Common Sense

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What's With All These Position Statements?

Issue: September/October 2020

Author: Jonathan S. Jones, MD FAAEM
AAEM President-Elect

 

You have likely noticed many recent position statements from the Academy. Some of these statements have been written by AAEM, while some are written by other organizations and endorsed by AAEM.

All of the Academy's position statements are published online at: www.aaem.org/resources/statements

There are several different types of statements, just click the corresponding links. AAEM has always held transparency in high regard as this is why you will always find all of the statements we have ever issued, openly published and accessible to everyone (members and non-members alike). If we feel strongly enough to issue a statement, then we won't ever try to hide it.

Dates of passage or endorsement can also be found. Due to the rapidly changing clinical and political environment, the last several months have seen a dramatic increase in the number of published and endorsed statements.

Given multiple recent questions as to why the Academy is releasing so many position statements, as well as several inquiries as to the content of the statements, on behalf of the board, I want to explain the process and answer some questions which the board has received.

How does AAEM decide what issues to address and what positions to take?

Issues are frequently presented by board members or officers. However, any AAEM member is welcome to bring any issue to the board. Other times, different medical organizations write a statement and ask AAEM to endorse it.

Decisions to publish or endorse a position statement are made by either the AAEM Board of Directors or the Executive Committee depending on the nature of the statement and timeliness of a reply. The Executive Committee is composed of the President, President-Elect, Immediate Past Present, Secretary-Treasurer, and Past-President's Council Representative. It is much quicker for the Executive Committee to discuss issues and so for timeliness sake, some statements are published or endorsed by with only the approval of the Executive Committee as per AAEM bylaws.

Regardless of who approves the statement, we always look at AAEM's mission statement and values in determining our stance. As all of our members, AAEM board members and officers have diverse viewpoints on many issues. Some would likely be described as liberal while others conservative. Some are likely democrats while others republicans and I know for a fact that one is proudly libertarian. However, while we have our own personal values and beliefs and do use these to determine the best course of action, when acting on behalf of AAEM, we strive to only consider the values of the Academy.

Why does the board not ask members how they feel prior to issuing a position statement?

The Academy is proud of its democratic principles and election process. However, just as the U.S. government is not a direct democracy, neither is AAEM. AAEM is a representative democracy. Each member has an equal vote in determining the leaders of the Academy. Those leaders are then entrusted with directing and managing the Academy in the best interest of all members. We function much like the U.S. government. Actually, we function much better with a singular focus. We debate and compromise and I assure you that no statement or position ever approved without genuine discussion.

However, it would be impractical and very nearly impossible to survey membership on every issue. Finally, it would be unclear how a membership survey should impact the decision to issue a statement as likely no issue, save our core mission, would garner unanimous member support.

All members are encouraged to communicate their thoughts to any AAEM board member, staff member, or other leader. Anyone may be contacted through info@aaem.org. Due to spam, etc. no member's, including no board member's, contact information is published online, but staff will quickly provide any board member's contact information once membership is verified.

But some of the recent position statements seem too political. Do they really have anything to do with emergency medicine?

The board feels that every position statement directly impacts emergency medicine. Otherwise we would not issue a statement. I will briefly discuss two recent statements which generated questions.

AAEM issued a joint position statement against a federal regulation which excludes transgender status from the legal definition of sex discrimination. It separately eliminated certain requirements for language translation as well as requirements for care of patients with a history of termination of pregnancy.

https://www.aaem.org/resources/statements/joint-endorsed/against-federal-regulation

AAEM also issued a joint statement on the death of George Floyd

https://www.aaem.org/UserFiles/file/AAEMReleasesStatementwithSAEMontheDeathofGeorgeFloyd.pdf

Why should AAEM get involved in race, police matters, transgender status, abortion, and foreign languages? Simply, AAEM is not getting involved in these issues as a whole. We view the federal regulation and racial inequalities in regards to our mission statement. The first line of AAEM's mission statement is: Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine.

The board knows that American’s and Academy member’s views differ on these issues and we respect that. The board neither supports nor opposes transgender issues in general, but we do support unencumbered access to emergency care for transgender patients. In our view, the federal regulation eliminated that access. We do not know exactly what happened in the situation with George Floyd and we are not calling for charges against the officers involved. However, we know that health disparities exist. We want every one of every race and every gender to feel welcome in the emergency department. Every individual should have unencumbered access to quality emergency care. It's really that simple.

I, our president, Dr. Lisa Moreno, and all board members welcome follow-up questions, comments, and any conversation. Common Sense encourages letters to the editor. Or contact any board member directly. AAEM is strong because of our diverse opinions coupled with our singular focus as the Champion of the Emergency Physician.

Featured Articles

Promoting Social Connection during COVID-19

 

Special Issue: AAEM Tales of COVID-19

Author: Al'ai Alvarez, MD FAAEM; Dr. Aneesha Dhargalkar, MD FAAEM; Carole Levy, MD MPH FAAEM; and Robert Lam, MD FAAEM

 

The COVID-19 pandemic has led to the implementation of social distancing, which has led to a decreased patient volume from non-COVID-19 related complaints. Along with canceled hospital elective surgeries and other major sources of revenue for the hospital, many emergency departments (ED) across the country, outside of New York City, the major hub of the pandemic in the United States, have implemented reduced staffing. Furthermore, some physicians are not working due to increased health risks, adding to the decreasing frequency of clinicians interacting with each other at work. We simply are not seeing each other in person as much as we used to. In-person department meetings have also been rapidly converted into remote meetings, further exacerbating this loss of physical contact among clinicians in the workplace.

With all the emotions that come with dealing with this global pandemic – fear, anxiety, grief, frustrations, and a clear sense of lack of control – physical distancing and the feelings of isolation add to the moral distress that clinicians experience.

Left unaddressed, the literature suggests loneliness and isolation in medicine lead to decreased productivity, burnout, depression, and other mental health disorders, physician suicide and is even a risk factor for death.1-5 Loneliness and social network size have even been linked to immune response as well as greater psychological stress, poorer sleep, and elevations in circulating levels of cortisol.6 A promising study of isolated senior citizens demonstrated that the use of SkypeTM for video chat had half the probability of depressive symptoms.7 Another study showed that an emotional connectedness similarly to in-person interactions could be achieved with video chat.8

In the time of social distancing, embracing technology as a tool to use with traditional strategies may promote teamwork, build community, and optimize use of positive psychology to enhance social connection.

We propose the following ways of combating isolation during the physical distancing restrictions of the COVID-19 pandemic:

Reinforce Purpose and Meaning

  • Celebrate together with colleagues when COVID patients recover and when they are discharged from the hospital.
  • Utilize journaling. Keep a log of each shift along with the thoughts and emotions of the day.
  • Be detectives for random acts of kindness. Pause and recognize whenever you see goodness happening around you.

Support and Improve Clinician Team

  • Send funny memes or words of encouragement. Be careful about patient information when messaging a group via a personal mobile. ContextTM is a HIPAA compliant app that you can use via cell phone or computer for chats.
  • Virtual cocktail hours can be beneficial for those who normally enjoy reveling in a post-work beverage with their friend or coworkers.
  • Playing online games as a group can be a nice way to socialize from a distance. Host an online game night, dance party, or escape room experience.
  • Lead with optimism.
    • As physicians, we are the team leader and we set the tone for the work environment. How we show up for work ultimately affects how the day will go for the entire team. Inspire.
  • Lead with appreciation and gratitude.
    • Highlight aspects of our work so that you can show appreciation and gratitude to your team and your leaders.
  • Continue to celebrate life events and other things that reinforce the cohesiveness of the team.
  • Make time for a formal or informal debrief at the end of each shift.
    • Check-in with your colleagues.
    • Consider using a modified three good things platform.
    • Focus on the positive things that happened during the shift.
  • Send postcards. There’s something uplifting about receiving a personal note from someone in the mail.

Encourage Connection to our Shared Humanity

  • Create a wall of post-it notes or memes in the break room or office space with encouraging messages or funny memes.
  • Post notes of encouragement from the community.
  • Bring in photos from home to post on the walls of the break room or office of the family, including fur babies. Include pictures from past social events.
  • Pin photos of yourself to your PPE suit to humanize you to your staff and patients.
  • Exercise and encourage self-compassion – treat yourself like you would treat a treasured friend.
  • Do the 36 Questions with friends.

Personal Improvement / Professional Development

Helping Others Has a Double Beneficial Effect

Reaching out to others right now will not only help others but it helps the helper: Helping others increases happiness and our own well-being.

  • Give blood if you are able. Convalescent plasma programs for clinicians that recover from COVID-19 can be a life-saving gift.
  • Be a battle buddy. A battle buddy is a fellow peer and colleague. The goal is to have two clinicians partner together to support one another.
  • Organize a PPE drive. Here is an example of medical students participating in #PPEdrive.

Our work in the ED, and medicine, in general, can be isolating with or without the COVID-19 pandemic. With social distancing, we can continue to physically isolate ourselves, while maintaining social connections. You can start now. Take a moment to reach out to someone. Go ahead. Text a friend and share a moment of gratitude.

 

References:

  1. Heinrich, Liesl M., and Eleonora Gullone. "The clinical significance of loneliness: A literature review." Clinical psychology review 26.6 (2006): 695-718.
  2. )Cacioppo, John T., et al. "Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses." Psychology and aging 21.1 (2006): 140
  3. Stravynski, Ariel, and Richard Boyer. "Loneliness in relation to suicide ideation and parasuicide: A population-wide study." Suicide and life-threatening behavior 31.1 (2001): 32-40.
  4. Seppala, Emma, and Marissa King. "Burnout at work isn’t just about exhaustion. It’s also about loneliness." Harvard Business Review 29 (2017).
  5. Holt-Lunstad, Julianne, et al. "Loneliness and social isolation as risk factors for mortality: a meta-analytic review." Perspectives on psychological science 10.2 (2015): 227-237.
  6. Pressman, Sarah D., et al. "Loneliness, social network size, and immune response to influenza vaccination in college freshmen." Health Psychology 24.3 (2005): 297.
  7. Teo, Alan R., Sheila Markwardt, and Ladson Hinton. "Using Skype to beat the blues: Longitudinal data from a national representative sample." The American Journal of Geriatric Psychiatry 27.3 (2019): 254-262.
  8. Sherman, Lauren E., Minas Michikyan, and Patricia M. Greenfield. "The effects of text, audio, video, and in-person communication on bonding between friends." Cyberpsychology: Journal of psychosocial research on cyberspace 7.2 (2013).

Resources:

  1. University of Washington Department of Science of Social Connection http://depts.washington.edu/uwcssc/content/staying-connected-during-covid-19
  2. Articles
  3. AMA
    1. Peer Support Program Strives to Ease Distress during Pandemic
      American Medical Association, April 14, 2020
      https://www.ama-assn.org/practice-management/physician-health/peer-support-program-strives-ease-distress-during-pandemic
    2. 5 Resources Built to Provide Emotional Support In Times of Crisis
      https://www.ama-assn.org/practice-management/physician-health/5-resources-built-provide-emotional-support-times-crisis
  4. Peer Support
    PeerRxMed - Free peer to peer program for physicians and others working in health care to provide support, connection, and encouragement. https://www.peerrxmed.com

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you for sharing your ideas with other members so we can get through this crisis together. We will continue to share new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submissions are now closed for this special feature.

 

<< Common Sense home page

 

Featured Articles

YPS Photo Collage of Life during COVID-19

 

Special Issue: AAEM Tales of COVID-19

Author: Danielle Goodrich, MD FAAEM 

 

To help showcase what we are going through during the COVID-19 pandemic, we requested YPS members submit photo representations of their lives during COVID-19. Please explore this photo collage from your Young Physicians Section.

 

YPS photo collage (PDF)

 

<< Common Sense home page

 

Featured Articles

My Life was Turned Upside Down by a COVID-19 Antibody Test

 

Special Issue: AAEM Tales of COVID-19

Author: Matthew C. Holden, MD

 

*As information about COVID-19 testing is rapidly evolving, please excuse data that may not be most up to date at the time of this publication.

I signed in for my shift at the freestanding emergency room I work at and found that in addition to answering the COVID-19 check in questions and getting my temperature taken I would also be getting a finger stick COVID-19 antibody test. I felt fine, had not been ill and had no known recent exposure to a coronavirus patient. I had no cough, sore throat, runny nose, headache, diarrhea, shortness of breath, or body aches. My sense of taste and smell were intact. These questions covered most of the current known symptomatology of the pandemic COVID-19 virus. I knew that there was considerable debate regarding the accuracy of antibody testing and how it should be used but I expected to get a negative antibody test. The two-part test would look for IgM antibodies that develop in the first 7-14 days of the infection. IgG antibodies begin to develop 14 days and peak between 21 and 28 days. They represent the antibodies of the recovery phase of the infection and remain elevated for weeks to months and possibly years. It is unknown whether IgG levels represent immunity to the COVID-19 virus.

Our current best test for active infection is not antibody testing but by real time reverse transcriptase polymerase chain reaction (PCR) test. PCR testing, although not perfect, is what we use to tell us who is infected now. It is the best screening test to help us with contact tracing and quarantine and treatment recommendations. This test identifies viral RNA beginning on or around day one of clinical illness but can remain positive, from current data, for weeks to months even without symptoms. COVID-19 viral RNA are found in nasal, oral or pulmonary tract secretions. They have more recently also been found in feces and sperm. There are multiple ways of obtaining specimen. The most common method involves inserting a nasal swab deep into the nasopharynx and preserving in either a dry or liquid medium. Turnaround times are variable. Some tests take as little as 15 minutes while others may take up to a week. PCR antigen testing is considered the gold standard for diagnostic purposes even though they have variable specificities and sensitivities. Some may only have 80-85% specificity. Sensitivity and false negative rates are also variable due to variable viral loads at different stages of illness, inadequate specimen collection, or problems with transport media or the lab testing itself.

The goal of antibody testing is to tell us what proportion of the population may have been infected and may possibly be immune to COVID-19 in hopes of reopening America safely, but experience thus far has been inconsistent and unreliable. It is not a good test to identify whether someone is acutely infected. By the time IgG and IgM antibody levels are detected, viral levels may already be decreasing or cleared from the system. As of April 21, the FDA had approved four antibody tests. These are all enzyme linked immunosorbent assay (ELISA) tests which can identify whether antibodies are present. The FDA had also allowed at least 50 non approved, mostly lateral flow immunodiffusion tests to be marketed. These are point of care tests that are supposed to be done on site in doctors’ offices or labs but are also sold online for home use similar to point of care pregnancy tests. They utilize small plastic cartridges where a drop of blood or serum is applied to one end, followed by a reagent that mixes with the blood sample and then diffuses up a strip of paper. Antibodies collect along lines as antibodies are deposited and provide a colorimetric reading when positive. A final control line validates the test. Many of the non-approved tests have 20-30% or less sensitivity, limiting their utility. Some of the best tests still have limited specificities. A positive IgM (acute phase) with a negative IgG (recovering phase) should lead to a patient getting a PCR antigen test to see if they have acute COVID1-9. A positive IgM and positive IgG may represent recovery from COVID-19 if it they are true positives, but they still do not rule out the presence of an active viral infection. One danger is that people with false positives may let down their guard and stop avoiding possible exposure and then actually contract COVID-19. Negative IgM antibody test results suggest absence of active illness but it may actually be negative because the patient is in the early and most infectious stage of infection before they start producing a measurable number of antibodies. Again, only PCR testing may provide an answer.

So, I got my finger stick antibody test at the ER and it was positive for IgM. I discussed the findings with my medical director, and he recommended I get a nasal swab PCR antigen study to send out to a lab. He suggested that even though I had no symptoms that I get another doctor to cover the rest of my shift and go home early to await final PCR test results in 2-3 days. I had very mixed emotions. First, I was excited to think that I may have an asymptomatic case of COVID-19. This would make my life as an emergency physician much easier since I could then evaluate and treat patients who may have COVID-19 without worrying if I was going to become infected. And I wouldn’t have to worry about catching the illness through exposure in the community. This is where we all hope to be in a couple of years as the illness spreads through the population and we eventually get immunized with a vaccine. Just maybe I was very very lucky. But I was also apprehensive that if I went home to quarantine with my wife that I might give her a COVID-19 infection that might make her very ill. Another possibility was that I had caught another common cold coronavirus infection from her that was giving me a cross reactive but false positive test. She had a sinus infection and a sore throat for a couple of weeks and had only recently started some antibiotics when it would not go away. To help resolve the dilemma I was able to bring home an antibody test and give her the finger stick test. If she tested positive we could both relax. I presented the test to her as soon as I got home in hopes of being able to avoid a long explanation about possible bad news. “Good news,” I said. “I got one of those antibody tests for you.”

Then the test was negative, and the questions started. Why did I test positive? What if I have it? How can she remain safe?  What does the antibody test mean? Can I get a repeat test somewhere else? Can I go get a nasal swab PCR test with instant results now? How long will we have to wait until we get the test results back from the lab? Can I call the ER tomorrow to see if the results are back and call every day until the results are back? I tried to put myself in her place and be patient and answer every question, every time she asked, in detail. I wore a mask and maintained a healthy separation. I slept in a spare bedroom and tried to stay in a different part of the house. I saw how hard it would be to safely quarantine in the same house with someone infected with COVID-19. As the weekend went on and I continued to feel healthy, I became less hopeful that I had an asymptomatic case. I became more confident that I had a false positive although nothing on the test kit instructions explained what that might be in my case. It was a long, tense weekend. She worried that she might develop COVID-19. I worried about how she might do if she got it. I called for results on Sunday. They were not back. On Monday I got the results phone call from the ER. It was negative. I told my wife I wanted a big hug and a kiss. She said no tongue. We were back to our normal routines in the COVID-19 era.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you for sharing your ideas with other members so we can get through this crisis together. We will continue to share new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submissions are now closed for this special feature.

