28 minute read
Diversity & Inclusion Transition from Trainee to Faculty
Transition from Trainee to Faculty
By Moises Gallegos, MD, MPH; Tiffany N. Mitchell, MD; Cortlyn Brown, MD; Arthur Pope, MD, PhD; Ashlea Winfield, MD, MSPH; and Alden Landry, MD, MPH, on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine
The SAEM Academy for Diversity and Inclusion in Emergency Medicine (ADIEM) recently sponsored a titled the “Transition from Trainee to Faculty.” Dr. Tiffany Mitchell welcomed Drs. Cortlyn Brown, Arthur Pope, and Ashlea Winfield in an insightful discussion of their experiences as junior faculty members. Highlights from the webinar are shared in this article. The full recording of the session may be found online.
The first year after residency is characterized by a steep learning curve. New doctors learn how to practice as (and not under the supervision of) an attending. They discover how medicine is practiced in different health systems and continue to develop their personal and professional selves. In academic medicine, this transition also involves stepping into roles in administration, education, and scholarship. The demands of being both a clinician and a faculty member can be challenging to anticipate and navigate.
“What was the biggest thing that surprised you as an attending?” The first six months can be challenging.
If you are leaving the location of your residency, where you have spent some considerable time and formative years, the geographic move can be difficult. Additionally, whether you relocate or not, you will find yourself looking for a new community of people as your coresidents move and start their attendingships. Clinically, you must adjust to a new medical system and the way that your new health care system practices. You’re working through the self-questioning process to solidify your personal practice pattern. Add to these stressors the need to study for boards and it’s easy to feel overwhelmed. “It was almost like being a first-year resident again….”— Dr. Pope
You’ll be busier than ever.
It’s common to walk away from the final shifts of residency looking forward to all the free time that will come with an attending schedule— until you realize that your schedule is suddenly busier than it was before. While you may find yourself working fewer shifts, your excitement to start in a new role will result in you volunteering for things, showing up to extra meetings, and trying to get your foot in the door. This is important and will help you find your niche, but it can quickly overload your schedule. During your first year, try to advocate for yourself. Protect your time, advance your interests, and promote your career. “I’m busier now than I was as a chief resident.” — Dr. Winfield
What’s important to you might not be valued by the institution.
As you step into your new role as a faculty member, you’ll start to take on projects that seem important. While it seems harsh to say, projects that are important to you may not always contribute to your career advancement.
“It was almost like being a firstyear resident again….” — Dr. Pope “It was surprising to me to learn the different things that are valued.” — Dr. Brown
This may be because your institution may not value the deliverable within their promotions process or may not allot clinical shift reductions for the work you complete. Before taking on new tasks or projects, assess if you have time, whether the project/task will help or hinder your career development, and whether or not you will enjoy the project. “It was surprising to me to learn the different things that are valued.” — Dr. Brown
“What has the process been like trying to find information about the criteria and requirements for promotion? When did you initiate the process?” Start early and understand the requirements.
It’s important to start thinking about the process of promotion from the day you join the faculty. Advancing from clinical instructor to professor looks different across institutions and among individuals. Review the criteria and requirements early to ensure you understand expectations or have time to seek clarification. While it may be several years before you come up for consideration, putting together a portfolio is a lot of work. Start early to compile an easily accessible folder of everything that can/should be included in a promotion application (e.g., student reviews, letters of support, acknowledgments, etc.) Waiting until the last minute may result in you needing things you didn’t know were required and therefore didn’t save or keep handy.
Different situations exist.
Institutions may have different pathways and criteria for promotion for the various faculty. Clinical faculty may not need much in the way of research or presentations, but research faculty may have a set number of expected publications and scholarship requirements. Some institutions may have a “grace period” during which junior faculty are not held accountable for productivity while they settle into their roles. It’s important to understand the policy in your department. Additionally, what is true in one system may not be the same in another. For example, achieving promotion in your current system may not seem immediately necessary as it may not affect your role, responsibilities, or compensation, but if you were to leave for another institution the promotion might impact your transition and time allocation.
“Did each of you have a clear idea of what you wanted to accomplish and what you wanted your role to look like before you started your job?” It’s OK not to know, but don’t forget yourself.
Starting off it can feel like you’re all over the place—doing this and doing that; interested in this, curious about that. This is how to easily find yourself overcommitted and burning out. It’s important to take a step back and remember what your passions are, what brings you joy, what you want to achieve, and who you are or want to be. “As long as I ‘come back to what drives me,’ I’m good.” — Dr. Winfield
Advocate for your interests.
