SAEM Pulse May-June 2023

SPOTLIGHT

FROM STAFF NURSE TO RESPECTED LEADER IN EM RESEARCH FUNDING AND TRAINING

An Interview with SAEM23 Keynote Speaker Jane Scott, ScD, MSN

SAEM STAFF

Chief Executive Officer

Megan N. Schagrin, MBA, CAE, CFRE Ext. 212, mschagrin@saem.org

Director, Finance & Operations

Doug Ray, MSA Ext. 208, dray@saem.org

Manager, Accounting

Edwina Zaccardo Ext. 216, ezaccardo@saem.org

Director, IT

Anthony "Tony" Macalindong Ext. 217, amacalindong@saem.org

IT AMS Database Specialist

Dometrise "Dom" Hairston Ext. 205, dhairston@saem.org

Specialist, IT Support

Dawud Lawson Ext. 225, dlawson@saem.org

Director, Governance

Erin Campo Ext. 201, ecampo@saem.org

Manager, Governance

Juana Vazquez Ext. 228, jvazquez@saem.org

Director, Communications & Publications

Laura Giblin Ext. 219, lgiblin@saem.org

Sr. Manager, Communications & Publications

Stacey Roseen Ext. 207, sroseen@saem.org

Sr. Director, Foundation and Business Development

Melissa McMillian, CAE, CNP Ext. 203, mmcmillian@saem.org

Sr. Manager, Development for the SAEM Foundation

Julie Wolfe Ext. 230, jwolfe@saem.org

Manager, Educational Course Development

Kayla Belec Roseen Ext. 206, kbelec@saem.org

Manager, Exhibits and Sponsorships

Bill Schmitt Ext. 204, wschmitt@saem.org

Director, Membership & Meetings

Holly Byrd-Duncan, MBA Ext. 210, hbyrdduncan@saem.org

Sr. Manager, Membership

George Greaves Ext. 211, ggreaves@saem.org

Sr. Manager, Education

Andrea Ray Ext. 214, aray@saem.org

Sr. Coordinator, Membership & Meetings

Monica Bell, CMP Ext. 202, mbell@saem.org

Specialist, Membership Recruitment

Krystle Ansay Ext. 239, kansay@saem.org

Meeting Planner

Kar Corlew Ext. 218, kcorlew@saem.org

AEM Editor in Chief Jeffrey Kline, MD AEMEditor@saem.org

AEM E&T Editor in Chief Susan Promes, MD AEMETeditor@saem.org

AEM/AEM E&T Peer Review Coordinator

Taylor Bowen tbowen@saem.org aem@saem.org aemet@saem.org

2023–2024 BOARD OF DIRECTORS

Wendy C. Coates, MD President

Los Angeles County Harbor-UCLA Medical Center

Ali S. Raja, MD, DBA, MPH President Elect

Massachusetts General Hospital/Harvard

Members-at-Large

Pooja Agrawal, MD, MPH

Yale University School of Medicine

Jeffrey Druck, MD

The University of Utah School of Medicine

Julianna J. Jung, MD

Johns Hopkins University School of Medicine

Nicholas M. Mohr, MD, MS University of Iowa

Michelle D. Lall, MD, MHS Secretary Treasurer Emory University

Angela M. Mills, MD Immediate Past President Columbia University Vagelos

3 President’s Comments Working Together to Ensure a Bright Future for Our Specialty

6 Spotlight

From Staff Nurse to Respected Leader in EM Research Funding and Training – An Interview With SAEM23 Keynote Speaker Jane Scott, ScD, MSN

10-13 23 Know Before You Go

14 Diversity, Equity & Inclusion

Language Accommodations: Best Practices for Working With Interpreters

18 Telementorship: A Promising Solution to Closing the Mentorship Gap for URM Physicians

20 DEI Perspective Overcoming Medical Saviorism: A Path to Improved Care for Sickle Cell Disease Patients

22 DEI Viewpoint Diversity, Equity, and Inclusion: How It Started, How It's Going

24 Education

The Importance of Residency Coordinators

26 PT and OT in the ED: Interdisciplinary Session Introduces Med Students to Value of Working With Multidisciplinary Team

28 Emergency Medical Services

The Evolving Role of Ultrasound and Telemedicine in Mobile Integrated Health

30 Ethics in Action A Patient in Custody and a Provider’s Dilemma

32 Faculty Development

The

50 Palliative Care

Nuances of ED-Based Palliative Medicine: Unexpected Challenges and Benefits

52 Research

Describing the Current Landscape of Research

Directors and Vice Chairs of Research: Results of the 2022 Research Director’s Interest Group Pilot Survey

55 Research Q&A

Funding for Research Supplements to Promote

Diversity: An Interview With Dr. Edouard Coupet Jr.

58 Sex & Gender in EM

Trauma Alert: Sex- and Gender-Based Differences in Trauma

60 Simulation

Five Tips for Effective Debriefing

62 Ultrasound

Point of Care Ultrasound for Small Bowel Obstruction: Tips and Tricks

64 A Case of Syncope: How POCUS Can Rapidly Help Diagnose Undifferentiated Shock

68 Wellness

Being More Than An Ally

70 Lactation Proclamation: The Need for Culture Change in the ED

74 Wilderness Medicine

Arctic Emergency Medicine: Navigating the Intersection of Climate and Health in Rural Alaska

76 Announcing the 2023 SAEMF Research and Education Grantees

80 SAEMF Challenges Provide a Way for Every SAEM Member to Participate In EM Research and Education Grant Funding

81 The 2023 SAEMF Chairs’ Challenge Results

Ava E. Pierce, MD UT Southwestern Medical Center, Dallas

Jody A. Vogel, MD, MSc, MSW Stanford University Department of Emergency Medicine

Resident Member

Michael DeFilippo, DO, MICP NewYork-Presbyterian - Columbia & Cornell

PRESIDENT’S COMMENTS

Angela M. Mills, MD

Columbia University Vagelos College of Physicians & Surgeons

2022–2023 President, SAEM

Working Together to Ensure a Bright Future for Our Specialty

Historically, emergency medicine (EM) has been a highly competitive specialty with nearly all residency positions filling in The Match. This changed significantly in 2022 with 219 unfilled residency positions followed by an unprecedented 555 unfilled positions in this year’s Match Nationally, the number of residency positions offered has increased in recent years from 2,493 positions in 2019 to 3,018 positions in 2023. At the same time the number of medical students applying to emergency medicine has decreased from 3,584 in 2019 to 3,282 in 2023. Together, the increase in residency positions and the decrease in medical student applicants to EM both have contributed to the significant number of initially unmatched positions this year.

Reasons for the lower numbers of interested medical students and the unfilled positions are multifactorial and have been considered to include COVID-19 pandemic stressors with resultant burdens of unparalleled ED boarding and staffing shortages, the

national crisis in acute behavioral health emergencies, increased workplace violence, burnout, the corporatization of medicine, and prior EM workforce surplus projections. SAEM is leading a multipronged approach to both identify specific factors contributing to unfilled Match positions and develop solutions to mitigate these factors.

Given the increased challenges emergency departments have faced over the past few years, the delivery of emergency care has often been difficult and stressful. Medical students have witnessed these challenges firsthand which may have potentially influenced their career choices. SAEM is committed to better understanding these complex challenges and choices and working to serve our members and advance academic emergency medicine. To identify causes for the decrease in medical student applications to EM, the SAEM Workforce Committee is currently working on a qualitative study of graduating students who seriously

considered EM but ultimately chose another specialty. Our SAEM Workforce Committee is also critically appraising more recent workforce data and projections since the pandemic.

Currently, students entering EM residencies are not as diverse as medical school graduates: 39% of EM residents are women compared to 51% of students and 15% of EM residents identify as underrepresented in medicine compared to 23% of students. There is great opportunity to expose all medical students to the incredibly rewarding specialty we have all chosen to be able to provide care by the mantra of anyone, anything, anytime – 24/7/365.

To better engage all medical students and expose them to our specialty, SAEM and SAEM-RAMS are creating promotional materials for students, including “I Love EM” videos and career vignettes of successful residents and faculty, to be distributed through medical school Emergency Medicine Interest Groups (EMIGs), in SAEM Pulse, as well as on social media. Throughout the upcoming academic year, the SAEM Clerkship Directors in Emergency Medicine (CDEM) academy is planning additional education and promotion of EM through webinars focused on students interested in EM, as well as one for EM

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“SAEM is leading a multipronged approach to both identify specific factors contributing to unfilled Match positions and develop solutions to mitigate these factors.”

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advisors on recent up to date workforce data and how to present EM as a career choice to students. SAEM-RAMS and CDEM will also be developing a toolkit for EMIGs to help advise students about emergency medicine.

SAEM will be engaged in several advocacy initiatives focused on the EM Match. SAEM routinely partners with the other EM specialty organizations and recently released a joint statement on the EM 2023 Match results (including SAEM, SAEM-RAMS, and AACEM) and SAEM-RAMS released an EM Match statement to members. SAEM also recently provided robust comments on the proposed Accreditation Council for Graduate Medical Education (ACGME) Residency Program Requirement Revisions.

SAEM is engaged in the All-EM Match Taskforce which will be working on identifying contributing factors to the Match results and strategies. This work may include understanding student factors for both those who choose and do not choose EM as a specialty. SAEM hosts the All-EM organizations to meet yearly at our annual meeting to discuss common goals and initiatives for the coming year. This year at SAEM23, we will also be inviting the Accreditation Council for Graduate Medical Education (ACGME) Review Committee (RC) for Emergency Medicine to join our All-EM

discussion. As medical school leadership advises and guides students in their career choices, SAEM with AACEM will also reach out to the Association of American Medical Colleges (AAMC) Council of Deans to meet and discuss challenges and next steps.

SAEM is dedicated to excellence and leadership in academic emergency medicine, developing and supporting academic leaders, and shaping the future science, education, and practice of emergency and acute care. SAEM is committed to serving our members and working to ensure the future is bright for our specialty. Many years ago, I left a surgical residency to enter The Match for the second time, but for emergency medicine – it was the best career decision I made in my life. We truly have the best specialty – using a tremendous breadth of knowledge, skill, compassion, and advocacy to care for all patients with the entire spectrum of illness; leading and excelling in

teamwork establishing trust with patients, families, nurses, and members throughout the health care system; excelling in the exhilarating, challenging, getting things done, and ever-changing environment of the emergency department while working in a specialty providing significant flexibility, variety, portability, and balance. Switching to emergency medicine allowed me to find significant meaning and purpose while working side by side with people I love. As with all great things, there are often bumps in the road, and I know together as emergency physicians and academic leaders we will move forward becoming even stronger.

ABOUT DR.

Angela M.

MD, is the J. E. Beaumont professor and chair of the department of emergency medicine at Columbia University Vagelos College of Physicians & Surgeons and chief of emergency services for NewYork-Presbyterian –Columbia

MILLS:

Mills,

“SAEM is dedicated to excellence and leadership in academic emergency medicine, developing and supporting academic leaders, and shaping the future science, education, and practice of emergency and acute care.”

CONSENSUS CONFERENCE

Precision Emergency Medicine: How Data Science, -Omics, and Technology Will Transform Emergency Medicine

Supported by:

Your story can help change a culture.

A critical component in decreasing mental health stigma and normalizing mental health experiences is by sharing stories. In support of this, we will be gathering to share such stories anonymously at SAEM23, and we need your help! We invite you to submit your anonymous story. With your permission, your story will be read aloud, without identifiers, by an audience member during the SAEM23 didactic session, "#StopTheStigmaEM: Shining a Light on the Hidden Mental Health Experiences of Emergency Physicians." As we listen to each other's stories and reflect together in Austin, we hope to see ourselves in each other, and in so doing, we can start to #StoptheStigmaEM.

FROM STAFF NURSE TO RESPECTED LEADER IN EM RESEARCH FUNDING AND TRAINING

An Interview With SAEM23 Keynote Speaker Jane Scott, ScD, MSN

Jane Scott, ScD, MSN, renowned and respected for her work as a leader in emergency medicine research funding and training, will present the SAEM23 Dr. Peter Rosen Memorial Keynote Address, “Advancing Emergency Care Research: Reflecting on Our Past, Looking to Our Future,” from 9:30-10 a.m. on Wednesday, May 17 during the SAEM23 opening session.

Dr. Scott began her career in the emergency care setting as a staff nurse at the Duke University Emergency Department and then as a nurse practitioner at the Johns Hopkins adult emergency department. She presented her first research abstract in 1981 at the University Association of Emergency Medicine meeting, which was followed by numerous emergency care publications. After obtaining a doctorate from Hopkins School of Public Health, Dr. Scott joined the Agency for Healthcare Research and Quality (AHRQ) as a program officer providing oversight to federally funded prehospital and ED studies. In 1995 she joined the University of Maryland National Study Center for Trauma and EMS followed by serving as research director of the program in trauma at the R Adams Cowley Shock Trauma Center. In 2005 Dr. Scott joined the National Institutes of Health (NIH) as director of the Office of Research Training and Career Development, Division of Cardiovascular Sciences at the National Heart, Lung, and Blood Institute (NHLBI). In 2008 she created the NHLBI K12 program in emergency care research, which she managed until her retirement, working extensively with the emergency medicine researchers at the eight training programs that have trained over 50 K12 scholars.

Dr. Scott has served on the SAEM Research Committee, ACEP-SAEM Federal Research Funding Workgroup, and as faculty at the EMF-SAEMF Grantee Workshop for over eight years. She has educated and mentored countless SAEM members on the K12 programs, presented at numerous SAEM annual meetings, worked closely with program officers on NIH-related matters, and taught many of our investigators how to become independently funded.

Dr. Scott (far left) and staff in the NHLBI, Division of Cardiovascular Sciences, Office of Research Training and Career development in 2017. “We were tiny, but held down a huge number of grants.”

Who or what influenced your desire to pursue a career in medicine?

I grew up on Long Island, just outside New York City. My dad was an internist, and my mom a retired Navy nurse. Dad was interested in medicine, and its evolution. He was the editor of the Nassau County Medical News publication for years. On his Thursdays off, he was a consultant to Grumman Aviation to monitor astronauts in training for travel to the moon. Growing up, I heard about medicine and clinical care routinely. What compelled your journey from patient care nursing, to earning your doctorate, and then into research, and eventually to the incredibly responsible leadership position you most recently held? What were some of the major challenges you encountered, specifically those you might have faced as a woman in the highest echelons of medicine? And how did you overcome those challenges?

I worked at two university medical centers known for their rich medical research environments. I enjoyed clinical work as an emergency department (ED) staff nurse, and ED nurse practitioner. I enjoyed working with patients; however, I participated in clinical research projects, which spurred my interest in pursuing a doctoral degree.

The role of women in health care delivery has fortunately evolved. In the early 1970s, there were substantially more men entering medical school than women. By 1974 most medical programs enrolled equal numbers of men and women; however, leadership roles in medical schools and schools of public health for women were rare and differences persist.

As an “ER” nurse back in the early days of the rugged, independent emergency department, you were among a special breed of pioneers to do the job. What are the most significant changes or advances you’ve seen in emergency medicine and in the ED, since those early days? What do you feel are the most urgent issues facing emergency medicine and, in the ED, today?

I worked in a large, 32 room ED, where there was a cardiac room, poison room, and six trauma beds. House staff from medicine, surgery, pediatrics, OB/GYN, and psychiatry

respectively covered their own services. Under this system, house staff were routinely rotated in and out of the ED. ED “continuity” was largely carried by the nursing staff, through their routine work. Patients were tallied on a large chalkboard, across from the nursing station by patient last name, chief complaint.

The ED had two 45 pound “portable” defibrillators. There was no monitoring equipment for heart rate and rhythm, blood pressure, and PO2 (partial pressure of oxygen). If someone was critically ill, staff stayed with the patient until they could be transported to their in-hospital bed. There was no prehospital communication. The only way we knew that something “critical” was arriving, was when the ambulance turned onto the ED drive flashing its red lights. Patient and hospital records were entirely paper. It would be another 15 years until computers and PCs would be integrated into practice. Emergency medical services (EMS) prehospital systems were just developing. Every so often, patients would be transported to the ED from remote rural sites by hearse.

Most notable advances: Today, computer tools, technology, decision aids and artificial intelligence are being rapidly developed. All clinical staff need to ask is how new tools were developed, tested, and what are the parameters for tool use? When does the tool work and in whom? When does the tool fail to work and in whom? Diversity, equity, and inclusion of health care services to patients is critically important as well. Physician, nursing, and support staff need to work to identify biases in health care delivery, and to eliminate biases.

You’ve been responsible for the institutional K-12 program development in EM, which has been very successful in launching research careers for EM doctors and setting up the entire training infrastructure for our specialty through this program and NHLBI. How have you seen EM research funding evolve during your career? How have you seen EM training evolve during your career? In what way/areas have you seen the biggest improvements?

I’d like to note that senior leadership from SAEM and ACEP met with the National Institutes of Health (NIH) director in 2005, to

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NHBI K12 Emergency Care Research Scholars meeting outside of the auditorium on the NIH campus Natcher Building. The last group meeting of the first K12 program that ran from 2011-2016.

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point out the deficiencies in the emergency medicine research infrastructure and ask for help. That meeting began an NIH wide evaluation of what NIH was funding. The National Heart, Lung, and Blood Institute (NHLBI) K12 program was created to train early career faculty into NIH competitive clinical investigators. The K12 program helped the site principal investigators (PIs) become familiar with NIH clinician research training programs and learn how to “run” an NIH training grant. The two NHLBI K12 Emergency Care Research programs were a $30M investment. These programs will not be renewed by NHLBI; however, two of the original K12 emergency care research program directors successfully obtained NHLBI T32 funding. A third T32 program led by EM investigators in cardiac resuscitation, has also been funded. More T32 programs are needed.

There is a role for everyone in research. The question is “what role do you want and how much time and energy do you have to pursue your research goals?” It’s important to know the goals of early career faculty. For those wishing to pursue a research career, research mentors and a research career timeline are invaluable.

It’s also important to recognize and thank many senior emergency medicine leaders who worked tirelessly through SAEM and ACEP over the past 20-30 years to promote research, research committees, and research training fellowships (Roger Lewis, Judd Hollander, Jeff Kline, Chuck Cairns, Lance Becker, Arthur Kellerman, Lynne Richardson, Bob Neumar, Rob Lowe, and many others). These individuals worked behind the scenes to create a culture of research in emergency medicine.

What has been the most rewarding aspect of working with the EM network that you helped bring to life over the years?

The most rewarding aspect of the program was working with the PIs, scholars, and K12 staff. There was terrific teamwork and faith that the program would succeed. The annual scholar meetings only enhanced communication and teamwork. The K12 “joint PI model” meant there was multidisciplinary leadership and multidisciplinary scholars who strengthened the scientific dialogue of the program.

What advice can you share with early career EM researchers who are pursuing a career in EM research?

The first question I generally ask is, why do you want to pursue research? For house staff and junior faculty, research could represent a real interest, or it could be a necessary requirement in training. It’s important to understand the trainees’ interests. It’s also important to know what training is necessary to meet the trainee’s career goals. Trainees and faculty need to understand what research resources exist within the institute and when to seek research training externally. Is there a Clinical and Translational Science Awards (CTSA) program? And are there T32 programs that might meet the training needs of the individual?

There is a research role for everyone in emergency care research. And while every role is important, not everyone wants to become an NIH funded principal investigator that demands 8-9 years of ongoing research training. There are more intermediate research roles that are important such

as being a site PI, study co-investigator, research reviewer, abstract reviewer, or paper co-author. There are many ways to contribute to the emergency medicine research enterprise.

I’m sure you’ve had many experiences in your long and illustrious career that have shaped you personally and professionally. Are there any that stand out and why?

I’ve always enjoyed site visits, visiting health care settings (EDs) and feeling the pulse of the place. When at UMD Shock Trauma (as director of research), I'd put on my lab coat and observe what was going on in the trauma receiving area on Friday or Saturday evenings. I always learned something. And when visiting K12 sites, I’d go for a tour of the ED and talk with staff.

My doctoral research was (funded by National Cancer Institute) related to adequacy of pap smear screening and follow-up care. I was invited to be part of a World Health Organization (WHO) advisory team to Romania, shortly after the revolution, to assess the adequacy of the country’s cervical cancer screening programs. The center of Bucharest was largely destroyed with thousands of bullet holes in walls and ruins around the city square. One building had been the state police headquarters and no one touched those ruins. The “new” police routinely patrolled the streets carrying automatic rifles. The entire trip was transformative. The lack of medical supplies and basic equipment such as light bulbs was staggering. Our Romanian colleagues shared unsettling stories of health care delivery under Communist rule. We worked together over a two-year period.

I helped establish the NHLBI global health initiative, partnering with United Health Care, to establish health promotion/disease prevention research centers in ten lowand middle-income countries. Each site was to include a research training plan to help meet the training needs of local scholars. I was part of a site visit team that reviewed two sites in Beijing. It was fascinating. We saw clinics and heard about community surveillance programs. We were briefed before the trip and understood that everyone and everything in China is under surveillance. We were told to expect that our hotel rooms and luggage would be searched when we were out of the rooms. I left my laptop at home. I found the idea of ongoing surveillance to be oddly disquieting and it persisted until I headed home.

On a personal note, three weeks after starting work at the UMD Study Center for Trauma and EMS, on my way to work one morning, a car from the opposite direction spun into my

Dr. Scott’s family, together in Wyoming

lane, and the ensuing crash, gave me first-hand experience in prehospital transport and interhospital transport. Ever since I’ve referred euphemistically to the crash (and surgery) as my “trauma field trip.”

Congratulations on being named the Dr. Peter Rosen Memorial Keynote speaker for SAEM23. Your keynote address is titled, “Advancing Emergency Care Research: Reflecting on Our Past, Looking to Our Future.” Can you give share with us some of the key points you ? Why do you feel this is an important topic to talk about? What overall message do you hope your message will convey?

I want my message to instill hope for the future of emergency care research. Research capacity is growing. There are more NIH R01 funded investigators than ever before. And the field recognizes research training is important, and that NIH funds many training programs. It’s critically important for individual institutional emergency medicine research programs to understand their own mission. What do they support? What do they not support? How will hiring strengthen research capacity? Successful research programs are focused and clearly understand their goals, objectives and milestones to achieve success.

One final but important point. Very few scientists and clinicians understand “exemption from informed consent research” (EFIC). I believe EFIC rules still hamper the approval and implementation of clinical trials in the prehospital and ED settings. At the same time, it’s also important to recognize there are other clinical disciplines facing the same hurdles: trauma surgery, trauma anesthesia, critical care/pulmonology, cardiology and interventional radiology. Perhaps “acute care investigators” could work together to understand what EFIC implementation obstacles exist and assess the scope of the science that has been delayed or that could not be implemented due to EFIC regulations.

Your condensed list of your achievements spans several pages. If you had to choose which single accomplishment of which you are most proud, what would it be? Similarly, if you could choose just one thing to be remembered for what would it be?

I am most proud of receiving the John Hume I award, given out annually to a single doctoral graduate for meritorious research by the school’s department of health policy and management. There were 16 people graduating, but I was selected for the award. Prior to this award, I’d attended schools of nursing. It was reassuring that I could be competitive in a larger group of scholars.

As for how I want to be remembered, I want to be remembered as a kind and generous person in my personal and professional lives. I am very proud of the accomplishments achieved by the K12 programs with the scholars and investigators. As for my professional life, I don’t need to be remembered, I simply want emergency care clinical research enterprise to flourish and grow.

What are you most looking forward to in your retirement?

I just retired three months ago, and so my retirement agenda is not fleshed out. I am catching up on sleep. I am going to take oil painting lessons again. I look forward to catching up with family and friends all over the United States. I have a place to stay in Wyoming and I’ve traveled there many times in the past decade. I want to travel throughout the British Isles. And, I want to travel to Turkey in order to visit the archaeological site Gobekli Tepe. I’m sure this list will expand. And of course, charity work.

What is the most interesting/exciting/fun vacation you’ve ever taken?

A trip to Czechoslovakia, shortly after the Velvet Revolution (and even before McDonalds arrived in the country). Prague was stunning. The city was not bombed in WWII, and so the castle and churches still stood. There were great bakeries, but food sold in corner stores was extremely limited. There were no “grocery” stores, but vodka was plentiful. Czechoslovakia had shrugged off its communist rule, but some habits in everyday life persisted. I wanted to see and possibly buy a crystal vase. Under communism, the price of each piece of crystal was set by the government. Without government controls, shopkeepers gossiped as to which stores were selling items above previously established ceilings. “For profit” enterprise and “for profit motives” were not well understood.

The second Emergency Care K12 Program is captured in this second photo. The second program had only four sites. An overall smaller program. 2016 or 2017. Photo taken in Rockledge II, an NIH satellite building, in Bethesda, MD.

KNOW BEFORE YOU GO 23 AUSTIN, TX • MAY 16-19, 2023

We Can’t Wait to See You!

We’re looking forward to seeing you in-person in Austin, Texas for what is sure to be one of the best live education events in academic emergency medicine! Whether it’s taking an educational deep dive into a workshop or forum, connecting with peers and leaders, or joining in some “friendly” competition, it’s all happening at SAEM23. Our Program Planner has the who, what, when, and where for all SAEM23 activities and events and is the perfect place to start planning your agenda. Just be sure to schedule time for fun because there’s so much to see and do in the vibrant city of Austin! Whether you’re looking for live music, authentic Texas cuisine, or scenic outdoor adventures Austin offers something for everyone. So just pick your “thing” and enjoy Austin like a local — relax, put your feet up, pull your hair back, and bask in the moment!

JW Marriott Austin: Your SAEM23 Host Hotel

Getting Around Austin

Transportation To and From the Airport

Capital Metro #20 — runs every 15 minutes between 6 am and 8 pm, seven days a week

Ride Hailing — follow the Ride App Pick Up signs outside of the arrivals area

SuperShuttle — skip the line and schedule a shared ride, non-stop trip, or black car option in advance

Transportation Options Around Town

Transit — use the Capital Metro Trip Planner tool to find the best route to your end destination

The JW Marriott Austin,110 E. 2nd St., Austin, TX, is the official host hotel for meetings, education, and several social events at SAEM23. The JW Marriott Austin meeting space is located on floors 2-4 and is accessible via escalator with additional space on the fifth floor, which is accessible by elevator.

Scooters — rent your favorite option through the vendor’s app: Bird, Lime, Link, Wheels

Bike Share — check out MetroBike, with over 75 stations and electric bikes

Ride Share — Austin has plenty of app-based car share and ride hailing options

Getting the Most Out of SAEM23

Registration

If You Preregistered

You received a barcoded email confirmation. Please save this to your mobile device or print it out to scan at our convenient, self-serve, preregistration kiosks, located near the SAEM23 registration desk on the fourth floor, outside of the exhibit hall/ JW Grand Ballroom. Forgot your confirmation? No problem! Just touch “User Lookup” on the screen and search for your name. Hit print and your badge and any applicable tickets will print out. Badge holders and lanyards will be available at the kiosks.

If You Are Registering On Site

As always, we will have a fully staffed registration desk available for those who need to add sessions or register on site. The SAEM23 registration area is located on the fourth floor, outside the exhibit hall/JW Grand Ballroom foyer. Registration hours are:

• Monday, May 15, 3–6 pm

• Tuesday, May 16, 7 am–6 pm

• Wednesday, May 17, 7 am–7:30 pm

• Thursday, May 18, 7 am–6:30 pm

• Friday, May 19, 7 am–1:30 pm

Please note that annual meeting participants (members, nonmembers, partners, children, guests) must register and wear badges for admission to sessions, the exhibit hall, and most events.

