Discharge Communications (2023)

May 15, 2023May 18, 2023 ~ iEM Education Project Team ~ Leave a comment

by Dominique Gelmann, Bret Nicks

Introduction

The process of emergency department (ED) discharge provides critical information for patients regarding the next steps of their care. Discharge instructions are often required by hospital accreditation and governmental organizations for quality or monitoring metrics. However, studies show that many patients do not fully understand or recall the instructions they receive [1,2]. In addition to patient-specific factors contributing to lack of comprehension and care compliance, the myriad situational challenges inherent to every emergency department as well as individual clinician skills and knowledge of best discharge practices further impact patient experience, understanding, and subsequent outcomes.

In many instances, the discharge process is often limited to a brief exchange of documents, prescriptions, and verbal description of the diagnosis, frequently leaving patients with uncertainty about their care plan. Understanding discharge instructions can be very challenging for a variety of reasons. Physical or emotional discomfort can impact receptiveness to and comprehension of imparted information, for example. Patients or family members eager to leave may be less interested in the instructions; conversely those presented with a devastating diagnosis may be less able to process specific details.

Moreover, a significant number of patients have low literacy and/or health literacy levels. In addition, the busy ED setting may distract the patient’s attention from such instructions. Understanding the challenges surrounding discharge communications in the ED from the patient’s perspective and having a clear approach and purpose is essential. Much more critical than an afterthought, discharge is the first step of a patient’s care transition and greatly impacts quality outcomes, litigation, experience, and team morale [3,4].

Understanding the Challenges

Emergency physicians face unique challenges while ensuring high-quality care due to distractions and time limitations that are common throughout ED settings. In most cases, emergency physicians have little or no previous knowledge of their patients and are unlikely to partake in the follow-up process, making effective communication paramount when patients are discharged from the ED. Providing clear and consistent communication throughout the entire patient care encounter, including the discharge process, is an important aspect of quality and patient-centered emergency medical care.

Unfortunately, many patients are discharged from the ED with an incomplete understanding of the information needed to safely care for themselves at home or when to promptly return to the ED [1, 5-6]. Patients have particular difficulty comprehending post-ED care instructions regarding medications, home care, and follow-up expectations. And while all patients discharged from the emergency department should be provided instructions for ongoing management of their medical condition, studies demonstrate that patient recall and understanding of diagnosis, treatment, and follow-up plan are generally quite poor [1,2,5-9]. This raises significant concerns for care plan adherence and medical outcomes, which studies show are poorer in cases of low health literacy. Given current trends toward value-based care and the fact that nearly half of the lawsuits in emergency medicine revolve around discharge instructions and plans, ongoing improvements in the discharge communication process is essential [3,4].

While some of this relates heavily to the ability of the provider to establish a trusting and positive patient-provider relationship within the ED constraints, several additional strategies can be used to enhance the recall of instructions, improve compliance, and minimize litigation.

Discharge Essentials

Effective discharge communication provides an opportunity for the emergency department team to summarize a patient’s visit, teach them how to safely care for themselves at home, and provide specifics regarding the next steps in their care process. It also gives ED physicians a chance to address any remaining questions or concerns, often augmenting patient and family understanding while improving care plan retention. Although patient education at discharge typically begins with initial assessments and conversations with patients and family, other factors can also influence the success or failure of how information is transmitted at discharge.

Common interventions promoting an effective ED discharge process include using a standardized approach to relaying content, providing various modes of information delivery and tailoring them to the individual patient, confirmation of comprehension, post-discharge care follow-up planning, review of vital signs, and a patient-centered closure (Table 1) [8,9].

Table 1: Interventions in the ED Discharge Process

Domain	Intervention
Content	Standardize approach
Delivery	Verbal instructions (language and culture appropriate)
	Written instructions (mindful of lower literacy levels)
	Basic Instructions (including return precautions)
	Media, visual cues, or adjuncts
Comprehension	Confirm comprehension (teach-back method)
Implementation	Resource connections (Rx, appointment, durable medical supplies, follow-up)
	Medication review

Content refers to the education provided to our patients related to their ED testing, procedures, and treatment, as well as further education on diagnosis, expected course of illness, post-ED treatment and follow-up plan, and medication reconciliation. Instructions should specifically highlight time-sensitive next steps in care plans, including when and how to schedule follow-up appointments with whom and why. Further, emergency physicians should assist in arranging critical follow up prior to discharge as able. Precautions regarding when to return to the ED versus waiting for any follow-up appointments should additionally be provided, as well as instructions for how to care for oneself until follow-up. These basic tenants of discharge, often described as the ‘rules of the road’ (Table 2), may serve as a basic framework for the discharge process.

Table 2: Rules of the Road for Successful Discharge

Have the right diagnosis
Time & Action Specific Instructions
- What to do
- When to do it
Provider Specific
- Who to contact
- Why and When
- Printed Information
- Verbally explained
- Verbally confirmed

In addition to the content itself, the importance of the quality and approach of its delivery cannot be overstated. The ED provider and care team members must consider the wide range in literacy, health literacy, cultural backgrounds, and access to outpatient resources when delivering the ongoing care instructions [6,7]. In many instances, EDs attempt to improve patient and family understanding of discharge instructions through standardization and simplification of written and verbal instructions. Due to literacy variability, current literature recommends instructions are written at a late elementary educational level [10]. Verbal discussions in conjunction with written instructions have been shown to be superior to written instructions alone [11]. For patients with a primary language differing from that of the clinician, use of interpreter services, when available, has been shown to improve quality of discharge communication and clinical understanding [12]. Other approaches that may benefit patient outcomes include providing supplemental written information and using visual and multimedia adjuncts to support understanding [8,9].

Essential to any successful approach is the comprehension of the patient regarding all of the information provided. After all, if the content and delivery are exceptional but the comprehension is poor, this should be seen as a discharge failure as it decreases care compliance and outcome quality. To address this specific aspect of the discharge process, instituting a read-back or teach-back method is recommended. This method involves asking the patient to repeat back their understanding of the information imparted, which allows the physician to identify any remaining gaps in understanding and provide additional instruction as needed.

The implementation of discharge care processes frequently falls short due to unidentified social and medical factors that prevent the plan from being carried out. Social factors could include homelessness, low income, uninsured/underinsured status, lack of transportation, or lack of primary care. Medical factors could include concurrent psychiatric illness, substance abuse, cognitive impairment, inability to care for self, or young/advancing age. Understanding these circumstances will help identify patients at high risk for discharge complications and trigger additional resource considerations for these patients.

The discharge process provides an opportunity to ensure the patient’s condition is well understood, that no additional medical red flags need to be addressed, and that the care plan and follow-up are well understood. In an online video, Dr. Oller provides another process to engage the ‘moment of safety‘ related to discharge and outlines 5 essential steps (Table 3) for any ED discharge [13].

Table 3: ED Discharge: Moment of Safety

Has the medical provider discussed the findings, diagnosis and plan of care (including medications and follow-up plan)?
Confirm the discharge instructions and prescriptions match the patient identifiers
Review all prescriptions and clarify any changes
Review current vital signs
Provide closure

Barriers to Successful Discharge

The barriers to successful discharge are myriad. Some are intrinsic to the ED work environment and nature of emergency department patient arrival and flow. Others relate to the challenging or often unidentified social and medical factors that prevent the plan from being completely carried out. In a recent American College of Emergency Physician Quality Improvement and Patient Safety section meeting, Dr. Pham shared a conceptual framework for understanding the barriers to success and improving the discharge process (Figure 1) [14].

Figure 1: Barriers to Successful ED Discharge

While this framework may not be uniformly representative of all EDs, it addresses many of the operational failures that occur outside of the ED and outlines opportunities for hospitals and health systems to align for improved patient care outcomes. And while screenings for high-risk discharges in EDs occur, the additional resources needed to ensure appropriate social work or case management care coordination are often limited.

Post-discharge follow-up processes for patients at risk for failing discharge instructions exist in some systems. This may include flagging a patient’s chart for a social work follow-up to assess and assist with the patient’s ability to obtain necessary medications, make and attend follow-up appointments, or address other concerns identified by the provider. Some physician groups routinely call patients the next day to see how the patient is doing and ensure understanding of their discharge instructions and care plan [7,8].

Types of Discharge Information Packets

Discharge instructions vary widely by practice location and resources available. However, there remain 3 primary means of providing discharge information and instruction: a basic care instruction note, a preformatted illness specific instruction sheet, and a templated software-based discharge product [8].

Commonly used, an instruction note is simply a set of instructions handwritten or typed on plain paper, without the assistance of computer programs. In settings with limited resources, this may be the only means of providing essential care information for the patient, their family, and the provider with whom they may follow-up. While uniquely tailored, they may lack substantial content for care, take time to prepare, and be limited by literacy and handwriting.

Information sheets are pre-printed education and instruction documents that describe care information related to one specific illness. They can be developed for the most common medical illnesses for each institution and have essential information regarding plans of care. Information sheets are immediately available, inexpensive, reproducible, and can be designed to include simple language and or pictorial education. They are not patient specific, may not provide adequate instruction in difficult or complicated cases, and require computer, printer, and copying capacity.

For settings with an integrated EHR, software products that create discharge packets (including discharge diagnoses, medications, medical care instructions and information regarding the illness, outlined care course after leaving the ED, and essential contact information for those next steps) are available. These are highly resource dependent and therefore may not be routinely available.

Each form of written discharge materials offers its own unique benefits and drawbacks. Regardless of type utilized, physicians should exercise the basic principles outlined above in ensuring appropriate readability and quality of information provided. While specific details are helpful and important, distilling instructions into a short, high-yield sheet has been shown to be more effective than providing a large stack of superfluous [information] that patients may not entirely review [15].

Leave Against Medical Advice and Elopement

In certain circumstances, patients may request to leave prior to completion of their medical evaluation and treatment. In this situation, it is essential for the last health care professional caring for the patient to clearly document why the patient left and attest that the patient had the mental capacity to make such a decision at that time. While some electronic documentation systems have templates in place to assist with this documentation, Table 4 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template [3,4,16,17].

Table 4: Documentation for Patients Leaving Against Medical Advice

Component	Description
Capacity	Establish a patient’s decision-making capacity, and clarify aspects of care which may affect capacity (i.e. patient is now clinically sober, etc.)
Risks	Specific condition-associated risks that were discussed (missed diagnosis, potential harms from untreated disease process, etc.)
Verify comprehension	Patient’s understanding of the risks
Patient’s decision	Include the patient’s decision, and any alternative plans (i.e. patient refused admission, but agreed to follow up with the primary physician tomorrow)
Signatures	Patient’s and provider’s signatures

An attempt should be made to provide the patient with appropriate discharge instructions, even in the event that a complete diagnosis may not yet be determined. Include advice for the patient to follow up with their own physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. In addition, it should be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if their symptoms worsen or if they change their mind about receiving care. Despite a common notion to the contrary, AMA discharge does not automatically provide the emergency physician with immunity from potential medical liability [16,17]. In the event that a patient lacks decision-making capacity to adequately understand the rationale and consequences of leaving AMA and their condition places them at risk for imminent harm, involuntary hospitalization is warranted and often legally required depending on the location of practice. In unclear circumstances and if available, a psychiatrist can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process in which patients disappear during the care process. While it is difficult to provide discharge paperwork for these patients, documenting the actions taken to find the patient is essential (e.g. searching the ED, having security check the surrounding areas). In addition, clinicians should attempt to reach the patient by phone to discuss their elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is critical in mitigating legal risks [3,4].

Conclusion

Discharge instructions are a very important part of the emergency department care process and record. It is essential to ensure each patient has a complete understanding of their instructions in order to promote care compliance and improve transitions in care. Verbal instructions remain more effective than written instructions, but both are needed and a multimodal approach to relaying information is preferable to a single modality. Be explicit, keep it simple, and have the patients repeat back instructions to ensure understanding. These simple steps will improve patient outcomes and compliance, and help clinicians avoid medical and legal pitfalls.

Authors

Dominique GELMANN

Dominique Gelmann is an Emergency Medicine resident at Wake Forest University. Her interests include patient-physician communication and health literacy. During medical school she completed a one-year research and leadership fellowship investigating health literacy as a social determinant of health, and helped author an institutional white paper with actionable strategies for improving health literacy education. She has given several lectures on the topic to various audiences, and developed a curriculum on health literacy and best-practice patient-provider communication principles for a free student-run health clinic. She looks forward to continuing strengthening her passion for this work throughout her career.

Bret NICKS

Bret Nicks, MD, MHA is an emergency physician that embraces the breadth of our specialty. He is a Professor and Executive Vice Chair of Emergency Medicine at Wake Forest University School of Medicine. He is the past president of the North Carolina College of Emergency Medicine. He served as the Chief Medical Officer of the award-winning Wake Forest Baptist Davie Medical Center. Dr. Nicks served as the founding Associate Dean for the Wake Forest Office of Global Health. He has lived, practiced, and led in many resource austere locations globally, although calls the academic tertiary care emergency department his home. He is passionate about, consults and lectures on the interface of clinical quality, leadership and team culture – and is dedicated to developing EM leaders for the future of our specialty and the transformation of healthcare. He loves anything outdoors, enjoys blogging on various life and leadership topics; http://www.bretnicksmd.com/blog, and recently published his first book.

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Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Discharge Communications (2023)," in International Emergency Medicine Education Project, May 15, 2023, https://iem-student.org/2023/05/15/discharge-communications-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/discharge-communications/

References

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Clark PA, Drain M, Gesell SB, et al. Patient perceptions of quality in discharge instruction. Patient Educ Couns. 2005 Oct;59(1):56-68.
Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2^nd Ed; 1759-65. Philadelphia, PA: Elsevier.
Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7^th Ed; 2021-31. McGraw-Hill.
Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997;15:1–7
Engel KG, Buckley BA, Forth VE, et al. Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest? Acad Emerg Med 2012; 19(9):1035-1044.
Sameuls-Kalow ME, et al. Unmet Needs at the Time of Emergency Department Discharge. Acad Emerg Med. 2015 Dec 18.
Taylor DM, Cameron PA. Discharge instructions for emergency department patients: what should we provide? J Acad Emerg Med. 2000; 17:86-90.
Zeng-Treitler Q, Kim H, Hunder M. Improving Patient Comprehension and Recall of Discharge Instructions by Supplementing Free Texts with Pictographs. AMIA Annu Sympo Proc 2008:849-853.
Choudhry AJ, Baghdadi YM, et al. Readability of discharge summaries: with what level of information are we dismissing our patients? Am J Surg. 2016 Mar; 211(3): 631–636. PMID: 26794665.
Al-Harthy N, Sudersanadas KM, Wagie AE, et al. Efficacy of patient discharge instructions: A pointer toward caregiver friendly communication methods from pediatric emergency personnel. J Family Community Med. 2016 Sep-Dec; 23(3): 155–160. PMID: 27625582.
Gutman CK, Cousins L, Gritton J, et al. Professional interpreter use and discharge communication in the pediatric emergency department. Acad Pediatr. 2018;18(8):935–943. PMID: 30048713.
Oller C. Discharge Moment of Safety. Available at: https://www.youtube.com/watch?v=xuLjBWkfomE Accessed January 30, 2016.
Pham JC, Ijagbemi M. Improving the ED Discharge Process. ACEP. Available at: http://www.acep.org/content.aspx?id=90940 Accessed January 15, 2016.
DeSai C, Janowiak K, Secheli B, et al. Empowering patients: simplifying discharge instructions. BMJ Open Qual. 2021 Sep; 10(3).
Levy F, Mareiniss DP, Lacovelli C. The Importance of a Proper Against-Medical-Advice (AMA) Discharge. How Signing Out AMA May Create Significant Liability Protection for Providers. J Emerg Med. 2012;43(3):516-520.
Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899-902.

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Shock (2023)

May 8, 2023May 7, 2023 ~ iEM Education Project Team ~ Leave a comment

by Joseph Ciano

You have a new patient!

A 55-year-old male enters your Emergency Department with sudden onset of shortness of breath with chest pain. He states his symptoms began several hours ago, and he is now feeling generally weak and dizzy. Vital signs on initial assessment are: 125 beats/min, 86/40 mmHg, 24 breaths/min, 37.5°C, and 93% SpO2 on room air. You are concerned by the patient’s vital signs and begin to organize your medical team for treatment of the patient.

