AEM Education and Training 02: A Global Health Milestones Tool

Welcome to the second episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to an AEM E&T Article or Article in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

           A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

           A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

Discussing open access article (with link to full text):

Development of a Global Health Milestones Tool for Learners in Emergency Medicine: A Pilot Project. Katherine Douglass, Gabriel Jacquet, et al. AEM Education and Training 2017;1:269-279.

Milestones have been a hot topic in medical education, particularly with the implementation of a milestones-based assessment tool across all residencies in emergency medicine. This week we discuss the creation of milestones for emergency medicine learners involved in global medicine.

LISTEN NOW: LEAD AUTHOR INTERVIEW WITH DR. KATHERINE DOUGLASS, MD, MPH

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Katherine Douglass MD MPH

Associate Professor of Emergency Medicine and Global Health

Director, Global Health Fellowship

The George Washington University

 

ARTICLE SUMMARY:

OBJECTIVE: Recognizing the vast array of global medicine opportunities available for emergency medicine learners (including students, residents and fellows) and the inherent challenge of assessing these learners, this paper outlines the process of the creation of a milestones-based “standardized assessment tool.”

 

METHODS: A working group involving over a dozen stakeholders used an iterative process to develop milestones for learners based on learning domains created by the Consortium of Universities for Global Health’s Education Committee.

 

RESULTS:  A standardized milestones assessment tool was created, with five levels of competency across eleven different domains. For example, in the “Sociocultural and Political Awareness Domain,” a Level 1 learner “demonstrate[s] understanding of general concepts [of] cultural proficiency…” while a Level 5 learner “creates of strengthens multidisciplinary partnerships across organizations…”

 

CONCLUSIONS: The authors developed a standardized framework for assessing learners in global emergency medicine. Their next steps include disseminating this tool to assess its effectiveness.

 

FURTHER READING:

Battat R, Seidman G, Chadi N et al., Global Health Competencies and Approaches in Medical Education: A Literature Review. BMC Med Educ 2010;10:94.

Identifying Interpersonal Global Health Competencies for 21st Century Health Professionals. Annals of Global Health, 81(2):239-247.

 

 

Community Case: Not Your Average Fainting Spell

A 36-year-old woman came into the ED by EMS with multiple ‘fainting spells’ throughout the day (her family thought it was because her blood sugar was low at 83 when they checked at home and treated with glucagon and candy).  I was handed this EKG by the receiving nurse:

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I walk into the Trauma Room to find a woman who is awake, alert, diaphoretic, and talking. I get handed this next EKG:

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Moments later the patient becomes suddenly unresponsive and this is what we see:

Screen Shot 2017-10-04 at 4.48.34 PM.png

Torsades de Pointes (TdP) = Polymorphic V Tach (PVT) + Long QT

So then what did we do?

*   Gave Magnesium 2 mg IV bolus x 2 immediately

*   iSTAT showed K 2.6 so started aggressive repletion, placed central venous access to increase rate of safe repletion

*   Started Magnesium drip, gave magnesium bolus PRN anytime there were prolonged runs of TdP

*   Gave lidocaine bolus 100 mg (dose can range from 0.5 to 0.75 mg.kg up to 1 to 1.5mg/kg)

*   Shocked patient three times (during prolonged runs of TdP associated with unresponsiveness):

Blue arrow indicates defibrillation; return of NSR afterward

Blue arrow indicates defibrillation; return of NSR afterward

*   Gave isoproterenol after confirming no history LQTS or prior prolonged QTc on prior EKGs (initial dose 0.05 to 0.1 mcg/kg/min in children and 2 mcg/min in adults)

*   She was transferred to the cardiology service in good condition, awake and alert

Torsades de Pointes ECG Pearls:

·      Long QT + PVT with characteristic morphology that seems to twist around isoelectric line

·      QT interval is inversely proportional to heart rate (HR)

o   The QT shortens at faster HR

o   The QT lengthens at shorter HR

o   There are formulas to calculate the QT interval (https://lifeinthefastlane.com/ecg-library/basics/qt_interval/)

·      TdP with HR >220 more likely to degenerate into VF

·      Bigeminy in a patient with known LQTS may herald imminent TdP:

This was the prehospital EKG

This was the prehospital EKG

Presence of abnormal giant T-U waves may also precede TdP.

Pathophysiology of TdP:

·      A prolonged QT reflects prolonged myocyte repolarization due to ion channel malfunction

·      This prolonged repolarization period also gives rise to early-after-depolarizations (EADs)

·      EADs may manifest on ECG as tall u waves; if these reach threshold amplitude, they may manifest as PVCs

·      TdP is initiated when a PVC occurs during a preceding T wave, known as ‘R-on-T’ phenomena

·      The onset of TdP is often preceded by a sequence of short-long-short PR intervals, so called ‘pause-dependent’ TdP with longer pauses associated with faster runs of VT

Clinical Significance:

·      TdP is often short lived and self-terminating, however can be associated with hemodynamic instability and ultimately may degenerate into ventricular fibrillation

·      If it does not spontaneously convert and the patient is unstable, it will need defibrillation

·      QT prolongation may be acquired and occur secondary to multiple drug effects, electrolyte abnormalities, medical conditions, or congenital long-QT syndrome (LQTS)

·      Recognizing the cause of TdP (acquired vs. congenital) allows initiation of specific treatment strategies

*   Defibrillation if unstable

*   Give magnesium (Mg 2-4 grams IV push followed by Mg drip of 3-10 mg/minute)

