SAEM Pulse November-December 2022

NOVEMBER-DECEMBER 2022 | VOLUME XXXVII NUMBER 6

www.saem.org

SPOTLIGHT STORYTELLING AS A POWERFUL TEACHING TOOL An Interview with

Shan Liu, MD, SD,

Leading expert in geriatric EM

FOCUS ON MEDICAL STUDENT AND RESIDENT RESEARCH page 42

Leading the advancement of emergency care through education and research, advocacy, and professional development in academic emergency medicine.

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 Macalindong Ext. 217, amacalindong@saem.org Specialist, IT Support Dawud Lawson Ext. 225, dlawson@saem.org Director, Governance Erin Campo Ext. 201, ecampo@saem.org Coordinator, 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 Manager, Digital Marketing & Communications Raf Rokita Ext. 244, rrokita@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 Sandi Ganji Ext. 218, sganji@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 Associate Editor, RAMS Aaron R. Kuzel, DO, MBA aaron.kuzel@louisville.edu

2022–2023 BOARD OF DIRECTORS Angela M. Mills, MD President Columbia University, Vagelos College of Physicians and Surgeons Wendy C. Coates, MD President Elect Los Angeles County HarborUCLA Medical Center Members-at-Large Pooja Agrawal, MD, MPH Yale University School of Medicine Jeffrey P. Druck, MD University of Colorado School of Medicine Julianna J. Jung, MD Johns Hopkins University School of Medicine Michelle D. Lall, MD, MHS Emory University

Ali S. Raja, MD, MBA, MPH Secretary Treasurer Massachusetts General Hospital / Harvard Medical School Amy H. Kaji, MD, PhD Immediate Past President Harbor-UCLA Medical Center Ava E. Pierce, MD UT Southwestern Medical Center, Dallas Jody A. Vogel, MD, MSc, MSW Stanford University Department of Emergency Medicine Resident Member Wendy W. Sun, MD Yale University School of Medicine

HIGHLIGHTS 3

President’s Comments The Time to Discuss Mental Health is Now

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Spotlight Storytelling as a Powerful Teaching Tool – An Interview With Dr. Shan Liu, MD, SD

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Admin & Clinical Operations ED Hallway Beds: The Patient Experience, Drawbacks, and Potential Solutions

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Admin & Clinical Operations Mobile Integrated Health: Can We Decrease Patient Returns to the ED?

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Admin & Clinical Operations Addressing Sexism in Emergency Department Operations

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Diversity & Inclusion Beyond Competency: Striving for Cultural Safety in Latinx Health Equity

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Diversity & Inclusion Recruiting, Engaging, and Retaining Diverse Faculty in EM: A Call to Action

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Education & Training Making Midlines Mainstream

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Emergency Medical Services Prehospital Advancements in Stroke Care

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Ethics in Action “A Patient Who Cannot Speak Freely Cannot Be Treated Appropriately”

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Faculty Development 4 Tips to Set Junior Faculty Members Up for a Successful Shift With a Resident Physician

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Article titles appearing in red font in the table of contents have been identified as being of particular interest to emergency medicine residents and medical students.

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Sex & Gender Perceptions and Avoidance of the ED Among Gender Minority Patients

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Simulation “Crash Testing the Dummy”: In-Situ Simulation in the Emergency Department

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Virtual Presence TikTok Takes on FOAMed

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Wellness Systems and Departmental Responses to Fatigue Management

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Wellness Fostering Social Connectedness in Residency Through Residency “Pods”

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Wellness Roe v Wade, Dobbs, and Reproductive Justice: A Case for Moral Injury to Physicians

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Wellness The Role of the Resident Wellness Chief in Contributing to the Well-Being of Residents

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Shifting Tides: Changing the Paradigm of Treating Opioid Use Disorder by Updating Resident Education

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SAEM Annual Awards: A Who’s Who of Emergency Medicine

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End of Year Donor Guide

Geriatric EM Virtual Specialty Care: Providers and Payors Unite!

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Global EM Alcohol Misuse and Its Impact on Emergency Medicine Across the Globe

Congratulations to the 2022 EMF/SAEMF Medical Student Research Grantees and Emergency Medicine Interest Group (EMIG) Grantees

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Innovation in EM Becoming the Cutting Edge: Lessons on Innovating in Emergency Medicine

Briefs & Bullet Points - SAEM23 - Journals - Featured News - SAEM Foundation - News & Info

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Research Optimization and Implementation Trial of a UserCentered Emergency Care Planning Tool for Infants with Medical Complexity

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SAEM Reports - Interest Group News Academic Announcements

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Research Focus on Medical Student and Resident Research

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SAEM Pulse is published bimonthly by the Society for Academic Emergency Medicine, 1111 East Touhy Ave., Ste. 540, Des Plaines, IL 60018. (847) 813-9823 Disclaimer: The views and opinions expressed in this publication are those of the authors and do not necessarily reflect the official policies, positions, opinions, or views of the Society for Academic Emergency Medicine or its members. © 2022 Society for Academic Emergency Medicine. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means without prior permission in writing from the copyright holder.

PRESIDENT’S COMMENTS Angela M. Mills, MD Columbia University Vagelos College of Physicians & Surgeons 2022–2023 President, SAEM

The Time to Discuss Mental Health Is Now

“It is critical that mental health services are available and easily accessible to the medical community.”

For the month of October, SAEM hosted its largest campaign yet: #StopTheStigmaEM Month. This first-ever Stop the Stigma EM awareness campaign was focused on breaking down the barriers for mental health care in emergency medicine. Successful efforts included a robust use of social media, events including an in-person session at ACEP, and free “Zoom Gatherings” and activities to get folks engaged, sharing stories, and talking about the importance of our mental health. I want to extend a special thanks to our SAEM Wellness Committee, our All-EM Mental Health Collaborative, and all of our members, staff, and partners who helped take our initial Stop the Stigma EM idea to the next level.

Over the past few years as department chair, I have witnessed firsthand the struggles that physicians and other health care professionals have endured during the pandemic, coping with sadness and loss, the changes to our everyday lives, and being stretched in new ways both professionally and personally. Personally, and for our group, the tragic loss of our colleague and friend, Dr. Lorna Breen, to suicide was devastating. As one physician dies by suicide each day in the United States, it is critical that mental health services are available and easily accessible to the medical community.

Earlier this year, President Biden signed the Dr. Lorna Breen Health Care Provider Protection Act into law, allocating $135 million in federal grants over three years to mental health efforts in suicide prevention and well-being for health care workers. While the availability of mental health treatment is important, we know there is significant stigma in seeking care within the medical community. A poll of emergency physicians demonstrated that 45 percent are not comfortable accessing mental health care and over half reported being concerned for their job if they were to access mental health treatment.

While the effects of the pandemic have changed over time, ongoing challenges in our emergency departments remain with staffing, boarding and other issues affecting our ability to provide the excellent care we strive to deliver for our patients and the education for our learners.

We know that burnout in emergency medicine was well documented prior to the pandemic.

Stress and anxiety have only been exacerbated over the past few years with a recent survey demonstrating 60 percent of emergency physicians struggle with burn-out.

Following the loss of our colleague, our department instituted confidential “opt-out” peer support sessions with a psychiatrist or psychologist. These one-on-one sessions were free, without any documentation in the electronic health record, and appointments were scheduled with the choice to “opt-out” to make things as convenient as possible. We know that folks who may be most in need of mental health treatment are sometimes also challenged in scheduling an appointment.

During the first year of our intervention in Spring 2020, 70 percent of our group took part in these one-on-one sessions. The following year 26 percent participated, and this past spring we had 12 percent of the group take part in these “opt-out” sessions. While the number of participants has decreased over time, I wonder if some of this may be attributed to more people engaging in ongoing mental health care with a few of our faculty having shared they meet with a mental health specialist regularly. With the goal of destigmatizing mental health care for all, I am grateful we have been able to continue the sessions for our group.

It is expected that we see our primary care provider yearly for a check-up and preventive care, just as we are expected to visit the dentist’s office every six months. Having an annual session to check in regarding our mental health should be no different. Our opt-out sessions assisted in breaking down the barriers to accessing mental health care, reducing stigma, and normalizing the discussion.

With the continued challenges facing emergency medicine and the recent signing of the Dr. Lorna Breen Act, the time is now to openly and regularly discuss mental health.

While our SAEM #StopTheStigmaEM Month campaign was focused in the month of October, I implore all of us to continue these efforts, regularly checking in on ourselves as well as those around us. It will take all of us to dismantle the culture of stigma to ultimately improve well-being for emergency medicine as well as in our greater community.

ABOUT DR. MILLS: Angela M. Mills, 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

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SPOTLIGHT

STORYTELLING AS A POWERFUL TEACHING TOOL An Interview With Geriatric EM Expert, Shan Liu, MD, SD

Shan Liu, MD, SD is an attending physician in the Department of Emergency Medicine at Massachusetts General Hospital (MGH).

She received her medical degree from Harvard Medical School, her doctorate in science in health policy from Harvard School of Public Health and completed her residency at the Harvard Affiliated Emergency Medicine Residency Program. She is currently an associate professor of emergency medicine at Harvard Medical School and the MGH Geriatric Emergency Medicine Division Fellowship Director. She is past president of SAEM’s Academy of Geriatric Emergency Medicine (AGEM) and has served on the executive board of the American College of Emergency Physicians’ Geriatric Emergency Medicine Section and the International Federation of Emergency Medicine Geriatric Emergency Medicine Special Interest Group. She is considered the international expert in the emergency department (ED) management of fall patients and leads the Geriatric Emergency Medicine Guidelines group. She has authored publications in U.S. News and World Report, CNN, and the forthcoming book, Masked Hero: How WuLien Teh Invented the Mask and Ended an Epidemic (Publisher Candlewick Press/MIT kids).

SAEM PULSE | NOVEMBER-DECEMBER 2022

Dr. Wu-Lien Teh: Inventor and "Plague Fighter"

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During COVID lockdown Dr. Liu and her daughter, Kaili, wrote a book entitled, Masked Hero: How Wu Lien-teh Invented the Mask and Ended an Epidemic. The book tells the true story of a boy who loved science and when a deadly disease came to China in 1910, how he used his learning, courage, and quick thinking to invent a mask that quickly ended the outbreak, saving countless lives in China and around the world. That boy was Dr. Liu’s great-grandfather, a physician renowned for his work in public health and particularly, as the “Plague Fighter” who stamped out the Manchurian plague of 1910–11 using the same precautions (wearing masks and restricting travel) taken during the COVID-19 pandemic more than 100 years later. The mask he invented was the Wu mask, the precursor of today's N95 mask.

Dr. Wu-Lien Teh was also the first Malayan and the first Chinese-heritage person nominated to receive the Nobel Prize in Medicine in 1935.

“It is frustrating when we know how to stop the spread of a disease but struggle to persuade the public to act on that knowledge.”

In the 1990s you spent a year as a Fulbright Scholar conducting health policy research on AIDS education policy in Honduras. In your experience with COVID-19 and AIDS, what similarities and differences have you found, especially regarding attitudes, stigma, discrimination, fear, misinformation, and inequities among vulnerable groups?

There is always a lot of fear with the unknown. And an easy way to cope with that fear is to blame others – with both AIDS and COVID, it is all too easy for society to place blame on those who fall ill and thus stigmatize them. Unfortunately, both diseases, at least early on with COVID, were related to socioeconomic factors – front-line workers, multigenerational families living together, people not having access to health information or access to testing. With AIDS, in many low-resource countries, people may not be able to afford condoms. And misinformation is easily spread during epidemics and even more so in the age of social media. In terms of differences, I think it has been a miracle to have a COVID vaccine roll out within a year – a truly amazing testament to the power of science, research, and technology.

What lessons learned from studying AIDs helped you in dealing with COVID, both from a practical/professional and a personal standpoint?

It is frustrating when we know how to stop the spread of a disease but struggle to persuade the public to act on that knowledge. Changing peoples’ behavior is difficult and requires more than simply disseminating information. We must gain their trust and make it clear how change benefits them. Studying the AIDS epidemic provided me with insights into why people resist measures that could save their lives. That in turn helped me

understand why some people refuse to be vaccinated against Covid-19. Unfortunately, that understanding doesn’t lessen my frustration.

When is the book you wrote with your daughter, Masked Hero: How Wu Lien-teh Invented the Mask and Ended an Epidemic, scheduled to publish? Did you learn anything new about your great-grandfather while writing the book? How important is “storytelling” when it comes to teaching? What is the most important message you would like this story to convey?

I am so excited to share that the book will be released in September 2023. Writing it taught me so much and working on it with my daughter made the experience all the more special.

Because my great grandfather was an expert in infectious diseases, the Chinese government dispatched him to Northeast China, in 1910, to confront a plague that was rifling through the population, killing nearly everyone it infected. Foreign doctors who were already there thought it spread through rats, but, after conducting an autopsy, Dr. Wu discovered the real culprits were the respiratory droplets that spread through coughs. That led him to invent a mask that proved essential to ending the epidemic. But the plague wasn’t his only foe. He also faced racism, especially from a French doctor who couldn’t believe that a “Chinaman” had unraveled the mystery. He refused to wear Dr. Wu’s mask and died from the infection, days after visiting a patient ward.

Storytelling is a powerful weapon against hatred because it shows that people who appear different from us really aren’t so

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continued from Page 5 different after all. I hope this story teaches children that people of any race or gender can be heroes. Telling Dr. Wu’s story is especially important now because of the pandemic and the racism and scapegoating Asian people have suffered because of it.

What have we learned — and not learned — about dealing with a pandemic in the 100 years since your great-grandfather eradicated the pneumonic plague in northern China?

Masking and social distancing are the best means of halting the spread of new respiratory infections, especially before vaccines and medications can be developed. Unpopular as these measures are, we have learned that people can endure them and that they do save lives. We also must invest in public health—today’s system suffers from underfunding and fragmentation that hamper rapid and effective responses to emerging threats. Finally, we need more global cooperation.

Shortly after the Manchurian plague ended, Dr. Wu convened a conference where experts worldwide gathered to learn about masking and to share knowledge with each other.

When the Influenza Pandemic broke out in 1918, masks were a vital part of the public-health response. Politics and nationalism will always exist, but if we learn one thing from the past, it should be that we can end disease outbreaks much faster when we put those things aside

Your great-grandfather was the first Malayan and the first Chinese-heritage person nominated to receive the Nobel Prize in Medicine in 1935. Google even dedicated a Doodle to him on what would have been his 142nd birthday! How has his story shaped your life? What is the greatest lesson and legacy he has passed along to you?

SAEM PULSE | NOVEMBER-DECEMBER 2022

Growing up I always wanted to be a doctor and work in public health—largely because of the stories of my great grandfather. Even today, I can’t imagine the courage he must have summoned to confront an epidemic with a near-100% mortality rate. I certainly felt fear in the initial phase of the

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“Genomics and personalized medicine will play an increasingly important role in patient care.” pandemic when so much about the virus was unknown. But in a crisis, we must put our fears aside and use our skills and gifts to help others. My great grandfather did just that, and his inspiration stays with me to this day.

Your great-grandfather was a devoted advocate and practitioner of medical advancement. In fact, he is known as the Father of Modern Medicine in China and is credited with establishing the standard for generations of doctors to follow. Looking back on your own career, what are some of the most significant changes or advances you’ve seen in emergency medicine since you started practicing medicine?

I am proud of the incredible growth of research in the emergency-medicine field. Technology has also made significant impact, but not always for the good. Early in my career, we wrote prescriptions and documented patient encounters on paper. Now we have electronic prescribing and electronic-medical records, which have reduced medication errors and sped up the process of obtaining records from other hospitals. But instead of finishing our paper documentation a few minutes after leaving the patient’s room, we now spend hours on electronic charting after our shift ends. That adds to the strain facing emergency physicians and contributes to burnout.

What do you think are the most urgent issues facing emergency medicine in the U.S. today?

My first publication, and later, my doctoral research, examined adverse events related to boarding in the emergency department. Crowding was bad back then, but it is even

worse today. We are seeing record numbers of patients coming into the emergency department, and it is taking a toll on staff who are still recovering from the shock of the pandemic. As a result, I see many talented and dedicated staff burn out and leave emergency medicine. It is a tragedy that we are losing so many amazing clinicians, and I fear that the high attrition rate will only worsen emergency department crowding.

In the coming years, what do you believe emergency medicine physicians will need to become experts at?

Genomics and personalized medicine will play an increasingly important role in patient care. For example, new blood tests promise to detect cancer earlier than conventional methods. As physicians we will have to learn how to interpret and utilize these and other emerging diagnostic and treatment technologies.

You are one of our specialty’s leading experts in geriatric emergency medicine…What inspired your interest and involvement in geriatric EM? My first academic focus was on boarding and crowding, two issues that affect the geriatric population significantly. The geriatric emergency medicine specialty started about 10 to 15 years ago, and I found the pioneers of the field to be incredibly warm and inviting. It was also easy to get involved because

there was, and still is, a tremendous need for more research to establish protocols to guide the care of the geriatric emergencymedicine patient.

What other research topics get you fired up and why?

I love to learn about other cultures and explore how cultural differences affect patients and the practice of emergency medicine. Quantitative research tells us what differences exist.

Hearing people’s stories helps us understand why they occur.

What led you to choose emergency medicine as your specialty and, specifically, why academics?

I was initially drawn to family medicine and pediatrics, but I quickly learned that I didn’t like peering into kids’ ears. I didn’t know how to get parents to hold their children still. Fortunately, in my second week of medical school, my anatomy and small group leader invited us to shadow him during a shift at MGH. I took him up on his offer, and, three hours later, I was hooked on emergency medicine. I loved the adrenaline and sense of camaraderie in the emergency department, and the breadth of cases was energizing. Academic emergency medicine appealed to me because it allows for the most flexibility. If you have interests beyond patient care you can also do administration, education, research, and policy work during your career.

Up Close and Personal 1. You have a full day off work… what do you spend it doing?

Exercise, take a walk with a friend, pick up kiddos early and play at the park, and watch some true crime series with husband.

2. Name three people, living or deceased, whom you would invite to your dream dinner party.

What a great question – Bono, Dr. Martin Luther King, Jr., and President Barak Obama. Their words can make people soar. We are in desperate need of leaders who can inspire us to see past our differences so we can reach common goals.

3. What is your guiltiest pleasure (book, movie, music, show, food, etc.)?

Peanut butter and chocolate. Hands down the best comfort food ever. And the new Top Gun movie was actually really entertaining.

4. When you were a child, what did you aspire to become?

I loved the surgeon general C. Everett Koop. I thought he was the perfect blend of a kind and caring doctor who spoke scientific truth. He drew a huge amount of criticism because he was politically appointed for certain values, but he used science to prevent the spread of AIDS, despite garnering a lot of political backlash. I wanted to be the surgeon general in 6th grade. However, I don’t think I could stomach the political world as it is today.

5. If you weren’t doing what you are doing now, what would you be doing instead?

More direct public health work.

6. What is the most interesting/exciting/fun vacation you've ever taken?

One of my colleagues is connected with these amazing 2-3 week private jet tours. We get to be the private doctor for 60-80 people who literally jet set around the world. The best tour I had was called Great Faiths. We had two religious professors and one art expert give lectures while we visited Rome, Tibet, Jerusalem, the Ganges river and multiple other pilgrimage sites; it was a crash course in comparative religion and just was life changing.

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ADMIN & CLINICAL OPERATIONS

ED Hallway Beds: The Patient Experience, Drawbacks, and Potential Solutions

SAEM PULSE | NOVEMBER-DECEMBER 2022

By Derrick Huang, MD; Meagan Hunt, MD; Tehreem Rehman, MD, MPH; Max Kravitz, MD, MBA; and Megan Davis, MD, MBA, on behalf of the SAEM ED Administration and Clinical Operations Committee

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Emergency department (ED) overcrowding is becoming more prevalent across the nation. This problem occurs when the demand for patient care in the ED exceeds the number of bays or rooms in which the emergency medicine team can provide care. Unsurprisingly, overcrowding has been associated with worse health outcomes, decreased patient satisfaction, and physician burnout.

Indeed, when the patient volume in the ED exceeds room capacity, patients may need be seen in hallway beds as opposed to private rooms.

Unfortunately, institutional failures to address inpatient boarding in our EDs create a visible inequity in care for our patients. Is it any surprise that patients ask, “Why am I being the one seen in the hallway?”

The Benefits of Hallway Beds

Why would EDs resort to care in hallway beds when such an approach can negatively impact the satisfaction of care for patients and their families?

The simple answer is that hallway spaces add capacity and one of the biggest drivers of patient satisfaction is wait time. Increasing capacity with hallway beds decreases the time a patient must wait to be seen. Hallway beds are also dynamic, simple to operationalize, and free to implement.

They allow departments to “flex up” as needed during busier days and times.

This impermanent solution comes at no cost to our hospitals and can be employed immediately by ED care teams desperate to care for more patients. Most importantly, this allows ED teams to decompress lower acuity

patients quickly to reduce overcrowding in swelling lobbies as quickly as possible when a volume surge occurs.

The Drawbacks

Unfortunately, patient care in hallway beds is associated with worse health outcomes. Care in the hallway goes beyond its strong association with prolonged length of stay and dissatisfaction from both patients and staff. Outside of a private room, hallway patients do not have access to the same level of electronic monitoring. The bedside nurse may be providing care that exceeds his or her usual patient load. While lower acuity patients can be managed in this scenario without safety concerns in many cases, the patient experience is that he or she is the lowest priority in the nurse’s assignment and often in their provider’s work list.

The hallway patient observes more acute patients receiving treatment while they remain waiting; they often report feeling that the care they do finally receive, is rushed. This can leave the patient feeling that his or her concerns are dismissed and not adequately addressed.

While the ED team is compelled to be highly aware of the acuity and emergent priority of its panel of patients, this is certainly not transparent to the layperson.

Our patients come to us feeling very vulnerable, scared, and worried about their symptoms being a life-threatening emergency. Although hallway beds theoretically allow the patient to reach a treatment space more rapidly, the patient may experience inequity in the response time of staff, decreased time spent at the bedside compared to time spent with other patients in other ED spaces, and a complete lack of privacy for their evaluation.

Unsurprisingly, the low priority status of the hallway patient and the limitations of hallway evaluation can result in unrecognized clinical deterioration.

Hallway patients have been found unstable, apneic, unconscious, and in a state of shock [1]. Coordination of care and communication among the ED, admitting, and consulting teams — not to mention patient family members — can be difficult to maintain. Derelict Intravenous lines, delays in medication administration, exposure to traumatic psychological events, and inadequate pain treatment follow naturally. These consequences are likely multifactorial and can also be partially explained as a consequene of inadequate resources and staffing.

Socioeconomic Bias

The decision involved in placing a patient in a hallway bed as opposed to a private room also brings up the concern of socioeconomic and ethnic bias in placement. This problem may be amplified by the decision to place patients who are undifferentiated and not triaged appropriately especially during busier ED hours. Prior studies have shown evidence of ethnic and racial bias, gender bias, and age biases in the often-chaotic environment of the ED. Indeed, evidence of bias in treatment by ethnicity and race have played a part in establishing policies toward pain management in the ED. Biases likely play a role in bed placement as well. For instance, in a large, retrospective study conducted

by Kim et al. at two academic EDs from 2013–2016, race was not found to be

an independent predictor for hallway bed assignment, whereas visits paid primarily

by Medicaid were found to have a disproportionate association with hallway bed assignment. The authors concluded that there was evidence for social determinants of hallway bed use that was likely multifactorial. Even so, results from these academic centers may not be generalizable to community settings.

Solutions

Treating patients in hallways is a natural extension of ED overcrowding [2]. As EDs reach capacity, wait times lengthen and the pressure to add capacity and, by extension, utilize hallway beds, is felt.

Many potential solutions to overcrowding and socioeconomic bias in patient care have been put forth. A key example is ACEP’s Emergency Medicine practice committee’s set of recommendations of high impact solutions to ED overcrowding that focus on input, throughput, and output variables as opposed to simply increasing capacity. For example, decreasing input by triaging patients to non-ED settings such as urgent care and increasing output via inpatient hallway boarding can reduce overcrowding and the pressure for hallway bed use.

