23 minute read
Emergency Medicine Network is Forging Ahead
Emergency Medicine Network is Forging Ahead: An Interview With Dr. Carlos Camargo
By Maurice Dick on behalf of the SAEM Research Committee
Dr. Carlos Camargo is a professor of emergency medicine, medicine and epidemiology at Harvard University, and the Conn Chair in Emergency Medicine at MGH. He founded and leads the Emergency Medicine Network (EMNet). Dr. Camargo’s research also focuses on nutrition and respiratory/allergy disorders, both in large cohort studies (e.g., the Nurses’ Health Studies) and in large randomized controlled trials; the health effects of vitamin D are a major focus. He has more than 1,100 publications with an H-index of 145. Dr Camargo is past president of the American College of Epidemiology, and has worked on several U.S. guidelines, including those on diet, asthma, and food allergy. In 2016, he received the ACEP Award for Outstanding Contribution to Research. Another important focus for Dr. Camargo is research training and mentorship; he was honored by Harvard with the Barger Excellence in Mentoring Award (2011) and by MGH with the Potts Faculty Mentoring Award (2019).
Can you expound on some of the challenges, gaps and or deficiencies that you encountered prior to the establishment of EMNet?
At that 1996 SAEM meeting, multiple investigators expressed frustration about doing single center studies with small sample sizes, low statistical power, and potentially limited generalizability. Moreover, recruitment at only one center typically required months (sometimes years), which extended far beyond the traditional fall burst in asthma exacerbations. The long duration of these studies did not match the mindset of many emergency physicians, who typically favor shorter, simple, intense experiences — and then done! In response to this, we agreed to 24/7 enrollment of all emergency department (ED) patients with asthma exacerbations during a two-week period that fall.
“A major factor that contributed to EMNet’s early growth and success was our open invitation to any highly motivated, detailCarlos Camargo oriented EM researcher to join us.” Ultimately, 12 sites enrolled greater than 80% of truly consecutive patients and we collectively enrolled more than 500 patients in a few weeks. Moreover, we were able to contact more than 80% of these patients at two-week follow-up!
EMNet has experienced exponential growth since inception (1996), including but not limited to, 24/7 medical centers and three distinctive programs (MARC, HSR, Social EM). What are some major factors that contributed to EMNet’s growth and success?
After that initial success, we quickly grew to 77 sites and then just kept growing as we expanded our focus to other respiratory/allergy emergencies (e.g., COPD, anaphylaxis, acute respiratory infections) and developed HSR research on the heterogeneity of EDs, both in the U.S. and internationally. Major HSR studies have focused on the emergency
medicine (EM) workforce and patient safety issues. We also undertook novel studies on more psychosocial aspects of emergency care, including suicide prevention.
A major factor that contributed to EMNet’s early growth and success was our open invitation to any highly motivated, detail-oriented EM researcher to join us. We typically develop simple protocols, for short duration studies (involving many sites), and emphasize the importance of disseminating our findings through national meetings and manuscript publications. To date, EMNet investigators have published over 850 manuscripts, with more than 800 named authors from more than 175 participating sites.
How has EMNet adjusted over the years, with reference to products, processes, and procedures, to medical, social, and technological trends and advancements?
The biggest change over the past 25 years involves funding. Initial studies were largely unfunded, with sites volunteering to participate for these intensive two-plus week studies. Alas, those days are long gone. Moreover, as we have grown to rely largely on NIH funding, we have had to focus on longer (e.g., five-year) studies with fewer sites and more challenging protocols. We still work on a variety of study designs (from short surveys to randomized controlled trials) but the large federally funded studies have pushed the EMNet Coordinating Center from 10-20 staff to its current 50+ staff. Without all these hard-working people, under the leadership of Ashley Sullivan, MPH, MS, we could not do all that we do.
Another important change has been technological. We started EMNet in the 1990s when email/internet was being introduced to academia, and we could not have advanced as we did without that technology. Over the past decade, we have turned over most of our data management to REDCap and similar programs, which have greatly improved the efficiency of our research operations.