 

<< Common Sense home page

 

Featured Articles

Should the 12-Hour Shift be of Historical Interest Only?

 

Special Issue: AAEM Tales of COVID-19

Author: David P. Lisbon, MD FACEP

 

I listened with sadness and despair as reports of the death of Dr. Lorna M. Been were broadcast. There were a series of interviews with her heartbroken family. The one that sticks with me was that of her sister. I felt she was most able to convey the sense of fatigue and exhaustion that Dr. Breen felt. In her interview she said, “She had 12 hour shifts.”

In my practice life, I’ve worked both 12 and eight-hour shifts. My first position after residency was one where I contracted to work 12, 12-hour shifts. I trained in a residency program that had eight-hour shifts; I made the adjustment. At the time, my community ED saw 27,000 patients a year, we admitted about 21%, and we were a Level II trauma center. The year was 1995 and I was 25 years younger, the internet was dial -up, there were no cell phone cameras and Tintinalli was soft-cover and could be read twice in residency!

As time passed, patient volume, patient acuity, patient admissions, patient psychosocial issues, and my age all increased. As my children later reminded me; I sometimes struggled to not doze off as I read bedtime stories over the years. As I look back and consider the moment we’re in now, a few other things are clear to me. First, humans are not nocturnal, being your best at 4:00am is just not likely. Two, when I think of the close calls with cognitive, diagnostic, or procedural error, they almost uniformly occurred between 3:00am and 7:00am. Third, the recovery time needed after a string of 12-hour ED shifts in a modern busy ED is at least 24 hours.

I had the great honor to be the founding program director for the emergency medicine residency at The University Kansas School of Medicine. I served for 10 years. I used to joke with my residents that I was open to a discussion about any and everything; except, the implementation of 12-hour shifts. I know that the 12-hour shift has its allure in that one works less shifts a month. I am also aware that very low volume emergency departments might have a logistical need to staff with 12-hour or longer shifts.

Notwithstanding the aforementioned realities, I still believe shifts shorter than 12 hours should be our future. My conversations with colleagues and observations over the years lead me to believe that once an ED gets to 40,000 visits and an admit rate of 25%, the 12-hour shift needs to be rethought. Shift length should be evaluated carefully for its effects on ED physicians. Certainly, a number of operational variables can be considered; staffing matrices, trauma center status, chest, and stroke center designation etc., but cognitive and physical workload over a distinct timespan at some point become germane.

As a frontline response to COVID-19, emergency medicine has and will endure a lot. The 12-hour shift had a place when our mission was perhaps more limited, before medical treatments and medical complexity shifted into high gear and before the pathogenic devastation of the coronavirus struck like a tidal wave. When considering coronavirus one might even ask what degree of concentrated time exposure becomes hazardous?

All of us on the frontlines of healthcare, like Dr. Breen will aim to bring the best of ourselves to each shift. It might be time to ask if it is fair and just to expect that best self to be present at hour 11 and 30 minutes into a 12-hour shift.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you for sharing your ideas with other members so we can get through this crisis together. We will continue to share new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submissions are now closed for this special feature.

 

<< Common Sense home page

 

Featured Articles

The Black Death

 

Special Issue: AAEM Tales of COVID-19

Author: Jeff Wade, MD FAAEM

 

“The Black Death, also known as the Great Plague or the Plague, or less commonly the Black Plague, was one of the most devastating pandemics in human history, resulting in the deaths of an estimated 75 to 200 million people in Eurasia and peaking in Europe from 1347 to 1351.”

-Wikipedia definition

 

The plague has been a huge thing in my life. My third year of college I was still pre-veterinary, but starting to be ready to change. I was working for a vet and he wasn’t seemingly happy at his job, and from what I could see the job wasn’t happiness inducing. People call pediatrics and geriatrics, veterinary medicine. Your patients at either extreme of the lifespan are not able to talk to you and tell you what is wrong, nor understand why you are hurting them. And worse, they can have parents/adult children/owners who can be at either extreme: overly helicopter-y and in-your-face about everything or abusive/neglectful assholes. That’s a pretty good argument against veterinary medicine, peds, or geriatrics in my book (literally in my book). And I had just finished a test in my agribusiness/pre-vet major. The test question was: ‘You have just inherited a large quantity of money. You decide to use this money to open a pig farm (EXACTLY what I would do conveniently enough). Please describe in detail how you would setup the farm with room for breeding, food storage, waste disposal, etc.’ Nice.

Then I had my first microbiology class. The teacher read a case report from the Centers for Disease Control’s Morbidity & Mortality Weekly Report (CDC MMWR), a sampling of trending infection or toxic events. The case he read was about a case of modern-day plague. It still exists today, but as people became more used to it after the Black Death & just people’s and bacterial evolution, it is rare and almost only associated with desert rodent exposure anymore.

He described how the bacteria literally fill the blood vessels. And how from getting sick to dying can be as fast as a day or less. They can get the black swollen lymph nodes in the groin & armpits called buboes. This is where the terms Black Death and Bubonic Plague come from. He also talked about how sometimes it can spread to the lungs and become much more easily spread by coughing instead of requiring rat fleas, the typical way of transmission.

This came at THE right time for me. That day I decided to change my major to microbiology and my goal to med school. And I made the right choice. People are much better conversationalists and by virtue of that, much more interesting to work with than animals. As long as you see non-demented/drunk/high adults or older children, you don’t have to torture things that don’t at least understand the reason for the torture. And the adult children/parents/owners issue doesn’t come up.

Since then I have had an interest in the plague. It literally changed the face of Europe. Before the Black Death, Europe was feudal, where the majority of people were essentially the property of the local lord. The tremendous social change initiated by the plague (and other historical trends at the same time), got rid of the feudal system in all but Russia within a 100 years or so. This freeing of the individuals to live where and how they wanted and general mobilization of society was one of the biggest contributors to the Renaissance and modernity in general.

I have found and read several books that deal with the plague since then. One of the best is by the French Nobel winner Camus and called The Plague. It describes a fictionalized version of one of the last modern widespread outbreaks of the plague in North Africa, where Camus was born and grew up. It is a riveting account that includes all the standard stuff you see in an outbreak: dead rats, buboes, mass graves. However, Camus was an Existentialist, meaning he was interested in how people should act in a world where there is not necessarily a God. So the book is also about more than just the rats, it focuses on a group of accidental friends who band together to deal with the situation. Everyone has a crisis of conscience, even the priest. Quite a great book, one of my all-time favorites.

Another is A Journal of the Plague Year by Daniel DeFoe, the writer of Robinson Crusoe. It is about the 1666 London Plague. He was born not long after the plague, so was able to draw on survivors and recent records. It is a purely journalistic account of the plague and gets into the reactions to and management of this overwhelming event. It’s a nice book if you are interested in the plague.

Much later, I found out that Oxford University has summer school for adults who can afford to study in Oxford. We made plans to do that a few years ago after visiting Oxford. When we looked online at the available courses, the one that jumped out at me, was called The Plague. Of course, I took that one. I brought a fake concert T-shirt that I have had for years. It looks like your standard black long-sleeved concert shirt. Except on the front, it has a picture of a rat surrounded by flies and ‘Black Death European Tour 1347-51.’ The back has the ‘concert’ locations. While there, we learned tons about the plague and its societal aftereffects. As this was right after the big Ebola outbreak, it was even more topical. ANY disease, from Ebola to the plague or even the common flu, can mutate overnite and turn drastically more severe and/or more contagious.

We live in a world where when, not if, the next big epidemic comes up, it will be spread worldwide within days.

Get your flu and other shots. And be afraid. Be not so very afraid…

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you for sharing your ideas with other members so we can get through this crisis together. We will continue to share new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submissions are now closed for this special feature.

 

<< Common Sense home page

 

Featured Articles

COVID-19 Has Made Emergency Physicians the Default Leaders of Medicine

 

Special Issue: AAEM Tales of COVID-19

Author: Mohamad Moussa, MD FAAEM

 

The emergency physician (EP) was flung into the spotlight during this COVID-19 pandemic. Every single day since early March 2020 we have seen our EP colleagues on news channels and websites of all kinds talking about COVID-19. Their calm and collected mannerisms on screens all over the country and world gave people the insight of what an EP is willing to do to help their patients—essentially risk their life for the life of another. What was so inspiring was the homogenous message that all EPs gave their communities no matter what part of the country or world they were in. They served as ambassadors of global health to teach and reinforce proper hand hygiene, social distancing, and stay at home measures. This was all in the background of extreme uncertainty about disease spread and treatment. The ability to lead in such a challenging environment and maintain composure for our patients sets us up as the lead doctors across the globe. And because of this unconditional care in this novel pandemic, that is why I say EPs are the new leaders in Medicine.

I say, EPs are the new leaders of medicine because of our practical nature. People understand EPs because we speak in their terms. No big medical terminology laced with the most recent literature. Rather, we use plain, basic language like stay at home, wear a mask, use social distancing, follow national and state COVID-19 protocols. After all, this is what EPs have been doing for years. We are the blue-collar physicians of our day and we do everything we can to blend in with our community. Many times, you cannot differentiate a patient checking in from an EP walking through for a shift in the main entrance lobby. EPs swimmingly shift between complicated Level One MVC trauma resuscitations and simple sore throat patients and carry on with their day. All the while, taking a bite from a peanut butter and jelly sandwich they packed from home. This versatility of an EP is what also made them shine as physician leaders in this relentless COVID-19 pandemic.

I say, EPs are the new leaders of medicine because we keep the calm in chaos. COVID-19 has brought nothing but uncertainty, anxiety, doubt, fear, and death. While hospital administrators, infection control personnel, and infectious disease physicians developed untested protocols, EPs were still covering the emergency department seamlessly in the midst of constant emergency department zoning changes. The EPs applied what they have learned all along in their training which was to adapt to whatever comes their way. The fluttering that now exists between intubating early or not, anticoagulating or not, and pronating or not did not deter the EPs from doing what was right for their patients in that moment. As many suggestions came through on COVID-19 patient care, the decisiveness of EPs remained keen and directed towards doing what is right for their patients.

I say, EPs are the new leaders of medicine because they make an immediate impact. Patients and family members see the lifesaving heroics that are made in the emergency department the minute they arrive. The eye contact from the EP to the patient’s family member about how serious the situation is forever memorable. There is no setting up appointments for another later visit, no blood draws without immediate results, and no insurance checks before a CT or MRI needs to be done. Patients feel the presence and advocacy of the EPs more than any other physician. Similarly, in front of the news cameras, EPs give calm and hope to people in their homes. We lead by example. We lead by our recycled N95 facial bruises. We lead by our worn and torn gowns and gloves. We lead from the very uncertain frontlines. And that is okay with us.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

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Featured Articles

I’m Not Really a Hero

 

Special Issue: AAEM Tales of COVID-19

Author: Gregory Jasani, MD

 

When I lived in Washington, DC, I would occasionally travel to Reagan National Airport to welcome Honor Flights to our nation’s capital. Honor Flight is a program dedicated to transporting military veterans to see the memorials of the wars they fought in, at no cost to the veterans. Anyone who has witnessed these events can tell you that they are filled with cheering crowds and lots of flags. It truly is a sight to behold, and it is a fitting tribute to those brave men and women. They are true heroes. Yet, the veterans I met always insisted that they did not deserve the title of hero. “I’m not a hero,” I heard far more times than I can count. I never could understand how they could feel that way.

I understand it now. I am an emergency medicine physician working during the coronavirus pandemic. To many, that makes me a hero. I have been truly touched by the outpouring of support from my friends, family, and even strangers. It has helped enormously during this challenging time. However, let me be clear, I do not consider myself a hero.

To me, a hero is someone who does something to benefit other people, despite the possibility of immense personal risk. Though COVID-19 is a serious disease, I am in my 20s and in good health. While I could get infected with coronavirus, I know my chances of succumbing to it are fairly low. I am also fortunate enough to work at a hospital that has provided us with adequate PPE. My wife even works in the same hospital as I do, so I do not have the added burden of wondering if I’m endangering her health. For me, the risk I have faced during this pandemic has been minimal.

Many health care workers are not as lucky as I am. Some have continued to work despite being at higher risk due to their age or their underlying health problems. Some work at institutions that face shortages of vital PPE. Some have had to sequester themselves away from their families for long periods of time, just to keep their loved ones safe. Some have even made the ultimate sacrifice and lost their lives during this pandemic. They strove to preserve the lives of others even at the cost of their own. These are the true heroes of this pandemic. Their sacrifice required courage beyond measure, and they exemplify the very best of the healthcare field. They should be held up for generations to come as the ideal of heroism that we should all aspire to.

I will always have the pride of knowing that I was a doctor during a difficult and perilous time. But I am not a hero. I am just doing my job. It is the same job I did before the pandemic, and I will continue to do it after COVID-19 has faded from the public mind. Many healthcare workers are being asked to face much higher risks and make greater sacrifices than I am. They are the heroes that we should honor and remember.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

<< Common Sense home page

 

 

Featured Articles

Dehumanized

 

Special Issue: AAEM Tales of COVID-19

Author: Puja Singh

 

They asked me, “How does the current pandemic situation make you feel as a future emergency medicine doctor taken out of your clinical rotations?” Dehumanized. Anxious. Heartbroken. Anxious about the upcoming residency application cycle, anxious about whether I will be able to do audition rotations at the prestigious institutions I have imagined myself going to for the past three years. Anxious about whether I can take Step 2 in time. But more than this, I feel as though our humanity has been snatched away. My mother, an internist in NYC and a single mom, has been isolated in her room, forced to stay away from my ten-year-old brother because she has been taking care of others’ loved ones. Dehumanized because when we got notice of my maternal grandmother, my Nani, passing away in California I had to stay away from my mom and could not go home to see her in order to abide by proper quarantine guidelines. Dehumanized because when we traveled to California to complete the last rites and rituals for my Nani, we were encaged by N95s. As we bid farewell to our grandmother, our hands could not touch her cold and limp body because of the gloves that lay in between us. Dehumanized because as we cried and grieved, we could not wipe each other’s tears away and hug one another, since we were all that we had left. We were all that we had left; and yet we were still so far from one another. Finally, 14 days after my Nani passed, I hugged my mother, I wiped my aunt’s tears away as they fogged her glasses, I brushed my little cousin’s hair as she sat in front of the mirror and cried, I rubbed my uncles back as he sobbed into his palms, and I squeezed my brother’s hand as he watched my mother’s heart break into a million pieces. I cried alone.

Four weeks ago, when I was pulled from my OB/GYN rotation, little did I know that this life changing event would happen in the midst of this global pandemic. My grandmother was my entire life – she raised me for 10 years by herself with no help whatsoever. She was a mother to me when my own mother couldn’t be after the death of my father, an internal medicine resident himself. She was my rock, my person, and now because of this pandemic I could never say goodbye to her the way I had imagined. I was never ready for this day; yet now there were a million barriers to what I had always wished I could do. We aren’t sure why she passed away, but I was sure that I wanted to help lighten the suffering of other families experiencing similar pain. Before my Nani’s passing, I had spoken to her about my idea of recruiting fellow medical students to conduct family phone calls to update them of their loved one’s status in the hospital since hospital visitation had been halted. She absolutely loved the idea! Since then, I have worked alongside my colleagues to develop an initiative to do this at our hospital and we have now called over forty families for COVID and non-COVID patients. The joy and happiness that this has brought me and my classmates, and hopefully the families with whom we have spoken, is a feeling that is unimaginable! To be able to make even a small difference in someone’s life when I, myself, am grieving is somehow healing me. Is this selfish? Or is this selfless?

My heart will never be put fully back together from the loss I have suffered, but it is somehow, just a little bit full and warm. Bliss. Gratitude. Human.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

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Featured Articles

The COVID-19 Experience Outside of the Epicenters

 

Special Issue: AAEM Tales of COVID-19

Author: Robyn Hitchcock, MD FAAEM

 

We’ve all read the heartbreaking stories of what’s going on in the epi centers in New York City, the Seattle area, Detroit, etc. Clinicians drowning in their work. Typical ICU care turned on its head because standard management of respiratory failure isn’t working. One day we’re told if they start to crump intubate early because using BiPAP and even nebulizers spreads and aerosolizes the virus putting everyone in the department at risk. The next day they’re telling us don’t intubate until very very late because even ventilating them puts them at risk. Then we’re told use higher lung volumes than you think and less peep and then the next day they switch it. Wait, now we need to try prone ventilation and even rolling your patient regularly to expand and drain different parts of the lung.

Nobody really knows how to manage this because it’s not playing by any typical rules. Everyone’s trying to figure out how to split one ventilator to be able to vent from two to four people because there’s such a shortage. Anesthesia societies and pulmonary societies are coming out against this practice but some places have no choice. Human rights groups are up in arms because some facilities and states with shortages are making age cut-offs, or not treating the mentally retarded as aggressively to save a vent for perhaps a college professor instead. We are hearing tearful pleas from nurses that are working in intensive care with staffing ratios that are inconceivable: 19 patients to one ICU nurse with no relief because their colleagues are getting sick or refusing to come to work because of the dangerous staffing ratios. Orthopedic surgeons, dermatologists, and ophthalmologists who have had their clinics closed are retraining for ICU and ER care to help their overwhelmed colleagues. These are the stories that most people are seeing and read about every day for the past month and more since this COVID pandemic has become real.

