COVID-19; Reflecting on a Globalized Response

COVID-19; Reflecting on a Globalized Response

As I write this is, it has been 200 days since the first reports in China came out regarding an unspecified viral illness in Wuhan, China. What is now the pandemic of COVID-19 has spread around the world, and in history books and our collective memory, the year 2020 will forever be closely associated with this virus. There have been nearly 14 million confirmed cases around the world and nearly 600,000 known deaths from COVID-19. Some countries have done incredibly well with containment measures, while others continue to see case counts grow every day.

It has been fascinating to see how the outbreak has had different impacts in communities around the world, including how local and global responses have efficiently controlled or been unable to contain this novel public health problem. Prevention and mitigation strategies continue to form the foundation of public health management of this outbreak. The capacity for any country or locality to provide the most invasive supportive care is widely variable, and even when it is available mechanical ventilation is certainly not a panacea as COVID-19 case-survival rates in those being mechanically ventilated have been low (from 14% to 25%).

At the core of the variable outcomes seems to be a mix of sociological issues: a mix of personal beliefs, geography, politics, socio-economics and health infrastructure which lead to vastly different outcomes around the globe.

The accumulation of more epidemiological data over the past 200 days has improved our collective understanding of the COVID-19 virus, as today we have improved models and a better understanding of the rates of asymptomatic carriers (estimated at 40%) and mortality rates (1.4%-15.4%). Yet still, uncertainties and local variability (even within countries) have made an accurate calculation of the COVID-19 basic reproductive number (R0; the number of people who are infected by a single disease carrier) difficult. In the early stage of the outbreak in Wuhan, R0 calculation ranged from 1.4-5.7, and some have suggested that instead of single R0 value, modellers should consider using ongoing contact tracing to gain a better range of transmissibility values.

We have seen how prevention strategies such as hand-washing, face-masking, and physical distancing can impact local and disseminated disease spread. While many communities have come together through a collective approach to lock-downs and universal masking measures, other localities have struggled to get adequate levels of citizen compliance. Others have struggled with obtaining testing supplies. Certain political systems allow for streamlined and unified directives while others have made it difficult to provide adequate centralized coordination.

As the COVID-19 pandemic has spread to almost every country in the world, outbreaks are smoldering in much of the global south. While the United States continues to see rising numbers of cases with numerous states confronting ongoing daily record high incident cases, other countries such as Brazil are seeing similar upward trends. At the global level, the curve of daily incident cases seemed to have “flattened” and held steady through much of April and into May with aggressive seemingly worldwide measures. However, since the last days of May, global incident cases have been again steadily increasing. This is likely due to a variety of reasons but is linked, at least in part, to efforts to reopen economies and return to pre-pandemic routines and lifestyles.

covid-19 daily cases
Source: Johns Hopkins University Coronavirus Resource Center https://coronavirus.jhu.edu/map.html, accessed July 17, 2020

As an American citizen and a physician with training in public health, it has been both interesting and frustrating to see the how some countries (including my own) have had deficiencies in dealing with testing and basic prevention (such as mandatory universal masking). While I don’t want to engage in political rhetoric or cast blame in any one place, I do think it is instructive to point out that in the United States (or anywhere else for that matter) the sociological factors of personal preferences and autonomy, geography, and local politics have had an overwhelming influence in determining the progress of the pandemic.

Quarantining has always been a unique problem that sits at the intersection of personal autonomy and communal wellbeing, and is implemented and respected by citizens in different ways around the world. It would seem, at least anecdotally, that cultures with an emphasis on personal independence and autonomous choice have had greater difficulty with containment or in obtaining high levels of compliance with masking and distancing measures, even when compared to other localities with similar socio-economic situations.

These sociological factors are key to responding to and managing any epidemic health concern. We have come to see that in our globalized world, our ability and desire to work together towards a common goal, even at the cost of personal sacrifice, will determine our ability to control both the COVID-19 pandemic and the next health crisis of the future.

Public health education and communication, it would seem, is at the crux to getting collective buy-in and global participation.

Unfortunately, as with so many things these days, such issues can be easily politicized and cause fractured and disparate approaches to response. In our globalized world, this coronavirus outbreak is unlikely to be the last public health crisis we must face as a worldwide community.

