SUMMER 2020
A PERSONAL TAKE ON PTSD AND MENTAL HEALTH PG 3
MEMBERSHIP GUIDE 2020–2021 PG 15
A GLOBAL VIEW OF WOMEN’S EXPERIENCE DURING THE CORONAVIRUS PANDEMIC PG 21
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The Pulse VOLUME XLIII No. 2
EDITORIAL COMMITTEE Timothy Cheslock, DO, FACOEP, Chair Justin Grill, DO, FACOEP Christine Giesa, DO, FACOEP-D
TABLE OF CONTENTS 3
PRESIDENT’S REPORT Robert E. Suter, DO, MHA, FACOEP-D
The Pulse is a copyrighted quarterly publication distributed at no cost by ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors, and liaison associations recognized by the national offices of ACOEP.
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THE ON-DECK CIRCLE G. Joseph Beirne, DO, FACOEP-D
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THE EXECUTIVE DIRECTOR’S DESK Adam Levy
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NEW AND UPDATED MEMBER BENEFITS!
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CONGRATULATIONS TO THE WINNERS OF THE 2020 NEW INNOVATIONS IN EMERGENCY MEDICINE!
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CASE STUDY COMPETITION WINNERS
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MEMBERSHIP GUIDE 2020-2021
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A GLOBAL VIEW OF WOMEN’S EXPERIENCE DURING THE CORONAVIRUS PANDEMIC
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WHAT WOULD YOU DO? ETHICS IN EMERGENCY MEDICINE Bernard Heilicser, DO, MS, FACOEP-D
The Pulse and ACOEP accept no responsibility for the statements made by authors, contributors, and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of The Pulse and will not be returned. Display and print advertisements are accepted by the publication through ACOEP, 142 East Ontario Street, Chicago, IL 60611, (312) 587-3709, or electronically at marketing@acoep.org. Please contact ACOEP for the specific rates, due dates, and print specifications. Deadlines for the submission of articles are as follows: January issue due date is November 15; April issue due date is February 15; July issue due date is May 15; October issue due date is August 15. Advertisement due dates can be found by downloading ACOEP's media kit at www.acoep.org/advertising. ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue. ©ACOEP 2020 – All rights reserved. Articles may not be reproduced without the expressed, written approval of ACOEP and the author. ACOEP is a registered trademark of the American College of Osteopathic Emergency Physicians.
PRESIDENT’S REPORT
Robert E. Suter, DO, MHA, FACOEP-D
OUR COMMITMENT TO INCLUSIVITY
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hese are extraordinary times, both for our society and our specialty. First, we are hit with the full force of the COVID-19 virus. We are experiencing tragic loss of life, massive unemployment, reduced ED volumes, and a corresponding reduction in hours and pay for emergency physicians and others. Travel restrictions and limits on social gathering led to Spring Seminar transitioning to a virtual format, and we look to the future to determine what this means for ACOEP as an organization. Then, the gut punch of another death of another Black man in police custody, leading to massive protests. ACOEP is a family, and we know that many of our members, especially people of color – physicians, residents, students, and staff – are hurting and angry. Our community is our strength, and so we must grieve together, while resolving to work together to create a better future. ACOEP stands united firmly against racism, unconscious bias, and unequal treatment in all its horrific forms. We are vehemently antiracist. As much as I want to empathize based on my own experiences, I cannot fully understand the realities Black Americans deal with on a daily basis.
If we recognize that we are a family, then we need to move forward together and resolve to eliminate policies and behaviors in society that are endangering our community. We will only solve the problems of our society together. We shall overcome, together. While not perfect, one of the more successful areas in our society regarding racial issues is the military where many policies require transparency when investigating potential racism or discriminatory issues. As a senior officer, I have been involved in addressing many of these cases. As emergency physicians dedicated to saving lives, the thought of the death of any human being as the result of any form
of discrimination is abhorrent. As individuals we will focus on providing compassionate care to all who come through our doors to reduce discriminatory disparities in the emergency department. We will continue to proudly fulfill this universal mission. ACOEP will contribute to this effort by adding hours of educational programing focused on identifying institutional racism and reducing unconscious bias to provide the knowledge and tools for all of us to help us better do our part. We can do this. We can be part of the solution, be part of creating a future in which we eliminate racism. If we all work together, our best days are ahead of us. –•–
THE ARC OF THE MORAL UNIVERSE IS LONG, BUT IT BENDS TOWARDS JUSTICE.” – DR. MARTIN LUTHER KING, JR.
THE ON-DECK CIRCLE
G. Joseph Beirne, DO, FACOEP-D
THE LONG AND WINDING ROAD
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n late February of this year, Bob Suter and I attended the AOA mid-year meeting in West Palm Beach, FL, representing ACOEP. At that time, COVID had not invaded my life, nor my practice. On the flight home, I read the stories and updates on CNN, from the CDC, and many other websites. Our hospital seemed prepared and things felt “normal.” A few short weeks later, my daughter, in her last semester of college, was notified that after spring break, the campus would be closed and all classes would be virtual through the end of the semester. As the cases began to climb in Washington, California, then Florida, the sense of impending doom began to creep into my daily life. When the index case in Missouri was announced in March, in my own county, life changed. This was no longer an event overseas or in another state – it was here, in my own backyard. Cases began to escalate in our area. We watched in our own ED, with horror, the situation that emergency departments in the New York metropolitan area were dealing with. How could we possibly run short of PPE? How could we not have enough ventilators? What do we do if someone in our own department contracts COVID? As the weeks progressed, the “new normal” began. Restaurants, gymnasiums, and retail stores
closed. Patients could not get in to see their primary care physicians. Elective surgeries were cancelled. In a matter of a few short weeks, our lives were turned upside down. As emergency physicians, we did what we do best. As Clint Eastwood as Gunnery Sargent Thomas Highway in Heartbreak Ridge said, “you improvise, you adapt, you overcome.”
