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.

Closing the gender pay gap in emergency medicine: Paradigms to consider for leaders, faculty, and trainees.

The gender pay gap among physicians is a well documented and persistent problem and has a profound impact on earnings over a career lifetime. This paper describes examples of concrete initiatives three institutions took to identify and address gender pay gaps. Salary audits at two academic emergency departments highlight the importance of not only ensuring equity in salary among physicians of the same rank but also monitoring whether women are achieving equal representation at higher academic ranks and leadership, elements that typically contribute to compensation. These audits reveal how senior rank and formal leadership roles are significantly associated with salary disparities. A third school of medicine-wide initiative entailed conducting comprehensive salary audits followed by review and adjustment of faculty compensation to achieve pay equity. Graduating residents and fellows seeking first jobs out of training and faculty looking to be compensated equitably would benefit from understanding the elements that drive their compensation and advocating for frameworks that are understandable and transparent.

Executive summary of the SAEM 2022 consensus conference to address racism in emergency medicine clinical research, training, and leadership.

INTRODUCTION: Racism has not only contributed to disparities in health care outcomes, but also has negatively impacted the recruitment, retention, and promotion of historically excluded groups in academic medicine. The 2022 Society for Academic Emergency Medicine (SAEM) consensus conference, "Diversity, Equity, and Inclusion: Developing a Research Agenda for Addressing Racism in Emergency Medicine," convened a diverse group of researchers, educators, administrative leaders, and health care providers to help address the impact of racism in three domains in academic emergency medicine: clinical research, education and training, and academic leadership. The main goals of the consensus process were to identify current knowledge gaps and create a research agenda within each domain using an iterative consensus-building methodology. METHODS: The planning committee identified three fundamental domains to develop a research agenda and created workgroups who completed a literature search to identify gaps in knowledge. After a consensus building process, potential questions were presented at the in-person consensus conference. Ninety SAEM members representing faculty and trainees participated in breakout groups in each domain to generate consensus recommendations for priority research. RESULTS: For clinical research, three research gaps with six questions (n) were identified: remedies for bias and systematic racism (3), biases and heuristics in clinical care (2), and racism in study design (1). For education and training, three research gaps with seven questions were identified: curriculum and assessment (2), recruitment (1), and learning environment (4). For academic leadership, three research gaps with five questions were identified: understanding the current diversity, equity, and inclusion (DEI) landscape and culture (1), analyzing programs that improve DEI and identifying factors that lead to improved diversity (3), and quantifying the value of professional stewardship activities (1). CONCLUSION: This article reports the results of the consensus conference with the goal of influencing emergency care research, education, and policy and facilitating collaborations, grant funding, and publications in these domains.

Horizontal Violence Toward Emergency Medicine Residents: Gender as a Risk Factor.

INTRODUCTION: Horizontal violence (HV) is defined as "persistent exposure to interpersonal aggression and mistreatment from colleagues." Our objective in this pilot, single-site study was to identify sources of HV toward emergency medicine (EM) residents, using the Negative Acts Questionnaire-Revised (NAQ-R). METHODS: In this investigation we used a descriptive cross-sectional survey design to categorize HV. All voluntary participants were residents in an Accreditation Council for Graduate Medical Education-approved, three-year academic EM residency. Data were collected via electronic survey and occurred six months into an academic year. We collected demographic information and responses to the NAQ-R in 2020. Horizontal violence is subdivided into three categories: work-related; person-related; and physical intimidation. Emergency medicine residents answered questions as they related to their interactions with residents and support staff, which included nursing. RESULTS: A total of 23 of 26 residents responded (89%). Participants were 56% women, 78% white, 11% Hispanic, and 89% heterosexual. Participant clinical year was 39% first-, 39% second-, and 22% third-year residents. Women reported a higher frequency of HV compared to men (1.3 vs 1.1, P =.01). By category, women indicated higher incidence of work-related violence from other residents (P = .05) and staff (P =.02). There was no difference in reported frequency of violence for interns compared to senior residents. CONCLUSION: Our pilot study demonstrated horizontal violence toward EM residents exists and is more prevalent in women.

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.

Adaptations to Protect Sideline Providers as They Respond to Sudden Cardiac Arrest During Sars-CoV-2.