If you have a specific set of skills or have worked heavily in a particular discipline, make this known.
You may not be able to negotiate all aspects of your contract in every academic setting, but you can advocate for your interests. When looking for a job, ask questions that help you determine if the institution or department aligns with your work and/or interests. Sometimes the answer will be yes, sometimes no. To help you determine if you can thrive in a setting, discuss the topics of protected time and buydown, titles, projects, and administrative support. “This is who I’m going to be, this is what I’m going to bring, I’m going to focus on these efforts, do they fit within your mission statement?”— Dr. Brown
“What if you need to make a shift?” You might hit a wall.
You will probably start off strong and hit the ground running with excitement about projects, energy for the job, and a drive to advance. Consider your mental health. Reach out to mentors and support systems. Figure out what you need to let go. If you find yourself in a place where you feel you are unable to make the changes needed to take care of yourself due to unsupportive leadership, it may be a sign that you need to go elsewhere.
“How do I ask for buydown?”
The topic of salary and clinical buydown in academic medicine can be difficult to navigate, especially as a junior faculty member. Upon starting their careers, many junior faculty find that they do not have as much time protected for academic projects, especially as new items are added to their plates. You may be wondering how to advocate for time off to pursue academic projects without coming across as complaining. You deserve recognition and compensation for what you’re doing. Here are some suggestions:
Be clear about departmental expectations as well as paths to promotion and clinical buy down.
In academic medicine, you will generally receive one hour of clinical shift buydown for every two to three hours of nonclinical work (e.g., teaching, research endeavors, serving on departmental committees), but this will vary per institution and by department. Your full-time employment (FTE) may be specifically allocated as percentages to different tasks, roles, and projects. The best time to advocate for reduced clinical duties may be before you even start the job. In your initial discussion with your potential employer be sure to ask what deliverables you are expected to produce at your current FTE; if you feel the expectation is not appropriate, negotiate. Also, be clear about projects you want to do and ask
if there is a path to protected time to complete those projects. This may be especially important for those doing work that is not traditionally leveraged in promotions processes, such as social justice initiatives, community volunteerism, etc.
Promote your contributions to the department.
Present data about your accomplishments and your progress to leadership. In the case of academic projects that are not quantifiable via surveys or numerical categorizations (e.g., “my project has resulted in an X increase in patient satisfaction”) it may be helpful to track how your time was utilized (e.g., time spent designing a simulation scenario or building a procedural model). The goal is to be clear about the impact you are having. If you are unsure how to present your work to leadership, consider asking a more senior faculty sponsor to serve as an advocate.
Look beyond the department.
Find the mentorship and support needed to advocate for your interests and productivity. If the department can’t give you protected time, find a role in the medical school or undergraduate campus for salary support. Roles within your associated medical school, such as teaching or serving on the interview committee, can also lead to additional pathways to buydown. If you are not affiliated with a medical school or university, explore institutional committees and leadership opportunities.
“As a junior faculty member at a new institution how did you navigate finding mentorship?” Make it a part of the interviewing process.
During your interview, ask about mentoring programs available to junior faculty. Do programs exist for URiM faculty within the department, or does the medical school provide opportunities? What existing programs are there for faculty development that are related to your areas of interest? If I pursue faculty development outside of the department (e.g., SAEM ARMED MedEd or Emerging Leader Development Program), are there departmental funds pay for these experiences, and am I able to have
reduced clinical duties during that time to pursue them?
Mentorship vs. Sponsorship.
As you dive into your new role, embrace the variety of mentors you will have: formal, traditional, focused, project-based, etc. Mentorship can come in various ways and will help all along the path. You will also need a sponsor who will act on your behalf and promote your career. As previously mentioned, sponsors can be helpful when negotiating for changes to FTE. If there are no mentors for specific areas in your institution, consider joining national committees such as SAEM interest groups where you can build relationships with faculty from across the county. Even if you have mentors in house, it is worth establishing contacts from other programs to collaborate for research and to gain additional perspectives.
“Talk more about the need to do fellowship before an academic job. We are told at 3-year programs that it will be necessary to do a fellowship before academic job” It depends.
While fellowships are meant to afford EM physicians the opportunity to become experts in their field, not all academic positions will require fellowship training. If you’re already doing the work as a resident and can show scholarship or productivity either through teaching or publications this may be enough. Having an advanced degree or demonstrating proficiency in other ways may still make you a competitive applicant. Be mindful that there are some positions, such as simulation or positions that include a directorship role, where fellowship training may be desired.
