ACEP NowACEP Now https://www.acepnow.com Tue, 15 Jan 2019 20:54:04 +0000 en-US hourly 1 https://wordpress.org/?v=5.0.3 Intoxication from Synthetic-Cannabinoid-Receptor Agonists Often Missed https://www.acepnow.com/article/intoxication-from-synthetic-cannabinoid-receptor-agonists-often-missed/ https://www.acepnow.com/article/intoxication-from-synthetic-cannabinoid-receptor-agonists-often-missed/#respond Tue, 15 Jan 2019 20:49:14 +0000 https://www.acepnow.com/?post_type=article&p=20818 Nearly half of patients with suspected synthetic-cannabinoid-receptor agonist (SCRA) intoxication test negative for an SCRA, and many...

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Nearly half of patients with suspected synthetic-cannabinoid-receptor agonist (SCRA) intoxication test negative for an SCRA, and many test positive for another substance, researchers report.

“Clinicians caring for patients with reported synthetic-cannabinoid exposures must have a high index of suspicion for other drugs of abuse, trauma, or other medical conditions, and should evaluate and treat accordingly,” said Dr. Maryann Mazer-Amirshahi from Georgetown University School of Medicine, in Washington, D.C.

“Additionally, for patients that are exposed to synthetic cannabinoids, look out for new or different symptoms and complications, as the chemical composition of these agents is rapidly evolving,” she told Reuters Health by email.

SCRAs, sometimes referred to as “K2” or “Spice,” have become popular recreational drugs due to their easy availability, legal ambiguity, inability to be detected by current drug screens, and the potent high associated with their use.

Acute SCRA intoxication presents with a wide range of symptoms and poses significant challenges to emergency medicine clinicians seeking to identify and manage these patients.

Dr. Mazer-Amirshahi and colleagues sought to characterize and confirm the constituents of reported or suspected SCRA exposures presenting to two academic emergency departments in Washington, D.C.

Among the 128 unique patients included in the study, only 71 (55.5 percent) tested positive for an SCRA. Most (40 out of 71) were positive for an SCRA alone, but 31 were positive for an SCRA and another substance.

Among those testing positive, 12 were positive for two SCRAs, four were positive for three SCRAs, and two were positive for four SCRAs, the researchers report in the American Journal of Emergency Medicine.

Of the 57 patients who tested negative for an SCRA, 28 (21.9 percent overall) tested positive for another substance, the most common being tetrahydrocannabinol (THC) and phencyclidine (PCP). The rest (22.7 percent of patients overall) tested negative for SCRAs and toxicology screens.

The most commonly detected SCRAs were AB-fubinaca (39.4 percent), ADB-fubinaca (21.1 percent), AB-chminaca 3-methyl-butanoic acid (21.1 percent), ADB-chminaca (19.7 percent) and 5-flouro-PB-22 (11.3 percent).

“Not surprising, but interesting was the composition of the synthetic cannabinoids detected,” Dr. Mazer-Amirshahi said. “There was a significant shift in the chemical constituents from prior studies, which is a known trend to avoid legal regulation.”

“As providers, we need to be aware of potential anchoring bias when patients present with suspected synthetic cannabinoid exposure and be sure to perform a thorough evaluation,” she said. “I encourage providers to report suspected cases to their local poison centers. With synthetic cannabinoid products rapidly changing constituents, we can potentially see new or more severe adverse events related to these drugs. Reporting can help with surveillance and prevention efforts.”

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Year 2068: The Next 50 Years in Emergency Medicine https://www.acepnow.com/article/year-2068-the-next-50-years-in-emergency-medicine/ https://www.acepnow.com/article/year-2068-the-next-50-years-in-emergency-medicine/#respond Mon, 14 Jan 2019 17:33:26 +0000 https://www.acepnow.com/?post_type=article&p=20714 DALLAS, Aug. 16, 2068 —“Good morning, Mr. Smith,” the nursing home’s artificial intelligence bot chimes. “Your heart...

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DALLAS, Aug. 16, 2068 —“Good morning, Mr. Smith,” the nursing home’s artificial intelligence bot chimes. “Your heart rate and respiratory rate have been trending upwards overnight. I also noticed that you were coughing and your oxygen levels are a bit low. Would you like me to call the ED?”

A moment later, the hologram of an emergency physician appears. “Place the auscultation sticker on your back. It sounds like you have some fluid in your lungs, which could be secondary to a variety of conditions. You don’t look so hot, and you’re 72, so I think you should come in for a 3-D ultrasound and possibly some IV antibiotics.”


Emergency medicine has come a long way since ACEP was founded in 1968, from the first training program at the University of Cincinnati in 1970 to the founding of the Emergency Medicine Residents’ Association (EMRA) in 1974 to finally being recognized as the 23rd medical specialty by the American Board of Medical Specialties (ABMS) in 1979. Fifty years later, TV shows like “M*A*S*H” and “ER” have been produced, EMTALA and the prudent layperson standard have been enacted, and more than 140 million patients seek care from us annually.

