How To Write A Manuscript

how to write a manuscript

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 14th episode is “How to write a manuscript”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "How To Write A Manuscript," in International Emergency Medicine Education Project, January 17, 2022, https://iem-student.org/2022/01/17/how-to-write-a-manuscript/, date accessed: January 17, 2022

Question Of The Day #72

question of the day

Which of the following is the most likely cause of this patient’s condition?

This patient presents to the Emergency Department with severe agitation and altered mental status.  His exam demonstrates hypertension, tachycardia, elevated temperature, restlessness, dilated pupils, and wet diaphoretic skin.  Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions.  This patient’s history and exam support the presence of a toxidrome.  See the chart below for a review of the most common toxidromes (toxic syndromes). 

*Treatment of all toxic ingestions should include general supportive care and management of the airway, breathing, and circulation of the patient. Examples include administration of supplemental oxygen in hypoxia, IV fluids in hypotension, cooling measures in hyperthermia, etc.
**Flumazenil is the antidote for benzodiazepine overdose, but it is rarely used clinically as it can trigger benzodiazepine-refractory seizures.

 

This patient has a sympathomimetic toxidrome (Choice C), which can be caused from cocaine, MDMA (ecstasy), methamphetamine, and other drugs.  The anticholinergic toxidrome (Choice A) has many overlapping features with the sympathomimetic toxidrome, such as elevated blood pressure and heart rate, elevated temperature, agitation, and dilated pupils.  One feature that can be used to differentiate these toxidromes is the skin exam.  Sympathomimetic agents commonly cause wet diaphoretic skin, while anticholinergic agents cause dry skin.  The cholinergic toxidrome (Choice B) presents with increased secretions (wet skin, diarrhea, vomiting, hypersalivation, bronchorrhea, etc.). One cause of this toxidrome is exposure to organophosphates.  This patient is diaphoretic, but otherwise does not possess the other features of the cholinergic toxidrome.  The opioid toxidrome (Choice D) would present with somnolence, as opposed to the CNS excitation seen in this patient.  Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #72," in International Emergency Medicine Education Project, January 14, 2022, https://iem-student.org/2022/01/14/question-of-the-day-72/, date accessed: January 17, 2022

Critical Appraisal Of An Article

critical appraisal of an article

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 13th episode is “Critical appraisal of an article”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "Critical Appraisal Of An Article," in International Emergency Medicine Education Project, January 10, 2022, https://iem-student.org/2022/01/10/critical-appraisal-of-an-article/, date accessed: January 17, 2022

Question Of The Day #71

question of the day
Which of the following is the most appropriate next step in management for this patient’s condition?  

This patient arrives to the Emergency Department with lethargy, decreased respiratory rate, hypoxemia, pinpoint pupils, and a normal glucose level.  The initial evaluation and treatment of this patient should be focused on management of the patient’s airway, breathing, and circulation (ABCs, also known as the ‘primary survey’).  The airway should be repositioned to minimize obstructions to breathing, such as the tongue.  Vomitus in the airway can also be removed manually or via suction to prevent obstruction of the airway or aspiration.  Next, supplemental oxygen should be provided to treat the patient’s hypoxemia. 

Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions.  This patient’s history and exam support the presence of an opioid toxidrome.  See the chart below for a review of the most common toxidromes (toxic syndromes). 

toxidromes
*Treatment of all toxic ingestions should include general supportive care and management of the airway, breathing, and circulation of the patient. Examples include administration of supplemental oxygen in hypoxia, IV fluids in hypotension, cooling measures in hyperthermia, etc.
**Flumazenil is the antidote for benzodiazepine overdose, but it is rarely used clinically as it can trigger benzodiazepine-refractory seizures.

In addition to supportive treatments, like airway repositioning and supplemental oxygen, the antidote to opioid overdose should be promptly administered.  Naloxone (Choice C) is the antidote to opioid overdose.  Naloxone can be administered intravenously, intramuscularly, and intranasally.   Naloxone should be started at a dose of 0.04mg and can be administered every 2-3 minutes at incrementally higher doses to a maximum total dose of 10mg.  The goal of Naloxone administration is to achieve independent ventilations.  Administering a larger initial dose of 0.4mg or 1mg can precipitate acute opioid withdrawal in a chronic opioid user. 