Set yourself up to succeed.
Talk to as many people as you can about the strength of your application. Understand what the institution is looking for. If you see that they traditionally only hire faculty with fellowship training, it may be hard to navigate this otherwise. During residency, work to build your CV in a way that frames your interests and promotes your successes. You may develop partnerships and relationships that can help you further delineate whether fellowship is the right fit for you.
3-year vs. 4-year
Some institutions will not hire a threeyear grad without either a fellowship or an additional year of experience. This can be the case for some four-year programs that prefer attendings and fellows to be a year further along in experience than the trainees they will work with.
“Were there any challenges in shifting from being a learner to a teacher? How do you balance teaching and taking care of patients?” It’s a balance.
You’ll need to figure out what kind of attending you want to be. You will discover with which residents and in what contexts you can observe and be more hands-off. While you should always “trust but verify,” you will have to find your own level of comfort working with each resident. You’ll find a balance between providing autonomy and providing support.
Don’t compare yourself to other people.
You will become your own “type” of attending. Some people will sit and talk about a paper, going through the evidence-based discussion of decision making. Others are great at teaching procedures just-in-time. You may be the attending that can teach flow, efficiency, and charting. Don’t compare yourself to your colleagues. Instead, focus on what you consider your strength and how you can teach that strength to others. “I am who I am, I teach the way I am, my strengths are my strengths, and that’s enough.” — Dr. Winfield
“What was it like to go from having a cohort of your peers, to being the youngest or most junior?” Bonding with residents while staying professional.
As early faculty, you will often find yourself closer in age and experience to the residents than your faculty
peers. The hardest thing can be finding a balance between bonding with new residents, earning their trust, and remaining professional as their supervisor. There is no hard rule that says you can’t hang out with residents. Recognize, however, that you may find yourself at times needing to provide critical and constructive feedback. It’s important to maintain professional boundaries. This might be as simple as clarifying early on whether you’re “okay” with first names, or prefer to be called by the title “Dr.”
Keep up with your residency group.
Maintain an active GroupMe, WhatsApp, etc. with your resident cohort. “Should I pull this out?” “Would you discharge this?” “You’ll never believe what I did tonight.” Those 3:00 a.m. texts can be centering and help create some levity. They can also be a quick poll/show-of-hands to remind you that you know what you’re doing.
Meet as many people as you can.
Some institutions will hold orientation activities or meet-and-greets for new hires. Seek out any new faculty from your own department or others. Summer welcome picnic for the nurses- get to know as many of them as you can!
“My future academic job doesn’t have any black faculty. I feel supported, but do you have any tips or suggestions for situations where mentorship by URiM colleagues isn’t an option?” Find your colleagues.
While mentorship traditionally comes from senior people in your field or department, URiM mentorship may come from colleagues going through it along with you. Stay in touch with people you meet along the way.
Look outside your institution.
If you do not have fellow URiM faculty in your department, make connections at other institutions. You will find people in the same shoes looking for the same thing. Find a community that you can build through conferences, talks, chance encounters. Start your network. Consider nonmedical and community partners as possible professional connections.
“Are there moments where you feel stuck in academics, and do you feel you can explore opportunities in the community?” Look for an opportunity to work in the community.
Working without residents or in a nonacademic site can be very useful in your first years out in that it will help you maintain a skill set, develop practice patterns, and continue to build your identity as a physician. Some institutions have clauses that don’t allow you to work at outside facilities, so if working solo shifts is important to you, try to find a job that allows you to work independently or allows the opportunity to moonlight.
Final Thoughts Know that you have put in the work.
A huge struggle is imposter syndrome and feeling the need to prove you’ve earned your title. You have earned your title you don’t need to prove it.
You may feel that you need to show you’ve earned your title and you can find yourself committing to too much as a result. You have earned your role, you don’t need to prove it.
Take care of yourself, physically and mentally.
It’s okay to feel overwhelmed. You will be going through a lot: studying for boards, new autonomy, new responsibility, new role, ongoing pandemic, etc. Consider proactively looking into self-help or mental health resources that can contribute to your well-being.
Find agency and find your voice.
Underrepresented minority physicians and female physicians frequently feel compelled to accept every opportunity and not miss a chance. It can be hard to say no, but it’s important to learn to advocate for yourself.
Learn to say no gracefully.