As thoughts turn towards what is to come, from vaccine development and distribution to numerous long-term economic impacts, we are not nearing the end of this outbreak yet.

The incidence curve is growing, and there is much work left to be done. My hope is that as we move into the second half of 2020, our global community can continue to find ways to improve communication and coordination in order to come together to approach and control this pandemic collectively. The fate of this outbreak, and likely the next, hangs in the balance.

Cite this article as: J. Austin Lee, USA, "COVID-19; Reflecting on a Globalized Response," in International Emergency Medicine Education Project, August 3, 2020, https://iem-student.org/2020/08/03/covid-19-reflecting-on-a-globalized-response/, date accessed: October 20, 2020

Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine

Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine

For a trainee in EM, it is useful to know about three types of cognitive practice that require caution.

While a knee jerk reaction may sometimes save time, a shotgun investigation may improve billing and a kitchen sink therapy may create the illusion of therapeutic rigor, arguably that’s all there is to it.

In reality, there is not much true value to any of these three missed approaches.

We will look at each one with a few examples and then briefly discuss below.

Knee Jerk

When I was rotating in the ED as an MS4, a visiting EM attending once told me that “adding a Type and Rh should become a knee jerk” for any patient with vaginal bleeding in early pregnancy. Whether or not taking the extra 30 seconds to scroll through the EMR for a previously documented Rh likely to be on file is a better strategy, this one is fairly simple.

Not all of our knee jerk reactions are equally simple or harmless.

I have seen adenosine being pushed before one could say “Mama” for anything from sinus tach to atrial flutter and A-fib with RVR: paramedics, physicians and even unsupervised nurses all being equally guilty. Why? Because a sustained heart rate above 180 is scary to some. And the reflex is to do something quickly because we don’t like to remain scared.

Nursing staff going straight for IV placement while forgetting not only the basic ABCs of resuscitation but even to disrobe the patient is another example. Starting any patient at 100% oxygen saturation who is short of breath on nasal cannula oxygen is yet another.

We like to do what we are trained to do well and/or what is easy. Our brains then compel us to prioritize doing it.

Once my ED team halted a verbal order for a whopping dose of colchicine blurted out to nursing by a careless consulting cardiology fellow – the patient had mentioned his ankle pain to the fellow in passing. The man was in acute renal failure and ended up with a septic ankle joint diagnosed later. Knee jerk is in part responsible for well-perpetuated ED mental formulas such as “gout = colchicine”, “fever = paracetamol”, “wheezing = albuterol” and “hypotension = 2 liter IV fluid bolus”.

The knee jerk is how we pick from our favorite antibiotics and how we generally prescribe, how we diagnose and order things on lobby and triage patients and how we even decide on CT scans and dispositions. Frequently, our hospitalist medicine colleagues will utilize the same reflex and unnecessarily or prematurely consult specialists.

On occasion, when the arrow released via a knee jerk reaction hits the bull’s eye, it feels and looks great. Knee jerk, unfortunately, is also how we assume, stereotype, over-simplify, ignore and ultimately miss.

Shotgun

This one does not have to be shot from the hip, though it certainly looks cooler that way. Often this is done thoughtfully, with a pseudo-scientific aroma to it.

I was on my MS3 internal medicine rotation when one day, the dreaded ED handed us an elderly female with a congratulatory thick paper chart, a bouquet of vague complaints and no clear diagnosis. When I asked my senior resident what we should do, the answer was a shoulder shrug and a confident “Lab ‘er up!”.

Shotgunning is not just about shooting out labs in the dark, however. It usually refers to a much wider “strategy” (actually, a lack thereof) of checking anyone for “anything” so as to not miss “something”.

Consider an ED evaluation of a headache involving some component of facial pain. Let’s order a migraine cocktail, CT and CTA of the head and neck, ESR to check for temporal arteritis; and when we find nothing, let’s do antibiotics in case of possible dental caries, otitis, mastoiditis or sinusitis. Sounds pretty thorough and terrific, doesn’t it? In fact, many patients would tend to think so. Clearly, after all that, we just could not miss something real badTM. We should remember that in EM you are worth every test that you order.

