26 minute read
Ethics in Action Who’s in Charge Here?
Who’s in Charge Here?
By Jeremy R. Simon, MD, PhD on behalf of the SAEM Ethics Committee
The patient, a 56-year-old male with a glioblastoma multiforme that has progressed despite resection and chemotherapy, arrives with his wife and other members of the family, including a nephew. Prior to arrival in the emergency department (ED), the patient had been on home hospice under the care of his wife and a visiting nurse service. However, on the day of his admission, other members of the family, including the patient’s nephew and sister, had called EMS. They were concerned because they believed the wife was mismanaging the patient, mixing up his medications, and physically abusing him. They claimed to have video of the wife hitting the patient and stated they had opened a case with Adult Protective Services (APS) earlier that day.
Although as recently as four months ago the patient had been participating in his care, recently he had been lethargic and non-verbal. It was this rapid decline that led to his placement in hospice. Aside from this abnormal mental status, the only positive finding on exam was a 2 cm ecchymosis on his right biceps. The nephew claimed this was a result of the wife’s abuse. The patient is otherwise well-appearing and does not appear malnourished or dehydrated on either exam or labs.
Despite the obvious difference in perspective between the wife and other family members, they all agreed that that the patient should be DNR/DNI, and that he should be transferred to inpatient hospice. Furthermore, social work contacted APS which said that while they had not yet begun investigating the case, given the allegations were concerning her, they did not want the patient discharged with the wife. The decision was therefore made to admit the patient to the floor to facilitate placement.
After the decision to admit was made, the patient’s sister approached the team and asked that the wife not be allowed to make decisions for the patient regarding which hospice to send him to. The team was unsure whether to grant this request. Although in most states, in the absence of a designated health care agent or proxy, a spouse, if available, would be the surrogate decision maker for an incapacitated patient, the team was concerned about the seriousness of the allegation and therefore consulted ethics. While this decision would likely not be made until the patient was accepted by the inpatient team, in our hospital there is often a substantial delay before this happens, and the ED team felt they should be able to respond to the request. Also, although it appeared unlikely that there would be any other decisions that needed to be made for the patient, who was clinically stable, they wanted to be prepared in case there were. It is not a small matter to terminate a surrogate’s right to decide, as they are the ones who are generally best placed to understand a patient’s desires and values. They are given the right to make decisions not only for their own sake, but also for the patient’s sake. All other things being equal, a wife is likely to know better than a child what a patient would want. In circumstances such as these we must consider both the nature of the concerns as well as the nature of the decisions under consideration. Regarding the concerns, here we have only an unsubstantiated report of abuse. Accusations do not generally rise to the standard we need to reach to terminate a surrogate’s rights. Anyone can file a report. Indeed, in this case, it was worth noting that wife was a second wife and not the mother of his children. It does not take much imagination to think of scenarios where an accusation of abuse might be made in bad faith under such circumstances. Therefore, unless the hospital staff itself witnessed abuse in the hospital, only once the report is investigated and substantiated can the staff take the charge of abuse as an unproblematic basis for making decisions. Nor is the hospital, and certainly not the treating team or ethics consultant, properly placed or prepared to carry out such an investigation.
However, given the seriousness of the allegations, it might be best, for the patient’s safety, to remove the wife from the decision pathway as a precaution. While there may be circumstances where this could be the case, this does not appear necessary or appropriate in this situation. The only decision that anyone anticipates needs to be made for the patient at this time is to which facility to send him. The wife is unable to put the patient at risk through this decision, thus there is no reason to suspend the wife’s rights “as a precaution” under these circumstances.
In this case, the ethics consultant told the team that unless and until APS found that the wife had abused the patient (or as noted above, staff had witnessed abuse), she should be given the benefit of the doubt, and the family’s request should not be granted. Indeed, unless or until something changed, it was the wife who had the authority to exclude the rest of the family from visiting, and not the other way around.
ABOUT THE AUTHOR
Dr. Simon is a professor of emergency medicine at Columbia University and serves on the ethics committees of Columbia University Medical Center, SAEM, and ACEP.