Don’t feel bad about saying “no,” but do so in a professional manner: “Thank you for thinking of me. I’m not sure this fits my interest.” “This sounds great, unfortunately, it doesn’t fit my career trajectory.” If you need more time to think about it or want more specifics about the project, don’t be afraid to ask. “You are competent, you are confident, you are great.” — Dr. Winfield.
ABOUT THE AUTHOR
Dr. Gallegos is clinical assistant professor and clerkship director, department of emergency medicine, Stanford University School of Medicine.
ABOUT THE WEBINAR MODERATOR
Tiffany N. Mitchell, MD, is an emergency medicine instructor at Mount Sinai School of Medicine. Dr. Mitchell is chair of the SAEM Equity and Inclusion Needs Assessment Committee and chair of ADIEM’s Social Media and Publications Committee.
ABOUT THE WEBINAR PANELISTS
Cortlyn Brown, MD, is vice director of diversity, equity, and inclusion and assistant professor of emergency medicine at Carolinas Atrium Health, Charlotte, NC.
Arthur Pope, MD, PhD, is clinical assistant professor of emergency medicine at Penn Medicine, Philadelphia, PA.
Ashlea Winfield, MD, MSPH, is assistant director of the Cook County Health Simulation Center and assistant professor of emergency medicine and chair of the diversity and inclusion committee at Cook County Health, Cook County, IL.
About ADIEM
The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the realization of our common goals of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Joining ADIEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
Alternative Pathways to Admission: The Use of Telehealth in Transfer Coordination
By K. Noelle Tune, MD and Emily M. Hayden, MD, MHPE, on behalf of the boarding and crowding subcommittee of the SAEM ED Administration and Clinical Operations Committee
As we continue to experience recurrent Covid-19 surges, increased utilization of telehealth for transfer coordination could alleviate strain on academic referral centers, while also providing high-quality care at local, community hospitals. A goal of such programs is to leverage telehealth technologies to accurately identify the need for a higher level of care. The potential avoidance of unnecessary transfers can keep health care dollars within local hospital systems and communities while simultaneously maintaining bed availability in tertiary care centers. Many health care systems, and emergency departments (EDs) in particular, have implemented telehealth systems to provide quality care to patients in alternative sites, such as the home or other affiliated health care facilities. It is commonplace for community EDs to utilize telehealth to access specialists in many fields, such as Psychiatry or Neurology, and there has been ample evidence suggesting that rural EDs have expedited dispositions when telehealth is utilized in the coordination of care. As such, telehealth infrastructure exists for emergency medicine to further leverage telehealth for improved transfer coordination across a more generalized patient population. Pre-pandemic, however, the vast minority of EDs used telehealth to assist with transfer coordination. We have witnessed the successful management of patients at affiliated hospitals utilizing telehealth capabilities coordinated through our academic ED to avoid unnecessary transfers. Video-based telehealth is available for use during the discussion between the clinicians at the originating and the
tertiary care EDs in the determination of patient disposition. For example, similar to ED colleagues going to a patient’s bedside to enhance their discussion of the patient’s care, video is available when the ED clinicians from the originating and referral sites want to use video to go to the patient’s bedside. A clinical example could be a patient with a particular neurologic finding that may be hard to describe verbally. Similar tele-emergency medicine programs exist in other regions of the United States. Multiple articles suggest that the availability of telehealth consultation, especially in sepsis, can result in avoidance of transfers and potentially improved outcomes. By providing teleconsultation with subspecialists, a significant percentage of transfers can be avoided. Neonatal resuscitation and hand surgery are two other examples of how utilization of telehealth can be impactful for transfer coordination.
Telehealth transfer coordination programs provide access to specialty consultations to patients in community hospitals, as well as critical access and rural sites, without the financial strain and disruption caused by long-distance transfers. Importantly, telehealth transfer coordination programs also allow medical personnel in community hospitals to provide high quality care with support from academic-centered specialists.
The pandemic has spurred innovative thinking in the emergency setting around ways to avoid transfers while also providing outstanding care to patients in community and rural hospitals. The challenge put forth to us by the pandemic likely expedited changes that would otherwise have taken a decade or more to evolve. We expect many of these innovations to remain active post pandemic and advocate for policy makers to opt for appropriate reimbursement of unique, patient-centric treatment models. Questions certainly remain, including ways to arrange financial relationships between facilities providing and utilizing telehealth services and how payors value and compensate systems for employing telehealth in transfer coordination. ABOUT THE AUTHORS
Dr. Tune is a telehealth fellow in the department of emergency medicine at Massachusetts General Hospital. She also practices emergency medicine at various community sites in eastern Massachusetts. Dr. Tune is focused on how telehealth can improve the quality of care in rural and underserved communities.