Hyperlaboratoremia and panscanosis are not the only clinical manifestations of the shotgun approach.

Though in all places, it is well-intended, there is a more buried shotgun in standardized chest pain workups, ED triage scales, pre-conceived clinical pathways and universal screenings than you may think.

Kitchen Sink

One might say that kitchen sink is the therapeutic twin of shotgun diagnostics, though one does not need to stem from the other.

The kitchen sink is how you and I treat most non-threatening and hence not easily identifiable ED rashes. As one of my professors once said: the rule of dermatology is that “if it is dry, use a wetting agent, if it is wet, use a drying agent, plus steroids and antibiotics for everyone”.

At its core, any kitchen sink approach violates two key pillars of modern medicine – evidence-based practice and personalized therapy.

Another example is the kitchen sink phase of resuscitation in a soon to be aborted CPR effort. While in the beginning, we do tend to follow certain parameters and algorithms, towards the end and well into the “futile” stage of CPR remedies like calcium, magnesium, bicarbonate, second and third anti-arrhythmic and so on all inevitably flow one after another regardless of the suspected cause of cardiac arrest or objective facts known.

While benign rashes are benign, and futile CPR is futile, most of the kitchen sink does not involve such obvious extremes. In fact, some of it is perfectly legitimized and even justified – have you ever thought of what “broad-spectrum antibiotics” in sepsis really implies?

Reasons For Need To Know

Why is knowing about the knee jerk, the shotgun and the kitchen sink ahead of time important?

First, the cognitive action patterns described are unavoidable and inescapable. It is precise because we will not be able to fully stop using all three on occasion, that we should know about them ahead of time.

Second, there is something positive and well-thought-out corresponding to the other side of each of the three behaviors:

Fundamentally, knee-jerk reactions rest on pattern recognition as the predominant cognitive pathway at work – something that physicians start to rely upon more and more as they mature. While risking the error of premature diagnostic closure (among others), pattern recognition does save time and resources. This mode is why, as some studies suggest, senior-most providers may be more effective in triage.

On the opposing side of the shotgun coin are the well-accepted mantras of keeping one’s differentials broad and of thinking outside the box. Such forced mental efforts help avoid anchoring among other cognitive errors.

Last, kitchen sink elements may indeed be acceptable in salvage type of situations or in uncharted waters, given multiple paucities in our scientific evidence and in our full understanding of physiologic processes. In such select cases, we humbly admit our limits and hope that something unknown may work at the last minute, while there is no further harm that can be done.

It would be a mistake, however, to confuse each of the positives described with the three patterns we started with when taken in their pure form.

Third, the limitations and harms encountered by not keeping the three tendencies in check are real and immediate:

  • Knee-jerk reactions do not yield beneficial results when the situation encountered is new and principally different from those experienced before, yet it has the external appearance of something familiar. Think of COVID.
  • Shotgun-galore practices subject multiple patients to unnecessary tests and to potentially harmful procedures and interventions that inevitably follow, further inflating the costs of healthcare.
  • Perpetuating myths and unmerited traditional practices, kitchen sink therapies also coach our patients into expecting both the unreasonable and the unnecessary for the next visit, undermining any accepted standard of care at its very core.

What Next?

A more in-depth discussion of all three phenomena presented would indeed be appropriate, including an investigation into any viable alternatives.

For now, I encourage all trainees to look further into the general and well-researched topic of cognitive errors in emergency medicine. 

We should also all strive to practice based on best available evidence and not to be coerced into questionable behaviors by external pressures such as performance metrics that may lurk as false substitutes for quality.

