ACEP NowACEP Now https://www.acepnow.com Wed, 22 May 2019 16:50:16 +0000 en-US hourly 1 https://wordpress.org/?v=5.2.1 Dr. Geesbreght: Leader and Caregiver for His Family, Community, and EM https://www.acepnow.com/article/dr-geesbreght-leader-and-caregiver-for-his-family-community-and-em/ https://www.acepnow.com/article/dr-geesbreght-leader-and-caregiver-for-his-family-community-and-em/#respond Fri, 17 May 2019 19:10:41 +0000 https://www.acepnow.com/?post_type=article&p=21347 Emergency physicians see people at some of their worst moments—traumatic injury, grave illness, the death of a...

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Dr. John Geesbreght and his wife, Priscilla.

Emergency physicians see people at some of their worst moments—traumatic injury, grave illness, the death of a loved one—and provide compassionate care without expectation of recognition or reward. For emergency physician John Geesbreght, MD, MS, FACEP, these principles have been a driving force in his life, guiding his decisions as a medical director, father, mentor, and member of the Fort Worth, Texas, community.

Dr. Geesbreght was born in south Chicago. The son of immigrant parents, he was inspired to become a physician in elementary school. He went on to practice in the emergency department in Fort Worth, where he served as emergency department medical director of Texas Health Harris Methodist Fort Worth for more than 40 years, providing care to his family and community. As a leader, Dr. Geesbreght searched for innovative solutions to make sure his emergency department would deliver the best patient care possible.

One of those solutions was founding PhysAssist Scribes, Inc., the first scribe company in the United States, in 1995. Initially, the company recruited pre-med students from Texas Christian University and trained them to work alongside emergency physicians to provide scribe services in the ED to improve communication and documentation, free up physicians’ time for patient care, and give students valuable medical experience. Both of Dr. Geesbreght’s sons went on to lead the company. Although neither became a physician, they both were guided by the principles of hard work and compassion they learned from their father and his career.

Dr. Geesbreght’s sons, Andrew and Alex, recently sat down with ACEP Now’s Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, to discuss their father’s career in emergency medicine and the influence he had on their own careers. Alex served as president of PhysAssist prior to its acquisition by TeamHealth in 2014. Andrew served as president of PhysAssist prior to its acquisition by HealthChannels in 2018 and is currently chief leadership officer at HealthChannels.

KK: Alex and Andrew, let’s discuss your father’s emergency medicine career and how it‘s influenced your life.

Alex G: The highlight for me was getting to work with my dad for 12 years. I was an attorney for a while and then was general counsel for his emergency medicine group.

Dr. Geesbreght (center) is suturing Alex’s bicycle injury while his mother, little sister, and brother Andrew watch.

Dr. Geesbreght (center) is suturing Alex’s bicycle injury while his mother, little sister, and brother Andrew watch.
Photos: John Geesbreght

When I was 9 years old, I started working, volunteering, with my dad down at the hospital and I thought, “Oh, my dad’s a doctor, maybe I’ll be a doctor.” I was 16, and I used to spend the night. I think I logged in 750 hours of community service through working at the emergency department. I very quickly realized when I got older that I couldn‘t handle being in that environment, and one of the things that I realized is that my dad never talked about what happened at the [emergency department]. When I started seeing people die, the horrible accidents, heartache, I remember thinking, “How could he not talk about this?”

Although he did shield us from the harm that some of the stories from the ED might do to a little kid, he took those lessons and was able to apply them to our world every day.

He is such a great teacher. He taught us all of these lessons and he had all of this wisdom. He never shared those stories with us, and I don‘t know why, but I kind of wish he had. This also speaks to his stability and his ability to separate family life from work life.

Andrew Geesbreght with his wife, Chelsea.

Andrew Geesbreght with his wife, Chelsea.

KK: Andrew? Some thoughts from you?

Andrew G: I learned early on as a child that my dad was doing something very important. I say that because I didn’t have to introduce myself. When I said my dad was Dr. Geesbreght, I frankly had intense pride. Any time someone had their worst day, they called my dad and there was a high level of trust in his ability to restore normalcy in families’ lives.

In an industry that didn’t have generally accepted rules at that time, he was helping create new standards. He was all the cliché terms: trailblazer, innovator, etc. We watched him do that, and at 75 years old, watching him at his retirement party, with others talking about him, it really crystallized that for me.

We used to talk about him blowing up at the smallest little things, but then when it was a really big deal, when I was at my worst moment, that’s when I could count on a hug and an encouraging word, and the limited amount of time I saw him in the ED, that‘s how he was with patients. He was reassuring and calm in their worst moment, and I loved that.

Alex Geesbreght with his wife, Carey.

Alex Geesbreght with his wife, Carey.

Alex G: One of the things he always said was, “There are doctors who work in an ER”—now, this is back when they called it an ER—but he said, “There are doctors who work in an ER and then there are ER doctors. I am an ER doctor.”

KK: How do you think his life as an emergency physician helped shape you as young professionals today?

Andrew G: Dad’s ability to handle stress, his restrained empathy, I learned from Dad to optimize my mental hygiene. Alex and I aren’t clinical, but I can say for sure that I’ve learned from him how to manage stress, to appropriately compartmentalize difficult things in our careers.