Solutions such as fast track, physicians in triage, and bedside registration are wellknown strategies that have been utilized to increase throughput. Furthermore, protocolization of patient hallway bed assignment can help to reduce bias in placement. This may include an emphasis on obtaining and using objective, clinical characteristics before hallway bed assignment in addition to recording demographic data of patients placed in hallway beds and providing propensity data to triage providers.

A common theme that connects these solutions is the need for transparency, multidisciplinary involvement, and interdepartmental and institutional support. For example, although inpatient hallway boarding has been shown to have tremendous potential in reducing boarding overall, would this solution be acceptable to the inpatient hospital team?

Without institutional support and pressure for initiatives that are unsavory to those outside the ED, a solution such as this is unlikely to succeed.

Are systems in place to facilitate transparency in the form of reporting clinical consequences or socioeconomic bias resulting from hallway care? We know that treatment in hallway beds can

be harmful for all our patients. Reporting of data on the effects of this practice can therefore be the starting point for interdepartmental and multidisciplinary discussion of possible alternative interventions. Continuing to pivot to these suboptimal spaces for care without further action comes at a cost to those of us working under these conditions and to our patients who are subjected to them. We recommend amplifying potential solutions to this issue like those proposed previously. Overcoming the pressures to continue the use of these spaces is a daunting challenge; however, we owe it to our patients to advocate for alternative solutions and support to provide better care.

ABOUT THE AUTHORS Dr. Kravitz is chief resident at Beth Israel Deaconess Medical Center Harvard Affiliated Emergency Medicine Residency.

He received his dual-degree MD/MBA at Temple University. r. Hunt an assistant professor D of emergency medicine at the Wake Forest University School of Medicine and serves as medical director for the adult emergency department at Atrium Health Wake Forest Baptist Medical Center.

Dr. Huang is the PGY-3 chief emergency medicine resident at Ocala Regional Medical Center in Florida.

Dr. Davis is a second-year emergency medicine resident at Emory University. She received her dual-degree MD/MBA at Boston University.

r. Rehman is a physician and D clinical instructor at CU Anschutz Department of Emergency Medicine. She is a section editor for the ED Administration, Quality and Safety section of the Western Journal of Emergency Medicine.

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ADMIN & CLINICAL OPERATIONS

Mobile Integrated Health: Can We Decrease Patient Returns to the ED?

SAEM PULSE | NOVEMBER-DECEMBER 2022

By Rida Farook; Thomas Hagerman, MD; Michael B. Holbrook, MD, MBA; Thomas Derkowski, MHA, CCEMT-P; Sean Drake, MD; Matthew Ball, MD; and Joseph Miller, MD, MS on behalf of the SAEM ED Administration & Clinical Operations Interest Group

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The transition from the emergency department (ED) to home carries risks for a substantial proportion of ED patients. These risks are particularly present among vulnerable patients who have barriers to timely outpatient follow-up. One potential solution to mitigate risk and improve overall patient care is the introduction of Mobile Integrated Health (MIH) and Community Paramedicine programs (MIH-CP).

These programs were first introduced in 1992 to address health care disparities experienced by patients in rural communities. Eventually, MIH-CP programs expanded beyond rural areas into suburban and urban communities to meet patients at their homes to address wellness, disease prevention, post discharge care, and medical compliance. In the past ten years, there has been a substantial increase in the number of these programs and the breadth of care provided. Existing small studies suggest that MIH-CP programs may reduce ED re-visits, improve the

“Existing small studies suggest that MIH-CP programs may reduce ED re-visits, improve the efficiency of patient care, and are associated with overall cost reduction.” efficiency of patient care, and are associated with overall cost reduction.

For example, when MIH-CP programs were implemented in Nova Scotia, ED readmissions were reduced by 23% in 2002 and 2003. The MedStart Mobile Health Program in Dallas-Fort Worth, Texas avoided 1,893 transports to the ED between January 2010 and February 2015, with an average patient satisfaction score of 4.9 out of 5. It also saved an average of $7,620 on payment charges per patient impacted by the program. Additionally, in the program in Dallas-Fort Worth, the readmission rate

for enrolled patients with congestive heart failure was found to be only 16.3% compared to the national readmission rate of 23%. In terms of patient costs, the MIH run by Niagara EMS in Ontario, Canada saved $171,573 per onethousand calls compared to regular ambulance responses in 2018. In Los Angeles, MIH and CP programs particularly assisted people experiencing homelessness in managing their health as they were found to have a 19 times higher rate for ambulance transport prior to implementation of these programs.

Additionally, in terms of increasing care

“While requiring substantial up-front investment, MIH-CP programs can be powerful for bridging the gap between the ED and recovery at home.” efficiency, patients directed to a mental health agency via an MIH spent an average of 26 minutes waiting for care compared to hours or even days when sent to the local ED. Henry Ford Health, an integrated health system in southeast Michigan, implemented an MIH program in 2020 with the intention of providing postdischarge assistance with patient health literacy, prescription support, home safety, and virtual physician visits.

Patients are referred to the MIH program through not only the ED, but also general post-discharge and outpatient clinics.

Paramedics that provide home visits have on-call physician support to guide management decisions and provide virtual visits using video and TytoCare technology. The MIH team provides all services at no cost to patients.

Since April of 2020, the MIH team at Henry Ford Health (HFH) has had over 7,990 home encounters. Around half of all referrals come from the ED with remaining coming from inpatient units, outpatient primary care physicians, and specialists. Among patients seen by MIH, 42% had Medicare or Medicaid insurance and 53.2% had an annual income less than $41,000. Around 49% of patients were non-Hispanic black. About 67% of the patients enrolled in the program had one or more chronic disease,s including but not limited to hypertension, diabetes

mellitus, chronic kidney disease, and congestive heart failure. Interventions have included patient education (47.4% of encounters), medication reconciliation (33.3%), medication administration (10.3%), and emergency food box provision (2.5%). During the pandemic, the program provided home infusions of monoclonal antibody treatment to more than 400 high-risk patients with COVID-19.

Encounters in the ED are costly and time-consuming, and discharged patients face a wide array of barriers to adequate follow-up and continued care after their encounter. While requiring substantial up-front investment, MIH-CP programs can be powerful for bridging the gap between the ED and recovery at home.

Further research into the effectiveness of MIH-CP interventions on patient outcomes is currently being conducted.

The HFH MIH team is participating in a PCORI funded implementation project to improve education and self-care in patients with acute heart failure after their ED encounter. This implementation project will track whether improving patient self-care reduces ED and hospital re-admissions. Further work to improve reimbursement strategies through Medicaid and commercial plans is also underway as systems such as HFH aim to close care gaps and provide high-value care to their most vulnerable patients.

ABOUT THE AUTHORS Rida Farook is a second-year medical student at Wayne State University School of Medicine.

Dr. Hagerman is a third-year resident in the combined emergency medicine and internal medicine residency at Henry Ford Hospital.

Dr. Holbrook is an operations and administration fellow at the University of Cincinnati and previously served as chief resident at Henry Ford Hospital. holbromb@ucmail.uc.edu Thomas Derkowski is the director of Henry Ford Health Mobile Integrated Health and has more than 30 years of EMS experience. He is a member of the board of directors for the National Association of Mobile Integrated Health Providers and the committee chair for Training & Education. tderkow2@hfhs.org Dr. Drake is the medical director for Complex Primary Care for Henry Ford Health. He is boardcertified in internal medicine and has worked in a variety of roles including inpatient rounding, outpatient clinic, and teaching. He oversees the Comprehensive Care Centers and the Virtualist Physicians for the Mobile Integrated Health Program. sdrake1@hfhs.org Dr. Ball is the lead ED physician consultant for Mobile Integrated Health and completed an emergency medical services fellowship at The Ohio State University School of Medicine. mball1@hfhs.org Dr. Miller is a clinical associate professor of emergency medicine and internal medicine at Henry Ford Hospital. jmiller6@hfhs.org

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Addressing Sexism in Emergency Department Operations SAEM PULSE | NOVEMBER-DECEMBER 2022

By Tehreem Rehman, MD, MPH on behalf of the ED Administration and Clinical Operations Interest Group

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The Role of Sex and Gender in the Patient Experience Disparities in Care Delivery

Significant disparities in care of women continue to exist, such as with respect to pain management, diabetes care, and treatment of acute coronary syndrome. Gender disparities in pain management could be partially attributed to the stereotypical view of women over-reporting or exaggerating their pain symptoms.

Within diabetes care, “women with type 1 diabetes have a 40% higher excess risk of premature death than men with the disease, and those

individuals with type 2 diabetes have up to 27% higher excess risk of stroke and 44% higher excess risk of coronary heart disease.” There is concern that “many drugs used in patients with diabetes have different adverse effects in men versus women — particularly for outcomes such as fractures and urinary tract and genital infections — which might affect adherence, yet guidelines rarely offer sex-specific recommendations on treatment.”

care such as with women less likely to be prescribed aspirin, statins, and ACE inhibitors compared to men.

Researchers have also found that women found to have a STEMI have higher mortality rates than men with results suggesting “Sex difference in mortality following STEMI persists and appears to be driven by prehospital delays in hospital presentation. Women appear to be more vulnerable to prolonged untreated ischemia.”

With respect to management of cardiac risk factors, there are known sex differences in the prescription of cardiovascular medications among patients at high risk or with established cardiovascular disease in primary

Patient-Physician Gender Discordance

Patient-physician gender discordance can exacerbate these disparities. For instance, one study demonstrated

“Despite growing numbers of women in medical school, female physicians remain underrepresented in leadership roles.” higher mortality among female patients admitted to the hospital with a heart attack when treated by a male physician.

At the same time, authors of this study also noted that “male physicians with more exposure to female patients and female physicians have more success treating female patients.” On the other hand, patient-physician gender concordance may equate to better health outcomes for female patients. According to one study, “elderly hospitalized patients treated by female internists have lower mortality and readmissions compared with those cared for by male internists.”

Such findings have implications about assessing potential gender differences in practice patterns and the merits of behaviors that may not traditionally be rewarded in a male-centric work environment. Growing research shows that female doctors spend more time with patients during consultations which may equate to improved communication, trust, and care experience. Efficiency of course is a balancing measure that operations leaders must consider, such as with longer consultation times improving patient experience but potentially reducing revenue through a fewer number of consultations provided.

Bias in Patient Satisfaction

Despite evidence suggesting that patientphysician gender concordance benefits female patients, it may inadvertently penalize female physicians. A recent study found that while female patients were more likely to choose a female physician, women who chose a female physician were the least satisfied.

Conversely, male patients of female physicians were the most satisfied.

One reason for these results may be heightened expectations of gendered stereotypical behavior such as “warmth” or “compassion” by female patients in choosing female physicians, which in turn leads to a greater risk for dissatisfaction.

Such gendered expectations may explain other disparities, such as female physicians consistently receiving worse online reviews compared to male physicians even after adjusting for specialty. Additionally, patients still disproportionately misattribute female

physicians to nursing or other staff which may impact their perception of the care they received as well.

Challenges Faced by Female Physicians Underrepresentation in Leadership Roles

Despite growing numbers of women in medical school, female physicians remain underrepresented in leadership roles. A recent study in the Journal of the American Medical Association (JAMA) pointed out how “the proportion of women at the rank of full professor in U.S. medical schools has not increased since 1980 and remains below that of men.” Authors of the study found that female academic physicians in the U.S. were significantly less likely to be full professors compared to male physicians, even after adjusting for age, experience, specialty, and measures of research productivity. Intentional development of female physician leaders leads to greater institutional gender equity. There is evidence that “an academic EM department was more likely to have a higher proportion of female faculty and a female residency program director when the department chairperson was female.”

Persistent Unequal Compensation

Within academic emergency medicine, Dr. Jennifer Wiler and team discovered that, “female physicians hold fewer leadership roles…and when they do, they work more clinical hours and are paid less than male physicians.” Dr. Wiler’s research also found that an unacceptable gender salary gap has remained unchanged in emergency medicine these past several years. In addition to investment in leadership development for female physicians, emergency departments will need to need to actively call out institutionalized sexism in medicine and its impact on internalized bias among emergency physicians themselves. Evidence suggests that such gender bias among emergency physicians is present as early as during residency, with one study demonstrating emergency medicine residents negatively

biased against women in positions of leadership. Such bias likely informs persistent gender disparities in leadership and compensation in emergency medicine.

Unique Work Demands and Unacceptable Risks

Both implicit and explicit gender biases influence the unique work demands and unacceptable risks experienced by female emergency physicians. This disproportionately hurts the work-life balance and mental well-being of women in emergency medicine. For example, female emergency physicians are not immune to problematic gendered norms on household work. According to one study, married female physicians spend more than 100 minutes per day on household chores and childcare compared to male physicians. This gendered imbalance in household work remains even after adjusting for each spouse’s expected work hours outside the home. At work itself, female physicians experience unique stressors, such as those related to barriers to breastfeeding during work or the heightened adverse health effects of night shifts during pregnancy.

Female emergency physicians are also at greater risk of experiencing trauma at work through sexual harassment and assault. One recent study involving women in academic emergency medicine across eight different institutions found that 68.4% of women experienced gender discrimination and almost one of out every ten female emergency physicians reported at least one encounter of sexual assault by a colleague or supervisor during their career. Greater work environment demands, and egregious risk of violence may partially explain why female emergency physicians have disproportionately left clinical practice over the past decade. We have yet to see the downstream effects of the COVID-19 pandemic on women in the workforce with gender disparities in emergency medicine likely to even worsen these next continued on Page 14

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few years unless institutions invest in policy and system redesign advancing gender equity.

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Adverse Impact of Sexism on Learners Bias in Evaluations Impede Training Potential

Assessments and feedback are intrinsic components of physician training, but there is now compelling evidence of significant gender disparities in evaluations of medical students and residents. One study found that although male and female trainees receive similar evaluations at the beginning of emergency medicine residency, “the rate of milestone attainment throughout training was higher for male than female

“Greater work environment demands, and egregious risk of violence may partially explain why female emergency physicians have disproportionately left clinical practice over the past decade.” residents…leading to a gender gap in evaluations that continues until graduation.” Another study found that female emergency medicine residents received more discordant feedback compared to their male counterparts, especially with respect to conventionally masculine traits such as autonomy and assertiveness. The authors go on to stress that female residents who disproportionately

receive inconsistent feedback are more vulnerable to “poorer-quality mentoring and instruction,” thus hurting their ability to progress and improve clinical performance.

Bias in evaluations is seen even before residency, thus impacting medical students as well. In a standardized patient interaction exam, “female medical students were viewed as significantly less confident than

male medical students.” Female medical students are also more likely to receive evaluations with descriptors such as “caring” and “empathetic” concentrated under the “compassion” skill domain, as opposed to the “ability” and “grindstone” skill domains in which female medical residents were most frequently described as “bright” or “organized.”

Diminished Psychological Safety in Teamwork

There is also evidence demonstrating gender disparities in evaluations of EM residents by non-physician colleagues, such as nurses. Even when there is a lack of difference in ability or competence as measured by in-service exam scores and milestone evaluations, nurses evaluate female residents lower in their abilities and work ethic compared to male residents.

Having crucial partners of your care team, such as nurses, judge you more harshly because of your gender naturally leads to a diminished perception of psychological safety at work. This has significant quality and safety implications when working in a fast-paced and dynamic health care setting, particularly in the emergency department. Additionally, exhibiting effective leadership during medical resuscitations is a vital component of being a successful emergency physician.

Despite assertiveness being deemed an ideal code leader behavior trait, female residents report greater discomfort and stress with adopting assertive behavior compared to their male counterparts.

Increased Risk for Burnout and Depression

Greater stress and lower psychological safety can hurt well-being and selfconfidence while increased exposure to gender-based discrimination and violence incurs trauma; this all contributes to higher rates of burnout among female physicians. Unsurprisingly, female physicians are more likely to experience depressive symptoms, although preliminary evidence suggests that this disparity can be partially alleviated by reducing work-family conflict that stems from gendered societal norms and power dynamics.

Recommend Next Steps Unfortunately, sexism continues to permeate the field of emergency medicine and it is incumbent upon everyone, especially those involved with operations and systems design, to address sexism head on.

Allyship and Being an Upstander First, all emergency physicians can and should engage in allyship. You can achieve this through seemingly small but powerful acts such as intentionally referring to female colleges as “doctor” to mitigate any microaggressions against them or by elevating a suggestion that a female colleague makes in a meeting.

However, allyship does not end there and compels you to act as an upstander when female physicians are significantly more likely than men to “encounter rudeness, be dismissed [and] face issues with procurement of supplies,” as noted in Dr. Michelle Suh’s presentation at a recent national emergency medicine conference. Department leaders can also leverage data analytics and visualization through dashboards to explicitly call out gender disparities in wages, shift categories such as weekend shifts, and membership in paid versus unpaid committees.

Mentorship and Sponsorship

Mentorship and sponsorship are other ways to address sexism in emergency medicine, by supporting the career development of women and helping close that persistent “leaky pipeline” in leadership. Mentorship can entail providing guidance on knowledge and skills such as negotiation, networking, communication, team dynamics, and the promotions process. Sponsorship can involve thoughtfully nominating women for leadership roles and other promotions. Sponsorship can be effectively institutionalized “by following a standardized process grounded in leadership characteristics and competencies that have been shown to increase numbers of women and racial/ethnic minority leaders.” Such standardized processes enable medical institutions to “see changes in their leadership that mirror the populations they lead and serve.”

Policy Reform and System Redesign

To maximize impact of efforts to counter sexism in emergency medicine, it is imperative as Dr. Carnes and team point out, “to move beyond ‘fixing the women’ to a systemic, institutional approach that acknowledges and addresses the impact of unconscious, gender-linked biases that devalue and marginalize women and issues associated with women, such as their health.” In a recent issue of AEM Education and Training journal, Dr. Pooja

Agrawal and her coauthors delineate strategies for recruitment, retention, and promotion of women in emergency medicine. These strategies include necessary policy reform and system redesign.

For instance, in response to literature showing “that working nights or on call can lead to pregnancy complications” and that “infant-parent bonding in the postpartum period is crucial for breastfeeding, health, and well-being,” Dr. Kimberly Chernoby and team developed a new policy for scheduling pregnant and new parents in EM residency that proved to be feasible to implement while improving trainee satisfaction and reducing risk for adverse pregnancy outcomes. Other similar interventions include providing 6-8 weeks of parental leave and ensuring easy access to private and comfortable lactation accommodations at work.

There is also a need for greater transparency and accountability in reporting mechanisms of gender-based discrimination and violence in the workplace. Additionally, it is imperative that EM leaders proactively counter the impact of bias in patient interactions and patient satisfaction measures that disproportionately hurt women. One low-cost intervention is the use of role identity badges with clear demarcation of doctor “to reduce role misidentification and address burnout” among female physicians. Moving forward, it is paramount that emergency medicine leaders, especially those involved with clinical operations, implement targeted interventions to promote female leadership, as well as psychological and physical safety at work.

ABOUT THE AUTHOR Dr. Rehman is an emergency physician and clinical instructor at the University of Colorado Anschutz Hospital.

Her interests include quality improvement, informatics, and clinical operations and she is developing deep expertise in system redesign to improve transitions of care and linkages to care. Dr. Rehman is also invested in leveraging population health frameworks to develop high-impact and equitable interventions in health care.

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DIVERSITY & INCLUSION

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Beyond Competency: Striving for Cultural Safety in Latinx Health Equity

By Moises Gallegos, MD, MPH and Edgardo Ordoñez, MD, MPH on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine As the push toward health equity and social justice continues to highlight opportunities for change in our health care systems, concepts of cultural competency, sensitivity, and inclusivity will make up many of the discussions.

But what does it mean to achieve cultural competency? Surely, cultural competency has its critics, as one cannot expect that sporadic reading, lectures, or workshops can provide the knowledge, skills, and attitudes necessary to fully engage the various

cultural drivers of health that influence the disease course for our patients.

The cultural diversity that exists in our country is too wide-ranging to ever truly grasp the intricacies of the impact that culture — comprising language, faith/ religion, customs, behaviors, attitudes, etc. — has on health. As described

by Curtis et al., the pursuit of cultural competency may be better described and thought of as striving to provide safe and respectful care. Cultural safety calls on us to create safe spaces that

are responsive to our patients’ cultural, political, spiritual, and linguistic realities.

The journey toward culturally safe, respectful, and inclusive care starts with awareness and develops through openness to learn about others. This article offers a glimpse of Hispanic and Latinx culture and highlights some key concepts and important considerations that demonstrate how eclectic communities that make up this cultural heritage are.

“Cultural safety calls on us to create safe spaces that are responsive to our patients' cultural, political, spiritual, and linguistic realities.”

Cultural and Ethnic Identity Hispanic vs. Latino/a

Hispanic and Latino/a originated in the political sphere during the civil rights movements of the 1950s and 60s. It’s important to understand that these terms describe ethnicity and culture, not race.

Hispanic and Latino/a people can be Black, White, Asian, and Indigenous.

For instance, some Black Latinos may identify themselves as Afro-Latino/a or Afro-Caribbean. Like race, these terms are also social constructs. There is also a difference in what Hispanic and Latino/a mean. Generally speaking, Hispanic means people who speak Spanish or are descendants from Spanish-speaking countries. Latino/a describes those that are from Latin American countries. Some prefer the word Latino/a over Hispanic due to the ties of the term Hispanic to colonialism. Additionally, many feel that

the word Hispanic was imposed by the United States government, unlike the phrase Latino/a, which is seen as a word chosen by communities and grassroots organizations. There are many nuances, but the most important thing is demonstrating respect for how individuals identify.

What about Latinx and Latine?

If you are involved in diversity, equity, and inclusion (DEI) spaces, you have seen these iterations of the pan-ethnic labels of Hispanic and Latino/a. The Spanish language is known to be gendered.

These terms are a newer, gender-neutral way to describe the Hispanic and Latino/a populations.

Outside of DEI spaces and academia, the words are foreign to many. Still, they have been established to introduce gender neutrality into languages and avoid the social construction of gender

binaries. Their use is not yet been standard practice and has brought about a significant debate among those who identify as Hispanic and Latino/a.

Critics will point to how they originated within American activist and corporate movements led by English speakers.

Others will suggest that Latinx and Latine are gender and LGBTQ-inclusive terms that reflect a global movement in gender identity. So how does one navigate this? Using the gendered terms of the Spanish language is entirely acceptable but using the non-gendered words will allow those who value and seek inclusive environments to know they are in safe spaces that will respect their identity.

Cultural Drivers of Care In discussing cultural drivers of health and social behaviors, it is important continued on Page 18

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to acknowledge the shortcoming and pitfalls that may come with overgeneralization and limited consideration of the structural drivers of health. There is value in recognizing common beliefs and practices that may influence a medical encounter. At the same time, we must be cautious and understand that Hispanic and Latinx cultures are not monolithic. Many customs, traditions, and social norms will vary based on geography and ethnic makeup. Here we discuss two brief examples that may apply to certain Latinx communities, but not all.

Familismo

Familismo, a deep connection to family values, is a central aspect of several Latinx communities. Individuals may develop and carry a strong tie to family and a commitment to loved ones. As a result, many personal choices are influenced by the impact that they have on family members. This can manifest as a patient neglecting their own care to prioritize the well-being of others in

“In discussing cultural drivers of health and social behaviors, it is important to acknowledge the shortcoming and pitfalls that may come with overgeneralization and limited consideration of the structural drivers of health.” the family. Delayed presentations for simple complaints now turned more complex may result. This may lead to patients presenting to the emergency department (ED) on holidays and weekends to avoid lost time at work and decreased income. Patients with delayed presentations of acute pathology perhaps would have wanted to come to the ED sooner but couldn’t due to their perceived responsibility to family.

Curanderismo

Spirituality and religion may represent

a core tenet of life for many Latinx countries. In several cultures, this extends to an interconnected relationship between medicine and faith-based healing. For example, the curandero from Latin America is a tradition that continues to exist in some U.S. cultures as an important community member for alternative healing practices. As a sobador, or masseur, the curandero is often sought after for musculoskeletal ailments.

