ACEP NowACEP Now https://www.acepnow.com Fri, 20 Jul 2018 14:46:38 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.7 Acetaminophen Overdose Diagnosis and Treatment https://www.acepnow.com/article/acetaminophen-overdose-diagnosis-and-treatment/ https://www.acepnow.com/article/acetaminophen-overdose-diagnosis-and-treatment/#respond Wed, 18 Jul 2018 21:14:17 +0000 https://www.acepnow.com/?post_type=article&p=19183 The Case The patient is a 17-year-old non-English-speaking Bengali female with no past medical history who presented...

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The Case
ILLUSTRATION: Chris Whissen & shutterstock.com

ILLUSTRATION: Chris Whissen & shutterstock.com

The patient is a 17-year-old non-English-speaking Bengali female with no past medical history who presented to the pediatric emergency department at 12:30 a.m. with complaints of abdominal pain, vomiting, and headache that began earlier that evening. She is accompanied by her mother, younger sister, and a male neighbor who was asked to come to help translate. She describes the abdominal pain as diffuse in nature without localization, with more than 15 episodes of non-bloody, non-bilious emesis. There is no food exposure to account for her symptoms as she has not had anything to eat that day. Her last menstrual period was about 20 days prior to ED visit and was normal. She denies recent travel, fever, chills, urinary symptoms, diarrhea, sick contacts, or taking medications for her symptoms.

On exam, she appears pale and uncomfortable, with dry mucous membranes. However, she is awake, alert, and oriented, with a Glasgow Coma Scale score of 15. The abdominal exam reveals mild diffuse abdominal tenderness without radiation, rigidity, or guarding. IV access is obtained, and blood work is sent at 1 a.m. Her complete blood count, complete metabolic panel, lipase, urinalysis, and urine human chorionic gonadotropin are all within normal limits. She is treated with a 1 L normal saline bolus, Zofran 4 mg IV, Pepcid 20 mg IV, and ketorolac 30 mg IV, and her symptoms improve.

In the setting of normal blood work and no clear reason for the vomiting, a bedside ultrasound is performed to evaluate the right upper quadrant. The bedside ultrasound is negative for any acute biliary pathology. The patient at this point has changed into a hospital gown and is noted to have self-mutilation marks on her left forearm in the shape of an “M.” When asked about these marks on her arm, she states that she cut herself while cooking. It becomes obvious that there is more to the story. The family and neighbor are asked to step out of the room, and CyraCom translation service is brought to the bedside. The patient is not very cooperative with questioning, but when asked if she took any medications, she admits to taking 27 650 mg Tylenol tablets at 2:30 p.m., about 10 hours prior to arrival. She states she took the pills because she was feeling sad because her boyfriend, whose name begins with “M,” broke up with her.

About one hour into the ED visit, an overdose panel is sent including acetaminophen, aspirin, and alcohol levels, plus a urine toxicology screen. The acetaminophen level is 143.1 ug/mL. A medical toxicologist is consulted, and N-acetylcysteine (NAC) is initiated. Initial aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are 40 U/L and 37 U/L, respectively. Within 24 hours, her AST and ALT peak at 4,453 U/L and 4,843 U/L, respectively, before starting to trend downward. The repeat acetaminophen level, drawn about eight hours after the initial level, goes from 143.1 ug/mL to 36.5 ug/mL. By hospital day two, the acetaminophen level is <10 ug/mL. The patient remains stable throughout the hospital course and is discharged on hospital day five.

Acetaminophen Overdose

Acetaminophen overdoses are a common cause of hepatotoxicity in both pediatric and adult patients. The availability of the drug and perception of its safety are likely factors in the large number of overdoses, both intentional and unintentional, seen. The metabolism of acetaminophen involves multiple enzymatic pathways. Glucuronidation accounts for the majority of metabolism, with normal dosing accounting for up to 42 percent to 67 percent. A secondary mechanism, sulfonation, is more active in the pediatric population and accounts for up to 20 percent to 46 percent. Both of the aforementioned pathways result in water-soluble metabolites that are renally excreted. Additional mechanisms responsible for the metabolism of acetaminophen are the cytochrome P-450 (CYP) hepatic isoenzymes. Of particular importance is hepatic isoenzyme 2E1, which results in the formation of a reactive metabolite NAPQI. When an overdose is taken, glucuronidation and sulfonation are saturated, resulting in increased metabolic activity of hepatic isoenzyme 2E1. The increased generation of NAPQI would normally be conjugated to glutathione to form an adduct. However, when glutathione levels decrease to approximately 30 percent, hepatotoxicity occurs, evidenced by an elevation in AST and ALT.

During stage I of the clinical course of toxicity, hepatic injury has not yet occurred, and even patients who will go on to develop hepatotoxicity may be asymptomatic, highlighting the importance of getting an acetaminophen level. Mild symptoms such as nausea, vomiting, pallor, and malaise may be present. A latent period may follow where the patient may have fewer symptoms or even appear clinically well. However, as glutathione stores deplete and NAPQI builds, hepatotoxicity ensues. Stage II represents the onset of hepatic injury, and signs and symptoms may vary with severity of hepatic injury. Most patients will develop elevations of AST and ALT within 24 hours of ingestion. By convention, acetaminophen-induced hepatotoxicity is defined as a peak ALT concentration above 1,000 IU/L.

Stage III represents the time of maximal hepatotoxicity occurring between 72 and 96 hours after ingestion. Patients can progress to fulminant hepatic failure, which clinically manifests as development of encephalopathy, coma, cerebral edema, coagulopathy, and gastrointestinal bleeding. Most deaths occurring from hepatic failure occur three to five days following acetaminophen overdose.1

Patients who survive this period reach stage IV, defined as the recovery phase. Survivors have complete hepatic regeneration, and the rate of recovery varies, but in most cases, most lab values normalize within seven days.2

Acetaminophen level, for those who present within 24 hours of a single acute ingestion, can be plotted on the Rumack-Matthew nomogram to determine the patient’s risk of hepatotoxicity (see Figure 1). For single ingestions, indications to treat with NAC include a four-hour level of ≥150 mg/L for a witnessed ingestion or a level of >10 mg/L in an unwitnessed event with unknown time of ingestion. NAC can be administered via the oral or intravenous routes.