Describe a significant challenge EMNet may have experienced and how was this challenge addressed?
The biggest challenge for EMNet has been the lack of dedicated infrastructure support for the network. Our annual budget (now $7.2 million) is entirely funded by individual research project grants, especially NIH R01 grants. EMNet funding started with an administrative supplement to my K award in 1996, which has been followed by multiple grants from NHLBI, NIAAD, AHRQ, CDC, and other federal sponsors; federal funding accounts for greater than 90% of our support. It has not been easy, but we’ve been able to secure continuous funding for 25 years and, as much as possible, to share these funds across the network.
Can you highlight at least two major accomplishments of EMNet?
The two main accomplishments of EMNet are its scientific publications and its mentorship of EM researchers. With regard to publications, the MARC program has shined a light on the importance of ED visits for asthma exacerbations and anaphylaxis and this has led to changes in NIH guidelines; the HSR program — partly through our annual survey of all U.S. EDs, called the National ED Inventory (NEDI)-USA — has emphasized the heterogeneity of U.S. EDs and its workforce and, thereby, influenced EM health policy; and the Social EM program has done important work on ED-based suicide prevention and the role of ED-based screening for adverse social determinants of health. Regarding EM research mentoring, EMNet studies have provided practical, “on-the-job” research training for hundreds and hundreds of EM faculty, post-docs, EM residents, and students, across the U.S. and worldwide. With collaborators at most academic EM programs, this mentorship and, ultimately, our shared learning is probably EMNet’s biggest contribution to EM.
Where do you see EMNet in the future?
We will continue to work on our three programs (MARC, HSR, Social EM), along with one-off projects on specific issues of interest. For example, we recently finished a scientific review of SAEM Annual Meeting abstracts over the past 30 years. I attended my first SAEM Annual Meeting in 1994 and the improvements since then have been remarkable! We set out to formally study this and confirmed my anecdotal impressions. It gives me great personal satisfaction to know that EMNet played a small but important role in this remarkable scientific progression.
ABOUT THE AUTHOR
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.
About EMNet
The Emergency Medicine Network (EMNet) was founded in May 1996 by a dozen SAEM members with a research interest in asthma. At the initial meeting, Dr Carlos Camargo, Massachusetts General Hospital (MGH), Harvard, was chosen to lead this voluntary, unfunded, multicenter initiative. The group launched its first asthma study in the fall of 1996. The network was originally known as the Multicenter Airway Research Collaboration (MARC) but it was quickly apparent that most problems of emergency department (ED) patients with asthma involved: a.) health care delivery/policy issues and b.) psychosocial issues. The collaboration was renamed EMNet, and it now includes three emergency medicine (EM) research programs: MARC, Health Services Research (HSR) in emergency care, and Social EM. EMNet is a research division in the MGH Department of Emergency Medicine; the EMNet Coordinating Center includes approximately 50 EM faculty, post-docs, analysts, clinical research coordinators, research assistants and administrators.
End-of-Life Care: Implementation of POLST and MOLST Forms
By Trudi Cloyd MD, MSc, on behalf of the SAEM Ethics Committee The Case
A 63-year-old female patient with a history of stage IIIC2 endometrial cancer presents from subacute rehab with hypotension and altered mental status; she is minimally responsive to pain. On review of her medical record, you see that she was discharged from the hospital four days ago after a month-long admission initially for malignant stricture of duodenum now stented. Hospital course was complicated by septic shock due to large gastric perforation. Prior hospital documentation was full code, but the rehab facility provides medical orders for life-sustaining treatment (MOLST) paperwork documenting do not resuscitate/do not intubate (DNR/ DNI) and limited medical interventions. The document is signed by the patient, facility nurse practitioner, and social worker the day after discharge from the hospital. The patient’s son, who is not officially health care proxy, is bedside, but has been unable to visit the facility due to COVID-19 restrictions. He had no knowledge of the updated goals of care status. Advance care planning can help patients and their families discuss and document their individual wishes for end-of-life care to health care providers, should patients be unable to express their wishes at that time. There are many formats for documenting these wishes, including physician orders for life-sustaining treatment (POLST), MOLST and medical orders for scope treatment (MOST) forms, do not attempt resuscitation (DNAR) orders, living wills, and durable powers of attorney for health care. Unfortunately, care of the acutely ill or dying patient in the emergency department is often initiated with limited information, including understanding of end-of-life wishes.
