Consensus-Driven Recommendations to Support Physician Pregnancy, Adoption, Surrogacy, Parental Leave, and Lactation in Emergency Medicine

The emergency department clinical environment is unique, and guidelines for promoting supportive and equitable workplace cultures ensure success and longevity for pregnant persons and parents in emergency medicine. There is paucity, variability, and dissatisfaction with current parental (historically referred to as maternity and paternity) leave policies. This paper describes the development of consensus-derived recommendations to serve as a framework for emergency departments across the country for incorporating family-friendly policies. Policies that foster a family-inclusive workplace by allowing for professional advancement without sacrificing personal values regardless of sex, gender, and gender identity are critical for emergency medicine recruitment and retention.

Diversity of leadership in academic emergency medicine: Are we making progress?

BACKGROUND

Faculty who identify as women or racial/ethnic groups underrepresented in medicine (URiM) are less likely to occupy senior leadership positions or be promoted. Recent attention has focused on interventions to decrease this gap; thus, we aim to evaluate changes in leadership and academic promotion for these populations over time.

METHODS

Successive cross-sectional observational study of six years (2015 to 2020) of data from the Academy of Administrators/Association of Academic Chairs of Emergency Medicine- Benchmark Survey. Primary analyses focused on gender/URiM differences in leadership roles and academic rank. Secondary analysis focused on disparities during the first 10 years of practice. Statistical modeling was conducted to address the primary aim of assessing differences in gender/URiM representation in EM leadership roles/rank over time.

RESULTS

12,967 responses were included (4589 women, 8378 men). Women had less median years as faculty (7 vs 11). Women and URiM were less likely to hold a leadership role and had lower academic rank with no change over the study period. More women were consistently in the early career cohort (within 10 years or less as faculty) : 2015 =-75.0% [95% CI:± 3.8%] v 61.4% [95% CI:± 3.0%]; 2020 =-75.1% [95% CI: ± 2.9%] v 63.3%, [95% CI:: ± 2.5%]. Men were significantly more likely to have any leadership role compared to women in 2015 and 2020 (2015 = 54.3% [95% CI: ± 3.1%] v 44.8%, [95% CI: ± 4.3%]; 2020 = 43.1% [95% CI:± 2.5%] v 34.8 [95% CI:± 3.1%]). Higher academic rank (associate/professor) was significantly more frequent among early career men than women in 2015 (21.1% [95% CI:± 2.58%] v 12.9%; [95% CI:± 3.0%]) and 2020 (23.1% [95% CI:± 2.2%] v 17.4%; [95% CI:± 2.5%]).

CONCLUSIONS

Disparities in women and URiM faculty leadership and academic rank persist, with no change over a six-year time span. Men early career faculty are more likely to hold leadership positions and be promoted to higher academic rank, suggesting early career inequities must be a target for future interventions.

The presentation of spontaneous coronary artery dissection in the emergency department: Signs and symptoms in an unsuspecting population

OBJECTIVES

Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women, although it is rarely discussed in the differential diagnosis for chest pain in the emergency department (ED). In a population otherwise considered low risk for myocardial infarction, there is a danger of incomplete workup and missed diagnosis. In this study, we aim to describe the clinical presentation of those who present to the ED with SCAD to increase awareness of this potentially fatal diagnosis among emergency practitioners.

METHODS

Data were queried from the Mayo Clinic "Virtual" Multicenter SCAD Registry, a large multisite international disease registry. The registry includes demographic information as well as data from both medical records and surveys administered following the SCAD event. Symptom presentation was abstracted from survey narrative responses. Data analysis was performed using descriptive statistics.

RESULTS

Of 1196 subjects included, chest pain was reported during initial SCAD event in 95.7%. Most common chest symptoms descriptors were pain, pressure/weight, and tightness, with radiation most often in one or both arms/shoulders. Other common symptoms included nausea, shortness of breath, and diaphoresis. Most common electrocardiogram (ECG) findings reported were ST elevation, T-wave abnormality, and normal ECG. Initial troponin values were within normal range in 20.1% of patients.