Credit: Merlin Cyrstal [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0], from Wikimedia Commons

Credit: Merlin Cyrstal [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0], from Wikimedia Commons

There are several variations in treatment protocols; however, the most common are a 21-hour intravenous infusion and a 72-hour oral-dosing protocol. The variation in treatment exists because treatment theoretically should be initiated when the patient is suspected to be at risk for hepatotoxicity, continue while the patient remains at risk, and cease once the risk or toxicity is gone. Studies have shown equal efficacy in preventing toxicity between the intravenous and oral routes.2 The recommended dose of intravenous NAC is 150 mg/kg IV x 1 over 60 minutes followed by 50 mg/kg IV x 1 over four hours followed by 100 mg /kg IV x 1 over 16 hours for both pediatrics and adults.

Specific indications for intravenous NAC include fulminant hepatic failure, inability to tolerate oral NAC, and acetaminophen poisoning in pregnancy. The major adverse effect associated with intravenous NAC can be a severe anaphylactoid reaction; however, this is rare. The recommended dose of oral NAC is a 140 mg/kg loading dose either orally or via enteral tube. Starting four hours after the loading dose, 70 mg/kg should be given every four hours for an additional 17 doses. The main disadvantage of oral NAC is the high incidence of vomiting, which, in turn, can delay care.2 This is most beneficial if treatment is initiated within eight hours after ingestion.1 Therefore, it is important to assess the patient’s risk for hepatotoxicity, and at times, it may be necessary to initiate treatment with NAC prior to laboratory studies in order not to delay care.

The effects of delaying care are far worse than initiating treatment that may ultimately not be needed, in which case therapy can be stopped. Additional elimination techniques exist, including hemodialysis. Indications for hemodialysis include patients with exceedingly high acetaminophen levels (greater than 500 ug/mL) who are at high risk for hepatotoxicity despite NAC therapy as well as those with elevated lactic acid levels and metabolic acidosis. Hemodialysis also removes NAC, and subsequently, NAC infusion rates need to be doubled during dialysis.2

Patients can also present with chronic acetaminophen toxicity from repeated supratherapeutic doses. However, the incidence of serious acetaminophen toxicity is small following chronic ingestion and much more common in acute, massive dosing. Patients at greater risk for hepatotoxicity following repeated supratherapeutic ingestions have increased activity of CYP 2E1 leading to increased NAPQI formation or have decreased glutathione stores and turnover rate. In patients with suspected chronic ingestion with risk of hepatotoxicity, an acetaminophen level and liver function enzymes should be obtained. Patients with elevated liver enzymes and/or elevated acetaminophen level should be treated with NAC to prevent further liver damage.2

Discussion

The responsibility to provide the best care for patients is incumbent on emergency physicians, and they may have to overcome numerous barriers to fulfill that responsibility. Language barriers can have deleterious effects, and patients who face such barriers are less likely than others to have a usual source of medical care. In 1998, the Office for Civil Rights of the Department of Health and Human Services issued a memorandum that states that the denial or delay of medical care because of language barriers constitutes discrimination. Ad hoc interpreters including family members, friends, and untrained members of the support staff are commonly used in clinical encounters. However, they are more likely to commit errors that may have adverse consequences. Ad hoc interpreters are unlikely to have had training in medical terminology and confidentiality. Their presence may inhibit discussions regarding sensitive issues such as domestic violence, substance abuse, or mental illness, as illustrated in this case.3 Barriers such as these leave emergency physicians more vulnerable to medical error that could be harmful to their patients. For this reason, it is important to be knowledgeable about the potential pitfalls and to approach each patient with the same objectivity.


Dr. PeñaDr. Peña is an emergency medicine resident at St. Joseph’s University Medical Center in Paterson, New Jersey.

Dr. Kashani Dr. Kashani is a medical toxicologist emergency medicine faculty at St. Joseph’s University Medical Center.

References

  1. Algren DA. Review of N-acetylcysteine for the treatment of acetaminophen (paracetamol) toxicity in pediatrics. World Health Organization website. Accessed Feb. 10, 2018.
  2. Hoffman RS, Howland MA, Lewin NA, et al. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill Education; 2014:447-458.
  3. Flores G. Language barriers to health care in the United States. New Engl J Med. 2006;335(3):229-231.

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Leaders Meet with The Joint Commission https://www.acepnow.com/article/leaders-meet-with-the-joint-commission/ https://www.acepnow.com/article/leaders-meet-with-the-joint-commission/#respond Wed, 18 Jul 2018 17:16:10 +0000 https://www.acepnow.com/?post_type=article&p=19198 Topics included our Geriatric ED Accreditation program, freestanding emergency departments, suicide screening, and pediatric readiness. The Joint...

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Topics included our Geriatric ED Accreditation program, freestanding emergency departments, suicide screening, and pediatric readiness. The Joint Commission (TJC) reiterated its standard that universal suicide screening in the emergency department was required for patients with behavioral health chief complaints. Where resources make it feasible, screening of other populations at risk within the population served is encouraged but not a standard. TJC also discussed the issue of inpatient and in-facility suicides. Their data shows that this is actually a rarer event than had been suggested. Nonetheless, they suggest that rooms that house patients with suicidal ideation be free of ligature risks. Among those who kill themselves in a hospital facility, most do so by hanging. 

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ACEP-Developed Opioid Bills Pass the House, Move to Senate https://www.acepnow.com/article/acep-developed-opioid-bills-pass-the-house-move-to-senate/ https://www.acepnow.com/article/acep-developed-opioid-bills-pass-the-house-move-to-senate/#respond Wed, 18 Jul 2018 17:16:09 +0000 https://www.acepnow.com/?post_type=article&p=19200 Two pieces of opioid legislation—the POWER Act and the ALTO Act—that ACEP developed and introduced to Congress have successfully passed...

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Two pieces of opioid legislation—the POWER Act and the ALTO Act—that ACEP developed and introduced to Congress have successfully passed the House of Representatives and are moving to the Senate. At LAC18 just last month, ACEP members advocated for the bills to their state representatives. Your advocacy works! 

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Emergency Physician Elected to American Medical Association Council https://www.acepnow.com/article/emergency-physician-elected-to-american-medical-association-council/ https://www.acepnow.com/article/emergency-physician-elected-to-american-medical-association-council/#respond Wed, 18 Jul 2018 17:16:09 +0000 https://www.acepnow.com/?post_type=article&p=19202 At the 2018 American Medical Association (AMA) Annual Meeting, ACEP member Stephen K. Epstein, MD, MPP, FACEP...

