hopeful will change in the future and how is that hope directing your career?

DP: You know, I really think disability is a social construct and I think we as a society disable people, in the traditional sense. So, I’d like to see a world where we celebrate people’s abilities and we empower people to do the most to their abilities and passions rather than focus on disabilities or deficits. That is the world I’d love to see and through my career both in and out of medicine that is something I can contribute to. I have already seen this be possible when people, like my medical school supervisors, have taken the time to get to know me and understand me as a human being.

LL: Absolutely, you are changing the world! Is there anything else that you want to tell the EM residents and students of AAEM/RSA? DP: Yes, two messages. First, there is so much power in the privilege that we have as physicians to create change in this world and to fight for people. We have to be responsible with that privilege and we have to use it to do good, so in addition to being excellent at the technical aspects of medicine, try to think about being agents of social change as well. Secondly, take a step back, when everything becomes hard, when work is challenging and when you are facing overwhelming difficulty, take a step back, be grateful and think about where we live and the job we get to do and the people around us. That is often enough to give us the strength to keep going.

LL: Thank you so much Dr. Palipana!

I really think disability is a social construct and I think we as a society disable people, in the traditional sense.”

If you are interested in learning more about Dr. Dinesh Palipana, you can find him on twitter at @dineshpalipana

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CONGRATULATIONS! Please join us in congratulating the following, who will take their seats on the AAEM/RSA Board of Directors and Medical Student Coucil on May 1, 2022.

2022-2023 AAEM/RSA Board of Directors

Leah Colucci, MD President

Corey McNeilly, MD Vice President

Nahal Nikroo, MD At-Large

Donna Okoli, MD At-Large

Lauren Lamparter, MD Anantha Immediate Past Singarajah, OMSIV President Secretary-Treasurer

Kaitlin Parks, DO At-Large

Heather Renfro, MD At-Large

Andrew Langille, DO At-Large

Loren Touma, DO At-Large

Mary Unanyan Student Representative

2022-2023 AAEM/RSA Medical Student Council

Mary Unanyan Chair

Chibuzo N. Opara Northeast Regional Rep 64

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Clara Pavesi-Krieger Vice Chair

Amanda Eukovich Southern Regional Rep

Shannon McDonnell Midwest Regional Rep

Nvard Sisliyan Western Regional Rep

Lindsay Callahan International Ex-Officio Rep

MEDICAL STUDENT COUNCIL CHAIR’S MESSAGE

Lessons from a Month in Addiction Medicine for an EM-Mindset Ashley Iannantone, MA

Prescriptions for naloxone and buprenorphine are life-saving, but they are under-utilized by emergency medicine physicians nationwide.

Prescribing naloxone to those with a history of opioid use disorder can save lives and reduce emergency department visits related to opioid use. However, a national retrospective review found that naloxone was prescribed after only 7.4% of ED visits for opioid overdose.

Similarly, buprenorphine was prescribed after only 8.5% of visits.3 This equates to an EM provider prescribing naloxone for 1 of every 13 patients they see after a non-fatal opioid overdose. The nature of the emergency department as a busy, fast-paced environment can often lead to conversations with patients regarding possible harm reduction strategies being neglected, but the importance of initiating these conversations and treatments while the patient is in the department and actively engaging with the medical system cannot be understated. It is irresponsible to assume these conversations can be delayed until the patient seeks follow-up outpatient care.

The old emergency medicine adage of seeing people “on the worst days of their lives” is especially true of those who are presenting for concerns related to substance use.”

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midst the shadow of the COVID-19 pandemic, the nationwide opioid epidemic has continued to surge. In 2020 there was a 30% uptick in drug overdose deaths—over 93,000 individuals died of drug overdose, largely attributed to the high prevalence and lethality of fentanyl.1 In response to this, Addiction Medicine has been steadily growing as a field over the past decade. There are now 86 fellowships nationwide (compared to 52 in 2018). The fellowship is an option for anyone who has completed residency training in one of the 24 primary specialties.

I recently spent an elective month working in both residential and outpatient treatment areas for addiction medicine and took note of some of the lessons I learned.

The stigma against those who have alcohol or substance use disorders exceeds that of other mental health conditions. Recent studies have found that while public stigma toward certain mental health conditions has been decreasing over the past decades, there is still an unacceptably high level of stigma toward those with substance use disorders. For example, when given a clinical vignette describing someone with alcohol dependence, 65% of survey participants responded that this condition might be caused by the individual’s “own bad character” (compared to only 33% saying the same regarding a vignette describing someone with depression). In the same study, 47% of survey participants indicated an unwillingness to socialize with the individual described in the alcohol dependence vignette (compared to only 15% responding the same for the depression vignette).2 This stigma can lead to discrimination against those with substance use disorders as well as decreased access to or utilization of available treatment resources.

And finally, a lesson that can probably be applied to every patient in the ED, but especially holds true for those with substance use disorders: Spend time trying to understand the person in front of you rather than just the medical condition. The old emergency medicine adage of seeing people “on the worst days of their lives” is especially true of those who are presenting for concerns related to substance use. Taking time to explore where a patient is at in their journey and how they got there can give you valuable information about how best to counsel on next steps and which treatment options can be offered from the ED.

References 1. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm 2. Pescosolido BA, Halpern-Manners A, Luo L, Perry B. Trends in Public Stigma of Mental Illness in the US, 1996-2018. JAMA Netw Open. 2021;4(12):e2140202. Published 2021 Dec 1. doi:10.1001/ jamanetworkopen.2021.40202 3. Chua KP, Dahlem CHY, Nguyen TD, Brummett CM, Conti RM, Bohnert AS, Dora-Laskey AD, Kocher KE. Naloxone and Buprenorphine Prescribing Following US Emergency Department Visits for Suspected Opioid Overdose: August 2019 to April 2021. Ann Emerg Med. 2021 Nov 18:S0196-0644(21)01349-4. doi: 10.1016/j.annemergmed.2021.10.005.

Epub ahead of print. PMID: 34802772.

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MEDICAL STUDENT COUNCIL CHAIR’S MESSAGE

New Year Resolutions from a Rising Intern Ashley Iannantone

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his time of year naturally provokes both reflection and resolutions. For better or worse, I have been existing in this mindset since submitting my residency application back in September. As I’ve gone through the interview cycle, I’ve been asked near-constantly to reflect on challenges and triumphs in my path thus far as well as what I’m looking forward to for the future. Through these reflections, I have arrived at a handful of resolutions that I am taking into the new year:

Learn to love discomfort Each year in medical training is one of growing pains, but certain times foster a bit more discomfort than others: the first year of medical school, switching from preclinical to clinical training, and intern year of residency. While it can be incredibly disheartening to exist in that mindset of uncertainty (especially for the stereotypical type-A, perfectionist medical student that I am), it can also be a time of immense growth. I’ve found that when I’m pushed above what I think I’m capable of (with the proper support), I tend to surprise myself. I look forward to continuously pushing above that threshold over the next year.

Remember why I’m here To help with this resolution I often return to the personal statement I wrote for my medical school application. Similar to many other pre-medical students across the country, I focused on how I wanted to help my future patients. This ultimate goal kept me motivated during long days of studying during preclinical years and began to be realized over the past two years as I got to touch the lives of a number of patients during my clinical rotations. The rhetoric in my original statement may seem slightly idealistic now, but the sentiment remains.

By sharing these resolutions I hope to not only hold myself accountable for the year ahead, but also to inspire others— regardless of where you are in your medical training or career—to reflect and create your own lists.”