How Medical Care Was Brought Into the Home in 2020: Interviews with Physicians
By Elizabeth M. Goldberg, MD, ScM on behalf of the SAEM Academy of Geriatric Emergency Medicine
Normally, I spend my time working clinically at our academic emergency departments (EDs) and leading studies on the most common reason for injuryrelated ED visits among older adults: falls. But in early 2020 a more pressing problem surfaced among our geriatric patients: COVID-19. The National Institutes of Health soon followed with a call for COVID-19 supplements to existing grants and we were lucky to receive funding to interview physicians on the front lines of geriatric care (emergency physicians, geriatricians, and primary care doctors) about how they met the medical needs of older adults during the early phases of the pandemic, from March 2020 to November 2020. Although many of us will remember those days as the darkest weeks for emergency medicine, it was also a major turning point in how we deliver health care. ED visits plummeted — most saw a 40% reduction in visits — and the growth of telemedicine offset two-thirds of the decline in in-person visit volume. We wanted to know how this major change in health care delivery was affecting older adults from the perspective of the physicians caring for them. A study in 2018 of 4,525 Americans aged 65 and older living at home revealed that 38% were not ready for video visits and only 80% could participate in a telephone visit due to a physical disability, dementia, hearing difficulties, or technology challenges. Many were concerned that
the telehealth boon would exacerbate disparities and older patients would be left behind.
In the beginning of the pandemic many medical offices closed and within two weeks several of the physicians we interviewed had moved to 100% telehealth visits. They described this adoption as “chaotic” and a “disaster,” but also acknowledged that despite the “glitches” they were able to connect with patients after an initial learning curve. One geriatrician in the southern U.S. noted, “we certainly had plenty of patients and, frankly, a couple of doctors who just did not take to it at first, but we've been able to bring it along with some coaching and hand-holding.”
Emergency physicians described using technology to reduce their COVID-19 exposure during personal protective equipment shortages and to reach patients remotely who wanted to avoid their own risk of exposure. Thirteen of the 15 physicians we interviewed described using phone calls, iPads, and robots with mounted screens to do in-ED patient assessments. Eleven physicians said they provided medical care to patients outside of the ED as part of virtual urgent care, occupational health, or chat-based visits. In the first few months of the pandemic these visits focused on providing public health guidance (e.g., how to obtain testing, whether to come to the hospital) and addressing traditional primary care complaints when offices were closed.
Over time, physicians learned to overcome barriers to connecting to older adults by leveraging caregivers and their devices, asking home visiting nurses or facility staff to conduct visits, or having office staff or students conduct pre-visit technology education. Although video visits weren’t always possible, most physicians said they could address patient needs with telephone calls, and after using telehealth they realized many visits — such as those for palliative care concerns, mental health needs, medication refills, and other urgent complaints — could successfully be completed remotely.
Read more about this study on interviewing physicians about their experiences using telehealth during COVID-19.
ABOUT THE AUTHOR
Dr. Goldberg is an associate professor of emergency medicine, and associate professor of health services, policy and practice at Brown University. She is the physician lead for geriatric emergency care initiatives for the Lifespan health system and treasurer on the 2021-2022 Executive Committee for SAEM’s Academy for Geriatric Emergency Medicine.
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.”
The HAPSA team and partners gather to assemble the home isolation kits
The COVID-19 Pandemic Fight on the Ground: Experiences from Nepal
When I returned to Nepal on April 1, 2021, it felt as though life had returned to normal for the first time since the pandemic began: airports and streets were packed, fewer people were wearing masks, and wedding season was in full swing. While Nepal had seemingly moved past the pandemic, India’s daily case count was slowly creeping up. As a global emergency medicine fellow at Brown University, I had been serving on the front lines of the COVID-19 pandemic in the U.S., staying active on social media and television, writing frequently in Nepali newspapers, and conducting COVID-19 training around the world over the last year. Even I was convinced that somehow Nepal had beaten COVID-19, although less than 5% of the population had been vaccinated. I was born in a small village in Nepal and moved to the U.S. at the age of 13. Over the years, I have returned to Nepal frequently, mostly for health advancement projects through a nonprofit organization I founded years ago called HAPSA. Now, amid the pandemic, I had received a grant and gotten approval from my university to travel and assess emergency care at seven tertiary hospitals in Nepal. Strong emergency care is recognized by the World Health Organization and many countries around the globe as a key to universal health coverage, and the first step is to understand the current landscape of emergency care.
