January/February 2024 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 31, ISSUE 1 JANUARY/FEBRUARY 2024

To AAEM’s ORAL BOARD EXAMINERS:

THANK YOU

President’s Message

Respect

Editor’s Message

Stories

Young Physicians Section

Giving Feedback as a Young Physician Can Be Tough—Here’s How to Do it Right

AAEM/RSA President's Message

Join Us at HPEM!

AAEM/RSA Editor's Message:

Washing Wounds

Table of Contents

COMMONSENSE

Officers President Jonathan S. Jones, MD FAAEM President-Elect Robert Frolichstein, MD FAAEM Secretary-Treasurer L.E. Gomez, MD MBA FAAEM Immediate Past President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Past Presidents Council Representative Tom Scaletta, MD MAAEM FAAEM Board of Directors Heidi Best, MD FAAEM Laura J. Bontempo, MD MEd FAAEM 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 Kraftin Schreyer, MD MBA FAAEM YPS Director Fred E. Kency, Jr., MD FAAEM

Letter to the Editor: A Message from the Editor............................................................................6 Women in Emergency Medicine Executive Council: First, Do No Harm....................................7 Letter to the Editor: Dobbs Decision Rebuttal...............................................................................8 Letter to the Editor........................................................................................................................9 Foundation Contributions...........................................................................................................11 PAC Contributions.......................................................................................................................12 LEAD-EM Contributions..............................................................................................................12 Oral Board Review Course: To AAEM’s Oral Board Examiners: THANK YOU!..........................13 AAEM Physician Group: Snake in the Grass: Kansas Emergency Physicians Stands Up Against TeamHealth’s Illegal Actionst......................................................................................22 Wellness Committee: #StopTheStigmaEM: A Movement for Transforming Perceptions on Physicians’ Mental Health........................................................................................................25 Young Physicians Section: Giving Feedback as a Young Physician Can Be Tough— Here’s How to Do it Right........................................................................................................26 AAEM/RSA President’s Message: Join Us At HPEM!.................................................................27 AAEM/RSA Editor’s Message: Washing Wounds.......................................................................28 The Joint Commission: Addressing Some Misconceptions........................................................29 Learning Auricular Hematoma Management Through a Personal “N of 1”...........................32 AAEM/RSA Resident Journal Review: Updates in Cardiac Arrest Management.......................34 AAEM Job Bank...........................................................................................................................39 Upcoming Events........................................................................................................................41

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 Edwin Leap II, MD FAAEM Executive Director Missy Zagroba, CAE Executive Director Emeritus Kay Whalen, MBA CAE Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Mel Ebeling, MS3, 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 2023

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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-0124-385

VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE

VOLUME 31, ISSUE 1

JANUARY/FEBRUARY 2024

COMMONSENSE Featured Articles

President’s Message: Respect

Is there any respect left in this world? Dr. Jones is not sure if there is. Yes, we should try to see things from another’s point-of-view but as physicians, we also need to stand our ground and be firm. We don’t just owe that to ourselves, but we owe it to every patient, nurse, or staff member. And remember, appeasement doesn’t work. Just ask Chamberlin or Churchill.

The Whole Physician: Amygdala Hijack: Why We Sometimes Lose Our Cool and How to Get it Back

Have you ever gotten so mad or scared that you reacted utterly contrary to your typical “mild-mannered doctor” personality and turned into “The Incredible Hulk?” Yes, we all have. Do you remember what causes this from your neuroscience days? Also yes, the amygdala. Is there a way to prevent being hijacked by your amygdala? Yes, but it’s a skill that takes time to develop and the Whole Physician doctors have some tips to help.

Wellness Committee: Serendipity in the Shadows of the Himalayas: My Unexpected Journey to Mindfulness during Sabbatical

Financial Wellness: Aging Parents

In this article, Dr. Alvarez reflects on the time he spent in Dharamshala, India, during his sabbatical. Not only does he share his reflections, he also recounts his experience meeting His Holiness, the Dalai Lama.

Editor’s Message: Stories

It’s a big deal, putting your words out there for everyone to see. It requires risk. It requires ownership. It is hard. But even with all the risk, there are pretty good odds that your story will be well received by at least one person. And when we write our stories, no matter the content, our writing can help others, and ourselves as well. So go ahead, Dr. Leap implores in his Editor’s Message, write your stories down and send them to us at Common Sense.

their emotions as they languished in foster care? Dr. Philip and his spouse did and while he admits, it has not been an easy journey, it was worth it.

Whether you have aging parents or are an aging parent yourself, financial concepts for those greater than 65 years of age are not much different than the rest of us. In this article, Dr. McNeil’s intention is to get you thinking about the broader topics to focus on when discussing finances with aging parents.

Do All Those Kids Belong to You?

What if we, as emergency physicians, could do more for neglected and abused kids rather than just recognizing the telltale signs of abuse or figuring out which psychiatric facility can handle a child who couldn’t control

Communicating with the C-Suite

Communication is critical. And communicating with hospital and health system leadership which is often crucial to promoting departmental initiavtives is challenging. In this article, Dr. Schreyer shares some tips on how to communicate with non-clinical C-suite leadership to find success.

COMMON SENSE JANUARY/FEBRUARY 2024

Respect

AAEM PRESIDENT’S MESSAGE

Jonathan S. Jones, MD FAAEM

ometimes I wonder if there is any respect left in this world. I’m not sure if I feel more like Aretha Franklin or Rodney Dangerfield but I do know that this whole world needs a lot more respect. And while I will get to respect in relation to physicians, respect is not simply limited to what one has earned by having a certain degree or experience. What about simple respect for a fellow human being? Yes, as physicians, we deserve respect and don’t think we need to feel ashamed or egotistical to want at least a little. And as physicians we lead by example and must show respect to everyone we encounter, patients, staff, and those outside of the hospital. I first started thinking about this issue a few days after Christmas (when I thought people may still be in a good mood, or at least maybe realize why Christmas is even celebrated), while I was out for a run. I don’t have a lot of hobbies, but running is one of them. I enjoy it, it clears my mind, it helps me sleep, and it’s good for you. Oh, and it actually improves knee osteoarthritis.1 I decided to do about ten miles because I had the time and it was a nice day. For longer runs, I drive to an area that has a long, dedicated walking/cycling trail, but for runs of this length or so, I typically just leave from my house and run around nearby neighborhoods, which is what I did this day. About seven miles into my run, a car drove way too close and ran me off the road. I was unhurt but waved my arms and yelled at them to slow down. The couple in the car stopped, backed up, yelled expletives, drove away, turned around, slowed when they were next to me, yelled more expletives and then threatened to cause physical harm. Wow! I know sometimes we are too centered on our own self and view everything from our own perspective so I tried to think what I had done

COMMON SENSE JANUARY/FEBRUARY 2024

Will we “behave

as Neville Chamberlin or Winston Churchill?

wrong. This was a purely residential street without sidewalks and I was as far over in the lane as I could get. I don’t think it is too self-centered to expect a car to move over and slow down a bit. Even disregarding the threat of physical violence, as I made my way home, I thought about the lack of respect shown for another human being, one who was apparently doing something foreign and annoying to this driver. I know most people don’t run so I tried to think what I had done wrong or to view the situation from their perspective. Well, I couldn’t really find how they were right in this situation. But I then started to think of situations where I may act one way which seems perfectly logical and even respectful but from another’s perspective, it may seem the opposite. While I’ve never stopped my car to curse at a pedestrian,

“

I know that I’ve been disrespectful at times. And I’m sure I’ve been disrespectful at times which I cannot even recall. Which made me think whether at times I may disrespect patients, nurses, staff, or others at work. (Yes, I thought about all my non-work interactions as well, but for this column, I’ll focus on work.) I specifically thought about one recent patient interaction. I had a very nice 50ish-year-old man with a complaint of left leg pain. He had the standard past medical history of diabetes and hypertension, was a bit overweight, but overall was fairly healthy. After my standard introduction and H&P, I determined that he had sciatica. It was a textbook example. I explained sciatica to him, explained that imaging and other tests were not needed, and explained the

If I could disrespect this patient who really was very nice, friendly, and polite, how often do I disrespect those patients who aren’t exactly on their best behavior?

AAEM PRESIDENT’S MESSAGE

treatment and expected prognosis as well as plans for follow-up and return precautions. He smiled, thanked me, and I left to complete his discharge and to see another patient. It seemed like an ideal encounter. He had pain, he felt better, he had a clear medical diagnosis (not like chest pain, abdominal pain, or back pain which we so often diagnose), and a good treatment plan. So, it came with great surprise when the nurse notified me that the patient left very unhappy. Unfortunately, the patient had already physically left the hospital by the time I found out, so I could not go back to him. The nurse mentioned that the patient was unhappy because we did not check him for a DVT. What had happened? How could I leave the patient encounter feeling like it was near perfect and he left disappointed and unhappy? Had I been too busy to fully explain my thought process or the diagnosis and plan? Did I fail to use non-medical terms? Did I fail to ask him if he had any other questions or concerns? Honestly, I don’t know. It was a busy shift and I usually do all the above, but maybe I got sidetracked or distracted. Did I disrespect him without even trying? It sure seems that I did. Wow! I thought. If I could disrespect this patient who really was very nice, friendly, and polite, how often do I disrespect those patients who aren’t exactly on their best behavior? But being respectful does not require being subservient or to allow abuse, physical or verbal. It does not take long practicing emergency medicine to experience abuse. I know that we all have. Luckily, the abuse is much more often verbal than physical. But what a sad situation that I must be thankful that typically we are only verbally abused.

Yes, if a patient is critically ill, delirious, or otherwise altered and is cursing or even swinging at us, we have an ethical responsibility to remain as calm as possible and be as gentle as possible with the patient while also ensuring the safety of others. We must treat this patient regardless of what the patient does. But how often are patients simply rude, disrespectful, offensive, racist, sexist, and even violent for the simple reason that they feel empowered by being a patient? More often than never which is too often. When we allow this behavior to continue, we encourage it. Will we behave as Neville Chamberlin or Winston Churchill? When we appease disrespectful patients, we end up neglecting and disrespecting our other patients, not to mention our nurses and staff. While I would like to think that emergency medicine is overall a non-zero-sum game, at many times the actual clinical practice of emergency medicine is zero-sum. The time and resources we give to one patient are time and resources that we don’t give to another patient. I considered this during a recent frustrating encounter. I had a routine encounter with a young patient who ended up having cholecystitis. I discussed my concern prior to the ultrasound

results and upon returning to her room to discuss the results and the planned admission and likely surgery, she had a few questions. Everything started fine, but she began asking very detailed questions about the surgery, such as exactly where the incision would be, detailed questions about risks and benefits, recovery time, etc. I had already informed her that I was not a surgeon and that the surgeon would be by and could explain these much better. I provided the best answers which I felt I could. Somehow, she became very upset and began ridiculing me and my lack of knowledge. She asked if I was actually a doctor. She asked for my credentials and to see my supervisor. My initial instinct was to acquiesce, but I decided against it. She was not simply inquiring about her diagnosis or treatment plan, she was insulting, raising her voice, and belittling. I calmly informed her that I would ensure that the surgeon answered all her questions, but that I was leaving her room to care for other patients and I did not plan to return except for an emergency. She insulted me using a curse while I closed the door. I don’t know if I handled the situation perfectly and am sure that I did not. However, I do know that I felt relief when I entered my next patient’s >>

Appeasement “doesn’t work.

While we must respect our patients, I believe it is equally our duty to demand respect in return. And to demand respect for oneself, but also for all staff in the ED. After all, we know that nurses bear the brunt of the disrespect. And I believe we try to support them, but do we always? Patient disrespect raises difficult ethical concerns, but not always.

COMMON SENSE JANUARY/FEBRUARY 2024

AAEM PRESIDENT’S MESSAGE

room to have a civil encounter. This patient likewise had many questions about her diagnosis, but it was a pleasure to answer them, reassure her, comfort her. It felt good to treat her with respect. It reaffirmed my decision to leave the other patient and spend my time and resources with others who needed them. What have these recent encounters helped me decide? I decided that we must try to see things from another’s point-of-view. I decided that we also need to stand our ground (maybe less so when a car is barreling down the road towards you), but otherwise we need to be firm. Appeasement doesn’t work. I decided that some people just suck the life out of you and sow discord wherever they go. While, given our chosen profession, we cannot avoid these people, we can minimize our time with them. We owe it to everyone else, every other patient, every nurse, every staff member. I also decided that it’s quite enjoyable to give respect to others, especially the vulnerable and those who may not be used to receiving it. Respect. Earn it and give it. Everyone deserves it, not least of all, you. References 1. Lo GH, Musa SM, Driban JB, Kriska AM, McAlindon TE, Souza RB, Petersen NJ, Storti KL, Eaton CB, Hochberg MC, Jackson RD, Kwoh CK, Nevitt MC, SuarezAlmazor ME. Running does not increase symptoms or structural progression in people with knee osteoarthritis: data from the osteoarthritis initiative. Clin Rheumatol. 2018 Sep;37(9):2497-2504. doi: 10.1007/s10067-018-4121-3. Epub 2018 May 4. PMID: 29728929; PMCID: PMC6095814.

COMMON SENSE JANUARY/FEBRUARY 2024

EDITOR’S MESSAGE

Stories Edwin Leap II, MD FAAEM

e are surrounded by stories. I have realized this since my childhood. From the time I learned to love books I have been entranced by them. As a child raised in Appalachia, I would lie on the floor in grandma’s house and listen to family tell tales from the lives of our ancestors, or relay funny events from the childhood of my uncles and father. They would share stories of their travels at sea or in war. I could never get enough. Fortunately, my job as an emergency physician only immersed me in more of the same. All day long I hear stories, and become part of stories, as patients share their symptoms, struggles, or life-crises. These stories may be tragic or ridiculous, but they’re worth hearing, if only so that they survive in someone else’s memory. Each of us is an archive while we live. In addition, the stories of co-workers have become part of the library I carry around in my memory. I have spent a career accumulating so many wonderful episodes; successes and failures, comedy and tragedy from people I loved and respected—and a few I seriously disliked.

When we read what others write, we discover new ways to overcome our own challenges as well. Our writing helps others. Sometimes it simply reminds them that they are not alone, sometimes it makes them say “well, I never thought about it that way.” Occasionally, it leads them to remove us from their Christmas card list. But that’s just the price of writing; the price of honesty. As physicians we have unparalleled access into the human condition. In fact, one of my favorite quotes comes from physician/poet Willam Carlos Williams, a primary care physician and pediatrician who cared for patients in Rutherfored, NJ, in the early 20th century.

If you are afraid, you aren’t “ alone. It’s a big deal, putting your

words out there for everyone to see. It requires risk and ownership.

Learning to go from being a writer to being an editor has been a challenge. But it has been a pleasant one. Because what I have had occasion to do, over and over, is say to a student, resident, or practicing physician, “send me your writing! I’d love to publish it!” Which means, I get to encourage these people to tell me more stories. It’s a little selfish, given my love of story. It makes me happy to learn what other people know, to see what they have experienced. But more than that, it lets me encourage others to embrace not only the stories of their lives but take the plunge and relay them to others. This is good for all of us. When we write our stories, whether about patient care, professional interactions, family life, or political/cultural viewpoints, the very act of writing accomplishes some important things. Writing is a way of thinking, so it helps us organize our own often chaotic thoughts. Writing is cathartic. It helps us to make real the things that trouble us; to drain our anxieties or struggles from the confines of our mind and make them visible before our eyes, on paper or screen. This can serve to help us find solutions, or sometimes make us see that they are less dramatic than we believed.

He said, “My ‘medicine’ was the thing that gained me entrance to these secret gardens of the self. It lay there, another world, in the self. I was permitted by my medical badge to follow the poor, defeated body into these gulfs and grottos.” (And I think, now, this means the gulfs and grottos of our colleagues’ lives as well.) What a beautiful thought! That despite the trials and hassles of modern medicine, we are granted this gift. Human experience being vast as it is, each one of us can see and share an insight or story with another. Sometimes only in conversation, but if desired, in the written word which may be shared over and over down the years. Many physicians, being perfectionists, raised academically in a world of mandatory certification, hesitate to write. They do not feel that they are qualified unless they have taken a class or obtained a writing degree. But >>

COMMON SENSE JANUARY/FEBRUARY 2024

EDITOR’S MESSAGE

“Each of us is an archive while we live. this is untrue. While an ability to write clearly is important, it can be developed with practice. I submit that what matters more is desire, dedication, the material to inspire, and a goal to achieve, however small or large. So, if you have a story to tell, even if it’s a fictional story that makes a point we need to hear, please consider writing and send it to me. If you are uncertain, we can discuss it. If you are afraid, you aren’t alone. It’s a big deal, putting your words out there for everyone to see. It requires risk and ownership. This is especially hard in times as contentious as these, since not everyone will (or should) agree with everyone else and some people are very unkind when confronted with things they do not understand or support.

Fortunately, our specialty is one of many backgrounds and interests. There are pretty good odds that what you write will be well received at least by someone. And this helps us to grow as a specialty as we understand how wide a group we are, and yet how united in fundamentals like the care of the sick and dying, and the stresses we endure in the process. So let me close with a simple homework project. Think of a story about someone you worked with and admired, or who made you better, made you happier. Write it down and send it to Common Sense. It can be as short as you like and can include their name or not. But give that person the gift of sharing how wonderful they were to you. Start there. It may open creative doors unimagined.