As a yerbero, or herbalist, they are often visited for relief from susto, fear,

“In patient care, research, and work in our communities, we must make every effort to provide culturally safe spaces for everyone, including in the use of language.” or anxiety, or for a limpia espiritual, or spiritual cleansing. Patients may present first to a curandero due to ease of access, immigration status, or financial concerns, before seeking care in a clinic or hospital. The use of a curandero is not always out of distrust for modern or Western medicine. It represents a connection to faith and tradition and is often considered by patients as a supplement to their primary care providers. Patients inquiring if there might be a prescription to treat their coughs, aches, or pains may be familiar with receiving a homemade remedy or concoction and may be looking for a similar tangible takeaway from you in the ED.

Language and Reconsidering Limited English Proficiency While Spanish is the most common language spoken in Latin American countries, many other languages are present, including several Indigenous and Latin-derived languages like Creole and Portuguese. As part of the health care system, the ED must provide interpreter services to non-English speakers, which is mandated by Title VI of the Civil Rights Act for all health care organizations.

Several studies have shown that patients who are non-English speaking do not receive equitable care. Causes of inequities can include improper informed consent and increased medical errors.

Providing language-appropriate services includes 1) language concordance and 2) medical interpretation in the health care setting. Language concordance has been shown to improve patient satisfaction and improve patient outcomes. Medical

interpreters also benefit patients when there is language discordance between patient and provider, but they are often underused. The National Standards for Culturally and Linguistically Appropriate Services exist to advance health equity for diverse communities regarding culture, language, and other communication needs, including individuals considered to have “limited English proficiency” (LEP).

or a preferred language. If it must be specified that English is the primary language in the community, one can say non-English language preference.

Reframing our perspectives on language and being intentional will help provide optimal care to our diverse patient population.

As part of the social justice movement, language justice has promoted the idea that everyone has the right to communicate in the language in which they feel most comfortable. Language justice is a practice used to foster inclusion, develop collective power, and dismantle systems of oppression that have traditionally disenfranchised non-English speakers. The goal is to create multilingual spaces where there is language equity and resistance to the dominance of any one specific language. This framework is essential to consider, given how people have been reprimanded, discriminated against, and discouraged from using their native languages. Understanding these concepts can help us change the narratives intended to be well-meaning but not equity focused. In line with this thinking, let’s consider the use of the term LEP. Think about how this term centers privilege and power of dominant groups. In patient care, research, and work in our communities, we must make every effort to provide culturally safe spaces for everyone, including in the use of language. The terms “limited” and “proficiency” can be stigmatizing because it suggests a deficit. Instead, a more equity-focused alternative describes individuals having a language preference

Beyond language, there exist cultural drivers of care that may influence how Latinx patients engage with the health care system. In the call to action for culturally safe, respectful, and inclusive care, awareness leads to understanding, understanding allows for personal growth, and personal growth results in betterinformed interactions with patients.

Final Thoughts

ABOUT THE AUTHORS Dr. Gallegos is a clinical assistant professor of emergency medicine at Stanford School of Medicine and clerkship director in the department of emergency medicine. He is the development officer for the SAEM Academy for Diversity and Inclusion in Emergency Medicine (ADIEM).

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 president of the SAEM Academy for Diversity and Inclusion in Emergency Medicine (ADIEM).

About ADIEM 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.”

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Recruiting, Engaging, and Retaining Diverse Faculty in EM: A Call to Action

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By Tabia Santos, MD; Annabella Salvador MD; and Nancy Kwon MD on behalf of the SAEM Equity and Inclusion Committee and Faculty Development Committee Health care disparities are a national issue, and disparities in health outcomes have been widely studied.

There is overwhelming evidence to support the existence of persistent gaps in health care and the need to find solutions to these inequalities, including diversifying the medical workforce.

When reviewing health outcome measures, historically marginalized communities have lagged white populations. When the patientprovider relationship is hampered by mistrust, satisfaction with health care services decreases and correlates with worse health outcomes (e.g., lack

“Emergency medicine has long been a critical gateway and safety net for patients with poor access to health care services.” in medication adherence and patient follow-up visits). Consequently, the Joint Commission is addressing these disparities as a quality and patient safety imperative.

Emergency medicine has long been a critical gateway and safety net for

patients with poor access to health care services. The emergency department (ED) is a clinical setting where patients should have equal health care regardless of their race, ethnicity, gender and/or ability to pay; yet health inequity runs rampant even in this setting.

“Although Hispanic, Black, and Native Americans represent roughly one-third of the United States population, physicians from these three racial and ethnic groups comprise only 5.8%, 5.0%, and 0.3% of the physician workforce, respectively — a proportion that has not changed substantially over the last three decades..”

Diversity in the health care workforce has been proven to improve the inequalities of health care outcomes, yet the medical workforce does not represent the diversity of the populations and communities that they serve. While there have been improvements in the representation numbers for some groups, such as women, significant imbalances remain. Multiple studies have shown that increasing the number of physicians that come from underrepresented communities improves overall quality of care, especially for patients that come from similar communities. However, physicians from traditionally marginalized communities remain underrepresented in medicine despite national efforts to increase diversity in the health care workforce.

Although Hispanic, Black, and Native Americans represent roughly one-third of the United States (U.S.) population, physicians from these three racial and ethnic groups comprise only 5.8%, 5.0%, and 0.3% of the physician workforce, respectively — a proportion that has not changed substantially over the last three decades.

The dearth and attrition of underrepresented health care providers begins in higher education, and more specifically during undergraduate medical education. Many schools of health professions struggle to recruit and support underrepresented-in-medicine (URM) students. Despite 50 years of increases in outreach and enrichment initiatives, admission, and financial changes, and using specific admission targets, the racial and ethnic composition of the physician workforce has not changed substantially over the last two decades. According to the AAMC Diversity in Medicine: Facts and Figures 2019 Executive Summary, despite the fact that women have surpassed men in applying to medical school, the growth

of Black or African American applicants, and graduates lags behind other groups.

As a specialty, emergency medicine (EM) is not faring any better in its diversity efforts. Residency training is the next step after medical school for the physician workforce, so increasing diversity at the residency level has a direct impact on the diversity of practicing physicians.

On the other hand, implicit bias and discrimination during medical school, residency, and beyond, has harmful effects resulting in inadequate workplace support and isolation.

Professional development and growth are impeded for URM physicians when there is a lack of diversity and in environments where implicit bias and microaggressions prevail. This may be a contributing factor to why only a small number of Black physicians choose to remain on faculty at academic medical institutions.

The Accreditation Council for Graduate Medical Education (ACGME) has developed requirements related to diversity, equity, and inclusion, including requirements pertaining to recruitment and retention of a diverse and inclusive workforce. Medical schools, residency programs, and academic institutions and health systems must determine their own strategies to achieve this goal. Improving the diversity, equity, and inclusion of our emergency medicine workforce requires a multiprong and longitudinal strategy and commitment.

Fortunately, examples of best practices do exist in literature and in programs across the country. The American Association of Medical Colleges (AAMC) is one of the national organizations that is working to “develop strategic initiatives to cultivate a diverse and culturally prepared workforce, advance inclusion, …and enhance engagement.” The AAMC has published a document titled “Equity, Diversity, and Inclusion Cluster:

Portfolios, Initiatives, and Programs 2022” and in included in this initiative is the Workforce Diversity Portfolio which has as its mission “to be a catalyst for the development of a diverse, culturally responsive healthcare workforce prepared to address societal health needs.” Some of the aims of the initiative include to: • “Develop programs and initiatives that attract, and support racial and ethnic minority faculty and leaders to thrive in academic medicine” • “Create and lead programs that improve access to information and resources for students who are underrepresented in the health professions” The Society for Academic Emergency Medicine has also made a commitment to diversity, equity, and inclusion (DEI). The SAEM Equity and Inclusion Committee is currently in its third year and doing a great deal of work, including building a multifaceted DEI educational curriculum. Furthermore, all of SAEM’s Committees have as a goal identifying, developing, and mentoring future leaders with an eye toward increasing the diversity of leadership on committees, sub-committees, and projects. In addition, one goal of the SAEM Equity and Inclusion Committee is to increase diversity and inclusion in academic emergency medicine through the implementation of a strategic longitudinal plan.

The Council of Residency Directors (CORD) recently published a paper on best practices for faculty recruitment, retention, and representation. These best practices include creating recruitment committees composed of members who are committed to diversity, encouraging accountability by tracking diversity metrics, and incentivizing staff for participation in diversity and inclusion continued on Page 22

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activities. Other best practices identified by the authors include employing an inclusive marketing strategy and targeted recruitment, utilizing a holistic process for reviewing candidates, standardizing the interview process, appointing URM faculty ambassadors to connect with applicants, and requiring interviewers to participate in implicit bias training. However, when recruiting faculty with an attention to diversity, it is important to acknowledge that the burden of responsibility is often disproportionally placed on

“Professional development and growth are impeded for URM physicians when there is a lack of diversity and in environments where implicit bias and microaggressions prevail.” underrepresented faculty. This is known as the “minority tax”; it is a major source of inequity in academic medicine and hindrance to professional advancement in academia. This “tax” burden comes at a professional cost for URM faculty as these types of

responsibilities can syphon time away from career-advancing activities, seldom count toward scholarship, and frequently go unrecognized, unrewarded, and uncompensated. As Christopher Johnson, a board member from the Nonprofit Leadership Center

“The paucity of diversity in academic medicine is a national crisis that needs to be addressed through constant commitment, effort, and attention.”

• Appointing diversity leaders such as a Chief Diversity Officer • Establishing a DEI council to create the climate of diversity, equity, and inclusion for the workforce and patients • Ensuring academic development opportunities for URM faculty • Promoting and URM faculty • Supplying memberships in national organizations to allow for networking and relationship-building opportunities • Implementing faculty development programs that target URM faculty • Encouraging local mentorship and sponsorship or URM faculty by both URM and non-URM faculty

says: “diversity, equity, and inclusion are everyone’s responsibility.”

Retention and engagement strategies are just as important as recruitment strategies. According to the CORD article establishing a culture of inclusivity is a chief way to retain and engage recruited residents. Some suggested methods for establishing an inclusive culture include: • Providing organization-wide implicit bias training • Supporting staff who encounter discrimination • Scheduling ongoing, facilitated discussions and dialogue on race and racism

The paucity of diversity in academic medicine is a national crisis that needs to be addressed through constant commitment, effort, and attention. In the literature, program directors have cited the lack of URM applicants as the most significant barrier to recruitment.

This scarcity of applicants needs to be addressed at all levels, from middle school to medical school. If we do not expose URM students to the medical professions, and provide programs to provide mentorship, guidance, and skills at earlier stages, there will be no pathway to medical school. We need to change current processes in order to improve upon this for the future.

For instance, when it comes to MCAT scores, there is increasing support for reviewing candidates holistically rather than placing so much weight on MCAT scores. Some institutions have implemented programs to assist candidates with the MCATs. The Indiana University School of Medicine, for example, reported improvements in MCAT scores for URM students who had enrolled in a program to improve testtaking skills on the MCAT.

The literature suggests that the diversity of faculty and residents should reflect the diversity of the patient population, otherwise health equity will never be achieved. Some of the best practices to achieve this goal are highlighted above, but these efforts entail a dedicated, coordinated, and honest approach that is owned by all. This is a call to action to embed racial justice and advance health equity to reform our medical workforce for the future.

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. Santos is a PGY-2 resident physician at Northwell Northshore-LIJ in NYC, NY and one of the leaders of the Diversity, Equity, and Inclusion Resident Subgroup Committee.

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.

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EDUCATION & TRAINING

Making Midlines Mainstream SAEM PULSE | NOVEMBER-DECEMBER 2022

By Michael Sherman, MD, MA, and Alexandra Nordberg, MD, on behalf of the SAEM Education Committee

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Difficult venous access is a daily problem encountered in the emergency department (ED), and emergency medicine (EM) has been at the forefront of this field since its inception. In the past, the expanding use of ultrasound guided IVs (US-IVs) was shown to decrease the placement of central lines needed for simple venous access; however, US-IVs continue to be plagued by a high failure rate. In recent years, midline catheters have enjoyed a renaissance, to provide reliable vascular access for patients with difficult venous access who would otherwise require multiple venipunctures or the use of central lines to obtain and maintain access.

History

Midline placement has been used clinically since the 1950s. These older midlines were usually upsized peripheral IV’s. As Seldinger technique revolutionized the placement of central lines, central line placement became commonplace. This procedure was then augmented by ultrasound guidance as a safe and reliable way to obtain venous access, and midlines fell to the wayside in clinical practice. Because of this, most of the guidelines and policy statements surrounding midlines comes from the days prior to Seldinger technique and the routine use of ultrasound for vascular access.

As the placement of central lines became routine, it became common to place central lines when faced with difficult venous access; this, however, exposed patients to the mechanical and infectious risks of central access, among other risks such as patient discomfort. In fact, some hospital systems required that patients with central femoral access to be on bedrest; national focus from the Centers for Medicare & Medicaid Services (CMS) began to highlight the morbidity and mortality associated with Central LineAssociated Bloodstream Infections (CLABSIs). Given the advent of bedside ultrasound, routine use of ultrasound guided IVs was shown to decrease the

Figure 1. Anatomic location of upper extremity veins used for midline catheter insertion.

placement of central lines for venous

multiple venipunctures. Newer midlines

Single Lumen vs Multi-lumen

“A midline is defined as a peripheral venous line of 8-25 cm in length that is inserted in upper arm veins (brachial, cephalic, basilic) and terminates at/before axilla.” access only, and became a staple of modern ED practice. However, the limited length of ultrasound peripheral IVs has led to a high rate of failure of up to 45% and clinical frustration by ED staff.

Old and New Tech

A midline is defined as a peripheral venous line of 8-25 cm in length that is inserted in upper arm veins (brachial, cephalic, basilic) and terminates at/before axilla. With modern materials, newer midlines can be rated for power-injection for IV contrast. With advances in sterile placement, newer generation midlines can now be rated for dwell time of up to four weeks. These two advances mark a renaissance of midlines that vastly expand their clinical utility.

Clinical Utility

The clinical utility of midlines has thus become exponential along two categories: difficult venous access and long-term dwell. Given their length, midlines can reach and maintain access in the deep veins in the upper arm and provide reliable vascular access that would otherwise require central lines or

are designed to provide adequate flow for power-injection for IV contrast studies such as CT angiography, often difficult to obtain in this patient population. The long-term dwell of the new midlines can thus provide sufficient, long lasting access and, in some cases, be the only access a patient needs for his or her entire hospital stay.

These factors give an immediate added benefit to the utilization of midlines; beyond this, the ability to place midlines has several additional advantages. For example, a midline program can also help expand the ED’s ability to help leverage disposition decisions. The ability to place a midline in the ED for peripheral infusions often negates the need to admit patients for PICC placement, and frequently avoids an ICU admission for a LTAC patient that would otherwise only need a PICC placement. Midlines can also facilitate discharge with reliable long-term IV access to nursing homes, hospice, and other home infusions. They also provide reliable access in patients with limited advanced directives who might otherwise decline central access.

The newer generation of midlines come in multiple forms, which is often bewildering to new users. Single-lumen fixed-length midlines provide rapid and easy placement using standard Seldinger technique or accelerated Seldinger technique under ultrasound guidance.

The placement of these lines is easily accomplished within the ED skillset, and accelerated Seldinger technique like commonly placed radial arterial lines.

Another iteration of midlines are trim-tofit midlines that come in single or, more often, multi-lumen versions. These lines are placed using Seldinger technique and require measurement from planned insertion site to the axilla. They are then cut to length by the provider and placed through a break-away introducer sheath.

In placement, these multi-lumen midlines are more similar to a PICC and require a slightly different skillset for placement; however, multi-lumen midlines provide the versatility and flexibility of multiple access points and approaches a true, central line replacement. continued on Page 26

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SAEM PULSE | NOVEMBER-DECEMBER 2022

EDUCATION & TRAINING

26

continued from Page 25

Controversy

Midline adoption is, however, often hampered by historical bias and common misconceptions. The most often cited concern is that due to the catheter length, an occult infiltration can occur and remain undetected; however, feared “occult” infiltration is not reported in any cohort examining the use of Midline catheters. (See this summative blog post for this and other references.)

Unlike PIV’s, midlines rarely infiltrate, and midlines fail less often and in different ways. PIV’s infiltrate/fail because of short distance from insertion site and

“Given their length, midlines can reach and maintain provide reliable vascular access that would otherwise catheter tip due to small veins and poor vein purchase. Midlines fail much later (often due to distal occlusions), and median time to failure can be up to 6.19 days after insertion.

Another related concern is that older guidelines often site that hyperosmolar solutions or “vesicants” are not midline safe; however, the newer safety data often obviates this concern, and a

common solution is to follow the hospital systems guidelines for standard peripheral medication administration.

These issues highlight the importance of leveraging the EM skillset and knowledge to advise and create hospital policy and multidisciplinary teamwork.

Billing

A successful midline program also requires the need for understanding

access.” Given these recent changes, we should note that CPT midline specific codes could later supplant those currently in use.

Resident/Attending Education

Instructing the department in the use of midlines is an important step to successful implementation; however, placing a midline uses already known techniques, and because of this, instruction can be done relatively easily with peripheral IV phantoms. Having someone dedicated to championing the introduction and implementation of midlines can help with on-shift education as well. For the sake of practicality, the use of fixed-length single lumen accelerated or standard Seldinger technique-based midlines is ideal for ED use and will appeal to the comfort level of most people. Nursing colleagues will also to be educated on the use of midlines.

Education and implementation, therefore, involves nursing, departmental, and hospital leadership.

Conclusion

Midline programs are a novel and evolving field of knowledge. A successful midline program requires understanding of the background, current best evidence, multidisciplinary teamwork, and administrative knowledge. Given emergency medicine’s position and facility with ultrasound, EM and the ED are poised to be leaders in the local adoption and implementation of an effective midline program in the ED and across hospital systems.

ABOUT THE AUTHORS

access in the deep veins in the upper arm and e require central lines or multiple venipunctures.” good documentation and reimbursement.

Current Procedural Terminology (CPT) govern midline reimbursement, but historically have not been immune to confusion. Previous CPT coding billed midlines as PICC lines with a modifier for reduced services, leading to the possibility of overbilling. In 2019, the American Medical Association issued new guidance for midline catheters;

“Midline catheters by definition terminate in the peripheral venous system. They are not central venous access devices and may not be reported as a PICC service.

Midline catheter placement may be reported with 36400, 36405, 36406, or 36410”. In the adult ED, the most used CPT code would be 36410 “venipuncture necessitating physician’s skill” and CPT 76937 “ultrasound guidance for vascular

Dr. Sherman is dual boarded in emergency medicine and critical care medicine and has extensive experience with midlines at multiple intuitions. He has successfully implemented and led a hospital-wide midline program at the University of Massachusetts Medical Center in Worcester, MA. Dr. Nordberg is an assistant professor of emergency medicine and point-of-care ultrasound.

She is the assistant program director for the emergency medicine residency program at the University of Massachusetts Chan Medical School in Worcester, MA

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EMERGENCY MEDICAL SERVICES

Prehospital Advancements in Stroke Care

SAEM PULSE | NOVEMBER-DECEMBER 2022

By Irfan Husain, MD, MPH, Elijah Robinson III, MD, and Reena Underiner, MD, on behalf of the EMS Interest Group

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Prehospital stroke care has historically been defined by two goals: early identification and rapid transport to the closest appropriate stroke center.

Traditionally, emergency medical services (EMS) agencies would use a validated stroke recognition scale (e.g., CPSS, LAPSS, FAST) to help identify a stroke quickly, limiting time on scene.

They would then proceed to transport the patient to the closest stroke center or acute stroke ready hospital (rural setting), while providing prenotification to the receiving hospital. The hospital would then activate the appropriate resources and personnel prior to arrival.

However, over the past several years we have seen some interesting new advancements in prehospital stroke management with stroke severity scales for large vessel occlusions and EMS agencies adopting mobile stroke units (MSUs).

“Regardless of the scale utilized, early identification of large vessel occlusions in the prehospital setting can lead to better clinical outcomes, as transport to either thrombectomy-capable stroke center or comprehensive stroke center can be prioritized, and earlier door-to-balloon times can be achieved.”

LVO Prediction in the Field

Thrombectomy for large vessel occlusion (LVO) has become the standard of care and data has come to support its use up to 24 hours since onset in select patients with LVO. As such, many EMS agencies are now adopting stroke severity scales for LVO to be used in conjunction with the stroke recognition scale to transport

suspected LVO strokes directly to thrombectomy-capable stroke centers (TSCs) or comprehensive stroke centers (CSC) (both offering thrombectomy).

Multiple prehospital stroke severity scales have been developed (e.g., VAN, RACE, C- STAT, FAST-ED, LAMS, NIHSS), with no clear consensus amongst EMS agencies as to which

“To decrease time to tPA administration, EMS agencies are increasingly implementing mobile stroke units (MSUs) — specialized ambulances equipped with the tools and personnel to diagnose and treat acute strokes in the field.” higher rates of excellent early outcome in comparison with later treatment.

The trial also demonstrated better functional outcome at 90 days for MSU in comparison to standard EMS care.

With MSUs estimated to cost around $1 million U.S. dollars (USD) to purchase and another $1 million USD to operate yearly, cost of MSU programs have been a concern. However, at the 2022 International Stroke Conference, findings using one-year follow-up data from the BEST-MSU trial showed MSU to be cost-effective, in part due to the reduced downstream stroke-related costs.

Mobile Stroke Units

is best. Several studies have compared the various LVO prediction scales, yet no one scale has been clearly superior.

Regardless of the scale utilized, early identification of LVOs in the prehospital setting can lead to better clinical outcomes, as transport to either TSC or CSC can be prioritized, and earlier doorto-balloon times can be achieved.

To decrease time to tPA administration, EMS agencies are increasingly implementing mobile stroke units (MSUs) — specialized ambulances equipped with the tools and personnel to diagnose and treat acute strokes in the field.

The concept of MSUs originated in Germany in 2008 and has since spread throughout the United States, where there are estimated to be approximately 20 MSU sites. Most MSU sites are in densely populated areas with the exact setup varying agency to agency. For example, in Atlanta, Georgia, Grady EMS has one MSU that contains a CT scanner, thrombolytics, blood pressure medications, anticoagulation reversal agents, and telemedicine capabilities.

Its staffing consists of a paramedic, emergency medical technician, registered nurse, and computed tomography technician. Telemedicine capabilities allow access to a neurologist. The BEST-MSU trial has shown MSUs result in faster onset-to-thrombolysis time, particularly in the “golden hour.” The golden hour refers to the first 60 minutes after onset of symptoms in which initiation of thrombolysis is associated with

As we advance in the realm of prehospital care, LVO prediction scales and MSUs are anticipated to become increasingly integrated in prehospital stroke care.

ABOUT THE AUTHORS Dr. Husain is an assistant professor of emergency medicine at Emory University School of Medicine. He also serves as the associate medical director for Sandy Springs Fire Department and MetroAtlanta Ambulance Service.

Dr. Robinson is an assistant professor of emergency medicine at Emory University School of Medicine. Dr. Robinson is the medical director for College Park Fire and Decatur Fire as well as the associate medical director for Grady EMS. Dr. Underiner is a third-year emergency medicine resident at Emory University School of Medicine, Atlanta, Georgia.

She is planning to pursue an EMS fellowship. Her career interests include emergency preparedness & disaster response, protocol development, and community violence prevention.

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ETHICS IN ACTION

“A Patient Who Cannot Speak Freely Cannot Be Treated Appropriately”

By Jeremy Simon, MD

SAEM PULSE | NOVEMBER-DECEMBER 2022

The Case

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One evening, police officers bring into the emergency department (ED) a 32-year-old male whom they’ve placed under arrest. According to triage, the prisoner himself has no complaints, but the police officers say that when they pulled him over, they saw him quickly put something in his mouth which they believe he swallowed. They are concerned that the “something” may have been drugs.