Our nation has gone from dermatologists treating our sickest and most vulnerable patients in emergency rooms to specialist emergency physicians providing care in sophisticated departments. We’ve transformed America’s acute care system. However, as the residents who lead EMRA, it’s our job to imagine and prepare for the future. Fifty years from now, emergency medicine will be as different from today’s specialty as we are currently from our 1968 roots.


By the time Mr. Smith arrives at his local freestanding emergency department, his vitals have been uploaded by EMS, he has been preregistered, and his copay has been automatically deducted from his virtual wallet. He skips the waiting room, and the Internet of Health Care Things–enabled ultrasound rolls itself to his stretcher. The operational software has used his transport time to preschedule an appointment with the ED ultrasound technician. Twenty minutes later, Dr. Casillas, his board-certified emergency physician, sits down on Mr. Smith’s bed and holds his hand as she delivers the difficult news of a new lung mass and likely malignant effusion. At the same time, a virtual natural language processing scribe documents their conversation, codes the encounter, submits it to a national clearinghouse for reimbursement, and prompts her to place orders that had been previously placed for patients with similar presentations.

Dr. Casillas is a first-generation American who might not have had the opportunity to attend medical school in the 20th century, but by 2040, medical school had become significantly more affordable by shortening the time spent to 2.5 years and through funding from local counties and states to produce physicians who would serve their communities. Residency programs had also dramatically changed, transitioning from time-based to competency-based curricula, resulting in training lasting a variable number of years. Though the news Dr. Casillas delivers is heartbreaking, it is another example of the human connections made and compassionate care provided every day in emergency departments around the world.


In our imagined future, emergency departments have changed significantly since 2018. Technological advances like artificial intelligence (AI), remote patient monitoring, and telemedicine have increased access to care (particularly for underserved patients); allowed for earlier detection of life-threatening illnesses; and led to more precise triaging of patients before arriving at the emergency department. This has allowed emergency departments to anticipate and prepare for most patient arrivals and for board-certified emergency physicians to perform medical screening exams remotely and schedule patients to see their primary care physician or a subspecialist if more suitable. The reimbursement landscape and the business model of emergency medicine have finally adapted to the world of value-based care, and emergency departments are actually being reimbursed for sending lower-acuity patients to primary care physicians and subspecialists.

Perhaps the biggest change has been the elimination of most inpatient general medicine beds in America. Based upon each patient’s individual pharmacogenetic profile, robots start IVs, administer medications, and draw blood work at home, then drones transport these samples to labs for analysis. Due to physicians being able to remotely monitor patients’ vital signs and clinical status, the need to admit patients has plummeted. This has resulted in the majority of America’s acute care hospitals being closed. However, the need for emergency physicians has only grown, with micro-hospitals and freestanding emergency departments popping up from coast to coast, driven by the need for every community to have access to the acute care system as well as a desire to have a highly trained diagnostician physically evaluate patients in an increasingly digitized world.


A few hours later, Mr. Smith’s clinical status starts to decline. He becomes more hypoxemic and tachypneic. The smart ultrasound wheels itself back to meet Mr. Smith in the resuscitation bay, and the AI software notices a dilated right ventricle with reduced tricuspid annular plane systolic excursion (TAPSE) consistent with a pulmonary embolism (PE). Dr. Casillas checks his advance directive through the national next-generation health information exchange prior to intubation and alerts his family members who had subscribed to his real-time care feed. The hype of medical informatics has been realized as patients’ social, wearable, clinical, and genomic data are finally integrated into electronic medical records. A few minutes later he codes, and Dr. Casillas initiates extracorporeal membrane oxygenation (ECMO) and pushes tissue plasminogen activator nanobots, which have replaced the need for intravenous thrombolytics and catheter-directed thrombolysis. Initiating ECMO on a 72-year-old had become routine since the mid-2030s, when life expectancy surpassed 100. The AI resource allocation software then notices that, given his need for dedicated PE and ECMO teams, as well as local bed availability and risk-adjusted patient outcomes data, it would be best to transfer Mr. Smith to a hospital 90 miles away, bypassing three local centers. A minute later, he is loaded into an ICU drone equipped with tele-ICU capabilities and a midlevel critical care proceduralist, and he is whisked away. Because of the efficiencies of transferring patients to the nearest open bed available with appropriate resources rather than the closest hospital or the hospital that just so happened to be connected to the emergency department, the word “boarding” has been relegated to “back in my day” stories.