References and Further Reading

  • Frye KL, Adewale A, Martinez Martinez CJ, Mora Montero C. Cognitive Errors and Risks Associated with Provider Handoffs. Cureus. 2018;10(10):e3442. Published 2018 Oct 12. doi:10.7759/cureus.3442
  • Oliver G, Oliver G, Body R. BET 2: Poor evidence on whether teaching cognitive debiasing, or cognitive forcing strategies, lead to a reduction in errors attributable to cognition in emergency medicine students or doctors. Emerg Med J. 2017;34(8):553-554. doi:10.1136/emermed-2017-206976.2
  • Schnapp BH, Sun JE, Kim JL, Strayer RJ, Shah KH. Cognitive error in an academic emergency department. Diagnosis (Berl). 2018;5(3):135-142. doi:10.1515/dx-2018-0011
Cite this article as: Anthony Rodigin, USA, "Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine," in International Emergency Medicine Education Project, July 20, 2020, https://iem-student.org/2020/07/20/knee-jerk-shotgun-and-kitchen-sink-in-emergency-medicine/, date accessed: October 20, 2020

Female Leadership in Emergency Medicine: Interview with Melanie Stander

Female leadership in Emergency Medicine - Melanie Stander MD

Currently, there are approximately 80 countries recognized emergency medicine as a specialty (click to see countries). As our specialty grows, an increasing number of students are interested in emergency medicine as a future career. For students, one of the important reasons to decide a career is the influential leaders and role models in specialties. Today, we are sharing an interview hosting one of the strong leaders of emergency medicine around the world, Dr. Melanie Stander.

Melanie Stander

As one of the first physicians to qualify in emergency medicine in South Africa, as the Immediate Past President of the Emergency Medicine Society of South Africa, and as one of the first women on the Board of the International Federation of Emergency Medicine, Dr. Stander has left an indelible mark on the development of emergency medicine in South Africa and has become an inspiration to other women who seek to follow her path of excellence, leadership and dedication.

Dr. Stander summarizes her inspiring talk in The Xth Mediterranean Emergency Medicine Congress; we hope you enjoy watching the interview. You can also listen to this interview as audio.

Cite this article as: iEM Education Project Team, "Female Leadership in Emergency Medicine: Interview with Melanie Stander," in International Emergency Medicine Education Project, February 10, 2020, https://iem-student.org/2020/02/10/female-leadership-in-em/, date accessed: October 20, 2020

This interview was recorded and produced by Arif Alper Cevik, Ali Kaan Ataman, Elif Dilek Cakal.

The Research of Predicting Septic Shock

How computational medicine is changing critical care in 5 questions

Participating in Research

As a new school year approaches, many medical students are opting to take a gap year dedicated to research. This trend is unique for students not in MD/PhD programs in the USA who have a deep interest in understanding and participating in research. A popular emerging field for the future of health care and medicine, known as computational medicine, is become an integral part of patient care. Regardless of location, students, as well as interns and health care professionals around the globe who are interested in emergency and critical care medicine, should consider this unique area of study as a part of their research gap year.

In this blog entry for the International Emergency Medicine Education Project (iEM), I discuss the role of computational medicine in detecting sepsis, one of the most important diagnoses to detect early, with Professor Rai Winslow, Director of the Institute for Computational Medicine at The Johns Hopkins University. As outlined on the Institute’s website, computational medicine “aims to improve health care by developing computational models of disease, personalizing these models using data from patients, and applying these models to improve the diagnosis and treatment of disease.” Patient models are being used to predict and discover novel sensitive and specific risk biomarkers, predict disease progression, design optimal treatments, and discover novel drug targets. Applications include cardiovascular and neurological diseases, cancer, and critical care and emergency medicine (1).

Rai L Winslow, Director Institute for Computational Medicine, The Raj & Neera Singh Professor of Biomedical Engineering, The Johns Hopkins University

How is computational medicine changing critical care?

5 Questions

5 Answers

Why Sepsis

What was the starting point for your work on sepsis and septic shock in adults?

A starting point for my work on sepsis and septic shock was reading a paper that demonstrated how every hour of delayed treatment in patients with septic shock could lead to an eight percent increase in mortality, per hour. That statement really stood out because what it told me was the natural time course of evolution of the disease, and whatever was happening in septic shock, was happening very quickly. Because of this rapid disease progression, this suggested that accurate prediction of those patients with sepsis who would progress to septic shock must be based on data collected from the patient on a time scale of minutes rather than hours. The challenge was that this high-rate data is not routinely collected in hospitals.

Data and algorithms

What live data are the algorithms capturing from patients for studying and understanding sepsis and septic shock?