YOU IMPROVISE, YOU ADAPT, YOU OVERCOME.” – GUNNERY SARGENT THOMAS HIGHWAY, HEARTBREAK RIDGE We learned to split ventilators, learned how to use PPE to its fullest extent, and learned that coronavirus taught us all that we have much to learn about infectious disease. Yet, we did not give up. We did not turn our head and hope it would go away. We learned from our colleagues all over the world how to combat this new threat. Emergency medicine became a virtual classroom showing the world who we are, what we do, and how we never give up. The road indeed has been a long one. We now embrace summer
in all its glory, yet we still live with restrictions. We wear masks to the store and we socially distance ourselves in public. COVID cases continue to occur, but we now know more about this pathogen and how to treat it. In the back of my mind, I continue to wonder if the vaccine will be effective. Have we truly flattened the curve? Will herd immunity ever arrive? When is the second wave coming? And, most importantly, what will the influenza season look like this fall and winter when we still have COVID in our daily practice? The road to victory over this virus seems long and arduous. But consider some of the successes that have come out of our battle with COVID: • Telemedicine has skyrocketed and given us a chance to reach patients that may never have been able to receive health care. • Zoom virtual meetings have become a part of our daily lives. Our own virtual Spring Seminar was a tremendous success, allowing us to provide quality CME to our members. • Emergency medicine led the way in innovative thinking and response to treating this pathogen. Any idea was considered worth pursuing if it provided a chance to defeat COVID. • As we sheltered in place, families united nationwide to provide support to everyone on the front CONTINUED ON PAGE 21
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THE EXECUTIVE DIRECTOR’S DESK
Adam Levy
A PERSONAL TAKE ON PTSD AND MENTAL HEALTH
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hen I began working at ACOEP over seven years ago, some of the first stories I heard from EM residents were about the first time they couldn’t save someone’s life in the emergency department. It floored me. To hear these stories firsthand, as opposed to examples in entertainment or the media was difficult to comprehend for myself, and apparently for them as well. My initial reaction was and still is, “Are these people OK?” Over the past five years, we’ve seen a renaissance of discussion surrounding mental health. We see it from business professionals, physicians, trade industries, entertainment, and certainly from individuals and families. Destigmatizing what it means to seek help has been incredible for those who otherwise would have remained silent and hurting. At ACOEP and many medical societies, we’ve discussed the topic of physician wellness and watched as it’s been said over and over again (appropriately so). Physician suicide hotlines. Free counseling services for physicians. Message boards on the internet. It’s clear that physician wellness, and mental health specifically, has been put to the forefront and it’s long overdue. As far as we’ve come with regards to physicians and any other group in removing the stigma of
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seeking mental health, we have a long way to go as a society and human race in creating greater access to mental help – foundationally, financially, and with how its regarded. With COVID-19, on top of an already demanding and draining career as emergency physicians, I have had many conversations with our members about their wellbeing and how they are “holding up.” At first, depending on location, some of our members were working 24-hour shifts, intubating multiple patients per hour. Others hadn’t seen a single COVID case yet. That was over three months ago and, unfortunately, we’ve seen how quickly things are changing one way or the other and back and forth repeatedly. It’s safe to say that everyone has felt the impact. PTSD is something we mostly talk about with regards to military personnel and veterans, but it’s finally coming out more with regards to any traumatic experience we as humans experience. Personally, I am not a physician, however I have five direct family members who are physicians, including my father-in-law who is a CMO in the Bronx in New York. He tested positive for COVID during the first weeks
of the New York City outbreak and became severely ill. Luckily, he avoided critical care components (intubation/ventilation) and, after nearly four weeks, began to feel better and returned to work. My father-in-law is a reproductive endocrinologist and an OBGYN by trade. He’s an excellent physician, but after practicing medicine for 40+ years and creating new life for so many parents, he was not prepared to be loading corpses into refrigerated trucks for weeks at a time. As he put it, “never in my lifetime.” We’re grateful he is alive, but what comes with that? When will he be able to slow down, reflect on what just happened, and take care of his mental health? The same question applies to all our members and the thousands of physicians who may be suffering mental trauma from COVID-19. Will those who need help feel comfortable seeking it? Will their employers ensure that if they seek mental health they do not suffer
WHEN WILL HE BE ABLE TO SLOW DOWN AND REFLECT ON WHAT JUST HAPPENED, AND TAKE CARE OF HIS MENTAL HEALTH?”
MAKE SURE TO PAUSE FOR A MOMENT, AND ENSURE YOU’RE TAKING CARE OF YOURSELF NOW MORE THAN EVER.” repercussions to their jobs and practice? Will congressional funding and safeguarding ensure our true heroes on the front lines of COVID are taken care of? I’m not sure any of us know these answers perfectly but I can tell you that ACOEP, as a staff and Board of Directors, is fiercely advocating for these. I’ll share with you a personal perspective. When my wife was pregnant with my twin children, she was diagnosed with two extremely rare issues impacting the placenta and we were quickly referred to an MFM practice which we visited at least four days a week. At 20 weeks, she experienced preterm labor and a visit to the ED. Steroids, magnesium – you name it. We spent two weeks in the hospital on bed rest. After going home at 24 weeks of pregnancy, the same thing happened again and we spent another two weeks in the hospital. After returning home, my wife, Rachel, went into full labor at 29 weeks and delivered our twins via emergency c-section at 4:00am. My girls are happy five-year-old kids now, but they were born under 3lbs. We experienced the joy of pregnancy for about twelve weeks, before everything was turned upside down. After that, it was nothing but intensity and worry. I interacted with just as many OB residents as I did with ACOEP’s residents. After 60
days in the NICU, my girls came home to two parents who were already exhausted and burnt out. There was an immense amount of PTSD between delivering the babies and keeping them alive. Besides the physicians in my family, we also have two social workers. They encouraged us (essentially forced my wife and I) to seek therapy for what we had been through. For ourselves as individuals, and as a couple to ensure we were setup to take care of our incredible, miracle babies. I can tell all of you reading this – friends, colleagues, strangers – that without months of ongoing therapy, I’m not sure I’d still be married, or as healthy as I am today. Why am I sharing all of this? Because there is absolutely nothing wrong with it. Zero. I’m not ashamed to have suffered something out of my control. I’m not ashamed to have admitted I needed help, no different than how I wouldn’t be ashamed to visit any of you in the ED if I had a broken femur. I am no less a person. I’ve surrounded myself with those who support my decisions and I realize that I only have one life on this earth and I’m going to make sure I take care of it. I hope that if any of our members are suffering now, or into the future, that you seek out help. Talk to someone – anyone! But especially the mental health
professionals who truly are miracle workers in the same way you all are as emergency physicians. Some people may be fine with a certain level of trauma, but that doesn’t mean something is wrong with anyone who is more deeply afflicted by it. Remember, we at ACOEP are a community – a tight-knit one and a unique one. Our physicians are trained with a different mindset. Our events welcome families and friends as more than just people in a big conference room. Our staff is deeply committed to treating you like a human and not just a number, and we want to understand and meet your needs. We are missing that community more than ever right now, but we are still here. If you aren’t sure of where to turn and are in ANY way suffering mentally due to COVID or life in general, email or call me anytime. I’ve told you about my own trauma, my own vulnerability, so you can be assured that the only thing you’ll get from me is an outstretched arm. My direct email is alevy@acoep.org, and my direct work line is 312-445-5710. Remember: You take care of others without pause. Make sure to pause for a moment, and ensure you’re taking care of yourself now more than ever. We’re here to help. –•–
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NEW AND UPDATED MEMBER BENEFITS!
