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Friday, June 16, 2017

BY SETH COLLINGS HAWKINS, MD; JUSTIN SEMPSROTT, MD; & ANDREW SCHMIDT, DO, MPH

Earlier this month a young child died following days of vomiting. He had been in shallow water in a Texas dike about a week before his death. The story was picked up as an alleged case of a rare condition called dry drowning or secondary drowning. (CNN. June 9, 2017; http://cnn.it/2rECrOV.) The media accounts went viral, spreading significant fear in parenting communities and among those learning about these alleged conditions from the news or social media.

Every death is tragic, especially when it is a child's. Our heartfelt sympathies go out to the family and to those who treated the patient. Drowning deaths are a common cause of pediatric death, and we need to be particularly vigilant about sharing correct, meaningful, and medically credible information.

Unfortunately, there is significant misinformation in the media reports of this case, and we hope this evidence-based discussion of drowning and the best practice medical care of drowning patients will help set the record straight.

1. The medical definition of drowning is "the process of experiencing respiratory impairment from submersion/immersion in liquid." (Definition of Drowning: A Progress Report. Bierens J, Drowning 2e. Berline: Springer, 2014.) Drowning has only three outcomes: fatal drowning, nonfatal drowning with injury or illness, or nonfatal drowning without injury or illness.

2. There are no medically accepted conditions known as near-drowning, dry drowning, and secondary drowning. The World Health Organization, the International Liaison Committee on Resuscitation, the Wilderness Medical Society, the Utstein Style system, the International Lifesaving Federation, the International Conference on Drowning, Starfish Aquatics Institute, the American Heart Association, the American Red Cross, and the U.S. Centers for Disease Control and Prevention (CDC) all discourage the use of these terms. (WHO, http://bit.ly/2rECxWT; Circulation 2003;108[20]:2565; Wilderness Environ Med 2016;27[2]:236, http://bit.ly/2sAR3nL; International Life Saving Federation, http://bit.ly/2s9hi33; Handbook on Drowning: Prevention, Rescue, Treatment. Berlin: Springer, 2006; Starfish Aquatics Institute, http://bit.ly/2sACGQd; Circulation 2005;112:IV-133, http://bit.ly/2tb2pLU; American Red Cross Statement on Secondary Drowning, 2014; Morb Mortal Wkly Rep 2004;53:447; Snopes, http://bit.ly/2sHayL1; CDC, http://bit.ly/2sxCsZh.)

Unfortunately, these terms still slip past the editors of major medical journals, allowing their use to be perpetuated. These terms are most pervasive in the nonmedical press and social media, where the term drowning seems to be synonymous with death. We must find a better way to educate the public on how to discuss drowning as a process, with a spectrum ranging from mild to moderate to severe with fatal or nonfatal outcomes.

Near-drowning. Historically, drowning was used to indicate death, while near-drowning was used to describe patients who survive. But many people suffer from strokes, cardiac arrest, or car collisions every year, and we wouldn't consider them near-strokes, near-cardiac arrest, or near-car collisions just because the person survived. The same is true for drowning and near-drowning. A person can drown and survive the same way that a person can have a cardiac arrest and survive.

Dry drowning. Dry drowning is a term that has never had an accepted medical definition, and has been used at different times to describe different parts of the drowning process. Many media reports use it as a synonym for secondary drowning (described below), but in the past, it was used to describe the finding that the lungs of drowning victims contained no water in about 10 to 20 percent of autopsies. About 10 to 20 percent of the time, no water is found in the lungs at autopsy. Laryngospasm may play a role in some of these cases. During the drowning process, very little water actually enters the lungs, typically less than 2 mL/kg body weight.

This would mean only 30 mL, or one ounce, of water would enter the lungs of an average 15 kg (33 lb.) 3-year-old. If a child is underwater for more than a minute or so, then the main problem is a lack of oxygen to the brain, and CPR should be started to restore oxygen to the brain. If the person is rescued before the brain runs out of oxygen, then that small amount of water in the lungs is absorbed and causes no problems, or it can cause excessive coughing that gets better or worse over the next few hours. The management is the same regardless of whether small amounts of water are present, so this distinction between wet and dry drownings was abandoned as clinically meaningless years ago by drowning specialists.