Speaker Ready Room

Mobile Tools Annual Meeting App

will be at the registration desk during registration hours and at SAEM Booth #120 during exhibit hours to lend a hand.

New to SAEM or the Annual Meeting?

Navigate SAEM23 like a pro by downloading the SAEM Annual Meeting app! Simply download the app from the Apple App Store or Google Play, then sign in with your SAEM username and password to launch the app. Browse through the full list of Advanced EM Workshops, educational sessions, meetings, events, and more. Review abstracts, learning objectives, and speakers for educational sessions. Find links to travel information and local dining and activities. Scope out the exhibit hall with the online floor plan and create your must-see list of exhibitors. As you browse, customize your schedule to create your individualized program before you arrive.

For assistance in downloading or navigating the SAEM23 App, please visit the App Desk located on the third floor, Lone Star Ballroom Foyer.

Need Assistance?

App Help Desk and Member Services

Will this be your first time attending the SAEM Annual Meeting or are you a new member of SAEM? Please stop by SAEM Booth #120 in the exhibit hall during exhibit hours and introduce yourself, have a professional headshot taken, grab a tee shirt and some SAEM swag, sign up for a drawing to win some fun prizes. Our friendly staff are excited to meet you and tell you about SAEM’s programs and services and how to get the most from the annual meeting.

Additional Information

Presenters who wish to review their presentation slides may do so in the Speaker Ready Room located in Room 306: Level Three. Due to SAEM undergoing a CME audit this year, all presenter disclosures, bios, changes, and presentations slides were due April 1. Speaker ready room hours are:

• Monday, May 15, 3–6 pm

• Tuesday, May 16, 7 am–5:30 pm

• Wednesday, May 17, 7 am–5:30 pm

• Thursday, May 18, 7 am– 5:30 pm

• Friday, May 19, 7 am–12:00 pm

Visit the App Desk and Member Services located at the Lone Star Ballroom foyer: Third Floor for assistance in downloading or navigating the SAEM Annual Meeting app and for help and information regarding your SAEM membership.

Medical Student Ambassadors

SAEM’s Medical Student Ambassadors will be stationed throughout the JW Marriott Austin Host Hotel to assist and answer questions. They will be wearing blue, SAEM-branded jackets, so they’ll be easy to spot. Additionally, SAEM staff

As a service to annual meeting registrants, SAEM will provide free wireless Internet access. Wi-Fi will be available in the meeting space of the JW Marriott Austin host hotel during SAEM23. Username: JWMarriott_ Conference. Password: SAEM23

Family Room

Our private family room, located in Room 309: Level 3, will be equipped with everything to meet baby and parent needs: refrigerator, wipes, sanitizer, burp cloths, changing table, comfy chairs, water, and snacks. Visit the SAEM23 Family Room during these hours:

• Monday, May 15, 3 pm - 6 pm

• Tuesday, May 16, 7 am–5 pm

• Wednesday, May 17, 7 am–5 pm

• Thursday, May 18, 7 am–5 pm

• Friday, May 19, 7 am–1:30 pm

COVID-19 Policy

• Vaccine: During the registration process, all attendees self-attested to having either received the COVID-19 vaccine or agreed to mask.

• Screening: All attendees are kindly asked to do a personal health screen each morning prior to attending the

conference. If you have any infectious symptoms, we ask that you do not attend.

• Masks: Mask wearing is welcomed, but not required. If you need a mask, please go to the registration desk in the JW Grand Ballroom Foyer: Level Four or the member services desk in the Lone Star Ballroom Foyer: Level Three for a complimentary mask.

Social Media

Follow us on SAEM Facebook and Twitter @SAEMOnline and @SAEM_RAMS (#SAEM23) during the annual meeting for up-to-date meeting announcements...and be sure to share your insights with other meeting attendees. Look here for social media best practices and suggestions on what to share.

SAEM23 Online Education

SAEM23 educational content will be open access and available online at SOAR (SAEM Online Academic Resources) beginning August 1. Experience convenient online and mobile viewing of Advanced EM Workshops, didactics, and forums — more than 120 hours of original educational content from SAEM23.

Downloadable PDFs and MP3 files provide convenient, on-the-go viewing. Watch presenters’ slides while listening to fully synchronized audio. Just log in with your SAEM username and password to enjoy the content.

Continuing Medical Education

The CME program offered by SAEM is targeted (but not limited to) emergency health care professionals such as medical students, allied health care providers (nurse practitioners, physician assistants), emergency medicine technicians, nurses, residents, fellows, researchers, faculty, and physicians.

Overall Program Objectives:

• To enhance participant knowledge of cutting-edge research being conducted in emergency medicine

• To provide physicians with the tools to address gaps in their knowledge competence, and experience

Join Accreditation Statement: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Cincinnati and Society for

Academic Emergency Medicine. The University of Cincinnati is accredited by the ACCME to provide continuing medical education for physicians. The University of Cincinnati designates this live activity for a maximum of 27.5 AMA PRA Category 1 Credits™. Physicians should claim only the credits commensurate with the extent of their participation in the activity.

SAEM23 Live on Facebook & YouTube!

Tune into SAEM's Facebook and YouTube channels, May 17-19, for 18 hours of SAEM23 programming, broadcast live from Austin, Texas.

May 17-18, 2023

9:00 AM – 11:00 AM CT

Awards, Keynotes, Plenaries

1:00 PM – 5:30 PM CT

Select Didactics

May 19

8:00 AM – 1:00 PM CT Select Didactics

Especially for Residents and Medical Students!

At SAEM23 residents and medical students can engage with expert faculty, experience excellence in innovation and research, and participate in tailored learning activities developed exclusively for emergency medicine residents and medical students. It’s a place to learn new things, reconnect with old friends, and network with the close-knit emergency medicine community. To help you build your personalized meeting agenda, Hamza Ijaz, MD, 2022-2023 RAMS president, and Wendy Sun, MD, 2022-2023 resident member of the SAEM Board of Directors, have created a “Can’t Miss List” of their favorite annual meeting activities, plus the events and educational sessions they are most looking forward to attending at SAEM23.

RAMS Members… Look for This Icon

Pro tip: When you see a Rams head icon next to an abstract, didactic, workshop, event or activity in the mobile app or program planner, that’s your sign that it is something you will find extra value in attending as a resident and/or medical student.

What to See, Taste, and Do While in Austin

13 Ways to Have a Good Time in Austin

1. Enjoy the live music

2. Dance the Texas Two-Step

3. Wander the shops and restaurants on South Congress

4. Watch the bats take to the sky

5. Say “cheers” at one of Austin’s Legendary Breweries

6. Explore the Lady Bird Johnson Wildflower Center

7. Take a hike

8. Buy a pair of cowboy boots

9. Enjoy a night on the town along 6th Street

10. Have a boot-scootin’ good time at a honky tonk

11. Go mural hopping.

12. Experience Austin from the water

13. Explore Austin outdoors

Austin Food & Drink Bucket List

Here are six iconic Austin foods and libations and recommendations on where you should try them:

1. Breakfast Tacos

• Tacodeli, at 13 locations

• Valentina’s Tex-Mex BBQ, 1150 Manchaca Rd.

• Rosita al Pastor, 1801 E. Riverside Dr.

• Joe’s Bakery & Coffee Shop, 2305 E. 7th St.

• Polvo’s Downtown, 2004 S. First St.

• Veracruz All Natural, 111 E. Cesar Chavez St.

• El Primo, 2011 S. 1st St,

2. Chili

• 24 Diner, 600 N. Lamar Blvd.

• Texas Chili Parlor, 1409 Lavaca St.

• Black Star Co-Op, 7020 Easy Wind Dr.

• Valentina’s Tex-Mex BBQ, 1150 Manchaca Rd.

Where to Find Austin’s Best Meals on Wheels

No matter where you are in Austin, you’ll find a food truck in every neighborhood and on every corner of town. While tacos and barbeque dominate the food scene, you can sample almost any type of cuisine at one of the food truck parks — from Nepalese to Venezuelan food, burgers to banh mi, pizza to pasta…there is a food truck for you in Austin. Here are a few food truck lots within walking or ubering distance from the SAEM23 host hotel where you can get a tasty meal on wheels:

• Rainey Street, 82 S. Rainey Street

• The Picnic Food Truck Park, 1720 Barton Springs Rd.

• Arbor Food Truck Park, 1108 E. 12th St.

• Ira and Bev’s Food Truck Park, 1311 S. 1st St.

For Live Music Head Over to the Red River District

While you can hear bands performing throughout much of Austin, the heart of the Texas capital’s live music scene can be found in the Red River Cultural District. Located on Red River Street along an eleven block stretch between 4th and 15th Streets, the Red River Cultural District is a creative community providing authentic Austin experiences through diverse local music, art, and food for every fan and guest.

3. Barbecue

• Franklin BBQ, 900 E. 11th

• La Barbecue, 2401 E. Cesar Chavez

• Micklethwait Craft Meats, 1309 Rosewood Ave.

• Stiles Switch BBQ & Brew, 6610 N. Lamar Blvd.

• Terry Black’s Barbecue, 1003 Barton Springs Rd.

• Interstellar BBQ, 12233 Ranch Rd. 620 N., Suite 105

• Distant Relatives, 3901 Promontory Point Dr.

• LeRoy and Lewis Barbecue, 121 Pickle Rd.

• Valentina’s Tex Mex BBQ, 11500 Menchaca Rd.

4. Tex-Mex

• Chuy’s,1728 Barton Springs Rd.

• Polvo’s Downtown, 2004 S. First St.

• Matt’s El Rancho, 2613 S. Lamar Blvd.

• Habanero Mexican Cafe, 501 Oltorf St.

• Maudie’s Tex-Mex, 1212 S. Lamar Blvd.

• Joe’s Bakery & Coffee Shop, 2305 E. 7th St.

• Valentina’s Tex Mex BBQ, 11500 Menchaca Rd.

5. Southern Texas Pecan Pie

• Tiny Pies, 1100 S. Lamar Blvd., Ste. 1116

• Upper Crust bakery, 4508 Burnet Rd.

• Quack’s 43rd Street Bakery, 411 E. 43rd St.

6. Best Tequila and Mezcal Bars

• Whisler’s Mezcalería Tobalá, 1816 E. 6th St.

• La Condesa, 400 W. 2nd St.

• Bar 508 Mezcalerita 2nd St.

• El Naranjo, 85 Rainey St.

• La Holly, 2500 E. 6th St.

• 400 Rabbits, 5701 W. Slaughter Ln.

Language Accommodations: Best Practices for Working With Interpreters

By Luke Johnson, MD, IV Mirus, MD, and Jason Rotoli, MD, on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine (ADIEM) and the ADIEM Accommodations Committee

Rochester has one of the largest per capita Deaf populations in the United States, and our hospital has 24/7 ASL interpreting available for Deaf patients and staff. In this article, we want to share some best practices for those who work in healthcare, particularly in emergency medicine, where time is of the essence and resources are limited.

Introduction

Research has extensively shown that patients face severe challenges when language barriers exist in health care settings. These challenges include worse clinical outcomes, difficulty navigating health care processes, and increased medical errors. In contrast, patients report better outcomes when medical interpreters are utilized, or

when their health care provider speaks their primary language. The importance of providing accessible health care to patients with limited English proficiency has been further emphasized by the joint commission’s establishment of Standard RI.01.01.03 in 2010, which asserts that patients have the right to receive medical information in a way they can understand. This requires hospital systems and providers to provide interpretation services to nonEnglish speaking patients, which can include portable virtual tablets, in-person interpreters, and language preference verification. Establishing the patient’s language preference is the first step towards providing accessible health information, and offering interpretation in their primary language through a

qualified interpreter is considered the gold standard. However, pitfalls while working with interpreters are common and include: unadjusted (fast) rate of speech, directing conversation to the interpreter instead of the patient, poor patient engagement, poor positioning, assumptions regarding the role of the interpreter, not giving enough time for the patient encounter, and inadequate cultural awareness.

To improve communication with our patients, it is crucial to establish effective working relationships with interpreters. So, how does one work with an interpreter? And is working with one for a spoken language the same as working with an ASL interpreter? Here, we provide a summary of best practices

to improve working relationships with interpreters to augment communication with our patients.

Best Practices

Guidelines for Working With All Interpreters

The following can be considered general advice for working with any language interpreter:

• In-person is strongly preferred.

• Use an interpreter that is trained and certified in medical interpreting

• Within reason, prepare the interpreters by giving context on the situation beforehand (e.g. “you will be discussing something emotionally intense, sensitive information,” or you are “concerned for altered mental status”).

• Direction of communication should be towards the patient and not the interpreter.

• Monitor your nonverbal communication such as body language, facial expressions, and posture.

• Minimize medical jargon to ensure maximum comprehension and efficient translation.

• Allow extra time for the visit as everything will be communicated at least twice (once by the speaker and once by the interpreter), unless using simultaneous interpretation.

• Allow the interpreter to ask open-ended questions, if needed, to clarify what an individual says. This may foster culturally sensitive information delivery

• Read your patient’s facial expressions and body language; if they appear confused or have an unexpected reaction that raises your suspicion for misunderstanding, ask the patient to repeat back to you or follow up with a simple “May I repeat this to make it clearer?”

• Position yourself correctly. In visual and spoken languages, correct positioning is crucial to effective communication. It is important to involve both the interpreter and patient in determining the best positioning for optimal communication; however, as a general guideline, the interpreter and health care provider should position themselves next to each other, allowing the patient to see both parties simultaneously with minimal need to shift their gaze (refer to figure 1). This approach can improve the patient’s ability to follow the conversation and maintain visual contact with all parties involved.

Guidelines for Working With ASL Interpreters

The following can be considered best practices for working with ASL interpreters:

• Be mindful of eye contact and body language. For ASL, there is a heavy emphasis on body language as greater than 50% of the language is communicated without the use of a specific sign. To maximize communication, always face the patient, smile, and be welcoming between pauses for interpretation. Be mindful of posture, gestures, and facial expressions as these can potentially convey incorrect information (similar to tone of voice or word selection with spoken language).

• The educational background of Deaf patients in the United States is diverse akin to their hearing counterparts, but the Deaf population typically has limited access to language-concordant education and lower English literacy levels compared to the general hearing population. This may result in lower health literacy levels and hinder effective communication with health care providers. Furthermore, the Deaf community, particularly Deaf+ (Deaf individuals with other disabilities), experiences additional social determinants of health due to limited access to advanced education and high-paying jobs. These further

continued on Page 16

Figure 1. Correct positioning of clinician and interpreter/VRI (video remote interpreter) and patient.

DEI LANGUAGE

continued from Page 15

compound the existing health disparities faced by this population.

• Deaf identity. Many Deaf patients do not see their hearing loss as negative or identify as having a disability. Those who identify as Deaf do not want their deafness addressed as a medical problem or labeled as hearing impaired, deaf, or mute (common outdated pejorative terms).

• Be aware of cultural differences.

o ASL vs English. Contrary to what some may believe, ASL is not the verbatim signed form of English. ASL has its own grammar and syntax, and providers should be careful about making any assumptions regarding the Deaf patient’s ability to read/write in English as English is often a second language.

o Storytelling. In the Deaf community, providers should be aware of storytelling and elaboration, as it is an important cultural nuance. Also, there are unique idioms within ASL and your interpreter may need more time to convey your patient’s side of the story. Providers must try to show patience in these situations as these stories may provide other context clues for the patient’s situation and help establish rapport.

o Regional and cultural dialect. There are regional dialects among ASL users, especially when comparing

signers from the west and east coasts. In addition, there is growing recognition of Black ASL, a dialect within ASL that is thought to have originated during segregation. These additional nuances may especially come into play if your interpreter or you are not familiar with one another.

o Information sharing preferences. In contrast to most hearing cultures, the Deaf community prefers information delivery to be direct and without extraneous details. After the piece of information is shared, providers can and should add an explanation to help clarify any questions. For example, if there is a mass on a chest X-ray and there is concern for malignancy, providers should start off by pointing out the mass on the X-ray and using the following language:

“This area of your chest X-ray appears cloudy and is not normal. It may be a kind of cancer.” Then, provide additional information, such as: “It may also be an infection or scarring from previous infection. Because of your symptoms (X, Y, Z), I would like to do the following things…”

As you describe a concept to your interpreter, be aware that they will use a lot of gestures and visual displays to convey your information which may also take more time. To assist the interpreter and improve comprehension, consider shifting your explanation to a more visual explanation. For example, when describing atherosclerosis, providers

could use the following language:

“Atherosclerosis is similar to a rigid pipe that is thickening and filling up along the edges.’

Special Considerations

Using Virtual Remote Interpreting or Audio Remote Interpreting

Commonly the clinician will need to rely on a tablet or app service to facilitate communication. Be aware of the following nuances that can complicate effective bidirectional communication while using remote interpreting:

• Not all languages can be staffed 24/7. If time permits, try to conduct your patient interviews on the earlier side of the day.

• Wait times are usually much shorter for common languages and during the daytime. With some communication platforms, you can ask them to call you when an interpreter is ready.

• For visual languages like ASL, be wary that the Deaf patient may have difficulty seeing the screen. If an inperson interpreter is unavailable, try to use a tablet with a large screen.

• As when using an in-person interpreter, the provider should face the patient with the tablet also facing the patient. Continue to maintain eye contact, appropriate body language, etc. (see Figure 1).

• Technology is imperfect, so be mindful of communication delays, WiFi connection problems, dying power source, poor screen visibility or image quality, and volume of the interpreter/

patient and surroundings. It may be helpful to perform a test run before beginning your interview to avoid some of these problems.

• Although convenient, video or telephonic interpreting significantly limits available context for the remote interpreter. Remote interpreters are often thrown into varying interpreting scenarios with little context as to the roles of the people speaking and what is being referenced. They may also not have the required training or experience to interpret in a medical setting, which can hinder effective and accurate communication.

When a Family Member or Friend Insists on Interpreting

Oftentimes, patients will bring family and friends to their appointments. Having family in the room can help bolster comfort, corroborate histories, and even add buy-in on health initiatives like dieting or medication adherence. However, in the case of interpreting, there can be some detrimental effects when using a family or friend as an ad hoc interpreter:

• Inability to remain impartial or unbiased. Due to cultural differences and/ or well-meaning intentions, informal interpreters may alter or shield the delivery of information such as a crucial cancer diagnosis or counseling regarding abstinence on certain activities, especially when western medicine conflicts with cultural beliefs.

• Filtering of information. One cannot verify the family/friend’s education level or ability to comprehend the medical information when they are attempting to deliver information to

About ADIEM

your patient. An informal interpreter may not understand much of the information they are trying to convey, inadvertently changing the meaning, or leaving out important details leading to misinformation.

• Misleading fluency. As one can imagine, the family or friend may overestimate their level of language fluency when attempting to translate complex medical terms between languages.

• Violation of privacy. A patient may feel pressured to disclose or hide some of their medical history when their family or friend is interpreting. This can be especially challenging to navigate unless discussed beforehand with the family and patient.

• Sensitive screenings. Consideration for intimate partner violence (IPV), obtaining a sexual history, and inquiring about human sex trafficking may be complicated (or nearly impossible) if the family/friend who brought the patient in for care is responsible for harm to the patient. Having a professional interpreter and asking for a moment alone with the patient as “standard operating procedure” may help create a safe space to communicate freely.

Conclusion

Collaborating with interpreters can have a positive impact on health outcomes by facilitating effective communication, maximizing the exchange of information, and promoting culturally sensitive delivery of health-related information. It is important to remember that in-person interpretation is the gold standard. During an interpreter-facilitated patient encounter, it is essential to engage

directly with the patient, position yourself appropriately, and remain mindful of nonverbal communication cues. By following these guidelines, we can promote equitable access to health care for all patients, regardless of their language or cultural background.

ABOUT THE AUTHORS

Dr. Johnson is an emergency medicine resident at the University of Rochester in Rochester, New York. He is a child of Deaf adults (CODA) and his first language is American Sign Language (ASL). Much of Dr. Johnson’s life experience working with interpreters or interpreting for family has fostered a deep passion for advocacy and working with the Deaf ASL user to improve access to care.

Dr. Mirus is an assistant professor of emergency medicine at UT Southwestern and Health Equity Scholar for UTSW/Parkland Health. He is a member of the ADIEM Accommodations Committee and was a previous ASL interpreter working in health care. Dr. Mirus is on the board of multiple nonprofits focusing on the Deaf community and has a specific interest in public health and health equity for the Deaf population.

Dr. Rotoli is associate residency director, Department of Emergency Medicine and director, Deaf Health Pathways, at the University of Rochester Medical Center.

The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the goal 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. Membership in SAEM's academies and interest groups is free. To participate in one more groups: 1.) log into SAEM.org; 2.) click “My Participation” in the upper navigation bar; and 3) click “Update (+/-) Academies or Interest Groups.”

“Establishing the patient’s language preference is the first step towards providing accessible health information, and offering interpretation in their primary language through a qualified interpreter is considered the gold standard.”

DIVERSITY, EQUITY & INCLUSION

Telementorship: A Promising Solution to Closing the Mentorship Gap for URM Physicians

By Sally Mahmoud-Werthmann, MD

Mentorship is critical to the personal and professional development of early and established emergency physicians. The benefits of mentorship include increased career satisfaction, grant funding, research publications, rates of promotion, preparedness for junior faculty, and a desire to mentor others in return. Mentored residents are twice as likely to describe their career preparation as excellent compared to non-mentored peers.

Mentorship is vital for residents who belong to groups that have historically been excluded from medicine. Trainees who are underrepresented in medicine (URM) face unique challenges, including microaggressions, discrimination, social

isolation, and identity suppression. Including microaggressions, discrimination, social isolation, and identity suppression. They also experience a minority tax, resulting from

the pressure to serve as race/ethnicity ambassadors, fix program challenges related to diversity, and serve as experts on racial/ethnic issues. The damage inflicted by these repeated insults are

“Telementorship allows for relationships that are not geographically bound, maximizing the opportunity to find mentors around the country who have a similar background if that is desired by the mentee.”

associated with long-term psychological distress, depression, and anxiety, leading to the devaluation of perspectives and contributions. Further, while the overall attrition rate among emergency medicine (EM) residents is low, some URM groups are more likely to leave residency. A lack of mentorship is a significant predictor of

resident withdrawal and an overall difficult training experience.

Despite the well-documented benefits of mentorship, URM physicians are much less likely to have mentors than their peers. This opportunity gap contributes to their chronic underrepresentation, underrecognition,

and undercompensation in academia, underscoring the importance of identifying solutions. Although the reasons for this disparity are multifactorial, difficulty finding mentors with similar lived experiences and/or shared demographic backgrounds is a likely contributor. How important is racial concordance in mentorship? Although research in this area is limited, the literature suggests that it may be very important to URM trainees This is problematic given the scarcity of URM faculty in academic medicine.

Telementorship represents a promising solution to closing the mentorship gap, yet it is underutilized. Telementorship allows for relationships that are not geographically bound, maximizing the opportunity to find mentors around the country who have a similar background if that is desired by the mentee. Algorithms automate the mentor matching process by considering the many components of an individual's social identity, preferences for demographic concordance, as well as other important shared personal and professional interests, easing the mentor finding process. Telementorship also fosters the development of mentoring networks, which is especially important given that a single mentor can rarely, if ever, provide all components a mentee requires for success. Mentoring networks (e.g., team mentoring) are becoming an increasingly popular alternative to the traditional, hierarchal dyadic mentoring model. Virtual platforms allow mentees to have convenient access to many different mentors, each addressing different needs.

We must urgently address the current mentorship gap that disproportionately harms the training and career experiences of URM physicians. Further, disparate access to mentorship contributes to the inequity in the recruitment, retention, and promotion of URM faculty. Leveraging technology and digital innovation allows us to develop accessible, equitable, and intersectionality-informed mentorship opportunities for all physicians

ABOUT THE AUTHORS

Dr. Mahmoud-Werthmann is fellowship trained in social emergency medicine and an emergency physician at Stanford. Her work intersects the areas of health equity, DEI, and clinical operations. twitter: @sallymahmoudMD

“Despite the well-documented benefits of mentorship, URM physicians are much less likely to have mentors than their peers. This opportunity gap contributes to their chronic underrepresentation, underrecognition, and undercompensation in academia, underscoring the importance of identifying solutions.”

Overcoming Medical Saviorism: A Path to Improved Care for Sickle Cell Disease Patients

By Omar Haggaz, OMS IV on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine

"All our system has to offer these kids is a full-blown drug addiction at 12 years old.” It was a lingering remark made during a discussion among physicians that still echoes in my mind. The speaker's voice carried a gravity akin to the dense atmosphere preceding a tempest. The statement's impact resonated with me, reflecting the isolation enveloping patients with sickle cell disease (SCD). The speaker spoke with such conviction, so certain of their stance, as if they could encompass the whole world in a single breath. However, the speaker’s words only scratched the surface, failing to see the intricate threads that weave through the lives

of patients with SCD. This moment, a poignant memory from my time as a third-year medical student, exposes the chasm separating health care providers from their patients' lived experiences. Saviorism in medicine, a cloud that looms over the relationship between physicians and patients with SCD, casts a shadow on their shared journey. Within this darkness, we must search for a way to bridge the gap, to let empathy and understanding illuminate the path forward.

Saviorism, a term that carries a heavy burden, is the inclination of health care providers to adopt a superior stance, disregarding patients' experiences,

and insights in favor of their own. This mindset, at times, permeates the field of medicine, and fosters the culture of implicit bias to affect SCD treatment. At the precipice of the encounter between our health care system and patients with SCD, a particular feeling of aphonic loneliness exists. In this situation, even though you uniquely endure this disease, your input is often overlooked. The course of your treatment becomes defined not by your own judgment, but by a stranger. Saviorism in medicine exacerbates this loneliness, casting patients with SCD adrift in a sea of misunderstanding and needless suffering. To navigate

these challenges, health care providers must first acknowledge the limitations of their own experiences and seek to understand the complex tapestry of the lives of patients with SCD. When the sound of one's own footsteps seems to come from a far-off place, empathy, and patient-centered care can bridge the distance between physician and patient. By listening attentively, recognizing the unique perspectives of patients with SCD, and tailoring care to meet their individual needs, health care providers can begin to dispel the notion of saviorism.

Patient-reported outcomes (PROs) offer a promising use case scenario, providing valuable insights into the subjective experiences of patients with SCD. By incorporating PRO tools such as PROMIS®, ASCQMe®, PedsQL™, and SF-36v2™ into clinical practice, health care providers can better understand patients' pain, physical functioning, emotional functioning, and overall improvement. Pain management is a crucial aspect of care for patients with SCD, who often experience recurrent acute pain episodes requiring hospitalization and potent pain medications. Unfortunately, many patients also develop chronic pain that is unresponsive to various treatment strategies, which leads to a reduction in their quality of life and functioning. As noted in the Expert Review of Hematology Journal, pain perception is inherently subjective, making the prevalent misapprehension of patients with SCD' pain crises particularly complex.