What do you need to know?

Importance

Shock is a true emergency. Shock has a wide array of clinical causes (e.g., sepsis, hemorrhage, pulmonary embolism), categories, and different hemodynamic physiologies. The mortality rate of untreated shock is high, but it varies depending on the specific cause and type of shock. For example, the mortality rate of septic shock is 26% and is almost 50% for cardiogenic shock [1]. This means that rapid identification and treatment of shock matters in order to improve outcomes.

Epidemiology

Because shock has many different causes and no single accepted test for diagnosis, it is difficult to measure its prevalence accurately. The different causes of shock may also vary across different country contexts. A systematic review defining shock as a systolic blood pressure under 90 mmHg estimated 0.4-1.3% of patients arrive at the Emergency Department in shock [2]. Other studies have shown variable rates among the different shock categories, but the obstructive shock is typically the least common type of shock [3,4].

Pathophysiology

Shock is a state of circulatory collapse where the body is unable to adequately perfuse tissues to meet the body’s metabolic demands. Shock is characterized by global hypoperfusion and hypoxia. The four major categories of shock are hypovolemic, distributive, cardiogenic, and obstructive shock. Each category of shock has differences in hemodynamics, causes, and treatments. If left untreated, shock will lead to multiorgan system dysfunction and failure. Shock is often associated with hypotension (systolic blood pressure under 90 mmHg), but shock can occur with a “normal blood pressure”. For example, a systolic blood pressure of 100-120 mmHg in conjunction with other signs and symptoms could be considered a relative hypotensive state and indicate shock in a chronically hypertensive patient. The chart below summarizes the different types of shock.

Type of shock	Hemodynamics	Potential causes	Potential treatments
Hypovolemic	↓preload ↑SVR ↓CO	Dehydration, vomiting/diarrhea, burns, hemorrhage (GI bleed, traumatic wound, etc.)	IV fluids Blood products (if due to hemorrhage)
Distributive	↓preload ↓SVR ↓/↑CO	Sepsis, anaphylaxis, adrenal insufficiency, neurogenic shock	IV fluids +/- antibiotics and vasopressors. Treat underlying cause. Epinephrine (anaphylaxis) Norepinephrine (sepsis or neurogenic) Phenylephrine (neurogenic)
Cardiogenic	↑preload ↑SVR ↓CO	Heart failure, tachy/bradyarrythmias, myocardial infarction, valve failure, myocarditis, cardiomyopathy, beta-blocker overdose	Dobutamine or Epinephrine Treat underlying cause
Obstructive	↓preload ↑SVR ↓CO	Tension pneumothorax, cardiac tamponade, pulmonary embolism	IV fluids Treat underlying cause. Tension Pneumothorax– Needle decompression then tube thoracostomy Cardiac tamponade-Pericardiocentesis then pericardial window Pulmonary embolism-Anticoagulation, consider thrombolytics or surgical embolectomy

(CO= Cardiac Output; SVR= Systemic Vascular Resistance)

Medical History

Key questions to ask on history-taking

Since shock has a multitude of causes, the patient’s history helps us identify shock and guides us in determining the underlying cause. Certain nonspecific presenting symptoms, such as generalized weakness, syncope, or altered mental status, can be seen in all types of shock as these symptoms indicate hypoperfusion. History-taking should be symptom based and also include review of the past medical history, past surgical history, medications, allergies, and drug or alcohol use. The mnemonic “OPQRST” (Onset of symptoms, Provoking/Palliating factors, Quality, Radiation, Severity, Timing) can be used to assist in gathering symptom-based information from the patient.

Being able to narrow down the potential causes will help decide which laboratory and imaging investigations to order and what initial treatments are indicated. Suggestions for key questions to ask are illustrated in the table below.

Type of shock

Presenting symptoms that may indicate shock

Key questions to ask based on cause of shock

Hypovolemic

Weakness

Syncope

Altered mental status

Vomiting/diarrhea

Hematemesis

Hematochezia/Melena

Burn injury

Trauma/fall

Dehydration

Last PO intake? Diuretic usage? Recent travel?

Vomiting/diarrhea

How many times? Presence of blood? Recent travel? Fevers?

Hemorrhage (GI bleed, traumatic wound, etc.)

How much blood loss? Any anticoagulant use?

Distributive

Weakness

Syncope

Altered mental status

Fever, chills

Cough

Difficulty breathing

Dysuria

Lip/tongue swelling

Rash

Sepsis

Fevers, cough, dyspnea, dysuria, skin changes, headaches, neck stiffness, chest or abdominal pain?

Anaphylaxis

Known inciting factor or allergies? Angioedema?

Adrenal insufficiency

Steroid use? Medication changes? TB history?

Neurogenic shock

Spinal trauma? Focal weakness/numbness?

Cardiogenic

Weakness

Syncope

Altered mental status

Chest pain

Back or shoulder pain

Palpitations

Difficulty breathing Orthopnea

Peripheral edema

Heart failure, Cardiomyopathy, Valve failure

Medication changes? Chest pain? Body edema or dyspnea?

Tachy/bradyarrythmias

Syncope? Palpitations/heart fluttering?

Myocardial infarction

Chest or back pain? Diaphoresis?

Obstructive

Weakness

Syncope

Altered mental status

Difficulty breathing

Chest pain

Penetrating chest trauma

Unilateral leg pain/edema

Tension pneumothorax

Chest trauma?

Cardiac tamponade

Chest trauma? History of renal disease, HIV, or cancer history?

Pulmonary embolism

Sudden onset dyspnea or chest pain? Leg pain or swelling? Use of hormones? Recent travel, hospitalizations, or surgeries? Cancer history?

Identifying “red flags”

Shock can sometimes be subtle without marked hypotension or tachycardia, so it is important to be vigilant for red flags detected on history-taking to aid in early identification. Some red flags include altered mental status or confusion, syncope, or chest pain. These symptoms may indicate hypoperfusion of the brain or heart and can point towards shock. Belonging to a special patient group, such as an elderly or neonatal patient, an immunosuppressed patient, or a pregnant patient, may be associated with a more atypical presentation of shock or less favorable patient outcomes.

Physical Examination

Key physical exam features

Shock is a state of global hypoperfusion, so many physical exam features will reflect this (e.g., delirium, comatose state, tachypnea, etc.). However, shock exists along a continuum of severity and is impacted by patient age, medications, comorbidities, the cause of shock, and other factors. Hypotension and tachycardia are often regarded as key findings of shock, but these vital sign changes may not be present on initial examination depending on where the patient is in the timeline of their shock, as well as other factors described above. For this reason, it is important to look at the combination of the patient’s physical exam findings, rather than a single finding to assist in the diagnosis of shock [1]. Refer to the chart below for physical exam findings seen in shock.

Identifying “red flags”

Similar to patient history-taking, it is important to identify “red flags” during physical examination to aid in the early identification and treatment of shock. Some red flags on physical examination include hypotension with a MAP below 65mmHg, severe bradycardia, low urine output, delirium or altered mental status, and angioedema of lips or tongue [5]. A MAP below 65mmHg indicates severe hypoperfusion that requires prompt aggressive intravenous fluid or vasopressor administration. Bradycardia below 45bpm in shock may indicate poor cardiac output and a lack of physiologic ability to increase cardiac output properly in a shock state. Low urine output and altered mental status are signs of renal and cerebral hypoperfusion, respectively. Angioedema can occur in anaphylactic shock and can pose an acute airway emergency.

Alternative Diagnoses

Shock can have a variety of causes and clinical presentations that can range from the subtle to the severe. Determining the patient’s type of shock and specific diagnosis responsible for the shock state is dependent on details from the patient history, physical exam, and diagnostic testing (discussed more in next section). See the chart below for a list of differential diagnoses for the different categories of shock. Use this table in conjunction with the tables provided in the previous sections to assist in differentiating shock types and causes.

Shock Type	Differential diagnosis ^5,6
Hypovolemic	GI losses (gastroenteritis, colitis, fistulas) Skin burns Renal losses (excess diuretic use, diabetes insipidus) Hemorrhage (e.g., GI bleed, traumatic wound, aortic aneurysmal rupture, ruptured ectopic pregnancy, coagulopathy, etc.)
Distributive	Sepsis Anaphylaxis Adrenal insufficiency (primary vs secondary causes) Thiamine deficiency (beriberi) Pancreatitis Thyroid storm Toxins (salicylates, cyanide, carbon monoxide) Neurogenic shock (trauma, spinal anesthesia)
Cardiogenic	Tachyarrhythmia or bradyarrhythmia Left ventricular failure/Cardiomyopathy Ischemic (myocardial infarction) Nonischemic (postpartum, Takotsubo, myocarditis, myocardial contusion, Ca channel/beta-blocker overdose, autoimmune) Valve dysfunction Endocarditis, post MI papillary muscle rupture, prosthetic valve problem LV outflow obstruction Hypertrophic obstructive cardiomyopathy (HOCM), aortic stenosis Device malfunction (ECMO, Ventricular assist device)
Obstructive	Tension pneumothorax Cardiac tamponade Pulmonary embolism Auto PEEP (“breath stacking”) in obstructive lung disease patient

Acing Diagnostic Testing

There is no single diagnostic test to rule in or rule out shock. The diagnosis of shock is based on a constellation of diagnostic test results in combination with the history and physical exam of the patient. Whenever possible, diagnostic testing should be based on the presumed cause of shock (e.g., CT pulmonary angiogram for pulmonary embolism, EKG for myocardial infarction, etc.). The table below summarizes different bedside tests, laboratory tests, and imaging tests to consider ordering in patients with shock. Rational and use behind these tests is discussed in more detail in sections that follow the table.

Bedside tests

Laboratory tests

Imaging tests

EKG
Point of care testing, if available (pregnancy, glucose, arterial or venous blood gas testing)

Serum lactate
CBC with differential
Serum chemistry (BUN, creatinine, electrolytes)
Hepatic function panel
Coagulation studies
Type and screen
Venous or arterial blood gas testing
Cultures (blood, urine, wound)
Pregnancy test
Urinalysis
Cortisol level

Chest X-ray
CT of chest/abdomen/pelvis as supported by history + physical
Ultrasound (lung, heart, abdomen)

Bedside Tests

The EKG is a basic screening test helpful in all shock patients to assess for cardiac dysrhythmias, myocardial infarction, or EKG interval disturbances from medication overdoses. The EKG is clearly valuable in potential cardiogenic shock patients, but it is also helpful in obstructive shock (e.g., low voltage QRS in cardiac tamponade, EKG changes in pulmonary embolism).

Point of care pregnancy testing can help rule out a ruptured ectopic pregnancy. Glucose testing screens for hypoglycemia which can be seen in septic shock, GI losses with decreased oral intake, and adrenal insufficiency. Point of care blood gas testing can aid in the assessment of the patient’s acid-base and blood gas status which can assist in immediate therapeutic decisions at the bedside.

Laboratory Tests

Lactate is a common test ordered and trended in shock. Lactate is a nonspecific marker for poor perfusion and anaerobic metabolism. An elevated lactate >2mmol/L can occur in all types of shock as it indicates poor perfusion, but it does not necessarily mean the patient has a diagnosis of shock. Increasing lactate levels have been associated with increased mortality in many shock types [1].

CBC and type and screen testing are helpful in hemorrhagic shock to measure hemoglobin and prepare for the need for blood product transfusion. The CBC can assess the white blood count which can be helpful in septic shock, especially when trended overtime. Serum chemistry, a hepatic function panel, and coagulation studies screen for signs of end-organ damage (e.g., acute kidney injury, transaminitis (“shock liver”), coagulopathy, etc.).

Blood gas testing is valuable as a screening test in any type of shock to evaluate acid-base and blood gas balance. Urinalysis testing and cultures, blood cultures, and wound cultures do not change management in the emergency department, but they are helpful in identifying sources of infection in septic shock which can be utilized to make antibiotic therapy more targeted as part of the patient’s larger plan of care. Cortisol testing can be beneficial in making the diagnosis of adrenal insufficiency.

Imaging Tests

The chest X-ray is another basic screening test that can be performed as a portable test in the unstable shock patient. The chest X-ray screens for pneumonia (septic shock), cardiomegaly (cardiogenic and obstructive shock), tension pneumothorax (diagnosis should be made clinically prior to X-ray), pulmonary edema (cardiogenic shock), hemothorax (hemorrhagic shock), amongst other relevant findings.

CT imaging can be used to identify the source of infection or bleeding in septic and hemorrhagic shock, respectively. However, it should be used after reviewing the risks and benefits in an unstable shock patient. For example, CT imaging may involve the patient travelling to a less monitored setting outside of the emergency department with less resources and tools for resuscitation. Contrast-induced nephropathy is another risk to consider when ordering CT imaging with IV contrast in shock patients who likely have hypo-perfused kidneys. Conversely, CT imaging can lead to a definitive diagnosis (e.g., acute appendicitis, retroperitoneal bleed, ruptured spleen, etc.) that can direct management [1].

Ultrasound is an incredibly valuable bedside diagnostic modality in shock. Ultrasound can be used to determine the patient’s type of shock through a physiologic assessment of the heart, lungs, and abdomen. Specific diagnostic information that can be gathered by ultrasound includes the cardiac ejection fraction, presence of a large pericardial effusion with right ventricular compression (cardiac tamponade), right ventricular dilation (may indicate pulmonary embolism), Inferior vena cava (IVC) dilation or collapse, presence of abdominal free fluid in trauma (hemoperitoneum), abdominal aortic aneurysm presence, absence of bilateral lung sliding (pneumothorax), pulmonary edema (cardiogenic shock if diffuse, infectious if localized), and pleural effusions (infectious or hemothorax depending on the historical context). Organized ultrasound protocols exist that aim to assess these body systems in an algorithmic manner. One example is the RUSH protocol (Rapid Ultrasound for Shock and Hypotension) [1,5]. This protocol can be executed using the curvilinear (abdominal) or phase-array (cardiac) probe. Operator competency is needed to obtain meaningful diagnostic data from bedside ultrasound, but with practice and education, proficiency can be achieved. See the images below for a visual representation of the RUSH protocol and a summary of ultrasound findings in the different types of shock [5,7].

Ultrasound findings in shock

Risk Stratification

Since shock has many potential causes and clinical presentations, there is no single risk stratification tool that is broadly applicable to all types of shock. There are some tools available to assist in early diagnosis of sepsis by identifying risk factors, like the SIRS criteria (Systemic inflammatory response syndrome criteria) and qSOFA score (Quick sequential organ failure assessment score) [8]. These scores are not specific and can be “positive” in conditions other than sepsis, like diabetic ketoacidosis or severe anxiety. The shock index measurement is another tool that takes into account heart rate and systolic blood pressure to identify occult shock, especially in trauma or acute hemorrhage. A shock index above 0.5-0.7 may point towards occult shock in the presence of normal vital signs [9].

Shock is ultimately a clinical diagnosis, so clinical assessment of the patient with the history, physical exam, and diagnostic test results are often used in combination with the clinical picture to predict risk. Clinical factors that may be associated with poorer outcomes are high serum lactate levels not responsive to fluid resuscitation, severe acidosis, low MAP, elderly and neonatal patient populations, and immunosuppressed patients [1,5,8].

Management

Initial management in unstable patients

Management of the shock patient starts with the primary survey, or the “ABCs” (Airway, Breathing, Circulation). The primary survey is an algorithmic approach used for ill patients to help organize patient assessment, identify life-threatening conditions quickly, and treat time sensitive conditions.

Airway (“A”)

Establishing a definitive airway may be needed to prevent aspiration or as the precursor to mechanical ventilation for respiratory failure. Listen for any gurgling sounds or poor effort in phonation that may indicate a risk for aspiration. Since shock is a state of hypoperfusion, many patients may have poor cerebral perfusion, somnolence, and require an invasive airway. Positive pressure ventilation and many pre-intubation sedation medications can cause hypotension, so strongly consider initiating volume resuscitation or vasopressors to improve hemodynamics prior to performing intubation [1].

Assess for any obvious external swelling of the face, lips, or tongue, which may occur in anaphylaxic shock. Although this angioedema should improve with prompt epinephrine administration, airway management is sometimes needed. Look for tracheal deviation which can occur in tension pneumothorax. Be sure to consider cervical spinal fracture and provide a rigid cervical collar for spinal immobilization in the presence of trauma.