But this is not the experience for most of the healthcare workers in this country, and at this time I am working primarily at places that have not yet peaked their use of resources. Right now I’m at a hybrid freestanding ER / urgent care facility in the southwest. Our usual complaint is volume. This facility was designed to see about 75 people a day and over the holidays we were seeing upwards of 150 to 200 and experiencing 5-hour waits routinely, etc. It was exhausting and frustrating for all of us. Things seemed to be settling down in January and February to a reasonable number to handle, typically between in the 120 to 140 a day range sometimes less. Then COVID-19 happened. In early March the very few patients we had coming through, we were able to put in our one negative pressure room, and have full PPE available for staff. I don’t think we had a test yet on site at that point, and we had to call the department of health to even get approval for the very few tests that were available.

In the interim I left to go back home and go to Stanford trying to get a loved one operated on which got canceled because of the pandemic. During this time I fortunately missed when one of these facilities was designated the local testing site and things were pretty chaotic for a while. They moved the elective testing site to a park outside of town so this site is now just seeing sick people again.

I returned to work April 8th. This is right around the time when the New York and California sites were starting to peak and finally flattening their curves, But the smaller communities with delayed onset of symptoms had often not even closed their federal facilities and parks, and certainly were nowhere near their peak. Many states issued a stay home order by mid-March but this state was just coming around to that on April 11th. The facility I’m working at which is always drowning in people, is barely seeing half of their previous volumes. That’s good and it means people are staying home like they’re supposed to. Unfortunately, the side effect of that is we’re seeing heart attacks stay home and not get intervention until it’s too late. I’ve seen abdominal pain stay home and progress from simple diverticulitis, which we can treat with antibiotics, to bowel perforation which needs surgery, a drain, and sometimes a colostomy. There are many, many people that come in with very minor symptoms like a runny nose, watery eyes, mild GI symptoms. The more we read about COVID the more we realize it can present with just about anything. So anyone with shortness of breath and cough, or a fever and just about any other symptom is “rule out COVID.” Many of these we are trying to see in the car and then our outdoor tent to avoid bringing them in to avoid exposing both our patients and our staff. If their vitals are normal and lungs are clear we will generally test them and send them on their way. If they’re sick enough to need more evaluation we bring them into the tent and if they’re really sick we bring them inside.

Again, most of these are going to test COVID negative and you know it, except when they don’t. So you have to don full PPE, we are given one N95 mask and face shield to reuse for the entire day. And then we’re even saving those at home at the end of the day in case they run out or in case our health system figures out how to reprocess them for reuse. We are also assigned one surgical mask a day, which we are supposed to wear all day long. This is actually our more important mask to protect our patients and each other. And it’s the most exhausting one to wear. I’m claustrophobic and struggle with wearing a mask at all for more than a few minutes. The N95 mask makes me absolutely feel like I can’t breathe so I’m stuck with a surgical mask most of the time and just switch to the N95 when I go in a patient room with suggestive symptoms or known COVID. It used to take a week to get the test back, now we’re seeing them generally in 24 to 48 hours, but it’s still not enough time for those of us on the frontlines to rule in or rule out needing PPE. It is really hard to maintain super caution in a high level of suspicion when you know what you’re dealing with is mostly not COVID. The rest of the time I am wearing a simple surgical mask which offers me little or no protection, but will protect my patients and coworkers at least somewhat if I’m an asymptomatic carrier. It would be ideal if they would do the same but some people (co-workers) keep taking their masks off. I would also prefer we mask every patient that came in the door for the same reason, but apparently we don’t have enough to do that so we’re only masking people with symptoms. Well, that works until it doesn’t.

People are thanking us for what we’re doing. We’re just going to work. At these facilities, the acuity isn’t very high and we’re not seeing very sick COVID patients. At least not often. We’re still at least two weeks away from our projected peak in New Mexico. People keep buying us food: lunches from local restaurants roll in with thank you notes. It feels somewhat disingenuous to accept this gift because really we’re working less than we typically do with the volumes being lower and all that. So add guilt to the table as well.

But the human fallout of this experience is very real. I’m extremely careful with hand washing and PPE, but not every one of my patients wears a mask and could be infecting me as I walk into any room. I have to assume I’m an asymptomatic carrier. So I’ve made myself into a leper. At my travel assignment, I will not allow housekeeping in my room until I leave to minimize their exposure. I am obsessive with the six foot social distance compliance. I wear a mask whenever I leave my room to protect others. I won’t go in an elevator if somebody else is in it. I move into clumps of weeds on a walking path to make sure I’m not exposing anyone going for a walk, etc. etc. It’s exhausting. I feel like I’m walking poison and must stay away from other people. This is not a pleasant feeling.

And what’s happening at work? Right now the facility I work at is actually pretty slow with low volume. We have a little too much time to spin and talk about the what ifs. Healthcare workers are being laid off all over the country. NOT just at elective facilities like eye clinics, low acuity doctors offices, outpatient surgery or procedure centers, dermatology and aesthetics, physiatrists and physical therapy, etc. Even ER nurses, yes ER nurses and doctors are being furloughed and/or asked to be take mandatory pay cuts because the volume is down. Much to my surprise many people (patients) actually are trying to stay home as much as they can. So not only are we putting ourselves at risk everyday by going to work, we’re being offered less work. Or less pay to do the same or both. Many are being forced to take less hours than they are contracted for or mandatory pay cuts. And it is strictly forbidden to travel to the areas that need help because then that puts you at risk and you would have to have a two-week quarantine before returning to work which would then put you in violation of your contract.

I understand the hospital administrations have to keep their patient population safe but the catch-22 of so many healthcare workers out of work, yet so many systems desperately needing help and the one not able to go to the other makes my soul cringe. Maybe one good thing that could come out of this, since all of the hard hit areas are offering fast track to licenses, which usually take 6 months or more, would be centralized licensing. The medical licensing community will realize we actually all have the same training and if you are licensed in one state you should be able to be licensed in any state. Medical licensing should be a national thing. It’s ridiculous to have to redo this process for every state you work in, and maybe there will be a push for this to happen but honestly I wouldn’t count on it. It would make too much sense.

I’m lucky so far that many of the facilities that I work at are single coverage, smallish places. You can’t really have less than one doctor on at a time. So far I’ve had all the shifts I need. Right now the places I’m working at haven’t surged and the volumes are down. I haven’t gotten sick and I haven’t brought the virus home to people I care about. Yet.

There’s a lot of talk of reopening the country, And the significant economic fallout of staying home and having things locked down. I wonder how we’re going to measure the toll that this virus is taking on all of us. The covered presentations, hospitalizations, and I see you length of stay as well as deaths are actually fairly easy to measure. But how do you measure everybody with chest pain that stays home or a heart attack that dies at home because they were afraid to come in? How do you measure the abdominal pains that turn into perforation or death because they didn’t come in? For the first time, I’m really understanding why people with what we consider to be minor or non-emergent problems need to feel that it’s safe for them to come in to the emergency department and not be ridiculed… That’s the only way we can ensure that the really sick people come. But they’re not coming or they’re not coming until it’s late. COPD exacerbations almost always have to be admitted or intubated because they delay presentations so long. Many systems have gotten telemedicine up and running or are managing more patients remotely. I hope that’s a change that sticks.

It’s way too early to be able to quantify the fallout from this pandemic, so right now we’re all just logging through the best that we can. I actually feel fortunate that I have a job that I can (and need to) go to outside the home. Nobody knows how long this will last. University of Washington cautiously is suggesting mid-May might be a good time to open the country back up. There are increasing protests about the stay home and social distancing orders. We’re seeing some countries that locked down illness right away like Singapore have huge spikes when they started opening things up again, but we don’t seem to be learning from it.

So I go to work. I wash my hands. I wear a mask, and when indicated full PPE. And just try to take things one day at a time and not think too hard about the what ifs. I truly do feel fortunate to still have full-time employment when so many people are out of work and so many things are closing. Times like these define us. Will it tear us apart, or bring us closer? I feel more connected than ever to my ED colleagues as we get through our shifts and try and keep our spirits up, together.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

<< Common Sense home page

 

Featured Articles

Class of 2020: Match Day during a Pandemic

 

Special Issue: AAEM Tales of COVID-19

Author: Gloria Felix

 

I opened my email on March 20, 2020 at 11:59 am: I matched into emergency medicine, at a program that serves my community and one where I used to volunteer when I was a teen. After years of living away from home, I get to come back!! I was overwhelmed with nerves, happiness, and joy.

At 12:15pm, I hear the familiar ringtone from my computer, time for our virtual match day party! My fellow 4th years shared our new destinations and jumped for joy for one another. For the past four years we’ve been each other’s support system, we’ve laughed together, studied together, cried together, and here we are – the day we’ve been dreaming of has arrived. We finally did it! We are going to be physicians serving communities all over the country. We laughed, shared silly stories and jokes with liners of “remember that time” or “O man I never thought I’d make it past class…” but here we are. We made it! After rounds of laughs and trips down memory lane we said our “see you later and stay safe everyone” farewells and signed off.

The screen shifted to black, I sat in front of my computer, and suddenly once the adrenaline started to wear off, I started to feel reality set in. I was going to be an emergency medicine intern at the epicenter of the pandemic. I began to feel fear. Will I be able to keep up? Will I know what to do when a family member sees MD on my ID badge and is asking for help? Will I get my family members sick when I come home? Suddenly the excitement and joy I felt was overshadowed by fear. A list of what if scenarios one after the other were playing in my mind on repeat.

I muted the fear, at least for that day, and tried to focus on spending time with my sister and nieces who I hadn’t seen for months. I sat around the table with them as we cut the fluorescent pink match day cake they had bought for me. My niece continued to sing a happy “match day” song on repeat and for a moment my doubts were silenced.

I woke up the next morning and I felt different. My world had changed overnight. I was no longer waiting for where I would be spending the next four years. I already knew. My contract offer was signed and emailed. My new EM family welcomed me and the intern group chat was already booming with funny emojis and excitement for meeting each other. I started to feel the familiar mixture of excitement and fear.

I reached out to my fellow 4th years and future co-interns and asked, “is it me or are you guys feeling kind of scared?” We all were prepared for the traditional novice feeling of moving from medical student to doctor. We’ve been reassured about it being completely normal and everyone feels that way, but no one would have imagined that the class of 2020 would have to be prepared for being novices in what has been compared to be a warzone, a fight against time, and an uphill battle to find resources to keep patients alive.

My worries were not just my own. My fellow 4th years shared the same concerns, my co-interns flooded the chat with words of encouragement and funny videos to ease the seriousness we are facing, and mentors began to share that although they felt immense joy for me, they also felt concern and wished me to be safe.

In sharing my fears, I began to feel less afraid. I am not alone in being scared. I am not alone in wanting to help but not being sure how to do so.

To my fellow 4th years who are entering or have already entered the frontlines of this pandemic, you’re not alone. The class of 2020 is resilient and we will make it through this together. Our voices and sharing our stories make us stronger and empower us during these uncertain times.

I congratulate all of the incoming interns and seniors who will soon be attendings for your accomplishments. It is a crazy time to join the emergency medicine family, but we are in this together!

Stay safe, stay resilient.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

<< Common Sense home page

 

Featured Articles

Embracing Femininity in a Pandemic

 

Special Issue: AAEM Tales of COVID-19

Author: Lauren Maloney, MD NRP FP-C NCEE

 

When I became an EMT in 2007, I could count on one hand the female paramedics I knew from working in the ER of a community hospital across the street from my high school. Female psych patient transports required a female provider in back, and because of how few women in EMS there were, some days the same paramedic would reappear half a dozen times. Those women were total badasses in my mind – they held their own, were wicked smart, quick with a joke, and could literally pull their own weight.

Later on in college as an 18-year-old female paramedic student in New York City, I quickly realized how naïve I was to the prevailing EMS culture. I was told by a preceptor that “women are supposed to be nurses, and men are supposed to be paramedics, so you might as well just quit medic school right now.” I had a signet ring worn by three generations of women in my family resized to fit on my pinky, as wearing it on my ring finger attracted attention from men who believed I was married and therefore more desirable. I learned how to weightlift so my partners wouldn’t be averse to working with a woman in the pre-powerlift stretcher era. I took up reading automotive magazines and watching local sports so I could make conversation across the daily gender and generational gaps. Most of all, I learned to show no emotion, even after a patient attempted to stab me with a knife enroute to the hospital one afternoon.

I continued to work as a paramedic, graduated as one of the few women in my biomedical engineering class, was accepted to medical school, and spent hundreds of hours becoming a state and nationally certified EMS educator. I earned my flight paramedic board certification which allowed me to take a highly coveted position as a critical care transport paramedic, and went on to become a resident emergency physician, still working shifts as a paramedic until I was granted my own medical license.

As I finish an EMS fellowship and become an EMS Medical Director, I feel like I’m finally in a position that I feel safe enough – respected enough – to show others that it’s okay to not be okay. That it takes more far courage to say, “I need help” than “Yeah, I’m fine. To say we need a safety net for rough calls and to diffuse the cumulative occupational stress we endure.

This winter I teamed up with a paramedic supervisor and we began to craft a program called the EMS Code Lavender. Code Lavender started in a Hawaiian hospital1 as a way for healthcare providers to recognize and begin to heal from traumatic situations and unexpected deaths. During a Code Lavender, a multidisciplinary team meets staff real-time, and while the team composition varies across institutions, all utilize some sort of lavender aromatherapy for the sense of calm and tranquility it’s believed to bring. To overcome operational challenges unique to EMS, we framed it in two parts: a consistent way to recognize and reach out to staff after acute events and a long-term wellness initiative. We formulated a set of initial criteria for notifying the Code Lavender Team about a call and hoped by making it analogous to using criteria to call a major trauma code, the program would be less threatening and remove the sense of “tattling” on each other. A webpage was created so that all the wellness and mental health resources already available to staff, though rarely known about, were in one location. We printed stickers with a QR code that links to the page for providers to put on the back of their ID badge. Finally, we created a Google Voice number for notifications to go to. We planned to screen the notifications to determine if it was appropriate to reach out to providers via text or phone call, or if a Code Lavender needed to be activated for an immediate in-person response. Our grand plans involved rolling the program out in May during a series of department-wide training days.

Then COVID-19 hit, blowing our seemingly brilliant plans right out of the water. Within a week, we realized we were soon-becoming an epicenter in the COVID-19 outbreak. If there ever was a time to hopefully get buy in about acknowledging and embracing mental health, surely it would be during a pandemic with no realistic end in sight. We sent out an email explaining the program to staff, hurriedly gave out the stickers, and made the notification line live within several days. Much as the medical response to COVID-19 has evolved on a daily basis, the EMS Code Lavender response has evolved as well. In addition to maintaining daily peer contact with providers who are quarantined, we gathered items for care packages and purple teddy bears to give to those under strict isolation precautions. We started weekly happy hours via Zoom as a way for folks to laugh and breath together while enjoying a seltzer or adult beverage of their choice. And we bought a supply of chalk for the therapeutic graffiti of EMS bay sidewalks to create visual reminders of the love, community, and gratitude that surrounds us.

I would like to believe that on some level, helping to spearhead this effort as a woman has made it more inviting and warmer. Channeling what I hope someday to be maternal love, to make it non-threatening and genuine. I admittedly have paused before I hit send on emails to the EMS staff, cringing, wondering about if what I’m writing is too “personal”, or “touchy-feely” or “emotional.” But then I think, so what if it is? Since when did saying, “I care about you as a fellow human” become taboo? I have endured what EMS is like without feelings and femininity, and I know that my EMS reality right now, even in the midst of the worst medical nightmare of my lifetime, is something I am so very proud of.

 

References:

  1. Karlamangla S. As health workers deal with mass shootings and fires, more hospitals are looking to help them cope. Los Angeles Times. 01/02/2018, 2018. https://www.latimes.com/local/california/la-me-ln-code-compassion-20180102-htmlstory.html

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

<< Common Sense home page

 

Featured Articles

The Moral Dilemma of COVID-19

 

Special Issue: AAEM Tales of COVID-19

Author: Andy Mayer, MD FAAEM — Editor, Common Sense

 

Certainly, there is only one issue which is dominating all thoughts, prayers, and efforts on our planet right now and it is COVID-19. Hopefully where you are, your life and practice will only be incredibly inconvenienced and that your family, your community, and your hospital will be spared the worst of this pandemic. Many areas may be relatively spared by early social distancing and the shutdown of many aspects of daily life which until last month we took for granted. This crisis has brought to the forefront many ethical and moral dilemmas which our society and world need to face with open eyes and minds. Our medical capabilities in our modern prosperous society are currently been taxed past the breaking point in the hotspots of the COVID-19 pandemic. We need as a profession and as a society to consider the correct response to the complex and difficult decisions which physicians on the frontlines are now making or may eventually be facing where conditions are worse. Even if we manage to make it through this pandemic without running out of ventilators and do not lose too many talented and selfless healthcare professionals there may be a next time.