A Message from the Editor

LETTER TO THE EDITOR

he recent column on the Dobbs decision by Dr. Wilbur caused quite a lively response. So, as an editor, all I can say is “wonderful!” Controversy is good for a publication. It engages readers, it causes them to evaluate and sometimes reevaluate their positions. I want to welcome various opinions to the pages of this publication. We are a very diverse specialty, so opinions will frequently conflict, but we are professionals who can handle disagreement. I will add two points here. One of the respondents asked to be anonymous. I was happy to accept that letter. It is worrisome that people believe that their opinions might expose them to physical danger. There are also those who speak to me at meetings, in hushed tones, with opinions in line with Dr. Wilbur. They are afraid to speak because of potential danger to their jobs and livelihoods. We should all hope for a society where our opinions do not pose a threat, either physically or professionally. Having said that, I hope you find the responses meaningful. Further dialogue on this issue (and so many others) is welcome. Edwin Leap, MD Editor, Common Sense

COMMON SENSE JANUARY/FEBRUARY 2024

To read the original “Dobbs Decision” article, please scan the QR code or visit aaem.org/publications/common-sense

WOMEN IN EMERGENCY MEDICINE EXECUTIVE COUNCIL

First, Do No Harm

irst, Do No Harm

The opinion piece by Dr. Jeremy Wilber in the September/October edition of Common Sense has the potential to cause harm, due to non-secular and misleading information regarding abortion. Background

Dobbs decision and have increasingly limited access to abortion care, emergency care, and reproductive services in general.11 This includes not only abortion care, but access to high quality birth control and board-certified OB-GYNs. The Hyde Amendment restricts women who receive federally funded healthcare (e.g. Medicare, Medicaid, federal/military plans) from being covered for abortion care, and most U.S. states do not provide additional funding for abortions. Pre- and post-natal care, which has a higher risk of death and disability than abortion, is covered federally.

Pregnancy is not a benign state. As of 2019, the United States has the highest maternal mortality rate of developed countries, which has steadily increased from 7.2 deaths per 100,000 births, to 17.6 deaths per 100,000 births, since the CDC started collecting data in 1987.1 Comparatively, the risk of death from a legal abortion is markedly less than childbirth (0.6 deaths per 100,000 abortions).2 The mortality Upon graduation from medical school, we all took an rate from unsafe abortion procedures is as high oath to treat all patients equally, and to never use our as 13%.3 Surveillance data from the U.S. showed medical knowledge to infringe on the rights of others. that, pre-Dobbs, elective abortions decreased by 11% over the previous ~10 years, and first trimester abortions accounted for >93% of all abortions.

“

While later-trimester abortions do have a higher complication rate, abortions after 20 weeks account for less than 1% of all abortions.4 These numbers do not take into account the known complications from spontaneous abortions, ectopic pregnancies, and other non-viable pregnancies. Contrary to the claims in Dr. Wilber’s opinion, abortion access has been shown to improve the mental health and well-being of women, both short and long-term, via multiple studies. Conversely, being denied abortion access detracts from mental health.5 The article cited by Dr. Wilbur regarding mental health and abortion prominently features the work of Dr. Priscilla Coleman, whose criticisms of the UCSF Turnaway study were retracted due to competing interests and lack of objectivity.6 Despite being used in the Dobbs v. Jackson decision, Dr. Coleman’s work has faced a significant amount of scrutiny for improper conclusions relating to abortion and mental health outcomes.7 As emergency physicians, we are the gatekeepers of pregnancy-related complications. Pregnancy-related ED visits comprise a significant percentage of all ED visits,8 with approximately one in three women visiting an ED during their pregnancy.9,10 Our patients that are already marginalized (including, but not limited to, people of color, low socio-economic status, immigrants, and people with disabilities) are more likely to feel the impact of the

Discussion

It is still too soon to numerically describe the burden that the Dobbs v. Jackson ruling has had on emergency departments and the incidence of post-abortion complications. We anticipate seeing increased complications of abortions (spontaneous, elective, or unsafe), ectopic pregnancies, and unwanted/high risk pregnancies, as well as the potential for legal consequences for providing evidence-based treatments well within the standards of care.12 It will be years before the objective evidence shows what we know subjectively: the Dobbs decision takes away bodily autonomy, human rights, and self-determination. Limiting access to abortion is not a moral issue, nor a religious one, but one that fundamentally affects the physical and mental well-being of women, and complicates our role as physicians providing safe, just, and equitable care. While we support the rights of others, including the rights to free speech, free press, and freedom of religion, we also support evidence-based medicine, bodily autonomy, patient safety, and reproductive freedom. Physicians must be able to use their judgment to provide appropriate medical care, free from fear of prosecution Countinued on page 10 >>

COMMON SENSE JANUARY/FEBRUARY 2024

LETTER TO THE EDITOR

Dobbs Decision Rebuttal Matthew Turner

pinion piece on the Dobbs decision in the September/ October 2023 issue of Common Sense, Dr. Jeremy Wilber refers to abortion using Medicare funding as an “atheistic form of health care” and celebrates the “small loss for abortion providers like Planned Parenthood” that the Supreme Court’s June 2022 decision inflicted. Ultimately, he asserts, this is a victory for the continued freedom of Americans. I respectfully disagree. In less than 18 months, the anti-choice policies that the Supreme Court has willfully allowed to run rampart across the United States have inflicted grievous harm on both the freedoms and health of the American people. Freedom

The American people do not support Roe v. Wade being overturned. A June 2023 poll showed that 61% of voters disagree with the Supreme Court’s decision.1 Seven consecutive states have directly voted in favor of abortion rights, in Kansas, Michigan, California, Vermont, Kentucky, Montana, and Ohio, in both left and right-leaning states.2

withholding reproductive health information.3 The fact is that legalized abortion is a boon to American’s health. The 15 states that have banned abortion have only banned legal abortion. Those with the time and resources will be able to have abortions out-of-state. Or worse, dangerous back-alley abortions that pose a threat to the health of the mother. As always, the poorest in society will suffer the most. Approximately 50% of all those who seek abortions live below the poverty line.4 The United States has long experienced one of the highest infant and maternal mortality rates in the developed world.5 Even before Dobbs, maternal mortality spiked in 2021, with 1,205 women in the U.S. dying of pregnancy-related causes. Since then, it has only worsened.6 Six of the states—Arkansas, Kentucky, Alabama, Tennessee, Louisiana, and Mississippi—with the highest maternal mortality in the country had automatic anti-choice “trigger” laws in place when Roe v. Wade was overturned. Access to abortion is a matter of public health. Anti-choice states on average have maternal death rates twice as high as pro-choice states.7

I agree with Dr. Wilber’s assertion that the decision to have an abortion should not rest with the federal government. It should not rest with the states either—it should be as granular as possible, resting solely with the individual involved. That is true freedom.

Anecdotes

Health

Allow me to present an alternative anecdote. In August 2023, a 13-year-old girl in Mississippi was forced to give birth after being raped by a stranger. Her mother was unable to afford the 9-hour drive to the nearest abortion provider in Chicago.4

Dr. Wilber cites the Foundations of Life organization to assert the health risks of abortion. This is an anti-choice organization and can hardly be considered an unbiased source of information. Indeed, there is controversy that Foundations of Life specifically is a “sham health clinic…known to mislead, judge and shame women to prevent them from obtaining abortions” often by

Dr. Wilber provides two anecdotes to support his anti-choice position. In one, he mentions a 20-year-old woman presenting for her tenth abortion, and portrays this “travesty” as a moral failing.

Countinued on page 10 >>

“I agree with Dr. Wilber’s assertion that

the decision to have an abortion should not rest with the federal government. It should not rest with the states either—it should [rest] solely with the individual involved.

COMMON SENSE JANUARY/FEBRUARY 2024

LETTER TO THE EDITOR

o the editors of Common Sense magazine.

The EM community is diverse just like our country and the patients we serve every day. It would make great sense that polarizing issues like abortion should be represented diversely. Before I fall into a coma due to the rage stroke I have suffered after reading Dr. Wilbur’s opinion articles on the Dobbs decision, I would like to discuss the publication of one man’s opinion on an essential part of women’s healthcare.

due to her trisomy 18 fetus, should completely eviscerate the argument that if a woman’s health is in danger, she will be able to get an abortion. What about Cox’s life? Does her life not matter to her or her family or her two existing children? Pro-life, I ask? Abortion is women’s healthcare, and women need to have full control of their health. Full stop.

Abortion “ is women’s

Perhaps I misunderstood the purpose of the Common Sense publication. I’ve always thought of it as an informative magazine for EM physicians, publishing well researched and written pieces about finances, advocacy, and just emergency medicine tidbits. Abortion could be considered advocacy, but not if you’re going to let a man write such garbage as “abortion care is essentially child sacrifice to the god of convenience.” The inflammatory nature of that statement does not belong in an EM focused publication. At least a warning label should be attached to the article for those of us that like our bodily autonomy. Or perhaps Wilbur and the editors think it is appropriate to mislead their readers. Abortion is not as divisive of an issue as people think. A Pew Research poll conducted in March 2022 right after the Dobbs ruling showed 71% of Americans believe abortion should be legal. That number has only gone up since then, and if the November elections across many states have shown Dr. Wilbur anything, it is that he is in the minority.

healthcare, and women need to have full control of their health. Full stop.

Dr. Wilbur’s article cited Forbes.com and Student For Life of America, sources that lean very much to the right. Why are these considered medically appropriate references for this topic? Where is the ACOG reference? Why did he neglect to mention the worsening maternal fetal health situation in all the states that have banned abortions?1 Where is his advocacy for improving SNAP benefits, Head Start funding, and Medicaid coverage for pregnant women and poor children if he is pro-life as his article implies? He wrote about two patient encounters that support his views. That would be akin to describing my hometown of Minneapolis as some kind of perpetual dystopian hellscape being overrun by gangs and looting because of what the TV showed after the George Floyd case. Should we even look at exhibit A of the hypocrisy of these medical exceptions that the right-wing politicians have touted as an olive branch to women? The grotesque cruelty inflicted upon Kate Cox, who had to flee her home state of Texas just to obtain an abortion

But let’s circle back to the argument Dr. Wilbur was making about him not wanting his hard-earned money to pay for poor women’s abortions, like those on Medicaid. There are plenty of things I do not want my hard-earned dollars to go towards, things I find offensive and not aligned with my moral values. Adultery is against my moral values. Should we have pharmacists check with married men’s spouses to make sure that Viagra prescriptions are to be used with their actual spouses? Should we stop funding treatments for hepatitis C if the patient became infected due to IV drug use or sex work because I am against drug use and promiscuity personally? I can go on. What is really offensive to me is that Dr. Wilbur is basically suggesting we intentionally further worsen health inequities within our system by dividing women into two tiers, those who can and those who can’t afford certain essential services. If there is to be future opinions articles on similar topics, I would strongly recommend a simultaneous publishing of counter opinions so there is balanced representation for your readers. Don’t forget your readers don’t all look or think like Dr. Wilbur. Sincerely and angry as hell, A woman and an EM physician References 1. https://www.npr.org/2022/08/18/1111344810/abortion-ban-statessocial-safety-net-health-outcomes COMMON SENSE JANUARY/FEBRUARY 2024

WOMEN IN EMERGENCY MEDICINE EXECUTIVE COUNCIL

Countinued from page 7

or the opinions of others. Upon graduation from medical school, we all took an oath to treat all patients equally, and to never use our medical knowledge to infringe on the rights of others. To provide unsubstantiated

perspective in lieu of evidence-based care undermines the physician, the physician-patient relationship, and our specialty in the house of medicine.

References

8. Goodwin, G., Marra, E., Ramdin, C., Alexander, A. B., Ye, P. P., Nelson, L. S., & Mazer-Amirshahi, M. (2023). A national analysis of ED presentations for early pregnancy and complications: Implications for post-Roe America. The American journal of emergency medicine, 70, 90–95. https://doi.org/10.1016/j.ajem.2023.05.011 9. Kilfoyle, K. A., Vrees, R., Raker, C. A., & Matteson, K. A. (2017). Nonurgent and urgent emergency department use during pregnancy: an observational study. American journal of obstetrics and gynecology, 216(2), 181.e1–181.e7. https://doi.org/10.1016/j.ajog.2016.10.013 10. Nazzal, E. M., Waller, A. E., Meyer, M. L., Ising, A. I., Jones-Vessey, K., Urrutia, E., & Urrutia, R. P. (2023). Pregnancy and Emergency Department Utilization in North Carolina, 2016-2021: A Population-Based Surveillance Study. AJPM focus, 2(4), 100142. https://doi.org/10.1016/j. focus.2023.100142 11. Kaufman, R., Brown, R., Martínez Coral, C., Jacob, J., Onyango, M., & Thomasen, K. (2022). Global impacts of Dobbs v. Jackson Women’s Health Organization and abortion regression in the United States. Sexual and reproductive health matters, 30(1), 2135574. https://doi.org/10.1080/2 6410397.2022.2135574 12. Samuels-Kalow, M. E., Agrawal, P., Rodriguez, G., Zeidan, A., Love, J. S., Monette, D., Lin, M., Cooper, R. J., Madsen, T. E., & Dobiesz, V. (2022). Post-Roe emergency medicine: Policy, clinical, training, and individual implications for emergency clinicians. Academic emergency medicine : oﬃcial journal of the Society for Academic Emergency Medicine, 29(12), 1414–1421. https://doi.org/10.1111/acem.14609

1. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancymortality-surveillance-system.htm 2. Raymond, E. G., & Grimes, D. A. (2012). The comparative safety of legal induced abortion and childbirth in the United States. Obstetrics and gynecology, 119(2 Pt 1), 215–219. https://doi.org/10.1097/ AOG.0b013e31823fe923 3. Bridwell, R. E., Long, B., Montrief, T., & Gottlieb, M. (2022). Post-abortion Complications: A Narrative Review for Emergency Clinicians. The western journal of emergency medicine, 23(6), 919–925. https://doi.org/10.5811/ westjem.2022.8.57929 4. MMWR. 2023;72(9);1-29. 5. Londoño Tobón, A., McNicholas, E., Clare, C. A., Ireland, L. D., Payne, J. L., Moore Simas, T. A., Scott, R. K., Becker, M., & Byatt, N. (2023). The end of Roe v. Wade: implications for Women’s mental health and care. Frontiers in psychiatry, 14, 1087045. https://doi.org/10.3389/ fpsyt.2023.1087045 6. Frontiers Editorial Oﬃce (2022). Retraction: The turnaway study: A case of self-correction in science upended by political motivation and unvetted ﬁndings. Frontiers in psychology, 13, 1130026. https://doi.org/10.3389/ fpsyg.2022.1130026 7. Davies M. Row over medical journal’s refusal to retract paper used to restrict abortion in US legal cases BMJ 2023; 382 :p1576 doi:10.1136/bmj. p1576

DOBBS DECISION REBUTTAL

Countinued from page 8

Dr. Wilber also discusses a distraught boyfriend in the ED, horrified that his girlfriend “decided to abort his first child in order to spite him.” A 10-year-old in Ohio was raped and, because of her state’s anti-choice laws, was forced to drive to Indiana to have an abortion. The incident made international news.4 References 1. Mark Murray, Bridget Bowman, Alexdra Marquez. “GOP’s real abortion problem: 60% disapprove of Roe v. Wade’s overturn.” NBC News. 13 Nov 2023. https://www.nbcnews.com/meet-the-press/first-read/gops-realabortion-problem-60-disapprove-roe-v-wades-overturn-rcna124857 2. Alison Durkee. “Ohio Voters Protect Abortion Rights in State Constitution – Joining Litany of States.” Forbes. 07 Nov 2023. https://www.forbes.com/ sites/alisondurkee/2023/11/07/ohio-voters-protect-abortion-rights-in-stateconstitution---joining-litany-of-states/?sh=761328d14c96 3. Justine Griffen. “ ‘Pregnancy centers’ draw scrutiny as lawmakers seek to elevate their status.” Tampa Bay Times. 12 Jan 2018. https://www. tampabay.com/news/health/-Pregnancy-centers-draw-scrutiny-aslawmakers-seek-to-elevate-their-status_164375121/ 4. Lauren Arantani. “Girl, 13, gives birth after she was raped and denied

COMMON SENSE JANUARY/FEBRUARY 2024

Conclusion

Dr. Wilber’s position is not a “pro-life” one—it is a forced-birth one. To call “state funded abortion care…essentially child sacrifice to the god of convenience” is an insult to the millions of women that are trapped in states that enforce this unjust and scientifically unfounded position. abortion in Mississippi.” The Guardian. 14 Aug 2023. https://www. theguardian.com/world/2023/aug/14/mississippi-abortion-ban-girl-rapedgives-birth 5. Lorenz JM, Ananth CV, Polin RA, D’Alton ME. Infant mortality in the United States. Journal of Perinatology. 2016 Oct;36(10):797-801. https:// www.nature.com/articles/jp201663 6. William Skipworth. “Most OBGYNs Say Pregnancy-Related Mortality Worsened After Roe V. Wade Was Reversed, Poll Finds.” Forbes. 21 Jan 2023. https://www.forbes.com/sites/willskipworth/2023/06/21/mostobgyns-say-pregnancy-related-mortality-worsened-after-roe-v-wade-wasreversed-poll-finds/?sh=7bd30bab55d5 7. Oriana González. “Health experts see rise in maternal mortality postRoe.” Axios. https://www.axios.com/2022/07/05/maternal-mortality-deathabortion-ban-roe

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ORAL BOARD REVIEW COURSE

To AAEM’s Oral Board Examiners: THANK YOU!

n behalf of the American Academy of Emergency Medicine (AAEM), we wish to extend our heartfelt gratitude to our Oral Board Review Course faculty for their unwavering commitment to the advancement of our educational initiatives. These volunteers exemplify the dedication and expertise we value so highly. Course Directors

Michael Bond, MD FAAEM Course Director Frank Christopher, MD FAAEM Course Director Mitchell Goldman, DO MAAEM FAAEM - Course Director Emeritus

Examiners

Bret Ackermann, DO MSS FAAEM Jason Adler, MD FAAEM Dennis Allin, MD FAAEM Terence Alost, MD MBA FAAEM Jeffery Baker, MD FAAEM Abdullah Bakhsh, MBBS FAAEM Kimberly T. Baldino, MD FAAEM Sudhir Baliga, MD FAAEM Hannah Bates, MD FAAEM Michael Billet, MD FAAEM Michelle Blanda, MD FAAEM Laura Bontempo, MD MEd FAAEM William Scott Boston, MD FAAEM Samara Bowen, MD FAAEM Nicholas Boyko, DO

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To our Oral Board Examiners, thank you for your dedication to emergency medicine education. Your integral role in fostering our community within AAEM are truly invaluable. We are deeply appreciative of your continued involvement and eagerly anticipate our continued collaboration in the new year. Stephanie K. Louka, MD Johnathan Scott Lowry, MD Martin Makela, MD FAAEM FACHE Edmundo Mandac, MD FAAEM Michael Matteucci, MD FAAEM FAWM Dan Mayer, MD FAAEM Brian J. McMahon, MD FAAEM Joel Miller, MD FAAEM Rebecca N. Mills, MD FAAEM Malia J. Moore, MD FAAEM Ian Moorhead, MD FAAEM FACEP Larissa Morsky, MD FAAEM Molly Mulflur, MD FAAEM Neeraja Murali, DO MPH FAAEM Hillary Harper, MD FAAEM FACEP Lindi Hayes, MD FAAEM Mitchell Heller, MD FAAEM Melanie S. Henif, MD JD FAAEM FAAP Dan Hornyak, MD MBA CPE FAAEM Kermit Huebner, MD MPH FAAEM Bakhtiar Ishtiaq, MD Kristopher J. Ivey, MD FAAEM Sharon Jia, MD Elizabeth J. Johnson, MD Seth M. Kelly, MD FAAEM David Kelton, MD FAAEM Danya Khoujah, MBBS MEHP FAAEM Paul Kleinschmidt, MD FAAEM Sasha Klemawesch, MD McKenna Knych, MD FAAEM Diane M. Kuhn, MD PhD Michael Lee, DO FAAEM Sally Liang, MD FAAEM Bryan P Lin, DO FAAEM Ann L. Long, DO

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Course Set One

All courses start at 10:45am CT and end at 4:00pm CT.