Today’s electronic health record (EHR) is typically used to store data such as vitals and lab results and clinical observations made at irregular intervals and at low rates. Given the rapid evolution of septic shock, we hypothesized that advanced prediction and early detection of septic shock must be based on data collected at the minute rather than hour time scales. This was the driving interest in developing a novel software platform called PhysioCloud. PhysioCloud captures physiological vital signs data at minute intervals from patient monitors. These data are then stored in a specialized database that is designed to capture large numbers of real-time data streams at high-rate. Data collection also includes waveforms, such as ECG, respiratory rates, and SpO2, sampled at 125 times per second. Nowhere else in the USA that I am aware of, is capturing these physiological data from patients, making them a part of the patient electronic health record. Our algorithm uses these high rate data, as well as low-rate data from the patient EHR, to predict those patients with sepsis who will develop septic shock.

The importance of the transition state to septic shock

Computational medicine and algorithms can be uncomfortable terms for medical students, interns and researchers who do not have experience with it. Simply put, how do research and studies such as this help doctors in emergency medicine and critical care units, in managing their patients?

Everyday critical care and emergency medicine physicians ask two questions of every patient they see: what is the state of my patient?; how will their state change over time? The latter is a prediction problem of the sort that data scientists often confront. In the context of sepsis, the physician would like to know if their patient will at some future time develop septic shock, or will their condition improve. If an algorithm can reliably predict those patients with sepsis who will develop septic shock at some future time point, then physicians will have a window of time in which they can intervene to prevent this transition from happening. Our goal was to develop such an algorithm. To do this, we utilized the obvious fact that if a patient has sepsis and their condition is getting worse and possibly evolving towards septic shock, it means their physiology must be changing over time as they get sicker. We, therefore, decided to develop a “risk score,” a number ranging between 0 and 1 that is the probability that a patient will develop septic shock. This risk score was computed in an optimal way from the minute by minute physiological vital signs data complemented by clinical data from the EHR. If this risk score exceeds a threshold value, then we decide that this patient with sepsis will develop septic shock at some future time point. This approach works very reliably, achieving high sensitivity and specificity. It’s the worlds simplest machine learning method. Predicting the transition from sepsis to septic shock can enable physicians the ability to follow their patients and see how various states are evolving over time, so that they can intervene to deliver earlier care. Right now, this approach is being applied in retrospective studies using patient data. In the future, we plan to compute this risk score in real-time, generating alerts for caregivers when the risk score exceeds threshold signaling that patients are likely to go into septic shock.

Pre-Shock

In a recent publication in Scientific Report (2), the new concept of a pre-shock state was outlined. How was this possible to do?

Our work hypothesized that it was possible to identify the presence of a physiological signature in sepsis patients before the clinical onset of septic shock was diagnosed. We were able to identify a signature to calculate a risk score for the pre-shock state. The changes in variables such as lactate and heart rate are so small; they are still statistically significant, but so small. When discussed with physicians, some say that they would not have noticed it. These variables are changing together in a small way, but the algorithm is able to catch the changes together and compute it into a risk score and make useful predictions. Some of our very new work not published yet shows that post-threshold, changes in patient risk score happen very quickly (30-60 minutes) and are very large. We have shown that the larger the post-threshold risk score, the more reliable is our prediction that the patient will go into shock. Positive predictive value can be as high as 80-90%.

Fluids and Vasopressors

Evidence-based studies and protocols such as the SOFA score (3), Surviving Sepsis Campaigns (4) are listed on the American College of Emergency Physician (ACEP) website (5) as well as the SALT-ED (6) and SMART (7) trials. These are referred to by emergency physicians in the emergency department, and EM residents are trained with these resources. How do these studies tie into computational medicine, machine learning and predictive analysis for developing septic shock?

Our algorithm looked at tens of thousands of patients, and computationally phenotyped them through every minute of data using the international consensus definition of septic shock, and based on early warning times, found clinical ground truth. We also discovered that the Sepsis 2 definition had a property that was temporarily unstable. This is to say that the state of a patient with sepsis as defined by Sepsis 2, was changing all the time, and it was not possible to predict ground truth. With found the Sepsis 3 definitions to be temporarily stable with few state transitions. The major factor was that the criteria in Sepsis 2 had included a diagnosis of SIRS before sepsis was considered as a diagnosis, and it was removed from 3. We believe that SIRS was causing frequent state changes, as an ambiguous diagnosis.