The implicit biases by health care providers may inadvertently result in underestimating patients' pain experiences, exacerbating the complexity of their care and management. To measure treatment response, experts have suggested using endpoints such as length of hospitalization or composite endpoints like time to crisis resolution. However, these endpoints may be influenced by various factors, such as additional health conditions, social factors that could prolong

hospital admission, and different clinical practices for prescribing and weaning pain medications. Pain intensity is a commonly measured patient-reported outcome, often assessed through numerical rating scales and visual analog scales. Recent advancements in the field have recommended incorporating additional domains into pain assessment, including physical functioning, emotional functioning, and participant ratings of overall improvement.

Furthermore, newer domain PRO measures in SCD have been developed to assess other aspects necessary for patients with chronic pain, including pain interference and sleep quality. The use of learning health system platforms like CHOIR (Collaborative Health Outcomes Information Registry) can help clinicians and researchers integrate these multiple PRO measures to test various pain aspects over time, which is an area that requires further research in SCD. Health care providers can work towards improving patient care and outcomes by focusing on pain management and addressing the widespread misjudgment of patients with SCD pain crises. The integration of PRO tools and the exploration of novel approaches to pain assessment can contribute to a better understanding of patients' pain experiences. The path to integrating PROs into clinical practice is not without obstacles. Challenges such as complexity and feasibility issues in collecting reliable data must be addressed to reap the full benefits of PROs. By investing in adapting and implementing these tools, the proper infrastructure for PROs can be built.

The seeds of change must be planted in the hearts and minds of our future health care providers. By not only focusing on traditional lessons in empathy and cultural competence but also tailoring medical education to include early clinical exposure to the lived experiences of patients with SCD, we can better equip future professionals to challenge the status quo and forge a new path forward. Through this commitment to education

and growth, we can dismantle the structures perpetuating health inequity and implicit bias in medicine. At the core of this journey toward understanding and empathy lies the patient's voice. By amplifying the stories and experiences of patients with SCD, we can challenge the preconceived notions and biases that fuel saviorism in medicine. Patient advocacy groups, social media campaigns, and public awareness initiatives all play a crucial role in this process, ensuring that the voices of patients with SCD are heard and respected. Acknowledging that imperfections are a part of human nature and that we are indeed susceptible to error, the reality is that our own biases inevitably influence the medical decisions we make and saviorism in medicine poses a risk to the delicate balance between physician and patient. Nonetheless, we can begin to bridge the gap that separates us by embracing empathy and patient-centered care, utilizing patient-reported outcomes, and striving to understand the complexities of sickle cell disease. Only through this journey of understanding can we fully support and uplift patients with SCD.

Together, as components of a more extensive system, we can dispel the culture of saviorism, allowing the light of empathy, compassion, and understanding to guide us in transforming the landscape of medical care. Let us remember that our shared humanity is the bridge that connects us all, and in the words of the poet John Donne, "No person is an island, entire of itself; every person is a piece of the continent, a part of the main."

ABOUT THE AUTHORS

Omar Haggaz is a rising fourthyear medical student at Edward Via College of Osteopathic Medicine.

“Saviorism, a term that carries a heavy burden, is the inclination of health care providers to adopt a superior stance, disregarding patients' experiences, and insights in favor of their own.”

DEI VIEWPOINT

Diversity, Equity, and Inclusion: How It Started, How It's Going

By Edgardo Ordonez, MD, MPH on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine

"If you are neutral in situations of injustice, you have chosen the side of the oppressor."

The concept of diversity as a core value has its origins in the civil rights movement of the 1960s, aimed at integrating workplaces, schools, and communities after the abolishment of Jim Crow Laws. Diversity was further developed to include addressing inequality around gender, sexual orientation, and other identities. Corporations and institutions of higher education understood the importance of representation, but striving for diversity alone proved insufficient, as it often led to tokenism. Inclusion emerged to ensure that historically excluded groups had a seat at the table and a voice. Equity followed and addressed the need to create opportunities to achieve equality with the understanding that the playing field is uneven. More recently, select organizations embraced justice initiatives to recognize and challenge unjust policies and practices. Collectively, diversity, equity, and inclusion have come to be known by the shorthand of "DEI." The principles of

DEI have frequently been updated and enhanced to help organizations evaluate and shift their practices to ensure equitable and inclusive environments in the workplace.

In the last few years, there has been a heightened awareness of the effects of systemic racism during the early stages of the COVID-19 pandemic. There were also the concurrent racial justice protests and championing of the Black Lives Matter movement after the killings of Ahmaud Arbery, Breonna Taylor, and George Floyd. These events seemed to galvanize a new undertaking in the field of medicine. Many student and facultyled initiatives prompted institutions to signal a commitment to change through antiracism statements, engaging in discourse about systemic inequities, and developing partnerships with the very communities that they have long excluded. This proactive introspection led to the creation of actionable solutions focused on fostering inclusive learning environments, developing policies to disrupt oppressive systems, and development of equity-conscious clinicians. Diverse representation in

the physician workforce was another area that gained attention, given its proven benefits in patient outcomes. There was also an understood need for pedagogical reform, which led to the recent American Association of Medical Colleges (AAMC) publication of its DEI Competencies as a framework for medical education throughout the continuum. After what appeared to be a well-received paradigm shift, discussions of DEI, justice, and antiracism are now under attack by those within and outside the house of medicine.

The term "woke medicine" has been thrown around by various dissidents who represent a mostly silent minority and argue that raising awareness of upstream societal issues that impact health care somehow prevents trainees from acquiring the knowledge to care for patients. Historically, the idea of "woke" was derived as a colloquialism that originated in the early 20th century around the idea of Black Americans needing to have increased sociopolitical consciousness. It became part of the Black vernacular as a creative way for one Black person to say to another,

—Desmond Tutu

"be mindful," "be conscious," and "keep your eyes open." Following the 2014 police killing of Michael Brown in Ferguson, Missouri, the phrase "stay woke" was frequently used by Black Lives Matter activists to warn people to be on the lookout for injustices in policing. Later, it took on a new form as part of performative social justice efforts in the mainstream and, as often seen, was appropriated by the masses. Now "wokeism" has become a catch-all weaponized in the culture wars to describe anything and everything that deals with social justice, from racism to climate change. The word targets any attempts to bring awareness to and challenge dominant narratives of primarily white, patriarchal, cisgender, heteronormative, able-bodied spaces. It has become a pejorative substitute for all concepts within the scope of DEI.

Recent legislative attempts have sought to curtail or eliminate discussions around racism in public schools, falsely labeling these teachings as indoctrination of Critical Race Theory (CRT). Although CRT is not part of primary or secondary education, these bans represent a coordinated effort to silence discourse on systemic racism and its impact on various aspects of society. This ahistorical stance significantly limits discussions about how racism has shaped our

nation's policies in education, housing, and health care. As a result, educational establishments are now being pressured to reexamine their DEI practices, with numerous anti-DEI bills introduced by legislators. Such legislation aims to ban topics like implicit bias, intersectionality, systemic racism, and sexism from being taught or discussed. Additionally, these bans seek to prohibit diversity statements in hiring and promotion and restrict holistic considerations in admissions or employment. It's certainly ironic that these bans exemplify exactly what systemic oppression is.

Opponents of DEI argue that historically excluded groups are now given unfair advantages, which is antithetical to equal opportunity; however, DEI efforts have never intended to meet quotas but are designed to provide opportunities that otherwise may not have been available to some. While DEI efforts have improved gender representation in the physician workforce, the same cannot be said for racial and ethnic groups that remain underrepresented. Unfortunately for some, being raceconscious is a zero-sum game. Those looking to eliminate considerations of holistic review are proponents of hiring based only on merit, with the flawed thinking that everyone has had equal opportunities to succeed. Merit, to many, has generally been based on metrics only, such as grade point average and standardized test scores. However, this idea of meritocracy and "pull yourself up by your bootstraps" rhetoric is a faulty view that often overlooks the influence of systemic inequities that create barriers to upward mobility, such as generational wealth. One needs to only look at social media exchanges to realize how this is rooted in anti-Black racism. The anti-DEI crowd will be adamant that nondominant group trainees are "quota hires" chosen because of their skin color and not traditional merit-based qualifications. In its current form, merit doesn't consider

other skills or attributes which may be equally important for developing competent future physicians. So, how do we reconcile this? The answer is that merit needs to be reimagined and include having awareness and knowledge about the structural drivers of health that affect our patients. To improve health outcomes for all, DEI must remain at the core of what we do in medicine.

The recent backlash and antiDEI sentiment shouldn't deter us as academic physicians from continuing to address systemic injustices through our various efforts. To be clear: DEI and anti-oppression are not synonymous; rather, DEI provides us with practical tools for implementing anti-oppressive practices in our work. While rebranding and reframing the narrative may be necessary, what remains crucial is our shared commitment towards achieving better health outcomes for all patients. We must continue advocating for a more inclusive, representative, and culturally responsive physician workforce to care for an ever-growing diverse patient population. Only by doing so can we ensure equitable healthcare for all and foster a more just society that values the well-being of every individual, irrespective of their background or identity. To keep moving forward, it's vital we embrace DEI's foundational principles while being aware of how it started, how it's going, and where it needs to be.

ABOUT THE AUTHORS

Dr. Ordoñez is an associate professor of emergency medicine and internal medicine at Baylor College of Medicine and director of justice, equity, diversity, and inclusion in the Henry JN Taub Department of Emergency Medicine. He is the outgoing president of the SAEM Academy for Diversity and Inclusion in Emergency Medicine.

“Opponents of DEI argue that historically excluded groups are now given unfair advantages, which is antithetical to equal opportunity; however, DEI efforts have never intended to meet quotas but are designed to provide opportunities that otherwise may not have been available to some.”

The Importance of Residency Coordinators

By Erin Simon, DO, Rebecca Merrill, MD, Ashley Heaney MD, on behalf of the SAEM Education Committee

Over the past 20 years, the emergency medicine program coordinator role has evolved from answering phones, taking minutes, organizing files, and keeping the program director's schedule to recruiting, ensuring all Accreditation Council for Graduate Medical Education (ACGME) requirements are met, advising residents, bridging residency program and graduate medical education, and event and wellness planning.

Every year the designated institution official (DIO) at Cleveland Clinic Akron General reviews all hospital residency programs and generates a list of strengths and risks. Several years ago, Graduate Medical Education Committee (GMEC) members at our institution voted to make a program

coordinator change a “high-risk” event. High risk because when the program coordinator changes, our institution's residency programs tend to see lower resident satisfaction, less effective communication between residents and faculty, and decreased compliance with ACGME requirements.

A recent 2022 survey sent to residency coordinators included 6,372

responses. They found that 92.4% identified as female, 69% white, 12.4% Latino, and 10.1% African American. The survey showed that the highestranked drivers of satisfaction were the coordinator's ability to interact with residents and fellows, ability to interact with program leadership (program directors and assistant program directors), sense of self-efficacy at work, interaction with other administrative

“A residency coordinator can make or break a program and is the glue that binds the residency together.”

staff, interactions with faculty, flexibility of the work schedule, and sense of meaning in their work. Drivers of stress included tracking faculty to complete tasks, low pay, tracking and reminding residents to complete tasks, and overall workload. While the title of “program coordinator” is the ACGME preferred verbiage, programs must understand that a different job title can be chosen. “Program manager” or “program administrator” often comes with better pay and more career opportunities and is preferred by coordinators.

A residency coordinator can make or break a program and is the glue that binds the residency together. Among the qualities of an excellent residency coordinartor are:

• organizational skills

• excellent communication skills

• approachability

• understanding of residents’ needs and requirements

• ability to maintain a good working relationship with program leadership

• knowledgeable of graduate medical education requirements (to assist with the preparation of the Annual Accreditation Data System documents and prepare for site visits)

In summary, protecting the residency program coordinator role is vital to the success of emergency medicine residency programs; however, in 2022, the ACGME reduced the protected time required for residency coordinators. As a result, a program of 20 residents may only have a 0.9 full-time equivalent (FTE) program coordinator. Not requiring even

one FTE underestimates a coordinator's contributions to a residency.

Key takeaways:

1. Ensure your coordinator feels respected and is compensated fairly.

2. The program coordinator's title within the health care system may directly reflect the compensation the coordinator receives.

3. Although the ACGME utilizes the "program coordinator" title, the hospital can give titles that better reflect the workload of program coordinators. The title of “program administrator” or “program manager” are alternatives that better reflect the role and may allow for better career advancement.

4. Ensure that discussions or decisions about the program coordinator's work involve the coordinator's input. Getting to know and supporting your residency coordinator should be a focus early in your residency or career.

ABOUT THE AUTHORS

Dr. Simon is a professor of emergency medicine at Northeast Ohio Medical University. She is research director for the Cleveland Clinic Akron General emergency medicine program and medical director for the Cleveland Clinic Bath emergency department. SimonE@ccf.org

Dr. Merrill is a graduate of the Medical Scholars Program at Michigan State University College of Human Medicine. She is currently the M3 clinical experiential director in emergency medicine for Northeast Ohio Medical University and the program director for the emergency medicine residency at Cleveland Clinic Akron General. She has a special interest in supporting women in academic emergency medicine and faculty development and enjoys speaking on these topics.

Dr. Heaneyis an attending physician in the department of emergency medicine at Cleveland Clinic Akron General. She currently serves as assistant clerkship director for the emergency medicine clerkship and associate program director for Cleveland Clinic Akron General’s emergency medicine residency.

PT and OT in the ED: Interdisciplinary Session Introduces Med Students to Value of Working With Multidisciplinary Team

By Elina Kurkurina, Lauren Dierks, Stephanie Balint, Catherine Meriano, JD, MHS, OTR/L, and Karen Blood, PT, DPT, DHSc

The ability of an emergency medicine physician to work well with a multidisciplinary team is integral to improving patient outcomes. As interprofessional education has repeatedly been shown to improve teamwork and colleagues’ perceptions of each other, an emergency medicine interest group at Quinnipiac University sought to develop an event to expose medical students to interdisciplinary consultations and services available in the emergency department (ED). To introduce students to physical therapy (PT) and occupational therapy (OT), the

interest group worked with PT and OT faculty on an interactive session that consisted of three case studies and hands-on assistive device orientation. Through cases of a patient experiencing hemineglect, an older adult following a fall, and an individual with a fracture of the tibia, students were introduced to the different roles PT and OT play in patient care.

Key Takeaways for PT

Falls are the most common cause of injury in the aging population, leading to 3 million ED visits and over 950,000 hospitalizations or transfers in the most

recent MMWR data. PTs play a crucial role in the disposition of these patients, as well as patients with a vast array of chief complaints and/or comorbidities. While emergency physicians consult and work closely with PT every day, research shows their role is not universally understood. PTs are trained to provide specific instructions on proper use of assistive devices, provide alternatives to medication-based pain management, and educate patients on injury prevention, safety, and body mechanics. They are well suited to determine a patient’s ability to return to

work or school and are instrumental in ensuring patients can regain and improve mobility following an injury or illness. PTs in the ED help improve patient outcomes and decrease hospital readmissions through safer discharges.

Key Takeaways for OT

The use of OT in the ED is in an infancy stage. Despite the increasing number of older adults in EDs, the referral rates for OT remain low. As a team member, OT can assist to reduce falls in collaboration with PT clinicians. In addition, because OT has a strong functional expertise, a full occupational profile of the patient’s skills and home surroundings can assess

safety for home discharge by considering functional status and life situations beyond the immediate medical concern. Within the skill set of OT, not only is selfcare addressed, but the patient’s ability to take care of others/pets, clean the home, do laundry, organize daily medications, use appropriate home equipment, and get groceries are also prioritized. These actions represent the functions of daily life that require cognitive skills, physical skills, and an appropriate environment that go beyond the medical diagnosis of a patient. OTs are instrumental in working with patients whose illness or injury has altered their ability to function at baseline.

For first- and second-year medical students, this interdisciplinary session highlighted the importance of functional needs, assistive devices, and home environment as key elements of a safe discharge. Emergency physicians should consider consulting PT and OT when patients have mobility or functional needs, new assistive devices, a change in home environment, or are being discharged in a state that is significantly different from their baseline.

ABOUT THE AUTHORS

Elina Kurkurina is a first-year medical student at the Frank H. Netter MD School of Medicine at Quinnipiac University. She holds a Master of Public Health in social and behavioral sciences from the Yale School of Public Health.

Lauren Diercks is a third-year medical student at the University of Texas Southwestern in Dallas, Texas. She is a medical student representative for the 20222023 SAEM RAMS Board and a member of the Membership Committee.

Stephanie Balint will be entering her third year as a medical student at Quinnipiac University. Prior to medical school she worked as an emergency medical technician, National Guard health care specialist, and emergency department registered nurse. Since 2020 she has worked as an advanced practice registered nurse in a small, 122-bed community hospital.

Catherine Meriano is a professor of occupational therapy at Quinnipiac University. She has been an occupational therapist for 35 years and has worked in a variety of settings, including acute/subacute care, homecare and currently an outpatient clinic. She is the interim assistant director of the Quinnipiac University Center for Interprofessional Healthcare Education.

Karen Blood is a clinical assistant professor at Quinnipiac University in the physical therapy department. She is board certified in geriatric physical therapy and has worked with older adults in many settings including acute care, short-term rehab, and outpatient over the last 20 years. She has presented at the state and national level on many topics related to the care of older adults.

“Physical therapists in the emergency department help improve patient outcomes and decrease hospital readmissions through safer discharges.”

The Evolving Role of Ultrasound and Telemedicine in Mobile Integrated Health

By Michael J. DeFilippo, MD, Shriman Balasubramanian, DO, Michael Stone, MD, Gabriela Galli, MD

Over the last decade, there has been a shift within the field of emergency medical services (EMS) from solely providing acute prehospital emergency medical care to a mobile integrated health platform. Mobile integrated health care (MIH) is a rapidly expanding field that allows prehospital providers to evaluate, diagnose, and treat patients in their homes or place of residence. An MIH team is multidisciplinary and geographically variable depending on the needs of the local population. Care may be delivered by paramedics, nurses, physician assistants, social workers, or behavioral health specialists. This specifically benefits patients who may not have access to longitudinal

care as well as those who are at high risk for repeat illness or readmission. While the scope of mobile integrated health is still being defined, the use of telemedicine and ultrasound utilization have been rapidly expanding within recent years.

Community paramedicine is a model of care within MIH that involves the integration of paramedics into the local health care system as community health providers. Through either a hospital or EMS system, they work under the direction of a team of physicians with background knowledge of prehospital emergency medicine as well as longitudinal disease management. Community paramedics

typically work with patients who have chronic conditions, recurrent need for hospitalization, or are at high risk for readmission. They provide longitudinal care and support to these patients in their communities to encourage healing at home. Ultrasound and video-based telemedicine consultation are two tools that have been introduced in recent years to aid with diagnosis and management in this setting.

Ultrasound has proven itself to be useful in the acute emergency medical setting as well as MIH. Ultrasound is used by paramedics to quickly evaluate patients in the field and provide rapid clinical information and aid diagnosis. For example, ultrasound is used by

paramedics in some health systems to evaluate cardiac function during cardiac arrest. In the longitudinal care setting, ultrasound is now being utilized to monitor chronic conditions and provide ongoing assessment and treatment. Trained community paramedics can use ultrasound to monitor patients with heart failure and assess for changes in pulmonary congestion or pleural effusion, giving valuable data used to

determine volume status. This can help guide management, such as changes in medication regimen, additional intravenous diuretic administration, or need for transport to an emergency department.

Direct oversight of community paramedics via video-based telemedicine complements the use of MIH ultrasound. Local images obtained by the paramedic can be either viewed

over video conferencing or transmitted to the physician via the internet for interpretation. This real-time transmission allows for accurate interpretation by a trained expert that can be immediately used to guide management. This remote method of interpretation expands the reach of emergency physicians and access to care for patients who may not have easy access to longitudinal care. This can be particularly useful in cases where paramedics are working with high-risk patients where early intervention can prevent costly hospital readmissions, such as those with advanced heart failure.

The use of ultrasound and telemedicine by community paramedics in MIH systems has the potential to safely improve patient outcomes, reduce health care costs, and expand the role of paramedics. As the field of mobile integrated health care continues to evolve, the integration of ultrasound and telemedicine into MIH and prehospital care will become an increasingly important component of both paramedic and prehospital physician practice.

ABOUT THE AUTHORS

Dr. DeFilippo is a chief resident in emergency medicine at NewYorkPresbyterian Columbia & Cornell and former paramedic. He is currently a member of the SAEM RAMS Board and chair of the RAMS Research Committee.

Dr. Balasubramanian is a second-year emergency medicine resident at NewYork-Presbyterian Columbia & Cornell and former EMT, from Poughkeepsie, NY.

Dr. Stone is a third-year emergency medicine resident at NewYork-Presbyterian Columbia & Cornell and former EMT with interest in EMS.

Dr. Galli is a first-year emergency medicine resident at NewYorkPresbyterian Columbia & Cornell and former paramedic.

“Trained community paramedics can use ultrasound to monitor patients with heart failure and assess for changes in pulmonary congestion or pleural effusion, giving valuable data used to determine volume status.”

IN ACTION

A Patient in Custody and a Provider’s Dilemma

By William Bruno, MD

The Case

A physician staffing the “jail ED,” which sees patients in police custody — either brought in directly from the street after arrest or referred from the county jail — brings in a young man for evaluation. The patient has no medical complaint, but the police insist he has swallowed an unknown substance, which they suspect to be drugs or other contraband. The patient denies this, has normal vital signs, and a reassuring physical exam. The physician’s initial plan is to discharge the patient back to police custody, but the police insist they need an abdominal x-ray to evaluate for a foreign body prior to intaking the patient into the county jail. The physician refuses this request given that the patient denies any ingestion, and he feels that the police have no role in dictating which diagnostic tests should be done in a clinical setting. The officers become frustrated and, in a terse manner, explain that because the provider is refusing to get the x-ray, the patient will have to be placed in the “hole” for “observation.” .

Case Discussion

Ostensibly, it was appropriate for the police to bring an incarcerated person to the emergency department due to a concern of a possible ingestion; however, in this case, the patient denied any ingestion and showed no

clinical signs of intoxication negating a need for further investigation. It is of course possible that the patient was being dishonest about the suspected ingestion, which poses the first ethical consideration of this case: Is there a role for a provider to continue a workup that would only be indicated under

the assumption that a patient is being dishonest? Doing so has the potential to compromise patient autonomy and agency, particularly if the patient’s reason for being dishonest is to avoid medical tests or interventions. However, if a patient consents to an evaluation and a provider can reasonably assume

there is a significant clinical value to the test, this would be permissible. For example, when a patient is being evaluated after a suicide attempt by way of attempted hanging yet denies any ingestions, it would be prudent for a provider to send an acetaminophen level.

In this case, however, the risk to the patient of forgoing diagnostic tests was deemed by the physician to be minimal. It had been well over 60 minutes since the suspected ingestion with no clinical signs or symptoms of intoxication, which one would expect to see by this point if the patient had indeed been a body-stuffer of clinical importance. The question then becomes: is it permissible to order a test with no clinical utility for some other purpose — in this case to placate the arresting officers? The answer is no. The principle of nonmaleficence dictates that providers weigh the potential benefits of any medical action against all potential risks. If, as in this case, there is deemed no clinical benefit, the action should not be taken.

The problem of providers being pressured to order tests that are not clinically indicated is not unique to interactions with law enforcement. For example, providers might feel that, despite a lack of clinical utility, ordering a certain test has the benefit of protecting

against litigation, or the provider might feel pressure from hospital administrators to order more diagnostics to generate revenue. These examples are clear violations of ethical practice and should be avoided at all costs. On the other hand, institutionally based clinical protocols or hospital policy might dictate that a specific action be taken, even when a clinician disagrees. In these circumstances, a certain level of humility is in recognizing that one’s own judgment might be in error. If, however, after careful consideration, the clinician feels certain that said protocol would violate the principle of nonmaleficence, the physician should not comply. In turn, to avoid a scenario in which the appropriate care for a patient is eclipsed by administrative regulation, any such protocol or policy should leave room for clinician judgment.

The Conclusion

The case discussed above did have an added level of ethical complexity. The officer’s statement about putting the patient in the “hole” if the provider did not acquiesce was taken by the physician as a threat. The implication being, “order this test, or the patient will suffer.” Given the relatively benign nature of the requested x-ray, the physician recognized that complying with the demand might be in the patient’s interest, and therefore

consistent with the principal of medical beneficence. However, the physician also saw that complying with this demand would be a tacit acceptance of the officer’s use of structural violence to manipulate the doctor-patient relationship to the officer’s desired ends. Complicity with such inexcusable behavior is not only inherently unethical but has the potential of reinforcing a corrupt system of abuse. Despite this, if after discussing the perceived threat, the patient opts for an x-ray to avoid the possibility of being relegated to the “hole,” the principals of autonomy and beneficence would argue for attaining the test. Ultimately, the provider in this case opted to discuss the situation with the officer’s supervisor and express concern about the perceived threat. The supervisor organized for an x-ray to be done at the county jail infirmary which, as it turns out, was standard protocol.

The paramount responsibility of an emergency physician is to provide the best possible medical care for patients. In so far as physicians interact with law enforcement, this responsibly must always take precedent. That is not to say that other considerations should be ignored. The physician in this case was justifiably concerned that complying with the officer’s threat would mean complacency with an inexcusable abuse of power. Refusing to do so, however, could have resulted in suffering for the patient. This case reinforces the imperative that providers think critically about the ethical dynamics of their practice. While patient beneficence and nonmaleficence should take precedent, providers must also resist becoming complacent in unethical systems and policies.

ABOUT THE AUTHOR

Dr. Bruno is a fellow in global emergency medicine at Columbia University. His work outside the emergency department is focused on the research and practice of humanitarian response.

“The principle of nonmaleficence dictates that providers weigh the potential benefits of any medical action against all potential risks.”

The New Joint Commission Standards to Reduce Health Care Disparities

By Annabella Salvador-Kelly, MD and Nancy S. Kwon, MD, MPA on behalf of the SAEM Faculty Development Committee, in conjunction with the SAEM Equity and Inclusion Committee

The Joint Commission implemented new accreditation standards to improve health care by reducing health care disparities. These standards became effective on January 1, 2023 and they apply to multiple settings including ambulatory care, behavioral health, and hospitals. The new standards include six new elements of performance (EPs) which address health care disparities as a quality and patient safety priority. The goal of this article is to outline the new standards and how emergency medicine is on the forefront of finding actionable solutions to reducing healthcare inequities.

Inherent to the six EPs to address health care disparities are the following principles:

Record of Care, Treatment, and Services (RC) requirement to collect patient race and ethnicity information that has been revised and will apply to the following Joint Commission–accredited programs:

• Ambulatory health care (Standard RC.02.01.01, EP 31)

• Behavioral health care and human services (Standard RC.02.01.01, EP 26)

• Critical access hospital (Standard RC.02.01.01, EP 25)

Record of Care, Treatment, and Services (RC) Chapter Note requirement assures that the medical records contain the patient’s race and ethnicity which will help to better understand the patient population as a whole and allow organizations to stratify key quality and

safety measures to identify potential disparities in care.

Rights and Responsibilities of the Individual (RI) requirement which prohibits discrimination (StandardRI.01.01.01, EP 29) and will apply to all Joint Commission–accredited ambulatory health care organizations, behavioral health care and human services organizations.

The 6 Elements of Performance (EPs)

1. Designate an individual(s) to lead activities to reduce health care disparities for the organization’s patients. Management-level leadership, physician leadership and team leadership have been consistently associated with successful quality improvement projects and is recommended.

