May/June 2022 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 29, ISSUE 3 MAY/JUNE 2022

28th Annual AAEM Scientific Assembly: Thank You for Joining Us! Page 9

President’s Message:

Goals

From the Editor’s Desk:

The Beatings Will Continue Until Morale Improves

Young Physicians Section:

Advocacy: What Can You Do?

AAEM/RSA President’s Message:

Cabinet of Delegates

AAEM/RSA Editor’s Message:

As the Streets Become More Dangerous for Members of the LGBTQ Community

Table of Contents TM

Officers President Jonathan S. Jones, MD FAAEM President-Elect Robert Frolichstein, MD FAAEM0 Secretary-Treasurer L.E. Gomez, MD MBA FAAEM Immediate Past President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Past Presidents Council Representative William T. Durkin, Jr., MD MBA MAAEM FAAEM Board of Directors Kimberly M. Brown, MD MPH FAAEM Phillip A. Dixon, MD MBA MPH FAAEM CHCQMPHYADV Al O. Giwa, LLB MD MBA MBE FAAEM Robert P. Lam, MD FAAEM Bruce Lo, MD MBA RDMS FAAEM Vicki Norton, MD FAAEM Carol Pak-Teng, MD FAAEM Kraftin Schreyer, MD MBA FAAEM YPS Director Fred E. Kency, Jr., MD FAAEM AAEM/RSA President Leah Colucci, MD MS Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD FAAEM Editor, Common Sense Ex-Officio Board Member Andy Mayer, MD FAAEM Executive Director Missy Zagroba, CAE 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.

COMMON SENSE MAY/JUNE 2022

COMMONSENSE

Regular Features

President’s Message: Goals................................................................................................................3 Editor’s Message: The Beatings Will Continue Until Morale Improves.................................................6 Letter to the Editor..............................................................................................................................8 Financial Wellness: A 5-part Series on Managing Money Wisely: Top Ten Financial Mistakes for New Attendings............................................................................20 Heart of a Doctor: The Man in the MICU...........................................................................................22 Young Physicians Section: Advocacy: What Can You Do................................................................31 AAEM/RSA President’s Message: Cabinet of Delegates.................................................................32 AAEM/RSA Editor’s Message: As the Streets Become More Dangerous for Members of the LGBTQ Community, it is Our Responsibility to Make Our Emergency Departments Safer.....................................................................................................33 Medical Student Council: Meet the new Medical Student Council................................................36 Foundation Contributions................................................................................................................18 PAC Contributions.............................................................................................................................18 LEAD-EM Contributions....................................................................................................................19 Upcoming Conferences....................................................................................................................19 Board of Directors Meeting Summary: April....................................................................................49 AAEM Job Bank.................................................................................................................................50

Special Features

28th Annual Scientific Assembly Recap.............................................................................................9 AAEM New Board of Directors.........................................................................................................14 AAEM New Section Leadership........................................................................................................15

Featured Articles

Palliative Care Committee: My Journey from ER to Palliative Care..................................................24 Women in Emergency Medicine Section: Human Trafficking and Natural Disasters.......................25 Academic Affairs Committee: Standing the Post..............................................................................27 Wellness Committee: A Colleague is making you Unwell: Options...................................................28 Emergency Ultrasound Section: Education in Point of Care Ultrasound.........................................29 AAEM Oral Board Review Course: Why You Should Volunteer as an Oral Board Review Course Examiner............................................................................................30 Critical Care Medicine Section: Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest...........................................................................37 Operations Management: Fellowships in ED Administration: Suggestions for a Standardized, Domain Based Curriculum.........................................................39 Diagnosis of PE in Pregnancy: Applying a Simple Algorithm to Reduce the Need for CT...............42 AAEM/RSA Resident Journal Review: Utility of Coronary Angiography in Cardiac Arrest Survivors without ST Elevation Myocardial Infarction............................................45

Mission Statement

The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles: 1. Every individual, regardless of race, ethnicity, sexual identity or orientation, religion, age, socioeconomic or immigration status, physical or mental disability must have unencumbered access to quality emergency care. 2. The practice of emergency medicine is best conducted by a physician who is board certified or eligible by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM). 3. The Academy is committed to the personal and professional well-being of every emergency physician which must include fair and equitable practice environments and due process. 4. The Academy supports residency programs and graduate medical education free of harassment or discrimination, which are essential to the continued enrichment of emergency medicine, and to ensure a high quality of care for the patient. 5. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members. 6. The Academy supports the establishment and recognition of emergency medicine internationally as an independent specialty and is committed to its role in the advancement of emergency medicine worldwide.

Membership Information

Fellow and Full Voting Member (FAAEM): $525* (Must be ABEM or AOBEM certified, or have recertified for 25 years or more in EM or Pediatric EM) Associate: $150 (Limited to graduates of an ACGME or AOA approved emergency medicine program within their first year out of residency) or $250 (Limited to graduates of an ACGME or AOA approved emergency medicine program more than one year out of residency) Fellow-in-Training Member: $75 (Must be graduates of an ACGME or AOA approved emergency medicine program and be enrolled in a fellowship) Emeritus Member: $250 (Please visit www.aaem.org for special eligibility criteria) International Member: $150 (Non-voting status) Resident Member: $60 (voting in AAEM/RSA elections only) Transitional Member: $60 (voting in AAEM/RSA elections only) International Resident Member: $30 (voting in AAEM/RSA elections only) Student Member: $40 (voting in AAEM/RSA elections only) International Student Member: $30 (voting in AAEM/RSA elections only) Pay dues online at www.aaem.org or send check or money order to: AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM-0422-248

Goals

AAEM PRESIDENT’S MESSAGE

Jonathan S. Jones, MD FAAEM

t was wonderful to be in person again at AAEM22. If you made it, I hope you had an excellent time, learned some great things, and made some fruitful connections. If you couldn’t make it, I hope that you can join us next April in New Orleans. And if you want to learn some great things, remember that all members have free access to AAEM online which has over 100 lectures with CME credit. Talks from SA22 have not yet been uploaded but will soon. And if you want to make some connections, help build the Academy, or just explore an interest, then please check out the multitude of sections, committees, and interest groups. I especially want to make everyone aware of our two newest interest groups, Rural Medicine and Aging Well in Emergency Medicine (the counterpart to the current Young Physicians Section). Now, about me and what I would like to help the Academy accomplish as President over the next two years. I am a community physician in Jackson, MS. I previously was an academician for over a decade, having served as a Residency Program Director and Vice-chair for Education. And while I still value academic medicine, I wanted more of what led me into EM in the first place—direct patient care. I find purpose in caring for my patients. I know we all do. We chose this specialty because we want to help people when they are most vulnerable. We want to help anyone, anywhere, with any problem. We work long hours. We work nights. We work weekends and holidays and miss important events with our families and friends. And I don’t think many of us really mind this. After all, people get sick and injured at all of these times and someone needs to be there to help them. I want to be that person and I know you do too. We enjoy the complex mental and physical challenges of caring for every condition which may enter the ED. And I’m not sure about you, but I’ll admit, that at times, I also enjoy the

simple smiles and laughter from the completely healthy toddler who is brought in for no apparent reason other than parental reassurance. I enjoy when I have a bit of extra time to spend at the bedside as I did recently with an incredibly friendly and committed yet poorly controlled diabetic. She couldn’t understand why her glucose was still way too high. Someone in her clinic told her to stop drinking soft drinks, which she did. Yet no one informed her that sweet tea wasn’t the ideal substitution.

with nothing wrong other than hunger, but who now likely has endocarditis. Or convincing my CEO that despite the fact that we have a part time hematologist, the patient in front of me in fact has a critical and life-threatening condition and needs to be transferred immediately to the tertiary hospital because our hospital just simply will not give this patient the best chance of survival. Or convincing said CEO and CMG groups that I am not just a warm body with a license and that there is an actual difference

I HAVE three specific goals for the Academy over the next two years: 1. Empower all of our members 2. End the corporate practice of medicine 3. Ensure true due process rights for all physicians We all have similar stories. But why do I relate that story or for that matter write the entirety of the paragraph above? It’s because this is what we should be doing. This is what we should be spending our time on. Our greatest challenges should be deciding what exact rhythm the patient has, whether the patient’s dizziness is actually a stroke, or how best to manage the airway in a patient with facial and neck trauma.

between a board-certified emergency physician and everyone else.

But those are not actually the greatest challenges that I face. Much more challenging is convincing my hospitalist to admit the IV drug user who has been to the emergency department 100 times over the last two years typically

1. Empower all of our members 2. End the corporate practice of medicine 3. Ensure true due process rights for all physicians

These are the battles that the Academy is fighting for you. These are the battles you are fighting as part of the Academy. These are the battles that I want to help us win. I have three specific goals for the Academy over the next two years:

>> COMMON SENSE MAY/JUNE 2022

AAEM PRESIDENT’S MESSAGE

Give me advice, give me support, let me know how I’m doing. Help us succeed. Let’s go and knock these goals off the to-do list.”

Empower Our Members This will be my primary focus as president. The success of the Academy depends on the success of its members, each and every one. Everything we have ever achieved has been achieved through the hard work and dedication of many people. And if we are to achieve the other listed goals, it will take every single one of us. But honestly, while true, that’s just boilerplate. What do I specifically mean? You, and every other member, joined the Academy for a specific reason. Every member’s reason is slightly different. However, most reasons have one thing in common and that is that the member wants to make a difference, they want to contribute. They have an idea that they want to explore, an initiative they want to start, or a goal to achieve. I don’t know the individual reason each member joined. And while I would like to know your individual reason for joining, I don’t actually need to know your specific reason in order to help you accomplish your goals. I will start by making communication simpler and more direct. Done. My personal email is jsjonesmd@gmail.com. Send me anything, I will respond (and I’ll give you my cell too, but I learned posting that online is not the best idea). Increasing transparency in decision making processes. Done. Brief agendas for all board meetings will now posted on the website prior to meetings. Additionally, an online comment link is nearby. You can submit questions, suggestions, or comments on any board agenda item or on a new business item. These can be submitted anonymously or with your name. Prior to each board meeting, all comments will be sent verbatim to each board member who will be expected to read and consider them prior to the meeting. Empowering Committees to create and do more. Done. Already each committee has been granted funds to use for any initiative they desire so long as it furthers the mission of the Academy. We have excellent and capable leaders of our committees; we should entrust them to do what is right without overburdensome management.

COMMON SENSE MAY/JUNE 2022

Ending the Corporate Practice of Medicine In December 2021 AAEM through the AAEM PG initiated a lawsuit in California, against Envision for the unlawful practice of medicine and violation on the state prohibition of the corporate practice of medicine. This is the most significant action any medical organization, emergency medicine or otherwise, has ever taken in an effort to restore all practice decision to physicians. The case is progressing well but it is still early. We need continued support from all members and non-members alike. While donations to the AAEM foundation are needed to support the legal effort, equally important is spreading the message, and not just to other emergency physicians. Tell everyone you know, colleagues, friends, family, pets, everyone! AAEM is not suing Envision for any financial gain. We are not asking for a settlement. We are suing Envision so that patients can receive proper care. We are suing so that physicians won’t suffer moral injury by trying their best, yet being stymied. Ask your non-medical friends, “When you visit an emergency department, would you like your medical decisions to be solely made by the physician or would you prefer if they were influenced or dictated by a private equity firm?” In addition to the suit, we are advocating at the state and federal level for stronger protections for physicians against undue influence from corporations. Please check out our campaigns on our website under “Advocacy” or click on “Take Action Now.”

Ensure Due Process Rights for Emergency Physicians We are closer than ever to finally obtaining a federal law ensuring due process rights for all emergency physicians. We have bipartisan sponsors of the bill in the House and close to having bipartisan sponsors in the Senate. Since the Academy’s founding, obtaining true due process rights has been a goal. Ensuring nonwaivable due process rights will allow physicians to better advocate for their patients. It will curtail intimidation and retribution from unethical corporate groups as well as hospital administrators. While simply having due process rights ensured won’t solve all of our problems, it will certainly be one giant step in the right direction. Will we be able to accomplish all these goals in the next two years? I don’t know. But I will end with a bit about my thought process. For years, I’ve always set what I call A, B, and C goals. I always set my A goal as something nearly unobtainable, not impossible, but very difficult to achieve. My B goal has been something which if I obtain it, I will feel happy, I will feel that I accomplished something worthwhile. My C goal is the minimum of which I will be satisfied. If I fail to meet my C goal, then I have failed and feel disappointed. I don’t know exactly when it started and I don’t know why. My earliest memory of my ABC goals is a high-school debate competition. It

AAEM PRESIDENT’S MESSAGE

was my first debate at a regional competition and my specific competition was the LincolnDouglas debate (I chose this because other members of the debate team told me it was the hardest…and because no one else signed up). My A goal was to win the entire competition. My B goal was to be in the top three. My C goal was simply to represent Edgewater High School in a dignified manner. I was only able to accomplish my C goal that day. Sure, I was a bit disappointed, but not too much. I knew I was capable, but I also learned that I needed to work harder.

I’ve been setting these goals ever since and they serve me well. I often am able to accomplish my B goal and occasionally my A goal. Sometimes I still fail to accomplish my C goal. But this system helps keep me motivated, helps me continue to set targets which may at first seem unobtainable, and also keeps me from getting too dejected when it doesn’t go perfectly right. My three goals listed above fall into those categories. Ending the corporate practice of medicine is my A. Honestly, we quite likely

won’t accomplish this in the next two years— but we sure need to try. Ensuring due process is my B. We are so close. We have actual bills in Congress. We have sponsors. We have interorganizational support. But we’re not there yet. Empowering members is my C goal. I must do this. Failure to accomplish this will, quite simply, be a failure. I close in asking for your help. Give me advice, give me support, let me know how I’m doing. Help us succeed. Let’s go and knock these goals off the to-do list.

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

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

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

Submit a Letter to the Editor at:

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

COMMON SENSE MAY/JUNE 2022

EDITOR’S MESSAGE

The Beatings Will Continue Until Morale Improves Andrew Mayer, MD FAAEM

very hospital has their own system of dealing with complaints and also of scoring and rating patient satisfaction. The intention of examining complaints and patient satisfaction scores is on the surface a reasonable one if done properly. Who would say that they do not have room for improvement and that there are not patients who did not receive good service or have a legitimate complaint? Every one of us would like to make our patients happy along with improving their health and quality of life. However, we have gone astray. Sadly, in reality, many systems and programs used to collect and analyze data related to “patient satisfaction” and those used to deal with complaints are severely flawed. The results of these patient satisfaction surveys are often statistically insignificant and the complaint resolution system simply fulfills a federally mandated requirement to deal with complaints without actually making any improvement in the “patient experience.” Conversely, the negative impact of this system on the morale of physicians and nurses in our emergency departments can be significant and further weaken our spirits. The new pandemic facing our emergency departments and the medical system overall is burnout. You can call it “moral injury” but the end result is the same. Unhappy and burned out providers are unlikely to be beaten into better attitudes. Remember the old adage that “the beatings will continue until morale improves.” Telling a burned-out doctor to be nicer is usually counterproductive. I am the medical director of my group and I have the dubious honor of dealing with the complaints and examining and digesting our

COMMON SENSE MAY/JUNE 2022

patient satisfaction scores. I just spent the last half hour speaking to the mother of teenaged patient with several different chronic pain syndromes. She called to complain that one of my partners refused to give her daughter intravenous morphine to help relieve her daughter’s pain. She insisted that only morphine and only IV helped. She could not understand how any doctor could refuse to give medicine that she knew was the right medicine. She bemoaned modern medicine and that doctors had too much power and in this instance refused medicine which her daughter “needed” to get well. We had a more pleasant conversation than I thought and I gave the usual explanation related to chronic pain in that it is a difficult condition to treat in the emergency department and that it was up to the treating physician which medication to order. We discussed the opioid epidemic, etc. This call eventually ended and I leaned back in my chair and looked out of the window onto a beautiful afternoon on my day off wondering how we had gotten to this point? I would never get back that 30 minutes of my life and also knew that this incident was not over as the wheels of the hospital’s grievance process needed to grind on until all of the many steps had been completed. I decided to close the curtains and not go outside and enjoy the beautiful weather. I forged on with the complaint process. I decided to go ahead and write the response to the complaint in our grievance system and write the initial grievance letter. I would need to produce this letter for our Grievance Committee when I had to go in person and explain the complaint and the “service recovery” which I had undertaken.

“UNHAPPY AND BURNED OUT PROVIDERS ARE UNLIKELY TO BE BEATEN INTO BETTER ATTITUDES.” This type of complaint can be such a morale sapper for a doctor. I had to reach out to my partner and ask him about the patient interaction. Who enjoys this conversation? It is not that he sent a sick patient home who had a bad outcome but simply the insanity which we are required to deal with despite the costs in money or morale. I always share my responses to the grievance process with the involved physician even if it is ridiculous to let them know about it. Hiding these types of issues from a doctor has a downside as there are things to learn from many of these situations and many times the doctor is surprised by the complaint. However, I think in many instances it would be better for them not to know about many of the more ridiculous complaints as I think it will only cause pain. Certainly, there are real complaints with real issues which need to be dealt with but this was not one of them. Even something as ridiculous as this leads to hours of wasted time and efforts and often leads to more burnout and discontent with our health care system. Unfortunately, somehow our health care system has been subverted to this level of insanity. The reason I mention this is to ask if there is a better way to deal with the issue of patient

EDITOR’S MESSAGE

satisfaction. Please consider how much money is involved. Your hospital most likely pays large amount of money to some company to survey your patients to provide a ranking of how you are doing compared to everyone else. This of course is a zero-sum game as there has to be winners and losers using our current ranking system. Every hospital or hospital system wants to proudly display billboards with whichever quality, safety, or satisfaction ranking or award which they have “won.” The hospital has to also have some sort of grievance process which involves many standing members and also the invited guests who are in the hot seat during any particular meeting. All of these people are usually highly paid individuals who are not providing health care during all of the time required for this process. How many nurses at your hospital are involved in this process? Nurses play many roles in the satisfac-

tion and quality process and are on the various safety and quality committees dealing with any complaint or quality issue. Would your hospital be better off and the patients more satisfied if these same nurses went back to actually taking care of patients? I have felt frustrated especially during Covid to sit in large meetings (many virtual) which include up to a dozen nurses who no longer nurse. Large committee meetings are held with many well-paid professionals who closely

analyze this data and the complaints. They propose ways to improve our patient’s satisfaction. They meet to review every grievance and discuss patient service recovery. They want to encourage every member of the health care team at the hospital to be nicer, faster, and more willing to bend over backwards for any patient or family complaint so that your “net promoter” scores can go up. It can be insanity in the making. The topic of the critical nursing shortage is usually discussed as a factor in all of these quality and satisfaction issues. I often sit wondering to myself what would happen if we could just put all of the nurses sitting in the meeting back into direct patient care? The current system of rating patient satisfaction is percentile based which means there has to be winners and losers. Each of us is compared to other members of our group and also to any other hospital which bought whichever expensive satisfaction monitoring tool which your hospital executives or system purchased. This data is often statistically insignificant but hospital executives like numbers. They want a number to “work” on. This also has led to a large and expensive army of consultants which your hospital probably has hired over the years to help the hospital improve their scores. These consultants advise executives in means of motivating the nurses and physicians to improve. These suggestions are often monetized leading to significant pressure on you to row harder and faster despite staff shortages, boarding, Covid, and low morale. Drs. Thom Mayer and Arjun Venkatesh in an article published online in JAMA on December 2, 2021 titled “Criterion-Based Measurements of Patient Experience in Health Care- Eliminating Winners and Losers to Create a New Moral Ethos” (doi:10.1001/ jama.2021.21771) suggest a possible change

which may warrant consideration. It is certainly not a panacea but may change the focus of this system to actually improve things instead of the current more punitive form which we deal with on a daily basis. They propose switching to a criterion-based measurement system from our current norm based system. Currently, there are winner and losers and in many systems, the importance of ranking scores are highly monetized and have led to a toxic environment of pay for performance. This can have a significant negative impact on physician burnout and led to overall dissatisfaction with the clinical practice of emergency medicine. Shifting to a ratings system instead of a ranking system could be a small step in the right direction. The authors point out that “there are 2 truths using measurements to improve patient experience. It is essential, and done poorly, it does far more harm than good.” They point to the current “metric madness” as the opposite of what is needed. They propose using a simple criterion-referenced ranking system in which everyone could succeed. If a specific criterion was reached then everyone could be “winners.” I certainly do not know the answer but somehow the focus of these systems has to change for the better. Society wants the whole system to improve and for us all to learn better and more adaptive ways to improve patient care. However, new attention needs to be paid to doing this while still protecting the mental and physical health of the dedicated physicians and nurses who are providing this same care.