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COEP is excited to announce a new partnership for our members with a webbased forum called DocMatter. DocMatter is an online forum for high-quality clinical discussions among our members. We believe this partnership will provide a valuable, private platform to connect with other members about various clinical and administrative topics, including information pertaining to COVID-19 and the ongoing pandemic. With so much changing information and limited ways for widespread collaboration, DocMatter will be able to assist in your ongoing preparation for COVID-19 cases, as well as on the effects of the virus on our emergency departments and hospitals. DocMatter will be able to connect you to strategize not only with fellow ACOEP members, but with members of other critical care groups across the country and the world. In addition to access to the members-only ACOEP community, you will also have access to the COVID-19 Global DocMatter Community, which has over 45,000 members from 125+ countries and represents over 11,000 institutions DocMatter provides personalized support
and organizes discussions to decrease the time and effort it requires to collaborate and increase future clinical references. We would like to note two important aspects of the ACOEP DocMatter Community: 1. You will be paired with a DocMatter employee, called a Clinician Advocate, who will be your liaison to DocMatter. They will support your use of the platform, from technical questions to customizing your notifications, settings, and overall experience based on your specific clinical interests. Your Clinician Advocate is also available to transcribe your dictated notes to post to the Community on your behalf. 2. The Community is completely private, so you can freely have open discussions with ACOEP members. A DocMatter profile is free of charge for all members of ACOEP. You should have already received an email with instructions for taking advantage of this valuable resource. If you have not received this email or if you have any questions, please email ACOEP’s Manager of Programs and Engagement, Kefah Spreitzer, at KSprietzer@acoep.org. –•–
ALL MEMBERS GET 75% OFF DIGITAL CLASSROOM FOR THE REMAINDER OF THE YEAR
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CONGRATUL ATIONS TO THE WINNERS OF THE 2020 NEW INNOVATIONS IN EMERGENCY MEDICINE! 1ST PLACE Dominic Williams, DO University of Maryland A Novel 3D Printed Task Trainer for Peritonsillar Abscess Drainage
2ND PLACE Alanna O’Connell, DO Thomas Jefferson University Hospital Making the Cut: Implementing a Low Cost, Low Fidelity Simulation Model for Teaching Emergency Thoracotomy Procedure
3RD PLACE Timothy Batchelor, MD Lehigh Valley Hospital STIR in the ED
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CASE STUDY COMPETITION WINNERS 1ST PLACE Justina Truong, DO, Kingman Regional Medical Center Sarcoidosis: A Less Common but Equally Important Cause of Chest Pain to Consider in the Emergency Department Author(s): Justina Truong, DO, & John Ashurst, DO, MSc, FACEP, FACOEP
2ND PLACE Jane Wieler, DO, Thomas Jefferson University Hospital Community-Acquired Methicillin-Resistant Staphylococcus aureus Necrotizing Pneumonia in a Previously Healthy Patient Author(s): Jane Wieler, DO, and Megan Stobart-Gallagher, DO
3RD PLACE Amber Walker, DO, Doctors Hospital An Interesting Case of Neuroborreliosis in an Unvaccinated Pediatric Patient Author(s): Amber R. Walker, DO
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SARCOIDOSIS: A LESS COMMON BUT EQUALLY IMPORTANT CAUSE OF CHEST PAIN TO CONSIDER IN THE EMERGENCY DEPARTMENT JUSTINA TRUONG, DO, & JOHN ASHURST, DO, MSC, FACEP, FACOEP INTRODUCTION Chest pain is the second most common complaint seen by emergency medicine providers and accounts for 6.4 million visits annually.1 Emergency clinicians must be able to differentiate the different causes of chest pain in order to minimize both acute and long-term morbidity and mortality. Although not normally a cause of short-term morbidity or mortality, pulmonary sarcoidosis should be considered as an acute cause of chest pain in the correct patient population and should be managed aggressively to prevent long-term complications from the disease. The authors present a case of pulmonary sarcoidosis in a 36-year-old male that was managed with urgent consultations and procedures to minimize his risk of longterm complications.
CASE REPORT A 36-year-old Caucasian male presented to the emergency department with a four-month history of leftsided chest pain with associated shortness of breath on exertion. He described the pain as a dull ache that occurred at rest and was not worsened by exertion. He also noted a chronic dry cough that he had for the last several years that was not associated with illness or exercise and a 12-pound weight loss over the previous month. Past medical history was noted for ureterolithiasis several years prior and he took no medications on a daily basis. His last purified protein derivative (PPD) skin test was several months prior and was negative. He also denied ever smoking and a family history of autoimmune or inheritable disorders. Upon arrival, his vital signs were all within normal limits and his examination exhibited only scant wheezes and coarse breath sounds in the left upper lobe. Egophony and whisper pectoriloquy were both negative in the concerned area. He also had no discernible skin lesions or clubbing of his nails. Electrocardiogram showed a normal sinus rhythm with 82 beats per minute without any signs of ischemia. Laboratory testing, including a complete blood count, complete metabolic profile, and troponin T, were all negative. Chest radiograph demonstrated diffuse interstitial nodular opacities throughout the lungs bilaterally with bilateral perihilar consolidations that were worse on the left
(Image 1). Computed tomography with intravenous contrast of the chest showed mid and upper lung nodularity with a perilymphatic distribution involving the central peribronchial vascular regions as well as subpleural and fissural surfaces causing conglomerate in the upper lobes centrally (Image 2). There was also mild symmetric bilateral hilar and mediastinal lymphadenopathy. After discussion with pulmonology, the differential included lymphoma, tuberculosis, fungal infections, and pulmonary sarcoidosis. The following day, the patient underwent bronchoscopy with endotracheal ultrasound and transbronchial biopsies. Bronchoalveolar lavage was negative for fungal infections, acid fast bacilli, and malignant cells. Endobronchial biopsies revealed numerous nonnecrotizing well-formed granulomas embedded in dense hyaline sclerosis. The patient was subsequently diagnosed with stage 3 pulmonary sarcoidosis and started on prednisone daily and sulfamethoxazole/trimethoprim three times a week for eight weeks. Following treatment, he had resolution in his symptoms.
DISCUSSION Sarcoidosis is a multi-system granulomatous disease without a known etiology. However, it is characterized by a T-helper cell response to CD-4 lymphocytes and activated macrophages that accumulate in the affected organs.2 Most studies suggest that the etiopathogenesis is related to an exaggerated immune response to an environmental factor, microbe, or antigen in a genetically susceptible individual. 3 Although the worldwide epidemiology of sarcoidosis is difficult to ascertain due to a large proportion of patients being asymptomatic, it has been estimated that 60 out of 100,000 adults in the United States will be affected by the disease.4 More than 80% of these cases will be diagnosed between the years of 20 and 50 with a second peak in incidence between 50 and 65 years of life. 2,3 Females, nonsmokers, and African Americans are more commonly diagnosed with the disease and 10% of cases will be familial.2-4 Mortality has been estimated at between 2 and 5% secondary to pulmonary complications, while morbidity can be substantial due to poor outcomes in chronic sarcoidosis. 5
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REFERENCES 1
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Jung J and Bord S. Emergency department management of non-STsegment elevation myocardial infarction. Emerg Med Pract, 2020;22(2), 1-24. Bargagli E and Prasse A. Sarcoidosis: A review for the internist. Internal and Emergency Medicine, 2018;13,325-331. Soto-Gomez N, Peters J, and Nambiar A. Diagnosis and management of sarcoidosis. Am Fam Physician, 2016, 93(10),840-848.
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Patterson K and Chen E. The pathogenesis of pulmonary sarcoidosis and implications for treatment. Chest, 2018;153(6),1432-1442. Gerke A. Morbidity and mortality in sarcoidosis. Curr Opin Pulm Med, 2014;20(5),472-478. Valeyre D et al. Pulmonary Sarcoidosis. Clin Chest Med, 2015 Dec;36(4):631-41. Kirkil G, Lower EE, Baughman RP. Predictors of Mortality in Pulmonary Sarcoidosis. Chest, 2018 Jan;153(1):105-113.