2. Assess the patient’s health-related social needs and provide information about community resources and support services. Health-related social needs may be identified for a representative sample of the organization’s patients or for all the organization’s patients. These are often described as social determinants of health, or SDoH. Some examples include transportation access, inability, or difficulty in paying for prescriptions or medical bills, education and literacy, and food and housing insecurity.

3. Identify health care disparities in the patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients. Organizations may focus on areas with known disparities identified in the scientific literature. Organizations determine which sociodemographic characteristics to use for stratification analyses.

4. Develop a written action plan that describes how it will address at least one of the health care disparities identified in its patient population. The organization can then build on the lessons learned and plan to address additional disparities in the future. This action plan should define: a) the health care disparity and the specific population(s) of focus; b) the organization's improvement goal; c) the strategies and resources needed to achieve the goal; and d) the process that will be used to monitor and report progress.

5. Steps to follow when goals established in the action plan are not achieved or sustained. These steps might include reviewing quality and safety metrics, collecting feedback from patients about new services or interventions, and evaluating staff training and education

6. At least annually, inform key stakeholders (including leaders, licensed practitioners, and staff) about the progress to reduce identified health care disparities.

These new health care equity accreditation standards put forth by the Joint Commission are pressing and timely, but health care entities and organizations should have been focusing on these all along. These are steps in the right direction to hold accredited organizations accountable to the principle of health

continued on Page 34

“In the emergency department setting, where access should be equitable for all, it is imperative that we achieve health equity by not only following the steps outlined by the Joint Commission, but also by being proactive and going beyond these expectations.”

FACULTY DEVELOPMENT

continued from Page 33

equity. Emergency departments and emergency medicine represent a safety net in health care for vulnerable patient populations that include those with poor access to health care, those who are underrepresented, and those challenged with social determinants of health. As the standards are relatively broad to allow health care organizations to achieve success, it is important to focus on each one to see how the greatest results and outcomes may be achieved.

Elements of Performance 1

This EP is to designate an individual(s) to lead activities to reduce health care disparities for the organization’s patients. Although many health care organizations have roles that may touch upon reducing health care disparities such as a chief medical officer or medical director, a quality lead, or other similar roles, the entire focus of these roles is not to reduce health care disparities. The requirement suggests that leadership at the management level, including physician and team

leadership is recommended as there is often a focus on quality. The leadership at the management level could be the designees to reduce health care disparities, but constant attention is needed to make a difference. In collaboration or as a separate entity, many healthcare organizations have identified chief diversity officers or other similar roles. As the expanse of this type of role often includes focusing on staff diversity as well, one might argue that multiple roles are required.

Elements of Performance 2

This EP focuses on social determinants of health (SDoH). Although prior models have utilized social workers to focus on these needs, based upon research and data it is clear that SDoH affects the lives and health of patients that frequent the emergency department and in their communities. Therefore, all health care workers need to pay attention to and address SDoH. Two examples that the Joint Commission gives are transportation access, and inability to pay medical bills. It is common for some patients to utilize the emergency department after work hours to access health care because they cannot miss

work to attend a scheduled appointment. They need to support their families and losing a day of work could be detrimental. These patients might be labeled as being nonadherent to outpatient followup without an understanding of how SDoH affect the patients. Some patients have trouble accessing transportation for appointments because they do not drive, or they cannot afford to pay for transportation like bus or car services. Sometimes patients may arrive to the emergency department in an ambulance for minor injuries or complaints as a means of providing transportation for healthcare.

Elements of Performance 3

This EP mandates health care organizations to identify health care disparities in the patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients. The data of health care organizations will allow for transparency and to identify the diseases and processes where there the greatest disparities exist. Health care organizations will need to leverage their electronic medical records (EMRs) and dashboards in order to identify the gaps.

Elements of Performance 4-6

These EPs outline the accountability that will come with the continuous goal of achieving health equity, including a written action plan, a way of addressing goals that are not achieved, and to annually report out the progress that is made. In the emergency department setting, where access should be equitable for all, it is imperative that we achieve health equity by not only following the steps outlined by the Joint Commission, but also by being proactive and going beyond these expectations. The possibilities of where to start are endless, and there is unfortunately no end in sight. The Joint Commission provides examples of areas to tackle, such as specific diseases, patient experience, and communication. If we take communication as an example, patients with limited English proficiency (LEP) can be faced with worse outcomes if certified translators are not utilized. There are many examples of this in the medicolegal literature leading to even death and severe disability. Emergency medicine can track utilization and documentation of certified translators in patients with LEP and compare outcomes for patients with LEP with patients who are proficient at English.

The Joint Commission also put forward a new Health Care Equity (HCE) certification program. This program will recognize hospitals and health care organizations that strive for excellence in their efforts to provide equitable care, treatment, and services.

These requirements put forth by the Joint Commission reflect the concept that Christopher Johnson from the Nonprofit Leadership Center endorses — that diversity, equity, and inclusion are everyone’s responsibility and that we need to be accountable now. This is the only way we will achieve health equity and improved outcomes for our patients, and emergency medicine has the tools to take the lead.

In today’s world, we still face social, economic, and other injustices that challenge patients in accessing high quality and safe health care. To achieve improvement, we need to approach health equity in the same manner we address other quality and patient safety issues — by understanding the root causes and implementing a corrective action plan. Only when we can work together can we improve our journey to obtaining equitable delivery of health care for all.

ABOUT THE AUTHORS

Dr. Salvador-Kelly is Northwell Health’s senior vice president of medical affairs, deputy chief medical officer, and associate professor of emergency medicine for the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. She leads medical affairs throughout Northwell Health, including credentialing, policies, and procedures, and curating talented physicians and team members. She is also responsible for standardizing pharmacologic/therapeutic interventions and procedural products across the entire clinical enterprise

Dr. Kwon is the vice chair of emergency medicine at Long Island Jewish Medical Center, which is part of Northwell Health. She has been an active member of SAEM as part of the Faculty Development, Research, and Equity and Inclusion committees and is presently a member of the SAEM Nominating Committee.

Reference: https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_disparities_july2022-6-20-2022.pdf

FACULTY DEVELOPMENT

Redefining Leadership for the Next Generation of EM Physicians

By Maneesha Sabharwal, MD, on behalf of the SAEM Faculty Development Committee

When I was an emergency medicine resident, I had amazing, knowledgeable attendings who taught me how to care for patients with acute, critical illnesses. When I left residency, I felt ready to take care of sick patients; however, I was immediately confronted with a new challenge that had not been part of my medical education and training: leadership in the trenches.

As a new attending on shift, everyone — residents, advanced practice providers, nurses, technicians — was looking for my guidance, direction, and leadership. So, what did I do? I barked orders — at everyone. I knew how to treat the acute pathology, but I didn’t know how to motivate the emergency department (ED) care team to deliver the best care for our patients. I was impacted by how little training I had on how to build

and lead a high-performing team. After a series of mistakes, I asked myself: What leadership skills do I have to motivate my team to deliver the best care?

During residency, I was told to “be nice, smile, be approachable, don’t argue, etc.” This isn’t leadership training! Medical school and residency didn’t train me on how to be a leader, so understandably, when I became an attending, I didn’t automatically have the skills to lead. Needless to say, my “natural” leadership tendencies, or my default way of leading, was not well received.

For most people, being an effective leader is something they unconsciously model from those they grew up around: parents, teachers, mentors etc. As a resident, have you noticed that you try to emulate the attending you most admire

or the ones that you are "supposed” to admire for their intellectual prowess? But do these individuals really know how to lead or are they just smart?

My biggest barrier to leading effectively was to identify the default leadership tactics I was utilizing. My research led me to discover that there are three, default inherited models of leaderships that are passed from generation to generation and prevent people from building high-performing teams. Initially, these were quite novel for my level of awareness around leadership.

Three Inherited Models of Leadership

Guilting and Shaming

I do this, you do this, we all do this! It is a human being phenomenon. Remember your parents saying, “If you

don’t get your grades up, you can’t have the car over the weekend!” Or at work, “You are seeing 15 patients per shift and Dr. Y is seeing 22, so you need to see more patients.”

What about the resident/attending feedback system? Why are evaluations anonymous? We are told that anonymity gives the reviewer the space to speak freely and avoid retaliation, but what if we taught physicians how to give feedback without guilting and shaming one another — and I don’t mean just providing the proverbial “compliment sandwich.” What if feedback was given in a way to empower the person to perform at a higher level? Guilting and shaming is a default way of leading that ONLY pushes people to run away, quit, lie, hide, cheat, and defend themselves. It is pervasive in society, and it does NOT result in higher performance!

Dominate/Avoid Domination

Like guilt and shame, dominant/avoid domination is a typical default behavior in human beings and is present in all relationships: parent/child, husband/wife, student/teacher, resident/attending, APP/ attending, nurse/attending, nurse/tech. (Remember how you interacted with your parents when you were a toddler, teenager or just off to college? The sentiment was probably “don’t tell me what to do!”) Basically, it is pervasive in life.

Let us look at the resident/attending relationship. As a resident, have you noticed that when you present a patient you want to prove yourself. You feel the need to defend your patient care decisions and fight to execute your desired level of care, despite what the attending is telling you to do. Do you feel dominated by the attending? Are you trying to avoid domination?

Although this type of dominating your workforce can sometimes be effective in getting desired results, when persistent and pervasive, it often results in cultural dysfunctions, low morale, and an unwell workforce. Can you recognize it in yourself and in your leadership?

Hidden Agenda When Listening to Others

Most of us have inherited a model for listening to each other that isn’t actually

listening to what a person is saying, but interpreting what we think the person is saying as he or she is speaking. And, these interpretations are guided by our hidden agenda, which then becomes our truth. In other words, we believe that our interpretation of what the person said is what the person ACTUALLY said. And, the most interesting part about this is that we don’t even know we have a hidden agenda.

How you listen to others determines your effectiveness as a leader. If you listen without interpretation and judgement, you have a better chance of hearing the other person’s true commitment. You have to listen past what you THINK they are saying to discover their true intention.

This default, hidden agenda when listening is often present in the nurse/ physician relationship. The moment we walk into a room, we already have a preconceived notion about the other human being without even knowing them. If you are a doctor “you already know how nurses are.” If you are a nurse “you already know how the doctor is going to be.” These assumptions limit our communication at the bedside.

Let’s look at the resident/attending relationship again. As a resident you will likely be listening for two things: 1.) to learn the medicine and best practices for patient care; and 2.) to find out who is the “best/favorite attending.”

Imagine you are working with an attending, who has a “reputation” and instead of listening from the perspective of learning, you are listening to determine the validity of that reputation. And, when you come across evidence to validate that reputation, you are no longer listening to learn. Suddenly, that attending becomes the attending “you don’t like to work with,” and you forget to listen for their contribution to your learning. This is known as listening through a hidden agenda.

Maybe the attending is still a terrible teacher, but if you change the way you listen, you can still learn from the attending that everyone dislikes! Anyone’s experience can teach you something if you remove your hidden agenda from your listening.

The starting point for providing effective leadership is to consider the possibility that we all utilize these inherited models for leadership and see how this prevents us from creativity, collaboration, alignment, progress, and wellness. Notice these models in your daily life and how your own leadership is constrained by them.

These old, traditional, default, inherited models for leadership are not elevating our ability to care for our patients and are creating an unwell workforce with low morale. Once we start to notice this, we can begin to attempt to break this cycle and disabuse ourselves from these models, enhancing our capacity to lead in a way that uplifts people and motivates them to perform at a higher level.

You may be likening these leadership distinctions to the ideas of emotional intelligence. I recognize the desire to fit these principles into an already existing bucket, but I am proposing a new bucket. Consider that our struggles in the emergency room may not be a lack of emotional intelligence but may stem from lack of effective leadership development. If we develop and implement new leadership training curricula into our medical schools and residency programs that address elevated leadership and communication practices, we will be able to undo pervasive cultural dysfunctions and restore the health and wellness of our health care providers.

ABOUT THE AUTHOR

Dr. Sabharwal has a Bachelor of Musical Art in saxophone performance from the University of Michigan and a pre-medical, postbaccalaureate at Northwestern University. She obtained her medical degree from the University of Missouri – Columbia. Her EM residency was completed at NYU/Bellevue Hospital in NYC, NY. For the past seven years she has been an attending at Emory University Hospital in Atlanta, GA where she is currently is an assistant professor of emergency medicine.

“Anyone’s experience can teach you something if you remove your hidden agenda from your listening.”

Home Health Care Education: Using the Residence to Train Residents

By Kyle R. Burton, MD, MPP, on behalf of the SAEM Academy for Geriatric Emergency Medicine

Home Health Care Education

Experience

During elective geriatric training in my final emergency medicine (EM) residency year, I spent one week joining Johns Hopkins Home-Based Medicine (JHome) geriatricians in several home health visits. Medical equipment in hand, we traveled home to home receiving warm family greetings as we completed extensive assessments and tended to urgent ailments. Although we could spend our entire career caring for patients in the hospital, this one week in home health care provided a unique perspective and intimate patient connection that all could benefit from.

Much of the evaluation that cannot take place in the emergency department (ED), but is critical to keeping people

healthy, can be conducted with home health visits. Even with the support of social workers, patients who are unstable or suffering from pain may not be able to participate in social support screenings. Extending the ED length of stay for these evaluations may not be feasible given the sheer ED volume with an abundance of patients

awaiting care. There is a broad range of medical, community, and social services to evaluate and support older patients in their home, but until recently home health- and community-based programs have been underutilized by ED providers. Medicare will even cover home health visits for those who are:

“Much of the evaluation that cannot take place in the emergency department (ED), but is critical to keeping people healthy, can be conducted with home health visits.”

Considered by Centers for Medicare & Medicaid Services criteria to be “homebound”

• Require skilled care to improve, manage, prevent, or slow a current health condition

• Evaluated through a physician in-person visit

EM trainees could benefit from home health care exposure through an increased understanding of their patient population, care resources, and future practice responsibility.

Gaining Patient Perspective

While once common practice for doctors to visit patients in their homes for both preventative care and medical treatment, it was later deemed no longer financially advantageous to do this compared to taking their practice into the office or hospital. According to Medicare data, and to the enhanced satisfaction of patients, house calls are once again on the rise. Like many fellow trainees, residency orientation consisted of learning about a community we would soon serve. My introduction to this community came in the form of Baltimore museum explorations, mural tours, and nonresidential care facility visits. Each of these experiences proved immensely beneficial for both social and clinical endeavors; however, it is critical to appreciate the clinical impact of the home — where most of our patients will sustain, and hopefully recover, from their ailments. Our patient population may have living conditions that you have to see, touch, and feel to understand. How can we care for someone without having some sense of where they are coming from and spending most of their time? While each patient home will clearly vary in design, each home health visit that I joined proved to be consistent in assessment of resources and accessibility. Among case specific evaluation and therapy, home health visits generally include:

• Screening for delirium, cognitive impairment, caregiver burden, function, fall risk, and elder mistreatment

• Inquiries about food insecurity, instrumental activities of daily living, medication risk/polypharmacy, home accessibility (entrance, stairs, and bathroom), transportation, home environment (fall risks, cleanliness, working utilities), and social support

• Evaluation, therapy, and monitoring for status of acute and subacute symptoms

Improved Health Outcomes

ED encounters increasingly serve as sentinel events that unmask unmet social and functional needs. Even older adults who are not completely homebound are likely to put off visiting their primary care doctor given challenges with facilitating this visit. As a result, their conditions worsen and their treatment becomes more expensive. The identification and home delivery of social and medical services can improve health outcomes.

Geriatric EDs (GEDs) tailor emergency care to meet the needs of older adults whose ED visits can be inconvenient, traumatic, and even dangerous. To combat long waits, uncomfortable beds, pathogen-filled halls, and the hectic pace of many EDs, GEDs offer structures, systems, and staff to optimize the older patient experience. They have utilized social workers and transitional nurses to avoid unnecessarily placing older patients at risk of the exposures and routine changes that come with hospitalization. Especially with older patients, providers may find themselves choosing to hospitalize for home safety concerns rather than medical management. In these scenarios, it is important to consider the “hazards of hospitalization”: increased cognitive impairment, a decline in functional status, and ultimate discharge to skilled nursing facilities rather than home. GED staff facilitate safe discharge by connecting patients with resources directly from the ED, including home health services. In doing so, these interventions have helped lower hospital readmission rates and prevent costly ER visits. 10% fewer patients who are discharged from the ED to home

health services, compared to those admitted for in-hospital stay following an ER visit, return to the hospital for care. Instead of admitting an older adult with complex care needs to the hospital, GED staff could even admit that patient to a hospital-at-home program or leverage telehealth and/or remote monitoring programs for follow-up.

Future Landscape

If improved patient outcomes were not enough reason to learn about home health care, our EM practice increasingly incorporates serving patients outside of the hospital. Barriers to this trajectory remain. The digital divide facing older adults with chronic illnesses may limit the accessibility and plausibility of telehealth check ins. Innovative approaches in these scenarios are trialing emergency physician deployment directly to homes or neighboring office spaces for acute care delivery. Learning about how home environments influence disease processes and therapeutic rehabilitation of our older patient population can make way for even more enhanced execution of home-based care alternatives.

As EM physicians, we take pride in suppressing barriers to health care access and keeping our finger on the pulse of the community. By educating on, facilitating, and maybe eventually conducting, home health visits, we continue to push the frontier that advances geriatric emergency care.

ABOUT THE AUTHOR

Dr. Burton is completing his emergency medicine residency with Johns Hopkins before serving as a physician partner with the Mid-Atlantic Permanente Medical Group. He obtained a dual degree from Harvard Medical School and Harvard Kennedy School of Government. Kyle has authored chapters in geriatric emergency medicine and care transitions.

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.”

Bayalpata Hospital: 15 Years and Forward

By Camille Lubetkin, MPH, and Derek Lubetkin, MD on behalf of the SAEM Global Emergency Medicine Academy

The final day of the 15th anniversary celebration of Bayalpata Hospital begins with a six-kilometer “marathon” up the hilly terrain of Sanfebagar, Nepal. Bayalpata is in the far-western region of Nepal in Achham district, one of Nepal's most remote regions with some of the country's highest poverty rates. White polo shirts specially ordered for the event are handed out to hospital staff. Those who do not run carry signs promoting health equity, a visual demonstration of the hospital's ethos. Following the race, preparations for the 15th anniversary ceremony are finalized. In moments, balloons are strung over a brightly colored stage, various forms of seating are arranged, and polo shirts are exchanged for saris. Everything is done with immense care and teamwork— a genuine reflection of the type of culture

and work ethic Bayalpata Hospital cultivates.

Since 2008, Nyaya Health Nepal (NHN), the non-profit which operates Bayalpata Hospital, has partnered with the Ministry of Health and Population and municipal governments of Nepal to improve health care for underserved communities. NHN's efforts have been recognized globally, including having received the United States Agency for International Development’s (USAID's) HRH2030 Global Resilience Award for 2020 due to its work in enhancing the effectiveness of rural health workers. The hospital's origins trace back to 2008 when an HIV clinic was opened in Sanfebagar. Two years later, with the support of the local community, they expanded into an abandoned hospital building on the grounds of what is

today's Bayalpata Hospital. In 2015, the hospital was redesigned and enlarged, a project that aligned with Bayalpata's goal of providing sustainable rural health care. Bayalpata Hospital was transformed into a 50-bed hospital with outpatient, inpatient, surgery, antenatal, emergency, and dental facilities, a pharmacy, and an on-site canteen. The hospital's architecture has won international recognition for its impressive, rammed-earth construction in which materials were locally sourced. The hospital buildings integrate harmoniously into the topography, instilling a wake of tranquility, but most importantly for the staff and patients, the buildings are earthquake resistant.

Bayalpata provides high-quality and completely free medical care to its patients. The hospital functions

as a public-private partnership with the combined support from the Nepal government and other local and international philanthropic support. The hospital serves the entire district of Achham, and the adjoining districts, and provides desperately needed care to the nearly 70,000 annual patient visits. Nearly 200 staff, with 135 based at Bayalpata Hospital, comprise the Nyaya Health Nepal team. There is one orthopedic surgeon, an advanced skilled birth assistant, five medical officers, and one dentist. The rest of the workforce is combined of allied health workers, community outreach, administration, and facility staff.

Since Bayalpata’s inception it has championed an integrated care service model through its extensive Community Health Worker (CHW) program. The program’s trained CHWs have made nearly 800,000 home visits, filling a significant gap in provision of care. Due to long transport times to the hospital (up to 8 hours) the CHW visits provide timely case identification, counseling, referrals, treatment, and follow-up. The primary focus of the CHW program has been in prenatal and postnatal care, chronic disease identification, and

posthospital follow up. Nearly all homes in the catchment area feature a blue plate containing a number allowing the CHWs to locate and identify their patients correctly. Furthermore, an innovative Electronic Health Record (EHR) system integrates data and coordinates the care taking place in patients' homes and the hospital.

At the center of Bayalpata Hospital is the uniquely talented Dr. Mandeep Pathak, an orthopedic surgeon, fellowship trained in orthopedic oncology, who also carries the title of Medical and Surgical Director of the hospital. He lives on the hospital campus full-time and is accompanied by other staff members who are required to be on call 24 hours a day in case of emergent cases. While Dr. Pathak leads hospital activities, Dr. Pratiksha Dhungana, a dentist who holds a master’s in public health leads the community health program.

We had the opportunity to participate in the hospital's momentous 15th anniversary celebration through a collaborative effort between Bayalpata Hospital and Brown University Division of Global Emergency Medicine, to implement a trauma training course for rural prehospital health care workers

in the surrounding municipalities. This pilot project utilizes tools from the World Health Organization- International Committee of the Red Cross (WHOICRC) open access Basic Emergency Care (BEC) course, the American College of Surgeons STOP THE BLEED program, and includes unique tools designed specifically for the CHWs in collaboration with the local team. The study is co-led by Dr. Mandeep Pathak and Dr. Ramu Kharel, a Nepali-born emergency physician at Brown University. Nepal, a country of 30 million people, is plagued by a high trauma injury-related morbidity and mortality rate. There have been previous efforts to expand trauma care training in Nepal; however, there has been limited literature assessing the effectiveness of various trauma training programs regarding the effect of the course on patient care interventions. This study is unique as it may be the first prospective cohort design with patient-care outcomes to evaluate the effectiveness of a trauma training course for pre-hospital healthcare providers in low- and middle-income countries. The two-day trauma course will train

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“Since 2008, Nyaya Health Nepal (NHN), the non-profit which operates Bayalpata Hospital, has partnered with the Ministry of Health and Population and municipal governments of Nepal to improve health care for underserved communities.”

GLOBAL EM

continued from Page 41

various community health care workers in the Ramaroshan municipality, with a focus on hands-on small group trauma skills stations, including immobilization, bleeding control, snake bite management, and airway protection maneuvers in the pre-hospital setting. Longitudinal data on knowledge sustainability, and assessment of patient care metrics will inform the study team on the utility of this innovative approach and set up for further expansion in the region and other similar settings. Additionally, an image-based handbook for primary trauma skills was designed and produced for this course.

Building a hospital is needed to provide care to patients; however, building a team of like-minded health

care professionals dedicated to improving the health of their community is critical for delivering sustainable rural health care. During our time at Bayalpata Hospital, we witnessed not just the delivery of high-quality and complex care, but a team of people united in their efforts and care for their patients and each other. Bayalpata Hospital is not just a building but a vessel for change. The hospital staff are not just health care providers; they are a family, a feature of this hospital's culture that provides the key ingredient for Bayalpata's success.

If you would like to learn more about Bayalpata Hospital and Nyaya Health Nepal, please see their website. If you are interested in collaborating with Bayalpata Hospital please contact Ramu Kharel, MD, MPH, CTropMed® at ramu_kharel@brown.edu.

ABOUT THE AUTHORS

Camille Lubetkin is a thirdyear medical student at Tufts University School of Medicine in the Maine Track Program. She is interested in medical education and training in limited resource settings and is a trained facilitator for the WHO/ICRC Basic Emergency Care course.

Dr. Lubetkin is a fourthyear emergency medicine resident at Brown Emergency Medicine. He is interested in emergency care capacity building in rural and resourceconstrained settings.

“Since Bayalpata’s inception it has championed an integrated care service model through its extensive Community Health Worker (CHW) program. The program’s trained CHWs have made nearly 800,000 home visits, filling a significant gap in provision of care.”

Developing an EMIG in a ResourceConstrained Environment: Lessons Learned From the First EMIG in West Africa

By Adebisi Adeyeye, MBBS, SimileOluwa Onabanjo, MBBS, and Faith Omimi Ibu, MBBS, on behalf of the SAEM Global Emergency Medicine Academy

Background

The field of emergency medicine (EM) evolved out of the necessity of caring for a rapidly growing population of patients seeking immediate and unscheduled medical care for emergency conditions. In the United States, community physicians began working part-time and full-time to staff the emergency department around the clock until residency training developed and emergency medicine was recognized as a standalone specialty over 50 years ago. The specialty of EM has since grown to become the bedrock of emergency care in more than 65 countries worldwide. In Nigeria, the National Postgraduate Medical College of Nigeria recognized EM as a specialty in 2019 and residency training commenced in 2022 at the University College Hospital, Ibadan.

A pilot study carried out in 2020 among medical students across the nation demonstrated a huge gap in knowledge of the specialty of EM, its scope and training. However, about 88% agreed that the specialty of emergency medicine would improve the Nigerian health care system and about 20.5% indicated interest in pursuing EM. This study highlighted the need for increased awareness and education about the specialty (Adeyeye et al, 2021).

Despite substantial interest in the specialty at the medical student level, specialized emergency physicians currently constitute less than 1% of the medical workforce in Nigeria. This is attributed to poor awareness, lack of training programs, mentorship, and guidance. For this to change, it is

imperative that medical students who show interest in the specialty be well informed, prepared, and guided to pursue their desired career path.

Emergency Medicine Interest Group, Nigeria (EMIG NG) was established to promote the specialty in the medical student community and provide an array of resources and support to EM-bound students, converting interest to reality.

The Process

The development of this group was completed in six stages.

1. Information sourcing

Being the first of its kind in Nigeria, we began by gathering information continued on Page 44

Faces of EMIG members

GLOBAL EM continued from Page 43

from similar organizations (mostly international and other medical studentbased organizations) to understand how interest groups are built and run. This process took over 4 months of consistent exploration and learning.

2. Core team formation

The core team consisted of the founding president, vice-president, and general secretary (two medical students and a recent medical graduate at that time) who went on to develop the interest group. The success of the group is attributable to the resilience, creativity, and dedication of the core team.

3. Organizational structuring

Next, the organizational structure was developed using information learned from similar organizations studied. The roles and responsibilities of the core team and other leadership roles were described and documented. The bylaws of the organization were written and the process capturing the history of the organization was documented at every point.

4.

Needs assessment

To understand the gaps, we designed a cross-sectional study which sought to understand the knowledge, attitudes, and willingness to practice emergency medicine residency and collected data from 439 medical students in six medical schools across the country. Our study found that 42% did not know EM is a specialty and only 32% had a good grasp of what the specialty entailed.

5. Curriculum development

We developed content carefully to match the needs our study. The curriculum first introduced the concept of EM as a specialty via webinars and contained sessions on subspecialty explorations delivered by EM physicians. We then created sessions on foundational EM topics and skills sessions for common procedures. We made sure to have at least 6-12 months of curriculum designed ahead of time, to be reviewed periodically as we reassess member needs.