In the early 1990s, health care professionals in emergency medicine, long-term care, and ethics convened a task force to address the need for a standardized portable medical order that could guide the medical team in the acute presentation of the decompensating patient. Advance directives or living wills were rarely available in a timely manner to guide decisions, and DNR/DNI orders failed
to address the nuanced medical choices available during resuscitation. In addition, DNR and DNI orders were restricted to a specific hospital admission and rarely follow the patient on discharge.
The POLST was developed as an alternative to DNR/DNI and advance director as it was designed to help patients provide nuance and clarity on their treatment wishes in the period before imminent death. POLST documents may also be referred to as MOST and MOLST, but all share the same core elements in form and design. They address such elements as IV fluids, antibiotics, artificial nutrition, and comfort measures as well as cardiopulmonary resuscitation (CPR) and intubation — and record the patient’s wishes regarding many of these issues. By allowing a nuanced selection of medical interventions, patients and their authorized surrogates can translate goals and wishes into orders that are specific to most medical encounters. This contrasts with DNR/DNI documents, which are much more limited in their scope and address only avoidance of resuscitation or intubation.
Physicians, and in some states physician assistants and nurse practitioners, can complete these forms after discussing goals of care with patients or their surrogates. In the case of the latter, the surrogate should be encouraged to make end-of-life care choices that are based on the patient’s preferences, values, and goals rather than the surrogate’s own preferences. The POLST orders are transferrable across health care settings and should be followed by emergency personnel, physicians, long-term care staff, nursing homes, and other health care providers.
Although POLST forms are ideally completed when patients can still express their wishes, they only become necessary to refer to once patients can no longer talk for themselves. Therefore, the presence of a POLST form does not obviate the need to confirm end-of-life preferences in patients with decisionmaking capacity, as patients may express changes to their previously expressed wishes. In such circumstances, a broader discussion is encouraged to review prognosis and goals of care. These discussions should include family as much as possible and appropriate to avoid future misunderstandings. In the absence of a patient with decisionmaking capacity, as in this particular case, the medical team should rely on the POLST documentation to guide care. Only in exceptional circumstances, for instance if the team does not believe the patient understood what was being signed, should documented POLST orders be adjusted, and in such a case it is recommended to include your hospital ethics service and/or risk management.
POLST, or one of its variants, is recognized in all 50 states and Washington, D.C. (www.polst.org), but they vary in their applicability and are not universally established as standard of care. However, the development of national and cloud-based POLST registries will likely further increase adoption and ease of access for emergency personnel and health care professionals enabling more timely and consistent recognition of patient preferences for end-of-life care.
As physicians and health care professionals, we uphold the ethical principle of respect for patient autonomy as well the legal principle of patient self-determination. While initial advance directives and DNR/DNI orders attempted to empower patients to make informed decisions on their end-of-life care, the information was limited or often not easily accessible to medical providers. The POLST form provides specific information on frequent medical interventions that can be more easily implemented across a variety of scenarios. It is the hope that with increased implementation and cloud-accessibility, health care providers can consistently honor these wishes, improving quality of life by ensuring care is provided in accordance with patients’ wishes.
Case Conclusion
The hospital ethics team was consulted after the patient’s son expressed concern that the new MOLST was not consistent with his mother’s wishes. Palliative care meetings with the family and patient during the previous admission documented plans for aggressive cancer treatment and full code status. The medical team elected to escalate care to antibiotics and peripheral vasopressors but not pursue intubation. Ultimately, the patient expired two days later.