“THE CURRENT SYSTEM OF RATING PATIENT SATISFACTION IS PERCENTILE BASED WHICH MEANS THERE HAS TO BE WINNERS AND LOSERS.” COMMON SENSE MAY/JUNE 2022

AAEM NEWS LETTER TO THE EDITOR

Letter to the Editor

For many years now in the United States, one of the worst possible accusations that could be made about someone is that they are a racist. It is right up there with pedophile. Imagine my surprise, then, to find myself and other emergency physicians labeled as racist by two of my colleagues, Watts and Gomez, on page 45 of the March/April issue of Common Sense. First of all, it isn’t clear if they are accusing all emergency physicians of racist bias, or just the white ones. If the latter, neither author knows me (or every other white member of AAEM) well enough to accuse me of racism based on my own individual behavior, and isn’t judging an individual based on nothing more than the color of his skin the very essence of racism? Second, and more substantially, big claims demand big evidence. So, what evidence do Watts and Gomez offer for their accusation that, “There is no doubt we hold these biases”? The only evidence they offer is “the now famous Harvard IAT (implicit association test).” They claim that IAT results prove that “we are all frail with regard to holding biases, particularly when considering our propensity to believe in such falsehoods as the inherent inferiority and threat of people with brown skin.” They also say, “Go ahead and take the Harvard IAT and fearlessly accept we all hold implicit biases.” However, the IAT is controversial and has not been proven to be a valid or reliable indicator of individuals prone to racist behavior.1-9 I am disappointed and surprised that emergency physicians would rely on such an unsubstantiated test to accuse their colleagues of something so horrible as racism. Finally, based on my own attitude and what I have seen from every other emergency physician I have encountered in the course of my 36-year career, I can offer Ms. Watts some reassurance. She says that when her brother suffered a gunshot wound she was worried his doctors might see him as “a black thug” and that would affect the quality of his resuscitation. We emergency physicians have freely chosen to take care of everyone, without regard to their race, gender, socioeconomic status, or even character. Whether the patient is a saint or a criminal, we do our best for everyone. Not out of personal affection for a specific patient, because we rarely know our patients, but out of our pride in and commitment to excellence, and commitment to the ethics of our profession. That is a far more reliable motivator than our personal feelings towards any individual patient. You can rest assured that your brother got the best his emergency physician could give. I am all for “justice, equity, diversity, and inclusion.” However, justice means justice for all, and making blanket accusations of racism without any basis in fact and without offering substantial evidence is horribly unjust. And from a more practical point of view, it isn’t a tactic that wins friends and allies. Andy Walker, MD MAAEM

References 1. Schimmack U. Invalid claims about the validity of implicit association tests by prisoners of the implicit social-cognition paradigm. Perspect Psychol Sci 2021;16(2):435-442. 2. Schimmack U, Howard A. The race implicit association test is biased: most African- Americans have positive attitudes towards their in-group. Replicability-Index 2021 July 28. 3. Oswald FL, Mitchell G, Blanton H, et al. Predicting ethnic and racial discrimination: a meta-analysis of IAT criterion studies. J Pers Soc Psychol 2013;105(2):171-192. 4. Oswald FL, Mitchell G, Blanton H, et al. Using the IAT to predict ethnic and racial discrimination: small effect sizes of unknown societal significance. J Pers Soc Psych 2015;108(4):562-561. 5. Carlsson R, Agerstrom J. A closer look at the discrimination outcomes in the IAT literature. Scand J Psychol 2016;57(4):278-287. 6. Azar B. IAT: fad or fabulous? Monitor on Psychology 2008;39(7):44. 7. https://psych.wisc.edu/Brauer/BrauerLab/index.php/implicit-bias/ 8. https://www.heritage.org/science-policy/report/the-implicit-association-test-flawed-science-tricks-americans-believing-they 9. https://www.vox.com/identities/2017/3/7/14637626/implicit-association-test-racism

Corrections In the March/April issue of Common Sense the articles “Six Hour Sacrifice” and “Spring” had textual errors. The corrected versions of the articles can be read at aaem.org/resources/publications/common-sense

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: aaem.org/resources/publications/common-sense

COMMON SENSE MAY/JUNE 2022

28 TH ANNUAL SCIENTIFIC ASSEMBLY RECAP 28TH ANNUAL AAEM SCIENTIFIC ASSEMBLY: THANK YOU FOR JOINING US! Co-Chair Laura J. Bontempo, MD MEd FAAEM, Co-Chair George C. Willis, MD FAAEM, and Vice Chair Christopher Colbert, DO FAAEM

he 28th Annual AAEM Scientific Assembly was held in Baltimore, MD from April 24-27, 2022. With a focus on cutting edge clinical medicine as well as practical application to patient care, this event was one of the most anticipated academic conferences of the year. This year’s Scientific Assembly took an innovative and practical look at various topics within emergency medicine that are shaping our field of practice. We were 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 were able to provide a resource to enhance the understanding of our beloved specialty. Additionally, special attention was dedicated to ensuring that participants’ health and safety were maintained throughout this phenomenal conference. Powerhouse plenaries included Drs. Haney Mallemat (Resuscitation), Michael Winters (Resuscitation), Corey M. Slovis (EMS), Ilene Claudius (Pediatrics), Mimi Lu (Pediatrics), Deborah M. Stein (Trauma), and Amal Mattu (Cardiology). Drs. Al’ai Alvarez, Cortlyn Brown, Italo M. Brown, David Davidson, and Joanne Williams joined us for the Justice, Equity, Diversity & Inclusion Panel. Dr. Jack Perkins and Joshua Morales were joined by sickle cell patients Kenya Thompson, Tenesha Dudley, and Isaiah Dudley for the Sickle Cell Patient Panel. There was also a transgender patient panel to discuss the challenges of being a transgender patient and caring for one in our current healthcare system.

This year’s keynote presentation, “Our Patients, Our Specialty: AAEM-PG Versus Envision and the Future of EM,” featured Drs. Robert M. McNamara and Mark Reiter who broke down what the lawsuit means for emergency physicians and our patients. 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. This is an enormous undertaking, but this is the hill we must fight on for the soul of our specialty.

medical ethics. For the fifth year in a row, the interactive Small Group Clinic sessions gave attendees hands-on practice in a variety of settings. The AAEM/RSA Resident Track - selected by residents, for residents - prepared students for their careers in emergency medicine by concentrating on topics such as career success, clinical topics, and social determinants of health. This session concluded with the AAEM/ RSA Breve Dulce Competition which featured five resident presentations on the theme of “Great Catch: A Difficult Diagnosis,” a challenging presentation, or a near-miss that might change the way that you approach that topic.

Another highlight of AAEM22 was the “Six EM Docs Walk into a Shift Show” talk which featured speakers from the AAEM Critical Care Medicine Section, EMS Section, Emergency Ultrasound Section, JEDI Section, Women in EM Section, and Young Physicians Section walking attendees through a series of patient encounters during a natural disaster. Dr. Molly Estes walked us through treating multiple patients in the wake of a hurricane and shared her thought process as she drew insight from all six AAEM sections to manage the storm after the storm.

We had an energetic group of medical student ambassadors, who were omnipresent and ever helpful in keeping the conference going. Special educational sessions were targeted toward their benefit. Thank you, student ambassadors!

With the conference being near Washington D.C., we were also able to have a few members of Congress lead a discussion on current health care advocacy issues and give attendees an opportunity to voice questions and concerns on how Congress can assist emergency physicians take better care of our patients. The ever-popular Breve Dulce sessions returned this year and continued to be some of the most attended sessions of AAEM22. “Meeting of the Minds” also returned for a second year which featured EM practitioners debating the pros and cons of the latest practice-changing articles in critical care and

There were also a wide variety of networking opportunities available at Scientific Assembly. Whether in the hallways, at receptions, or near the coffee stations during breaks the level of interactions between attendees was high. The JEDI off-site reception, Women in EM lunch, the AAEM Chapter and Sections social, and Airway at AAEM were all highly anticipated and attended. The Wellness Committee also hosted a Wellness Room for all attendees to relax and recharge throughout the conference. We sincerely hope that you enjoyed the Assembly this year. Our goal is to continue in the tradition of bringing in a combination of your perennial favorites and some new speakers to keep you educated, inspired, and coming back every year for more.

Please let us know your thoughts and we hope to see you in New Orleans, Louisiana for the 29th Annual AAEM Scientific Assembly from April 21-25, 2023!

COMMON SENSE MAY/JUNE 2022

28 TH ANNUAL SCIENTIFIC ASSEMBLY RECAP

AAEM22 Planning Subcommittee Co-Chairs Laura J. Bontempo, MD MEd FAAEM George C. Willis, MD FAAEM

Total Registered for AAEM22: Total number of exhibitors: 35

Vice Chair Christopher Colbert, DO FAAEM Advisors Joelle Borhart, MD FAAEM FACEP Christopher I. Doty, MD MAAEM FAAEM Kevin C. Reed, MD FAAEM Subcommittee Member David J. Carlberg, MD FAAEM (Education Committee Vice Chair) William T. Durkin, Jr., MD MBA MAAEM FAAEM (AAEM Past Presidents Council Representative) Molly K. Estes, MD FAAEM FACEP David A. Farcy, MD MAAEM FAAEM FCCM (Board Liaison) David Fine, MD (AAEM/RSA Representative) Robert A. Frolichstein, MD FAAEM (AAEM Secretary-Treasurer) Harman S. Gill, MD FAAEM Jason Hine, MD FAAEM Jonathan S. Jones, MD FAAEM (AAEM President-Elect) Siamak Moayedi, MD FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM (AAEM President) Jack C. Perkins Jr., MD FAAEM Teresa M. Ross, MD FAAEM (Education Committee Chair) Joanne Williams, MD MAAEM FAAEM

COMMON SENSE MAY/JUNE 2022

836

Number of sponsors: 13

Number of speakers: 184

Number of poster competition submissions: 257 Number of oral abstract competition submissions: 36 Number of awards awarded: 65 Number of mobile app downloads: 608 Number of Catch the Code Participants: 21 Number of Airway at AAEM participants: 85 Number of WiEM lunch attendees: 74 Number of JEDI social attendees: 53 Number of Wellness yoga participants: 6 Number of Wellness Paint ‘N Sip participans: 19 WiEM Ramadan Iftar Dinner attendees: 30

28 TH ANNUAL SCIENTIFIC ASSEMBLY RECAP

2022 AAEM Award Winners Administrator of the Year Thomas Tobin, MD MBA FAAEM David K. Wagner Joanne Williams, MD MAAEM FAAEM Young Educator Award Italo M. Brown, MD MPH Mitchell Goldman Oral Board Service Award - 10 Courses* Gary M. Gaddis, MD PhD MAAEM FAAEM FIFEM Hillary Harper, MD FAAEM Amanda C. Rodski, MD MBA FAAEM George C. Willis, MD FAAEM Mitchell Goldman Oral Board Service Award - 20 Courses Michael C. Bond, MD FAAEM Marilyn R. Geninatti, MD FACC FAAEM CWSP Mitchell Goldman Oral Board Service Award - 40 Courses Frank L. Christopher, MD FAAEM Amin Kazzi International Emergency Medicine Leadership Award Gary M. Gaddis, MD PhD MAAEM FAAEM FIFEM James Keaney Teresa M. Ross, MD FAAEM Joanne Williams Award Adeola Kosoko, MD FAAEM Robert McNamara Award Christopher I. Doty, MD MAAEM FAAEM Resident of the Year Lauren E. Lamparter, MD Joe Lex Educator of the Year Frank L. Christopher, MD FAAEM Advocate of the Year Deborah D. Fletcher, MD FAAEM Master of the AAEM David A. Farcy, MD MAAEM FAAEM FCCM Master of the AAEM Gary M. Gaddis, MD PhD MAAEM FAAEM FIFEM Master of the AAEM Mitchell J. Goldman, DO MAAEM FAAEM FAAP *Recipients listed here for the Goldman Award are the on-site recipients only. The full list of 2022 Goldman recipients will be in the Nov/Dec issue. COMMON SENSE MAY/JUNE 2022

28 TH ANNUAL SCIENTIFIC ASSEMBLY RECAP

AAEM22 Competition Winners Open Mic Competition Winner Rebecca Kreston, MD Christopher J. Lemon, MD FAAEM YPS-AAEM Research Competition 1st Place: Lulu Wang, MD 2nd Place: Nicole Lucas, MD 3rd Place: Bailee Wilson, BS AAEM/JEM Resident and Student Research Competition 1st Place: Benjamin Ciccarelli, MD 2nd Place: Amanda Studer, DO 3rd Place: Elle Schultz, DO and Emily Cobb, MD AAEM/RSA & WestJEM Population Health Research Competition 1st Place: Dakota Peterson, MD 2nd Place: Zachary Bopp, BA 3rd Place: Marie Wofford, MD MPH YPS-AAEM Research Competition 1st Place: Lulu Wang, MD 2nd Place: Nicole Lucas, MD 3rd Place: Bailee Wilson, BS Photo Competition 1st Place: Haruka Ono, MD 2nd Place: Vanessa Hannick, MD 3rd Place: Leandra Trydal, DO AAEM/RSA Breve Dulce Competition 1st Place: Yuliya Pecheny, DO 2nd Place: Christina Powell, DO 3rd Place: Rebecca Kreston, MD

Number of impressions:

24,795

(3x the average impressions for a five-day period on AAEM’s account!)

AAEM

Twitter Impression (April 23-28): 25.1K Twitter Mentions (Month of April): 589

Instagram Impressions (April 23-28): 595 Facebook Impressions (April 23-28): 2,190

AAEM/RSA

Twitter Impression (April 23-28): 60.5K

Twitter Mentions (Month of April): 219

Instagram Impressions (April 23-28): 1,010 Facebook Impressions (April 23-28): 359

AAEM Social Media Impressions: 28,500 AAEM Twitter Mentions in April: 589

AAEM/RSA Social Media Impressions: 62,100

AAEM/RSA Twitter Mentions in April: 219

Social Media Impressions (Overall): 90,500 Twitter Mentions in April (Overall): 808

COMMON SENSE MAY/JUNE 2022

28 TH ANNUAL SCIENTIFIC ASSEMBLY RECAP

2021-22 AAEM/RSA Award Winners Kevin G. Rodgers Program Director of the Year Award Rahul Bhat, MD FAAEM

AAEM/RSA at AAEM22 Almost 400 residents and medical students participated at AAEM22 Nearly 100 attendees went to the AAEM/RSA and YPS-AAEM Social and Airway Storytelling Event

Five residents presented in the AAEM/RSA Breve Dulce Competition Eight lectures were presented during the AAEM/RSA Resident Track drawing resident, medical student, and attending-level attendance

Sixty medical students took in the lectures by our fabulous faculty speakers and panelists during the Medical Student Track

Twenty medical students participated in the first hands-on Stop the Bleed practical course during the Medical Student Track

Program Coordinator of the Year Award Lily Hu Faculty Mentor of the Year Award Jose Torres, MD FAAEM National Medical Student of the Year Scholarship Award Ashley Iannantone National Medical Student of the Year Scholarship Award Runner-Up Sara Urquhart Committee Member of the Year Award Resident: David Fine, MD Student: Mary Unanyan Southern Regional Faculty Mentor Award South: Jeffery Baker, MD FAAEM West: Jessica Fujimoto, MD FAAEM Midwest: Michael Schindlbeck, MD FAAEM Northeast: Scott Plasner, DO FAAEM International: Ravi Chauhan, DO FAAEM Regional Medical Student of the Year Scholarship Award South: Lauren Rosenfeld Midwest: Susan Siraco Northeast: Sophia Gamez International: Matthew Carvey Diversity & Inclusion Residency Application Scholarship Abdoul Kone William Mundo Anantha Singarajah Kristen Woody Michael Chiang EMIG of the Year Award St. George’s University EM Club

COMMON SENSE MAY/JUNE 2022

AAEM BOARD OF DIRECTORS

New Board of Directors

AAEM is proud to welcome the newly elected board of directors!

President Jonathan S. Jones, MD FAAEM

President-Elect Robert Frolichstein, MD FAAEM

Secretary-Treasurer L.E. Gomez, MD MBA FAAEM

Immediate Past President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM

Past Presidents Council Representative William T. Durkin, Jr., MD MBA MAAEM FAAEM

At-Large Director Kimberly M. Brown, MD MPH FAAEM

At-Large Director Phillip A. Dixon, MD MBA MPH FAAEM CHCQM-PHYADV

At-Large Director Al O. Giwa, LLB MD MBA MBE FAAEM

At-Large Director Robert P. Lam, MD FAAEM

At-Large Director Bruce Lo, MD MBA FAAEM RDMS

At-Large Director Vicki Norton, MD FAAEM

At-Large Director Carol Pak-Teng, MD FAAEM

At-Large Director Kraftin Schreyer, MD MBA FAAEM

YPS Director Fred E. Kency, Jr., MD FAAEM

AAEM/RSA President Leah Colucci, MD MS

Editor, Common Sense Ex-Officio Board Member Andy Mayer, MD FAAEM

Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD FAAEM

COMMON SENSE MAY/JUNE 2022

New Section Leadership

AAEM SECTION LEADERSHIP

Please join us in congratulating the new Section leadership council members!

