Author: Arthur Martins, Brasil

Medical Student at the Federal University of Rio Grande do Sul (UFRGS), Brazil, leader of the #FOAMed Project, from International Student Association of Emergency Medicine (ISAEM), and a great supporter of the #FOAMed movement. Passionate about Emergency Medicine, with a special interest in trauma, disaster medicine, point of care US, wilderness medicine and medical education, both in academia and in community-oriented health education projects. Besides medicine, loves books, travel, math & physics, music and a big cup of coffee.

Special Populations in the ED: Drug Users

~ Arthur Martins, Brasil ~ Leave a comment

Drug users have a different reputation among health care providers, especially in the ED. According to World Health Organization (WHO), in 2018, an estimated 269 million people, or 5.4 percent of the global population aged 15–64, had used drugs in the previous year (1). Here we will focus on opioid users, which accounts for 57.8 million people globally in 2018, specifically the acute pain management in these patients.

What do I have to know about them:

Patients with opioid dependency can have three major obstacles to pain management

  1. Opioid-Induced Hyperalgesia (OIH): A sensitive disorder is caused by chronic use of opioids; It can affect patients under opioid use for chronic pain control, patients under substitution therapy (methadone and buprenorphine), and those abusing heroin. OIH typically produces diffuse and not well-defined pain.
  2. Opioid tolerance: These patients report higher pain scores, have slower pain resolution, and experience a longer hospital stay with an increased chance of readmission, compared with opioid-naive patients. Tolerance to CNS, respiratory, and analgesic effects develops quickly, while tolerance to constipating effects may not happen. (3). Cross-tolerance is a tolerance that patients taking chronic methadone need higher doses of morphine for pain relief than occasional IV heroin users (3), suggesting a cross-tolerance between methadone and other opioids.
  3. Opioid withdrawal: Symptoms are caused by sympathetic activation: tachycardia, sweating, insomnia, diarrhea, and anxiety. Opioid substitution therapy (OST), usually with methadone, is crucial in treating those in rehab from opioid abuse.
drug users 2

How could this be a problem?

  • Overtreatment: Higher dose equals more toxicity. Because of the OIH and opioid tolerance, higher doses may be necessary to relieve pain in these patients. Clinicians are generally afraid to give a higher amount of opioids due to the risk of toxicity, especially respiratory depression.
  • Relapse x undertreatment: Another common fear among clinicians is inducing a relapse in an abstinent patient or OST, leading to undertreatment of pain. This, instead of opioid use, has more power to cause a relapse. (2)

Acute pain management in the chronic opioid user

  • OIH (2): Multimodal analgesia, using acetaminophen, non-steroidal anti-inflammatories, and local anesthetics as “opioid-sparing drugs.” Adjuvant therapies also play an essential role, with ketamine, gabapentin, and pregabalin showing promising results in reducing OIH.
  • Withdrawal (2): Methadone in small doses (10 – 20 mg) can be used to prevent withdrawal symptoms in patients who are not in OST. Methadone can cause QT-interval prolongation
  • Toxicity (4): As commented above, chronic opioid users develop tolerance to respiratory and CNS effects as well, giving more space to higher doses of opioids for pain management. If toxic effects happen, provide ventilatory support and use antidotes (naloxone) if needed. Classic signs of opioid toxicity are as follows; decreased respiratory frequency (best predictor if < 12), depressed mental status, miotic pupils (however, normal pupils does not exclude opioid toxicity). 
  • Tolerance (3): Around the clock dosing is recommended rather than “as needed.” For patients on OST, their regular dose of methadone/buprenorphine should be continued alongside additional doses of short-acting opioids and other analgesics for adequate pain control.

Disposition to home (3)

The most crucial action here is to contact the assistant physician who is prescribing the opioids and make he/she knows what happened, how it was managed, what medications were prescribed, and in which dose. If opioids are needed for pain control at home, consider the services available in the outpatient setting: 

  • Immediate-release preparations are more effective for acute pain relief but carry a higher risk of abuse. If it is possible to arrange more frequent appointments, small doses of the medication can be prescribed, and the patient can be closely monitored.
  • If a closer follow-up is not possible, long-acting formulations are the safest way to provide good analgesia with a smaller risk of abuse.
Cite this article as: Arthur Martins, Brasil, "Special Populations in the ED: Drug Users," in International Emergency Medicine Education Project, March 10, 2021, https://iem-student.org/2021/03/10/drug-users/, date accessed: December 11, 2023

Recent Blog Posts by Arthur Martins

References and Further Reading

  1. United Nations World Drug Report 2020 (available at https://wdr.unodc.org/wdr2019/) 
  2. Quinlan J, Cox F. Acute pain management in patients with drug dependence syndrome. Pain Rep. 2017;2(4):e611. Published 2017 Jul 27. doi:10.1097/PR9.0000000000000611
  3. Vadivelu N, Lumermann L, Zhu R, Kodumudi G, Elhassan AO, Kaye AD. Pain Control in the Presence of Drug Addiction. Curr Pain Headache Rep. 2016;20(5):35. doi:10.1007/s11916-016-0561-0
  4. UpToDate: https://www.uptodate.com/contents/acute-opioid-intoxication-in-adults?search=opioid&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4
  • UN World Drug Report 2020 – https://wdr.unodc.org/wdr2020/index.html
  • Haber PS, Demirkol A, Lange K, Murnion B. Management of injecting drug users admitted to hospital. Lancet. 2009;374(9697):1284-1293. doi:10.1016/S0140-6736(09)61036-9
  • Sahota PK, Shastry S, Mukamel DB, et al. Screening emergency department patients for opioid drug use: A qualitative systematic review. Addict Behav. 2018;85:139-146. doi:10.1016/j.addbeh.2018.05.022



Special Populations in the ED: Athletes

special populations in the ED athletes
~ Arthur Martins, Brasil ~ Leave a comment

It is common to hear that “when you work in an Emergency Department (ED), you have to be prepared for everything”. In my experience as a medical student, this could not be more true. I’ve seen tea overdose, collision scooter vs horse, and anything in between. All these experiences will contribute to my formation and made me realize that we are not prepared for many situations. Some of these situations may involve specific populations we’re not so familiarized with and sometimes can change the way we manage an emergency.