Dr. Hayden is the director of telehealth and associate director of the virtual observation unit, department of emergency medicine, Massachusetts General Hospital and was chair of the 2020 SAEM consensus conference on telehealth in emergency medicine. She aims to facilitate the thoughtful transformation of the specialty using the tools of telehealth.
A Career in Research? EM-Bound Students Have Concerns
By Maurice Dick and James H. Paxton, MD, MBA on behalf of the SAEM Research Committee
Engagement in medical research has been shown to stimulate and enhance medical students' learning capacity, influence academic achievements, build critical thinking skills, and solidify learning outcomes. However recent evidence suggests that medical students may have very specific concerns about pursuing a research career after graduation.
Studies by AlGhamdi et al. and Funstun et al. found both welcoming and unwelcoming views of research among medical students. Some of the negative perceptions articulated by students include lack of adequate training courses, difficulties in obtaining approvals from relevant departments, lack of funding, stress, lack of professional supervisors, excessive time requirements, perceived lack of clinical significance, and low availability of study participants. Conversely, students acknowledged potential benefits as well, including enhanced academic achievement, the opportunity to increase scientific knowledge, and an opportunity to contribute positively towards the welfare of patients. According to results from a study by Snyder et al., perceptions of a researchoriented career may also vary according to gender, influenced by considerations such as work-life balance, patient care responsibilities, perceived autonomy, and financial security. In that study, female medical student respondents ranked careers in patient care and community service most highly, while male respondents were more likely to prefer a career in research and medical education. Female students appeared to be more likely to report concerns that responsibilities such as raising children, caring for elderly parents, and providing financial support might hinder them from pursuing a research career. Early intercalation of research training into medical school curricula may help to dispel some of these concerns. Studies by Bierer et al. and Sorial et al. both showed intercalated students to have a significantly higher research self-efficacy rating and other academic
benefits. Intercalation also had careerenhancing effects and positively impacted participants’ overall perception of the importance of research. A correlation between students’ interest in clinical research careers and their perception of research was also observed. DiBiase et al. found that the incorporation of a scholarly concentrations program boosted students’ research self-efficacy scores, self-perceived research skills, and the probability that they would pursue scholarly work. In their study of an eightweek research elective module, Howell et al. found that participants could convey a greater understanding of medical research than controls. Participants also recommended opportunities for early exposure to structured research electives and modules such as fundamentals of research to advance their knowledge and experience in research.
While medical students’ perceptions of research are clearly influenced by a variety of factors, effective methods of encouraging our best and brightest to pursue a career in emergency medicine research remain elusive. Additional studies are needed to identify ways to overcome these obstacles to increase research engagement for EM-bound students. ABOUT THE AUTHORS
Maurice Dick is a third-year medical student at Saint James School of Medicine and a 2021 SAEM Medical Student Ambassador. His aspiration is to become an emergency medicine physician devoted to underserved communities. His major interests in emergency medicine include critical care, pointof-care ultrasound, and simulation education.
James H. Paxton, MD, MBA, is the Director of Clinical Research at Detroit Receiving Hospital (DRH) and an Associate Professor in the Department of Emergency Medicine at Wayne State University (WSU) School of Medicine (Detroit, Michigan). He is currently Chair of the SAEM Research Committee, and a long-time advocate for medical student research.
Navigating Ethical Principles in an Adolescent Behavioral Health Patient in a Pediatric Emergency Department
By Mindy Stimell-Rauch, MD and Joan Bregstein, MD, on behalf of the SAEM Ethics Committee The Case
A 16-year-old female is brought to the pediatric emergency department (ED) by emergency medical services (EMS). She is accompanied by her mother who says her daughter has refused for several days to take the aripiprazole prescribed for her for nonspecific psychosis. She is now showing signs of psychosis and violent behavior. There is no suicidal ideation.