This futuristic thought experiment highlights two unique business models: micro-hospitals and hyper-acute specialty hospitals. In the emergency medicine of tomorrow, the latter, generally one every 100 miles, have been formed because in addition to the economies of scale within larger centers, a growing body of evidence had shown that high-volume centers, whether they be performing coronary artery bypass grafting or delivering ICU care, perform far better than lower-volume centers in terms of patient outcomes. A mix of large academic centers and corporations raced to consolidate the hospital market in the 2030s and created these 5,000-bed megaplexes of health care, just as Walmart and Amazon had done in the retail space during the early 2000s. Americans still needed access to acute care within a reasonable distance from their homes, and so the micro-hospital was born. Part freestanding emergency department with resuscitation bays and imaging in-house, part observation unit, and part heliport to efficiently ferry critical patients in specially made ICU drones to the specialty hyper-acute hospitals, these centers have proliferated, with emergency physicians at the helm.

While our specialty will evolve dramatically over the next 50 years, we believe the need for emergency physicians will only continue to grow. Tomorrow’s emergency physicians will build upon the giants who founded emergency medicine by being diagnosticians who can make sense of all the noise generated from enhanced triaging and remote patient monitoring, availabalists who see patients 24-7-365, resuscitationists who bring people back from death’s doorstep, and dispositionists who quarterback care in an increasingly hyper-specialized system. Most important, in an ever-virtualized world, they’ll serve as the humanists who actually take a few minutes to sit down and talk to their patients, bringing an element of sanity to the chaos of 2068.

NOTE: The views represented in this futuristic thought experiment solely belong to the authors and do not represent those of EMRA.


Dr. ManiyaDr. Maniya is the President of EMRA and a resident at The Mount Sinai Hospital in New York.

Dr. JarouDr. Jarou is the immediate Past President of EMRA and an administration fellow at the University of Chicago.

Dr. HughesDr. Hughes is the President-Elect of EMRA and a resident at the University of Cincinnati. 

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Health Information Exchanges Can Reduce Utilization and Cut Costs https://www.acepnow.com/article/health-information-exchanges-can-reduce-utilization-and-cut-costs/ https://www.acepnow.com/article/health-information-exchanges-can-reduce-utilization-and-cut-costs/#respond Mon, 14 Jan 2019 17:30:37 +0000 https://www.acepnow.com/?post_type=article&p=20765 Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article....

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EMRA+POLICYRx HEALTH POLICY JOURNAL CLUB

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

Since the passage of the Affordable Care Act (ACA), there have been substantial investments in developing health information exchanges (HIEs) to electronically transfer medical records between health care providers. The goals of using exchanges are to minimize service duplication, length of stay, avoidable admissions, and associated costs. However, studies debate how effective HIEs have been on reaching these goals both within and outside of the emergency department.

A recent study was designed to determine the effect of HIEs on six outcomes: length of stay in the emergency department, medical charges, hospitalization rates, and use of three modes of imaging (CTs, MRIs, and X-rays).1 A unit clerk would fill orders for medical records by either requesting records electronically from hospitals with compatible HIEs or calling to request medical records be faxed, which were then scanned and uploaded.

The study analyzed the use of an HIE within the University of Michigan Health System (UMHS) emergency departments. The UMHS emergency departments have approximately 100,000 visits annually and have Epic’s Care Everywhere, the HIE system used by approximately 20 percent of US hospitals. Of the requests made by HIE, 72 percent (n=566) were completed. Eighty-four percent of fax requests (n=3,082) were completed.

Information from HIEs was returned 51.0 minutes faster (P<0.001), translating to an emergency department visit that was 26.9 minutes shorter (P=0.099). No other outcomes were affected by the use of Care Everywhere. However, the time it took retrieve patient information, regardless of method, was significant. For each hour saved, emergency department visits were 52.9 minutes shorter and patients were 2.5 percent less likely to receive a CT, 1.6 percent less likely to receive an MRI, 2.4 percent less likely to receive a radiograph, and 2.4 percent less likely to be admitted (P<0.001 for all). Charges were 6.3 percent lower than average, resulting in savings of $1,187 per visit (P<.001).

HIEs provide benefit only to the extent that they decrease time to access medical records. Thus, efforts to improve information exchange should focus on improving the speed of health record access. It should also be noted that only 18 percent of requests could be made using Care Everywhere and only 72 percent of HIE requests made were completed. Therefore, universality, interoperability, and completion of requests are other factors upon which vendors should improve. 


Ms. Goldstein is a dual-degree student at NYU School of Medicine and the Wagner Graduate School of Public Service in New York City.

Reference

  1. Everson J, Kocher KE, Adler-Milstein J. Health information exchange associated with improved emergency department care through faster accessing of patient information from outside organizations. J Am Med Inform Assoc. 2017;24(e1):e103-110.

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The Health IT Evolution—Has It Been Good or Bad? https://www.acepnow.com/article/the-health-it-evolution-has-it-been-good-or-bad/ https://www.acepnow.com/article/the-health-it-evolution-has-it-been-good-or-bad/#respond Mon, 14 Jan 2019 17:29:50 +0000 https://www.acepnow.com/?post_type=article&p=20761 Even with the significant investments made by the federal government, hospitals, and physicians over the past 10...