Here, I want to discuss some of these “special populations” which may demand a different approach than the usual – and that is what makes emergency medicine so interesting. Let’s talk about one of these subgroups of patients: athletes, and what makes them unique.

Athletes: What do I need to know about them?

  • Heart and Hemodynamic: The “athlete’s heart syndrome (1)”
    • Morphological, functional and electrical changes
      • Lower heart rate;
      • Hypertrophic left ventricle (LV)
      • Lifelong cardiac remodelling could lead to arrhythmogenic pathways
  • Changes in autonomic nervous system – vagal tonus
  • Pulmonary efficiency:
    • Unlike what may be the first thought, the respiratory system does not differ greatly in athletes from non-athletes (2).
  • High energy trauma:
    • Be aware that professional athletes are constantly at risk of high energy traumas, in special head traumas (concussions) and limb trauma (fractures);

How could this be a problem?

  • Late signs of hypovolemia
    • The athlete’s autonomic nervous system has pronounced vagal tonus, which leads to the famous resting bradycardia – this could disguise a tachycardia, one of the early signs of hypovolemia (2).
  • Delay in seeking help
    • Elite athletes may delay seeking help or admit they are not feeling well for fear of losing a competition or training sessions.
    • Besides that, in amateur (and sometimes even in professional) level competitions, staff and coaches often are not trained to identify conditions that need prompt medical assistance

Common situations and how to manage

Exercise and health always have been put together in a “cause and consequence” relation. Besides their undeniable positive effects, exercise on the professional level also has its sidebacks and associated risks. Here I want to discuss some physiological changes we observe in the elite athletes and a very common condition in the ED: the sport-related concussion.

Sport-related concussion (3,4) is a traumatic brain injury induced by biomechanical forces. It may be caused either by a direct impact to the head or by a force transmitted from the impact elsewhere in the body; It typically presents with rapid onset of short-lived signs and symptoms; However, the course is sometimes unpredictable and may evolve in minutes to hours; It may or may not have a decreased level of counsciousnes.

The current literature organize the signs and symptoms of sport-related concussion in 4 domains

  1. Somatic
    • Headache, dizziness, gait disturbances, vertigo, nausea and vomiting, near vision impairment
  2. Cognitive
    • Impaired memory (amnesia), slowed speech, confusion,
  3. Sleep
    • Insomnia
  4. Emotional
    • Irritability, labile humour

Given the rapid onset and short duration, the patient might present to the ED with minor or no symptoms; However, the emergency physician still plays an important role, providing supportive care to relieve remaining symptoms and rule out more severe conditions.

Attention

  • Due to the mechanism of trauma, always rule out cervical spine lesions or instability.
  • Also, signs of basilar skull fracture (racoon eyes, Battle’s sign, CSF rhinorrhea)
  • A Glasgow Coma Scale < 13 should raise awareness for a more severe brain lesion.
  • Does this patient need a head CT?
    • Canadian CT head rule (adults)
    • PECARN CT rule (under 16)   

Management (4)

Headache: 86% had significant pain reduction, and 52% had complete headache resolution after receiving an intravenous dose of one or more of the following: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Common orally administered analgesics such acetaminophen, non-steroidal anti-inflammatories and triptans have shown efficacy for pain relief, but there are no studies in the ED setting.
 
Dizziness: Suspicion for peripheral vertigo can be confirmed by the Dix-Hallpike manoeuvre and treated with the Epley manoeuvre. Meclizine (vestibular suppressant) and diazepam can be used with caution because of potential side effects on cognition and alertness.
 
To date, rest continues to be recommended for the acute (24-48h) injury period. After that period, patients can be encouraged to become gradually more active, always below their cognitive and physical limits.

When to admit

This decision is based on the patient’s clinical status. Persistent symptoms and alterations on head CT are the most common indications for admission. 
 
Discharging to home: Education is key for recovery and prevention of recurrence (4). Current evidence indicates that written educational material is more effective than orally given instructions only; Important information that should be present in the educational material are expected symptoms, their management and a timeframe of resolution. 
Cite this article as: Arthur Martins, Brasil, "Special Populations in the ED: Athletes," in International Emergency Medicine Education Project, March 8, 2021, https://iem-student.org/2021/03/08/special-populations-in-the-ed-athletes/, date accessed: December 11, 2023

Recent Blog Posts by Arthur Martins

References and Further Reading

  1. Carbone A, D’Andrea A, Riegler L, Scarafile R, Pezzullo E, Martone F, America R, Liccardo B, Galderisi M, Bossone E, Calabrò R. Cardiac damage in athlete’s heart: When the “supernormal” heart fails! World J Cardiol 2017; 9(6): 470-480 Available from: URL: http://www.wjgnet.com/1949-8462/full/v9/i6/470.htm DOI: http://
    dx.doi.org/10.4330/wjc.v9.i6.470
  2. ACSM’s advanced exercise physiology. — 2nd ed.;Peter A. Farrell, Michael Joyner, Vincent Caiozzo ISBN 978-0-7817-9780-1
  3. McCrory P, Meeuwisse W, Dvorak J, et al. Br J Sports Med 2018;51:838–847
  4. Bazarian JJ, Raukar N, Devera G, et al. Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med. 2020;75(4):471-482. doi:10.1016/j.annemergmed.2019.05.032

Doctor, My Head Hurts!

DOCTOR, MY HEAD HURTS
~ Arthur Martins, Brasil ~ Leave a comment

February was the last of my three months at Family Medicine clinical rotation. In addition to normal clinical consultations, we also had to take turns attending spontaneous demands coming “from the street”, in a primary care resource center that works similar to a green zone setting in the ED. During these three months, I’ve noticed that, sometimes, the easiest patient to manage is that one with a major complaint like chest pain, severe dyspnea, altered mental status, and so on. Things become more difficult, however, when you have a patient that has just a headache, a very common symptom, but one that could be related to an enormous variety of conditions, some of which life-threatening. Sometimes, you dig under the “green” patient and discover a secret “yellow” or even a “red” condition.

Next, I will try to put some light on the investigation of one of the most common complaints I’ve seen, and one of the symptoms that always put a bug in the ear: Headache.