Alex G: I would say that Andrew got more of the knowing when to be quiet from my dad than I did. I’m far more transparent to a fault, even with employees, but I would say my leadership style is rooted in his; he’s an inspirational leader.

One of his greatest strengths is that he understands almost intuitively what moves the needle. Back when they were doing the ED redesign, how to make people happy in the ED was all the rage. Many of the experts said, “Well, give them coffee,” and “Give them a blanket when they get triaged,” and “Go back,” and my dad said, “They’re not here to get coffee. They can get coffee at home. They have blankets at home. They’re here to see a doctor.” So, he made certain the very first thing they did was see the doctor. He knew that every moment they waited prior to seeing the doctor was wasted time waiting.

KK: Emergency physicians tend to be selfless and giving. We do not always need recognition for our efforts. Do you have an example of your father’s selflessness?

Andrew G: One thing I learned from my dad that I still carry with me today is all ED doctors have the ability to sort through thousands of different possibilities and deduce a specific solution to whatever the complex problem presents. When Dad used to talk to us about problems, he would look through this complex prism of perspectives and possibilities to help us think through all of those different angles, and that‘s something that I know that Alex and I use all the time. I use it daily and I’ve gotten it directly from him. My dad didn’t require public recognition. It was enough for him in almost all cases to just do the right thing.

Recently, I ran into a guy who I played high school soccer with. I hadn’t seen him in probably 25 years. We ran into each other at an over-30 indoor soccer league. He came up to me, put both of his arms on my shoulders, stopped me, looked me right in the eye, and said, “Andrew, it’s Jaime. Do you remember me?” I said, “Of course,” and we hugged, and he launched right into this story. He said, “I just want you to know that your dad changed my life.” So, I sat my bag down and said, “Well, you‘ve got my full attention, Jaime. Tell me more.” He said, “You probably don’t know this but in middle school we were at a YMCA tournament and your dad came up to me afterwards and said, ‘Hey, you‘re good. Would you like to play on our select team next year?’”

Jaime said he was immediately saddened by this because he knew he couldn’t afford it. His dad wasn’t in his life and his mom worked multiple jobs. He told my dad that he couldn’t afford it, but thank you for the opportunity anyway. So, my dad took his number, and a few days later called him and said, “Jaime, this is Dr. Geesbreght. I don‘t know if you remember me, but we talked at the tournament.” Jaime said, “Yes, I remember you.” Dad said, “I just wanted to let you know that we’re going to take care of your league fees so that you can play on our team.” Jaime was saddened even more and said, “I really appreciate it. I can’t pay for travel. I can’t pay for food. I barely have enough for gear.” Dad paused and said, “Well we‘re going to take care of all of that for you too.”

What was so astounding is for four years, when he was 14 to 18, my dad unceremoniously took care of every single bill, invoice, fee, lunch, travel, and everything else that would have been a cost to him and his family. My dad took care of this and never told a soul. Jaime said, “He did that because he was so generous. He didn’t need the credit, but he also didn’t want to embarrass me.” So he never mentioned it to anybody. He didn‘t tell my mom. He didn‘t tell me.

KK: Very touching story that really exemplifies his selfless service. Thank you both for your time and sharing your thoughts with us. Emergency physicians truly have an impact beyond the care they deliver.

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Tips for Spotting and Treating High-Altitude Illness https://www.acepnow.com/article/tips-for-spotting-and-treating-high-altitude-illness/ https://www.acepnow.com/article/tips-for-spotting-and-treating-high-altitude-illness/#respond Fri, 17 May 2019 19:06:30 +0000 https://www.acepnow.com/?post_type=article&p=21337 The diagnosis and treatment of high-altitude illness (HAI) require an understanding of the interplay between physics and...

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Credit: Shutterstock.com

The diagnosis and treatment of high-altitude illness (HAI) require an understanding of the interplay between physics and physiology. As altitude increases, pressure decreases, affecting the partial pressure of oxygen and thus decreasing the amount of oxygen diffusing into the tissues. This hypobaric hypoxia results in a cascade of events known as HAI. In an effort to acclimate, the respiratory rate increases, leading to respiratory alkalosis with metabolic compensation. This also causes an overall left shift of the oxygen-hemoglobin dissociation curve, increasing oxygen uptake in the lungs. Hypoxemia causes increased release of erythropoietin, leading to an increase in red blood cell production and overall better oxygen-carrying capacity to the tissues.

The most important syndromes that make up the spectrum of HAI are high-altitude pulmonary edema (HAPE) and acute mountain sickness (AMS), which can progress to high-altitude cerebral edema (HACE). Younger athletes and males are at greater risk of HAI since they are more likely to engage in vigorous activity prior to acclimatization or continue ascent despite symptoms. Other risk factors include chronic obstructive pulmonary disease, restrictive lung disease, cystic fibrosis, pulmonary hypertension, congestive heart failure, and sickle cell disease. Contrary to popular belief, neither well-controlled asthma nor pregnancy (up to 3,000 meters) increase the risk of HAI.