After an initial evaluation, the physician assistant (PA) reports that the patient denies having swallowed anything, but the police repeat the observation they initially reported to triage. On exam, the patient has normal

“...it is important to remember that although the patient cannot leave against medical advice, he or she also cannot be compelled to accept treatment...” vitals, is in no apparent distress, and has no abnormal findings. The PA and attending agree that the case may be difficult for two reasons. First because the police have no apparent motive to report that the patient swallowed something and if the police are believed to be telling the truth, then the report is presumptively reliable. Therefore, since the patient does not provide any details

as to what he swallowed (in terms of both substance and quantity), the medical team feel obligated to admit the patient for prolonged observation until they are comfortable that any swallowed drugs have been passed or safely absorbed through the gastrointestinal tract. The second reason the case may prove difficult is that the police may ask that medical staff hand over any

“All patients have a right to privacy, but a prisoner, whose words can be used to directly harm him or her, has an even greater need for it.”

drugs passed that are passed to use as evidence against the prisoner/patient; this is something they do not feel comfortable with.

Before proceeding, the attending asks where the police were located during the interview with the patient. The PA responds that they were seated in a chair at the foot of the patient’s bed.

The attending suggests that the PA ask the officers to step out of earshot and then reinterview the patient. When the PA does this, the patient opens up and confesses that he indeed put some drugs in his mouth, but that it was less than a half-dose (for him) of heroin in an open packet, and that he made sure it was all absorbed in his mouth.

With this new information, and comfortable that any potential adverse effects would already have manifested, the attending and PA agree that the patient can be discharged immediately.

The Conclusion

This case raises, at least potentially, several ethical issues regarding the care of patients in police custody. First, although the question was never raised with the patient, it is easy to imagine a patient in this circumstance becoming upset at the possibility of being admitted.

He would know that there was nothing wrong with him and would want to

move through the process of being arraigned and possibly released as soon as possible. Or he might simply refuse admission, as frequently occurs even with patients who aren’t under arrest.

Can a prisoner sign out against medical advice (AMA)? In many jurisdictions police will not remove a patient from the ED if they are leaving AMA because the police are not willing and/or able to take responsibility for possible future decompensation. Because the patient in this case is a prisoner, he may indeed be prevented from leaving the hospital, as prisoners do not have the right to go where they want. Therefore, if the police are unwilling or unable to remove the patient from the ED, the only alternative may be to admit him. However, it is important to remember that although the patient cannot leave AMA, he or she also cannot be compelled to accept treatment; thus, even though the patient cannot leave AMA, if he has capacity, he can refuse any testing, intervention, or medical treatment.

The second ethical issue this case raises is centers around the possibility of possession of evidence or contraband.

May a health care worker turn over substances retrieved from a patient (or a bed pan) to the police, with the knowledge that it might used as evidence against the patient? The answer is certainly, preferably no. However, whether a health care worker can do so without putting themselves in legal jeopardy, or at least at risk of being arrested, is likely case-specific. One can imagine the police arresting for possession of narcotics a physician who refuses to turn over the drugs. Given the complexity of the issue, as well as the risk to the provider, hospital risk management should become involved in a case such as this early on.

Hospital security might also be called upon to hold onto the drug material while a resolution is worked out.

But it is the final point that is most valuable, because it is relevant to all encounters with patients in custody, and not just those that involve refusal of care or a specific question of dealing with contraband. All patients have a right to

privacy, but a prisoner, whose words can be used to directly harm him or her, has an even greater need for it. As the case above illustrates, protecting prisoners’ privacy protects them not only from legal jeopardy, but from medical harm as well. A patient who cannot speak freely cannot be treated appropriately. Police officers have no right to hear discussions that occur between a patient and his or her medical caregiver. It is highly unlikely to be necessary for police be within earshot to perform their job of maintaining custody of the prisoner. Although in some case a bit of creativity, or relocation, may be necessary, police should never be able to hear the medical interview. The main exceptions to this rule are in situations where the safety of either patient or staff is involved. If relocating the police out of earshot would unacceptably delay lifeor limb- threatening care, care should proceed without delay, especially if it is not certain that lack of privacy would in fact harm the patient. At the other extreme, caregivers are not required to put themselves in harm’s way to maintain patient privacy. Although most prisoners pose no heightened risk of harming others, some prisoners, especially those with a documented history of violence, may present a true risk if officers are not close at hand. If a caregiver has a reasonable fear for their safety, police may need to be nearby, even during an interview.

Caring for patients in custody raises many challenges. Most of these can be met by remembering that these are patients like any other, and extremely vulnerable ones at that.

ABOUT THE AUTHOR Dr. Simon is a professor of emergency medicine at the Columbia University Medical Center, in addition to serving as faculty associate at the Columbia Center for Clinical Medical Ethics. Dr. Simon is also a senior research associate for the department of philosophy at the University of Johannesburg

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SAEM PULSE | NOVEMBER-DECEMBER 2022

FACULTY DEVELOPMENT

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4 Tips to Set Junior Faculty Members Up for a Successful Shift With a Resident Physician

By Shehzad Muhamed, MD Just one month ago, we welcomed our inaugural class of emergency medicine (EM) residents at Northeast Georgia Medical Center. Each teaching shift brings excitement and apprehension as I transition into my new role as a junior faculty member and bear the responsibility of postgraduate training.

Through trial and error over the past several weeks, I have found four specific behaviors that help me be a better educator. I implement these steps each shift and find them to be quite effective.

“Goal setting helps increase motivation, guide focus and direction, and increase productivity.”

Give them a try and modify to a version that works for you.

1. Explain your workflow to the resident and describe how they best fit into it.

From the time we start as interns, EM physicians spend countless hours

mastering our workflow. Should we see a new patient? Follow-up on labs?

Re-evaluate an existing patient? Spend 30 seconds to fill in part of a patient’s chart? We try, try, and try again until we find the right formula that gets us through a busy shift with maximum efficiency. Suddenly, there’s an added

“A little insight on how you navigate your own tasks during a shift will help you maintain your efficiency, but also serve as a template for the resident to design his or her own method.” piece to the puzzle: a resident. The easiest way to incorporate this new “puzzle piece” is to explain how you operate. I take this a step further and describe specific actions the resident can take to minimize interruptions. A little insight on how you navigate your own tasks during a shift will help you maintain your efficiency, but also serve as a template for the resident to design his or her own method.

2. Set SMART goals

At the beginning of your shift, ask residents if they have any goals they are working towards; if they don’t, help them create one or two SMART (specific, measurable, achievable, relevant, timebound) goals. These can be goals for the current shift or near future but should be tangible. Goal setting helps increase motivation, guide focus and direction, and increase productivity. I find that goal setting also leads to residents having a higher sense of work satisfaction, which

can help combat burnout.

3. Outline communication expectations for the shift

Effective communication is hard work.

Exchanging information and balancing communication styles in a high stress environment like the emergency department is even harder. Make life easier for yourself and your learner by setting some ground rules. Personally, I share how I like to be addressed (by title when interacting with patients and by first name otherwise). This removes any ambiguity and creates a sense of collegiality. I also share my most important rule: it’s okay to say, “I don’t know,” but never be dishonest. I find this statement establishes trust by creating a safe learning environment.

4. Provide digestible educational content

time; when you’re busy and tired, it’s probably even less than that. Residents are juggling so much more than just learning how to practice medicine. Their neurons are occupied with recalling patient histories, putting together facts to present to consultants, and remembering responsibilities outside their roles as residents. So, provide them with casebased, bite-sized pearls that exploit the benefit of association. For bonus points, direct your resident to a resource on the topic that they can review later.

ABOUT THE AUTHOR Dr. Muhamed is a junior faculty member for the emergency medicine residency program at Northeast Georgia Medical Center, Gainesville, Georgia.

Our short-term memory can hold only five to nine pieces of information at a

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GERIATRIC EM

Virtual Specialty Care: Providers and Payors Unite!

SAEM PULSE | NOVEMBER-DECEMBER 2022

By Mary Mulcare, MD, on behalf of the SAEM Academy of Geriatric Emergency Medicine

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One year ago I wrote a segment for this publication on the transformation of the digital care landscape, which focused on older adults. The virtual provision of medical care supports faster access to high quality physicians, while alleviating the traditional barriers to care, including transportation, available caregiver support, sensory concerns (e.g., difficulty hearing in loud environments), and more. In both academia and industry, virtual care has contributed to significant innovation and improved the health care landscape and experience for patients and providers. I am happy to report that older adults have been benefactors of these advancements and are becoming a greater focus as recipients of virtual care.

“In both academia and industry, virtual care has contributed to significant innovation and improved the health care landscape and experience for patients and providers.”

Patients and providers have accepted and adopted virtual care. For many providers, the opportunity to conduct virtual visits provides balance and new perspectives in patient interactions.

For patients, they have come to expect a virtual option. Knowing this

patient expectation, employers are implementing telehealth into their health benefits packages as a necessary offering for employee satisfaction and retention.

Payors are next to see the value of virtual health, especially virtual specialty

care, where payors and providers are primed to collaborate. Medicare Advantage plans, for example, work hard to retain their members. Each year an average of 9% of Medicare Advantage members disenroll from their plan, with some plans reaching as high as 23% disenrollment. The top reason for disenrollment is lack of coverage with doctors and hospitals.

Up to 27% of Medicare beneficiaries have trouble finding a specialist. Once they find a specialist, wait times for an appointment are several weeks and those appointments on average last between 15-20 minutes.

Virtual specialty care is a likely, cost-effective solution for Medicare Advantage plans. This type of care brings convenience, speed, and quality to the process of identifying and connecting with appropriate specialists, all while allowing older adults to see the physician

from the comfort of their home. These visits can last upwards of one hour, so members can get answers to all their questions.

For Medicare Advantage plans, virtual specialty care has the potential to: • Reduce unnecessary emergency department visits and roaming in the health care system • Provide an alternate high-convenience option for emergency department discharge follow-up visits • Reduce hospital admission rates • Give geriatric and primary care colleagues the support needed to maintain their role as the medical home for their patients while ensuring adequate guidance, when needed • Increase medication adherence while reducing polypharmacy and adverse drug events

This list goes on, but the fact of the matter is that older adults have much to gain from Medicare Advantage plans that offer virtual specialty care.

ABOUT THE AUTHOR Dr. Mulcare is fellowship trained in geriatric emergency medicine and is a clinical assistant professor of emergency medicine at NewYork-Presbyterian/ Weill Cornell Medicine. She has held several educational leadership roles at NYP/Weill Cornell and is currently chief medical officer for Summus, a leading virtual specialty care platform. She is a member-at-large on the executive committee of SAEM’s Academy of Geriatric Emergency Medicine (AGEM).

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.”

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GLOBAL EM

Alcohol Misuse and Its Impact on Emergency Medicine Across the Globe

SAEM PULSE | NOVEMBER-DECEMBER 2022

By Alena Pauley, MScGH; Frida Shayo, MD, MMed; and Catherine Staton, MD, MScGH on behalf of the SAEM Global Emergency Medicine Academy

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As a core component of the health care safety net, emergency departments (EDs) have always seen epidemics before or as they rise; our worsening rates of alcohol use disorder are no different. This alarming trend joins the other sociocultural factors impacting who uses and frequents EDs, bringing now more women into this environment.

Just within the United States (U.S.), for example, the last 20 years have seen over 50% more alcohol-related ED visits, disproportionately so from women. One study found that from 2006 to 2014, there was a 70% increase in alcohol-related ED visits in U.S. women compared to a 58% increase in men. To effectively tackle this trend that stands to have a tremendous impact at both the local ED and

“...the growing number of alcohol-related visits stand to create greater disruptions around ED patient flow and care.” wider population level, multi-pronged approaches that focus on systemic, preventative care and greater resources to EDs worldwide will be needed.

What exactly will this increase in alcohol use mean for emergency medicine? In the short term, the growing number of alcohol-related visits stand to create greater disruptions around ED patient flow and care. As most

ED physicians can attest, intoxicated patients not only tend to be more aggressive—potentially causing harm to themselves, health care staff, and/or other patients—but their altered status makes their complaints more difficult to identify and treat. When EDs across the U.S. are already overwhelmed with critically ill and injured patients packed in overcrowded waiting rooms most days of the week, a rise in intoxicated

patients is yet another factor with which our overstressed clinics must contend.

At the population level is the disproportionate physiological harm women stand to face from increased alcohol intake. For a myriad of reasons, women have higher blood alcohol concentrations at similar or lower amounts of drinking. Women who drink unhealthy amounts of alcohol are also at higher risk for heart disease, brain damage, and liver damage than men.

With the ED serving as health care's catch-all, this could mean a higher incidence of chronic conditions, cardiac arrests, or psychiatric complaints down the line.

These trends are rising at a concerning pace, even more rapidly on a global scale, and especially so in low- and middle-income countries. Global per capita alcohol use has surged by almost 30% in the last 25 years, with countries like China and India driving this uptick. In settings that have limited resources and trained personnel to help treat alcohol use disorders and related issues, the social, physical, and financial strain this could place on patients, communities, and local EDs is daunting. To illustrate this, the U.S. has similar rates of alcohol consumption as Uganda (in both locations, the average person drinks between 9.5 to 10 liters of alcohol every year). However, Uganda has a gross domestic product (GDP) per capita more than 75 times less than that of the U.S., leaving Uganda with comparatively little funds available to devote to alcohol-related services.

The Duke Global Health Institute’s Global Emergency Medicine Innovation and Implementation ((GEMINI) Research Center has held a long-term interest in alcohol use in global ED settings, facilitated by a strong, ongoing partnership with the Kilimanjaro Christian Medical Centre (KCMC) in Tanzania.

For us at GEMINI and KCMC, the global rise in women’s alcohol use parallels our growing research interest in this area, which emerged after the implementation of an ED-based intervention to minimize excessive alcohol

consumption. It was in this clinical trial housed within KCMC that we first observed significant inequities in how Tanzanian women access alcohol-related treatment services, even when controlling for the higher rates of use among men.

To better understand this discrepancy, we conducted a study at KCMC that explored gender differences in alcohol use. In the interviews completed as part of this, several participants noted that some men and women in Tanzania now drink almost equal amounts. Shifting gender roles has been a primary driver of this change, with more Tanzanian women working outside the home and being financially productive or independent.

In a society where this behavior among women was unheard of only twenty years ago, this upward trend is arguably even more dramatic than in the U.S., with profound implications for the future of global emergency medicine.

While current treatments like the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model adopted and adapted from high-income countries are effective linkages to care, those resources in many settings don’t exist to meet the demand. Just like in high-income settings, a renewed focus on infrastructure development, mental health, and substance abuse treatment services must be a priority to understand and avert the sociocultural drivers

of unhealthy alcohol use. It is these changes, paired with concrete policy change, that will enable us to protect our coming generations.

ABOUT THE AUTHORS Alena Pauley is a Peace Corps Volunteer in Nepal and a recent graduate of the Masters in Global Health program at Duke’s Global Health Institute.

She works currently as a clinical research coordinator within Duke University’s emergency department which she balances alongside her ongoing research endeavors.

Dr. Shayo is a practicing emergency medicine physician at the Kilimanjaro Christian Medical Center, Moshi, Tanzania.

Dr. Staton is an associate professor of emergency medicine, neurosurgery, and global health with tenure at Duke University; cofounder of the Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center in the Duke Department of Emergency Medicine and the Duke Global Health Institute.

About GEMA 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.”

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INNOVATION IN EM

Becoming the Cutting Edge: Lessons on Innovating in Emergency Medicine

By Richard Ngo, DMD; Jonathan Oskvarek, MD, MBA; Zaid Altawil, MD; and Nicholas Stark, MD, MBA; on behalf of the SAEM Innovation Interest Group

SAEM PULSE | NOVEMBER-DECEMBER 2022

The following is a summary of panel session entitled "Innovating in EM" that was presented during ACEP22 in San Francisco.

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An innovation-focused mindset is increasingly finding use in emergency departments (EDs) as a vehicle for improving patient care. Innovation in the health care context incorporates elements of design thinking — an iterative process centered on empathizing with end-users — while also fostering out-of-the-box thinking by encouraging multidisciplinary perspectives. In a fast-paced, technology-enhanced world, innovation is essential in moving health care forward in a thoughtful and empathetic manner. Many emergency medicine (EM) physicians and trainees are expressing increasing interest in

innovating in health care, from creating new technology to improving existing medical devices to augmenting system design. In light of this, the newlyformed SAEM Innovation Interest Group partnered with the non-profit, physicianled Emergency Medicine Innovation Collaborative to host an innovationfocused panel in October 2022, at ACEP22 in San Francisco.

The panelists who shared their unique perspectives and expertise on innovating in acute care included: • Dr. Monique Smith, Founder/Director at Health DesignED • Dr. Jesse Pines, National Innovation Director at US Acute Care Solutions • Dr. Delphine Huang, Medical Director at IDEO

• Dr. Kalie Dove-Maguire, Senior Director of Clinical Informatics at Carbon Health The panelists discussed a range of topics, from incorporating innovation into clinical practice to cultivating and growing an innovation-friendly culture.

Here, we summarize some of the most salient points that are applicable to the full spectrum of EM trainees and physicians, from medical school through late career.

How can physicians incorporate innovation into their clinical practice?

Emergency medicine physicians must synthesize patients’ core needs into appropriate assessments and plans within short timeframes; they are well positioned to extrapolate these skills

“In a fast-paced, technology-enhanced world, innovation is essential in moving health care forward in a thoughtful and empathetic manner.” to innovate in the health care setting.

Dr. Huang states that incorporating innovation into clinical practice can be achieved in several ways: • Through focusing on patient needs and problems that patients may face throughout their visit, including during critical time periods, such as the transition from the ED to home. For example, physician innovators may consider solutions to common issues that patients face when transitioning home after discharge from the ED, such as an elderly patient’s ability to open tamper-safe prescription bottles.

• By considering how physicians use clinical data to inform decision making.

An important focus should include the translation of data into actionable next steps. This is fundamental in identifying ways to continue improving systems to better deliver care.

• By prototyping potential innovations early, with a focus on both the process and the end-user’s values. When creating patient-facing innovations, it is important to remember what is valuable to each individual patient, as well as the reasons why they may or may not be using certain technologies.

• Through homing in on pain points.

Physicians can use their clinical experience to design and innovate around challenging aspects of care, from workflows to logistics and devices.

All our panelists encouraged physicians to take risks, seek advice, and make mistakes.

How can physicians grow a culture of innovation at their institution and workplace?

The foundation of a successful culture of innovation lies in three areas: language, incentives, and leadership.

Dr. Dove-Maguire asserts that it is critical to first agree on language that your institution can get behind. For many institutions, building an innovative culture around the language of quality improvement is most effective. For others, there may be opportunities to speak more directly about innovation.

Drs. Smith and Pines emphasize the importance of ensuring that incentives are aligned. By focusing on both improving health and the bottom line, there is opportunity to align incentive structures to foster an innovative culture. Further, by focusing on innovations that improve both health and financials, early innovative products are likely to gain more traction.

For example, incentive shifts during the early stages of the COVID-19 pandemic enabled many institutions to open previously closed doors in the space of virtual care and telemedicine. Institutions are most successful when innovation is prioritized and viewed as a long-term investment.

The panelists also emphasized that obtaining support from key executives and leaders is crucial. These leaders can help bolster common language and align incentives through powerful drivers and ultimately help foster a culture of innovation at all levels of an institution, from environmental services and technicians to nurses and physicians, thus fostering the creative potential for every member of the team to innovate results in maximal productivity.

How can innovation be used to work toward health equity?

Health equity is achieved when every person has the opportunity to attain their full health potential. Dr. Smith posits that “innovation without an equity focus is just invention,” and that innovation can help accelerate health equity through an emphasis on patient values, outcomes, and cost containment.

In an interesting example on how innovation negatively impacted health equity, Dr. Huang noted that when one institution recently implemented a “hospital at home” program, they noticed that many patients opted out of home-based health care. Upon further investigation, the team learned that this avoidance was not due to a referral or administrative issue, but rather because of psychological safety shortcomings: patients’ families were worried that their loved ones might not receive the same quality of care at home compared to the

inpatient setting. This example highlights that it remains important to empathize with patients and work to build trust as health systems work toward innovating to improve health equity.

Innovation in health care is critical.

Innovation will continue to be essential to improving health care. Incorporating innovation into clinical practice requires focusing on and designing around patient needs and translating data to inform decision making. By aligning the incentives of all stakeholders and focusing on patient needs, EM physicians and trainees can foster a culture of innovation that can improve patient care.

ABOUT THE AUTHORS Dr. Ngo, DMD, University of California San Francisco, School of Medicine

Dr. Oskvarek, is a research director and clinical instructor in Emergency Medicine, Summa Health System, Department of Emergency Medicine r. Altawil, Boston University D School of Medicine, is an attending physician in the Department of Emergency Medicine at Lawrence General Hospital and cofounder of the Emergency Medicine Innovation Collaborative Dr. Stark is a clinical instructor and the assistant director or the Acute Care Innovation Center at the University of California, San Francisco; director of operations at Mercy Medical Center Merced Hospital; and cofounder of the Emergency Medicine Innovation Collaborative

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RESEARCH

A Q&A With K23 Recipient Dr. Christian Pulcini

Optimization and Implementation Trial of a User-Centered Emergency Care Planning Tool for Infants with Medical Complexity SAEM PULSE | NOVEMBER-DECEMBER 2022

By Brian Milman, MD, on behalf of the SAEM Research Committee

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Christian D. Pulcini

Christian D. Pulcini, MD, MEd, MPH, is a pediatric emergency physician at the University of Vermont Medical Center and UVM Children’s Hospital, as well as an assistant professor of emergency medicine and pediatrics at the University of Vermont Larner College of Medicine. His current areas of research focus are emergency care of children with medical complexity, childhood firearm injuries, and pediatric acute mental health.

Congratulations on your K23, “Optimization and Implementation Trial of a UserCentered Emergency Care Planning Tool for Infants with Medical Complexity.” Can you give a summary of your project?

Thank you, and of course. Who doesn’t like to talk about their research? The research portion of the K23 involves optimizing the Emergency Information Form (EIF) jointly recommended for

children with special health care needs by the American College of Emergency Physicians (ACEP) and American Academy of Pediatrics (AAP) in 1999 and then reaffirmed in 2010. Despite this joint recommendation, there is little evidence supporting the efficacy of these forms. The targeted population for my project will be infants with medical complexity, notably infants

graduating from the neonatal intensive care unit (NICU). This population has been shown to have higher rates of emergency department (ED) visits and admissions to acute care hospitals in the first year of life, therefore we felt our outcomes would be more adequately measured among this population. The first two years of the project will involve assessment of the key stakeholders in the emergency care of infants with medical complexity, with medical complexity defined as “children with multiple significant chronic health problems including multiple organ systems, which result in functional limitations, high health care needs or utilization, and often require need for, or use of, medical technology.” We will focus specifically on optimizing the EIF

to fit local needs, as well as barriers for implementation. The latter three years of the project will be a randomized controlled trial of the optimized EIF, comparing outcomes such as ED visits, inpatient visits, etc. The overall goal is to become an independent implementation scientist with the ability to implement and measure interventions for diverse populations receiving emergency care in a general, rural emergency department.

In 2020-2021, you completed SAEM’s Advanced Research Methodology Evaluation and Design (ARMED) course. How did ARMED impact your path to NIH funding?

ARMED certainly moved up my timeline as it made my application higher-quality in a faster timeframe than I expected.

I am honored to receive this career development award two years out of fellowship, and I don’t think it would have been possible without the mentorship and guidance attained through the ARMED program. The ARMED course provided some needed accountability during a challenging time when I was transitioning to an attending role. There was a diverse group of individuals involved in the ARMED program who were always willing to review portions of the NIH application, which was instrumental in the grant development and writing process. It takes a village to submit a career development award, therefore in combination with local mentorship, the ARMED course certainly played an instrumental role in submitting the best possible K23 application in an accelerated timeframe.

How did you develop an interest in research?

As a medical student I did a research fellowship between my first and second year which kickstarted my interested in research. In full disclosure, the only reason I applied to the research fellowship is because I had a mentor who spoke to me about the impact of research on health policy and advocacy.