Epidemiology

Headache is a very common complaint at the Emergency Department, being the fifth leading cause of ED visits¹. Alarmingly, about 0.5% of patients who had presented with a headache and discharged home have returned with a serious condition, of which 18% were acute ischemic stroke.²

Clinical Presentation

Patients can describe headache, a very nonspecific and hard to clarify complaint, in diverse ways, ranging from saying solely “my head hurts” to making a circular gesture around his/her head with. Therefore, identifying potential risk factors that can alert us to potential adverse outcomes. Here are a few decision rules for patients with headache:

SNNOOP10

The mnemonic SNNOOP10³ refers to the red flag symptom and findings to screen, which may point to related secondary headaches.

snnoop10

Ottawa Subarachnoid Hemorrhage Rule

Ottawa Subarachnoid Hemorrhage Rule fundamentally helps to rule out (Sensitivity: 100% Specificity: 15%) subarachnoid hemorrhage (SAH) in patients with headache. You can apply this rule ONLY IF:

  • The patient is alert and older than 15 years old with
  • New severe non-traumatic headache, reaching maximum intensity within 1 hour and
  • NO new neurological deficits, no history of intracranial tumors, previous SAH or aneurysms, and similar headaches (≥ 3 episodes over ≥ 6 months)

Risk factors are:

  1. Age ≥ 40
  2. Neck pain or stiffness
  3. Witnessed loss of consciousness
  4. Onset during exertion
  5. “Thunderclap headache” (defined as instantly and immediately peaked pain)
  6. Limited neck flexion on examination (defined as the inability to touch chin to chest or raise head 3 cm off the bed if supine)

If ANY of these factors is present, SAH can not be ruled out, and this patient needs further investigation. A recent study has assessed the performance of the Ottawa decision rule for patients presenting with headache in the ED, showing that it is a highly sensitive test (100%), making it useful in order to “not miss the disguised red patient.”5 Not by coincidence, Tintinalli’s book states with bold letters: “Acute onset of a severe headache is subarachnoid hemorrhage until proven otherwise.”

Acute onset of a severe headache is subarachnoid hemorrhage until proven otherwise.

Tintinalli's Comprehensive Study Guide Tweet

Investigation

Neuroimaging is a valuable diagnostic tool but is also an expensive one. Besides, it can be harmful due to radiation exposure or contrast use.

There is a lot of controversy in the literature regarding the question “When to image patients with a headache?”, but the consensus is to image when a patient presents with red flags, especially those related to vascular causes, raised intracranial pressure and focal signs.4

CT scan is the preferred method to investigate SAH, with excellent sensitivity and specificity (both bigger than 90%) in the first 6 hours of hemorrhage.6 However, if more time has passed, other diagnostic tools will probably be required in this case. Also, as said before, the costs are a major factor regarding neuroimaging, and sometimes you have to use what you have.

Lumbar Puncture

  • Indications7:
    • Suspected infectious disease of the CNS
    • Suspected SAH
    • Suspected idiopathic intracranial hypertension – as diagnostic and treatment
  • Contraindications7:
    • Coagulopathy (including anticoagulant drugs) or thrombocytopenia
    • Infection at the puncture site
    • Suspected epidural abscess
    • Findings on the CT scan to deferring LP
    • Brainstem herniation
    • Mass with signs of compression of the 4th ventricle
    • Signs of increased intracranial pressure or midline shift
    • Acute intracranial hematoma

Disposition and Follow-up(7,8)

  • Most patients can be discharged with a simple painkiller prescription. About 95% of patients presenting to the ED with headache have a benign etiology and don’t need further investigation in the ED.
  • The acute benign headache usually resolves with acetaminophen, NSAIDs, hydration, and rest.
  • An adequate follow-up plan is a good practice since most headaches are due to chronic conditions that may benefit from pharmacologic prophylaxis as well as lifestyle modifications.

This subject is open to discussion. Although it looks (and it is) a simple and easy-to-manage condition 90% of times, it has the potential to give the doctor some headache, too!

References and Further Reading

  1. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Headache:, Godwin, S. A., Cherkas, D. S., Panagos, P. D., Shih, R. D., Byyny, R., & Wolf, S. J. (2019). Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. Annals of emergency medicine, 74(4), e41–e74. https://doi.org/10.1016/j.annemergmed.2019.07.009
  2. Dubosh, N. M., Edlow, J. A., Goto, T., Camargo, C. A., Jr, & Hasegawa, K. (2019). Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain. Annals of emergency medicine, 74(4), 549–561. https://doi.org/10.1016/j.annemergmed.2019.01.020
  3. Do, T. P., Remmers, A., Schytz, H. W., Schankin, C., Nelson, S. E., Obermann, M., Hansen, J. M., Sinclair, A. J., Gantenbein, A. R., & Schoonman, G. G. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology, 92(3), 134–144. https://doi.org/10.1212/WNL.0000000000006697
  4. Good C. (2019). British Society Of Neuroradiologists Guidelines for Headache. Retrieved July 23, 2020, from https://bsnr.org.uk/_userfiles/pages/files/standards_and_guidelines/bsnr_guidelines_for_imaging_in_headache_april_2019_final.pdf
  5. Wu, W. T., Pan, H. Y., Wu, K. H., Huang, Y. S., Wu, C. H., & Cheng, F. J. (2020). The Ottawa subarachnoid hemorrhage clinical decision rule for classifying emergency department headache patients. The American journal of emergency medicine, 38(2), 198–202. https://doi.org/10.1016/j.ajem.2019.02.003
  6. Kwiatkowski T. and Friedman B. W. (2018). Headache Disorders. In: R. M. Walls, R. S. Hockberger, M. Gausche-Hill, K. Bakes, J. M. Baren, T. B. Erickson, A. S. Jagoda, A. H. Kaji, M. VanRooyen, R. D. Zane, (Eds.) Rosen’s Emergency Medicine Concepts and Clinical Practice (9th ed. pp: 1265-1277). Philadelphia, PA: Elsevier.
  7. Perry, J. J., Stiell, I. G., Sivilotti, M. L., Bullard, M. J., Emond, M., Symington, C., Sutherland, J., Worster, A., Hohl, C., Lee, J. S., Eisenhauer, M. A., Mortensen, M., Mackey, D., Pauls, M., Lesiuk, H., & Wells, G. A. (2011). Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. British Medical Journal (Clinical research ed.), 343, d4277. https://doi.org/10.1136/bmj.d4277
Cite this article as: Arthur Martins, Brasil, "Doctor, My Head Hurts!," in International Emergency Medicine Education Project, August 24, 2020, https://iem-student.org/2020/08/24/doctor-my-head-hurts/, date accessed: December 11, 2023

Who Takes Care of You While You Take Care of Others?