CCMS-AAEM Council 2022-2023

Section Chair: A. June Gordon, MD FAAEM

Section Chair-Elect: Elias E. Wan, MD FAAEM

Secretary/Finance Chair: David Hirsch Gordon, MD

Section Immediate Past Chair: Skyler A. Lentz, MD FAAEM

Allyson M. Hynes, MD FAAEM

Gregory P. Wu, MD FAAEM

Secretary/Finance Chair: Rachel Ely, DO FAAEM

Section Immediate Past Chair: Brett A. Rosen, MD FAAEM

Stephen Harper, MD FAAEM

Katherine Raczek, MD FAAEM

Section Chair-Elect: Neha Bhatnagar, MD FAAEM

Secretary/Finance Chair: Alexis Salerno, MD FAAEM

Section Immediate Past Chair: Melissa Myers, MD FAAEM

Priya Ghelani, DO FAAEM

Cara Kanter, MD FAAEM

Shawn Sethi, DO

Councilors:

Frederick Gmora, DO

Harman S. Gill, MD FAAEM

RSA Rep: Matthew Carvey, MD EMT-P FP-C

EMSS-AAEM Council 2022-2023

Section Chair: C.J. Winckler, MD FAAEM

Section Chair-Elect: Bryan Everitt, MD

Councilors:

Bret T. Ackermann, DO MS FAAEM

Craig Cooley, MD MPH EMT-P FAAEM

RSA Rep: Mr. Andrew P. Zwijack

EUS-AAEM Council 2022-2023

Section Chair: Allison Zanaboni, MD FAAEM Councilors:

Eric Chin, MD MBA FAAEM

RSA Rep: Ms. Heather Marie Pol COMMON SENSE MAY/JUNE 2022

AAEM SECTION LEADERSHIP

JEDI-AAEM Council 2022-2023

Section Chair: Italo Brown, MD

Section Chair-Elect: Cortlyn Brown, MD FAAEM

Secretary/Finance Chair: Kristyn Smith, DO

Section Immediate Past Chair: Paul Petersen, MD FAAEM and Joanne Williams, MD MAAEM FAAEM

Councilors:

Burr Fong, DO FAAEM

Kristin Fontes, MD FAAEM

Adeola Kosoko, MD FAAEM

Yamila Vasquez-Gonzalez

RSA Rep: Alyssa Eily, MD and Jordan Vaughn, MD

WiEM-AAEM Council 2022-2023

Section Chair: Vonzella A. Bryant, MD FAAEM

Section Chair-Elect: Danielle E. Goodrich, MD FAAEM

Secretary/Finance Chair: Elisabeth Calhoun, MD FAAEM

Section Immediate Past Chair: Loice A. Swisher, MD MAAEM FAAEM

Councilors:

Jennifer A. Reyes, DO FAAEM

Kraftin Schreyer, MD MBA FAAEM

Sara A. Misthal, MD FAAEM

Megan R. Gillespie, DO

RSA Rep: Anantha Singarajah, DO

YPS-AAEM Council 2022-2023

Section Chair: Jessica Fujimoto, MD FAAEM

Section Chair-Elect: Moiz Qureshi, MD MBA

Secretary/Finance Chair: Jefferey Holoman, DO

Section Immediate Past Chair: Cara Kanter, MD FAAEM

Michelle Romeo, MD

Alan Sazama, MD FAAEM

Priya Ghelani, DO FAAEM

Councilors:

Jennifer Rosenbaum, MD

COMMON SENSE MAY/JUNE 2022

RSA Rep: Corey McNeilly, MD

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

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

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

Donate Now

$2.5 million by 2025

75% 50% 25%

Gifts in Honor and Gifts in Memory Gifts at all levels can be given In Honor Of or In Memory Of a program director, mentor, and/or colleague. Notification of gifts made In Honor or In Memory will be sent to the honoree or their family and listed in our Annual Report.

Ways to Give • • • • •

Donate Online Scan QR Code Employer Matching Gift Return the Donation/Pledge Form Planned Giving

The AAEM Foundation gratefully accepts IRA distributions, contributions through donor-advised funds, planned gifts and bequests.

American Academy of Emergency Medicine Foundation 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 (414) 276-7390 • (800) 884-2236 • Fax: (414) 276-7390

https://www.aaem.org/donate/aaem-foundation The AAEM Foundation is a 501(c)(3) non-profit organization. EIN: 20-2080841

COMMON SENSE MAY/JUNE 2022

ACMS-0718-026

AAEM Foundation Contributors – Thank You! AAEM established its Foundation for the purposes of (1) studying and providing education relating to the access and availability of emergency medical care and (2) defending the rights of patients to receive such care and emergency physicians to provide such care. The latter purpose may include providing financial support for litigation to further these objectives. The Foundation will limit financial support to cases involving physician practice rights and cases involving a broad public interest. Contributions to the Foundation are tax deductible. Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 1-1-22 to 3-1-22 (please note that any donations made during Scientific Assembly will not reflect until our next issue).

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

John R. Matjucha, MD FAAEM Joseph W. Raziano, MD FAAEM Robert Hanrahan, MD Ron Koury, DO FAAEM Sahibzadah M. Ihsanullah, MD FAAEM

Contributions $500-$999

Contributions $100-$249

David A. Farcy, MD MAAEM FAAEM FCCM Kathleen P. Kelly, MD FAAEM Mark Reiter, MD MBA MAAEM FAAEM Philip Beattie, MD FAAEM

Contributions $250-$499 Allison Zanaboni, MD FAAEM Azalea Saemi, MD FAAEM Bradley Judson, MD FAAEM Bryan K. Miksanek, MD FAAEM Charles Chris Mickelson, MD FAAEM David Thomas Williams, MD FAAEM Douglas W. McFarland, MD FAAEM Eric D. Lucas, MD FAAEM Eric W. Brader, MD FAAEM Frosso Adamakos, MD FACEP FAAEM John H. Kelsey, MD FAAEM

Ann Loudermilk, MD FAAEM Anthony J. Callisto, MD FAAEM Anthony R. Rosania, III, MD FAAEM Brent R. King, MD FAAEM FACEP FAAP Brian R. Potts, MD MBA FAAEM Bryan Beaver, MD FAAEM Carlos F. Garcia-Gubern, MD FAAEM Catherine V. Perry, MD FAAEM Chaiya Laoteppitaks, MD FAAEM Christopher F. Tana, FAAEM Clayton Ludlow, DO FAAEM Dan M. Mayer, MD FAAEM Darin E. Neven, 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

Eric S. Kenley, MD FAAEM Floyd W. Hartsell, MD FAAEM Fred Earl Kency, Jr., MD FAAEM FACEP Ian R. Symons, MD FAAEM James G. Sowards, MD FAAEM Jeffrey A. Rey, MD FAAEM Jeffrey John Glinski, MD FAAEM Jorge L. Infante, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Julianne Wysocki Broadwater, DO FAAEM Justin P. Anderson, MD FAAEM Kathleen Hayward, MD FAAEM Kevin S. Barlotta, MD FAAEM Mark E. Zeitzer, MD FAAEM Matthew B. Underwood, MD FAAEM Megan Algeo, MD FAAEM Merlin T. Curry, MD FAAEM Mike Lesniak Nicholas G. Ross, MD FAAEM Paul W. Gabriel, MD FAAEM Robert Bruce Genzel, MD FAAEM Sabrina J. Schmitz, MD FAAEM Sameer D. Mistry, MD CPE FAAEM Shanna M. Calero, MD FAAEM

Steven Schmidt Sundeep J. Ekbote, MD FAAEM Valerie Hoerster, MD William K. Clegg, MD FAAEM William T. Freeman, MD FAAEM

Contributions up to $99 Alex Kaplan, MD FAAEM Andrea C. Santoyo Chris Hummel, MD FAAEM Evan T. Burdette, MS Ivan Novikov James Cirone, DO Jason D. May, MD FAAEM Jason Hine, MD FAAEM Joanne Williams, MD MAAEM FAAEM Julia Alegria Astudillo Kasey Gore Kennadie P. Campbell Nancy Conroy, MD FAAEM Peter M.C. DeBlieux, MD FAAEM Ron S. Fuerst, MD FAAEM Sierra Cloud Theodore B. Olson II, DO Trecia Henriques, 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 (please note that any donations made during Scientific Assembly will not reflect until our next issue).

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

Contributions $250-$499 Allison Zanaboni, MD FAAEM Brian J. Cutcliffe, MD FAAEM Charles Chris Mickelson, MD FAAEM Eric D. Lucas, MD FAAEM Eric W. Brader, MD FAAEM Garrett Sterling, MD FAAEM John R. Matjucha, MD FAAEM Joseph T. Bleier, MD FAAEM Kevin Allen, MD FAAEM Ron Koury, DO FAAEM Sahibzadah M. Ihsanullah, MD FAAEM

COMMON SENSE MAY/JUNE 2022

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

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

Jeffrey A. Rey, MD FAAEM Jeffrey J. Thompson, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Julianne Wysocki Broadwater, DO FAAEM Justin P. Anderson, MD FAAEM Kathryn Getzewich, MD FAAEM Lauren P. Sokolsky, MD FAAEM Matthew B. Underwood, MD FAAEM Matthew W. Turney, MD FAAEM Megan Long, MD FAAEM Michael R. Magoon, MD FAAEM Nate T. Rudman, MD FAAEM Paul E. Stromberg, MD FAAEM Penelope Goode, MD FAAEM Philip Beattie, MD FAAEM Rebecca N. Mills, MD FAAEM Rhett W. Silver, MD FAAEM Robert Bruce Genzel, MD FAAEM Ryan L. Tenzer, MD FAAEM

Sameer D. Mistry, MD CPE FAAEM Sundeep J. Ekbote, MD FAAEM Thomas B. Ramirez, MD FAAEM Thomas Heniff, MD FAAEM Trisha Anest, MD FAAEM William T. Freeman, MD FAAEM

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

LEAD-EM Contributors – Thank You! The AAEM Institute for Leadership, Education & Advancement in the Development of Emergency Medicine, Inc. (LEAD-EM) was established after the tragic and unexpected death of AAEM president, Dr. Kevin G. Rodgers. The Kevin G. Rodgers Fund and the Institute will LEAD-EM just like Dr. Rodgers did. The funds will support important projects such as development of leadership qualities, and clinical and operational knowledge of emergency physicians with a view toward improving and advancing the quality of medical care in emergency medicine, and public health, safety and well-being overall. LEAD-EM would like to thank the individuals below who contributed from 1-1-22 to 3-1-22 (please note that any donations made during Scientific Assembly will not reflect until our next issue).

Contributions $1000 and above Mercy M. Hylton, MD FAAEM

William E. Hauter, MD FAAEM Zachary Worley, DO FAAEM

Contributions $500-$999

Contributions $100-$249

Mark Reiter, MD MBA MAAEM FAAEM

Contributions $250-$499 Anthony J. Callisto, MD FAAEM Eric D. Lucas, MD FAAEM Eric W. Brader, MD FAAEM Joseph T. Bleier, MD FAAEM Michael R. Burton, MD FAAEM Sahibzadah M. Ihsanullah, MD FAAEM

Ann Loudermilk, MD FAAEM Brian R. Potts, MD MBA FAAEM Christopher Kang, MD FAAEM Clayton Ludlow, DO FAAEM Cory Duncan, MD FAAEM FACEP Daniel Elliott, MD FAAEM David W. Kelton, MD FAAEM David W. Lawhorn, MD MAAEM Deborah Dean, MD FAAEM

Eric S. Kenley, MD FAAEM Floyd W. Hartsell, MD FAAEM Fred Earl Kency, Jr., MD FAAEM FACEP Ian R. Symons, MD FAAEM John R. Matjucha, MD FAAEM Joshua A. Pruitt, MD FAAEM CMTE Kathleen Hayward, MD FAAEM Marc D. Squillante, DO FAAEM Mark E. Zeitzer, MD FAAEM Melissa Ann Barton, MD FAAEM Nate T. Rudman, MD FAAEM Nimish Mehta, MD FAAEM

Paul W. Gabriel, MD FAAEM Sabrina J. Schmitz, MD FAAEM William T. Freeman, MD FAAEM

Contributions up to $99 Ana Maria Navio Serrano Sr., MD PhD Jason D. May, MD FAAEM Marianne Haughey, MD FAAEM Nancy Conroy, 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: https://www.aaem.org/education/events

AAEM Events

Recommended

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

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

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

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

Jointly Provided

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

Re-Occurring Monthly Unmute Your Probe: Virtual Ultrasound Course Series Jointly provided by EUS-AAEM www.aaem.org/eus July 15-17, 2022 Miami Beach Point-of-Care Ultrasound Conference (Surfside, FL) Jointly provided by Miami Beach Emergency Medicine Please contact Cassandre Jones to register cassandre.Jones@msmc.com July 27-29, 2022 Coalition for Physician Well-Being 10th Annual Conference (Denver, CO) Jointly provided by the Coalition for Physician Well-Being https://www.forphysicianwellbeing.org/ November 2-6, 2022 Emergency Medicine Update: Hot Topics (Waimea, HI) Jointly provided by UC Davis https://ces.ucdavis.edu/emh2022

COMMON SENSE MAY/JUNE 2022

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

Top Ten Financial Mistakes For New Attendings James M. Dahle, MD FACEP FAAEM

he first year out of training is the most important financial year of your life. Get it right and you are likely to build massive sums of wealth that will provide you financial security, the ability to help others, and career opportunities you can now only dream of. Get it wrong and it will feel as though you are spinning your wheels as you slowly burn out on your career. Today we will consider the top ten ways that doctors get it wrong.

# 1 No Plan If you fail to plan, you plan to fail. The default option for most physicians is not pretty. Without any sort of check on it, most people will spend all of their income and then some, leaving nothing to use for building wealth. Ideally, every graduating resident would already have a written financial plan for their first 12 paychecks. They will have already decided how much to save for retirement, how much to put toward their student loans, and how much to put toward a house or other short-term goal.

# 2 Inadequate Savings Rate The typical attending physician should be saving 20% of gross income for retirement, with any amounts for other goals such as paying off a mortgage, saving for college, or that new shiny Tesla in addition to that. However, the new attending is in a unique position that he or she will never be in again. This doctor is used to living on an income of $5060,000 per year and making $200,000, $300,000, or even $400,000 per year. The difference between those two figures can be used to jumpstart any wealth building plan. Consider how quickly new doctors could pay off debts and build wealth if they were willing to live the same lifestyle they had as a resident for just a few years. Even after paying the additional tax burden, a doctor making $300,000 and only spending $50,000 a year would have something in the neighborhood of $175,000 per year to use to build wealth. Even $400,000 in student loans won’t last long against that onslaught. Live like a resident for two to four years after residency and you will solve almost every future financial problem you could ever have.

monthly payments required to qualify for tax-free forgiveness of the remainder of those loans. If you are not working for a non-profit, refinance your student loans. It is not unusual for a doctor with 7% federal student loans to refinance to 3%. On a $300,000 loan, that is an extra $12,000 per year that can go toward principal instead of interest.

“IF YOU FAIL TO PLAN, YOU PLAN TO FAIL.”

# 4 Inadequate Insurance There are some risks that you cannot self-insure against no matter how well you save, at least for a few more years. Buy insurance for these risks including disability, death, loss of valuable property, health, and both personal (umbrella) and professional (malpractice) liability. If your malpractice policy is claims-made instead of occurrence, know what the plan is for paying the tail when you break up with your employer. Insure well against financial catastrophes. That usually means a five figure benefit for disability insurance and seven figures worth of term life and liability insurance.

# 3 Wrong Student Loan Plan

# 5 Failed to Invest

While this is arguably more important for residents to get right than attendings, it can still result in the waste of tens of thousands of dollars of income. If you are employed full-time by a 501(c)3 (non-profit), enroll your federal student loans in the Public Service Loan Forgiveness plan by making payments under an Income Driven Repayment program. The earlier in your training that you do this, the sooner you will reach the 120

Some people save just fine, but fail to actually put the money into any sort of investment. They may find they have half a million dollars or more just sitting in their checking account. Meanwhile, they have missed out on thousands of dollars in tax savings and compound interest that could have been theirs if not for their paralysis due to fear of loss or unwillingness to put time into developing an investing plan.

COMMON SENSE MAY/JUNE 2022

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

# 6 Missed the Forest for the Trees Occasionally I run into a physician with a bizarre collection of investments with no underlying plan. One-fourth of your money in your favorite stock, one-fourth in Bitcoin, one-fourth in Gold, and one-fourth in your brother-in-law’s failed restaurant is not a reasonable investing plan. If you will build your plan from the top down instead of the bottom up, you can avoid this error.

# 7 Didn’t Understand Contract Too many physicians sign contracts they do not understand and would have never signed if they had. Don’t assume that others, including other physicians, have your best interests at heart. Have employment and partnership contracts reviewed by a competent health care attorney or contract review service. Don’t be penny-wise and pound foolish; the few hundred dollars you spend is likely to pay for itself.

# 8 Bought Whole Life Insurance If ever there were a product designed to be sold, not bought it would be whole life insurance. Selling it to a new doctor with hundreds of thousands in student loans is the equivalent of financial malpractice in my view. While there are a few niche uses of this product, almost no new attending has a need for any of them. Buy term life insurance if anyone else depends on your income and avoid the hard-sell, high-commission, whole life insurance agent no matter how convincing he may be.

# 9 Hired a Bad Advisor There are a plethora of financial professionals who call themselves financial advisors. The vast majority are sales agents paid on commission masquerading as financial planners. It’s fine to buy things from salespeople, but don’t rely on them to tell you if you need their product in the first place. The answer to that will always be yes. When it comes to financial advice, you want a minimally-biased, fee-only, fiduciary, experienced financial planner +/- an asset manager. You want good advice at a fair price. Get second and third opinions until you are sure that you are getting it.

# 10 Bad Housing Decisions

“Don’t assume that others, including other physicians, have your best interests at heart.”