Sadly, I work in one of the initial hotspots of New Orleans. The citywide healthcare system became inundated within days. The whole medical community has come together to try and work through the new complex daily challenges which we are required to meet each and every day. The process, which we worked out the day before, can be quickly scrapped or modified as we learn or try new things. The idea that a new disease can come out of seemingly nowhere and challenge every treatment concept we have is a humbling experience. When you realize that we truly are wandering in the desert when it comes to what is the best course of action for the dying patient is front of you, it is terrifying but also enlightening. How far are we really removed from the “plaque doctor” of old?

Many of us have quickly been through the protocols of early intubation, late intubation, prone ventilation, CPAP, BiPAP, non-rebreather masks, no non-rebreather masks, viral filters, or whatever in an attempt to figure a path forward. Just walk through an ICU of any COVID filled hospital and you quickly see the reality of this pandemic and the current limitations of the available treatments. The prospect of throwing away much of what we thought we knew in regards to treating critically ill patients can make one question much of what we thought were sound and scientifically based principles. Listening to the various experts proposing yet another way to do things differently for this novel disease is fascinating as the medical community having to throw out, at least partially, our “evidence-based” mindset.

Consider the ethical dilemma of trying a novel ARDS protocol or giving a medicine normally used for malaria or lupus with known serious side effects on only anecdotal evidence. Certainly, the intention of using these techniques or medications by physicians in the trenches seeing their ICU and emergency departments filled with patients struggling to breath and dying all around them is noble and in the finest traditions of medicine. The usual treatments and protocols which we have all learned to use are not working and in an act of desperation a dedicated and caring physician who is putting their very own life on the line is attempting to save the patient in front of them. However, there will always be critics and naysayers who will demand to see the evidence and the trial, which shows the safety and efficacy of what is proposed. Many of these ideas will fail and patients will continue to die. I fear the personal consequences for these innovative physicians down the road when the tired old pundits and plaintiff attorneys come out to denounce the medical experimentation, which went on while they were safely home in self isolation. I certainly think that sovereign immunity should be granted to all physicians in this crisis to allay any fears of later recrimination after the dust settles. AAEM has sent letters to all of the governors of our states asking for relief from the fear of medical malpractice liability during this crisis. Will it be fair to pass judgment on the actions of these same doctors who literally placed themselves in danger to treat these patients knowing that our treatments were untested and were driven by their professionalism and compassion to try novel treatment options, which may or not work?

I certainly know what I believe, but more and more I feel like I am a plaque doctor of old. Dealing with a novel disease which is cutting a swathe thorough my community is humbling to say the least. Our emergency department early in the pandemic tried new methods to try and depressurize the department and hospital. Trying to keep a COVID-free area became almost impossible as despite a patient’s chief complaint, in the end everything became COVID. We started seeing patients via Zoom while they were in triage to help start workups and triage to see who needed the next available bed while preserving our limited personal protection equipment supplies and to try and limit exposure to the providers. The fire marshal allowed us to put army type cots along a long hallway outside of the waiting room to see patients when there was no other available space. The scene was surreal walking past six ambulance stretchers waiting on the wall to see people in pediatric area, which we had also cannibalized for sick adults. I never would have thought that I would order so many ferritin or LDH levels in my career.

The potential of the need to ration care when your department seems to be drowning in COVID can become a pressing thought. This is especially true when your local nursing homes become infested with the virus. At one point, we would have nursing homes calling and stating they were sending five patients at a time. Who to see first? Who would get the bed? Would we have enough ventilators? Who to put on hydroxychloroquine? The crucial question, sadly on the initial presentation on some of these patients, is quickly reviewing the code status and immediately trying to call families to discuss treatment options. On some days, it seemed that our number one consulting service was palliative care. Hopefully this time is past for my emergency department, but please think about these questions now before you are doing this in a time of crisis. Please consider beefing up your medical ethics committee. There was a good article in JAMA related to this issue of the potential liability of the rationing of care  (https://jamanetwork.com/journals/jama/fullarticle/2764239).

The reality of the shortage of personal protective equipment (PPE) is another moral dilemma. Can you expect any worker in the hospital from an emergency physician to the poor housekeeper dutifully deep cleaning the COVID rooms to enter these contaminated rooms without proper safety equipment? Can we judge them if they are too scared to work? Should only staff less than sixty who do not have significant comorbidities be asked to see these patients? Should older staff members with these comorbidities be asked not to place themselves at risk? Should pregnant staff members be excused from direct patient care? The questions can be endless and I think the answers will also be drastically different depending on your hospital and your perspective. My hospital was spared the worst of this PPE shortage, except for the fact we were given one N95 mask and told we needed to use it for five days and to wipe off the gowns and reuse them. I am thinking of having my first N95 mask bronzed to have as a memento of this pandemic. Luckily, one of my partners “knew a guy” who owned a contracting company and gave us a small supply of nicer masks, which seemed to fit better. Our hospital system seemed to work miracles and we were able to obtain real respirator masks relatively quickly compared to the stories out of New York.

The other remarkable fact about these COVID profession is truly on the frontlines of a real pandemic and that our work entails real risk makes me feel two paradoxical emotions. One is pride that we are professionals who have taken an oath and are dedicated to trying to save the lives of at times an overwhelming number of critically ill patients with the realization that we are putting ourselves and our coworkers at a potential real personal risk. The conflicting emotion is a sense of humility and insignificance that in our advanced and modern medical system we can be seemingly vanquished by a tiny piece of RNA.

Please reflect on these issues even if you have not been required to face them, as the moral and ethical issues related to COVID are real and significant. Hopefully this pandemic is a generational one, but we can never be sure and should be prepared. I would ask you to consider sharing your thoughts on these or any other COVID issues. Working together as a profession can help us all deal with the stress and uncertainty of our new reality.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

<< Common Sense home page

 

Featured Articles

The Role of Quarantined Medical Students

 

Special Issue: AAEM Tales of COVID-19

Author: Jason Wang, MBS

 

I had the opportunity to recently travel to Eagle Butte, SD to work with the Indian Health Services Hospital on the Cheyenne River reservation. With limited resources and providers, I was given the opportunity to work closely with patients as a third-year medical student. My attending physician entrusted me with the responsibilities of an intern, inputting orders and creating treatment plans. As a student, I learned the necessity of calling down to the laboratory when I added another request after initial blood collection. I researched society guidelines to learn proper antibiotic dosages. It was a great opportunity to be thrust onto the forefront of emergency medicine, seeing patients, seeing results in real-time, and making clinical decisions accordingly.

This experience also proved to be quite nerve-wracking. On my first day in the ED, I was uncertain that I had put in all the correct orders, constantly double-checking my orders and plans with my attending. I poured over and reread the same articles multiple times to make sure I had memorized the correct duration of treatment for otitis media versus streptococcus pharyngitis. Falling asleep at night became more difficult, as I ruminated about each day’s decisions and whether I had mistakenly over- or under-diagnosed my patients. Fortunately, I was never tasked with the most complicated patients, but I couldn’t shake the worry.

Watching my colleagues and peers being thrust onto the frontlines in New York, Washington, and California, I am both envious and nervous. I trust that our academic preparation and clinical training. I know that we are capable of seeing patients and understanding what diseases may be afflicting them. However, I still worry that we are being thrust into positions for which we may not be ready. What happens if we overreact and place a patient under droplet precautions and unnecessarily waste PPE? What if we don’t recognize a PUI and expose healthcare professionals to the disease?

Our hospitals, and more specifically our emergency rooms, are being overwhelmed. As our healthcare professionals are drowning in this COVID-19 pandemic, I want students to step up to the calling that drew them into healthcare. I also want to caution against reaching out to whatever resources are available, especially if they can be harmful to the system. I know that we are capable, but there is definite training that we will need in order to contribute to emergency rooms. I’m disappointed that clinical rotations were suspended. Even though this was necessary to redirect personnel to direct healthcare, it unintentionally interrupted our training. This lapse has left medical students scrambling to catch up. We have missed a critical opportunity to train medical students in proper triaging skills, or as scribes for overburdened resident and attending physicians. Now, as hospitals are starting to call students back to help, I am hopeful that we will help with this pandemic and hopeful that those who aren’t returning to rotations will be spending this time getting the training to be even more effective once we finally get back into the emergency room.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

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The Sun Is Rising

 

Special Issue: AAEM Tales of COVID-19

Author: Monica Anita Gupta

 

The sun is rising with each shivering step I take.
It’s still dark out, but I see pink creeping into the blue:
spring pastels to match the canary yellow gowns inside.
Cotton candy dreams. A veneer of peace.

A flock of birds welcomes it in, nibbling,
eager for a taste of life,
thirsty for the warmth of sun.

Show me how you fly, you birds.
How, on little nibbles, you get by,
consuming little, yet soaring
long and wide and far and singing,
enthused about the dawn you’re bringing,
with faith in the power of the morning sun.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

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Featured Articles

One Month

 

Special Issue: AAEM Tales of COVID-19

Author: Stephanie Benjamin, MA MD

 

February 29, 2020
Happy Leap Day! Sitting in my backyard, listening to the birds and the wind chimes, pushing aside my ever-growing concerns about COVID-19. I checked my old journals but apparently didn’t write anything on the last leap day. Makes sense – 4 years ago I was in the midst of my intern year of my EM residency. But now, I’m more than halfway through my EMS fellowship, casually house hunting, and chats with my hubby have recently revolved around starting a family.

March 1, 2020
About to head into a nightshift. One of several emails today noted that our N95 masks are now under lock and key behind the nursing station. So many sick people. Washing my hands a lot. Hoping to not get sick…

March 6, 2020
Planted our summer garden! The usual array of squash, tomatoes, eggplants, potatoes and peppers are in, as well as a variety of herbs.

March 9, 2020
People are panicked and freaking out, spreading rumors and gossip on social media. Seems like everyone is worried, but no one is staying home. I can’t stay home, I need (and want) to keep working, but other than my ED shifts, I’m not leaving my house. I don’t want to contribute to the societal burden. Told my 70-year-old parents (who live in Manhattan), and my sister (who has 4 small kids) to hunker down.

March 11, 2020
Trying to order COVID testing is a mess. “Infection control” (not infectious disease, to be clear: infection control folks are NOT doctors) implemented a password restriction on obtaining tests. The password is only given if they (again, NOT doctors) approve the test. One of my patients arrived in respiratory distress, and met all the high-risk criteria and classic symptoms, except for recent travel to China or Italy. Infection control declined my test request. ALL requests for testing last night were declined. A co-worker hacked the system and we covertly ordered the tests anyway. It’s insane. People are going to die as a result of the ineptitude.

March 12, 2020
Between not being able to test patients, the projected number of millions infected and dying, and seeing the empty grocery store shelves, my morning began with a panic attack. I stress-cleaned the house within an inch of its life. Then I moved on to stress-cooking. I made stir-fry with a mix of homegrown and store-bought veggies. I’m calmer now, but still worried about my parents.

March 13, 2020
The constant emails and texts and online meetings are a continual source of stress. Probably should avoid social media for a while, at least until I calm down, and probably after that, too. Reminding myself that there’s nothing else I can do helps. We have plenty of food and water and toiletries and entertainment. But my mind keeps wondering if I’ll get sick. Or my family. Or my husband. It feels as if the world is pressing in on me.

March 14, 2020
The situation continues to evolve (unravel, devolve, dissolve?) into chaos. We’re still limited in the amount of testing we’re allowed to do. I’ve had over 100 emails today about COVID and am trying not to spend my day on the news.

March 15, 2020
9/11 and Katrina put me on the path to disaster medicine. In the past, I couldn’t do anything. I was helpless. Now, I’m an EM/EMS physician. I’m writing and reviewing protocols, and contributing my medical opinion on topics ranging from neb treatments to paramedicine to PPE. I can fight now. I’m not helpless anymore, yet at the same time, I feel as if I’m a pawn being shuffled around at the whim of our psychotic government. Deep breath. It’s been an emotional few days and now it’s late. I should go to bed. Need to be ready for more meetings and more bad news tomorrow.

March 16, 2020
All the bars will close indefinitely at midnight. And no dining-in anymore. At all. How surreal. What a simple thing – going out to eat. I wonder the next time we’ll eat at a restaurant. Months? Years? And I leaned that my city currently has a three week supply of masks. Seems like we’ll run out right at the peak of things. Well, who knows when the peak will be. Everything is speculative. Perhaps people will stay home, and we won’t have a peak? Ha. Yeah right. In the meantime, I’ll keep working on protocols/policies for the county and the city and doing whatever else is needed from me. This is my job. I’m here to help.

March 17, 2020
Things are changing rapidly. Time to read a bit (American Gods, by Neil Gaiman). I’ve taken to avoiding social media before bed. Any wonderful news or any terrible news makes me cry. A cartoon of superheroes looking at an ED doc and saying, “Welcome to the Club,” triggered the waterworks. The Spanish citizens who cheered from their balconies as medical staff returned home from a shift unleashed the dam as well. So far I’m keeping my shit together at work.

March 18, 2020
We had a St. Patrick’s Day online happy hour with our friends last night. Seems like everyone around the country is having similar experiences with anxiety and fear and frustration, but seeing their faces and hearing their voices was a needed reminder that I’m not alone.

March 19, 2020
The deluge is coming. I can feel it. People are on spring break, ignoring social distancing, spreading it around. People are going to die. A lot of them. A million? Less? More? My own odds: almost certain to get infected, unlikely to die. Maybe I already had it and am fine. Need to pace myself at work, not burn out. Need to be ready for the long haul. It feels like I’m in a movie, one where a small group knows what lies ahead, and everyone else in society is voluntarily/volitionally clueless. And then all hell breaks loose. We’re at that point. All hell is about to break loose.

March 20, 2020
Watching The Lord of the Rings. Needed an epic, courageous tale of heroes across the realms banding together, a reminder of hope in dark times, and the triumph of good over evil. I lost it when Pippin said, “I don't want to be in a battle, but waiting on the edge of one I can't escape is even worse.”

March 21, 2020
The thought of starting a family has slipped out of our reach. We can’t. Not now. I worry everyday about my friends that are currently pregnant. I’ve accepted who I am and what my response will be. I will work. I’ve already picked up extra shifts, and signed up to be available for backup for when others cannot work. I will accept the consequences, even if that means getting sick – though of course I will do everything possible to protect myself.

March 23, 2020
Work is terrifying. I wonder if anyone else feels his or her pulse quicken or anxiety flare when donning PPE. I felt the panic. I faced it. I cared for my patients. I don’t see how it’s possible not to get sick. Even with all the hand washing and hand sanitizing and whatnot. We all work in such close quarters.

March 24, 2020
(Remote) meetings all day. All. Day. All about COVID-19. Hospital, regional, city, county, state, and national meetings. As the EMS fellow I’m invited to join all of them, which means I learn all the concerns that everyone has about everything related to this pandemic, from limited PPE to hacking ventilator tubing to keeping EMS safe to nursing homes and prison outbreaks, to the homeless to the lack of any convincing evidence for any effective treatment. The tsunami is about to hit. I hope we’re ready.

March 25, 2020
I range between feeling okay, and abject panic. Yesterday was a rough day. Today so far is better, but if I think too much about the lack of ventilators and the exponential number of cases then I’m sure I’ll panic again. For now, staying home (as usual), and then off to another ED shift tonight.

March 26, 2020
Home from another shift, freshly showered, and disinfected. The skin on my hands, especially my right hand, is cracked and red and burning from all the hand sanitizer. The respiratory cases are increasing. Had a tricky case with one of my interns and even though we stabilized the patient, I’m still rethinking every order and every medication we gave, trying to make sure I didn’t miss something. The admitting physician commented something to the effect that it probably doesn’t matter what we did, because if the patient ends up being COVID positive, they will probably die anyway. Ouch. That doesn’t mean we don’t try! It’s 2:30am, time for bed. I’m hoping to fall asleep and not dream/nightmare about work. Again.

March 26, 2020
Trying to remember what life was like before COVID. I had recently accepted an EM/EMS faculty position at my University. I had been writing and publishing a ton. My husband and I were planning a trip to Italy. My husband and I were planning to start a family. My whole family, all in NY, was planning to visit us here in California.

I’m scraping the barrel for silver linings: We planted a large garden, which is minimizing my husband’s trips to the grocery store. Our recipes have become more creative as ingredients run out. The dogs love that we’re home more. I talk to my family a lot on FaceTime, and so far everyone is still healthy. I thank them every day for heeding my warnings to self-quarantine before NY turned into the cesspool that it is today.

March 27, 2020
PPE is spread thin. I have a single N95 per shift, but way more than 1 potential COVID patient per shift these days. The healthcare system is on the brink of collapse. Perhaps in NY it already has collapsed. Same with the economy. The government is still working against us. My friends and colleagues are getting sick. More every day. Young people are dying. A cardiology fellow died. Someone like me, right on the cusp of completing a dozen years of medical training, dead. I lost it.

March 28, 2020
Going to work feels like playing Russian roulette. I updated my will. Well, technically I didn’t update it, I wrote one. I never had one before. I’m 36-years-old. Having to write a will when you’re still paying off student loans seems unfair, even absurd. I suppose a lot of this is, though. And so much of it was preventable. So much. Help us. Please. Stay home.