IV Lorazepam (Choice A) is a benzodiazepine and would make the patient more sedated.  Benzodiazepines are helpful in patients with an active seizure, severe agitation, or anxiety.  Anticholinergic overdose (atropine, scopolamine) or sympathomimetic overdose (cocaine, methamphetamines, MDMA) are also responsive to benzodiazepines.  IV Atropine (Choice C) is an anticholinergic agent.  Atropine would worsen this patient’s borderline hypotension and mild bradycardia.  IV Dextrose (Choice D) would be a reasonable medication to give if the glucose was unknown.  The question stem provides a normal glucose level. Correct Answer: B

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #71," in International Emergency Medicine Education Project, January 7, 2022, https://iem-student.org/2022/01/07/question-of-the-day-71/, date accessed: January 17, 2022

Dx: Burnout

burnout

Author: Brenda Varriano

Guest Author: Jason M White

What is Burnout?

Most of us have experienced some component of Burnout in one shape or another. I know that I myself experienced burnout while preparing for my STEP 1 shelf exam. While I was able to hit my goal, I experienced immense fatigue and mental fogginess for weeks following. Fortunately, I recovered.

For those who are curious if they have experienced Burnout, the AAMC defines and measures it by three indicators: 1) emotional exhaustion associated with work-related stress, 2) feeling of detachment toward patients and 3) a low sense of personal accomplishment. Though I was not in my clinical rotations yet, my feeling of detachment resonated into my personal life and relationships.

Introducing Dr. Jason M White

Dr. Jason M White is an Emergency Medicine physician with over 30 years of clinical experience.  He has almost a decade of experience at the C-suite level as a Chief Medical Officer (CMO). His administrative responsibilities have included Medical Student and Graduate Medical Education, Quality, Physician Relations, Trauma and Emergency Services. His expertise includes Wellness, Patient Safety, Coaching, Leadership Development, and Patient Experience. He is a board certified by the American Board of Emergency Medicine (ABEM) and the Commission of Medical Management. He is a Clinical Assistant Professor in the College of Medicine at Central Michigan University and has over 40 years of experience teaching medical students and residents. It is with great pleasure that I introduce Dr. White to the iEM community to discuss his experience with Burnout.

Figure 2: Dr. Jason White

Q: What is your experience with Burnout?

The relationship between the specially of Emergency Medicine and Burnout goes back for almost half of the century.  When I was in residency 40 years ago, Burnout was already a major topic of discussion.  In fact, we used to joke that our residency program was so advanced that we graduated already “burned out” after just three years of training. 

In addition, you must remember that early in the history of the specialty many practitioners of Emergency Medicine were itinerant Physicians or Physicians from other specialties since there were few accredited Emergency Medicine residency training programs until the late 1970s.

Therefore, much of the longevity and Burnout data at the time was skewed by the presence of Physicians who were transitioning either into or out of their medical careers. I remember seeing data at that time that said that the average emergency physician only practiced for 7 years.

Nonetheless it put the topic of Burnout on the radar screens of the specialty very early on and I believe for this reason became part of the foundation of the curriculum of our specialty and much discussion.

I don’t believe that I personally experienced Burnout during my clinical career.  However, I saw many of my colleagues floundering in the specialty and experiencing Burnout.  In many ways the emergency Physicians are the canaries in the coal mine.  If our work environment is toxic and unhealthy, we may be among the first to demonstrate symptoms.  Much of the emphasis around Burnout has been focused on the individual practitioner which is appropriate.  However, it is an incomplete picture if we don’t also consider the practice environment as a significant component of the problem of Burnout.

Q: What are tactics to avoid Burnout?

I believe that there are several excellent tactics which have had success in helping practitioners to avoid Burnout.  The basics are all about self-care.  We all need to eat healthy, exercise and get an adequate amount of sleep.  However, the specialty of Emergency Medicine, by its very nature, is in direct opposition to those fundamental aspects of self-care.  The hectic, unpredictable pace of the emergency department makes it difficult to eat right or even at all sometimes.  The varied nature of shiftwork and swinging shifts is the enemy of developing good sleep patterns and regular exercise practices.

These foundational factors make it even more important that we understand the factors that contribute to Burnout, the symptoms of Burnout and the ways of preventing, avoiding, and healing from Burnout.

Q: What makes a good Wellness program?

There are as many definitions of Wellness programs as there are Wellness programs. One of the challenges of starting Wellness programs is not everybody has the same definition.  I can’t tell you how many times I would try to discuss developing Wellness programs with hospital administrators, and they would already have their own biases and oversimplifications of what successful programs work.

The conversations would quickly devolve into talks about having New Year’s resolution inspired weight-loss competitions and offering $25.00 gasoline gift cards as incentives.  Or they would quickly default into discussions about yoga classes and barriers to participation and cost. 