Breathing (“B”)

Assistance in respiration is sometimes needed in the shock patient due a primary pulmonary cause of shock (e.g., septic shock due to pneumonia), respiratory compensation for lactic acidosis, or respiratory changes due to toxic overdoses causing shock (e.g., distributive shock from salicylate overdose). Noninvasive positive pressure ventilation, such as BIPAP or CPAP, or invasive mechanical ventilation with intubation may be required to manage work of breathing and respiratory failure.

Circulation (“C”)

Shock is a state of systemic hypoperfusion, so a key part of treatment often involves some type of volume resuscitation. Most commonly this involves administration of crystalloid fluids (e.g., normal saline, lactated ringers solution) or blood products. If the specific type or cause of shock is unclear after assessment of the patient, start with administration of small volume boluses of fluids with frequent reassessments. A 250-500mL crystalloid fluid bolus is a reasonable initial intervention in the undifferentiated shock patient. Fluid should be administered rapidly over 5-20minutes to a total of 20-30mL/kg, depending on the cause of shock [1]. Balanced isotonic crystalloid fluids, like lactated ringers solution, may provide a small mortality benefit over normal saline, especially if large volumes of fluid administration are expected [1]. Large volume administration of normal saline can also cause hyperchloremic metabolic acidosis. For this reason, if lactated ringers solution is readily available and a cost-effective alternative to normal saline, it may be a worthwhile alternative. Blood products, rather than crystalloid fluids, should be prioritized if hemorrhagic shock is the assumed cause of shock.

Although volume resuscitation is a crucial component of treatment, caution should be taken in aggressive fluid administration in the presence of cardiogenic shock as this may lead to pulmonary edema. If the patient remains hypotensive after fluid administration with a MAP below 65mmHg, vasopressors should be initiated [1,5].

Medications

Intravenous crystalloid fluids and blood products are common treatments in shock, but depending on the cause of shock, additional medications may be needed. Some examples are broad spectrum antibiotics in septic shock, steroids in adrenal insufficiency, or thrombolytics in massive pulmonary embolism with obstructive shock. See the charts below for a list of adjunctive medications along with their doses and uses.

Common antibiotics used in shock

Drug name (Generic)	Potential use	Dose	Frequency	Maximum Dose	Cautions / Comments
Piperacillin-Tazobactam	Intra-abdominal, genitourinary, skin/soft tissue, pneumonia infections, febrile neutropenia	3.375-4.5g (IV)	Q6 hours	4.5gm IV	Common first line broad spectrum antibiotic in septic shock
Cefepime	Intra-abdominal, genitourinary, skin/soft tissue, meningitis, pneumonia infections, febrile neutropenia	1-2g (IV)	Q8-12 hours	2gm IV	Common first line broad spectrum antibiotic in septic shock. Similar uses as piperacillin-tazobactam
Vancomycin	Severe bacterial infections, especially MRSA, pneumonia, endocarditis, systemic anthrax, meningitis	15-20 mg/kg/ dose (IV)	Q8-12 hours	3gm IV	Common first line broad spectrum antibiotic in septic shock used in combination with cefepime or piperacillin-tazobactam
Ceftriaxone	Meningitis, pneumonia, UTI, endocarditis, typhoid fever, gonococcal infections, pelvic inflammatory disease	1-2g (IV)	Q24 hours	2gm IV	First line medication for bacterial meningitis in adults, also commonly used for UTIs and community-acquired pneumonia
Ciprofloxacin	UTI, intra-abdominal infections, prostatitis, pneumonia, bone/joint infections, typhoid fever, salmonella/shigella infections	200-400mg (IV)	Q8-12 hours	400mg IV (1000mg PO)	Can prolong QT interval and increase risk for tendon rupture
Metronidazole	Anaerobic coverage for intra-abdominal infections, Pelvic inflammatory disease, C. difficile	500mg (IV)	Q8-12 hours	500mg IV (500mg PO)	Causes disulfiram-like reaction with alcohol (avoid alcohol with this medication)
Azithromycin	Community-acquired pneumonia, chlamydial infections, COPD exacerbation, MAC treatment, pertussis	500mg then 250mg (IV)	Q24 hours	500mg IV (1000mg PO)	Can prolong QT interval Often given IV with ceftriaxone for community acquired pneumonia patients

Common vasopressors used in shock

Drug name (Generic)	Potential use	Dose	Frequency	Maximum Dose	Cautions / Comments
Norepinephrine (Noradrenaline)	First line vasopressor for most types of shock, especially if loss of vascular tone is primary problem	0.02-1 mcg/kg/min (IV)	Titrate as needed to maintain MAP >65	See dose	May cause tachyarrhythmia
Epinephrine (Adrenaline)	First line for anaphylactic shock	0.05-2 mcg/kg/min (IV) 0.3-0.5mg (SubQ or IM)	Titrate as needed to maintain MAP >65	See dose	In anaphylaxis, start with 0.3mg subQ/IM dose. This can be repeated every 10min as needed versus starting a continuous infusion. May cause tachyarrhythmia
Dobutamine	Frequently used in cardiogenic shock due to heavy beta-adrenergic receptor preference	2-20 mcg/kg/min (IV)	Titrate as needed to maintain MAP >65	See dose	May cause tachyarrhythmia
Phenylephrine	Pure alpha-adrenergic receptor agonist used as a 2^nd or 3^rd line vasopressor in shock	10-200 mcg/min (IV)	Titrate as needed to maintain MAP >65	See dose	May cause reflex bradycardia and headache Consider use when tachydysrhythmias are present
Vasopressin	Often used as a 2^nd or 3^rd line vasopressor after norepinephrine or epinephrine	0.01-0.04 units/min (IV)	Titrate as needed to maintain MAP >65	See dose	Primarily causes vasoconstriction, similar to phenylephrine

Common additional adjunctive medications used in shock

Drug name (Generic)	Potential use	Dose	Frequency	Maximum Dose	Cautions / Comments
Acetaminophen	Fever or pain	325-1000mg PO or IV	Q4-6 hours	4gm daily	Be careful with dosing this common medication to avoid overdose
Ibuprofen	Fever or pain	200-800mg PO	Q4-6 hours	3200mg daily	Can cause GI upset and increase risk for peptic ulcer disease
Morphine	Moderate-severe Pain	2.5-10mg (IV)	Q2-6 hours	n/a	Risk of respiratory depression, addiction and abuse, hypotension Use naloxone for reversal
Hydrocortisone	Adrenal crisis, vasopressor-refractory hypotension in shock	100-300mg (IV)	Q6-8 hours	1200mg daily for septic shock adjunct	Start at 100mg IV for adrenal insufficiency Taper dose over 5-7 days for septic shock adjunctive treatment
Dexamethasone	Adrenal crisis, vasopressor-refractory hypotension in shock	0.03- 0.15 mg/kg/ day	Q6-12 hours	0.15mg/kg daily for adrenal insufficiency	Alternative to hydrocortisone
Alteplase	Massive PE with obstructive shock	100mg (IV)	Single dose over 2 hours	100mg	Bleeding is main side effect

Procedures

Some patients in shock may need emergent procedures as part of their treatment plan. The chart below summarizes relevant procedures that may be encountered in the care of the shock patient.

Indication or Problem	Procedure
Tension pneumothorax	Needle thoracostomy (Followed by tube thoracostomy)
Cardiac tamponade	Pericardiocentesis (Followed by pericardiotomy)
Persistent hypotension despite intravenous fluids with need for prolonged vasopressor administration Inability to establish IV access in hemodynamically unstable patient	Central venous line placement (Triple lumen catheter)
Inability to establish IV access in hemodynamically unstable patient	Intraosseous line placement (or central venous line)
Respiratory failure or inability to protect airway	Endotracheal tube placement (Intubation)
Empyema, hemothorax, or after needle decompression of tension pneumothorax	Tube thoracostomy (Chest tube placement)

Patient reassessment

Reassessment is an important part of management. The primary survey (“ABCs”) is conducted on initial evaluation of the patient to guide management, but it can be repeated after therapies have started as clinical changes can occur. Fluid administration too rapidly in a patient with cardiac or renal comorbidities may result in pulmonary edema, requiring fluid administration to be halted. Patients may develop worsening mental status or hypoxemia overtime due to respiratory muscle fatigue, requiring supplemental oxygen or more aggressive airway management. Complications can develop after procedures, such pneumothorax after internal jugular central venous line placement or re-expansion pulmonary edema after chest tube placement. These changes in clinical course are only identified if the patient is reassessed after treatment is initiated.

Bedside ultrasound can also assist in patient reassessment. A RUSH exam can be repeated or used as a framework to guide sonographic reassessments. Some examples of pertinent findings on reassessment include pulmonary B-lines after IV fluid administration (alveolar fluid present), the absence of lung sliding (may indicate pneumothorax), or changes in the IVC size after IV fluid administration (a flat IVC may indicate fluid responsiveness) [5,7].

Special Patient Groups

Pediatrics

Pediatric patients in shock are often well compensated physiologically and may not have hypotension on initial presentation. For this reason, unexplained tachycardia in the pediatric patient should always raise concern for possible occult or early shock [10]. Hypovolemic shock is the most common type of shock in the pediatric patient population, while obstructive shock is the least common type of shock. Volume status in infants can be assessed through evaluation of the fontanelles (flat or sunken), the presence or absence of tears, and changes in urine output estimated by the number of wet diapers per day (e.g., less than baseline or baseline) [10]. Similar to adults, shock should be managed aggressively with volume resuscitation with the exception of cardiogenic shock where fluids should be used judiciously and vasopressors used early (e.g., epinephrine). Septic shock is the most common type of distributive shock in pediatric patients, and volume resuscitation should be aggressive with up to three 20mL/kg fluid boluses given (60mL/kg total) [10]. This should be contrasted with the recommendation of a 20-30mL/kg fluid bolus in adults for most types of shock [1].

Geriatrics

The diagnosis and treatment of shock in geriatric patients may be more challenging due to unique factors associated with this population. Unlike pediatric patients, elderly patients often do not have a robust physiologic reserve to compensate in a shock state. Elderly patients often have more comorbidities and take more medications than adults and children which may blunt the tachycardia response or lead to an atypical clinical presentation [11,12]. For example, beta blockers and calcium channel blockers may prevent a tachycardic response in a hypoperfusion state. Blood pressure may also be “normal” in elderly patients in shock who are chronically hypertensive [11]. For example, blunt trauma patients over 65 years-old with systolic blood pressures below 110mmHg and heart rates above 90 beats/min have an association with an increase in mortality [12]. Elderly patients with sepsis are also less likely to have a fever or leukocytosis than younger adult patients [13]. Do not rely only on vital signs or abnormal investigations to diagnose shock in the elderly patient.

Management of shock in the elderly patient should involve more gentle volume resuscitation with small fluid boluses (e.g., 250-500mL) and frequent reassessments for response or a change in clinical status (e.g., pulmonary edema). Have a low threshold to start blood products in elderly hemorrhagic shock patients to avoid excess crystalloid fluid administration and volume overload [12]. Consider drug-drug interactions and the impact of baseline comorbidities (e.g., chronic renal insufficiency) when prescribing antibiotics or other therapies for the elderly patient in shock [13].

Pregnant patients

Pregnant patients have physiologic and hormonal changes that make certain causes of shock more likely than others. Some common causes of shock to consider in the pregnant patient include pulmonary embolism, hyperemesis gravidarum, peripartum or postpartum hemorrhage, pyelonephritis, and peripartum cardiomyopathy amongst other causes.

Other pregnancy-related factors include a higher circulating plasma and blood volume in pregnancy, hypercoagulability due to hormonal changes, and risk of vena caval compression by the growing uterus [14]. Volume resuscitation in pregnancy should accommodate for the pregnant patient’s increase in blood and plasma volume. It is recommended that a 50% additional volume of fluids be given to the pregnant patient in shock to account for this [14]. Standard vasopressors administered in shock, like norepinephrine (noradrenaline), dopamine, and vasopressin, may decrease uterine blood flow from vasoconstriction but have limited data on use in pregnancy. However, these medications are typically given in pregnant shock patients as the benefit of restoring normal maternal perfusion and hemodynamics outweighs any potential risk to the fetus [14]. Treatment of the pregnant shock patient should also incorporate positioning the patient in the left lateral decubitus position. This avoids compression of the inferior vena cava by the gravid uterus which could reduce cardiac preload [14].

Other patient groups

Other patient groups that may have more nonspecific or atypical findings in shock are immunosuppressed patients, such as those on chemotherapy for malignancies, post-splenectomy patients, post-transplant patients on immunomodulators, or patients on chronic steroid therapy [5,8]. Diagnosing shock in these special patient groups starts with identifying risk factors and keeping occult shock on the differential diagnosis list. These patient groups should, similar to typical adult patients, receive aggressive and early volume resuscitation, vasopressors when needed, and adjunctive therapies as appropriate (e.g., broad spectrum antibiotics for septic shock).

When to admit shock patients

All patients with a diagnosis of shock should be admitted due to the high morbidity and mortality associated with shock [1]. Many patients may need to go to a hospital ward with a high level of monitoring, such as an intensive care unit, due to risk of hemodynamic decompensation [1]. Although some causes of shock are “reversible”, such as tube thoracostomy for tension pneumothorax, these patients should be admitted for further monitoring and treatment due to high risk for poor outcomes.

Revisiting your patient

You identify that your patient is hypotensive, tachycardic, tachypneic, and appears to be in a shock state. You quickly perform a primary survey and note that the airway is patent, lungs are clear bilaterally, and distal extremities are cool with bounding pulses. Two large bore peripheral IV lines are placed, comprehensive laboratory investigations are drawn and sent, supplemental oxygen is applied, and 2 liters of normal saline are administered rapidly.

A 12-lead EKG demonstrates sinus tachycardia without acute ischemic abnormalities. A bedside ultrasound exam shows diffuse pulmonary A lines (no alveolar fluid) with good lung sliding bilaterally, no pericardial effusion, and a dilated inferior vena cava. The right ventricle appears dilated and hypokinetic. You diagnose the patient with obstructive shock, likely due to massive pulmonary embolism. You rule out tension pneumothorax and cardiac tamponade as alternative diagnoses with your physical exam and bedside ultrasound findings. Thrombolytics are promptly administered. The patient’s vital signs slowly stabilize, and he is admitted to the medical intensive care unit for continued monitoring and care.

Author

Joseph CIANO

Dr Ciano is an Emergency Medicine Physician from New York, USA. He completed his Emergency Medicine Residency in Brooklyn, NY and a Fellowship in Global Emergency Medicine in the Northwell-LIJ Health System. He is interested in building the educational infrastructure of EM in countries where Emergency Medicine is not yet recognized as a field and in countries that are in the early stages of this process. He has partnered with international NGOs in Emergency Medicine educational projects and works as a visiting Emergency Medicine faculty member in West Bengal, India. He is excited to collaborate with the other authors of the iEM Education Project to contribute to the world of FOAM-ed.

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Cite this article as: iEM Education Project Team, "Shock (2023)," in International Emergency Medicine Education Project, May 8, 2023, https://iem-student.org/2023/05/08/shock-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/shock/

References

Nicks BA, Gaillard JP. Approach to Nontraumatic Shock. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed January 31, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=218079826

Gitz Holler J, Bech CM, Henriksen DP, et al. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: A systematic review. PLoS One. 2015;10(3): e0119331. doi: 10.1371/journal.pone.0119331.

Gitz Holler J, Jensen HK, Henriksen DP, et al. Etiology of Shock in the Emergency Department: A 12-Year Population-Based Cohort Study. Shock. 2019;51(1):60-67. doi:10.1097/SHK.0000000000000816

Bloom JE, Andrew E, Dawson LP, et al. Incidence and outcomes of nontraumatic shock in adults using emergency medical services in Victoria, Australia. JAMA Netw Open. 2022;5(1): e2145179. doi:10.1001/jamanetworkopen.2021.45179

Farkas J. Approach to shock. EMCrit Project. https://emcrit.org/ibcc/shock/ . Published November 29, 2021. Accessed January 31, 2023.