*   Removal of offending agent in acquired long QT

*   Correct any electrolyte abnormalities (especially hypoMg, hypoK, hypoCa)

*   Correct contributing factors such as respiratory alkalosis (which can worsen hypoK, etc)

*   Remove any offending agents (such as certain anti-arrhythmics, antibiotics, anti-emetics, psychotropics, or methadone)

*   Lidocaine may help because it can suppress PVCs, and therefore stop the R-on-T phenomena

*   Overdrive Pacing (usually at a rate of 100 bpm due to heart rate dependent effects of QT)

*   Only in acquired long QT: beta-adrenergic stimulation with isoproterenol

*   Only in LQTS: give beta-blockade (start with esmolol, then propranolol if not effective)

*   Patients with LQTS may require permanent pacing and ICD

*   Amiodarone may be harmful because it lengthens the QT interval and can possibly cause PVCs (although amiodarone has never been specifically shown to cause Torsades)

ACC/AHA/ESC Guidelines:

The 2006 American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) guidelines for the management of ventricular arrhythmias and the prevention of SCD addressed the management of TdP in the setting of acquired LQTS:

*   Intravenous magnesium

*   Temporary pacing

*   Isoproterenol

References:

· Up To Date: https://www.uptodate.com/contents/acquired-long-qt-syndrome?source=search_result&search=torsades%20de%20pointes&selectedTitle=1~150

· Life In the Fast Lane: https://lifeinthefastlane.com/ecg-library/basics/qt_interval/

· HQMedEd:   http://hqmeded-ecg.blogspot.com/2013/10/polymorphic-ventricular-tachycardia.html

https://en.wikipedia.org/wiki/Torsades_de_pointes

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Faculty Reviewer: Dr. Kristina McAteer

AEM Early Access 06: Gender and Racial Disparities Among Academic Emergency Medicine Physicians

Welcome to the sixth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A collaboration between AEM Journal and Brown Emergency Medicine

A collaboration between AEM Journal and Brown Emergency Medicine

Full text of this month's article (open access through November 1, 2017):click below

Tracy E. Madsen, et al., “Current Status of Gender and Racial/Ethnic Disparities Among Academic Emergency Medicine Physicians,”  A Joint 2015 Report by Academy for Women in Academic Emergency Medicine (AWAEM), Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) and Academy of Administrators in Academic Emergency Medicine (AAAEM).

LISTEN NOW:

INTERVIEW WITH LEAD AUTHOR, DR. TRACY MADSEN

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Dr. Tracy Madsen

Assistant Professor, Division of Sex and Gender in Emergency Medicine (SGEM)

Department of Emergency Medicine

Alpert Medical School, Brown University


ARTICLE SUMMARY:

Objective: A 2010 survey identified disparities in salaries by gender and underrepresented minorities.  With an increase in the EM workforce since, the authors aimed to 1) describe the current status of academic EM workforce by gender, race and rank, and 2) evaluate if disparities still exist in salary or rank by gender.

 

Methods: Information on demographics, rank, clinical commitment, and base and total annual salary for full-time faculty members in U.S. academic EDs was collected in 2015 by the Academy of Administrators in Academic Emergency Medicine (AAAEM) Salary Survey.  Multiple linear regression was used to compare salary by gender while controlling for confounders.

 

Results:

  • Response rate was 47% for 1371 full-time faculty

  • 33% were women

  • 78% White, 4% Black, 5% Asian, 3% Asian Indian, 4% other, and 7% unknown race

  • White vs nonwhite race:

    • 62% vs 69% instructor/assistant

    • 23% vs 20% associate

    • 15% vs 10% full professors

  • Women vs men (p<0.05):

    • 74% vs 59% instructor/assistant

    • 19% vs 24% associate

    • 7% vs 17% full professors

    • 37% vs 31% fellowship trained

    • 59% vs 64% Core Faculty

    • 47% vs 57% had administrative roles

    • 1069 vs 1051 clinical hours worked

  • 15% of 113 Chair/Vice-Chair positions were women, 18% were nonwhite race

  • Mean salary: $278,631

    • Mean salary of women was $19,418 less (SD +/- $3,736, p<0.001) even after adjusting for race, region, rank, years of experience, clinical hours, core faculty status, administrative roles, board certification, fellowship training

 

Conclusions: In 2015, disparities in salary and rank persist among full-time U.S. academic EM faculty, even after controlling for key factors that have been speculated to contribute to salary differences, such as rank, clinical hours, and training.  There were also gender and underrepresented minority disparities in rank and leadership positions.  Future efforts should focus on evaluating salary data by race and developing system-wide practices to eliminate disparities.

 

Recommendations for further reading:

Jena AB, Olenski AR, Blumenthal DM, A S, P U, R J. Sex Differences in Physician Salary in US Public Medical Schools. JAMA Intern Med. 2016;176(9):1294. 

Heron SL, Lovell EO, Wang E, Bowman SH. Promoting Diversity in Emergency Medicine: Summary Recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup. Acad Emerg Med. 2009;16(5):450-453. 

Choo EK, Kass D, Westergaard M, et al. The Development of Best Practice Recommendations to Support the Hiring, Recruitment and Advancement of Women Physicians in Emergency Medicine. Pines JM, ed. Acad Emerg Med. June 2016. 

 

Faculty Editor/Reviewer: Dr. Gita Pensa 

Podcast credits: Intro/exit music by Scott Holmes and freemusicarchive.org. Also featuring "Money", Pink Floyd, from The Dark Side of the Moon.