I obtained an MPH prior to medical school with the goal of implementing programmatic interventions for at-risk and vulnerable populations. After witnessing my research mentor in a legislator’s office providing data from research they performed and watching it impact health policy, I was sold on it as a career focus. I still approach every research project from the 30,000-foot view before I engage, asking questions of “why does this matter?”, “who will be impacted by this research?”, and “how can I design this so it matters?”. This approach may be

different than some researchers, but it is what keeps me actively engaged as a budding physician-scientist.

What has been the biggest milestone in your research career so far?

Certainly the receipt of the K23 is the biggest milestone. It felt like a confirmation that this is the road I should be on after some serious hard work and doubts. I also recently won a young investigator research award from the American Academy of Pediatrics (AAP) (named after Dr. Ken Graff), given to a pediatric emergency medicine researcher deemed to have a high potential for impactful research. This is a great honor and I look forward accepting this award at the national AAP meeting. Lastly, I recently published my first senior author paper in Academic Emergency Medicine journal focused on mental health boarding in rural EDs in Vermont. That certainly felt like a milestone as well.

If you could go back in time, what advice would you give yourself when you were a medical student?

I taught middle school science through the Teach for America program and obtained an Master of Public Health prior to medical school, therefore I was fairly goal-driven coming into medical school.

I would probably tell myself to focus on what I enjoyed and worry less about five and ten years down the road. Initially I was surprised I liked research as much as I did, and that presented a crossroads for me. I think if I had not been resistant to committing to a career involving research, things may have been easier for me. With that said, I had a wonderful experience in medical school and am still in contact with my first research mentor.

Some other unsolicited advice I recently gave a medical student, which has been instrumental to my own success, is always build bridges instead of letting them break down. It is a small community of academic EM and pediatric EM physicians, and it is so important to build and maintain positive relationships even if the basis of that relationship is not the highest priority at that point in time.

What does an average week look like for you?

I work 1-2 ED shifts a week now, which frees up time to do the certificate program in implementation science in my K23 training plan as well as coordinate 5-6 mixed-methods studies that are getting off the ground. I also do a fair bit of collaborative research through national research groups, and always have some

local and national committee meetings each week. This is in addition to local teaching engagements and other projects which are ongoing focused on firearm violence prevention, acute mental health, and trauma-informed care. Although this sounds like a lot, I am still coaching soccer three times a week for my three kids and exploring Vermont with my family.

What has been the most challenging aspect of your research career?

It is the constant balance between clinical, administrative, teaching, and research. I am fortunate in that my institution and department is highly focused on bolstering the research portfolio in our ED, and I am seen as a central piece of achieving that goal. As a bit of advice for someone considering a similar career in research, I would highly encourage getting a feel for this balance while interviewing by asking specific questions of what this looks like in their division/department. I found that this varies quite a bit both before and after receipt of the award, and the interview can help future clinician-researchers better understand the expectations.

Lastly, ensure that your goals align well with the division/department, and do not be afraid to ask this directly.

What has been the most rewarding aspect of your research career?

I have had patients, families, community, and national groups thank me for what I am doing. This affirms to me that what I am doing matters to the patients and families I am seeing in the ED, and that is the most meaningful and rewarding aspect for me personally.

I am just embarking on this journey with the career development award, however, and I sincerely look forward to measuring how my future research can positively impact vulnerable populations seeking emergency care across diverse healthcare settings.

If you have additional questions about an NIH K23 award, you can contact Dr. Pulcini at christian.pulcini@uvmhealth.org.

ABOUT THE AUTHOR Dr. Milman is an assistant professor of emergency medicine and associate residency program director at the University of Oklahoma School of Community Medicine.

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RESEARCH

SAEM PULSE | NOVEMBER-DECEMBER 2022

Focus on Medical Student and Resident Research

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Research Spotlight is a new initiative by the SAEM Research Committee to highlight research presented by students and residents at SAEM regional and national meetings. Full abstracts for all of the projects highlighted below can be found in the SAEM22 Annual Meeting Abstract Supplement.

Evaluation of Dispositions During a Marathon Raymond Jabola, DO; Haley Durdella, DO; Dylan Henry; Benjamin Boswell, DO; Jason Zeller, MD; Frank Forde, MD; Jeffrey Luk, MD

First author Raymond Jabola, DO, is an emergency medicine (EM) graduate of Case Western Reserve/ University Hospitals Raymond Jabola and currently works as an emergency physician in Denver, Colorado. He was a resident when he worked on this project.

Author Conclusion: This study showed that the vast majority of race participants presenting to a medical station will be treated with no transport.

However, medical staff should be

prepared for some participants refusing recommended transport, and medical procedures should detail procedures for such a disposition. While few participants are transported to hospitals, it should nevertheless be anticipated, and appropriate coordination with transport agencies as well as hospitals is imperative to ensure proper care of these patients.

Most rewarding aspect of my work on this project: I am grateful to have had the opportunity to mesh my interests in both EMS and sports medicine into a project that can help others planning to work medically at mass sporting events

Most rewarding aspect of my work on this project: Impact. Our research has been highlighted on local news, cited in a recent New York Times article, and presented to members of the Vermont legislature. Hopefully, we can bring about positive change through raising awareness of this issue.

Coinfections of SARS-CoV-2 with Other Respiratory Pathogens: Prevalence and Outcomes Ryan S. Waters, MD, PhD; Austin Porter, DrPH; Crystal Sparks, MSAM; Thomas Maloney, BS; Susan Hurley, MD; Ericka Olgaard, DO, MBA; Carly Eastin, MD

Emergency Department to Emergency Department Transfers: What happens to these patients?

Kristen Septaric, MPH; Courtney M. Smalley, MD, FACEP; Jessica A. Krizo, PhD; Caroline Mangira, MPH; Baruch S. Fertel, MD, MPA; Erin L. Simon, DO First author Kristen Septaric is a secondyear medical student at Northeast Ohio Medical University in Rootstown, OH. She is a student research assistant with the Kristen Septaric department of emergency medicine at Cleveland Clinic Akron General. As a future physician, she plans to pursue a career in emergency medicine.

Author Conclusion: Our study found nearly 75% of all ED-to-ED transfers to be necessary due to the need for specialty consultation or admission at the receiving facility.

Most rewarding aspect of my work on this project: The most rewarding element of working on this research project was being able to be involved in the study from start to finish. Often, medical students only assist in one aspect of large studies, so I appreciated the opportunities to grow in my research skills through long-term involvement in this project. I began working on the data collection about one year ago and helped to draft the manuscript once the results came back from our statistician.

I was honored to be the member of our

research team to ultimately present our findings to the emergency medicine community at SAEM22.

Characteristics of Children Boarding in Emergency Departments for Mental Health Conditions in a Rural State

Ryan S. Waters

First author, Ryan, S. Waters, MD, PhD, is a chief resident in the department of emergency medicine at the University of Arkansas for Medical Sciences.

First author, Taylor Marquis, MD, is a graduate of the University of Vermont Larner College of Medicine and a current intern in the Brown University Taylor Marquis Emergency Medicine Residency program. His interests include public health research, political advocacy, and community engagement. He was a medical student when he worked on this project.

Author conclusion: Patients who tested positive for SARSCoV-2 were less likely to test positive for other respiratory pathogens and vice versa. Overall, 10.2% of our population tested positive for SARS-CoV-2 while 5.7% tested positive for non-SARSCoV-2 respiratory pathogens. Only 0.2% tested positive for SARS-CoV-2 and another pathogen simultaneously.

Additionally, patients who tested positive for SARS-CoV-2 had higher 30-day mortality (6%) versus patients who were negative for all pathogens (4.4%) or positive for a non-SARS-CoV-2 respiratory pathogen only (0.5%). Our next steps are expanding the dates of our data set through February 2022 to examine whether coinfection patterns have changed as more SARS-CoV-2 variants have emerged over time.

Author conclusion: In this multicenter study of Vermont hospitals, we found that the duration of Emergency Department boarding for mental health conditions exceeded Joint Commission standards in a large sample of children. Our data highlight the severity of mental health conditions among a rural pediatric population despite many receiving prior outpatient treatment, as well as prolonged boarding times in all types of Emergency Departments across the state.

Most rewarding aspect of my work on this project: I have appreciated the opportunity to work with colleagues across other disciplines and foster relationships outside of my typical clinical sphere. Gaining insights from our colleagues in the public health department and pathology has provided new perspectives on some of the interesting challenges we have faced during the pandemic. In the end I hope that our insights can improve the care we provide to our community.

Taylor Marquis, MD; Peter Callas, PhD; Nathan Schweitzer; Mark Bisanzo, MD; Haley McGowan, DO, MA; Ryan J. Sexton, MD; Christian D. Pulcini, MD, MEd, MPH

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SEX & GENDER

Perceptions and Avoidance of the ED Among Gender Minority Patients

SAEM PULSE | NOVEMBER-DECEMBER 2022

By Elaine Hsiang, MD and Alyson McGregor, MD on behalf of the SAEM ADIEM LGBTQ+ Task Force

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There is a growing body of literature illustrating the health care disparities experienced by gender minority patients, including those who identify as transgender, non-binary, genderqueer, agender, and more. With the rise in proposed and enacted anti-trans legislation in the United States, it is imperative that emergency providers recognize the impact of this on the health of gender minority patients, including delays or avoidance in seeking care in the emergency department.

Avoidance of emergency care is markedly higher among gender minorities: a regional needsassessment in Colorado reported a 3.8 increased odds of lifetime emergency care avoidance by gender minorities compared to cisgender individuals.

Another study in Rhode Island found that nearly half of participants reported having avoided the emergency department when they needed acute

care. Qualitative data reveal avoidance is often related to fear of and negative experiences with discrimination based on gender identity, as well as the lack of provider care competency of gender minority patients.

A recent scoping review of emergency care of sexual and gender minorities highlights a number of urgent opportunities for improvement, including standardized training in sexual and gender minority health, the need to systematically collect sexual orientation and gender identity data, and direct community involvement in quality improvement and research efforts in acute care settings.

The SAEM ADIEM LGBTQ+ Task Force expands on many of these suggestions in a recent paper to reiterate that our emergency departments should continually work to provide a safe and inclusive

environment that is free from discrimination. We can and must make emergency medicine a trans-inclusive and gender affirming specialty.

ABOUT THE AUTHORS Dr. Hsiang is a third-year emergency medicine resident at the University of California, San Francisco, with an interest in LGBTQIA+ health. @egnaish r. McGregor is a professor D of emergency medicine and serves as associate dean of faculty affairs and development at the University of South Carolina School of Medicine Greenville. @mcgregormd

SIMULATION

Crash Testing the Dummy” In-Situ Simulation in the Emergency Department

By Suzanne Bentley, MD, MPH, Kate Lin, Muhammad Waseem MD, and Miriam Kulkarni, MD, on behalf of the SAEM Simulation Academy Emergency Medicine teams are experts in the management of critically ill and injured patients, relying heavily on maximized teamwork and communication to work effectively and collaboratively in an expedited fashion. In addition to team factors and dynamics, physicians must be prepared to identify and manage an extensive range of clinical pathologies including high acuity, low occurrence (“HALO”) procedures, and rare, timecritical, but life-threatening conditions, some of which clinicians may never have previously encountered. Medical education in teamwork training has evolved significantly over the years, with simulation education as an established standard and recognized technique for conveying necessary knowledge about teamwork, developing the skill of teamwork among participants,

and enhancing attitudes and shared understanding regarding teamwork.

departmental and hospital processes in real-time and in real locations.

Simulation is a technique, not simply a tool, that can be employed to meet a variety of educational and systemsbased objectives for practice, learning, evaluation, testing, or to gain an understanding of systems of human actions. In-situ or unit-based simulation training takes simulation directly into the workplace environment. Potential applications include its use to examine workflow, improve culture, practice teamwork, familiarize oneself with equipment, improve communication, orient staff to new policies and procedures, assess the efficiency of a system, identify gaps, and practice rare events, without risk of patient harm. It allows teams to test their effectiveness in a controlled manner and to interrogate

In-situ simulation can formally be used as a “team-based training technique conducted in actual patient care units using equipment and resources from that unit and involving actual members of the healthcare team.” Less formally, in-situ simulation has been described as “crash testing the dummy.” Deliberate practice and integration of teamwork skills in a time-pressured environment generates realism and is a rich resource for identifying latent threats and system issues. While simulation has often been used as a strategy to train individuals in both technical and nontechnical (e.g., leadership, communication, and

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SIMULATION

continued from Page 45

SAEM PULSE | NOVEMBER-DECEMBER 2022

teamwork) skills, in-situ simulation is used to evaluate system competence and identify medical errors. Given that the simulations are conducted in actual clinical space, there are opportunities to identify hazards and safety threats in clinical systems, the environment, and the provider team.

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The benefits of conducting simulations in-situ in the clinical environment include everything from improved training logistics to adult learning theory. Kolb’s theory of experiential learning, for example, provides a rationale for conducting in-situ simulation from the perspective of the educator and the learner. This theory relies on experiences, reflections, and active experimentation so that “new ideas and concepts can be used in actual practice.” Experiences in simulation labs may accomplish this to some degree, but in-situ simulation is more closely aligned with the actual “work” of the health care provider and is more likely to achieve teamwork training objectives.

In-situ simulations also offer the advantage of training efficiency. In-situ simulations occur during the workday, often utilizing on-duty clinical providers, thus alleviating the need to schedule participants, pay overtime, or schedule additional providers to “backfill” while one team of clinical workers is in the simulation training center. Additionally,

“In-situ simulation can formally be used as a “team-based training technique conducted in actual patient care units using equipment and resources from that unit and involving actual members of the healthcare team.” because they are conducted with on-duty clinical providers, in-situ simulations are most commonly conducted with interdisciplinary teams, offering great benefit to teamwork and communication training. It also provides an opportunity to more frequently review the skills related to high-risk, infrequent events. This enhanced efficiency must be balanced by conducting in-situ simulations for all shifts, not just the more convenient day shift to achieve, competencies for all health care professionals.

Most in-situ studies focus on behavioral skills (sometimes called “nontechnical skills”) and interprofessional education, shown to be paramount for patient safety. Notable outcomes by researchers using insitu simulation include improving individual participant technical proficiency and clinical competency evaluations, continual reinforcement of communication and teamwork, improved safety culture of the system,

capture and mitigation of latent safety threats, and improvement in clinical outcomes. Additionally, in-situ simulations, like in-center simulations, allow opportunities to formally debrief participants, something that infrequently occurs after actual patient encounters.

Despite these many benefits, the implementation of in-situ simulation with working clinical teams presents challenges related to time pressures, acuity, patient census in a busy ED, technical issues and equipment availability and costs, lack of privacy, frequent distractions, and logistical issues. Performance anxiety of health care providers poses a significant challenge with reluctance on the part of staff to participate in the care of simulated patients. Concerns are frequently raised regarding the impact of in-situ simulations on patient care and reinforce the need for the creation of institution-specific “no go” criteria developed and agreed to by the simulation team and the ED leadership

“The benefits of conducting simulations in-situ in the clinical environment include everything from improved training logistics to adult learning theory.” (e.g., census limits or staffing constraints under which the in-situ simulation will be postponed). Additionally, patient and family perceptions have been expressed and some providers noted concerns that family members would find the in-situ simulation exercises disruptive or intimidating; however, many providers noted that families have expressed appreciation for the training their providers receive. This suggests that deliberate attention and provision of information to patients and family members in the department during simulation can advertise the benefits of the educational exercise versus “scare” those that may observe the in-situ case in progress.

In conclusion, in-situ simulation is a well-supported technique that

offers a multitude of potential benefits for emergency medicine. Multiple publications and guidelines exist discussing strategies and best practices for implementing effective in-situ simulations, however, conduction will vary based on local emergency department factors, needs, and culture. A structured approach to in-situ simulation training and assessment based on systems thinking, coupled with awareness of unique departmental needs, is required for a sustained improvement of team performance and patient safety. Some tips for implementing in-situ simulation from Spurr et. al, the AHRQ, and the New York City Health + Hospital Simulation Center for implementing in-situ simulation are provided.

ABOUT THE AUTHORS Kate Lin is a current senior at NEST+m High School in New York City and is an aspiring premed student.

Dr. Kulkarni is the program director for the emergency medicine residency at St. John's Riverside Hospital in Yonkers, NY. She has been a resident educator and simulationist for the last 15 years. r. Waseem is a professor D of emergency medicine and Pediatrics at Weill Cornell Medicine, New York. He serves as the research director for the Emergency Medicine Department and vice chair for the Institutional Review Board at Lincoln Medical Center in the Bronx, New York.

Dr. Bentley is an associate professor of emergency medicine and medical education at the Icahn School of Medicine and the chief wellness officer and director of Simulation Innovation & Research at NYC Health + Hospitals/Elmhurst in Queens, NY.

TIPS AND CONSIDERATION FOR IMPLEMENTING IN-SITU SIMULATION 7

Work to maximize psychological safety: Pre-brief participants, ensure everyone knows goals and how the simulation will proceed, emphasize confidentiality, reinforce the “basic assumption” and need for mutual respect among participants, and ensure participants are aware of the planned use of findings (e.g. not punitive but to correct identified safety threats).

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The debriefing is key: plan on how it will be structured (hint: many published tools and guides are available), who will lead it, and allow 1-2 times the length of the simulation itself to conduct the debriefing.

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Proactively establish a system to link what you find in simulation to your clinical governance systems to ensure closed-loop debriefing and mitigation of identified safety threats. Consider closed-loop debriefing structure to close loop with participants afterwards and share lessons learned (e.g. post-event email to participants or shared with department).

Structure your simulations to be as close to real life as possible.

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Conduct interdisciplinary simulations, ideally run such that any member of the team who would be present if it was a real patient is in the simulation.

Utilize formalized and agreed upon “no go” considerations to keep the real patients safe and protect staff such that the simulation does not add additional stress to an already over-stressful shift.

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Start small, start somewhere, learn a lot, iteratively improve, and keep expanding your program!

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Secure interprofessional leadership buy-in and support.

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Needs assessment: discuss departmental needs that can best be addressed using in-situ simulation and/or perform a formal needs assessment to identify the problem or gap.

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Start simple before scaling up complexity: consider a lower stake, more straightforward team scenario to simulate as your in-situ simulation program initially starts (both to introduce the in-situ simulation concept, minimize the size of the team to start, and streamline your debriefing).

Over time, endeavor to work up to “multi-team” training inclusive of scenarios such as high acuity trauma involving participation by the ED, surgery, radiology, and other departments.

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Agree on your learning objectives for participants and the department.

About Simulation Academy The Simulation Academy focuses on the development and use of simulation in emergency medicine education, research, and patient 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.”

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VIRTUAL PRESENCE

TikTok Takes on FOAMed

SAEM PULSE | NOVEMBER-DECEMBER 2022

By Steven Haywood, MD, on behalf of the SAEM Virtual Presence Committee

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Every day in the United States, 105 million hours of short form videos are viewed on the platform TikTok. In fact, TikTok has been the most downloaded app for the past three years. The success of TikTok has driven other social media platforms to offer options for short format videos. This explosion in short format video has presented medical educators and public health advocates with a unique opportunity to communicate important health information and education. Here are some tips gleaned from some of the early literature regarding this format.

Create Factual, Evidencebased Content!

When creating short form videos for the purpose of public health education, factual accuracy is most important. With the COVID-19 pandemic, inaccurate

“When creating short form videos for the purpose of public health education, factual accuracy is most important.” public health information caused doubts in our health care system.

Vaccination rates quickly stalled due to misinformation. Many lives were lost because of medical misinformation.

The allure of viral status may cause some to drift from the underlying goal of dissemination of factual, high-quality information. Medical misinformation on TikTok has been found in at least 11.6% of videos claiming to be “for the purpose of medical education.”

Conversely, a review of health education videos by Om et.al., found that content published by physicians was most likely to be factual. We need physicians to create medical education and public health content!

Consistency is King!

A group of researchers in China led by Chengyan Zhu evaluated how TikTok was being used for public health information dissemination. They found

that the public health agencies that posted consistently had significantly higher engagement rates. Posting videos frequently increases the likelihood that users will see your content and engage with that content. Frequent content creation and posting also increases familiarity with the app and increases the quality of content that is delivered.

Most recommendations for consistency recommend posting daily; however, due to the demands on physicians, creating a daily, high-quality, short form video is not possible. Thus, for institutions that are interested in using short form video, collaboration from multiple contributors is essential to consistency.

Stick to your talents

Users such as Dr. Glaucomflecken (@drglaucomflecken) create videos with characters and skits that consistently appear on user’s “For You Page”; however, when looking at videos published by public health agencies, researchers found that documentary style videos had the highest engagement rates.

Conversely, engagement rates dropped significantly when skits were incorporated into public health videos. Yet skits are entertaining and can be effectively used for public health education provided that you the creator does not lose sight of

the primary goal of the skit, which is to educate and inform. The key is to stick to your talents. If you are not comfortable acting out skits and creating characters, then don’t. Even documentary and lecture style videos perform well when delivered in a charismatic manner.

Add Music

Music has long been known to increase cerebral engagement; thus, not surprisingly, adding music to a short form video was found to increase engagement rates. Additionally, any background noise inadvertently recorded during the video will be blunted by background music.

The key to adding music to a short form video is to keep the volumes low and choose music that will not distract from the content of the video. Zhu, et. al., found that when original music was incorporated into videos the engagement rate rose significantly. All social media platforms that have a short format video option make it easy to add stock background music to your videos.

Monitor the Comments (And Block the Trolls)

The comments section of short form video platforms is also a great way to create a two-way conversation with the public; however, the comments section

is also a place where misinformation and confusion can spread and therefore it needs to be monitored. Social media platforms allow you to place filters on the comments section whereby the use of certain keywords will automatically initiate the removal of a comment. That said, sometimes the comments section includes genuine questions and healthy discussion that can increase engagement in a productive way. One way to increase engagement and feedback in the comments section is by adding a question in the video for users to answer in the comments.

ABOUT THE AUTHOR Dr. Haywood is assistant professor of emergency medicine at Nova Southeastern University and simulation director at Magnolia Regional Medical Center.

Dr. Haywood is the chair of the SAEM Virtual Presence Committee and a senior editor on CriticalCareNow.com. Dr. Haywood has a passion for online education providing medical education across social media platforms under the handle @HeySteveMD.

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SAEM PULSE | NOVEMBER-DECEMBER 2022

Night Shifts — I Used to Love Them!

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Systems and Departmental Responses to Fatigue Management

By Katren Tyler, MD, on behalf of the SAEM Wellness Committee Many of us started our emergency medicine (EM) careers as bright-eyed, 20-somethings who had no problems with shift work, working multiple overnight shifts and rapid schedule transitions. Frankly, this is reasonably easy to keep up in our 30s as well, even as our external responsibilities get more complex. And then your 40s happens.

Ludicrously, I have done two residencies in EM – one in Australia and one in the United States. But in this one regard, I am a bona fide expert: in my adult life, I have never not been a

shift worker. As a resident in Australia, I spent more than 20 weeks in one year on a rotating night-float shift schedule and loved it. Night shifts: I used to love them. I was a night owl and proud of it.

Until I didn’t and wasn’t.

I don’t like night shifts anymore. I understand that we are a 24/7/365 business. But now, in my 50s, I am at my best early in the morning – the circadian opposite of being a nocturnist Night shifts, without a doubt, put me at my highest risk for a cognitive error at work, and I don’t think I am alone.

Chronotypes are how sleep researchers describe your chronobiology. Your chronotype reflects your individual preference for going to sleep at night and getting up in the morning. As much as possible, you should estimate your chronotype when you are free of the external responsibilities of your life (e.g., work, kids, pets, all the business of modern life) – ideally when you are on a vacation or at least during a nonwork weekend.

For the most part, researchers classify chronotypes as early, intermediate, and late. Sleep researchers recommend

“The evidence is clear: shift work, especially night shifts, get harder as we get older; night shifts are associated with short-term cognitive impairment across all industries.” that we should try and make our work schedules match our chronotypes.

Obviously, this is a challenge in our specialty. For many people, our chronotype gets earlier as we get older and our tolerance for late shifts and night shifts is reduced.