High-Altitude Pulmonary Edema

There are two types of HAPE: classic, which occurs in low-altitude residents who rapidly ascend, and reentry, which occurs in high-altitude residents re-ascending after being at low altitudes. The pathophysiology of HAPE consists of breakdown of the pulmonary blood-gas barrier secondary to increased pulmonary artery pressure and uneven pulmonary vasoconstriction resulting in fluid accumulation within the alveoli. This typically occurs around 3,000 meters. Patients present with a dry cough that progresses to a productive cough with frothy pink sputum and increased dyspnea within four to six days of arrival at altitude. Patients demonstrate tachycardia, tachypnea, inspiratory crackles, and low pulse oximetry on physical exam. Chest X-ray reveals patchy infiltrates, but it is not required to make a diagnosis.1

The treatment of stable patients with HAPE involves simply giving oxygen via high-flow nasal cannula and decreasing cold exposure to resolve the elevation in pulmonary artery pressure. Unstable patients should descend as soon as possible, and if that is not possible, use hyperbaric therapy as indicated.1 Medications can be used for treatment. However, they are more effective as preventative measures. Nifedipine can reduce pulmonary vascular resistance and decrease pulmonary artery pressure, and phosphodiesterase 5 inhibitors can increase cyclic guanosine 3’,5’-monophosphate (cGMP) to augment the pulmonary vasodilatory effects of nitric oxide. Nitric oxide is a potent pulmonary vasodilator, released from endothelial cells, that decreases hypoxic pulmonary vasoconstriction and the pulmonary hypertension associated with HAPE. Inhaled beta-agonists can be used as an adjunct, but they have limited effectiveness as a sole treatment option.2–4

Acute Mountain Sickness and High-Altitude Cerebral Edema

The pathophysiologies of the neurological forms of HAI—AMS and HACE—are similar in that there is an increase in the permeability of the blood-brain barrier causing reversible vasogenic edema. The mechanism of this increased permeability is unclear. There is a possible increase in cerebral blood flow, loss of intracranial pressure autoregulation, and resultant alterations in endothelial permeability via increased nitric oxide levels and increased vascular endothelial growth factor (VEGF), which promotes angiogenesis. AMS and HACE are along a spectrum of disease, with AMS occurring around 1,500 meters with typical transition to HACE at more than 4,000 meters. The diagnosis for AMS is clinical, with symptoms that resemble a hangover, such as headache, anorexia, nausea, and vomiting.1 Onset of AMS generally occurs within six to 12 hours of reaching altitude and resolves within one day, but it can recur as ascent continues. The Lake Louise AMS score is the gold standard to self-monitor for AMS during ascent or for a clinician evaluating a patient.5,6 HACE is a clinical diagnosis, with onset at 12 hours to three days from ascent. The patient will present with ataxia, encephalopathy, and a progressive decline of mental function and level of consciousness. Patients may first only appear to be withdrawn; clinical suspicion should be high. Physical examination will reveal a patient with impaired finger-to-nose or heel-to-shin testing. All labs and imaging are fairly nonspecific, but they may show leukocytosis and possibly cerebral edema.1,7

TYpical Elevations for High-Altitude Illness

TYpical Elevations for High-Altitude Illness
ILLUSTRATION: Chris Whissen & shutterstock.com

Treatment of AMS consists of symptomatic management with nonsteroidal anti-inflammatory drugs (NSIADs), antiemetics, and a pause in ascent for 48 hours for acclimatization to occur. Treatment for HACE is immediate descent. If that is not possible, the patient should be treated in a hyperbaric chamber, along with 2–4 L nasal cannula and dexamethasone for alleviation of symptoms related to cerebral edema. In the event the patient becomes unresponsive, consider protecting the airway.2,4

Prescription medications can be used for treatment but are better as preventative measures. Acetazolamide, a carbonic anhydrase inhibitor, initiates metabolic acidosis, theoretically stimulating respiratory drive and hastening acclimatization, but its side effects can be mildly irritating, with peripheral paresthesia, polyuria, and a metallic aftertaste. Dexamethasone can be used to alleviate symptoms, but it does not accelerate acclimatization. The risk with dexamethasone is that it masks symptoms and therefore may increase the risk of AMS progressing to HACE as ascent continues.2,4

For AMS and HACE, the gold standard for prevention is gradual ascent, acetazolamide, and +/- dexamethasone. Dexamethasone is typically used in prevention of AMS/HACE for patients who require rapid ascent but does not hasten acclimatization. There are multiple drugs that, when compared to placebo, do show improvement for prevention, such as acetazolamide and dexamethasone. As a selective 5-hydroxytryptamine receptor agonist and a cerebral vasoconstrictor, sumatriptan shows promising results for AMS prevention; however, only one study has been published, which showed decreased prevalence of AMS in sumatriptan versus placebo when used for prophylaxis.8 Further studies would need to be completed prior to utilizing sumatriptan as a preventative medication. Antioxidants, magnesium, ginkgo biloba, and cocoa leave use have very limited data and scattered anecdotal reports, with no significant difference shown when compared to acetazolamide and dexamethasone.2,4,9

Pediatric Patients

Pediatric patients present a unique cohort in risk factors and presentation for HAI. Risk factors for HAI include congenital cardiopulmonary disease (eg, cardiac shunting, pulmonary hypertension), cystic fibrosis, sickle cell disease, and Down’s syndrome. Also at risk are any infants born preterm, those less than six weeks old, and those who required oxygen within their first year of life.