Doerschug KC, Schmidt GA. Shock: Diagnosis and Management. In: Oropello JM, Pastores SM, Kvetan V. eds. Critical Care. McGraw Hill. Accessed February 07, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=1944&sectionid=143516997

Weingart SD, Duque D, Nelson B. The RUSH exam: Rapid ultrasound for shock and hypotension. EMCrit Project. https://emcrit.org/rush-exam/. Accessed February 8, 2023.

Puskarich MA, Jones AE. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed February 08, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=220292051

Shock index. MDCalc. https://www.mdcalc.com/calc/1316/shock-index. Accessed February 8, 2023.

Orsborn J, Braund C. Emergencies & Injuries. In: Bunik M, Hay WW, Levin MJ, Abzug MJ. Current Diagnosis & Treatment: Pediatrics, 26e. McGraw Hill; 2022. Accessed February 22, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=3163&sectionid=266216337

Levine M. Geriatric trauma and medical illness: Pearls and pitfalls. emDocs. http://www.emdocs.net/geriatric-trauma-medical-illness-pearls-pitfalls/ Published August 21, 2016. Accessed February 22, 2023.

Fleischman RJ, Ma O. Trauma in the Elderly. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed February 22, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=221180950

Clifford KM, Dy-Boarman EA, Haase KK, Maxvill K, Pass SE, Alvarez CA. Challenges with Diagnosing and Managing Sepsis in Older Adults. Expert Rev Anti Infect Ther. 2016;14(2):231-241. doi:10.1586/14787210.2016.1135052

Burns BD, Fisher ES. Resuscitation in Pregnancy. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. Accessed February 23, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=206322334

Acknowledgement

The patient image was created with the assistance of DALL·E 2 by iEM editorial team.

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Communication and Interpersonal Interactions (2023)

May 1, 2023May 16, 2023 ~ iEM Education Project Team ~ Leave a comment

by Nicholas Mackin, Bret Nicks

Introduction

Emergency Medicine and the situations within the department can present a stressful, rapidly changing environment where it may feel as though there is too little time for effective patient communication, patient-centered care, or the opportunity to establish an appropriate provider-patient relationship. It is also an environment unlike any other in medicine, where a unique team of individuals facing varying degrees of chaos with limited available information work together to address the medical conditions of those presenting to the department. Few would recommend entering such an environment in the absence of an established care process and means of clearly communicating. Understanding that preconceived notions and prejudices must remain at the door from the moment you walk in to the emergency department (ED) sets the tone for the entire shift.

It is no surprise that high-performing emergency departments have high-performing, well-communicating teams. Clearly defining and communicating why we are there and how we care for patients for every member of the team sets the tone for every interpersonal interaction. This is true not just with our patient-provider interaction, but our interaction with nursing, ancillary, and consultant staff [1]. Establishing a team mentality and acknowledging the value of the contributions of our colleagues and staff to the ED is essential to practicing high-quality, safe emergency medical care.

The skills that non-physician health professionals bring to the team can help us to better understand our patient’s expectations and needs – facilitating the best care that can be offered in the ED [2].

Essentials of Communication

The approach to provide high-quality patient care in the ED starts with recognizing the inherently mismatched perspective between the patient and physician [3]. It is essential to recognize the patient-physician relationship starts with a large power imbalance. Attempts should be made to normalize or reduce this power imbalance, so as to empower the patient and their families to openly discuss their medical concerns and assist with making informed decisions for their care. Acknowledge the wait or process they have already endured prior to seeing you. Thank the patient (and family) for coming to the ED and allowing you to address their medical concerns. Also, take the time to introduce yourself to everyone in the room with the patient and find out who they are in relation to the patient as this can help establish rapport with the patient and those around them [4-6]. When introducing yourself and other members of the care team, be sure to clearly define roles in terms the patient can understand. This is of particular importance when working with trainees. Patients tend to have a poor understanding of medical education and training, but want to know the role and level of training of their providers [7].

While many believe the environment of care is the greatest limiting factor to quality communication, literature would suggest otherwise. Establishing a positive patient-provider relationship is essential. Recognizing that you may not be able to solve the patient’s condition or chronic illness, but using effective communication skills and providing a positive patient experience will assuage many patient fears [8]. Keep in mind, in general, patients remember < 10% of the content (what was actually said), 38% of how you say it (verbal liking), and 55% of how you look saying it (body language) [3]. Effective provider communicators routinely employ these 5 Steps:

1. Be Genuine

Most people are able to quickly intuit when someone is not being forthcoming. Although we are often balancing competing interests for our time and attention, make every effort to ensure that you are taking a genuine, transparent approach to both receiving and providing information. An effective means of achieving this is to take an earnest interest in your patient. This often requires putting aside personal fatigue and bias. If you can entrain a genuine interest in a patient’s concerns, your interaction will be more natural and the patient will be more likely to trust you.

2. Be Present

As emergency providers, we are interrupted more than perhaps any other specialty. However, for the brief time that we are engaged with the patient or their family, be fully attentive. If there is a planned interruption upcoming, make it known prior to starting a discussion. Be focused on them and the conversation – and value what they have to share. At the end of your encounter, briefly summarizing what the patient has told you can help to reassure the patient that you were listening and also give them the chance to clarify discrepancies.

3. Ask Questions

To effectively communicate, one must listen more than they talk. After introducing yourself, inquire about the patient’s medical concern Give them 60 seconds of uninterrupted time. Most patients provide unique insights that may otherwise not have been obtained. Then begin with the specific questions needed to further differentiate the care concern. By asking questions and allowing for answers, you make it about them and give them an avenue to share with you what they are most concerned about and allow you to address those concerns.

4. Build Trust

Given the nature of the patient-provider relationship in emergency medicine, building trust is essential but often difficult. Building trust is like building a fire, it starts with the initial contact and builds with each interaction – and is based on culturally acceptable interactions (e.g. handshake, affirming node, hand-on-shoulder, engaging posture, etc.) [4].

5. Communicate Directly

By the end of the initial encounter, ensure that you have established a clear plan of care, what the patient can expect, how long it may take, and when you will return to reassess or provide additional information. Doing this also allows the patient to be more involved in their care and ask further questions regarding their workup and treatment plan. Additionally, helping the patient to understand what they can expect while in the department can help to alleviate fear associated with unannounced tests or imaging studies, especially when these tests may require them to be temporarily taken out of the department (e.g. a trip to the CT scanner). While patients generally trust physicians to make decisions about advanced imaging such as CT, they still want to be included in the decision-making process [9].

Empathy

When considering this, it is essential to understand that much of this relates to empathy – the ability to understand and share another person’s experiences and emotions. It is often said, try to understand the patient’s agenda: ‘Help me understand what brought you in today’, ‘help me understand what I can do for you’, ‘tell me more’. This will help to normalize the patient’s situation and gain unique insights into their care concerns. There are 4 easy steps to improve reflective listening and perceived empathy in the ED:

Echo: Repeat what the patient says; this gives the message that you heard the patient.
Paraphrase: Rephrase what the patient says; this gives the message that you understand the patient.
Identify the feeling: Say, for example ‘you seem frustrated’, ‘worried’, ‘upset’ as this produces trust.
Validation: Validate the patient’s feelings verbally such as ‘I can see why you feel that way’.

It is human nature that empathy will be more intuitive for some, but all can practice empathic communication skills to better identify the needs of your patient. By implementing the above approach, physicians can improve their ability to elicit concerns that a patient may not have been able to otherwise articulate. Using a predefined approach may feel mechanical or forced, but standardized communication interventions have been shown to positively impact patients’ perception of the encounter [10].

For those seeking additional structure to practice, there is also a great online module and mnemonic for Empathetic Listening skills development [11]. The RELATE mnemonic is:

Reassure – share your qualifications and experience.
Explain – describe in clear concise language what the patient can expect.
Listen – not just hear and encourage the patient to ask questions.
Answer – summarize what they have said and confirm their understanding.
Take Action – discuss and define the care steps (and what to expect)
Express Appreciation – thank the patient for allowing you to care for them.

The Approach

As with many things, effective communication is the glue that helps establish connections to others and improve teamwork, decision-making, and problem solving. It facilitates the ability to convey even negative or difficult messages without creating conflict or distrust. Recognizing this, the right approach for successful patient communication is essential. In addition to understanding the above 5 steps of effective communication, the approach to this must also be refined by each individual and adjusted for the unique circumstances of each patient encounter. For a moment, consider seeing the situation from the patient’s perspective regarding your approach and set the tone with these 3 starting points.

The 3 Starting Points:

1) Approach and Appearance:

Sit down next to the patient
Maintain an open posture (avoid crossing your arms)
Maintain eye contact appropriate to local cultural norms
Use non-verbal cues to acknowledge what is being said (e.g. nodding, smiling, using eyes to show interest)
Dress appropriately

2) How to speak:

Speak slowly and clearly (given the constraints of the ED)
Use a low, calm tone in your voice
Be mindful that patients will sense any frustration or impatience in your tone

3) What to say:

Introduce yourself in a culturally appropriate manner
Use the patient’s last name, particularly if introducing yourself by your last name (this helps to minimize power imbalance)
Acknowledge everyone in the room and clarify their relationship to the patient
Adjust medical wording based on patient’s medical literacy

In addition to understanding the 5 essentials of communication and setting the tone with the initial care approach, it is important to understand some of the most common reasons communication is successful and fails in the Emergency Department. While a single approach framework doesn’t always fit every situation, there are some essential Do’s and Don’ts that must also be considered.

Do's

Let the patient tell their story [9].
Establish the patient’s goals of the encounter.
Elicit any feared conditions or diagnoses, as well as any desired therapeutics or diagnostics (It is generally better to address these pre-existing desires early in the encounter).
Provide the patient with information regarding what will happen during their stay. This puts patients more at ease and improves satisfaction [6].
Provide honest estimates of expected wait times. Some experts suggest overestimating the time for results and consultant services (Disney Technique).
Explain reasons for delays, and readily apologize for
Map out the next steps in the process in the ED after your history and physical.

Don'ts

Fold your arms over your chest as this displays an aggressive posture
Ask why the patient did not come in earlier
Say ‘I guess’
Repeatedly ask ‘why’
Use the words ‘never’ or ‘always’
Ignore elephants in the room
Dismiss their concerns without explanation

The Difficult Patient

When engaging difficult patients in the emergency department, understanding the situation and the drivers for the patient may help to better navigate the communication challenges that are present. A difficult patient encounter in the emergency department can often be frustrating for both the physician and the patient. These patients often present with chronic medical issues that are exacerbated by social disparities [13-14]. These are just a few examples of types of patients that one may encounter in the emergency department:

Angry Patient

Don’t ignore that a patient may be angry or upset. Their frustration is often related to delays, expectations, or care concerns. Try to explore this by asking neutral and non-confrontational questions. If possible, identify and acknowledge their dominant underlying emotion. Statements as simple as “It seems like you’re frustrated” or “I suspect we’re not meeting your expectations today” can lead to meaningful dialogue when a patient feels acknowledged. A simple but genuine apology can completely change the end of an encounter, such as apologizing for a long wait or for not being able to do more in our limited capacity in the ED.

Manipulative Patient

While these patients may clearly have secondary gain, their medical complaints are often still legitimate. Approach these patients with an open mind and differential, but be prepared to say “no” to requests that are not clinically indicated. When in doubt, give patients the benefit of the doubt rather than prematurely dismissing a legitimate need.

Frequent Fliers / High Utilizers

High recidivism may be frustrating, but it is important to understand that there may be an underlying reason for frequent ED visits. Socioeconomic factors resulting in poor access to care are common reasons. Maintaining familiarity with available resources (e.g. social workers, clinical support nursing) can make a tremendous difference.

Combative, Agitated, or Intoxicated Patient

It is most important to keep both the patient and the staff (including yourself) safe. Redirecting the patient and emphasizing the importance of caring for them medically may help to calm the situation. It is remarkably easy to inadvertently escalate an agitated patient’s behavior. Maintain firm boundaries while maintaining a calm, reserved demeanor. Psychopharmacological intervention may be necessary at times.

In difficult encounters, there are times when an impasse is reached and it is clear that the goals of the patient will not be met. Even if your care is medically appropriate and effort has been made to respect the patient’s autonomy, these scenarios are sometimes unavoidable. In such situations, it is important to emphasize that you are acting in what you feel to be the patient’s best interest. If appropriate, apologize for their frustrations or any misunderstanding. Give the patient time to express themselves, but also practice identifying when it is time to give the patient space.

For a deeper dive into effective patient communication related to managing difficult patients, listen to Episode 51: Effective Patient Communication – Managing Difficult Patients by Anton Helman. http://emergencymedicinecases.com/episode-51-effective-patient-communication-managing-difficult-patients/

The Culturally-Discordant Encounter

The emergency department is a nexus not just for all members of a community, but for anyone in the area needing assistance. Physicians in the emergency department can expect to encounter a diverse patient population, regardless of physical location. Healthcare professionals will therefore invariably encounter those of cultural backgrounds that differ from their own. These cultural backgrounds include race, religion, and nationality, among many others. While an entire chapter could be dedicated to communication in this setting, here are a few key points to form a foundation.

1. Minimize any language barrier

Making efforts to minimize a language barrier is often easier said than done. For any encounter in which the primary languages of the patient and physician are not the same, an interpreter should be offered whenever possible. It can be immensely tempting to over-estimate a patient’s fluency in a language to avoid having to use a language interpreter. However, it is well-demonstrated that language barriers are associated with a variety of negative impacts on patient care including decreased diagnostic confidence, increased ancillary testing, decreased patient satisfaction, and delays in analgesia [15-17]. Family members should not be used as interpreters whenever possible. They can have their own agendas and biases, as well as variable health literacy.

2. Be mindful of one’s own biases

It is an unfortunate truth that implicit biases exist in every person. Healthcare professionals should be mindful of the poorer communication and health outcomes minority races tend to receive [18,19]. Employing a genuine, empathic style of communication is an excellent foundation for mitigating one’s biases.

3. Familiarize yourself with differing cultural norms

There are far too many cultural norms for any one person to know. If there are specific communities of differing cultural backgrounds in your area, make an effort to learn differences in verbal and non-verbal cues. If unsure, it is generally prudent to “be yourself” and exhibit calm, deliberate mannerisms.

The Handoff

Communication between providers and specifically patient care transitions present one of the well-known challenges in patient care and errors in care management. This handoff communication, often perceived as the ‘gray zone’, has been characterized by ambiguity about patient medical condition, treatment and disposition [20]. Communication errors, particularly related to patient hand-offs, account for nearly 35% of ED related care errors. Establishing a standardized process to ensure quality and clarity of transitions in care are essential. One such example is the I-CAN format, which is specifically focused on the ED patient population.

I - Introduction

Briefly describe what brought the patient into the emergency department today. For example: Patient is a 53 yo male with past medical history of COPD who presents today with productive cough, wheezing and shortness of breath.

C - Critical Content & Interventions Performed

Relate information that helps the receiving provider understand the ED course. For example: On initial evaluation the patient was unable to speak in full sentences and O2 saturation was 88% on room air. We started him on NIPPV and provided nebulizer treatments and IV steroids.

A - Active Issues

Provide an overview of the patient’s current condition. For example: Patient improved after an hour of NIPPV and was transitioned to high flow nasal cannula with O2 saturation at 93%. We are currently attempting to wean O2 requirements as tolerated.

N - Next Steps & Anticipated Disposition

Describe to the receiving provider what will need to be followed up and anticipated disposition of the patient. For example: The patient will need to be admitted for a COPD exacerbation with a new O2 requirement. He can go to a floor bed if he remains stable on nasal cannula.

While many examples for a unified handoff exist, identifying a defined approach and establishing the expectation for routine use, especially when integrated into the electronic health record at transitions of care, ensure improvement with patient care, quality and throughput [20,21]. If the patient and family are involved with this handoff, not only will they understand care expectations, but better understand issues with delays, next steps, and care updates.

Conclusion

Most agree that providing patient care in the ED poses many challenges. The situations within which we work can present a stressful, rapid environment where it may feel as though we have too little time for effective patient communication, patient-centered care or opportunity to establish a great patient experience. However, it is also evident that improved communication between the care team and patients not only improves the care experience but also improves patient care outcomes. Quality communication improves patient outcomes, compliance and satisfaction – not to mention job and team satisfaction.