In health care, we place most of the responsibility for coping with shift work on the individual health care worker.

System- and department-wide responses to the impacts of shift work as we age, or experience other physiologic challenges, are limited. My call to arms for fatigue management systems is that our lack of protections for shift workers are also likely harming our patients, and that surely makes it a systems issue.

We know that shift work is a burden for emergency physicians and their families in terms of circadian desynchronization and fatigue. The evidence is clear: shift work, especially night shifts, get harder as we get older; night shifts are associated with short-term cognitive impairment across all industries. Moreover, longer periods of duty, especially longer night shifts, are associated with short-term cognitive impairment and increased errors across all industries.

System Suggestions

We have known for decades that sleep deprivation can be as serious as alcohol intoxication. It is unacceptable to be inebriated at work, yet we idealize and reward being exhausted in medicine. We have socialized and normalized fatigue in medicine for decades, recent changes notwithstanding.

Health care in general, and EM in particular, has not acknowledged the cognitive load and patient safety risks of shift work. There are very little systemic protections for physicians after training, and honestly, not that many protections during residency. We do not systemically evaluate if individuals tolerate shift work.

Even if we acknowledge differences, we almost always put the responsibility on the individual. Multiple studies in health care and in other industries show

people make more cognitive errors the longer they have been awake. It is no surprise that other industries, especially the airline industry and some manufacturing industries, have made stronger commitments than medicine to fatigue management. Sleep is the only way to reverse sleepiness. Fatigue management systems promote a shared responsibility between the employee and the system. Sequelae of shift work include social jetlag/circadian desynchronization, cognitive impairment, and sleep disruption. Suggestions for protecting health care shift workers and their patients include evaluating the risks to ourselves and our patients, including pregnancy outcomes in health care workers, chronotype scheduling, access to sleep clinics, breaks on night shifts or extended shifts, access to food and water including cafeteria access, and the availability of call rooms or rideshare options. Driving home after a night shift is a significant risk for motor vehicle crashes. We have work to do on the systemic role of sleep and aging physicians; most literature acknowledges sleep deteriorates with age, especially in shift workers.

Departmental Suggestions

As people age, our chronotype typically gets earlier, meaning we generally need to go to sleep earlier and wake up earlier.

We typically experience this change starting in our mid 40s. If you are lucky, you have some late chronotypes on your faculty. Physiologically, late chronotypes can tolerate later shifts, including night shifts, with more sleep before and between night shifts. Late chronotypes may struggle with early morning shifts.

Some individuals keep the same sleepwake patterns they had when they were younger, are better able to tolerate shift work as they get older, and are referred to as healthy shift workers.

Many departments have night shift crews and incentivize the night shift; indeed, the night shift crews should be incentivized as much as possible in time or money. In our department, for some

years, we have been able to opt out of night shifts at 55, and recently lowered the age to opt out of night shifts to 50.

This earlier opting out of night shifts at age 50 added 2-3 nights shifts per year to faculty age 40 and younger.

Pregnancy

Pregnancy is a common physiologic challenge faced by health care workers and the health systems that employ them. Pregnancy outcomes are worse in shift workers and those working longer than a standard 40-hour week.

It is harder to protect the first trimester because schedules are often in place before people know they are pregnant, but protecting the third trimester and parental leave periods should be more straightforward than many emergency departments make it. Our department has adjusted our shift requirements for pregnant faculty so that there are no required night shifts in the third trimester, and no clinical shifts in the emergency department after 36 weeks’ gestation.

As a department, we do have the option of telemedicine if pregnant faculty need to continue working clinical hours. Our health system provides 90 days of pregnancy leave for all faculty.

Moving forward, we should think about how we collectively protect ourselves and each other from the impacts of shift work — for ourselves, for our colleagues and for our patients.

ABOUT THE AUTHOR Dr. Tyler is a clinical professor of emergency medicine, age-friendly emergency department physician lead, geriatric EM fellowship director, and vice chair for geriatric emergency medicine and wellness in the Department of Emergency Medicine. Dr. Tyler also serves as the medical director of physician wellness at the University of California, Davis. @katren_tyler

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WELLNESS

Fostering Social Connectedness in Residency Through Residency “Pods”

SAEM PULSE | NOVEMBER-DECEMBER 2022

By Suzanne Bentley, MD, MPH and Daniel Lakoff, MD, MBA, MS on behalf of the SAEM Wellness Committee

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Stress is rampant among health care professionals with resident physicians often facing particularly high levels of stress and overall strain on wellness and social connection. A 2022 survey revealed that from 2021 to 2022, there was a major increase in burnout in emergency physicians from 43% to 60%, landing emergency medicine in the #1 most burned-out physician specialty.

Residents face unique stressors, some throughout residency and others more unique to individual residency years. Fortunately, there are several strategies and techniques to increase resident support.

Target Social Isolation

One key intervention is to target the social isolation that can occur as

new interns begin residency and find themselves dealing with a magnitude of life changes. Away from their home cities, friends, and other supports, the initial few months of residency are challenging for all, but overwhelming for others. While these initial challenges do improve over time, new and different challenges occur over the course of the residency program. Fortunately, these challenges can often be eased through connectedness and support among coresidents.

Peer Support Systems: Residency Pods

To aid in establishing meaningful, friendly, collegial, mentoring relationships among residents that will assist and support them in navigating the complexity of residency, consider

peer support systems. An effective type of peer support system is the residency “pods” concept. Residency pods are effectively a variation on more common peer support models and similarly offer the benefit of normalizing and encouraging psychologically safe discussions around the shared experience of practicing modern clinical medicine; associated stresses; and possible stigma. Overall, the goal of the residency pod is to foster and enhance social connectedness among colleagues.

Structure of Residency Pods

Residency pods may be structured in a variety of ways at the discretion of the individual residency program and continued on Page 54

Some Important Questions to Guide You in Starting a Residency Pod What does the faculty selection process entail? How will you solicit volunteers?

Should you hold an open call to all faculty at attending meeting? A call for volunteers to core faculty? Will PD/APDs be included as faculty mentors?

What type of incentive/support will be provided to faculty?

Is a stipend possible for individual faculty? Is financial support in a set amount provided to support pod gatherings? (Note: some of the most meaningful activities are free or low-cost, e.g. picnic, hike, shared meal at pod member’s house)

What is the desired structure for the pod?

This should be based on logistics, size of program, and other preferences and used to guide the number of faculty mentors who are recruited. Conversely, pods may be structured to accommodate the number of faculty who volunteer.

Goal: inclusion across training years of a size that is manageable for group conversation without being so large that internal “subgroups form. If staffing allows, it is preferable to have more than one faculty mentor to ensure meetings can occur, even if just one of the two mentors are free.

What is the process for establishing and maintaining pods? Who will assume the task of assigning residents, by year, to a mentor?

Some programs utilize chief residents to establish the pods and assign new interns at start of each academic year; other programs are developed and maintained by the residency program director.

What is the best way to establish pod composition?

The goal is to decrease social isolation and build connectedness and networks; with this in mind, work to ensure pods are either randomly assigned or somewhat deliberately “mixed up” with friends being assigned to different pods when possible so that new interns will feel less like outsiders.

Another goal is for pods to compliment organically

occurring residency friendships and collegiality and potentially provide a lifeline to socially isolated trainees struggling with forming connections on their own.

Who will be responsible for ensuring the pods are successfully meeting?

Senior resident expectations should be clear: they are tasked with collaborating with faculty mentors to assist in leading the pod (planning events). The faculty mentor should not be tasked with all the effort of finding convenient dates, scheduling, and planning. Since residents rotate every year, everyone will have the opportunity to fulfill this duty at some point. Additionally, senior residents are expected to act as the “big sibling” to the junior residents — checking in on them regularly.

Every resident can offer wisdom, guidance, and support to more junior residents below them.

What meeting schedule and cadence will the pod follow? What type of activities will they conduct?

Scheduling, cadence, and type of activity is at the preference and decision of the pod. Some pods may predesignate dates at the start of the year to allow for advanced planning or during a recurring protected day/time (e.g. evening before academic conference). Pods may consider holding some gatherings with other pods (e.g., larger Thanksgiving gathering) to increase the potential for fostering social connectedness.

What resources, tips, and/or ideas might be offered to pods to bolster engagement?

Senior residents or other volunteers could be tasked with collating resources to make pod initiation and engagement easier. Provide suggestions for ice-breaker games for initial meetings and low-cost local activities (e.g., hikes, parks, happy hours, museum free days, etc.).

Consider multiple pod meetups, meet-ups with inter-residency pods, and extending an occasional invitation for nursing or other ED staff to join in a pod’s activity. Be creative!

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“Residency pods are effectively a variation on more common peer support models and similarly offer the benefit of normalizing and encouraging psychologically safe discussions around the shared experience of practicing modern clinical medicine; associated stresses; and possible stigma.”

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based on considerations such as size of residency program, expectation of level of faculty involvement, and other logistics.

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A common and recommended model for a residency pod consists of an attending faculty mentor (or multiple mentors); senior resident(s); mid-program resident(s); and intern(s) assigned at the start of every academic year to replace graduating senior resident(s) (although some graduating seniors who remain local may continue their involvement with their pods).

With this model, the composition of the pods remains the same over the residency years, unless changes in structure are made. Ideally, the pod concept is designed to work best with ongoing pod formation, so interns remain in the same pods for their entire residency, with new junior residents being added as others progress through the years. Changes can obviously occur as needed (e.g. swapping in a new

faculty mentor) or if conflicts or other extenuating circumstances arise.

Alternatively, if there are no faculty willing or available participate, a pod may consist of a senior resident(s), mid-program resident(s), and intern(s) — again with assignment of new intern(s) at the start of each new academic year.

Pods may be similarly implemented at non-residency sites and structured to include an array of attending faculty members who, ideally, have volunteered to be a part of the program, are aware of and willing to commit to expectations (e.g., at least monthly pod check-ins), and agree to serve as the pod leader and mentor. Faculty are expected to meet with the group in a mutually agreed upon social setting for a minimum number of times annually (e.g., 3-4 times per year). These gatherings could be for a meal, hike, or any other type of outing or activity on which the pod agrees. Additional meetings can be scheduled at the discretion of the group. Individual meetings are also encouraged for one-to-one guidance and support and a faculty mentor is expected to serve as a point person for

residents in the pod, to field questions, offer advice, and ensure a reliable and invested advisors for all residents.

ABOUT THE AUTHORS Dr. Bentley is an associate professor of emergency medicine and medical education at the Icahn School of Medicine and the chief wellness officer and director of simulation innovation and research at NYC Health + Hospitals/Elmhurst in Queens, NY. Her passions are workforce wellness and advocacy, debriefing, simulation, and medical education.

Dr. Lakoff is an assistant professor of emergency medicine, associate director of clinical services, and associate director of the healthcare leadership and management fellowship at NewYorkPresbyterian/Weill Cornell. With a clear vision to improve compassionate patient-centered care, he has turned his attention to optimizing the quality of work-life experience for physicians.

WELLNESS

Roe v Wade, Dobbs, and Reproductive Justice: A Case for Moral Injury to Physicians

By Stephanie Balint and Cindy Bitter, MD, MA, MPH, on behalf of the SAEM Wellness Committee The day the Supreme Court decision on Dobbs v. Jackson Women’s Health Organization was leaked, I was studying with my first-year medical student friends.

We discussed the ramifications of the decision on our intended specialties; nursing students and faculty joined in the discussion as they passed by. We were united in our disbelief and sense of powerlessness to affect the final decision that might disrupt access to reproductive health care. A common theme in modeling perinatal mortality in a post-Roe era is that complications and mortality will

disproportionately impact those living at the poverty level. As medical students, it felt like the values we espouse — health equity, evidence-based medicine, improving geographic disparities — would be destroyed by this decision.

Defining Moral Injury

Dissonance between one’s values and an act one witnesses or perpetrates can lead to “moral injury.” Moral injury can also occur when one simply fails to intervene when witnessing a situation that contradicts one’s values. In health care, moral injury describes the challenge

of “simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.”

Emergency medicine (EM) is a field with a great deal of experience dealing with moral injury. We treat victims of interpersonal violence and preventable complications of untreated disease and honor patient autonomy when the patient’s desired treatment goes against evidence-based recommendations. continued on Page 56

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Emergency department personnel recently faced amplified moral threats as we encountered an overwhelming pandemic with inadequate personal protective equipment, then treated patients with COVID-19 who had declined vaccination. We continue to try to find ways to limit poor outcomes caused by delays in care and full waiting rooms due to inadequate staffing and boarding of inpatients. Just as we began to adjust to a new scope of COVID-19-related moral injury, the Supreme Court decision added another potential threat. Regardless of one’s political affiliation or views on abortion,

I believe most physicians do not want to stand idly by as a woman becomes septic and dies while the lawyers and legislators argue about how imminent the threat to her life must be before she can be offered a termination.3-5

Implications of the Supreme Court Decision

Our obstetrics and gynecology (OBGYN) colleagues were the first to feel the impact of the Dobbs decision.

Dr. Caitlin Bernard, and Indianapolis, IN OB-GYN, has been at the center of a firestorm after treating a victim of pediatric sexual assault who was referred to her for pregnancy termination. In a CNN interview, Dr. Bernard stressed that when treating medical emergencies there are not

seconds to spare to consult with an attorney. In a specialty where timecritical decision making is common, these delays have the potential to impact patient outcomes and bring further assault to physician values. In a New England Journal of Medicine opinion piece, OB-GYN, Dr. Lisa Harris highlighted the need for hospitals to prepare, system-wide, for the repercussions of the Dobbs decision.

As medically supervised terminations become less available, patients may seek alternative methods of termination which are projected to be associated with higher pregnancy-related mortality.1,8-9 The EM community is already researching and disseminating information on managing the life-

threatening emergencies created by these alternative attempts at pregnancy termination.10-11

What Can We Do?

With this new, potential source of moral injury upon us, we look to the literature for possible mechanisms for coping.

The first step in reducing moral injury is awareness. Identifying the source of one’s discomfort as a moral injury can lead clinicians to seek support from peers and take their concerns to leadership to ensure that hospital protocols facilitate patient-centered behavior and values are upheld. In a 2019 commentary, Dr. Wendy Dean, et al., suggest that long-term solutions will come from collaboration between administrators and physicians. This is consistent with the Quadruple Aim, which adds the wellbeing of health care workers to reducing costs, improving population health, and improving the patient experience as ways to optimize the health care system.

Additionally, physicians are often able to advocate for policy changes on a broader level. Physician advocacy has been

crucial to the development of seat belt regulations, expansion of the Children’s Health Insurance Program, and ensuring coverage of indicated treatments for conditions such as opioid use disorder and hepatitis C. Dean, et al., suggest that “every physician leader has and uses the cell phone number of his or her legislators.”

Other proposed strategies for reducing moral injury include educational workshops, moral empowerment programs, social work interventions, nursing ethics huddles, reflective debriefing, and a multifaceted resiliency bundle.12-13 The paucity of evidencebased tools for dealing with moral injury presents an opportunity for research and innovation. Given the many moral threats EM faces, the specialty is uniquely equipped to be at the forefront of tackling this issue.

Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the views or positions of the Society for Academic Emergency Medicine.

ABOUT THE AUTHORS Dr. Bitter is an associate professor, department of surgery, division of emergency medicine at Saint Louis University in Missouri. She attended medical school at the University of Kansas and completed her emergency medicine training at the Medical College of Wisconsin, and completed an International EM & Global Health Fellowship at the University of Illinois at Chicago.

Stephanie Balint, a second-year medical student at Quinnipiac University, applied to medical school with the goal of becoming an emergency department physician. Prior to medical school she worked as an emergency medical technician, National Guard Healthcare Specialist, and for five years, as an emergency department registered nurse. Since 2020 she has worked as an Advanced practice registered nurse in the ED at a small 122-bed community hospital in Connecticut. @stephfosterski1

Read more: • The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant •R eframing Clinician Distress: Moral Injury Not Burnout • Abortion ban leads to more maternal deaths in Nicaragua • When There’s a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals • Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women: an analysis of the death of Savita Halappanavar in Ireland and similar cases •C NN speaks to the doctor who performed an abortion on 10-year-old •N avigating Loss of Abortion Services — A Large Academic Medical Center Prepares for the Overturn of Roe v. Wade • F atal necrotizing fasciitis in illegal abortion and the negligence tort • S tate Abortion Policies and Maternal Death in the United States, 2015-2018 • The Emergency Department After the Fall of Roe: Are You Prepared?

• P ost Abortion Complications •R eflective Debriefing: A Social Work Intervention Addressing Moral Distress among ICU Nurses • E ffective interventions for reducing moral distress in critical care nurses 57

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SAEM PULSE | NOVEMBER-DECEMBER 2022

The Role of the Resident Wellness Chief in Contributing to the WellBeing of Residents

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By Megan Anderson, DO Emergency medicine (EM) residency is a fast-paced, adrenaline-filled marathon of hands-on learning where residents are forced to pivot minute-to-minute between the highs and lows of patient care. It is no wonder topics such as well-being, burnout, and mindfulness have been brought to the forefront of discussion among EM residency programs, especially during COVID-19.

Given this, general, residency is a time where areas of wellness such as mental and physical health are placed on the back burner due to time and energy limitations. Ironically, it is optimized wellness itself that can improve energy

levels, sleep hygiene, confidence, mood, and overall career satisfaction.

As physicians, we strive to improve the health of our patients; however, we cannot effectively take care of others if we are not first taking care of ourselves.

It is for these reasons that interventions from a wellness chief are essential to an EM residency program.

“Wellness” is defined differently by everyone. While some residents find wellness in physical activity or being outdoors, other residents may discover wellness from reading a book for pleasure in a quiet space. Traditionally, there are seven components of well-

being: 1.) emotional, 2.) physical, 3.) intellectual, 4.) spiritual, 5.) social, 6.) environmental, and 7.) financial. As the wellness chief of the Medical College of Wisconsin EM residency program, I wanted to discover what “wellness” meant to each of our residents so that I would have a more effective impact on resident well-being. To assess components of wellness that our residents valued most, I created a survey for residents to complete at the beginning of the academic year.

The survey was voluntary, and most responses were submitted by our PGY1 residents, followed by PGY-3, then

“As physicians, we strive to improve the health of our patients; however, we cannot effectively take care of others if we are not first taking care of ourselves. It is for these reasons that interventions from a wellness chief are essential to an EM residency program.”

PGY-2, with a total of 17 submissions for a program of 35 residents. The figure below is a graph revealing the results of this survey with the top contributing factors of resident wellness.

When asked to choose “the top five activities that personally make you well” from a list of options, an overwhelming proportion (15/17 or 88%) of residents selected “spending time with friends, family, and co-workers.” Most residents (13/17 or 76%) also felt that spending time in nature positively impacted their wellness. Additionally, both free food and physical fitness was found to be beneficial to 12 of the 17 residents (70%). Given that these four activities were chosen by a substantial number of residents, I felt it imperative to focus on implementing or continuing wellness initiatives related to these areas (e.g., group events, exercise encouragement, and increased opportunities for free food at conferences or in the resident lounge). As for the remainder of the options, a smaller majority of residents (9/17 or 53%) listed time alone, time with animals, or pleasure reading as an activity that contributes to their wellness. With this data in mind, we have begun discussions around starting a book club and bringing service animals to conference on occasion. Finally, the last three options were selected by fewer than half of the residents; listed in order these include games/competitions

(8/17 or 47%), cooking (3/17 or 17%), and therapy (0/17 or 0%). While only a minority of residents chose some of these options, it is helpful to keep them in mind for future activities. Also, it is interesting to note that in this group of individuals, no residents felt that therapy would contribute to their wellness. While we already have mental health resources in place, it is helpful to know that other interventions may be a better option for these residents.

As stated above, in response to these submissions, our wellness committee has been able to address different components of wellness through peer guided suggestions. We have started a non-medical, ED-wide book club and are planning for a cookbook competitionthemed journal club. During warmweather months, we get together once a month for “Sunday Funday,” during which a group of EM faculty, residents, family members, and pets are encouraged to walk one of the many Greater Milwaukee trails together, ending with food and beverages. I have created a mentorship program called “Life Support” in which we match residents and attendings based on survey results focusing on academic/personal interests. Additionally, our department participates in a biannual physical fitness competition between our “house groups” to encourage physical health. We have embedded resident

bonding opportunities and games into conference days with free breakfast/ coffee at every conference. Finally, we have an array of mental health programs such as our peer support system “SOS” as well as a new initiative called “Talk-o Tuesday” where small groups of EM residents can choose to get together over tacos to discuss difficult cases or stressors of residency.

Ultimately, the role of wellness chief is dynamic and persistent throughout the academic year as morale fluctuates rotation by rotation and season to season. My goal with this survey and my intention overall is to not only positively impact the wellness of each of our residents individually this year but to teach them how to be well going forward in their life and careers.

ABOUT THE AUTHOR Dr. Anderson is a PGY3 emergency medicine resident at Medical College of Wisconsin in Milwaukee, WI. She is passionate about wellness and its implications on the operations/administration aspect of emergency medicine. She was selected as a fellow of CORD’s Mini-Fellowship in Wellness Leadership.

WELLNESS SURVEY

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Shifting Tides: Changing the Paradigm of Treating Opioid Use Disorder by Updating Resident Education

By Corey Hazekamp, MD, MS; Dana Sacco, MD, MS; and Bernard Chang MD, PhD

SAEM PULSE | NOVEMBER-DECEMBER 2022

This article highlights work from the 2022 NIDA Mentor-Facilitated Training Award, supported by the National Institute on Drug Abuse (NIDA) from the National Institutes of Health (NIH) and sponsored by the SAEM Foundation

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Emergency medicine has long been the front line of patient care for a diverse range of acute and chronic conditions and the clinical milieu where providers can support some of the most vulnerable patients in health care. In the face of the recent opioid epidemic striking our health care system, Emergency departments (ED) have faced increasing numbers of patient with behavioral health concerns and substance use disorder complications.

At the onset of my career as an emergency medicine provider, treating patients with opioid use disorder (OUD) in the ED was a humbling experience that inspired me to learn more. However, I quickly encountered

the challenges of utilizing life-saving medications for opioid use disorder (MOUD) in the ED, specifically how to initiate buprenorphine.

I soon learned of the NIDA MentorFacilitated Training Award, supported by the National Institute on Drug Abuse (NIDA) from the National Institutes of Health (NIH) and sponsored by SAEM Foundation. My plan was to learn how to overcome barriers to EDinitiated buprenorphine as a resident and disseminate information to other residents interested in learning how to counteract the ongoing opioid epidemic.

The result of the project that I proposed, “Shifting Tides: Changing the Paradigm of Treating Opioid Use Disorder by Updating Resident Education,” is a framework we conceptualize as “The 3B’s of Buprenorphine: Basics, Barriers and Beyond the ED.” This framework was created with the intent of helping to better educate residents, as well

as other ED providers, about how to successfully initiate buprenorphine treatment in the ED. In our framework, the Basic reason to offer buprenorphine to patients with OUD in the ED is that it decreases mortality. A randomized control trial showed that patients who are initiated on buprenorphine in the ED had increased retention in treatment and decreased self-reported opioid use.

When a patient comes to the ED in opioid withdrawal, if untreated, they are more likely to return to opioid use upon discharge, increasing their risk of overdose and possibly death. Furthermore, there are clinical benefits to using buprenorphine in the ED. Compared to methadone, buprenorphine has less of a risk of apnea and QTc prolongation.

The Barriers addressed in our framework include (1) learning how and when to initiate buprenorphine in the

ED, (2) working in a department without a protocol for ED-initiated buprenorphine, and (3) addressing internal biases that may prevent us from offering MOUD. There is no unified protocol or algorithm for how and when to initiate buprenorphine. The American Journal of Emergency Medicine and Annals of Emergency Medicine have both published guidelines for ED-initiated buprenorphine.

