ACEP NowACEP Now https://www.acepnow.com Tue, 30 Jun 2020 18:24:28 +0000 en-US hourly 1 https://wordpress.org/?v=5.4.2 Investing Lessons from the CoronaBear https://www.acepnow.com/article/investing-lessons-from-the-coronabear/ https://www.acepnow.com/article/investing-lessons-from-the-coronabear/#respond Mon, 29 Jun 2020 18:07:54 +0000 https://www.acepnow.com/?post_type=article&p=23354 Note: This column was written on April 30. Economics, like the coronavirus itself, is an evolving situation....

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Note: This column was written on April 30. Economics, like the coronavirus itself, is an evolving situation. Please take that into account as you read the following:

Question: What lessons can we draw from the recent coronavirus-associated economic downturn, or the “CoronaBear” market?

Answer: Even at this early juncture, I think there are at least six lessons that can be drawn from this collective economic experience.

Stocks Are Risky

For many physicians, especially those younger than 40, the recent market downturn was their first experience losing a large amount of real money. At its nadir, the stock market was down 35 percent. A physician with a $2 million portfolio composed of 80 percent stock would have lost over half a million dollars. That might represent twice the cost of their education, more than the value of their house, or a decade worth of retirement account contributions. This is not a mere academic financial experience but an emotional and behavioral one. You likely learned a lot about your risk tolerance and can now adjust your investing plan going forward accordingly. If you did not have a written investing plan, you likely learned the value of having one. You also learned the value of having less-risky assets like bonds in a portfolio.

There are three good ways to protect yourself from stock market risk. First, don’t put all of your money into the stock market, placing at least some of it into less-risky assets like bonds. Second, diversify. Rather than trying to pick the winning companies out of the economy, simply use low-cost, broadly diversified index funds that hold thousands of stocks to ensure you get the market return. Finally, hold those stock index funds for decades. Money you need any time soon does not belong in stocks.

Markets Recover

The second lesson that can be drawn from this experience is that markets are resilient and recover eventually. I did a Twitter survey of more than 1,000 investors, mostly physicians, at the bottom of the market in March. Pessimism abounded. About 93 percent of them expected stock market losses to continue, and the majority expected losses greater than those experienced in the 2008 global financial crisis. As the market rapidly recovered throughout April, it was widely described as a “dead cat bounce,” meaning the market was sure to soon go right back down. Those who attempted to time the bottom found themselves missing out on years’ worth of gains in just a few weeks. While every bear market is unique, they all end eventually. Those who pay attention to financial history “have seen this movie before and know how it ends.” They know the difficulty of trying to time the market, so they don’t even try. They simply follow their investing plan unemotionally and make sure they’re still in the market to capture those market gains when the recovery does happen. Ensure your investing plan does not require a functioning crystal ball to reach your reasonable financial goals.

Physician Incomes Are Not Secure

Perhaps the biggest surprise of the CoronaBear was seeing physicians lose both assets and income at the same time. Medicine, especially emergency medicine, is generally considered to be relatively insulated from economic downturns. People need medical care in both good times and bad, the thinking goes. Especially during a pandemic, one would expect physicians to be working and earning more than they usually do, not less. Thus, we were surprised to see ED volumes drop by 50 percent or more. Those of us who own our jobs took massive pay cuts. Employees were furloughed or even asked to take voluntary pay cuts, all while facing greater personal health risks to themselves and their families. Instead of being able to take advantage of the economic situation by “buying stocks on sale,” we were forced to dramatically cut spending and saving just to make ends meet. The lesson is that physicians need an emergency fund just like everyone else. An emergency fund is generally considered to be three to six months of living expenses invested in a very safe, liquid place like a high-yield savings account or money market fund. Physicians who were furloughed without one will never forget that mistake.

Government Help Isn’t Always Fair

The CARES Act and similar legislation were rushed through Congress at nearly the bottom of the stock downturn. The impact of the law had varied across the economic spectrum. For example, a family of four with an adjusted gross income of $150,000 per year received $3,400 in stimulus money. A family of four with an adjusted gross income of  $200,000 per year received nothing. A single employee earning $100,000 per year received nothing, while an independent contractor with the same income would have been eligible for a forgiveable loan of more than $16,000. While on a macroeconomic scale the stimulus may have accomplished many of its goals to prop up the economy, on a microeconomic scale it demonstrated the challenges of rapid, massive government intervention in the economy.

Ownership Matters

Many physicians have learned that it really does matter who they work for. Those employed by the military, government, and large universities saw no changes in their monthly paychecks and benefits. Many of those employed by private employers, including contract management groups and other private equity–backed enterprises, were told to use their paid time off or asked to take a “voluntary” 20 to 50 percent pay cut. They may have even been furloughed or laid off entirely. Some of those doing locum tenens work saw the pool of available shifts dry up or were only offered work in the most dangerous parts of the country. Partners in democratic groups experienced the risk they have been taking for years. While they keep the benefits when the group is profitable, they also suffer the losses when it is not. Overall, I was disappointed to see so few examples of servant leadership in the crisis among the owners of physician practices. Good leaders (and owners) eat last. When there isn’t enough “food” to go around, they don’t get any. Expecting employees who never reap the benefits of business profit to take a pay cut at threat of job loss when there are business losses is profoundly unfair in any but the most dire business circumstances.

Wellness Matters

Finally, we learned that wellness matters. Although we all experienced some of the “war-like” attributes of fighting a pandemic, the experience of emergency physicians in New York City, New Orleans, Detroit, and similar hot zones was profoundly different from that of physicians in other areas, with resulting stress, anxiety, posttraumatic stress disorder, and worse. While there is much more to wellness than finances, adding financial stress to the mix at such a time demonstrates the benefits of having a solid financial plan.

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Residency Spotlight: Mount Sinai-Elmhurst https://www.acepnow.com/article/residency-spotlight-mount-sinai-elmhurst/ https://www.acepnow.com/article/residency-spotlight-mount-sinai-elmhurst/#respond Wed, 24 Jun 2020 16:19:39 +0000 https://www.acepnow.com/?post_type=article&p=23456 Mount Sinai-Elmhurst Twitter: @SinaiEM Location: New York City (NYC) Year founded: 1994 Current number of residents: 25...