March 29, 2020
Sitting in my backyard, listening to the birds and the wind rustling the leaves. It’s been a month. Everything’s changed. One day my hubby and I will revisit our plans to buy a home and start a family. Not anytime soon. My anxiety still occasionally peaks, but overall has numbed to a dull ache. I’d write more but I have to get ready for my next shift. I’ll keep working until I get sick. Until I can’t. And when I get better, I’ll go back to work and keep at it. I’m assuming I’ll recover. I should be okay, right? And perhaps this will all be under control by the summer. Or by next spring. Or perhaps by the next Leap Day.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

<< Common Sense home page

 

Featured Articles

JAFERDs Can Do It

 

Special Issue: AAEM Tales of COVID-19

Author: Elizabeth Paterek, MD FAAEM

 

It is the calm before the storm where I practice in Philadelphia (at least it is at the time I’m writing this). New York and Northern New Jersey are already struggling and I fear what’s coming next. We are poised to fight a war without adequate protection or support nationally. I want to believe that we can do it.

 


AAEM Tales of COVID-19

AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.

 

<< Common Sense home page

 

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Does AAEM Advocacy Resonate with Residents?

Issue: March/April 2020

Author: Jonathan S. Jones, MD FAAEM
AAEM Secretary-Treasurer

 

The Academy recently released a position statement on the replacement of physicians by non-physician providers at urgent care centers in the Edwards-Elmhurst health system. There was some healthy internal debate within the Academy and within the EM Workforce Committee about whether AAEM should speak out about this situation given that it involved urgent care centers as opposed to emergency departments. Do employment decisions at urgent care centers impact EM physicians? Could we have any actual influence over the decision? Do our members care about this? Are there more important things on which to focus?

Ultimately, the Academy decided that this situation was important to us and we published a statement on December 3, 2019 (https://www.aaem.org/current-news/edward-elmhurst-health).

Separately, on December 5, I was visiting the Kingman Regional Medical Center EM Residency Program in Kingman, AZ as part of the Academy’s commitment to visit as many EM residency programs as possible to explain the Academy and mission to residents. I often start my discussion by asking the audience what they know about AAEM. The first response was something along the lines of, “Didn’t AAEM just do something about doctor’s getting replaced by NPs?”

I couldn’t have been happier. (Well I suppose I would be happier if physicians weren’t replaced by non-physicians, but we’re still working on that.) While we have a template for residency presentations, I didn’t really use it at all. What followed was instead, an open, informative, sometimes scary, sometimes inspiring conversation between me, an AAEM representative, and a room full of eager and excited EM residents. It was great.

While our statement on the Edwards-Elmhurst situation may not change the decision that organization has made, it absolutely helped inform residents and Academy members. I am fairly certain that it added a few members to our Academy and even more certain that these members will be engaged and contribute to the future of emergency medicine. For that, I want to thank the EM Workforce Committee members and particularly Evie Marcolini and Julie Vieth for their leadership. Job well done.

Statement of the American Academy of Emergency Medicine (AAEM) on the Edward-Elmhurst Health Firing of Physicians and Replacement with Non-Physician Providers

The American Academy of Emergency Medicine is expressing it concerns over the recent firing of 15 physicians from the urgent care centers operated by Edward-Elmhurst Health in Chicago. The Academy represents board-certified emergency physicians, some of whom practice in urgent care settings, and most of whom receive patients sent from urgent care centers when their medical condition requires a higher level of care. Urgent care centers, while created to serve lower acuity patients, do in fact see a significant number of patients who have serious medical problems. It is well known that even a routine complaint such as a headache may be the harbinger of a life-threatening illness. We therefore are concerned by the report that these physicians were fired in a cost-cutting move by Edward-Elmhurst Health. The AAEM believes that the skills and training of non-physician clinicians requires that they function as part of a physician-led team with immediate, onsite, physician supervision. The AAEM asks that the decision to replace physicians with NPs and PAs be reconsidered. The community served must be informed and deserves a chance to be heard on the removal of these physicians. There are better ways to cut costs of health care delivery than removing the most qualified person who cares for the patient.

Approved: December 3, 2019

 

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My First “Sick” Patient

Issue: January/February 2020

Author: Alexandria Gregory, MD

 

Everyone knows the most fundamental part of emergency medicine residency is learning how to determine “sick versus not sick,” which is often easier said than done. One night, at the end of my shift, a nurse grabbed me, saying the patient in room six needed a doctor now. The patient was a young asthmatic who had apparently walked into the emergency department minutes earlier, but was now unresponsive, gray, and with an oxygen saturation in the 50s. I had no trouble determining she was sick; as a relatively new intern, the bigger problem was figuring out what to do next. To quote Michael Scott from The Office episode “Stress Relief,” in that moment, “I knew exactly what to do, but in a much more real sense I had no idea what to do.” I knew I needed to focus on the ABCs and I knew what medications the patient needed in terms of asthma management, but in the acuity of that moment, it all jumbled together. I quickly grabbed an attending and we worked through the ABCs together as the proper medications were administered and the patient stabilized.

That patient taught me several important lessons about intern year and residency as a whole:

  • You know more than you think you do, but you’re not expected to know everything. Looking back on that case, the first thing that struck me was that the nurses had enough faith in me to see this critically ill patient. Perhaps it was simply because I was the closest physician in proximity, but it still serves as an important reminder that even as an intern, people may look to you to make critical decisions. At the same time, no one expects that you have all the answers—after all, that is the point of residency. Someone should always be available to have your back and you should not be afraid to ask for help when you feel stuck.
     
  • Slow down, even when you feel there is no time to do so. Inevitably, as you start to see critical patients as a beginner, just knowing that the patient needs quick interventions will tempt you to rush. However, the best decisions are usually made when you take a step back and look at the big picture. While taking a moment to think may feel like you are wasting precious time, making the right decision for the patient is usually more important than saving a few seconds.
     
  • Your demeanor can have real impact on patient outcomes. Similar to the above, the way you handle yourself in critical moments is almost as important as the actual decisions you make. While it is natural to be flustered in unfamiliar situations as a new learner, being able to remain calm and compassionate in such scenarios is part of what makes an emergency medicine physician. Medicine, and perhaps emergency medicine especially, is unique in that our day-to-day decisions, even seemingly small ones, have direct impact on people’s lives. Mastering the way you carry yourself as you make such decisions is just important as learning the medicine itself.
     
  • Emergency medicine is a team sport. I have known this for a while, and it is part of why I chose to practice emergency medicine specifically, but cases like this are always a good reminder. When I was asked to see the patient with asthma, I was far from alone. I was surrounded by nurses, medics, respiratory therapists, and multiple attendings who came to assist. Everyone had his or her own role, but at the end of the day, we were all there to save our dying patient. While being a resident can feel isolating and challenging at times, remembering that you are part of a team with a shared goal can go a long way.

 

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Development of a Focused Designation of Clinical Practice in Ultrasound

Issue:November/December 2019

Authors: Melissa Myers, MD FAAEM and Alexis Salerno, MD

 

Emergency physicians have been an essential part of the development of Point-of-Care Ultrasound (POCUS). In the 1970s, POCUS started as part of the trauma resuscitation. Since then, emergency physicians have expanded the boundaries of POCUS to evaluate and treat a wide range of medical conditions. As early as 1988, emergency physicians began publishing on the use of bedside ultrasound in the emergency department. Within a few years, in 1991, both the American College of Emergency Physicians (ACEP) and the Society of Academic Emergency Medicine (SAEM) published policy statements regarding the utility of bedside ultrasound in the emergency department.1

Emergency physicians have also led the way in developing curriculum. The first published curriculum in 1994 by Mateer et al has led to multiple well-developed curriculums based in educational research. Today, POCUS is considered an essential skill and was recognized as such in the 2013 Model of the Clinical Practice of Emergency Medicine. Modern emergency medicine residencies include rigorous and extensive training in POCUS with graduates performing a wide array of POCUS skills to diagnosis and treat their patients.

Some emergency physicians choose to pursue ultrasound training beyond that required during residency, by completing an emergency ultrasound fellowship. During one or two year fellowships, these physicians become experts in advanced ultrasound modalities and ultrasound education. The presence of ultrasound fellowship trained faculty at residency sites correlates with a higher number of faculty credentialed to perform ultrasound and may assist with quality assurance for ultrasound performed in the ED.2 Fellowship trained emergency physicians also continue to develop new ways to improve the use of POCUS and to study best practices for use on shift.

The Society for Clinical Ultrasound Fellowships (SCUF) currently lists 50 fellowships, though this list is not exhaustive, and does not include the military programs. Until recently, there has been no established way to recognize physicians who choose to pursue this extra training or to credential these fellowships.  While some have chosen to pursue recognition through the exams offered by the American Registry for Diagnostic Medical Sonography or other similar organizations, these exams were not developed by emergency physicians and do not reflect the use of POCUS in the emergency department. As noted by Dr. Gibbons in the May/June 2019 edition of Common Sense, emergency physicians do not need these merit badges to legitimize our training.3

Following an extended debate and vote, members of these fellowships and ultrasound societies nationwide felt that attempting to establish a subspecialty board could have unintended consequences for the practice of POCUS by those who did not choose to pursue a fellowship. The alternative chosen was a “Focused Practice Designation (FPD).”

The FPD, which is approved by the American Board of Medical Specialties, “recognizes physicians who devote a substantial portion of their practice to a specific area of a specialty.”4 This will hope to recognize emergency physicians with expertise in emergency ultrasound beyond the requirements for ABEM certification. It will be a recognition developed by emergency physicians which will be specific to the requirements of our specialty. There will be three pathways to obtain this designation, the fellowship training pathway, the training-plus-practice, and the practice-only pathway.5

In the fellowship training pathway, physicians will complete an Advanced Emergency Medicine Ultrasound (AEMUS) fellowship accredited by the Emergency Ultrasound Fellowship Accreditation Council (EUFAC). The Society of Clinical Ultrasound Fellowships (SCUF) will be charged with the creation of this council. For those who do not know, the current SCUF website helps potential fellows compare various ultrasound fellowships and complete fellowship applications. In the future, the EUFAC will release regulations to obtain fellowship accreditation and a curriculum for the fellows. The curriculum will expand on the basic emergency medicine ultrasound knowledge by including advanced measurements and views. Although the curriculum has not been released yet, potential topics may include muscular tendon assessment, arterial doppler assessment or even cardiac diastology. The curriculum will most likely also cover administrative topics such as billing and workflow solutions.  

In the training-plus-practice pathway, physicians must complete an acceptable non-EUFAC accredited fellowship. This pathway will most likely be for recent emergency ultrasound fellows who graduated prior to the date of the first accredited fellowship. The physician must also demonstrate 24 months of AEMUS practice including performing or supervising 300 studies per year and reviewing for quality assurance 500 studies per year. This pathway will only be available to physicians for five years from the date of the first EUFAC-accredited AEMUS fellowship. Those who are considering applying for this pathway, may wish to start logging ultrasound scans and QA’ed studies.

In the practice-only pathway, physicians must demonstrate 36 months of AEMUS practice with 300 performed or supervised studies and 500 reviewed studies. In addition, physicians will have to demonstrate additional knowledge in the area by prior work in leadership administration, publications, or teaching. This pathway will most likely be for more senior faculty that continue to have a strong interest in ultrasound. And just as in the training-plus-practice pathway, this will only be available to physicians for five years from the date of the first EUFAC-accredited AEMUS fellowship.

Physicians who meet the eligibility criteria will also need an appropriate verifier who can confirm the physician has the hand-eye-motor coordination to perform ultrasound tasks. Finally, physicians will be able to take a multiple-choice examination to gain FPD. The first exam is scheduled to be offered in 2022.

Through these pathways, emergency physicians who devoted significant time and attention to practicing point-of-care ultrasound will be able to obtain recognition of their expertise. This exciting development will likely continue to evolve over the next few years as ultrasound societies nationwide work together to develop the exam and fellowship credentialing guidelines. To keep updated on the progress of the AEMUS FPD check out the SCUF website at eusfellowships.com and don’t forget to check out EUS-AAEM newsletter, the POCUS Report.

References:

  1. Kendall, J. L., Hoffenberg, S. R., & Smith, R. S. (2007). History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Critical care medicine, 35(5), S126-S130.
  2. Das, D., Kapoor, M., Brown, C., Ndubuisi, A., & Gupta, S. (2016). Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States. Critical ultrasound journal, 8(1), 6.
  3. Gibbons, Ryan. “Emergency Ultrasound Merit Badges...There’s No Need.” Common Sense, May/June 2019.
  4. Focused Practice Designation. Focused Practice Designation | American Board of Medical Specialties. https://www.abms.org/board-certification/focused-practice-designation/. Accessed August 18, 2019.
  5. Advanced EM Ultrasonography. American Board of Emergency Medicine. https://www.abem.org/public/become-certified/focused-practice-designation/advanced-em-ultrasonography. Accessed August 18, 2019.

 

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Queuing Patients in the Emergency Department: Can It Work?


Issue: September/October 2019

Authors: Andrea Blome, MD

 

What is queuing theory?

Queuing theory originated more than a century ago from the study of telephone delays and congestion. A simple queue is defined by a stream of arriving customers or tasks that are handled by a server. The goal of queuing models is to eliminate the disparity between the demand for service and the capacity to meet that demand. The concept is used in many service industries to strategize how to improve efficiency.1  For instance, a grocery store that struggles with long lines for check-out could add an express lane for customers with smaller amounts of items to reduce waiting time overall. In addition, call centers for customer service have used technology to improve caller wait times with the ‘virtual queue,’ which keeps the caller in line, but calls the customer back when the agent is free.2

How does it work in the ED?

In the emergency department (ED), decreasing patient wait times is vital. Increased wait times lead to delayed diagnosis, poor patient satisfaction, and increased morbidity and mortality. The ED can be simplified to a ‘multiple server, single phase’ queue, in which patients wait in one line (the waiting room) for servers, including the triage nurse, the bedside nurse, and the physician.3

In health care, queuing calculations are generally based on patient arrival rate, service rate (time for exam, tests, treatment), and the number of servers (number of providers and ancillary staff).4 Most models use the Poisson arrival process, which assumes patients arrive according to a random process. Arrival and service times can vary based on the time of day, the season, etc.1

In the ED queue, interventions should focus on either reducing the server utilization or reducing variation. To reduce server utilization, the rate of service can be increased, with the goal of identifying wasteful elements and reducing or eliminating them. To reduce variation in service, the alignment of the staffing should first match demand before adding additional servers to the system. By predicting the average distribution of patient arrivals by hour, the staffing model can be adjusted to have more servers during high demand times.1 To reduce variation, the variation in arrival and/or the variation in service should be decreased. Reducing variation in arrivals can be difficult, as not much can be done to impact the timing of emergencies. Variation in service is usually related to issues of process, layout, supplies, equipment, and supporting services. For instance, a laceration repair might take longer if supplies are not readily available and stocked in the room where the procedure is being done. Even small adjustments to these issues can reduce service variation.1

Figure 1: Opportunities to Reduce Variation5

 

Can it work?

Queuing theory can be used to predict the effect of patient arrivals, treatment time, and ED boarding on the patients who leave without being seen (LWBS). One institution used a queuing model to analyze the ED flow model currently in place and found that a queuing model was able to predict the variation in patients who LWBS.6

Lehigh Valley Health Network in Pennsylvania took the theory one step further. The institution used a queuing model to identify that the ED was understaffed during peak hours and overstaffed during non-peak hours. After aligning resource capacity with hourly demand, the hospital saw a reduction of length of stay by 20% and reduced walk-out rates by 58%.5

Figure 2: How to Implement Queuing in the Emergency Department

 

  • Determine patient arrivals/hour
  • Understand the server staffing model
  • Match patient demand with staffing
  • Reduce service variation
  • Analyze patient wait times/LWBS rates

 

ED’s are complex, especially in large, academic teaching hospitals. Relying solely on averages to determine forecasts can certainly affect the model. Accounting for residents and medical students in the formula can also impact predicted outcomes. However, queuing models can and should be considered in ED’s in order to improve efficiency and decrease wait times.

References:

1 Crane, Jody, and Noon, Chuck. “The Definitive Guide to Emergency Department Operational Improvement.” CRC Press, 2011, (119-145).

2 Kulbyte, Toma. “5 ways to manage (and reduce) your customer service queues.” November, 2018. https://www.superoffice.com/blog/customer-service-queues/.

3 “Introduction to Queuing Theory.” What is Six Sigma? https://www.whatissixsigma.net/queueing-theory-introduction/.

4 Chowdhury, Naser, et al. “Using Queuing Theory to Reduce Wait, Stay in Emergency Department.” Sept 2018. https://www.physicianleaders.org/news/queuing-theory-reducing-wait-stay.

5 Hu, Xia, et al. “Applying queueing theory to the study of emergency department operations: a survey and a discussion of comparable simulation studies.” Intl. Trans. in Op. Res. 25 (2018) 7–49 DOI: 10.1111/itor.12400.

6 Wiler, JL, et al. “An emergency department patient flow model based on queueing theory principles.” Acad Emerg Med. 2013 Sep;20(9):939-46. doi: 10.1111/acem.12215.

 

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A Sad But True Story


Issue: July/August 2019

Authors: Andy Mayer, MD FAAEM

 

The issue of the appropriate role of advanced practice providers (APPs) in our emergency departments has been recently analyzed by a task force of AAEM and a new position statement has been approved. AAEM recently published this position statement and AAEM and this editor also submitted contributions to other emergency medicine publications (EM News, April, 2019) related to this issue. Common Sense has recently been contacted by a member of AAEM related to the impact of the increasing use and role of mid-levels in our emergency departments.

This member has recently been told by the new contract management company which took over her hospital’s emergency department staffing contract that there would no longer be any shifts available for her and the other part-time physicians, as the company would be bringing in midlevel providers to take these shifts. Common Sense thought an interview with her would be a good way for our members to understand the risks to our practices by the expanded use of midlevels. Will we be replaced by Doctors of Nursing Practice (DNPs)?