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Illustration: Vasiliy Kosyrev/Getty Images & Chris Whissen

Even with the significant investments made by the federal government, hospitals, and physicians over the past 10 years, it is critical to remember that health information exchange is an evolution, not a revolution.1 The migration from paper to electronic records has been fraught with difficulty, resulting in decreased productivity among physicians during implementation and clunky user interfaces and possibly contributing to burnout—but it has changed the practice of medicine for good. Instead of making clinical care easier, physicians now only spend 49 percent of their time with patients. The majority of their time is spent striking the keys behind the computer.2

Physicians truly display a love-hate relationship with health information technology in the clinical setting. On one hand, charts are legible, it is easy to look up old visits, and macros make documentation easier. On the other, there is an inordinate amount of useless text in the notes; the system is built for billing, not medical care; and it is nearly impossible to figure out how to order an insulin drip these days.

Yet the electronic takeover of health care does come with some tangible benefits to patients and to the overall health care system. Two recently reviewed studies, applicable to health information exchange in the emergency department setting, demonstrate shorter emergency department visits and decreased utilization of CT scans, MRIs, radiographs, and hospital admission.3,4

According to the ACEP revised policy, “Health Information Technology Standards,” emergency physicians demand “seamless integration of data” and request that patient information is available in a “timely, usable, and secure manner.”5 As these data demonstrate, when these goals are achieved by an electronic health record, patient visits are more efficient and less costly. Patients faced charges that were nearly $1,200 lower when clinicians used the electronic medical record (EMR) than with paper records.

ACEP additionally recommends that its members become proponents of interoperable systems prior to institutions implementing expensive platforms that do not suit the needs of emergency physicians. If there is a system you think is especially useful, let your C-suite know about it before it invests in a product that will relegate you to being a disgruntled data-entry monkey.

Policymakers, hospital executives, and EMR entrepreneurs should all heed the words of Louis Yu, MD, MA, from our EMRA+PolicyRx Health Policy Journal Club: “Better, faster, and more interconnected systems for information exchange have the potential to make a difference in patient care and in the cost of care provided.”6Another EMRA+PolicyRx Health Policy Journal Club article, reprinted here, examines the effect of health information exchanges on several patient-oriented outcomes.


Cedric Dark, MD, MPHDr. Dark is assistant professor of emergency medicine at Baylor College of Medicine in Houston and executive editor of PolicyRx.org.

References

  1. Douglas M. Misadventures in interoperability. Policy Prescriptions website. Accessed Dec. 14, 2018.
  2. Jacobs R. Docs spend too much time behind a computer. Policy Prescriptions website. Accessed Dec. 14, 2018.
  3. Goldstein E. Is there benefit to HIE in the ED? Policy Prescriptions website. Accessed Dec. 14, 2018.
  4. Medford-Davis L. Less is more: HIE prevents repeat tests. Policy Prescriptions website. Accessed Dec. 14, 2018.
  5. American College of Emergency Physicians. Health information technology standards. ACEP website. Accessed Dec. 14, 2018.
  6. Yu L. Sharing is caring. Policy Prescriptions website. Accessed Dec. 14, 2018.

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Reimbursement Leadership Development Program Participants Chosen https://www.acepnow.com/article/reimbursement-leadership-development-program-participants-chosen/ https://www.acepnow.com/article/reimbursement-leadership-development-program-participants-chosen/#respond Mon, 14 Jan 2019 17:21:40 +0000 https://www.acepnow.com/?post_type=article&p=20731 More than 70 candidates from 22 ACEP state chapters applied for the ACEP Reimbursement Leadership Development Program...

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More than 70 candidates from 22 ACEP state chapters applied for the ACEP Reimbursement Leadership Development Program (RLDP), which is designed to identify and train future leaders in emergency medicine reimbursement. ACEP will fund chosen applicants to travel to the ACEP Reimbursement and Coding conferences, the Leadership & Advocacy Conference, the Emergency Department Practice Management Association’s Solutions Summit, ACEP headquarters structured sessions, and possibly an American Medical Association (AMA) CPT and Specialty Society Relative Value Scale Update Committee (RUC) meeting.

The inaugural RLDP class will include:

  • B. Bryan Graham, DO
  • Steven Kailes, MD, MPH, FACEP, FAAEM
  • Lisa Maurer, MD, FACEP
  • Archana Shah, MD, MBA
  • James Shoemaker Jr., MD, FACEP

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Letter to Editor Thanks ACEP Now for LGBT Support https://www.acepnow.com/article/letter-to-editor-thanks-acep-now-for-lgbt-support/ https://www.acepnow.com/article/letter-to-editor-thanks-acep-now-for-lgbt-support/#respond Mon, 14 Jan 2019 17:21:40 +0000 https://www.acepnow.com/?post_type=article&p=20729 It is rare for an article to inspire a letter to the editor; however, after reading “More...