• Tuesday, April 2: Oral Board Review Course* • Wednesday, April 3: Oral Board Review Course* • Thursday, April 11: Oral Board Review Course*

Become an Examiner.

Course Set Two

• Tuesday, August 27: Oral Board Review Course* • Wednesday, August 28: Oral Board Review Course* • Thursday, September 5: Oral Board Review Course*

Ready to become an Examiner yourself? We are always in need of new Examiners! All Examiners are eligible to receive a stipend, attend the Examiner’s at Scientific Assembly dinner, and can qualify for other new benefits like complimentary Scientific Assembly registration and complimentary AAEM membership. Please visit the Oral Board Course website to learn more.

Course Set Three

• Tuesday, November 12: Oral Board Review Course* • Wednesday, November 13: Oral Board Review Course* • Thursday, November 21: Oral Board Review Course* *Six single-patient case encounters and two structured interview case encounters.

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aaem.org/education/oral-boards

THE WHOLE PHYSICIAN

Amygdala Hijack: Why We Sometimes Lose Our Cool and How to Get it Back Amanda Dinsmore, MD FAAEM, Laura Cazier, MD FAAEM, and Kendra Morrison, DO

Not infrequently, physicians will describe experiences occurring at work where they completely lost emotional control. They are dealing with a difficult patient or family member and suddenly lose their cool completely. Why?

ave you ever gotten so mad or scared that you reacted utterly contrary to your typical “mild-mannered doctor” personality? Think “The Incredible Hulk.” What’s behind this, and is there a way to prevent us from “losing it” this way in the future? In his 1996 book “Emotional Intelligence: Why It Can Matter More Than IQ,” author Daniel Goleman coined the term “Amygdala Hijack” to describe this Hulk-like phenomenon. What is the amygdala, and how does it hijack us?

When we feel unsafe, our brains don’t think we need to use reason or logic. The brain and body go into “fight or flight” mode. Cerebral blood flow is directed away from the neocortex (the thinking, rational brain) to the amygdala, the “emotional” or as it is sometimes called, the “primitive” brain. So if we feel unsafe, maybe because some kid almost clips our new Audi or because we work in an emergency department with unruly patients and insufficient security—we are vulnerable to amygdala hijack. The amygdala will trigger a highly emotionally charged reaction in an effort to protect us, but this often causes us to say or do something we later regret. It becomes likely that we will not show up as our best selves.

As we recall for a moment our neuroscience days, we remember that the amygdalae are almond-shaped bundles of nuclei in the deep medial temporal lobes, responsible for detecting threats and processing emotional responses, among other functions. The amygdala is sometimes referred to as the This is why “smoke detector of the brain,” and is constantly scanning when we are raging, our surroundings for danger. Its motto is “better safe than we typically aren’t sorry,” and once activated, it diverts blood flow from the fully rational—as if a prefrontal cortex, the “thinking” part of the brain. This is why when we are raging, we typically aren’t fully rational—as if little gremlin crawled a little gremlin crawled over from the backseat to grab the over from the backseat steering wheel—hence, amygdala hijack. to grab the steering

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wheel—hence, amygdala The amygdala is more easily triggered when we are overhijack. tired or under stress, and what emergency physician is not under stress? The more stress we experience, the more sensitive our amygdala becomes. And lest you think that more stress somehow could make us stronger, consider this question: Is more stress an appropriate treatment for a person with PTSD? Of course not. The amygdala has been described as Is it possible to short-circuit the amygdala hijack? an overpowered and obsolete brain function—like taking down a fly with a Yes, but it’s a skill that takes time to develop. Here are a few tips to help: shotgun. The fly is dead, but there sure is a lot of collateral damage. z Name your emotions. Affect-labeling is a skill of emotional granularity, or the ability to recognize and name emotions and experience Occasionally, something will happen and we find ourselves reacting way them in a context-specific way.1 Extensive research shows that if we out of proportion to what we would normally consider appropriate. For have a surge of negative emotion and then name it (“this is rage” or “I example, the other day a woman followed my (Laura’s) 17-year-old son am despairing”), it diminishes the intensity of the feeling significantly. home, got out of her car and proceeded to scream and swear at him (Interestingly, being able to name positive emotions enhances our because he offended her in some way with his driving (he’s a teenage experience of them.)2 boy—I don’t love his driving either). Who knows what kind of person she is but I bet she doesn’t think of herself as a crazy person like the rest of the neighborhood did that day. So what made her behave in that way when she was otherwise probably a pretty rational person?

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THE WHOLE PHYSICIAN

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The amygdala will trigger a highly emotionally charged reaction in an effort to protect us, but this often causes us to say or do something we later regret. z Remember that anger/rage are typically secondary emotions, and what lies beneath them is often fear, anxiety, frustration, or some unmet need. Why are you angry? What was the trigger? Why? Writing these down may create an additional calming effect. z If you are indeed physically unsafe, get yourself to a place where you are safe. If you are not actually in danger, hold a hand to your heart and say, “I am safe” or “everything is okay.” z Practicing deep breathing will engage the diaphragm, stimulate the vagus nerve, and help switch from sympathetic activation to parasympathetic, helping to calm you down.3 The 4-7-8 breathing technique (four seconds inhalation, seven second hold, eight second exhalation, repeat up to four times) is a great one to try.

z When approaching a difficult conversation (with a patient, consultant, or anyone) that might become emotional, try this trick. Hold a pen in your hand as if you are about to write something. Holding a pen helps keep you in “thinking brain” because you are conditioned to be using the neocortex whenever you are writing (doing math problems or spelling difficult words are other options to try). z If you find yourself activated, spiraling down into “emotional brain” and reactivity (i.e., ”freaking out,” “riled up,” heart racing, wanting to punch someone or scream at them), remove yourself from the situation if at all possible. Practice something requiring thought, such as reciting the causes of anion gap metabolic acidosis or reviewing renal physiology to get you back up into “thinking brain.” z To help prevent amygdala hijack, practice meditation and mindfulness, as there is some evidence these can develop the skill of emotional regulation.4 Developing the ability to respond rather than react is time-consuming, but it is so worth it. We can choose how we want to speak, behave, and interact rather than allow the primitive brain to drive the train, so to speak. Through neuroplasticity, we can strengthen the prefrontal cortex so that we will be less subject to amygdala hijack in the future. Rewiring our brains in this way will help us keep ourselves calm, cool, and collected and keep the Hulk out of the emergency department. thewholephysician.com

References 1. Wilson-Mendenhall CD and Dunne JD (2021) Cultivating Emotional Granularity. Front. Psychol. 12:703658. doi: 10.3389/fpsyg.2021.703658 2. Torre, J. B., & Lieberman, M. D. (2018). Putting Feelings Into Words: Affect Labeling as Implicit Emotion Regulation. Emotion Review, 10(2), 116-124. https://doi.org/10.1177/1754073917742706 3. Gerritsen RJS, Band GPH. Breath of Life: The Respiratory Vagal Stimulation Model of Contemplative Activity. Front Hum Neurosci. 2018

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Oct 9;12:397. doi: 10.3389/fnhum.2018.00397. PMID: 30356789; PMCID: PMC6189422. 4. Wu R, Liu LL, Zhu H, Su WJ, Cao ZY, Zhong SY, Liu XH, Jiang CL. Brief Mindfulness Meditation Improves Emotion Processing. Front Neurosci. 2019 Oct 10;13:1074. doi: 10.3389/fnins.2019.01074. PMID: 31649501; PMCID: PMC6795685.

FINANCIAL WELLNESS

Aging Parents Chris McNeil, MD

ife happens to us all. My beard is more gray than I remember it (my kids say white), I can no longer suture a wound, use an otoscope, or read a book without glasses (I refuse to make the font on my phone larger), and I have aging parents. My kids would also say they have an aging parent. If you are reading this, you may be an aging parent and identify with some of my troubles. But I’m more confident that most of you have, will have soon, or are caring for aging parents, so this information is pertinent to all of us. Financial concepts for those greater than 65 years of age are not much different than the rest of us. The nuances primarily surround cognitive abilities and end of life care. Certainly, specific investments and risk tolerances change as we age. However, my intention with this article is to get you to start thinking from a broad perspective about how to frame a dialogue with your parents and what broad topics to focus on when discussing finance. We are not going to get into the weeds. Nothing here is rocket science, but the following are the most common topics I cover with clients to consider in regard to their aging parents. Early communication. As our parents age, the uncertainties of life don’t change, but the anxieties of running out of retirement money, maintaining independence, developing worsening health conditions, and having cognitive declines take center stage. Start your discussions slowly to ensure they are accepting of your concerns and develop a plan together. Include the rest of the family so no one feels left out to avoid hard feelings in the future. Consider beginning to speak to your children about your financial future as well. Communication is the key and best done when everyone is of sound mind and body. Try to avoid having these conversations only after a crisis has occurred. Protect yourself and your own assets first. Not dissimilar to a flight attendant telling you to put your oxygen mask on before helping those next to you, one thing that is often overlooked and can derail the best-intentioned retirement plan is inadequately projecting the financial support you will be contributing to aging parents. If you anticipate your aging parents will require financial support, consider saving a bit more while you are still working and place the funds in a dedicated account to help in the future. Consider reviewing your life and disability insurance policies to ensure you are adequately covered should they become financially dependent upon you in the future. Review, update, or create estate planning documents. You could also review your own important documents with your kids at this time, too. The critical documents include wills, trusts, advanced care directives, medical power of attorney, and financial power of attorney. Get the full picture of your parents’ financial situation. Inventory their assets, real estate, accounts, investments, and businesses so you have an idea of what resources are available. This is also a good time to review and ensure the desired beneficiary designations are listed correctly on all investment accounts.

Prepare for future health care costs. As we all know, long term care is very expensive and dwindles a retirement nest egg rapidly. It is not uncommon for those needing long Financial term care to spend several concepts for those hundred thousand dollars on greater than 65 these services. Either having your parents save a bit extra years of age are not or saving a bit extra yourself much different than and keeping a health care the rest of us. slush fund separate from retirement funds may be helpful. In addition, long term care insurance policies and other insurance products exist to help fund these costs. Depending on your situation, the age and health of your parents, it may be worth investigating these products. It would be wise to consider future health care costs in any financial plan (parents or your own).

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Monitor for financial exploitation of your aging parents. Older people may feel less confident about making financial decisions and have a more difficult time understanding household bills and financial statements. They are at a greater risk of being targeted by financial scams. I have personally seen older clients befriended by an online personality who talked them into “helping out” by transferring a large sum of money to an international bank account. This happens more frequently than most of us are aware. The more you are involved and speak to them about their finances, the more you can help protect them from frauds and scams. Some signs that you may need to step in include unusual purchases, piles of unopened mail, complaining about money, physical or health problems, and increasing memory problems. One very important thing you can do is have your parents list you as a “trusted contact” on their investment accounts. This way, you may be alerted to suspicious transactions by your parent’s financial institution. We are all experienced in caring for advanced aged patients and their family members. We know what to expect from the aging process when it comes to the physical, cognitive, and psychological/behavioral aspects of our patients. Yet, assuming responsibility for certain aspects of our aging parent’s lives can be emotionally, physically, and financially taxing. The sooner we start thinking about and discussing this inevitability, the more prepared we will be. Dr. Chris McNeil, the author of this article, is an emergency physician and former emergency medicine residency program director who transitioned his career to finance. He owns a registered investment advisory firm, VitalStone Financial, LLC, and specializes in financial planning for physicians. COMMON SENSE JANUARY/FEBRUARY 2024

Do All Those Kids Belong to You? Dr. Christo Philip, Community Emergency Medicine Physician

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id you make your wife give birth to all those 10 kids?” “You have enough kids to start a football team!” These are just a few of the many befuddled comments I have heard from patients and colleagues as they discover some details about our family. A brief comment about our 10 children and raising them is often a good ice breaker with some patients as parents try to corral their children running dizzying laps around the emergency room. As emergency medicine physicians, we are faced daily with the brokenness of this world and many times we are the first point of contact for families and children who are neglected or abused.

boy who had come into care. Most of my colleagues thought we were crazy when we decided to start foster care in the middle of medical school with two children under the age of two. Loving this little boy and caring for him until CPS could find a better living situation for him was hard. The process of foster care and his temporary placement with us for a few months convinced us that we were better meant to be adoptive parents than foster parents. The heartache of loving a child and then knowing that they would potentially be placed elsewhere (sometimes into a situation or home environment that you knew wasn’t the best place for the child) was too difficult for us to bear. We decided that in the future we would only consider adoptive placements—kids in foster care where parental rights had already been terminated and so they were ready for a forever home. Fast forward 11 years. We had just moved back to the U.S. We had to take a pause on adoption as we moved abroad to serve at a medical mission hospital on the border of India and Nepal. We had three biological kids who were now 12, 10, and 7 and we were ready to start the process again of adding to our family. We initially thought maybe three or four kids to add to our family but God had different plans and over the past seven years we have added another seven children to our family through adoption from Texas foster care. We initially adopted a sibling group of five children in 2017 and when CPS became aware that our kids had two younger sisters who were born, they asked us if we would consider adopting them as well. We brought our youngest two girls into our family in 2018 and 2019.

We are often the same physicians who care of these same kids through their many years in foster care and the many mental health struggles kids have when they drift through life without the anchor of a stable family. What if we could do more for neglected and abused kids rather than just recognizing the telltale signs of abuse or figuring out which psychiatric facility can handle a child who couldn’t control their emotions as they languished in foster care? My wife and I decided early on in our marriage that adoption would be part of how God would build our family. We limited the number of biological children we had so that we could have the option to adopt to add to our family. Our first foray into the world of foster care began when I was a second-year medical student at the Mayo Clinic. Our oldest daughter was about two years old when we went through the training to foster a child in the state of Minnesota. A few months after we finished licensing, CPS asked us if we would be willing to take an 18-month-old

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These past seven years have brought tremendous joys and sorrows as we have helped incorporate seven more kids into our home who needed the stability and love of a home and parents to heal. Has it been an easy journey? Not at all. When kids have lost everything and been hurt over and over again and been failed by the adults meant to protect them, it is hard to regain their trust and help them not push people away—even people who want to love them dearly. One of our kids was on three >>

“When kids have lost everything and been hurt

over and over again and been failed by the adults meant to protect them, it is hard to regain their trust and help them not push people away—even people who want to love them dearly.”

DO ALL THOSE KIDS BELONG TO YOU?

different psychiatric medications when she came to our family because no one in foster care could figure out how to control her violent behavior. Thankfully my background as an emergency physician was helpful in figuring out how to wean her off most of the potent antipsychotics as we realized that much of her behavior stemmed from being hurt over and over again and feeling like she had no control over her life. These past seven years have taught us much about unconditional love. We have also seen that with constant love and stability, kids can, and do, heal and the tremendous progress we have seen our kids make has been amazing. Kids that came to us struggling with multiple daily temper tantrums can now make it months before they have a melt-down. Kids that didn’t know how to read or write and couldn’t pay attention to a book for more than two minutes can now read books that are hundreds of pages long without assistance. Of course, not everything is rosy. This past year was one of the hardest for one of our kids with a several month psychiatric hospitalization as we hit some difficult teen years. But even with that we have seen slow progress and been thankful for God whose grace has been sufficient through difficult times. I’m especially thankful for my wife whose steady love and grace has been instrumental in helping our children heal. She does the heavy lifting of being emotionally present for our 10 children, somehow manages to make sure they all have clean laundry and food to eat and until recently was homeschooling seven of our kids to help them catch-up educationally. Definitely a wonder woman!