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Mount Sinai-Elmhurst

Mount Sinai-Elmhurst

Twitter:
@SinaiEM

Location:
New York City (NYC)

Year founded:
1994

Current number of residents:
25 per class

Program length:
4-year program

Secret weapons (medical)

Patients bring their pathology from all over the world to the cutting-edge Mount Sinai system and Elmhurst Hospital Center, which is in the most diverse immigrant neighborhood in the country. Resident shifts in dedicated critical care areas and a strong EM-critical care faculty presence at both Sinai and Elmhurst leave residents prepared to treat any condition. Our 4-year curriculum offers one of the best-developed scholarly track programs in the country, backed by an unusual amount of curriculum time, mentoring, and department resources devoted to career development. Our residents are very involved in every department initiative and on a national level in their areas of interest and often graduate into leadership positions.

Secret weapons (non-medical)

Being among our big family in a vibrant city makes it easier to face the challenges of residency (even when you become the epicenter of the epicenter of a pandemic). There are endless ways to play in NYC and so many residents live near each other—in the same building or within a few blocks—that bonding is inevitable. See the results weekly at Tuesday Night Fun or any time you walk into our break rooms. Also, it‘s NYC so we get every imaginable kind of food delivered straight to the emergency department at all hours!

Recent publications of note:

Trivia

More than 130 languages are spoken in the Elmhurst Hospital neighborhood. Within three blocks of the hospital you can buy a sari, have some coffee from a Colombian coffee shop, and sweat in a Korean sauna.

—Elaine Rabin, MD, FACEP, program director, residency in emergency medicine

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Dispelling 5 Ovarian Torsion Myths https://www.acepnow.com/article/dispelling-5-ovarian-torsion-myths/ https://www.acepnow.com/article/dispelling-5-ovarian-torsion-myths/#respond Wed, 24 Jun 2020 16:14:53 +0000 https://www.acepnow.com/?post_type=article&p=23460 The Case A 28-year-old female presents with severe lower right quadrant pain. Her intermittent pain started three...

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The Case

A 28-year-old female presents with severe lower right quadrant pain. Her intermittent pain started three days ago. She has had several episodes of non-bloody emesis, which usually occurs when the pain worsens, but she denies vaginal bleeding, vaginal discharge, urinary symptoms, fever, diarrhea, back pain, or other symptoms. She is significantly tender in the right lower quadrant, but a pelvic exam is unrevealing.

Abdominal and pelvic pain are common presentations in the emergency department, ranging from benign to serious. One important and dangerous condition not to miss is ovarian torsion.

Ovarian torsion occurs when the ovary completely or partially rotates on the ligamentous supports, resulting in necrosis and infertility if missed.1–5 Here are five myths that can mislead the emergency physician.

Myth #1: Only Women of Reproductive Age Experience Ovarian Torsion

While ovarian torsion most commonly affects women of reproductive age, typically around 30 years old, the risk factor most strongly associated with torsion is an adnexal mass >5 cm, occurring in up to 80 percent of patients with torsion; underlying risks include polycystic ovarian syndrome, undergoing fertility therapies, history of previous torsion, and history of tubal ligation.3–16

Approximately 15 percent of ovarian torsion cases occur in pediatric patients, which is thought to occur due to an elongated utero-ovarian ligament.3–5,11–13 Unlike other patient populations, more than half of pediatric patients with ovarian torsion have normal ovaries.3–5,9–16 Postmenopausal patients account for another 15 percent of cases, although almost all of these patients have an enlarged ovary or mass within the pelvis. Pregnant patients are also at risk, accounting for 10 to 25 percent of all cases.5,9,16–20 In fact, pregnancy is a significant risk factor for torsion, primarily due to progesterone increasing the risk of ovarian cyst formation.16–20 Most patients with torsion during pregnancy experience it in the first 17 weeks (81 percent), and 73 percent of these patients have undergone fertility therapy.4,18–20 Fertility treatments can result in ovarian hyperstimulation, further increasing the risk of ovarian cyst formation.5,15

Key Point: Consider ovarian torsion in female patients of all ages.

Myth #2: All Patients with Ovarian Torsion Present with Acute Severe Pain and Vomiting

Symptoms of ovarian torsion occur due to occlusion of vascular flow from torsion of the vascular pedicle. We classically associate this with abrupt, severe pain in the lower abdomen that radiates to the flank or inguinal area as well as nausea and vomiting.4–7,10,21,22 However, sudden, severe pain only occurs in 50 percent of patients.4–7,22 Some form of pain is present in up to 90 percent of patients, but the description of the pain varies.4–7,22 Symptoms can be vague, lasting for days to months, and be constant or episodic due to intermittent torsion and detorsion of the ovary.23,24 Pain may resemble that of appendicitis, urolithiasis, ectopic pregnancy, and other conditions. Nausea and vomiting occurs in up to 70 percent of patients, and fever may also occur in 2 to 20 percent of patients, further complicating the diagnosis.4,6,7,12,23,24 Diagnosing torsion in infants is extremely difficult, as these patients may present with irritability, fussiness, vomiting, or feeding intolerance.5,11–13 Pediatric females can present with diffuse pain and fever, typically resulting in delayed diagnosis.5,25,26

Importantly, the critical ischemia time for the ovaries that results in necrosis is unknown. Patients may have symptoms for hours to days, and there is no specific time cutoff that reliably predicts irreversible necrosis.4,5,27–29

Key Point: Patients with ovarian torsion may present with constant, severe, abrupt, intermittent, or mild pain.

Myth #3: A Normal Physical Exam, Including Pelvic Exam, Can Rule Out Torsion

Up to one-third of patients have no tenderness on either an abdominal or pelvic exam.4–7,10 One of the key risk factors is an ovarian mass or cyst, but unfortunately, exams are also unreliable in detecting the presence of adnexal tenderness or mass, with an inter-examiner reliability ranging from 23 to 32 percent.5,30 Results are no better with a gynecologist-performed exam, with a sensitivity of detecting a mass >5 cm of 15 to 36 percent.5,31 The exam’s reliability further decreases in the setting of increased patient weight (defined as >200 pounds) and in patients older than age 55.32

Key Point: A normal abdominal or pelvic exam does not exclude ovarian torsion.