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At the 2018 American Medical Association (AMA) Annual Meeting, ACEP member Stephen K. Epstein, MD, MPP, FACEP was elected to the AMA Council on Medical Service. This council studies the social and economic aspects of medical care and recommends policies. Congratulations, Dr. Epstein!

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How Independent Contractors Can Set Up Retirement Accounts https://www.acepnow.com/article/how-independent-contractors-can-set-up-retirement-accounts/ https://www.acepnow.com/article/how-independent-contractors-can-set-up-retirement-accounts/#respond Wed, 18 Jul 2018 17:16:09 +0000 https://www.acepnow.com/?post_type=article&p=19227 Q. I am starting a new position as an independent contractor. My former employer had a 401(k)....

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ILLUSTRATION: Chris Whissen & shutterstock.com

Q. I am starting a new position as an independent contractor. My former employer had a 401(k). I want to continue to save for retirement, but I’m not sure how to do it without that 401(k). How can an independent contractor continue to save for retirement?

A. Good news! There are many advantages of being self-employed when it comes to saving for retirement. As an independent contractor (ie, paid on a 1099 instead of a W-2), you are considered to be running your own business. Just like your employer gets to pick the benefits it offers, you now get to choose (and pay for) your own benefits. While you will no longer get a 401(k) match from the employer, you are also no longer limited by the employer’s contribution limits, plan fees, or often poor investment options.

The mainstay of retirement saving for an independent contractor should be an individual 401(k), sometimes called a solo 401(k). These plans allow you to make an $18,500 “employee” contribution ($24,500 if older than age 50) and then make “employer” contributions of 20 percent of your net income up to the plan contribution limit of $55,000. While you only get one employee contribution no matter how many jobs or 401(k)s you have, the $55,000 limit is a per-plan limit. That means if you have an employee job with a 401(k) and do some work as an independent contractor, you can still open an individual 401(k) and just contribute the employer contribution to it.

Solid individual 401(k) plans can be easily opened at any of the large mutual fund or brokerage companies such as Vanguard, Fidelity, Charles Schwab, eTrade, or TD Ameritrade. While all of these plans are good plans with diversified, low-cost investments available, some plans offer features that others do not. For example, Vanguard doesn’t allow IRAs to be rolled into their plan. Fidelity and Charles Schwab don’t offer a Roth 401(k) option. eTrade and TD Ameritrade charge (admittedly low) commissions to buy and sell many mutual funds and exchange-traded funds.

Be sure the plan you choose has the features you need, such as Roth contributions, IRA rollovers, or 401(k) loans. You will also need to get an Employee Identification Number from the IRS to open an individual 401(k), but this is free and only takes a few minutes online. You do not need to form an LLC or corporation to use an individual 401(k). By virtue of receiving a 1099, you are automatically a sole proprietor, and that is enough to start a plan.

Some doctors, and even their accountants, consider using the slightly simpler SEP-IRA instead, which has the same $55,000 total contribution limit. However, thanks to the employee contribution feature of an individual 401(k), you can hit the maximum contribution of $55,000 with a much lower income. In addition, using the 401(k) instead of a SEP-IRA allows you to do a backdoor Roth IRA since the balance of a SEP-IRA is included in the required pro-rata calculation (explained below) but the balance of a 401(k) is not.

Whether you are employed or self-employed, you can also contribute to a personal backdoor (indirect) Roth IRA and, if married and you have sufficient income, a spousal backdoor Roth IRA. These became permitted in 2010 when Congress began allowing high-earners to do Roth conversions. Instead of a direct Roth IRA contribution, you first contribute to a traditional IRA, which is not deductible due to your high income, and then move that money to a Roth IRA.

Since you never received a deduction, there is no tax cost for the conversion, and the end effect is the same as if you had contributed directly to a Roth IRA. Annual contribution limits are $5,500 if younger than age 50 and $6,500 if older than age 50. Be aware that due to the pro-rata rule, the conversion is only tax-free if you have no balance in a SEP-IRA, SIMPLE IRA, or traditional IRA on Dec. 31 of the year of the conversion. If you do have one of those accounts, you may wish to roll it into a 401(k), such as your new individual 401(k), to facilitate future backdoor Roth IRAs.

A health savings account (HSA) can also function as a stealth IRA and is an excellent account to use for retirement savings. Not only does it give you an upfront tax break and tax-protected growth like a 401(k), it also provides for tax-free withdrawals if the money is used for health care. This makes it the most tax-advantaged account available to the investor. These funds can be invested in mutual funds like a typical retirement account. The contribution limit for 2018 is $3,450 for individuals and $6,900 for families. If you end up not needing it for health care, you can withdraw the money penalty-free after age 65. However, you would need to pay taxes on that withdrawal, just like a 401(k).

Another option for independent contractors, although more rarely used, is a personal defined benefit/cash balance plan. This retirement account is best thought of as an extra IRA masquerading as a pension. It has higher expenses than an individual 401(k) due to a requirement for annual actuarial calculations and typically is not invested as aggressively. However, the contribution limits can be quite high, particularly for physicians in their 50s or 60s. It is an option worth exploring for someone interested in saving large amounts for retirement.

Investing in a nonqualified, taxable brokerage or mutual fund account for retirement is also an option. While the tax and asset protection benefits are much more limited, the additional flexibility can be a useful feature. Alternative investments, such as real estate, are also much easier to invest in outside of retirement accounts.

As you can see, an independent contractor has plenty of excellent options to use for retirement savings. While the main pillar should be an individual 401(k), a Roth IRA, HSA, cash balance plan, and taxable account provide additional options.

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Can Tranexamic Acid Decrease Maternal Mortality? https://www.acepnow.com/article/can-tranexamic-acid-decrease-maternal-mortality/ https://www.acepnow.com/article/can-tranexamic-acid-decrease-maternal-mortality/#respond Wed, 18 Jul 2018 17:16:08 +0000 https://www.acepnow.com/?post_type=article&p=19231 The Case A 27-year-old primiparous woman arrives at the emergency department after a prolonged labor at home;...

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The Case

A 27-year-old primiparous woman arrives at the emergency department after a prolonged labor at home; she is fully dilated and crowning. She has no significant health history and is only taking prenatal vitamins.