A house is often the most expensive purchase of your life, although an education may rank a close second. Doctors make all kinds of housing-related errors, including buying a house before they are ready to do so, spending too much on a house, or getting an above market rate mortgage. Try to keep your mortgage to less than two times your gross income. You might have to stretch a little in a high cost of living area (stretching is three to four times, not ten times), but realize this will have consequences on the rest of your financial life. In order to come out ahead on a purchase decision, expect to need to stay in the house for five or more years so that appreciation can overcome the substantial transaction costs. Do not buy a house until you are sure you like your job and your job likes you. Doctors are well-known for making lots of financial mistakes. Avoid these big ones and your nest egg will later thank you for it. 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.

COMMON SENSE MAY/JUNE 2022

The Man in the MICU

HEART OF A DOCTOR

Pavitra Parimala Krishnamani, MD MS

fter graduating medical school, physicians embark on a new journey as they start a medical residency program, meant to give us three to seven years of specialty-specific experience. As medical residents, the wealth of knowledge we gain from our programs’ structured educational curricula and the 60-80 hour weeks we spend making critical medical decisions uniquely positions us to leave our programs as experts in our fields ready to independently practice in our specialties. Our journey through medical school and residency molds us not only as physicians, but also as people, and it is humbling to reflect on the beginning of my clinical experience as I get ready to graduate alongside my co-residents.

everything I could was obvious. And when I was sent to help with a Code Blue alongside my resident, my enthusiasm resounded with every light-footed step I took as we ran to the MICU.

This is a story for the almost 40,000 new medical residents who will be taking our places soon. It is a story of how the best of medical education happens under the most challenging of circumstances. It is a story of how we, as medical students and physicians, share in our patients’ vulnerability and how that empathy can feel like a double-edged sword. It’s the story of a man in the Medical Intensive Care Unit (MICU), who was the first patient to teach me about how it feels when the person whose life you are trying to save decides it’s their time to move on…

My resident watched me mirror him, putting away my white coat and grabbing a pair of gloves so that I could be of use if directed to help. He was clearly weighing my apparent lack of physical fitness against the adrenaline-driven enthusiasm reflected in my eyes.

Lights. Sirens. Action. In almost every Hollywood medical drama, there is a scene in which a patient crashes. Usually, it is an obvious event, with a nurse immediately calling a Code Blue and hordes of doctors quickly painting the room white. Suspenseful music keeps viewers holding their breath as medical personnel burst into action and give life-saving CPR. Thanks to their heroic actions, the patient’s eyes fly open as they take a deep, life-affirming breath once again.

“Medicine is a career I chose despite the sorrow of losing patients, because every life saved or positively impacted makes the challenges of training and practicing completely worth it.” Although almost three out of every four of these lucky Hollywood patients survive to discharge, real life is not so forgiving. A 2015 National Academy of Medicine-commissioned a report showed that barely a quarter of patients who undergo CPR while in the hospital survive to discharge, many of whom battle devastating neurological outcomes after resuscitation. Despite knowing that Hollywood’s portrayal was a far cry from the realities of medicine, there was no way before my clinical education that I could have been entirely prepared for my experience with a man I saw in my hospital’s MICU during my second week rotating in the wards. New to the clinical world, my fresh-faced excitement to see and learn about

COMMON SENSE MAY/JUNE 2022

“Have you ever done CPR?” my resident asked. “Only on a dummy,” I responded, out of breath after running up the stairs.

“Okay then. This is different. Compressions on real people take more force,” he warned me, “Go ahead and stand in line.” He directed me to the line of blue scrubs waiting to do chest compressions on the rotund middle-aged gentleman lying on the bed in front of us. I understood the gravity of the situation. Yet, the exigent atmosphere around me clouded my ability to fully recognize what it meant that the human being in front of me no longer had a pulse. It was as I stood on a stool, leaning over the patient’s body, that it finally occurred to me that my compressions could keep this patient’s blood flowing to the rest of his body, or they could deprive him of the oxygenation he needed to even have a fighting chance at life. The moment of clarity that followed was paired with a laser focus I can neither describe nor recreate on command. The room disappeared around me, along with its people and its noises. I disappeared. My line of sight fixated on my hands, which were layered atop one another, sitting firmly on the chest in front of me. My elbows locked. “One,” I counted to myself, channeling what felt like my entire body’s weight through my palms and past an already cracked breastbone. In those moments, all that mattered to me was that I push down as hard as I could for as long as I could. A resounding crash outside the patient’s room, accompanied by howls echoing down the hallway, finally severed my focus. I saw a woman banging at the glass door, begging to be let in, as I switched off my compressions with a nurse who had earlier congratulated me on seeing a code so early in my career. The room looked different now. As the woman’s friend pulled her away from the glass door, I noticed all the lines, wires, and tubes running into

HEART OF A DOCTOR

the patient in front of me. I noticed his gown, torn open in the center, falling off of him. His wife outside the room was now calmer, sitting in a chair with her hand grazing her forehead and peering through the glass doors at what must have looked like a savage scene before her. The next time I stood over the patient, I knew he wouldn’t make it. After a few more compressions, he was pronounced dead. The nurses, techs, residents, and others on the patient’s medical care team dispersed as quickly as they had arrived. My resident had left earlier, urging me to get as much from the experience as possible by staying until the end. A kind nurse used some sheets to cover the patient up before leaving the room. It shocked me how everyone could just move forward without a glance back. Walking out of the room I had so eagerly rushed into, I noticed the patient’s wife had gotten back up and was wailing while beating on the floor, her friend now sitting on her to restrain her.

Medicine, I soon came to learn, is as much about death as it is about life. Yet, there seems to be a culture of bravado in the field, passed down through generations of doctors who have lived up to a perception of never having to shed a tear. The man in the MICU will certainly not be the only patient I see die, but the compartmentalization of sorrow that must occur in the aftermath of death doesn’t require a complete disregard for the emotion. We talked about this in 2015 when we made a hero of the emergency physician in a viral photograph for grieving in private and putting himself back together before caring for his next patient. We discussed the heavy emotional burden that comes with medicine. Yet, only recently do we see the culture of medicine start to catch up to the conversation; and we are still waiting for the profession to create robust support systems to encourage physicians’ emotional resilience. In the meantime, while collectively mourning physician suicide, we have begrudged resident work hour restrictions, increased uncompensated documentation hours, and talked extensively about self-care without guaranteeing physicians the time or resources necessary to care for themselves.

“MEDICINE, I SOON CAME TO LEARN, IS AS MUCH ABOUT DEATH AS IT IS ABOUT LIFE.”

“Please, dear God, just come by here and bring my husband back to me,” she cried as I walked past her to pick up the white coat I had so hastily discarded. My feet felt like lead, and my coat, now heavy on my arm, felt futile, for all I could say was, “I’m so sorry for your loss.” At the time, I was too young to understand that medicine is as much about caring for our patients’ families when they have suffered a tragic loss as it is about caring for our patients when they are alive. Every physician remembers the first patient they watched die. I’m no different. To this day, as I sit here and write about this man whose name I never had a chance to learn, I can visualize his face, his chest, the last teardrop that rolled down his cheek as if to apologize for not having a chance to say farewell to his family. All of it comes back to me and I am transported to a time when I was shocked into silence. For days afterwards, I couldn’t sleep. Was I wrong, I wondered, to let the situation affect me for so long—was I weak? How many codes must one see to move on without feeling anything at all? When I finally asked those questions of my mentor, he smiled empathetically. “I think, in some way, you’ll always feel that sadness when a patient dies. I still feel it,” he said, “In fact, it’s when you feel nothing that you know it’s time to stop practicing medicine.”

We still view tears as unprofessional and, in some specialties, take pride in depriving ourselves of food and sleep, expecting of ourselves efficiency levels that are difficult to ask of a human being. All while the very human existences of real people, like the man in the MICU, extinguish in front of us every day. Medicine is a career I chose despite the sorrow of losing patients, because every life saved or positively impacted makes the challenges of training and practicing completely worth it. And, as I graduate, I cannot emphasize how important it is for our physician leaders, attending physicians, and resident physicians to advocate for the culture of wellness that we want to practice in. After all, our efforts will set the stage for a new generation of physicians to practice safely and happily in a field inherently racked with emotional challenges. Lights. Sirens. Actions? I can’t wait to see what we will do next.

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PALLIATIVE CARE COMMITTEE

My Journey from ER to Palliative Care Alexa Gale, MD FAAEM

y family was braced for this day: the day of my mother’s death. It was a sad separation, but it did not feel like a final goodbye. Hers was a better death than what we had prepared for months earlier—it could have been filled with much more suffering. As I held my mother’s hand at her last, I wished her well on her journey. She had been a flight attendant for sixty years; for this, her final flight, I hoped it would take her somewhere special, somewhere amazing, to some final destination where we may meet her again. The day was July 1, 2019. In 2014, my mother was diagnosed with idiopathic pulmonary fibrosis. I remember the call from the pulmonologist. I knew the prognosis and the likely timeline. It was not long before her health was waning—it was time for hospice. I initiated the discussion, and it took many discussions before she accepted hospice and was at peace with the decision. The process took time, quiet contemplation, and compassion. This event, like so many other life-changing events, made me pause and reflect; that reflection would ultimately lead me to a change of career path. Since 2013, a time span that includes the years of my mother’s illness, I’ve worked as an emergency physician in busy, urban emergency departments. My clinical career has been defined by the adrenaline rush of the medical emergency: the hectic pace, the momentum to push cases through, the chaos of the code. My day-to-day medical environment stood in stark contrast to that of my mother’s hospice care. From the start of my career in emergency medicine in 2010, I knew I did not completely fit the mold of a typical ER doctor. But why? I was highly competent, I was good with the patients, and I could handle the fast-paced tempo of the ER. I had been recognized and awarded for the excellence of my practice. So again, why? Despite my clinical competence, my conscience would cause me to pause because I felt an off-ness: sometimes I would stand, with an ET tube in my hand, and think “this is not right, this is not what this patient wants, this is what not what this patient needs.” This put me at odds with my job description, and this was not the first time I had felt this off-ness. Even in residency, attending physicians instructed me thus: “let’s just tube them and get them to the ICU, they can talk to the family about their options.” I was there to learn, so I would push my thoughts aside, tube and line the patient, admit them to the ICU, and move on. That was what the job required so I made my peace with it, but I sorely missed the opportunity to connect with my patients. As the years in the ER went by, I tried to soothe my conscience with the following mantra: “I’m not trained for those conversations, this is not in my scope of practice, move on, the waiting room is full, you have metrics to keep up with.” Abbreviated conversations, limited scope, churning through patients, metrics being key—these are what the logistics of emergency medicine require in order to operate with efficiency, so I conformed. However, that voice remained—a little voice that grew louder as I gained experience. Clearly, I had not made peace with it. 24

COMMON SENSE MAY/JUNE 2022

In 2014 my mother became ill; in 2018, she entered hospice care; in July of 2019, she died. Then, in January 2020, the Covid-19 epidemic hit the United States in full force. Now, in the ER, I was intubating Covid patients on a hope and a prayer; now, the only comfort I could offer them and their loved ones was “it's going to be OK,” knowing it probably would not be. It was obvious that intubation was not saving our Covid patients. Now, I watched them say goodbye to their loved ones over an iPad, which I held before them, a stranger intruding on their landscape of grief, a stranger wearing full protective gear so as not to bring such a death home to my own loved ones or the loved ones of others. This vicarious experience of death was a turning point for me: the stark contrast of an often unexpected death in physical isolation from loved ones—-as became the emotionally excruciating norm with Covid patients—with the relative comfort of a hospice death—like my mother’s recent passing— kicked my conscience into a full, shouting voice. It would no longer be soothed or quieted. I was forced to acknowledge and listen, and then to begin a conversation first with myself, and then with many others around me. What I needed was the ability to treat patients using a whole-patient approach. This is a challenge in the ER, but this was also the answer to the nagging question of “why?”

“[S]ometimes I would stand, with an ET tube in my hand, and think ‘this is not right, this is not what this patient wants, this is what not what this patient needs.”

With this answer to my conscience acquired, in 2021 I began investigating how to change my career path, learning more about hospice and palliative medicine and opportunities therein. Could I integrate this specialty into my day-to-day practice? The more I learned, the more I believed it possible to integrate the two, and the more motivated I became. I made the decision to incorporate the call of palliative medicine into my current practice of emergency medicine. The first step would be to apply for a fellowship in hospice and palliative care, which would entail some financial loss. I am, however, lucky to have both the financial means and the support of my family and friends to do so. And so, with a leap of faith, I applied for a match to a fellowship in palliative care. I am ecstatic to report that in July of 2022, I will begin a Hospice and Palliative fellowship. Will it be the correct choice for both myself and for my patients? My little voice will be sure to let me know.

WOMEN IN EMERGENCY MEDICINE

Human Trafficking and Natural Disasters Myra Khushbakht, BS, Karin Brown, MS, Catherine Wertz, BA, Jennifer Reyes, DO FAAEM, Marianne Haughey, MD FAAEM, and Loice Swisher, MD MAAEM FAAEM

ntroduction

Environmental stressors greatly impact vulnerable populations, resulting in an increased risk for human trafficking in situations where a natural disaster has occurred. As health care providers, it is imperative to recognize red flags to determine if a patient could be experiencing trafficking. In the event of a natural disaster, emergency providers have an increased chance to identify and support persons experiencing trafficking (PET). An estimated 24.9 million people worldwide are currently victims of human trafficking. A risk factor in becoming a person experiencing trafficking (PET) can include having a vulnerable background (i.e., foster care, homeless youth, migrant laborers, refugees).1 Trafficking does not necessarily need to happen across borders. According to the US Department of State, trafficking is the “act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex through the use of force, fraud, or coercion.”2 There are several forms of trafficking. Both sex trafficking and forced labor are covered as “severe forms of trafficking in persons” under the Trafficking Victims Protection Act (TVPA), a US federal law that was deemed one of the first comprehensive federal laws to address this issue.3 The US Department of Homeland Security (DHS) also runs the Blue Campaign, which is a “national public awareness campaign designed to educate the public, law enforcement and other industry partners to recognize the indicators of human trafficking, and how to appropriately respond to possible cases.”4 Under this campaign, the Federal Emergency Management Agency (FEMA) runs a mandatory course for employees on trafficking prevention.2 The agency even provides a six-minute course to recognize and report suspected trafficking during a disaster response.5

Trafficking and Natural Disasters Both natural and political disasters disrupt normal social, economic, and societal structures and lead to an increase in human trafficking.6 After the 2010 earthquake in Haiti, the US State Department noted the increased risk of sex and labor trafficking for survivors in internally displaced camps, especially children and women from low socioeconomic backgrounds.7 Understanding that displaced persons are vulnerable, traffickers will prey on those who lack basic needs (i.e., food, water, and shelter), social connections, and a stable income. Frequently, traffickers appear intentionally friendly or helpful to the intended victim. Because individuals in these situations are often in survival mode, experiencing acute trauma, and may be physically harmed as well, they may not be fully attuned to discern from whom they should accept help. They may not know to seek out specific organizations, such as the Red Cross,

International Rescue Committee, or FEMA, as safe places to accept aid and direction. Traffickers can take advantage of these turbulent situations to use force, fraud, or coercion to manipulate these at-risk individuals and sell them into trafficking situations. Not only do natural disasters destabilize already vulnerable populations due to a disruption of basic needs such as housing, food, and water, the aftermath can result in an influx of workers that are encouraged to take fraudulent jobs where wages are not what they seem, freedom of movement is restricted, and even mislead individuals into sex trafficking situations. After Hurricane Katrina, there was a huge need for laborers to help with the rebuilding and recovery in New Orleans and the surrounding regions. A number of subsequent civil cases have focused on the resulting labor exploitation in the region at the time, including instances of debt bondage at luxury hotels, labor trafficking through the H-2B guest worker program, and exploitation of manual laborers who were repairing residential properties. The temporary relaxation of regulations coupled with destabilized situations can lead traffickers to capitalize on their exploitative behavior.2

What You Can Do As a Health Care Provider Studies indicate that over 80% of PET come into contact with health care providers at some point during captivity and a majority of visits happen at the emergency department.8 General indicators that may indicate abuse include lack of proper identification, inappropriately dressed for the weather, and noticeable unexplained bruising. In addition, patients may be fearful, anxious, avoid eye contact, and limit their answers to

COMMON SENSE MAY/JUNE 2022

WOMEN IN EMERGENCY MEDICINE

questions. If the “boss” or “boyfriend” is present, they may refuse to leave the exam room, or they may insist on having control over certain situations such as functioning as the translator if foreign language interpretation is needed.

Identifiers for Sex trafficking: Some sex trafficking indicators include visits for multiple STIs or unwanted pregnancies, vaginal or anal foreign bodies (FBs), oral trauma, pelvic pain, use of slang of commercial sex work, branding on the body (i.e., “property of”), and lack of control regarding safe sex. Substance abuse is seen almost universally and should be viewed as a symptom.

Identifiers for Labor Trafficking: Labor trafficking indicators include signs of poor working conditions, injury due to lack of protective equipment, occupational injury with no worker’s compensation, chemical exposures, sun exposure, machine-related injuries, and ergonomic injuries. During a general examination, patients would appear overworked, malnourished, or anemic with considerably poorer hygiene. They may present as with excessive dental caries, have continuous muscle spasms, or nerve impingements resulting from repetitive motions.9

6 principles of providing Trauma-Informed Care Safety Trustworthiness + transparency Peer support Collaboration Empowerment + choice Recogninzing and addressing cultural, historicalo, gender stereotypes and biasis Figure 1: Six Principles of Providing Trauma-Informed Care. Source: Jennifer Reyes, DO FAAEM.

Practicing trauma-informed care can help patients feel comfortable and encourage them to be open about their situation. Knowing local trafficking laws and protections and having ready information about local social services organizations and local authorities can be essential. Many organizations provide emergency housing, long-term housing, counseling, family reunification, legal services, and job training for persons experiencing trafficking. For more information, guidance, and resources, call the National Human Trafficking Hotline at +1 (888) 3737888. Taking the time to provide this phone number to a patient during a private moment or posting such information in bathrooms can be another helpful and supportive measure providers can take. By practicing trauma-informed care and understanding what resources are available for PET, physicians can help play an important role in aiding patients in vulnerable situations.

COMMON SENSE MAY/JUNE 2022

References

“Studies indicate that over 80% of PET come into contact with health care providers at some point during captivity and a majority of visits happen at the emergency department.”