Myth #4: A Normal Ultrasound Can Rule Out Torsion

Transvaginal ultrasound (TVUS) with grayscale imaging and Doppler flow is usually the go-to imaging modality to evaluate for torsion. While TVUS has high specificity, it has poor sensitivity, ranging from 35 to 85 percent.33–35 The most common finding is an enlarged ovary due to edema, often with a mass.5,16,17,33–36 Other signs include an ovary displaced to the midline. The “string-of-pearls sign,” in which an enlarged ovary is lined around the periphery by follicles, suggests torsion.5,16,17,33–36 Grayscale may demonstrate a hypoechoic appearance of the ovary due to edema. Color Doppler may reveal decreased or absent intraovarian venous flow, which may be followed by absent arterial flow later in the disease (see Figure 1).5,16,17,33–36 One major pitfall with TVUS use is reliance of normal arterial flow to exclude torsion, as the ovaries have dual blood flow from the ovarian and uterine arteries.5,34 Torsion initially occurs with lymphatic and venous outflow obstruction. Arterial inflow is not compromised until later in the disease course.35,36 Arterial flow is completely normal in more than 25 percent of patients with surgery-confirmed torsion, and more than half of patients will have detectable arterial flow.16,17,35,36 Therefore, assessing venous flow is a better indicator. However, intermittent or partial torsion may also result in normal venous flow TVUS.

Figure 1 (ABOVE) Ovarian torsion on ultrasound with enlarged ovary and absent vascular flow.

Figure 1 (ABOVE)
Ovarian torsion on ultrasound with enlarged ovary and absent vascular flow.
Case courtesy of Dr. Maulik S. Patel, Radiopaedia.org, rID: 30458

Literature suggests that combining ultrasound findings can improve sensitivity and specificity compared to only focusing on vascular flow.5 Evaluating for free fluid within the pelvis, ovarian enlargement and edema, and vascular flow can improve sensitivity.5 The whirlpool sign is strongly suggestive of torsion; it consists of a circular collection of blood vessels within an enlarged ovary or mass.5,37,38

Key Point: Do not rely on normal vascular flow to rule out ovarian torsion. A combination of TVUS findings such as ovarian enlargement and mass, free fluid in the pelvis, and vascular flow may improve your ability to diagnose ovarian torsion.

Myth #5: CT of the Abdomen and Pelvis Has No Role in Evaluating Ovarian Torsion

Figure 2 (RIGHT) CT depicting twisted follicle and enlarged ovary.

Figure 2 (RIGHT)
CT depicting twisted follicle and enlarged ovary.

Patients with undifferentiated abdominal pain often undergo CT, but can CT assist in ruling in or out ovarian torsion? CT with IV contrast will often display findings suggestive of torsion.5,16,33,39–42 Findings on CT with high specificity for ovarian torsion include a twisted vascular pedicle (see Figure 2), a thickened fallopian tube with target/beak-like appearance, absent or reduced ovarian enhancement with contrast, and an enlarged ovary with a follicular ovarian stroma and peripherally displaced follicles.16,33,39–42 Features that are commonly found but not specific include an enlarged ovary, an adnexal mass, adnexal mass mural thickening, free pelvic fluid, fat stranding surrounding the ovary, uterine deviation toward the torsed ovary, and ovarian displacement toward the uterus.16,33,39–42 CT with contrast demonstrates a high sensitivity for these secondary findings, approaching 100 percent.16,33,39–42 If one of these secondary findings is present, TVUS and OB/GYN consultation should be expedited. If these findings are not present and the ovary is normal in size, TVUS may not be needed, depending on the any changes in the clinical course. If the ovary is abnormal on CT, then obtain TVUS.

Finally, if suspicious of torsion based on your history and exam, an ob-gyn consultation should be initiated prior to imaging. If an ob-gyn is unavailable, a general surgery consultation is warranted. Torsion is a time-sensitive condition; early involvement of specialists is paramount.

Key Point: A normal CT of the abdomen and pelvis with contrast that has no secondary findings displays high sensitivity for excluding ovarian torsion. If secondary findings such as an enlarged ovary are present, then obtain TVUS.

Case Conclusion

The CT of the abdomen and pelvis reveals a normal appendix but an enlarged right ovary. A small amount of pelvic free fluid and fat stranding around the right ovary are observed. You consult the ob-gyn on call, who requests a TVUS. The TVUS reveals an enlarged ovary with decreased venous flow on Doppler. The ob-gyn evaluates the patient and takes her to the operating room, where detorsion is successful.


Dr. Long is an emergency physician in the San Antonio Uniformed Services Health Education Consortium at Fort Sam Houston, Texas. Dr. Koyfman (@EMHighAK) is assistant professor of emergency medicine at UT Southwestern Medical Center and an attending physician at Parkland Memorial Hospital in Dallas. Dr. Gottlieb is associate professor, ultrasound division director, and ultrasound fellowship director in the department of emergency medicine at Rush University Medical Center in Chicago.

Key Points

  • Ovarian torsion can affect women of all ages.
  • Pain in the setting of ovarian torsion can vary significantly; it may be abrupt, intermittent, or not present at all.
  • The exam is unreliable. Do not use it to exclude ovarian torsion.
  • Use a combination of factors on TVUS when evaluating torsion: Doppler flow, ovarian size, and free fluid within the pelvis.
  • A completely normal CT of the abdomen/pelvis with contrast is sensitive for ovarian torsion. If there are secondary findings (eg, enlarged ovary), obtain a TVUS.
  • Consult an ob-gyn early in the care of these patients.