Obstetrics and pediatrics are called stat, but the patient rapidly delivers in the emergency department—a healthy 6-pound, 8-ounce girl with only a first-degree laceration. Pediatrics arrives quickly and provides neonatal assessment. Obstetrics, however, is busy doing an emergency cesarean delivery.

Shortly after the delivery of the placenta, the patient has brisk vaginal bleeding. Her vital signs are normal and stable. Lab tests are requested, and the nurse has already given oxytocin 10 mg IM and started an IV. Knowing that uterine atony is the number-one cause of postpartum hemorrhage (PPH), you start performing fundal massage. While waiting for obstetrics to show up, you think about drugs other than oxytocin that could be used for PPH (methylergonovine, misoprostol, and prostaglandins), and you remember reading something about tranexamic acid (TXA).

Background

TXA is a synthetic analog of the amino acid lysine and acts as an antifibrinolytic agent. It binds to lysine receptor sites on plasminogen, blocking its action on fibrin. The ultimate result is that the fibrin matrix structure is maintained and bleeding is reduced.

PPH is defined by the World Health Organization as “a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process.” PPH is one of the leading causes of maternal mortality around the world.1

The American College of Obstetricians and Gynecologists published guidelines for the management of PPH, including the use of TXA. It gives TXA a Level B recommendation: “Given the mortality reduction findings, tranexamic acid should be considered in the setting of obstetric hemorrhage when initial medical therapy fails.”2

Clinical Question

In women with PPH, does TXA improve survival?

Reference

WOAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116.

  • Population: Women older than 16 years with a diagnosis of PPH after vaginal birth (>500 mL blood loss) or cesarean delivery (>1,000 mL blood loss) or blood loss causing hemodynamic instability and the clinician was uncertain whether to use TXA.
    • Exclusions: If the clinician felt that TXA would clearly be or not be beneficial.
  • Intervention: 1 g TXA slowly infused with the optional second 1 g dose if bleeding continued for 30 minutes or more or stopped and restarted within 24 hours.
  • Comparison: Placebo.
  • Outcome:
    • Primary: All-cause mortality or hysterectomy within 42 days.
    • Secondary: Mortality due to bleeding, thromboembolic events, surgical interventions, other complications, adverse events, quality-of-life measurements, and thromboembolic events in breastfed babies.

Authors’ Conclusions

“Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.”

Key Results

They enrolled 20,021 women in the trial. Maternal death occurred in 2.4 percent of all women within 24 hours, and 9 percent of the deaths were within one hour after randomization.

For the primary outcome of all-cause mortality or hysterectomy, there was not a statistical difference (see Table 1).

Table 1: Key Results from the WOMAN Trial

(click for larger image) Table 1: Key Results from the WOMAN Trial

EBM Commentary

1) Inclusion Criteria: The inclusion criteria in this study were vague. Clinical diagnosis of PPH was based on a subjective estimation of blood loss. Hemodynamic instability was not defined, and the clinician had to be unsure whether to use TXA.

2) Power Calculation: The trial was originally powered for a 25 percent relative reduction (1 percent absolute) in all-cause mortality or hysterectomy. After the trial started, they figured out the decision to do a hysterectomy usually was made at the same time as randomization. Therefore, they recalculated the sample size for a 25 percent relative reduction (0.75 percent absolute) in all-cause mortality. As a result, the sample size increased from 15,000 to 20,000.

Trials are often criticized for being underpowered but not for being overpowered. Trials are usually designed to find a difference between two things, and if you have a large enough trial, you will find a statistical difference because no two things are identical. Despite having more than 20,000 women, they did not find a difference in all-cause mortality.

3) Subgroup Analyses: A number of subgroup analyses for the primary composite outcome were considered a priori. The only statistical difference observed was if TXA was given in less than three hours postpartum. This result should be viewed with skepticism because subgroup analyses are considered hypothesis-generating and should not be overinterpreted.

4) Fragility of the Study: The fragility index is a way to measure the robustness of the results obtained.3 It is calculated by converting one patient (treatment or control) from a “non-event” to an “event.” In this case, how many women would have to have a different outcome for the study not to be statistically significant (P ≥ 0.05)?

This was a negative trial for the primary outcome of all-cause mortality or hysterectomy. However, there was a statistical difference in death due to bleeding. But the fragility index of this secondary outcome was zero, which emphasizes the lack of robustness of the WOMAN trial.4

The fragility index for the subgroup analysis of the secondary outcome of bleeding mortality treated in less than three hours is nine. This means if nine women switched from an event to a non-event in either group, the results of this hypothesis-generating result would no longer be considered statistically significant.

5) External Validity: The vast majority of these patients came from developing countries. It is unclear what resources their health care system had to address PPH compared to the United States and if these results could be applied to our health care system.

Bottom Line

This study does not provide good evidence that TXA improves survival in women with PPH.

Case Resolution

The fundal massage and oxytocin seem to work, and the bleeding slows. The patient is still hemodynamically stable when the obstetrical team arrives. She is transferred to the postpartum unit for further management and does not receive TXA.

Thank you to Nick Papalia, MD, who is currently completing his third year of obstetrics and gynecology residency at the University of Calgary in Alberta, for his help with this review.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine

References

  1. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-33.
  2. Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186.
  3. Nickson C. Fragility index. Life in the Fast Lane website. Accessed June 20, 2018.
  4. Fragility index calculator. ClinCalc website. Accessed June 20, 2018.

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How to Implement Ultrasound-Guided Nerve Blocks in Your ED https://www.acepnow.com/article/how-to-implement-ultrasound-guided-nerve-blocks-in-your-ed/ https://www.acepnow.com/article/how-to-implement-ultrasound-guided-nerve-blocks-in-your-ed/#respond Wed, 18 Jul 2018 17:16:08 +0000 https://www.acepnow.com/?post_type=article&p=19243 Ultrasound-guided nerve block (UGNB) is an extremely useful technique for emergency physicians as a multimodal approach to...

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Ultrasound-guided nerve block (UGNB) is an extremely useful technique for emergency physicians as a multimodal approach to the acutely injured patient. In the emergency department, UGNBs are an adjunct for pain management and can be an ideal way for clinicians to reduce the overreliance on systemic opioids.1–3 In patients with contraindications to procedural sedation, UGNBs may also be the only suitable method for targeted analgesia. Recent end-point data indicate early ultrasound-guided femoral nerve blocks improve functional outcomes in patients with hip fractures, making the integration into emergency medicine practice imperative.4 Unfortunately, despite evidence indicating both the feasibility and utility of UGNBs in the ED management of the acutely injured patient, reports indicate poor penetration in emergency medicine clinical practice.5

In our 10-year experience with UGNBs, we believe that one of the major limitations for physicians is the lack of a simple location for all supplies needed to perform a UGNB. Using basic design thinking methodology to streamline the process for the clinician, we developed prearranged block bags that contain the basic supplies needed to perform a UGNB.