6. Recruitment

Lastly, we collected and reviewed applications for membership and officially opened the group, with its first set of members, on October 17, 2020.

Outcomes and Successes Momentum

The student interest group contributed to the momentum of efforts driven towards EM development in Nigeria by advocacy, meaningful engagement of stakeholders, and research. The group witnessed the commencement of EM residency in Nigeria in 2022.

Numerical Strength

The first call for applications went out in October 2020 and resulted in over 500 applications. After screening, 55 members were selected based on interest in emergency medicine.

Following three more calls for applications, the numerical strength of the interest group has grown to 319

Presentations by EMIG members at AfCEM22

members comprising medical students and recent graduates across most states in the country.

Trainings/Webinars

Since inception in October 2020, a total of 42 training webinars have been held featuring local and international experts, spanning carefully handpicked topics, and curated to educate our members on pertinent topics related to emergency medicine. Topics covered include career related topics on pursuing EM residency locally and internationally; academic topics on resuscitation and airway management; personal development topics on the role of research, networking, and mentorship; social issues in EM; and finances, to mention a few.

These sessions were aimed at equipping our members with holistic knowledge.

Research

To improve interest in research and contribute to the body of knowledge on emergency care locally, 12 research teams were created for interested members. So far, over 10 oral and poster presentations have been delivered at international conferences by members and six papers were presented at our maiden EMIG NG Scientific Conference held on May 28, 2022. The second season of our research bootcamp for 2023 is currently in session.

Mentorship

Prior to our mentorship initiative, with only four EM trained physicians in Nigeria and over 200 members, access to mentorship in EM for many of our members was almost impossible. Hence, we created mentorship pairings between interested members and both local and international volunteer mentors based on preference and common interests.

Leadership Opportunities

Due to growth and expansion, more opportunities on the executive board

About GEMA

opened, creating opportunities for leadership experience for interested members. In addition, leadership structure has grown from the initial three founding members to a team of eight core executives and other volunteers.

Member Achievements

• We have members in leadership positions in international EM based organizations including the African Federation for Emergency Medicine (AFEM) Student Council and the Global Organization for Wilderness Medicine Education (GOWME).

• We have had two members match into EM residency in the United States and another match into the FM/EM pathway in Canada. We also have a few others about to commence training in the UK and in the recently commenced Nigerian EM residency.

• A student representing West Africa attended the 2022 International Federation of Emergency Medicine (IFEM) medical student symposium

• EMIG NG members presented indigenous research papers at local and international emergency medicine related scientific conferences

International affiliations

EMIG Nigeria is affiliated with the AFEM Student Council and ACEP-EMRA.

Next Steps

Short term

• Skills bootcamp to fill in the gap created by a current lack of EM undergraduate training and teach important lifesaving skills to medical students.

Long term

• Create a detailed website with an easyto-use interface with detailed information

• Create a blog for EM-related content with submissions from members

• Partner with organizations invested in emergency medical services in different parts of the country to provide regional skill training sessions for members.

• Advocate for a structured and graded EM undergraduate curriculum in Nigeria

Conclusion

The initiative of the Emergency Medicine Interest Group, Nigeria has revolutionized the interest in and access to specialized EM training amongst medical students in Nigeria. We have worked tirelessly in a constrained environment with limited resources to fulfill our mission of equipping EM Bound Nigerian medical students with the information, resources, and support to fulfill their dream of becoming emergency physicians.

ABOUT THE AUTHORS

Adebisi Adeyeye, MBBS (Lagos) is a clinical research assistant at the Duke-Nigeria GEMINI research group with interest in emergency and disaster medicine and medical education. She serves as president of the EMIG, Nigeria and the co-vicepresident of the African Federation for Emergency Medicine (AFEM) Student Council. @Anthoniabc

SimileOluwa Onabanjo, MBBS (Lagos) is an aspiring emergency medicine physician with special interest in cardiac emergencies and improving prehospital care, particularly timeliness of resuscitative efforts, in Nigeria. She currently serves as vice president of the EMIG, Nigeria. @OSimileOluwa

Faith Omimi Ibu, MBBS is a firstyear resident at the University of Missouri-Columbia emergency medicine residency program. She graduated from College of Medicine, University of Lagos, Nigeria and is the general secretary of EMIG, Nigeria. @faithybb_

The Global Emergency Medicine Academy (GEMA) focuses on improvement of the worldwide delivery of emergency medical care. Membership in SAEM's academies and interest groups is free. To participate in one more groups: 1.) log into SAEM.org; 2.) click “My Participation” in the upper navigation bar; and 3) click “Update (+/-) Academies or Interest Groups.”

“The initiative of the Emergency Medicine Interest Group, Nigeria has revolutionized the interest in and access to specialized EM training amongst medical students in Nigeria.”

Feedback and Difficult Conversations for ED Leaders

By Rob Flint, MD

Those that aspire to be great leaders in medicine must understand the giving and receiving of feedback. Feedback is defined by Miriam Webster Dictionary as “the transmission of evaluative or corrective information about an action, event, or process to the original or controlling source also: the information so transmitted.” We take it as inevitable that leaders in medicine at some point in their careers will be required to deliver or receive this type of information. Emergency department medical directors will provide feedback to physicians, advanced practice providers, and nursing staff both as routine performance evaluations and as needs and events dictate. Residency program directors will provide feedback to residents, students, assistant program directors and other faculty that interact

with residents. Department chairs will provide and receive feedback to/from their direct reports (which may include medical directors, vice-chairs, program directors), other department chairs, and health system administrators.

Developing a positive, productive mechanism for giving and receiving feedback will differentiate a great leader from a good manager. An excellent leader will know the appropriate time and setting for providing both positive and constructive feedback. Being clear with purpose and intent is vital when providing this information to employees, colleagues, and others. Creighton University outlines a very appropriate example of what feedback is:

“Feedback is not advice, praise, or evaluation. Feedback is information about how one is doing in effort to reach a goal. There are two types of

feedback-giving and receiving- and both are not the easiest. Understanding of how to give feedback and to receive feedback is important in a leadership role. Feedback is: Written comments, electronic comments, meetings with individuals or suggestions from peers.”

Know How to Have a Difficult Conversation

To develop a constructive style of giving and receiving feedback an effective leader must know how to have a difficult conversation. The effective leader also must have a concrete plan in these conversations, know how to document the conversation, and know their desired outcome. Effective listening is also critical when receiving feedback. Anticipating and preparing for a difficult conversation is vital when providing feedback, negotiating, or during other difficult interpersonal interactions.

Cleverism.com offers us a definition of a difficult conversion as “... any situation where the needs/wants, opinions, or perceptions of the involved parties are diverse, with their feelings and emotions running strong. Usually, the reason behind such strong feelings and emotions is that they have a lot at stake, and they dread the consequences such as a conflict.”

Understanding that emotions are the saboteurs of important conversations is the first critical function in preparing for and having difficult conversations. These conversations are difficult because they involve conflict, strong emotions, and difference of opinion. You are likely conveying information that is difficult to hear or accept. There is no limit to what type of conversation we can define as difficult. We must accept when we convey information it is possible it will be a difficult conversation.

Know Who You Are

As with anything at which you want to succeed, difficult conversations require preparation and practice. The initial step in preparation is knowing who you are. Are you someone who makes decisions based on emotion? Do you tend to be intellectual and analytical when it comes to making decisions? Are you conflict adverse? Are you afraid of not being liked? Are you direct and devoid of emotion when giving bad news? There is no correct answer. Read that again. There is no correct answer. Your personality and traits are what they are. Most excellent leaders know themselves and know their strengths and weaknesses. Knowing the type of person you are allows you to prepare for a difficult conversation and anticipate where you may struggle. How do you know who you are? You can ask trusted advisors and family about your traits. You can self-reflect on previous giving or receiving of feedback. You can engage with a coach or councilor. Knowing your strengths and weaknesses allows you to have the most affective conversations.

Prepare for the Conversation

Once you know who you are and how you tend to make decisions and interact

with people, you can prepare for the conversation. Gather the data you need to make the point you are trying to articulate. You do not need every shred of evidence or information. You want to make sure your point is well supported. From there it is a good idea to rehearse what you want to say. The more experience with these conversations you have the less you may need this step, however going over your thoughts in your head prior to the conversation leads you to clarity of purpose and presentation. You should then anticipate the reaction of the other participant. Anticipate your reaction to their reaction. You can reasonably make assumptions based on what you know about the person. Do not script the conversation! If you try to script out exactly what will happen, you will come across as artificial and will often be thrown off course when the other participant does not react the way you imagined. These conversations require flexibility and dexterity. Rigidity often leads to increased emotion and failure to convey your thoughts.

Be in the Correct Emotional State

Be sure to be in the correct emotional state when you start these conversations. Control the elements you can control, such as timing, location, participants, and how the participants are invited. Make sure you have set aside the proper amount of time for the conversation. Too little time can make you feel hurried, uninterested, and harsh. Too much time can lead to awkward silence or unnecessary side conversations. By knowing your personality type you will be prepared to address your weakness. If you are a conflict avoider, have the conversation as soon as possible and do it first thing in your day. If you tend to be a fast talker and very forceful, cut back your caffeine intake that day. Most important of all is knowing what message you need to convey in that conversation and knowing this is not a win-lose conversation.

Have an Objective

Approaching these conversations without a clear, measurable, and

understandable objective dooms them to failure. If you are setting the stage to fire an employee, they need to leave that meeting knowing it is a very strong possibility they will be fired. If you want the other participant to understand how valuable to the organization they are, make direct concrete statements as such. This is not the time for platitudes, ambiguity, uncertainty, or soft pedaling your thoughts and needs. It is also preferable to lead with the most important point. Lengthy lead-ins and useless data can lead to misunderstanding, ambiguity, and disinterest. Be direct, succinct, and honest. Know before you go in how much feedback you want to receive from the other participant. Is this a conversation with give and take or is it strictly for you to convey your thoughts and needs?

Know Your Purpose

Do not look at these conversations as war, win or lose, do or die or any other adversarial contest. Your purpose is to transmit information. It may be unpleasant information, but it is a necessary task for your organization or the other participant to grow and achieve your goal. If this is a negotiation situation, look for a winwin position. Again, taking emotion out of the conversation will lead to a more satisfactory outcome.

The best leaders know how to provide and receive feedback to accomplish their stated goals. Learn how to have a difficult conversation. Learn to be an active listener. Learn who you are and how you best communicate. Armed with these skills, you will become a great leader within the house of medicine.

ABOUT THE AUTHOR

Dr. Flint is an assistant professor in the department of emergency medicine at the University of Maryland School of Medicine in Baltimore, MD. He has experience in emergency medical services and emergency department medical direction. @robflint97

“Developing a positive, productive mechanism for giving and receiving feedback will differentiate a great leader from a good manager.”

NIH OFFICE OF EMERGENCY

I Have a Research Proposal for NIH. Now

what?

By Jeremy Brown, MD

In the last column I discussed the pros and cons (and yes, there are cons) of getting funded from the National Institutes of Health (NIH). Usually, (but not always) the pros win, and you would like to proceed with an application to the NIH. So what should you do?

First, make sure you have a one-page (and not a word over) written summary that explains the problem you want to address, why it is important, and how you propose to carry out the research. If it is a clinical trial, explain the endpoints, the number of subjects in each arm, and how long it will take. Finally, include a very rough estimate of the cost. No one will hold you to any of this and your final proposal is sure to look different

(and cost more), but it helps the NIH project officer get an idea of what you and your project are all about. It is best not to contact an institute with an idea that you have not yet fleshed out to the degree of a one-page summary.

Now that your one-page summary is ready, what next? Well, it depends on who you are, where you are in your

academic track, what your project addresses, and where you work. In other words, it is hard to provide a simple answer to this straightforward question. But let’s give it a shot, and start with an easy case:

I am a previously funded NIH researcher, and now I have new proposal.

“It is best not to contact an institute with an idea that you have not yet fleshed out to the degree of a one-page summary. ”

CARE RESEARCH

If you already have a relationship with one of the institutes at the NIH (and remember, there are some 27 different institutes at the NIH) and you have been funded, you are likely to stay with the theme of your previously funded grant. That means you already have a contact at one of those institutes, and that is certainly the most logical and best place to start. Talk to your project officer and ask if the institute would be interested in your new proposal. Explain what is similar and what is different when compared to the prior award, and then sit back and listen to the advice the project officer gives you. Of course, some NIH funded researchers change the focus of their work or move to an area of research that is outside of the mission of the original institute. If that is the case, ask your project officer for suggestions as to whom to reach out. If there are no suggestions, well, you’ve already done this before (and were successful) so use the very same methods that you used when you tracked down the right institute and project officer the first time. But if you are still not sure, then read on.

I have never been funded by the NIH or even submitted a proposal.

Great. The NIH is particularly keen to fund new researchers. You should start with NIH Reporter, which describes, in detail, every funded NIH project. Begin with a search of the topic you are interested in and go deeper and deeper. The goal here is to find a project that is like yours, and that has been funded. Then you can find out which was the funding institute, and who was the program officer. You can also see in which study section the similar proposal was reviewed, which is very helpful as you consider the kind of expertise you will need your reviewers to have. And just like that, ta-da, you have a place to

start. Now email your summary to and set up a call with the program officer.

I had no luck with the NIH Reporter, and I really don’t know where to begin.

Don’t worry, this is common, and you will, eventually find the right NIH contact. First, ask your colleagues for suggestions. If that doesn’t yield results, then you should reach out to the Office of Emergency Care Research. These are precisely the sorts of questions we are here to answer; my email is Jeremy. brown@nih.gov. With the contacts we have across the NIH we can usually get you to the right person. And if we don’t know who that is, we know who to ask.

ABOUT THE AUTHOR

Dr. Brown is the director of the Office of Emergency Care Research (OECR) where he leads efforts to coordinate emergency care research funding opportunities across NIH. Additionally, Jeremy is the primary contact for the NINDS Exploratory and Efficacy FOAs and serves as NIH's representative in government-wide efforts to improve emergency care throughout the country. He is also the medical officer for the SIREN emergency care research network which is supported by both NINDS and NHLBI. Jeremy.brown@nih.gov

“Explain what is similar and what is different when compared to the prior award, and then sit back and listen to the advice the project officer gives you. ”

Nuances of ED-Based Palliative Medicine: Unexpected Challenges and Benefits

By Caroline Meehan, MD, and Leah McDonald, MD

Given the proven benefit of palliative care — including improved quality of life and decreased health care costs — there is an increased interest in moving this care upstream and into the emergency department (ED). Accordingly, there are a growing number of palliative medicine programs embedded within the ED, and this treatment model has become a new topic of research and program development. At The Miriam Hospital (A Lifespan community hospital and teaching affiliate of Brown University, located Providence, Rhode Island), we recently initiated such a program led by a dual-trained ED and palliative medicine physician. The following vignettes highlight some of the nuances and challenges of practicing palliative medicine within the ED setting.

Rapid Prognostication and Medical Recommendations

With Limited Information Scenario: A 72-year-old female with history of metastatic lung cancer not actively undergoing cancer-directed therapy presents to the ED with altered mental status. The family reports that the patient has had an abrupt decline over the last week. The patient is no longer taking anything by mouth, is minimally responsive, and dependent for all activities of daily living. Laboratory workup and imaging have not yet resulted. The family inquires, “how much time does she have?”

Moreso than some other disciplines, ED providers must inherently be comfortable with making decisions with an element of uncertainty. Each shift, we must decide, with limited

information, whether someone is safe to be discharged or requires admission to the hospital. Palliative care in this setting involves a similar element of uncertainty. A key component of training for palliative physicians is learning how to prognosticate. In the inpatient setting, prognostication is often based on days of hospital data on a patient’s health status and disease trajectory. When we have palliative discussions in the ED, however, prognostication occurs with extremely limited hospital-based data, as patients are often early in their workups. Instead of guidance based on a prolonged hospital course, prognosis is instead based on recent status prior to hospital presentation which may be difficult to assess, particularly in patients with cognitive impairments or instances when family is not available to provide collateral information.

Since the implementation of our palliative ED embedded program, we have had several patients decide to forgo medical admission and instead transition to hospice care. There is always an element of individual provider comfort with decisions regarding transitions to comfort-focused care. It is not uncommon for patients to be “ready” for end-of-life before medical professionals are. As we are seeing more patients and families elect to move to hospice straight from the ED, there is increasing emergency physician comfort with stopping life-prolonging measures in an area of medicine previously very focused on “saving lives.”

Navigating Fragmented Goals of Care Conversations

Scenario: You are at the bedside of a 73-year-old patient with advanced heart failure who presented with dyspnea and increasing oxygen requirement. Reviewing his chart, you see he has been admitted three times for heart failure exacerbations in the past three months. The patient tearfully explains that he is tired of being in the hospital and wishes to focus on controlling his symptoms and spending the remainder of his life at home. You are about to provide a recommendation that he transition to comfort-focused care, but the transporter arrives to take the patient to x-ray.

ED physicians are accustomed to medical treatment plans changing abruptly based on new information. Emergency providers must constantly task switch — jumping from patient to patient and discussion to discussion. By contrast, palliative physicians are used to more prolonged visits armed with extensive clinical information available from the last day. If patients are in a test, a palliative provider may wait until later in the day for the visit or return the next day.

ED-based palliative visits require comfort with stopping important conversations so that critical medical care (imaging, lab draws by nurses, line placement) can take place. The skill provided in ED training allows for more seamless fragmented conversations inherent to this care area.

Awareness of DispositionFocused Care

Scenario: An 81-year-old male presents to the ED after sustaining a fall from his porch. A CT head scan reveals a large subarachnoid hemorrhage with shift. The patient is intubated for airway protection. Neurosurgery deems he is not a surgical candidate and recommends comfortfocused care. The family is trying to determine what that course of care would look like. The ED asks for your assistance discussing the transition to comfort and appropriate location for continued care.

Effective emergency care relies on “departmental flow.” Determining a patient’s ultimate disposition is vital to ensure patients efficiently move through the department, allowing new ED patients to be seen. In the inpatient setting, palliativefocused disposition decisions, such as a discharge home on hospice, can often take days to coordinate, whereas in the ED such disposition plans must happen more expeditiously. Knowledge of these factors helps us better communicate with ED staff so that we can efficiently care for palliative patients in this context. We can often move patients who are choosing hospice directly to that level of care from the ED. However, in cases where transition to hospice cannot occur in a timely manner or more family wishes to be involved in final decisions, we may recommend admission to the hospital for further care to allow for movement in the ED patient flow.

Importance of Supportive Care Visits During Long ED Visits

Scenario: A 47-year-old male with locally advanced SCC of the head and neck undergoing chemotherapy and radiation with curative intent presents to the ED with inability to tolerate oral intake. Due to ED volume, he is in ambulance triage for six hours and is awaiting a CT for two hours at the time of your visit for supportive care and complex symptom management.

Hospitals nationwide are seeing increasingly long length of stays in the ED. These stays often translate to increased patient frustration with uncertainty about their treatment plan.

Later in their inpatient stays, patients are sometimes resistant the involvement of palliative care, equating their care as “giving up.” Fortunately, we have seen most patients in the ED quite welcoming of a visit from a palliative provider with more time to discuss important aspects of their life and health allowing time for questions and exploration of worries and fears their ED visit is invoking. Additionally, patients who are ultimately admitted to the hospital may be more welcoming and less wary of the continued involvement of palliative care, having met them at the very beginning of their stay.

Conclusion

Despite the challenges of navigating palliative medicine in a new practice environment, there is a tremendous benefit and need for palliative care in the ED. In the first few months of our program alone we have seen a dramatic reduction in median length of stay for patients who are seen by palliative care in the ED in comparison to those who are not seen by palliative care until they are admitted. Perhaps more impactful, however, are the unmeasurable effects palliative medicine can have on ED patient care. By gaining understanding of what is most important to our patients, we better reflect their goals in every aspect of their medical care.

ABOUT THE AUTHORS

Dr. McDonald is dual boarded in hospice and palliative medicine and emergency medicine. She practices palliative medicine and emergency medicine across multiple sites. She serves as site clinician for the ED-embedded palliative care program at Miriam Hospital.

Dr. Meehan is a current fellow in hospice and palliative medicine at Brown University. She recently completed her residency in emergency medicine. She plans to focus her career on the intersection of palliative medicine and emergency medicine

“Moreso than some other disciplines, ED providers must inherently be comfortable with making decisions with an element of uncertainty.”

RESEARCH

Describing the Current Landscape of Research Directors and Vice Chairs of Research: Results of the 2022 Research Director’s Interest Group Pilot Survey

By Kiran Faryar, MD, MPH, Sara Heinert, PhD, MPH, Madeline Odigie, Josh Davis, MD, Martin Wegman, MD, PhD, and Jeffrey Druck, MD

Growth and further development of the research mission of emergency medicine (EM) have been identified as key strategic foci for the specialty overall and for EM departments seeking to increase their academic standing and compete successfully for extramural funding. Research director (RD) and/or vice chair of research (VCR) positions are increasingly being leveraged to achieve these goals; however, the breadth of responsibilities and resources available vary significantly across programs. As more EM programs emerge, particularly smaller, community-based, or hybrid programs, it is essential that research continues with high fidelity among all academic faculty and residents with their programs’ RD/VCR leading these efforts. Similarly, as RD/VCR positions become more widespread, advocating

for guidelines and best practices regarding expectations, funding, salary, and protected time across departments is crucial for allowing faculty to advocate for appropriate resources and maximize their potential.

Periodically, surveys of RDs/VCRs have been conducted to understand the characteristics and responsibilities of this position, with the most recent survey conducted in 2005 and published in 2006. In this 2005 survey, EM research productivity was found to be associated with the presence of nonclinical faculty, dedicated research coordinators, and reduced clinical hours for research faculty. Major responsibilities of RDs included pursuing their own studies, obtaining funding, research mentoring, and research administration. Interestingly, the presence of an RD was not associated

with greater research productivity among EM programs compared to those without a RD. They also found that “internal research funding, grant development support, and support from other faculty” are inadequate unmet needs across EM programs. (Karras,

2006)

The SAEM Research Director Interest Group (RDIG) surveyed a convenience sample of SAEM members of the SAEM RDIG, SAEM Research Committee (RC), and SAEM Vice Chairs Interest Group (VCIG) to better understand the demographic characteristics, effort, responsibilities, and scope of current RDs and vice chairs of research among SAEM members. A pilot survey designed by RDIG members was sent to all members of the RDIG, RC, and VCIG in November 2022. Twentyfour (n=24) members responded over

6 weeks. The geographic spread of participants is displayed in Figure 1.

Demographic and Professional Characteristics

The majority of respondents were male (59%) with 89% white, 4% Black/ African American, 3% American Indian or Alaskan, and 4% more than one race. Regarding position title, 63% held the title of RD, 26% VCR, 4% chair of division of research, and 7% other. The majority of participants were physicians (MD/DO, 64%), while 25% were PhDs and 11% were both MDs/PhDs. Many participants reported additional degrees including MPH (n=4), MS (n=9), MSCR (n=1), MBA (n=1), and post-doctoral training (n=3), while 7 reported completing a research fellowship (n=7), as depicted in Figure 2. With regards to practice setting, 64% were from academic settings, 14% from community programs and 22% from hybrid settings. Lastly, most participants considered themselves employees (88%), while 8% were independent contractors, 4% were with a democratic group, and none identified as working for a contract management group (CMG).

RD Position, Funding, and Responsibilities

Half (50%) of respondents reported that their position has been at their institution for over 10 years. Over a quarter (29%) said their position had existed for less than 5 years and 21% for 5-10 years. The position for most respondents was funded by their department (64%), followed by 18% by more than one source, 11% funded partially through grants, 4% through institutional support, and 3% solely through grants/contracts. The mean effort for this position was 0.36 full-time equivalent (FTE) (standard deviation [SD] ± 0.31 FTE) and the median was 0.25 FTE (interquartile range [IQR] 0.1-0.5 FTE). For support staff (participants could select all that apply), 39% have research administrative assistant support, 75% have research coordinator support, 43% have other support, and 4% have no support staff. The most common responsibilities of the position (Figure 3) were: faculty research (93%) and collaboration with researchers/ investigators (93%), followed by faculty development (82%), clinical trials (79%), mentorship of residents/students (79%), work on personal grants (71%), resident

FacultyDevelopmentMedicalStudentResearchResidentResearchFellowResearchFacultyResearch

AcademicResearchAssociateProgramFundingforDepartmentProjectsGrantProgramsClinicalTrialsState-widePrograms

MentorshipofResidents/StudentsMyOwnGrants Collaborationwith Researchers/Investigators

Figure 1. Geographic spread of survey participants

Figure 2. Additional Degrees of Survey Participants

Figure 3. Responsibilities of the Research Director / Vice Chair of Research role

continued from Page 53

research (71%), fellow research (64%), medical student research (61%), funding for department projects (61%), grant programs (39%), academic research associate program (29%), and statewide programs (18%).

The two most common reasons that respondents cited for the creation of their RD/VCR position were that it was residency-related (n=7) and to expand research productivity/mission (n=4). Notable comments from the survey regarding the creation of the position include “.there were residents interested in research and someone needed to be in charge of wrangling them.”

Another respondent reported that their position was created due to a “need for additional research leadership beyond vice chair of research due to growing demand for faculty development and the desire to increase research funds in the department.”

Both comments speak to the growing research mission of academic EM programs inherent to this role.

Best Practices

To help provide guidance to current and aspiring RDs/VCRs, we asked respondents to share best practices in their role. Respondents reported that the four most common best practices to share with current or prospective faculty are:

1. Develop standardized research processes/standard operating procedures (SOPs) for your department (n=4). One respondent recommended “clearly defined and written process for how folks access research resources (grant submission, research staff, bio stats etc.).”

2. Strong team/infrastructure (n=3). As an example, one respondent wrote

“Research Assistant programs based on trial revenue work well. An associate/ assistant research director for resident grand rounds / [evidence-based medicine] EBM / scholarly activity is useful.”

3. Incorporating a journal club (n=3) including creating “resident research blocks around article review and discussion with researchers.”

4. The importance of mentorship (n=3). Specifically, “early initiation of scholarly effort, mentorship of nonresearch faculty, [and] research methods teaching combined with journal club during lecture time” can contribute to mentorship throughout an EM department leading to research growth as a whole.

Overall, this survey aimed to describe the range of RD/VCR responsibilities and best practices which can be applied and disseminated on a national stage. While the number of responses was too small to draw any generalizable conclusions, this pilot RDIG survey provided a preliminary glimpse of the landscape of the RD/ VCR role among SAEM members. The responses from this survey will also lead to further research around national expectations for research directors/ vice chairs of research. The RDIG is planning a second round of survey questions, further developing these questions and responses, which will be disseminated during SAEM23 in May. With a clearer and more comprehensive understanding of national trends around this academic position, we expect to be able to assist RDIG members in their roles and help modify expectations around compensation, resources, salary support, and productivity.

Reference: Karras DJ, Kruus LK, Baumann BM, Cienki JJ, Blanda M, Stern SA, Panacek EA. Emergency medicine research directors and research programs: characteristics and factors associated with productivity. Acad Emerg Med. 2006 Jun;13(6):637-44. PMID: 16636359.