References

  1. Oelsner G, Shashar D. Adnexal torsionClin Obstet Gynecol. 2006;49(3):459-463.
  2. Hibbard LT. Adnexal torsionAm J Obstet Gynecol. 1985;152(4):456-461.
  3. Adelman S, Benson CD, Hertzler JH. Surgical lesions of the ovary in infancy and childhood. Surg Gynecol Obstet. 1975;141:219-226.
  4. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001;38(2):156-159.
  5. Robertson JJ, Long B, Koyfman A. Myths in the evaluation and management of ovarian torsion. J Emerg Med. 2016;52(4):449-456.
  6. White M, Stella J. Ovarian torsion: a 10-year perspective. Emerg Med Australas. 2005;17(3):231-237.
  7. Huchon C, Panel P, Kayem G, et al. Does this woman have adnexal torsion? Hum Reprod. 2012;27(8):2359-2364. 
  8. Varras M, Tsikini A, Polyzos D, et al. Uterine adnexal torsion: Pathologic and gray-scale ultrasonographic findingsClin Exp Obstet Gynecol. 2004;31(1):34-38. 
  9. Bouguizane S, Bibi H, Farhat Y, et al. Adnexal torsion: a report of 135 cases. J Gynecol Obstet Biol Reprod (Paris). 2003;32(6):535-540.
  10. Tsafrir Z, Hasson J, Levin I, et al. Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence. Eur J Obstet Gynecol Reprod Biol. 2012;162(2):203-205.
  11. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005; 159(6):532-535.
  12. Tsafrir Z, Azem F, Hasson J, et al. Risk factors, symptoms, and treatment of ovarian torsion in children: the twelve-year experience of one center. J Minim Invasive Gynecol. 2012;19(1):29-33.
  13. Worthington-Kirsch RL, Raptopoulos V, Cohen IT. Sequential bilateral torsion of normal ovaries in a child. J Ultrasound Med. 1986;5(11):663-664.
  14. Schmeler KM, Mayo-Smith WW, Peipert JF, et al. Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol. 2005;105(5 Pt 1):1098-1103.
  15. Gorkemli H, Camus, M, Clasen K. Adnexal Torsion after gonadotropin ovulation induction for IVF or ICSI and its conservative treatment. Arch Gynecol Obstet. 2002;267(1):4-6.
  16. Chiou SY, Lev-Toaff AS, Masuda E, et al. Adnexal torsion: new clinical and imaging observations by sonography, computed tomography, and magnetic resonance imaging. J Ultrasound Med. 2007;26(10):1289-1301.
  17. Albayram F, Hamper UM. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med. 2001;20(10):1083-1089.
  18. Hasson J, Tsafrir Z, Azem F, et al. Comparison of adnexal torsion between pregnant and nonpregnant women. Am J Obstet Gynecol. 2010;202(6):536.e1-6.
  19. Johnson TR Jr, Woodruff JD. Surgical emergencies of the uterine adnexae during pregnancyInt J Gynaecol Obstet. 1986;24(5):331-335. 
  20. Yen CF, Lin SL, Murk W, et al. Risk analysis of torsion and malignancy for adnexal masses during pregnancyFertil Steril. 2009;91(5):1895-1902.
  21. Karaman E, Beger B, Çetin O, et al. Ovarian torsion in the normal ovary: a diagnostic challenge in postmenarchal adolescent girls in the emergency departmentMed Sci Monit. 2017;23:1312-1316.
  22. Rey-Bellet Gasser C, Gehri M, Joseph JM, et al. Is it ovarian torsion? A systematic literature review and evaluation of prediction signsPediatr Emerg Care. 2016;32(4):256-261.
  23. Ashwal E, Hiersch L, Krissi H, et al. Characteristics and management of ovarian torsion in premenarchal compared with postmenarchal patients. Obstet Gynecol. 2015;126(3):514-520.
  24. Ashwal E, Krissi H, Hiersch L, et al. Presentation, diagnosis, and treatment of ovarian torsion in premenarchal girls. J Pediatr Adolesc Gynecol. 2015;28(6):526-529.
  25. Schmitt ER, Ngai SS, Gausche-Hill M, et al. Twist and shout! Pediatric ovarian torsion clinical update and case discussion. Pediatr Emerg Care. 2013;29(4):518-523; quiz 524-526.
  26. Poonai N, Poonai C, Lim R, et al. Pediatric ovarian torsion: case series and review of the literature. Can J Surg. 2013;56(2):103-108.
  27. Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound evaluation of gynecologic causes of pelvic pain. Obstet Gynecol Clin North Am. 2010;38(1):85-114.
  28. Taskin O, Birincioglu M, Aydin A, et al. The effects of twisted ischaemic adnexa managed by detorsion on ovarian viability and histology: an ischaemia-reperfusion rodent model. Hum Reprod. 1998;13(10):2823-2827.
  29. Oelsner G, Cohen SB, Soriano D, et al. Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function. Hum Reprod. 2003;18(12):2599-2602.
  30. Close RJH, Sachs CJ, Dyne PL. Reliability of bimanual pelvic examinations performed in emergency departments. West J Med. 2001;175(4):240-244.
  31. Padilla LA, Radosevich DM, Milad MP. Accuracy of the pelvic examination in detecting adnexal masses. Obstet Gynecol. 2000;96(4):593-598.
  32. Ueland FR, Depriest PD, Desimone CP, et al. The accuracy of examination under anesthesia and transvaginal sonography in evaluating ovarian size. Gynecol Oncol. 2005;99(2):400-403.
  33. Swenson DW, Lourenco AP, Beaudoin FL, et al. Ovarian torsion: case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department. Eur J Radiol. 2014;83(4):733-738.
  34. Wilkinson CSanderson A. Adnexal torsion—a multimodality imaging review. Clin Radiol. 2012;67(5):476-483.
  35. Ben-Ami M, Perlitz Y, Haddad S. The effectiveness of spectral and color Doppler in predicting ovarian torsion. A prospective study. Eur J Obstet Gynecol Reprod Biol. 2002;104(1):64-66.
  36. Nizar K, Deutsch M, Filmer S, et al. Doppler studies of the ovarian venous blood flow in the diagnosis of adnexal torsion. J Clin Ultrasound. 2009;37(8):436-439.
  37. Valsky DV, Esh-Broder E, Cohen SM, et al. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsionUltrasound Obstet Gynecol. 2010;36(5):630-634.
  38. Vijayaraghavan SB, Senthil S. Isolated torsion of the fallopian tube: the sonographic whirlpool signJ Ultrasound Med. 2009;28(5):657-662.
  39. Hiller N, Appelbaum L, Simanovsky N, et al. CT features of adnexal torsion. AJR Am J Roentgenol. 2007;189(1):124-129.
  40. Dhanda S, Quek ST, Ting MY, et al. CT features in surgically proven cases of ovarian torsion—a pictorial reviewBr J Radiol. 2017;90(1078):20170052.
  41. Duigenan S, Oliva E, Lee SI. Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation. AJR Am J Roentgenol. 2012;198(2):W122-131.
  42. Moore C, Meyers AB, Capotasto J, et al. Prevalence of abnormal CT findings in patients with proven ovarian torsion and a proposed triage schema. Emerg Radiol. 2009;16(2):115-220.