Our block bags contain the minimum supplies necessary for a basic ED-based UGNB. All anesthetics remain in our ED automated medication dispensing system until ordered by the clinician. Weight-based dosing parameters and a preprocedural timeout checklist are not placed in the block bag but are easily located online to simplify the process. Lipid emulsion (20%) is kept with our anesthetics, and all providers who are performing UGNBs are familiar with dosing if there is concern for local anesthetic systemic toxicity (see www.lipidrescue.org for details). A standard ED policy should be in place with dosing guidelines and references whenever anesthetics are used (ultrasound-guided or landmark-based).

Assembling the Bag

  1. Each block bag contains (see Figure 1):
  2. Two 20-cc syringes
  3. 20-g 3.5-inch blunt-tip block needles
  4. IV extension tubing
  5. Two 10-cc normal saline (NS) flushes
  6. 18-g needle
  7. Tuberculin (TB) or insulin needle/syringe (for skin wheal)
  8. Transparent dressing for probe
  9. Alcohol pads and clorhexadine swab
  10. Body marking pen
Figure 1 (ABOVE): The various labeled components are placed in a specimen bag so that clinicians can quickly grab supplies for a UGNB. Anesthetic is ordered by the clinician and brought to the bedside by the nurse.

Figure 1: The various labeled components are placed in a specimen bag so that clinicians can quickly grab supplies for a UGNB. Anesthetic is ordered by the clinician and brought to the bedside by the nurse.

Procedural Tips

  1. Consent should always be obtained before performing a UGNB.
  2. A discussion with consulting services (orthopedics, general surgery, etc.) and determination of which injuries are (and are not) ideal for UGNBs should be performed in advance of performing the procedure.
  3. Scan the patient to determine the location of the nerve. Position the patient and ultrasound screen to allow for optimal ergonomics. We recommend that the ultrasound screen and site of injection be in direct view of the clinician so that minimal head movement is needed to perform the block. In most cases, this would mean that the ultrasound system is contralateral to the site of injury.
  4. The patient should be placed on a cardiac monitor for the duration of the block and for about 10 to 15 minutes after completion.
  5. Once the ideal location and needle pathway has been determined, a skin wheal should be placed at the expected site of needle entry.
  6. For a low-volume block (10 cc or less), a single operator technique can be used (needle on syringe), as shown in Figure 2.
  7. For a higher-volume block (10–20 cc anesthetic), we prefer a two-operator technique (hand on needle), as shown in Figure 3.
Figure 2. For low-volume blocks (less than 10 cc), we recommend a single-operator technique. A two-operator technique (see Figure 3) can be used if the operator is a novice and would benefit from normal saline (NS) hydrodissection to ensure proper needle visualization. The operator is using an in-plane technique to perform an interscalene brachial plexus block. SCM: sternocleidomastoid muscle; AS: anterior scalene muscle; MS: middle scalene muscle; yellow dashed line: brachial plexus at the level of the interscalene muscles.

Figure 2. For low-volume blocks (less than 10 cc), we recommend a single-operator technique. A two-operator technique (see Figure 3) can be used if the operator is a novice and would benefit from normal saline (NS) hydrodissection to ensure proper needle visualization. The operator is using an in-plane technique to perform an interscalene brachial plexus block. SCM: sternocleidomastoid muscle; AS: anterior scalene muscle; MS: middle scalene muscle; yellow dashed line: brachial plexus at the level of the interscalene muscles.

Figure 3. For higher-volume blocks (more than 10 cc), we recommend a two-operator technique. The operator is using an in-plane technique to perform a distal sciatic nerve block in the popliteal fossa. A) NS flush is attached to the IV tubing and block needle. Fluid is flushed to remove air from the circuit. B) After scanning the area and placing a skin wheal (with the insulin or TB syringe), hydrodissect the tissue with NS gently until the needle tip is in the ideal location for anesthetic placement. Remove the NS flush and attach the 10-cc syringe of local anesthetic. Inject slowly (aspirating after every 1–2 cc to ensure lack of vascular puncture) with clear needle tip visualization.

Figure 3. For higher-volume blocks (more than 10 cc), we recommend a two-operator technique. The operator is using an in-plane technique to perform a distal sciatic nerve block in the popliteal fossa. A) NS flush is attached to the IV tubing and block needle. Fluid is flushed to remove air from the circuit. B) After scanning the area and placing a skin wheal (with the insulin or TB syringe), hydrodissect the tissue with NS gently until the needle tip is in the ideal location for anesthetic placement. Remove the NS flush and attach the 10-cc syringe of local anesthetic. Inject slowly (aspirating after every 1–2 cc to ensure lack of vascular puncture) with clear needle tip visualization.

Conclusion

Putting systems in place that allow clinicians to optimize clinical care is crucial to maintaining best practices and efficient flow in the emergency department. Simple design solutions reduce barriers, increase compliance, and ideally improve patient care. Our simple block bag, which is composed of common items found in most emergency departments, may increase the number of UGNBs performed in your department. With more emergency departments attempting to reduce overreliance on opioids for acute pain management, this design innovation can aid in facilitating the integration of UGNBs into clinical care.


Dr.  Nagdev is director of emergency ultrasound at Highland General Hospital in Oakland, California.

Dr. Brant-Zawadzki is a fellow in wilderness medicine at the University of Utah in Salt Lake City.

Dr. Herring is associate director of research at Highland General Hospital.

References

  1. Tirado A, Nagdev A, Henningsen C, et al. Ultrasound-guided procedures in the emergency department-needle guidance and localization. Emerg Med Clin North Am. 2013;31(1):87-115.
  2. Herring AA. Bringing ultrasound-guided regional anesthesia to emergency medicine. AEM Educ Train. 2017;1(2):165-168.
  3. Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013;20(6):584-591.
  4. Morrison RS, Dickman E, Hwang U, et al. Regional nerve blocks improve pain and functional outcomes in hip fracture: a randomized controlled trial. J Am Geriatr Soc. 2016;64(12):2433-2439.
  5. Amini R, Kartchner JZ, Nagdev A, et al. Ultrasound-guided nerve blocks in emergency medicine practice. J Ultrasound Med. 2016;35(4):731-736.