Secondary drowning. Sometimes known as delayed drowning, this term also has no currently accepted medical definition. Its historical use reflects the reality that patients may sometimes worsen after water exposure. The take-home point is that anyone who experiences respiratory symptoms after a drowning incident (using the modern definition above) should seek medical care. There has never been a case published in the medical literature of a patient who received a clinical assessment, was initially without symptoms, and who later deteriorated and died. People who have drowned and have minimal symptoms will either get better or worse within two to three hours.

We know from a study of more than 41,000 lifeguard rescues that 0.5 percent of patients with initially minimal symptoms and five percent of patients with initially moderate symptoms ultimately died of drowning. (Chest 1997;112[3]:660.) This is the valid part of the concern about drowning patients who initially have only minimal symptoms: They should seek medical care. What are minimal symptoms? Using an experience familiar to almost everyone, we recommend that care be sought if symptoms seem any worse than the experience of a drink going down the wrong pipe at the dinner table or severe coughing that does not resolve in minutes.

Usually these patients can be observed for four to six hours in an emergency department and be released if normal. More significant symptoms would be persistent cough, foam at the mouth or nose, confusion, or abnormal behavior, all of which warrant attention. Drowning deaths do not occur due to unexpected deterioration days or weeks later with no preceding symptoms. The lungs and heart or their passages do not fill up with water, and water does not need to be pumped out of the lungs.

As noted earlier, only small amounts of water are needed to disrupt the surfactant that lines the cells in the lung responsible for exchanging oxygen and other gases. The problem in drowning, especially in cases of mild drowning that worsens, is surfactant disruption, not a measurable level of fluid in the lungs that fills up like a cup and prevents breathing. After a mild or moderate drowning, inflammation and infections in the lungs can cause the initial symptoms to get worse. Parents should seek additional care whenever a child has an excessive cough, isn't breathing normally, or isn't acting right immediately after being pulled from the water. If the child is 100 percent normal upon exiting the water and concerning symptoms develop more than eight hours later, then parents should seek care and providers should consider diagnoses other than primary drowning. In our experience, spontaneous pneumothorax, chemical pneumonitis, bacterial or viral pneumonia, head injury, asthma, heart attack, and chest trauma have been misattributed to delayed drowning.

3. Nonfatal drownings of this sort are common. Cases where a person has mild to moderate symptoms after a drowning incident, such as cough, pulmonary edema (fluid in the lungs), or confusion, are far more common than fatal drownings. It is often quoted in the media that this type of drowning is rare, but that is incorrect. It is actually the most common presentation of drowning. It is estimated that there are five nonfatal drownings for every fatal drowning in children. (AHRQ; http://bit.ly/2ta8RTxCDC; http://bit.ly/2rz1d85.) There are almost 13,000 emergency department visits per year for drowning (AHRQ; http://bit.ly/2ta8RTx), with only about 3,500 drowning deaths in the United States. (CDC; http://bit.ly/2rz1d85.) In fact, 95 to 99.5 percent of patients who have mild to moderate symptoms and a normal blood pressure survive. (New Engl J Med 2012;366[22]:2102; http://bit.ly/2sGEU02.)

What is rare is for these minimally symptomatic cases to progress to death. Similarly, this is also true of heart attacks: Most cases don't progress to death. Nonetheless, they can certainly deteriorate or progress, which is why we encourage people to seek care immediately when they have warning signs like chest pain. The warning signs for drowning are submersion or immersion followed by difficulty breathing, excessive coughing, foam in the mouth, and not acting normally. Subsequent death or complication from drowning is no more a secondary or delayed drowning than subsequent death or complication from heart attack is a secondary or delayed heart attack.