On arrival, the patient is disoriented, uncooperative, and agitated. She is experiencing auditory and visual hallucinations and is speaking incoherently. Her thought content is paranoid and delusional. The patient is seen by the pediatric psychiatry consult service which recommends aripiprazole 5 mg PO at bedtime and lorazepam 1 mg PO as needed for mild agitation. For more severe agitation, or if the patient refuses oral medications, the consult recommends intramuscular (IM) administration of lorazepam, with the
“The ethical question is whether the mother, by refusing, increased the risk of harm to her daughter, the ED staff, and other ED patients.” possible addition of IM haloperidol. As this hospital has no inpatient adolescent behavioral health service, the patient remains in the crowded tertiary care ED, in a queue for transfer to an outside behavioral health facility. While awaiting transfer, the patient refuses all medications and her mental status deterioraes. Despite round-
the-clock security and 1:1 clinical observation, she manages to punch and damage the exam room wall and assault a physician. By day three, the medical team becomes concerned for dehydration, as the patient has refused food and drink and has not urinated.
The mother expresses anger that the ED staff will not “force feed” her daughter the aripiprazole, stating that by failing to treat her daughter, staff is contributing to her worsening condition. The mother, however, refuses to permit IM interventions, e.g., lorazepam, which the staff feels might sufficiently calm her daughter so that she will take the aripiprazole, or haloperidol, which would calm her and possibly also treat her psychosis.
On ED day five, the patient is approved for transfer to an inpatient psychiatric facility. This is unacceptable to the mother, who refuses to approve the transfer, stating that she prefers that her daughter be transferred to the hospital to which she had previously been admitted, which has no open adolescent beds and is out-ofnetwork for the patient’s insurance.
On ED day six, the patient is accepted for transfer to a hospital acceptable to the mother, although insurance authorization will take at least 24 hours to obtain, if it is obtained at all. The mother pays outof-pocket for the transfer, and the child leaves by ambulance.
This case features troubling themes often experienced with ED patients with behavioral health emergencies. A further complication is the patient’s age—she is old enough to have reached age of assent but incompetent to make independent decisions and therefore dependent on the decision-making of her guardian mother.
This case brings up the following questions: • Can an older minor,14-17 years of age, with psychosis be forced, without her assent, to accept treatment per medical recommendation? • To what extent can the guardian of the advanced age minor direct care, and at what point does the ethical principle of autonomy endanger the integrity of beneficence? • Can a physician sedate a pediatric patient against the guardian’s will if the minor is deemed harmful to herself and/ or the staff? • Can a guardian refuse care, or transfer to a higher level of care, if refusal is causing a threat to life or limb? To what extent does EMTALA conflict with ethical principles, and which one should prevail? • To what extent should prioritizing the needs of a single patient be allowed if the care of other patients in the department is impacted?
The patient was a psychotic patient refusing medication, without which she would be a danger to herself and others. Based on her psychiatric illness, she lacked the capacity to fully understand her situation and appreciate the consequences of her medication refusal which would include danger to herself and her providers. In this circumstance, it would be ethically acceptable to administer sedation without patient assent.
In pediatrics, when reasonable, we routinely engage in shared decisionmaking and family centered care. In this case, the mother refused the sedation, arguing it would delay the patient’s definitive treatments. She instead favored force-feeding her the aripiprazole, which was unacceptable to the medical staff because of the potential risk to the patient of personal restraint or choking, and to the staff of biting, spitting, or physical injury.
To be sure, the administration of an IM sedative to an agitated patient can be a dangerous procedure to both patient and staff. But the benefit of restraining her to administer parenteral sedation and haloperidol would have been to quickly ensure her safety and lessen her psychotic symptoms. This would have been in her best interest.
This case also highlights the issue of EMTALA, which requires consent from patient or guardian for transfer to an outside facility, usually for higher level of care. In the case of this patient, the mother refused to sign consent for transfer to the first facility offered to her daughter. The ethical question is whether the mother, by refusing, increased the risk of harm to her daughter, the ED staff, and other ED patients. It would be an additional 24 hours before the mother would deem the transfer to be acceptable, and during that time, the ED was at over-capacity. Denied the higher level of care she required, the patient became dehydrated, and her psychosis worsened. There is a fine line between what is reasonable, shared decision-making and what is obstructionist behavior that compromises medical care. In this case, the wishes of the mother were honored, and the patient waited in the ED. In the end, the child may have suffered more than was necessary because EMTALA prevailed at the expense of the expeditious care of the child.
Additionally, this patient— in a private room for six days — consumed scarce resources of a 1:1 clinical tech, security guard, social worker, nurse, pediatrician, and psychiatry staff in a busy ED during the COVID 19 pandemic. The mother, desperately seeking help for her daughter, freely wandered through the department “shopping” for staff who would listen to her concerns, interrupting the care of other patients. The extensive resource requirement by this one patient impacted the care and safety of all patients in the department.
ABOUT THE AUTHORS