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ACEP Revises Venous Thromboembolism Clinical Policy https://www.acepnow.com/article/acep-revises-venous-thromboembolism-clinical-policy/ https://www.acepnow.com/article/acep-revises-venous-thromboembolism-clinical-policy/#respond Wed, 18 Jul 2018 00:43:13 +0000 https://www.acepnow.com/?post_type=article&p=19220 In February 2018, the ACEP Board of Directors approved a revised clinical policy on the evaluation and...

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ILLUSTRATION: shutterstock.com

ILLUSTRATION: shutterstock.com

In February 2018, the ACEP Board of Directors approved a revised clinical policy on the evaluation and management of adult patients presenting with suspected acute venous thromboembolic disease.1 The policy is available at www.acep.org/patient-care/clinical-policies.

Venous thromboembolism (VTE), including both deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major public health problem. Undiagnosed, untreated patients are believed to be at substantial risk for progressive disease and sudden death typically because of worsening right-sided heart strain and ultimately cardiovascular collapse. Treated patients are at risk for chronic sequelae (ie, vein scarring, leg swelling, and pulmonary hypertension) and adverse events from ongoing anticoagulation (ie, hemorrhage and other medication adverse effects).

One significant challenge for health care providers evaluating patients for VTE lies in the variability of signs and symptoms of the disease that are related to clot burden, location, and the individual patient’s cardiopulmonary reserve. Without perfect, cost-effective tests for the diagnosis of VTE, providers have come to rely on Bayesian decision making to guide their workup, using pretest probability to interpret diagnostic evaluations and generate posttest probability of disease. Doing this allows providers to maximize diagnostic accuracy while minimizing over-testing and patient harm from the risks associated with unnecessary evaluation and treatment.

Table 1. Translation of Classes of Evidence to Recommendation Levels

Table 1. Translation of Classes of Evidence to Recommendation Levels

Efforts to refine this Bayesian approach in emergency medicine have been ongoing. Original studies to determine pretest probability and the accuracy of various screening tests have been validated, and the limits of their efficacy are being explored. Additionally, substantial efforts are being made to advance the treatment of VTE by balancing outcomes, anticoagulation risks to patients, and patient preferences. Non–vitamin K antagonist oral anticoagulants (NOACs) are particularly appealing for long-term anticoagulation because of their simple oral dosing regimens with no need for routine laboratory monitoring.

This most recent revision investigates five areas of interest or controversy in the evaluation and management of VTE. The first two critical questions address the role of unique clinical prediction rules and age-adjusted D-dimer testing in the diagnosis of PE, and the remaining three questions focus on optimal treatment and disposition for individuals receiving a diagnosis of venous thromboembolic disease.

For each critical question, a structured literature review was performed, evidence was systematically graded (see Table 1), and evidence-based recommendations are presented.

Critical Questions

Question 1. In adult patients with suspected acute PE, can a clinical prediction rule be used to identify a group of patients at very low risk for the diagnosis of PE for whom no additional diagnostic workup is required?

Patient Management Recommendations

  • Level A: None specified.
  • Level B: For patients who are at low risk for acute PE, use the Pulmonary Embolism Rule-out Criteria (PERC) to exclude the diagnosis without further diagnostic testing.
  • Level C: None specified.

Question 2. In adult patients with low to intermediate pretest probability for acute PE, does a negative age-adjusted D-dimer result identify a group of patients at very low risk for the diagnosis of PE for whom no additional diagnostic workup is required?

Patient Management Recommendations

  • Level A recommendations: None specified.
  • Level B recommendations: In patients older than 50 years deemed to be at low or intermediate risk for acute PE, clinicians may use a negative age-adjusted D-dimer result to exclude the diagnosis of PE. For highly sensitive D-dimer assays using fibrin equivalent units (FEUs), use a cutoff of age × 10 µg/L; for highly sensitive D-dimer assays using D-dimer units (DDUs), use a cutoff of age × 5 µg/L.
  • Level C recommendations: None specified.

Question 3. In adult patients with subsegmental PE, is it safe to withhold anticoagulation?

Patient Management Recommendations

  • Level A recommendations: None specified.
  • Level B recommendations: None specified.
  • Level C recommendations: Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental PE without associated DVT should be guided by individual patient risk profiles and preferences (consensus recommendation).

Question 4. In adult patients diagnosed with acute PE, is initiation of anticoagulation and discharge from the emergency department safe?

Patient Management Recommendations

  • Level A recommendations: None specified.
  • Level B recommendations: None specified.
  • Level C recommendations: Selected patients with acute PE who are at low risk for adverse outcomes as determined by Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), or the Hestia criteria may be safely discharged from the emergency department on anticoagulation, with close outpatient follow-up.

Question 5. In adult patients diagnosed with acute lower-extremity DVT who are discharged from the emergency department, is treatment with a NOAC safe and effective compared with treatment with low-molecular-weight heparin (LMWH) and a vitamin K antagonist (VKA)?

Patient Management Recommendations

  • Level A recommendations: None specified.
  • Level B recommendations: In selected patients diagnosed with acute DVT, a NOAC may be used as a safe and effective treatment alternative to LMWH/VKA.
  • Level C recommendations: Selected patients with acute DVT may be safely treated with a NOAC and directly discharged from the emergency department.

In summary, the evaluation and management of patients with suspected VTE in the emergency department is rapidly evolving and increasingly nuanced. Newer clinical algorithms using PERC and age-adjusted D-dimer may improve the efficiency and effectiveness of evaluations. Similarly, advances in the understanding of whom to treat, in which setting and with what optimal therapy can improve patient-centered outcomes.


Dr. Wolf is co-chair of the ACEP Clinical Policies Committee, director of service for emergency medicine at Denver Health Medical Center, and vice chair within the department of emergency medicine at the University of Colorado School of Medicine in Aurora.

Reference

  1. Wolf SJ, Hahn SA, Nentwich LM, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease. Ann Emerg Med. 2018;71(5):e59-e109.