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Recognize my privilege I’m now within six months of graduating from medical school, a goal I have dreamed of since I was too young to understand what that actually meant. Within this calendar year I will walk into a patient’s room and introduce myself as their doctor for the first time. The position of privilege that comes with this statement is not at all lost on me, especially in the field of emergency medicine, where patient encounters are brief and rapport and trust are established within minutes. Over the next year I want to focus on earning this title’s privilege by keeping myself focused on resolution two. Now is my time to act on the resolution I wrote four years ago in my personal statement, and use my position to advocate for and empower patients with every chance I get. Make time to stay grounded I would be ignorant to write the above three resolutions and think I could achieve them without recognizing the importance of protecting my own wellness. These past years have proven that the practices we foster to keep ourselves well are just as important on a daily basis as the communication and procedural skills we use to care for patients. For me, this means making time to connect with those who lift me up, spending time outdoors, and the occasional Netflix-series binge.

By sharing these resolutions I hope to not only hold myself accountable for the year ahead, but also to inspire others—regardless of where you are in your medical training or career—to reflect and create your own lists. Wishing you all happiness and health in the year ahead!

This article was supposed to appear in the January/February issue of Common Sense.

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Does Ultrasound Guidance During Insertion of Central Venous Catheters Increase Risk of Infection?: A Review of Recommendations and What You Can Do to Reduce this Risk Stephanie Sorensen, DO PGY 3, Daniel Puebla, MD PGY 2, and Mark A Newberry, DO FAAEM

oint-of-care ultrasound continues to evolve into a favorite tool in the emergency physician’s arsenal, especially when it comes to procedural guidance. There is an abundance of evidence supporting its use to prevent mechanical complications (e.g. inadvertent arterial puncture, hematoma formation) and increase chance of success at the first attempt during central venous catheter (CVC) placement.1 However, a recent post hoc analysis published by Buetti et al calls attention to a lesser-studied complication—catheter-related infections. Surprisingly, use of ultrasound was associated with higher rates of catheter-related bloodstream infections (CRBSIs), major catheter-related infections (MCRIs), and catheter colonization for both jugular and femoral sites compared to anatomic landmarks.2 In this discussion, we will take a closer look at this publication and offer some evidence-based recommendations for how to mitigate this risk in your department.

To begin, we will summarize the highlights of this recent publication. Data from three randomized controlled trials (RCTs) taking place in French intensive care units were used to evaluate the effect of specific prevention measures (e.g. type of dressing, skin cleaning solution, site selected) on the risk of intravascular catheter complications.3-5 During a post-hoc analysis, these data were additionally used to determine if there was an association with CRBSIs, MCRIs, and catheter colonization for ultrasound guidance versus use of anatomical landmarks alone. Ultrasound guidance was utilized at the non-random discretion of treating intensivists. For jugular and femoral CVCs, the use of ultrasound guidance was associated with: • Increased CRBSI with a hazard ratio (HR) of 2.21 (CI 1.17-4.16, P = 0.014) • Increased MCRI with a HR of 1.55 (CI 1.01-2.38, P = 0.045) • Increased catheter colonization after removal if in-situ for seven days or less (P = 0.0045) The authors offer explanations as to why these results may have been obtained. They note that all of the RCTs in the review were performed during a time when ultrasound guidance was not a standard practice among all intensivists. Additionally, there was no randomization to ultrasound versus anatomical landmarks alone, and there was no information reported about the hygiene of the ultrasound equipment. Taking

into consideration this publication wasn’t designed to generate these outcomes and while there are many potential confounds, we continue to conclude that special care should be paid to the hygiene of ultrasound equipment in an effort to curtail risk of infection. Hospitals should take caution to ensure that all departments follow appropriate machine hygiene protocols.

Many sources discuss guidelines for infection prevention in ultrasonography.6,7,12,24 We will use these guidelines to offer tips for reducing risk of microorganism introduction during ultrasound-guided CVC placement and provide the evidence as to why these recommendations matter.

Wash hands before and after the procedure.

In the wake of the growing infectious and monetary burden of health care associated infections, simple basics such as hand hygiene become crucial. In most health care institutions, hand hygiene is only performed in up to 40% of indicated situations. Furthermore, the hands of

In the wake of the growing infectious and monetary burden of health care associated infections, simple basics such as hand hygiene become crucial.”

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healthcare workers are commonly colonized with multi drug-resistant bacteria.8,9 Proper hand washing can eliminate most harmful microorganisms from healthcare workers’ hands, including methicillin-resistant Staphylococcus aureus.10 In summary, proper hand washing is a cheap and effective way to prevent cross-contamination during ultrasound-guided procedures.

Use a high-frequency linear probe, remove all particulate matter, then clean it with a disinfectant wipe before the procedure.

A European study found that bacterial contamination of an endocavitary ultrasound transducer after cleaning with a paper towel alone was higher than bacterial contamination of public toilet seats or bus poles.11 The same study went on to compare bacterial contamination of the endocavitary transducers before and after a 30 minute educational session for staff about disinfection with an alcohol-free wipe. There was a statistically significant decrease in the median colony count of the transducers after this training session (P < 0.001).11 This study calls attention to two points.

First, it is important to remove particulate matter from the probe, but doing so with a paper towel is not effective in wiping off invisible residue.

They may also scratch the transducer. Soap and water or a wipe are preferred. Secondly, the probe must be disinfected after particulate matter is removed.

Three different levels of disinfection exist:

Reusable ultrasound gel due to its viscosity, components, and pH can become a nidus for bacterial growth under the right conditions. Notably, there have been outbreaks of nosocomial infections that can be traced back to reusable ultrasound gel. Bacteria implicated in such events include Klebsiella pneumoniae, Staphylococcus aureus, and Burkholderia cepacia.13-16 When performing ultrasound examinations on intact skin, standard non-sterile bottles are acceptable. These gel bottles should be used within a short time frame to prevent infection. Bottle warmers are ill-advised as they can create more optimal conditions for bacterial growth within the gel itself. Sterile gel should be used for all endocavitary probe use and major/minor ultrasound-guided procedures. Due to the porosity of ultrasound probe covers discussed above, sterile gel should be utilized both inside and outside of the transducer cover.17-18

Prepare your sterile field and maintain sterility throughout the procedure.

Use a sterile cleansing solution to prepare the site for CVC insertion.

Allow the appropriate time for this cleansing solution to dry before the skin is broken. Ensure you have all necessary equipment, including a sterile gown, cap, sterile gloves, face mask with eye shield, and sterile drapes.

After use, the transducer should undergo disinfection. Allow the transducer to dry completely prior to being used again.

• Low-level disinfection (LLD) “destroys most bacteria, some viruses, and some fungi” and consists of use of soap and water or quaternary ammonium sprays/wipes without mycobacterial labeling.6 • Intermediate-level disinfection (ILD) destroys “vegetative bacteria including tubercle bacilli and many viruses”, consisting of quaternary ammonium agents with mycobacterial labeling and phenolic germicidal agents.6 • High-level disinfection (HLD) “removes all microorganisms except for bacterial spores” and consists of chemical sterilants, germicides, and/ or physical sterilization.6 There is no evidence to support that HLD of a transducer is necessary prior to a percutaneous procedure. Low to intermediate-level disinfection is more appropriate, especially given that it can be easily performed just prior to the procedure without causing significant interruption to a provider’s workflow.6,12 It is important to select an alcohol-free disinfectant wipe as alcohol can dry out the piezoelectric crystals within the ultrasound transducer. Wipes containing bleach can additionally stain the transducer.