ABOUT THE AUTHORS

Dr. Faryar is chair of the Research Director’s Interest Group, University Hospitals Cleveland Medical Center; director of research, in the department of emergency medicine at University Hospitals Cleveland Medical Center; and assistant professor, Case Western Reserve University.

Dr. Heinert is assistant professor and co-director of research at Rutgers Robert Wood Johnson Medical School in New Brunswick, NJ.

Madeline is a fourth-year medical student at Saint James School of Medicine. She recently completed her core clinic.

Dr. Davis is assistant medical director of quality, research, and ultrasound at Vituity and clinical instructor at University of Kansas School of Medicine in Wichita, KS.

Dr. Wegman is research director, department of emergency medicine, Orange Park Medical Center, Orange Park, Fla.; and senior research fellow, American College of Emergency Physicians. He has expertise in quasi-experimental research design and leads several national research training courses.

Dr. Druck serves as The University of Utah School of Medicine Vice Chair for Faculty Advancement, DEI, and Wellbeing.

“The majority of respondents were male (59%) with 89% white, 4% Black/African American, 3% American Indian or Alaskan, and 4% more than one race.”

Funding for Research Supplements to Promote Diversity: An Interview With Dr. Edouard Coupet Jr.

By Joshua Lupton, MD, on behalf of the SAEM Research Committee

Edouard Coupet Jr, MD, MS, is a NIDA-sponsored Yale Drug Use, Addiction, and HIV Scholar (DARHS) and assistant professor in Emergency Medicine. Dr. Coupet graduated from the University of Illinois at UrbanaChampaign. He completed medical school at the University of Chicago Pritzker School of Medicine and his residency training at the Jacobi/Montefiore emergency medicine program. Following his residency, he completed a Center for Emergency Care Policy & Research fellowship at the University of Pennsylvania. Dr. Coupet’s primary research interests are in the intersection between substance use & community violence, emergency department-based interventions for substance use and substance use disorders, and socioeconomic and racial/ ethnic disparities in access to addiction treatment.

Congratulations on your grant! Tell us a bit about your project and what grant you received?

Thank you! I’m very excited about this project and to share this heavily underutilized funding option. My primary research interests are in increasing equity in addiction treatment access among racial/ethnic minoritized and assault-injured populations. With that, I received the NIH National Institute on Drug Abuse Helping to End Addiction Long-term (NIDA HEAL) Initiative

Research Supplement to Promote Diversity in Health-Related Research. It is a two-year supplement intended to expedite scientific solutions to the national opioid public health crisis. The parent award, funded under the HEAL Initiative, is Clinical Trials Network (CTN) 0099 Project ED INNOVATION. It is a multisite clinical trial that is comparing the effectiveness of sublingual to extendedrelease buprenorphine on emergency department (ED) patient engagement in addiction treatment seven days after their

initial ED visit. The goal of my project is to elicit potential targets for ED-based interventions that improve engagement in addiction treatment among Black and Latino individuals with untreated opioid use disorder. To accomplish this, I will be performing a qualitative study to elicit the patterns of barriers and facilitators to engaging in addiction treatment among Black, Latino, and non-Latino white individuals with untreated opioid

continued on Page 56

RESEARCH Q&A

continued from Page 55

use disorder in the ED. I will also be performing a secondary analysis of factors previously identified as predictors of worse treatment outcomes using data collected from the parent study, CTN 0099.

How did you hear about the NIH diversity supplement grants in general and specifically to your project?

I heard about NIH diversity supplement grants from a good friend of mine and former colleague, Dr. Dowin Boatright. Dr. Boatright has been an outstanding champion for them and has even published a paper in the Journal of the American Medical Association (JAMA) about how infrequently they are used. My mentor and principal investigator of the parent study, Dr. Gail D’Onofrio, told me about my current grant funded by the HEAL Initiative. I have been fortunate enough to be surrounded by some truly amazing peers and mentors.

How did you go about finding a mentor/funded investigator to partner with or did they reach out to you?

I was already doing research in ED access to addiction treatment with each of my mentors, so the HEAL Initiative Diversity Supplement was the ideal fit for me. In general, I’m a huge proponent of having a large interdisciplinary mentorship team and my team is amazing. As an example, you may have a mentor(s) for a specific methodology, one or more for content, and one for navigating your academic career. Above all, fit (e.g., personality, interests) and time/availability, in my opinion, are the

most important parts of the mentormentee relationship when applying for a diversity supplement — much like any other grant.

Tell us a bit about the process of applying for the NIH diversity supplement grants?

I like to think of NIH diversity supplement grants as smaller NIH K awards. While each supplement requirements may be slightly different, the application typically includes a specific aims page, abstract, research strategy, mentorship plan, bibliography, budget, etc. Deadlines usually differ

“While each supplement requirements may be slightly different, the application typically includes a specific aims page, abstract, research strategy, mentorship plan, bibliography, budget, etc.”

from the more traditional NIH cycle, so it’s important to look closely at the funding announcement when planning an application. There is usually a program officer listed in the announcement that can provide more information about the requirements that may be unique to the grant. Another important note is that NIH diversity supplement grants are usually reviewed administratively as opposed to the more traditional peer-review process, so the turnaround time for the review process is often a bit faster.

What do you wish you would have known ahead of time?

When you’re planning your proposal, two years may seem like a lot of time, but it truly passes by fast. For all those considering applying, I encourage you to “hit the ground running” as best as you can. That means getting and submitting your Institutional Review Board (IRB) application together as early as possible, finalizing your recruitment/enrollment strategy, considering hiring an RA, and whatever else you may need to start the project. Also, much like a K award, NIH diversity supplement grants are primarily

designed for career development and salary support. They do provide some research funding, but you will likely have to investigate additional funding opportunities to support the research itself. This may take time, so I strongly recommend having a plan before you apply.

What advice would you give to SAEM members who have eligible funding (eg: R01) from the NIH who might be interested in being a mentor for an NIH diversity supplement application?

If you have independent funding such as an R01 and know of an eligible candidate from a population that has historically been underrepresented in academic medicine who may be interested, I strongly encourage you to investigate an NIH diversity supplement funding announcement within your institute! I cannot stress enough how much of a gravely underutilized opportunity these are to expand your scope of research. Further, you will have the opportunity to improve our overall quality of research for years to come by diversifying the next

generation of independent investigators. Eligible mentees range from college students to junior faculty. What advice would you give to SAEM members who might want to pursue an NIH diversity supplement themselves, working with eligible mentors?

Think about your next steps, postsupplement, early. What do I want my academic career to look like in two, five, and 10 years? What am I passionate about? Long-term, what questions do I want to answer? Once you have answered these, what questions do I need to answer in the short-term to answer my long-term questions? What funding options (e.g., type of institute, K vs. R award) do I want to target? What will I need to accomplish this (e.g., mentors, institutional support, resources, overall academic environment)? It’s okay if you don’t have ALL these answers now; however, it’s worth giving them some thought sooner rather than later. NIH diversity supplement grants are a fantastic funding opportunity that can be a bridge to independent funding if you plan accordingly.

ABOUT THE AUTHOR

Dr. Lupton is an assistant professor in the department of emergency medicine at Oregon Health & Science University and a member of the SAEM Research Committee.

“NIH diversity supplement grants are a fantastic funding opportunity that can be a bridge to independent funding if you plan accordingly.”

Trauma Alert: Sex- and GenderBased Differences in Trauma

By Lauren A. Walter, MD, on behalf of the SAEM Sex and Gender in Emergency Medicine Interest Group

Anyone who has spent time in an emergency department can attest to gender-based differences in trauma patient volume. Lifestyle and behavior choices, impacted by socialized gender norms, heavily skew trauma presentation statistics which consistently demonstrate that boys and men are more likely than girls and women to present with and die of traumatic injury. However, in addition to epidemiologic makeup discrepancies, recent analysis performed and published by Nutbeam et al., also raises questions about sex-based differences in trauma treatment, specifically as it relates to tranexamic acid (TXA) — the

only drug proven to reduce deaths after traumatic injury. While no sex-based differences were found with regards to TXA efficacy, in terms of mortality, examination of data from the Trauma and Audit Research Network (TARN) demonstrated that females were less

likely than males to receive TXA in both prehospital and hospital settings and regardless of risk category (BATT score). The authors of the review speculate that this discrepancy may be due to unconscious gender bias, the use of stereotypes in medical education, and

“Anyone who has spent time in an emergency department can attest to genderbased differences in trauma patient volume.”

sex-based differences in the presentation of trauma symptoms.

Sex- and gender-based discrepancies in trauma triage and management have been demonstrated previously. In 2016, Wahlin et al., described gender-related differences in the prehospital care of severely injured trauma patients, noting that male patients were more likely to receive the highest prehospital priority compared to female patients, even after controlling for injury mechanism and vital signs on scene. An earlier study by Gomez et al., demonstrated a similar gender-based pattern; a smaller proportion of females received trauma center care compared with males

even after adjustment for confounders. Further, emergency medical service personnel were less likely to transport females from the field to a trauma center compared with males while physicians were less likely to transfer females to trauma centers compared with males. Similar reasons for differential access were suggested and again and were thought to potentially be related to perceived difference in injury severity or subconscious gender bias.

Trauma remains the fourth leading cause of death in the United States Timely triage and evidence-based treatment can save lives. Consistent inclusion of sex- and gender-based

medicine in medical education is needed to counter a traditionally stereotyped approach to trauma assessment and management. In addition, future research should focus on assessments and interventions to improve equity in trauma care.

ABOUT THE AUTHOR

Dr. Walter is an associate professor of emergency medicine at the University of Alabama at Birmingham Heersink School of Medicine

“Consistent inclusion of sex- and gender-based medicine in medical education is needed to counter a traditionally stereotyped approach to trauma assessment and management..”

Five Tips for Effective Debriefing

By Tina Chen, MD, Tiffany Moadel, MD, and Diana Yan, MD on behalf of the SAEM Simulation Academy

High-fidelity simulation is widely embraced as an effective educational modality for adult learners. In a 2008 survey of emergency medicine residency programs, 91% of programs used simulation for training Debriefing is an integral component of simulation education, allowing learners to reflect upon the simulation experience and assimilate new knowledge, skills, and attitudes. Successful debriefing, led by effective facilitators, maximizes the learning opportunities from simulation education.

Here are five tips to improve your debriefing skills, boost the benefits of your simulation education, and engage your trainees in the development of clinical judgment and critical thinking:

Tip #1: Good debriefing begins with good prebriefing

A strong introduction sets the stage for effective learning. During prebriefing, the

facilitator describes the agenda of the simulation session, prepares learners to engage in the simulation environment, and obtains buy-in from learners. Essential prebriefing elements include:

• Orientation. Facilitators should describe logistical matters, such as the duration of the simulation session and debrief, guidelines for interacting with standardized patients or manikins, and safe equipment use.

• Psychological safety. Facilitators should convey that the simulation environment is a confidential place for learners to grow and develop their clinical skills without fear of judgment. Learners should respect the growth process for both themselves and their peers.

• Fiction contract. For learners to maximize the educational benefits of simulation, facilitators should ask learners to treat the simulated

scenario as real, even if it does not perfectly replicate the clinical environment.

• Expectations. Facilitators should outline facilitator and learner roles, such as how communication will occur during the simulation scenario, how learners will be assessed, and how confidentiality will be protected. Effective prebriefing enables learners to engage in the simulation session with a sense of control and clarity, deepening their capacity for self-reflection during debriefing.

Tip #2: A debriefing structure keeps discussion organized

Debriefing involves interactive, bidirectional, open-ended conversation between facilitators and learners. A debriefing structure can help ensure that this discussion occurs in an orderly manner, with clearly defined opportunities for learner self-reflection.

PHASES BRIEF DESCRIPTION

Plus/Delta Plus Delta Learners discuss and write positives in one column and write things to change in a second column.

GAS Gather Analyze Summarize

Facilitators lead learners through development of a shared mental model, self-reflection and analysis of learner actions, and summarization of key learning points.

ADVANTAGES

Simple and easy to remember. Many learners are familiar with this model and know what to expect.

Gives learners more structured reflection time and prioritizes development of a shared mental model.

PEARLS

Setting the Scene Reactions Description Analysis Summary

Facilitators begin by briefly articulating goals for debriefing. Then, facilitators solicit initial learner reactions, develop a shared mental model of simulation events, analyze learner actions, and summarize key learning points.

Comprehensive, multiphase structure that incorporates a recap of debriefing goals and guidelines, which allows a second opportunity to establish psychological safety.

Some commonly used structures are described in Table 1.

Many debriefing structures exist, often sharing essential elements, such as re-establishing psychological safety, developing a shared mental model of simulation events, generating open-ended discussion for learner self-reflection, and summarizing key learning points that align with educational objectives.

Tip #3: Debriefing facilitators are cognitive detectives

Simulation is distinct from other types of education in that the facilitator’s role is to guide, not to lecture or give feedback. To benefit from the debriefing process, learners must critically examine their own performance, discuss and analyze their actions, and be motivated towards behavioral change through self-reflection. Facilitators can promote this spirit of selfinquiry by asking open-ended questions aimed at investigating learners’ thought processes. Examples of open-ended questions may include: “What made you notice that the blood pressure was low?” or “What airway equipment did you choose?”

In addition to asking open-ended questions, facilitators must actively listen to learner responses and seek to understand the rationale behind learners’ thoughts and actions. Learners generally choose clinical actions based on a foundation of prior knowledge and experiences; if facilitators fail to recognize

this previous foundation, it limits their ability to encourage growth and change.

Tip #4: Silence is golden

Debriefing requires bidirectional conversation between facilitators and learners; however, learners commonly report being intimidated by the debriefing environment due to fear of judgment, embarrassment in front of their peers, or unfamiliarity with the expectations of the simulation environment. They may require time to formulate their thoughts in response to an open-ended question. By intentionally pausing after an open-ended question, facilitators give learners the opportunity to consolidate their thoughts and create behavioral change. However, although simulation facilitators are generally trained to spend debriefing time listening to learners, facilitators often spend more time talking than learners during the debrief, which negatively impacts learners’ experience of the simulation experience. This further highlights the patience and discipline facilitators must have to effectively debrief.

Tip #5: Summarization is an effective memory strategy

At the conclusion of the debrief, facilitators can ask each learners to share one unique takeaway. This could be a new fact they learned, a new change in their future practice, or a new perspective they plan to incorporate. Summarization enables learners to solidify an actionable piece of knowledge, incorporate key learning points into long-term memory,

and add clarity to their simulation experience.

Conclusion

Debriefing is an essential component of simulation-based education. Simulation educators should be aware of the many challenges of effectively facilitating debriefing, and intentionally incorporate best practices into their debriefing sessions.

ABOUT THE AUTHORS AND EDITORS

Dr. Chen is an assistant professor of emergency medicine and the associate dean of simulation and clinical skills at Saint Louis University School of Medicine.

Dr. Moadel is an assistant professor of emergency medicine at the Zucker School of Medicine at Hofstra/Northwell Health and the director of the healthcare simulation fellowship within the Emergency Medicine Service Line at Northwell.

Dr. Yan is an assistant professor of emergency medicine and pediatrics at Icahn School of Medicine at Mount Sinai and the lead for graduate medical education at Mount Sinai Beth Israel.

“Debriefing is an integral component of simulation education, allowing learners to reflect upon the simulation experience and assimilate new knowledge, skills, and attitudes.”

Table 1. Summary of three common debriefing structures.

Point of Care Ultrasound for Small Bowel Obstruction: Tips and Tricks

By Arion Lochner, MD, on behalf of the SAEM Education Committee

Bowel obstruction is a common diagnosis representing around 2% of patients with abdominal pain presenting to the emergency department. The gold standard for diagnosis is CT scan however bedside ultrasound represents a new method of diagnosis which is faster, cheaper and has no radiation. With its faster time to diagnosis, theoretically, bedside ultrasound can result in quicker disposition and better patient care.

How to Perform Exam

• Use low frequency probe (curvilinear is best)

• Use the “lawn mower technique,” to scan all 4 quadrants and epigastric area. While doing this assess bowel size, wall thickness and direction of peristalsis.

Key point: The air will be anterior so starting more lateral can help visualize fluid filled bowel loops.

What to Look For

• Dilated loops of bowel

o Small bowel with diameter > 30 mm although 25mm is a more conservative cut off

 It should be present in more than one (preferably three) loops of bowel (figure 1)

• Ineffective peristalsis

o Results in “to-and-fro” or “whirling” appearance of intra-luminal contents

• Findings that should make you more worried that bowel has begun to become ischemic

o Extraluminal free fluid - known as the Tanga sign (blue arrow)

o Bowel wall thickening >3 mm

Key point: you can also see plicae circulares which indicate that you are looking at small bowel not large bowel

Evidence

• Abdominal X-ray has a sensitivity of 6677% and specificity of 50-57%.

• CT scan: sensitivity ranged from 93 to 96% and specificity ranged from 93 to 100%, +LRs of 3.6

• Ultrasound

o Important Literature

 Gottlieb et al. (2018): SBO US has sensitivity 92.4% and specificity 96.6%, with associated +LR of 27.5 and -LR of 0.08

 Taylor and Lalani (2010): SBO US has a +LR of 9.55 and a –LR of 0.04 for beside scans

o Most sensitive US findings

 small-bowel dilation ≥ 25 mm (sensitivity: 0.87, Specificity: 0.87)

 abnormal peristalsis (sensitivity: 0.82, specificity: 0.85)

o Most specific US findings

 Transition point (sensitivity: 0.82, specificity: 0.98)

 Intraperitoneal free fluid (sensitivity: 0.82, specificity: 0.93)

 Bowel wall edema (sensitivity: 0.76, specificity: 0.93)

Common Pitfalls

• Stomach vs Small Bowel

o When imaging the LUQ, it can be easy to confuse the stomach for distended small bowel. Look for plicae circularis to identify small bowel.

• Gastroenteritis vs Small Bowel Obstruction

o In gastroenteritis, bowel loops can be fluid filled, but are not typically dilated.

o Peristalsis may be increased but remains unidirectional.

• Ileus vs Small Bowel Obstruction

o Distinguishing between the two can be difficult

o Ileus can also have fluid filled, distended loops of bowel

o A helpful finding is that peristalsis may be reduced in ileus but is still unidirectional or not seen at all.

ABOUT THE AUTHOR

Dr. Lochner is an ultrasound fellow in the department of emergency medicine at the University of Utah. He completed residency at Henry Ford Hospital in Detroit, Mich. and medical school at California Northstate University.

“The gold standard for diagnosis is CT scan however bedside ultrasound represents a new method of diagnosis which is faster, cheaper and has no radiation.”

Figure 1

A Case of Syncope: How POCUS Can Rapidly Help Diagnose Undifferentiated Shock

By John Zucal, MD, Brittany Rooney, MD, Courtney M. Smalley, MD, on behalf of the SAEM Academy of Emergency Ultrasound

A 48-year-old male with a history of hypertension, hyperlipidemia, and unknown arrhythmia on anticoagulation presents to the emergency department (ED) with three episodes of syncope at work. The patient had an episode of unresponsiveness while enroute with emergency medical services (EMS) but was not on the cardiac monitor during this time. On arrival, the patient is diaphoretic, with initial vital signs notable for hypotension and normal pulse rate.

“With the ability to provide real-time information, POCUS has been shown to improve the diagnostic accuracy of patients with undifferentiated shock, thereby improving patient outcomes.”

While IV access was being established in the ED, the patient had a subsequent episode of unresponsiveness with bradycardia. Upon awakening, a point of care ultrasound (POCUS) of the heart was performed, demonstrating a moderatesized pericardial effusion with increased echogenicity concerning for clot formation and signs of early tamponade, raising suspicion for dissection. The patient was given a small fluid bolus with improvement in blood pressure and emergently taken for a computed tomography angiography (CTA) dissection

study. Expedited read by emergency radiology reported dissection with rupture of the left side of the proximal ascending thoracic aorta. Cardiothoracic surgery was consulted, and the patient was taken immediately to the operating room. Ultimately, the patient had a successful repair of his Type A dissection and was discharged from the hospital after nine days.

Over the last decade, the utilization of point-of-care ultrasound (POCUS) at the bedside has significantly expanded

in emergency medicine (EM). EM physicians frequently make time-sensitive decisions with limited information, with repercussions often being the difference between a successful resuscitation and not. With the ability to provide real-time information, POCUS has been shown to improve the diagnostic accuracy of patients with undifferentiated shock, thereby improving patient outcomes. The case above illustrates how beneficial

continued on Page 66

“POCUS is a rapid tool that will allow improve a patient’s outcome by providing immediate information at the bedside to help make the right resuscitative choices.”

Subxiphoid view of large pericardial effusion with right ventricular collapse

POCUS can be to determine etiology of an undifferentiated hypotensive patient. Below, we will review transthoracic windows of the cardiac ultrasound and describe the findings to diagnose cardiac tamponade with POCUS. In addition, we will provide tips for image acquisition and pearls and pitfalls of image interpretation.

Image Acquisition

• For transthoracic echocardiography (TTE), use the phased array transducer and set the POCUS machine to the cardiac preset.

• For proper patient positioning the exam can be conducted with the patient in the supine position. However, if it is a struggle to obtain

a clear window, the patient can be moved to the left lateral decubitus position to bring the heart away from the sternum and closer to the chest wall.

• Given the anatomical position of the lungs in relation to the heart in the thorax, lung artifact and respiratory phasicity can often obstruct the exam. To improve the view, have the patient exhale and hold their breath at the end of the exhalation. The reduced lung volume and lack of phasicity during the hold should allow enough time to obtain an improved image.

• In patients with obstructive lung disease who have hyperinflated lungs, it may be difficult to obtain a parasternal long-axis (PSLA) view. If difficulties are encountered, try moving to a subxiphoid window and have the patient take a breath in and hold.

The diaphragm will move down with inspiration and this will allow a better view of the heart.

• If rib shadowing obscures the view, try moving a rib space above or below the targeted view and angling the probe back toward the heart.

Pearls and Pitfalls

Pearls

• The right heart is most important when evaluating for tamponade, and findings include signs of right ventricle (RV) end-diastolic collapse, right atrial (RA) systolic collapse, and plethoric inferior vena cava (IVC).

• The earliest sign of tamponade is RA systolic collapse due to the lower pressure in the RA compared to the RV.

• The literature shows that RA collapse is very specific but less sensitive

Apical 4 chamber view of large pericardial effusion

compared to RV diastolic collapse, which is both highly sensitive and specific.

• The best views for evaluating RV and RA collapse will be in the apical fourchamber and subxiphoid views. Also, in the setting of significantly tachycardia, it can be difficult to assess for RV collapse. M-mode in the PSLA view can be used in this scenario to help the operator evaluate RV diastolic collapse.

• Based on literature review, a dilated, plethoric IVC with minimal respiratory variation (defined as diameter > 2.1 cm and <50% inspiratory reduction) has a high sensitivity for tamponade (95-97%) but low specificity (~40%)

Pitfalls

• Any anechoic or echogenic space adjacent to the heart is a risk of being confused with a pericardial effusion.

About AEUS

Remember, false positives can be pleural effusions, ascites, pericardial cysts, and epicardial fat pads.

• In the apical four-chamber view, anechoic fluid seen next to the RV can be confused for pericardial or pleural fluid, thus requiring the operator to obtain a second view to differentiate the two. Using the PSLA view, assessing for anechoic fluid anterior to the descending aorta can help differential pericardial versus pleural fluid. Fluid tracking anterior to the descending aorta is confirmed pericardial effusion and not a pleural effusion.

• Epicardial fat pads can be confused with pericardial effusions. However, fat pads generally contain internal echoes and move with the heart. Conversely, pericardial effusions will exert some displacement of the adjacent structure and are usually completed anechoic.

• Small effusions, as little as 100-150 mL of fluid, can cause tamponade physiology if there is a rapid fluid collection. Therefore, it is essential to scan multiple windows to decrease the chance of missing these small collections.

• It's important to note that most cases of tamponade will present with tachycardia. However, this may not always be the case in beta and calcium channel-blocked patients.

This article provides a brief overview of how one can start implementing POCUS into a practice for the hypotensive patient with cardiac tamponade. It cannot be understated that the patient in undifferentiated shock requires quick and immediate action to prevent them from cardiac arrest. POCUS is a rapid tool that will allow improve a patient’s outcome by providing immediate information at the bedside to help make the right resuscitative choices

ABOUT THE AUTHORS AND EDITORS

Dr. Zucal is a first-year resident in the Case Western Reserve University/MetroHealth Medical Center/Cleveland Clinic emergency medicine residency.

Dr. Rooney is assistant director of emergency ultrasound at Cleveland Clinic and assistant professor, Cleveland Clinic Lerner College of Medicine

Dr. Smalley is director of emergency ultrasound, Emergency Services Institute; associate professor, Cleveland Clinic Lerner College of Medicine; and assistant residency program director, Case Western Reserve University/MetroHealth Medical Center/Cleveland Clinic Emergency Medicine Residency Program. @smallssono

The Academy of Emergency Ultrasound is an international forum bringing together clinician sonologists with the common goal of advancing patient care and safety through the use of bedside ultrasound. Joining AEUS is free! Just log in to 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.”

Being More Than An Ally

By Amanda M. Ritchie, MD, Michelle Lall, MD, MHS, and Stephanie Balint on behalf of the SAEM Wellness Committee

Those who came before us paved the way for much of the work that today supports the LGBTQIA+ community; unfortunately, microaggressions, media influences, and new challenges still face the community. Thus, while allyship may not be a new concept, its role is as important as ever.

Allyship is defined as the active process of supporting the breakdown of bias and inclusion of a marginalized group where the person is not a member of the group itself. Considering physicians spend roughly 40-60 hours per week at work, our work environment can greatly impact not only our professional life but our coworkers’ professional lives as well. It’s not surprising that marginalized groups such as people of color, LGBTQIA+, and women are more likely to face conflict or discrimination. As the world continues to move and develop at an evolving fast

pace, with more time involving virtual communication, allies can strengthen their role by identifying unconscious bias.

National Resident Matching Program® (NRMP®) applicant surveys consistently demonstrate that emergency medicine (EM) applicants cite “perceived goodness of fit” as one of the most influential factors in their rank lists. This sense of belonging is highly valued even before someone

joins the team. As EM physicians face many challenging cases, make difficult decisions, and lead the coordination of interdisciplinary care, it is important that the entire team feels supported by their colleagues. Workplace performance is directly impacted by well-being and psychological safety, and it’s understandable that our colleagues may feel disconnected when none of those factors are present. The messages

“Allyship is defined as the active process of supporting the breakdown of bias and inclusion of a marginalized group where the person is not a member of the group itself.”

we put out via social media, the way we support our friends and patients, are all ways in which someone can feel welcomed into a community.

How to Be an Ally

• A one-size-fits-all approach isn’t going to work for LGBTQIA+, people of color, and women

• Be proactive and understand your implicit bias — tests available on websites such as Project Implicit can help you delve into your unconscious bias

• Allyship is a lifelong growth mindset

• Lift others up by advocating

• Recognize systemic inequities

• Listen, support, and self-reflect

How to Be More Than an Ally

• Call out inappropriate behavior

• Task your peers and colleagues with getting involved in DEI initiatives

• Use inclusive language

• Recognize your privilege and use it to support and amplify underrepresented voices

Remember, allyship can be small actions and small actions can lead to great things. There has been tremendous progress

recently, but there is still work to be done to ensure we and our colleagues live and work in an environment that holistically supports us through our daily lives.