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The Forces that Shaped Emergency Medicine over the Decades https://www.acepnow.com/article/the-forces-that-shaped-emergency-medicine-over-the-decades/ https://www.acepnow.com/article/the-forces-that-shaped-emergency-medicine-over-the-decades/#respond Sun, 15 Jul 2018 23:14:28 +0000 https://www.acepnow.com/?post_type=article&p=19225 As emergency physicians look back on the growth of the specialty, we have the opportunity to note...

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ACEP Celebrates 50th Anniversary with Year of FestivitiesAs emergency physicians look back on the growth of the specialty, we have the opportunity to note significant internal milestones along that path, such as the establishment of dedicated emergency department coverage by physicians in Alexandria, Virginia, in 1961; the formation of the American College of Emergency Physicians in 1968; the first emergency medicine residency at the University of Cincinnati in 1970; and the recognition as a specialty by the American Medical Association and American Board of Medical Specialties in 1979.

Just as important is understanding the external social, political, and financial policies that created the need for emergency medicine and have shaped our profession over the decades. As these forces continue to evolve, so will emergency medicine. Knowing how we got here is as essential as knowing where we need to go.

Genesis of Emergency Departments

In the mid 1940s, with Americans returning from World War II, President Harry Truman signed the Hill-Burton Act, which provided grants and loans for the construction of hospitals and other health facilities, dramatically expanding the U.S. health care infrastructure. This era saw a huge boost in the U.S. population (the baby boom), which continued for a decade. The Hill-Burton Act also placed hospitals in a new area of growth, the suburbs, as growing families moved out from city centers. By 1960, one-third of American families lived in suburban areas.

This act, lasting until the late 1990s, was partially motivated to address lack of access to care in many communities and is responsible for many of the hospitals in which emergency physicians practice today. The Hill-Burton Act stated that funded hospitals would provide care to patients who were unable to pay for free or at reduced cost, making the hospital an access point for all.

As the population boomed, so did the need for unscheduled and acute care, but the medical community could not meet those demands. As a result, the local hospital’s small emergency room became the community access point and a physician on call was assigned to respond. A 1958 New England Journal of Medicine article reported survey responses from 63 hospitals in the Midwest and Atlantic seaboard.1 It found a nearly 400 percent increase in emergency room visits in the 15-year period of 1940–1955, with a 16.2 percent admission rate.

The driving force for patient visits to the emergency department was limited access to their physicians on nights and weekends, as well as physicians’ concerns that the patients’ needs were more than could be provided for in their offices. The authors noted that, “The study reflects an apparent change in thinking upon the part of physicians and the public and suggests that physicians and hospitals should plan for the future by increasing emergency room facilities. It is believed that this trend is dictated by the public.” The study recommended expansion of dedicated floor space to the emergency room.

A tripling of emergency room visits nationwide occurred between the 1940s and the 1960s. The decade of the 1960s represents a confluence of policy and social changes that lit the match for the creation of emergency medicine and the transformation of the emergency room into the emergency department. By 1961, the first groups of physicians dedicated to providing care in the emergency department started.

Several major events in the 1960s converged to change social thinking and the health care landscape. In 1966, the National Academy of Sciences and National Research Council published the landmark report, “Accidental Death and Disability: The Neglected Disease of Modern Society,” which highlighted the magnitude of the injury problem in America and the poor state of ambulance and emergency services.2 Motor vehicle injuries, during a time in which automobiles and highways were also booming, were a matter of particular concern. The report noted that soldiers injured in the Korean War on the front lines were systematically moved to emergency care better and faster than Americans at home injured in motor vehicle crashes. This white paper had a huge impact on EMS and emergency services in hospitals.

Emergency medicine can look back at 50 years of change and recognize that our growth and advancement is underscored by the profession’s commitment to the needs of patients and communities.

Health Care Goes National

In 1965, health care became a national issue. About half of Americans age 65 or older (called “the aged”) lived in poverty and had no insurance. In response to growing public concerns, Medicare and Medicaid were enacted to provide insurance for the aged and money to the states to provide Medicaid to the poor. This was overseen by the Bureau of Health Insurance, which became the Health Care Financing Administration, and then became the Centers for Medicare and Medicaid Services. Hill-Burton–financed hospitals were obligated to accept these new insurances.

The resulting expansion of patients with insurance caused greater demand for care that existing doctors’ offices and clinics could not meet, so people turned to the emergency department for care, often sicker than if they had had routine care.

In 1966, President Lyndon Johnson, responding to a March report from the President’s Committee for Traffic Safety, made it a priority in his State of the Union address. He championed legislation, the Highway Safety Act, that included driver education, law enforcement, crash prevention, engineering standards, and medical care and transportation of the injured. The Department of Transportation was formed, and within it, the National Highway Traffic Safety Bureau was formed, later becoming the National Highway Traffic Safety Administration (NHTSA). EMS was expanded federally due to the death toll from motor vehicle crashes, which is why NHTSA has always played a large role in EMS and still does today. In 1971, NHTSA’s Office of EMS published the first guidelines for training emergency medical technicians.

In the 1970s, Congress enacted the Emergency Medical Services Systems Act of 1973 to authorize the Department of Health, Education, and Welfare to provide funding for planning and development of EMS systems throughout the United States. The act identified 15 specific components of EMS systems including manpower, training, communications, and data collection and led to the development of more than 300 regional EMS systems across the United States, both extending emergency care to the community and delivering higher-acuity patients to the emergency department.

In 1996, NHTSA brought the various participants in EMS together to create a common vision, The EMS Agenda for the Future, which helped modernize EMS and better integrate it with today’s complex health systems. That vision is currently being revised toward 2050, building upon the remarkable progress of the last few decades.

All of these have collectively placed a greater focus on emergency response and care and became a tipping point for emergency medicine, which began to grow as a specialty in response to needs of the increasingly complex patients arriving to emergency departments.

EMTALA, ACA, and Beyond

Congress inserted the Emergency Medical Treatment and Active Labor Act (EMTALA) into a budget bill in 1986 in response to national media focus on stories of unstabilized insured patients, including inpatients, being sent from private hospitals to public hospitals after a “billfold” biopsy. It was signed into law by President Ronald Reagan in 1987 and placed obligations on all hospitals to medically screen patients to determine if an emergency medical condition exists prior to inquiring about payment or insurance, provide care until stabilized for those with an emergency medical condition, and, if a transfer is required, to make it within the provisions of EMTALA. EMTALA has had many changes over the years, and its effects, both good and bad, are significant. It continues to be a major force in the provision of emergency care and establishing emergency departments and emergency physicians as the safety net for the United States.