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Emergency Departments Can Help Get Patients Registered to Vote https://www.acepnow.com/article/emergency-departments-can-help-get-patients-registered-to-vote/ https://www.acepnow.com/article/emergency-departments-can-help-get-patients-registered-to-vote/#respond Wed, 24 Jun 2020 16:11:51 +0000 https://www.acepnow.com/?post_type=article&p=23428 Rates of electoral participation in the United States continue to rank in the bottom quartile among developed...

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Waiting room sign with a text message regisstration trigger.
Alister Martin

Rates of electoral participation in the United States continue to rank in the bottom quartile among developed nations.1 Resulting from a number of factors, poor voter turnout has characterized our democracy for decades.2 Can emergency departments help? It might seem like an oddly arranged marriage, but it isn’t.

A majority of U.S. voters consistently rank health care as their top policy priority. Simultaneously, voter rolls are shrinking. This suggests that a smaller and smaller group of people are having their voices heard on the direction of health policy.3,4 This is especially troubling for communities of color, those living in poverty, and the young, who are often among the least politically active. COVID-19 has led to the closure of motor vehicle registration offices and other traditional voter registration venues, resulting in plummeting rates of voter registration nationwide. We know that these marginalized patient populations use emergency departments at disproportionately higher rates than the average population because of a lack of access to traditional forms of health care.5 The discrepancies in ED use along the lines of age, race, and socioeconomic demographics represent both a challenge and an opportunity for health care workers as the needs of these populations often extend beyond traditional health care boundaries.

Rising to the Challenge

Many health care professionals have risen to this challenge by broadening their scope of care, engaging more deeply with the social determinants of health, and administering programs that address larger societal issues affecting their patients such as housing, food insecurity, and opioid addiction.6,7 Marginalized patient populations benefit most from these and larger structural changes needed to improve health care delivery systems. But they also have the lowest rates of voter registration.

For example, a disproportionately large share of eligible Americans who were not registered in the 2016 presidential election were low-income citizens and people of color.8 Among eligible voters, 31 percent of African Americans, 43 percent of Hispanics, and just over 43 percent of low-income Americans were not registered to vote in that election.9 Rates among the nation’s young voters are not much better: Only 50 percent of millennials voted in the 2016 election compared to 69 percent of baby boomers and 63 percent of generation X.10

Regardless of party affiliation, policy endorsement, or stance on a given issue, we can all agree that to be pro-democracy we must be pro-participation. Further, most can agree that without claiming their role in our democracy, these groups will never achieve true equity in and risk being politically voiceless.

Previous Efforts

Alister Martin

Alister Martin

Health care-based nonpartisan voter registration has worked before. In 2008, the National Association of Community Health Centers ran a voter registration drive in health centers that resulted in more than 18,000 low- and middle-income citizens added to official rolls.11 Another program, conducted in 2012 at two Federally Qualified Health Centers in the Bronx, New York, demonstrated that successful nonpartisan voter registration initiatives can be run out of community health centers without requiring significant physician effort, disrupting clinic workflows, or compromising the patient-doctor relationship.11

Patients have been extremely receptive to nonpartisan voter registration services, with one study finding that 89 percent of individuals approached in a health center waiting room expressed openness to registering to vote.11 These models, specifically directed toward low-acuity patients, are readily adapted to hospital ED waiting rooms.

Another Initiative: VotER

Accordingly, emergency departments across the United States have already begun implementing such voter registration efforts. VotER is one such effort that was founded at Massachusetts General Hospital in Boston and has since been adopted at more than a dozen emergency departments across the United States. The program uses iPad-based kiosks and posters and discharge paperwork with QR codes in low-acuity emergency department waiting areas to offer patients a convenient, nonpartisan, and optional opportunity to register to vote or check their registration status while waiting.

The platform does not interrupt clinical care or rely on doctors, physician assistants, or nurses providing care to interact with the voter registration process. Patients are guided through the voter registration application on their phone or the iPad-based kiosk in 90 seconds or less. Emergency departments can play a critical role in encouraging patients to register to vote without detracting from the delivery of care using platforms like VotER. Groups like VotER, Patient Voting, and Med Out The Vote are launching the first Civic Health Month in August 2020 to bring a renewed focus to helping patients get to the ballot box, particularly when COVID-19 has made voting in a safe and healthy way a public health issue.

Health care professionals must be concerned with our democracy’s health and mindful of who gets to participate in it. The demographic overlap of patients who lack access to stable care—and therefore use the emergency department at higher rates—and those who historically have low civic engagement affords a natural opportunity to pilot and develop voter registration efforts in the emergency department.

ED-based nonpartisan voter registration via nonintrusive platforms such as VotER is  an innovation that can improve our civic system and the well-being of the communities we serve. With an eye toward national elections later this year, emergency departments have the potential to elevate all patient voices in our national dialogue of how to deliver effective, affordable health care in the United States.

Visit www.vot-ER.org to learn more.  


Mr. KusnerMr. Kusner is 2021 MD candidate at Harvard Medical School in Boston.

Dr. DeanDr. Dean is an emergency medicine resident at Massachusetts General Hospital/Brigham and Women’s Hospital in Boston.

Dr. MartinDr. Martin is faculty at the Center for Social Justice and Health Equity at Massachusetts General Hospital.