1. Global Estimates of Modern Slavery: Forced Labour and Forced Marriage. (2017). [Report]. http://www.ilo.org/ global/publications/books/ WCMS_575479/lang--en/index. htm 2. Stahl, M. (February 2018). Trafficking Prevention and Disaster Response. Retrieved March 21, 2022 from 3. https://nhttac.acf.hhs.gov/ sites/default/files/2020-02/ Trafficking%20Prevention%20 and% 20Disaster%20 Response%20Literature%20 Review.pdf. 4. What is Trafficking in Persons? Retrieved March 21, 2022, from https://ctip.defense.gov/What-is-TIP/ 5. Blue Campaign | Homeland Security. Retrieved March 21, 2022, from https://www.dhs.gov/blue-campaign 6. FEMA - Emergency Management Institute (EMI) Course | IS-1151: Blue Campaign Disaster Responder Training. Retrieved March 21, 2022, from https://training.fema.gov/is/courseoverview.aspx?code=IS1151&d=11/17/2021 7. Bales, K. (2021). What is the link between natural disaster and human trafficking and slavery? Journal of Modern Slavery, 6(3), 36–47. https:// doi.org/10.22150/jms/MOJJ8604 8. U.S. State Department (2014). 2014 Trafficking in Persons Report. Retrieved March 21, 2022, from https://2009-2017.state.gov/documents/ organization/226846.pdf 9. Human Trafficking in the Emergency Department: Improving Our Response to a Vulnerable Population. The Western Journal of Emergency Medicine. Retrieved March 21, 2022, from 10. https://westjem.com/articles/human-trafficking-in-the-emergencydepartment-improving-o ur-response-to-a-vulnerable-population.html 11. Reyes, Jennifer. Human Trafficking in the Emergency Department. Grand Rounds Lecture Series, Staten Island University Hospital. June 23, 2021. Staten Island, New York, United States.

ACADEMIC AFFAIRS COMMITTEE

Standing the Post Mary Claire O’Brien, MD FAAEM

“W

people show up sick as stink with Covid pneumonia and expect us to fix it.”

hy are you still working?” my adult children ask me. “You need more hobbies.” “Hobbies?” I say. “Hobbies are for normal people. I am still working because I am not a wimp! I am an emergency physician. It is my job to Stand the Post.” Why am I still Standing the Post, after 36 plus years? Some days I am not even sure myself. “Hey,” a colleague said. “What lights your fire? Why do you get out of bed in the morning?” “Taking care of patients,” I answered. “Helping patients and their families.” This is a crazy time to be practicing emergency medicine! The whole thing is a cluster. Staff shortages, budget constraints, vaccine wars, opioid crisis, gun violence, racial inequity, climate change, inflation, health system mergers, new payment models, JCAHO, Covid—Covid!

Believe me, we clinicians are all worn out with this. We are mad at the patients. Here is the great irony: we are mad at each other! We are careful, compassionate emergency professionals who make the best decisions we can—under pressure, with incomplete information, with limited resources—every day, just doing the best we can. After two years of Covid chaos and severe staffing shortages, we are struggling to give one another grace—when someone forgets to check the labs, misses some-

“HERE IS THE THING: THIS IS NOT MY FIRST RODEO.”

Here is the thing: this is not my first rodeo. When I was a resident in the mid-1980s, we did not understand the illness we now call AIDS. An infectious agent called HTLVIII was killing people on the fringe. We heard it had something to do with eating bush meat in Africa—so why were people in Philadelphia dying of it? Patients who were intravenous drug users developed a terrible wasting illness, or severe hypoxic pneumonia caused by a “parasite,” or a horrible blotchy purple skin cancer. All with no cure. They lay alone in the hallways, and died. We had no idea what was going on. As clinicians, we did not know if touching the patients with “HTLV-III” would make us sick. Transmissibility had not yet been defined. How did they get it? Would we get it? Would we give it to our spouses? Our children? We did not know. We Stood the Post. SARS: “Have you travelled to Asia?” MERS: “Have you travelled to the Middle East?” Ebola: “Have you travelled to Africa?” Covid-19: “Have you been to the grocery store?!” “Are you mad at the patients?” asked a resident. “I’m mad.” “Of course I am mad,” I said. “I am mad because at this point in the pandemic, so much of it seems preventable. I am mad because the vaccines are not keeping health care workers safe. I’m mad because unvaccinated

thing on an X-ray, didn’t speak with the consultant yet, hasn’t wrangled a disposition in a timely fashion. Mental assessment: “You are leaving me an ED that is a mess. OMG, WHAT A MESS!” Pre-Covid verbal reply: “No problem! Give me the keys, Friend. I know how to drive this bus.” Responses of late: much less amiable. Because now—it feels like every day is a bad day! For almost four decades my prayer while walking from the parking lot to the ED has been: “Help me help the people.” These days it is: “Help me not lose my temper for 8 and a half freaking hours.” Give me the grace to encourage those around me. Help me Stand the Post .

COMMON SENSE MAY/JUNE 2022

WELLNESS COMMITTEE

A Colleague is Making You Unwell: Options? David Hoyer, MD FAAEM

uffering the slings and arrows of working in our medical-industrial complex takes a significant toll on emergency physicians. Evidence for this toll can be seen in the ongoing drumbeat of our publications showing fatigue, burnout, depression, and suicides. Having suffered some of these wounds myself, here are some tips to my fellow emergency medicine colleagues to hopefully avoid being a casualty. The first step is to take ownership of your wellness, which needs to be tended like a garden throughout your career. Limit alcohol to the CDC’s recommendation of 1-2 drinks per day, avoid other drugs, exercise regularly, meditate, nurture relationships, get 7-8 hours of sleep daily when you are off and learn to say “no.” Once you have established wellness, carefully evaluate jobs. Some shops may look like good places to work until problems arise. Before you sign on the dotted line, read your contract carefully. Find out how patient complaints are handled. Does the medical director make the final call on the validity of a complaint or is it business people? If it is the latter, particularly if you are working as an independent contractor without due process, you are at the mercy of someone who could arbitrarily damage your career and wellness. Of course a trustworthy medical director who is not a spineless bagman for administration can make a big difference to your wellbeing. Avoid shops where there is a cap on the number of complaints acceptable, because you will be “walking on eggshells” or worse if you happen to be on duty when complaint-prone patients seek your care. Finally, avoid those jobs that say they are providing “concierge care” (or a similar term), which is business code for “the patient is always right” and, therefore, the physician is wrong for “allowing” a complaint to occur. Sadly bad business practices continue to corrupt the practice of medicine and subject physicians to moral injury on the job while contributing to the overuse of antibiotics and pain medicines and rising health care costs.1 Let’s say you are working at a job where you suffer some criticism. If you feel it is an unfair criticism it needs to be confronted, in a calm venue where you can effectively defend yourself. Sometimes the tendency is to not “make waves,” but you will feel better about yourself, then and later on, if you stand up to unfair criticism.

affecting patient care, keep records of patients affected. HIPAA generally does not apply here, although you will want to confirm that with your particular board. If a political issue related to medicine makes you unwell, our professional societies can be a significant source of support. While dues to these societies can sometimes seem excessive, you can view the money as an investment in your wellness. Starting with your local county medical society you can submit motions on a policy that can go to the state medical association and on to the AMA if a national policy is involved. A good way to take a break from the rigors and possible unwellness of shift work is by doing telemedicine. Patients may be less sick and, perhaps, less exciting, but you can practice evidence-based medicine at your leisure without Press Ganey and other inventions of the medical-industrial complex hanging over you. Since telemedicine patients are not subject to big bills after seeing you, they tend to be grateful when antibiotics or extensive testing are not indicated. Finally, until we get rid of due process waivers that so many of us must sign to work, we will be at a disadvantage with colleagues who can negatively affect our wellness. Getting the ER Hero and Patient Safety Act (HR 6910) passed into law would make due process waivers illegal and make our workplaces fairer. Some people think HR 6910 has loopholes that should be tweaked before going to a vote.2 If the above options don’t make you well, you may want to consider professional help. I previously published my story in “I Came Back from Depression, and So Can You,” available online and on the AAEM website.3 Be well beloved colleagues.

References 1. Giwa A. et al. Addressing Moral Injury in Emergency Medicine. J Emerg Med. 2021; 61(6):782-8. doi.org/10.1016/j.jemermed.2021.07.066 2. Sullivan W. Making a Stronger Hero (Act). EPMonthly; January 2021:13. 3. Hoyer D. I Came Back from Depression, and So Can You. Emergency Medicine News. 2018;40(9):20. doi: 10.1097/01.EEM.0000546141.79545.c3

If you are being made unwell by a job issue that cannot be remedied by verbal confrontation, you may want to contact your state medical board. For example, if you think that the corporate practice of medicine is

“The first step is to take ownership of your wellness, which needs to be tended like a garden throughout your career.” 28

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EMERGENCY ULTRASOUND SECTION

Education in Point of Care Ultrasound Melissa Myers, MD FAAEM

We must acknowledge that this is a barrier to the continued adoption of POCUS and followed established guidance prior to incorporating new exams into our practice. Initiatives from both from AAEM and the EUS section are ongoing to meet this need. At this year’s scientific assembly, the ultrasound pre-course will include the second iteration of a skills competency exam. Those who attend the ultrasound pre-course can opt into a skills test where they will perform a single modality multiple times to receive feedback and ultimately certification of competency in this modality. In addition, the EUS section has restarted an initiative to bring ultrasound courses to community hospitals. Physicians with a strong background in POCUS need to be willing to follow these initiatives from AAEM with strong continued training and quality assurance image review programs in community hospitals. With these initiatives, and through many others initiated across our specialty, I firmly believe that we can meet and overcome this barrier.

idespread adoption of Point of Care Ultrasound (POCUS) in Emergency Medicine (EM) has accelerated over recent years. This increase in the use of POCUS has led to safety concerns by those outside our specialty about the use of ultrasound outside of radiology.1 These concerns do not consider the efficiency and accuracy of emergency physician performed ultrasound or reflect an understanding of the environment in which we operate.2,3 In general, I consider these fears to be inaccurate. I do believe that there is one problem with the widespread adoption of POCUS which has not been completely acknowledged. This potential problem is training pathways for physicians who did not have access to training in the use of POCUS during residency. Medical students frequently start residency after having learned the basics of POCUS during medical school. In addition, POCUS training is a requirement for EM residencies. At many programs, including my own, this training takes the form of a month-long rotation with immediate feedback from fellowship-trained faculty and ongoing quality assurance. These residents graduate fully competent to perform and interpret any core ultrasound exam. Many physicians who are currently practicing did not have access to POCUS training during residency. Safety concerns arise when physicians who are not adequately trained perform these exams as with any other procedure. Performing an ultrasound exam without adequate training leaves the physician open to misinterpretation of the results or missing an important finding. Previous research has shown that it may take up to 50 exams, with feedback from an expert to be fully competent in performing the E-FAST exam.4

References 1. Myers, M. and Chin, E. (2020). Is Emergency Physician Performed Bedside Ultrasound Dangerous? Common Sense, March/April 2020. 2. Randazzo, M. R., Snoey, E. R., Levitt, M. A., & Binder, K. (2003). Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Academic Emergency Medicine, 10(9), 973-977. 3. Volpicelli, G. (2011). Sonographic diagnosis of pneumothorax. Intensive care medicine, 37(2), 224-232. 4. Blehar, D. J., Barton, B., & Gaspari, R. J. (2015). Learning curves in emergency ultrasound education. Academic Emergency Medicine, 22(5), 574-582.

“Performing an ultrasound exam without adequate training leaves the physician open to misinterpretation of the results or missing an important finding.”

COMMON SENSE MAY/JUNE 2022

Why You Should Volunteer as an Oral Board Review Course Examiner

AAEM ORAL BOARD REVIEW COURSE

Frank L. Christopher, MD FAAEM and Michael C. Bond, MD FAAEM

ince Joe Lex, MD MAAEM, created the Academy’s Oral Board Review Course (OBRC) in 1996, the course has undergone continuous evolution to match the format and content of the American Board of Emergency Medicine (ABEM) Oral Certification Examination. In the past three years alone, OBRC has migrated from an in-person hotel-based format held biannually in several different cities using paper and computer based stimuli, to a more frequent web-meeting format utilizing screen-shared digital stimuli. Triplepatient encounters have been phased out and the structured interview format encounters phased in. While the structure, format, and content have changed, some things remain constant. First and foremost, the course relies entirely on board-certified volunteer members of the Academy to serve as instructors. Secondly, the AAEM OBRC is recognized across the emergency medicine community as the premier preparation platform for our new colleagues scheduled to take the Oral Certification Examination. Additionally, membership in the Academy is enhanced as new residency graduates, who may not have joined while in training, become members, whether it be for the discounted course rate or upon learning more about the Academy’s mission and vision. The AAEM OBRC is the only preparatory course that uses the identical software platform as ABEM. Feedback from those who have taken our course has been overwhelmingly positive, indicating that we mimic the complexity, style, and format of the actual Oral Certification Examination exactly.

None, to sign up and get on the instructor list. Whenever the courses are offered, you will be contacted and given the opportunity to volunteer for the course date. Each course runs for approximately five and a half hours. If you’ve never taught before, examiner orientation is provided by AAEM with instructional videos and/or one-on-one web-hosted training.

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

The sheer volume of graduating residents continues to grow, with hundreds of new colleagues preparing to take their Certification Examination every year. With a one-to-one instructor to student ratio, OBRC’s course size is only limited by the number of available examiners. Larger courses, of course, increase AAEM’s exposure to the community, promulgate our educational mission, and partially subsidize other Academy activities. Many examiners desire to “give back” to AAEM but don’t necessarily have the time or opportunity to participate in committees, interest groups, or other leadership positions with larger time requirements. Participating in the OBRC gives them an opportunity to connect with each other, and with the Academy at large, with a smaller time commitment. Many Academy leaders, including the current and several Past Presidents, started their AAEM involvement as OBRC examiners.

COMMON SENSE MAY/JUNE 2022

What’s the commitment?

Build confidence with each case encounter!

Why should you volunteer?

Your participation allows our new colleagues to interact with examiners from all walks of EM life—academic, non-academic, urban, rural, government, etc. The course presents diversity in all facets of examiner makeup.

What are the benefits of serving as an examiner? Mentoring future board-certified emergency medicine physicians, networking with fellow AAEM examiners, national involvement for those needing it for promotion, faculty CME, an invitation to attend an annual reception at Scientific Assembly, and a stipend ($100) for each course. As ABEM’s Becoming Certified initiative presents recommendations for changing how our EM colleagues achieve initial board certification, you can be assured the AAEM OBRC will continue to evolve concurrently to ensure we retain the high quality and relevancy expected of the Academy. Interested in sharing your knowledge to help prepare candidates for their Oral Certification Exam, please submit the Volunteer Eaminer Interest Form by scanning the QR code below. Please contact Tom Derenne, AAEM Program Manager, at tderenne@ aaem.org or (800) 884-2236 with any questions.

YOUNG PHYSICIANS SECTION

Advocacy: What Can You Do? Joshua Bucher, MD FAAEM

he Young Physicians Section hosted a webinar on March 15 regarding advocacy and what we can do as physicians in our local communities. This was a great opportunity to hear from several AAEM members, including Julie Vieth, MD FAAEM, the current chair of the Workforce Committee as well as Debbie Fletcher, MD FAAEM, a member of the Workforce Committee. As physicians, we are the experts in evidence-based care and should be advocates for patient safety. Politicians do want to hear what we have to say. Few politicians are in health care and even fewer are physicians. Therefore, we can use our expertise to make connections, offer advice, and give input when the opportunity arises. You can make connections with your politicians as easy as reaching out through social media, sending an email, calling their office, or any other way of making contact. Politicians want to hear from us, their constituents, and the best way to start that is by telling a story. Stories can be very moving to politicians and draw their attention to an issue they may not have considered. Personal stories can lead to further conversations involving important issues and the research and numbers to support it. We often do not get involved in politics since we are balancing many different items on our plate; whether it be family, personal or professional, our truly “free time” is limited. There are also not many organizations we can join that can fully represent our views. Dr. Fletcher spoke about her experiences in Louisiana where they organized a group of physicians to advocate for patient safety issues regarding scope of practice. While the

“Stories can be very moving to politicians and draw their attention to an issue they may not have considered.” nurse practitioner lobbies spoke about improving access, the physicians demonstrated increased scope of practice did not lead to increased access to care, one of the most important aspects for politicians who are debating these issues. They were able to prevent the passage of a bill allowing increased scope by demonstrating these facts. Some of you may ask, why should I care? Scope of practice and other patient safety issues will affect all of us, and it is important to be educated and aware of these bills when they arise. This is yet another reason we should be reaching out to our local politicians in state houses and assemblies; we can ally with them, and they or their staff can contact us when certain bills arise. Advocacy is an important yet underutilized tool in our toolbox. Forming relationships with our local politicians can be invaluable for the future of medicine, and we should all be involved.

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 three new AAEM Interest Groups:

Aging Well in Emergency Medicine Interest Group Rural Medicine Interest Group Simulation Interest Group All AAEM Members can sign up to participate!

aaem.org/get-involved/interest-groups COMMON SENSE MAY/JUNE 2022

AAEM/RSA PRESIDENT’S MESSAGE

Cabinet of Delegates Lauren Lamparter, MD

mergency medicine (EM) as a specialty was built by tenacious young leaders who advocated for their patients to receive something better—dedicated care for their emergencies by a specialist. As EM evolved, leaders in advocacy arose, creating the American Academy of Emergency Medicine to advocate for patients by ensuring their care is provided by the best possible—the board-certified emergency medicine physician. These leaders have shaped our specialty, and it has been my utmost privilege to participate in leading medical students and residents as the President of RSA for the past year. The American Academy of Emergency Medicine Resident and Student Association is working hard to be a tenacious advocate for students and residents, and we would love for you to join us! To create further connection within RSA and mentor the future leaders of emergency medicine, we are so excited to launch our cabinet of delegates! We would love for you to get involved in leadership with us and we are actively recruiting an AAEM/RSA resident delegate from each EM residency program and an AAEM/RSA student delegate from each medical school to serve as a champion of AAEM/

RSA to their program. The AAEM/RSA Cabinet of Delegates will be tasked with the below duties as well as initiatives set by the AAEM/RSA Board.

As an AAEM/RSA Delegate to your residency or medical school you will be our liaison to: • Inform residents and students of upcoming national and regional AAEM/RSA events • Distribute educational materials to residents and students in your programs or medical schools • Communicate with AAEM/RSA about how we can best support you and your fellow residents and students • Coordinate activities or events sponsored by AAEM/RSA with residents or medical school EM interest group leaders • Be ready to represent your program’s viewpoint by voting when AAEM/RSA needs to collect resident opinions • Provide contact information of your co-residents and students who wish to be placed on AAEM/RSA’s mailing list and provide a specific resident and EMIG contact

• Designate a resident or student who will take your place as the AAEM/RSA Delegate when your role is completed

Benefits • Gain valuable experience in networking with residents and students from around the country • Share your voice to the AAEM/RSA board and help us advocate for the future of emergency medicine • Gain leadership experience at your residency or medical school and continue to build your CV • Meet with fellow Cabinet members in-person at the AAEM Annual Scientific Assembly • Have the opportunity to coordinate relevant activities for the residents or EM bound students at your program • Be the first to know about ongoing AAEM/ RSA events Please apply on the website today (aaemrsa. org) or for more information email info@aaemrsa.org. We look forward to working with you to change the future of emergency medicine!