ABSTRACT: The 2019 severe acute respiratory syndrome coronavirus 2 has dramatically changed the sports landscape, compelling sports medical providers to adapt to evolving scientific discoveries and adopt ever-changing guidelines that protect our athletes, ourselves, and our staff. To best serve our athletes, providers need to be proactive and anticipate potential complications in providing care for athletes as athletic events resume.

The role of salivary vesicles as a potential inflammatory biomarker to detect traumatic brain injury in mixed martial artists.

Traumatic brain injury (TBI) is of significant concern in the realm of high impact contact sports, including mixed martial arts (MMA). Extracellular vesicles (EVs) travel between the brain and oral cavity and may be isolated from salivary samples as a noninvasive biomarker of TBI. Salivary EVs may highlight acute neurocognitive or neuropathological changes, which may be particularly useful as a biomarker in high impact sports. Pre and post-fight samples of saliva were isolated from 8 MMA fighters and 7 from controls. Real-time PCR of salivary EVs was done using the TaqMan Human Inflammatory array. Gene expression profiles were compared pre-fight to post-fight as well as pre-fight to controls. Largest signals were noted for fighters sustaining a loss by technical knockout (higher impact mechanism of injury) or a full match culminating in referee decision (longer length of fight), while smaller signals were noted for fighters winning by joint or choke submission (lower impact mechanism as well as less time). A correlation was observed between absolute gene information signals and fight related markers of head injury severity. Gene expression was also significantly different in MMA fighters pre-fight compared to controls. Our findings suggest that salivary EVs as a potential biomarker in the acute period following head injury to identify injury severity and can help elucidate pathophysiological processes involved in TBI.

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 on 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 and 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.

Here to chair: Gender differences in the path to leadership.

OBJECTIVE: Career paths leading to department chair positions are elusive. Women represent only 11% of academic emergency department (ED) chairs. It is unclear whether the pathway to chair is different for men and women; the characteristics, achievements, and qualifications among those who become ED chairs is unknown. METHODS: This study is a cross-sectional analysis of curriculum vitae (CV) of current ED chairs in departments with Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs. Former women chairs were included due to paucity of current women chairs. Statistics were calculated using bivariate and multivariate analysis. RESULTS: Of 163 eligible chairs, 88 CV (54%) were obtained, including six former women chairs. A majority (86.4%) self-identified as White/Caucasian, 21.5% were women, 46% were chief residents, 28.4% completed additional postgraduate degrees, and 21.8% were fellowship trained. At time of chair appointment, 58% were professor rank, 53.5% held ED operations roles, and 32% served as vice chair. Women were more likely to be in educational (53% vs. 22%) versus operational (26% vs. 61%, p = 0.02) roles. Women obtained more advanced degrees (47% vs. 25%, p = 0.02), were awarded more nonfederal grants (median = 7 vs. 3, p = 0.04), and achieved more national committee leadership (median = 4 vs. 1, p = 0.02). There were no gender differences in fellowship training, awards, leadership training programs, publications, federal grants, or national/international lectures after adjusting for years in practice. CONCLUSION: While the majority of chairs held prior leadership roles in ED operations, only one in five women chairs did, suggesting gender differences in the path to chair attainment. These differences in paths may contribute to persistent gender disparities in ED chairs and may be influenced by career path choices, implicit bias, and structural barriers.

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.

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.

A Statewide Cross-Sectional Survey of School Nurses' Knowledge and their Role in the Management of Concussed Students.

The school nurse plays a vital role in reintegrating the concussed student into the academic environment. The objective of our survey study was to understand the self- reported level of knowledge of school nurses regarding the diagnosis and management of patients presenting with symptoms of concussion, what responsibilities they have to the concussed student, and to identify the educational resources used. We had a 91.7% response rate and found that most school nurses did not learn about concussions in nursing school; 85% used the CDC HEADS UP website as their educational resource, and the majority reported their knowledge level as fair and wanted more information. Furthermore, 81% took care of at least one concussed student during the past 3 months, 78% had managed the return-to- learn protocol, and 40% managed the return-to-play protocol. Areas for improvement are highlighted and preferred methods to educate were surveyed.