COMMUNITY-ACQUIRED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS NECROTIZING PNEUMONIA IN A PREVIOUSLY HEALTHY PATIENT JANE WIELER, DO, AND MEGAN STOBART- GALLAGHER, DO INTRODUCTION Infections occurring from community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) occur primarily in the skin or soft tissues and rarely as sepsis, meningitis, or necrotizing pneumonia. Medical centers in the United States have seen an increase in the number of community and hospital-acquired MRSA infections throughout the past several decades. Nosocomial strains of MRSA have affected the lungs of hospitalized patients worldwide and have been slowly increasing as a cause of late-onset pneumonia in ICU patients.1-3 In contrast, CA-MRSA pneumonia presents in young, healthy adults after an influenza-like illness. Symptoms often present with respiratory distress, hemoptysis, leucopenia, hypotension, and multi-lobular consolidations on chest x-ray. A preceding influenza-like illness has been described in 67-75% of the noted cases in the United States, Europe and Japan.3-6 The morbidity and mortality of illness of patients with CA-MRSA pneumonia is extremely high. A case series published in Emerging Infectious Diseases in 2006 showed that 81% of patients with this illness required the intensive care unit, 62% required intubation, 46% required chest tube placement for drainage of empyema, and 29% succumbed to their illness.4 In 2007, a case review of 50 patients revealed a mortality rate of 56% with a median survival
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rate of only 10 days.6 There have been studies outlining the benefits of novel therapy but, interestingly, there has been little change in description of this disease process and patient characteristics.7,8 The high level of mortality in these communityacquired necrotizing pneumonias is likely related to the production of Panton-Valentine leukocidin (PVL) by the bacterium. Strains of MRSA all contain the SCCmec element with the mecA gene encoding for methicillin resistance. Nosocomial strains contain SCCmec type II element while CA-MRSA are likely to have SCCmec type IV element which includes the PVL gene. 5,9 PVL is a cytotoxin with direct toxic activity to polymorphonuclear leukocytes.6,11 Specifically in lung tissue, PVL mediates severe tissue necrosis through adherence to the basement membrane, upregulation of lung proinflammatory protein A, and infiltration of neutrophils and macrophages.9-13 In a study of 172 S. aureus strains, PVL genes were detected in 85% of patients who were inflicted with severe necrotic community acquired hemorrhagic pneumonia.14 The factors most associated with a fatal outcome in necrotizing CA-MRSA were leukopenia, acute respiratory distress syndrome, and the need for inotropic support. Dr. Rubinstein et al in 2007 suggest that the presence of hemoptysis may be used as both a diagnostic sign
of necrotizing pneumonia as well as a predictor of fatal outcome.6 Hemoptysis was the presenting symptom of our patient and, thus, a high-index of suspicion for rare CA-MRSA pneumonia was warranted.
CASE REPORT A 61-year-old, previously-healthy male presented with the chief complaint of “coughing up blood.” The patient described one week of productive cough, night sweats, subjective fever, and mild dyspnea on exertion, and had been diagnosed with bronchitis by his primary care physician. The hemoptysis developed over the last 2 days and was described as approximately one tablespoon of blood daily. Upon review of systems, patient denied any headache, gastrointestinal upset, weight loss, urinary changes, syncope, or rash. He had not received the Influenza or Pneumococcal vaccine. He denied any recent travel, a history of tuberculosis, or recent incarceration (incarcerated during the 1970s with negative TB skin testing). He reported testing negative for HIV one year prior. His significant past medical history was only of a traumatic splenectomy in his early teens. He denied smoking cigarettes, drinking alcohol, or using any illicit drugs. He was in a sole heterosexual relationship with his wife and was retired. Patient was not on any home medications or supplements and denied any known drug allergies. On presentation, the patient’s heart rate was 103bpm, blood pressure 110/76, respiratory rate 22bpm, and temperature 37.4 C orally, with a room air pulse oximetry of 95%. He exhibited pharyngeal erythema, 5-6 word conversational dyspnea, and bilateral wheezes. The patient’s sputum was dark red in color when examined. A 2-view chest radiograph showed a thick-walled cavity in the right upper lobe associated with volume loss that likely represented cavitary pneumonia (Figure 1) prompting the patient to be placed in respiratory isolation. Treatment was initiated with broad spectrum antibiotics, and RIPE therapy for possible tuberculosis was considered. His initial laboratory studies were remarkable for hemoglobin: 16.6 gm/dL, WBC: 1.3 x 103, platelets: 112, a creatinine of 1.2 mg/dL, and normal electrolytes and coagulation studies. Subsequent studies resulted at a later time and were negative for Influenza A and B, and his urine was negative for both the Streptococcal pneumonia antigen and Legionella antigen. Despite receiving beta agonists and intravenous normal saline, the patient became more dyspneic with an oxygen requirement of 4L by nasal cannula to maintain saturation above 90%. A CT scan of the chest with IV contrast was obtained and showed a large 5.5 x 4.1 x 4.7 cm cavity in the anterior segment of the right upper lobe as well as a smaller 2.7 x 1.9 x 2.8 cm adjacent cavity with surrounding consolidation and ground glass opacity that was “concerning for cavitary pneumonia or less likely tuberculosis” as shown in Figure 2. The patient continued
to decompensate with worsening dyspnea due to the development of massive hemoptysis and was intubated with bedside bronchoscopy performed by the critical care team in the ED. The bronchoscopy showed no evidence of acute tracheobronchial bleeding. During the first 24 hours of admission, the patient continued to decompensate, developing a necessity for vasopressor support, increased ventilator support due to an underlying severe metabolic acidosis, and subsequent renal failure requiring continuous renal replacement therapy. The patient’s blood cultures grew gram positive cocci in clusters, while the acid-fast stains of the sputum culture remained negative for mycobacterium. Infectious Disease recommended stopping the ant tuberculosis “RIPE” therapy after three AFB cultures total were negative and to continue broad spectrum coverage with vancomycin and piperacillin-tazobactam. A bedside 2D Echocardiogram was performed by cardiology to rule out endocarditis, with no vegetations noted. Within 72 hours, the patient had developed fulminant multi organ system failure and, despite aggressive resuscitation and appropriate treatment in the intensive care unit, the patient developed disseminated intravascular coagulopathy and he succumbed to his illness within 96 hours of presentation to the hospital
DISCUSSION Our case is another representation of how MRSA is becoming a tragically virulent community-acquired organism and should be aggressively managed with first line vancomycin and/or linezolid. When compared to the populations affected by hospital-acquired MRSA, those affected by CA-MRSA are much younger, lack co-morbidities, and have a substantially faster progression of disease. The majority of cases reveal that patients who have developed severe soft tissue infections or necrotizing pneumonia from CA-MRSA have no history of hospitalization or contact with the health care system.6, 15 Our patient’s presentation was similar to other CA-MRSA pneumonia cases, with a 1-week history of viral-like symptoms and rapid progression including development of leucopenia, as well as need for inotropic support. A study in 2005 suggested that patients whose history is lacking a preceding viral respiratory infection or influenza-like illness prior to presentation may have better clinical outcomes.16 In addition to the initial presentation including hemoptysis, it is speculated that leucopenia may also be an important prognostic marker of high mortality due to the ability of bacterial PVL to directly lyse neutrophils.6, 12 While our patient was initially treated for presumed tuberculosis, there was no delay in antibiotic treatment for the ultimate diagnosis that was discovered from bronchoalveolar lavage and blood cultures growing methicillin resistant Staphylococcus aureus. Treatment with linezolid is the first-