Who Takes Care of You While You Take Care of Others
~ Arthur Martins, Brasil ~ Leave a comment

The COVID-19 Pandemic has changed our lives in so many ways that sometimes it is difficult to remember how life was without all these changes. We got used to the “new normal”, which includes a constant concern about contamination, economic crisis, and isolation. When we consider emergency physicians and other healthcare professionals, technical and scientific challenges regarding the pandemic response are also added to the equation.

Recently we completed three months since the first case of COVID-19 in Brazil and, since then, more than 300.000 have been infected and at least 23.000 people have died. These astonishing numbers could be 8 to 10 times higher if it wasn’t for under-notification¹ in countryside areas. The psychological effect of these numbers can be seen every day while people try to cope with the situation, and it may be even more intense in those who are in the frontline of the healthcare system. With this in mind, the question emerges: Who takes care of you while you take care of others?

What are the major psychological symptoms we can expect in healthcare providers three months into the COVID-19 pandemic?

After 3 months of COVID-19, we are not dealing with acute and immediate psychological response anymore; this next phase can be called assimilation, where we already understand better the new workflows, protocols and forms of living. However, we are still in a context of insecurity, fear, and loss of control over things we used to know how to deal with. The major psychological symptoms that are expected and considered to be normal in this context are:2

  • Fear (of getting sick and dying, losing people, being socially stigmatized, being separated from people you care about and transmitting the virus to other people);
  • Stress reactions such as anger, anxiety, confusional states, apathy
  • The recurrent feeling of impotence, irritability, anguish, and sadness;
  • Behavioral changes: changes in appetite and sleep habits, and interpersonal conflicts

Which strategies we can use to minimize these effects?

It’s very important to understand these reactions as being normal reactions in the context we currently live in. However, that doesn’t mean there is nothing we can do to ease them. It’s very important to intervene as early as possible as a way to prevent the chronification of those symptoms and progression to psychological disorders. Here are some strategies that can help2:

  • Recognize these feelings and accept them as real and valid; try to talk about them with people you trust
  • Think back to the strategies and tools you used in moments of crisis in the past. When it comes to dealing with difficulties, everybody has some preferred methods, which were tried and worked. Resume those actions that have worked for you and try to find ways of applying them to this new context
  • Keep your social network active by establishing -even if virtual- contact with family, friends, and colleagues,
  • Avoid watching, reading or listening to news that makes you feel anxious or distressed; look for information only from reliable sources
  • Avoid using alcohol and drugs as coping mechanisms
  • Ask for help if you find your strategies inefficient

There are lots of health professionals who are self-isolating from their families to prevent “bringing the enemy home”. How can self-isolation affect our mental health?

Isolating from family and friends means physically isolating from your support network. It’s relevant, in this context, to understand that physical isolation doesn’t mean affective and emotional isolation. As said before, it’s important to find new ways to be present in people’s lives and keep the social network active. Maintaining these contacts is also a way to ensure that when you leave the hospital and arrive at your rest place, you can actually disconnect from the routine and difficult times by talking to family members and listening about their day, their stories, and so on. In this moment of isolation and fear, we also witness the stigmatization of healthcare professionals3. People can direct their feelings of fear and uncertainty at health professionals, potentially causing behaviors of avoidance, rejection, aggressiveness and violence. If you find yourself in this situation, it’s key to understand that these reactions are not directed towards you personally, but to the global state of insecurity and fear, we are currently living.

Have you seen any changes in the problem-solving and decision-making capabilities of the physicians in the ED due to the stressed environment?

Interpersonal conflict, due to constant changes in protocols and workflows is expected in times of crisis and might be affecting problem-solving and decision-making processes. Here are some strategies to prevent it:

  • Try to maintain a supportive work environment, including designated spaces to eat and rest
  • Have moments to let the team talk about their mental state to help to develop a sense of community
  • Alternate workers between activities of high and low attention and tension, if possible,
  • Recognize effort made and encourage mutual respect among professionals
  • Map and disseminate mental health care actions. Even if most workers will not need individual assistance, knowing that there are services that they can rely on when needed makes them feel supported

Finally, do you have any special tips for emergency physicians who are in the frontline against COVID-19 at this moment?

It’s important to know and to understand when the frequency and intensity of the normal symptoms indicate that you should see a specialized mental health professional.2

  • Persistent symptoms
  • Intense suffering
  • Risk of complications, especially suicidal ideation and substance abuse
  • Significant impairment of social and daily functioning
  • Significant difficulties in family, social or work life
  • Major depression, psychosis, and PTSD are conditions that require specialized attention

We know that healthcare workers bear considerable suffering and symptoms, but usually, this group of people refuses to seek or receive help. Among others, the main reason is that having difficulties to deal with all the emotional demands is -wrongly- seen as a sign of weakness or incompetence. At this moment, it’s more important than ever to understand that we can only take care of others if we, first, take care of ourselves. And taking care of our mental health is as important as our physical health to be at the front lines of COVID-19 response.