Most of us live lives with so much “ abundance…But what you may not

realize is that our hearts also have extra room to love others who did not initially belong to us.

Lots of people have questions about whether they have the resources to adopt a child. All you need is a willing heart and the ability to make yourself vulnerable. Did you know that in many states, if you adopt a child from foster care, there is no cost to the family for the legal fees? Many people think that adoption costs tens of thousands of dollars (which it does if you do an infant private adoption or adopt internationally) but if you adopt from state foster care all the legal costs are covered. Did you know that state provides medical insurance for any children you adopt until they are age 18? Did you know a monthly monetary supplement is often provided to help with costs for caring for the child? And did you know, in many states, all kids adopted from foster care have their tuition and fees waived for any state colleges or universities including costs for undergraduate and graduate studies?

I think as a group, emergency medicine physicians have some unique traits that make adoption easier. We are used to dealing with chaos day in day out and so not many things surprise us. We also know when to get concerned and when not to overreact which can be so helpful when kids push the boundaries and they just need a calm parent who can set limits and not get flustered. Even though our schedules are erratic it does allow us time off when many people don’t have that freedom. My emergency medicine schedule has allowed the flexibility for numerous doctor’s visits, meetings with therapists and counselors, and court appointments in ways that a job with more typical hours might not allow. Most of us live lives with so much abundance. We all have homes with extra bedrooms, extra food, and extra clothing. But what you may not realize is that our hearts also have extra room to love others who did not initially belong to us. Before adoption, I only thought I had enough love in my heart for my three biological kids but through adoption I’ve learned there is plenty extra—even for another seven! The reality is that millions of children go to bed each night wondering if God sees them or hears their cries. Millions of children want to belong, to be part of a family, to be loved unconditionally. Just in the U.S. alone there are over 400,000 kids in foster care and over 120,000 kids who are ready for adoption just waiting for a family to say yes. In the U.S., the average child spends two to five years waiting for a home and over 20% of kids wait over five years before they get adopted and over 10% of kids age out of the system at age 18 never having found a family to call their own.

So that is my challenge to you as emergency medicine physicians. Think about the blessings you have been given through your career as emergency medicine physicians and the unique role you play in the lives of so many people on the hardest days of their lives. In adoption, there is an opportunity for you to rewrite the story of someone’s life and not let them become another statistic. We would love to have many more of you join us on this journey. It’s not for the faint of heart but of course that is not you or you wouldn’t have chosen to become an emergency medicine physician!

COMMON SENSE JANUARY/FEBRUARY 2024

Serendipity in the Shadows of the Himalayas: My Unexpected Journey to Mindfulness during Sabbatical

WELLNESS COMMITTEE

Al’ai Alvarez, MD FAAEM*

eflecting on the past year, I frequently find myself thinking back to my sabbatical in Dharamshala, a meaningful retreat I earned through years of service at my institution. This reflection brings a mix of emotions. I take pride in my achievements, but also regret unfinished or failed projects, missed opportunities, and tasks from 2023 that remain incomplete. I also feel grief for lost loved ones and dear friends.

Unfamiliar with the process and relying on advice from new acquaintances in town, they suggested I sit behind the main gompa, a path known to be taken by HHDL. However, I reevaluated my initial seating choice and shifted to a location I assumed offered a better view, directly facing HHDL’s anticipated seating area. Unfortunately, this move placed me on the opposite side of his expected path, leaving me filled with a sense of regret and longing for what could have been. Despite this initial disappointment, I reminded myself that a few months prior to this, I never would have thought I’d be attending an event taught by HHDL himself and that this time last year, I didn’t even consider being in Dharamshala. This reminder brought a profound sense of peace, affirming that I was exactly where I needed to be. As HHDL’s teaching concluded, the procession resumed. This time, instead of returning to his initial entry point, he walked towards the elevator near my seat. Feeling a mix of excitement, gratitude, and awe, I watched him pass by, pausing to acknowledge and bless people. Observing his gestures, I whispered in amazement, “This is really awesome,” and the woman next to me tearfully chimed in agreement, “Yes. It really is awesome.”

Author meeting and receiving the blessing of HHDL.

Three months have passed since my return, but December’s looming deadlines make my time in Dharamshala feel like a distant memory. I recall the early days of planning this journey back in January, motivated by a desire to enhance my grasp of mindfulness and meditation directly from its daily practitioners, the Tibetan Buddhist monks. Also embedded in this aspiration was the hope of meeting His Holiness, the Dalai Lama (HHDL), considering Dharamshala’s importance as both the home of the Tibetan government-in-exile and HHDL himself. My journey to Dharamshala unfolded with a sequence of serendipitous events. One month prior to my trip, I discovered that HHDL would be teaching for two days during my stay in town. This exceptional chance required handling logistics in a language not supported by Google Translate. This process entailed arranging the necessary paperwork for background checks and securing the best seats a day or two before the event.

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Weeks later, I had the privilege of attending a morning event with HHDL, culminating in a brief personal audience and receiving his blessing. As an agnostic who had not delved into Buddhism before, I found this experience deeply moving. Despite my personal beliefs, the unmistakable positive impact HHDL has made on numerous lives struck me, reflecting his extraordinary humanity and presence. On my final day in Dharamshala, an unexpected flight delay prolonged my stay. Throughout the past month, I had deliberately avoided emails to fully engage in my sabbatical. The delay led to a stream >>

WELLNESS COMMITTEE

of updates, prompting the emergency physician in me to consider a taxi from Dharamshala to Delhi as a 12-hour-long contingency plan. When I eventually left for the rescheduled 3:45pm flight, we passed the Dalai Lama Temple amidst a flurry of familiar faces and a closely monitored traffic flow. It turned out HHDL was returning to McLeodganj after teaching at a nearby village. The flight delays fortuitously allowed me to capture a video of HHDL waving as he passed by us, offering a serendipitous end to an extraordinary journey. McLeodganj, with its distinctive mix of spiritual aura and natural splendor, has left a lasting impression on me. It stands as a vivid reminder that we are often exactly where we need to be, even when it feels otherwise.

McLeodganj, with its distinctive mix of “ spiritual aura and natural splendor, has left a lasting impression on me. It stands as a vivid reminder that we are often exactly where we need to be, even when it feels otherwise.

Reflecting on these experiences, I feel profoundly grateful for the lessons I’ve learned, the connections I’ve forged, and the unexpected moments that defined my sabbatical. And so, as I bid farewell to 2023, I acknowledge my achievements, failed projects, missed opportunities, unfinished tasks, and the grief I’ve faced. Moving into the new year, my focus is on practicing letting go, aligning more deeply with my values, and embracing self-compassion. The experiences of 2023, especially my sabbatical, have taught me the integral role of this process in my journey. Most importantly, I hope that wisdom and compassion will continue to emerge from within us, regardless of what the future brings. References

* Chair, AAEM Wellness Committee; Director of Well-Being, Stanford Emergency Medicine; @alvarezzzy † Chandrakirti’s “Entering the Middle Way” in Conjuntion with the “Autocommentary.” https://www.dalailama.com/videos/chandrakirtis-entering-the-middle-way-in-conjuntion-with-the-autocommentary Editor’s Note: Due to copyright restrictions we are unable to reprint a photo of HHDL passing by Dr. Alvarez in his procession. You can view the video of the session attended by Dr. Alvarez by scanning the QR code below or navigating to the link provided in the references.

COMMON SENSE JANUARY/FEBRUARY 2024

AAEM PHYSICIAN GROUP

Snake in the Grass: Kansas Emergency Physicians Stands Up Against TeamHealth’s Illegal Actions Mark Reiter, MD MBA MAAEM - CEO, AAEM Physician Group

ansas Emergency Physicians (KEP) staffs five EDs within the AdventHealth system in Kansas City. We are honored to have Kansas Emergency Physicians as member group of the AAEM Physician Group. KEP embodies a quality, independent, democratic emergency physician group practice with a longstanding commitment to their community. In 2018, with minimal fanfare, KEP’s billing company was purchased by TeamHealth. The billing company was allowed to remain an independent entity, now owned by TeamHealth. An agreement was signed between the billing company, TeamHealth, and KEP, that specifically noted that TeamHealth, now in possession of KEP’s insider financial information, would not approach KEP’s hospital system for expansion, as this would give TeamHealth an unfair advantage. Eighteen months ago, KEP’s independent, democratic legacy came under threat. Without KEP’s knowledge, TeamHealth reached out to KEP’s hospital network and provided an RFP to take over all of their hospital contracts, undercutting KEP. This led to a series of negotiations where KEP retained its contract but which negatively impacted their financial standing, as KEP’s hospital subsidy was significantly reduced due to TeamHealth’s proposal. Despite the existence of KEP’s contract rider specifically prohibiting TeamHealth’s actions, TeamHealth brazenly sought KEP’s contract and looked to undermine KEP’s relationship with the hospitals KEP has called home for 50 years. KEP decided that litigation was necessary to hold TeamHealth accountable for their breach of contract and its subsequent impact on its practice. The AAEM Physician Group fully supports KEP in enforcing their rights when TeamHealth, armed with KEP’s financial information, went behind KEP’s back trying to steal the KEP contract, despite clear contractual prohibitions on this action. Thankfully, AdventHealth recognized the value of continuing to partner with KEP, but TeamHealth’s actions caused significant strife and financial harm to KEP. KEP is taking a bold step in enforcing its rights against TeamHealth’s illegal actions. We are confident

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that KEP will be successful in its litigation and hope the court will punish TeamHealth severely. Quality medicine is best provided by physicians with close ties to the patients they see and who are invested in their community. This is best achieved by independent, physician owned local groups. KEP is taking important actions to safeguard their practice of medicine and ensure the quality and compassion our patients have come to expect. Corporate interference in medicine continues to degrade the quality of our field and this will only change when we stand up and defend ourselves.

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KEP’s bold action against TeamHealth, like that of AAEMPG’s action against Envision, are important steps in emergency physicians taking back control of emergency medicine.

As our members are aware, AAEM-PG is in the midst of major litigation in California against Envision for its illegal, anticompetitive actions, such as violating corporate practice of medicine laws and anti-kickback laws. Now bankrupt American Physician Partners, which ceased operations in July, did not pay some of their physicians in July or pay their medical malpractice insurance. Emergency physicians continue to be harmed by the illegal abuses by corporate medical groups. It is time for emergency physicians to stop getting exploited by private equity backed lay corporations. KEP’s bold action against TeamHealth, like that of AAEM-PG’s action against Envision, are important steps in emergency physicians taking back control of emergency medicine.

Communicating with the C-Suite Kraftin E. Schreyer, MD MBA FAAEM

ommunication is critical. It’s critical for coordinated, patient-centric, high value clinical care. It’s also critical for promoting operational and administrative changes and improving quality and safety. Typically, as one progresses through departmental leadership in emergency medicine (EM), communication within the department becomes more effective. However, communicating with hospital and health system leadership, which is oftentimes crucial to promoting departmental initiatives, can be much more challenging. This is of particular importance because CMS recently updated their Quality Assessment and Performance Improvement program to include an expectation that governing bodies “share accountability” have an “opportunity to collaborate” on improvement initiatives.1 The differences in communication strategies and styles between the two groups are multifactorial. Most obviously, figuring out who is who in the C-Suite can be like decoding alphabet soup. While all hospitals have a Chief Executive Officer (CEO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO), some have a variety of other C-suite members, including a Chief Operating Officer (COO), Chief Clinical Officer (CCO), Chief Quality Officer (CQO), Chief Informatics Officer (CIO), and Chief Experience Officer (CXO). Beyond deciphering titles, determining each individual’s role is necessary to ensure the communication is directed toward the appropriate party.

Additionally, and, more importantly, communication with non-clinical personnel is not the same as communication with those with clinical backgrounds. And, a new report recently found that only 24% of board members have clinical backgrounds.2 Not only do clinicians and non-clinicians literally speak a different language, so clinical jargon must be translated into lay-speak, but clinicians have different priorities than non-clinicians in the C-suite and on the board. Clinicians spend years training and honing their skills, and in return, expect investment and support. They also value wellness at work. C-suite and board members must balance needs amongst a larger stakeholder group, and, as such, place more value on the financial health of the organization, strategic direction, return on investment, legal and regulatory risk, recruitment and retention of staff, and community relations. While clinicians answer to patients primarily, C-suite and board members answer to Bond Rating Agencies and to the community at-large. Communication between clinicians and non-clinicians typically centers around the proverbial “ask,” in which clinicians ask the C-suite for something for their department. Oftentimes, clinicians frame the ask in terms of patient safety, the literature, and the basic need. Non-clinicians in the C-suite and on the board, however, value the alignment with institutional strategy, the return on investment and the completeness of the solution. Misalignment of the values on either side of the ask leads to unsuccessful communication. >>

Communication with non-clinical leaders, particularly those in the “ C-suite and on the board can be successful, you just have to learn to speak their love language.

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COMMUNICATING WITH THE C-SUITE

A typical, misaligned, ask might go something like this: ED: We need a new piece of equipment for the ED. New studies in the New England Journal show how valuable it is, and it is clearly best for patients.

“Most obviously,

C-Suite: Hmm, that does sound important, but we don’t have enough money.

figuring out who is who in the C-Suite can be like decoding alphabet soup.

ED: But we need it… C-Suite: But we can’t afford it… While the ED has the patient’s best interests in mind, they failed to take into account the priorities of the C-suite. Prior to any conversation with health system or hospital leadership, it behooves departmental leaders to consider all of the stakeholders, the process of implementation, return on investment, potential benefits, and potential risks.

C-Suite: Why wasn’t this equipment purchased already?!

When the priorities of the hospital leaders are considered and incorporated into the ask, that same conversation might instead go something like this:

To ensure effective communication, it’s key to think outside your departmental silo, adequately prepare, align the ask to institutional priorities, anticipate downstream issues, and highlight key areas of concern.

ED: We need a new piece of equipment for the ED. Anesthesia and Pulmonary also need similar equipment from the same vendor. We think now is the time to get a good deal if we buy in bulk, and we can save money on servicing the equipment we already have.

Communication with non-clinical leaders, particularly those in the C-suite and on the board can be successful, you just have to learn to speak their love language.

C-Suite: Hmm, how urgent is this need? ED: It’s urgent for patient safety. Recently, there were two bad outcomes related to the old equipment. One of them is in litigation now and the expected payout on that case is more than the total spend for all three departments combined. That outcome likely could have been avoided if we had the newer equipment. We should also mention we’ve already put together a plan for training and maintenance and have the documentation ready to file for DOH approval.

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Author acknowledgement: Dan DelPortal, MD MBA References 1. https://www.beckershospitalreview.com/quality/only-24-of-hospital-boardmembers-have-clinical-backgrounds.html 2. https://www.beckershospitalreview.com/quality/only-24-of-hospital-boardmembers-have-clinical-backgrounds.html

WELLNESS COMMITTEE

#StopTheStigmaEM: A Movement for Transforming Perceptions on Physicians’ Mental Health Maulik Lathiya, MBBS,* Al’ai Alvarez, MD FAAEM,† and Amanda J. Deutsch, MD‡

he #StopTheStigmaEM campaign works actively to transform physician perceptions of mental health from stigma to advocacy. This effort involves intentional actions to improve physician well-being by normalizing mental health care for physicians. During the month-long #StopTheStigmaEM campaign, organizers highlight key strategies for maintaining mental health wellness, emphasizing the understanding of barriers, and stigma. The Unspoken Battles

Many consider mental illness an “invisible disease.” Unlike the common physical illnesses that emergency physicians see and treat, mental illness is more challenging to identify, even for those experiencing it. This invisibility contributes to the stigma around mental health. Moreover, the shame and stigma attached to mental health issues often lead to silence. Consequently, despite its higher prevalence among health care workers compared to the general population, individuals often battle mental illness alone, exacerbating its impact on their well-being. The Effects of Stigma

#StopTheStigmaEM: Bringing the Movement to Light:

Raising awareness. Collaborating with 14 national EM organizations, we aim to initiate open, vulnerable conversations that challenge stigma and normalize the common struggles affecting mental health. Education. Through research and education, we actively expand our efforts to combat the stigma associated with physicians seeking help for mental health illnesses and the natural challenges to mental health. The #StopTheStigmaEM campaign provides a variety of programs, including webinars, in-person storytelling events, advocacy, and visible initiatives like visual arts. Empathy and Compassion. The #StopTheStigmaEM campaign actively promotes empathy, encouraging physicians to view themselves as human beings similar to their patients and colleagues. This compassion helps us recognize our shared experiences and move from awareness to action. Check out the hashtags #DoctorsAreHumansToo and #IamHuman

Stigma surrounding mental illness often deters colleagues from seeking You can play your part: the help they need, thereby worsening their challenges. This reluctance Educate yourself on how working as an emergency physician can result in increased internal struggles, impaired concentration, impacts mental health and availdisrupted sleep, and reduced able support strategies. productivity. It can also negatively affect patient care and teamwork. Be kind to yourself. Such avoidance often worsens Just as we quickly offer help to a the experienced mental illness. friend, family member, or coworkDistinguishing between mental iller, it’s equally vital that we extend ness and mental health is crucial. the same kindness to ourselves While daily fluctuations in mental that we readily offer others. health affect everyone, not all poor Speak up and share Unlike the common mental health constitutes a mental your experience. Being physical illnesses that illness. Similarly, a diagnosis of vulnerable and sharing our exemergency physicians mental illness does not mean an periences enables us to connect inability to work. There is a critical see and treat, mental with others and helps us realize need to improve preventative care illness is more challenging we are not alone. This connection practices for mental health and to identify, even for those also normalizes the everyday acknowledge the persistent exischallenges emergency physicians experiencing it.” tence of stigma. face. This approach is key to breaking the stigma.