We are able to predict those patients with sepsis who will transition to shock many hours before they go into shock. We are also able to identify distinct temporal patterns of the risk score corresponding to patient populations with high (up to 60%) versus low (10-20%) mortality. For each of these groups, we looked at comorbidities, diagnoses such as kidney failure and cancer, but we do not know what the relationship is or what is different about these patient groups and the fact that they are in the 60% mortality pool. We know their physiology is saying they are in the mortality pool, but not why. What this means is how these patients are being treated could be the issue (physicians with different levels of training, and other factors involved in treatment decisions). In our work, patients were classified into high and low risk. We found that patients in the low risk received vasopressors and adequate fluid resuscitation and for patients in the high-risk pool, fewer had received vasopressors or fluids. The question is, why are these patients not getting these things. Our algorithm to predict the transition to septic shock can positively influence treatment decisions made by many physicians, to confirm the value of treatment and prevent the development of septic shock. We’ve also identified and know the time to look for proteomic and genomic biomarkers for the early predictive shock signature that could correlate with this high risk/these measures are not routinely done clinically, and this line of work could be very helpful in understanding the fundamental biology of the very rapid change in patient state when they cross the risk score threshold.

Thank you to Professor Winslow for taking the time to discuss the research involved in computational medicine and investigating the transition from sepsis to septic shock. In closing, regardless of medical specialty interests, medical students around the globe interested in taking a gap year to gain research skills will find the experience invaluable and will be introduced to new ways of thinking, writing, and understanding the scientific influences on patient management and health care. Research such as this in the USA can also be implemented at international hospitals and remote clinics, to further aid patient care and management. There are many areas of interest in which research is taking place in critical care units and emergency departments, and discovering the technology involved such as machine learning and computational medicine, is a step towards understanding the potential advances in the future of medicine and patient care.

Please feel free to share your own particular research area(s) of interest and pose any questions you may have in the comments section below.

References and Further Reading

  1. The Institute for Computational Medicine (ICM) –  https://icm.jhu.edu/
  2. Liu R, Greenstein JL, Granite SJ, Fackler JC, Bembea MM, Sarma SV, Winslow RL. Data-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU. Scientific reports. 2019 Apr 16;9(1):6145. – https://www.nature.com/articles/s41598-019-42637-5.pdf
  3. Faust J. No SIRS; quick SOFA instead. Annals of Emergency Medicine. 2016 May 1;67(5). – https://www.annemergmed.com/article/S0196-0644(16)00216-X/pdf
  4. Surviving Sepsis Campaign (SSC) – http://www.survivingsepsis.org/Pages/default.aspx
  5. ACEP Statement on SSC Hour-1 Bundle – https://www.acep.org/by-medical-focus/sepsis/
  6. Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD. Balanced crystalloids versus saline in noncritically ill adults. New England Journal of Medicine. 2018 Mar 1;378(9):819-28. – https://www.nejm.org/doi/full/10.1056/NEJMoa1711586
  7. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD. Balanced crystalloids versus saline in critically ill adults. New England Journal of Medicine. 2018 Mar 1;378(9):829-39. –  https://www.nejm.org/doi/full/10.1056/NEJMoa1711584
Cite this article as: Bryn Dhir, USA, "The Research of Predicting Septic Shock," in International Emergency Medicine Education Project, August 12, 2019, https://iem-student.org/2019/08/12/the-research-of-predicting-septic-shock-how-computational-medicine-is-changing-critical-care-in-5-questions/, date accessed: October 20, 2020

Interview – Vicky Noble – US training in medical schools

We interviewed with world renowned emergency and critical care US expert “Vicky Noble” about US training in medical schools.

https://youtu.be/3Bh2uCyESuM

Read US Chapters and Posts

Interview: Jesus Daniel Lopez Tapia

We interviewed with Dr. Jesus Daniel Lopez Tapia. He is the Dean of University Monterrey, College of Medicine and immediate past president of Mexican Society of Emergency Medicine. 