Within a few weeks of my arrival, Nepal overtook India as the country with the worst per capita COVID-19 cases and the highest viral replication in
In-person training of health care workers at the Kathmandu municipality isolation center
the world. With world news focused on the Indian COVID-19 crises, Nepal was overshadowed and forgotten globally. This reality became clear to me when I received an SMS (Short Message Service) text from a close friend in the U.S.: “Hey man, how are you? I heard things are bad in India. Stay safe in Nepal.”
Unlike previous disasters, it felt as though Nepal was alone in its response to this crisis. This is what motivated me to join a newly formed group, COVID Alliance for Nepal, which included volunteers and organizations working from different sectors. The Alliance had two main goals: 1) Raise awareness about the situation in Nepal to the world. 2) Keep as many people at home as possible to reduce the strain on the health system. We worked on these goals through vaccine advocacy, creating protocols, conducting training, and providing service.
Advocacy
COVID-19 vaccines have highlighted the pre-existing worldwide inequities in global health. While Nepal has only fully vaccinated 5.3% of its population, vaccines are being wasted in developed countries. Our first focus was on vaccine advocacy for Nepal. We started a petition to the United States government with support from influential Nepalis and concomitant support by our partners in the U.S. through phone call-in campaigns to U.S. lawmakers. This led to Nepal’s situation being discussed during a congressional hearing, and our petition being delivered to the White House. I personally called in to shows like The Brian Lehrer Show to discuss Nepal's situation and global vaccine inequity. Our efforts were followed by other groups in the United Kingdom and Canada launching their own advocacy campaigns. In the recent weeks, Nepal has received vaccine donation commitments from a few countries, including Japan and the U.S.
In Nepal, we frequently met with the mayors from Kathmandu, the capital city, and other municipalities across the country. Furthermore, we met with officials from the Ministry of Health, the Department of Health Services, and the COVID Crises Management Center to discuss vaccine distribution and supply chain, and provide our time and expertise as needed. The fight to procure adequate amounts of vaccines in Nepal will likely need continued advocacy in and outside of Nepal for years to come.
Protocols and Training
I had gained significant experiences managing COVID-19 while working in the U.S. during the peak of the pandemic, as well as closely with a surge hospital in Rhode Island. Furthermore, I have been one of the trainers for a Project HOPEled virtual, four-day COVID-19 training around the world since June 2020, and have conducted multiple trainings globally. I felt equipped to help in Nepal.
For nearly 30 million people, Nepal has 1,200 ICU beds, less than 500 ventilators, and a major lack of health care human resources. One of the key strategies to help the health system during a surge is to establish alternate hospitals, like surge sites or isolation centers, and to keep as many people at home as possible. Our team from COVID Alliance created a guide/blueprint for local officials, administrators, and health care workers on starting their own isolation/surge center to manage COVID-19 patients. We listed necessary supplies, defined service delivery, created specific treatment protocols based on the Nepal Medical Council’s guideline, and made these resources publicly available. Using this guide, we conducted numerous in-person and virtual trainings at surge/isolation centers. I remember one question from a pre-and post-test survey after a two-hour training on key management guidelines where we asked if participants felt comfortable managing mild COVID-19 cases. While before the training 37% had said yes, after the training 98% said yes. We knew these training sessions were helping the management of COVID-19.
All items that are included in the home isolation kits
GLOBAL EM
continued from Page 19
On a near-daily basis, I attended multiple social media interviews and hosted several social media platform events (namastedoctor). I have appeared on multiple national TV/ radio news networks, and have written articles in Nepali and English to dispel myths and answer questions related to COVID-19.
Service
COVID Alliance Nepal team was directly involved in providing essential services like food distribution, oxygen cylinder and plant procurement, and home isolation kits delivery. Through HAPSA, I led the effort in designing home isolation kits, raising funds, and distributing them across the country. The kit included medications like paracetamol and cough syrup, with detailed instructions on dosing, masks, soap, sanitizer, vitamins, thermometer, and quality-checked pulse oximeters. It also included a detailed instructional video link/QR code on how to use the kit and a 90-minute public health COVID-19 information session. In order to coordinate relief efforts with the local government, we partnered with local municipalities to distribute these kits. As of July 18, 2021, we had raised nearly $65K US via a crowdfunding campaign and other organizational donors. We have delivered home isolation kits to nearly 25 municipalities across the country. As Nepal is heading towards a third wave, we hope to have the resources to support anyone in home-isolation with these essential kits.