4. How do we communicate better information through the media? Some media reports noted that the terms dry drowning and secondary drowning are discredited in the medical community, but they went on to use them throughout their story. Often, we hear that these terms are more familiar to the public, which is likely true. Of more concern is that some physicians continue to use these terms (and older definitions of drowning that equate drowning exclusively with death) during media interviews and in clinical care and publications. The paradox is that the medical community invented these terms, not patients. The novelty of this storyline—and its appeal to media outlets—is precisely the unfamiliarity of these terms to the general public and the perceived mysterious looming threat. As clinicians and researchers, we should drive popular culture definitions, not the other way around. Rather than discuss these terms as semantics or technicalities, we have an opportunity to present facts, highlight the dangers of drowning and the importance of prevention, and to promote simpler but correct language that is easier for us and our patients to understand.

5. The bottom line. Near, dry, wet, delayed, and secondary drownings are not medically accepted diagnoses. We urge you to abandon these terms in favor of understanding and communicating drowning as a process that can be mild, moderate, or severe with fatal or nonfatal outcomes. Someone who drowns and survives has suffered a nonfatal drowning.

Drowning is a leading cause of preventable pediatric death. The danger is real and not esoteric or rare, and we should use this as an opportunity to discuss with the media and our patients the most important tool for treating drowning—primary prevention. Such prevention includes swimming lessons, touch supervision for toddlers, life jacket usage, appropriate pool fencing (four-sided with a locking gate), and continuous, uninterrupted supervision while kids are in the water, even if a lifeguard is present. If a drowning incident still occurs, anyone with symptoms should receive medical attention. Alternative diagnoses should be sought for those with an asymptomatic period of more than eight hours followed by other symptoms developing. Health care providers should understand and share modern drowning science and best practices, which will reduce fear, improve resource utilization, and prevent potentially deadly consequences due to misunderstanding or misinterpretation of incorrect terminology.


​Additional Resources

Find peer-reviewed information in the practice guidelines from the Wilderness Medical Society (Wilderness Environ Med 2016;27[2]:236; http://bit.ly/2sAR3nL) and an excellent review from the New England Journal of Medicine. (2012;366[22]:2102; http://bit.ly/2sGEU02.) There are also good review articles specifically written for pediatric (PEMNetwork Blog; http://bit.ly/2rEm9Wh) and rural emergency medicine providers (J Rural Emerg Med 2015;2[1]:1; http://bit.ly/2sH9nev) as well as for family practitioners (Am Fam Physician 2016;93[7]:576; http://bit.ly/2roz8w2) and lifeguards. (Starfish Aquatics Institute; http://bit.ly/2sACGQd.)


A​bout the Authors

Dr. Hawkins is an emergency physician in active clinical practice, an assistant professor at Wake Forest University School of Medicine, and a lifelong competitive swimmer. He is the medical director of Starfish Aquatics Institute, Landmark Learning, the Burke County EMS Special Operations Team, and the North Carolina State Parks system. He is an author of numerous medical textbook chapters about drowning and of the Wilderness Medical Society's evidence-based practice guidelines for drowning. He serves as a board member of Lifeguards Without Borders, and is a certified wilderness lifeguard instructor. Follow him on Twitter @hawk_sc.

Dr. Sempsrott is an emergency physician who started out as a beach lifeguard in 1996, and was a founder of the nonprofit Lifeguards Without Borders, now serving as its executive director. He also serves as the medical director for the International Surf Lifesaving Association, Starfish Aquatics Institute, and Innovative Attraction Management Starguard Elite. He is a founding member of the International Drowning Research Alliance and a frequent author and lecturer on drowning prevention, rescue, and treatment.

​Dr. Schmidt is an assistant professor with the University of Florida-Jacksonville Department of Emergency Medicine, where he also serves as deputy medical director for the TraumaOne Flight Program. His specific areas of research and teaching are drowning resuscitation and prehospital medicine. Other positions held include the medical director for Jacksonville Beach Ocean Rescue and a director of Lifeguards Without Borders.



Monday, April 3, 2017

BY JACKIE LAM

The American College of Emergency Physicians' public censure of Peter Rosen, MD, shed light on how expert witness testimonies are especially problematic for EPs. Emergency Medicine News spoke with David Sklar, MD, a distinguished professor emeritus of emergency medicine at the University of New Mexico and an author of the paper, The Expert Witness in Emergency Medicine, about the reasons behind that and the need for an alternative system to address medical errors. (Ann Emerg Med 2014;63[6]:731.)