Gabriele H. Gomes

Psychologist, current Critical Care & Emergency Psychology Resident at Hospital de Clínicas de Porto Alegre (HCPA)

References and Further Reading (Portuguese only)

  1. https://ciis.fmrp.usp.br/covid19-subnotificacao/
  2. https://www.fiocruzbrasilia.fiocruz.br/wp-content/uploads/2020/04/Sa%c3%bade-Mental-e-Aten%c3%a7%c3%a3o-Psicossocial-na-Pandemia-Covid-19-recomenda%c3%a7%c3%b5es-gerais.pdf
  3. https://www.sbponline.org.br/arquivos/To%CC%81pico_4_Trabalhando_com_profissionais_de_sa%C3%BAde_que_enfrentam_rea%C3%A7%C3%B5es_negativas_das_pessoas_ao_redor_durante_a_COVID-19_No_T%C3%B3pico_4_abordamos_como_entender_e_minimizar_a_estigmatizacao_dos_profissionais_de_sa%C3%BAde1.pdf
  4. https://www.fiocruzbrasilia.fiocruz.br/wp-content/uploads/2020/04/Sa%c3%bade-Mental-e-Aten%c3%a7%c3%a3o-Psicossocial-na-Pandemia-Covid-19-recomenda%c3%a7%c3%b5es-para-gestores.pdf
Cite this article as: Arthur Martins, Brasil, "Who Takes Care of You While You Take Care of Others?," in International Emergency Medicine Education Project, August 5, 2020, https://iem-student.org/2020/08/05/who-takes-care-of-you-while-you-take-care-of-others/, date accessed: December 11, 2023

A Song of Ice and Fire

A Song of Ice and Fire
~ Arthur Martins, Brasil ~ Leave a comment

As the year comes to an end, the holidays approach and, for lots of people, it means traveling to different places around the world. For those who live in the southern hemisphere, like me, the summer comes with al power, with temperatures as high as 35°C (95°F) or 40°C (104°F). For those who live in the northern hemisphere, “the winter is coming” and bring with him temperatures below 0°C (32°F) in some places. With these temperature extremes, we have some conditions to have in mind when working in the ED. How to treat a homeless patient who has slept on the streets on a freezing night? And how about an elderly person who lay on the beach sand under a blazing sun?

Hyperthermia

What is hyperthermia?

By definition, hyperthermia is a condition when there is a failure of the body’s thermoregulatory mechanisms to handle extrinsic and intrinsic heat. It’s common to see the expression “Heat-related Illness” to describe the conditions associated to the exposure to environmental heat.

Physiology

The heat-related illness (HRI) develops following a progressive pattern, divided in 3 phases [1].

  • ACUTE PHASE: 
    • Activation of inflammatory mediators, especially in the blood vessels; 
    • Gastrointestinal tract hypoperfusion, leading to bacterial translocation
    • Respiratory alkalosis due to hyperventilation
  • ENZYMATIC PHASE:
    • Coagulopathy, leading to a hypercoagulability state 
    • Endothelial injury and microvascular thrombosis 
    • All of this leading to disseminated intravascular coagulation (DIC)
  • LATE PHASE:
    • Liver dysfunction secondary to DIC
    • Kidney failure due to dehydration and hypotension
    • CNS lesions leading to cerebral edema and hemorrhage 
    • Cardiovascular dysfunction, worsening hypotension and causing vasoconstriction

Risk Factors

  • Extremes of age
  • Obesity
  • Elevated humidity rate
  • Lack of acclimatization and/or fitness
  • Ambient temperature
  • Dehydration
  • Cardiovascular disease
  • Drugs/medication (i.e alcohol, diuretics, amphetamines)

Categories of heat illness

  • Minor Heat Illness:  
    • Heat cramps: Intermittent muscle cramps likely related to salt deficiency and muscular fatigue, although the exact mechanism is not well known.
    • Heat Edema: Swelling of the feet and ankles typically in non-acclimatized people
    • Heat Syncope: Similar to orthostatic hypotension, caused by the physiologic response to the heat: volume depletion, peripheral vasodilatation and a reduced vasomotor tonus. More common in elderly people.
    • Prickly Heat: cutaneous rash caused by pores and sweat gland obstruction
  • Heat Exhaustion:
    • Occurs with a moderate elevation in the body core temperature (<40°C or 104°F) – RECTAL temperature is the most reliable method (even though is a level C evidence)
    • Usually accompanied by symptoms related to conditions described in the Minor Heat Illness and other nonspecific symptoms like nausea/vomiting, weakness and headache
    • DOES NOT PRESENT WITH ALTERED MENTAL STATUS
  • Heat Stroke:
    • Body temperature above 40° (104°F) WITH ALTERED MENTAL STATUS
    • Target organ damage
    • Usually dry and pale skin, however athletes can present with warm and wet skin

Management

  • Primary, we need to proceed with the basic measures: secure airway, monitorize and place IV fluids in order to maintain a mean arterial blood pressure > 60 mmHg [2].
  • The second step is to perform a rapid cooling, targeting a temperature <39°C (102°F) in the first 30 minutes. After reaching this goal, the active cooling should be stopped in order to avoid overshoot hypothermia
    • Cold water immersion is the best method available (level C evidence) [3].
      • Treat shivering with benzodiazepines if needed (avoiding extra heat generation)
    • DO NOT USE ANTIPYRETICS, they are not effective in this scenario [4].

Disposition

  • Patients with heat stroke should be admitted to a ICU to monitoring organ dysfunction, electrolytes disturbances and rebound hypothermia.
  • Young and otherwise healthy patients with heat exhaustion can be discharged home 
  • Be aware for the risk of recurrent hyperthermia when considering discharge a patient (returning to the same ambient)

Hypothermia

What is hypothermia?

  • Condition in which the body loses heat at a higher rate than its capacity in maintain the core temperature or elevate the heat production
  • Clinically defined as unintentional decrease of body temperature below 35°C (95°F)
  • In other settings, we can talk about “secondary hypothermia”, when the patient has an impaired thermoregulation due to a clinical condition such as hypothyroidism, ketoacidosis, malnutrition etc – In this article we will focus on accidental hypothermia, related to environmental exposure

Physiology

  • Initially, the metabolic rate increases, peripheral blood flow is shunted towards vital structures, and shivering initiates to increase heat production
  • If these compensations are not enough, the body temperature continues to drop, with the CNS being affected when it reaches 35°C (95°F). 
  • Cardiovascular: initial increase in heart rate and blood pressure; however, as core temperature declines, progressive bradycardia and hypotension occurs. In more severe hypothermia, myocardial irritability increases, leading to a high risk of arrhythmias.
  • Oxygen consumption: At a temperature of 28°C (82°F), the oxygen consumption is decreased by 50%, leading to a protective effect in CNS and other vital organs – but just if it develops before asphyxia (there are several studies trying to better understand the role of hypothermia as a protective measure in cardiac arrest) [5].