Resources that ED providers can utilize in real time when encountering opioid withdrawal include MDCalc’s Emergency Department-Initiated Buprenorphine for Opioid Use Disorder (EMBED) tool and the BUP Initiation app, both of which include a screening tool to evaluate for OUD, a brief negotiating interview, the clinical opioid withdrawal score (COWS), dosing, and discharge instructions. The X-waiver has long been considered a barrier to emergency physicians (EPs) prescribing buprenorphine. The Drug Addiction Treatment Act of 2000 requires eligible providers to complete eight hours of training to obtain what is known as an “X-waiver” in order to prescribe buprenorphine. Adjustments made during the COVID-19 pandemic led to the creation of a notification of intent (NOI) which allows providers to discharge patients with buprenorphine prescriptions without any additional training. If a provider does not have an X-waiver, they can still order buprenorphine while a patient is in the ED and have the patient return to the ED later for additional dosing if necessary. An option for a patient whose withdrawal is not yet severe enough for buprenorphine in the ED is to provide instructions for home induction of buprenorphine. Patients can be discharged with a prescription for buprenorphine and specific instruction on induction. The Buprenorphine Home Induction app provides step-by-step instruction on how to do a buprenorphine home induction and also provides a search function to find a buprenorphine provider.

Another potential barrier and/or challenge to patients being offered buprenorphine in the ED occurs at the operational and clinician level. Humans experience cognitive biases daily – a deviation in our thought processes based on external influences. We’re also vulnerable to utilizing heuristics, a type of cognitive shortcut, to make decisions quickly. Previous research has shown that cognitive biases may lead to diagnostic inaccuracies or premature diagnostic

closure. In a recent paper, Dr. Dan Ly found that EPs were vulnerable to the availability heuristic – that our assessment of an event’s likelihood of occurring is influenced by how easily this event comes to mind. In other words, we’re more likely to think of a diagnosis if we have seen it recently. This may have implications when managing patients with OUD in the ED. A recent unpleasant experience with a patient who has OUD may or may not have led us to believe that this patient was exhibiting drug-seeking behavior. Regardless, we should all make a conscious effort to prevent this kind of previous experience from influencing our approach to the patient in front of us. All patients deserve to be offered comprehensive care and treatment, which includes MOUD such as buprenorphine for patients with OUD. Finally, the Beyond the ED portion of our framework encompasses one of the most important components of initiating buprenorphine in the ED: linkage to long-term treatment. Not all hospitals are created equally; we work in a wide variety of environments and have access to different resources.

Patients who undergo ED-initiated buprenorphine require long-term follow up. Three common models used by ED providers are (1) the Bridge model, (2) the ED-Bridge model, and (3) the Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model. The Bridge model requires an ED provider to initiate buprenorphine in the ED and the patient follows up with a different provider in the same hospital; whereas in the ED-Bridge model the ED provider initiates buprenorphine in the ED and can serve as a longterm buprenorphine provider. ASSERT utilizes addiction team services along with peer educators and community workers. Some states have extensive referral systems such as California, CA Bridge, and New York, NY MATTERS. If none of these are available within your hospital, harm-reduction clinics are useful resources, and some offer buprenorphine treatment. Familiarizing yourself with the resources your department, hospital, and community have for patients with OUD will take a small amount of time but will be invaluable in helping serve some of the most in-need patients that visit the ED.

a patient in cardiac arrest, there is not a single set of guidelines regarding the timing and dosing of buprenorphine. Most current emergency medicine residents likely do not train in a department with a protocol for initiating buprenorphine. And there is no specific ACGME requirement for teaching residents how to initiate buprenorphine. Despite these limitations, we hope to help residents recognize the importance of offering MOUD, especially buprenorphine, to their patients with OUD. Clinicians practicing emergency medicine are passionate advocates for their patients. We sustain this passion and carry it over to how we treat all our patients. For some of society’s most vulnerable patients, such as those with substance use disorders, EPs can play a vital role in supporting their short and longterm wellbeing. Hopefully the resources provided here can help anyone interested get started in learning how to appropriately initiate buprenorphine in the ED.

ABOUT THE AUTHORS Dr. Hazekamp is a secondyear emergency medicine resident at NYC H+H/Lincoln.

He is interested in researching healthcare disparities. @coreyhazekamp Dr. Chang is vice chair of research and associate professor of emergency medicine at Columbia University, with research interests in health psychology, clinician health, and neuropsychiatric disease Dr. Sacco is a practicing emergency physician at NYP-Columbia University Irving Medical Center, and is involved with substance use disorder research

Dr. Hazekamp talks about his research…

Unlike ACLS guidelines which dictate when and how much epinephrine and amiodarone to give while resuscitating

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SAEM PULSE | NOVEMBER-DECEMBER 2022

SAEM Annual Awards: A Who’s Who of Emergency Medicine

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Emergency medicine (EM) quietly turned 50 last year, five decades after Gail V. Anderson was named the first chair of emergency medicine at Los Angeles County, University of Southern California (LAC/USC) Medical Center in October 1971. Although formation of the Emergency Medical Residents’ Association (EMRA) in 1974 and the American Board of Emergency Medicine (ABEM) in 1979 served to solidify our specialty’s place in the firmament of medical practice, we are still considered newcomers in the medical world. One of the most exciting aspects of our specialty is that some of our founders are still alive, perhaps even practicing and teaching EM to the next generation of practitioners.

The Society for Academic Emergency Medicine (SAEM) was founded in 1989, as an amalgamation of the University Association for Emergency Medicine

(UAEM) and the Society of Teachers of Emergency Medicine (STEM). Our purpose for the last 33 years has been to, “improve care of the acutely ill and injured patient by improving research and education.” But the improvements that we seek are not easily won and are often achieved by those working quietly behind the scenes to advance our specialty. Each year, SAEM honors the best and brightest EM physicians with its annual awards ceremony, recognizing those individuals who have shown, “excellence in our field, for contributions improving the health of society, and for academic achievements.”

A review of the past winners of these awards reads like a “who’s who” of emergency medicine. The names of women and men who built our specialty from the ground up are preserved here, their examples continuing to inform

and inspire the rest of us. For those unfamiliar with these awards, here are some of the highlights:

John Marx Leadership Award This award honors a, “SAEM member who has made exceptional contributions to emergency medicine through leadership – locally, John Marx regionally, nationally or internationally – with priority given to those with demonstrated leadership within SAEM.” Trained under Peter Rosen, Dr. John Marx left Denver General after 10 years with Carolinas Medical Center, where he served with distinction as chair for

20 years. His research interests focused on abdominal trauma and alcohol-related emergencies. In addition to editing three editions of Rosen’s Emergency Medicine textbook, he was a founding member of the editorial boards of Academic Emergency Medicine and Journal of Emergency Medicine, accumulated 38 visiting professorships, and served as President of SAEM. The first John Marx Leadership Award was presented in 1989 to Ronald L. Krome, MD.

Excellence in Research Award This award honors a, “SAEM member who has made outstanding contributions to emergency medicine through the creation and sharing of new knowledge.” Candidates are evaluated based on key criteria including research accomplishments, training and mentorship of other investigators, and research service.

The first excellence in Research Award was presented to Jeffrey A. Kline, MD, who presently serves as the editor in chief of Academic Emergency Medicine journal.

Hal Jayne Excellence in Education Award

Steve Lowenstein

his award honors T a, “SAEM member who has made outstanding contributions to emergency medicine through the teaching of others and the improvement of pedagogy.”

A 1969 graduate of Wayne State University School of Medicine and early faculty member at Detroit General Hospital, Harold A. Jayne was also the founder and Chief of the University

of Illinois EM program, longstanding Annals of Emergency Medicine Editorial Board member, and a prominent early contributor to the success of ACEP, ABEM, and SAEM. His sudden death in 1986 at the age of 43 cut short what would have undoubtedly been a long and fruitful academic career.

The first Hal Jayne Excellence in Education award was presented in 2009, to Steve Lowenstein, MD, MPH.

Marcus L. Martin Leadership in Diversity and Inclusion Award This award honors a, “SAEM member who has made exceptional contributions to advancing diversity and inclusion in emergency medicine through leadership Marcus L. Martin – locally, regionally, nationally or internationally – with priority given to those with demonstrated leadership within SAEM.” A pioneering champion for diversity and inclusion within EM, Dr. Martin was the first Black American graduate of Eastern Virginia Medical School (EVMS) in 1976, later serving as Chair (1996-2006) at the University of Virginia (UV) and UV Vice President and Chief Officer for Diversity and Equity since 2011. A past President of both SAEM and CORD, Martin was recently elected Rector of the EVMS Board of Visitors in 2021.

The first Marcus L. Martin Leadership in Diversity and Inclusion Award was presented in 2014 to Joel Moll, MD.

Advancement of Women in Academic Emergency Medicine Award

has made significant contributions to the advancement of women in academic emergency medicine.”

Both men and women are eligible, and key criteria for Rita Cydulka this award include evidence of mentoring and support of women in academic EM, national leadership in the spirit of this award, and vital contributions to the advancement of EM. The award was first presented in 2008 to Rita Cydulka, MD, MS.

Other Annual Awards Additional SAEM Awards include the Mentor Award, Mid-Career Investigator Award, Public Health Leadership Award, FOAMed Excellence in Education Award, Arnold P. Gold Foundation Humanism in Medicine Award, Early Investigator Award, Early Educator Award, a host of Academy awards, and several awards recognizing outstanding medical students, residents, and fellows.

As our specialty embarks on its second fifty years, we should all pause and reflect on the accomplishments of EM’s pioneers and titans, but also recognize that their tradition of excellence in research, leadership, and academic EM lives on in this generation of academicians.

Let’s all show our support of SAEM and of the exceptional people who are working behind the scenes to advance our specialty by nominating a candidate for one of these prestigious awards. We all know someone who deserves to be recognized, and now is the time to act.

Award nominations close on December 9, 2022.

For more information on these and other awards, or to submit a nomination, please visit the SAEM Awards website.

This award honors a “SAEM member who

Nominate Yourself, a Colleague, or a Mentor for an Award!

Awards season is back and we’re celebrating excellence in academic emergency medicine research, education, and leadership. Nominate a colleague, mentor, or yourself for an SAEM or RAMS award by December 9, 2022. These awards, among several others (including a RAMS video contest!), recognize the very best in our field. Learn more about the awards and nomination process and apply today!

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End of Year Donor Guide Special Digital Insert

Click here to read this special digital insert.

R A E Y F O D N E DE I U G R O N O D

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2022 EMF/SAEMF Medical Student Research Grantees The Emergency Medicine Foundation (EMF) and Society for Academic Emergency Medicine Foundation (SAEMF) jointly award stipends to encourage medical students (our future emergency medicine researchers and educators) to engage in and to be exposed to emergency medicine research. We applaud this year’s cohort of grantees and wish them all the best as they move forward with their research training.

Aneeqah Naeem, BA The Warren Alpert Medical School of Brown University for “Feasibility and Barriers to Implementation of an Emergency Department Community Health Worker-Peer Recovery Specialist Program for Patients with Substance Use Disorders”

Sara Lin Vanderbilt University School of Medicine for “Examining Insurance Status and Presentation to Percutaneous Coronary Intervention Capable Facility for Patients with ST-Elevation Myocardial Infarction”

Grant McDaniel, MS niversity of Toledo for U “Using Simulation to Assess Bag Valve Mask Performance in Stressed Emergency Medicine Residents and Physicians”

For more information or to apply for these grants, please visit our website. Join the Annual Alliance today to support more future leaders like these grantees.

Congratulations to the 2022 Emergency Medicine Interest Group (EMIG) Grantees SAEMF recognizes the valuable role of emergency medicine medical student interest groups (EMIGs), and awards $500 grants to support these groups' educational activities. EMIG grant goals are to: • Promote growth of emergency medicine education at the medical student level • Identify new educational methodologies advancing undergraduate education in emergency medicine • Support educational endeavors of an EMIG Learn more about these grants or apply for the 2023 grants. Your charitable gift of $500 will help to make one EMIG possible — donate today!

We applaud the following 2022 grantees for being awarded these important educational grants for their programs:

Alexa Curt and Raylin Xu

Jasmanpreet Kaur and Amanda Schoonover

Harvard Medical School for "Pediatric Emergency Bootcamp: Targeted Procedural and Simulation Skills for the Developing Physician"

Michigan State University College of Human Medicine for “'Stop The Bleed' Events: A Missed Opportunity for the Inclusion of Firearm Safety and Education in U.S. Medical Schools"

Kristina Gueco and Shaylyn Fahey

Harry Fillmore and Thomas Heisler

Virginia Tech Carilion School of Medicine Pilot for "CPR/AED Education and Outreach Project for Local Nepalese Community"

Columbia University Vagelos College of Physicians and Surgeons for "First Responder Competition"

Carter Griest The Perelman School of Medicine at the University of Pennsylvania for "Advanced Cardiac Life Support (ACLS) and Related Clinical Skills Session for Preclinical Students"

Julia Horiates East Carolina University, I-TEAM Day: Interprofessional Triage for "Emergency Assessment, and Management Day"

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BRIEFS & BULLET POINTS SAEM23 SAEM23 Didactic Submissions Smash All Records!

SAEM members, you have outdone yourselves again. The SAEM annual meeting program committee is thrilled to report that SAEM23 didactic submissions achieved an all-time high of 376! We are grateful to our members for ensuring that SAEM’s annual meeting continues to set the standard for the highest level of research and education in emergency medicine! We look forward to seeing everyone in May 1619, 2023 for SAEM23 in Austin, Texas.

Accepting Abstracts, Innovations, and IGNITE! Submissions Abstracts SAEM Annual Meeting abstracts reflect the daily interaction of the emergency department with the most vulnerable persons in society and cover a relevant mix of topics that encompass a day in the emergency department. These abstracts represent the work of thousands of researchers and educators who have created new knowledge and thinking about emergency care that adds valuable confirmation of previous work, presents evidence that might change the practice of EM for the better, and elevates the outcomes and experiences of every patient who seeks emergency medical care. Collectively they reflect a global experience of emergency care that together tell the story of important challenges and the need for more knowledge. Each year accepted abstracts are published in a special supplement of Academic Emergency Medicine journal. From among the more than 1,000 submissions, a select few will be chosen as the best of the best, to be presented during a special plenary session. Platform closes January 3, 2023.

Learn more.

Innovations Innovations is a forum for members to present novel ideas and approaches in undergraduate and graduate medical

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education as well as advances in other nonclinical areas such as faculty development and operations. Platform closes: January 11, 2023. Learn more.

IGNITE! IGNITE! is a highly energetic, captivating, fast-paced, and engaging speaking competition. Each IGNITE talk is five minutes in length with 20 automatically advancing slides. A panel of judges selects a “Best of IGNITE!” winner from each IGNITE session. An “Audience Choice Award” is also given at each session based on audience polling.

Because there are no limitations on submission topics, you will be exposed to all sorts of interesting issues in EM. Speakers are selected from all levels of training from all parts of the country.

Platform closes January 11, 2023.

Learn more.

Submit Equity and Inclusion Proposals to SAEM23!

The SAEM Equity and Inclusion Committee encourages SAEM members to consider submitting IGNITE!, Innovation, and abstract proposals in the following areas: history and ongoing presence of racism, sexism, homophobia, transphobia, ability, bias in medicine, and strategies to change structures. Additionally, the committee urges speakers and panelists to acknowledge health equity, social needs, and social determinants of health involved in the care of emergency department patients.

SAEM23 Registration Opens December 1

The SAEM Annual Meeting offers something for everyone from seasoned faculty to medical students just starting their careers. Featuring cuttingedge research from the best minds in academic EM, expert educational content from world-class faculty, workshops that strengthen knowledge and skills in specific topic areas, energetic experiential learning competitions, and expansive networking events and career development opportunities to take your

career to the next level. Plan now to join us in Austin, Texas, May 16-19, for SAEM23. Registration opens December 1! Early bird deadline is March 14. Visit the SAEM23 website to stay up to date on all the latest news and information.

Also Opening December 1 • Medical Student Ambassador applications • SimWars team lottery • MedWars team registration • Dodgeball team registration • Sonogames team registration • Clinical Images Exhibit submissions

SAEM23 to Offer Childcare

SAEM is pleased to announce that we have contracted with Jovie’s team of childcare professionals to look after your children, infant through age 12, at SAEM23 so you can enjoy and participate in the annual meeting knowing they are being well cared for. Jovie will provide childcare via an onsite day camp at the SAEM23 host hotel, with age-appropriate arts, crafts, and fun activities for children.

Registration is now open. Reserve your spot by March 14.

SAEM JOURNALS Academic Emergency Medicine AEM Senior Editorial Board Seeks Applications for Editor of Statistics and Methodology

Academic Emergency Medicine (AEM) journal is seeking an individual to fill a vacancy on the Senior Editorial Board as the Senior Editor of Statistics and Methodology. View full application details and required materials. Submit all completed application materials to Laura Giblin at lgiblin@saem.org. Application deadline is November 15, 2022. The decision process will include an interview by videoconference. A decision will be made by December 1, 2022.

SAEM FEATURED NEWS Applications Open November 30 for the Emerging Leader Development Program

The Association of Academic Chairs in Emergency Medicine (AACEM) and the Society for Academic Emergency Medicine (SAEM) are proud to bring you the Emerging Leader Development Program (eLEAD). This year-long course will begin at the SAEM23 Annual Meeting, which takes place May 16-19, 2023 in Austin, Texas, and will provide emerging leaders in academic emergency medicine with a structured, longitudinal experience designed to develop foundational leadership skills, cultivate a meaningful career network, and build a bridge to countless opportunities in their field.

Learn more. Application deadline is January 13, 2023.

eLEAD Testimonial Amy Zosel, MD, MSCS Associate Professor of Emergency Medicine and Medical Toxicology, Medical College of Wisconsin What unique benefits does the eLEAD program provide for participants?

The benefits to the program for participants are vast. The top benefits from my perspective are the opportunity to learn from top leaders in Dr. Amy Zosel academic emergency medicine as well as develop a network of peer leaders from across the nation. Thus far, eLEAD has introduced us to several helpful tools to lead ourselves and others. It’s been great to receive several helpful techniques and tools hand-picked by experts and presented in an efficient, thoughtful manner.

So far, how has eLEAD impacted your work and career trajectory?

The eLEAD program has allowed me the structure and space to be more reflective on my own personal leadership style as well as the relationships of those I lead daily. Time management and conflict resolution are just some of the topics discussed.

Who is the ideal candidate for this program, and why would you recommend it to them?

I would highly recommend this program to any mid-level faculty that has had some leadership experience and is looking to become a better leader at work and in the community.

November 30 Is the Application Deadline for ARMED MedEd SAEM is proud to offer the Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) course. This course builds upon the fundamental knowledge and skills of health professions education researchers and equips them to design a high-quality medical education research project and grant proposal. The course is for those who have an interest and basic level of understanding or experience in medical education research, although this is not a requirement. Apply

by November 30, 2022. Scholarships are available.

Kevin R. Scott, MD MSEd Assistant Residency Director; Director, Education Scholarship Fellowship; Associate Clinical Professor, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania What unique benefits does the ARMED MedEd program provide for participants?

ARMED MedED offers that “next step” beyond other education research training programs that exist. Having Dr. Kevin R. Scott had a foundational understanding of education scholarship, I found that ARMED MedED reviewed the basics but then utilized leaders in the field to deliver content at that next level. In addition, the mentorship structure allows for access to multiple leaders in the field of med ed scholarship.

How has ARMED MedEd impacted your work and career trajectory?

ARMED MedEd has had a significant impact on my personal scholarly work and career trajectory. Through the mentorship program and discussion of my work and interests with leaders in ARMED MedEd, I have been fortunate enough to join a multisite study/grant which has led to further opportunities within the larger medical education community. I have also been fortunate to have developed new mentorship and personal relationships with leaders in medical education.

Who is the ideal candidate for this course, and why would you recommend it to them?

ARMED MedED is perfect for the educators who want to take that next step in building their understanding and skillset with regards to education scholarship. I believe those that are currently completing or have completed some formal concentrated program in medical education are likely to find the largest benefit from participating in the program.

What was your best takeaway from ARMED MedEd? I am most grateful for the expansion of my network of trusted colleagues and experts. Even a year after completing ARMED MedEd we continue to work closely together with many more years on the horizon.

Anything else you’d like to share?

Having been part of the first cohort and now part of the second as a peer mentor and associated faculty, I have seen firsthand how leadership responds to feedback and is constantly adjusting the program to meets the needs of the learners.

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BRIEFS & BULLET POINTS continued from Page 67

Accepting Nominations Through November 11 for 2023-2024 Leadership Positions!

Nominate yourself or someone else for an elected positions to SAEM’s Board of Directors, RAMS Board, SAEM Nominating and Bylaws committees, the executive committees for AACEM and SAEM academies, and the SAEM Foundation Board of Trustees. Leadership positions should be filled by committed individuals who have a wide range of perspectives and possess the relevant skills and experience to effectively lead.

If you, or someone you know, fit that description, we invite you to submit a nomination by visiting the nominations webpage. Deadline is November 11, 2022.

There’s Still Time to Nominate Yourself, a Colleague, or a Mentor for an Award!

Awards season is back and we’re celebrating excellence in academic emergency medicine research, education, and leadership. Nominate a colleague, mentor, or yourself for an SAEM or RAMS award by December 9, 2022. These awards, among several others (including a RAMS video contest!), recognize the very best in our field. Learn more about the awards and nomination process and apply today!

SAEM FOUNDATION Apply by February 15 for the $25,000 GEMSSTAR Grant

The National Institute on Aging (NIA) offers a grant called the Grants for Early Medical/Surgical Specialists’ Transition to Aging Research (GEMSSTAR) Program. The GEMSSTAR program uses an NIA-funded small research project (R03) mechanism. As part of the R03 application, investigators may include a Professional Development Plan (PDP) to run concomitantly with the R03 award which is to be supported through non-R03 funds. In order to support emergency medicine GEMSSTAR applicants in their Professional Development Plan, SAEMF and the Emergency Medicine Foundation (EMF) jointly created this GEMSSTAR for Emergency Medicine Supplemental Funding Program. This program has a separate application process from the NIA R03. Learn more here and then apply

by February 15, 2023.

SAEM Members: Let’s Give Together on GivingTuesday 2022

• Visit your local schools to talk about what you do when you become an academic EM • Download the “SAEMF Unselfie” graphic, print, personalize, and post to tell others to join you in supporting the best ED care through research and education.

• Share your donor story on social – post your Unselfie But, why wait until November 29? Donate now to help make more possible through EM research and education.

SAEM Foundation Announces 2022 Challenge Winners!

Apply by December 31 for the 2023-2024 CAEMA Program

The purpose of the Certificate in Academic Emergency Medicine Administration (CAEMA) program is to provide education and a certificate for those professionals who have attended the program and demonstrated proficiency in the body of knowledge required of administrators in academic emergency medicine. The program is specifically geared towards the knowledge base of administrators in an academic environment, encompassing resident education, post residency training, inclusion of medical students, and research in emergency medicine.

Apply by December 31, 2022.

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GivingTuesday is a global generosity movement unleashing the power of radical generosity. GivingTuesday was created in 2012 as a simple idea: a day that encourages people to do good.

Since then, it has grown into a year-round global movement that inspires hundreds of millions of people to give, collaborate, and celebrate generosity. Everyone can give something on GivingTuesday: • Host a small social gathering and donate proceeds to SAEMF • Donate your time to an organization in your community

A special thanks to all our donors and group leaders who made this another record-breaking year possible for the Challenge. This year’s donors raised $81,210 during the Challenge period and unlocked SAEM’s generous $10,000 match to raise the total to an unparalleled $91,210 for EM research!

Miss the opportunity to donate? Keep the momentum going – donate now. Here are the 2022 winners: Highest Participation • Academy of Geriatric Emergency Medicine

• Bylaws, Finance, Grants committees • Vice Chairs Interest Group Most Funds Raised • Academy for Diversity and Inclusion in EM

awards, curricula, and more. Take charge of your career journey by exploring all that SAEM has to offer!

Membership in SAEM Academies and Interest Groups is FREE!

• Research Committee • Vice Chairs Interest Group

SAEM NEWS & INFO

Here Are SAEM’s NIH Funded EM Investigators!

Searching for That Next Job in Your EM Career? We Can Help!