ABOUT THE AUTHOR
Dr. Cloyd is an assistant professor in emergency medicine at Columbia University and assistant residency program director at New York-Presbyterian emergency medicine program
When Is It too Late? Lifestyle Medicine for Older Adults
By Mary Mulcare, MD, on behalf of the SAEM Academy of Geriatric Emergency Medicine
The “wellness” conundrum poses a challenge to health care; what makes one person well is very different from that which makes the next person feel equally well. Most approaches to wellness to date have been a series of point solutions that are narrow in their scope. The evidence behind these solutions is lacking and the adherence to these programs varies dramatically. What is the right (or potentially right) answer?
Lifestyle Medicine (LM) is changing the wellness landscape. The American College of Lifestyle Medicine has defined LM as “the use of evidencebased lifestyle therapeutic intervention – including a whole-food, plantpredominant eating pattern, regular physical activity, restorative sleep, stress management, avoidance of risky substances and positive social connection—as a primary modality, delivered by clinicians trained and certified in this specialty, to prevent, treat and often reverse chronic disease.” In a more distilled format, this translates to replacing unhealthy behaviors with positive ones in these six areas. As I was discussing this concept with some colleagues, the question arose: when is it too late to bring lifestyle medicine into one’s life? At what age? As someone trained in geriatrics, that seemed like a ridiculous question. It is never too late! A skilled LM provider
“A skilled lifestyle medicine provider assesses the patient’s current state and meets them there, creating simple, feasible goals to move the patient towards a healthier state.” assesses the patient’s current state and meets them there, creating simple, feasible goals to move the patient towards a healthier state. The goal is nonpharmacologic intervention. Let’s briefly unpack the six pillars further as we think about the older patient cohort:
1. Nutrition
Plant-based diets have antiinflammatory effects, reduce cardiovascular disease, and impact the
onset of many common malignancies. For patients suffering from constipation, nutritional changes can provide the motility enhancement needed.
2. Exercise
Moderate exercise in one’s routine likewise reduces cardiovascular disease, obesity, and diabetes, among other things. For our older adults, it allows them to maintain independent living for longer, work on balance, and provides strength to be functional with activities of daily living (ADLs).
3.Sleep
Understanding healthy sleeping habits may prevent insomnia or changes in sleep-wake cycles experienced by many older adults, as well as allow them to reduce the deleterious sleep aids often trialed.
4. Stress management
Stress is one component of emotional resilience, a life-long skill that allows people to return to their “pre-event” status after an acute issue.
5. Avoiding risky substances
Alcohol can be especially dangerous in older adults as their metabolism changes. Older adults are more likely to fall, lead to devastating consequences, and suffer from unrecognized alcohol withdrawal upon losing access to drinks in acute scenarios compounding life-threatening situations.
6. Social connectedness
Older adults who stay connected with their community have increased longevity and better brain health. Social constructs facilitate the goals in all the above categories.
We can incorporate an introductory discussion to Lifestyle Medicine with our care in an emergency department. We are often left with unrevealing workups. What if instead of trying to explain to the patient why it is a good thing you don’t have an explicit answer for their pain, you spend a few minutes outlining some of the positive changes they might make in one of these six pillars that may prevent them from having similar trips to the emergency department in the future? Education and awareness is key to the Lifestyle Medicine mission. Take a few minutes to explore the American College of Lifestyle Medicine.
ABOUT THE AUTHOR
Dr. Mulcare is clinical assistant professor of emergency medicine at Cornell University and chief medical officer for Summus Global. She brings deep medical experience and a commitment to patient and physician education, particularly that related to older adults, to her current positions.
About AGEM
The Academy of Geriatric Emergency Medicine (AGEM) works to improve the clinical care of older patients, prepare trainees to care for older patients, and advance the geriatric EM research agenda. Joining AGEM 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.”