Highlights from the interview

How many medical school in Mexico?

180

What percentage medical schools have EM course for medical students?

80%

How many EM residency spot every year?

400

How many EM residency program in Mexico?

75

What do graduates do after the graduation?

80% starts working in the EDs. 20% starts residency.

Video Interview – Rob Rogers – Part 3

Great messages for medical students, interns and new EM residents!

Watch the part 3 here!

You can listen full interview here!

Expert Opinion: Luis Vargas – ED Overcrowding

EMERGENCY DEPARTMENT OVERCROWDING

Dear students, emergency departments are suffering overcrowding since long time. There are various causes of this situation as well as solutions. It is better to know about ED overcrowding before your first shift. Dr. Luis Vargas from Colombia summarizes his lecture presented in 30th Emergency Medicine Congress of Mexican Society in Cancun.

ED Overcrowding - English

Manejo y consecuencias del sobrecupo en urgencias

Cite this article as: iEM Education Project Team, "Expert Opinion: Luis Vargas – ED Overcrowding," in International Emergency Medicine Education Project, March 29, 2019, https://iem-student.org/2019/03/29/expert-opinion-luis-vargas-ed-overcrowding/, date accessed: October 20, 2020

Video Interview – Rob Rogers – Part 2

Great messages for medical students, interns and new EM residents!

Are you ready to meet the genuine people behind the professional?

iEM team proudly presents the ICON360 project. In this pleasantly educational series, world-renowned experts will share their habits, give advice on life, wellness and the profession.

Our guest is Dr. Rob Rogers.

Trained in Emergency Medicine and Internal Medicine, Rob Rogers currently practices Emergency Medicine at the University of Kentucky’s Chandler Hospital in the Department of Emergency Medicine. An innovative medical educator on the cutting edge of creativity, he shares his knowledge on the monthly medical education Medutopia Podcast. Rob co-founded The Teaching Institute and in 2014 created The Teaching Course at The University of Maryland. As a passionate medical education enthusiast, podcast evangelist, learning choreographer, and entrepreneur, Rob works tirelessly to change the world of medical education by reinventing it.

The full interview is 24 minutes long and includes many advice on life, wellness, and our profession. We will be sharing short videos from this interview. However, the full interview will be published as an audio file in our Soundcloud account. 

This interview was recorded during the EACEM2018 in Turkey. We thank EMAT.

Arif Alper Cevik

Elif Dilek Cakal

Murat Cetin

Cite this article as: iEM Education Project Team, "Video Interview – Rob Rogers – Part 2," in International Emergency Medicine Education Project, March 25, 2019, https://iem-student.org/2019/03/25/video-interview-rob-rogers-part-2/, date accessed: October 20, 2020

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 document clearly why the patient left and attested that the patient had the mental capacity to make such a decision at that time (Henry, 2013). While some electronic documentation systems have templates in place to assist with this documentation, Table 2 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template (Henry, 2013; Siff, 2011; Levy, 2012; Devitt, 2000).

What to do?

Interventions in the ED Discharge Process

DomainIntervention
ContentStandardize approach
DeliveryVerbal instructions (language and culture appropriate)
Written instructions (literary levels)
Basic Instructions (including return precautions)
Media, visual cues or adjuncts
ComprehensionConfirm comprehension (teach-back method)
ImplementationResource connections (Rx, appointment, durable medical supplies, follow-up)
Medication review

An attempt should be made to provide the patient with appropriate discharge instructions, even if a complete diagnosis may not yet be determined. Include advice for the patient to follow up with his physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. It should also be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if his symptoms worsen, or if he changes his mind. Despite a common notion to the contrary, simply leaving against medical advice does not automatically imply that physicians are immune to potential medical liability (Levy, 2012; Devitt, 2000). If a patient lacks decision-making capacity to be able to adequately understand the rationale and consequences of leaving AMA and his condition places him at risk for imminent harm, involuntary hospitalization is warranted. In unclear circumstances and if available, psychiatry can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process where 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, attempt to reach the patient by phone to discuss his elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is very important (Henry, 2013; Siff, 2011).

To Know More About It?