While I was fortunate to have access to the COVID-19 vaccine, many around the world, including my fellow Nepalis, have no idea when they will get vaccinated. Nepal has a great vaccine delivery infrastructure, and our recent survey has shown that nearly 95% of people in Nepal are willing to take the vaccines. Vaccines must be prioritized to prevent further devastation.
I left Nepal heavy-hearted while the country was still on lockdown, but I continue to work with the team there virtually. With the rise of monsoon floods, we have adjusted our home isolation kits to include water purifiers, and continue to raise funds to support them. While the current focus has been on acute response, these few months have highlighted the importance of developing a strong emergency care infrastructure.
ABOUT THE AUTHOR
Dr. Kharel is a global emergency medicine fellow in the department of emergency medicine at Brown University. His research focuses on emergency system strengthening in Nepal. He is the founder of HAPSA, a grassroots non-profit organization based in Nepal. ramu_kharel@brown.edu @erdockharel
From Tuk Tuks to Ambulances: Setting up a Universal Access Prehospital System in a Developing Country
While driving 60 kilometers away from Colombo, the capital city of Sri Lanka, one Saturday night, we became stopped in traffic created by a road accident. Two motorcycle riders were lying on the ground — one mortally wounded and lying in a pool of blood with both lower limbs amputated at mid-thigh, the other unconscious with a mangled left leg below the knee. As my husband checked the response of the two injured, I called an ambulance. In two minutes, the ambulance arrived and rushed the two men to the nearest hospital.
I serve as a registrar of emergency medicine at the National Hospital Accident Service (the largest trauma center in Southeast Asia). The next day I saw the patient with the mangled limb, transferred from the regional hospital for a belowknee amputation. This story would have been very different five years ago. Until 2016, Sri Lanka did not have an organized prehospital emergency medical service.
How Patients Reach Hospitals in the Developing World
Sri Lanka is a lower middle-income island country in South Asia with a population of 21.2 million. In 2016, 3,000 road fatalities were registered, according to data from the World Health Organization (WHO). Sri Lanka’s reported annual road accident deaths per capita of 17.4 are double the average rate in high-income countries and five times that of the world’s bestperforming countries. Until four years ago, all road traffic victims were primarily transported to hospital by three-wheeled motorized rickshaws, known locally as “Tuk Tuks.” When emergencies occurred at night, people often would not present to the hospital due to fear of snake bites and elephant attacks on the way to the hospital. In urban areas, people would not touch a traffic accident patient for hours because of fear of litigation. The likelihood of an accident patient being transported to a hospital in a timely manner was grim, leading to substantial but unreported prehospital mortality. Similar situations are common in other developing countries.
What Is Unique About Health Care in Sri Lanka
Sri Lanka has a universal free health care system that covers antenatal health, child health, including vaccination and prevention of communicable and non-communicable diseases and has achieved impressive results, including a high life expectancy of 77 years and a low maternal mortality rate (MMR) comparable to high-income countries; however, free, universal, reliable transport of emergency patients to the hospital was a fundamental gap in the national health care system until 2016 when the 1990 Suwa Seriya Ambulance Service was introduced.
How Suwa Seriya Started
Dr. Harsha De Silva, the former deputy minister of National Policies and Economic Affairs, led the development of Suwa Seriya in 2016. The Indian government’s grant of $7.55 million to Sri Lanka was established as a token of friendship between the two nations. Phase 1 of this project was launched on July 28, 2016 and provided 88 ambulances for the southern and western provinces, funding for call center development, and the running cost for one year. Commencing July 21, 2018, under Phase II, 209 ambulances covered the rest of the country with another grant from the people of India of $15 million. Since 2018, 297 ambulances have operated under the 1990 Suwa Seriya Foundation set up by an act of parliament in 2018.
Operational Procedures of the Suwa Seriya
The public can access the Emergency Command and Control Center (ECCC) through the 1990 unified number or a free 1990 mobile application, which allows for identification of the patient’s location. The public are encouraged to use the app, continued on Page 22
rather than a direct number, to place an incident.
This island-wide ambulance service is centrally managed from the state-of-theart ECCC in Colombo. Call to wheel time (time from assigning the case to leaving the base) should be less than 90 seconds. Response time varies by province due to geographic factors, population density, access to good roads, and patient location. The average response time is 11 minutes and 52 seconds island-wide and eight minutes and 32 seconds inside Colombo. To date, approximately 908,371 incidents have been attended by Suwa Seriya. Of these calls, 26% were due to road traffic accidents.