Unfortunately, much of the literature around the topic of Wellness has been done in industrial and manufacturing environments where employers may be self-insured and are interested in saving money on their Health Insurance costs by supporting stop-smoking programs or weight-loss programs.

So, the first step is to understand that Health Care providers need a different approach than the manufacturing community. In addition, much of the literature about Burnout in the healthcare environment is anecdotal.  This is what we did, and this is how it worked.  The bias is to report the elements and components of what are perceived as successful programs while never reporting failures.

In addition, the endpoints of success are highly subjective, challenging to reproduce, and often lack sustainability. For these reasons, we need both better design and better execution of the studies about Wellness and it must be focused on the Health Care community.

I believe that a good Wellness Program for Healthcare Providers should include the following elements at a minimum:

  1. Acknowledge that we are all at risk for Burnout.
  2. Educate ourselves about the symptoms of Burnout in ourselves and our colleagues. [see Stages of Burnout]
  3. Preform self-assessments on a regular basis (probably quarterly) to identify at risk areas in our personal lives. [see Gazelle, Wheel of Life]
  4. Educate ourselves on successful strategies to address our at-risk areas and tailor them to our unique situations. [see Being Well in Emergency Medicine: ACEP’s Guide to Investing in Yourself]
  5. Develop a written plan for how we are going to address our at-risk areas.
  6. As leaders, educators, and administrators, we must make the “coal mine” as healthy as possible and create an environment of support and emotional safety. We can also provide resources and advisors to assist practitioners in their self-assessments and creation of their personal Wellness plans.

Q: This last question is for fun. I know the quote below is from your medical school interview. Does it still hold true?

Yes! Absolutely still true! However, I might modify it slightly and change it to: “Because I love medicine, I want to help people, and I want my life’s work to have meaning.

Thank you, Dr. White, for taking to time to share your experiences and research on EM Burnout and physician Wellness. I learnt a lot, and I believe, we are acknowledging what will be a shift in how medicine is practiced over the next few years.

References and Further Reading

Cite this article as: Brenda Varriano, Canada, "Dx: Burnout," in International Emergency Medicine Education Project, January 5, 2022, https://iem-student.org/2022/01/05/dx-burnout/, date accessed: January 17, 2022

How To Present Your Research

how to present your research

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 12th episode is “How to present your research”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "How To Present Your Research," in International Emergency Medicine Education Project, January 3, 2022, https://iem-student.org/2022/01/03/how-to-present-your-research/, date accessed: January 17, 2022

Question Of The Day #70

question of the day
712 - deep fore arm laceration
Which of the following is the most appropriate next step in management for this patient’s condition?  

This patient arrives to the hospital after a suicide attempt with multiple bleeding arm wounds, hypotension, tachycardia, and a depressed mental status. This patient is in hemorrhagic shock.

The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The airway and breathing status of this patient have been assessed with no acute issues as noted in the question stem.  On assessment of the patient’s circulation, he is tachycardic, hypotensive, and has an actively bleeding extremity wound.  The first step in managing a bleeding wound is to apply constant direct pressure to the site.  Direct pressure to the site for 15 minutes should control bleeding in most cases.  If the origin of the bleeding is difficult to identify for direct pressure application, or if direct pressure fails, the next step is to apply a tourniquet (Choice D).  If a tourniquet is not available, an easy alternative is to apply a blood pressure cuff proximal to the bleeding wound and inflate the cuff to 250mmHg or until the bleeding stops.  This will allow careful examination and repair of the bleeding wound.  Topical tranexamic acid (Choice A) and subcutaneous lidocaine with epinephrine injections (Choice B) can work as adjuncts to tourniquet application.  Suturing the area will also help tamponade the bleeding site and aid in clot formation after a tourniquet is applied.  Checking a serum toxicology screen (Choice C) may be helpful to evaluate for a concurrent overdose, but this is not as important as initial hemorrhage management.   

Other steps to hemorrhage control and treatment include establishing large bore IV access, administering IV fluids or blood products as needed, and reversing coagulopathy. Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #70," in International Emergency Medicine Education Project, December 31, 2021, https://iem-student.org/2021/12/31/question-of-the-day-70/, date accessed: January 17, 2022

How To Analyse Your Study Data

data analysis 1

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 11th episode is “How to analyse your study data”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "How To Analyse Your Study Data," in International Emergency Medicine Education Project, December 27, 2021, https://iem-student.org/2021/12/27/how-to-analyse-your-study-data/, date accessed: January 17, 2022

Question Of The Day #69

question of the day
Neck injury with fish
Which of the following is the most appropriate next step in management for this patient’s condition?  