“

Countinued on page 28 >>

COMMON SENSE JANUARY/FEBRUARY 2024

Giving Feedback as a Young Physician Can Be Tough—Here’s How to Do it Right

YOUNG PHYSICIANS SECTION

Jennifer Rosenbaum, MD FAAEM

iving and receiving feedback is critical in a medical career, but as a young physician, giving feedback can be uniquely challenging. Many physicians never receive formal training on giving feedback. I remember attending one lecture during residency on the subject. One of my biggest takeaways was “avoid the feedback sandwich.” This model describes sandwiching constructive feedback between two pieces of positive feedback. I knew this model doesn’t work, yet when I started giving feedback to students and residents, I found myself sandwiching the bad between two slices of good. Why did I feel so challenged by giving feedback? To me, it boiled down to a few issues. First, I was no longer receiving regular feedback and it is harder to model good feedback when you are not regularly witnessing the behavior. Feedback also takes time and vulnerability. It takes effort to

“

It is my hope that by admitting my own limitations and knowledge gaps to learners, I’m encouraging them to do the same. I believe medical culture needs to accept that feedback is crucial to growth.

critically think about a resident’s performance and deliver that information. I was still working on my own efficiency and teaching style and I did not want those to suffer. Lastly, and probably most importantly, I suffered from imposter syndrome. As a new and young attending, I was fearful of the learner’s response from someone close to their level of training. Imposter syndrome has been well described in medical literature. It essentially boils down to a feeling of doubting your own abilities. Studies have shown that imposter syndrome affects up to 60% of medical students and 44% of residents—yet personally, I never felt like more of an imposter than when I was asked to give feedback to other physicians.1 I still find it easier to give feedback to medical students and non-physician practitioners than I do to very competent senior residents. Over the years, I’ve learned to accept my imposter persona and now focus on that vulnerability as a strength. I admit my knowledge gaps and request

feedback in return. It is my hope that by admitting my own limitations and knowledge gaps to learners, I’m encouraging them to do the same. I believe medical culture needs to accept that feedback is crucial to growth. I’m certainly not an authority on giving feedback, but I’ve put a lot of thought into the matter. And after unmasking my own imposter syndrome, true to form, I asked for help from my mentors. I surveyed some of the doctors that I thought delivered the most helpful feedback when I was a resident. Here are some common feedback pearls. Create a Supportive Atmosphere

“First, I find it tough to give constructive feedback. It takes real vulnerability on the part of both the evaluator and resident. The most important thing is that you have established a relationship with them, and you demonstrate that you care—they can tell if you don’t.” “As the teacher, you ask the learner if they are willing to receive feedback. If the learner isn’t ready to receive feedback...they are never going to hear you.” “Feedback is done in an area distinct from the main ED. I always try and find a secluded place away from everyone. I don’t want the resident to feel like they are on public display, I want them to feel like they can be open with me and have no barriers to talking about any difficult topics.” Set Up an Expectation of Feedback

“In the spirit of developing self-directed learners, I ask residents to identify for themselves the areas that they want to grow and receive feedback. Usually at the beginning of the shift I tell them, ‘In the first hour of the shift, let me know something you have been working on or want feedback on so I can keep an eye out and give you good targeted feedback along the way or after the shift.’”

Countinued on page 33 >>

COMMON SENSE JANUARY/FEBRUARY 2024

Join Us At HPEM!

AAEM/RSA PRESIDENT’S MESSAGE

Leah Colucci, MD MS

hat is HPEM?

HPEM is the Health Policy in Emergency Medicine Symposium. This event provides you a crash course in activism, all while allowing you to network and engage with our AAEM leaders and possibly state legislators. The focus is grassroots advocacy through experiential learning. You will acquire practical experiences and leave the day with a better idea of what impacts you as an emergency physician. I personally love HPEM, because residents need to equip themselves with the tools to fight for our specialty. I want them to be encouraged that although there are issues we are facing, we can take part in the solutions. Where Is It? This will be a post-conference course (May 1) at AAEM Scientific Assembly 2024 in Austin, Texas. We will try to go into the Texas State Capitol for hands-on learning. What to Expect at HPEM? No prior hill experience is required to get the most out of HPEM! You will get an introduction to the advocacy process and how to be a part of grassroots advocacy in your state. This will be followed by legislation you need to know—both local and national laws that can and will be impacting your career as an EM physician.

I personally love HPEM, because residents “ need to equip themselves with the tools to fight for our specialty. You will take part in mock legislative meetings to practice the skills you learned and have a better understanding of how to sell your viewpoint about the legislation you are hoping to encourage or block. An advocacy day would not be complete without education on scope creep and a refresher about what we can do to address it in our home states! Throughout the day there will be a focus on what you can start doing right now in order to enact change. . Being an EM Physician puts you in a unique position to be an advocate for our patient populations and against the tragedy we see daily. The skills you learn at HPEM will be applicable to almost any topic you want to address for yourself or your patients. Cost? There will be a very small registration fee to cover the cost of this event. You will get all of this for less than the cost of an uber ride. The good news is the earlier you sign up the better the rates!

AAEM Members: $20 early bird rate, $30 after April 5, 2024 AAEM/RSA Residents and Students: $10 early bird rate, $20 after April 5, 2024. Non-members are not eligible for the course. By attending HPEM at SA you will have first dibs to attend HPEM as a fly in, in D.C. in June! I hope you register, and I look forward to seeing you at Scientific Assembly!

COMMON SENSE JANUARY/FEBRUARY 2024

AAEM/RSA EDITOR’S MESSAGE

Washing Wounds Mel Ebeling, BS

resh face blemished only by the occasional pimple and immature hairs on the upper lip. Joints made for the track or a soccer field, not yet corrupted by the snaps, crackles, and pops that come with a golden jubilee. The metabolism to slam five Gordita Crunches without a second thought. And the energy to pull an all-nighter without concern for the school day ahead. His body is in its prime— his mind, on the other hand, is plagued with blue devils.

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We have communion here, a mixture of silence and the exchange of those hopes and dreams between Healer and Healing.

He is ready to get out of this town, I can tell, the black nail polish a hint that his peers and family never understood his depths. If it were not for those pesky laws preventing juveniles his age from driving and universities requiring a high school diploma, he would be far away from here by now. He told me all about it, how he dreamed of the day when he could finally perch up in an ivory tower and photograph the world like nobody ever had before.

But the depression had a way of overshadowing all his hopes and dreams, and now he is here with me, boarded in the barren psychiatric room at the end of the hallway in the emergency department. Intentional or not, the consequences look the same: innumerable parallel lines are etched into the skin of each of his forearms, and he is plastered with blood. He regrets it, but this is not the first time he has. Pulling a chair and an overbed table into the room, I prepare my workstation with the same care and precision as one would the dining room table at Thanksgiving. While not fine china, the stack of 4x4s and clean basin filled generously with sterile water communicate the same respect. Luckily, his cuts are superficial and will not require any sutures, but the challenge remains of washing the dried blood from his wounds. I get to work, pushing up the sleeves of my pressed white coat, generously soaking each piece of gauze before gingerly wrapping his arms from wrist to elbow. Joseph of Arimathea could not have done a better job. We have communion here, a mixture of silence and the exchange of those hopes and dreams between Healer and Healing. After the eternity of those ten minutes, a commodity I am privileged to have at this point in my training, the blood wipes straight off and the wounds are bandaged. I pack up my supplies and say my good-byes, knowing the next person to enter the room will be to admit him upstairs. I hear an earnest “Thank you…” as I exit the room. Something tells me I will see his pictures one day. Author’s Note: Details have been changed to protect privacy.

WELLNESS COMMITTEE

Countinued from page 25

The #StopTheStigmaEM campaign offers resources specifically designed to support emergency medicine physicians at different career stages. Recognizing the challenging nature of this journey, the campaign highlights the importance of not facing it alone. No matter where we are on this path, we can arm ourselves with tools that foster resilience, empowering us to withstand and thrive amidst the inevitable ups and downs.

COMMON SENSE JANUARY/FEBRUARY 2024

References

*Research Fellow - US EM Residency Applicant, Mayo Clinic Health System - Emergency Medicine †AAEM Wellness Committee Chair, Director of Well-Being, Stanford Emergency Medicine, @alvarezzzy ‡AAEM Wellness Committee Member, SAEM Wellness Committee, #StopTheStigmaEM Subcommittee Chair, Director of Wellness, Thomas Jefferson Emergency Medicine, @amandajdeutsch

The Joint Commission: Addressing Some Misconceptions Gary M. Gaddis, MD PhD FIFEM MAAEM FAAEM

ntroduction

•

Much to many emergency physicians’ dismay, none of the currently existing hospital accreditation organizations have enacted standards that must be met to retain accreditation, regarding the patient-harming and burnout-enhancing matter of emergency department crowding and boarding (EDB&C). - EDB&C has existed for more than three decades. EDB&C has been called a “crisis,” but this term no longer fits. No “crisis” can last three decades. Accreditation bodies have systematically turned a blind eye toward EDB&C, and the COI that exists between the accreditation bodies and the organizations they accredit provides an explanation regarding why we and our patients have been systematically ignored and continue to suffer.

•

Many physicians believe that TJC deserves blame for enabling our nation’s current opioid death epidemic, via its pain assessment standard that was implemented in 2002. - That standard initially stated, “Pain is (to be) assessed in all patients.”1 (In fairness, this requirement was eliminated in 2009 from all programs except behavioral health care.1) The clear implication was that if physicians would act on these assessments and order more opiate analgesia, patients would benefit. - The stipulations of this initiative were quickly and formally criticized as unclear by the Council on Scientific Affairs of the American Medical Association (AMA), the report of which was adopted by the AMA’s House of Delegates at its June 2002 Annual Meeting.2 - To quote a document issued by TJC that addressed controversies introduced by its 2002 pain assessment requirement, TJC spokesman David W. Baker, then the Executive Vice President for TJC’s Division of Healthcare Quality Evaluation, stated in 2017, “Concerns had been raised two years earlier that requiring all patients to be screened for the presence of pain and raising pain treatment to a ‘patients’ rights’ issue could lead to overreliance on opioids.”3 - This concern was raised within the AMA’s flagship journal, the Journal of the American Medical Association (JAMA), in 2000.4

Many physicians and nurses believe that The Joint Commission (TJC) is a monopoly, and as a monopoly, functions as the only organization that can perform third-party oversight and accreditation of hospitals and hospital organizations for participation in the Medicare program.* Others believe that TJC is an organization funded or chartered by some level of government. Both beliefs are false. However, because TJC provides “third party oversight” of the preponderance of the hospital environments in which we work, it is worth spending time and effort toward understanding what role this and other similar organizations fill, what these organizations are not, and why meeting their requirements is so important for the hospitals in which we work. Also, many physicians do not know that TJC, as well as the other organizations credentialed to accredit hospital organizations, are directly funded by fees paid by the very organizations that they visit and accredit. Selected consequences of this seldom-discussed conflict of interest (COI) will be noted. Relevance

There is clear relevance to AAEM members of understanding these hospital accreditation organizations, because earlier this year, the AAEM Board of Directors approved the creation of a Joint Commission Reform Task Force (of which I am the founding Chair). Our task force has several goals, which are outlined in a separate article in this edition of Common Sense.† One of those goals is to educate AAEM members regarding the role of hospital third party oversight/accreditation organizations, the largest of which is The Joint Commission. This article provides that education. Only by understanding the role of these organizations can emergency physicians intelligently advocate for reforms that will benefit us as health care professionals, and more importantly, the patients whom we serve. Clearly, reform is indicated. Selected examples include:

“

Many physicians and nurses believe that TJC is a monopoly, and as a monopoly, functions as the only organization that can perform third-party oversight and accreditation of hospitals and hospital organizations for participation in the Medicare program.

COMMON SENSE JANUARY/FEBRUARY 2024

THE JOINT COMMISSION (AND OTHER HOSPITAL ACCREDITATION BODIES): ADDRESSING SOME MISCONCEPTIONS

Others believe that TJC is an organization funded or “ chartered by some level of government. Third Party Oversight and Accreditation Can Be a Good Thing, and All Large Organizations Need It

•

Do not misunderstand. Clearly, TJC and the other third-party review/accreditation organizations serve an important and useful function. Here is why: All large organizations can “normalize deviance,” and hospitals and hospital systems are no exception.

•

What is meant by “normalizing deviance?” Consider the way that many hospitals handle workplace violence committed by patients or visitors against their employees. Rather than encouraging the wronged employee to file criminal charges against the perpetrator, which would be rational and proper, administrators acting on behalf of their organization instead typically ask the harmed employee, the victim, how they could have handled the situation that led to violence more effectively, so that the violence that occurred could have been avoided. This situation clearly illustrates organizational normalization of deviance! It is deviant because hospital leadership’s first inclination has been to blame the victim. Fortunately, TJC has developed new standards regarding the reporting and handling of violent incidents. This is but one example of a “good” accomplished by meaningful third-party review of hospital organizations. Unfortunately, TJC and the other hospital accrediting bodies are also large organizations, and they have demonstrably normalized deviance, by failing to enact standards to alleviate EDB&C, and by TJC’s prolonged requirement to comply with its flawed pain standard. The oversight body itself needs better oversight! Why Third-Party Accreditation and Oversight is Crucial to Hospitals

Accreditation is crucial to hospital organizations, because accreditation is a precondition to enable payment from commercial insurers, as well as from the Medicare and Medicaid programs, for services rendered to covered individuals. Without accreditation, there can be no income to hospitals. To attain accreditation, hospitals and hospital organizations must demonstrate that they meet various safety and operational requirements. The benefits to a hospital organization of maintaining accreditation are presented at the accrediting organizations’ websites, and can be summarized to include: • Continued accreditation is essential to the securing of contracts between organizations that fund health care and the organizations that provide health care.

COMMON SENSE JANUARY/FEBRUARY 2024

Accreditation facilitates health care organizations’ ability to claim to patients and potential patients that they provide quality health care. Accreditation commits health care organizations to the task of maintaining a commitment to quality.

Which Organizations Provide Oversight and Accreditation?

It is a misconception that TJC functions as a monopoly. TJC is one of four bodies that exist to accredit hospital organizations. Founded in 1951, TJC is the oldest and largest of the organizations that accredit hospitals. TJC currently accredits more than 20,000 health care organizations. Approximately 85% of hospitals that are accredited in the U.S. are accredited by TJC.5 TJC accreditations are provided to general hospitals, psychiatric hospitals, children’s and rehabilitation hospitals, critical access hospitals, home care organizations, nursing homes, rehabilitation centers, long term facilities, behavioral health organizations, addictive services, ambulatory care providers, and independent or freestanding clinical laboratories. The fee charged for the accreditation to the organization being reviewed is assessed against that organization, and the fee assessed depends upon the number of sites and number of visits required to complete the accreditation assessment.6 Other CMS-approved hospital accreditation organizations include the Accreditation Commission for Health Care (ACHC), the Center for Improvement in Healthcare Quality (CIHQ), and DNV Healthcare (DNV).7 • ACHC was founded in 1986, and has CMS deeming authority for acute care hospitals, ambulatory surgical centers, clinical laboratories, critical access hospitals, as well as several other aspects of health care of low relevance to emergency physicians. It is funded by fees assessed against the organizations seeking accreditation. • CIHQ was founded in 1999 and also has CMS-granted authority to accredit acute care hospitals, critical access hospitals and acute psychiatric hospitals. It is also funded by fees assessed against the organizations seeking accreditation. • DNV Healthcare, also known as Det Norske Veritas, was founded in 1864 in Norway as a maritime members association that guaranteed insurance for its members. Its focus in the United States is to function as a CMS-approved accreditation body for hospitals and healthcare systems. Again, it is funded by fees assessed against the organizations seeking accreditation. >>

THE JOINT COMMISSION (AND OTHER HOSPITAL ACCREDITATION BODIES): ADDRESSING SOME MISCONCEPTIONS

Other organizations in the health care accreditation space exist but do not accredit hospital organizations. Some examples include: • The Commission on Accreditation of Rehabilitation Facilities (CARF), founded in 1966, which accredits more than 6000 facilities, but limits these accreditations to organizations that provide rehabilitative care.6 • The Council on Accreditation (COA), founded in 1977, which accredits more than 1800 child and family services and behavioral health organizations.6 • The National Committee for Quality Assurance (NCQI), founded in 1990, is not in the hospital accreditation business. It accredits organizations and individuals ranging from health plans including Health Maintenance Organization (HMOs) and Preferred Provider Organizations (PPOs) to physician networks, medical groups, and individual physicians.5 The Accreditation Association for Ambulatory Health Care (AAAHC) accredits only Ambulatory Surgical Centers (ASCs).6 • The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) does what its name implies.6

expensive changes of hospital processes to allow continued accreditation, that organization would risk losing the business of that hospital organization to other accreditation bodies. Most physicians are unaware of this COI. However, awareness of this COI helps explain why accreditation organizations have not created or enforced meaningful standards that might bring about amelioration of EDB&C. Summary

This article has provided a brief overview of the organizations that accredit hospitals to participate in the Medicare and Medicaid programs, as well as that permit hospitals to be reimbursed by commercial insurers. Contrary to widely held beliefs, TJC is not a monopoly. Three other accreditation organizations exist, but only 15-20% of U.S. hospitals look to them for accreditation, and thus their market share is very small. TJC is the “gorilla in the room.” Neither TJC nor the other accreditation organizations are government entities.