The ultrasound transducer, cables, and machine itself provide a surface on which microorganisms can colonize for weeks to months.19 Therefore, proper disinfection after patient contact is crucial. When using an ultrasound transducer on intact skin, LLD is sufficient. If a probe with a cover comes in contact with bodily fluids, as it would during a percutaneous procedure, the authors suggest utilizing ILD thereafter. If the probe is used on internal, mucosal surfaces (e.g. transesophageal, transvaginal, intra-oral) or if the probe cover becomes broken during use, high-level disinfection should be utilized.6 Even with the use of sterile probe covers, contamination can still be detected on internal probes that come into contact with mucosal surfaces after low-level disinfection.13,17,18,21,22 Transducers should be allowed to completely dry as probes that remain wet may prevent proper disinfectant penetration.21,23 At minimum, adhere to the appropriate contact time or “wet time” (product specific time the disinfectant must stay wet on a surface to be effective) before use of the equipment. Each machine manufacturer provides guidance on appropriate cleaning/disinfection products.

Use a sterile probe cover for your procedure.

It is the practice of the authors to disinfect with an ILD quaternary ammonium agents wipe before and after all procedures where a probe cover is utilized and remains intact. An alternate method would be to apply the appropriate level of disinfection after use, then place an indicator on that transducer that it is appropriately disinfected and ready for use (e.g. covering the transducer with a glove), thereby bypassing the need for disinfection prior to use.

Sterile probe covers are available in most emergency departments. It is important to understand that these covers are not completely impenetrable to all microorganisms given that they have pores, which is why disinfection before the procedure is so important. Probe covers with pore sizes less than 30 nm are available and will prevent transmission of most (but not all) bacteria and viruses. Sterile adhesive films (e.g. Tegaderm) can also be considered an effective barrier against organisms.6

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Special considerations for the cleaning of ultrasound machines and transducers during the COVID-19 pandemic have been recommended by many national and international societies. One way to prevent unnecessary contamination from droplets is to remove non-essential materials from ultrasound machines. This includes IVs, plastic dressings, and towels. It is especially important for patients in whom COVID-19 is a consideration to disinfect the transducer, machine surfaces, and other surfaces that were touched, however, high level disinfection is not required for use of probes on intact skin. Finally, in environments where there is a high chance of aerosolization, the probes and machines should be covered if possible, and the entire machine should be cleaned with low level disinfection between uses. Machines should be stored outside of a patient’s room whenever possible.24 To conclude, ultrasound is an incredibly useful adjunct for many procedures that occur in the emergency department. Just as training is necessary to master the mechanical skills required to execute your ultrasound-guided procedure, training is also required to keep the equipment in a hygienic state, thereby reducing risk of infection to your future patients. There will undoubtedly be more literature to come investigating whether or not an association between ultrasound guided CVC placement truly exists; in the meantime, this guide reinforces some evidence-based recommendations for preventing infections of catheters placed under ultrasound guidance.

References 1. Wrzosek, A. (2015). How do outcomes compare for ultrasound guidance and anatomical landmarks for internal jugular vein catheterization?

Cochrane Clinical Answers.

2. Buetti, N., Mimoz, O., Mermel, L., Ruckly, S., Mongardon, N., Dupuis, C., Mira, J.-P., Lucet, J.-C., Mégarbane, B., Bailly, S., Parienti, J.-J., & Timsit, J.-F. (2020). Ultrasound guidance and risk for central venous catheter–related infections in the intensive care unit: A post hoc analysis of individual data of 3 multicenter randomized trials. Clinical Infectious Diseases, 73(5).

3. Timsit JF, Mimoz O, Mourvillier B, et al. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med 2012; 186(12): 1272-8.

4. Mimoz O, Lucet JC, Kerforne T, et al. Skin antisepsis with chlorhexidinealcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial.

Lancet 2015; 386(10008): 2069-77.

5. Parienti JJ, Mongardon N, Megarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015; 373(13): 1220-9.

6. Guideline for ultrasound transducer cleaning and disinfection. (2021).

American College of Emergency Physicians Policy Statement.

7. Nyhsen, C. M., Humphreys, H., Koerner, R. J., Grenier, N., Brady, A., Sidhu, P., Nicolau, C., Mostbeck, G., D’Onofrio, M., Gangi, A., & Claudon, M. (2017). Infection prevention and control in ultrasound - best practice recommendations from the European Society of Radiology Ultrasound Working Group. Insights into Imaging, 8(6), 523–535.

8. Mathur P. Hand hygiene: back to the basics of infection control. Indian J Med Res. 2011;134(5):611-620.

9. Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev. 2004;17(4):863-893.

10. Pitet D. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356:1307–12 11. Sartoretti, T., Sartoretti, E., Bucher, C., Doert, A., Binkert, C., Hergan, K., Meissnitzer, M., Froehlich, J., Kolokythas, O., Matoori, S., Orasch, C., Kos, S., Sartoretti-Schefer, S., & Gutzeit, A. (2017). Bacterial contamination of ultrasound probes in different radiological institutions before and after specific hygiene training: Do we have a general hygienical problem?

European Radiology, 27(10), 4181–4187.

12. Disinfection of Ultrasound Transducers Used for Percutaneous Procedures. (2021). American College of Emergency Physicians Policy Statement.

13. Ma ST, Yeung AC, Chan PK, Graham CA. Transvaginal ultrasound probe contamination by the human papillomavirus in the emergency department.

Emerg Med J. 2013;30(6):472–475.

14. Hutchinson J, Runge W, Mulvey M et al (2004) Burkholderia cepacia infections associated with intrinsically contaminated ultrasound gel: the role of microbial degradation of parabens. Infect Control Hosp Epidemiol 25:291–296 15. Weist K, Wendt C, Petersen L, Versmold H, Ruden H (2000) An outbreak of pyodermas among neonates caused by ultrasound gel contaminated with methicillin-susceptible Staphylococcus Aureus. Infect Control Hosp Epidemiol 21:761–764 16. Gaillot O, Maruéjouls C, Abachin E et al (1998) Nosocomial outbreak of Klebsiella Pneumoniae producing SHV-5 extended-spectrum betalactamase, originating from a contaminated ultrasonography coupling gel.

J Clin Microbiol 36:1357–1360 17. Masood, J., Voulgaris, S., Awogu, O., Younis, C., Ball, A. J., & Carr, T. W. (2007). Condom perforation during transrectal ultrasound guided (TRUS) prostate biopsies: a potential infection risk. International urology and nephrology, 39(4), 1121-1124.

18. Milki, A. A., and J. D. Fisch. “Vaginal ultrasound probe cover leakage: implications for patient care.” Fertility and Sterility 69.3 (1998): 409-411.

19. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006 Aug 16;6:130.

20. Casalegno JS, Le Bail CK, Eibach D, ValdeyronML LG, Jacquemoud H, et al. High risk HPV contamination of endocavity vaginal ultrasound probes: an underestimated route of nosocomial infection? PLoS One. 2012;7(10):e48137.

21. Kac G, Podglajen I, Si-Mohamed A, Rodi A, Grataloup C, Meyer G (2010) Evaluation of ultraviolet C for disinfection of endocavitary ultrasound transducers persistently contaminated despite probe covers 31(2):165-70 22. M’Zali F, Bounizra C, Leroy S, Mekki Y, Quentin-Noury C, Kann M. Persistence of microbial contamination on transvaginal ultrasound probes despite low-level disinfection procedure.

23. Ngu A, McNally G, Patel D, Gorgis V, Leroy S, Burdach J. Reducing transmission risk through high-level disinfection of transvaginal ultrasound transducer handles. Infect Control Hosp Epidemiol. 2015;36(5):581–584.