The neck is a compact anatomical area with many vital structures, including blood vessels that provide oxygen to the brain, the aerodigestive tracts (trachea and esophagus), nerves, and the apices of the lungs.  A penetrating injury to the neck can be catastrophic and requires prompt examination and appropriate management.  The neck is divided into 3 anatomical zones, and each zone houses different anatomical structures.  Zone 1 is from the clavicle to the cricoid cartilage, Zone 2 is from the cricoid cartilage to the mandible, and Zone 3 is from the angle of the mandible to the base of the skull.  See the reference below for pictures and further descriptions of each zone.

The presence of any “hard signs” of aerodigestive or neurovascular injury should prompt emergent operative management.  These “hard signs” include airway compromise, expanding or pulsatile hematoma, active and brisk bleeding, hemorrhagic shock, neurological deficit, massive subcutaneous emphysema, and air bubbling through the wound.  If the patient is hemodynamically stable and does not have any of these dangerous “hard signs”, it is reasonable to pursue CT angiography of the neck (Choice A) to evaluate for any vascular, aerodigestive, or neurologic injuries.  The fish should not be removed (Choice B) in the Emergency department as this may result in uncontrolled bleeding.  A more controlled environment, like an operating theater, is a more appropriate setting to remove a penetrating foreign body.  The patient in this case has 2 hard signs (bubbling through wound and airway compromise), so he will need operative management (Choice C).  However, the patient’s airway compromise is a more emergent and time-sensitive issue that needs to be addressed first with endotracheal intubation (Choice D).  Intubation is the next best step in management.  Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #69," in International Emergency Medicine Education Project, December 24, 2021, https://iem-student.org/2021/12/24/question-of-the-day-69/, date accessed: January 17, 2022

Data Collection

data collection

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The tenth episode is “Data Collection”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "Data Collection," in International Emergency Medicine Education Project, December 22, 2021, https://iem-student.org/2021/12/22/data-collection/, date accessed: January 17, 2022

Can you identify the signs of human trafficking in the Emergency Room?

human trafficking

Definition and Importance

Human trafficking is a global problem enclosing the spheres of international law, human rights, organized crime, public health and medicine. It is best defined by the United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons as “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or a position of vulnerability or the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs.”

According to the Federal Bureau of Investigation (FBI), human trafficking is considered the third-largest criminal activity in the world. Despite issues regarding data collection, the US State Department was able to report that around 20,000 people per year are trafficked inside the United States. It is also estimated that up to 900,000 people per year are being transported across borders with the intention of slavery and exploitation.

Why should physicians care about it?

A 2014 study showed that 87.8% of human trafficking survivals had access to healthcare services during their trafficking situation and of this, 68.3% went to the emergency room. The data above highlights the importance of healthcare professionals, especially those at the emergency department, when it comes to the identification and help of trafficking victims. It also reinforces the role of the emergency doctors as front-line healthcare providers for those in vulnerable situations and/or who lack proper medical care.

What are the signs that can be marked as "red flags" to identify victims of human trafficking?

According to the guidelines provided by National Human Trafficking Resource Center (NHTRC) there are some indicators, and they are divided into General Indicators and Health Indicators or consequences of Human Trafficking. They can be physical and/or mental signs. It is important to say that not all the victims will have the same indicators and each sign isolated may not be a trafficking situation. However, if several “red flags” are detected, further assessment may be needed.

GENERAL INDICATORS

  • The patient may tell an inconsistent story or be reluctant to describe details and answer questions about the injury or illness.
  • The accompanying individual does not let the patient have privacy or even speak for themselves.
  • They are unable to provide his/her own address and/or are unaware of the current time and location.
  • The patients` document may not be in his/her possession, and rather held by the accompanying individual.
  • The patient may not have the appropriate clothing for the weather.
  •  The presence of tattoos or any branding form demonstrating possession or serial numbers and bar codes may be found in the patient’s body. 
PHYSICAL INDICATORS
  • Signs of abuse or inexplicable injuries such as bruises, burns, cuts, wounds, blunt force trauma, broken teeth, fractures or any other sign of torture such as restraint marks 
  • Neurological conditions such as unexplained memory loss or traumatic brain injury  
  • Dietary issues such as extreme weight loss or malnutrition
  • Signs of potentially forced substance abuse
  • Issues regarding the reproductive system such as Sexually Transmitted Diseases (STDs), genitourinary problems, forced abortions or several unwanted pregnancies. 
  • Effects of prolonged exposure to unhealthy environments such as extreme temperatures, industrial or agricultural chemicals 
  • Somatization symptoms 
  • Poor dental hygiene 
  • Untreated skin infections 
MENTAL HEALTH INDICATORS
  • Anxiety
  • Post Traumatic Stress Disorder
  • Depression with or without suicide thoughts
  • Nightmares and/or flashbacks
  • Hostile behavior 
  • The patient may present with a feeling of disorientation or an unrealistic perception of his/her surroundings.  
  • Stockholm syndrome
  • Paranoid or extreme fearful behavior 