The Patient Protection and Affordable Care Act (ACA), in response to a growing number of Americans who were uninsured because of low income or rising costs of insurance, passed in 2010 and was signed by President Barack Obama. It reinforced emergency care as an essential health benefit and expanded health insurance coverage for millions of Americans, either through private insurance or Medicaid expansion by states that chose to do so. Mired in politics and the challenges of change, its lasting effects will continue to play out. Increased coverage has not translated to increased access to care and already stressed emergency departments have seen volumes rise.

Three interconnected trends are reshaping both the emergency department and emergency medicine: the aging of the population, growth of chronic disease, and the move from inpatient to outpatient care. These older patients are more complicated and require complex evaluation and treatment. The disposition mindset has reversed. In the past, we admitted patients to have them worked up. Now, these patients are worked up to determine if they need to be admitted. As a result, emergency physicians are increasingly the decision makers for hospital admissions and have expanded their scope to manage observation units. These trends will likely continue and grow to include more telehealth, telemedicine, admissions to “hospital at home,” and placing satellite emergency departments placed in the communities closer to the patients.

Emergency medicine can look back at 50 years of change and recognize that our growth and advancement are underscored by the profession’s commitment to the needs of patients and communities. It has always been this way and always will be.


Dr. Martinez is chief medical officer for Adeptus Health in Irving, Texas; assistant professor of emergency medicine at Emory University in Atlanta; and an ACEP Now editorial board member.

Reference

  1. Shortliffe EC, Hamilton TS, Noroian EH. The emergency room and the changing pattern of medical care. N Engl J Med. 1958;258(1):20-25.
  2. National Academy of Sciences and National Research Council Committee on Trauma; National Academy of Sciences and National Research Council Committee on Shock. Accidental death and disability: the neglected disease of modern society. Washington, D.C.: National Academies Press (US); 1966.

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When Unconscious Bias Hits Home (Again) https://www.acepnow.com/article/when-unconscious-bias-hits-home-again/ https://www.acepnow.com/article/when-unconscious-bias-hits-home-again/#respond Sun, 15 Jul 2018 22:29:03 +0000 https://www.acepnow.com/?post_type=article&p=19209 It was surprising to receive an email advising me that I had appeared on the front page...

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Figure 1: The Atlanta Journal Constitution website showing the image of Dr. Hany Atallah and Dr. Sheryl Heron. Note that Dr. Heron was not listed as Dr.

It was surprising to receive an email advising me that I had appeared on the front page of the Atlanta Journal Constitution (AJC), the local newspaper in Atlanta. Without reading the article, which addressed the end of the flu crisis in Georgia, there I was with my colleague and friend Hany Atallah, MD. There was an image of Dr. Atallah and me. I was advised the image was quite reflective of the seriousness of the flu season and the flu season finally coming to a close. What I didn’t see, which my husband immediately brought to my attention, was the verbiage underneath the photo. My husband simply stated, “Now that’s unconscious bias right there on the front page.” Puzzled, I didn’t understand what he meant. However, there it was. My colleague and friend Hany was noted as Dr. Hany Atallah, and I was noted as Sheryl Heron, not Dr. Sheryl Heron (see Figure 1).

As one who has spent a large part of my professional life giving local and national presentations on unconscious bias, there it was staring me in the face. As an African-American woman, full professor in emergency medicine, vice chair as the article noted, and assistant dean, why wasn’t I afforded the title of doctor as my male colleague was?

The data are clear on gender and racial bias, with more studies addressing this reality each day. These biases contribute to microaggressions and the continuous need for women and underrepresented minorities (URMs) to feel they have to prove themselves.

My colleague Michelle Lall, MD, MHS, president of the Academy for Women in Academic Emergency Medicine (AWAEM), and I were co-authors on a paper addressing the current status of gender and racial/ethnic disparities in academic emergency medicine physicians.1 The paper revealed that gender and URM disparities exist and persist as it relates to salary and rank among full-time US academic emergency medicine faculty. There are also gender and URM disparities in rank and leadership positions. Women earn less than men regardless of rank, clinical hours, or training. There are multiple studies showing that women physicians lag behind their male counterparts in compensation, research funding, leadership opportunities, and achievement.2–9 These trends have been consistent over the last 15 to 20 years and are not improving.

As we continue to examine unconscious bias, not calling attention to examples such as these when they occur will only serve to perpetuate the problem. We’ve earned the right, as our male colleagues enjoy, to be addressed as doctor, and we count on the media to help us recognize these biases. We can and must do better.


Dr. HeronDr. Heron is professor and vice chair of administrative affairs in the department of emergency medicine, assistant dean of clinical education and student affairs, and associate director for education and training at the Injury Prevention Research Center at Emory University School of Medicine in Atlanta.

References

  1. Madsen TE, Linden JA, Rounds K, et al. Current status of gender and racial/ethnic disparities among academic emergency medicine physicians. Acad Emerg Med. 2017;24(10):1182-1192.
  2. Jagsi R, Griffith KA, Stewart A, et al. Gender differences in the salaries of physician researchers. JAMA. 2012;307(22):2410-7241.
  3. Lo Sasso AT, Richards MR, Chou CF, et al. The $16,819 pay gap for newly trained physicians: the unexplained trend of men earning more than women. Health Aff (Millwood). 2011;30(2):193-201.
  4. Seabury SA, Chandra A, Jena AB. Trends in the earnings of male and female health care professionals in the United States, 1987 to 2010. JAMA Intern Med. 2013;173(18):1748-1750.
  5. Grisham S. Physician compensation report 2017. Medscape website. Accessed June 12, 2018.
  6. Jena AB, Khullar D, Ho O, et al. Sex differences in academic rank in US medical schools in 2014. JAMA. 2015;314(11):1149-1158.
  7. Wehner MR, Nead KT, Linos K, et al. Plenty of moustaches but not enough women: cross sectional study of medical leaders. BMJ. 2015;351:h6311.
  8. Cheng D, Promes S, Clem K, et al. Chairperson and faculty gender in academic emergency medicine departments. Acad Emerg Med. 2006;13(8):904-906.
  9. Boiko JR, Anderson AJM, Gordon RA. Representation of women among academic grand rounds speakers. JAMA Intern Med. 2017;177(5):722-724.

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