24. Guideline for ultrasound transducer cleaning and disinfection. Ann Emerg Med. 2021;72(4):e45-e47.

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ith the ongoing emphasis on reducing health care costs in the United States and in reducing emergency department wait times and crowding, observation medicine has become an increasingly important field to help address these issues. Observation units have been shown to help decrease overall health care costs, reduce unnecessary admissions and overall length of stay, and help improve emergency department patient flow. Unfortunately, there has not always been a consensus on how to best define observation medicine and what the specific role emergency physicians (EP) should hold in providing this care. While there has been over decade of literature supporting the role of EPs in providing and supervising observation medicine, as well as EPs possessing the mental models of care delivery that are consistent with the sort of cognitive and operational skills required for observation medicine, there remains debate as to whether emergency medicine is best suited to deliver such observation care.1 Presently, many of us in emergency medicine lead observation units and programs which seem to blur the lines between observation and inpatient status. This is often done in academic centers, and is done intentionally, driven by a

Observation medicine is emergency medicine, it is best practiced in a protocol driven fashion, and ultimately you are likely already doing it.” desire to expand our knowledge, to innovate and simply to prove “what’s possible” in the field of observation medicine. While this is important to the advancement of the field, it only further blurs the lines of the central role of observation medicine. It is not uncommon we are asked by medical directors and administrators in

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Observation Medicine – It’s Common Sense Anthony R. Rosania, MD MHA FAAEM Akiva Dym, MD

smaller institutions how observation medicine can be of help to them and their stakeholders.

To answer this, we need to step back from the large, complex, observation unit and look at the fundamentals of observation medicine. As outlined by Ross and Granovsky in 2017, a few basic principles govern observation medicine: focused goals, limited duration and intensity of care, and appropriate setting and staffing.

We propose a similar model: focusing on the guardrails that keep the care focused and cost effective.2 These guardrails, or principles, are appropriate patient selection, protocol driven care, and defined endpoints for discharge and admission. When adherent to these basic principles, observation medicine is approachable, easily implemented, and highly scalable.

In this article, we aim to discuss the basis as to why many believe that observation medicine belongs within the purview of emergency medicine, as well as discuss how to best initiate and implement small scale observation within the emergency department without significant demand for additional space or personnel.

Lastly, we will briefly discuss some of the financial aspects which are unique to observation medicine.

Observation Medicine Is Emergency Medicine Before beginning a discussion as to why observation medicine is part and parcel to the specialty of emergency medicine, it is important to draw a distinction between the practice of observation medicine and the hospital status of “observation.” While the two should be closely linked, it is quite often they are not. There are many patients with poorly defined endpoints and high intensity of service who end up on observation status when the principles outlined above are not followed. The principled practice of observation medicine is best defined by CMS Medicare Benefit Policy Manual: Observation care is a well-defined set of specific, clinically appropriate services, which include

ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.3

Observation medicine is not really a shortening of inpatient medicine/stays but rather a lengthening of what previously had been normal emergency department visits.

Central to this definition of observation is the last statement which states “to make a decision concerning their admission or discharge.” Is this not a central concept within emergency medicine? Determining patient need for admission or discharge within observation is an extension of triage and disposition, simply over a longer period of time. The CMS Manual goes on to define that time as usually less than 24 hours.

Thus, observation medicine is not really a shortening of inpatient medicine/stays but rather a lengthening of what previously had been normal emergency department visits. As our in-patient admission criteria have changed, so too has the amount of time required to determine if a patient needs to be admitted grown longer. However, this does not change the fact that this determination of disposition is fundamentally related to the concepts of triage and disposition which is at the core of emergency medicine.

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This distinction is critical, because without a focus on the work required to make that disposition decision, there can be a tendency to incur unnecessary costs. This is where clinical protocols are important, as they create guidelines on the management of observation patients, ensuring that the further clinical work up and treatment are limited to those things necessary to make the determination regarding discharge or admission.

Observation Medicine—You’re Already Doing It One of the most frequent questions I receive from emergency physicians looking to develop observation care either within their existing ED or in a separate unit is “how do I start?” The first thing I tell them is to focus on the first principle—patient selection. The second thing I tell them is that they are already doing observation medicine, they just don’t know it (or they do and are unwilling to admit it). One way to begin is by looking for trends in your ED patients with long length of stay, especially those who are there for diagnostic or monitoring reasons. If you are already keeping any patient for a period of six hours or more, you may be able to begin billing observation care for those patients.

While Medicare requires a minimum of eight hours on observation status, many private payers will pay for slightly shorter stays. Many types of patients who can be categorized into this “six plus hour” group are those presenting with common ED presentations such as chest pain, allergic reactions, persistent asthma, and gastroenteritis. Most of these are commonly managed ED complaints and easily managed

by EPs under protocoled care. Note that some observation protocols and conditions are purely diagnostic, others can be therapeutic. A general rule of thumb is that the therapeutic ones are less predictable and prone to a longer length of stay and a higher “conversion rate” to inpatient status.

After identifying which patients are suitable for observation medicine, it is important to develop protocols for clinical care. However, numerous existing resources can provide protocols for many common ED presentations and can service as a foundation for

developing your department’s protocols. Some of the well-known resources include online published protocols as well as within the Observation Medicine textbook by Mace et al.4-6 Furthermore, most observation medical directors are more than willing to share their existing protocols and guidelines within the ED community, and can be found on individual program websites and within shared group forums such as those hosted by AAEM and ACEP. Critical components to any good protocol include well-defined exclusion criteria (frequently, those criteria which meet admission), strict clinical parameters (to limit care to essential components), and admission triggers (to ensure that patients are not kept on observation if meeting admission criteria).

It’s a Status (and a Mindset), Not a Location

Step 1: Identify your primary patient presentations with long stays (six plus hours) for your first protocols (e.g., chest pain) Step 2: Develop (or steal) protocols for each category of patient (e.g., chest pain, asthma) Step 3: Partner with hospital stakeholders to create observation order and status Step 4: Begin coding observation stays Step 5: Expand protocols to include those patients requiring more diagnostics (e.g., syncope, TIA)

Coding For Observation A full discussion of observation and the coding options open to emergency physicians is beyond the scope of this work and multiple strategies do exist.8 However, the simplest is to bill the observation codes instead of the emergency department codes for evaluation and management.

It is important to note that a separate unit is not required to practice observation medicine.

While observation units are ideal for providing The simplest codes are the same day obserobservation care, they are far from necessary. vation codes which are used when a patient All that is needed are patients suitable for is placed on observation and is discharged observation (and we have ED Codes Only Observation already established that all RVUs Codes EDs will have them), beds within the ED (beds which Patient Observed & 99285 99236 are already being occupied Discharged On Same 5.18 RVU 6.15 RVU by the patients mentioned Day

above), and the EMR order 99285 99220 + 99217 Patient Observed and and clinical status change Discharged the Next Day 5.18 RVU 7.28 RVU to place the patient on observation. The last step will Table 1: Difference In RVU Between ED and Observation Codes require partnership with the hospital to develop, however this should not be within the same day. For the highest complexity a barrier, every patient placed in observation patients, you code a 99236, which is valued at can generate 5x the revenue as compared to 6.15 RVUs in 2021. For an equivalent ED visit an ED visit alone (for example, ~$500 for an (99285), you would only get 5.18 RVUs. That is average level 5 ED visit as compared to ~$2500 almost a whole RVU more for performing equivfor a comprehensive observation stay).7 Future alent work. Work, we have already established, steps can include developing order sets and you are already doing in your ED.9 note templates for each category of patient Now, what happens if that patient stays into the under observation, however this is not required next day (past midnight)? You can then you can or necessary to provide observation care. code a 99220 on the first day of observation at Thus, there are 5 simple steps to begin 5.21 RVUs, and then on the day of discharge, practicing observation medicine within your an additional 2.07 RVUs for the discharge. department: That’s two full additional RVUs for work, once again, you are already likely doing in your ED.

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The RVUs for same day observation approach those of critical care, and like critical care, observation services should be a critical part of maximizing your revenue (see Table 1).

Conclusion This discussion of observation care has been brief and just scratches the surface. Obviously, the implementation of this has nuances and the billing and coding can be complex at times, but most ED coding groups will be able to guide you through the process. Additionally, the AAEM Operations Management Committee as well as the AAEM Physician Group are both great places to start if you require further information.