The service has been highly efficient, particularly in major mass casualty incidences like building collapses, major bus accidents, floods, and the Easter Sunday-terrorist bomb attack in 2019 when nine locations, including churches and luxury hotels, were simultaneously bombed, injuring more than 500 people and resulting in more than 250 casualties, including 38 foreign tourists.
Training of Staff
New emergency medical technician (EMT) recruits are sent for two months of initial training in Hyderabad, India. EMT recruits undergo classroom training (including BLS and Intermediate Life Support), simulation training, hospital training, and field training in the ambulance. Upon return, they receive another training on practical and communication skills and a onemonth internship, prior to assignment to a location, under the supervision of a senior EMT. All EMTs and pilots need recertification regularly.
Collaboration with Emergency Medicine
The doctor of medicine (MD) degree in emergency medicine specialty by the Postgraduate Institute of Sri Lanka took place independently prior to the launch of Suwa Seriya with the first cohort of emergency medicine trainees recruited in 2013. The Sri Lankan Society of Critical Care and Emergency Medicine (SSCCEM), established in 2002, became actively involved in teaching emergency medicine and critical care from 2006 with the help of Australian emergency physicians. Simulationbased refresher training, including adult and pediatric BLS for EMTs, is organized by the emergency medicine registrars, SSCCEM, and led by Dr. Sanj Fernado, an emergency physician in NSW, Australia. The emergency trainees also work shifts at the head office to guide EMTs over the phone to stabilize before transportation. Suwa Seriya is working on the accreditation process for the EMTs through the SSCCEM under the guidance of the Australian and New Zealand College of Paramedicine.
Rising With the COVID-19 Waves
Suwa Seriya transferred the first COVID-19 patient identified in Sri Lanka — a Chinese national — in 2020. During both pandemic waves, Suwa Seriya provided both emergency services and pandemic-related requests, straining the limits of this free emergency service in the nation. Suwa Seriya used to receive approximately 5,300 calls and handle an average of 1,000 cases a day. The calls rose to over 9,000 calls and 1,500 cases per day during the first wave of the pandemic; however, transmission of the disease would have been much greater if patients had been transported by public transport or personal cars.
Some exciting developments planned in the future include: • Plans with the National Institute of
Mental Health and the Ministry of
Health to implement a standard operational procedure for safe transportation of violent patients with psychiatric illness • Collaboration with the Sri Lanka Heart
Association to develop a STEMI early detection and fast track PCI program • Telephone CPR project • Implementation of a triage system based on patient’s illness severity
Perception of the Public
This service has achieved great popularity among the public and is available free-of-charge for Sri Lankans and foreign nationals irrespective of their backgrounds; however, further public awareness is needed. Being unaware of the role of coordinated prehospital EMS services may lead to hesitancy to call an ambulance or move out of the way when an ambulance with flashing beacons approaches. Also, appropriate first aid and bystander CPR is essential to prehospital care.1990 Suwa Seriya was also a part of “World Restart Heart Day 2019,” which encouraged bystander CPR and prompt transport to the hospital. With continued support, this service can thrive and save many lives in the future, potentially serving as a benchmark for similar prehospital systems in other developing countries.
ABOUT THE AUTHOR
Dr. Thilakasiri is senior registrar in emergency medicine, PGIM, University of Colombo, Sri Lanka.
About GEMA
The Global Emergency Medicine Academy (GEMA) focuses on improvement of the worldwide delivery of emergency medical care. Joining GEMA is free! Just log in to your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
continuously face. I am hopeful that post-pandemic life may compel the distillation of American ideals and the restructuring of systems of power that have abandoned our communities at their most vulnerable. As we emerge into a brave new world of our own devising, may we always remember la familia.
The initial stages of mandatory quarantine are where I first noted despair and social disconnect brewing in my community. People were glued to their televisions and struggling to decipher a barrage of information. They were severely isolated, especially young adults and recent immigrants who had not yet built family structures or robust support systems. Without such networks in place, stay-at-home orders became challenging, and those with relatives abroad were forced to weather the pandemic alone.