It is important to keep in mind that the signs presented above are not exclusive to a trafficking situation and many other clinical conditions may cause the appearance of those groups of symptoms. That being said, if after spotting some “red flags” you are still unsure whether or not that patient is a potential victim, there are a few screening questions you can ask that might help to confirm your suspicions, such as: 

  • Are you in possession of your identification documents?
  • How is a normal day at your work? 
  • How is it like at the place where you work?
  • Describe the place where you sleep and eat.
  • Are you free to come and go whenever you please?
  • Do you get paid for your work?
  • Where is your family?
  • Is anyone threatening you?

What to do in case you come in contact with a victim?

Dealing with trafficking victims is a very sensitive matter which requires discretion and an approach centered on the victim. That means once it is confirmed that the situation is indeed about human trafficking, the doctor’s aim is to try to provide a safe environment and inform the person of his/her rights. In order to do that, you should try to meet the patient`s basic needs, always trying to build trust and rapport, avoiding any potential re-traumatization situation.

Some protocols will depend on the specific situation. It is also important to know that legal requirements regarding contacting the authorities will be different in each country. That said, it is your responsibility as an emergency doctor to be informed about the protocol regarding your geographic location.

In the US, there is a National Hotline (1-888-373-7888) that provides the victims with a safe and confidential space to talk and report the trafficking. This line is operational 24/7 and offers access in more than 200 languages.

In conclusion, doctors have a privileged position when it comes to recognizing and helping human trafficking victims. That is why it is very important to be attentive to spot possible “red flags” and be informed of the right protocols to follow in case you need to assist a victim.

References and Further Reading

Cite this article as: Brenda Feres, Brazil, "Can you identify the signs of human trafficking in the Emergency Room?," in International Emergency Medicine Education Project, December 20, 2021, https://iem-student.org/2021/12/20/human-trafficking-signs/, date accessed: January 17, 2022

Question Of The Day #68

question of the day
Which of the following is the most appropriate next step in management?

This elderly man presents to the Emergency Department after a mechanical fall down the stairs with left flank pain.  He is on anticoagulation.  His chest X-ray shows 3 lower rib fractures.  The diagnosis of rib fractures is clinical in conjunction with imaging.  A history of rib trauma with pleuritic chest pain, tenderness over the ribs, and skin ecchymoses over the chest all support a diagnosis of rib fracture.  Chest X-ray is often performed as an initial test, but it should be noted that about 50% of rib fractures are not able to be visualized on chest radiography alone.  Bedside ultrasonography and CT scanning are more sensitive in detecting rib fractures than plain radiography.  Treatment for rib fractures is mainly supportive and includes pain management and incentive spirometry (or regular deep inspiratory breaths) to prevent the development of atelectasis or pneumonia as complications.  Many patients with rib fractures can be discharged home with these supportive measures.

Another important part of rib fracture management is evaluation for the complications or sequalae of rib fractures.  This includes pulmonary contusion, pneumonia, atelectasis, flail chest, traumatic pneumothorax or tension pneumothorax, hemothorax, and abdominal viscus injuries.  Elderly patients with multiple rib fractures are more likely to have poor outcomes and should be admitted for close observation.  Admission to the hospital for pain management (Choice A) may be needed in this case, but it is not the best next step.  Placement of a chest tube (Choice C) is not needed in this case as there are no signs of a pneumothorax.  Incentive spirometry (Choice D) is important to prevent atelectasis or pneumonia, but it is not the best next step.  The presence of multiple lower rib fractures (ribs #9-12) as seen in this case should prompt evaluation for abdominal injuries, such as hepatic or splenic lacerations.  Potential abdominal injuries should be of greater concern since this patient is on anticoagulation for his atrial fibrillation.  The best next step is a CT scan of the chest, abdomen, and pelvis (Choice B).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #68," in International Emergency Medicine Education Project, December 17, 2021, https://iem-student.org/2021/12/17/question-of-the-day-68/, date accessed: January 17, 2022