However, we hope that we have impressed upon you the basic principles we feel should guide not only its provision, but its practice: observation medicine is emergency medicine, it is best practiced in a protocol driven fashion, and ultimately you are likely already doing it. It is our hope that this will encourage you to dig deeper into the subject and explore the possibilities it offers for enhanced revenue generation as well as the provision of outstanding patient care.

References 1. Ross MA, Hockenberry JM, Mutter R, Barrett M, Wheatley M, Pitts SR. Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Aff (Millwood).

2013;32(12):2149-2156.

2. Ross MA, Granovsky M. History, Principles, and Policies of Observation Medicine. Emerg Med Clin North Am. 2017;35(3):503-518.

3. Center for Medicare Services. Medicare Benefit Policy Manual Chapter 6 Sec 20.6. In. https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/bp102c06.pdf2020.

4. Emory Healthcare. EMERGENCY DEPARTMENT CLINICAL DECISION UNIT. In: https://www.acep.org/globalassets/uploads/uploaded-files/acep/ clinical-and-practice-management/resources/observation/emory-cdumanual-and-protocols.pdf2014. Accessed February 1, 2022.

5. Mace SE. Observation medicine : principles and protocols. Cambridge, United Kingdom ; New York, NY, USA: Cambridge University Press; 2017.

6. Various Authors. http://www.obsprotocols.org/tiki-index.php. Accessed February 1, 2022.

7. American College of Emergency Physicians. APC (Ambulatory Payment Classification) FAQ. Published 2021. Accessed February 1, 2022.

8. Baugh CW, Suri P, Caspers CG, Granovsky MA, Neal K, Ross MA. Financial Viability of Emergency Department Observation Unit Billing Models. Acad Emerg Med. 2019;26(1):31-40.

9. American College of Emergency Physicians. Observation - Physician

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Efficacy of the HINTS Exam by Emergency Medicine Physicians Zachary Rogers, MD, Cody Couperus, MD, Jordan Parker, MD, Samantha Yarmis, MD, and Sharleen Yuan MD, PhD Editors: Kami M. Hu, MD FAAEM FACEP and Kelly Maurelus, MD FAAEM

Question: Can emergency physicians safely utilize the HINTS exam to rule out central causes of vertigo?

Introduction Posterior circulation stroke has long been an underrecognized and poorly understood entity in emergency medicine (EM), with a miss rate up to 2.5 times higher than that of anterior strokes.1 With patients complaining primarily of vertigo, incoordination, double vision, and nausea and vomiting rather than the more-recognized symptoms of facial droop, arm weakness, and speech difficulty associated with anterior circulation stroke, a posterior stroke’s vague presentation can lead it to be overlooked by patients and practitioners alike. Additionally, computed tomography (CT)— the standard initial modality for stroke imaging evaluation—has a poor sensitivity for posterior stroke (as low as 41.8% in one study).2-5 Although much more sensitive than CT, brain magnetic resonance imaging (MRI) has also been shown to have only an 82-88% sensitivity for posterior stroke when performed in the first 48 hours.6-9 This atypical presentation, combined with the poor sensitivity of available imaging modalities, leads to a misdiagnosis rate of 28-59% for acute posterior stroke.1,10 The HINTS (Head Impulse, Nystagmus, and Test of Skew) exam is a quick, noninvasive bedside test with the potential to accurately rule out posterior stroke in the patient with acute vestibular syndrome (AVS), generally defined here as sudden-onset continuous vertigo or imbalance. In 2009, Kattah et al. demonstrated that the HINTS exam, when performed by a neuro-ophthalmologist, was more sensitive for acute posterior stroke than MRI, achieving a sensitivity of 100% and specificity of 96%.11 Newman-Toker et al essentially replicated these findings in 2013 with a HINTS exam sensitivity of 96.5% and a specificity of 84.4% for posterior stroke, again utilizing neuro-ophthalmologists. 12 The results of these studies have led to the increasing utilization of the HINTS exam by EM physicians to guide decisions regarding additional diagnostics, treatment, and disposition. The use of the HINTS exam in the emergency department is, however, a very different scenario than was originally tested. In this review we discuss the current available literature regarding utilization of the HINTS exam specifically by EM physicians to rule out posterior circulation stroke.

Kerber KA, Meurer WJ, Brown DL, et al. Stroke risk stratification in acute dizziness presentations: A prospective imaging-based study. Neurology. 2015 Nov 24;85(21):1869-78.

This study was a single center, prospective, imaging-based study conducted to evaluate the ability of history and neurologic exam elements to risk stratify patients presenting with dizziness. The primary outcome was

the presence of acute cerebral infarct or intracranial hemorrhage on MRI. The study was performed at a single level 1 trauma center emergency department. Inclusion criteria were dizziness as a primary presenting problem, continuous dizziness at the time of evaluation, and nystagmus or imbalance. Exclusion criteria were new moderate to severe neurologic exam findings, suspected alternative etiology for symptoms, characteristic findings of benign paroxysmal positional vertigo on provocative testing, greater than 14 days of symptoms, or chronic recurrent dizziness.

Structured history and physical exam were obtained for each enrolled patient. The history included elements of the ABCD2 score13 and identified patients with prior stroke. Components of the ABCD2 score included age ≥ 60, systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg, clinical findings of unilateral weakness or speech disturbance without weakness, duration of symptoms, and history of diabetes. A neurologic exam was performed by either a neurologist fellowship-trained in neuro-otology or vascular neurology or an EM physician fellowship-trained in vascular neurology. The exam included an oculomotor assessment with components of the HINTS exam. A three-category schema was used to classify the HINTS exam findings—no nystagmus or skew, positive, or negative. A negative HINTS exam indicated non-central nystagmus, an abnormal head impulse test (HIT), and negative test of skew (TOS). In contrast, a positive HINTS exam indicated central nystagmus, normal HIT, or positive TOS. If a clinical MRI was not obtained, patients were offered a research MRI to be completed greater than 24 hours after symptom onset.

In total, 320 patients were included and 272 (85%) obtained MRI imaging within 14 days of symptom onset. Patients were evaluated in the emergency department (89%), inpatient/observation units (10%), or in an outpatient setting (1%). Acute cerebral infarct or hemorrhage was identified in 29 (10.6%) patients. Of the patients with stroke, HINTS exam was classified as positive in only 20 (69%) and no nystagmus or skew was identified in 5 (17%). Neurologic exam interrater reliability was only fair for comparison with a second investigator (0.29) or exam video review (0.40).

To evaluate the discriminatory ability of history and exam finding combinations, a multivariable logistic regression model was trained. The independent variables included the ABCD2 score (continuous), HINTS exam findings, any other CNS features (binary), and history of prior stroke (binary). Model risk stratification categories were prespecified as low (<5%), moderate (5% to <10%), or high (≥10%). Variables achieving statistical significance included the ABCD2 score (p<0.01) and other CNS features (p<0.05). The HINTS exam was borderline significant

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(p=0.06). C-statistic was 0.77 indicating good ability to define risk stratification. Training set validation identified zero stroke cases in the low-risk category (0/86), 9 in the moderate risk category (9/94), and 20 in the high-risk category (20/92). Neither holdout set nor external validation were reported. A second model was trained replacing the HINTS exam with nystagmus assessment (central, non-central, or absent). C-statistic for this model was 0.78. One patient in the low-risk category (1/109) was identified to have acute cerebellar infarction.

This prospective imaging-based study was performed to assess the ability of history and neurologic exam elements to risk stratify patients with dizziness in regard to stroke. The strengths of the study include robust enrollment methods, thorough structured neurologic exam, research MRI availability for patients without a clinical MRI, and a patient population that likely reflects that in a typical emergency department. Acute stroke was identified in 29/272 (10.6%) of the patients. The HINTS exam was only positive in 20/29 and no nystagmus or TOS was identified for 5/29.