Strengthen Global Toxicology: An Antidote to Disparities in Global and Country-Level Toxicology Systems
By Jonathan Meadows, MD, and William Weber, MD, on behalf of the SAEM Global Emergency Medicine Academy
Over the past two years, the SARSCoV-2 COVID-19 pandemic has unearthed new and exacerbated existing challenges in treating toxicological conditions. One major example is misinformation driven treatments, such as taking hydroxychloroquine (HCQ) or sodium hydroxide (bleach) to neutralize SARSCoV-2, which has prompted responses such as the following Twitter post from the Food and Drug Administration:
“You are not a horse. You are not a cow. Seriously, y’all, Stop it.” – Twitter post, 8/21/2021, US Food and Drug Administration. This article presents the current state of global toxicology within the crucible of the COVID-19 pandemic, as well as progress towards all countries having emergency health systems to manage toxic exposures. These health care system components include but are not limited to the following: support for individual exposures at the health care facility level, systems for monitoring & addressing significant exposure incidences, and preventive approaches to future toxic exposures. This article will also discuss aspects of systems for toxicologic management in the context of COVID-19 including individual exposures, monitoring systems for significant exposure incidences, and preventive approaches to future toxic exposures. The global burden of toxicological disease can be approximated from injury data from the World Health Organization (WHO). Since 2014, 10% of deaths have been due to self-inflicted harm, which includes poisoning. Updated data regarding poisoning within the context of COVID is published by stakeholder organizations, such as the WHO and poison center data registries, such as the Toxicology Investigators Consortium (ToxIC)
registry. Providing real time aggregated and disaggregated data regarding acute and chronic poisoning can be challenging amongst the stakeholders and the COVID-19 pandemic’s impact on trends is being elucidated currently. Articulating and addressing the asymmetric burden of poisoning in low-middle income countries can also be additional disaggregated data points.
Efforts to meet this global burden of disease are ongoing and are continuations of historical efforts. In the US, one of the first poison information systems ever started was in the 1930’s by registered pharmacist Louis Gdalman at St Luke’s hospital in Chicago, IL. Throughout the 1940s and 1950s, efforts to increase public awareness were undertaken, such as the American Academy of Pediatrics’ national efforts to reduce child poisoning. At the global level, the first poison information centers were started in the Netherlands in 1949. The US poison center at Presbyterian-St Luke’s Hospital was formally recognized in 1953. Afterwards, poison control centers spread throughout the US. Today, poison control center development serves as additional opportunities for growth. Only 47% of countries have one or more poison control centers (Image 1). These centers may be concentrated in high-resource areas, given that the WHO has documented severe all-type medical staff shortages in low- and middle-income countries, leading to the low likelihood of am accessible trained medical toxicologist for intervention & consultation. The WHO has guides to establish centers, such as the 2021 publication “Guidelines for establishing a poison centre.”
Thus, a need to address the global burden of toxicological disease is clear and can be undertaken with global cooperation amongst poison control centers, and toxicology societies, potentially under the coordination with the WHO and/or International Committee of the Red Cross (ICRC). These societies include the International Union of Toxicology or regional toxicology societies, such as MENATOX (Middle East and North Africa Clinical Toxicology Association), AACT (American Academy of Clinical Toxicology), and ACMT (American College of Medical Toxicology).
Thus, galvanizing toxicological management capacity can include the key following actions: • Building poison control centers. • Improving surveillance reporting systems (pharmacovigilance). • Expanding acute care systems, such as updating physical and technological structures. • Crafting strong administrative policies. • Establishing training programs in toxicology. • Improving mandatory reportable disease policies & systems. • Strengthening the interlocking emergency medical systems (EMS)emergency department (ED)-intensive care unit (ICU) care systems. • Additional steps & actions are noted by organizations, such as the WHO.