Children typically experience reentry HAPE, the risk of which is increased with any respiratory infection. Kids have increased respiratory distress over one to two days that presents as decreased playfulness, disrupted sleep, and increased fussiness and crying. Treatment and prevention are the same as HAPE in adults.

In AMS and HACE, younger kids present with decreased playfulness, poor sleep, and increased fussiness. Teenagers present similar to adults with headache, shortness of breath, nausea, vomiting, and anorexia. The diagnosis is clinical and treatment is the same as for adults. Dexamethasone should not be used for prevention in children as it can lead to adrenocortical suppression.1,10


Dr. JacobsonDr. Jacobson is an emergency medicine resident physician at Mayo Clinic in Rochester, Minnesota.

Dr. RaukarDr. Raukar is an emergency medicine consultant and associate professor at Mayo Clinic in Rochester, Minnesota.

Key Points

  1. Do not ignore the signs and symptoms of high-altitude illness.
    1. HAPE: Dry to productive cough with dyspnea within four to six days of arrival
    2. AMS and HACE: Headache, nausea, vomiting, fatigue that progresses to ataxic gait, and encephalopathy within six hours to three days
  2. Definitive treatment is descent. Can temporize with:
    1. HAPE: high-flow nasal cannula, rest
    2. AMS and HACE: NSAIDs, antiemetics progressing to dexamethasone, acetazolamide, hyperbaric therapy
  3. Prevention: gradual ascent
    1. HAPE: nifedipine, phosphodiesterase 5 inhibitors
    2. AMS and HACE: acetazolamide, dexamethasone

References

  1. Auerbach P, Cushing T, Harris N. Auerbach’s Wilderness Medicine. 7th ed. Philadelphia: Elsevier; 2017:1-39.
  2. Luks AM, McIntosh SE, Grissom CK, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of acute altitude illness: 2014 update. Wilderness Environ Med. 2014;25(4 suppl):S4-S14.
  3. Nieto Estrada VH, Molano Franco D, Medina RD, et al. Interventions for preventing high altitude illness: Part 1. Commonly‐used classes of drugs. Cochrane Database Syst Rev. 2017;6:CD009761.
  4. Simancas‐Racines D, Arevalo‐Rodriguez I, Osorio D, et al. Interventions for treating acute high altitude illness. Cochrane Database Syst Rev. 2018;6:CD009567.
  5. Roach RC, Hackett PH, Oelz O, et al. The 2018 Lake Louise acute mountain sickness score. High Alt Med Biol. 2018;19(1):4-6.
  6. Meier D, Collet TH, Locatelli I, et al. Does this patient have acute mountain sickness? The rational clinical examination systematic review. JAMA. 2017;318(18):1810-1819.
  7. Gallagher S, Hackett P. Acute mountain sickness and high altitude cerebral edema. UpToDate. 2018. Accessed April 22, 2019.
  8. Jafarian S, Gorouhi F, Salimi S, et al. Sumatriptan for prevention of acute mountain sickness: randomized clinical trial. Ann Neuro. 2007;62(3):273-277.
  9. Seupaul RA, Welch JL, Malka ST, et al. Pharmacologic prophylaxis for acute mountain sickness: a systematic shortcut review. Ann Emerg Med. 2012;59(4):307-317.e301.
  10. Pollard AJ, Niermeyer S, Barry P, et al. Children at high altitude: an international consensus statement by an ad hoc committee of the International Society for Mountain Medicine, March 12, 2001. High Alt Med Biol. 2001;2(3):389-403.

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Emergency Physician Named CEO of American Osteopathic Association https://www.acepnow.com/article/emergency-physician-named-ceo-of-american-osteopathic-association/ https://www.acepnow.com/article/emergency-physician-named-ceo-of-american-osteopathic-association/#respond Fri, 17 May 2019 18:53:09 +0000 https://www.acepnow.com/?post_type=article&p=21302 ACEP Board member Kevin Klauer, DO, EJD, FACEP, has been appointed chief executive officer of the American...

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ACEP Board member Kevin Klauer, DO, EJD, FACEP, has been appointed chief executive officer of the American Osteopathic Association (AOA), the professional membership organization for more than 145,000 osteopathic physicians and medical students. As CEO, he will be responsible for strategy, operating results, organizational growth, and advocacy.

“We are thrilled for Dr. Klauer to join the AOA as our next CEO,” said AOA President William S. Mayo, DO. “The DO profession is undergoing significant growth, with approximately one in four medical students attending a college of osteopathic medicine. This is a pivotal moment for the osteopathic profession and health care overall, and we are confident in Dr. Klauer’s experience to lead us through a dynamic and evolving landscape.”

Dr. Klauer, an ACEP member since 1992 and current Medical Editor in Chief of ACEP Now, will finish his current term on the ACEP Board in October and will help transition a new emergency physician into the role of ACEP Now Medical Editor in Chief. Read a letter from Dr. Klauer about the transition and his new role.

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ACEP Board Considers Flu, Firearm Safety, Protected Time, and More during April Meeting https://www.acepnow.com/article/acep-board-considers-flu-firearm-safety-protected-time-and-more-during-april-meeting/ https://www.acepnow.com/article/acep-board-considers-flu-firearm-safety-protected-time-and-more-during-april-meeting/#respond Fri, 17 May 2019 18:52:16 +0000 https://www.acepnow.com/?post_type=article&p=21300 The ACEP’s Board of Directors convened April 10–11, 2019, and discussed several issues impacting the specialty of...