If you find yourself somewhat lost and don’t know where to start to learn more about initiatives taking place across the country, the upcoming SAEM23 meeting will include several excellent education sessions and events, including:

• ADIEM LGBTQIA+ Trivia Event on Wednesday, May 17, 4:30-5:20 p.m. Small teams will engage in some friendly trivia competition about LGBTQIA+ pop culture as well as must-know health topics

• Beyond Microaggressions: Upstander Training for Allyship, May 16, 8:00 a.m.12:00 p.m.

• Allyship and Advocacy in #SoMe: Amplifying Voices, Thursday, May 18, 12:00-12:20 p.m.

• Representation Matters: Why Including Diversity in Your Medical Education Presentations Matters, May 19, 12:0012:20 p.m.

• Inclusion and Not Assimilation: Why Fitting In Is Not Enough to Advance Diversity and Equity, May 19, 12:0012:20 p.m.

• Check out the SAEM23 Program Planner for many more!

ABOUT THE AUTHORS AND EDITORS

Dr. Ritchie is a second-year emergency medicine/internal medicine resident at Louisiana State University, Baton Rouge, La.

Dr. Lall is an associate professor, associate residency director, and director of well-being, equity, diversity and inclusion medical at Emory University, Atlanta, Ga. She is a member at large on the SAEM Board of Directors and a former president of SAEM’s Academy for Women in Academic Emergency Medicine (AWAEM).

Stephanie Balint is a secondyear medical student at the Frank H. Netter MD School of Medicine, Quinnipiac University, Hamden, Conn.

Lactation Proclamation: The Need for Culture Change in the ED

By Ashley C. Rider, MD, MEHP, Shubhi Goli, MD, and Mia L. Karamatsu MD on behalf of the SAEM Wellness Committee and the SAEM Academy for Women in Academic Emergency Medicine

Imagine a typical shift in the emergency department. You’re busy. You are caring for patients at their bedside, speaking with consultants, placing orders, and documenting the patient encounters. In the midst of it all, you realize you did not eat, drink or take a bio break. Now imagine you are a lactating physician. You need extra time to express milk, perhaps multiple times throughout your shift. As emergency physicians, we take pride in our ability to manage a department full of patients; however, our habit of putting others’ needs before our own is not only detrimental to our overall health, but also leads to more

negative repercussions, especially for the lactating physician. This culture is the antithesis to what is needed for lactation success.

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for six months, and recently released a new policy that supports breastfeeding for two years or more, as desired by parent and child. On average, a lactating individual will need to pump or direct feed every 2-3 hours for a young infant, with decreasing frequency as the infant grows. For lactating emergency

physicians, this entails months to years of integrating pumping time on shift in a specialty that does not naturally accommodate a model of “stepping away.” A survey of United States physicians demonstrated that only 28% reached breastfeeding goals, and those without a dedicated space or scheduled time were less likely to meet breastfeeding milestones. Barriers to pumping on shift may also contribute to complications such as painful engorgement, clogged ducts, mastitis, and reduced milk production, which in turn hinders lactation success. It limits breastmilk benefits for the infant which

has been shown to impact infant mortality and infant weight.

A scoping review of physicians and trainees highlighted similar barriers to lactation across several studies, including time, space, inflexible scheduling, and lack of supportive culture. Trainees also face an additional layer of barriers, with a high rate of complications due to pumping challenges. In a survey of breastfeeding residents, the most common reason for discontinuation (80%) was work schedule. Students, residents,

and fellows often work more shifts than faculty counterparts and longer hours when on off-service rotations. In emergency medicine, even when there is a supervising attending on-shift, trainees are expected to be the primary providers in their patients’ care. Furthermore, while a hospital building may have designated lactation rooms for staff and/or patients, the ED may rarely have such a space. Federal law section 7(c) of the Fair Labor Standards Act requires employers to provide a reasonable break time for an employee to express milk, and a place,

other than a bathroom, for employees to express milk. Hospitals must abide by this for all employees, but the proximity and location of the space are not specified. Even when breaks are theoretically guaranteed, cultural hierarchical barriers and a personal dedication to patient care on the part of the trainee, may interfere with leaving the ED for lactation needs. The Accreditation Council for Graduate Medical Education (ACGME) also has a

continued on Page 72

“As emergency physicians, we take pride in our ability to manage a department full of patients; however, our habit of putting others’ needs before our own is not only detrimental to our overall health, but also leads to more negative repercussions, especially for the lactating physician.”

WELLNESS

continued from Page 71

requirement for a lactation room, but adherence and accessibility to such a space is unclear.

Another barrier for trainees is inadequate maternity leave time. Previous research has shown that shorter maternity leaves correlate with less than six months of breastfeeding. While the ACGME Common Program Requirements stipulate an “appropriate length of absence” for parental leave, it does not provide specific guidelines on length. Additionally, the American Board of Emergency Medicine (ABEM)’s Policy on EM Residency Training Requirements specifies 46 weeks of training per year of residency. Thus, residency maternity leaves in the United States are often limited to 4-8 weeks and may use vacation and elective weeks. Residents may shorten parental leave to fit within ABEM restrictions to graduate on time. Finally, trainees that did not meet breastfeeding goals have cited associated negative emotions and potential interference with counseling patients on lactation practices.

A call-to-action for a universal policy published in the Journal of Graduate Medical Education outlines action steps that would contribute to lactation accessibility. Goals of such a policy would include: 1.) a culture of supporting resident lactation, 2.) access to appropriate facilities, and 3.) adequate time for milk expression. A previous survey of pediatric trainees on lactation also revealed themes that would help support medical trainees, such as support from their residency program and colleagues, adequate facilities, balance of personal needs and patient care, extended parental leave, and less emphasis on exclusive breastfeeding. For this reason, we need greater advocacy for trainees at the program and graduate medical education (GME) levels at each institution. Establishment of GME-level lactation policies for all trainees at an institution would help enforce standards of time and space. Programs could then identify specialty-specific barriers and

“A survey of United States physicians demonstrated that only 28% reached breastfeeding goals, and those without a dedicated space or scheduled time were less likely to meet breastfeeding milestones.”

leverage policy to address them.

It is a tragedy that such significant barriers to basic physiologic functions exist for emergency physicians, especially when providing nourishment to their own infants. We can do more to help our physicians and trainees achieve lactation success. A recent robust qualitative study of EM attendings, trainees, and nurses revealed that despite policies, cultural barriers in our specialty still exist for lactation. Positive culture examples included colleagues and coworkers who encouraged them to pump on shift and tone-setting by the program director. The authors further recommend that for trainees, a shared understanding of informing an attending, rather than asking for permission, would facilitate lactation.

There are many ways in which we can collectively support lactating physicians in the ED. First, policies surrounding lactation in EM should be created not just at the departmental level, but also at the national level by thought leaders in this space. Departmental and/or institutional efforts should ensure access to a well-equipped space for lactation. This includes directly within or near the ED, especially if ongoing patient care is expected to occur. This space should

ideally have a working fridge for storing milk after it has been pumped, a nearby sink for washing pump parts, and a workspace with electronic health record (EHR) access to continue monitoring patient care. This space needs to be private, with a door that closes and locks, no windows, and no cameras. As it may not be possible to establish a space that is solely dedicated to lactation in the ED, unofficial lactation rooms that are otherwise multipurpose, but can be prioritized for lactation, are also an option. EM trainees and attendings should selfadvocate when they are lactating. They should request a copy of their institutional or departmental policy. Trainees should inform attendings at the beginning of the shift of the need to step away for lactation; attendings should inform colleagues of the same for patient care coverage. Nonlactating individuals can serve as important allies by offering to cover patient care zones, understanding the facts of lactation, and engaging others to support lactation.

Moving forward, formal policies should be a given, but cultural overhaul should be our goal. This will require support and cooperation from the entire community of emergency medicine,

including all residents, program directors, departmental leadership, and GME oversight. Our specialty is the master of adaptability and can accomplish this, but we must start with a shared commitment to lactation

ABOUT THE AUTHORS AND EDITORS

Dr. Rider is a clinical assistant professor of emergency medicine at Stanford University and assistant program director for the EM residency program.

Dr. Goli is a second-year pediatric emergency medicine fellow at the Stanford University School of Medicine.

Dr. Karamatsu is an assistant professor of emergency medicine and pediatrics at the Stanford University School of Medicine.

“Previous research has shown that shorter maternity leaves correlate with less than six months of breastfeeding.”

Arctic Emergency Medicine: Navigating the Intersection of Climate and Health in Rural Alaska

By Lorenzo Albala, MD, on behalf of the SAEM Wilderness Medicine Interest Group

“We might be able to charter a plane from Big, he might be willing to land and pick her up.”

You wouldn’t expect to hear this in the back room of an emergency department (ED). After spending some time in Kotzebue, however, something like this wouldn’t seem out of place at all. Kotzebue is located on Alaska’s western coast, about 33 miles north of the arctic circle. The population of a few thousand Inupiat is served by a small hospital with a 6-bed emergency department. When I first arrived, I couldn’t help but wonder — can you really practice “wilderness” medicine in a place that people call home?

The short answer is yes. I believe that working in Kotzebue’s ED highlights

you really practice “wilderness” medicine in a place that people call home?”

the scope of wilderness medicine. I had to rethink my (recently minted) way of practicing emergency medicine: no in-house specialty support, no MRI, no ICU, a 90-minute flight time to the closest tertiary center. There is no shortage of bread-and-butter cases such as necrotizing marine zoonotic infections, hypothermia, or frostbite. Some days, it feels like a cultural immersion: an elder may describe his symptoms with a peppering of Inupiaq words. These words soon become

wonderfully familiar, you chat about muktuk (whale blubber) and seal oil, and you wonder “am I really still in America?”

I move to my next patient, a middleaged woman living at camp, her lifestyle defined by subsistence hunting and fishing. With a grimace, she describes how she now needs to be careful snowmachining into town, because although it’s the middle of January, there are still holes in the river ice. I recently read an article shared by Harvard Kennedy School’s Arctic Initiative,

“can

which supports “the proposition that Arctic warming has been proceeding at almost 4X the global rate, rather than the often quoted 2-3X.” The daily impact of a warming environment is much more tangible at these latitudes.

I doubt residency training prepares you for the work that goes on in the “radio room.” Imagine running medical control for several villages scattered across an area the size of Indiana. The population of these villages varies from a handful to a few hundred people. Their clinics are staffed by a community health aide, a trained community member who functions as your eyes, ears, and hands. Through a patchwork of Zoom, phone calls, and written notes, I became a telemedicine “regular” in between ED

patients. When planning a village transfer, since there are no roads connecting any of these villages, I begin the following mental gymnastics: is this patient stable for the commercial flight tomorrow? If not, do I save the local crew for a potential future critical patient, and send the Anchorage crew instead?

When we only have 90 minutes of daylight and a village with an emergency has broken runway lights, we get creative (see line 1). Often, we see communities come together in amazing ways for patients: an entire village rallying on a dark morning to line dozens of ATVs and snowmachines along the length of the runway, lighting the way for the plane to land. Kotzebue is an example of how wilderness medicine is so much more. It

is within the walls of this ED that the idea of wilderness medicine blurs with rural medicine, global health, EMS, and climate health.

ABOUT THE AUTHOR

Dr. Albala is a recent graduate of the Harvard Affiliated Emergency Medicine Residency and is currently a Wilderness Medicine Fellow at Massachusetts General Hospital. His interests include wilderness medicine education and global emergency medicine development. Outside of the hospital he is an avid surfer and kiteboarder.

“Imagine running medical control for several villages scattered across an area the size of Indiana.”

Announcing the 2023 SAEMF Research and Education Grantees

The SAEM Foundation (SAEMF) is the philanthropic arm of SAEM which works to bridge the research funding gap in emergency medicine (EM), advance the science and innovation at the heart of the specialty, and build the pipeline of talented EM research and education leaders for the future.

SAEMF seeks to inspire, empower, mentor, and connect the next generation of EM investigators and educators who are conducting innovative research and education in all areas of EM. This year, SAEMF is honored to announce that the SAEM Foundation (SAEMF) Board of Trustees recently approved investing close to $850,000 – one of the highest funding levels in our history – to fund the work of 20 promising researchers and educators in academic emergency medicine. Whether it is

Dr. Mehruba Parris’ exploration of adverse events of high dose buprenorphine for MOUD in the ED, or Dr. Kean’s assessment of novel models of remote diagnosis of treatment to highly contagious infectious diseases, or Dr. Horace’s work to better understand and improve the ED Psychiatric Intake and Safety Assessment process to reduce bias during ED intake of psychiatric patients –SAEMF grantees are taking on challenging projects that stand to advance future ED care and improve the health of our communities.

Join us in celebrating these bright minds and changemakers who are the 2023 SAEMF Grantees. We are certain these grantees will go on to do big things thanks to their SAEMF funding which is only possible through the partnership of the Annual Alliance Donors.

Celebrating the 2023 SAEMF Research and Education Grantees

Michelle Nassal, MD, PhD

The Ohio State University

SAEMF Research Training Grant - $300,000

“Artificial Intelligence for Dynamic, Individualized CPR Guidance: AID CPR”

Rebecca E. Cash, PhD

Massachusetts General Hospital

SAEMF Research Large Project Grant - $150,000

“An Evaluation of the Current State of Prehospital Routing Decisions for Stroke”

Carl M. Preiksaitis, MD

Stanford University

SAEMF Education Research Training Grant - $100,000

“The Evaluation of Learning Resources (EvaLeR) in Emergency Medicine”

Efrat R. Kean, MD

Thomas Jefferson University

SAEMF Emerging Infectious Disease and Preparedness Grant - $100,000

“Assessment of a Novel Model of Remote Diagnosis and Treatment of Highly Contagious Infectious Diseases”

Anita Chary, MD, PhD

Baylor College of Medicine

GEMSSTAR for Emergency Medicine Supplemental Funding Program - $25,000

“Identifying Implementation Strategies for Emergency Department (ED) Delirium Screening in Older Adults”

Nathan L. Haas, MD

University of Michigan

SAEMF ARMED Pilot Grant - $25,000

“Accuracy of Continuous Glucose Monitor in DKA (ACID)”

Jennifer L. Carey, MD

UMass Chan Medical School

SAEMF ARMED MedEd Pilot Grant - $25,000

“Building on Leadership and Diversity in EM (BOLD-EM): Investigating Program Impact”

Di Coneybeare, MD, MHPE

Columbia University Vagelos College of Physicians and Surgeons

SAEMF Education Project Grant - $20,000

“Professional Identity Formation in Emergency Medicine Fellows: A Qualitative Investigation to Define the Transformation”

Angadpreet Sidhu, DO, MS

NYCHHC Harlem & Metropolitan Hospital

SAEMF NIDA Mentor-Facilitated Training Award - $12,000

“Increasing Bupe Admin for OUD in the ED at Harlem and Metropolitan Hospital”

Karrin Weisenthal, MD, MHS

Boston Medical Center

SAEMF NIDA Mentor-Facilitated Training Award - $12,000

“Decreasing Risk and Stigma Among Patients Who Use Drugs”

Mehruba A. Parris, MD

Rutgers Biomedical and Health Sciences

MTF/SAEMF Toxicology Research Grant - $20,000

“Efficacy and Incidence of Adverse Events of High Dose Buprenorphine for MOUD in the ED”

Adam D. Laytin, MD, MPH

Johns Hopkins University School of Medicine

SAEMF/GEMA Research Pilot Grant - $10,000

“Developing a Context-Appropriate VAP Prevention Strategy in Ethiopia”

Anisha R. Turner, MD, MBA

Baylor College of Medicine

SAEMF/ADIEM Research Grant - $6,000

“Combining Interprofessional Education Simulation and Coaching to Teach Health Equity”

Preeti Panda, MD

Stanford University

SAEMF/AWAEM Research Grant - $5,000

“Health Disparities of Trafficked Children Presenting to Emergency Departments”

Hillary C. Moss, MD

Montefiore Medical Center

SAEMF/Simulation Academy Novice Research Grant - $5,000

“Creating a Novel Simulation Based Palliative Care Curriculum for the EM Resident”

Colin J. O’Shea, MD, MPH

Vanderbilt University Medical Center

SAEMF/CDEM Innovations in Undergraduate Emergency Medicine

Education Grant - $5,000

“Implementation of A Video-based ECG Curriculum for Medical Students”

Hirotaka Ata, MD, PhD

Duke University

SAEMF/RAMS Resident Research Grant - $5,000

“CRISPR-based, Rapid Bedside Bacteremia Detection for ED Sepsis Management”

Connor M. Bunch, MD

Henry Ford Hospital

SAEMF/RAMS Resident Research Grant - $5,000

“Resuscitation of Severely Bleeding Patients Guided by Resonant Acoustic Rheometry”

Reuben W. Horace, DO, MPH, MBA

Duke University

SAEMF/RAMS Resident Research Grant - $5,000

“Patient Perspective on Reducing Bias During ED Intake of ED Psychiatric Patients”

Giselle Appel, BA

Sidney Kimmel Medical College; Thomas Jefferson University

SAEMF/RAMS Medical Student Research Grant - $2,500

“Optimizing the EM Clerkship through Trauma-Informed Medical Education”

EMF/SAEMF Medical Student Research Grantees - $5,000

To be announced, Summer 2023

Emergency Medicine Interest Group Grantees - $500

To be announced, Summer 2023

SAEMF Challenges Provide a Way for Every SAEM Member to Participate In EM Research and Education Grant Funding

A donor once told us “I can’t commit to doing the research, but I can commit to writing a check to help fund it.” Did you know that there are 8,400 SAEM members and approximately 5% are likely donate to support SAEMF's grants in 2023? This number grows each year, and we celebrate that several hundred SAEM members and 100% of SAEM’s staff and SAEMF's Board have already signed on to support the work of SAEMF’s grantees this year through their Annual Alliance contributions.

Even with that, it is going to take more resources each year to continue to build a robust pipeline of future EM researchers and educators, to encourage more trainees to pursue a research career in academic EM, and to support the vibrant outcomes of SAEMF’s grantees like those featured in this issue. This is why SAEMF conducts its annual fundraising Challenges – and, there’s a Challenge for every SAEM member to take part in! Take a look below and then participate by donating or pledging (email jwolfe@saem.org).

NEW! VICE CHAIRS’ CHALLENGE VICE CHAIRS’ CHALLENGE

See saem.org/challenge for details.

SAEM groups compete to be recognized for raising the most funds for future grants and/or to be the group with the highest donor participation.

To move your group up the Challenge Leaderboards, donate a gift of any amount. The best part: between May 1 - August 31, 2023 (the Challenge period), all donations and pledges, up to the first $10,000 raised, will be matched $1:$1 by SAEM! That’s amazing ROI!

Donors can also choose to pledge a gift (email jwolfe@saem.org) and staff will send a reminder to donate later in the year.

Annual Alliance recognition is provided for donors AND winning groups receive special honors as the Challenge winners.

Help your group WIN! Donate today.

See saem.org/vicechairschallenge for details.

SAEMF’s new Vice Chairs’ Challenge showcases the generous giving that comes from our vice chairs each year and serves as a rallying call to unite vice chairs in support of more funding for future EM researchers and educators.

Vice Chairs' committed giving is essential to SAEMF grant funding. We know that the Vice Chairs are often the people who make things happen in your departments. You are the hubs, the guides, the innovators, the catalysts.

Help us meet the goal of raising $40,000 in new gifts to support EM grants by May 30:

• Donate or email jwolfe@saem.org to pledge your support.

• A gift of any amount makes a difference.

See the SAEMF Donor Guide for more information about grants and the impact of a gift.

The 2023 SAEMF Chairs’ Challenge Results

Are In!

The 2023 Chairs’ Challenge was a tremendous success. This year’s AACEM member donors generously donated $145,598 in support of SAEMF’s work and to make more research and education grants possible. The annual Chairs’ Challenge has been the backbone of SAEMF’s vital annual gifts since 2019. We are grateful to AACEM’s Chairs and to all of the SAEM members who have supported our mission this year through the Annual Alliance. Make a charitable donation today to join these colleagues or email Julie Wolfe for details.

BRIEFS & BULLET POINTS

RAMS

RAMS Statement Regarding the 2023 Match

In a statement issued Tuesday, May 28, the SAEM RAMS Board welcomed graduating medical students and reflected on the recent National Resident Matching Program (NRMP) results. The statement also discussed challenges facing emergency physicians in the emergency department, addressed concerns surrounding future job prospects, and outlined some of the things SAEM is doing to confront these issues. Read the full statement here.

SAEM JOURNALS

Academic Emergency Medicine

AEM Announces 2023-24 Resident Editors

Academic Emergency Medicine (AEM) is pleased to announce two residents have been selected to join the AEM editorial board for the 2023-2024 term. Jasmine Thompson, MD, from the LSU Spirit of Charity Residency Program and Courtney Wechsler, MD from the Detroit Receiving Hospital Residency Program, were selected from our most competitive application pool ever. According to Mark B. Mycyk, MD, associate editor and director of the residentin-training program for AEM, “The decision this year was not easy—our specialty is lucky to have so many talented and enthusiastic residents interested in this program — if we had the capacity, we would have offered each of our applicants a position on the board.” During their one year-term on the AEM editorial board, these senior residents will be immersed in every aspect of peer review, editing, and publishing of medical research manuscripts to enhance their future career in scientific publication and emergency medicine. In addition to experiencing the duties involved in journal editing, the resident editors will participate in a mentored curriculum to learn about all aspects of publication ethics.

Academic Emergency Medicine

Announces Outstanding Peer Reviewers

Academic Emergency Medicine (AEM) Editorin-Chief Jeffery A. Kline, MD, has named the following individuals as the AEM Outstanding Peer Reviewers. These exceptional peer

reviewers are essential to presenting the high-quality academic contributions that fill the pages of AEM each month.

Outstanding Reviewer 2018-2022

• Jill Stoltzfus, PhD

Outstanding Reviewers 2022

• Beau Abar, PhD

• Joshua Broder, MD

• Laura Burke, MD, MPH

• Jon Cole, MD

• Daniel Courtney, MD

• Brian Driver, MD

• Robert Ehrman, MD, MS

• Ross Fleischman, MD

• Daniel Good, MD

• William Grant, MD

• Jeffrey Hom, MD

• Benton Hunter, MD

• Joshua Lupton, MD, MPH

• William Meurer, MD, MS

• Andrew Moore, MD

• Sergey Motov, MD

• Paul Musey, MD

• Joseph Pare, MD

• Jesse Pines, MD

• Maria Raven, MD, MPH

• Richard Sinert, DO

• Jill Stoltzfus, PhD

• Henry Thode, PhD

AEM Education & Training

AEM E&T Names Two to Fellow Editorin-Training Program for 2023-2024

Academic Emergency Medicine Education and Training (AEM E&T) is pleased to announce that Carl M. Preiksaitis, MD, and Michelle I. Suh, MD, have been selected from a competitive pool of applicants as the 20232024 AEM E&T Fellow Editors-in-Training. Dr. Preiksaitis is a clinical instructor and medical education scholarship fellow in the Department of Emergency Medicine at Stanford University School of Medicine. Dr. Suh is a resident physician at Baylor College of Medicine. The fellows appointment to the editorial board of AEM E&T is intended to mentor a medical education fellow in the process of peer review, editing, and publishing of education research manuscripts.

AEM Education and Training Names

Outstanding Peer Reviewers

Academic Emergency Medicine Education and Training (AEM E&T) Editor-in-Chief Susan B. Promes, MD, MBA, has named the following

individuals as the AEM E&T Outstanding Peer Reviewers.

Outstanding Reviewers 2018-2022

• Joshua Davis, MD

• Nikhil Goyal, MD

• Ryan Pedigo, MD, MHPE

Outstanding Reviewers 2022

• Matthew Ball, MD

• Ryan Bodkin, MD

• Jeremy Branzetti, MD

• Merle Carter, MD

SPONSORED CONTENT

New Podcast Series: Current and Novel Approaches

to Sepsis Detection in the Emergency Department

Dive into the world of sepsis care in the emergency department with our new podcast series! Dr. Michael Puskarich and Dr. Robert Ehrman discuss different approaches to sepsis screening and treatment with other respected experts in the specialty. This five-episode series, sponsored in part by Beckman Coulter and bioMerieux, focuses on sepsis, best practices for early identification and improved patient outcomes, and the research surrounding biomarkers in an acute clinical setting.

New Resources to Educate Patients About COVID-19

Check out our newest patient education materials about severe COVID-19 risk factors and treatment options. These free print and digital resources include information from the U.S. Centers for Disease Control and Prevention’s We Can Do This campaign to increase public confidence in COVID-19 vaccines and educate the public about COVID-19 treatments. SAEM members are encouraged to download and/or print these materials to support their patient education programs.

Emergency Physicians Can Improve Patient Care While Supporting Antimicrobial Stewardship

The emergency department (ED) is a critical setting for antimicrobial stewardship efforts. Learn about the need to support antimicrobial stewardship programs in the ED to improve patient health while combating the rising threat of multidrug resistance organisms through this new content, provided in part by bioMérieux, a proud supporter of SAEM.

Dr. Jasmine Thompson

Dr. Courtney Wechsler

Dr. Carl M. Preiksaitis

Dr. Michelle I. Suh

SAEM FOUNDATION

SAEMF Grant Applications Now Open

Every year the SAEM Foundation (SAEMF) aims to award close to $850,000 to SAEM members to enhance their career development and study the most critical challenges in emergency medicine (EM). To date, the SAEMF, together with SAEM, has awarded more than $12.5 million to over 540 academicians. Check out this year’s grant funding opportunities and apply by 5 p.m. CT August 1, 2023!

Grant Funding Opportunities

• Research Training Grant (RTG)$300,000

• Research Large Project Grant (LPG)$150,000

• Education Research Training Grant (ERTG) - $100,000

• Emerging Infectious Disease and Preparedness Grant - Up to $100,000

• NEW! SAEMF/ED Benchmarking Alliance Clinical Operations Research Grant - $50,000

• SAEMF ARMED Pilot Grant - $25,000

• SAEMF ARMED MedEd Pilot Grant$25,000

• Education Project Grant (EPG)$20,000

• MTF/SAEMF Toxicology Research Grant - $20,000

• NEW! Geriatric Emergency Medicine Research Catalyst Grant, Supported by Michelle Blanda, MD, $10,000

• SAEMF/Academy of Emergency Ultrasound (AEUS) Research Grant$10,000

• SAEMF/Global Emergency Medicine Academy (GEMA) Research Pilot Grant - $10,000

• SAEMF/Academy for Diversity and Inclusion in Emergency Medicine (ADIEM) Research Grant - $6,000

• SAEMF/Academy for Women in Academic Emergency Medicine (AWAEM) Research Grant - $5,000

• SAEMF/Simulation Academy Novice Research Grant - $5,000

• SAEMF/Clerkship Directors in Emergency Medicine (CDEM) Innovations in Undergraduate Emergency Medicine Education Grant - $5,000

• SAEMF/Resident and Medical Student (RAMS) Research Grants - $2,500$5,000

Funding for Wellness-Focused Projects

Check out our Notice of Special Interest (NOSI) to develop the science of physician wellness in EM and contribute to careers of researchers focused in this area. Questions? Contact us at grants@saem. org or visit saemfoundation.org for detailed information.

Meet Your 2023-2024 Leaders!