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It is rare for an article to inspire a letter to the editor; however, after reading “More Than Just ‘I Do’” in the October issue of ACEP Now, I realized that sending you a note was more important than an extra 10 minutes of sleep.

I have always felt the professional support of ACEP—issues ranging from burnout to balance billing. However, I wish to thank you and your editorial staff for including an article touching on the unique challenges facing the LGBT physician community. I realize that we are a distinct minority among the ranks of our specialty. In fact, I’ve only met two other “out” LGBT ED physicians. Knowing that ACEP acknowledges these challenges and values our experience to the point of placing an inspirational article on the cover page of our monthly magazine nearly brought tears to my eyes.

Thank you for supporting our community and making me feel even more like I belong to our EM tribe.

Douglas P. Brosnan, JD, MD, FACEP
Roseville, California

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We Must Start Paying Attention to Physician PTSD in Emergency Medicine https://www.acepnow.com/article/we-must-start-paying-attention-to-physician-ptsd-in-emergency-medicine/ https://www.acepnow.com/article/we-must-start-paying-attention-to-physician-ptsd-in-emergency-medicine/#respond Mon, 14 Jan 2019 17:21:40 +0000 https://www.acepnow.com/?post_type=article&p=20723 I cried at work the other day. It’s not that crying in reference to a sad case is...

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photo: kupicoo

cried at work the other day. It’s not that crying in reference to a sad case is new to me; it’s just new for the person who I am now.

A young woman rolled into my emergency department, trying to bleed to death; there was so much blood. Immediately my team flooded her room. Adrenaline took over, leaving no time for me to think or process or feel anything about the case. For what seemed like an eternity, I stood by her bedside, ignoring every other patient in the department. I did what any one of us would do: bark orders, call the blood bank, and run around with my team to do everything we can to resuscitate her. I stroked her hair as she cried. I stood by her husband as he was paralyzed in fear, all while watching her monitor with my heart racing.

We resuscitated her for over an hour before she was finally stable enough for the operating room. Finally, the chaplain was able to enter the room. He held hands with the patient and her husband and prayed with them while they cried.

Out of nowhere, I was suddenly triggered. I flashed back to a scenario many years ago, where a chaplain sat with me as I cried in a hospital. Every emotion from that day rushed at me in a matter of seconds. I turned on my heel, left the patient’s side abruptly, and fled the room. My nurses were startled by my quick and dramatic departure. Before I could stop it, I found myself crying, vulnerable in front of my staff. I walked quickly, trying so hard to keep my tears hidden and avoid embarrassment. After years in practice, I finally felt like a leader in my department. I couldn’t help but feel like I had shattered my reputation by giving in to my emotions in public.

I spend much of my young physician life struggling to deal with the stress and emotions surrounding our specialty. I succumbed to my emotions often during residency and my first years as an attending. Now, after years of caring for patients, I know I have become more and more disconnected, and I find difficult scenarios no longer impact me like they used to.

Table 1: Summary of Criteria for PTSD

  • Exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence
  • Intrusion symptoms
  • Avoidance
  • Negative alterations in cognitions and mood
  • Alterations in arousal and reactivity
  • Duration of symptoms greater than one month
  • Symptoms create distress or functional impairment
  • Symptoms not due to medication, substance use, or other illness

In addition to the above criteria, the patient must have one of the following specifications:

  • Dissociative specification: Depersonalization and/or derealization

OR

  • Delayed specification: Full diagnostic criteria are not met until at least six months after the trauma(s), although symptom onset may occur immediately

When I think back to a few of the horrific cases I have seen over the years, I should really be in tears daily. Instead I have compartmentalized these tragedies further and further into the recesses of my mind. I ignore how they impact me until I just cannot overcome their cumulative weight. Even the smallest tasks are intolerable and impossible until I gather myself again. When I really pause to think about it, these responses are not normal—not for me or for anyone else in health care.

Recently, there has been some recognition of the fact that posttraumatic stress disorder (PTSD) is a real possibility in health care workers, particularly those who work with critically ill or injured patients. The American Psychiatric Association describes PTSD as a condition that occurs “in people who have experienced or witnessed a traumatic event.” It further explains that PTSD sufferers “may relive the event through flashbacks or nightmares; they may feel sadness, fear, or anger; and they may feel detached or estranged from other people.”1 As some of you read this, the symptoms may sound very familiar.

According to an article in the Journal of Medical Practice Management, the types of physicians most prone to developing PTSD are physicians who practice emergency medicine in rural areas with limited resources, who are in residency training, who are involved in malpractice litigation, and/or who are indirectly exposed to trauma.2 There are some of us who, unfortunately, fit into many of these categories.