CONCLUSION

With young healthy women often considered "low risk" for ACS, it is important to understand that SCAD is a cause of ACS, and familiarity with presentation can improve awareness among emergency physicians. Our data can provide insight in helping to identify young women who present with chest pain due to SCAD so they can be appropriately evaluated.

Implications of SARS-CoV-2-Associated Myocarditis in the Medical Evaluation of Athletes

CONTEXT

Myocarditis is a known cause of death in athletes. As we consider clearance of athletes to participate in sports during the COVID-19 pandemic, we offer a brief review of the myocardial effects of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) through the lens of what is known about myocarditis and exercise. All athletes should be queried about any recent illness suspicious for COVID-19 prior to sports participation.

EVIDENCE ACQUISITION

The PubMed database was evaluated through 2020, with the following keywords: myocarditis, COVID-19, SARS-CoV-2, cardiac, and athletes. Selected articles identified through the primary search, along with position statements from around the world, and the relevant references from those articles, were reviewed for pertinent clinical information regarding the identification, evaluation, risk stratification, and management of myocarditis in patients, including athletes, with and without SARS-CoV-2.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Since myocarditis can present with a variety of symptoms, and can be asymptomatic, the sports medicine physician needs to have a heightened awareness of athletes who may have had COVID-19 and be at risk for myocarditis and should have a low threshold to obtain further cardiovascular testing. Symptomatic athletes with SARS-CoV-2 may require cardiac evaluation including an electrocardiogram and possibly an echocardiogram. Athletes with cardiomyopathy may benefit from cardiac magnetic resonance imaging in the recovery phase and, rarely, endocardial biopsy.

CONCLUSION

Myocarditis is a known cause of sudden cardiac death in athletes. The currently reported rates of cardiac involvement of COVID-19 makes myocarditis a risk, and physicians who clear athletes for participation in sport as well as sideline personnel should be versed with the diagnosis, management, and clearance of athletes with suspected myocarditis. Given the potentially increased risk of arrhythmias, sideline personnel should practice their emergency action plans and be comfortable using an automated external defibrillator.

Roundtable on Preseason Heat Safety in Secondary School Athletics: Environmental Monitoring During Activities in the Heat

OBJECTIVE

To develop best-practice recommendations using thermal indices to determine work-to-rest ratios and facilitate further implementation of environmental monitoring for heat safety in secondary school athletics in the United States.

DATA SOURCES

A narrative review of the current literature in environmental monitoring for heat safety during athletics was conducted by content experts. A list of action-oriented recommendations was established from the narrative review and further refined using the Delphi method.

CONCLUSIONS

Assessment of wet bulb globe temperature at the site of activity throughout the duration of the event is recommended to assist clinicians and administrators in making appropriate decisions regarding the duration and frequency of activity and rest periods. Activity modification guidelines should be predetermined and approved by stakeholders and should outline specific actions to be followed, such as the work-to-rest ratio, frequency and timing of hydration breaks, and adjustment of total exercise duration, equipment, and clothing. Furthermore, integration of exertional heat illness injury data with environmental condition characteristics is critical for the development of evidence-based heat safety guidelines for secondary school athletics. Athletic trainers play an essential role in conducting prospective injury data collection, recording onsite wet bulb globe temperature levels, and implementing recommendations to protect the health and safety of athletes.

Best Practices in Managing Cardiac Arrest in the Emergency Department During the COVID-19 Pandemic

Infection by severe acute respiratory syndrome coronavirus 2 has led to cardiac complications including an increasing incidence of cardiac arrest. The resuscitation of these patients requires a conscious effort to minimize the spread of the virus. We present a best-practice model based in four guiding principles: (1) reduce the risk of exposure to the entire health care team; (2) decrease the number of aerosol generating procedures; (3) use a small resuscitation team to limit potential exposure; and (4) consider early termination of resuscitative efforts.