References

  1. Desliver D. US trails most developed countries in voter turnout. Pew Research Center website. Accessed May 20, 2020.
  2. Oltman A. Why voter turnout is so low in the United States. Jacobin website.  Accessed May 18, 2020.
  3. Americans’ domestic priorities for President Trump and congress in the months leading up to the 2020 election. Politico website. Accessed May 18, 2020.
  4. KFF health tracking poll. Kaiser Family Foundation website. Accessed May 18, 2020.
  5. Augustine JJ. The latest emergency department utilization numbers are in. ACEP Now. 2019;38(10):36.
  6. Hawryluk M. Why hospitals are getting into the housing business. Medscape website. Accessed May 18, 2020.
  7. Cullen D, Blauch A, Mirth M, et al. Complete eats: summer meals offered by the emergency department for food insecurity. Pediatrics. 2019;144(4):e20190201.
  8. File T. Who votes? Congressional elections and the American electorate: 1978–2014. United States Census Bureau website. Accessed May 18, 2020.
  9. Voting and voter registration as a share of the voter population, by race/ethnicity. Kaiser Family Foundation website. Accessed May 20, 2020.
  10. File T. Voting in America: a look at the 2016 presidential election. United States Census Bureau website. Accessed May 18, 2020.
  11. Liggett A, Sharma M, Nakamura Y, et al. Results of a voter registration project at 2 family medicine residency clinics in the Bronx, New York. Ann Fam Med. 2014;12(5):466-469.

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Data Snapshots: U.S. Influenza and Pneumonia Deaths 2013–2020 https://www.acepnow.com/article/data-snapshots-u-s-influenza-and-pneumonia-deaths-2013-2020/ https://www.acepnow.com/article/data-snapshots-u-s-influenza-and-pneumonia-deaths-2013-2020/#respond Wed, 24 Jun 2020 16:06:23 +0000 https://www.acepnow.com/?post_type=article&p=23449 Dr. Ashoo is founder and CEO of Admin EM. More at admin-em.com

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A seasonal pattern of influenza and pneumonia deaths is seen annually. In 2020, there is a large increase in pneumonia deaths accompanying COVID-19. Source: CDC

(click for larger image) A seasonal pattern of influenza and pneumonia deaths is seen annually. In 2020, there is a large increase in pneumonia deaths accompanying COVID-19.
Source: CDC


Dr. Ashoo is founder and CEO of Admin EM. More at admin-em.com

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To Combat Potential Implicit Bias in EMS, Diversify the Workforce https://www.acepnow.com/article/to-combat-potential-implicit-bias-in-ems-diversify-the-workforce/ https://www.acepnow.com/article/to-combat-potential-implicit-bias-in-ems-diversify-the-workforce/#respond Wed, 24 Jun 2020 16:04:20 +0000 https://www.acepnow.com/?post_type=article&p=23497 Unconscious bias, the subject Uché Blackstock, MD, wrote a November 2019 column on in ACEP Now, can...

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Chris Whissen & Shutterstock.com

Unconscious bias, the subject Uché Blackstock, MD, wrote a November 2019 column on in ACEP Now, can be defined as “a person’s tendency to associate a group or category attribute, such as being black, with a negative evaluation (unconscious prejudice) or another category attribute, such as being violent (unconscious stereotype).”1 People in all walks of life throughout society, including physicians, possess these unconscious (or implicit) biases.

These subtle subconscious feelings that we and other health care workers might harbor toward our patients have likely been present since the beginnings of the profession. However, it is only relatively recently that we have recognized these implicit biases, sought to better understand them, and devised strategies to ameliorate them.2 Racial and ethnic disparities in the emergency department delivery of analgesia for something as universally painful as a long-bone fracture have been known for several decades; a recent study extends the concern about a potential unconscious bias prevalent in prehospital care.3

Controlling for socioeconomic status and geography, researchers investigated if patients were transported to safety-net facilities based on their race. For black patients, transport to a safety-net facility by EMS occurred approximately 5 percent more often than for white patients; for Hispanic patients, transport to a safety-net facility occurred about 2.5 percent more often.4

These data reflect a snapshot in time, suggesting—but not proving—implicit biases may be at play in the prehospital setting. We should ask whether these are the results of individual decisions made by prehospital health care workers. Or are these results the effect of systemic issues involving medical direction protocols? Or perhaps they can be explained by less nefarious means, such as patient preference.

Regardless of the cause(s), the National Association of EMS Educators recommends the following as one possible solution: “A diverse EMS workforce, representative of the patients it serves, is crucial to promote understanding among EMTs and paramedics, patients and other providers in the health care system, and to eliminate disparities in care experienced by minority patients.”

As in business and in medicine, the time for greater workforce diversity in prehospital care is at hand.  


Dr. DarkDr. Dark is assistant professor of emergency medicine at Baylor College of Medicine in Houston and executive editor of PolicyRx.org.

References

  1. Blackstock U. Overcoming unconscious bias takes strategy and collective effort. ACEP Now. 2019;38(11):19.
  2. Brownstein M. Implicit bias. Stanford Encyclopedia of Philosophy website. Accessed May 11, 2020.
  3. Todd KH, Deaton C, D’Adamo AP, et al. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16.
  4. Hanchate AD, Paasche-Orlow MK, Baker WE, et al. Association of race/ethnicity with emergency department destination of emergency medical services transport. JAMA Netw Open. 2019;2(9):e1910816.

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Is There Systemic Racism in EMS? https://www.acepnow.com/article/is-there-systemic-racism-in-ems/ https://www.acepnow.com/article/is-there-systemic-racism-in-ems/#respond Wed, 24 Jun 2020 15:58:52 +0000 https://www.acepnow.com/?post_type=article&p=23494 Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article....

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Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article.

Recent research has provided insight into what could prove to be another example of systemic racism in the delivery of health care.1 According to a 2019 study, EMS are more likely to transport a black or Hispanic patient to a safety-net hospital than their white counterparts even when such patients come from the same ZIP code. The authors used data from a nationwide Medicare data bank and then identified ZIP codes with an adequate amount of diversity as well as transports by EMS services. They also controlled for a multitude of variables, including socioeconomic status and location. Ultimately, they assessed whether the patient was transported to a safety-net hospital versus a reference hospital based on the patient’s race.

The point is quite clear: There are disparities in the way prehospital medicine is administered to minority patients. It is not understood whether this disparity has resulted in a difference in outcomes. However, it points to a need for more focused studies on prehospital medicine and the potential for racial disparities. 