“Both beliefs

Now that AAEM members have this information available, we can begin to discuss how to reform these organizations, starting with the largest one, TJC. You are encouraged to join the first official meeting of the Joint Commission Reform Task Force in Austin during the 2024 AAEM Scientific Assembly. (Editor’s note: more information regarding the task force and its AAEM24 meeting can be found in the March/April 2024 Common Sense issue due out in early April.)

are false.

Conflict of Interest

Because the fees that accrue to The Joint Commission, and indeed to all hospital accreditation organizations, are paid directly by the organization being reviewed, all of them have an inherent conflict of interest. If an accreditation organization’s site surveyor’s findings were to require References *Formerly called “The Joint Commission for Accreditation of Hospital Organizations” (JCAHO) †See page ## 1. Jointcommission.org. Common myths about the Joint Commission Pain Standards. https://www.jointcommission.org/-/media/enterprise/tjc/ imported-resource-assets/documents/pain-myths-poster11x17pdf.pdf Accessed November 29, 2023. 2. American Medical Association. Report 4 of the Council on Scientific Affairs, 2002 Annual Meeting of AMA House of Delegates. Pain management standards and performance measures. American Medical Association, Chicago, IL. 3. Baker DW. The Joint Commission’s Pain Standards. Origin and Evolution. The Joint Commission, May 5, 2017. 4. Hansen G. Assessment and management of pain. JAMA.2000;284(18): 2317-8.

5. The Joint Commission. Hospital Accreditation Fact Sheet. https://www. jointcommission.org/resources/news-and-multimedia/fact-sheets/factsabout-hospital-accreditation/#:~:text=Approximately%2080%25%20of%20 the%20nation’s,accredited%20by%20The%20Joint%20Commission. Accessed November 29, 2023. 6. BHM Healthcare Solutions. The big five health care accreditation organizations-side by side compa risons. https://bhmpc.com/calltoaction/ accreditation-comparison-cta/Accreditation-Comparison-Tool.pdf Accessed November 30, 2023 7. ACHC, www.achc.org; CIHQ, www.cihq.org; DNV, www.dnvglhealthcare. org). Centers for Medicare and Medicaid Services. CMS-approved accrediting organizations. https://www.cms.gov/medicare/providerenrollment-and-certification/surveycertificationgeninfo/downloads/ accrediting-organization-contacts-for-prospective-clients-.pdf Accessed November 30, 2023.

COMMON SENSE JANUARY/FEBRUARY 2024

Learning Auricular Hematoma Management Through a Personal “N of 1” Denis Ostick, MD and Max Cooper, MD RDMS

y left ear had a warm, tender feeling to it following a jiu-jitsu session where I spent most of it smashed into the mats. I looked in the mirror and saw two areas of swelling near the antihelix and just above the helical crus. Putting slight pressure on these “bubbles” caused a sensation of moving fluid. The clinical diagnosis of auricular hematoma was made. The blood was accumulating in a potential space made by the shearing between the perichondrium and cartilage.1,2 I knew I had to seek medical care or risk “Cauliflower Ear,” a permanent distortion due to stimulation of mesenchymal cells in the perichondrium and formation of new fibrocartilage.3 I would learn there are multiple ways to go about treating an auricular hematoma. Plan A was for needle aspiration and an external pressure dressing which was successful—until additional fluid reaccumulated in a day (Figure 1).

Figure 1. Needle Aspiration Technique

This technique was a failure despite multiple pressure dressings including gauze/tape and a commercial product consisting of two connected magnets. The dressings were bulky, required frequent changing, and struggled to maintain direct pressure on the correct sites. So on to Plan B. This time, an emergency physician performed a successful modified auricular block or “diamond block.” The auricular block anesthetizes the entire ear except the concha and meatus which are innervated by the vagus nerve (Figure 2).4 The top half of the “diamond” was all that was needed for analgesia given the area of my hematoma. Following incision and drainage, the physician utilized the “sewn-in bolster dressing technique” using a small pledget and nonabsorbable suture. The suture was placed using a through-and-through horizontal mattress approach, cinching the bolster dressings in place. For the second hematoma, an ENT physician used a larger sized pledget, but both techniques were effective (Figure 3).

Figure 2. Auricular Block

A dental roll is an alternative option for bolster dressing.2 Another option is a bolster-less (suture only) technique that has been described in the literature with great cosmetic outcome and earlier return to activity.5 Topical antibiotic ointment was applied daily while the dressings were left in place for one week. I chose to look out for perichondritis with frequent skin checks rather than take prophylactic antibiotics with pseudomonal coverage such as ciprofloxacin. Following suture removal, the ear had marked improvement back to its original shape and there was no repeat accumulation (Figure 4). >>

Figure 3. Sewn-In Bolster Dressings

COMMON SENSE JANUARY/FEBRUARY 2024

LEARNING AURICULAR HEMATOMA MANAGEMENT THROUGH A PERSONAL “N OF 1”

I learned some valuable lessons for ED management of auricular hematoma. First, timely evacuation is crucial. Cauliflower ear may be a badge of honor for some, but once fibrosis sets in, it’s essentially permanent. The only option at that point would be otoplasty, so proper counseling is important.6 Secondly, the external pressure dressFigure 4. One week post Sewn-In ing-only technique relies Bolster Dressing heavily upon patient adherence to the bulky dressings and fluid re-accumulation can still re-occur. Shared decision making with the patient should be had discussing aspiration and pressure dressing technique versus I/D and suture technique with or without a bolster dressing. I will incorporate this experience and review in my practice for any future wrestlers, boxers, or traumatic earpiercers I encounter.

References 1. Chapter 168. Auricular Hematoma Evacuation. In: Reichman EF. Eds. Emergency Medicine Procedures, 2e. McGraw Hill; 2013. Accessed November 30, 2023. https://accessemergencymedicine.mhmedical.com/ content.aspx?bookid=683&sectionid=45343816 2. Modi, S. (2020, September 9). Mastering minor care: Auricular hematoma. Taming the SRU. https://www.tamingthesru.com/blog/mastering-minorcare/auricular-hematoma#:~:text=The%20ideal%20approach%20to%20 managing,the%20re%2Daccumulation%20of%20blood. 3. Ghate, S.K., Kalambe A, Maldhure, S. Auricular haematoma an avoidable cosmetic deformity: A chance or negligence, American Journal of Otolaryngology, Volume 43, Issue 1, 2022, 103232, ISSN 0196-0709,https://doi.org/10.1016/j.amjoto.2021.103232.(https://www. sciencedirect.com/science/article/pii/S0196070921003331) 4. Hatfield, L. M. (2017, April 21). Facial nerve blocks. emDOCs.net - Emergency Medicine Education. http://www.emdocs.net/facial-nerveblocks/ 5. Kakarala K, Kieff DA. (2012). Bolsterless management for recurrent auricular hematoma. The Laryngoscope, 122(6), 1235–1237. doi: 10.1002/lary.23288 6. Auricular hematoma - statpearls - NCBI bookshelf. (n.d.). https://www. ncbi.nlm.nih.gov/books/NBK531499/

YOUNG PHYSICIANS SECTION

Countinued from page 26

Tailor Feedback to tHe Learner

Consider Using a Feedback Framework

“I think one of the things I strive to do with feedback is really tailor it to the learner, both in terms of their level of training and needs/opportunities for growth. Generally, I’ll have something in mind that I’d like to convey (based on our interactions throughout the shift), but in my opinion, the learner ideally identifies that goal independently. So, when I give feedback, I always start open ended and then narrow down. For example, ‘what did you think about the shift?’ or ‘is there something in particular you’re looking to focus on during this block/shift/time of year.’”

“Learn the SBI model (Situation, Behavior, Impact) and keep it in your pocket as a way to give effective feedback anywhere, anytime.”

Avoid Bias and Never Presume Motivation

“I think the golden rule is to never presume motivation—I speak to behaviors, their effects, and what they might do differently the next time.” “Don’t give feedback to women (or anyone) on their confidence! It’s not helpful and it’s gendered. There’s data on this. Focus on specific behaviors instead.”

A model like this helps give behavior-based feedback that is timely and actionable. Here’s an example from a mentor: ‘I noticed earlier when we were in the resuscitation bay…you were at the bedside performing an ultrasound when you were also the team leader…when you directly participate in other tasks you can lose focus on the overall resuscitation. Consider standing at the foot of the bed and staying there.’” Be Open to Receiving Feedback in Return

Remember, feedback helps you grow. References 1. Gottlieb M, Chung A, Battaglioli N, Sebok‐Syer SS, Kalantari A. Impostor syndrome among physicians and physicians in training: A scoping review. Medical Education. 2019;54(2):116-124. doi:10.1111/medu.13956

COMMON SENSE JANUARY/FEBRUARY 2024

AAEM/RSA RESIDENT JOURNAL REVIEW

Updates in Cardiac Arrest Management Authors: Stephanie Adjei, MD, Jonathan B. Hurst, MD, and Zachary R. Wynne, MD Editors: Kami M. Hu, MD FAAEM FACEP and Donald Doukas, MD

Clinical Question: What updates are there in the management of cardiac arrest? Introduction

According to the American Heart Association, there are an estimated 350,000 out-of-hospital cardiac arrests (OHCA) and approximately 290,000 in-hospital cardiac arrests (IHCA) that occur each year in the United States. As these events are associated with an overwhelmingly high mortality, it is crucial to incorporate evidence-based interventions to yield the best outcomes possible. Due the high acuity of this population, there is a scarcity of trials that appropriately challenge many of our current practices and guidelines. Here we discuss recent updates in interventions that one may consider utilizing more or less frequently during their next cardiac arrest resuscitation. Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. New Engl J Med. 2018;379(8):711-721. doi:10.1056/nejmoa1806842

Current ACLS guidelines recommended administration of 1mg of epinephrine every three to five minutes via intravenous (IV) or interosseous (IO) access. The PARAMEDIC2 trial was a multicenter, randomized, double-blind, placebo-controlled trial which looked to determine if epinephrine is an effective treatment for OHCA. Eligible patients were those who suffered OHCA in a participating ambulance region within the United Kingdom. Exclusion criteria included those with known or apparent pregnancy, age less than 16 years, etiology of cardiac arrest being either anaphylaxis or asthma, or the administration of epinephrine prior to a trial-trained paramedic. Patients were randomized to trial medications if initial attempts at resuscitation with CPR and defibrillation were unsuccessful, receiving either 1mg of epinephrine or saline administered IV or IO every three to five minutes. Treatments continued until there was sustained return of spontaneous circulation (ROSC), resuscitation was discontinued, or care was transferred to the receiving hospital. The primary outcome was the rate of survival at 30 days. Secondary outcomes included hospital and ICU length of stay (LOS), rates of survival until hospital admission, discharge, and at three months, and neurologic outcomes at hospital discharge and at three months. Of the 10,623 patients screened for participation in the trial, 8,103 were eligible and 8,014 were eventually randomized with 4,015 patients in the epinephrine group and 3,999 in the placebo group. Baseline characteristics were similar between groups, including etiology of arrest, rates of bystander CPR, and shockable versus unshockable rhythm, as well as time to emergency medical services and key treatment events. Rate of ROSC was higher in the epinephrine group (36.3%) compared to the placebo group (11.7%), as was survival at 30 days (13.2% versus 2.4%, respectively, p=0.02).There was no significant difference between groups 34

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for survival at 30 days with a favorable neurologic outcome, defined as a modified Rankin scale (mRS) score of three or less (epinephrine group 2.2%, placebo group 1.9%, CI 0.86-1.61). In addition, survival with a severe neurologic disability (mRS of four or five) was more common in the epinephrine group (31.0%) compared to the placebo group (17.8%). The trial had several limitations. First, patients with early ROSC were excluded, limiting generalizability of the study’s results to this cohort. The quality of CPR was only collected for the first five minutes of resuscitation in a small minority of patients. Also, 1mg of epinephrine was used exclusively after initial efforts at resuscitation had failed. It is unclear whether CPR quality, varying dosing strategies, or earlier use of epinephrine could play a role in outcomes. There was also a 20 percent loss of follow-up in both groups, making conclusions about secondary outcomes less clear. In conclusion, the PARAMEDIC2 trial showed that the use of epinephrine for treatment of OHCA resulted in increased survival but with a higher proportion of survivors with severe neurological impairment. Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest. JAMA. 2021;326(22):2268. doi: 10.1001/jama.2021.20929

Data supporting empiric calcium administration during cardiac arrest is scarce, but it is still commonly given in various settings. Vallentin et al. completed a similar study to the PARAMEDIC2 trial, instead seeking to investigate if administering calcium either IV or IO during OHCA resuscitation increases likelihood of ROSC. This investigator-initiated, placebo-controlled, parallel group, double-blind, superiority, randomized clinical trial occurred in central Denmark, which utilizes a two-tiered EMS system responding to cardiac arrests via ambulance with a physician-manned mobile emergency care unit. Patients with ROSC or continued CPR were taken to a university hospital with capabilities for coronary catheterization and percutaneous coronary intervention, extracorporeal cardiopulmonary resuscitation, and care after cardiac arrest (e.g., targeted temperature management). Eligible patients included adults (≥18 years old) with OHCA who received at least one dose of epinephrine. Patients were excluded if there was known or suspected pregnancy, arrest due to trauma, prior enrollment, epinephrine given from a unit that was not included in the trial, or presence of a known clinical indication for calcium during the arrest (ex. hypocalcemia, hyperkalemia). The intervention arm received a rapid bolus of 5mmol calcium chloride (200mg calcium or 735mg of calcium chloride dihydrate), while the placebo arm received 9mg/mL of sodium chloride. The trial drug was given immediately following the first dose of epinephrine. If the patient remained pulseless a second dose of >>

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the trial drug could be given after the second dose of epinephrine. Sustained ROSC was the primary outcome, defined as “spontaneous circulation with no further need for chest compressions for at least 20 minutes.” Secondary outcomes included 30-day survival, 30-day survival with a favorable neurologic outcome (a score of zero to three on mRS). Tertiary outcomes included health-related quality of life (via 5-dimensional, 5-level EuroQol on a scale of 0 to 100, with higher scores indicating a higher health-related quality of life) at 30 days, 90 days, 180 days, and one year. The published study included results from 30- and 90-days. Organ dysfunction via the Sequential Organ Failure Assessment score was collected at 2, 24, 48, and 72 hours after the cardiac arrest. The trial was halted early once the independent data and safety monitoring committee recommended discontinuing the trial due to concerns for harm in the calcium group. This came as a result of unblinded data from an initial 383 patients included during the trial. During this time period, there were 1,221 total out of hospital cardiac arrests in the central Denmark region, and 397 had received the investigation drug. Of these, six patients were excluded due to traumatic cardiac arrest, and they were further divided into 193 patients in the calcium group versus 198 patients in the saline group. Baseline characteristics between the two groups were similar; on average, 68-year-old majority male (71%) patients who experienced cardiac arrest at home (82%) with an initial non-shockable rhythm (75%). Median time from cardiac arrest to the drug administration was 18 minutes, most commonly via IO (60%). Two doses of the trial drug were given to 73% of patients. The primary outcome of continued ROSC occurred in 19% of the calcium group and 27% of the placebo group (RR 0.72 [95% CI, 0.49-1.03], p=0.09). There were similar outcomes for any return of ROSC and ROSC at hospital arrival between groups. There was a trend toward decreased survival at 30 days in the calcium group compared to placebo (5.2% versus 9.1%; risk ratio 0.57 [95% CI 0.27-1.18]; risk difference, −3.9% [95% CI −9.4%-1.3%]; P=.17), as in the incidence of favorable neurological outcome (3.6% versus 7.6%; risk ratio 0.48 [95% CI 0.201.12]; risk difference, −4.0% [95% CI −8.9%-0.7%]; P=.12). Regarding tertiary outcomes, the quality-of-life scores were decreased in the calcium group. In summation, treatment with calcium versus normal saline placebo did not yield significant differences for obtaining ROSC, overall survival, or favorable neurologic outcomes. The study unfortunately was halted early due to concerns that patients receiving calcium had worse outcomes and is therefore unable to defend the routine use of empiric calcium during out of hospital cardiac arrests. Andersen LW, Isbye D, Kjærgaard J, et al. Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest. JAMA. 326(16):1586–1594. doi:10.1001/jama.2021.16628

Granfeldt A, Sindberg B, Isbye D, et al. Effect of Vasopressin and Methylprednisolone vs. Placebo on Long-Term Outcomes in Patients with In-Hospital Cardiac Arrest A Randomized Clinical Trial. Resuscitation. 2022 Apr 28:S0300-9572(22)00135-6. doi: 10.1016/j. resuscitation.2022.04.017