While many techniques exist to improve ED communication, establishing a culture in the ED to habitually adapt these practices is essential. The ED is indeed an environment unlike any other in medicine, where a unique team of individuals work in varying degrees of chaos with limited available information working together to address the medical conditions of those presenting to the department. Doing so with effective communication can make a difference.

Authors

Nicholas MACKIN

Nicholas Mackin, MD is a Clinical Assistant Professor in the Department of Emergency Medicine at Wake Forest Baptist Medical Center in Winston Salem, NC, USA.

Bret NICKS

Listen to the chapter

Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Communication and Interpersonal Interactions (2023)," in International Emergency Medicine Education Project, May 1, 2023, https://iem-student.org/2023/05/01/communication-and-interpersonal-interactions-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/communication-and-interpersonal-interactions/

References

Gluyas H. Effective communication and teamwork promotes patient safety. Nurs Stand. 2015 Aug 5;29(49):50-7.
Klauer K, Engel KG. Patient-centered Care. Emergency Medicine Clinical Essentials, 2^nd Ed. Elsevier, 2013; 1784-89.
Helman A. Effective Patient Communication. Available at: http://emergencymedicinecases.com/episode-49-patient-centered-care/ Accessed December 18, 2015.
Chan EM, Wallner C, Swoboda TK, et al. Assessing Interpersonal and Communication Skills in Emergency Medicine. Acad Emerg Med 2012; 19:1390-1402.
Cinar O, Ak, M, Sutcigil L, et al. Communication skills training for emergency medicine residents. Eur J Emerg Med. 2012; 19:9-13.
Hobgood CD, Riviello RJ, Jouriles N, Hamilton G. Assessment of communication and interpersonal skills competencies. Acad Emerg Med. Nov 2002; 9(11):1257-69.
Hemphill RR, Santen SA, Rountree CB, Szmit AR. Acad Emerg Med. 1999 Apr;6(4):339-44.
Mole TB, Begum H, Cooper-Moss N, et al. Limits of ‘patient-centeredness’: valuing contextually specific communication patterns. Med Educ. 2016 Mar; 50(3):359-69.
Caoili EM, Cohan RH, Ellis JH, et al. Medical Decision Making Regarding Computed Tomographic Radiation Dose and Associated Risk: The Patient’s Perspective. Arch Intern Med. 2009;169(11):1069-1081.
Custer A, Rein L, Nguyen D, et al. Development of a real-time physician–patient communication data collection tool. BMJ open quality. 2019 Nov 1;8(4):e000599.
The History of Empathy – SMACC. Available at: http://broomedocs.com/2014/09/the-history-of-empathy-from-smacc-gold/ Accessed February 20, 2016.
Roscoe LA, Eisenberg EM, Forde C. The Role of Patient Stories in Emergency Medicine Triage. Health Commun. 2016 Feb 16:1-10.
Hull SK, Broquet K. How to manage the difficult patient. Family Practice Management. 2007 June: 30-34.
Dudzinski DM, Timberlake D. Difficult Patient Encounters. Ethics in Medicine. Available at: https://depts.washington.edu/bioethx/topics/diff_pt.html Accessed February 20, 2016.
Garra G, Albino H, Chapman H, Singer AJ, Thode Jr HC. The impact of communication barriers on diagnostic confidence and ancillary testing in the emergency department. The Journal of emergency medicine. 2010 Jun 1;38(5):681-5.
Gaba M, Vazquez H, Homel P, Likourezos A, See F, Thompson J, Rizkalla C. Language barriers and timely analgesia for long bone fractures in a pediatric emergency department. Western Journal of Emergency Medicine. 2021 Mar;22(2):225.
Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. Journal of general internal medicine. 1999 Feb;14:82-7.
Shen MJ, Peterson EB, Costas-Muñiz R, Hernandez MH, Jewell ST, Matsoukas K, Bylund CL. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. Journal of racial and ethnic health disparities. 2018 Feb;5:117-40.
Hagiwara N, Slatcher RB, Eggly S, Penner LA. Physician racial bias and word use during racially discordant medical interactions. Health communication. 2017 Apr 3;32(4):401-8.
Akper J, Mallak LA, Gibson SC. Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007 Oct;14(10):884-94.
Rourke L, Amin A, Boyington C, et al. Improving residents’ handovers through just-in-time training for structured communication. BMJ Qual Improv Rep. 2016 Feb 8;5(1).

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

The Importance of the Emergency Medicine Clerkship (2023)

April 17, 2023May 3, 2023 ~ iEM Education Project Team ~ Leave a comment

by Linda Katirji and Farhad Aziz

Introduction

The emergency medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some medical schools may have an optional elective or a core rotation during the third year. Whether or not you plan to specialize in emergency medicine, the rotation is an important part of your medical education that will help you develop unique skills. The emergency room is a unique learning environment which is different than any other setting in the hospital. It provides clinical opportunities that are largely unavailable in other clerkships and rotations, and one of the few places you will encounter a completely undifferentiated patient. During residency, many specialties will also spend a significant amount of time in the Emergency Department (ED). This may be within a structured EM rotation, or while admitting or seeing patients for a certain medical or surgical service. Therefore, it is important to gain an understanding of the flow of the ED as well as the unique thought process that must be employed with emergency department patients. This chapter will discuss some of the unique aspects of the emergency department, some of the skills to acquire during the EM clerkship, as well as how to best be successful and take the most away from your rotation.

Unique Aspects of The Emergency Department Environment

The high volume and acuity of patients in the ED create a time pressure and forces physicians to employ a different style of practice than in most other settings. A steady stream of patients, some of whom may require immediate life-saving measures, means that many times there is little to no time to review history or any medical records prior to evaluating a patient. Most of the time you will need to assess a patient without knowing anything about their background. Therefore, it is important to gain an understanding of what the most important pieces of information to gather are for each patient. This can be difficult since most patients will arrive with completely undifferentiated complaints. Some common examples of these undifferentiated complaints are “chest pain” and “abdominal pain”, where the etiology can range from completely benign to immediately life-threatening, or “weakness”, where the differential diagnosis includes essentially the entire spectrum of medical pathology.

This undifferentiated patient is the standard in the ED. However, they can present in any medical setting. It is important to learn the thought process and develop a strategy for thinking through these types of patients whether you plan on a career in EM or not. Emergency physicians (EPs) must employ and master a completely different style of practice than most physicians. EPs must always think worst case scenarios for each chief complaint and must be knowledgeable and comfortable with associated the workup and treatment. A good example of this is chest pain. Even though many times the complaint of “chest pain” is found to be caused by a non-acutely life threatening etiology, EPs must immediately think of six fatal causes of chest pain: acute coronary syndromes, aortic dissection, pulmonary embolism, pericardial tamponade, pneumothorax, esophageal rupture. Additionally, ED doctors must use a different thought process in determining the disposition, or outcome, of the patient. The ED doctor essentially wants to avoid sending a patient home that is not safe to go home, where as a consultant, or admitting service, does not want to admit a patient who does not need be admitted. This may seem trivial, however this difference in thought process can occasionally create tension between the ED and admitting services.

Teaching in the ED is different than most other settings in the hospital as well. There is usually no time set aside for formal rounds, so most teaching is done actively at the bedside or at the time the student or resident presents the patient to the attending physician. Many times, attending physicians will pick out “teaching points” for each patient. Each physician will have a different teaching style. Your learning will generally be more active than passive, and likely more short and frequent rather than one long teaching sessions or lecture on rounds.

Lastly, the ED is a great place for medical students and first-year residents to learn to take responsibility for their patients. Students often time have an increased level of autonomy compared to other rotations. Many times, the student will be the first person to assess the patient, which is a very important role. It is important to learn to distinguish whether a patient is “sick” or “not sick”, and whether or not at first glance you think this patient could go home or needs to be admitted no matter what the diagnosis may be.

Unique Skills To Take Away From EM Clerkships

Emergency medicine is a wonderful rotation that exposes you to not only different patient populations but also a variety of pathology and diseases. This diverse collection of patients and pathology lends emergency medicine residents and students a unique opportunity to gain a mastery of different skills. These skills range from a knowledge of how to approach critically ill patients, gaining procedural skills, reading radiographs and CT scans, performing ultrasounds and much more.

Often you may be busy doing different tasks when you must drop everything to manage a critically ill patient. This is one of the exciting aspects of emergency medicine. These patients offer students a great opportunity to learn the principles of resuscitation, such as managing airways and circulatory collapse, identifying causes for the patient’s decompensation, and instituting the appropriate treatment. Whether you pursue a career in emergency medicine or choose to pursue a different specialty, critically ill patients will likely always be a part of your patient population. Understanding how to approach and stabilize these patients is an important part of being a physician.

Though learning the art of resuscitation is a vital part of the EM rotation, this is also an opportunity to gain competence in a variety of procedures. Whether you intend to pursue a career in pediatrics, internal medicine, orthopedics, general surgery or any other specialty, your rotation through the ED will expose you to a wide array of procedural skills ranging from intubating and placing central lines and arterial lines in the critically ill to performing lumbar punctures and fracture reductions in children. Autonomy is encouraged with procedures, and you will have the opportunity to improve your skills and techniques under the guidance of residents and attendings. EM is a very hands-on specialty. You should take advantage of medical student and resident didactics as an opportunity to learn. These usually consist of lectures on different subjects but also may include ultrasound practice, procedure labs on mannikins or cadavers and simulation. This will give you an opportunity to practice and provide better patient care during your rotation.

In addition to becoming familiar with a wide array of procedures, your EM clerkship will also allow you to familiarize yourself with a variety of imaging modalities ordered in the ED. There is a tremendous amount of pathology found in the ED which lends itself to a range of imaging. Whether it be learning to perform bedside ultrasonography on a crashing patient or simply learning how to approach reading a chest x-ray or a CT scan of the abdomen on your own, your EM rotation will give you plenty of opportunities to become proficient in a skill you will need later in your career.

Though your EM clerkship gives you exposure to a tremendous amount of skills which will help you become a savvy doctor, no skill is more important than compassion and humility. Every day, you will meet patients on the worst day of their life. Many will have gone through traumatizing experiences, or have a life changing chronic condition, or be in a severe amount of physical or emotional pain. Realizing this and comforting patients and their families is paramount to your success as a physician. You will also encounter a variety of consulting physicians. Speaking with consulting physicians about a patient is an art form in itself that EM physicians must master. While most consultants will be polite and professional, its not uncommon in to meet push-back from a consultant. Occasionally, some may be out right rude. Having a general understanding that they all have knowledge that you can learn from will set you up for a successful career in medicine.

How To Be Successful on Your EM Clerkship

Many of the of the same qualities that allow you to be successful in other rotations will help you to be successful in the ED. It is important to be hardworking, proactive, and knowledgeable. Keep a close eye on your patients, re-evaluate them frequently, and make sure to follow up on any results, including labs, imaging, and any recommendations by consultants. The unique aspects of the ED and EM clerkship discussed previously mean the first few shifts may be stressful and seem chaotic and hectic. For every student and resident that rotates through the ED there is a significant learning curve – with each shift you spend in the ED, things will feel less and less daunting. It’s important during this time that you know your limitations and what you are comfortable and not comfortable with. Many times you will be the first person to assess the patient. You should have a low threshold for alerting an upper-level resident or attending if the patient appears to be sick, or if they present with a complaint you are uncomfortable with. At the same time, you should be confident in what you do know and take the opportunity to learn how to diagnose, treat, and manage your patient.

The best way to build confidence during your EM rotation is to gain experience and knowledge. Try to be proactive in learning new procedures or treatments with attending or resident assistance. Additionally, it’s very important to keep up with reading and studying. In the emergency room, you may see medical pathology you’ve only read about and will be expected to know how to diagnose and treat these diseases properly. When you have the time, use the resources you have at your disposal and look things up before presenting to your resident or an attending, and have a plan to disposition (ie, admission or discharge) already made for the patient.

Good communication is essential for a physician in any specialty, and in the ED, it is an imperative skill to have. You will be working with a large team of nurses, technicians, consulting doctors, social workers, and paramedics, just to name a few. When you see a patient, it is a good idea to speak with the nurse before you enter the room to gain a better understanding of the patient’s complaint, as well as gather any information that was relayed by EMS. By communicating the plan of care to the nurse and supporting staff, you will not only improve patient care and reduce mistakes but also forge relationships that will enrich your experience in the ED. In acute settings such as a patient code or rapidly decompensating patient, good communication with the entire team is critical. As a medical student or rotating resident, this is a great time to practice and improve your communication skills in these acute settings under the direction of residents and attendings.

Your EM rotation will be an exciting, unique experience during medical school and residency. Whether you plan to specialize in EM or not, you will learn many procedural skills, improve your own method of diagnosing and treating patients and be able to practice a different method of medical decision making.

Authors

Linda KATIRJI

University of Kentucky, Department of Emergency Medicine

Farhad AZIZ

The Ohio State University, Department of Emergency Medicine

Listen to the chapter

Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "The Importance of the Emergency Medicine Clerkship (2023)," in International Emergency Medicine Education Project, April 17, 2023, https://iem-student.org/2023/04/17/the-importance-of-the-emergency-medicine-clerkship-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/the-importance-of-the-emergency-medicine-clerkship/

References

EMRA and CORD Student Advising Guide (https://www.emra.org/books/msadvisingguide/msag/)
EMRA Medical Student Page (https://www.emra.org/students/)
The Emergency Medicine Clerkship Primer (https://www.saem.org/docs/default-source/saem-documents/students/em-clerkship-primer_0_0.pdf)

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Emergency Medicine: A Unique Specialty (2023)

April 7, 2023May 3, 2023 ~ iEM Education Project Team ~ Leave a comment

by Anthony Rodigin

What is EM?

Emergency Medicine (EM) does not claim its own body part or a physiologic system. With Vascular Surgery or Endocrinology things are straightforward. But what do we have?

Most of our procedures are shared with other specialties. We use many of the same tools and instruments. Emergency physicians also value evidence-based practice. And like providers in other fields, we believe in disease prevention, palliation, empathy, the Hippocratic oath and the magic of human touch.

In some places, emergency medicine is confused with the mere lights and sirens of ambulances or with various types of outpost facilities providing as little as vaccinations and screenings. And even if unmistakable emergency departments (EDs) are present, it is not apparent to many ED patients that the doctors seeing them are not just any doctors from somewhere else in the hospital.

It is easy to say that emergency medicine deals with emergencies. True – we initiate life-saving interventions, commence stabilizing treatments and ultimately supervise the patient’s transition to definitive care. But who is best positioned to select out these emergencies in the first place? And in what other settings besides the ED should our skills be called upon and applied? Real essence of modern EM cannot be understood without thinking through these questions.

So once again, who are we and what is EM?

Evolution of EM

History

Both prehospital emergency care and ancestral emergency rooms predate the emergency medicine specialty itself. Out of the many wars and civilian side catastrophes came the realization that competent care was needed before and during transport to a hospital. At the same time, early emergency rooms, often small and inconveniently located in basements or on second floors, served as the natural intersection for walk-ins, ambulances and hospital wards in the early and mid-twentieth century.

The technological boom following the Second World War was in part responsible for the transition from outpatient to hospital-based medicine. More could be done and in a quicker time frame inside of a hospital, and the sickest of the sick now perhaps had a chance of survival. A natural demand for expanded and better-equipped casualty (aka accident- or emergency-) departments was created. At the same time, more patients presenting to EDs with non-traumatic complaints underscored the need to move beyond mere trauma and injury.

Still, as the earlier version of this chapter correctly stated, “Only a few decades ago, emergency departments…were staffed by physicians with a variety of training backgrounds. The vast majority of these physicians had little to no emergency medicine training at all. General surgeons, family physicians, neurologists, and even psychiatrists were among those that staffed emergency departments…throughout the world” [1].

In the 1960s and 1970s things began to change rapidly. As ambulance care and destination decisions improved, in some nations relying on physicians and in others on newly established paramedics, so did the understanding that a dedicated provider specializing in ED services was invaluable. In the United States, pioneer physicians who chose to work exclusively at EDs provided additional advantages to the lifestyles and efficiency of specialists. Freeing up the latter to concentrate on more complex specialty-driven tasks led to their higher reimbursements. Thus, both the absence of competing emergency care physicians in the prehospital domain and economic incentives created by EM for narrow specialties pushed EM development in the US somewhat ahead of other parts of the world. The vast and ubiquitous benefits of EM to the general public were to follow.