Recent studies revealing the prevalence of PTSD in health care workers are disconcerting. Approximately 18 percent of all nurses, 15 to 17 percent of emergency physicians, and 11.9 to 21.5 percent of emergency medicine residents meet diagnostic criteria for PTSD.3–5 Those are frightening numbers.

Clearly, this is a real and valid concern. So what do we need to do for our colleagues with PTSD?

Developing a departmental or, better yet, institutional approach to assisting PTSD sufferers will require a change in the way we view our profession, colleagues, and the impact emergency medicine has on our lives. Recommendations need to be accepted and practiced universally. At the crux of it, recognition should be the top priority. For all levels of health care providers in our field, the evidence says our approach to address PTSD should include:5

  • Cognitive behavioral therapy (CBT)
  • Team debriefing after care of critical patients
  • Mindfulness-based stress management (MBSR)
  • Teaching effective methods to use meditation or mental cues to “self-relax”

Studies examining the efficacy of CBT have demonstrated that this treatment has been useful and effective for a wide range of psychological problems, particularly in mental health disorders in children.6 However, at present, there is minimal and low-quality evidence that CBT and mental and physical relaxation reduce occupational stress more than no intervention in health care workers.7 Many of us are not in the practice of utilizing CBT or mindfulness in our daily work and may not be aware of what these practices involve. CBT involves increasing happiness by changing the way we respond emotionally and behaviorally to certain problems. MBSR encourages a person to focus only on their immediate present, paying attention to emotions, thoughts, and somatic feelings at that given moment. It is targeted to teach an individual to calm the mind, in turn helping to cope with times of stress. With successful use of CBT and MBSR, an individual can then move on to using meditation or verbal cues to relax and regroup in times of high stress.

Team debriefing is best led by physicians or charge nurses after a critical event. This can allow the group involved to reflect on the experience. These few minutes can also be used as an opportunity to recognize team members traumatized by events and identify them for follow-up in case they require assistance.

Education of these critical methods may be accomplished by involving our psychiatry colleagues or specialists in these fields to develop learning programs geared toward emergency medicine physicians.

To those of you who have been practicing for some time, this all may sound a little “kitschy.” We trained and began our careers in an era where we view outward emotion as a sign of weakness. Perhaps we see it that way because we have become hardened, disconnected, and estranged. We are no longer in touch with the normal emotions associated with the illness, trauma, and death all around us. Perhaps we should view expression of our emotions in a different light, a sign of our own humanity.

As a group, we must have a high index of suspicion for PTSD in our colleagues (see Table 1 for a list of criteria for PTSD). We need to have our leaders advocate for effective support programs for our colleagues with PTSD. We need to develop real programs for individuals with PTSD to seek help without recourse, whether it is psychiatric therapy or time off. The road to recovery for emergency physicians who suffer from PTSD requires that we finally recognize it and ensure it is not ignored. 


Dr. ShahDr. Shah is assistant professor of emergency medicine and associate chief medical informatics officer at Rush University Medical Center in Chicago.

References

  1. What is posttraumatic stress disorder? American Psychiatric Association website. Accessed Dec. 19, 2018.
  2. Lazarus A. Traumatized by practice: PTSD in physicians. J Med Pract Manage. 2014;30(2):131-134.
  3. Mealer M, Burnham EL, Goode CJ, et al. The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses. Depress Anxiety. 2009;26(12):1118-1126.
  4. Lowry F. Emergency department staff not immune to traumatic stress. Medscape website. Accessed Dec. 19, 2018.
  5. Vanyo L, Sorge R, Chen A, et al. Posttraumatic stress disorder in emergency medicine residents. Ann Emerg Med. 2017;70(6):898-903.
  6. Hofmann SG, Asnaani A, Vonk IJ, et al. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.
  7. Ruotsalainen JH, Verbeek JH, Mariné A, et al. Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev. 2015;(4):CD002892.

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Dr. John Lumpkin, a Pioneer of EM https://www.acepnow.com/article/dr-john-lumpkin-a-pioneer-of-em/ https://www.acepnow.com/article/dr-john-lumpkin-a-pioneer-of-em/#respond Mon, 14 Jan 2019 17:21:39 +0000 https://www.acepnow.com/?post_type=article&p=20745 A lthough John R. Lumpkin, MD, MPH, FACEP, FACME, FAAN, was initially drawn to a career in biophysics,...

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John R. Lumpkin, MD, MPH, FACEP, FACME, FAAN

A lthough John R. Lumpkin, MD, MPH, FACEP, FACME, FAAN, was initially drawn to a career in biophysics, his desire to combine a love of science with a need to help people caused him to shift his focus to medicine. An evening working with a family friend in the emergency department at Oak Park Hospital in Oak Park, Illinois, cemented his interest in emergency medicine. A few years later, in 1976, he became the first African American emergency medicine resident, training at the University of Chicago under Peter Rosen, MD. After finishing residency, he joined the emergency medicine faculty at the University of Chicago.