Recent effort by the WHO and the ICRC to standardize basic emergency care incorporates toxidromes (toxicological clinical presentations and features along with their antidotes) appropriately under the “Altered Mental Status” section. This Basic Emergency Care (BEC) course is used to teach emergency medical response & medical stabilization skills in resource poor settings. In the same direction, strengthening EM academic programs globally have been ongoing. Academic centers can capture toxic ingestion cases and sequala related to the COVID pandemic (such as bleach ingestions, ivermectin paste use, or high dose HCQ ingestions as dangerous treatment alternatives) and expand the number of local toxicologists (in an effort to forward the “decolonization movement” in global health). Professional society educational programs, such as ACMT’s Global Educational Toxicology Uniting Project (GETUP), also provide outreach training to advance toxicology knowledge and capacity.
Future advancements of capacity for toxicological services include the use of telemedicine, which has been adopted by many toxicology fellowship training
GLOBAL EM
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programs and academic centers with toxicology services. The incorporation of the internet as a surveillance tool for word searches can be used to add additional information for incidence response. Other novel technologies are being applied in the forefront of toxidrome management, such as social media and wearable devices.
Current events of large scale toxicological threats, such as the Russian military occupation of the Zaporizhzhia nuclear power plant in southeastern Ukraine or the ammonium nitrate 2020 Beirut explosion, articulate the need for toxicological disaster preparedness and HAZMAT responses. Medical implications of such disasters require specialized training and response, such as participation in Advanced Hazmat Life Support (AHLS) courses along with domestic and international training events. Knowledge in these areas were critical for responses to previous nuclear & radiological incidences, like Chernobyl and Fukushima. Organizations, such as Organization for the Prohibition of Chemical Weapons, monitor chemical weapon use globally and utilize toxicological principles to combat the use of banned weapons, such as nerve agents. Linkages to climate change and environmental toxicology can be monitored and addressed with global toxicology through these aforementioned efforts, such as hydrocarbon exposures, air pollution, persistent water organics, and organophosphate pesticide use on farms that face water precipitation changes.
Finally, advocacy is critical to preventing poisoning and building capacity for toxicological clinical response in the US and globally. Academic institutions, such as Karolinska Institutet in Sweden, are teaching courses that link global toxicology to the United Nations (UN) Sustainable Development Goals (SDG), international legislations and policies for chemical safety. Chemical safety policy also encompasses US and European post-marketing drug reporting in research studies as well as adverse drug event reporting are required. European Registration, Evaluation, Authorization and Restriction of Chemicals (REACH) legislation requires companies to adhere to higher industry standards, testing guidelines, and regulatory processes that protect human health and the environment. Furthermore, advocacy is needed to earmark public funds for poison control centers, toxicology surveillance systems. This places global toxicology not only in the sphere of global health governance, and other initiatives like global addiction medicine & pharmacosurveillance, but also broader global efforts, such as the aforementioned WHA declaration, and tropical medicine’s One Health initiative. This connects toxicology to tropical medicine as function of emerging diseases and neglected tropical diseases (NTDs) within the overlaps of veterinary and human use of chemicals, such as organophosphate pesticide, snakebites, insect bites (and their sequelae), and antibiotics.
Addressing toxicological diseases through emergency care systems to meet the UN SDG, ensuring timely of acutely ill toxicological patient, can be achieved with realization of the aforementioned points of expanding poison control centers, academic toxicology training centers, toxicology training programs, disaster response efforts, and advocacy efforts. Global toxicology advocates not only can strengthen the health care systems, but can advocate directly to the public to prevent poisoning through public health communication messaging in times of pandemics, such as through Health Alert Networks towards health care providers and news articles to the lay public to prevent exposures, such as pediatric sodium azide COVID test kit exposure.
ABOUT THE AUTHORS
Dr. Meadows is an EM resident at Franciscan Health Olympia Fields applying for toxicology fellowships. His professional experiences range from disaster response, WASH development, food borne disease outbreak investigation, disaster preparedness, to correction medicine in global health. He’s served on EMRA leadership and is completing the ACEP EMBRS course. Dr. Weber practices at Beth Israel Deaconess Medical Center. He helped found the Medical Justice Alliance to advocate for the health of individuals in carceral settings. On the side, he helps lead ACEP's Public Health and Injury Prevention Committee and developed Chart Decoder, an app to help patients understand their medical records.