There is more to be done, and it can be done now. Of the limitations with this paper, I find the most astonishing to be a product of American society: Out of 38,423 ZIP codes, only 5,606 of them had enough diversity to be included in the study. The requirements for diversity in this study meant having at least 10 percent white, black, and Hispanic patients in the same ZIP code. Only 15 percent of ZIP codes in America contain at least 10 percent of the three largest races and ethnicities in this country. These are the real-life ramifications of generations of segregation and redlining. Our generation must still actively and aggressively challenge segregation, a problem possibly now worse than ever due to gentrification.

Nationwide, EMS personnel are 83 percent white, and in the last 10 years, there has not been much increase in the 8 percent of black paramedics. This aspect of health care workforce diversity has not garnished as much attention as the racial disparities among physicians.

We don’t need a study to tell us this is unacceptable. We should diversify our EMS personnel, especially given that blacks are nearly 50 percent more likely to use the emergency department for health care than whites. 


Dr. Ellis is an emergency medicine medical education fellow at Beth Israel Deaconess Medical Center in Boston.

Reference

  1. Hanchate AD, Paasche-Orlow MK, Baker WE, et al. Association of race/ethnicity with emergency department destination of emergency medical services transport. JAMA Netw Open. 2019;2(9):e1910816.

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COVID-19 Testing: What’s Available, and Each Test’s Pros and Cons https://www.acepnow.com/article/covid-19-testing-whats-available-and-each-tests-pros-and-cons/ https://www.acepnow.com/article/covid-19-testing-whats-available-and-each-tests-pros-and-cons/#respond Tue, 16 Jun 2020 22:33:10 +0000 https://www.acepnow.com/?post_type=article&p=23421 Editors’ Note: This article was accepted on April 28, 2020, and was accurate at that time. Because...

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Editors’ Note: This article was accepted on April 28, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.

When SARS-CoV-2 appeared, we had no tests. The disease spread unchecked and unmeasured.

Today, we have several tests, each with its own unique roles and limitations. How should these be used, and what strengths and weaknesses affect their use?

Nucleic Acid-Based Tests

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These tests have been the work horses in diagnosing acute cases of COVID-19. The two primary analytic methods are reverse transcriptase polymerase chain reaction (RT-PCR) and loop-mediated isothermal amplification (LAMP). Regardless of the technique, the basic principle is the same: RNA from viral particles are bound to complementary DNA sequences, which are then copied. Repeated cycles of copying produce exponential amplification that, in sufficient quantity, reaches a defined threshold for a positive test. Absent specific SARS-CoV-2 RNA, minimal amplification occurs, and the test never reaches the threshold for positivity.

These tests are designed for those actively infected and shedding virus. Their analytic sensitivity and specificity are considered excellent, with limitations related to mismatches between the DNA primers and small alterations in the SARS-CoV-2 RNA genome. The DNA primers used may match fragments of other RNA found in samples but typically not to the extent where cross-reactivity impairs amplification of the target.

The sensitivities for these tests are limited by two main factors. The first issue is the process through which the specimen is obtained. The most widely recognized version of this test is the nasopharyngeal swab. An inadequate sampling technique will diminish the quality of the specimen, lowering sensitivity.

Second, viral load and shedding also decrease with time, contributing to diminishing sensitivity.1 Overall clinical sensitivity in practice appears similar to our expectations for common influenza tests, in a range approximating 70 to 80 percent.1 As many of us have  already experienced in our clinical workflow, a single negative nasopharyngeal swab does not adequately exclude COVID-19 infection when the remaining clinical picture is supportive. A positive test is, however, virtually unimpeachable.

Antibody Tests

Serological tests are designed to detect the presence of antibodies to SARS-CoV-2. The antibodies of interest include the acute-phase immunoglobulin (IgM), the late-phase (IgG), and occasionally IgA.1 These tests have been promoted widely as a critical part of plans to reopen America and are in frequent use in population prevalence studies.

Antibody tests are more complicated than DNA-based tests, however. Two main types, enzyme-linked immunosorbent assay (ELISA) and lateral-flow immunoassay (LFIA), are in use. These tests are more difficult to develop because the developers of these assays must synthesize their own novel viral fragments. This involves an analysis of the actual protein coat of the virus, typically focusing on the unique features of the spike protein and cell-entry apparatus. When serum or plasma containing antibodies to SARS-CoV-2 are mixed with the assay antigens, the test reporter systems provide a positive result.

The most pressing issue with these antibody tests is accuracy.

The ELISA tests require significant time and reagent cost but offer the advantage of quantitative antibody titers. These tests are valuable for accurately identifying high levels of circulating antibody for those being considered as possible donors for convalescent plasma donation (although the efficacy of this strategy remains unknown). The prolonged turnaround time and biohazard safety requirements for ELISA reduce its practicality for widespread testing.

In far greater use are LFIA-based devices, which are the widely seen cartridge-based tests. These tests do not typically report a quantitative measurement but provide positive and control color-change lines using a technique similar to home pregnancy tests. The major advantages of these tests are speed and cost. However, they lack the quantitative precision of ELISA.

The most salient issue with these antibody tests is accuracy. The sensitivity limitations of antibody tests are readily apparent because even acute-phase IgM responses are not immediate, usually taking a few days to develop. Therefore, a single antibody test should not be the sole mechanism for diagnosing acute infections. Consideration ought to be given to the time of symptom onset to determine the likelihood of a false negative, as well as either a DNA-based test or a plan to repeat the antibody test in a few days, if negative.

The other accuracy issues stem from antigen synthesis. The challenge for antigen synthesis involves creating a match for a piece of the virus that is both unique to SARS-CoV-2 while also stable enough not to result in mismatches as the virus naturally mutates. The most stable components of SARS-CoV-2 are also the ones conserved across multiple other coronaviruses, resulting in cross-reactivity and false positives. Several common-cold coronaviruses (eg, HKU1, NL63, OC43, 229E, etc.) are known to react with the antibodies in several developed serological tests. A false-positive test may endanger an individual by suggesting potential immunity from SARS-CoV-2 where none exists.