Unlike other medical specialties, emergency physicians often have to treat based on incomplete information, with patients they don't know, and whose conditions are not always clear. "In many cases, what you're dealing with are probabilities. For example, someone has chest pain," Dr. Sklar said. "They may have a five percent probability of a heart attack, so now you have to make a decision. Is five percent a high enough number that I need to admit this person to the hospital, knowing that 95 percent of the time they are not going to be having a heart attack?"

These probabilities could lead different physicians to manage a patient differently. This gray area of uncertainty and lack of consensus open up room for expert witnesses to give widely different opinions in the courtroom. "An expert could come in and say, 'In my experience, I would never send someone home when we have a one percent chance of a heart attack.' And now you have the jury sitting there thinking, 'Gee, I don't know. Is one percent high or low? The expert just said he would never do it,'" Dr. Sklar said. "Then you have another expert saying, 'One percent is low. We send them all home all the time.' Then they'll try to look at what the guideline is saying, and the guidelines may not be absolutely clear either."

Given the conditions under which EPs are pressured to make decisions, Dr. Sklar said it's inevitable that they will make some mistakes. "You can always in retrospect see something and say, 'Obviously, he made a mistake, the person died,'" Dr. Sklar said. "But when you are the person practicing, you don't know what is going to happen."

Many different factors, individual and systemic, contribute to medical errors. Most medical injuries are the result of the inherent risk in the practice of medicine or system errors, not negligence. (Int J Gen Med 2013;6:49.) "For example, is information from radiology getting back to the emergency physician accurately and quickly?" Dr. Sklar asked. "Did the nurse and the doctor communicate the right directions to the patient before discharge? To deal with all of those, we have to be able to talk about errors and identify them."

The current medical malpractice system, however, not only zeroes in on care providers to blame but also discourages physicians from addressing their medical errors and preventing future ones. The most commonly cited barrier to disclosure and apology by physicians is fear of legal liability. (Clin Orthop Relat Res 2009;467[2]:376.) Most medical errors are also the result of unavoidable human error, which can only be reduced through system changes. (To Err is Human: Building a Safer Health System. Washington: National Academy Press; 2000.) Punishment for errors will not reduce future errors. It might, however, incentivize workers to hide rather than report these errors.

There is, therefore, a need to replace the existing medical malpractice system with one that would address errors in a constructive way. "It's a human thing to make errors, but it doesn't necessarily mean if you make an error, the person has to suffer," Dr. Sklar said. "We need to change the malpractice system so that it's not emphasizing blame. When you're trying to find an individual to blame, you're essentially saying that it was this person's fault. But most errors are not like that. Most of them are what they call a Swiss cheese model where there are multiple things that happen."

Dr. Sklar said EPs need a good mechanism to deal with medical errors, a support system to talk to when they happen, and a way to move past them so they can continue to practice. He encourages his students to talk about their mistakes and support each other when a medical error happens. He holds a weekly morbidity and mortality conference to talk about medical errors, including surprises and bad outcomes. Having seen many of his colleagues go through medical malpractice suits and quit the profession, Dr. Sklar said that it's key to retaining people in emergency medicine. "We spend so many years training folks. We can't lose them after they have an error," he said.​

Read "Rosen, Censured by ACEP, Disputes Claims as 'Unjust,'" at http://bit.ly/2oCGhrQ​


Wednesday, March 29, 2017

Eight major emergency medicine organizations have formed the Coalition to Oppose Medical Merit Badges, pledging to eliminate hospital requirements that board-certified emergency physicians obtain certification in advanced resuscitation, trauma care, stroke care, cardiovascular care, or pediatric care needed for medical staff privileges.

The organizations also said mandat
ory continuing medical education requirements "do not offer any meaningful value for the public or for the emergency physician who has achieved and maintained board certification," saying those conditions are often promulgated by others who "incompletely understand the foundation of knowledge and skills" acquired by successfully completing an emergency medicine residency program approved by the Accreditation Council for Graduate Medical Education.