Interrater reliability was fair, corroborating studies showing significant variation in HINTS exam findings between clinicians. The multivariable logistic regression model suggests that there may be some combination of history and exam elements that sufficiently risk stratify patients such that advanced imaging is not required. Despite successful risk stratification, in the absence of holdout set or external validation it is not possible to determine any level of generalizability from this model. These findings demonstrate that ABCD2 and oculomotor assessment (HINTS exam) results are linked with the probability of stroke. However, this study does not support the use of either to sufficiently rule out central causes of AVS, suggesting that a reassuring HINTS exam alone is insufficient to rule out acute ischemic or hemorrhagic infarct in patients presenting with dizziness.

Gerlier C, Hoarau M, Fels A, et al. Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study. Acad Emerg Med. 2021 Jul 10. doi: 10.1111/ acem.14337.

A single-center, prospective, cohort study assessing the ability of the HINTS exam to diagnose central causes of vertigo and unsteadiness, this investigation also compared the diagnostic accuracy of the HINTS examination to that of the ABCD2 score and the STANDING algorithm.14 It included patients that presented to the ED with anywhere from 1 hour to 1 week of vertigo or vestibulo-visual and postural symptoms, and excluded patients who had resolution of symptoms at time of examination, had obvious localizing neurologic deficits, alternative diagnoses at time of admission, or were unable to have thorough assessment completed.

The primary outcome was the diagnostic accuracy of emergency physicians for a central etiology for vertigo and unsteadiness.

Nine emergency physicians were trained by otologists on how to effectively perform and interpret the maneuvers used in the HINTS examination and the STANDING algorithm. During the study period, the emergency physicians performing the HINTS exam and STANDING

algorithm were blinded to the care of the patient. The ABCD2 score was calculated retrospectively. The standard for diagnosing the presence of a central etiology was diffusion-weighted MRI, or CT angiography if there was a contraindication to receiving a brain MRI. In total, 300 patients were included and 62 of the patients were diagnosed with central pathology while the other 238 were diagnosed with a peripheral etiology for their symptoms. The HINTS exam correctly diagnosed 59/62 cases of central vertigo and 159/238 cases of peripheral vertigo, with a sensitivity of 96.7%, specificity of 67.4%, positive predictive value (PPV) of 43.4%, and a negative predictive value (NPV) of 98.8%. The STANDING algorithm correctly recognized 58/62 cases of central vertigo and 178/238 cases of peripheral vertigo, with a sensitivity of 93.4 %, specificity of 75%, PPV of 49.1%, and NPV of 97.8%. There was no significant difference between the HINTS exam and STANDING algorithm in terms of sensitivity and negative likelihood ratio (LR), but the STANDING algorithm performed better with respect to specificity (p < 0.001) and positive LR (p = 0.004).

The ABCD2 score was inferior to the HINTS exam in terms of sensitivity (p < 0.001), specificity (p < 0.001), and negative LR (p < 0.001).

The single center nature of the study limits its generalizability, as does the specific training undergone by emergency physicians and their use of specialty Frenzel glasses—a tool which increases the ability to detect minute ocular findings but is not available in most emergency departments. There was no assessment of interrater reliability or emergency physician accuracy in performing and interpreting the HINTS and STANDING algorithm, and the possibility remains that the emergency physician performing the HINTS exam and STANDING algorithm was biased in their interpretation of one of the tests based on results of the other. The authors concluded that the HINTS exam and STANDING algorithm can be used by the emergency physician to rule out a central etiology for vertigo. While both methods were found to have a high sensitivity in this setting, they were not very specific and in practice may lead to further unnecessary testing for patients with a peripheral etiology of their symptoms.

Ohle R, Montpellier R, Marchadier V, et al. Can Emergency Physicians Accurately Rule Out a Central Cause of Vertigo Using the HINTS Examination? A Systematic Review and Meta-analysis. Acad Emerg Med. 2020 Sep; 27(9):887-896.

This study was a systematic review and meta-analysis aimed at determining the diagnostic accuracy of the HINTS exam in ruling out central causes of vertigo when performed by emergency physicians versus by neurologists. The authors included prospective studies of adult patients who presented to an emergency department with AVS defined as vertigo, nystagmus, head motion intolerance, ataxia, and nausea or vomiting. Other inclusion criteria were a fully described HINTS exam, a CT scan and/or MRI, and final diagnosis of stroke versus other cause.

The QUADAS-2 tool was used to evaluate the quality of evidence, risk of bias, and applicability. Sensitivity, specificity, and likelihood ratios were calculated using a bivariate random-effects model. Heterogeneity was

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determined based on the I2 statistic and forest plots, and only studies without significant heterogeneity (I2 < 40%) were included.

In total, the authors screened 2,695 articles, of which only 11 met inclusion criteria after full-text review. Six of these were subsequently excluded due to incomplete HINTS exam, overlap with other studies, resolution of vertigo, or retrospective data. Ultimately, five studies were included, with a total number of 617 patients. There were reportedly no studies that included only emergency physicians, so the authors compared HINTS performed by neurologists or neuro-ophthalmologists alone to HINTS exam performed by a pooled cohort of neurologists and emergency physicians. Prevalence of stroke ranged from 8.8% to 44% in the included studies. The sensitivity and specificity of the HINTS exam performed by neurologists was 96.7% (95% CI: 93.1-98.5%) and 94.8% (95% CI: 91-97.1%), respectively. The sensitivity and specificity when performed by emergency physicians and neurologists combined was 83% (95% CI: 63-95%) and 44% (95% CI: 36-51%), respectively.

There are several limitations to this study as a meta-analysis. There was significant variability in the definition of AVS among the various included studies, despite the definition provided by the authors. Many of the studies used excluded patients whose symptoms were attributed to peripheral causes based on history, as well as those with more obvious signs of stroke (such as significant cranial nerve deficits). Exclusion of the former may falsely increase sensitivity and specificity, and limits the usefulness of the HINTS exam for all-comers with acute vestibular syndrome.

Exclusion of the latter would decrease sensitivity and specificity, although HINTS exam is likely not useful nor necessary for patients with obvious central pathology. In addition, the included studies had an overall high prevalence of stroke with two of the studies only including patients with at least one known stroke risk factor, further limiting generalizability. An important major limitation of this study is the inability to perform a headto-head comparison of neurologists and emergency physicians. Only one study that of Kerber et al., included emergency physicians at all; the sensitivity and specificities reported above for the pooled emergency physician/neurologist cohort comes directly from this study alone. In addition, the included emergency physicians had additional training in vascular neurology, which is certainly not representative of the average emergency physician. Despite this added experience, there was significantly lower sensitivity and specificity in this cohort compared to studies including only neurologist-performed HINTS exams, suggesting that, despite excellent performance of the HINTS exam when conducted by neurologists, emergency physician-performed HINTS exams are neither adequately sensitive nor specific in evaluating for central etiology of vertigo.

Dmitriew C, Regis A, Bodunde O, et al. Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review. Acad Emerg Med. 2021 Apr;28(4):387-393.

This retrospective chart review examined the role of the HINTS exam and its sensitivity when performed by emergency physicians in the emergency department setting. The overall objective was to assess the frequency of the use of the HINTS exam, the characteristics of patients for which this tool is applied, and the sensitivity and specificity of the HINTS exam in evaluating for a central cause of dizziness as used by emergency medicine physicians in a tertiary care ED in Ontario, Canada.