Early in his career, he recognized the importance of government and politics in serving the needs of emergency physicians and their patients. He worked on key emergency medical services legislation in Illinois and went on to serve as director of the state’s Department of Public Health under three different governors.

Andrea Green, MD, FACEP

Andrea Green, MD, FACEP

He has also been an active member of the Illinois College of Emergency Physicians and ACEP for most of his career, serving in many leadership positions in both organizations. He served as Speaker of the ACEP Council from 1985 to 1987 and on the ACEP Board of Directors from 1987 to 1993, and he was the first African American to hold either position.

Dr. Lumpkin recently sat down with Andrea Green, MD, FACEP, an emergency physician and Chair of ACEP’s Diversity, Inclusion, and Health Equity Section, to discuss his career, his accomplishments, and his vision for the future of emergency medicine leadership. Here are some highlights from that discussion.

AG: John, your background and career have been impressive. What have been some of your guiding principles?

JL: I guess the best way to describe me is that I’m a believer in the ultimate goodness of my fellow man. I believe that I am a person who’s dedicated to service of my fellow man. That has been something that has guided me throughout my entire life, from my days in high school through my current career.

AG: Could you describe for us the career journey that you chose based on the way that you wanted to live your life and help other people?

JL: As I was growing up, I was always very interested in math and science. As I was going through high school, I said, “Well, I think I want to be a scientist. I’d like to be a biophysicist,” because I liked biology, physics, and chemistry. When I went off to school, my first year at MIT, I began to realize that so much was going on in the world with the war in Vietnam and the civil rights movement, and if I actually became a biophysicist, I would spend all my life in the laboratory. I wanted to have an impact upon people and their lives. At that point, I knew I wanted to go to medical school and was fortunate to get into Northwestern.

My freshman year of medical school, I spent Christmas Eve working with Vera Markovin, MD, who was one of the early founders of the Illinois College of Emergency Physicians. She was a family friend, and it was that evening in 1971 that really got me interested in emergency medicine.

As I went through medical school, I really designed my career to do two things: one, to begin to take courses that would better prepare me to go into emergency medicine and, two, maintain my contacts. I was working with the Medical Committee for Human Rights and other organizations. I was fortunate to be able to join the emergency medicine residency at the University of Chicago and to train under Peter Rosen, MD.

While I was training as a resident, I worked with Harold Washington’s campaign; he was running for mayor in Chicago.

The Illinois Emergency Medical Services Systems Act was up for approval, and I assisted the chapter with it. Because of my activities on that, I was appointed chair of the EMS council by Illinois Gov. James R. Thompson, and I began to have more and more experience with government and governmental bodies.

It was at that point in my career that I felt I needed to have more training because, as every emergency physician knows, the things that bring people into the emergency department often aren’t their clinical problems.

I went on to get a master’s degree in public health. One of the people I had worked with, who subsequently became the director of the Department of Public Health in Illinois, invited me to come in as a deputy director. When he left, I was appointed director, first under Gov. Thompson, then Gov. Jim Edgar, and then finally, Gov. George Ryan. I served in that position for 12 years. Throughout that time, my own personal identity was that I was an emergency physician first, and that always influenced me as I thought about my career.

I think it‘s really critical for emergency physicians to avoid seeing themselves as someone just showing up for a shift, but to recognize they’re part of a broader system. —John R. Lumpkin, MD, MPH, FACEP, FACME, FAAN

AG: Tell us a little bit about how you decided to pursue positions of leadership within ACEP.

JL: I started my career in ACEP with the Illinois College of Emergency Physicians. I joined the board of directors of the Illinois College, and I became the President-Elect and then the President of the Illinois College. I was very active in academic emergency medicine. I served as Chair of the Society of Teachers of Emergency Medicine while I was at the University of Chicago. That organization was one of the precursors for the Society for Academic Emergency Medicine. They merged with the University Association for Emergency Medicine to form the Society for Academic Emergency Medicine. I was active in a number of committees of the College. I chaired a committee that was established to determine the length and content for residencies in emergency medicine. In 1983, I was elected as Vice Speaker of the ACEP Council, and then, two years later, I was elected Speaker of the Council. I went on to the Board of Directors, where I served for two terms.

AG: Is there anything that you would tell someone who is preparing themselves for becoming a leader?

JL: The first thing I would say, and I believe this is a quote from Woody Allen, is “80 percent of success in life is showing up.” The role of ACEP is to do two things: protect the best interest of the patients that we serve and protect the specialty. There’s a third: to be concerned about those who commit themselves to providing emergency services as emergency physicians. Not only is it showing up, but I think my success has been related to benefiting from my commitment and service to the Colleges of Emergency Physicians.

