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#ACEP18: Preparing EPs for Real-World Challenges

Lam, Jackie

doi: 10.1097/01.EEM.0000546133.64298.43
#ACEP18

Ms. Lam is the associate editor of Emergency Medicine News.

As the world changes, emergency medicine changes with it. Happenings in the nonmedical world like natural disasters resulting in drug shortages have a direct impact on the decisions emergency physicians make every day. This year's Scientific Assembly of the American College of Emergency Physicians in San Diego Oct. 1-4 is packed with lectures, like the ones below, aimed at preparing EPs for these unforeseen challenges.

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Quick Doc: Providers in Triage

Wednesday, Oct. 3 1:30 p.m.-1:55 p.m.

There is no doubt that having clinicians in triage is an effective tool against ED crowding, but the name is somewhat of a misnomer. That's because it takes more than just a physician or nurse practitioner to make this model work, said Thom Mayer, MD, who was involved in one of the nation's first successful programs at Inova Fairfax Hospital in Falls Church, VA.

His preferred terminology? Team triage and treatment, or T3, as they call it at Inova. One-person triage lowered the number of patients who left without being seen, but Dr. Mayer said more patients left before treatment was completed. “We get them started, but we don't actually speed up their flow. We put them into another queue, another bottleneck, waiting for labs, waiting for x-ray, waiting for nursing orders,” he said.

The T3 model at Inova involves not only a physician and a nurse but also a tech, a registrar, and a scribe. “It's not that we're just triaging them; we're beginning and in many cases completing their treatment before they ever get back in the first place,” said Dr. Mayer, the founder and CEO of Best Practices, Inc., and a clinical professor of emergency medicine at George Washington University. “It's a team approach. It's got to be treated as such in a comprehensive fashion.”

Having more than one health care professional in triage also helps minimize liability, he said. “If I see two doctors instead of one, if I see two nurses instead of one, that's going to decrease my liability because I have another set of eyes, another judgment, another set of people to be able to say this doesn't look like an aneurysm out front, but it looks like an aneurysm back here,” he said.

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Above Us Only Sky: Exploring Transitions, Challenges, and Strategies of Women in Leadership Roles

Monday, Oct. 1 / 12:30 p.m.-1:20 p.m.

The #MeToo movement has brought the challenges that women face to the fore, including those of women in medicine. One that merits attention but has received little so far, especially in medicine, is the gender leadership gap.

Few studies have looked at this issue in depth, but the information currently available highlights its severity. The Association of American Medical Colleges (AAMC) found that only 21 percent of full professors, 15 percent of department chairs, and 16 percent of deans were women in 2013. (http://bit.ly/2Nn5Icf.) More specifically, only 15 percent of full professors in emergency medicine were women in a 2011-2012 AAMC survey, the fourth lowest among the 18 clinical specialties included. (http://bit.ly/2JwxhNV.) The landmark study by Cydulka, et al., summed up the inequality that women in academic EM face in career advancement: They “were less likely to hold major leadership positions..., published less in peer-reviewed journals, and were less likely to achieve senior academic rank in their medical schools.” (Acad Emerg Med 2000;7[9]:999.)

Nicole Franks, MD, the chief quality officer and an associate professor of emergency medicine at Emory University Hospital Midtown, said some challenges that female EPs face when pursuing leadership positions are under their control, but some are not. “[Those] under the EM woman's control include the ability and/or desire to self-advocate, meaning promoting your brand, work-life integration, and the personal versus professional choices that have to be made to achieve this, and deciding that you want to lead and the readiness to be flexible on the path to the right leadership position,” she said.

Not removing these external obstacles and promoting female leadership could mean fewer talented physicians for the specialty. With almost 50 percent of medical students being women and fewer choosing EM, this could result in a smaller group of potential candidates from which to recruit the next generation of practitioners and faculty. (Acad Emerg Med 2008;15[8]:762.) It will also be more difficult to recruit the best women trainees if they are not exposed to and mentored by successful senior women because a study found that having women in leadership positions attracts other women to the department. (Acad Emerg Med 2006;13[8]:904.)

Dr. Franks said she hopes that women who wish to become leaders or are trying to understand why they are not advancing will walk away with some insights into what they may or may not be doing to improve their success, that senior female leaders will leave with a renewed sense of responsibility and inspiration to mentor other women and men on these issues, and that men in leadership positions will understand the unique challenges that women face and start or continue to be better mentors for women seeking to advance.

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Black Box Drugs We Use—What's the Risk?

Tuesday, Oct. 2 / 8 a.m.-8:25 a.m.