Antibody tests are also being deployed to evaluate the spread of COVID-19 in some communities. This renders false positives especially important. In communities in which little infection is thought to have occurred, the number of false positives can exceed the number of true positives, even in a test with high specificity. These false positives lead to overestimation of the number of potentially immune persons  and may misinform public policy decisions.

Conclusion

Each of the several SARS-CoV-2 tests can play a role in detecting individual cases and evaluating the spread of COVID-19. Results must be carefully interpreted in the context of how common (and therefore likely) the disease is. Otherwise, both false-negative and false-positive results from these tests may ultimately place patients, their families, and health care professionals at elevated risk.

The opinions expressed herein are solely those of Dr. Radecki and do not necessarily reflect those of his employer or academic affiliates

References

  1. He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med. 2020;26(5):672-675.
  2. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA. 2020;323(18):1843-1844.
  3. IDSA COVID-19 antibody testing primer. Infectious Diseases Society of America website. Accessed May 11, 2020.

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Look to ACEP’s New Wellness Hub for Support During the COVID Crisis https://www.acepnow.com/article/look-to-aceps-new-wellness-hub-for-support-during-the-covid-crisis/ https://www.acepnow.com/article/look-to-aceps-new-wellness-hub-for-support-during-the-covid-crisis/#respond Tue, 16 Jun 2020 22:33:09 +0000 https://www.acepnow.com/?post_type=article&p=23452 There is no such thing as a one-size-fits-all way to cope with a global pandemic. We’re complicated...

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There is no such thing as a one-size-fits-all way to cope with a global pandemic. We’re complicated people; what we need often changes by the day. This virus has ripple effects that extend to your family, your finances, and your career. Because every day is a new challenge, ACEP has created a new Wellness Hub to help you find the support you need, when you need it. Here’s a peek:

Support Pathways

Not sure what assistance would be best? The Wellness Hub is organized into support pathways that make it simple to parse your options, from peer forums and support to a list of companies offering free crisis support for frontline health care workers.

Peer Support

Sometimes you just need to talk to someone who “gets it,” and no one really understands what you’re going through like fellow emergency physicians.

  • Let’s Talk is a member-only online forum that aims to create a safe space where members can discuss ongoing challenges within their roles, emergency departments, and life in general. We understand some topics are difficult to discuss, so this is the only EngagED forum that allows anonymous posting—even the moderator can’t see identifying information.
  • ACEP is developing a peer support program that launched with an introductory webinar on June 11. “Who’s Got Your Back? Psychiatric Awareness & Team Support” focused on the value of peer support and how emergency physicians can support one another during times of crisis. The program is based on the concept that peer support provides a sense of belonging through shared experiences. When you can express frustrations, share coping strategies, and have honest conversations about your experiences, you can build a common foundation and deeper relationships.
  • COVID Captures is ACEP’s new platform created to record COVID-19 history as it happens. Research shows that keeping a diary—written or recorded—can help a person process their experiences. The mission of COVID Captures is twofold: 1) make it simple for emergency physicians to record firsthand accounts of pandemic response that can informfuture generations; and 2) give ACEP members a place to record video diaries as a way of processing the COVID-19 experience alongside their peers.

Crisis and Wellness Support

ACEP4U: Find the Right Support During COVID CrisisWhen ACEP released a joint statement supporting the removal of barriers to clinician mental health care (see “Advocating for Physician Wellness and Breaking Down Stigmas” at right), ACEP President Bill Jaquis, MD, FACEP, emphasized: “A physician’s choice to address his or her mental health should be encouraged, not penalized.”

To that end, the Wellness Hub provides a full list of free counseling and wellness coaching options available to ACEP members. Whether you prefer in-person sessions or you’d rather text with a professional counselor, you can find an option that works for you.

ACEP’s Wellness & Assistance Program offers members three free crisis support, counseling, or wellness sessions in partnership with Mines & Associates. Sessions are available 24-7 by phone, text, or online messaging, or you can schedule a face-to-face appointment near your office, home, or school. Sessions can cover COVID-19-related stress or everyday issues, including stress, anxiety, depression, family issues, drug and alcohol abuse, relationships, death and grief, and more. This program also includes wellness coaching sessions, 30-minute phone calls with National Board of Medical Examiners–certified wellness coaches who can help you set specific wellness goals and plan for progress checks along the way to help you reach your objectives. This program is strictly confidential.

Many organizations are stepping up to provide free crisis support to health care workers during COVID-19. Whether you prefer to have a video chat or simply text back and forth with someone, there are many options available. We’ve gathered them all into a list so you can find the best fit for you.

Sources of Stress and Topical Tools

For those who want to start at the source, resources have been organized into some of the most common contributors to stress for emergency physicians: patient care, workplace, financial, personal, and litigation.

The concept of “physician wellness” is such a broad umbrella that encompasses many specific areas of research, so the Wellness Hub provides a topic-based section covering COVID-19, posttraumatic stress disorder, compassion fatigue, physician suicide, burnout, and diversity/equity issues.

We’re in This Together

As we settle into the long-term stage of this pandemic, just remember that it’s okay to not be okay. This isn’t a Pixar movie; this real-life “hero work” is exhausting. Just like a marathon runner stops for hydration and energy bars along the route, you may need to check in with your peers or a crisis counselor to keep yourself in the race. Find the support you need.


Ms. Grantham is ACEP’s communications manager.

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ACEP’s COVID-19 Center Curates the Content You Need https://www.acepnow.com/article/aceps-covid-19-center-curates-the-content-you-need/ https://www.acepnow.com/article/aceps-covid-19-center-curates-the-content-you-need/#respond Tue, 16 Jun 2020 22:33:09 +0000 https://www.acepnow.com/?post_type=article&p=23447 To keep up with its growing library of resources, ACEP’s COVID-19 website has been redesigned to make...

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To keep up with its growing library of resources, ACEP’s COVID-19 website has been redesigned to make it easier to find what you need, when you need it. Visit www.acep.org/covid-19 for more than 400 clinical resources organized by topic, plus COVID-specific advocacy updates, webinars, discounts, and more. It’s also home to our most popular resource, the Field Guide to management of COVID-19 in the emergency department, a living document that has grown to more than 300 pages and been translated into five languages.

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