Risk Factors

  • Fatigue
  • Sleep deprivation
  • Rain, wind and water immersion
  • Burn
  • Extremes of age
  • Trauma
  • Alcohol
  • Hypoglycemia
  • Hypothyroidism
  • Hyperthermia treatment (rapid cooling)

Classification

Stage 1: Mild Hypothermia

  • Core temperature: 32 – 35°C (90 – 95°F)
  • Initially presenting with tachycardia, hypertension, shivering and vasoconstriction
  • Gradually develops ataxia, poor judgement, amnesia, apathy, dysarthria

Stage 2: Moderate Hypothermia

  • Core temperature 28 – 32°C (82 – 90°F)
  • Loss of shivering, lethargy, mydriasis, hyporeflexia, alterations in cardiac rhythm (Osborne J waves on EKG)

Stage 3: Severe Hypothermia

  • Core temperature: 24 – 28°C (75 – 82°F)
  • Hypoventilation, ventricular fibrillation, acid-basic disturbances, anesthesia, pulmonary edema 

Stage 4: Profound Hypothermia

  • Core temperature: below 24°C (75°F)
  • Oliguria, fixed pupils, asystole, apnea, coma 
  • Curiosity: 13,7°C (56,7°F) is the lowest temperature registered at which CPR was performed with satisfactory results [6].

Management

  • The first thing we need to do is to stop the cooling process 
    • Remove the environmental factor (take the patient out of the street, take off wet clothes etc.)
    • Try stop heat loss, putting up barriers like warm clothes, blankets, sleep bags, etc
  • Second step, we should identify the degree of hypothermia to guide our approach:
    • For Mild hypothermia, besides the strategies described before, we need to offer calories (food and warm drinks), monitoring for at least 30 minutes and warm the trunk
    •  [F]or Moderate hypothermia, we also need to keep the patient laid down and still, start volume reposition with warm fluids (40 – 42°C/104 – 107°F), Avoid food and beverage.
    • For Severe hypothermia: All the above and check for pulse and breathing – of pulse/breathing is absent, START CPR. – Consider transferring to a facility where ECMO is available
      • ECMO is the best option for severely hypothermic patients without signs of life who do not respond to initial resuscitative efforts. It has been shown to improve neurologically intact survival (48% to 63% survival with ECMO, <37% without ECMO) [7]. 

 “Nobody is dead until warm and dead”

Patients with core temperatures of <28°C have decreased electroencephalographic activity and loss of brainstem and pupillary reflexes, all of which may mimic death. Because of that, the patient can not be considered “dead” until his body temperature reaches at least 32°C.

Some conditions allow us to presume death even in patients with body temperature below 32°C and no vital signs: obvious lethal injury (i.e. decapitation), frozen body, potassium > 12, avalanche victims with burial > 35min or airway packed with snow.

References and Further Reading

The primary reference for this article was the recently launched book: “Medicina em Áreas Remotas no Brasil” (Wilderness Medicine in Brazil): JULIANA R. M. SCHLAAD e SASCHA W. SCHLAAD, Medicina em Áreas Remotas no Brasil, 1ed, Barueri (SP), Manole, 2020

Other sources of information as numbered and referred in the text:

  1. Powers SK, Howley ET. Regulação de temperatura. In: Powers SK, Howley ET. Fisiologia do exercício: teoria e aplicação ao conhecimento e ao desempenho. 9ed. Barueri: Manole; 2017. p.261-281.
  2. Tran TP. Heat emergencies. In: Ma OJ, Cline DM, ed. Emergency medicine manual. 6th ed. McGraw-Hill, NY: 2004:564-565
  3. Becker J, Stewart L. Heat-related illness. Am Fam Physician. 2011;83(11):1325-1330
  4. Lipman GS, Eifling KP, Ellis MA, Gaudio FG, Otten EM, Grissom CK. Wilderness medical society practice guidelines for the prevention and treatment of heat-related illness: 2014 update. Wilderness Environ Med. 2014; 25:S55-S65
  5. Soar J, Perkins G, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81(10):1400-1433.
  6. M. Gilbert, R. Busund, A. Skagseth, Nilsen PÅ, J.P. Solbø Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest Lancet, 355 (2000), pp. 375-376
  7. Brown DJ et al. Accidental hypothermia. NEJM 2012; 367(20): 1930-1938. PMID: 23150960
Cite this article as: Arthur Martins, Brasil, "A Song of Ice and Fire," in International Emergency Medicine Education Project, December 25, 2019, https://iem-student.org/2019/12/25/a-song-of-ice-and-fire/, date accessed: December 11, 2023

A Study in Yellow

A Study in Yellow
~ Arthur Martins, Brasil ~ 1 Comment

In Brazil and many other countries around the world, we got used to know September as the suicide prevention month, represented by the yellow ribbon, with September 10th being the World Suicide Prevention Day. As said by Sherlock Holmes in “A Study in Scarlet,” “There is a scarlet thread of murder running through the colorless skein of life, and our duty is to unravel it, and isolate it, and expose every inch of it.” Despite the dramatic content of Holmes’s words, it is possible to draw a parallel with the current situation related to suicide in society. There is a visible red stain in front of us, and we need to unravel it, understand it, deal with it. Moreover, everything should start somewhere…

If we think about the role of the emergency department (ED) and the emergency physician in the suicide prevention and response, we will see that it is of indispensable importance, as many patients at risk of attempting suicide are sent to the ED in order to be evaluated and to stay in a “24h safe environment.” Also, many actual suicide attempts arrive at the ED requiring immediate care – for the patient and for the family. However, World Health Organization estimate that for every death by suicide, there are 20 suicide attempts, making us to questioning our capability to give extended care for those patients. Besides, if we look to the big picture, which has suicide one of the major preventable causes of death worldwide, we can ask ourselves how many patients with suicidal thoughts are seen at the ED every week due to other health problems and go unnoticed. The ED, along with the primary care in the communities, is the main entry door to the health care system and like no other, act as a nexus between outpatient and inpatient care. Gairin et al. have found that approximately 40% of people who died by suicide have visited an ED in the year before, one third of them because of self-harm injuries. (1) If we look to the last attendance before death, those who have presented with self-harm injuries presented less than two months before ending their lives.