Inclusion criteria included a triage diagnosis of dizziness, vertigo, lightheadedness, or unsteadiness. Exclusion criteria included patient leaving without being seen, dizziness lasting longer than 14 days, recent trauma, Glascow coma score (GCS) less than 15, hypotension, or syncope/loss of consciousness. The primary outcome was the diagnostic accuracy of the HINTS exam—specifically, the number of patients who had an exam suggesting central etiology, whether stroke, transient ischemic attack, brain tumor, or white matter lesion that was later confirmed by CT, MRI, or on the basis of neurology consult. Secondary outcomes included the number of dizzy patients with AVS defined as ongoing continuous dizziness with nystagmus and unsteady gait, who were appropriately evaluated with a HINTS exam as well as the proportion of HINTS exams performed on dizzy patients who were not appropriate candidates and the number of patients presenting with dizziness who received both the HINTS exam and the Dix-Hallpike maneuver.

A total of 3,109 patients presented to the ED with dizziness, vertigo, unsteadiness, or lightheadedness during the time frame of the study, with 2,309 meeting inclusion criteria, and only 39 (1.7%) of these meeting the study definition of AVS. A total of 450 patients overall underwent a HINTs exam, with only 14 (3.1%) meeting the definition for AVS and 220 (49%) also receiving a Dix-Hallpike exam. Of the 39 patients with AVS only 14 (36%) received a HINTS exam. Six out of the 39 were ultimately diagnosed with a central etiology for their symptoms, but none of these patients underwent HINTS testing. There were 60 patients found to have a central etiology for their symptoms, with only 6 of these patients meeting criteria for AVS based on chart documentation. None of these patients underwent a HINTS exam, resulting in an inability to calculate a sensitivity for the HINTS exam. Specificity was poor, with 16 out of 450 completed HINTS exam thought to be suggestive of central pathology 16/450 (3.6%) and none of them eventually found to have CNS pathology.

The results of this study indicate that the HINTS exam was widely misapplied. The vast majority of patients in whom HINTS exam testing was performed did not have true acute vestibular syndrome and were inappropriate for HINTS testing. Almost half of patients who had a HINTS exam performed also underwent a Dix-Hallpike maneuver, again suggesting that emergency department physicians are uncertain which patients

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are appropriate candidates for the HINTS exam. Additionally, accurate performance and interpretation of the HINTS exam is operator-dependent and therefore reliant on the level of experience and training of the clinician performing the exam. The combination of misapplication and unskilled testing rendered the HINTS exam results useless in this study.

The results of this single-center, retrospective chart review may not be generalizable to other centers. The authors could not control for individual physicians, their education, or their level of expertise. Due to its retrospective nature, in some cases, insufficient chart documentation may lead to incorrect categorization of patient’s symptoms and thus their AVS grouping. Additionally, the small number of patients with AVS who were ultimately diagnosed with a central cause of dizziness (6 patients) limits the ability to accurately measure sensitivity and specificity in this population.

Discussion While the HINTS exam has been demonstrated in prior studies to be highly accurate in highly specialized and trained hands, the results of these studies outlined above raise concern with its use by the average EM physician. The majority of studies that utilized EM physicians either utilized physicians with additional training in neurology or specialized instruction for the HINTS exam. Additionally, one of the studies also employed the use Frenzel glasses, a tool not readily available to most emergency physicians. The only existing study that provided no additional training and reviewed real-life current utilization of the HINTS exam in the emergency department demonstrated abysmal results.

Use of the HINTS exam in the emergency department by emergency physicians should not be portrayed as standard of care in the ever-increasing work load of the EM physician. While emergency physicians are the jacks-of-all-trades, those who wish to utilize the HINTS exam in daily practice should have additional training and ongoing skill maintenance to master its application, and should always utilize expert backup as appropriate until further studies demonstrate EM physicians can perform the exam as well as specialist.

Question: Can emergency physicians safely utilize the HINTS exam to rule out central causes of vertigo?

Answer: The existing data evaluating the accuracy of the HINTS exam does not support its use by the average emergency physician to discriminate between central versus peripheral causes of vertigo or the acute vestibular syndrome.

References 1. Arch AE, Weisman DC, Coca S, er al. Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services. Stroke. 2016;47(3):668-73.

2. Ahsan SF, Syamal MN, Yaremchuk K, et al. The costs and utility of imaging in evaluating dizzy patients in the emergency room.

Laryngoscope. 2013;123(9):2250-3.

3. Hwang DY, Silva GS, Furie KL, Greer DM. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct. J Emerg Med. 2012;42(5):559-65.

4. Kerber KA, Schweigler L, West BT, et al. Value of computed tomography scans in ED dizziness visits: analysis from a nationally representative sample. Am J Emerg Med. 2010;28(9):1030-6.

5. Lawhn-Heath C, Buckle C, Christoforidis G, Straus C. Utility of head CT in the evaluation of vertigo/dizziness in the emergency department. Emerg Radiol. 2013;20(1):45-9.

6. Kabra R, Robbie H, Connor SE. Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo.

Clin Radiol. 2015;70(7):736-42.

7. Choi JH, Kim HW, Choi KD, et al. Isolated vestibular syndrome in posterior circulation stroke: Frequency and involved structures. Neurol Clin Pract.

2014;4(5):410-418.

8. Saber Tehrani AS, Kattah JC, Mantokoudis G, et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014;83(2):169-73.

9. Edlow BL, Hurwitz S, Edlow JA. Diagnosis of DWI-negative acute ischemic stroke: A meta-analysis. Neurology. 2017;89(3):256-62.

10. Calic Z, Cappelen-Smith C, Anderson CS, et al. Cerebellar Infarction and Factors Associated with Delayed Presentation and Misdiagnosis.

Cerebrovasc Dis. 2016;42(5-6):476-84.

11. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke.

2009;40(11):3504-10.

12. Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness.

Acad Emerg Med. 2013;20(10):986-96.

13. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007;369(9558):283-292.

14. Vanni S, Pecci R, Casati C, et al. STANDING, a four-step bedside algorithm for differential diagnosis of acute vertigo in the Emergency Department. Acta Otorhinolaryngol Ital. 2014;34(6):419-426.

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ABEM NEWS

ABEM Recognizes Physicians Achieving 30 Years of Board Certification

A

BEM recognizes physicians who, as of December 31, 2021, have marked 30 years of being board certified in Emergency Medicine.

Because board certification is a voluntary process, this landmark accomplishment reflects a dedication to the specialty of Emergency Medicine, a commitment to continuous professional development, and the long-standing provision of compassionate, quality care to all patients.

To maintain their ABEM certification for 30 years, physicians must participate in continuing professional development and learning in the specialty.

The ABEM continuing certification process assists certified physicians keep current on medical advances and provides opportunities for practice improvement.

ABEM salutes these physicians for their dedication to the specialty, their recognition of the value of board certification, and their commitment

to caring for acutely ill and injured patients. A special certificate will be mailed to each of these physicians to recognize and honor them. ABEMcertified physicians are among the finest health care providers in the United States. Each of them exemplifies the ABEM mission, “To ensure the highest standards in the specialty of Emergency Medicine.”

Emergency Medicine was recognized as the 23rd medical specialty in 1979, administered the first certification examinations in 1980.

A list of the nearly 700 physicians who reached this milestone in 2021 is available online.1

References 1. https://www.abem.org/public/docs/default-source/default-documentlibrary/30-year-certificate-recipients-2022.pdf

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February Board of Directors Meeting Summary

February Board of Directors Meeting Summary The members of the AAEM Board of Directors met in-person and virtually at the Confidante Miami Beach on February 10, 2022, to discuss current and future activities. The members of the board appreciate and value the work of AAEM committee, section, interest group, and chapter division members and chairs as they strive toward the AAEM mission and to be the specialty society of emergency medicine. Over the course of the meeting, a number of significant decisions and actions were made. Here are the highlights:

Presentations

Approvals

Miscellaneous

President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM presented her President’s report which highlighted the many activities that she and other leaders have been involved in. Highlights of the report included leadership meetings with other emergency medicine organizations to discuss the lawsuit against Envision, and updates from the AAEM Representatives to other organizations.