Are you looking for that next job or thinking about expanding your professional network? Check out SAEM’s EM Job Link — the niche job source for the academic emergency medicine community. You›ll find tidbits related to guidance for every step of your career journey, featured jobs, and more!

Update Your Member Profile: Add Pronouns and Fellowships!

SAEM recently rolled out some new features for membership profiles which all SAEM members are encouraged to use and act on. With the new feature update, member profiles now include pronoun identification and fellowships, which were introduced earlier this year. Add your pronouns, fellowships, and related demographical information to keep the community and your fellow colleagues in the know. Update your profile here!

SAEM’s Career Roadmap Helps You Take Charge of Your Career Journey The SAEM Career Roadmap is a comprehensive guide for individuals at every level of their academic emergency medicine career — chairs, faculty, administrators, fellows, residents, and medical students. It provides an overview of all the tools SAEM can provide, including leadership opportunities, courses, meetings, networking opportunities, grants, scholarships and

with Association of Academic Chairs of Emergency Medicine (AACEM), are available to assist individuals, departments, and institutions with developing, evaluating, and/or improving various services; developing departmental status for EM divisions; subspecialty expertise (research, ultrasound, etc.); and billing, patient safety, etc.

SAEM members who wish to explore a specific specialty area are encouraged to join one or more SAEM academies or interest groups. SAEM academies provide a forum for members to network, exchange information, collaborate on educational initiatives, develop policy, perform research, and provide faculty development pertaining to their area of special interest or expertise. SAEM interest groups provide a mechanism for members interested in a specific topic or specialty area to meet, share ideas and network in an unstructured and informal fashion. Membership in SAEM academies and interest groups is 100% free!

The Community Forum Is One of the Many Perks of an SAEM Membership

One of the benefits of your SAEM membership is full access to the SAEM Community Site, an online space for connectedness, collaboration, and communication. At the SAEM Community Site you will be able to network with your peers and colleagues to collaborate on educational initiatives, develop policy, perform research, and provide faculty development pertaining to your area of special interest or expertise. Connect today to start making the most of your SAEM membership!

SAEM Consultation Services Helps You With Teaching, Research, and EM Practice Issues SAEM committee and academy members possess expertise in teaching, research and other aspects of academic emergency medicine (EM) practice. Through SAEM Consultation Services, these experts, in consultation

SAEM, in partnership with the research committee, is honored by the work of its members who have been published in high impact journals using NIH PubMed. We are excited to share our first-ever list of NIH Funded SAEM Investigators that now can be found within the research section of our website. We are proud of these investigators who have received federal grants in this publication pursuit.

Download the complete list.

Fellowship Success Story Romeo Fairley, MD, MPH, FACEP University of Texas Health Science Center San Antonio Fellowship Type: Disaster Medicine Year of Completion: 2017 Dr. Romeo Fairley

What advice would you give to someone who was on the fence about doing a fellowship? i.e., What did you see as the costbenefit?

Think about long term career goals. A fellowship is a stepping stone to get you the job you want.

What was the most careerenhancing, or eye-opening thing, you gained from the fellowship?

I have a passion for public health and enjoy being involved in research.

Who is best suited for this type of fellowship?

Someone who is interested in being a proficient physician in the worst of scenarios and environments while spending most of their time fighting to prevent those scenarios from happening. Learn more.

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SAEM REPORTS INTEREST GROUP NEWS Evidence-Based Healthcare and Implementation Call for Submissions: Rakesh Engineer Award

Are you submitting an implementation science abstract to the SAEM Annual Meeting? The EvidenceBased Healthcare and Implementation Interest Group is seeking submissions of accepted abstracts that are focused on implementation science for our annual Rakesh Engineer Award! This award honors the late Dr. Rakesh Engineer, who was passionate about implementation methodology and bringing science to the bedside. Accepted abstracts are eligible if they are focused on a project or study that evaluates the implementation, or de-implementation, of a process that leads to an evidence-based improvement in patient care. Written abstracts will be judged by members of the Evidence-Based Healthcare and Implementation Interest Group and the top 3 finalists will be judged live at SAEM23. Click here for more information, or scan this QR code or click this link to nominate yourself or a colleague!

You can’t pour from an empty cup.

Take care of yourself first. #StopTheStigmaEM

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ACADEMIC ANNOUNCEMENTS Dr. Katren Tyler Named Vice Chair for Geriatric EM at UC Davis Katren Tyler, MD, was recently named vice chair for geriatric emergency medicine and wellness at UC Davis Health. She is the first to be named to this role in the nation.

A UC Davis Emergency Medicine faculty since 2005, Dr. Tyler developed a geriatric emergency medicine fellowship five years Dr. Katren Tyler ago, the fourth in the U.S. and the only one on the West Coast. She also served as physician lead in the development, recognition, and recent accreditation of the UC Davis Age-Friendly Emergency Department.

Dr. Tom P. Aufderheide Selected for Medical College of Wisconsin Dean’s Award Tom P. Aufderheide, MD, MS, professor, department of emergency medicine, Medical College of Wisconsin Medical School, has been selected for the Medical College of Wisconsin Dean’s Award for Clinical and Translational Research 2022.

The Dean’s Award in Clinical & Translational Dr. Tom P. Aufderheide Research was created to recognize MCW faculty and staff who have made a significant contribution to advancing translational science to improve the health of our patients through research and discovery.

Dr. Jonathan Rubin Appointed Informatics Officer at Medical College of Wisconsin Jonathan Rubin, MD, professor, department of emergency medicine, Medical College of Wisconsin Medical School, was recently appointed Inpatient Platform Medical Informatics Officer at Froedtert & Medical College of Wisconsin Froedtert Hospital.

Dr. Rubin will continue in his role as Chief, Dr. Jonathan Rubin Division of Informatics, in the department of emergency medicine.

Dr. Matthew Chin Awarded Funding for EMS Mental Health Project Matthew Chinn, MD, associate professor, department of emergency medicine, Medical College of Wisconsin Medical School, in partnership with the Center for Suicide Awareness was awarded funding from the Advancing a Healthier Wisconsin Endowment for a project entitled, Dr. Matthew Chinn “Wisconsin EMS Workforce Development: Addressing Occupational Trauma with Resiliency Training.”

The aim of this project is to provide training to improve the mental health and resiliency of EMS providers throughout the state of Wisconsin.

Dr. Ben Weston Selected as a National Academy of Medicine Fellow Ben Weston, MD, MPH, associate professor, department of emergency medicine, Medical College of Wisconsin Medical School, was selected as the National Academy of Medicine’s (NAM) Fellow to Advance State Health Policy.

Chosen based on his professional Dr. Ben Weston qualifications, reputations as a scholar, professional accomplishments, and the relevance of his current field expertise to the work of the NAM and the National Academies of Sciences, Engineering, and Medicine.

Dr. Kathleen Williams Receives Lennon Award for Clinical Teaching Kathleen Williams, MD, associate professor, department of emergency medicine, Medical College of Wisconsin Medical School, was the recipient of the 2022 Edward J. Lennon, MD, Endowed Clinical Teaching Award. The Lennon Award is given annually to a junior faculty member Dr. Kathleen Williams engaged in clinical practice who has demonstrated a proclivity for teaching at the Medical College of Wisconsin and is committed to excellence in teaching or educational development.

Dr. Eddy Lang Appointed to the Canadian Academy of Health Sciences Eddy Lang, MD, professor and department head, Department of Emergency Medicine, Cumming School of Medicine at the University of Calgary, Canada, has been inducted into the Canadian Academy of Health Sciences (CAHS). Dr. Lang is an internationally recognized leader in Dr. Eddy Lang academic emergency medicine as well as evidence-based medicine, knowledge translation and clinical practice guidelines. He is the scientific director of the Alberta Health Services Emergency Strategic Clinical Network, chair of the Academic Section of the Canadian Association of Emergency Physicians, and former chair of the SAEM Evidence-Based Healthcare & Implementation Interest Group.

CAHS fellows are selected for their demonstrated leadership, creativity, and distinctive contributions to advancing health sciences.

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NOW HIRING

Share your story.

One of the most powerful things you can do to help break down barriers to mental health is to talk openly about your personal mental health journey. Share your story and help stop the stigma.

saem.org/StopTheStigmaEM

#StopThe StigmaEM

American Board of Emergency Medicine

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 December 1.

For specs and pricing, visit the SAEM Pulse advertising webpage.

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WASHINGTON DC – The Department of Emergency Medicine at the George Washington University is offering Fellowship positions beginning July 2023: H e a lt h P o lic y & A d v o c a c y

T e le m e d ic in e & D ig ita l H e a lth

I n t e r n a t io n a l E m e r g e n c y M e d ic in e & G lo b a l P u b lic H e a lt h

W ild e r n e s s & T e le m e d ic in e C o m b in e d F e llo w s h ip

M e d ic a l L e a d e r s h ip a n d E D O p e r a t i o n s

W ild e r n e s s M e d ic in e

U ltra so u n d fo r E m e rg e n c y M e d ic in e

C lin ic a l R e s e a rc h

U ltra so u n d fo r F a m ily M e d ic in e

M e d ic a l E d u c a t io n

H e a lt h E q u it y a n d S o c ia l E m e r g e n c y M e d ic in e

M e d ic a l S i m u l a t i o n

D isa ste r & O p e ra tio n a l M e d ic in e

M e d ic a l T o x ic o lo g y

Fellows receive an academic appointment at The George Washington University School of Medicine & Health Sciences and work clinically at a site staffed by the Department. The Department offers Fellows an integrated, interdisciplinary curriculum, focusing on research methodologies and grant writing. Tuition support for an MPH or equivalent degree may be provided, as per the fellowship’s curriculum.

Complete descriptions of all programs, application instructions, and Fellowship Director contacts can be found at: https://smhs.gwu.edu/emed/education-training/fellowships

Are you ready for ACEP22?

Three Ways to Connect With Us Envision Resident Networking Event OCT. 2, 5-8 P.M. Booth #712 OCT. 1-3

EMRA Job and Fellowship Fair OCT. 1, 5-7 P.M.

W San Francisco 181 3rd St San Francisco, CA 94103

Featured Emergency Medicine Opportunities GME FACULTY OPPORTUNITIES HCA Florida Kendall Hospital Miami, FL

PEDIATRIC EMERGENCY MEDICAL DIRECTOR Morristown Medical Center Morristown, NJ

RESIDENCY PROGRAM DIRECTOR HCA Florida Lawnwood Hospital Fort Pierce, FL

ULTRASOUND DIRECTOR NewYork-Presbyterian Queens Flushing, NY

Reach out to our experienced recruiters today to learn more about these featured opportunities.

855.649.0805 EVPS.com/SAEM

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Penn State Health Emergency Medicine About Us: Penn State Health is a multi-hospital health system serving patients and communities across 29 counties in central Pennsylvania.

The system includes Penn State Health Milton S. Hershey Medical Center, Penn State Children’s Hospital, and Penn State Cancer Institute based in Hershey, PA; Penn State Health Holy Spirit Medical Center in Camp Hill, PA; Penn State Health St. Joseph Medical Center in Reading, PA; and more than 2,300 physicians and direct care providers at more than 125 medical office locations. Additionally, the system jointly operates various health care providers, including Penn State JOIN OUR TEAM Health Rehabilitation Hospital, Hershey Outpatient Surgery Center, Hershey Endoscopy Center, Horizon Home Healthcare and Pennsylvania Psychiatric Institute.

EMERGENCY MEDICINE OPPORTUNITIES In December 2017, Penn State Health partnered with Highmark Health to facilitate creation of a value-based, AVAILABLE community care network in the region. Penn State Health shares an integrated strategic plan and operations with Penn State College of Medicine, the university’s medical school.

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 an 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

FOR MORE INFORMATION PLEASE CONTACT: Heather Peffley, PHR CPRP - Penn State Health Physician Recruiter

hpeffley@pennstatehealth.psu.edu

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.

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THE NEXT STEP IN YOUR EMERGENCY MEDICINE CAREER STARTS HERE At TeamHealth, our purpose is to perfect the practice of medicine, every day, in everything we do. To improve the experience of our clinicians, we empower them to act, free them from distractions, invest in learning and development, and foster an environment where continuous improvement is a shared priority.

SCAN QR CODE TO LEARN MORE ABOUT ACADEMIC EM JOBS To apply, go to teamhealth.com/emergencymedicine Search Emergency Medicine

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EMERGENCY MEDICINE JUNIOR FACULTY EMERGENCY MEDICINE JUNIOR FACULTY EMERGENCY MEDICINE JUNIOR FACULTY

University of California University of California University of California San Francisco San Francisco San Francisco The University of California San Francisco, Department of Emergency Medicine is recruiting for full-time faculty. We seek individuals who meet the following criteria: Clinically-oriented emergency medicine faculty with experience (3+ years preferred), and outstanding and original contributions The University of California San Francisco, Department ofseries Emergency Medicinewith is qualifications. recruiting to administration and/or diversity and equity at the rank of assistant professor.

Step and will be commensurate

The University of California San Francisco, Department of Emergency Medicine is recruiting

for full-time faculty.

We provides seek individuals meet services the following criteria: Clinically-oriented The Department of Emergency Medicine comprehensivewho emergency to a large local and referral population at multiple academic for full-time faculty.

We seek individuals who meet the following criteria: Clinically-oriented hospitalsemergency across the Sanmedicine Francisco Bay Area, including UCSF Hellen(3+ Diller Medical Center, Zuckerberg San Franciscoand General Hospital, and the faculty with experience years preferred), and outstanding original emergency withandexperience yearsofpreferred), and outstanding and original UCSF Benioff Children’smedicine Hospitals infaculty San Francisco Oakland.

The (3+ Department Emergency Medicine a fully accredited 4-year Emergency contributions to administration and/or diversity and equity at the rank of hosts assistant professor. toand administration and/or diversity equity at rank and of growth assistant professor.

Medicinecontributions residency program multiple fellowship programs.

There areand opportunities for the leadership within the Department and UCSF and series will be commensurate with qualifications.

School ofStep Medicine.

Step and series will be commensurate with qualifications.

Board certification in Emergency Medicine is required. All applicants should excel in bedside teaching and have a strong ethic of service to their Theprofession.

Department of Emergency Medicine provides comprehensive emergency services to a patients and

The Department of Emergency Medicine provides comprehensive emergency services to a

large oflocal and referral population at multiple academic hospitals across the San excellence Francisco Bayscience and The University California, San Francisco (UCSF) is one of the nation’s top five medical schools and demonstrates in basic large local and referral population at multiple academic hospitals across the San Francisco Bay Area, including UCSF Hellen Diller Medical Center, Zuckerberg San Francisco General clinical research, global health sciences, policy, advocacy, and medical education scholarship. The San Francisco Bay Area is well-known for its great Area, including UCSF Hellen Diller Medical Center, Zuckerberg San Francisco General food, mild climate, beautiful scenery, vibrant culturalChildren’s environment, and its outdoorinrecreational activities.and Oakland. The Hospital, and the UCSF Benioff Hospitals San Francisco Hospital, and the UCSF Benioff Children’s Hospitals in San Francisco and Oakland. The ONLINE AT: 4-year Emergency Medicine Department of Emergency Medicine PLEASE hosts aAPPLY fully accredited Department of Emergency Medicine hosts a fully accredited 4-year Emergency Medicine residency program and multiple fellowship programs. There are opportunities for leadership https://aprecruit.ucsf.edu/JPF04170 residency program and multiple fellowship programs. There are opportunities for leadership and growth within the Department and School of Medicine.

Applicants’ materials must list UCSF current and/or pending qualifications upon submission. and growth within the Department and UCSF School of Medicine.

UCSF seeks candidates whose experience, teaching, research, and community service has prepared them to contribute to our commitment to diversity BoardUCSF certification Emergency Medicine required.

All applicants excel in bedside and excellence. is an Equalin Opportunity/Affirmative Actionis Employer.

All qualified applicantsshould will receive consideration for employment Board certification in sex, Emergency Medicine is required.

All applicants should excelveteran in bedside without regard to race, color, religion, sexual orientation, gender identity, national origin, disability, age or protected status.

For additional teaching and have a strong ethic of service to their patients and profession. teaching andourhave a strong ethic of service to their patients and profession. information, please visit website at http://emergency.ucsf.edu/.

The University of California, San Francisco (UCSF) is one of the nation’s top five medical The University of California, San Francisco (UCSF) is one of the nation’s top five medical schools and demonstrates excellence in basic science and clinical research, global health schools and demonstrates excellence in basic science and clinical research, global health sciences, policy, advocacy, and medical education scholarship. The San Francisco Bay sciences, policy, advocacy, and medical education scholarship. The San Francisco Bay Area is well-known for its great food, mild climate, beautiful scenery, vibrant cultural Area is well-known for its great food, mild climate, beautiful scenery, vibrant cultural environment, and its outdoor recreational activities. environment, and its outdoor recreational activities.

PLEASE APPLY ONLINE AT: PLEASE APPLY ONLINE AT: https://aprecruit.ucsf.edu/JPF04170 Vice Chair of Diversity and Inclusion https://aprecruit.ucsf.edu/JPF04170 Applicants’ materials must listof current and/or pending qualifications upon Department Emergency Medicine Applicants’ materials must list current and/or pending qualifications upon submission.

Hennepin Healthcare System, Inc. (HHS) is seeking an be eligible for an appropriate academic appointment at the submission. inspirational faculty leader for the position of Vice Chair of University of Minnesota. seeks candidates whose experience,Weteaching, research, andto community Diversity and UCSF Inclusion for our Department of Emergency are deeply committed teaching and working in an UCSF seeks candidates whose experience, teaching, research, and community Medicine. Reporting to the Department Emergency Medicine service has preparedofthem to contribute to our commitment to diversity and environment characterized by celebrating Chair, the successful will demonstrate cultural service candidate has prepared them to contribute to our commitment to diversity and diversity, equity, inclusion, and belonging. excellence.

UCSF is an Equal Opportunity/Affirmative Action Employer.

All awareness, knowledge and provide vision and leadership for excellence.

UCSF is an Equal Opportunity/Affirmative Action Employer.

All Hennepin Healthcare is an integrated of care that diversity and qualified inclusion initiatives the department’s applicantsacross will receive consideration for employment without regardsystem to qualified applicants for employment without regard toLevel I Adult and includes HCMC, a nationally recognized clinical, research, and educational work.will receive consideration race, color, religion, sex, sexual orientation, gender identity, origin, Pediatric Trauma Centernational and acute care hospital. The race, color, religion, Responsibilities as Vice Chair will include sex, sexual orientation, gender identity, national origin, comprehensive system includes a 484 bed academic disability, age or protected veteran status. For additionalhealthcare information, please visit disability, age or protected veteran status. For additional please visit • providing professional development opportunities for faculty medical center, ainformation, large outpatient Clinic & Specialty Center, and our website at http://emergency.ucsf.edu/. and administrative staff on pertaining to diversity, a network of primary and specialty care clinics in Minneapolis our website at issues http://emergency.ucsf.edu/. equity, and inclusion

• Working closely with faculty and staff search committees, and department/division leaders to provide effective strategies for identifying diverse candidates • Driving the development of diversity-related goals and programs and activities to meet those goals • Developing and monitoring metrics applicable to the department’s diversity and inclusion goals The Vice Chair will also hold Physician responsibilities and will

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and in suburban communities. Hennepin Healthcare has a large psychiatric program, home care and hospice, and operates a research institute, innovation center and philanthropic foundation.

Interested candidates can send their curriculum vitae and cover letter to: Jessica Endres Senior Talent Acquisition Specialist Hennepin Healthcare Jessica.endres@hcmed.org

National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) Dissemination Initiative

SCAN THE QR CODE AND GO TO...

Educational Podcasts

Implementing Drug and Alcohol Screening in Primary Care Interactive Online Screening Resource

VIDEO

Fentanyl Harm Reduction Video & Fact Sheet

Visit www.bit.ly/NIDACTN to access these resources.

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Innovation - does being a part of a “think-outside-the-box team” poised to change the way emergency medicine will be provided in the future excite you? Impact - do you want to shape the future of healthcare? If so, come join our team. The Department of Emergency Medicine at The Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, PA continues to expand its faculty complement aimed at revolutionizing the way emergency care will be taught to our students, residents and faculty and provided to populations of patients. A new and innovative focus on telemedicine, population health, emergency medical services, access to care, patient flow, clinical research and patient outcomes is ongoing. We are interested in emergency physicians that wish to be a part of a department that will revolutionize acute unscheduled care.

We have an extensive and robust clinical footprint, with the opportunity to practice across the acute care spectrum. We provide faculty and resident coverage at two emergency departments - Thomas Jefferson University Hospital (TJUH) Center City, a 700-bed academic quaternary-care, Level 1 trauma center and the Methodist Hospital Division of TJUH, a 140-bed community hospital – that together see over 100,000 patients annually. The EM Residency Program is a three-year program and has 51 total residents.

Faculty provide patient care and bedside teaching of students and residents in the ED and the clinical decision unit. Additionally, clinical faculty have opportunities to become involved in administration, clinical operations, undergraduate and graduate medical education. Faculty have the opportunity to pursue academic interests in medical education, ultrasound, design thinking, basic and clinical research, wilderness medicine and administration.

Additional information on the department can be found at: https://www.jefferson.edu/academics/colleges-schools-institutes/skmc/departments/emergency-medicine.html The Sidney Kimmel Medical College at Thomas Jefferson University values a diverse and inclusive community as it allows us to achieve our missions in patient care, education, and research and best allows us to serve the healthcare needs of the public. Thomas Jefferson University and Hospitals is an Equal Opportunity Employer. Jefferson values a diverse and inclusive community diversity and encourages applications from women, those underrepresented in medicine, Lesbian, Gay, Bisexual and Transgender (LGBT) individuals, disabled individuals, and veterans. Interested candidates are invited to send their curriculum vitae to: Bernard L. Lopez, MD, MS, FACEP, FAAEM Executive Vice Chair, Department of Emergency Medicine Bernard.lopez@jefferson.edu

Tell us what you’re doing.

Sharing fosters support, inspires others, and is a powerful tool for making a difference. We invite you to share what your department and/ or institution is doing to reduce the stigma surrounding mental illness in emergency medicine.

saem.org/StopTheStigmaEM American Board of Emergency Medicine

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#StopThe StigmaEM

Join Us in Advancing the Science and Practice of Emergency Medicine The Department of Emergency Medicine at the Yale School of Medicine is seeking faculty interested in joining a nationally leading academic department of emergency medicine. We are hiring faculty of all ranks commensurate with prior experience, and are seeking applicants with a strong interest in generating academic impact and caring for nearly 200,000 patient visits every year across our three campuses.

We are seeking faculty across the broad and diverse areas of Department expertise with unique needs in Simulation, Education, or nocturnist coverage. We offer an extensive faculty development program for junior and more senior faculty. For faculty interested in research, we offer a well-established track record of interdisciplinary collaboration with other renowned faculty, obtaining federal and private foundation funding, and a mature research infrastructure. For those seeking educational leadership opportunities, we are home to one of the nation’s largest fouryear EM residency programs, a PA residency program, a world-class medical-school simulation program housed in the Department of EM, and numerous fellowship programs. Clinical and administrative opportunities include a range of acuity from our primary academic campus, a Level 1 trauma and comprehensive stroke care center, to community and freestanding EDs as well as the opportunity to practice a range of acute care services from critical care to observation medicine.

Candidates will enter at the Instructor/Assistant/Associate level, commensurate with experience and credentials. Candidates must be residencytrained and board-certified or board-eligible in emergency medicine. Women, minorities, veterans, people from the LGBTQ communities and people with disabilities are strongly encouraged to apply. To join our team, applicants should submit their cover letter and CV to: Andrew Ulrich, MD c/o Donna Nemeth at donna.nemeth@yale.edu Professor & Interim Chair Yale University, Department of Emergency Medicine 464 Congress Avenue, Suite 263 New Haven, CT 06510 203-737-6084 Yale University is an Affirmative Action/Equal Opportunity employer. Yale values diversity among its students, staff, and faculty and strongly welcomes applications from women, persons with disabilities, protected veterans, and underrepresented minorities.

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.

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See You in Austin, Texas

May 16-19, 2023 | JW Marriott Austin