"This position gives you a unique opportunity to advocate for your peers and voice any needs your program may have, all while gaining valuable leadership experience that can make you an even better physician."

Apply by June 15th!

aaemrsa.org/get-involved/cabinet-of-delegates

COMMON SENSE MAY/JUNE 2022

TAI DONOVAN,

Vice Chair of the Cabinet of Delegates Committee

As the Streets Become More Dangerous for Members of the LGBTQ Community, it is Our Responsibility to Make Our Emergency Departments Safer

AAEM/RSA EDITOR’S MESSAGE

Kasha Bornstein, MD MPH MSc Pharm EMT-P*

he past year has seen a proliferation of bills advanced across state legislatures that target lesbian, gay, bisexual, transgender, and queer people. From the controversy-generating Parental Rights in Education bill signed into law in Florida, to statewide laws barring local protections for trans and queer people, to numerous laws limiting the rights of transgender and nonbinary people to participate in sports, use bathrooms, and receive gender-affirming care, more anti-LGBTQ laws have been advanced this year than ever before.1 Contrary to the recommendations of the American Medical Association, the American Academy of Pediatrics, the American College of Physicians, the American College of Obstetrics and Gynecology, and the North American Society for Pediatric and Adolescent Gynecology, legislators and allied state administrators have pushed forward on writing laws and issuing guidelines that discriminate against transgender and gender non-conforming (GNC) youth and their families seeking gender-affirming care.2,3 While on some level this is a wedge issue used to inflame culture wars and gin up controversy for political gain, these legislative efforts have major real-world impacts for a population that already faces outsized disparities across multiple facets of life. Members of LGBTQ communities experience greater housing insecurity, lower health insurance rates, and multiple barriers to employment.4,5 In addition, LGBTQ communities face heightened health risks around substance use, sexually transmitted infections, cancers, cardiovascular diseases, and trauma, as well as a greater psychiatric illness burden of anxiety, depression, and suicide. LGBTQ youth in particular are two to three times more likely to attempt suicide

versus the general population, and some 11-40% experience homelessness, placing them even further at risk for becoming victims of violence, engaging in unsafe drug and alcohol use, experiencing exacerbation of psychiatric illness, and suffering malnutrition.6,7 Alongside this surge in discriminatory legislation, the past several years have seen an escalation in hate crimes against members of LGBTQ communities. Sex and gender identity-based hate crimes rose from 2.2% of all hate crimes in 2018 to 2.7% in 2019, and 2021 was the deadliest year for transgender and GNC people in the US on record.8 This violence intersects with many other structural forces at play in discrimination: 85% of victims since 2013 were transgender women, and 84% of victims were people of color.8 Statistics on these cases of violence are confounded by underreporting and misreporting: victims of these acts are frequently misgendered in police reports and hospital charts, resulting in an undercount of the true figures.8 When survivors of these vicious acts of violence arrive in the hospital, we have an opportunity to limit further trauma and start the process of healing. However, recent research has revealed that emergency departments are often sites of retraumatization for members of these communities. “Fear of discrimination was identified as a barrier to seeking care more frequently by gender minorities compared to sexual minorities. Of those with a history of care avoidance, 45% of gender minorities and 29% of sexual minorities reported a prior negative ED experience as the reason for avoidance…41% of these respondents believing they were treated differently than other patients, reporting hearing homophobic/transphobic

“While on some level this is a wedge issue used to inflame culture wars and gin up controversy for political gain, these legislative efforts have major real-world impacts for a population that already faces outsized disparities across multiple facets of life.” COMMON SENSE MAY/JUNE 2022

RSA EDITOR’S MESSAGE

language in the ED.9 Respondents who self-identified as LGBTQ+ parents also reported difficulties presenting with a child for care, including needing to correct staff on correct pronoun usage. “I’ve been expected to coach attending medical staff on pronouns and grammar while receiving emergency care and also while being interrogated (and argued with) about biological sex (because they didn’t understand being intersex nor did they understand the difference between gender and sex).”9 In sum, as LaPlant et al (2021) write, “Emergency care avoidance within the gender minority community occurs significantly more often than in the heterosexual cisgender community.”9 As members of the frontline workforce and some of the first faces a person sees after a traumatic event, when seeking emergency care, or simply when seeking a safe place to sleep and get linked to resources, we can do better. Many of the medical organizations joining court battles against this spate of anti-LGTBQ legislation are doing so on behalf of their patients because of a vested interest in providing the best evidence-based care for their patients as gynecologists, surgeons, adolescent medicine physicians, family doctors, and internists. However, LGBTQ patients are our patients too. As a medical community, we can advocate with our collective voice to fight the laws and directives that make society more dangerous for vulnerable patients. On the home front, there is even more we can do to make our departments welcoming for LGBTQ patients. We can train our front desk staff to tactfully navigate potentially awkward situations, particularly around legal names and gender markers on ID cards. We can rewrite inequitable policies. Some best practices, adapted from Gorton and Berdahl (2018) for LGBTQ-friendly care in the ED include:10

Policy • Make public spaces and exam rooms alike welcoming, with brochures, posters, and magazines reflective of the diversity of patients we serve. • Update forms to include the patient’s legal name, chosen name, pronouns, sex assigned at birth (e.g., male, female, intersex), and gender (e.g., cisgender man, cisgender woman, transgender man, transgender woman, nonbinary, genderqueer, prefer not to say). • EHR systems should be updated to document chosen name, gender identity, pronouns, and sex assigned at birth in EDs. • Include trans/GNC people in the development of policies and practice guidelines for ED clinicians and staff. • If possible, have accessible, single-use, all-gender restroom facilities for patients. Many transgender and non-binary individuals avoid public bathrooms. This means not eating or drinking, and consequently, these individuals may experience episodes of hypoglycemia, dehydration, urinary tract infections, or other kidney problems.

COMMON SENSE MAY/JUNE 2022

Practice • Be respectful and affirming of patients’ gender identities, including using their chosen name and pronouns. Regardless of their legal name, pronouns, and gender markers, use what they share with you! • Use inclusive language, such as gender-neutral pronouns and terminology, and medically accurate terminology for reproductive organs, avoiding referring to them as “male parts” or “female parts.” • Physical examination should be relevant to what anatomy the patient has, regardless of their gender presentation. If necessity of an aspect of the exam is not obvious, consider explaining why you are doing what you are doing. • Ensure a staff member chaperones intimate exams, regardless of the sex and gender of the patient and the provider. • Use appropriate, discrete, and patient-specific language for the anatomy they have—if you are uncertain, you can ask what the patient’s preferred nomenclature are. • If possible, allow patients to self-collect or self-swab vaginal and anal/ rectal test specimens. • Asking open-ended questions about patient’s sexual history, when appropriate, can invite more trust and honest answers. • Leave personal religious beliefs out of health care practice and interpersonal interactions with patients.

Education • Ensure your nursing and allied health staff are aware of these best practices! Working with nursing leadership in the department can help extend these standards of care during shift huddles and meetings. • Engage LGBTQ people and experts from local trans-led organizations in the development and delivery of training. • Provide training on gender-affirming care for current and future clinicians and staff. • Incorporate information about transgender/GNC health into medical and nursing school curricula, including clinical experiences with transgender/GNC patients during this professional training.

“As a medical community, we can advocate with our collective voice to fight the laws and directives that make society more dangerous for vulnerable patients.”

RSA EDITOR’S MESSAGE

References

Key Terms to Know • Pronouns are used in place of a proper noun such as someone’s name. He/him and she/her are commonly used, but there are others people may choose. Gender-neutral pronouns include but are not limited to they/them, xe/xem, and ze/zem. • Sex is a label—male, female, or intersex—assigned by a doctor based on the anatomic presentation of external genitalia at birth. It does not necessarily match someone’s gender or gender identity. • Gender is complex. It encapsulates social and legal status as well as expectations from society about behaviors, characteristics, and thoughts. • Gender identity is the internal perception of one’s gender and how they label themselves. • Cisgender applies to someone whose gender matches their assigned sex at birth. • Transgender applies to a person whose gender is different from their assigned sex at birth. • Transmasculine describes a person who was assigned female sex at birth but who identifies with masculinity. • Transfeminine describes a person who was assigned male sex at birth but who identifies with femininity. • Two-spirit describes a person who embodies both masculine and feminine spirits. This is a culture-specific term used in Native American cultures. • Nonbinary is a spectrum of gender identities that are not exclusively masculine or feminine and are outside the gender binary of male and female. • Genderqueer people, similar to nonbinary, may feel they move between genders or have a fluctuating gender identity. • Genderfluid applies to a person who does not identify as having a set gender. • Misgendering is to use the wrong pronouns or other gender-specific words when referring to or speaking to someone, especially a transgender person.

1. *PGY-I, Louisiana State University Internal Medicine/Emergency Medicine Program 2. Glueck K, Mazzei P. Red States Push L.G.B.T.Q. Restrictions as Education Battles Intensify. The New York Times. April 12, 2022. 3. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Annals of Internal Medicine. 2015;163(2):135-137. 4. American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, American Psychiatric Association. Frontline physicians oppose Texas legislation that interferes in or criminalizes reproductive patient care. News release. September 2, 2021. 5. Macapagal K, Bhatia R, Greene GJ. Differences in Healthcare Access, Use, and Experiences Within a Community Sample of Racially Diverse Lesbian, Gay, Bisexual, Transgender, and Questioning Emerging Adults. LGBT Health. 2016 Dec;3(6):434-442. doi: 10.1089/lgbt.2015.0124. Epub 2016 Oct 11. PMID: 27726496; PMCID: PMC5165667. 6. Rhoades H, Rusow JA, Bond D, Lanteigne A, Fulginiti A, Goldbach JT. Homelessness, Mental Health and Suicidality Among LGBTQ Youth Accessing Crisis Services. Child Psychiatry Hum Dev. 2018 Aug;49(4):643-651. doi: 10.1007/s10578-018-0780-1. PMID: 29322361. 7. Corliss, H. L., Goodenow, C. S., Nichols, L., & Austin, S. (2011). High Burden of Homelessness Among Sexual-Minority Adolescents: Findings From a Representative Massachusetts High School Sample. American Journal of Public Health, 101(9), 1683–1689. doi:10.2105/ AJPH.2011.300155 8. Ream GL. An Investigation of the LGBTQ+ Youth Suicide Disparity Using National Violent Death Reporting System Narrative Data. J Adolesc Health. 2020 Apr;66(4):470-477. doi: 10.1016/j.jadohealth.2019.10.027. Epub 2020 Jan 22. PMID: 31982330. 9. Human Rights Campaign. An Epidemic of Violence 2021. https://reports. hrc.org/an-epidemic-of-violence-fatal-violence-against-transgender-andgender-non-confirming-people-in-the-united-states-in-2021. Published 2021. Accessed 4/20/22. 10. LaPlant WG, Kattari L, Ross LK, Zhan J, Druck JP. Perceptions of Emergency Care by Sexual and Gender Minorities in Colorado: Barriers, Quality, and Factors Affecting Identity Disclosure. West J Emerg Med. 2021 Jul 14;22(4):903-910. doi: 10.5811/westjem.2021.3.49423. PMID: 35354007; PMCID: PMC8328175. 11. Gorton RN, Berdahl CT. Improving the Quality of Emergency Care for Transgender Patients. Ann Emerg Med. 2018 Feb;71(2):189-192.e1. doi: 10.1016/j.annemergmed.2017.12.003. Epub 2018 Feb 5. PMID: 29447861.

Tell Us Your Opinion! The editors of Common Sense want to hear from you! What articles did you like or which ones, not so much? Submissions are open for future issues. Please visit aaem.org/resources/publications/common-sense or contact cseditor@aaem.org for more information. This is where your voice can be heard! COMMON SENSE MAY/JUNE 2022

MEDICAL STUDENT COUNCIL CHAIR’S MESSAGE

Meet the new Medical Student Council! Ashley Iannantone, MA

t has been my absolute honor to serve as the Medical Student Council Chair for the past year, and it is an even greater honor to introduce you to the fantastic medical students who will make up next

year’s council. My goal going into this role was to become an advocate for the specialty of emergency medicine on a much greater scale than I had previously been able to. I couldn’t have possibly achieved this goal without the hard work and dedication of my fellow council members—their work ethic, passion, and diverse interests constantly inspired me and pushed us to create new experiences for medical students nationwide throughout the year. We have had an amazing year of collaboration and growth by building upon the great foundation of resources already in place including the regional/national conferences and Medical Student Monday webinars/ podcasts. All four regions were again able to put on successful conferences this fall focusing on exposing medical students to career options within EM and opportunities within AAEM. We also put on a plethora of Medical Student Monday panels covering topics such as transitioning to M1 and M3 year and virtual interviewing/away rotation tips and tricks. New this year, we were able to coordinate mock interviews with program directors and virtual “hangouts” for specific student populations such as parents and IMGs.

COMMON SENSE MAY/JUNE 2022

I look forward to watching next year’s council continue to work on these projects and create new ones. We have a strong Medical Student Council for the upcoming year, which will be led by Mary Unanyan of Western University of Health Sciences. Mary is a familiar face within AAEM/RSA and served as this year’s Advocacy Committee Vice Chair. This experience will undoubtedly serve her well as she continues to advocate for core issues within EM as well as medical student members in her new role as MSC Chair. She will be supported by Vice Chair Clara PavesiKrieger from Loyola Chicago Stritch SOM, who is passionate about encouraging minorities and disadvantaged students to become a part of the EM community. There will also be fresh faces for each of the regional representative positions: Shannon McDonnel (Loyola Chicago Stritch SOM) will serve as Midwest Representative, Chibuzo Opara (Howard Univ College of Medicine) will serve as Northeast Representative, Amanda Eukovich (Nova Southeastern University) will serve as Southern Representative, Nvard Sisliyan (Western Univ of Health Sciences) will serve as Western Representative, and Lindsay Callahan (St. George’s University) will serve as the International Ex-Officio Representative. You can read more about the incoming council members’ backgrounds and interests here: aaemrsa.org/about/leadership/medical-student-council. I cannot wait to see what they accomplish in the upcoming year!

CRITICAL CARE MEDICINE SECTION

Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest Matthew Stampfl, MD,* Benjamin Rezny, DO FAAEM,† Editor: Elias Wan, MD FAAEM

Why ECPR for OHCA?

hat is ECPR?

Extracorporeal cardiopulmonary resuscitation (ECPR) is the use of extracorporeal membrane oxygenation (ECMO) in patients with cardiac arrest. The theory is to bypass the patient’s malfunctioning heart, buying time to address the underlying issue that led to the cardiac arrest and then removing the support once the heart has recovered. Towards that end, ECPR specifically uses venous-arterial (VA) ECMO to replace the forward flow of blood.1 This is in contrast to venous-venous (VV) ECMO, which oxygenates the blood but does not replace the work done by the heart. A recent example of VV ECMO use are the many severely ill COVID patients who ended up on this treatment due to their profound difficulty oxygenating. VA ECMO relies on a venous catheter to withdraw blood, which is oxygenated by the circuit and then pumped back to the body under pressure through the arterial catheter. ECMO cannulation can be achieved centrally via a sternotomy with catheters in the right atrium and ascending aorta or peripherally through various large vessels, most commonly the femoral vein and artery (Figure 1). For ECPR, peripheral cannulation is preferred due to the emergent nature of the procedure. Systemic anticoagulation is typically applied to prevent clotting of blood in the ECPR circuit.2

ECPR is an intriguing modality for improving the dismal outcomes of out-of-hospital cardiac arrest (OHCA) with conventional treatment. Approximately 350,000 cases of OHCA occur annually in the United States and rates of survival with a good neurologic outcome barely reach 8%.3 But when ECPR is used for OHCA, a meta-analysis of more than 3000 patients across 44 studies found 18% survived with good neurologic outcome.4 Taken at face value, this would suggest a number-neededto-treat (NNT) of 10, which is superior to many treatments in emergency medicine, including aspirin for myocardial infraction, which has a NNT of 42.5 In addition, a randomized controlled trial of ECPR versus conventional treatment in refractory shockable arrests found a survival to hospital discharge of 43% vs 7% with most of the ECPR patients having good neurologic outcomes.6 However, these encouraging numbers are likely something of an overstatement, as the study was only a single center study and not all OHCA patients are appropriate ECPR candidates for various reasons, including the need for timely intervention.

What are the challenges of ECPR? Aspirin administration for myocardial infarction is a much simpler intervention than placing cardiac arrest patients on ECMO. In comparison, implementing ECPR is far more challenging. First of all, ECPR is an extremely time-sensitive intervention, with the time from arrest to cannulation and administration of ECPR being repeatedly demonstrated to be a key predictor of survival.7,8 Moreover, providing ECPR requires extensive institutional coordination and capacity in order to emergently place a patient on ECMO and manage these patients in specific intensive care units afterward. Furthermore, ECPR is an expensive, resource-intensive, and complex treatment that many community hospitals or health care systems simply cannot provide, and many patients who do receive this intervention will still not survive.9 ECPR could also be viewed as harmful for patients that survive but have no meaningful recovery, and can unnecessarily prolong the process of dying.10 Finally, providing ECPR in an emergency medicine setting potentially requires transporting OHCA patients who are still pulseless. Transportation of these patients can compromise the quality of resuscitation due to the challenges of transport and has been associated with decreased survival.11

Which patients may benefit from ECPR?

Figure 1: Venous-arterial ECMO circuit diagram (I don’t seem to have this one (there is also a figure 2 below) so I reached out to the authors)

Given the costs and challenges of ECPR, careful patient selection is important.12 Timeliness to ECPR is one of the most important criteria, as prolonged exposure to the low-flow state of chest compressions worsens outcomes. Another key determinant of patients who might benefit is the presence of a reversible cause of the cardiac arrest. As mentioned above, ECPR serves as a bridge therapy, replacing the work of the heart while the body recovers or interventions are performed to reverse the

COMMON SENSE MAY/JUNE 2022

CRITICAL CARE MEDICINE SECTION

initial insult, such as cardiac catherization for myocardial infarction. Thus, ECPR has special promise for cases where recovery is expected with time, such as overdoses of certain cardiac toxins.13 Hypothermic arrests are a unique potential application of ECPR as the cold temperature is neuroprotective and no other means of rewarming is as effective as ECMO.14 Conversely, ECPR is less appropriate for patients with significant comorbidities (severe lung disease, end-stage renal disease, cirrhosis), severely compromised neurologically, or those with contraindications to anticoagulation such as patients with massive hemorrhage. Conditions that may benefit from ECPR

Conditions that contraindicate ECPR

Myocardial infarction

Intracranial hemorrhage/other major bleed

Pulmonary embolism

Severe neuro-cognitive impairment

Cardiac toxin overdose

Advanced chronic obstructive lung disease

Primary arrhythmia

End-stage renal disease

Hypothermia

Cirrhosis / Metastatic malignancy

Figure 2: Interaction of ECPR with various conditions

Conclusion Although ECPR requires significant resources and institutional capacity, it offers promise for improving OHCA outcomes in selected patients. While ECPR has already been implemented in some hospital systems, further technological advancement and a growing evidence base may lead to this treatment expanding its reach.