Diving further to investigate other medications used during cardiac arrest, the VAM-ICHA trial (Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest) trial sought to determine if the incorporation of vasopressin and glucocorticoids increases ROSC during in-hospital cardiac arrest. Results of the longer-term follow-up were presented by Granfeldt et al. This multicenter, randomized, double-blind, placebo-controlled trial coordinated between 10 Denmark hospitals consisted of 512 adult patients who suffered IHCA. Eligible patients included those who received at least one dose of epinephrine during the cardiac arrest. Exclusion criteria included OHCA, an active do-not-resuscitate order, previous trial enrollment, presence of invasive mechanical circulatory support (ex. extracorporeal circulation or left ventricular assist device), or pregnancy. Patients were randomized to receive infusion of drug from kits containing either 9mg/mL of sodium chloride (placebo) or vasopressin 20 IU and methylprednisolone 40mg. Medications were given soon after the first dose of epinephrine. Subsequent doses of vasopressin could be given following each epinephrine dose up to a max of four doses (80 IU). ROSC was selected as the primary outcome, while secondary outcomes included survival at 30 days, survival at 30 days with favorable neurologic outcome (a Cerebral Performance Category [CPC] Score of one or two). Neurologic outcome by mRS and health-related quality of life assessment at 30, 90, 180 days and one year were also assessed, with the 30- and 90-day results available at time of publication. Organ dysfunction following ROSC was measured with the Sequential Organ Failure Assessment (SOFA) score over the following 24, 48, and 72 hours after cardiac arrest, and vasopressor- and ventilator-free days in the first 14 days after arrest were noted. A total of 501 patients were included in the trial, 237 in the methylprednisolone/vasopressin group and 264 in the placebo group. The two groups were of similar profiles; the majority of patients were male (64%) with an average age of 71 years, and 90% of the cases presented with an initial nonshockable rhythm. Median time to administration of epinephrine was five minutes and eight minutes, respectively. ROSC was achieved in 42% of the intervention group compared to 33% in the placebo group (risk ratio 1.30, 95%CI 1.03-1.63; risk difference 9.6%, 95% CI 1.1%-18.0%, p=0.03). When controlling for site and prognostic factors the risk ratio was noted to be higher: 1.38 (95% CI 1.1-1.72). Median time to ROSC was 16 minutes in the intervention group compared to 18 minutes in the placebo group. >>

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With respect to secondary outcomes, there was no difference in survival at 30 days (9.7% in the intervention group compared to 12% in the placebo group) or survival with a favorable neurological outcome, either by CPC or mRS score. There was no difference for the health-related quality of life at 30 days or 90 days, and no difference between groups for post-cardiac arrest organ dysfunction. Long term outcomes of the trial showed no difference between groups in survival, favorable neurologic outcome, or health-related quality of life at six months or one year. Strengths of the current trial included its relatively large sample size, multicenter capability, dedication to try to replicate real clinical scenarios, and ability to obtain data in regard to long term outcome without any loss to follow-up. Limitations included a relatively high number of potentially eligible patients who were excluded (for example, due to logistic reasons or treating physician preference) which may have introduced bias. Also, some patients had delays in drug delivery which might have influenced the results, but this is also valid as it replicates real-life clinical practice. A high proportion of patients had pulseless electrical activity (PEA) as their initial rhythm, and results may not be as generalizable across other groups. There was also no data provided regarding proportion of patients with fever post-ROSC, which could have been a confounding factor. Next, the rates of ROSC in the trial were actually lower than the study was powered for, potentially leading to incorrectly finding a difference where one does not exist. With a fragility index of three, this study’s evidence that vasopressin and methylprednisolone improve rates of ROSC remains tenuous, without evidence of any other benefit in the IHCA population. Cheskes S, Verbeek PR, Drennan IR, et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. New Engl J Med. 2022;387. doi: 10.1056/nejmoa2207304

Cheskes et al. sought to determine if there was a difference in outcomes in cardiac arrest with alternative defibrillation strategies. Prior observation studies had shown no significant difference between alternative defibrillation strategies but were lacking specific timing and requirements for shock attempts and CPR. This cluster-randomized trial was conducted with six Canadian paramedic services in the Ontario province. Each paramedic service was randomized to one of three defibrillation strategies: double sequential external defibrillation (DSED) defined as anterior-lateral and anterior-posterior placement, vector-change (VC) defibrillation, defined as switching from anterior-lateral to anterior-posterior placement with single set of pads, and standard defibrillation with anterior-lateral placement. Eligible patients, enrolled from September 10, 2019, to May 18, 2022, were 18 years of age or older presenting with OHCA with refractory ventricular fibrillation (VF) of presumed cardiac cause (initial rhythm of VF or pulseless ventricular tachycardia that was present after three consecutive rhythm analyses). Traumatic cardiac arrests, patients with do-not-resuscitate orders, and cardiac arrest due to drowning, hypothermia, hanging, or suspected drug overdose were excluded. Each paramedic service crossed over every six months between these treatment groups. 36

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The primary outcome measured was survival to hospital discharge. Secondary outcomes included termination of VF, ROSC, and good neurologic outcome at hospital discharge (mRS score of two or lower). A total of 405 patients were enrolled: 136 in the standard group, 144 in the VC group, and 125 in the DSED group. Over two-thirds of arrests were witnessed by bystanders and 58% received bystander CPR. Median age was 63.6 years old and 84.4% were men, with 30.4% of DSED patients (adjRR 2.21; 95% CI 1.33-3.67) and 21.7% of VC patients (adjRR 1.71; 95% CI 1.01-2.88) survived to hospital discharge compared to 13.3% of standard group. Termination of VF occurred in 84.0% of DSED group (adjRR 1.25, 95%CI 1.09-1.44) and 79.9% of VC group (adjRR 1.18, CI 1.03-1.36) compared to 67.6% in the standard group. ROSC occurred in 46.4% of the DSED group (RR 1.72, CI 1.22-2.42) and 35.4% of the VC group (RR 1.39, CI 0.97-1.99) compared to 26.5% in the standard group. Survival with good neurologic outcome occurred in 27.4% of the DSED group (RR 2.21, CI 1.26-3.88) and 16.2% of the VC group (RR 1.48, CI 0.81-2.71) compared to 11.2% in the standard group. A fragility index was calculated and suggested that a change in nine patients in the DSED or one patient in the VC group would have caused the primary outcome to become nonsignificant. Both DSED and VC strategies were associated with statistically significant increases in survival to hospital discharge and termination of VF compared to standard care. DSED alone was associated with statistically significant increase in ROSC and survival with good neurologic outcome compared to standard care. Of note, this study was not powered to see differences between the DSED and VC strategies. This trial did an excellent job standardizing CPR and the remainder of the ACLS protocol (medication dosing and timing, compression fraction, etc.), making the chance of confounders less likely. Additionally, the cross-over protocol with EMS units minimized the chance of regional or unit-based differences in outcomes confounding the results. The results certainly support the DSED strategy. VC did show increased survival and termination of VF compared to standard care. As DSED strategy may be difficult to implement in rural and resource limited settings, VC may have potential benefits and might be easier to implement, especially in the prehospital setting. Strengths of this trial included cluster-randomized design, well controlled and standardized CPR, and relevant outcomes. Limitations included limited sample size as trial was stopped early, and lack of fixed follow up time. Overall, DSED and VC strategies in refractory VF were shown to have improved survival to hospital discharge compared to standard care in OHCA. Yannopoulos D, Bartos J, Raveendran G, et al. 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. The Lancet. 2020;396(10265):1807-1816. doi:https://doi.org/10.1016/s0140-6736(20)32338-2 >>

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The ARREST trial was a phase two, single-center, open-label, randomized clinical trial performed at the University of Minnesota to compare survival rates following OHCA in those managed with early veno-arterial extracorporeal membrane oxygenation (VA-ECMO) versus standard ACLS. Patients were included following OHCA in which the initial rhythm was either VF or pulseless VT with ROSC not achieved after three defibrillation attempts. Patients had ongoing CPR via a mechanical chest compression device. Exclusion criteria included: EMS to emergency department transport time greater than 30 minutes, etiology of arrest being blunt, penetrating, or burn-related injury, drowning, or overdose, known pregnancy, prisoner status, nursing home resident status, terminal cancer, cardiac catheterization laboratory not being available, absolute contraindications to angiography, contrast allergy, if resuscitation discontinuation criteria were met for ECMO-group only (two or more of the following: end-tidal CO2 <10mmHg, PaO2 <50mmHg, SpO2 <85%, lactate >18mmol/L), or active gastrointestinal or internal bleeding. After meeting the inclusion and exclusion criteria, patients were randomized to undergo further resuscitation via ECMO or standard ACLS. In those randomized to the early ECMO-facilitated resuscitation group, patients were transported immediately to the cardiac catheterization laboratory for VA-ECMO cannulation and angiography performed as clinically necessary. In those randomized to the standard ACLS group, patients were transported to the emergency department for further care. Resuscitation continued for at least 15 minutes after arrival. After this, ROSC was either achieved or the resuscitation could be discontinued at the emergency physician’s discretion. Patients could then be transferred for angiogram, angioplasty, or circulatory support as needed. The primary outcome was survival to hospital discharge. Secondary outcomes included survival with favorable neurologic outcome (defined as modified Rankin score of three or less) at hospital discharge and three months. During the trial period, 36 patients were screened with 30 randomized, 15 patients to the ECMO group and 15 patients to the standard ACLS group. One patient in the ECMO group withdrew consent following randomization and was not included in primary analysis. Aside from trial interventions, patient characteristics and treatments were similar between groups. Survival to hospital discharge was more common in the ECMO group compared to the standard ACLS group (43% versus 7%, p<0.0001). Survival at three and six months was also improved in the ECMO group (p=0.0063). All survivors in the ECMO group had favorable neurologic assessment scores at six months. The single survivor in the ACLS group had a modified Rankin score of five at hospital discharge and died prior to completion of the three-month interval; comparisons for neurologic status between groups could not be calculated. The trial was discontinued following interval assessment of results due to superiority of early ECMO-facilitated resuscitation as compared to ACLS treatment. This trial had several limitations. First, it was performed at a single center with infrastructure and expertise to facilitate cannulation and further care

of critically ill ECMO patients. The results may lack generalizability to other facilities that lack similar resources within the EMS and inpatient teams. A larger-scale, multicenter, phase three trial is necessary to further assess the results seen in this trial. Conclusion

There are proposed mechanisms for a benefit in survival with a tradeoff of deleterious effects on neurologic outcomes with the use of epinephrine in OHCA. The alpha-adrenergic stimulation leads to arterial vasoconstriction and improvements in aortic diastolic pressure and coronary perfusion pressure during CPR. It may also lead to deleterious effects due to platelet activation promoting thrombosis and potential impairment in cerebral microvascular blood flow, worsening cerebral ischemia during CPR and heightening cerebral injury once ROSC is achieved. Vasopressin’s role as a vasoactive agent carries a similar theoretical benefit to coronary perfusion pressure, although previous studies have not shown benefit in OHCA. Other studies have demonstrated lower cortisol levels in non-OHCA survivors than in survivors, leading to the postulation that non-survivors may have a hindered endocrinologic response. The VAM-ICHA study did report a benefit to ROSC with use of methylprednisolone and vasopressin, but the true statistical significance, in light of lower ROSC rates and a low fragility index, call the results into question, and no survival benefits were seen. The success of early VA-ECMO for resuscitation in refractory cardiac arrest with a shockable rhythm has been proposed to be related to three mechanisms. Early ECMO provides normalization of perfusion, allows for cardiopulmonary support while the etiology of arrest is investigated, and allows time for additional therapies to be delivered. Clinical Question: What updates are there in the management of cardiac arrest? Answer: Epinephrine in OHCA increases likelihood of ROSC but does not improve rates of survival with favorable neurologic outcome, and actually carries a higher rate of severe neurologic disability in survivors. There remains no support for the empiric administration of calcium in OHCA, with potential for worsened outcomes with its use. Utilization of double-sequential external defibrillation and vector change defibrillation in the management of refractory VF resulted in improved arrhythmia termination and survival to discharge compared to maintaining standard A-L pad placement, and early VA-ECMO cannulation improved survival and survival with favorable neurologic outcome in a specific subset of patients suffering OHCA with a shockable rhythm. For IHCA, the use of methylprednisolone and vasopressin may result in higher chance of ROSC, but without other survival or neurologic benefits.

COMMON SENSE JANUARY/FEBRUARY 2024

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

Positions Available For further information on a particular listing, please use the contact information listed. Section I: Positions listed in Section I are in compliance with elements AAEM deems essential to advertising in our job bank. Fairness practices include democratic and equitable work environments, due process, no post contractual restrictions, no lay ownership, and no restrictions on residency training and have been given the AAEM Certificate of Workplace Fairness. Section II: Positions listed in Section II are in compliance with elements AAEM deems essential to advertising in our job bank. Fairness practices include democratic and equitable work environments, due process, no post contractual restrictions, no lay ownership, and no restrictions on residency training but have not been given the AAEM Certificate of Workplace Fairness. Section III: Positions listed in Section III are hospital, non-profit or medical school employed positions, military/government employed positions, or an independent contractor position and therefore cannot be in complete compliance with AAEM workplace fairness practices.

SECTION I: POSITIONS RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK CRITERIA AND GIVEN THE AAEM CERTIFICATE OF WORKPLACE FAIRNESS COLORADO

Southern Colorado Emergency Medical Associates (SCEMA) is hiring full time and part time emergency medicine physicians. Must be BC/BE in emergency medicine. We are looking for hard-working team players to join our group. SCEMA is a rare, democratic group of over 30 years based in Southern Colorado with a 2-year partnership track. Come live and work in the beautiful Front Range of Colorado. We offer a superior financial package including a competitive hourly compensation pre-partnership with initial hiring range of 230K-280K and partnership income based on productivity. Partners average over $370k/yr, plus additional benefits valued over $70k/yr including 13% profit sharing in a 401k, a SCEMA funded cash

balance plan, $6k/yr CME, and productivity bonuses. Full time status only requires approximately 14 shifts/month, 8-10 hours shifts, between two facilities based in Pueblo, CO associated with Parkview Medical Center. Please email Dr. Whitney at mcwhit515@gmail.com for further information. (PA 2011) Email: mkodonnell7@gmail.com

VIRGINIA

DEMOCRATIC GROUP TOP TIER COMPENSATION EQUAL PARTNERSHIP Fredericksburg Emergency Medical Alliance (FEMA) in Fredericksburg, Virginia. We are a small democratic group located an hour south of Washington DC currently staffing 3 EDs in the Mary Washington Health Care system.

We are looking to hire several new partners after a couple of recent retirements and the addition of a new freestanding ED, anticipated opening in 2024. Mary Washington ED is a level 2 trauma center with annual volumes of ~65k. Stafford is a community hospital ED that sees ~40k. Our Lee’s Hill FSED is on track to see ~35k this year. We use EPIC EMR, are supported by FEMA-employed APPs and scribes, and offer equitable scheduling from day one. We operate under a fee for service payment model. Top tier compensation. Please upload CVs to www.femainc.com or send directly to Cheema.samia1@gmail. com Feel free to reach out if you have any questions! (PA 2005) Email: aalvarezfema@gmail.com Website: https://www.femainc.com/

SECTION II: POSITIONS RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK CRITERIA CALIFORNIA

California Rare Northern California partnership opportunity. We are members of AAEM-PG! We are Mountain Medicine P.C. in Yreka, California. We staff a beautiful ED with everything that you could want as an emergency physician. We are a level 4 trauma center seeing about 12,500 patient per year with APP coverage. Short, transparent partnership track. $275 per hour. Yreka is situated in the Shasta Valley & surrounded by the Klamath Mountains. Small town feel, relaxed lifestyle and one of the most affordable places to live in California. Alpine living with hiking, fishing and camping right outside of your doorstep as well as some of the nation’s best backcountry skiing and mountaineering. Live in nearby Mount Shasta, a spiritual and outdoor recreation mecca, or in Ashland, Oregon, an academic and cultural hub hosting Southern Oregon University and The Oregon Shakespeare Festival. Opportunities abound! Contact: recruitment@ruralpacmed.com (PA 2022) Email: recruitment@ruralpacmed.com

COLORADO

CarePoint Health is seeking Full Time Emergency Physicians to join their team in Denver, Colorado. CarePoint is an independent democratic physician-owned and led practice. We have no outside investors or debt and have over 300 equal physician owners. We staff six busy Denver Metro Emergency Departments and seven Freestanding Emergency Departments. We offer a highly competitive incentive/benefits package, and a three year partnership track. Apply to learn more! (PA 2030) Email: hduncan@carepointhc.com Website: https://carepointhc.com/

IDAHO

Full-time opportunity available within the EPIC TVI Division at West Valley Medical Center. West Valley Medical Center is a 27k visit ED with 12-hour single covered shifts and 30 hours of overlapping APP coverage M-F and 20 hours of APP coverage Sat and Sun. West Valley Medical Center is located in Caldwell, Idaho (Boise is 20 minutes away). Annual volume of approximately 27,000. Daily volume averages approximately 74. Admission rate of approximately 13%. Associate rate starts at $200/hour. This is a 2-year partnership position with benefits. (PA 2028) Email: hduncan@carepointhc.com Website: https://carepointhc.com/

KENTUCKY

Full-time Emergency Department physician positions available summer of 2024. Looking for emergency medicine residency trained physicians ABEM eligible or certified. Compass Emergency Physicians is a democratic group located in Northern Kentucky. We staff the six hospitals owned by St. Elizabeth Healthcare. Five of the hospitals are in Northern Kentucky and one of the hospitals is in southeastern Indiana. Our group consists of 54 ABEM certified physicians and 40 APPs. (PA 2007) Email: rgeers@compassemergencyphysicians.com Website: http://compassemergencyphysicians.com