48-year-old with Coronavirus Disease 2019

CASE PRESENTATION

A 48-year-old male who presented with signs and symptoms suggestive of an upper respiratory infection was seen at an urgent care, he had a negative chest radiograph and was discharged. With no other cases of coronavirus disease 2019 (COVID-19) in the state, the patient presented to the emergency department two days later with worsening shortness of breath.

DISCUSSION

There are a variety of findings on both chest radiograph and computed tomography of the chest that suggests COVID-19.

Inflammation-related gene expression profiles of salivary extracellular vesicles in patients with head trauma

At present, there is no reliable biomarker for the diagnosis of traumatic brain injury (TBI). Studies have shown that extracellular vesicles released by damaged cells into biological fluids can be used as potential biomarkers for diagnosis of TBI and evaluation of TBI severity. We hypothesize that the genetic profile of salivary extracellular vesicles in patients with head trauma differs from that in uninjured subjects. Findings from this hypothesis would help investigate the severity of TBI. This study included 19 subjects, consisting of seven healthy controls who denied history of head trauma, six patients diagnosed with concussion injury from an outpatient concussion clinic, and six patients with TBI who received treatment in the emergency department within 24 hours after injury. Real-time PCR analysis of salivary extracellular vesicles in participants was performed using TaqMan Human Inflammation array. Gene expression analysis revealed nine upregulated genes in emergency department patients (LOX5, ANXA3, CASP1, IL2RG, ITGAM, ITGB2, LTA4H, MAPK14, and TNFRSF1A) and 13 upregulated genes in concussion clinic patients compared with healthy participants (ADRB1, ADRB2, BDKRB1, HRH1, HRH2, LTB4R2, LTB4R, PTAFR, CYSLTR1, CES1, KLK1, MC2R, and PTGER3). Each patient group had a unique profile. Comparison between groups showed that 15 inflammation-related genes had significant expression change. Our results indicate that inflammation biomarkers can be used for diagnosis of TBI and evaluation of disease severity. This study was approved by the Institutional Review Board on December 18, 2015 (approval No. 0078-12) and on June 9, 2016 (approval No. 4093-16).

Sports Medicine Update: Concussion

A systematic approach is required for patients with a suspected concussion. Although standardized tools can aid in assessment, the diagnosis of concussion remains a clinical one. At the time of diagnosis, patients should be given both verbal and written review of the common symptoms of concussion, expected course of recovery, as well as strategies to manage symptoms. Most patients benefit from a brief period of rest, followed by a gradual reintroduction of activities, and a graduated return-to-sport protocol. Patients with prolonged recovery from a concussion may benefit from exercise, vestibular, and cognitive rehabilitation programs.

Dedicated MRI in the emergency department to expedite diagnostic management of hip fracture

PURPOSE

To determine the effect on time to diagnosis of making MRI imaging for hip fractures available directly in the emergency department (ED).

METHODS

We conducted a retrospective observational study of patients with MRI imaging of the hip for suspected occult fracture, comparing time to diagnosis and time to disposition of populations imaged in the year preceding and the year following installation of an MRI scanner in the ED.

RESULTS

Time to diagnosis of hip fractures was 709 min before installation of a dedicated ED MRI scanner and 280 min after, a 60% reduction. Including the MRI in the diagnostic workup did not increase ED throughput time, and we were able to save 48% of the patients who had an ED-based MRI from an admission to the hospital.

CONCLUSION

Implementation of an MRI scanner for dedicated emergency department use enables faster hip fracture diagnosis and surgical consultation, or definitive disposition without increasing ED throughput time.