From the 1970s and on rapid growth of EM residencies took place, together with the founding and strengthening of EM national boards and EM national and international societies. Brian Zink’s famous “Anyone, Anything, Anytime” comprehensively describes the history of modern EM in the United States [2]. Another excellent resource is this documentary from the Emergency Medicine Residents’ Association (EMRA). Such a trajectory was closely matched by EM’s path in the United Kingdom, Canada, Australia and other culturally Western nations, steadily but surely spreading throughout most of the world.

With every decade that followed, the number of countries developing EM increased exponentially. Arguably, each nation’s own EM chronicles are best regarded and studied in tandem with texts like Ryan Corbett Bell’s “The Ambulance”, which ought to describe the contemporaneous evolution of not only prehospital medicine but of the overall emergency care landscape in each nation as the precise background for EM’s necessity, birth and its coming of age [3].

The Future

Emergency medicine and its place within the emergency care endeavor are not going anywhere, but the scope of EM will undoubtedly change.

We can anticipate with a high degree of probability that, somewhat paradoxically to its origins, EM will continue to expand its reach beyond the emergency department. Very possibly, post-residency training via fellowships will become the norm rather than the exception. Further integration with prehospital services and sharing of EM workplaces with non-physician EM specialists (e.g. Advanced Practice Providers) will persist. Natural and technologically driven disasters will maintain high demand for EM’s unique combination of versatility and focused expertise.

The future may not bring ready solutions to all of the clinging problems. Lack of access to universally accepted standards of emergency care in rural, remote and low-income areas is one. EM’s ambivalently viewed safety net function arising from any healthcare system’s gaps and incapacities in non-EM arenas like primary care and preventative medicine is another example. In addition, proper relationship of EM with other conceptual definitions and terms such as Frontline Medicine, Emergency Medical Services (EMS), Acute Critical Care and Pediatric EM will have to be philosophically teased out further on a global scale.

Finally, an area of medicine that has matured to its most commonly used name of Global Health (GH) needs to be mentioned in this context. Current involvement of EM physicians in GH projects, while not uncommon, is not something universally anticipated. Today it still rests on enthusiasm of individual participants or institutions. The future may call for things to change drastically in the long run.

The prognoses mentioned are not exhaustive, but they should all be met with optimist and eagerness. It is beyond any doubt that unprecedented opportunities await future EM trainees not only through engagement in primary clinical work and research in the ED, but also in domains ranging from local policy making to transnational epidemiology, and vice versa.

The Present

Today it can be surmised with justification and pride that the battle for EM’s existence, its independence and its own standards matching or surpassing those of more traditional medical specialties has been largely won.

Distinctive and concrete advantages of EM include flexibility in work schedules and lifestyles and the balance of individual expertise with teamwork. Further, EM offers multiple areas for gaining additional proficiency – ranging from bedside ultrasound to basic research and from business practices to international health. Last but not least, EM features an unparalleled interconnected global community of people just like you. If in doubt, you should strive to attend an EM International Congress (ICEM) or a regional EM conference in your area. See for yourself!

Of course, visible and hidden currents remain in motion, bringing in tides of new trials. Efforts toward fair employment practices, workplace safety, non-malevolent legal climate, job security and sustainability, EM’s influence on healthcare policies – these are only a few of today’s pressing themes. Still, such challenges are neither unprecedented nor unique to EM, and are not anything to be afraid of for future EM clinicians.

Above all else, one should know that EM is an exciting, versatile and dynamic specialty to consider as one’s top choice for a career in medicine.

Why EM?

Who are EM docs?

Our field is not without its stereotypes. A common one is that all EM physicians are adrenaline junkies and type A immediate gratification personalities. When we are not intubating in the ED, we are skydiving or playing extreme sports. In truth, there are as many characters, hobbies and interests in EM as there are in the world at large. The passion in EM that we all share is to be found it its mission. We believe in equal opportunities to receive competent emergency care world-wide and in EM’s unique approach to the undifferentiated patient.

What sets EM physicians apart?

In the next two chapters, you will discover more words of wisdom and advice about why EM is a great choice for a specialty, and how EM physicians think differently from other providers. Here, we will come back to the two questions mentioned at the beginning of this chapter.

The first had to do with the selection of those patients who truly do have urgent, emergent and even life-threatening conditions. Of course, some selection is self-selection, as it happens at the patient’s own home or wherever they happened to be. At other times, primary care, walk-in or ambulance services may be involved and may even play a great part. All countries differ in how the tiers of access to emergency services are designed and staggered. Interestingly and controversially, the ethics of what and to what extent an emergency care system is allowed to miss also varies by locale depending in part on culture, in part on the level of public education and in part on historical precedent shaping expectations.

In general, however, EM does not rely on or trust other types of medical providers to do this selection for us. Our specialty was designed specifically to work with the population at large presenting with all health concerns, worries or issues. These truly can be anything coming from anyone at any time. Thus, at least a third of our jobs is to figure out who truly is at risk no matter what the actual diagnosis. This task relies on a completely different set of skills than dealing with someone you already know is critical. Afterwards, we have to perform the next crucial step and stabilize our sick patients. Like bread and butter, it is hard to imagine our field without both of these essential components of practice intertwined together. Of course, in reality, we do much more than caring only for the very ill, which is the last third. From bedside psychology and social advocacy to primary pediatrics, second opinions and after-hours dermatology – we do it all.

The other question was about applying ourselves beyond the ED. EM skills are not only for the hospital. Over the last few decades, it has become obvious that EM physicians function superbly in multiple other settings, from ground and helicopter EMS (including direction and planning) to disaster relief and event medicine. EM physicians make excellent wilderness docs, public and organizational consultants, surgical assistants on GH medical missions (sometimes functioning as the only “anesthesiologist”), proceduralists, tactical support physicians, academic researchers, critical care and ICU providers and much more. All of these cojoined fields provide and will continue to provide ample opportunities for worldwide EM practice for generations of EM aficionados to come.

So, would you like to join in on the fun?

Author

Anthony RODIGIN

Anthony has practiced clinical EM in the San Francisco Bay Area since 2010 and has lived in California for nearly thirty years. A fourth-generation doc, he was awed as a kid by his great-grandmother’s ambulance stories spanning decades. EM’s versatility has been a personality match from the get-go.

Since residency, choices for EM projects have been guided mainly by fun and intellectual curiosity, trying to mimic a childhood hero Sherlock Holmes. Anthony does not play a horrible violin, but rather a lousy synth keyboard. He has been passionate about education since a university TA and has comparatively studied nations’ emergency care systems for twenty years instead of sleeping. He continues to work at a busy community ED, volunteers as an EMS medical advisor for the US National Park Service, and has experience with telemedicine, urgent care, academic shifts and admin leadership. He is also a couch househusband with a spouse, two kids and a real scaredy cat.

Listen to the chapter

Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Emergency Medicine: A Unique Specialty (2023)," in International Emergency Medicine Education Project, April 7, 2023, https://iem-student.org/2023/04/07/emergency-medicine-a-unique-specialty-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/emergency-medicine-a-unique-specialty/

References

Sanderson W., Cuevas D. and Rogers R. “Emergency Medicine: A Unique Specialty”. iEmergency Medicine for Medical Students and Interns. 1^st edition, Version 1, 2018.
Zink, Brian J. “Anyone, Anything, Anytime: A History of Emergency Medicine”, 2nd Edition Hardcover – January 1, 2018
Bell, Ryan Corbett. “The Ambulance: A History”. Reprint edition, McFarland & Company, Inc., 2009

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Journal Club 10/17/22: Global Burden of Disease

April 3, 2023March 23, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

The Economic Impact of Ebolavirus in West Africa: A Burden the Size of Iceland by Andrew L. Mariotti

Between 2014 and 2016, West Africa experienced an Ebola virus epidemic that resulted in 28,000 cases, 11,000 deaths, and a loss of up to $32.6 billion in gross domestic product. To put this in perspective, America’s 2021-2022 flu season culminated in 9 million cases, 5,000 deaths, and a loss of up to $8 billion in GDP. In other words, a single Ebola infection represents a nearly 1200 times greater economic cost, emphasizing the intense strain this disease places on West African nations.

Factors precipitating these costs are multi-faceted and stem not only from the increased morbidity of Ebola but also from structural constraints. The 16 countries of West Africa represent a GDP of $726 million and struggle with a human capital index (see figure below) of 0.40, nearly 0.17 points under the global average. Given this set of conditions, it’s no wonder a disease as serious as Ebola can lead to losses greater than the size of Iceland’s economy ($24.4 billion GDP).

While many strategies to ameliorate these issues emphasize the importance of developing new infrastructure and creating jobs, it’s worth considering how treating Ebola – and reducing the associated disease burden – could palliate a gargantuan economic burden holding this region back from development. How to accomplish this aim would require an entirely new blog post. However, the thought of what a $32.6 billion investment could return for the future growth and development of these underserved populations is worth consideration.

Further Reading:

Promoting Health, Preventing Disease: Is There an Economic Case?; a policy summary from the World Health Organization, Organization for Economic Cooperation and Development, and European observatory on Health Systems and Policies. https://www.euro.who.int/__data/assets/pdf_file/0004/235966/e96956.pdf
Prioritizing Health: A Prescription for Prosperity; McKinsey and Company July 2020 Report. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/prioritizing-health-a-prescription-for-prosperity
Stein, F., & Sridhar, D. (2019). Back to the future? Health and the World Bank’s Human Capital index. BMJ, l5706. https://doi.org/10.1136/bmj.l5706

Discussion Questions:

What barriers to effective Ebola treatment and containment would provide the greatest benefit to individuals in endemic regions were it to be realistically mitigated?
How does the way we think about the importance of treating epidemics change when considering the economic impact it has on a country and could decreasing disease burden be an effective strategy for helping developing nations become more industrialized?

Chapter 4: Global Health and the Global Burden of Disease by Kelsey Yenney

In this chapter, a focus was placed on common terms used to describe the health of a population as well as discuss two ongoing projects that guide policymakers when setting priorities. Throughout this post I will refer to the ‘global burden of disease’; authors in this book have provided the definition as “quantity of diseases/conditions AND their impact on the population”.

Describing the health of populations is done in terms of descriptive statistics and there are many reasons to quantify the burden of disease. The health of a population must be measured and understood for the healthcare system to adequately respond. Quantifying the burden of disease allows for planning, policy making, executing delivery and program evaluation. For example (as used by the author of this chapter), the Minister of Health of Malawi may learn that there were 260 new cases of tuberculosis per 100,000 people in one year. Given that the population at the time was 15.5 million, she can plan that 40,300 people will be diagnosed and treated in her country in the coming year to achieve universal coverage of TB. Descriptive statistics allow policy makers, practitioners, and other healthcare providers to attempt to stay “one step ahead” of the ebbs and flows of epidemiology.

Understanding the burden of disease requires disease surveillance. In 1992, the World Bank commissioned WHO to quantify the global burden of disease; until that time, there was historically insufficient data with which to estimate the burden of disease in many countries, thus leading to an insufficient understanding of the global burden of diseases. In those studies, it was determined that less than 30% of the data on disease and death came from medically certified documents. A new project in 1994 (“Global Burden of Disease”) looked at 107 conditions and over 400 sequelae or secondary outcomes from disease. Diseases were grouped into different categories and countries were grouped based on their “established market economies”. Later in 1994, the term “DALY” (Disability-Adjusted Life Year) was created which describes the number of years of life that is lost or affected by disease.

When thinking about the transitions of epidemiology, Abdel Omran named four significant concepts that describe observed shifts in the types of diseases that affect a population as economic conditions improve. For example, malnutrition becomes less frequent as a country gains food security, water sanitation, etc. However, as infrastructure and economy grow, diseases caused by cigarette smoke, processed foods, etc. can increase. The four stages of population health described by Omran were as follows:

Age of Pestilence and Famine: high mortality due to infectious disease and starvation
Age of Receding Pandemics: life expectancy increases as food security; access to housing and clean water improves
Age of Degenerative and Manmade Diseases: fertility rate decreases, infant mortality continues to fall; major causes of death are non-communicable diseases
Age of Delayed Chronic Disease: primary prevention of disease

The above stages were used by policymakers to create a prioritized stepwise process to promote the cheapest and easiest approach to targeting a country’s biggest threat based on where they “fell within the stages”. However, diseases do not occur in a stepwise approach and each country has a diverse range of disease burden. All nations, no matter the GDP, must prevent and plan for infectious disease, mental health, non-communicable disease, etc.

In 1977, Milton Weinsten and William Stason proposed a formula that became known as cost-effectiveness to make choices between different medical interventions. They proposed that a health intervention was only cost-effective if it was to be under 3x the per capita health costs. This meant that in the US, for example, at the time, a health intervention would be cost-effective if it was less than several thousand dollars because the per capita health expenditure of the US healthcare system is high. However, in impoverished countries, a health intervention would need to fall within $5-15 to be deemed cost-effective. This does not fall anywhere close to the ideals of equity. Using cost-effectiveness as a sole model to reduce global burden of disease severely limits the right to health as it does not consider the many aspects of disease.

Discussion Questions:

What are some conditions/public health concerns that may not be prevalent at the time but can be planned for?
For example, no matter what stage of population health a country may be in, infrastructure for flooding may be put in place. What are some major limitations you can see with the proposed cost-effectiveness model?
What are some ways that countries are or could be dealing with increasing chronic disease in settings still with large burdens of transmissible disease?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these two topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings. Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Andrew L. Mariotti, MS3

University of Colorado School of Medicine

Kelsey Yenney, MS3

Washington State University
Elson S. Floyd College of Medicine

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Jeff Downen, PGY2

Blog Editor
University of Florida - Jacksonville

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Resources

Drame, M.L., P. Ferrinho, and M.R.O. Martins, Impact of the recent Ebola epidemic with pandemic potential on the economies of Guinea, Liberia and Sierra Leone and other West African countries. Pan Afr Med J, 2021. 40: p. 228.
de Courville, C., et al., The economic burden of influenza among adults aged 18 to 64: A systematic literature review. Influenza Other Respir Viruses, 2022. 16(3): p. 376-385.
Joia Mukherjee. An Introduction to Global Health Delivery : Practice, Equity, Human Rights. Oxford University Press; 2018. Chapter 4: Global Health and the Global Burden of Disease

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 10/17/22: Global Burden of Disease," in International Emergency Medicine Education Project, April 3, 2023, https://iem-student.org/2023/04/03/journal-club-10-17-22-global-burden-of-disease/, date accessed: September 27, 2023

Journal Club 9/19/22: Medical Tourism

March 27, 2023March 23, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Telemedicine in Low-Resource Settings by Rachel Patel

Telemedicine is defined as the delivery of health care and the exchange of health-care information across distances.

The types of telemedicine are as follows:

Live, two-way (or real-time) synchronous audio and video allows specialists, local physicians, and patients to see and hear each other in real-time to discuss conditions
Store-and-forward sends medical imaging such as X-rays, photos or ultrasound recordings to remote specialists for analysis and future consultation
Remote patient monitoring collects personal health and medical data from a patient in one location and electronically transmits the data to a physician in a different location

The advantages of telemedicine in low-resource settings include:

Increasing health access across geographical barriers
Cost-effectively providing services, from radiology to dermatology to at least some of the millions of patients who lack adequate healthcare
Contact precautions (e.g. COVID-19 pandemic)
Surveillance and monitoring of medical emergencies, generating health data to inform international aid programs and policies
Interconnected network of data sharing as well as funding for international crises

Limitations include:

Patients who have emergent health conditions, or need a physical exam or laboratory testing for medical decision making
If sensitive topics need to be addressed, especially if there is patient discomfort or concern for privacy
Limited access to technological devices (e.g., phones, tablets, computers) or connectivity

Discussion Questions:

What are some of the ethical implications of telemedicine?
How do you see telemedicine factoring into medical care as we move forward in a post-COVID world?
Is there a place for telemedicine in emergency medicine?