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The ACEP’s Board of Directors convened April 10–11, 2019, and discussed several issues impacting the specialty of emergency medicine. Among their decisions, they voted in favor of:

  • Surveying the Council for a representative viewpoint on firearm safety, firearm injury-related research, and College policy
  • A policy statement from the EMS Committee about salary and benefits considerations for EMS professionals
  • A policy statement about violence prevention and intervention in EMS systems
  • Hosting ACEP24 in Las Vegas
  • Creating a national wellness award to celebrate institutions or organizations that demonstrate best practices when it comes to physician wellness, with the inaugural award presented during ACEP20
  • Partnering with the Center for Improvement in Healthcare Quality to develop an accreditation process for freestanding emergency centers
  • Approving an influenza ED best practices information paper
  • Submitting a white paper to Annals of Emergency Medicine about the potential impact of the Accreditation Council for Graduate Medical Education’s proposed policy that would lessen the requirement for protected time for core faculty

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ACEP Supports Workplace Violence Prevention Act https://www.acepnow.com/article/acep-supports-workplace-violence-prevention-act/ https://www.acepnow.com/article/acep-supports-workplace-violence-prevention-act/#respond Fri, 17 May 2019 18:52:16 +0000 https://www.acepnow.com/?post_type=article&p=21304 Violence in the emergency department is a serious and growing concern. ACEP’s 2018 survey reported that nearly...

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Violence in the emergency department is a serious and growing concern. ACEP’s 2018 survey reported that nearly half of emergency physicians polled had been physically assaulted, with more than 60 percent of assaults occurring in the past year. ACEP recently worked with Congressional offices to refine for H.R. 1309, The Workplace Violence Prevention for Health Care and Social Service Workers Act, and sent a letter of support asking Congress to consider how emergency departments in particular are staffed to ensure the important provisions of this legislation are implemented appropriately. ACEP‘s letter requested additional clarity of the legislation‘s wording to ensure any new federal requirements do not create any unintentional burdens for entities that do not directly control the health care workplace. Read more at EDsafety.

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ACEP Submits Statement on Surprise Billing, Bundled Payments https://www.acepnow.com/article/acep-submits-statement-on-surprise-billing-bundled-payments/ https://www.acepnow.com/article/acep-submits-statement-on-surprise-billing-bundled-payments/#respond Fri, 17 May 2019 18:52:16 +0000 https://www.acepnow.com/?post_type=article&p=21306 On April 2, 2019, ACEP submitted a statement for the record to the House Committee on Education...

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On April 2, 2019, ACEP submitted a statement for the record to the House Committee on Education and Labor’s Subcommittee on Health, Employment, Labor, and Pensions that urged legislators to take into account the unique nature of emergency medicine, while examining the surprise billing issue. The letter explains how EMTALA has disincentivized health plans from entering into fair and reasonable contracts to provide services at appropriate in-network rates.

This letter also explains ACEP’s stance on recent proposals related to bundled payments being discussed as part of negotiations to develop federal balance billing legislation: “We also note our strong concerns with proposals that would either provide a single bundled payment from a hospital for emergency services or would set a benchmark payment at a certain level of Medicare rates. A bundled payment would not actually address the underlying cost issues, but instead merely shift the venue for negotiation under the assumption that hospitals would somehow be able to better negotiate with physicians than insurers.”

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Want to Make History? You’ll Need This Formula for Success https://www.acepnow.com/article/want-to-make-history-youll-need-this-formula-for-success/ https://www.acepnow.com/article/want-to-make-history-youll-need-this-formula-for-success/#respond Fri, 17 May 2019 18:52:16 +0000 https://www.acepnow.com/?post_type=article&p=21287 “The history of the world is but the biography of great men [and women].” —Thomas Carlyle It’s...

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ILLUSTRATION: Chris Whissen & shutterstock.com

“The history of the world is but the biography of great men [and women].”
—Thomas Carlyle

It’s not all about you. In fact, when it comes to achieving the summit of success, it’s often not about you at all. For most of us, understanding this can mean the difference between having a fulfilling professional life or feeling like a failure.

The Formula

FROM TOP: Dwight Eisenhower, Jackie Joyner-Kersee, Jesse Owens, and Marie Curie.Carlyle’s statement above is thought-provoking but incomplete. Great women and men are indeed integral to history, but whether history made them or they made history is a matter for debate. The distinction between the top few percent of high performers and the top one-tenth of 1 percent about whom history books are written is often one of opportunity, not awesome intrinsic personal ability. Aware of this, we increase our chances for professional success while also enjoying our accomplishments and minimizing disappointment in our careers.

I enjoy studying U.S. presidential and ancient Roman history, particularly through biographies of those who have helped shape their times. Though these impactful people vary greatly from one another, common themes, nonetheless, unite them. Most were bright and/or talented. Most worked exceedingly hard to excel in their work. However, nearly all, not just most, are persons of historic interest because unique circumstances afforded them unique opportunities. Stated as a formula: historic achievement = ability + effort + opportunity.