References * University of Wisconsin † University of Iowa Carver College of Medicine 1. Inoue, A., Hifumi, T., Sakamoto, T., & Kuroda, Y. (2020). Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Adult Patients. Journal of the American Heart Association, 9(7), e015291. https://doi.org/10.1161/JAHA.119.015291 2. Sy, E., Sklar, M. C., Lequier, L., Fan, E., & Kanji, H. D. (2017). Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. Journal of critical care, 39, 87–96. https://doi.org/10.1016/j.jcrc.2017.02.014 3. Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Delling, F. N., Djousse, L., Elkind, M., Ferguson, J. F., Fornage, M., Khan, S. S., Kissela, B. M., Knutson, K. L., Kwan, T. W., Lackland, D. T., Lewis, T. T., … American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee (2020). Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation, 141(9), e139–e596. https://doi. org/10.1161/CIR.0000000000000757 4. Downing, J., Al Falasi, R., Cardona, S., Fairchild, M., Lowie, B., Chan, C., Powell, E., Pourmand, A., & Tran, Q. K. (2022). How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis. The American journal of emergency medicine, 51, 127–138. https://doi.org/10.1016/j. ajem.2021.08.072

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5. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. (1988). Lancet (London, England), 2(8607), 349–360. 6. Yannopoulos, D., Bartos, J., Raveendran, G., Walser, E., Connett, J., Murray, T. A., Collins, G., Zhang, L., Kalra, R., Kosmopoulos, M., John, R., Shaffer, A., Frascone, R. J., Wesley, K., Conterato, M., Biros, M., Tolar, J., & Aufderheide, T. P. (2020). Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet (London, England), 396(10265), 1807–1816. https://doi. org/10.1016/S0140-6736(20)32338-2 7. Reynolds, J. C., Grunau, B. E., Elmer, J., Rittenberger, J. C., Sawyer, K. N., Kurz, M. C., Singer, B., Proudfoot, A., & Callaway, C. W. (2017). Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates. Resuscitation, 117, 24–31. https://doi. org/10.1016/j.resuscitation.2017.05.024 8. Park, J. H., Song, K. J., Shin, S. D., Ro, Y. S., & Hong, K. J. (2019). Time from arrest to extracorporeal cardiopulmonary resuscitation and survival after out-of-hospital cardiac arrest. Emergency medicine Australasia: EMA, 31(6), 1073–1081. https://doi.org/10.1111/1742-6723.13326 9. Bharmal, M. I., Venturini, J. M., Chua, R., Sharp, W. W., Beiser, D. G., Tabit, C. E., Hirai, T., Rosenberg, J. R., Friant, J., Blair, J., Paul, J. D., Nathan, S., & Shah, A. P. (2019). Cost-utility of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest. Resuscitation, 136, 126–130. https://doi.org/10.1016/j. resuscitation.2019.01.027 10. Zotzmann, V., Lang, C. N., Bemtgen, X., Jäckel, M., Fluegler, A., Rilinger, J., Benk, C., Bode, C., Supady, A., Wengenmayer, T., & Staudacher, D. L. (2021). Mode of Death after Extracorporeal Cardiopulmonary Resuscitation. Membranes, 11(4), 270. https://doi.org/10.3390/ membranes11040270 11. Grunau, B., Kime, N., Leroux, B., Rea, T., Van Belle, G., Menegazzi, J. J., Kudenchuk, P. J., Vaillancourt, C., Morrison, L. J., Elmer, J., Zive, D. M., Le, N. M., Austin, M., Richmond, N. J., Herren, H., & Christenson, J. (2020). Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA, 324(11), 1058–1067. https://doi. org/10.1001/jama.2020.14185 12. Karve, S., Lahood, D., Diehl, A., Burrell, A., Tian, D. H., Southwood, T., Forrest, P., & Dennis, M. (2021). The impact of selection criteria and study design on reported survival outcomes in extracorporeal oxygenation cardiopulmonary resuscitation (ECPR): a systematic review and metaanalysis. Scandinavian journal of trauma, resuscitation and emergency medicine, 29(1), 142. https://doi.org/10.1186/s13049-021-00956-5 13. Upchurch, C., Blumenberg, A., Brodie, D., MacLaren, G., Zakhary, B., & Hendrickson, R. G. (2021). Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations. Clinical toxicology (Philadelphia, Pa.), 59(10), 877–887. https://doi.org/10.1080/15 563650.2021.1945082 14. Swol, J., Darocha, T., Paal, P., Brugger, H., Podsiadło, P., Kosiński, S., Puślecki, M., Ligowski, M., & Pasquier, M. (2022). Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review. ASAIO journal (American Society for Artificial Internal Organs: 1992), 68(2), 153–162. https://doi.org/10.1097/MAT.0000000000001518

Fellowships in ED Administration: Suggestions for a Standardized, Domain Based Curriculum

OPERATIONS MANAGEMENT COMMITTEE

Erin Muckey, MD MBA, Akiva Dym, MD, Kraftin Schreyer, MD MBA FAAEM, and Anthony Rosania, MD MHA FAAEM

development. This has led to the independent development of administrative fellowships, thus contributing to the significant variability which exists within the curriculums, structure, and duration of the varying administrative fellowships.

ntroduction

As health systems grow ever larger and more complex, it has become readily apparent that there is a critical need for skilled physician leadership at all levels of hospital and clinical administration. In particular, this assessment has spurred the development and growth of Emergency Medicine (EM) Administrative Fellowships around the country.1 The breadth of health care experience of an EM physician makes them uniquely positioned for leadership roles both within their own departments and the entire health care system. While other fellowships such as Observation Medicine, Toxicology, Telehealth, EMS and Event Medicine, Critical Care, and Sports Medicine have all offered Emergency Medicine the ability to expand the footprint of EM beyond providing “traditional”

LEADERSHIP & CHANGE MANAGEMENT

CLINICAL OPERATIONS

FINANCIAL OPERATIONS

LEGAL & POLICY ISSUES

The Seven Domains

PATIENT SAFETY & QUALITY

PROFESSIONAL & ACADEMIC DEVELOPMENT

While a variety of curricular approaches have been developed by the individual administrative fellowship programs themselves, there has been little done thus far to standardize these approaches. In the subsequent paragraphs, we will attempt to outline a standardized domain-oriented model for health care administration fellowship programs. While this outline of a seven-domain model is far from exhaustive, we hope that this will serve to help foster further discussion and deliberation within the EM community and serve as a starting point for further development of a standardized approach to the administrative fellowship.

DATA & INFORMATICS

emergency medicine care, administrative roles may allow for EM physicians to continue to expand into another important area which had previously been underutilized. Furthermore, as the EM SIT AMET workforce continues to expand, it will become increasingly important for EM physicians to also continue to expand the careers and opportunities which exist outside of the “four walls” of the emergency department (ED).2 There are over 40 current administrative-related fellowships to which residents can apply for formally structured training.3 These fellowships are presented under a variety of titles, such as administration, administration and leadership, administration and patient safety, operations and administration, quality improvement, and so forth. Many, but not all, are included in the Society for Academic Emergency Medicine Fellowship Directory.4 Currently, the Accreditation Council for Graduate Medical Education (ACGME) website outlines suggested program requirements for a “Health Care Administration, Leadership, and Management Fellowship” (HCALM).5 However, no current certifying board exists as of yet, and the program accreditation process remains under

The first step in any curriculum development is to identify the key domains which must be addressed within the educational model, and then determining the knowledge required within each domain. Mapping the required body of knowledge to specific domains is consistent with the work done for other EM fellowship programs and with what others have done for administrative fellowships. By starting at the domain level, one can define the specific body of knowledge required. The necessary crosswalks and mapping of individual topics to the best learning modality can then be performed. The lecture format may not always be the ideal modality for all learning, and some skills and knowledge may be best imparted via other formats such as readings, case studies, and experiential settings. We have placed the seven domains in a pyramid structure: as one moves up the pyramid, the domains begin to become increasingly focused and “hard skill” oriented, with the domains at the bottom of the pyramid forming the foundational skills required for the upper tiers of the pyramid.

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OPERATIONS MANAGEMENT COMMITTEE

Leadership & Change Management Most central to the training of EM physician leaders and thus at the top of our pyramid is the development of a robust leadership skill set. Medical training alone rarely prepares physicians for the challenges of leadership, and thus additional education and training is required. Some of the specific leadership skills required include both the “high-end” skills such as emotional intelligence, management theory, and change management; as well as the “nuts and bolts” skills such as project and meeting management. Strategic thinking, critical to identifying and overcoming threats and challenges, is often very contrary to the “in the weeds” nature of physician work. Physician leaders must also be excellent communicators and learn how best to use different communication tools in appropriate settings. Another critical leadership skill is self-assessment, which can allow one to best understand their own leadership style and communication barriers. Lastly, diversity and equity training is of paramount importance for the modern health care leader. Leadership skills can be learned through advanced degree programs, but education in these areas should additionally include experiential experiences with high level department, hospital, and health system administrators.

Clinical Operations Clinical operations should be at the core of an administrative subspecialty, as operations models and practices impact everything within health care systems. This domain of clinical operations should not be limited to the operations of the ED itself, but rather to all operations within the hospital/health care setting. This is important for two main reasons. First, a whole hospital flow model is consistent with the current mental model of ED throughput—directly linking the ED flow to whole hospital flow, and eliminating “silos” and focusing on a systems approach. Second, administrative fellowships should prepare fellows for the leadership positions both within and beyond the ED, enabling them to pursue careers and leadership positions at all levels within a hospital or health care system. EM leaders should be experts in the key metrics important to health care systems as

well as the strategies and models used to improve clinical operations. This domain also covers an understanding of care models beyond the traditional ED such as telehealth, observation medicine, and EMS.

Patient Safety & Quality While clinical operations may be at the core of an administration education, operations and efficiency must always be balanced with patient safety and quality care. It is critical that all administrative fellows obtain a well-rounded and comprehensive education in best safety and quality practices. Fundamental safety practices, including building a just culture, peer review, RCA management, error identification, and error reporting, are crucial to the work of a health care administrator and exposure to them additionally prepares fellowship candidates for careers in more directly patient safety facing roles. Alongside safety sits quality, which includes an understanding of whole hospital metrics and quality indicators such as STEMI, stroke care, sepsis care, and opioid use reduction. Lastly, the domain includes broad, strategic safety and quality initiatives such as Lean Six Sigma and High Reliability theory. From an educational approach, a multidisciplinary exposure to patient safety and quality, with educational opportunities (practical or didactic) as well as direct hospital committee involvement will be important in helping fellows obtain the necessary exposure required to become successful leaders within the realm of patient safety and quality.

Financial Operations Financial operations is the first of four “foundation” domains that are more skill oriented than the previously described overlying domains. Financial operations skills include focused topics such as coding and billing and revenue cycle management, but should also include an understanding of health care economics such as facility billing, payer modalities, and risk-contracting. The impact of value-based payment models and innovations as well as changes in payment models (APMs, MSSP, etc.) should also be addressed. Additionally, an understanding of basic financial management is important, and while it may be obtained via concomitant Masters in Business or Health Care Administration curriculums, it should also be addressed to some degree within the fellowship curriculum. Lastly, it is essential that fellows have a comprehensive understanding of basic departmental management, such as assessment of staffing needs and of varying physician payment models. For these topics, involving hospital finance and accounting professionals can help provide robust context and a deeper understanding.

Legal & Policy Issues Legal issues abound in EM and across all of health care. A sound understanding of EMTALA, Medicare Conditions of Participation, Local Certificate of Need processes, and other compliance issues that impact health systems is invaluable to the physician administrator. Internally, a basic understanding of Human Resources (HR) compliance is a critical skillset. Lastly, while navigating the complexities associated with medical malpractice is something that all physicians need to be familiar with, the physician administrator needs to also be able to advise others on these topics as well. Administrative leaders need also be facile with policy writing and in the skills needed to enforce policies and procedures. By engaging HR and compliance professionals in a didactic and practical learning environment, it can provide an optimal multidisciplinary educational approach to these topics.

Data & Informatics While Clinical Informatics is a separate boarded specialty, it shares much in common with health care administration, leadership, and management. Central to this domain is a deep understanding

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OPERATIONS MANAGEMENT COMMITTEE

of the impact of the electronic medical record (EHR) on patient safety, physician work and wellness, and clinical operations, as well as how it impacts nursing and other staff. Without a thorough understanding of EHRs and informatics, institutions and leaders can be either slow to adopt innovative technological solutions, or perhaps worse, adopt new innovations too quickly due to an inability to foresee potential pitfalls. Again, multidisciplinary exposure is important, as a basic understanding of health IT processes and procedures can equip a future administrator to better champion the development and implementation of new initiatives In addition to patient facing informatics issues, this domain includes a foundational understanding of data governance, data validation, and the use of visualizations and data analysis to derive knowledge from data.

Professional & Academic Development As discussed, we have a responsibility to graduate fellows who have a broad skill-set applicable beyond the ED so that they may eventually serve as leaders at a hospital or health system level. In addition, they should be prepared to serve in a diversity of settings, including academic and community hospitals. For this reason, they need a skillset that includes an understanding of basic teaching and pedagogical theory, as well as basic research skills. This includes not only the development of a question, but grant writing and basic research methods and analysis as well. At the

same time, we should be preparing them to succeed in a corporate environment. Skills relevant to this include basics such as curriculum vitae development and interviewing, but also areas such as self-assessment, personal development, presentation skills, and an understanding of negotiations. Once again, a multidisciplinary educational approach utilizing existing academic and research programs/resources within a department or institution can allow for the optimal development of these important skillsets.

Conclusion In closing, we feel that to develop Health Care Administration, Leadership and Management fellowships in EM we need to begin to standardize approaches and define the body of knowledge in a method which is consistent. In this article, we have presented the beginnings of a domain-based model for an administrative fellowship. The next steps will include the development of subdomains and distinct content areas to further define the core knowledge of an administrative fellowship. While the ACGME may introduce the potential for program accreditation under a 12- or 24-month format, we strongly believe that this extensive body of knowledge is best suited to a 24-month format. In addition, programs should continue to offer advanced degrees, such as Masters in Business Administration or equivalent (Masters in Health Care Administration, Masters in Public Administration) degrees as part of their curriculum. These degree programs include in their curriculum work that covers many of mentioned domains, and are generally taught by individuals who further emphasize the multidisciplinary nature of the knowledge we are trying to impart.

References 1. Bome, A. Why You Should Do a Fellowship in Administration. Common Sense. 28(4), 31-32. 2. Marco, C., Courtney, D., et al. (2021). The Emergency Medicine Physician Workforce: Projections for 2030. Annals Of Emergency Medicine. 78(6), 726-737. 3. EMRA Fellowship Guide: Administration/ED Operations/ Patient Safety & Quality Improvement. (2022). Retrieved 1 April 2022, from https://www.emra.org/books/fellowship-guide-book/2-adminedopspatient-safety/ 4. Society for Academic Emergency Medicine Fellowship Directory. (2022) Retrieved 1 April 2022 from: https://member.saem.org/SAEMIMIS/SAEM_Directories/Fellowship_Directory/SAEM_Directories/P/ FellowshipMap.aspx?hkey=573c442c-03ee-4c33-934a-5fda0b280835 5. Health Care Administration, Leadership, and Management. (2022). Retrieved 1 April 2022, from https://www.acgme.org/designated-institutional-officials/sponsoring-institution-based-fellowships/ health-care-administration-leadership-and-management/

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Diagnosis of PE in Pregnancy: Applying a Simple Algorithm to Reduce the Need for CT Manuela Noriega, DO and Christopher Perry, MD

he diagnosis of pulmonary embolism (PE) in pregnancy represents one of the most challenging scenarios faced by emergency medicine physicians. Pregnant patients are not only at higher risk for venous thromboembolism (VTE), but also present a number of unique diagnostic challenges for the clinician. The rate of VTE among pregnant or postpartum patients has been estimated at 1.72 per 1000 deliveries,1 with a relative risk of 4.29%.2 Exacerbating the issue is that fears of radiation exposure and iodinated contrast to the mother and fetus often make the clinician, and the patient, hesitant to proceed with necessary imaging studies.

diagnosis was felt to be PE. A d-dimer level was also measured in parallel with this assessment.

Unfortunately, a scarcity of strong data on the subject has led to a lack of consensus recommendations from international societies on how to proceed in the management of pregnant patients presenting to the ER with signs or symptoms suggestive of PE.3-5

Over the course of the study, 510 consecutive pregnant women with clinically suspected pulmonary embolism were screened, of whom 12 were excluded. Of the 498 remaining patients, 252 (51%) met none of the three YEARS criteria, and 246 (49%) met at least one of the criteria. Of those who met at least one of the criteria, 19 (7.7%) had hemoptysis, 47 (19%) had clinical signs of deep-vein thrombosis, and 218 (89%) were considered to have PE as the most likely diagnosis.

In 2019, the Artemis Study Investigators6 adapted the previously validated YEARS criteria7 to pregnant patients with clinically suspected PE. In this multicenter, international study, pregnant patients over the age of 18 were prospectively screened over a ﬁve year period if they were suspected to have a PE, based on having new onset chest pain or dyspnea with or without hemoptysis or tachycardia. Management followed the pregnancy-adapted YEARS criteria (Figure 1). Three criteria were assessed: presence of clinical signs of deep venous thrombosis (DVT), reported hemoptysis, and whether the most likely Figure 1: Pregnancy Adapted YEARS Criteria

If a patient had signs suggestive of DVT, two-point (inguinal and popliteal) compressive ultrasonography of the deep veins of the symptomatic leg was performed. If this conﬁrmed DVT, then the diagnosis of PE was felt to be established and no further diagnostic imaging was performed. Otherwise, the rest of the algorithm was followed. The diagnosis of PE was considered ruled out if a patient met none of the three YEARS criteria and the d-dimer level was less than 1000 ng per milliliter, or if they met one or more of the criteria and the d-dimer level was less than 500 ng per milliliter. If PE was not ruled out, the patient underwent CT pulmonary angiography (CTPA).