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line treatment option for nosocomial MRSA pneumonia, and should also be considered as first line for CA-MRSA due to its improved lung parenchymal penetration, increased bioavailability and inhibition of toxin production.17-18 Antimicrobial agents that inhibit protein synthesis may prevent the production of the deadly toxin that gives this strain of CA-MRSA its virulence. As demonstrated in the animal literature, at minimum inhibitory concentrations, linezolid was able to suppress the expression of multiple Staphylococcal virulence factors including PVL.14,17 Another therapy consideration is intravenous immune globulin having in vitro activity against PVL.22 Patients with severe respiratory failure at presentation may benefit from Extracorpeal membrane oxygenation (ECMO) therapy, although so far has only been studies in case reports.7-8 Research on this topic has been limited in the human population due to its overall low incidence. In our case, we were unable to use polymerase chain reaction to test for the presence of PVL. However, it can be suspected that the strain of CA-MRSA that resulted in our patient’s death was likely PVL-positive due his rapid decline and demise. Based on the reviewed case reports, the 48-hour survival rate for patients who progressed rapidly to severe necrotizing pneumonia was 63% in PVL-positive patients compared to 94% to PVL-negative patients. 3 Genotyping strains of methicillin resistance Staphylococcus aureus to determine both community acquired vs. hospital acquired as well as PVL-positive vs. PVL-negative strains may become increasingly valuable to provide targeted therapy. This data is presented to encourage a high index of suspicion both for recognition of this rapidly progressive necrotizing pneumonia, as well as the alternatives to treatment if response to typical agents, such as vancomycin, are limited. It must also be stressed to the emergency physician that coverage for CA-MRSA is not represented in the current empiric treatment of communityacquired pneumonia.20-21
REFERENCES 1
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Rogers DE. Staphylococcal infections. In: Kasper DL, Braunwald E, Fauci A, Hauser S, Longo D, Jameson JL, eds. Harrison’s principles of internal medicine. 4th ed. New York: McGraw-Hill Professional, 1962. Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-care associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005;128:3854-62. Gillet Y, Issartel B, Vanhems P, et al. Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotizing pneumonia in young immunocompetent patients. Lancet. 2002; 359:753-9. Hageman JC, Uyeki TM, Francis JS, et al. Severe community-acquired pneumonia due to Staphylococcus aureus, 2003-2004 influenza season. Emerg Infect Dis. 2006;12:894-9.
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Gillet, Y, Vanhems P, Lina G, Bes M, Vandenesch F, et al. Factors Predicting Mortality in Necrotizing Community-Acquired Pneumonia Caused by Staphylococcus aureus containing Panton-Valentine Leukovicidin. Clin Infect Dis. 2007; 45:315-21 6 Takigawa Y, Fujiwara K, Saito T, et al. Rapidly Progressive Multiple Cavity Formation in Necrotizing Pneumonia Caused by Community-acquired Methicillin-resistant Staphylococcus aureus Positive for the PantonValentine Leucocidin Gene. Intern Med. 2019;58(5):685–691. 7 He, H., Wang, H., Li, X. et al. Successful rescue combination of extracorporeal membrane oxygenation, high-frequency oscillatory ventilation and prone positioning for the management of severe methicillin-resistant Staphylococcus aureus pneumonia complicated by pneumothorax: a case report and literature review. BMC Pulm Med. 2017;17,103. 8 Panchabhai TS, Khabbaza JE, Raja S, Mehta AC, Hatipo!lu U. Extracorporeal membrane oxygenation and toilet bronchoscopy as a bridge to pneumonectomy in severe community-acquired methicillinresistant Staphylococcus aureus pneumonia. Ann Thorac Med. 2015;10:292-294. 9 Kwong, J.C., Chua, K. & Charles, P.G.P. Managing Severe CommunityAcquired Pneumonia Due to Community Methicillin-Resistant Staphylococcus aureus (MRSA). Curr Infect Dis Rep. 2012;14,330–338. 10 Pham J, Asif T, Hamarshi MS. Community-acquired Pneumonia with Methicillin-resistant Staphylococcus Aureus in a Patient Admitted to the Intensive Care Unit: A Therapeutic Challenge. Cureus. 2018;10(1):e2019. 11 Quie, PG. Bactericidal function of human polymorphonuclear leukocytes. E. Mead Johnson Award Address. Pediatrics. 1972; 50(2):264-70. 12 Kong B, Prevost G, Piemon Y, et al. Effects of Staphylococcus aureus leukocidins on inflammatory mediator release from human granulocytes. J Infect Dis. 1995;171:607-613. 13 Labanderia-Rey M, Couzon F, Boisset S, et al. Staphylococcus aureus Panton Valentine leukocidin causes necrotizing pneumonia. Science. 2007;315:1130-3. 14 Lina G, Piemont Y, Godail-Gamot F, et al. Involvement of Panton-Valentine leukocidin producing Staphylococcus aureus in primary skin infections and pneumonia. Clin Infect Dis. 1999;29:1128-1132. 15 Gorak E, Yamada S, Brown J. Community-acquired methicillin-resistant Staphylococcus aureus in hospitalized adults and children without known risk factors. Clin Infect Dis. 1999;29:797-800. 16 Alonso-Tarres C, Villegas ML, de Gispert FJ, Cortes-Lletget MC, Rovira Plarromani A Etienne J. Favorable outcome of pneumonia due to PantonValentine leukocidin-producing Staphylococcus aureus associated with hematogeous origin and absence of flu-like illness. Eur J Clin Microbiol Infect Dis. 2005;24(11):756-759. 17 Vien TM, Hoan N, Pinheiro MG, et al. Effects of Tedizolid Phosphate on Survival Outcomes and Suppression of Production of Staphylococcal Toxins in a Rabbit Model of Methicillin-Resistant Staphylococcus aureus Necrotizing Pneumonia. Antimicrobial Agents and Chemotherapy. 2017;61(4):e02734-16. 18 Zhang W, Xu N, Bai T, et al. Efficacy and safety of linezolid versus vancomycin for methicillin-resistant Staphylococcus aureus (MRSA)related pneumonia: updated systematic review and meta-analysis. Int J Clin Exp Med. 2019;12(4):3185-3200. 19 Bernardo K, Pakulat N, Fleer S, et al. Subinhibitory concentrations of linezolid reduce Staphylococcus aureus virulence factor expression. Antimicrob gents Chemother. 2004; 48:546-555. 20 File T, Garau J, Blasi F, et al. Guidelines for empiric antimicrobial prescribing in community-acquired pneumonia. Chest. 2004;125:1888-901. 21 Vayalumkal J, Whittingham H, Vanderkooi O, et al. Necrotizing pneumonia and septic shock: suspecting CA-MRSA in patients presenting to Canadian emergency departments. Can J Emerg Med. 2007;9(4):300-3. 22 Gauduchon V, Cozon G, Vandenesch F, Genestier AL, Eyssade N, Perol S, et al. Neutralization of Staphylococcus aureus Panton-Valentine leukocidin by intravenous immunoglobulin in vitro. J Infect Dis. 2004;189(2):346-353. 5
AN INTERESTING CASE OF NEUROBORRELIOSIS IN AN UNVACCINATED PEDIATRIC PATIENT AMBER R. WALKER, DO
INTRODUCTION This case describes a patient who presented to the emergency department (ED) for evaluation of a prolonged febrile illness associated with multiple other systemic and neurologic symptoms. He was found to have Lyme neuroborreliosis (NB), an early disseminated form of the disease, with specific findings of meningitis and polyradiculitis. What is interesting about this case is the atypical neurologic involvement accompanied by other nonspecific symptoms, leading to a delay in diagnosis of the disease.