Prospective study of myelin water fraction changes after mild traumatic brain injury in collegiate contact sports

OBJECTIVEMild traumatic brain injury (mTBI) in athletes, including concussion, is increasingly being found to have long-term sequelae. Current imaging techniques have not been able to identify early damage caused by mTBI that is predictive of long-term symptoms or chronic traumatic encephalopathy. In this preliminary feasibility study, the authors investigated the use of an emerging magnetic resonance imaging (MRI) technique, multicomponent driven equilibrium single pulse observation of T1 and T2 (mcDESPOT), in visualizing acute and chronic white matter changes after mTBI in collegiate football and rugby players.METHODSThis study was a nonrandomized, nonblinded prospective trial designed to quantify changes in the myelin water fraction (MWF), used as a surrogate MRI measure of myelin content, in a group of male collegiate football and rugby players, classified here as a contact sport player (CSP) cohort, at the time of mTBI diagnosis and 3 months after injury when the acute symptoms of the injury had resolved. In addition, differences in the MWF between the CSP cohort and a control cohort of noncontact sport players (NCSPs) were quantified. T-tests and a threshold-free cluster enhancement (TFCE) statistical analysis technique were used to identify brain structures with significant changes in the MWF between the CSP and NCSP cohorts and between immediately postinjury and follow-up images obtained in the CSP cohort.RESULTSBrain MR images of 12 right-handed male CSPs were analyzed and compared with brain images of 10 right-handed male NCSPs from the same institution. A comparison of CSP and NCSP baseline images using TFCE showed significantly higher MWFs in the bilateral basal ganglia, anterior and posterior corpora callosa, left corticospinal tract, and left anterior and superior temporal lobe (p < 0.05). At the 3-month follow-up examination, images from the CSP cohort still showed significantly higher MWFs than those identified on baseline images from the NCSP cohort in the bilateral basal ganglia, anterior and posterior corpora callosa, and left anterior temporal lobe, and also in the bilateral corticospinal tracts, parahippocampal gyrus, and bilateral juxtapositional (previously known as supplemental motor) areas (p < 0.05). In the CSP cohort, a t-test comparing the MWF at the time of injury and 3 months later showed a significant increase in the overall MWF at follow-up (p < 0.005). These increases were greatest in the bilateral basal ganglia and deep white matter. MWF decreases were seen in more superficial white matter (p < 0.005).CONCLUSIONSIn this preliminary study, MWF was found to be increased in the brains of CSPs compared with the brains of controls, suggesting acute/chronic MWF alterations in CSPs from previous injuries. Increases in the MWF were also demonstrated in the brains of CSPs 3 months after the players sustained an mTBI. The full clinical significance of an increased MWF and whether this reflects axon neuropathology or disorderly remyelination leading to hypermyelination has yet to be determined.

Consensus Statement- Prehospital Care of Exertional Heat Stroke

Exertional heat stroke (EHS) is one of the most common causes of sudden death in athletes. It also represents a unique medical challenge to the prehospital healthcare provider due to the time sensitive nature of treatment. In cases of EHS, when cooling is delayed, there is a significant increase in organ damage, morbidity, and mortality after 30 minutes, faster than the average EMS transport and ED evaluation window. The purpose of this document is to present a paradigm for prehospital healthcare systems to minimize the risk of morbidity and mortality for EHS patients. With proper planning, EHS can be managed successfully by the prehospital healthcare provider.

Advancing the Use of Administrative Data for Emergency Department Diagnostic Imaging Research

Administrative data are critical to describing patterns of use, cost, and appropriateness of imaging in emergency care. These data encompass a range of source materials that have been collected primarily for a nonresearch use: documenting clinical care (e.g., medical records), administering care (e.g., picture archiving and communication systems), or financial transactions (e.g., insurance claims). These data have served as the foundation for large, descriptive studies that have documented the rise and expanded role of diagnostic imaging in the emergency department (ED). This article summarizes the discussions of the breakout session on the use of administrative data for emergency imaging research at the May 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The authors describe the areas where administrative data have been applied to research evaluating the use of diagnostic imaging in the ED, the common sources for these data, and the strengths and limitations of administrative data. Next, the future role of administrative data is examined for answering key research questions in an evolving health system increasingly focused on measuring appropriateness, ensuring quality, and improving value for health spending. This article specifically focuses on four thematic areas: data quality, appropriateness and value, special populations, and policy interventions.