KANSAS

CarePoint Health is seeking well-trained emergency physicians to join our practice in Wichita, Kansas. Our team is responsible for covering four Emergency Departments in Wichita, including Wesley Medical Center: A Level I Trauma Center. Completion of an ACGME accredited emergency medicine residency is required. New graduate emergency medicine physicians and Visa applicants are encouraged to apply. The Wall Street Journal just ranked Wichita a top place to live based on its affordable cost of living, excellent housing opportunities, excellent job market, wonderful cultural opportunities, and a strong community spirit. (PA 2029) Email: hduncan@carepointhc.com Website: https://carepointhc.com/

COMMON SENSE JANUARY/FEBRUARY 2024

SECTION III: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA 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 is 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. For more information, email your CV and cover letter to recruit@cchealth.org. EOE (PA 2023) Email: recruit@cchealth.org

COLORADO

The Department of Emergency Medicine of the Denver Health and Hospital Authority is recruiting a passionate and talented Emergency Physician to serve as Clerkship Director and Assistant Residency Program Director for the Denver Health Residency in Emergency Medicine (DHREM). The Clerkship Director will be responsible for the education of emergency medicine bound medical students at both Denver Health and the University of Colorado School of Medicine, ongoing mentorship for EM-bound students as core EM Specialty-Specific Advisor, and oversight of off-service residents/fellows rotating through the Denver Health emergency department. As an Assistant Residency Director, this position will serve as a core member of the Residency Leadership team, focusing on projects related to health equity and pipeline programs, recruitment, and supporting all educational and academic missions of the residency program. The Denver Health Residency in Emergency Medicine is one of the oldest and most highly regarded Emergency Medicine training programs in the country with a longstanding legacy of training future leaders in our specialty. The department educates over 60 local and visiting emergency-medicine-bound students each year, providing an unparalleled clinical experience with students working at both of our core clinical sites, Denver Health and the University of Colorado Hospital. Students are exposed to our breadth of faculty expertise through didactics, mentorship, and unique educational opportunities focusing on Emergency Medical Service (EMS), Social Emergency Medicine, and Ultrasound. With one of the first funded externships for Underrepresented in Medicine (UiM) Emergency Medicine applicants in the country, our department continues to push opportunities to support and diversify our program and our specialty. With more than 12 fellowship programs across our core institutions, the Department of Emergency Medicine has a deep commitment to educational excellence and scholarship and a robust group of hard-working and committed educators. Applicants should submit CV and cover letter to: Aaron Ortiz, Manager Provider Recruitment aaron.ortiz@dhha.org (PA 2015) Email: aaron.ortiz@dhha.org Website: https://www.denverhealth.org

COLORADO

The Department of Emergency Medicine at Denver Health Medical Center is recruiting a passionate and talented Emergency Physician to serve as Director of Quality and Safety. This position will serve as a core member on our clinical operations team, focusing on setting strategy, implementing initiatives and tracking outcomes related to the quality and safety of the care provided to our patients. The emergency department at Denver Health includes 57 adult beds, 19 pediatric beds, and a separate 23-bed clinical decision unit. With a combined annual census of more than 100,000 patients from highly diverse cultures and backgrounds, the ED at Denver Health is the second busiest in Colorado. The Ernest E Moore MD Shock Trauma Center at Denver Health is the primary trauma referral center for the Rocky Mountain Region. Additionally, the acuity managed by the adult ED is high, with a 25% admission rate. Staffing in the adult and pediatric EDs is provided by board-certified emergency physicians, emergency medicine residents and subspecialty fellows, and advanced practice providers. Strong and extremely collaborative relationships exist among physicians, advanced practice providers, nursing, and consultative services. Denver Health is a large urban health care center that is proud to serve as a primary Anchor Institution to the Denver metro area, and its diverse community. Denver Health is a major academic affiliate of the University of Colorado School of Medicine, based at the

COMMON SENSE JANUARY/FEBRUARY 2024

University of Colorado Anschutz Medical Campus. All faculty ultimately report to the Director of Service for Emergency Medicine at Denver Health, contributing to our mission of excellence in patient care, education, research, and professional development, and have meaningful responsibilities and faculty appointments in the University of Colorado School of Medicine’s academic Department of Emergency Medicine. Applicants should submit CV and cover letter to: Aaron Ortiz, Manager Provider Recruitment aaron.ortiz@dhha.org (PA 2016) Email: aaron.ortiz@dhha.org Website: https://www.denverhealth.org

COLORADO

The Department of Emergency Medicine at Denver Health Medical Center is recruiting a passionate and talented senior Emergency Physician to serve as Director of Diversity, Equity, Inclusion and Belonging. This position will serve as a core member on our department’s leadership team, developing, implementing, and monitoring outcomes of strategies to enhance our departmental DEIB efforts, institutional including the recruitment, retention, and support of faculty. The emergency department at Denver Health includes 57 adult beds, 19 pediatric beds, and a separate 23-bed clinical decision unit. With a combined annual census of more than 100,000 patients from highly diverse cultures and backgrounds, the ED at Denver Health is the second busiest in Colorado. The Ernest E Moore MD Shock Trauma Center at Denver Health is the primary trauma referral center for the Rocky Mountain Region. Additionally, the acuity managed by the adult ED is high, with a 25% admission rate. Staffing in the adult and pediatric EDs is provided by board-certified emergency physicians, emergency medicine residents and subspecialty fellows, and advanced practice providers. Strong and extremely collaborative relationships exist among physicians, advanced practice providers, nursing, and consultative services. Denver Health is a large urban health care center that is proud to serve as a primary Anchor Institution to the Denver metro area, and its diverse community. Denver Health is a major academic affiliate of the University of Colorado School of Medicine, based at the University of Colorado Anschutz Medical Campus. All faculty ultimately report to the Director of Service for Emergency Medicine at Denver Health, contributing to our mission of excellence in patient care, education, research, and professional development, and have meaningful responsibilities and faculty appointments in the University of Colorado School of Medicine’s academic Department of Emergency Medicine. Applicants should submit CV and cover letter to: Aaron Ortiz, Manager Provider Recruitment aaron.ortiz@dhha.org (PA 2017) Email: aaron.ortiz@dhha.org Website: https://www.denverhealth.org

CONNECTICUT

Trinity Health Of New England seeks BC/BE EM Physicians to join our emergency medicine teams at Mercy Medical Center in Springfield, Massachusetts, Saint Francis Hospital and Medical Center in Hartford, Connecticut and Saint Mary’s Hospital in Waterbury, Connecticut. Our practice model empowers our physicians to work at their highest level, while allowing time for professional development and family life. Whether you are focused on providing outstanding patient-centered care or driven to grow into a leadership role, you will thrive at Trinity Health Of New England. To learn more, visit our provider portal at www. JoinTrinityNE.org (PA 2024) Email: dhowe@trinityhealthofne.org Website: https://www.jointrinityne.org/Physicians

DELAWARE

ChristianaCare, a recognized leader in healthcare, is seeking Emergency Medicine Physicians. You will be part of a dynamic team covering four state-of-the-art Emergency Departments in Delaware and Maryland. Why ChristianaCare? • The ED’s at ChristianaCare’s Christiana Hospital, Wilmington Hospital, Union Hospital, and the free-standing emergency department in Middletown, Delaware treat a combined total of more than 225,000 patients each year. • Christiana Hospital ranks in the top 25 in the country for emergency visits and is Delaware’s only Level I trauma center that treats adults and children - the only center of its kind between Philadelphia and Baltimore. (PA 2019) Email: megan.hopkins@christianacare.org Website: https://christianacare.org/us/en

FLORIDA

The Schmidt College of Medicine at Florida Atlantic University is seeking an Assistant Program Director to join its Emergency Medicine Residency Program. This position is intended for faculty with experience in teaching, leadership, innovation and

clinical service in an emergency medicine residency program. All applicants must apply electronically on the FAU Office of Human Resources’ career website (https://fau.edu/jobs) by completing the required online employment application. When completing the online application, please upload the required cover letter and curriculum vitae. To review the full minimum qualifications and requirements and to apply, visit www.fau.edu/jobs and go to Apply Now (REQ16576). (PA 2010) Email: none@notavailable.com Website: https://fau.wd1.myworkdayjobs.com/en-US/FAU/job/ Clinical---Off-Campus-Location-COM-use-only/AssociateProgram-Director--Emergency-Medicine-Residency--AssistantAssociate-Professor-_REQ16576?q=REQ16576

LOUISIANA

Ochsner Health is seeking board certified/board eligible physicians to join our Division of Pediatric Emergency Medicine at Ochsner Medical Center and Ochsner Hospital for Children. Our opportunity includes an employed physician group that offers competitive fair market compensation plus benefits; an in-house pediatric intensivist and hospitalist attendings 24/7 to assist with streamlined pediatric admissions and patient care; all facilities utilizing Epic electronic health records integrating care across the system and facilitating seamless multi-hospital practice; and all specialties available for consultation and easy one-call transfer from our community emergency departments to our main campus. (PA 2033) Email: courtney.lawhun@ochsner.org Website: https://ochsner.wd1.myworkdayjobs.com/ OchsnerPhysician/job/New-Orleans---New-Orleans-Region--Louisiana/Pediatric-Emergency-Medicine_REQ_00158668

MINNESOTA

Mayo Clinic is seeking board-certified and board-eligible Emergency Medicine Physicians to join our world-class clinical and academic communities throughout the country. You can choose from opportunities at our large medical centers in Minnesota, Arizona, and Florida, or a community-based practice within Mayo Clinic Health System locations across Minnesota, Iowa, and Wisconsin. Ranked as the #1 hospital in the nation by U.S. News & World Report in 2022-2023, Mayo Clinic physicians deliver excellence in patient care through active engagement in clinical care, teaching, research, and leadership. A Mayo Clinic Career Offers: •Competitive Compensation •Comprehensive Benefit Package (https://jobs.mayoclinic.org/ benefits) •Funded CME and travel days •Generous Relocation Assistance •Malpractice covered by Mayo Clinic To view and apply to current opportunities, please visit jobs.mayoclinic.org/ emergencymedicine. (PA 2003) Email: hooks.aaron@mayo.edu Website: https://jobs.mayoclinic.org/emergencymedicine

MINNESOTA

Winona Health is seeking a BC/BE EM Physician to join our Emergency Medicine team located in a Midwest college community along the banks of the Mississippi River. • Full-time and part-time, employed positions joining an established team of Physicians, Physician Assistants, nurses and support staff • Full-time and part-time nights or day/night opportunities • Responsible for the acute care of ER patients • 11,000-12,000 visits annually • Level IV trauma and stroke certified facility • Electronic Medical Record, CPOE, patient tracking, bedside US, Dragon • Progressive team of providers committed to quality; evidence-based care, exceptional patient satisfaction; and integrated technology • Competitive hourly compensation & benefits package including sign-on incentive, paid malpractice with tail coverage, $7,500 annual CME & dues/license, moving expenses, health/life/dental insurance, retirement programs and more (PA 2031) Email: dholtzclaw@winonahealth.org Website: http://www.winonahealth.org

NEW YORK

Stony Brook University and the Renaissance School of Medicine seek an accomplished and dynamic academic leader to serve as the Chair, Department of Emergency Medicine. This is an extraordinary opportunity for a new Chair to lead a highperforming group of distinguished faculty and staff to further the advancement of clinical care, education, and research in Emergency Medicine within an exceptional, growing University and academic healthcare system. The Department of Emergency Medicine, recognized as a regional leader for comprehensive care - providing contemporary emergency services, is home to 50 accomplished adult and pediatric faculty, a robust residency program, and five fellowship programs. Emergency Medicine is

SECTION III: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA — continued one of 25 academic departments in the Renaissance School of Medicine at Stony Brook University, conducting research and providing services to a patient population of 1.5 million people in Suffolk County on Long Island in New York. The Renaissance School of Medicine is a public medical school in Stony Brook, New York; it is part of Stony Brook University, a designated flagship institution of the State University of New York (SUNY) system and one of 62 members of the Association of American Universities (AAU) - the invitation-only organization of the best research universities in North America. The School of Medicine educates 500+ medical students, 750+ residents and fellows with 57 ACGME accredited residencies and fellowships in a broad range of specialties. The School of Medicine is one of five health sciences schools within the overarching Stony Brook Medicine organization, which is also home to 628-bed Stony Brook University Hospital and Stony Brook Children’s Hospital, Long Island’s premier academic medical center, two additional community hospitals and multiple outpatient care sites. The successful candidate will bring exceptional leadership and operational skills, the ability to enhance clinical operations in emergency medicine across the system and build upon an exceptional research and educational programs. This leader will provide strategic leadership of adult and pediatric emergency services and shape the advancement of a comprehensive emergency medicine clinical care model. The Chair, in collaboration with senior leadership, will foster innovative care delivery models, viable approaches to enhance patient throughput, length of stay, reduction in cost, and elevate the patient experience. This leader will have demonstrated success leading within a complex academic health system and possess the ability to initiate and lead change through collaboration and inspiration. Applicants must hold an MD or MD/PhD degree (or equivalent degree), current certification by the American Board of Emergency Medicine, must have or be eligible to obtain a New York medical license, and possess academic accomplishments that merit appointment at the rank of associate professor or higher. For confidential nominations or expressions of interest,

please contact Aaron Mitra, Linda Komnick, or Kim Smith through the office of Katie Haddock via khaddock@wittkieffer.com. The Stony Brook University Renaissance School of Medicine values diversity and is committed to equal opportunity for all persons regardless of age, color, disability, ethnicity, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status protected by law. (PA 2036) Email: khaddock@wittkieffer.com Website: http://www.stonybrook.edu/

OHIO

Job Overview: As one of the oldest medical schools in the country, the University of Cincinnati College of Medicine (COM) has a reputation for training best-in-class health care professionals and developing cutting-edge procedures and research that improves the health and clinical care of patients. In partnership with the UC Health academic healthcare system and Cincinnati Children’s Hospital Medical Center, College of Medicine doctors transform the world of medicine. The Department of Emergency Medicine’s world-renowned faculty and staff offer an outstanding research, teaching, and medical practice environment. The University of Cincinnati (UC), College of Medicine (COM) invites applications and nominations for the Chair of the Department of Emergency Medicine. Reporting to the Dean of the College of Medicine, the Chair will model next-level leadership empowering faculty and staff, setting a tone of shared purpose with the College and UC Health, and establishing the highest standards in patient care and educational outcomes, research impact, and financial stewardship. Essential Functions: The Chair will be responsible for recruitment, development, and retention of an exceptional and diverse faculty. The Chair will foster opportunities to expand research across divisions and institutions, with a focus on interdisciplinary and collaborative team-based scholarship. The Chair will elevate the department in this moment of true transformation at a systems level and promote partnerships across the College of Medicine, UC Health, community partners and external stakeholders. The applicant must demonstrate

a record of educational and scholarly achievement, with recognition at the national level, and a strong commitment to advancing the practice and education of emergency medicine. The successful candidate will be an accomplished leader who understands current trends in healthcare and medical education and values the tripartite mission academic medical institutions promote. It is of the utmost importance that the Chair is a visible, democratic, and collaborative leader who advocates for patients, learners, staff and faculty members within the Department, College of Medicine, University and Health System. Minimum Qualifications: • An outstanding MD, MD/PhD, DO, or equivalent clinician with substantial leadership experience. • Significant academic, clinical, and administrative experience in a University Health Science Center or comparable organization, preferably at the rank of a Professor or Associate Professor academically. • American Board of Emergency Medicine Certified with demonstrated understanding of all elements of health care delivery, including strategy, business planning, operations, and finance. (PA 2039) Email: adrienne.piontek@uc.edu Website: https://jobs.uc.edu/job-invite/94816/

ONTARIO, CANADA

Located in beautiful Windsor, Ontario, Canada, our client, Windsor Regional Hospital (WRH), is situated directly across the border from Detroit, Michigan. WRH is the regional provider of advanced care in complex trauma, renal dialysis, cardiac care, stroke, neurosurgery, intensive care and acute mental health. WRH is seeking a Chief, Department of Emergency Medicine who will provide strong leadership across the Department and Program for service delivery, resource utilization and metrics driven performance management. CPSO Pathway licensure is easily available for U.S. Board Certified Physicians. Please forward a CV and cover letter in confidence to: Marcy SaxeBraithwaite, E-mail: msaxe-braithwaite@medfall.com (PA 2004) Email: msaxe-braithwaite@medfall.com Website: https://www.medfall.com/

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

AAEM Events 2024 Oral Board Review Courses Dates Announced aaem.org/education/oral-boards/ March 6, 2024 DVAAEM Annual Residents’ Day www.aaem.org/get-involved/chapter-divisions/dvaaem/ April 27-May 1, 2024 30th Annual Scientific Assembly (Austin, TX) www.aaem.org/aaem24 May 31-June 1, 2024 12th Annual FLAAEM Scientific Assembly (Miami, FL) www.aaem.org/get-involved/chapter-divisions/flaaem/

Jointly Provided Re-Occurring Monthly Unmute Your Probe: Virtual Ultrasound Webinar Series Jointly provided by EUS-AAEM aaem.org/get-involved/sections/eus/resources/unmute-your-probe/

Re-Occurring Monthly Spanish Education Series* Jointly provided by the AAEM International Committee aaem.org/get-involved/committees/committee-groups/international/spanish-education-series (CME not provided) June 25-29, 2024 UC Davis Emergency Medicine Summer Conference: InformED October 21-25, 2024 19th Annual Emergency Medicine Update: Hot Topics 2024

Recommended April 10-14, 2024 2024 ACMT Annual Scientific Meeting & Symposia aaem.org/event/2024-acmt-annual-scientific-meeting-symposia/ Online CME Recognizing Life-Threatening Emergencies in People with VEDS thesullivangroup.com/TSG_UG/VEDSAAEM/

COMMON SENSE JANUARY/FEBRUARY 2024

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