Andy Mayer, MD FAAEM
Editor, Common Sense

 

Dr. Mayer: So, please tell us a little about yourself, where you went to school, your path to emergency medicine and training.
MEMBER: I am an emergency physician in Louisiana. I went to LSU Medical School in New Orleans, and originally wanted to be a pediatrician. During my third year of pediatric residency, I did a rotation in a pediatric ED and loved it. It was then that I decided to do EM. My initial plan was to do Peds EM, but when I did a second residency in emergency medicine, I found out that I really like adults too!

Dr. Mayer: How did you end up in in practice in Louisiana?
MEMBER: I am from Louisiana and I decided to stay home to be around my family after residency. My first real job was with my current hospital system, and have been with them for around 15 years (other than a brief time at another local hospital to help them start their pediatric ED).

Dr. Mayer: Tell us about the group you joined and the working conditions.
MEMBER: The physician group here has been great to be a part of for many years. It really has been a family-type of atmosphere. We have over 30 ED physicians, and have been providing good care in our region. In fact, we are the only hospital in our area with all board certified emergency physicians working in our emergency departments. I went to parttime work when my daughter was in kindergarten, and she is in 4th grade now. I was an older mom, and wanted to enjoy being a mom. I could be flexible and work more when there was a need and could work less when needed less. Interestingly as a side note, part-time work has been advocated as one avenue to help physician burnout, and I agree. Being part-time has helped me enjoy work more.

Dr. Mayer: Your group sounded great and a place many of us would have been proud to work with. Please tell us what happened? How did the changes to your group by the new contract holder affect you and the other board certified emergency physicians working there?
MEMBER: The hospital was in the process of rolling out a new contract for the ED physicians. In fact, I had just signed the new contract two weeks before that day in August when we were told on a group text that an outside contract management group would be taking over our contract effective November 1. We were blindsided. It was a surprise even to the directors. The corporate management group said that the pay would not change significantly. They gave the staff information on new changes in March.

One change they planned on implementing was to bring on advanced practice providers. Board certified emergency physician hours would be decreased to make room for these midlevel providers. I was told that this was because the labor cost for these midlevel providers was cheaper. This meant that the part-time doctors would no longer be needed as their shifts would be filled with the midlevels, and many of the full-time doctors would have their hours cut. We were all board certified emergency physicians, most with 19+ years of experience. One has been a loyal ED doctor in our system for almost 40 years. Many of us are doctor moms (who work full-time at home, too). Others are also employed at our VA hospital and supplement their income for their families with part-time shifts at our hospital. No more work for us in the hospital system we have been serving for years. We will not be needed, as non-doctors will be replacing us on the schedule.

My residency advisor, who is now one of the administrators at the CMG, had to tell me in April (ironically the day after Doctor’s Day) that there will not be any more shifts for me or the other part-time doctors when the APPs will be implemented. I told her that it stinks. She said it was business. So emergency medicine is just down to business now. How will patient care suffer? I do understand the business part, but replacing doctors with non-doctors is not right. Also, the physicians who remain with the system will be required to work with APPs. It would be different if you have
a midlevel provider in an office setting, where you can hire and train them to work as you do. However, in the ED there are so many different doctors
to work with and different individual approaches to patient care. The ED doc has no voice in whom to hire or who they will work with on shift. They can be required to work with them even if they would have treated a patient differently, and this opens the physician up to more risk of litigation. True point, there are now malpractice lawsuits where this has happened and the doctor was sued — and lost.

Dr. Mayer: Where are you working now?
MEMBER: I still love emergency medicine. I am blessed to be in a field where I can work on a part-time basis. I have been working some at our
VA and in rural emergency departments lately. The work is good, and I have time to talk and visit with my patients. For Doctor’s Day, the rural hospital gave all the docs a nice engraved mug with candy. (I was told that even the pharmacists were involved in helping with the Doctor’s Day gifts!) That is definitely a different experience. Yes, there is a physician shortage in the rural areas. Part of the solution was to have midlevel providers in these areas. Weren’t they originally started as an entity to help doctors, not to replace them? Ironically, they are taking my job in the city, and now I drive out to the rural areas to work.

Dr. Mayer: Tell us what you are looking for and what message you have for your fellow emergency physicians in this changing work environment.
MEMBER: Please know that there are many advanced practice providers who I think are excellent — and they can be of great assistance to doctors in many fields. However, I do not think they should take the place of a board certified physician in the ED just because they are less expensive labor. Less expensive does not always equal similar quality. Would construction companies stop using steel to make buildings because it is too expensive? They might use aluminum because it is cheaper, and looks the same, but there will be detrimental long-term effects.

I have contacted ACEP and AAEM — it would be great if our societies could work together on this issue. Do board certified emergency physicians want full independent practice for advanced practice providers at the risk of making ourselves obsolete and diminishing patient care? If we can be replaced by a nurse with an online degree what message would that send to the medical students and emergency medicine residents who are spending years and huge sums of money to reach the goal of board certification? Does this mean that our training is not that important during medical school and residency? Do the number of hours required to become a midlevel compare in any way to the sacrifices required to become an actual emergency physician? The depth of knowledge is not the same. The recent exponential rise of online NP programs with their clinical hours of shadowing doctors should not replace the years of clinical training and experience of a physician, but it has. They use our education and board certification and dilute its value. How can I recommend to my pre-med niece to be an emergency physician, when we are so easily replaceable? Also, how could it be recommended to be ABEM board certified, to jump through all of the hoops we have to, like MOC, when someone who has DONE NONE OF THIS can take your job?

My message to our ED docs is this — we need to be proactive with our contracts because our jobs and patient care are at stake. We might talk to our anesthesia colleagues, as they have been working against full independent practice of their APPs/CRNAs for years before us. We need for the public to be aware of this shift in medical care so they can have a voice in who treats them in the ED. We could refuse to cosign charts of patients we have not been consulted on, or chart a disclaimer that the patient was not independently evaluated by the MD while they were in the ED. We need for ACEP and AAEM to help speak for physicians who are afraid to do so on this issue for fear of job loss. The contract management groups have become too powerful, but we also need to realize this is not just a CMG problem. It is also going on in academic centers, hospital based departments, and smaller partnership groups. We also need to become more business oriented, maybe depending less on CMGs and more on working together with administration to form our own groups. I understand that it is a business, but our patients should be the first priority. In a post from April, Dr. Edwin Leap talked about things we can do as physicians to improve our situation and satisfaction. He said, “I hope that over time we can push back, steadily, against bad ideas. ...To start by calling them out in the light so that physicians aren’t bullied into thinking that they’re alone, or that they’re complainers. Shine the light on the demons and they scatter. And look smaller than we thought when we stand together.”

In Louisiana, we love our Saints football. To use a football analogy, we don’t need another blown call while those with the power to change things look away and say “It’s not my problem.” This is a blown call for patient care in the ED. Our founding EM physicians fought hard to make our specialty separate and valuable for patients in emergency situations, not to give our specialty away to the lowest bidder. Job security is a thing of the past.

 

Editor's Note

The really sad truth of this whole story is the courage it took for this emergency physician to come forward to share her story. When did we subjugate the
practice of medicine to corporate management groups and hospital administrators? There are many emergency physicians who have been adversely affected by the increasing role of mid-levels working in our nation’s emergency departments. AAEM cares about this issue and wants to hear your story. AAEM has created a form where you can submit ways the increasing role of advanced practice providers has affected you. We want to hear your stories and we understand if you want to be anonymous. The fear of retribution by CMG’s and the like is sadly a real and increasingly oppressive force in modern emergency medicine. AAEM wants to clarify the role of mid-levels in our emergency departments and support the practice of emergency medicine led and controlled by board certified emergency physicians. Please submit a concern or send a letter or comment to the editor. Submit a concern here: https://www.aaem.org/get-involved/committees/committee-groups/em-workforce.

— Andy Mayer, MD FAAEM
Editor, Common Sense

 

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Getting Off the Ground: Developing an ED Patient and Family Advocacy Council to Improve Patient Experience


Issue: May/June 2019

Authors: Jonathan D. Sonis, MD; Maryfran Hughes, RN MSN NE-BC; Cassie Kraus; Robin Lipkis-Orlando, RN MS NE-BC; Linda Kane, MSW LCSW; Benjamin White, MD FAAEM

Patient experience continues to be a growing area of focus for hospital and emergency department (ED) leaders across the United States.1, 2 Despite this, existing avenues of obtaining accurate data regarding the most critical drivers of ED patient experience are limited and, importantly, largely missing the perspective of patients and family members themselves.3 While many U.S. EDs employ a postvisit survey tool (i.e., Press Ganey, Healthstream, QDM, and others), survey data may be limited by poor response rates, non-response bias, and restricted by the scope of the responses reported.4

To address the critical need for patient and family member input in improving patient experience, Patient and Family Advocacy Councils (PFACs), which include both invited patients and family members and selected staff, have been employed at the hospital and specialty level with increasing frequency over the past decade. In early 2018, recognizing a void of the patient’s voice in our own ED patient experience improvement efforts, we set out to create the first-ever ED PFAC at Massachusetts General Hospital.

Planning and Staff Recruitment

The first step in developing the ED PFAC was ensuring that stakeholders from all branches of the department’s leadership were supportive of the concept and would be willing to devote time and resources to the project. Early on, the ED Nursing Director, ED Clinical Director, and Executive Director all recognized the value in forming such a council and agreed to participate. Given the need for experience with PFAC formation, we also reached out to and gained the support of the director of our hospital’s Office of Patient Advocacy (OPA), who provided not only invaluable expertise and support, but also a source of potential participants.

To create balance within the group, it was decided that the PFAC would be co-chaired by a nurse (ED Nursing Director) and a physician (ED Administrative Fellow) with plans to also include a representative from ED Administration (Administrative Manager for Quality and Process Improvement) and the OPA (Advocacy Representative), as well as the ED Clinical Director.

Patient and Family Recruitment

Based on recommendations from the OPA, we sought to have an approximate one-to-one ratio of patients and family participants to staff participants in our PFAC. Therefore, five patient and family participants were sought out. Three participants were identified by the OPA as they had expressed interest in joining a PFAC and had experienced several episodes of care in the ED. Another two participants were identified directly by the PFAC co-chairs through communication following ED visits. Finally, a sixth patient participant who had already expressed long-term interest in supporting ED patient experience improvement efforts was asked to join the group. All participants were interviewed prior to being selected to participate on the council.

First Meeting Logistics

An initial meeting was scheduled for January 2019 after consulting the schedules of each participant. The agenda for the initial PFAC meeting was developed by the co-chairs with assistance and feedback from the OPA with the goal of introducing all participants and providing a general “lay of the land” of the major challenges facing our ED as well as existing solutions. This included a brief explanation of the PFAC’s development and the importance of patient and family perspective in improving ED patient experience followed by participant introductions, a brief summary of ED statistics and a demonstration of previous and current patient experience improvement efforts. While a formal agenda was utilized, extensive discussion among participants occurred throughout the meeting.

Challenges

A key challenge throughout the planning and recruitment process was ensuring that the resulting group was diverse and as representative as possible of the population served by our ED. In particular, we found it more difficult to recruit younger participants than retirees, who often expressed increased time flexibility compared to their working counterparts. Ongoing recruitment efforts will focus particularly on underrepresented groups.

An additional challenge revolved around management of the meeting itself. Because all participants were eager to share their experiences and personal interests, some group members were more vocal throughout, at times making it challenging for others’ voices to be expressed. Moving forward, each meeting will begin with a summary of meeting expectations, including adhering to time limits and avoiding interruption.

Lastly, maintaining momentum and enthusiasm throughout the PFAC group will continue to be a challenge, both for patient and family participants and for staff. We plan to schedule meetings quarterly for the first year in order to continue to build momentum, with the option of decreasing frequency to three times annually in the second year.

While it is too early to determine whether the formation of the ED PFAC will lead to quantitative improvement in ED patient experience, initial feedback has been universally positive, with patients, family members, staff, and departmental leadership enthusiastic about the promise of gaining the patient and family member perspective in our ongoing patient experience efforts. Despite the challenges in providing excellence in patient experience in the ED, this relatively low-effort, low-resource project has the potential to bring significant and longstanding improvement for our patients and their families.6-8

References

1. Emergency Department Patient Experiences with Care (EDPEC) Survey. Accessed via: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/ed.html, January 2019.

2. HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems. Accessed via: http://www.hcahpsonline.org/, January 2019.

3. Working with patient and families as advisors (Implementation Handbook). Agency for Healthcare Research and Quality. Accessed via: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf, January 2019.

4. Tyser AR et al. Evidence of non-response bias in the Press-Ganey patient satisfaction survey. BMC Health Serv Res. 2016 Aug 4;16.

5. Massachusetts General Hospital 2017-18 Patient and Family Advisory Council Annual Report. Accessed via: https://www.massgeneral.org/patientadvisorycouncils/assets/pdf/2017-18-massgeneral-pfac-annualreport.pdf, January 2019.

6. Welch SJ. Twenty years of patient satisfaction research applied to the emergency department: a qualitative review. Am J Med Qual. 2010;25(1):64-72.

7. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15(9):825-831.

8. Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg Med J. 2004;21(5):528-532.

 

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Why Did AAEM Take a Stand Against APP Independent Practice?

Physician members of the American Academy of Emergency Medicine have voiced concerns about the use of advanced practice providers (APPs) in the emergency department and their push for independent practice without the supervision or even availability of a physician. The task force spent hours discussing the issues, comparing the education of physician assistants, nurse practitioners, and board-certified emergency physicians, speaking to physicians about their concerns, and examining the literature. (J Emerg Med 2004;26[3]:279; Acad Emerg Med 2002;9[12]:1452; J Emerg Med 1999;17[3]:427; Acad Emerg Med 1998;5[3]:247; Ann Emerg Med 1992;21[5]:528.)

Most emergency physicians have worked with APPs and appreciate that they are talented clinicians who improve emergency department flow, efficiency, and quality of care under the guidance of the emergency physician-led team. Many emergency physicians are aware of situations that place APPs in clinical environments that are beyond their capabilities, level of training, and even scope of practice. This is not the quality of care our emergency patients deserve.

There is a vast difference in the clinical training of APPs compared with EPs. Some APP training programs require only 500 hours of unregulated, supervised clinical experience before graduating, while physicians must complete approximately 4,000 hours of clinical experience during medical school and an additional 8500 hours of highly regulated and supervised training as an emergency medicine resident before entering independent clinical practice. (J Emerg Med 2015;48[4]:474.)

APPs do have a valuable role in many emergency departments, but their skills should be used as part of a team led by an ABEM/AOBEM emergency physician. APPs as members of that team should fill a role clearly defined by the emergency physicians in that department which professionally stimulates the APP and results in quality care. The cost of employment is lower for APPs than for EPs. As increasing patient volume drives increased need for coverage, the potential for increased profits grows if APPs replace EPs. The delivery of safe, expert physician-led care to every patient must be the primary factor when making staffing decisions, not profit.

The physicians staffing an emergency department are best capable of determining the needs of their department. Physicians should not be told by management that they must use APPs who have been hired for them. Rather, they should decide how many APPs they need and hire only those candidates who have the expertise and personality to mesh well with the culture of their emergency department team.

We are aware of situations where EPs are expected to supervise three, four, or even five APPs while simultaneously seeing patients primarily. The reality of those situations is often that the EP has only a cursory knowledge of the patients that the APP sees and little or no time to evaluate those patients independently. If defined patients and scenarios are deemed safe for the patient to be seen by the APP with the supervising physician providing only guidance and backup, then a bill should not be sent in the physician’s name. We support meaningful patient care by the physicians who are billing for it and transparency to patients. A signature in medicine implies that the signatory attests to the accuracy of the document. Without direct evaluation of the patient, how can one know the accuracy of the document?

Emergency medicine residency is a time for physicians to learn how to practice their profession. Residents should be trained by those who practice the profession in which they are seeking board certification. In a situation where APPs are practicing alongside EM residents, it is imperative to establish processes so that the training of the EM residents is not compromised. Residents need to complete a certain number of procedures to become competent. Attaining these skills should be a priority, and the residents should be the first priority to perform a procedure to become independently skilled.

It is challenging, if not impossible, for a patient to determine the role of all the people with whom they interact in the emergency department. Patients can easily be misled by non-physicians using the term doctor. They should not be expected to understand the difference between an MD or DO and a DNP or DScPAS (doctorate of science in PA studies). Patients deserve full transparency about who is caring for them, and non-physician clinicians must truthfully represent their level of training.

Throughout its history, AAEM has consistently asserted that ABEM/AOBEM certification is essential. The academy has also spoken against emergency departments staffed by non-ABEM/AOBEM physicians. Supporting the independent practice of APPs in our emergency departments is inconsistent with these core values. If APP independent practice is tolerated, a logical profit-driven next step is staffing entire emergency departments with APPs and even developing staffing companies to provide that coverage.

Our specialty owes its identity to our founders who demonstrated that the skills required to manage an emergency department expertly were unique in the house of medicine. They struggled to establish the specialty of emergency medicine and define the training required to become a specialist in emergency medicine. The independent practice of APPs has the potential to undermine all the efforts of those men and women who created the specialty of emergency medicine.

©2019 Wolters Kluwer Health, Inc. This article first appeared in Emergency Medicine News, and is reprinted with permission. www.em-news.com.