CASE REPORT A 6-year-old male with history of minimal vaccinations presented with his parents for evaluation of fatigue, headache, and vomiting that started after 2 weeks of a rash. Symptoms initially started 3 weeks ago with malaise, nausea, and tactile fevers. Upon resolution, a painful, nonpruritic, circular rash started on his right ankle and spread up his legs and back. He went to urgent care (UC), was diagnosed with viral hives, and was discharged home with 5 days of prednisone. The rash improved initially but returned completely, though no longer painful, after completion of the steroid burst. 4 days prior to arrival to the ED, fatigue worsened again with return of tactile fevers, new onset headache, vomiting (non-bloody, non-bilious), photophobia, diplopia, myalgias, and worsening rash. He went to another UC, was diagnosed with erythema multiforme, and was discharged on alternating Tylenol and Motrin, as well as Claritin. He slept all day and night in the 3 days prior to presentation. Mother was also concerned because his gait was slow and he appeared unsteady on his feet due to persistent leg pain. Several siblings lived at home with him, but none of them were sick. Mother denied known tick or other animal bites. He denied chest pain, shortness of breath, sore throat, cough, abdominal pain, and diarrhea. On examination, he was a very tired but nontoxic appearing male with normal vital signs for his age. There was a large blanchable, asymmetric, annular papular rash on the torso, legs, and back. There was no neck rigidity. Neurological examination was significant for decreased abduction of both eyes without complete paralysis. No other focal cranial deficits were noted. Neuromuscular
exam demonstrated normal strength and sensation of all extremities. Deep tendon reflexes were 2+ throughout. Gait was slow and somewhat unsteady. A head CT was obtained and showed no intracranial lesions. Blood work showed WBC: 11,300 u/L (range 5,000-14.500 uL) with 84.4% neutrophils (36.0-72.0%), ESR: 45 mm/h (0-13 mm/h), Mono screen: negative. Lumbar puncture results (tube 3); WBC: 22 cells/uL with 28% PMN, 50% lymphocytes, 22% mono/macro; RBC: 0, CSF color: clear, Glucose: 45 mg/dL, Protein: 18 mg/dL. CSF biofire negative. With the overall benign lab evaluation and head CT combined with the CSF pleocytosis and rash resembling large erythema migrans, there was concern for early disseminated Lyme Disease complicated by meningitis. He was thus started on Ceftriaxone 75 mg/kg daily and admitted to the hospital for further infectious disease and neurologic workup. This was later confirmed by positive Lyme IgM/IgG antibodies of the blood and CSF. His hospitalization was complicated by sacral radiculopathy causing urinary retention, CN 6 palsy, and increased intracranial pressure with optic nerve swelling requiring initiation of Diamox. He was discharged home on hospital day #5 with 16 days of oral Doxycycline and had complete recovery on follow up office visits.
DISCUSSION Lyme disease is caused by the spirochete Borrelia burgdorferi and is the most common tick-borne disease in the United States.1 Initial symptoms are mostly nonspecific and include fever, headache, fatigue, myalgias, and the characteristic erythema migrans rash 1-2 weeks after exposure. If left untreated, hematogenous spread can lead to involvement of multiple organ systems. 2 NB is a disseminated form of the disease where the spirochetes invade the nervous system and cause meningitis and inflammation of cranial and peripheral nerves. 3 Borrelia specific antibodies in CSF are mandatory for definitive diagnosis of NB. 3,4 Treatment of choice includes IV cephalosporins or penicillin for 14 days. In older children, doxycycline has also been shown to provide full resolution of symptoms. 3,5 Upon literature review, children with neuroborreliosis typically presented with a facial nerve palsy and/or CONTINUED ON PAGE 21
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MEMBERSHIP GUIDE 2020 – 2021
ACO E P I S YO U R H O M E F O R E D U CAT I O N, CA R E E R A DVA N C E M E N T, A N D N E T W O R K I N G. I T ’ S Y O U R H O M E F O R C O M M U N I T Y A N D S U P P O R T. W E LCO M E TO YO U R E M E RG E N CY M E D I C I N E H O M E A N D O U R E M F A M I LY.
YO U R H O M E F O R
C M E!
A C O E P I S D U A L LY A C C R E D I T E D! ACOEP is accredited by both the American Osteopathic Association (AOA) and the Accreditation Council for Continuing Medical Education (ACCME) to provide CME credits to physicians. Earn AOA Category 1-A credits and AMA PRA Category 1 Credits™ at Spring Seminar and Scientific Assembly.
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LEADERSHIP
Fast track your career, cultivate high-level connections, and make a difference in emergency medicine!
H AV E YO U R V O I C E B E H E A R D ACOEP’s committees are an incredible way to get involved, influence policy, and put you on a path to leadership. Committees are open to members and include: • • • • • • • • • • •
Emergency Medical Services ACOEP’s Committee for Women in Emergency Medicine Awards and Nominations Practice Management Bylaws Continuing Medical Education Fellowship Graduate Medical Education Member Services New Physicians in Practice Program Directors (open to PDs, APDs, and faculty of residency programs) • Research and Academic Awards • Resident Student Advisory Committee
Members are invited to sit in on any open committee meeting, and to take advantage of leadership opportunities!
BE A LEADER Our team is always adding new opportunities for career development and leadership training. Past opportunities have included a CME-eligible Faculty Development Track, opportunities to lecture at a national conference and speaker training, and the new MedEd track for aspiring medical educators. At ACOEP you will find mentors to help you on your journey to leadership, and a community built on support and inclusion.
S C H O LA R LY A C T I V I T Y ACOEP is proud to provide access to a myriad of scholarly activity opportunities. These include: • FOEM Research Review Source • ACOEP-ACGME Paradigm Research Project • Publication in WestJEM • Research Competition Participation or Judging • National Committee Membership Appointment • Serving as Faculty at an ACOEP or RSO conference • Item Writing for the EMAAT Committee
For more information on each committee and how to get involved, visit www.acoep.org/committees.
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THE PULSE
R E S E A RC H C O M P E T I T I O N S
ACOEP proudly distributes The Pulse, a biannual magazine with the latest on ACOEP’s activities, as well as helpful articles for physicians. Published digitally and mailed out in print, The Pulse is not only an excellent informational resource, it is also a chance for members to print expert opinions, share interesting cases, and more. If you are interested in contributing, please email esernoffsky@acoep.org.