In four patients, proximal deep venous thrombosis was diagnosed. Three of these had clinical signs of DVT and the fourth met both the criterion of PE as most likely diagnosis as well as d-dimer >1000. Acute PE was diagnosed in 16 patients on the basis of CTPA or V/Q scanning, 15 of whom met at least one YEARS criteria and had a d-dimer level above the threshold. The one patient diagnosed with PE who met none of the three YEARS criteria had a d-dimer above the pre-speciﬁed threshold. Patients in whom the diagnosis of PE was considered ruled out were then followed over a three month period, during which time none were diagnosed with PE. Even in a worst-case scenario, where all the patients who had been lost to follow-up during this period had developed a PE, the incidence among those not undergoing CTPA would have

been 0.42% (2 of 478 patients; 95% CI, 0.11 to 1.5).6 The results of the study showed that a pregnancy-adapted version of the YEARS algorithm was capable of safely ruling out PE in pregnant women who

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DIAGNOSIS OF PE IN PREGNANCY

presented with signs or symptoms suggestive of this diagnosis. By applying this algorithm, CTPA and its associated costs and radiation exposure could be avoided in 39% of such patients.6 The evaluation for PE in pregnancy remains a high-stakes diagnostic challenge for the emergency medicine clinician. The Artemis study may provide a useful tool for helping rule out this life-threatening condition while avoiding the dangers and cost of CT imaging. Reprinted from “Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism.” van der Pol LM, Tromeur C, Bistervels IM, et al. N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/ NEJMoa1813865. PMID: 30893534. Reprinted with permission.

References 1. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol. 2006 May;194(5):1311-5. doi: 10.1016/ j.ajog.2005.11.008. Epub 2006 Apr 21. 2. Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30- year population-based study. Ann Intern Med. 2005 Nov 15;143(10):697-706. doi: 10.7326/0003-4819-143-10-200511150-00006. 3. Konstantinides SV. 2014 ESC Guidelines on the diagnosis and

AAEM

management of acute pulmonary embolism. Eur Heart J 2014;35:31453146. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315352. British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470-483. van der Pol LM, Tromeur C, Bistervels IM, Ni Ainle F, van Bemmel T, Bertolem L, Couturaud F, van Dooren YPA, Elias A, Faber LM, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Nijkeuter M, Roy PM, Sanchez O, Schmidt J, Ten Wolde M, Klok FA, Huisman MV; Artemis Study Investigators. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865. PMID: 30893534. van der Hulle T, Cheung WY, Kooij S, et al. Simpliﬁed diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet 2017;390:289-97.

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AAEM/RSA RESIDENT JOURNAL REVIEW

Utility of Coronary Angiography in Cardiac Arrest Survivors without ST Elevation Myocardial Infarction Authors: Christianna Sim, MD MPH, Taylor M. Douglas, MD, Wesley Chan, MD, Christopher Kiang, MD Editors: Kelly Maurelus, MD FAAEM and Kami M. Hu, MD FAAEM FACEP

Introduction More than 350,000 out of hospital cardiac arrests (OHCA) occur in the United States annually.1 The prognosis of OHCA remains poor with an up to 70-90% mortality and significant morbidity in terms of chronic organ dysfunction in survivors.1 Pulseless ventricular tachycardia and ventricular fibrillation are the initial rhythm in 25-50% of cases of OHCA with coronary artery disease found in about 60% of these patients.2 While the finding of ST-elevations on a post-resuscitation electrocardiogram necessitates immediate coronary angiography (CAG) for possible primary percutaneous coronary intervention (PCI) as standard of care,3 it is less certain what the role of CAG is following non-ST-elevation (NSTEMI) OHCA. Investigating the utility of CAG in OHCA patients with NSTEMI and identifying which of these individuals would best benefit from early CAG may help improve mortality and morbidity within this population. Question: What is the utility of early coronary angiography after cardiac arrest in adult patients with non-ST-elevation myocardial infarction on electrocardiogram?

Khan MS, Shah SM, Mubashir A, et al. Early coronary angiography in patients resuscitated from out of hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis. Resuscitation. 2017;121:127-134. doi:10.1016/j.resuscitation.2017.10.019 This meta-analysis and systematic review compared the outcomes of neurologic function and mortality in patients undergoing early or delayed (or no) CAG after OHCA. Articles were pooled from a comprehensive literature search using multiple databases between the inception of the selected databases until February 4, 2017. Of the 2,446 articles identified, seven observational studies and one randomized controlled trial were included after standard removal of duplicate articles, reviews, case reports, conference abstracts, non-English studies, studies on non-human test subjects, and studies that lacked or provided incomplete outcome data. In the eight included studies, a combined 940 patients underwent early CAG and 1,193 patients underwent delayed or no CAG. Common baseline characteristics between the early CAG group compared to the late or no CAG group included male sex (81% vs 76%), witnessed cardiac arrest (77% vs 74%), bystander basic life support (59% vs 56%), and initial shockable rhythm (92% vs 81%). The mean age of the patients in the studies was 62 years. Patients were followed for 6-14 months in most of the studies with a mean follow-up period of nine months. In the early CAG group 35% of patients underwent PCI compared to 15% in the delayed/no CAG group.

Good neurological outcome was defined as a Cerebral Performance Categories (CPC) score of 1-2. When compared with late or no CAG, early CAG in NSTEMI patients with OHCA was associated with decreased mortality at hospital discharge (19.6% in the early CAG group vs 35.6% in the delayed/no CAG group) and a trend towards decreased mortality at long-term follow up (23.7% vs 30.0%, OR=0.59, 95%CI; 0.44-0.74, p<0.001). Additionally, more of those undergoing early CAG displayed favorable neurological outcomes at discharge (34.8% vs 27.5% in delayed/no CAG, OR = 2.00, 95% CI: 1.50-2.49; p<0.001) with a trend towards more improvement at long term follow up (23.1% vs 18.4%; OR=1.48, 95% CI: 1.06-1.90; p<0.001). It is important to note some limitations identified by the authors. For one, heterogeneity between the included studies regarding the definition of “early” CAG (on admission vs within 2 hours vs between 6 and 12 hours of hospital admission) may have impacted differences in results among the studies and limited identification of patients who would best benefit from an early CAG approach. Furthermore, seven of the eight included studies were observational studies and the selection biases inherent to this study design may have resulted in favorable outcomes misattributed to the benefits of PCI. Overall, while this analysis supports early CAG as part of a standardized post-resuscitation plan in all NSTEMI patients following OHCA, the study’s findings correspond to a low level of evidence as per GRADE framework due to the large number of observational studies used.

Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without STSegment Elevation. N Engl J Med. 2019;380(15):1397-1407. doi:10.1056/NEJMoa1816897 The Coronary Angiography after Cardiac Arrest (COACT) study was a randomized, multicenter, open-label trial in the Netherlands that aimed to prove that immediate coronary angiography would be superior to delayed angiography with regards to overall survival at 90 days. Patients were included if they experience an out of hospital arrest with initial shockable rhythm but no STEMI, shock physiology, or obvious non-coronary cause of death. Some exclusion criteria included pregnancy, acute ischemic stroke, acute intracranial hemorrhage, known severe renal disease, and poor baseline functional status (CPC 3 or 4). The immediate group received angiography as soon as possible and within two hours of randomization. In the delayed group, the procedure was deferred until after neurologic recovery, unless the patient demonstrated cardiogenic shock, recurrent arrhythmia, or recurrent ischemia during

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AAEM/RSA RESIDENT JOURNAL REVIEW

their hospitalization. While not possible to blind the care team, a blinded group evaluated all the angiography results. The trial was well-powered to detect a 40% difference. Eight pre-specified subgroups were identified, and all data was analyzed as intention-to-treat.

interview at one year. Between a roughly three-year period, 552 patients eligible were enrolled in 19 participating Dutch Centers. 538 patients were available for analysis, with 13 patients who refused consent for the one-year follow up and three patients who were lost to follow up.

The two groups were well-matched in baseline characteristics, 273 in the immediate group and 265 in the delayed group. The majority were male (79%) with a mean age of 65.3 years with about 36% known CAD in each group. An acute thrombotic occlusion was found in 3.1% of patients (eight of 256) in the immediate group and 7.8% of patients (13 of 167) in the delay group. For the primary end point of survival at 90 days, there was no significant difference (64.5% vs. 67.2%, OR 0.89). There was similarly no significant difference in survival to discharge or neurologic outcome, in fact the only secondary outcome with a difference between groups was mean time to target temperature (6.5 vs.5.5 hours, OR 1.19, 95% CI: 1.04-1.36). Other secondary outcomes included thrombolysis in myocardial infarction (TIMI) major bleeding, recurrence of ventricular tachycardia, acute kidney injury, laboratory markers of myocardial ischemia, and markers of shock. Of the 8 pre-specified subgroups, age (<70 vs. >70 years) and history of CAD demonstrated heterogeneity of treatment effect and identified areas of future study to see if these subgroups may benefit from early angiography.

For the one-year analysis, the authors found similar rates of secondary outcomes: myocardial infarction, revascularization, hospitalization for heart failure, or ICD shock since the index hospitalization in the two groups. They hypothesized that the similar rates were likely related to the relatively stable nature of the atherosclerotic disease in this population group. Interestingly, the study also found no significant difference in survival at one year, in comparison to previous observational studies which found survival benefits at one year for patients treated with immediate coronary angiography.

In the discussion the authors identify several possible causes of their results: a low overall rate of unstable coronary lesions and therefore less likelihood of benefit from acute intervention, later attainment of targeted temperature management in the immediate PCI group, and a higher than expected survival rate with more patients dying from neurologic causes than cardiac causes. The incredibly low mortality rate (2.2%) is quite impressive and perhaps other aspects of the patient study characteristics could be examined and identified as areas of future study. Some of the limitations of this study that were not addressed include the potential confounding effect of differing medical therapies, as patients in the immediate group were treated more with gIIb/IIIa inhibitors while the delayed group received salicylates and/or P2Y12 inhibitors. The authors identify the randomization failures (13 in immediate group and three in delayed group), but do not discuss the impact of the 38 patients in the delayed group who required urgent coronary angiography. The effect size of the primary outcome was not close enough to their hypothesis to be changed by this number of patients, but a group this large warrants more consideration. Overall, this study strengthens the evidence against immediate coronary angiography in OHCA without STEMI and provides areas for further research in its subgroup analyses.

Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography After Cardiac Arrest Without ST Segment Elevation: One-Year Outcomes of the COACT Randomized Clinical Trial. JAMA Cardiol. 2020;5(12):13581365. doi:10.1001/jamacardio.2020.3670 The original COACT trial investigators performed a follow-up of study participants at one year to look at more long-term outcomes. Followup data were obtained by a blinded research member via telephone

COMMON SENSE MAY/JUNE 2022

The COACT trial concluded that there was no significant difference in 90-day survival for post-ROSC patients without STEMI who underwent delayed versus immediate coronary angiography. The authors acknowledged several limitations including lack of blinding and potential confounding by treating physician-directed anticoagulant and revascularization strategies. Medical treatment effects on outcomes were not studied, and the study group excluded patients with shock, severe renal dysfunction, or persistent ST segment elevation. While there remains some possibility of selection bias as the majority of the patients in this study did not have unstable coronary lesions as the cause of their cardiac arrest, the study does provide some evidence that not all cardiac arrest requires immediate coronary angiography.

Desch S, Freund A, Akin I, et al. Angiography after Outof-Hospital Cardiac Arrest without ST-Segment Elevation [published online ahead of print, 2021 Aug 29]. N Engl J Med. 2021;10.1056/NEJMoa2101909. doi:10.1056/NEJMoa2101909 The TOMAHAWK trial investigators sought to evaluate the utility of post-ROSC angiography regardless of rhythm, as shockable heart rhythms only account for an estimated 60% of out-of-hospital cardiac arrests. In this multicenter, non-blinded, randomized controlled trial, the authors included patients aged 30 years of age or older with ROSC after OHCA without ST elevation who had either shockable or non-shockable rhythms. Patients were screened at over 30 sites in Germany and Denmark. Of the 558 eligible patients, 554 were randomly assigned to either the immediate coronary angiography group (n=281) or the delayed (more than 24 hours after cardiac arrest) coronary angiography group (n=273). Baseline characteristics of the study groups were similar, although the frequency of coronary revascularization in the delayed-angiography group (43.2%) was slightly higher compared to the immediate-angiography group (37.2%). There was no significant difference between treatment groups in primary outcome of all-cause mortality at 30 days (54.0% in immediate-angiography group, 46.0% in delayed-angiography group, hazard ratio 1.28, 95% CI 1.00-1.63, p = 0.06). The authors claim that the composite of

AAEM/RSA RESIDENT JOURNAL REVIEW

death or severe neurologic deficit (defined as a CPC of 3-5) occurred more frequently in the immediate-angiography group (64.3%) than in the delayed-angiography group (55.6%) with a reported relative risk of 1.16, but while the 95% confidence interval does not cross 1.0 it ranges from 1.00-1.34, no p value was reported. There was no significant difference between the groups in any other secondary efficacy or safety outcomes of myocardial infarction at 30 days, length of stay in ICU, serial values for the Simplified Acute Physiology Score (SAPS) II, rehospitalization for congestive heart failure within 30 days, peak release of myocardial enzymes, moderate to severe bleeding (type 2-5 on Bleeding Academic Research Consortium scale), stroke, or acute kidney failure requiring renal-replacement therapy. Unfortunately, 4% of those randomized were unable to be included in the analysis which led to a slight reduction in the statistical power of the study. While the authors acknowledge their study may have been underpowered, they concluded that their findings support those of the COACT trial that there was no benefit in immediate coronary angiography in post-cardiac arrest patients without ST elevation.

Conclusion Early observational studies suggested a benefit in mortality and neurological outcomes among NSTEMI OHCA patients with ROSC who underwent early CAG.3 The COACT randomized trial and one-year follow up study did not find any evidence of benefit to immediate angiography in non-STEMI post-ROSC OHCA, nor did the TOMAHAWK trial, although underpowering and broader inclusion criteria may have had an effect. As with all studies, variabilities will exist between different study populations, especially across different countries, which may have different models of emergency service systems, rates of bystander CPR, and baseline health characteristics. It would be helpful to conduct future

studies investigating potential population subsets that would benefit from early CAG after OHCA NSTEMI rather than deciding upon the utility of early CAG as part of a standardized post-resuscitation plan in all NSTEMI patients following OHCA. Question: What is the utility of coronary angiography after cardiac arrest without ST-elevation in adult patients? Answer: The current evidence does not support a one-size-fits-all early angiography requirement for all-comer cardiac arrest survivors without STEMI, although a subpopulation of patients without ST elevation are still found to have culprit lesions when they do undergo catheterization and these patients may have better outcomes with early intervention.7 It is important to consider each individual’s presentation, cardiovascular risk factors, and the overall clinical suspicion for coronary ischemia as the cause of the cardiac arrest.

References 1. Cardiac Arrest Infographic - An Important Public Health Issue. https:// www.cdc.gov/dhdsp/docs/cardiac-arrest-infographic.pdf. Accessed December 13, 2021. 2. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131:e29-322. 3. Yannopoulos D, Bartos JA, Aufderheide TP, et al; American Heart Association Emergency Cardiovascular Care Committee. The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2019;139(12):e530-e552. doi: 10.1161/CIR.0000000000000630. PMID: 30760026. 4. Dumas F, Bougouin W, Geri G, et al. Emergency percutaneous coronary intervention in post-cardiac arrest patients without ST-segment elevation pattern: insights from the PROCAT II Registry. JACC Cardiovasc Interv. 2016;9:1011-8.

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April Board of Directors Meeting Summary

April Board of Directors Meeting Summary The members of the AAEM Board of Directors met in-person at the 2022 Scientific Assembly at the Baltimore Hilton Inner Harbor on April 23, 2022 and April 27, 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:

2022-2023 Elected Board of Directors

Presentations

Approvals

Miscellaneous

On April 23 , 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:

The Board will hold a strategic planning session in Washington, DC on June 21st, followed by hill visits on June 22nd. The following task forces were also created: LEAD-EM Task Force, Lobbyist Task Force, Board Election Task Force, and Leadership Development Task Force.

On April 23rd, 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. On April 27th, President Jonathan S. Jones, MD FAAEM welcomed the 2022-2023 board members. He provided an overview of his goals for his time as President, which included empowering members, fighting to end corporate practice of medicine, and ensuring due process for all emergency physicians.

• An updated AAEM Mission Statement (located on page 2 of this issue) • Renewal of Quorum Software for advocacy efforts • Clinical Practice Committee Statement: ECMO in ED for Out of Hospital Cardiac Arrest • Clinical Practice Committee and Wellness Joint Statement: Interruptions in the Emergency Department • $500 annual budget for each committee to be utilized at their discretion on projects and/ or initiatives that help further the mission of the Academy

The Next Board of Directors Meeting When September 21, 2022

Where On-site at MEMC22 | St. Julian’s, Malta

COMMON SENSE MAY/JUNE 2022

AAEM Job Bank Service

Promote Your Open Position

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

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

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

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

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

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

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

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

CALIFORNIA

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

CALIFORNIA

The Department of Emergency Medicine at Stanford University is seeking a Board-Certified Emergency Medicine physician to join the Department in the role of Medical Director of the Adult Emergency Department. The position includes a full-time faculty appointment in the Clinician Educator Line. Rank will be determined by the qualifications and experience of the successful candidates. Applicants who meet criteria for the rank of Associate Professor or Professor are preferred. Stanford Emergency Medicine has a strong focus on precision emergency medicine - the use of information and technology to improve the care of individual patients and their communities. Key areas of focus include optimizing Access to Care, capitalizing on Technology and Digital Health Tools, Leveraging Human-Centered Data to Individualize Treatment Decisions, Advancing Population and Global Health, and Redesigning Medical Education. Of particular interest are Adult Medical Director candidates who have experience in health innovation and information technology to advance and optimize the delivery of emergency care. Clinical responsibilities will include patient care in the emergency department at Stanford Hospital, a world-renowned, academic medical center with approximately 90,000 adult Emergency Department visits annually. Our faculty

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

CALIFORNIA

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

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

CALIFORNIA

The Department of Emergency Medicine at Stanford University seeks board-certified academic faculty in Emergency Medicine

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

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

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

CALIFORNIA

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

OREGON

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

COMMON SENSE MAY/JUNE 2022

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

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May/June 2022 Common Sense

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AAEM/RSA President’s Message: Cabinet of Delegates

Standing the Post