With all of this in mind, what strategies we can use to assess suicidal thoughts and behavior at the ED? Which reliable tools are available for emergency physicians to recognize and classify these patients? Let’s take a look at the last American College of Emergency Physicians (ACEP) recommendations.

ICAR2E

IDENTIFY

IDENTIFY suicide risk – actively ask about suicidal ideation.

  • Evidence shows that as many as 10% of suicidal patients may not disclose ideation unless asked (1) 
  • In the other hand, none of the standardized questionnaires and methods currently available have strong evidence supporting its use as a universal screening tool at the ED.
  • As there is no universally accepted standard reference for suicidal ideation, the sensitivity and specificity of these methods are unknown.
  • The authors’ conclusion is that suicidal ideation should be screened in the ED, as recommended for other authorities (2,3).

COMMUNICATE

COMMUNICATE with the patient.

  • Actively ask maybe not enough when we talk about mental health problems with patients and make them feel comfortable is the first step to improve the communication 
  • The ED is not what we can call a “cozy” or “receptive” environment for most of the patients, so the authors recommend providers try to make it an emotionally-safe place, using methods to improve physical and mental comfort of the patient (i.e giving blankets if its cold, providing food, do not stigmatize)
  •  Ask open questions as “what’s that been like for you?” and be clear on what you are asking when necessary – prefer “are you thinking about ending your life?” over “are you gonna be ok?”.

ASSESS

ASSESS for (medical) life-threats and ensure (environmental) safety.

  • The authors did not find ED-based studies assessing this topic specifically, but a consensus emerges when we think on the best practice for this step of evaluation: A complete history, a good physical exam, mental status assessment and laboratory testing as needed.
  • Regarding the environment, besides the strategies commented before (communicate), the best practice and the common sense tell us to keep the environment as safe as possible and free any kind of weapons and other objects that could be used for self-harm (sharp objects, loose wires, medications, etc.).
  • Continuous monitoring should be done in all patients with suicidal ideation, as no ED-based studies are addressing whether all patients should be observed continuously or not.

RISK assessment

  • This step assumes that, regardless of how the patient was identified (first step), there is suspicion of potential suicide risk.
  • Even though there is no reliable and easy to use tool to predict which patients will try to commit suicide in the near future, there are lots of evidence establishing risk and protective factors for a suicide attempt. 
    • Risk factors: previous suicide attempt, access to lethal means, current impaired mental status or psychiatric illness (psychosis, depression, mood changes, anxiety crisis), substance abuse, external stressors such death of loved one, financial crisis, divorce.
    • Protective factors: family and friends support, established mental care, with patient’s good adhesion, cultural and/or spiritual beliefs
  • The authors do not recommend any specific risk assessment scale. The evidence for that comes from a meta-analysis from Carter et al.(4) that investigates the predictive validity of risk scales in determining the level of risk. According to the data from this study, the currently available tools have low accuracy, so the authors recommend not to use one scale alone to determine if the patient can be discharged home or not.
  • With this in mind, the recommendation is that all patients identified as being at potential risk of attempt suicide should go under one standardized tool for risk assessment, using this as a complementary tool, along with mental status examination, history taking and evaluation of risk and protective factors.

Some scales and risk assessment tools to know

  1. Columbia Protocol – link
  2. Patient Safety Screener and Tip Sheet (PSS-3) – link
  3. Secondary screener from ED-SAFE – link

REDUCE the risk

  • Safety Planning Intervention is a collaborative process in which patient and provider develop a plan on what to do if the symptoms worsen. It usually involves contact with trusted individuals, lethal means counseling, hotlines, and local resources in the community. 
  • The adherence of ED on this practice is very low, although some evidence shows that safety planning could reduce future suicide attempts (5).
  • Hospitalization is a complicated topic in this scenario. As seen on recommendations above, it is difficult to formally classify a patient as a “high-risk” for suicide in the near future. Knowing that the authors recommend hospitalization for those patients who “felt to be likely to attempt suicide after the discharge,” and voluntary admission should be preferred over involuntary.

EXTENDED CARE beyond the ED visit

  • There is good evidence that follow-up contact after the ED can help reduce the risk of subsequent suicidal behaviors.
  • The follow-up contact can be made by letters, phone calls, postcards and even in-person visits.
  • Of course, a follow-up with a mental health professional is key to good care of these patients.

How about us?

Despite all the fame and social prestige traditionally linked to doctors, it is well documented that physicians, residents and medical students experience one of the highest rates of depression and suicidal behaviors among all professions. More than that, physicians can have a risk of suicide from twice to even six times higher than the general population depending on the country (6,7). And it starts early: almost 50% of medical students experience burnout before residency (8). High rates of depression, sleep deprivation, substance abuse, stressful work environment, burnout, easy access to and wide knowledge of lethal means, all of these contribute to killing our colleagues, professors, students, and friends. Four hundred physicians per year in the US (6,7) – more than once per day. Speaking specifically of emergency physicians and residents, the specialty had always reached the top 5 in the burnout rankings (8) and less than one third will seek for help, according to a Medscape survey. We have been trained to save lives, but sometimes we also need to be saved – from ourselves.

If you are in crisis, experiencing burnout symptoms, feeling sad or suicidal, or know a friend who is, please seek for help as soon as you can.