Research competitions are a great chance for students, residents, and attendings to showcase their knowledge, earn scholarly activity, and make a national name for themselves!
PUBLICATION
WESTJEM ACOEP is a sponsoring organization of the Western Journal of Emergency Medicine, or WestJEM, a publication indexed in PubMed, PubMed Central, Scopus, CINAHL, and the Directory of Open Access Journals. ACOEP members enjoy free online submissions, full open access and copyright retention, and discounted article processing fees. Through ACOEP’s partnership, program directors, and departments can also enjoy discounted department sponsorships, waived processing fees for three articles per year, hard copies and pdfs delivered, and free online CME advertisements and job postings.
UPDATE
ACOEP: LOOKING AHEAD
PEDIATRIC FEVER
CONCUS SION RECOVE RY TIME FOR TEEN GIRL ATHLETE S IS LONG AS IT IS FOR BOYSTWICE AS PG 14
TIMES CHANGE, FRIENDSHI PS REMAIN PG 7
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PROUD PAST, STRONG FUTURE PG 16
Annual events and competitions include: • • • • • • •
Research Study Poster Competition Case Study Poster Competition Clinical Pathological Case Competition Oral Abstract Competition Research Paper Competition sponsored by WestJEM New Innovations in Emergency Competition 5K
FOEM also provides grants to deserving researchers and is your link to tax-deductible giving and the chance to promote growth in emergency medicine.
T H E F O E M R E S E A RC H N E T W O R K The FOEM Research Network is an easy-to-use platform that makes it easy for researchers to discover research opportunities to further the body of knowledge in the Osteopathic emergency medicine field. Research institutions are invited to promote their available opportunities in our database. Clinical research organizations are encouraged to learn more about the research sites offering these opportunities. Learn more at frn.foem.org.
SPRING 2019
FALL 2019
R E S E A RC H
SUMMER 2019
HELPING VULNERABLE POPULATIONS
DIAGNO SIS CONCUS SION: A PERSON AL STORY PG 15
PARENT ING IS EASY PG 17
HELPING PATIENT S WITH AUTISM AND THEIR FAMILIE S NAVIGAT E EMERGE NCY VISITS PG 15
CREATIN G A GERIATR IC FRIENDLY EMERGE NCY DEPARTM ENT PG 21
PSYCHO LOGICAL BARRIER S TO CARE FOR THE HOMELE SS PATIENT PG 33
ACOEP Members are invited to submit articles to The Pulse, ACOEP’s magazine, distributed nationally.
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Research competitions are a great chance for attending members to earn scholarly activity!
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CO M M U N I TY
Our College is a community and within that home we offer specialized niches to help with your specific needs. The New Physicians in Practice (NPIP) Committee brings together attending physicians in their first five years of practice. The NPIP provides CME-accredited learning opportunities, networking events, parties, and so much more. From offering advice on contract negotiation to new skills practice, the NPIP eases the intense transition from resident to attending and helps new physicians jumpstart their careers. The Committee for Women in Emergency Medicine has become ACOEP’s fastest-growing section. Open to all, this committee connects women in EM, hosts tracks at conferences, provides lunch-and-learn opportunities, and honors the incredible contributions women have made to emergency medicine.
Connect with the NPIP on Facebook or on Twitter @ACOEPNPIP
ONLINE
Stay connected! Our online community is always growing. Through our social media channels, newsroom, dedicated emails, and more, we invite you to connect with your fellow members!
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A CA R E E R
Employers seek out ACOEP’s Career Center to find the best talent in emergency medicine. Free for members to use, this online hub is invaluable for job-seekers. Peruse openings in every location, with opportunities for members at every level of their career.
ACOEP’s Career Center is open to members only and is your direct link to exciting new jobs!
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A Global View of Women’s Experience During the Coronavirus Pandemic
T
he coronavirus was first identified in Wuhan, China, in December 2019 and it has quickly spread throughout the world. It was characterized as an international pandemic by the World Health Organization on March 11, 2020, and has had a significant global impact. Resources became scarce, the economy was negatively affected, and individuals within and outside of the healthcare field have been shaken by the significant morbidity and mortality brought on by the coronavirus. The pandemic has left many of us in medicine feeling fearful, confused, and unsure of what our future will look like. While our experience with this pandemic differs depending on where in the world we are practicing, there are significant emotional similarities. The ACOEP Women’s Committee reached out to female healthcare professionals throughout the world to share what they have been through. Common themes found among female providers were an overwhelming feeling of uncertainty and a continuous battle for balance.
Here, we share the experiences of a diverse group of women from Chile, Bolivia, Germany, the United States, and Liberia. These medical doctors, midwives, epidemiologists, resuscitation, and ambulance nurses, and administrators have worked in a variety of capacities. The Coronavirus has significantly altered the way we practice medicine. One of these changes that occurred is the increased use of telemedicine. Diana May-Ganswind, a midwife in Germany, was able to perform many tasks over teleconference and only work in person for births, pregnancy related problems, and newborn family visits. However, others have been working directly with COVID positive patients within a hospital,l as well as in the pre-hospital setting. Dr. Jacqueline Dziedzic, an emergency physician in Arlington Heights, IL, practicing in a level 1 trauma center has been directly on the frontlines of this pandemic. She says, “in addition to the daily logistical changes there is also a stronger emotional component. Especially in the
beginning, it was scary. I didn’t know what life at work was going to look like. Would we be intubating super sick people left and right in the hallway? Would I have to make terrifying decisions on who gets a ventilator?” From their writings, it is clear that there has been an overwhelming sense of fear among healthcare professionals. Many of these women live at home with family members, spouses, children, or parents and they felt a constant fear of both themselves becoming infected while at work, as well as bringing the virus home to potentially infect their loved ones. Consuelo Veronica Gutierrez Aqueveque, a resuscitation nurse working in Chile, says that she needed to self-isolate at home due to fear of infecting her elderly parents who suffer from multiple co-morbidities. Dr. Wahdae-mai Harmon-Gray from Liberia works in an office setting, as well as the COVID suspect ward of a hospital. She too feared bringing the virus home to her spouse and two young children. She says she never became “complacent
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with following the guidelines and health protocols.” She recalls the anxiety of caring for suspected COVID patients and says that it “is as mentally taxing as it is physically.” Dr. Dziedzic explained that it “has always been a juggling act between career and taking care of my family. The COVID-19 pandemic has added a few new balls to juggle.” She says that as soon as she gets home, she “washes away the virus and fear and tries to focus on the positive.” While the decontamination rituals varied among healthcare providers, most included a mad dash to the shower upon arrival home and striving to keep distance from loved ones within the home, yet another mental stressor the entire family must grapple with. Diana May-Ganswind shared her concerns of working with pregnant women and newborns and the potential of her being an asymptomatic carrier possibly spreading the virus to this high-risk population. The uncertainty surrounding this new disease brought about high levels of anxiety to everyone, from the general public, to frontline healthcare workers, to public health experts. Dr. Dziedzic expressed that, “this [anxiety] amplified when a colleague was hospitalized and another was intubated in the ICU. That hit a little too close to home.” Dr. Harmon-Gray speaks on the time spent waiting for test results explaining, “the risk is especially heightened as there is always an almost tangible and stark anxiety amongst patients that sometimes lead them to behave in ways that put direct front liners in harm’s way.” The Coronavirus pandemic has brought many philosophical questions to the table. As a resident physician practicing in a suburban emergency department in New York, which quickly became the