Drug shortages are not a new problem, but have not been adequately addressed despite being a longstanding issue. Worse, the FDA's list of drugs in limited supply continues to grow, pushing physicians to turn to alternative medications, sometimes even black box drugs, which could place them and their patients at risks.

Close to 150 national antibiotic shortages occurred in the United States between 2001 and 2013. (Access Medicine Foundation. May 31, 2018; http://bit.ly/2L6PoQu.) The Emerging Infections Network found the number of physicians reporting shortages had dropped only by eight percent between 2011 and 2016, and 60 percent said drug shortages have become common during that time period. (Open Forum Infect Dis 2018;5[4]:ofy068.) More importantly, the percentage of physicians reporting that a drug shortage affected patient outcomes adversely rose to 73 percent in 2016 from 52 percent in 2011. The most common concerns among these physicians were that shortages were affecting patient care by using broader-spectrum drugs (75%), beig more costly (58%), being less effective second-line (45%), or being more toxic agents (37%).

Antibiotics, however, are only part of the picture. Frank LoVecchio, DO, a professor of emergency medicine at the University of Arizona College of Medicine and an associate medical director at the Banner Poison and Drug Center, said recent shortages of saline solution and morphine have led to changes in treatment plans. Pfizer announced that a shortage of their morphine products is due to manufacturing delays and issues. (ASHP. July 17, 2018; http://bit.ly/2L6xA87.) Hurricane Maria also disrupted production of saline bags in Puerto Rico, and experts expect shortages of other drugs, medical devices, and medical supplies to follow. (New York Times. Oct. 23, 2017; https://nyti.ms/2L7tEE2.)

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As a result of these shortages and other constraints like patient allergies, emergency physicians have increasingly opted to use black box drugs like quinolones, NSAIDs, Haldol, and metformin that carry certain risks, according to Dr. LoVecchio. “Some [of these drugs] cause Torsades,” he said. “Some cause suicidal thoughts. Some cause tendon rupture.”

To minimize risk, Dr. LoVecchio said EPs should consider the following questions in deciding whether to use a black box drug: “Best choice? Are alternative therapies contraindicated? Is this patient unlikely to sustain an adverse event?” He added: “Documentation of why you used a certain medication with boxed warning is important. Box warnings are meant for patient safety. EPs should know why the drugs received a box warning and what precautions, if any, are possible.”

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FOAMed Part 1: How to Froth the FOAM – Creating FOAMed

Tuesday, Oct. 2 / 10 a.m.-10:25 a.m.

FOAMed Part 2: Drinking Your FOAM – How to Utilize FOAMed

Tuesday, Oct. 2 / 10:30 a.m.-10:55 a.m.

“Traditional texts are dead,” tweeted Mel Herbert, MD, the founder of EM:RAP, back in 2012 when the term “FOAM” had just been coined.

Not only have online resources like UpToDate been found to be quicker and more accurate compared with books and journal article databases such as PubMed for researching clinical questions (PLoS One 2011;6[8]:e23487), but emergency medicine residents actually prefer online blogs and podcasts to journals and textbooks as sources of information. (Acad Med 2014;89[4]:598.) Are traditional texts really dead?

A long-time FOAM follower and content creator, Mizuho Spangler, DO, an assistant professor of clinical emergency medicine at LAC + USC Medical Center and the editor-in-chief of Hippo Education's medical podcasts, said FOAM does not replace textbooks and other primary sources like peer-reviewed journals. “Core material that we get through our lectures and residencies and training and textbooks should still be our foundational education and practice pattern,” she said. “FOAM is really intended to be supplemental icing on top.”

One reason is that not all FOAM content is peer-reviewed and as reliable or evidence-based as traditional learning resources, Dr. Spangler said. “There is less accountability unless there is a peer-review process,” she said. “[FOAM is] not a formal scientific publication, so while it's easier to disseminate, discuss, and debate back and forth, it does not yet have a standardized peer-review process.”

Not all FOAM resources are created equal, however. Dr. Spangler named a few groups that review prior to publication, including ALiEM, R.E.B.E.L. EM, and Core EM. When used right, FOAM can be a great resource for new and continuing learners in medicine. “As millennial students and residents are coming down the pipeline, it's important for us to stay up-to-date with the various platforms that younger trainees are using,” said Dr. Spangler, who frequently tweets about FOAM (@mizspangler).

Together, traditional medical education and FOAM can be a nice symbiotic relationship, Dr. Spangler said. “The reality is medicine is constantly changing,” she said. “Turnaround time for textbooks and scientific publications is obviously slower and appropriately so because they have a far more extensive peer-review and publication process. FOAM doesn't have those restrictions and limitations. It is a great way of getting up-to-date, cutting-edge education and information out there to stay ahead; you just need to know how to use it. I think you need both.”

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