The Roots of Global Health Inequity by Grace Bunemann

** A short blog post & presentation are far too brief of formats to discuss this extensive topic adequately. The following is an overview of Chapter 1 from Dr. Joia S. Mukherjee’s book entitled An Introduction to Global Health Delivery. **

To simply explain LMIC (lower middle-income country) Health Systems today, it is important to review the history of slavery and colonialism which led to years of resource extraction ultimately resulting in weak health systems seen in LMIC countries today.

Prior to World War II, the conduct of a government against its own people was considered a matter of national sovereignty, however global opinion changed following the liberation of the Nazi concentration camps. After WWII, it was believed that all people, regardless of their country of origin, have an inalienable set of human rights. These principles were upheld in the Universal Declaration of Human Rights in 1948.

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

The same European countries that were championing human rights had little issue with the continuation of colonialism and denying those who were colonized their human rights. Importantly, only four independent African countries were able to vote for the Declaration (South Africa, Egypt, Ethiopia, and Liberia).

In 1978, the International Conference on Primary Health Care was held in Alma Ata (currently Almary, Kazakhstan). The conference hosted 600 representatives from the 150 WHO member states and aimed to discuss models for care delivery and develop solutions for people living without access to health care.

In parallel to the Cold War, socialist republics advocated for government funds to deliver on the promise of health as a human right by building public health systems with doctors, nurses, and hospitals while capitalist states argued that health systems could not be built until economic growth occurred and reasoned that volunteers could be used to deliver basic health services in impoverished countries.

It is important to note a majority of delegates advocated for the public provision of health as a human right and the Alma Ata Declaration is the result. It advocated for health as a human right and included the need to address the social factors related to ill health, such as lack of food, water, and sanitation. The declaration set modest yet concrete goals like 90 percent of children should have weight for an age that corresponds to reference values, every family should be within a 15-minute walk of potable water, and women should have access to medically trained attendants for childbirth.

The concept that health demanded more resources than those available within an impoverished country’s budget and that health should be financed through international collaboration were radical notions. Several factors impacted the Alma Ata Declaration including physician opposition, Cold War geopolitics, and neoliberal reforms.

In 1979, a proposed alternative to the Alma Ata Declaration was published in the New England Journal of Medicine entitled ‘Selective Primary Health Care — An Interim Strategy for Disease Control in Developing Countries.’ It praised the goals of Alma Ata as laudable, but ascertained the objective was unrealistic given the impoverishment of those countries with the highest disease burden. This publication countered that it is more realistic to target scarce resources to prevent and control the spread of diseases that account for the highest mortality and morbidity. Selective Primary Health Care became the new standard for global health efforts for years to come.

“It is impossible to understand global health delivery without understanding the destructive history of slavery, colonialism, and neoliberalism that left governments impoverished and unable to fulfill the right to health.”

Wrap up!

Thank you to our authors and presenters!

Rachel Patel, MS4

Rutgers Robert Wood Johnson Medical School

Grace Bunemann, MS4

Campbell University School of Osteopathic Medicine

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
GEMS LP Co-Director & Blog Editor

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Resources

Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. New England Journal of Medicine 2020; 328; 1679–1681
Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. Journal of Pain and Symptom Management 2020; https://doi.org/10.1016/j.jpainsymman.2020.03.019external icon
Ohannessian R, Duong Ta, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill 2020;6(2):e18810 doi: 10.2196/18810.
Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, Clemensen J, Caffery LJ. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). Journal of Telemedicine and Telecare 2020; DOI: 10.1177/1357633X20916567
Tuckson, R., Edmunds, M., Hodgkins, M. Telehealth. New England Journal of Medicine 2017; 377:1585–1592. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMsr1503323
Tolone S, et al. Telephonic triage before surgical ward admission and telemedicine during COVID-19 outbreak in Italy. Effective and easy procedures to reduce in-hospital positivity. International Journal of Surgery 2020; 78 : 123–125.
Perez Sust P, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill 2020;6(2):e19106) doi: 10.2196/19106
Project ECHO: Provides resources to connect frontline healthcare professionals with experts for distance learning and consultation
Joia Mukherjee. An Introduction to Global Health Delivery : Practice, Equity, Human Rights. Oxford University Press; 2018. Chapter 1: The Roots of Global Health Inequity.
Boston 677 HA, Ma 02115 +1495‑1000. ALMA-ATA at 40: A Milestone in the Evolution of the Right to Health and an Enduring Legacy for Human Rights in Global Health. Health and Human Rights Journal. Published September 6, 2018. https://www.hhrjournal.org/2018/09/alma-ata-at-40-a-milestone-in-the-evolution-of-the-right-to-health-and-an-enduring-legacy-for-human-rights-in-global-health/
Alma-Ata 40 years on | Health Poverty Action. http://www.healthpovertyaction.org. Accessed February 22, 2023. https://www.healthpovertyaction.org/news-events/alma-ata-40-years-on/

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 9/19/22: Medical Tourism," in International Emergency Medicine Education Project, March 27, 2023, https://iem-student.org/2023/03/27/journal-club-9-19-22-medical-tourism/, date accessed: September 27, 2023

Thinking Like an Emergency Physician (2023)

March 20, 2023May 3, 2023 ~ iEM Education Project Team ~ Leave a comment

by Joe Lex

Emergency Medicine is the most interesting 15 minutes of every other specialty.

Dan Sandberg, BEEM Conference, 2014

Everyone in medicine knows that Emergency Medicine is different, even if they can’t put the reason into words. We know why. We work in an environment that is different, in hours that are different, and with patients who are different more than any other medical specialty. Our motto is “Anyone, anything, anytime.” No other specialty of medicine makes that claim.

While other doctors dwell on “What does this patient have? – that is, “What’s the diagnosis?” – emergency physicians are instead thinking “What does this patient need right now? In 5 minutes? In two hours?”

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues. Yet we do it on a daily basis, many times during a shift. The idea of juggling decisions for several sick people simultaneously is beyond the capabilities of almost everyone else in medicine. They are used to working with one patient at a time in a linear fashion.

I retired a few years ago after more than 45 years in Emergency Medicine, dating back to my time as an Army medic in Vietnam. Every time I introduced myself to a patient, I never knew in advance which direction things were going to head. I never knew whether I could help the patient in 30 seconds or 30 minutes, if at all. I felt like I should have given this disclaimer.

Hello stranger, I am Doctor Joe Lex. I will spend as much time with you as it takes to determine whether you are trying to die on me, and whether I should admit you to the hospital so you can try to die on one of my colleagues.

You and I have never met before today. You must trust me with your life and secrets, and I must trust that the answers you give me are honest.

After today, we may never see one another again. It may turn out to be one of the worst days of your life. For me, it is another workday. I may forget you minutes after you leave the department, but you will probably remember me for many days or months, possibly even for the rest of your life. I will ask you many, many questions. I will do the best I can to ask the right questions in the right order so that I come to a correct decision. I want you to tell me your story, and for me to understand that story, I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part. In an average 8-hour shift I will make about 10,000 conscious and subconscious decisions – who should I see next, what question should I ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, and is that really an infiltrate, which consultant will give me the least pushback about caring for you, is your nurse one whom I can trust with the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home? And so on… So even if I screw up just 0.1% of these decisions, I will make about ten mistakes today.

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio. Gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG, shingles, a dental abscess, an eye foreign body … I can recognize and treat those things without even thinking. If, on the other hand, your problem has a lot of background noise and vague signs and symptoms, I am more likely to be led down the wrong path and come to the wrong conclusion.

I am glad to report that the human body is very resilient. We as humans have evolved over millennia to survive, so even if I screw up, the odds are very, very good that you will be fine. Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.” For the most part, this has not changed. And Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves. Most things, in fact, are better by morning.” On the other hand, the path to dying is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.

Remember, you don’t come to me with a diagnosis: you come to me with symptoms. You may have any one of more than 10,000 diseases or conditions that we know about, and – truth be told – the odds of me getting the absolute correct diagnosis are small. You may have an uncommon presentation of a common disease or a common presentation of an uncommon disease. If you are early in your disease process, I may even miss such life-threatening conditions as heart attack or sepsis. If you neglect to truthfully tell me your sexual history or your use of drugs and alcohol, I may not follow through with appropriate questions and might come to a totally incorrect conclusion about what you need or what you have.

You may be disappointed when you feel that you are not being seen by a “specialist.” Many people believe that when they have their heart attack, they should be cared for by a cardiologist. They think that the symptom of “chest pain” is their ticket to the heart specialist. But what if the heart attack is not chest pain, but nausea and breathlessness? And what if the chest pain is aortic dissection? Or a pneumothorax? Or a ruptured esophagus? So, you are being treated by a specialist – one who can discern the life-threatening from the trivial, and the medical from the surgical. We are the specialty trained to think like this.

We started our training in a state of unconscious incompetence – we were so poor at what we did that we did not even know how bad we were. We were lucky if we could care for four patients in an 8-hour shift. But we quickly learned and reached a level of conscious incompetence and multi-tasking – we knew that we were inadequate, but we felt ourselves getting better at our job on a day-to-day basis. By the time we finished our training we had reached the next level: conscious competence. We could deal with almost anything, but we still had to think hard about much of our decision making. After a few more years of practice, we reached our pinnacle of unconscious competence

If you insist on asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know what you have, but I do know it is safe for you to go home.” Sometimes I can do this without doing a single test. I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved. Worse yet, other doctors will anchor on my false diagnosis, and you may never get the right answers.

Here’s some good news: we are probably both thinking of the worst-case scenario. You get a sudden headache and wonder “Do I have a brain tumor?” You get some belly pain and worry “Is this cancer?” The good news is that I am thinking exactly the same thing. And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about. I understand that no matter how trivial your complaint, you have a fear that something bad is happening.

While we are talking, I may be interrupted once or twice. See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, clarifying orders for nurses and technicians. Or I may get suddenly called away to care for someone far sicker than you. I will try very hard to not let these interruptions derail me from doing what is best for you today.

I will use my knowledge and experience to reach the right decisions for you. I know that I am biased, but knowledge of bias is not enough to change it. I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this condition at least half the time it occurs.

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by pattern recognition or use analytical reason. Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking). Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking). It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you. This is to document what I have found and how I have worked up your complaint, so the hospital and I can get paid. The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier. But that chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process. In my eight-hour shift today I will click about 4000 times.

What’s that? You say you don’t have insurance? Well, that’s okay too. The U.S. government and many other governments in the world have mandated that I have to see you anyway without asking you how you will pay. No, they haven’t guaranteed me any money for doing this – in fact, I can be fined a hefty amount if I don’t do it. A 2003 article estimated I give away more than $138,000 per year worth of free care because of this law.

But if you are having an emergency, you have come to the right place. If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracotomy, I’ll do it. If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too. I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter. I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure or your nosebleed, and I can talk you through your bad trip.

Emergency medicine really annoys a lot of the other specialists. I think that it is primarily because we are there 24 hours a day, 7 days a week. And we really expect our consultants to be there when we need them. Yes, we are fully prepared to annoy a consultant if that is what you need.

I saw thousands of patients, each unique, in my near-50 years of experience. But every time I thought about writing a book telling of my wondrous career, I quickly stopped short and told myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others. What you see as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes. Take fifty of our current proverbial sayings– they are so trite, so threadbare. None the less they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong. Has any man ever attained to inner harmony by pondering the experience of others? Not since the world began! He must pass through fire.”

Have you ever heard of John Coltrane? He was an astonishing musician who became one of the premiere creators of the 20th century. He started as an imitator of older musicians but quickly changed into his own man. He listened to and borrowed from Miles Davis and Thelonious Monk, Coleman Hawkins and Lester Young, African music and Indian music, Christianity and Hinduism and Buddhism. And from these seemingly unrelated parts he created something unique, something no one had ever heard before. Coltrane not only changed music, but he changed people’s expectations of what music could be. In the same way, emergency medicine has taken ideas from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and orthopedics, and we have created something unique. And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?

Author

Joe LEX

Joe Lex was involved in Emergency Medicine for more than 49 years – as a Vietnam combat medic, ER Tech, Certified Emergency Nurse, and Emergency Physician. For five years he was Education Chair for the American Academy of Emergency Medicine, which renamed their Educator of the Year Award the “Joe Lex Award.” After 14 years in the community, he joined the Emergency Medicine faculty at Temple University in Philadelphia. He is a “godfather” of free electronic open-access medical education and his website (www.FreeEmergencyTalks.net) taught thousands of people worldwide.

Since he retired in 2016 as a Professor of Emergency Medicine, he does a weekly radio show called “Dr. Joe’s Groove,” featuring 60-year-old news and jazz. He writes an occasional blog called “Notes from Nam” based on 170 letters he wrote home in 1968 and 1969. He is also an amateur cemetery historian and volunteer tour guide for Laurel Hill Cemetery in Philadelphia and West Laurel Hill Cemetery in Bala Cynwyd, in addition to researching and producing their monthly podcasts “All Bones Considered: Laurel Hill Stories” and “Biographical Bytes from Bala: West Laurel Hill Stories.”

Joe and his wife Andrea celebrate 50 years together in June. His publicity picture is quite old – add 15 years and 40 pounds.

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Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Thinking Like an Emergency Physician (2023)," in International Emergency Medicine Education Project, March 20, 2023, https://iem-student.org/2023/03/20/thinking-like-an-emergency-physician-2023/, date accessed: September 27, 2023

2018 version of this topic – https://iem-student.org/thinking-like-an-emergency-physician/

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Emergency Medicine Clerkship, 100 MCQs (2023) – A free book is ready

March 15, 2023March 15, 2023 ~ iEM Education Project Team ~ Leave a comment

We are pleased to introduce our very first multiple choice question (MCQ) book at the International Emergency Medicine Education Project. Our goal is to provide medical students with useful resources to aid in their clinical decision-making, critical thinking, and clinical reasoning skills related to emergency medicine.

The book features MCQs and explanations for common medical problems encountered in emergency medicine. Our hope is that this book will be an informative and valuable learning tool for our students.

We are grateful for the opportunity to offer this resource and look forward to receiving feedback from our students and educators as we continue to improve and develop our educational offerings in emergency medicine.

Author

Joseph Ciano, Do, MPH, MS

Editor

Arif Alper Cevik, MD, FEMAT, FIFEM

Project Proposal 12/20: Developing a Community Education Program to Combat Envenomation in India

March 9, 2023February 24, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Problem Statement

The WHO classified snakebite envenomations as an NTD in 2017 for causing enormous suffering, disability, and premature death worldwide. Bites by venomous snakes can cause paralysis, fatal hemorrhages, irreversible kidney failure, tissue damage and more, leading to permanent disability and limb amputation. Over half the world’s envenomation events and deaths occur in India; this epidemic has been termed “the neglected famer’s tragedy” due to a disproportionate increase in agricultural areas, and a “therapeutic black hole” due to ineffective or unavailable interventions within the region. With 5.8 billion people at risk of encounters, and 2.7 million reported cases of envenomings, it is estimated that there are between 81,000 to 138,000 deaths and countless more debilitating injuries each year in the country.

The WHO developed the Snakebite Envenoming Strategic Plan which calls for a 50% reduction in mortality and disability caused by snakebite envenoming by 2030 through 4 goals:

Empower and engage communities.
Ensure safe, effective treatment.
Strengthen systems.
Increase partnerships, coordination, and resources through strong collaboration.

Project Proposal

Our project focuses on the first WHO goal; Empower and engage communities. However, it includes aspects of all the 2030 goals by creating an education system that will help prevent envenomations and arm the community with a safe plan to approach such events to reduce morbidity and mortality. The project will focus on educating and engaging community leaders, to promote sustainability and community engagement. These community leaders will be trained to teach and discuss topics including characteristics of venomous and non-venomous snakes, dispelling, and discussing common misconceptions surrounding proper envenomation management, first-aid, initial management, and stabilization. Community leaders and community members will also be connected with national partners like the National Snake Bite initiative (NSI) as well as international partners like WHO through The Platform, an interactive Application that allows the public to participate in reporting events and venomous snake sightings, slowly creating a regionalized database.

Qualitative surveys before and after educational campaigns on community knowledge, perceptions, sociocultural and spiritual understanding and depiction of snakes and snakebite envenoming can help to measure how receptive communities have been to the program. Since envenomation events are underreported, it is difficult to assess any qualitative differences (hospital admission events), however, since we plan to implement this program on a community-by-community basis it may be possible to investigate numbers through local health ministries, clinics, and hospitals to assess different trends before and after program implementation.