In the best of times, mental health often receives little attention in immigrant communities. When compounded with the pandemic, mental health vulnerabilities were exacerbated. New immigrants tend to have limited support, insufficient health care access and cultural barriers that limit them from developing mental health coping skills. As a result, many suffered from unrecognized health issues ranging from depression to panic attacks and major psychotic breaks.
Mass vaccination is nearly within reach to help mitigate this crisis, yet health providers must now find empathetic ways to tackle a new challenge: vaccine hesitancy. I have witnessed Latinx (predominantly Catholic) and African (predominantly of strong faith backgrounds) community members defer this decision to religious leaders because of historical mistrust of medicine in American underserved communities. Just as we began to see hope on the horizon with the release of vaccines distrust has been fueled by religious leaders claiming the vaccines are “anti-Christ”, “mark of the devil” or unethical. All untrue assertions by trusted sources in immigrant communities. Well-informed community and health leaders committed to evidence have large roles in rebuilding trust while showing empathy to address misinformation for the sake of public health
Duty Calls
As physicians, our voices have to be louder than the megaphones of those who are spreading misinformation or disinformation. It is our duty to ensure
people make informed decisions rooted in evidence. It is imperative to seek to understand the communities we serve — underserved and immigrant alike — to provide better equitable care which will be SGEM: DID YOU KNOW? the beginning steps to address the health disparities that have long plagued medical communities with distrust and fear from our patients Differences in the Treatment and . Outcomes of Patients with Acute ABOUT THE AUTHORS Coronary SyndromeDr. Shafer is an assistant professor of emergency medicine physician and medical toxicology at Baylor College of Medicine. Dr. Bicette is an assistant professor of emergency medicine at Baylor College of Medicine and a medical director in the Baylor St. Luke's healthcare system. @DrRichiMD Dr. Turner is an education and administration fellow at Baylor College of Medicine. anisha.turner@bcm.edu @DestinedDoc SGEM "Did You Know?" is a recurring SAEM Pulse submission designed to represent concise facts that demonstrate how patient sex and gender effect emergency care. We welcome submissions. Please send contributions to the coeditors Lauren Walter and Alyson J. McGregor at sgem@lifespan.org.
By Kathryn Wiesendanger, BSc, and Angela Jarman, MD, MPH, on behalf of the SAEM Sex and Gender in Emergency Medicine Interest Group
The sex-specific pathophysiology of coronary artery disease is complex and involves differences in anatomy, hormonal profile, and comorbid risk factors. Despite this, women have historically been underrepresented in clinical trials of cardiovascular disease, contributing to the predominantly male-centric model for diagnosis and management.
When we visualize a patient presenting with acute coronary syndrome (ACS), we see an obese, older man clutching his chest and gasping for air. Women, however, more commonly experience nonspecific symptoms such as nausea, vomiting, malaise, palpitations and epigastric pain. Lack of public knowledge of these differences make women more likely to delay seeking medical care. This, in combination with clinician failure to acknowledge and understand sex-based differences, may make women presenting with ACS more likely to be misdiagnosed and mistreated, contributing to worse clinical outcomes and higher mortality.
In contrast to men, who typically present with obstructive coronary disease, women are more likely to suffer from myocardial infarction with nonobstructive coronaries (MINOCA), caused by microvascular coronary disease. Estrogen is thought to be cardioprotective making women more likely to develop coronary artery disease later in life as estrogen levels decline. Attention should thus be made to consider alternative causes of myocardial infarction in younger women, before these estrogen-mediated effects take place. Commonly ordered cardiac investigations such as troponins and EKGs are thus less sensitive for women than men, and may contribute to improper diagnosis in a clinical setting.
Emergency department providers are the first physicians to evaluate undifferentiated patients, giving them the unique opportunity to consider sex and gender differences in ACS etiology, presentation, management, and clinical outcome. Efforts should be made to educate communities and medical providers alike on the sex and gender differences in presentation, and institutions should encourage implicit bias training to combat the disparities in treatments provided. Further, more women should be included in clinical trials to further establish sex-specific guidelines for management of acute coronary syndromes. ABOUT THE AUTHORS Kathryn Wiesendanger is a fourth-year medical student at the Royal College of Surgeons in Ireland. Dr. Jarman is an assistant clinical professor in the department of emergency medicine at UC Davis. She is fellowship-trained in sex and gender in emergency medicine and studies sex differences in the acute presentations of disease.