FROM TOP: Dwight Eisenhower, Jackie Joyner-Kersee, Jesse Owens, and Marie Curie.These three elements are neither universally possessed nor reliably attainable. Ability is most common, intense personal effort less so, and special opportunity is notably scarce in comparison to the others (see Figure 1). To reach historic levels of individual achievement in leadership or any endeavor, all three are required.

Three Essential Elements

First, some measure of innate ability is the necessary raw material of any exceptional leader. This being said, many people possess sufficient ability to excel in one or more areas of human endeavor. However, while most incapable people may never become transformational leaders, it is also true that many highly capable people never become exceptional leaders. In a relative sense, ability is essential, abundant, and insufficient. Ability requires two additional elements, each progressively less common, to produce exceptional performance.

The second essential element is effort. Deluded leaders believe their own awesome genius is the key to their success. Grounded leaders understand that the difference between very good and great is usually not intrinsic ability but effort. Hard, focused, sustained effort is essential to shape and polish innate ability to diamond-like brilliance. While there are exceptions, individuals whose performance is truly exceptional still must make an extraordinary effort. Olympic athletes, world-class musicians, high-achieving leaders, etc. frequently started their journeys young, pursued a singular activity with uncommonly intense focus, and sustained this concentrated effort over an unusually long period of time. Thomas Edison’s well-known remark memorably captures this sentiment: “Genius is 1 percent inspiration, 99 percent perspiration.”

FROM TOP: Dwight Eisenhower, Jackie Joyner-Kersee, Jesse Owens, and Marie Curie.There remains a third essential element, both rare and subject at best to influence but seldom under our control. This third element is opportunity. Some might refer to this as fate, luck, or chance. Countless highly able and hard-working persons live out very productive, high-performing lives without reaching the pinnacle of achievement and prominence in their fields because they lacked opportunity. On this point, egotistic leaders go astray, whereas self-aware and grounded leaders recognize they have benefitted from uncommon opportunity(ies) and, at times, exhibit inspiring humility arising from sincere gratitude for their good fortune.

The Elements in Action

As an example, President Dwight Eisenhower was a young army officer during World War I, after which the U.S. military shrank dramatically in size, promotions were scarce, and careers stagnant. He served in the U.S. Army with distinction for decades, earning accolades from his superior officers but languishing at lower ranks for extended periods with little hope of promotion. Then, World War II changed everything, as the U.S. Army experienced its largest-ever expansion from fewer than 200,000 soldiers in 1939 to more than 8 million soldiers in 1945. This 40-fold growth exponentially increased the need for senior officers and provided previously stagnant but able and hard-working officers the opportunities they needed to achieve prominence on the global stage. Eisenhower, one of these men, served as Supreme Allied Commander in Europe, where he worked closely with the leading men of his age and was ultimately hailed as the man who defeated Hitler. He returned home such a widely acclaimed national hero and with such a rich network of affluent connections that it seemed to many a foregone conclusion he would become president. He is a prime example whose legacy as a person of history rather than a capable but forgotten soldier was made possible by unique opportunity.

How Does This Apply to Us?

FROM TOP: Dwight Eisenhower, Jackie Joyner-Kersee, Jesse Owens, and Marie Curie.

FROM TOP: Dwight Eisenhower, Jackie Joyner-Kersee, Jesse Owens, and Marie Curie.

As emergency physicians, our academic and professional achievements are evidence of our ability. In large measure, we are intelligent, innovative, and emotionally intelligent. We should take satisfaction in the gifts of ability we have been given. If we seek rarified heights of professional accomplishment, we need to focus further to identify our unique personal abilities toward which to deploy still more effort to enhance our chances of exceptional achievement.

Emergency physicians are also no strangers to focused and sustained effort. Logging 11 years or more of post–high school education and enduring workweeks so intense that they are capped at 80 hours, we epitomize outsized effort applied to maximizing our inherent abilities. Emergency medicine is still a large field, so historic achievement requires further focus. Ultrasound, toxicology, cardiovascular disease, etc. offer paths to focused clinical excellence. Many of us possess talents in education, health policy, politics, executive management, etc. If we seek to truly excel, we must focus further, identify our differentiating abilities, and refine them through hard and sustained effort.

Even in possession of the above, we still require that essential third element: opportunity.

Opportunity and Choices

For those of you who believe you can change the world and think you are of historic potential, may the wind be at your back! Just remember, armed with all your genius, talent, beauty, and brawn, you will only get so far without the secret sauce of opportunity. Rarest of the three elements, the probability for opportunity can be optimized. It should also motivate us to reflect upon the values we hold, the examples we set, and how we choose to live our lives.

First, figure out in your own life where your unique talents overlap your passions and then commit to long, hard work to be the very best in this sliver of the universe. Beware: This will require forgoing other important parts of your life so that you can devote innumerable hours to the pursuit of excellence. Historic people often sacrifice a lot to be historic. They have been imprisoned, tortured, assassinated, impoverished, and mentally and physically unwell, among other challenges. However, great accomplishment often requires great sacrifice. If you desire graphic illustration of this, spend a weekend watching Harry Potter, The Lord of the Rings, The Hunger Games, etc. The glory of heroism frequently extracts a high cost. It’s costly, tedious, and uncertain, but if you want to reach the pinnacle, this intensity is generally required.