These merit badges, the news release stated, add no additional value for board-certified emergency physicians and devalue the board certification process by failing to recognize the rigor of ABEM's Maintenance of Certification program. "In essence, medical merit badges set a lower bar than a diplomate's education, training, and ongoing learning," the coalition said.

T
he eight groups acknowledged that changing the requirements for medical merit badges will be "a long and challenging struggle," but promised to develop a long-term strategy to create success and a pathway to recognize clinical excellence.

The members of the coalition are:

  • American Academy of Emergency Medicine (AAEM)
  • American Academy of Emergency Medicine/Resident and Student Association (AAEM/RSA)
  • American Board of Emergency Medicine (ABEM)
  • American College of Emergency Physicians (ACEP)
  • Association of Academic Chairs of Emergency Medicine (AACEM)
  • Council of Emergency Medicine Residency Directors (CORD)
  • Emergency Medicine Residents' Association (EMRA)
  • Society for Academic Emergency Medicine (SAEM)

Friday, February 10, 2017

UPDATE, March 29, 2017: SummaHealth lost its ACGME appeal, and its emergency medicine residency will close July 1


The emergency medicine residency program at Summa Health in Ohio lost its accreditation and was placed on probation by the Accreditation Council on Graduate Medical Education, according to the Akron Beacon Journal. (http://bit.ly/2ku7ryw.)

ACGME said it will withdraw the accreditation on July 1, though Summa said it would appeal the decision within the 30 days ACGME allotted for that process.

Other emergency medicine residency programs in Ohio have offered to help Summa's first- and second-year residents find new slots to finish their training, but nothing official has been announced.

The SUMMA emergency medicine residency program was started in 1980 by Summa Emergency Associates (SEA), the physician group that staffed Summa's five emergency departments for 40 years but that lost its contract on Jan. 1 to US Acute Care Solutions.

​Read the EMN article about that below.


Thursday, February 2, 2017

BY RUTH SORELLE, MPH

The lightning-swift switch in emergency department physician staffing at Summa Health System in Akron, OH, turned out to be the final straw for the hospital's board of directors. What started with the emergency physician group being replaced on Jan. 1 ended only 25 days later with the Summa board of directors accepting the resignation of Thomas Malone, MD, the controversial president and CEO whose actions sparked the turmoil.

summa hospital.jpg

Those involved in the dispute between the Summa Health System and the emergency medicine group, Summa Emergency Associates (SEA) that staffed its emergency departments for 40 years, agreed on one thing: At midnight on New Year's Eve, the system's contract with SEA ended and one hastily written and approved with US Acute Care Solutions (USACS) was activated.

"The night of the transition, they [physicians from USACS] came in an hour early," said Jeffrey Wright, MD, the president of SEA. "We had all the patients taken care of, and we did an appropriate checkout. They took over the new patients at 11:15 p.m. We checked out, and our doctors left at midnight. Dr. Malone walked us out."

Prior to Dr. Malone's resignation, nearly 250 doctors had voted no confidence in the administration as had the 230 residents in its well-respected residency programs.

Letters from the American College of Emergency Physicians, the American Academy of Emergency Medicine, the Society of Academic Emergency Medicine, and the Emergency Medicine Residents Association all pointed to the need for careful consideration in selecting a leader of the residency program and its faculty. "USACS must also commit itself to the preservation of the academic missions, including the Emergency Medicine residency program, at the Summa Health System Hospitals," SAEM wrote in its statement. "High-stakes negotiations take time, effort, and ultimately, compromise. All stakeholders, including the public, payers, health care administrators, and physicians, must recognize the danger this failed negotiation represents to Emergency Medicine, and ultimately, to the care of critically ill and injured patients. SAEM fully stands with and supports those who have dedicated their academic careers to our specialty as well as the residents and fellows who have trusted Summa Health to provide them with the high-quality training they expected."

There is no question that negotiations between Dr. Malone and Dr. Wright began late. The three-year contract that Summa Health and Summa Emergency Associates operated under until Dec. 31 came about as a request for proposal issued in 2013, said Dr. Wright. To win the contract, his group had to agree to staff emergency departments at the Akron and Barberton campuses, and at Wadsworth-Rittman, Summa Health Green, and Summa Health Medina. Negotiations began in the summer, he said. Only the first two emergency departments were profitable for the group, and SEA told the administration that the hospital had to subsidize operations at the other three facilities for the physician group to avoid a huge financial loss.