 

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Highlights for Scientific Assembly 2019

Don’t Miss the Keynote Speaker

We could not be more excited for Scientific Assembly 2019 in Las Vegas. Don’t gamble on missing any of the opportunities to meet with your colleagues
from across the country and hear some of the latest scientific material from your favorite speakers and some exciting new talent. Our ,keynote speaker this year, Matthew Wetschler, MD will share his perspective on life and career. Matthew is an emergency physician, artist, and former professional athlete who drowned and suffered ten minutes of cardiac arrest. Even though he has sustained right-sided weakness, he has developed his artistic talents, and works to explore our relationship with limits, edges, and the space beyond. We are looking forward to his message.

Come Early: Pre-Conference Opportunities

Our pre-conference sessions will include the ever-popular ultrasound, resuscitation, ECG, and LLSA reviews, as well as Medication Assisted Treatment (MAT) waiver training and a session on military hemorrhage control. New this year will be a Written Board Review Boot Camp, for those of you taking the ABEM exam in April, and AAEM will jointly provide a teaching program with the Teaching CoOp, for those of you looking to brush up your teaching and presentation skills.

Back by Popular Demand

This year — back by popular demand — we will double the number of highly popular hands-on small group sessions. Our plenary speakers will cover the latest knowledge on cardiology, sepsis, trauma, resuscitation, critical care, and neurology. Also by popular demand, we will have the Airway Storytelling session, hosted by the unstoppable Billy Mallon. There will be many other events to participate in, such as Open Mic, Resident and Student Research Competition, WestJEM Competition and the RSA sessions. The Wellness Committee has some fun plans, including a new attendee welcome and a coffee crawl for you early risers.

New Panel: Patient as Educator

On Tuesday, the AAEM Scientific Assembly Subcommittee is delighted to announce a pilot format featuring patients as the educators in a session entitled: “Oncology Patient Perspective Panel.” In some diseases, there is no better way to learn about “best practice” than to hear from the patients themselves and see the emergency department (ED) encounter through their eyes. In this session, Dr. Jack Perkins (FAAEM) will serve as the moderator, and the panel will consist of oncologist Dr. Jennifer Vaughn, her patient Mr. Ben Bane, and the wife of her late patient Mr. Jason Price. Both Mr. Bane and Mr. Price spent dozens of hours in the ED with neutropenic fever, various chemotherapy complications, and other oncology related issues. Mr. Bane and Mrs. Susan Price will discuss details of their ED encounters in terms of what went smoothly, as well as opportunities for improvement. Dr. Vaughn will provide insight and expertise in a discussion of optimal collaboration between the emergency medicine provider and the patient’s oncologist.

This session will introduce a new “patient as the educator” format for educational sessions that may be utilized for future scientific assemblies. We will cover best practice in evaluation of neutropenic fever, optimal ways to initiate goals of care or end of life discussions, and the critical importance of collaboration with the patient’s oncologist regardless of the perceived severity of the presenting complaint. Please come to hear this engaging panel where the patients will give us their perspective. We guarantee it will be insightful and valuable.

Join Us!

Because we will be in Las Vegas, you will also have easy access to flights, and the opportunity to take in a show or maybe even practice your card shark skills. Don’t play the odds — join us for some of the best emergency medicine education and a great time!

Read the full feature article here!

 

Featured Articles

Tattered Tarp or New Roof: Who Gets Included in Disaster Recovery?

In the bend of the south Texas coast, a community comes together to reflect on a year gone by since many lost everything. We danced in the streets, honored one another’s hardships and congratulated each other’s resilience, and I reflect on my own experience.

The last move my husband and I made before evacuating with our toddler and seven month- old was to throw an anchor from our sailboat, sitting on its trailer, in the front yard, a hundred feet from the water’s edge. “Maybe that will keep her from surfing into the neighbor’s second story living room,” my husband half-heartedly joked as he climbed into our small RV, wet from the first bands of the storm blowing ashore. At 5:30am, we left our home, driving in 20-minute shifts, exhausted from a day and a night of increasingly frantic preparation. Less than 12 hours later, the eye-wall of Hurricane Harvey made landfall directly on our small hometown of Rockport, Texas.

We returned to “The Charm of the Texas Coast” two days after the storm. Half of the structures were damaged beyond repair, the electrical grid was a tangle of wires and snapped poles, there was no running water, and overnight there was a new homeless population. The nearest hospital was destroyed and the majority of doctors’ offices closed due to damage. Rockport (Aransas County), Texas, was already designated a Medically Underserved Area. Like so many coastal communities, it is a glaring example of wealth inequality and social stratification; vacation homes and trailer homes. The storm’s destruction exacerbated an already failing safety net of health care and left our vulnerable population struggling with added mental and physical stress, financial devastation, and decreased access to primary care resources. It was obvious that the community needed a local medical response. After a short and self-guided course on legal protections for volunteer medical professionals in disaster zones, approval from the city Emergency Manager, and crucial support, both on the ground and remote, from a small group of graduates of the Latin American School of Medicine, I founded the Rockport Strong Mobile Medical Unit (RSMMU). For four months, RSMMU served as a pop-up urgent care clinic, staffed with volunteer physicians, nurses, and community health workers, operating out of the same RV in which my family had evacuated. Working alongside Emergency Management and FEMA, we provided free medical attention to over 400 patients.

Our team conducted a survey analysis to determine some characteristics of the population seeking our services. Some of the more important questions we asked our patients were if they had a primary care provider (61.5% reported they did not) and if they had health insurance (68% said no). And to the question, “Do you use the ED as your primary care provider?” 34% said they did. Of note, 74% of patients reported negative effects of the storm on their physical and/or mental health. The stories of the people represented in these figures were just as disconcerting: “I lost everything. I didn’t qualify for assistance. I don’t have a spare dollar to my name. My house is molding. I can’t afford my prescriptions.”

A year later, tattered blue tarps fail to cover the holes in roofs spaced throughout the community. Whose roof, though? Well, this is a diversity and inclusion column, so I bet you can guess. First, let’s talk about disaster vulnerability and how social conditions and location lend to the potential for greater harm to some social groups during a disaster and in the immediate aftermath. Social class factors force the poor to live in substandard housing, often located in physically vulnerable areas such as flood zones and in proximity to industrial sites, and reduce the ability to undertake loss-reduction measures (boarding windows, stockpiling supplies). In the U.S., race and ethnicity are strongly correlated with social class and are also associated with increased vulnerability to disaster.1

In the intermediate phase of disaster recovery, the same differential presents itself. Research conducted in the months following Hurricane Harvey found that the population affected differs by geography, race/ethnicity, and income, the largest impact felt by Blacks, Hispanics, and those with a self-reported income <100% FPL.2 Loss of income and employment disruption had a larger effect on Hispanic, Black, and lower-income residents. Among those with home damage, low-income, Black and Hispanic residents were less likely to have had insurance. Blacks and low-income residents also reported in higher percentages that they were not getting the help they needed. Language barriers arose as a contributing factor to sluggish recovery. Three in ten individuals answering a survey in Spanish reported that it was very or somewhat difficult to find information in Spanish regarding recovery assistance. The study also conveyed that undocumented migrants are particularly vulnerable to the effects of natural disasters, in part out of fear of exposing themselves or family member’s immigration status, and in another part due to ineligibility for benefits.

Now let’s look at long-term recovery and what has recently come to light. A study published in August (2018) concludes that wealth inequality increases along the lines of race, education, and home ownership in counties badly hit by natural disasters.3 In areas with at least $10 billion in damages, Black, Hispanic, and Asian communities saw their wealth decrease by an amount between $10,000 and $29,000, while white communities increased their wealth by an average of $126,000. The study suggests that the money follows the higher levels of reinvestment via infrastructure improvements and low-interest loans after a disaster occurs, as more privileged residents gain access to new resources. Meanwhile, low-income and non-property owners are more likely to experience financial strain from losing one’s job, moving, paying higher rents due to housing shortages, and depleting savings trying to compensate. Contrary to an often repeated myth, this data does not support the idea of disasters being “great equalizers.” It does however bring attention to the fact that for some people the resources which flow into disaster zones can be a silver lining to a universally bad situation. I witnessed this in Rockport as it became a temporary boomtown for construction contractors, clean-up crews, and donation sites across town. The issue is that the silver doesn’t seem to be making it into all folk’s pockets, especially for people of color.

What can we do? Disasters are great disruptors, and where there is disruption, there is room for innovation. After Hurricane Mitch slammed Honduras in 1998, Cuba responded by founding an international medical school, The Latin American School of Medicine (Escuela Latinoamericana de Medicina), designed to train doctors from lesser developed countries, mostly people of color, who would return to their medically underserved area when they graduate so that these communities would be healthier and more prepared for disasters in the future. This plan obviously took a very long view of disaster response, as the first graduates would have returned home some seven years after Mitch made landfall. It’s an example of a long-term disaster response that promotes inclusion and diversity in terms of both the medical profession and access to health care. The free mobile clinic in Rockport was a much= smaller and shorter-term response, but was still a successful innovation that brought resources to a medically underserved disaster zone. It is a model that can easily be recreated when the need presents.

The scientific community warns us that our warming planet will make high-magnitude weather events like hurricanes Katrina, Harvey, and Maria more frequent over the coming years. What does this mean for the health of communities of color exposed to these forces of destruction? Unfortunately, if disaster recovery maintains the pattern of reinforcing gaps in wealth along racial lines and the strong correlation between socio-economic status and individual health is also maintained, it’s likely that the health of communities of color will disproportionately suffer. While the issues are systemic, there are roles that individual physicians can take to immediately address some of the social determinants of health at play in post-disaster communities. Here are three suggestions:

  1. Set up a free clinic or volunteer to staff if one is already operating.
  2. Consider in-kind donations of medical equipment.
  3. Get involved with Emergency Management and advocate for the funding of programs that will improve access to health care (a community health center, for example).

Innovate. We need to change the trajectory of who gets to recovery from a disaster. The resilience and diversity of our communities depend on it.

References:

1. Tierney, Kathleen. (2006). Social inequality, hazards, and disasters. On Risk and Disaster: Lessons from Hurricane Katrina. 109-128.

2. Hamel, L. et al. (2017). An Early Assessment of Hurricane Harvey’s Impact on Vulnerable Texans in the Gulf Coast Region: Their Voices and Priorities to Inform Rebuilding Efforts. Kaiser Family Foundation and Episcopal Health Foundation. http://www.episcopalhealth.org/files/7315/1240/4311/An_Early_Assessment_of_Hurricane_Harveys_Impact.pdf

3. Junia Howell, James R Elliott. (2018). Damages Done: The Longitudinal Impacts of Natural Hazards on Wealth Inequality in the United States, Social Problems, spy016, https://doi.org/10.1093/socpro/spy016

Featured Articles

Highlights of AAEM's Legal Advocacy for Emergency Physicians

In the 25 years since AAEM’s founding, the Academy has been very active in advocacy and legal efforts on behalf of individual emergency physicians and independent groups. AAEM continues to be the only emergency medicine (EM) professional society ever to take legal action against contract management groups (CMGs) in defense of emergency physicians. The Academy’s willingness to put the interests of individual emergency physicians over corporate interests has had a major impact on our specialty.

Corporate Practice of Medicine

Catholic Healthcare West (CHW) and Emergency Physician Medical Group (EPMG)

In 1997, CHW, one of the largest hospital chains in the country, announced the purchase of EPMG, a privately held emergency medicine (EM) group. For the first time, a large hospital system had taken over a large EM group, converting hundreds of private prac­tice emergency physicians into hospital employees. The $36 million purchase price was to be recouped by CHW from revenue taken from the professional fees of those emergency physicians. EPMG’s principal owners earned millions of dollars on the sale, and were then given jobs in the new CHW managed services organization, Meriten, which was essentially a contract management group. All current EPMG physicians — staffing eight of the 37 CHW hospitals — immediately became part of Meriten. Even more concerning, the independent emergency physician groups staffing the 29 CHW hospitals that were not part of EPMG were to be forced under the control of Meriten, which planned to take a 28% fee from its emergency physicians’ fees for expenses and profit.

With 29 contracts at risk, the regional implications were profound. AAEM also recognized national implications, as every large hospital system would see the opportunity to control and profit from their emergency phy­sicians. After AAEM wrote letters of concern to the board of CHW, CHW in turn threatened AAEM. Undeterred and with AAEM’s help, the practic­ing emergency physicians of CHW organized into the Affiliated Catholic Healthcare Physicians (ACHP). With the support of AAEM, ACHP — along with the California Chapter of AAEM and the California Medical Association (CMA) — filed a lawsuit alleging violations of corporate practice of medicine (CPOM) and fee-splitting laws. The CMA recognized both the threat to emergency physician autonomy and the wider threat, as Meriten would also be positioned to control other hospital-based specialists. ACEP was asked to participate in these actions but declined, saying it was a private business matter.

The amicus curiae (friend of the court) brief filed by AAEM in this case can be found here.

After initial court hearings seemed to go against it, CHW sold EPMG back to its original owners, who then reorganized EPMG into a fairer, independent, physician-owned group. If CHW had been successful in this endeavor it would have opened the door to other hospital chains taking over emergency physician groups large and small, dipping into emer­gency physicians’ professional fees as a new source of revenue, and dra­matically reducing the number of private EM groups. AAEM, at the time a fledgling organization, was the only EM society willing to stand with the ACHP physicians. This stand changed the course of EM in California. In the aftermath of this failed attempted takeover of EM, the chief medical officer (CMO) and chief executive officer (CEO) of CHW both resigned.

Restrictive Covenants

Mount Diablo Hospital (MDH), California Emergency Physicians (CEP), and TeamHealth

In 2003, Quantum Health, a subsidiary of TeamHealth, the second larg­est EM contract management group (CMG) in the United States, lost its contract at Mount Diablo Hospital in Concord, California to CEP. Three of the emergency physicians there wanted to continue working at MDH, where they had each been on staff for years. One was even a former Medical Staff President. In response, Quantum Health filed suit against these doctors, seeking damages from them for their supposed role in the loss of the contract. The emergency physicians went to ACEP for help and were told, as in the CHW matter, that it was a private business matter. They then came to AAEM and were provided advice, support, and legal assistance. The doctors joined AAEM in a counter-suit against TeamHealth, alleging that TeamHealth was using corporate subsidiaries to hide its violation of California’s prohibition on the corporate practice of medicine (CPOM). AAEM sought a declaratory judgment, requesting that all ED staffing contracts held by TeamHealth subsidiaries in California be voided, in light of California’s CPOM laws. This counter-suit was the first legal action ever taken against a CMG by an EM professional society.

All parties reached a settlement whereby TeamHealth dropped its lawsuits against the emergency physicians, who were able to continue working at MDH, and AAEM dropped its lawsuit against TeamHealth for violating California CPOM laws. In 2005, AAEM assisted in similar cases in Rhode Island and Indiana, also with favorable outcomes.

A copy of the AAEM counter-suit can be found here.

Read the full story from Emergency Medicine News here.

CMGs and Malpractice Coverage

PhyAmerica Bankruptcy

In 2003, PhyAmerica, one of the largest CMGs, went bankrupt. In 2004, Sterling Healthcare, another large contract management group, purchased PhyAmerica’s bankrupt assets, including its ED contracts. PhyAmerica then told its emergency physicians that their self-insured medical malpractice/legal defense fund had been exhausted. 200 PhyAmerica emergency physicians who had already been sued were told they no longer had malpractice coverage, and must pay all attorney fees and legal judgments out of their own pockets. And of course, PhyAmerica emergency physicians had no malpractice coverage for future suits. In response, AAEM organized a Working Group from among the affected emergency physicians, handled logistics, and offered free legal counsel. The Academy also filed an amicus curiae brief before the Baltimore Bankruptcy Court.

In April of 2005 a court order guaranteeing the protection of the physi­cians’ personal assets was handed down. AAEM also negotiated with Sterling Healthcare for partial reimbursement of the emergency physi­cians’ legal costs.

Corporate Practice of Medicine

Emergency Physicians Professional Association (EPPA) and EmCare

In 2004, EmCare, the largest emergency medicine CMG, acquired the contract at Methodist Hospital in St. Louis Park, Minnesota. EPPA, a private democratic group serving the hospital since 1969, was not even told the contract was up for bid until after the contract was awarded to EmCare. No request for proposals was issued. EPPA’s physicians initially reached out to ACEP for support through its state chapter, but were told this was not allowed by national ACEP. EPPA then asked AAEM for help. AAEM Past President, Dr. Robert McNamara flew to Minnesota and met with nearly 100 emergency physicians. The Academy offered legal counsel, went to the hospital on EPPA’s behalf, and filed complaints with the state attorney general and Board of Medicine. In December of 2004, AAEM and EPPA jointly filed suit against EmCare for violating CPOM and fee-splitting laws, and filed suit against the hospital for breach of contract. A copy of the suit can be found here.

Three weeks later, Methodist Hospital terminated its relationship with EmCare and re-contracted with EPPA. EPPA continues to serve Methodist Hospital and several other local hospitals. AAEM then sent a letter to every hospital administrator in the state of Minnesota, informing them of this matter and sending the message that AAEM is watching what they do with their EDs. This action had a chilling effect on the desire of layperson-owned CMGs to move into Minnesota, and they have been unable to establish a significant foothold in that state.

Read more from EM News.