Injury due to mechanical falls: future directions in gender-specific surveillance, screening, and interventions in emergency department patients

The Centers for Disease Control and Prevention report that among older adults (≥65 years), falls are the leading cause of injury-related death. Fall-related fractures among older women are more than twice as frequent as those for men. Gender-specific evidence-based fall prevention strategy and intervention studies show that improved patient-centered outcomes are elusive. There is a paucity of emergency medicine literature on the topic. As part of the 2014 Academic Emergency Medicine (AEM) consensus conference on "Gender-Specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," a breakout group convened to generate a research agenda on priority questions to be answered on this topic. The consensus-based priority research agenda is presented in this article.

Biomechanics of head impacts associated with diagnosed concussion in female collegiate ice hockey players

Epidemiological evidence suggests that female athletes may be at a greater risk of concussion than their male counterparts. The purpose of this study was to examine the biomechanics of head impacts associated with diagnosed concussions in a cohort of female collegiate ice hockey players. Instrumented helmets were worn by 58 female ice hockey players from 2 NCAA programs over a three year period. Kinematic measures of single impacts associated with diagnosed concussion and head impact exposure on days with and without diagnosed concussion were evaluated. Nine concussions were diagnosed. Head impact exposure was greater in frequency and magnitude on days of diagnosed concussions than on days without diagnosed concussion for individual athletes. Peak linear accelerations of head impacts associated with diagnosed concussion in this study are substantially lower than those previously reported in male athletes, while peak rotational accelerations are comparable. Further research is warranted to determine the extent to which female athletes' biomechanical tolerance to concussion injuries differs from males.

Gender- and sex-specific sports-related injury research in emergency medicine: a consensus on future research direction and focused application

Title IX, the commercialization of sports, the social change in sports participation, and the response to the obesity epidemic have contributed to the rapid proliferation of participation in both competitive organized sports and nontraditional athletic events. As a consequence, emergency physicians are regularly involved in the acute diagnosis, management, disposition, and counseling of a broad range of sports-related pathology. Three important and highly publicized mechanisms of injury in sports relevant to emergency medicine (EM) include concussion, heat illness, and sudden cardiac death. In conjunction with the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," a consensus group consisting of experts in EM, emergency neurology, sports medicine, and public health convened to deliberate and develop research questions that could ultimately advance the field of sports medicine and allow for meaningful application in the emergency department (ED) clinical setting. Sex differences in injury risk, diagnosis, ED treatment, and counseling are identified in each of these themes. This article presents the consensus-based priority research agenda.

Intramuscular ketorolac injections in the athlete

Background:

Pain control is a factor in the sideline treatment of competitive athletes. Ketorolac injections by team physicians as a pain control measure are seemingly becoming more mainstream, although there have been very little data published on its use.

Hypothesis:

Intramuscular ketorolac injections are being used regularly by orthopaedic surgeons and primary care sports medicine physicians in their care of athletes.

Study Design:

Descriptive epidemiology study.

Methods:

A 19-question survey was generated online for physician members of the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North America, and the American Medical Society for Sports Medicine. The survey link was e-mailed, with reminders sent every 1 to 2 weeks, and results were collected from April to June 2011.

Results:

The survey was e-mailed to 6950 physicians, with 1100 respondents completing it (60% orthopaedic surgeons, 40% nonsurgical sports medicine physicians). Approximately 49% use intramuscular ketorolac in the treatment of athletes, primarily at the collegiate and professional levels; 95.8% reported effective pain control after administration; 2.9% reported bleeding complications; and 1.9% reported kidney complications from its use.

Conclusion:

Intramuscular ketorolac injections are used by approximately half of all team physicians in their sideline treatment of competitive athletes.