Dr. Wright said Dr. Malone put him off when he asked about the contract renewal before late November. "We were offered the first contract in this negotiation on Nov. 28," he said. He said he discussed it briefly with Valerie Gibson, RN, the system's chief operating officer. "That first contract cut GME funding by 20 percent, which took it from 10 core faculty down to five," Dr. Wright said.


summa malone.jpg
 Dr Thomas Malone

That would not meet the requirements of the Accreditation Council for Graduate Medical Education, he said, because the program's 30 residents required 10 faculty members. His rewrite contained a request for a 15-year contract.

"I didn't expect to see it. However, the first contract did not address the low patient volume at the low-performing hospitals," Dr. Wright said. "One hospital sees 21 patients per day. Eighty percent of the patients are urgent care. Another hospital see 31 patients a day. Both have low acuity and volume."

That contract revision also contained a raise for the core faculty and suggested taking them out of two of the poorly performing emergency departments. He suggested making those facilities urgent care, closing them, or finding someone else to staff them. Dr. Wright said he was concerned because the contract suggested by the Summa Health leadership was worse than the one they had received three years before. During these contract negotiations, he said, Vivian von Gruenigen, MD, a senior vice president and the chief medical officer for Summa, took part in the negotiations, a fact that concerned him because she is the wife of Dominic Bagnoli, MD, the chief executive officer of USACS. "That's a major conflict of interest," said Dr. Wright.

Marty Richmond, the director of corporate communications for USACS, which is based in Canton, OH, said his understanding was that "she was peripherally involved in the negotiations with SEA. When it became obvious they would have to look for alternatives, she recused herself."

Mr. Richmond said Summa contacted USACS for the first time on Dec. 24 because he was told negotiations with SEA had stalled. "On the 27th, we were asked for a proposal," he said. "We submitted on the 29th, and by the evening of the 29th, we were told we would begin staffing [all five emergency rooms] at midnight on the first."

Mr. Richmond said USACS has a bank of Ohio physicians from which they could draw to staff the Summa EDs. "The residents were not there when we showed up" on Dec. 31, he said. "They had been sent home for the month of January." USACS officials met with the residents on Jan. 3, and the residents returned that afternoon. Scott Felten, MD, was named interim program director, and Mr. Richmond said Dr. Felten is interviewing faculty replacements. "The door is still open for the former physicians," he said. "The quickest way to continuity for the residency program is through the SEA physicians."

​Sharhabeel Jwayyed, MD, the former director of the residency program, said the loss of the contract and his job "was like an ambush." He said Drs. Wright and Malone talked several times, meeting face-to-face for the first time on Dec. 26. On the 27th, he said, Dr. Malone said SEA was done.

The USACS physicians were given emergency credentials on New Year's Eve and New Year's Day. Kevin Rodgers, MD, the president of the American Academy of Emergency Medicine, said that was a red flag. He said a reasonable search for a residency director and 10 core faculty cannot be done in the five days that USACS had to fill those academic spots. The Accreditation Council for Graduate Medical Education is currently evaluating the program.

Dr. Rodgers said USACS is no longer a strictly physician-owned practice because a hedge fund is involved. USACS was established in May 2015 by Dr. Bagnoli's group, Emergency Medicine Physicians (EMP), and the investment firm of Welsh, Carson, Anderson & Stowe. "AAEM doesn't endorse that," he said.

"What is the bottom line here?" he said. "What about patients, residents and medical staff?" Dr. Rodgers asked. SEA was offered a contract extension, but Dr. Wright said he saw no advantage in that, and Dr. Rodgers agreed. "Jeff Wright looked at the offer for an extension and decided what was good for them. The contract was a bad choice and an extension would put them in a bad place," he said. He acknowledged that opinions on that differ, and said Dr. Wright and the SEA leadership were a bit complacent because of their track record with the hospital group. "There's no one not at fault here," he said.