SAEM Board of Directors

Members-at-Large

Pooja Agrawal, MD, MPH Yale University School of Medicine

Jeffrey Druck, MD The University of Utah School of Medicine

Julianna J. Jung, MD Johns Hopkins University School of Medicine

Nicholas M. Mohr, MD, MS University of Iowa

Ava E. Pierce, MD UT Southwestern Medical Center, Dallas

Jody A. Vogel, MD, MSc, MSW Stanford University

Department of Emergency Medicine

Resident Member

Michael DeFilippo, DO, MICP NewYork-Presbyterian - Columbia & Cornell

SAEM Bylaws Committee

James H. Paxton, MD, MBA (Chair) Wayne State University/Detroit Medical Center

Angela Lumba-Brown, MD

Stanford University Department of Emergency Medicine

Ronny Otero, MD, MSHA Medical College of Wisconsin

AACEM Executive Committee

President

Wendy C. Coates, MD Los Angeles County Harbor-UCLA Medical Center

President-Elect

Ali S. Raja, MD, DBA, MPH

Massachusetts General Hospital/Harvard

Secretary-Treasurer

Michelle D. Lall, MD, MHS

Emory University

Immediate Past President

Angela M. Mills, MD Columbia University Vagelos

SAEM Committees

SAEM Nominating Committee

Ali S. Raja, MD, DBA, MPH (Chair, SAEM President-Elect)

Massachusetts General Hospital/Harvard

Angela M. Mills, MD (SAEM Immediate Past President) Columbia University Vagelos

Al'ai Alvarez, MD

Stanford Emergency Medicine

Prasanthi (Prasha) Govindarajan, MD, MAS Stanford University Department of Emergency Medicine

President

Lewis S. Nelson, MD, MBA

Rutgers New Jersey Medical School

Wendy C. Coates, MD

Lewis S. Nelson, MD, MBA

SAEM leaders, L to R: Ali S. Raja, MD, DBA, MPH; Michelle D. Lall, MD, MHS; Angela M. Mills, MD; Pooja Agrawal, MD, MPH; Jeffrey P. Druck, MD; Julianna J. Jung, MD; Nicholas M. Mohr, MD, MS; Ava E. Pierce, MD; Jody A. Vogel, MD, MSc, MSW; Michael J. DeFillippo, DO, MICP

President-Elect

Jane H. Brice, MD, MPH

University of North Carolina at Chapel Hill School of Medicine

Secretary-Treasurer

Ian B.K. Martin, MD, MBA

Medical College of Wisconsin

Immediate Past President

Richard J. Hamilton, MD, MBA

Drexel University College of Medicine

Members-at-Large:

Rawle A. Seupaul, MD

University of Arkansas for Medical Sciences College of Medicine

Mary E. Tanski, MD, MBA

Oregon Health & Science University

RAMS Board

Laura Barrera, MD, Capt., USAF Virginia Commonwealth University

Taylor E. Brown, MD

Beth Israel Deaconess Medical Center, Harvard Medical School

Emily (Ly) Cloessner, MD, MSPH

Washington University in St Louis

Zoë Fisher, MD

University of Texas, Health Sciences Center at Houston

Patricia Hernandez, MD

Harvard-Affiliated Emergency Medicine Residency at Massachusetts General Hospital

Jennifer Reyes Lin, MD, MPH

Washington University in St. Louis

Giovanni Rodriguez, MD Harvard-Affiliated Emergency Medicine Residency at Massachusetts General Hospital

SAEM Foundation Board of Trustees

Members-at-Large

Michelle Blanda, MD

Northeast Ohio Medical University/ Western Reserve Hospital

Steven L. Bernstein, MD

Geisel School of Medicine At Dartmouth

Cherri Hobgood, MD Penn State Health

UNC

James J. McCarthy, MD, MHA

Memorial Hermann Health System

Zachary F. Meisel, MD, MPH, MSHP

Paul I. Musey, Jr., MD, MS Indiana University School of Medicine

Susan B. Promes, MD, MBA

Penn State Health

Neha Raukar, MD, MS

Mayo Clinic & Mayo Clinic Health System

Richard E. Wolfe, MD

Beth Israel Deaconess Medical Center

SAEM Grants Committee Chair

Bryn Mumma, MD, MAS

University of California, Davis, School of Medicine

SAEM Finance Committee Chair

Marquita S. Norman, MD, MBA

UT Southwestern Medical Center, Dallas

SAEM President

Wendy C. Coates, MD

Los Angeles County Harbor-UCLA Medical Center

SAEM President-Elect

President

Daniel N. Jourdan, MD, NRP

Henry Ford Hospital

Secretary-Treasurer

Mitchell Blenden, MD

McGaw Medical Center of Northwestern University

Immediate Past President

Hamza Ijaz, MD

University of Cincinnati College of Medicine

Medical Student Representatives

Stephanie Balint

Quinnipiac University

Lauren Diercks

UT Southwestern Medical Center, Dallas

Members-at-Large

Daniel Jose Artiga, MD

University of Cincinnati College of Medicine

President

Manish N. Shah, MD, MPH

University of Wisconsin School of Medicine and Public Health

President-Elect

J. Scott VanEpps, MD, PhD University of Michigan

Secretary-Treasurer

Ted Corbin, MD, MPP

Rush University Medical Center

Immediate Past President

Joseph Adrian Tyndall, MD, MPH

Morehouse School of Medicine

Ali S. Raja, MD, DBA, MPH

Massachusetts General Hospital/Harvard

SAEM Secretary-Treasurer

Michelle D. Lall, MD, MHS Emory University

SAEM Immediate Past President

Angela M. Mills, MD

Columbia University Vagelos

Daniel N. Jourdan, MD, NRP

Manish N. Shah, MD, MPH

SAEM REPORTS

ACADEMY REPORTS

Simulation Academy

Spotlight on the Simulation Young Physican’s Section Navigating a career in academic medicine can be challenging, particularly as a trainee or junior faculty. To increase mentorship to junior simulationists interested in academic medicine, the SAEM Simulation Academy created the Young Physicians Subcommittee. The goal of this subcommittee is to create a group to foster collaboration and connection within the young simulation community. The group meets monthly and aims to improve mentorship, collaborate on projects, and connect members to the larger Simulation Academy community. This past winter, we hosted our first mentorship panel via a zoom session during the Simulation Academy’s quarterly open membership meeting which drew a mix of residents, simulation fellows, junior faculty, and seasoned simulationists. In total, eight invited panelists provided an overview of their career paths, touching upon the importance of mentorship within the SAEM community, collaboration on research endeavors, and continuing education. Guiding questions were provided to the panel and the session ended with an open question and answer session. Key themes were elicited from a post-survey sent to attendees.

Advice to Faculty Regarding Improving Simulation Skills and Knowledge Without Fellowship Training

• Seek out a simulation-based training course on your own.

• There are a variety of courses. Some popular ones include:

o CMS debriefing course for a focus on simulation design and debriefing

o MERC Course for a focus on medical education research

o ACEP Teaching Fellowship to enhance teaching skills

• Subscribe to a simulation journal and hold monthly journal clubs to review literature.

Advice Regarding Fellowships

• As the field of simulation grows, there is a general expectation to complete a simulation fellowship to shift into a simulation career.

• Unlike residency programs, simulation fellowship programs are not standardized. While they share a lot in common, each simulation fellowship program has something unique to offer. Seek out a fellowship that will match your goals and needs as a learner.

• Consider whether you want to complete an advanced degree during your training.

Funding:

• Have a team when applying for grant.

• Identify key stakeholders to help with your research project.

• Include a mentor who has applied for or received grants before or has been on a grant committee.

• Grants range from small seed grants to large NIH/AHRQ grants.

• Consider applying for grants outside of the simulation realm.

Advice Regarding Job searches for fellows

• Network- don’t be afraid to reach out to department chairs or simulation directors directly as jobs aren’t always posted.

• Be flexible- needs within a department or area can change overtime, though balance these needs with your professional goals.

• Think about what value you can bring to a department overtime.

General Tips for Success

• Have a team of mentors- different mentors have different areas of expertise.

• Consider interprofessional connections.

• Developing a career in simulation is a lifelong process.

• Work to understand your specific academic environment as there can be different.

Future Plans

Based on significant interest in our first sessions, we are planning to continue a mentorship series throughout the 2023 season. We will collaborate with Simulation Academy

Leadership to host dedicated sessions on topics including pursuing advanced degrees, grant writing, simulation fellowship overview and application process, academic promotion, securing your first academic EM/simulation job.

This report was written by Christina Matulis, MD, and Alaa Aldalati, MBBS, on behalf of the SAEM Simulation Academy. Dr. Matulis is a simulation fellow at the Yale Center for Healthcare Simulation and clinical instructor in emergency medicine at Yale School of Medicine. Dr. Aldalati is a simulation fellow at Brown Emergency Medicine and clinical instructor in emergency medicine at Alpert Medical School of Brown University.

Academy of Administrators in Academic Emergency Medicine

Congratulations to the AAAEM Awards Recipients

The following individuals were recipients of annual awards from the SAEM Academy of Administrators in Academic Emergency Medicine (AAAEM). The awards were presented on March 21, 2023, at an awards luncheon held during the 2023 AACEM/ AAAEM Annual Retreat in Dana Point, Cali.

Rising Star Award

Brendan Russell, MBA, Vice President of Enterprise Emergency Medicine, Mass General Brigham

Significant Contributions Annual Award

Louis E. Burton, Sr., MHSM, Director, Finance & Administration, UT Health of San Antonio

Significant Contributions Annual Award

Becky L. McGowan, MBA, Vice Chair, Finance and Administration, Department of Emergency Medicine, University of Colorado School of Medicine

James J. Scheulen Lifetime Achievement Award in Academic Emergency Medicine Administration

David W. Calder, MBA, Administrative Director, Loma Linda University Health Emergency Medicine

James J. Scheulen Lifetime Achievement Award in Academic Emergency Medicine Administration

Janet Baker, Director of Management Operations, Department of Emergency Medicine, UTHealth Houston

How to Make the Most of Your SAEM Medical Student Membership!

SAEM provides a pathway for medical students to cultivate their interest in emergency medicine (EM) through leadership opportunities, scholarship, and networking with the top academic EM physicians in the country. An SAEM membership opens the door to a variety of opportunities for medical students to immerse themselves in the various niches of EM and to develop critical academic and clinical skills. Visit this spot in the next several issues of SAEM Pulse and we’ll advise you on how to make the most of your SAEM medical student membership!

Connect With Your Community at the SAEM Annual Meeting

Ask almost any SAEM member what one of the biggest member benefits they’ve received, and most will tell you about the community of friends and mentors they have built over the years. For medical students, one way those friendships develop is through their involvement in RAMS, but another key way to find and connect with other medical students who share your interest in emergency medicine is at the SAEM Annual Meeting.

At SAEM23, medical students can engage with expert faculty, experience excellence in innovation and research, and participate in tailored learning activities developed exclusively for emergency medicine residents and medical students. Check out this “Can’t Miss List” of annual meeting activities, events, and educational sessions you will want to be certain to attend!

Aside from those you’ll meet while attending the many events, educational sessions, and activities at annual meeting, here is another, very unique opportunity just for medical students that you should take the time to investigate!

Medical Student Ambassador Program

If you apply for and are one of the lucky few to selected to be a part of the Medical Student Ambassadors (MSA) program you’ll have the opportunity and important responsibility of working with SAEM leadership and your fellow medical students to help with the planning, coordination, and on-site execution of SAEM’s Annual Meeting. Medical Student Ambassadors, learn about new technology by assisting with the latest AV equipment, sharpen their organizational and problem-solving skills, attend research and didactic sessions, and even have a social coordinator to plan fun “after hours” outings and events. If you’re attending SAEM23 be on the lookout for this year’s team of MSAs. They’ll be wearing branded blue “team” jackets and would love to tell you all about the program. Applications for SAEM24 Medical Student Ambassador program opens in December 2023. Plan now to apply for this unique and exclusive opportunity for medical students! .

The following individuals contributed to this report:

Lauren Diercks, a third-year medical student at the University of Texas Southwestern in Dallas, Texas. Lauren is a Medical Student representative for the RAMS Board and is involved in the Membership Committee.

Tanner Reed, a third-year medical student at Louisiana State University School of Medicine in New Orleans.

Dustin Williams, MD, an associate professor of emergency medicine and residency program director at UT-Southwestern Medical Center. Dr. Williams is a member of the SAEM Membership committee and is the current co-chair for the SAEM’s Academy for Diversity and Inclusion in Emergency Medicine (ADIEM) LGBTQIA+ subcommittee.

Cassandra Kim Bradby, MD, program director at Brody School of Medicine at East Carolina University Health Emergency Medicine Residency and the president-elect of ADIEM.

SAEM REPORTS

COMMITTEE REPORTS

Membership Committee

Member Benefits Focus: Podcasts and Webinars

SAEM’s podcast library contains over 200 free podcasts on subjects ranging from academic emergency medicine to medical education and including special podcast series for residents and medical students.

• Academic Emergency Medicine (AEM) Podcasts

• AEM Education & Training Podcasts

• RAMS (Residents and Medical Students) Podcast Series

o Who’s Who in Academic Emergency Medicine Podcasts

o SAEM Academy Podcasts

o RAMS BioSketch Podcasts

o RAMS Ask a Chair Podcast

• ARMED MedEd Podcasts

• MedEd Sound Bites Podcasts

• SAEM Emergency Care Podcasts

• EM Stud Podcasts

In addition, SAEM offers dozens of live and recorded webinars on a variety of emergency medicine topics, ranging from innovative research to professional development to physician health and wellness. SAEM webinars are a great way to stay current and learn from your colleagues. SAEM webinars are free for SAEM members and webinar recordings are available after each event. SAEM podcasts and webinars are free for members and are just two of the many benefits you can access as a member of the Society for Academic Emergency Medicine! Join SAEM today!

This report was written by Viral Patel, on behalf of the SAEM Membership Committee. Dr. Patel is assistant professor and assistant residency program director, UMass Chan Medical School, Department of Emergency Medicine.

SAEM AFFILIATE REPORTS

Association of Academic Chairs of Emergency Medicine

Congratulations to the AACEM Awards Recipients

The following individuals were recipients of annual awards from the Association of Academic Chairs of Emergency Medicine (AACEM). The awards were presented on March 21, 2023, at an awards luncheon held during the 2023 AACEM/AAAEM Annual Retreat in Dana Point, Cali.

Distinguished Service Award

Francis L. Counselman, MD, Professor and Chairman, Department of Emergency Medicine, Eastern Virginia Medical School

Distinguished Service Award

Robert W. Neumar, MD, PhD, Professor and Chair of Emergency Medicine, University of Michigan

Lifetime Service Award

Sandra M. Schneider, MD, Senior Vice President for Clinical Affairs, American College of Emergency Physicians

Training

AEM E&T Fellow Editor-in-Training Program

The Academic Emergency Medicine Education and Training (AEM E&T) Fellow Editorin-Training program is a one-of-a-kind opportunity is open to any SAEM member who is a current resident and about to start a medical education fellowship or is a current fellow in a two-year medical education fellowship program. The 12-month, fellow appointment to the editorial board of AEM E&T is intended to mentor a medical education fellow in the process of peer review, editing, and publishing of education research manuscripts. The program director is Esther Chen, MD, who is a decision editor for AEM E&T. The application period runs from December through February of each year. For more information contact Dr. Chen at esther.chen@ucsf.edu. In this article, the 2022-2023 fellow editors-in-training reflect on their year with the program. They share more of what they learned in an upcoming podcast to be available soon.

otherwise not experienced. Thirdly I have come to realize the importance of developing working relationships within medical education.

Dr. Davis is a medical education fellow and assistant residency director at the University of Michigan in Ann Arbor, Michigan. She served as a Fellow Editorin-Training for Academic Emergency Medicine Education and Training during the 2022-2023 academic year.

Over the past year I have had the wonderful opportunity to participate as the Academic Emergency Medicine Education and Training (AEM E&T) Fellow Editor-in-Training program. This experience has made me realize three important areas of growth. The first being the importance of peer-review in one’s personal development as a researcher and educator. The second is that I have gained experience in many other realms of medical education that I may have

As a medical student, resident, fellow, or faculty, many of us have gone through the experience of drafting a manuscript for publication. I often felt as if I was blindly following the author guidelines and recommendations from mentors. The experience of thoughtfully and systematically reviewing manuscripts for this position has given me a much deeper understanding of the manuscript submission and review process. I feel more confident when drafting and writing manuscripts, but also more capable when reviewing other authors’ manuscripts. I developed a better understanding of the conceptual framework that is required for a solid manuscript. These skills will continue to benefit me as I move forward throughout my career.

Through this experience I knew the focus would be on reviewing manuscripts; however, I did not realize the amount of incredible other experiences that I would gain, such as drafting and creating a podcast. Before this fellowship I had zero experience in creating a storyboard for a podcast or recording the final product. This fellowship allowed me to gain experience in other areas of medical education that will be invaluable when entering my career as a medical educator.

Finally, over this past year I have developed relationships with Dr. Esther Chen, my AEM E&T co-fellow, Dr. Chris Nash, and other AEM E&T board members. The experience of meeting and discussing new ideas has demonstrated the importance of ongoing working relationships. At our regular meetings we discussed concepts in medical education, but also new areas of research that we could pursue. During some of these meetings, we were fortunate to have guest speakers such as Dr. Sally Santen and members of the publishing staff who provided expertise on different areas of medical education. This support and ability to “bounce ideas” off each other has allowed me to grow as a medical educator. I was also fortunate to be able to help guide peer review workshop sessions with Dr. Jeffrey Siegelman, which allowed me to strengthen my skills in peer review, but also taught me how to effectively facilitate workgroups. The invaluable guidance given by my mentor, Dr. Esther Chen, gave me a window into how I can be a better mentor for my own mentees.

This incredible opportunity allowed me to grow in so many ways. I am very fortunate to have this experience as a medical education fellow and junior faculty early in my career. I am looking

continued on Page 90

Mallory G. Davis, MD, MPH

forward to continuing being involved in the peer-review process and strengthening my medical education research.

Christopher J. Nash, MD, EdM

has supplemented my medical education fellowship, permitting me to learn under the guidance of some of the thought leaders of our field. When preparing for a career in academia, a complex world with its own vocabulary (e.g., grantsmanship, h-index, impact factor, etc.), the process of sharing your discoveries via publication is central but rarely formally taught in medical training. This fellowship has demystified this hidden curriculum for me, and I would like to share my experiences as an opportunity for readers to learn along with me.

Apart from peer review, the fellowship afforded the chance to learn more of the nuts and bolts of how a journal works. I had the opportunity to follow the journey of an article after it is uploaded—from decision-making to copy editing to availability on PubMed.

Dr. Nash is a medical education fellow and attending physician in the Massachusetts General Hospital Emergency Department. He served as Fellow Editor-in-Training for Academic Emergency Medicine Education and Training during the 2022-2023 academic year.

At the start of this academic year, I was fortunate enough to begin an editor-in-training fellowship through Academic Emergency Medicine Education and Training. This experience

After an article is submitted, peer review is a critical step to protect the integrity of research. I certainly respected the importance of peer review previously, but how to “do” a peer review felt like a black box to me. I had done only one review, and I recall how challenging it was to wade through on my own. I tried my best to teach myself, ultimately choosing the (in retrospect) dubious strategy of following along with a process recommended by an academician on his YouTube channel. After submitting my review, I never received feedback on my review, nor did I have the chance to learn how to improve. In contrast, during this fellowship I received valuable specific and personalized feedback on my reviews, strengthening my skills and confidence considerably. What had previously seemed to be a daunting task now feels much more manageable and, dare I say, fun.

Furthermore, through joining editorial board meetings, I learned about how editors and staff make strategic decisions about the journal at large. I was surprised to realize that most reviewers are well-qualified yet unpaid volunteers who lend their expertise and time to journals primarily out of passion. Their dedication and infectious enthusiasm have made me reflect on how I can contribute to the field in the future. Their impact is international, if understated, and I have a deeper appreciation of how their dedication promotes the advancement of our field.

A short Pulse article does not do full justice to the experiences I had this year. I was able to gain hands-on experience in peer review and received direct mentorship by field leaders. I was exposed to different research methodologies, and I obtained a much deeper understanding of how a journal operates. The fellowship has undoubtedly prepared me for my own academic career in medical education, and it has connected me with amazing mentorship to help me along. If you’re going into a MedEd fellowship, I would certainly advise you to apply. I’m definitely glad that I did!

Check companies advertising jobs on SAEM’s EM Job Link against your LinkedIn contacts. Leverage professional connections for more information about the company or request a referral.

NOW HIRING

POST YOUR OPEN JOBS IN FRONT OF OUR QUALIFIED CANDIDATES!

Accepting ads for our “Now Hiring” section!

Deadline for the next issue of SAEM Pulse is June 1.

For specs and pricing, visit the SAEM Pulse advertising webpage.

Climate Change is a Health Emergency

Step up to be part of the solution.

Climate and Human Health Fellowship

Department of Emergency Medicine | BIDMC

2 Years | Master’s Degree | Funded Research

Mentored by faculty a liated with:

• Harvard C-CHANGE

• Harvard FXB Center

• Harvard University Center for the Environment

To learn more, visit climateandhumanhealth.org and https://bit.ly/2YELgi4.

Envision

Centerpoint

Dallas, TX

RESEARCH

Morristown,

Tampa, FL

Penn State Health Emergency Medicine

About Us:

Penn State Health is a multi-hospital health system serving patients and communities across central Pennsylvania. We are the only medical facility in Pennsylvania to be accredited as a Level I pediatric trauma center and Level I adult trauma center. The system includes Penn State Health Milton S. Hershey Medical Center, Penn State Health Children’s Hospital, and Penn State Cancer Institute based in Hershey, Pa.; Penn State Health Hampden Medical Center in Enola, Pa.; Penn State Health Holy Spirit Medical Center in Camp Hill, Pa.; Penn State Health St. Joseph Medical Center in Reading, Pa.; Penn State Health Lancaster Pediatric Center in Lancaster, Pa.; Penn State Health Lancaster Medical Center (opening fall 2022); and more than 3,000 physicians and direct care providers at more than 126 outpatient practices in 94 locations. Additionally, the system jointly operates various health care providers, including Penn State Health Rehabilitation Hospital, Hershey Outpatient Surgery Center, Hershey Endoscopy Center, Horizon Home Healthcare and the Pennsylvania Psychiatric Institute.

We foster a collaborative environment rich with diversity, share a passion for patient care, and have a space for those who share our spark of innovative research interests. Our health system is expanding and we have opportunities in both academic hospital as well community hospital settings.

Benefit highlights include:

• Competitive salary with sign-on bonus

• Comprehensive benefits and retirement package

• Relocation assistance & CME allowance

• Attractive neighborhoods in scenic Central Pennsylvania

Penn State Health is fundamentally committed to the diversity of our faculty and staff. We believe diversity is unapologetically expressing itself through every person’s perspectives and lived experiences. We are an equal opportunity and affirmative action employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.

Department of Emergency Medicine

FELLOWSHIP TRAINING OPPORTUNITIES

TAKE YOUR CAREER TO THE NEXT LEVEL – Exceptional Care Without Exception

The Department of Emergency Medicine at the Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center is recruiting Fellowship candidates in the areas of:

Addiction Medicine Emergency Department Administration Emergency Medical Services (EMS) Emergency Ultrasound (EUS)

Global Health Equity Local Health Equity

Neurocritical Care(NCC)

We offer 1- and 2-year Fellowship Training opportunities for graduates of accredited Emergency Medicine Residency Programs. We train 6-8 Fellows per year in a collaborative and nurturing community of practice and support them from orientation to graduation through the Fellowship Academy. BMC Emergency Medicine provides exceptional training in the care of critically ill/injured patients, point-of-care ultrasound, prehospital & EMS, public health, social EM, and research

BMC is the safety-net hospital for the city of Boston, serving a diverse, multicultural population in a ‘county’-type practice environment, set in a world-renowned tertiary hospital system.

Applications are being accepted now, please send your letter of interest to BMCFellowships@bmc.org for further instruction.

At BMC we welcome and support those who have faced barriers to practicing medicine, specifically those who identify as minorities, whether defined on the basis of race, ethnicity, socioeconomic status, gender, sexual orientation, physical ability, religion, first generation in higher education, or otherwise In 2022, the Lown Institute ranked BMC 4th in the nation for racial inclusivity and #1 in Massachusetts.

BMC EMERGENCY DEPARTMENT is a LEVEL 1 TRAUMA CENTER

130,000 annual patient visits

Care for 70% of penetrating trauma victims in Boston

4 year EM Residency Program

Provides medical control and oversight for Boston EMS

In-person interpreters for 17 languages

22% of residents are URM (national average is 11%)

BMC ED PATIENT DEMOGRAPHICS

70% Black or Hispanic

32% do NOT speak English as their primary language

>50% have annual household income <$20,400

Black or African American: 24.4%

Hispanic or Latino of any race: 17.5%

Native American: 0.4%

Asian: 8.9%

EM clinicians work closely with the BUSM Departments of Surgery, Pediatrics, Neurology, and Geriatrics, the Boston University School of Public Health, the Massachusetts Department of Public Health, and other regional and national injury research centers. Successful candidates must be a graduate of an ACGME-accredited Emergency Medicine residency an can apply for a 1or 2-year program, if pursuing an advanced degree (MPH or MBA). Fellows are expected to work alongside and train EM residents and medical and PA students. The position comes with an excellent benefits package, and a faculty appointment. BMC/BUSM is an equal opportunity/affirmative action employer. The BMC Department of Emergency Medicine is exceptionally committed to diversity and inclusion within our faculty and residents and welcomes applicants from diverse backgrounds. Find out more @ BMCFellowships@bmc.org

BROWSE OPEN ACADEMIC

EMERGENCY MEDICINE JOBS!

• Explore new career opportunities for FREE!

• Click on any websites, emails, and videos to learn more.

• Download the guide to look back on organizations and positions that appeal to you.

WE'RE HIRING EMERGENCY MEDICINE PHYSICIANS!

The Mid-Atlantic Permanente Medical Group (MAPMG) proudly provides the highest quality integrated care for over 800,000 members in Virginia, Maryland, and the District of Columbia We invite physicians to apply for our non-traditional emergency medicine career opportunities Reach out to hear how we differ from other organizations

We are offering a generous $200,000 Forgivable Loan Eligibility at select locations in addition to our excellent compensation and rich benefits package.

I n c o l l a b o r a t i o n w i t h t h e K a i s e r F o u n d a t i o n H e a l t h P l a n o f t h e M i d -

A t l a n t i c S t a t e s w e p r o v i d e h i g h - q u a l i t y , p a t i e n t c e n t e r e d h e a l t h c a r e T h r o u g h t h i s p a r t n e r s h i p , o u r p h y s i c i a n s a r e p a r t o f a n i n d u s t r yl e a d i n g h e a l t h c a r e d e l i v e r y m o d e l , h a v i n g a c c e s s t o a d v a n c e d t e c h n o l o g i c a l t o o l s a n d r e c e i v i n g c o m p r e h e n s i v e p r a c t i c e s u p p o r t

MAPMG physicians are salaried, without the pressures of alternative payment models or fee-for-services Our members have easy access to specialists and medical records, thus allowing you to treat the whole patient.

We invite you to apply! Contact: Katherine.X.Eide@kp.org or call (704) 437-7914 | Visit midatlantic.permanente.org/careers

3 Ways You Can Help Your Group Win