AG: What role do you see for emergency medicine or emergency physicians in helping to address health disparities in our day-to-day encounters with patients and our operations?

JL: I think it’s really critical for emergency physicians to avoid seeing themselves as someone just showing up for a shift but to recognize they’re part of a broader system.

The emergency department and emergency physicians are in an ideal position to go beyond their shifts and be engaged with hospital administration, and also with the community, to think about that visit and that person in the emergency department as someone who is disconnected, and understanding that the emergency department can play a critical role in connecting them. The emergency physician becomes the connector, the pivot point, that can make the difference between someone chronically using the emergency department day after day and someone who actually is living a better life. I think our responsibility as emergency physicians is to think about the whole patient.

AG: What do you see as factors that could help move the needle successfully in solving some of the issues that we face?

JL: I think the factors that need to be addressed are both internal and external to the emergency department. First, there’s clear evidence that physicians and everyone in our society have biases and stereotypes. There’s clear evidence that the longer you work on a shift, the more likely you are to use those biases in decision making. I think it’s important for emergency physicians to understand how this occurs and to develop systems, including the use of electronic health records, to improve medical decision making.

The second is recognizing the issues that impact patients’ lives. For us in emergency medicine, we need to recognize that we can have an impact on those issues by being an advocate for those patients, and being an advocate not just to make sure that they get the best care but being advocates for the goal to create the environment where everyone has a fair and just opportunity to be as healthy as possible.

AG: Tell me a little bit about your role in the Robert Wood Johnson Foundation.

JL: I’m one of two program senior vice presidents. We’re responsible for the various programs that are supported and funded by the Robert Wood Johnson Foundation. My specific role is to oversee our work related to developing leadership, engaging business, and transforming health and health care systems.

We are seeking to change the environment but also to have health care coordinate with public health and social services so that the needs—not only in the clinical setting but where people live, learn, work, and play—are addressed.

AG: Can you highlight some of your accomplishments?

JL: When I look back on my career, I hope I’ve contributed to the specialty through leadership, and one of my high points was being both Speaker and on the Board of Directors of the College and being the first African American to do that.

AG: I thank you so much for not only taking the time today but also for the inspiration that you’ve been and the example you’ve set for so many, particularly minorities in the field of emergency medicine.

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ACEP Meets with SAMSHA About Suicide Hotline https://www.acepnow.com/article/acep-meets-with-samsha-about-suicide-hotline/ https://www.acepnow.com/article/acep-meets-with-samsha-about-suicide-hotline/#respond Mon, 14 Jan 2019 17:21:39 +0000 https://www.acepnow.com/?post_type=article&p=20737 Sandy Schneider, MD, FACEP, ACEP’s associate executive director for practice, policy, and academic lines of service, met...

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Sandy Schneider, MD, FACEP, ACEP’s associate executive director for practice, policy, and academic lines of service, met with the Substance Abuse and Mental Health Services Administration (SAMHSA) to discuss an enhanced national suicide hotline and a national phone number, such as 611.

ACEP responded to a request for comments from the Federal Communications Commission (FCC) related to the National Suicide Hotline Improvement Act of 2018. This act requires the FCC to conduct a study that examines the feasibility of designating a simple, easy-to-remember three-digit dialing code (such as an N11 code) that would be used for a national suicide prevention and mental health crisis hotline system. ACEP supports the creation of a new three-digit dialing code for mental health emergencies, as it would improve access to appropriate care and could reduce the prevalence of psychiatric boarding. However, ACEP believes that in addition to the new number, there must be adequate resources and services in the community that can provide feasible and safe alternatives to patients seeking care in the emergency department.

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ACEP Opposes Proposed Rule Regarding Immigrants, Medicare, Medicaid https://www.acepnow.com/article/acep-opposes-proposed-rule-regarding-immigrants-medicare-medicaid/ https://www.acepnow.com/article/acep-opposes-proposed-rule-regarding-immigrants-medicare-medicaid/#respond Mon, 14 Jan 2019 17:21:39 +0000 https://www.acepnow.com/?post_type=article&p=20735 ACEP responded to a proposed rule issued by the Department of Homeland Security (DHS) that would implement...

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ACEP responded to a proposed rule issued by the Department of Homeland Security (DHS) that would implement new restrictions for some legal immigrants to obtain green cards if they have previously used public benefits such as food stamps, public housing, Medicare Part D low-income subsidies, or nonemergency Medicaid. In line with the public statement ACEP released immediately following the announcement of the rule, ACEP asked DHS to rescind the rule. ACEP believes that if finalized, the rule would cause fear and confusion, causing millions of Americans to disenroll from essential programs and stop receiving benefits for which they are eligible. The loss of Medicaid coverage, especially, would result in poorer health and health outcomes for affected individuals. It also could drive up ED use, uncompensated care costs, maternal and infant health risks, and transmission of infectious diseases.

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