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epicenter of the pandemic in the United States, I often found myself counseling patients presenting to the emergency department with respiratory symptoms, not consistent with Coronavirus, but instead with symptoms of anxiety and panic disorder. Being a resident physician comes with its own obstacles and challenges. Attempting to navigate patient care within a busy emergency department while working very long hours is difficult in and of itself, let alone during a pandemic. Having to isolate from family members who fear being too close to you as they know you are the one involved in very highrisk procedures with COVID positive patents, including intubations and placing central lines only heightens the anxiety. Social isolation has taken a toll on many individuals’ mental health. The principal of isolation precautions within an ICU is a very different concept than precautionary measures taken in a public setting, and we as practitioners must continuously change our mindsets and equipment use depending on the environment. Ms. May-Ganswind expressed the disappointment of missed events during these careful and quarantined times, “birthing time is the worst. The husband was not allowed to be present, which was really sad! Even when I was called to help my own sister give birth.” Dr. Ana Maria Suxo, an epidemiologist in Bolivia, questioned the resiliency of her previous public health interventions as she writes, “I see COVID as the greatest test to help determine whether the projects developed during my life are flexible enough to adapt to the circumstances.” While it is clear that COVID has caused an overwhelming sense of fear among healthcare professionals, another ubiquitous theme is the pride
they take in their work and the sense of reward that came with successfully treating a COVID positive patient. Dr. Harmon-Gray exclaims, “[it] is elating when you nurture a patient back to health or present a negative COVID-19 test result to others.” Monica Peralta Butt, an ambulance nurse practicing in Chile, states, “it is truly exhausting to do my best at work and care for myself with scarce availability of personal protective equipment (PPE),” yet she perseveres and has continued to respond to her family’s needs in a healthy and responsible way. As Dr. Dziedzic explained, “my perspective has changed from fear and anxiety to hope. I will continue to be the best physician I can be, do the best I can for each patient in front of me, and then go home and be the best mom and wife I can be.” These women have put their lives on the line to serve their diverse communities and patients with the highest of standards. They are true role models for generations to come. Dr. Harmon-Gray summarizes all of our sentiments well when she concludes that the “battle line was drawn when the first COVID-19 case was announced and as a mother, wife, daughter, medical doctor, and public health expert I stand firm and resilient on the frontlines fighting for my family, my nation, and my world.” –•– CONTRIBUTORS Wahdae-mai Harmon-Gray, Doctor, Liberia Jacqueline Dziedzic, Emergency Medicine Doctor, United States Ana Maria Suxo, Doctor, Bolivia Diana May-Ganswind, Midwife, Germany Consuelo Veronica Gutierrez Aqueveque, Resuscitation Nurse, Chile Monica Peralta Butt, Ambulance Nurse, Chile Monica Espinoza, Ambulance Nurse, Chile Nicole Vigh, Emergency Medicine Resident, United States Teagan Lukacs, Emergency Medicine Resident, United States
What Would You Do?
Ethics in Emergency Medicine Bernard Heilicser, DO, MS, FACOEP-D
If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at esernoffsky@ acoep.org. Thank you.
In this issue of The Pulse we present a dilemma sent to us by a seasoned paramedic. A private ambulance crew was dispatched to transport a female patient to a clinic for a termination of pregnancy procedure. A female crew member refused to participate in this call, necessitating a second ambulance be dispatched. The refusing crew member was subsequently fired from her job. If you were the EMS medical director for this ambulance company and the EMT, how would you approach this situation? Not getting into the corporate legal aspects, would you support the company in their concern that the EMT refused to participate in patient care based on her religious convictions? Or, would you accept the EMT’s denial of patient care? How might you mitigate such a dilemma?
WHAT WOULD YOU DO? Please visit www.acoep.org/newsroom and share your thoughts on this case.
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lines. Socially we may have been distant, but emotionally we were closer than ever before. The road has been dark over this time span. We have lost loved ones and seen patients of all ages succumb to this pathogen. Friends, family, and coworkers who have been taken from us we count as warriors in the
fight, not statistics. Their sacrifice, and memories are the fuel that keeps our eternal flame of hope ablaze. The road has begun to wind back to a point where we see our daily victories leading us closer and closer to success. Let us not rest until we reach the end of that road, triumphant in our battle against a
disease that threatened our existence, yet taught us how to use our skills, our knowledge, and our passion for the good of the world. I am proud to belong to ACOEP and be on the front lines with each and every one of you, my fellow emergency physicians. –•–
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lymphocytic meningitis, but there has been documentation of other rare manifestations.4,6-10 The diagnosis of NB in children can be difficult because the symptoms may be nonspecific, leading to the possibility of a wide range of diseases and significant delay in diagnosis.4 Thus, it is crucial for emergency medicine physicians to consider evaluation of CSF for pleocytosis and B. burgdorferi antibodies in patients that present like this case with viral-like illness and unusual neurological symptoms.
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Marques AR. Lyme Neuroborreliosis. CONTINUUM: Lifelong Learning in Neurology. 2015;21(6):1729-1744. Hardin JM. Cutaneous Conditions. In: Knoop KJ, Stack LB, Storrow AB, Thurman RJ, eds. The Atlas of Emergency Medicine. 4th ed. New York, NY: McGraw-Hill Education; 2016. Skogman BH, Nordwall M, Eknefelt N, et al. Lyme Neuroborreliosis in Children: A Prospective Study of Clinical Features, Prognosis, and Outcome. Pediatr Infect Dis J. 2008;27(12):1089-1094. Uncommon manifestations of neuroborreliosis in children Baumann M, Birnbacher R, Koch J, et al. Uncommon manifestations of neuroborreliosis in children. Eur J Paediatr Neuro. 2010;14(3):274-277. Pachner AR. Early disseminated Lyme disease: Lyme meningitis. Am J Med. 1995;98(4):30-43.
Esposito S, Bosis S, Sabatini C, et al. Borrelia burgdorferi infection and Lyme disease in children. Int J Infect Dis. 2013;17(3):153-158. 7 Ewers EC, Dennison DH, Stagliano DR. A Unique Case of Adolescent Neuroborreliosis Presenting with Multiple Cranial Neuritis and Cochlear Inflammation on Magnetic Resonance Imaging. Pediatr Neurol. 2015;52(1):107-109. 8 Roaldsnes E, Eikeland R, Berild D. Lyme neuroborreliosis in cases of non-specific neurological symptoms. Tidsskr Nor Laegeforen. 2017;137(2):101–104. 9 Miller MM, Müllegger RR, Spork KD, et al. Lyme borreliosis of central nervous system (CNS) in children: A diagnostic challenge. Infection. 1991;19(4):273-278. 10 Vukelic D, Bozinovic D, Morovic M, et al. Opsoclonus-myoclonus syndrome in a child with neuroborreliosis. J Infect. 2000;40(2):189-191.
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