Second, grow your network of people both within your area of expertise and in areas directly adjacent to it. In doing this, be sincere, not a suck-up. Genuinely appreciate the company of these others and enjoy your shared interests on their own merits. At the end of the day, being a good person still matters, and over the long haul, it is a substantial asset to you and those with whom you associate. Uncommon opportunities frequently present themselves through these personal relationships. Since you will seldom accurately predict which single relationship will result in your special opportunity, nurturing a wide array of connections increases your odds.

Last but most important, if your opportunity to make history fails to materialize, remember that misery loves company and that you are in the company of 99.9 percent of all people! However, if you correctly identified an area in which you excel, worked diligently to be your best at it, and forged friendships with others who share your passion, you will have done well. If you step back from your ambitions to reflect on your journey, you may just find that, while books may not be written about you, you have nonetheless enjoyed a life worth living and positively impacted the lives of many others along the way.


Dr. StackDr. Stack is an adjunct professor at the University of Tennessee Haslam College of Business in Knoxville; an emergency physician at CHI St. Joseph East in Lexington, Kentucky; and past president of the American Medical Association.

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ACEP, NAEMT Partner to Celebrate EMS Week https://www.acepnow.com/article/acep-naemt-partner-to-celebrate-ems-week/ https://www.acepnow.com/article/acep-naemt-partner-to-celebrate-ems-week/#respond Fri, 17 May 2019 18:52:16 +0000 https://www.acepnow.com/?post_type=article&p=21308 The 45th National EMS Week is May 19-25, 2019, bringing together local communities and medical personnel to...

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The 45th National EMS Week is May 19-25, 2019, bringing together local communities and medical personnel to publicize safety and honor the dedication of EMTs. In 1974, President Gerald Ford authorized EMS Week to celebrate EMS practitioners and the important work they do in our nation‘s communities. Presented by ACEP and the National Association of EMTs (NAEMT), our EMS Week 2019 theme is “BEYOND the CALL.” Each weekday has a different emphasis:

  • May 20: Education
  • May 21: Safety Tuesday
  • May 22: Emergency Medical Services for Children Day
  • May 23: Save-A-Life (CPR and Stop the Bleed)
  • May 24: EMS Recognition Day

Looking for ways to celebrate EMS practitioners during EMS Week?

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Congratulations to the 2019 ACEP Award Winners https://www.acepnow.com/article/congratulations-to-the-2019-acep-award-winners/ https://www.acepnow.com/article/congratulations-to-the-2019-acep-award-winners/#respond Fri, 17 May 2019 18:52:16 +0000 https://www.acepnow.com/?post_type=article&p=21298 The Board approved the following award winners during its April meeting and congratulates the recipients. The winners...

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The Board approved the following award winners during its April meeting and congratulates the recipients. The winners will be honored at ACEP19 in Denver.

  • John G. Wiegenstein Leadership Award: Sandra M. Schneider, MD, FACEP
  • James D. Mills Outstanding Contribution to Emergency Medicine Award: Ramon W. Johnson, MD, FACEP
  • Judith E. Tintinalli Award for Outstanding Contribution in Education: William “Ken” Milne, MD, FACEP
  • Outstanding Contribution in Research Award: Rebecca M. Cunningham, MD, FACEP; and Gail D’Onofrio, MD, FACEP
  • Outstanding Contribution in EMS Award: Robert E. O’Connor, MD, FACEP
  • Colin C. Rorrie, Jr. Award for Excellence in Health Policy: Peter J. Jacoby, MD, FACEP
  • Policy Pioneer Award: Megan L. Ranney, MD, FACEP
  • John A. Rupke Legacy Award: Juan A. Gonzalez-Sanchez, MD, FACEP
  • Honorary Membership Award: Lowell Gerson, PhD, and Laura Gore
  • Pamela P. Bensen Trailblazer Award: Andrew I. Bern, MD, FACEP
  • Diane K. Bollman Chapter Advocate Award: Elena Lopez-Gusman
  • Spokesperson of the Year (2018): Benjamin A. Savitch, MD, FACEP
  • Council Meritorious Service Award: John H. Proctor, MD, FACEP
  • Teamwork Award: Anne Zink, MD, FACEP; Laura Tilly, MD, FACEP; Brad Gruehn; and the SHIELDS Act Team
  • Horizon Award: Zachary Jarou, MD
  • Champion of Diversity & Inclusion: Bruce Lo, MD, FACEP
  • Curmudgeon Award: Bradford L. Walters, MD, FACEP

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Using Point-of-Care Ultrasound to Confirm Endotracheal Tube Placement https://www.acepnow.com/article/using-point-of-care-ultrasound-to-confirm-endotracheal-tube-placement/ https://www.acepnow.com/article/using-point-of-care-ultrasound-to-confirm-endotracheal-tube-placement/#respond Fri, 17 May 2019 18:52:15 +0000 https://www.acepnow.com/?post_type=article&p=21371 The Case A 52-year-old patient is in cardiac arrest and needs endotracheal intubation. You’ve read some studies...

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The Case

A 52-year-old patient is in cardiac arrest and needs endotracheal intubation. You’ve read some studies recently saying point-of-care ultrasound (POCUS) could confirm placement.