The Fight Against Alternate Boards

The American Board of Physician Specialties (ABPS) began approaching state medical boards seeking formal recognition beginning in the early 2000’s. State boards do not generally control what specialties different physicians may practice, but several state boards limit how physicians may describe their specialization, typically in the form of advertising. The ABPS describes itself as “… the official multi-specialty board certifying body of the American Association of Physician Specialists (AAPS).” It offers certification in 20 different specialties, but review of its website reveals that the majority of its diplomats are certified in a single specialty: Emergency Medicine. Their designation is “Board of Certification in Emergency Medicine” (BCEM).

AAEM believes that “A specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).” The fundamental problem with the BCEM process is that it does not require formal ACGME accredited Emergency Medicine training. Rather, an ap­plicant can qualify after completing one of a large number of alternative specialty training programs or even one of 14 EM fellowships, harkening back to the ABEM and AOBEM “Practice Track ” provisions that closed in the late 1980’s. State board recognition of BCEM allows these physicians to misleadingly represent themselves as EM specialists.

In 2002, AAPS certified physicians were approved by the Florida Board of Medicine for such advertising. In 2010, similar recognition was granted in Texas. However, AAEM has been a staunch opponent of back-door paths to proclaim “board certification” outside the ABEM/AOBEM process.

AAEM played a key role in successful efforts in Oklahoma, North Carolina, Utah opposing AAPS’s attempts to gain similar status in these states. AAEM member Dr. Howard Roemer, was awarded AAEM’s James Keaney Award for his key role in convincing the Oklahoma State Legislature to reject AAPS’s proposal. AAEM remains the only EM or­ganization requiring board certification to be a full voting member and a fellow of AAEM.

Read the February 6, 2006 letter to OK Board of Osteopathic Examiners.

Read the AAEM Values Statement, describing EM Specialist.

Restrictive Covenants in Tennessee

In 2005, legislation was introduced to allow restrictive covenants in phy­sician employment contracts in Tennessee. AAEM and its Tennessee chapter strongly opposed these efforts and made this issue a top legisla­tive priority for the next two years. TN-AAEM Board members Dr. David Lawhorn and Dr. Andy Walker testified before the House committee reviewing the bill, and explained to committee members how such non-compete clauses harm both patients in general and emergency physicians in particular.

While TNAAEM was not able to kill the bill entirely, emergency medicine was exempted. Emergency physicians in Tennessee remain free of restrictive covenants to this day.

Read more at EM News.

Corporate Practice of Medicine

TeamHealth and the Memorial Hermann Hospital System (MHHS)

In 2007, MHHS, a large hospital network in Houston, awarded eight emergency department contracts to TeamHealth. Several emergency physicians contacted AAEM for assistance in this matter, including a private group with a 20-year history with MHHS, which was ousted in this move. AAEM and the private group — with AAEM’s financial as­sistance — filed suit against TeamHealth and MHHS, citing violation of Texas CPOM laws. AAEM felt the case had substantial footing, as the Texas Medical Practice Act prohibits physicians from being employed by lay corporations for the practice of medicine. Additionally, previous Texas case law (Flynn Brothers, Inc. v. First Medical Associates, Dallas 1986) held that lay persons could not profit from an ED contract. AAEM’s efforts were funded through donations to the AAEM Foundation.

Unfortunately, a state district court held that it did not have jurisdiction to hear the case. Despite an amicus curiae brief filed in support of AAEM by the Texas Medical Association, a state appeals court affirmed the district court’s decision. The court of appeals held that AAEM lacked standing to challenge the contract between MHHS and TeamHealth, as well as the contracts between TeamHealth and its emergency physicians. One of the plaintiff physicians actually signed a contract with the TeamHealth sub­sidiary, but even then the court would not grant a declaratory judgment enforcing the state CPOM laws, holding that private individuals could not enforce the Texas Medical Practice Act. The court did leave open the possibility that physicians could file suit to nullify their contracts with a lay-owned corporation, as such contracts may violate state CPOM laws.

AAEM then appealed to the Texas Supreme Court, which refused to hear the appeal. As a result, neither the Academy nor the plaintiff physicians ever got the chance to argue the merits of their case before a judge or jury, and no judgment on the merits of AAEM’s corporate practice of medicine claim was rendered. AAEM still believes it could win in court on the issue of the corporate practice of emergency medicine in Texas.

Read more from EM News.

Due Process / Whisteblower Case

Dr. Genova versus Banner Health

In January of 2010, emergency physician Dr. Ronald Genova contacted the hospital administrator on-call, the hospital CEO, requesting to imple­ment a “Code Purple” to divert patients to other hospitals, because he believed the ED at North Colorado Medical Center could no longer provide appropriate and timely screening to patients due to excessive crowding. According to the facts alleged in Dr. Genova’s lawsuit, a patient with a GI bleed had already collapsed in the waiting room bathroom while awaiting evaluation and two heart attack patients had just presented to the ED. According to Dr. Genova, the hospital CEO refused the request. Two weeks later, in apparent retaliation, Dr. Genova was removed from ED duties.

Dr. Genova filed a lawsuit noting that his removal from the schedule vio­lated EMTALA whistle-blower protections and the covenant of good faith and fair dealing implied in contracts by Colorado law. The federal District Court dismissed Dr. Genova’s suit, citing that Dr. Genova signed away his right to sue the hospital when his group contracted to provide physi­cian coverage of the ED. Dr. Genova then asked for AAEM’s assistance. In November of 2012, Dr. Genova appealed, and AAEM filed an amicus curiae brief asking the appellate court to overturn the dismissal and have the allegations in the complaint adjudicated on its merits. AAEM argued that the District Court imposed too narrow a reading of EMTALA’s whis­tle-blower protections. AAEM also argued that a hospital should not be al­lowed to insist on a waiver of the covenant of good faith and fair dealing, as that implied covenant serves not only to protect the physician but also patients. While the 10th Circuit Court of Appeals favorably discussed the arguments made by AAEM, it ultimately upheld the dismissal. Although AAEM is disappointed with the outcome, this case demonstrates the Academy’s willingness to come to a member’s aid when their practice rights are threatened.

The AAEM amicus curiae brief can be accessed here.

Cross Subsidization, Fee Splitting, CPOM

Tenet Health

In 2014, Tenet Health, one of the largest hospital networks in the country, put the contracts out for bid at 11 of its hospitals in California, to replace their emergency medicine, anesthesiology, and hospitalist groups. Many of these groups had served their hospitals and their communities well for decades. Such a change would be highly disruptive to the hundreds of physicians who have learned the systems and processes of their practice over time, and have developed relationships with their hospitals and medi­cal staffs — not to mention the disruption to local nursing staffs, patients, and communities. Most of the hospitalist contracts and some of the anes­thesiology contracts included a subsidy from Tenet, while most of the EM contracts generated enough revenue through collected professional fees to be entirely self-supporting and quite profitable.

Tenet solicited several large CMGs seeking a no-subsidy arrangement for all contracts. Essentially, Tenet wanted the profits from the emergency medicine contracts to cover its losses on the hospitalist and anesthesiol­ogy contracts. In addition, the emergency medicine practices will serve as a piggy bank to be raided by the CMG and the hospital. Of course, the CMG needs to show a nice profit to its investors too, which is hard to do without the anesthesiology and hospitalist subsidies. So, this also raised concern for future belt-tightening at the affected hospitals: less physician coverage, greater use of NPs and PAs, and lower pay for physicians. Federal fee-splitting laws, enacted to prevent kickbacks and abuse, pro­hibit the distribution of part of a physician’s professional fee to any entity, in excess of the fair market value of services provided to that physician. When part of a physician’s professional fee is being distributed to a hos­pital or CMG, the parties involved may be in violation of those laws. If an emergency physician’s professional fees were to go towards subsidizing other hospital-based specialists, or to pad the bottom line of a for-profit corporation, this would appear to be an extreme violation of federal fee-splitting laws. It is also important to recognize that California has some of the strongest corporate practice of medicine (CPOM) laws in the country. These laws, drafted to protect the public due to the potential for abuse when a corporation’s fiduciary duty to its shareholders is in conflict with a physician’s duty to his or her patients, prohibit non-physician, lay corpora­tions from owning or controlling physician practices.

The leaders of several groups affected contacted AAEM and asked for our assistance. AAEM and its California chapter provided advice to the affected groups, sent letters outlining AAEM’s concerns to the relevant hospital leaders, hospital boards, and medical staffs; and engaged in discussions with Tenet Health leadership. AAEM and the affected groups organized a highly effective public relations campaign. AAEM President Dr. Mark Reiter was quoted in many media outlets, noting his concerns that Tenet Health’s proposal was bad for Tenet’s hospitals, bad for its phy­sicians, and bad for its patients. Soon after, Tenet’s leadership informed AAEM that they were no longer considering this course of action, and that the local groups would remain.

Read the September/October 2014 President’s Message: Tenet Wants Emergency Physicians to Subsidize the Rest of the Hospital.

Read the November/December 2014 President’s Message: Tenet Health Update & Opportunities with AAEM.

Fee Splitting, Anti-Kickback, CPOM

Joint Ventures

Over the past decade, the largest hospital network in the country, Hospital Corporation of America (HCA), entered into a joint venture with EmCare/Envision, the largest CMG in the country. Under this arrangement, via the joint venture, the hospital and the CMG jointly own the emergency physi­cian group and split the profits resultant from the emergency physician professional fees. Although CMGs have profited handsomely from emer­gency physician professional fees for decades, this was new territory for hospitals. In the past few years, HCA has brought most of its EDs under the joint venture, destroying dozens of independent EM groups. In return for being able to keep working in the same ED, many of these physicians are forced to take significant pay cuts and lose much of their indepen­dence and job security. Several other hospitals and CMGs have engaged in similar arrangements on a smaller scale.

Since hospitals and CMGs are typically not physician-owned corpora­tions, having a hospital-CMG joint venture owning or controlling a physi­cian practice may violate corporate practice of medicine laws in many states. In addition, federal fee-splitting laws, drafted to prevent kickbacks and abuse, prohibit any portion of the physician professional fee from being distributed to any entity in excess of the fair market value of any services provided. In addition, there is concern that these arrangements violate federal anti-kickback laws.

AAEM, in conjunction with a prominent law firm, has been actively inves­tigating potentially illegal activities and hopes to enforce any prohibitions on such activity. AAEM has brought its concerns to a variety of federal and state agencies, many of which have voiced significant concerns with the legality of these arrangements and continue to investigate. AAEM has also passed a position statement noting its opposition to these joint venture arrangements and has discussed the issue with the media.

Unfortunately, we have not been successful in shutting these joint ven­tures down, but we will continue to be the only professional organization that is fighting for its members on this important issue.

Read the May/June 2014 President’s Message: Hospital-Contract Management Group Join Ventures: A Disturbing Trend.

AAEM Physician Group

For years, AAEM has been the strongest advocate in the house of medi­cine for physicians owning and controlling their own practices. Practices owned by a small subset of their physicians or entirely owned by lay cor­porations are much more likely to lack transparency, political equity, and financial equity. This can create conditions ripe for exploitation. AAEM has worked hard to promote equitable, democratic, physician-owned practices throughout its existence. Despite AAEM’s efforts, physician-owned practices are under significant threat. Small practices may have difficulty developing and maintaining the infrastructure needed to be suc­cessful in the new reality of health care reform, accountable care organi­zations, and value-based purchasing.

In 2016, the AAEM Physician Group was launched to combine the advan­tages of small, democratic groups of physician owners, with the econo­mies of scale, expanded services, and clout of large groups. Likewise, the AAEM Physician Group can help minimize the time, resources, and risk to emergency physicians who want to create their own EM group, or to bring the control of their group back to the physicians actually practic­ing in their ED. AAEM has created a new paradigm whereby smaller EM groups could become part of a national collaborative with access to best-in-class practice management services provided at fair market value. For existing groups, we believe the addition of more profes­sional management will help them maintain their contracts and facilitate possible expansion. Moreover, as part of AAEM, we believe affiliated groups will garner significant legal protection under the existing pro­hibitions on corporate practice of medicine and fee-splitting. Unlike the Memorial Hermann case mentioned above, AAEM will now have “stand­ing” in any threat to the contract. Likewise, AAEM Physician Group can seek new, high quality ED con­tracts and then set up and install local, democratic groups at these sites. We developed a set of fairness principles that would be required for participating groups to meet (i.e., financial transparency, reasonable path to partnership, due process, political and financial equity) to ensure that the commitment to a fair environment would be maintained.

The AAEM Physician Group is off to an excellent start. We now have multiple EDs representing hundreds of thousands of patient visits part­nering with us as part of the AAEM Physician Group. Each group main­tains local ownership and control while being obligated to follow AAEM’s Fairness Principles. If your group is interested in learning more about the AAEM Physician Group, please contact its CMO, Dr. Robert McNamara at cmo@aaempg.com

www.aaemphysiciangroup.com

Read the September/October 2015 President’s Message: The AAEM Physician Group at: http://www.aaem.org/UserFiles/file/CS_SepOct2015_ President.pdf

Conclusion

As you can see, the Academy has been extremely active in protecting the practice rights and livelihoods of emergency physicians, who often have nowhere else to turn for support in such matters. Many of our advocacy and legal actions have been successful and substantial, with significant benefits to the emergency physicians involved — including saving their jobs. There is still much to do, however, especially in an environment where lay-owned, corporate, contract management groups — which often have a very poor track record regarding restrictive covenants, due pro­cess, and other practice rights — control a large proportion of emergency medicine jobs. Your AAEM membership, your active support of its work, your recruitment of new Academy members, and your donations to the AAEM Foundation provide the resources the Academy needs to be a suc­cessful advocate for the practicing emergency physician.

 

The links below are further readings on this matter:

 

Featured Articles

Emergency Medicine at Risk?

You may have heard it said that we really don’t have a health care system, rather a health care mess. I disagree. Our system is actually quite good at doing what it is designed to do. Let me explain by starting with some definitions.

Health care is the prevention, treatment, and management of illness or injury by health professionals.

Physicians deliver health care along with the advance practice providers, nurses, techs, respiratory therapists, physical therapists, etc. that we guide. Hospitals, insurance companies, pharmaceutical companies, pharmacies don’t deliver health care. They may be part of a system within which health care is delivered but they don’t deliver health care. What should their role be? Let’s look at another definition.

According to the Business Dictionary a system is an organized, purposeful structure that consists of interrelated and interdependent elements (components, entities, factors, members, parts etc.). These elements continually influence one another (directly or indirectly) to maintain their activity and the existence of the system, in order to achieve the goal of the system.

If you think of the various entities in our “system” — pharmaceutical companies, hospitals, insurance companies, medical device manufacturers, contract management groups, pharmacies, and a host of others — they are certainly interrelated and continually influence on another to maintain their activity. They just have the wrong goal. Their goal is to make money and as evidence by the fact that we spend around 18% of our GDP on the delivery of health care they are very good at it. The goal should be to support the delivery of health care. Everything these entities do should foster and facilitate the physician-patient relationship. We all know from our various experiences that our system does not support but rather uses and in some cases corrupts the physician-patient relationship. That corruption is the root cause of much of the burnout we observe in our practices, in my opinion. But I digress.

Change is going to happen because the economists and other “experts” believe that the spending is not sustainable. They are probably right but it is a by-product of our system so efforts to control the spending must necessarily change the system. This will be a monumental task simply because there is so much money involved and no one will voluntarily give that up. Those with the best lobbyist have their turf protected. Physicians are very bad about organizing and devoting their time and money to protect their turf, believing the sanctity of the patient physician relationship will protect them. I may be cynical but I think that belief is naive.

I think this poses a very real threat to emergency medicine. It is widely believed that the care delivered in the emergency department is too costly. Efforts to show that it is only a small part of the overall health care spend are important but I believe will not be enough to protect our turf. Strides to defend the prudent layperson standard and prevent post treatment denials of payments such as Anthem has announced, are crucial. I am not sure they will be enough. I believe that someone will figure out how to keep the patients that “don’t need to be there” out of the emergency department. I am not talking about the patients that we can all agree that don’t need to be there — they probably don’t even need a doctor. I think the big challenge is those patients that we see every day that don’t need to be there but we don’t know this until after we see them. Pay attention during your next shift. How many patients can you determine after one or two minutes don’t need to be there? I know that the professional fees are not the problem. The facility fees are typically 5-10 times the professional fees. The hospitals are not going to bring those in line. Anthem and United recognize this and that is why they are retrospectively denying payments.

With challenges comes opportunity. Emergency medicine is a unique specialty we are defined by a patient population (those that present to an emergency department) and not, like most other specialties, defined by an organ system or disease process. We still may be defined by a patient population but within the house of medicine our role has evolved. We are now the specialty that treats almost all patients with undifferentiated acute illness. We are the specialty that puts the puzzle together and makes the diagnosis. Our skill set is crucial. Is it necessarily tied to hospital based emergency departments? Sure, we need some tools to do our job but the decreasing cost of tools no longer necessitates them being in hospitals. The growth of freestanding emergency centers (FSEC) in many areas of the country was fueled by this recognition and may be part of the solution. However, the “cost” of the FSECs are not much less than the hospitals. Urgent care centers largely lack the expertise and equipment to make a big impact.

Emergency medicine needs to understand that change is coming and that it is a particular threat to our specialty. But also recognize that our expertise is crucial and put forth “out of the box” solutions before the “system” defines our role going forward. Our “system” is very good at what it does — make money. If we don’t define the solutions we run the risk of being left out of the money.