Further Readings

References

  1. Gairin, I., House, A., & Owens, D. (2003). Attendance at the accident and emergency department in the year before suicide: Retrospective study. British Journal of Psychiatry, 183(01), 28–33. doi:10.1192/bjp.183.1.28
  2. Suicide Prevention Resource Center. Caring for adult patients with suicide risk: A consensus guide for emergency departments. 2015; http://www.sprc.org/sites/default/files/EDGuide_full.pdf. Accessed May 30, 2018.
  3. Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;56:1-7.
  4. Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ. Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017;210(6):387-395.
  5. Miller IW, Camargo CA, Jr., Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570.
  6. Stehman CR, Testo Z, Gershaw RS, Kellogg AR. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. West J Emerg Med. 2019;20(3):485–494. doi:10.5811/westjem.2019.4.40970
  7. Kishore S, Dandurand DE, Mathew A, et al. Breaking the culture of silence on physician suicide. National Academy of Medicine. 2016. Available at: https://nam.edu/breaking-the-culture-of-silence-on-physician-suicide/Accessed March 15, 2019.
  8. Burnout in medical students before residency: A systematic review and meta-analysis Frajerman, Ariel et al. European Psychiatry, Volume 55, 36 – 42
Cite this article as: Arthur Martins, Brasil, "A Study in Yellow," in International Emergency Medicine Education Project, September 30, 2019, https://iem-student.org/2019/09/30/a-study-in-yellow/, date accessed: December 11, 2023

Self-Directed Learning

~ Arthur Martins, Brasil ~ Leave a comment

  • Diagnose your learning needs

    What I don’t know? What is important for me to know? i.e., “I’m not confident enough to quickly read and interpret an ECG with acute conditions - I think this is important to know.”

  • Formulate your learning goals

    What I expect to learn on this rotation? i.e., “I want to learn how to read an ECG in the ED effectively.”i.e., “I’m not confident enough to quickly read and interpret an ECG with acute conditions - I think this is important to know.”

  • Explore resources

    What resources are available for me to learn? Are there lectures available? FOAMed? i.e., “The medical staff are accessible, there are weekly ECG case discussions at the ED and FOAMed resources as the ECG library in the LITFL.”

  • Choose the learning strategies

    What is the best method for me? i.e., “I have a good visual memory, I may find it easier to take a look at the ECG library and then to discuss with my professor when the cases show up.”

  • Evaluate the outcomes

    Did I achieve my goals? i.e., “At the end of my rotation, I can successfully identify major acute conditions on an ECG.” After thinking about the outcomes you had and the goals you have achieved, you can identify your needs and establish learning goals once again.

The technique can sound quite simple – and it is! The hard part is to have it on your mind when you are about to start a new clinical rotation or observership, but it becomes part of your routine with a little time.

Reference

Education Theory Made Practical: Volume 1; Published by Academic Life in Emergency Medicine, San Francisco, California, USA, 2017  chap 7, pgs 59 – 69

Cite this article as: Arthur Martins, Brasil, "Self-Directed Learning," in International Emergency Medicine Education Project, July 3, 2019, https://iem-student.org/2019/07/03/self-directed-learning/, date accessed: December 11, 2023

Learning Experiences in the ED

~ Arthur Martins, Brasil ~ Leave a comment

Introduction

Every student, regardless of the area and grade, should have recognized that the process of learning is different depending on the environment and the situation. For medical students, it very often depends on the clinical rotation, the type of structure of the hospital and the epidemiologic profile of the population in the area. Thinking about the Emergency Department (ED), we have critical patients, urgent measures to be taken and no much time to have second thoughts, all of this in a very dynamic – sometimes chaotic – environment.

What is the evidence on Medical Education in the ED? How can we improve our experience as a student in such context? Is it possible to have – and give – good feedback? These are some of the points we are discussing in this article, which features a quick conversation with one of the most incredible and enthusiastic emergency physicians I ever know – and who has taught me a lot.

Juliana is an Emergency Physician. I had the pleasure to learn from her with in the field, as well as attending some of her brilliant lectures for the EMIG which I’m part of. She work as an emergency physician in São Paulo and th coordinator of the “Basic and Advanced Airway Digital Course."

What are the singularities you see when giving and receiving feedback in Emergency Department?

“It’s a very dynamic environment and, sometimes, the moment for feedback can be completely ignored if the opportunity is not taken at the right time since the room can always become even more chaotic. For me, one of the greatest advantages is that everything is happening here and now, and the learner can be observed and taught closely. However, this could be a problem if the learner feels insecure while being watched, or if the professor interferes too much during the procedure or the history taking and examination.”

How do you think learning takes place in this environment? Is it possible to learn and teach with each case without disturbing the emergency dynamics?

As I said earlier, although it is a very dynamic environment, I see an emergency department as a valuable environment for the teaching-learning process because we can take advantage from each case in its entirety (from the evaluation to the outcome) or in key situations, important for that learner. Also, the fact that the patient is right there, requiring interventions, instigates the student to want to participate, take action and understand what is going on. Another thing I like very much about teaching in this environment is how we can be very practical in exemplifying and exercising the ED mindset, developing in the learner the clinical reasoning of the emergency, which, as we know, operates in a different logic.”

With the recognition of the specialty in Brazil, what can change in relation to the teaching and mentoring in the emergency department?

“I think the change that many of us are already experiencing is to have emergency medicine specialists in these settings, which qualifies the teaching of mindset and the purpose of acute and severe patient care.”

What tips would you give to students who go through emergency medicine internships to learn more and better?

“One exercise I often do with my students is to always think not about what the patient has, but what he needs. In many cases, the definitive diagnosis is absolutely secondary in immediate care. That is the mindset. Another important point is to observe the emergency room like an orchestra, which the emergency physician is there to conduct: how do we organize physical space? What should I solve first? What patient needs most of my attention right now? What people from the multidisciplinary team are fundamental there? these are skills that we develop with practice, sometimes even without noticing, but when we pay attention to all of this we understand the complexity of the critical care, of the specialty, and the potential that the emergency medicine has in changing patient’s outcomes.”

And for teachers and residents, what tips would you give to improve students learning from the ED routine?

“Everything that shows up is an opportunity for learning, including an empty room, without patients: if you knew how much students don’t know about the physical organization of the room, support materials and ventilators, monitors, defibrillators, multi-professional teams and so on, we would not feel moments without patients as idle time. So I wanted to tell you never to let go of these moments. Another thing that is poorly discussed by us, but that in the Emergency Medicine is essential: health policies, emergency departments situation, organization of health structures. Emergency medicine is an excellent thermometer to measure the efficiency of the system and, if we stop and think a little, to discuss and debate the context that we are inserted (even without all the answers), we develop a more critical and interested generation, not only in Emergency Medicine but in improving the system as a whole.”

Cite this article as: Arthur Martins, Brasil, "Learning Experiences in the ED," in International Emergency Medicine Education Project, July 1, 2019, https://iem-student.org/2019/07/01/learning-experiences-in-the-ed/, date accessed: December 11, 2023