Background

There are a number of ways to confirm endotracheal tube (ETT) placement. Quantitative waveform capnography is thought to be one of the best methods. However, in cardiac arrest, some studies suggest it is correct only about two-thirds of the time.1–3 

An ACEP policy statement lists various methods to confirm ETT placement, which include:

  • A physical exam (ie, auscultation of chest and epigastrium, chest wall movement, and condensation/fogging in the tube)
  • Direct visualization or video laryngoscope of the tube passing through the vocal cords
  • Pulse oximetry
  • Chest X-ray
  • Esophageal detector devices
  • End-tidal carbon dioxide (CO2) detection (ie, continuous waveform capnography, colorimetric capnography, and non-waveform capnography)

Clinical Question

What is the accuracy of POCUS for ETT placement confirmation?

Reference

Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the confirmation of endotracheal tube intubation: a systematic review and meta-analysis. Ann Emerg Med. 2018;72(6):627-636.

  • Population: Prospective or randomized controlled trial (RCT) of adults undergoing assessment of transtracheal POCUS for ETT placement confirmation
    • Excluded: Case reports, case series, retrospective studies, cadaver studies, pediatric studies, and conference abstracts
  • Intervention: Transtracheal POCUS to confirm ETT placement
  • Comparison: Confirmatory testing of ETT placement such as end-tidal capnography, colorimetric capnography, or direct visualization
  • Outcome:
    • Primary Outcome: Accuracy of transtracheal POCUS versus other forms of confirmation
    • Secondary Outcome: Time to confirmation and subgroup analyses

Authors’ Conclusions

“Transtracheal sonography is rapid to perform, with an acceptable degree of sensitivity and specificity for the confirmation of endotracheal intubation. Ultrasonography is a valuable adjunct and should be considered when quantitative capnography is unavailable or unreliable.”

Table 1: Diagnostic Accuracy of Transtracheal POCUS  for ETT Placement

(click for larger image) (Table 1: Diagnostic Accuracy of Transtracheal POCUS for ETT Placement

Key Results

The search identified 15 prospective observational studies and two RCT, including a total of 1,595 patients. A majority of the studies (12 out of 17) were performed in the emergency department. The mean patient age was 55 years, with 57 percent being male. The esophageal intubation rate was 15 percent.

  • Primary Outcome: Diagnostic accuracy of transtracheal POCUS for ETT placement (see Table 1)
  • Secondary Outcome: Mean time to confirmation was 13.0 seconds (95% CI, 12.0–14.0).
  • Subgroup Analyses: These did not demonstrate a significant difference by location, provider specialty, provider experience, transducer type, or technique.

Evidence-Based Medicine Commentary

  1. Included Studies: The 17 studies included were relatively small with wide confidence intervals. Fifteen of the 17 were observational studies. Only 216 patients (14 percent) were in RCTs. Thirteen of the 17 studies used convenience sampling instead of consecutive patients, which can introduce bias and thereby limit the strength of the conclusions.
  2. Lack of Gold Standard: A number of methods are available and often used in combination, but there is no gold standard. Each confirmation method has limitations. Auscultation can prove inaccurate, especially in loud environments. Chest X-ray takes too long, and as previously mentioned, capnography in cardiac arrest has low sensitivity.
  3. Esophageal Intubation Rate: This was very high (15 percent) and may be due to studies including medical students and residents in addition to attending physicians. A previous study has shown the rate of esophageal intubation in the emergency department to be only 3 percent.4
  4. Fast: POCUS for ETT placement was not only accurate but also fast, with a mean of 13 seconds. For comparison, it takes 48 seconds for the standard auscultation and capnography combination.5 It is not known if this difference in time results in a patient-oriented benefit.
  5. Publication Bias: The funnel plot analysis demonstrated evidence of publication bias. This is a well-known phenomenon in the medical literature and could have skewed the results to make transtracheal POCUS ETT confirmation look better than it actually is.

Bottom Line

In conjunction with other methods, POCUS represents a potentially fast and accurate method to help confirm ETT placement.

Case Resolution

You directly visualize passage of the ETT through the vocal cords on video laryngoscopy. Waveform capnography confirms an appropriate ETT placement. POCUS is then placed on the neck and also confirms correct tube placement.

Thank you to Chip Lange, an emergency medicine physician assistant and creator of the blog/podcast TOTAL EM and the educational company Practical POCUS.

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

References

  1. Takeda T, Tanigawa K, Tanaka H, et al. The assessment of three methods to verify tracheal tube placement in the emergency setting. Resuscitation. 2003;56(2):153-157.
  2. Tanigawa K, Takeda T, Goto E, et al. Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patients. Anesthesiology. 2000:93(6);1432-1436.
  3. Tanigawa K, Takeda T, Goto E, et al. The efficacy of esophageal detector devices in verifying tracheal tube placement: a randomized cross-over study of out-of-hospital cardiac arrest patients. Anesth Analg. 2001;92(2):375-378.
  4. Brown CA 3rd, Bair AE, Pallin DJ, et al. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015;65(4):363-370.
  5. Bache S, Pfeiffer P, Rudolph SS, et al. Temporal comparison of ultrasound versus auscultation and capnography in verification of endotracheal tube placement in obese patients. Br J Anaesth. 2012;108(S2):ii118.

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