References

  • Brooten J, Nicks B. Discharge Communications. In: Cevik AA, Quek LS, Noureldin A, Cakal ED (eds) iEmergency Medicine for Medical Students and Interns – 2018. Retrieved February 27, 2019, from https://iem-student.org/discharge-communications/
  • Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2nd Ed; 1759-65. Philadelphia, PA: Elsevier.
  • Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7th Ed; 2021-31. McGraw-Hill.
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What every Med Student/Intern should know about EM

james-holliman

Rob Rogers

Joe Lex

C. James Holliman

Learn the secrets of Emergency Medicine from the fabulous four chapters prepared by three worldwide experts. Listen or read, but know these stuff as early as possible in your medicine/emergency medicine career.

Thinking Like an Emergency Physician

by Joe Lex Emergency Medicine is the most interesting 15 minutes of every other specialty. – Dan Sandberg, BEEM Conference, 2014 Why are we different?

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Choosing the Emergency Medicine As A Career

by C. James Holliman The specialty of Emergency Medicine (EM) is a great career choice for medical students and interns.  In August 2013, I celebrated

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The Importance of The Emergency Medicine Clerkship

by Linda Katirji, Farhad Aziz, Rob Rogers Introduction The Emergency Medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some

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Emergency Medicine: A Unique Specialty

by Will Sanderson, Danny Cuevas, Rob Rogers Imagine walking into the hospital to start your day – ambulances are blaring, the waiting room is clamoring, babies

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Being A Woman In Emergency Medicine

being a women in EM

Gül Pamukçu Günaydın

Turkey

Watching the famous TV series “ER” in my 3rd year of medical school I decided to be an “ER doctor.” I started my Emergency Medicine residency in 2003. So this is my 15th year in Emergency Medicine. I have not regretted my choice yet, and I cannot imagine myself being anything else but an Emergency Physician.

Emergency medicine is indeed a fulfilling career choice for a variety of reasons: first of all, we are cool, we never panic over an emergency. Secondly, emergency medicine is never boring, every shift in the Emergency Department is filled with diverse cases waiting to be solved, like a puzzle. We treat patients in every age group with all kinds of chief complaints, and we hear all sorts of exciting stories. We are there for people who need us most, 24/7, on one of the worst days of their lives, regardless of their background and financial status. We bring patients who are near death back to life, and in every shift, we feel that we make a real difference.

Having said all this, I admit that the life of an Emergency Medicine physician is not a perfect fit for everyone. For example, although shift work is flexible by its nature and you have control over your schedule, shift work is not desirable to everyone. If you plan ahead shift work will allow you to take more vacations any time during the year but if something comes up last minute, there is a pretty good chance that you will miss it. Night shifts may easily disrupt your body cycle even if you follow the recommendations for sleep and it gets harder with age. Working weekends and holidays will mean missing some family gatherings or events at your children’s school and may make your social life difficult. On the bright side, you will always have free weekdays to run errands or catch up with friends on their lunch breaks. Although you do not bring work to your home, (when your shift is over you just pass your patients to another doctor, leave emergency department, and you are not on call) sometimes your shift is so physically exhausting and emotionally draining that you have little energy left for home.

If you are living in a culture where child raising, housework or care of the elderly is seen primarily as women’s duty, or you choose a partner that thinks so, you may have a harder time in life regardless of the specialty you choose as a woman. You may solve some of this issue by willing to accept all help you are offered from close ones and purchase help when necessary to share some of these duties. You may find fewer role models in Emergency Medicine compared to your male peers, but if you look carefully, you will recognize female or male leaders close to you, who understand the difficulties you face and offer you their mentorship.

When choosing any specialty, think about not just now but try to imagine what would make you happy in 10-20-30 years. Yes, being an Emergency Medicine specialist has its challenges and is harder in some aspects compared to other specialties, but I think most of the challenges are there regardless of being men or women. I also believe that with a little flexibility and creativity you can overcome the difficulties, so join us who find joy and feel content in the vibrant and exciting environment of emergency medicine.

Suggested Chapters

Choosing the Emergency Medicine As A Career

C. James Holliman

Emergency Medicine: A Unique Specialty

Will Sanderson, Danny Cuevas, Rob Rogers