A number of approvals took place during the meeting including:

In addition, there were updates regarding AAEM’s lawsuit against Envision. Envision asked for a dismissal of the lawsuit and failing that dismissal, they asked to have the lawsuit sent from state level to the federal court level.

Discussions were also held regarding the location of MEMC 2023 which is yet to be determined.

Treasurer Robert Frolichstein, MD FAAEM reported on AAEM and AAEM subsidiaries financial performance through December 31, 2021.

Overall, AAEM remains in a very good financial situation. He also reported that the 2021 audit was in progress.

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2021-2022 Elected Board of Directors

COMMON SENSE MARCH/APRIL 2022

• April 28, 2022 Hill Visit during AAEM Scientific Assembly • AAEM to increase the Marketing Budget • Continuation of Scientific Assembly International Scholarships • Formation of a Faculty Development Resource Committee • SA 2022 will be live-streamed however all speakers present in-person • The formation of a PAC Advisory Council

The Next Board of Directors Meeting When April 23, 2022

Where AAEM Scientific Assembly, Baltimore, MD

Membership Categories Fellow and Full Voting – FAAEM Dues: $525 Board certified in emergency medicine or pediatric emergency medicine

Associate Dues: $250 Graduate of an ACGME or AOA approved emergency medicine training program and not yet taken or passed your EM board

Fellow-in-Training Dues: $75 Graduate of an ACGME or AOA approved emergency medicine training program and currently enrolled in a fellowship

International Member AAEM is the leader within our field in preserving the integrity of the physician-patient relationship by fighting for a future in which all patients have access to board certified emergency physicians and physician rights are protected.

Dues: $150 Physicians with an interest in emergency medicine who practice outside of the United States or Canada

Emeritus Member Dues: $250 Full voting member who has practiced emergency medicine for 30 or more years and has been a full voting member for a minimum of 10 years -or- at least 65 years of age and have been a full voting member for a minimum of 10 years Special circumstances may lead to a request for emeritus membership and will be reviewed on a case-by-case basis. See www.aaem.org/membership for more information.

Member Benefits Publications

Learn more and join today at: www.aaem.org/membership

Free subscriptions to the Journal of Emergency Medicine and Common Sense

Group Membership

Education Free registration to the Annual Scientific Assembly with refundable deposit and discounted registration for other AAEM events

AAEM offers group memberships to allow hospitals/groups to pay for the memberships of all their EM board certified & board eligible physicians.

Members-Only Section

Criteria: All board certified and board eligible physicians at your hospital/ group must be members

Access the AAEM Job Bank, your Advanced Resuscitation Expertise Card (for Full Voting members), and other academic and career-based benefits Learn more about these and other member benefits at www.aaem.org/membership/benefits American Academy of Emergency Medicine 555 East Wells Street, Suite 1100, Milwaukee, WI 53202-3823 (800) 884-2236 info@aaem.org www.aaem.org

100% ED Group Membership Discount: 10% discount on membership dues

ED Group Membership Criteria: Two-thirds of all board certified and board eligible physicians at your hospital/group must be members Discount: 5% discount on membership dues For group memberships, AAEM will invoice the group directly. If you are interested in learning more about the benefits of belonging to an AAEM ED group, please contact us at info@aaem.org or (800) 884-2236.

Join Today! www.aaem.org/membership COMMON SENSE SEPTEMBER/OCTOBER 2021

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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

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

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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

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 1879) Email: emedacademicaffairs@stanford.edu

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

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.) 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 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

INDIANA

The Indiana University School of Medicine seeks a strong academic leader to serve as our Emergency Ultrasound Fellowship Director. IUSM has long been regarded as one of the premier training programs for emergency medicine, and our Division of Emergency Ultrasound is one of the largest Emergency Ultrasound divisions in the country. This role offers full-time hours with a split between clinical practice (~80%,) and academics (~20%), dual employment with the IU School of Medicine & IU Health Physicians, and requires two years of clinical experience post-fellowship training. To learn more, contact Patti Crabtree at pcrabtree@iuhealth.org, or visit https:// bit.ly/3i4OJxh. (PA 1876) Email: pcrabtree@iuhealth.org Website: https://iuhealthrecruitment.org/Physician_Job/Details/ IU-Health-Physicians--Emergency-Ultrasound-FellowshipDirector-Methodist-and-Eskenazi-Hospitals/40555

MASSACHUSETTS

Trinity Health Of New England—the region’s largest nonprofit health system—seeks a BC/BE Emergency Medicine Physician to join our growing team at Mercy Medical Center in Springfield, Massachusetts. It’s an exciting time to join our emergency medicine team where our dedicated staff provides comprehensive services for high acuity cases in a highvolume center. We are seeking full-time physicians for day and

nocturnists shifts within this 40 bed ED that sees approximately 80,000 visits per year. Springfield offers a tremendous selection of welcoming neighborhoods to live, excellent public/ private schools and colleges, great restaurants, shopping, music, museums, and historical areas. (PA 1884) Email: dhowe@TrinityHealthofNE.org Website: https://www.jointrinityne.org/Physicians

NEW JERSEY

The Department of Emergency Medicine at Rutgers New Jersey Medical School is recruiting a board-certified emergency physician and medical toxicologist as Director of our Medical Toxicology Fellowship. The fully-accredited training program is integrated with both our inpatient and outpatient consultation services as well our Poison Control Center. We are committed to developing a diverse faculty. Applicants should have a desire for advancing clinical, educational, academic, and administrative excellence. The ideal candidate is committed to engaging in opportunities for scholarship and collaboration. Three years or more as a core faculty member in an ACGME-accredited medical toxicology program is required. (PA 1869) Email: rosanian@njms.rutgers.edu Website: https://njms.rutgers.edu/departments/emergency_ medicine/

NEW JERSEY

The Department of Emergency Medicine at Rutgers New Jersey Medical School is actively recruiting talented Emergency Physicians interested in clinical education and professional growth opportunities. We are home to an enthusiastic and diverse group of emergency physicians who are committed to education, scholarship, research, service, and outstanding clinical care. We are committed to fostering a diverse and inclusive faculty. Applicants should have a desire for clinical, educational, or academic advancement. The ideal candidate is committed to engaging in the numerous opportunities for professional development that the department and institution offer, while sharing our commitment to inclusive excellence. (PA 1870) Email: rosanian@njms.rutgers.edu Website: https://njms.rutgers.edu/departments/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 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

PHYSICIAN - PEDIATRIC ORTHOPAEDIC URGENT CARE CENTER (Los Angeles) SUMMARY: Under the general supervision of the Urgent Care Medical Director, coordinates and delivers the care of pediatric patients in the outpatient and the urgent care settings managing acute, chronic, surgical and congenital musculoskeletal conditions. The Physician is responsible for providing musculoskeletal care in the urgent care setting, including fracture treatment. REQUIRED QUALIFICATIONS: • Graduated from an accredited medical school and residency program AND have a current unrestricted valid license to practice medicine in the State of California,

including DEA license. • Fluoroscopy X-Ray Supervisor and Operator Certificate, issued by the California Department of Public Health. • Must be comfortable seeing pediatric patients who are between the ages of 2 and 18 years of age. •ACLS/ PALS certified (PA 1872) Email: mrpeters@mednet.ucla.edu Website: https://workforcenow.adp.com/mascsr/default/mdf/ recruitment/recruitment.html?cid=1fe50326-beac-4a7c-a564-f8 a14f9c5bb0&ccId=19000101_000001&jobId=412173&lang= en_US&source=CC4

COMMON SENSE MARCH/APRIL 2022

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COMMONSENSE

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