Based on the WHO Snakebite Working group budget we estimate this project would not cost more than $15,000 USD, with much of the funds allocated to program creation, program coordinators and educators, community leaders, and program creation. The WHO allocated over $140 million USD over 10 years worldwide to this problem and $650,000 USD to community education in 10 countries. Using this logic, we estimated that more than $65,000 would be allocated to a country like India. If this project were to pilot its educational campaign in a specific region, we estimate no needing more than $15,000 USD.

By partnering with national partners on the ground like the NSI and community leaders who will continue to train and educate, this program will become sustainable through working with those that are inherently invested in more positive outcomes through education in their own communities. Additionally, the WHO’s Platform application will be promoted during educational programming to further engage and empower the community to take an active role in their own education and safety by sharing photos of potentially venomous snake sightings along with their location data. By promoting effective interventions involving education surrounding proper venomous snake identification, snake education, medical interventions, and effective reporting this program will reduce snake bite deaths and long-term disability and empower at risk communities in India to take their safety into their own hands.

Discussion

After presenting the proposal to the group, we engaged in discussion on this proposal. One of the questions that sparked deep and insightful conversation was “Why is the focus of this project education, and not ensuring that are adequate and strategically placed life saving anti-venom available?”

Below is a summary of the most pertinent ideas posed:

1. Many companies producing have stopped/gone out of business and even if there was plentiful supply it would still not help with preventing or addressing the problem when most cases of snakebite envenomation that occur are not reported.

2. With an educational campaign the people are able to take power into their own hands.

3. The cost benefit ratio of this method is extremely low. Many people reside far away from any form of health care and in India, the cost of initial treatment has been reported to be as high as USD$ 5,150, which makes investments in anti-venom unsustainable.

References

https://www.who.int/health-topics/snakebite#tab=tab_1
https://www.who.int/activities/preventing-and-controlling-snakebite-envenoming
https://www.who.int/publications/i/item/9789241515641
https://www.who.int/india/health-topics/snakebite
https://www.nature.com/articles/d41586-020-03327-9#ref-CR
Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008;5(11):e218. doi:10.1371/journal.pmed.0050218
Yanamandra U, Yanamandra S. Traditional first aid in a case of snake bite: more harm than good. BMJ Case Rep. 2014;2014:bcr2013202891. Published 2014 Feb 13. doi:10.1136/bcr-2013-202891
Chauhan V, Thakur S. The North-South divide in snake bite envenomation in India. J Emerg Trauma Shock. 2016;9(4):151-154. doi:10.4103/0974-2700.193350
International Journal of Mental Health Systems, vol. 9, no. 1, 12 Mar. 2015, 10.1186/s13033-015-0007-9. Accessed 13 June 2020.

About GEMS LP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Nikkole Turgeon, MS4

University of Vermont Larner College of Medicine

Racheal Kantor, MS4

Medical School of International Health, Ben-Gurion University

Nicholas Imperato, MS4

Philadelphia College of Osteopathic Medicine

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Project Proposal 12/20: Developing a Community Education Program to Combat Envenomation in India," in International Emergency Medicine Education Project, March 9, 2023, https://iem-student.org/2023/03/09/developing-a-community-education-program-to-combat-envenomation-in-india/, date accessed: September 27, 2023

Project Proposal 12/20: Establishing an Objective Risk Assessment for Road Traffic Accidents in Ghana

March 1, 2023March 8, 2023 ~ Global EM Student Leadership Program ~ Leave a comment

Background

Worldwide, road traffic accidents (RTAs) account for about 1.3 million fatalities and, on average, 3% of a given country’s GDP. Over half of these deaths occur among vulnerable road users, such as pedestrians, cyclists, and motor cyclists. Approximately 93% of all of the world’s RTA-associated mortalities occur in middle- to low-income countries, even though they have only 60% of the world’s vehicles. Road traffic injuries cause considerable economic losses to individuals, their families, and to countries as a whole that take a considerable toll even years or decades after the incident occurred. These losses arise from the cost of treatment as well as lost productivity for those killed or disabled by their injuries, and for family members who need to take time off work or school to care for the injured.

The country of Ghana experiences, on average, 2,000 RTA-associated deaths and 14,000 RTA associated injuries annually. At the Korle-Bu teaching hospital in Accra, Ghana, the largest health facility and teaching hospital in Ghana and the main referral site for all of southern Ghana, between 2016 and 2017, 62% of deaths in the hospital’s accident center were related to RTAs. These RTA-associated deaths and injuries cost the country around 1.6% of its GDP, which amounts to over $1.3 million per year.

In the early 2000s, the Ghanaian government began to recognize the serious socio-economic impact of RTAs on its country. To address the issue, the National Road Safety Commission (NRSC) was established to collect data on RTAs and propose solutions and policies in response. Various data was collected, such as the number of annual deaths and injuries and road user classes associated with these fatalities. Data collected demonstrated that, in Ghana, the road user class with the highest share of fatalities was consistently pedestrians (824; 39.5%) followed by motorcycle users (437; 21%) and bus occupants (364; 17.5%). Considering RTAs in the context of emergency care, studies showed that, again at the Korle-Bu Teaching Hospital, almost 40% of emergency care visits were from RTAs, followed distantly by falls and interpersonal violence. Of the victims that died upon or after arrival to the hospital, 50% were pedestrians, 31% were passengers, and 18.7% were motorists.

From the numbers provided, it’s readily apparent that deaths caused by injuries, and, specifically, RTA-associated injuries, rank among the top ten causes of death in Ghana. It was concluded that underlying drivers of this issue were broadly two-fold: there was a high proportion of RTA-associated injuries due to poor road conditions and unregulated driving practices, and emergency care providers were lacking in proper, formal trauma-based care, both prehospital and when they arrived to an emergency care facility.

To address these shortcomings, various sizable mitigation measures were adopted by Ghana’s government in an attempt to decrease the number of RTAs and their associated costs. In 2004, Ghana established a National Ambulance Service (NAS), providing over 200 ambulances staffed with formally trained, BLS-certified EMTs for pre-hospital care. Ghana’s first EM residency program was established in 2009, followed one year later by its first 2-year Emergency Nursing degree program. More recently, in 2019, the NRSC passed the National Road Safety Authority Acts that were designed to promote and mandate best road safety practices, both in road users and road developers. However, despite these resolutions, RTAs and their associated injuries and deaths continue to remain consistently high in the country.

A literature review of available research on Ghanian RTAs revealed several limitations in the studies. While the NRSC has been instrumental in collecting RTA data and devising protocols to mitigate RTAs, there is still a lack of detailed, objective research on RTAs in Ghana. Additionally, there are significant inconsistencies in the source of the data and whether it is a registry-based report or a population-based study. The causes of accidents are not well-documented, and there is limited data available detailing where the majority of RTAs occur aside from the regions most heavily affected. According to data from 2016, over 75% of RTAs occur in 5 regions (Ashanti, Greater Accra, Eastern, Central and Brong Ahafo), of which four of the five regions correspond to the four most populous regions (with the exception of Ahafo, which is the least populated). Interestingly enough, however, about 60% of RTA fatalities were in non-urban sections of the road networks. Despite this information, we were unable to find details regarding where the specific accidents occur within each region.

Research collected by the University of Ghana’s School of Public Health identified the following risk factors that were highly associated with RTAs: stop-light violations, improper signaling, speeding. However, we believe that the study used to determine these risk factors relied too heavily on subjective analysis, leading to potentially erroneous and biased data. Therefore, we propose utilizing traffic cameras for gathering objective data in areas with a high burden of RTAs. This analysis will allow local authorities to identify risk factors that lead to RTAs, resulting in the utilization of emergency medicine services.

In short, an objective method of identifying common risks, causes, and associations of RTAs is crucial in order to decrease morbidity and mortality as well as the need for emergency care. This is especially important, as Ghana spends over $130 million USD each year on RTA-related injuries alone.

Project Proposal

We believe one way to do this is to utilize traffic cameras that are already in place in these high traffic areas to analyze accidents. As the infrastructure is already in place for surveillance – all we need to do is collect and analyze the footage, which has limited costs associated with it. We would need to pay salary to 1-2 data analysts in order to analyze the information. If more cameras were needed, this would cost anywhere from $65-80,000 USD per camera installation. After installation and retrieval of the camera data, what information will we collect? First, we would like to identify what specific intersections and roadways are involved in RTAs. We also would collect temporal statistics such as day of the week, month and time of day as well as weather conditions. The type and number of vehicles involved in the accident as well as identifying whether the drivers are local versus nonlocal are also important characteristics. Lastly, we would look at whether drivers violated traffic laws such as running a redlight or were speeding as well as being in the incorrect driving lane.

The data collected from this proposal can be used to promote infrastructure changes to lessen the risk of future RTAs. In particular, the installation of crosswalks have been proven to mitigate incidences of motor accidents. According to a 2017 study, 68% of pedestrian fatalities from RTAs in Ghana are related to “pedestrian crossing behaviors.” However, the study was limited in its ability to deduce further information from these incidents, such as the causality of the accident. The review of the stop light camera footage from the event would allow the local government to determine if more facilities such as crosswalks may be beneficial to install in populated intersections.

Conclusion

The high prevalence of RTAs in Ghana is a public health concern that dramatically burdens the emergency medical community. We believe that the data collected from traffic cameras can be used to more concretely understand the risk factors that lead to motor accidents in Ghana. Ultimately, this information can be used to improve infrastructure features to mitigate risk of future accidents.

References

https://www.cdc.gov/injury/features/global-road-safety/index.html
Blankson PK, Lartey M. Road traffic accidents in Ghana: contributing factors and economic consequences. Ghana Med J. 2020 Sep;54(3):131. doi: 10.4314/gmj.v54i3.1. PMID: 33883755; PMCID: PMC8042801.
Blankson PK, Nonvignon J, Aryeetey G, Aikins M. Injuries and their related household costs in a tertiary hospital in Ghana. Afr J Emerg Med. 2020;10(Suppl 1):S44-S49. doi: 10.1016/j.afjem.2020.04.004. Epub 2020 May 26. PMID: 33318901; PMCID: PMC7723915.
Zakariah A, Stewart BT, Boateng E, Achena C, Tansley G, Mock C. The Birth and Growth of the National Ambulance Service in Ghana. Prehosp Disaster Med. 2017 Feb;32(1):83-93. doi: 10.1017/S1049023X16001151. Epub 2016 Dec 12. PMID: 27938469; PMCID: PMC5558015.
https://ugspace.ug.edu.gh/bitstream/handle/123456789/36413/Injury%20Patterns%20and%20Emergency%20Care%20in%20Road%20Traffic%20Accidents%20in%20Accra.pdf?sequence=1&isAllowed=y

About GEMSLP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Holly Farkosh, MS4

Marshall University Joan C. Edwards School of Medicine

Andrew McAward, MS2

Marshall University Joan C. Edwards School of Medicine

Tram Lee, MS3

University of Oklahoma Health Sciences Center

Blog Editorial Team

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
GEMS LP Co-Director & Blog Editor

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Project Proposal 12/20: Establishing an Objective Risk Assessment for Road Traffic Accidents in Ghana," in International Emergency Medicine Education Project, March 1, 2023, https://iem-student.org/2023/03/01/project-proposal-12-20-establishing-an-objective-risk-assessment-for-road-traffic-accidents-in-ghana/, date accessed: September 27, 2023

Why is emergency medicine training important in medical schools?

February 24, 2023February 22, 2023 ~ iEM Education Project Team ~ Leave a comment

The ability to promptly and accurately diagnose and treat patients in critical condition is a crucial skill that students learn in emergency medicine programs. This exposure is especially important for doctors who practice in fast-paced environments like emergency rooms, urgent care clinics, and hospitals immediately after their graduation in some countries.

The ability to promptly recognize and stabilize critically sick patients is a key skill that is taught to prospective doctors as part of emergency medical training. This entails not only the ability to see the warning indications of illnesses like heart attacks, strokes, and septic shock, but also to initiate life-saving treatments like cardiopulmonary resuscitation (CPR) and the administration of antibiotics.

Medical students can learn to function well under pressure by participating in emergency medicine rotations. It’s very common for emergency departments to be noisy and hectic due to the high volume of people who are there for immediate attention. So, in order to offer the best treatment for their patients in situations where time and resources are limited, and many distractors in the environment, all doctors need to be able to think fast and make choices on the fly.

Learning to work with other medical professionals is also a crucial part of emergency medicine education. Patients in emergency departments are usually cared for by a multidisciplinary group consisting of doctors, nurses, and other medical experts. Medical students learn how to interact and coordinate with these other clinicians as part of their emergency medicine training.

In addition, emergency medicine education is crucial because it prepares future doctors to treat patients with a wide variety of acute and chronic disorders. Every doctor should be able to treat patients of different ages, ethnicities, and economic statuses, and they should do so in a way that is respectful of their cultural origins. Therefore, emergency departments create great opportunities with its unique learning environment for medical students.

Last but not least, emergency medicine education is critical since it helps students get a feel for the field. Physicians who have completed emergency medicine training are better equipped to deal with the high-stakes, high-stress scenarios they will experience in practice, as emergency medicine is one of the most rigorous and demanding specialties in medicine. All medical students, including those who want to specialize elsewhere, should acquire emergency medicine skills, familiarize themselves with how the emergency health care system operates, and be prepared to work in this field if necessary.

IFEM, or the International Federation for Emergency Medicine (ifem.cc), is an organization that supports the advancement of emergency medicine globally. One way that IFEM supports emergency medicine training in medical schools is by providing resources and guidelines for curriculum development. IFEM has created a set of guidelines for emergency medicine training, which can serve as a framework for medical schools to develop their own curricula. Additionally, IFEM offers training opportunities and conferences for medical educators to learn from each other and share best practices.

To improve emergency medicine training in their own countries, other nations can look to IFEM’s guidelines as a starting point for developing their own curricula. They can also seek out partnerships with IFEM and other organizations, to share knowledge and resources. Providing opportunities for medical students to gain hands-on experience in emergency medicine, such as through clinical rotations or simulation training, can definitely be effective in preparing them for the challenges they may face in the future clinical practice. Finally, investing in the development of emergency medicine residency programs can help to ensure that there is a pipeline of well-trained emergency physicians to serve the needs of the community.

In conclusion, emergency medicine training is a crucial part of a medical education because it prepares students for the realities of practice by teaching them how to quickly and accurately assess and treat critically ill patients, how to work effectively in high-stress environments, how to collaborate with other healthcare providers, how to care for patients from a wide variety of backgrounds and with a wide variety of medical conditions. Without this exposure, medical students would be less equipped to deal with complicated and challenging circumstances in clinical practice. Therefore, we highly recommend medical schools consider opening emergency medicine rotations or increasing the time of exposure to emergency medicine education.

Introduction

Understanding the Challenges

Discharge Essentials

Barriers to Successful Discharge

Types of Discharge Information Packets

Leave Against Medical Advice and Elopement

Conclusion

Authors

Dominique GELMANN

Bret NICKS

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References

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

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You have a new patient!

What do you need to know?

Importance

Epidemiology

Pathophysiology

Medical History

Key questions to ask on history-taking

Identifying “red flags”

Physical Examination

Key physical exam features

Identifying “red flags”

Alternative Diagnoses

Acing Diagnostic Testing

Bedside Tests

Laboratory Tests

Imaging Tests

Ultrasound findings in shock

Risk Stratification

Management

Initial management in unstable patients

Medications

Common antibiotics used in shock

Common vasopressors used in shock

Common additional adjunctive medications used in shock

Procedures

Patient reassessment

Special Patient Groups

Pediatrics

Geriatrics

Pregnant patients

Other patient groups

When to admit shock patients

Revisiting your patient

Author

Joseph CIANO

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References

Acknowledgement

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

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Introduction

Essentials of Communication

1. Be Genuine

2. Be Present

3. Ask Questions

4. Build Trust

5. Communicate Directly

Empathy

The Approach

Do's

Don'ts

The Difficult Patient

Angry Patient

Manipulative Patient

Frequent Fliers / High Utilizers

Combative, Agitated, or Intoxicated Patient

The Culturally-Discordant Encounter

The Handoff

I - Introduction

C - Critical Content & Interventions Performed