Intimate Partner Violence Experienced by Physicians.

PURPOSE: World Health Organization (WHO) defines intimate partner violence (IPV) as physical, sexual or psychological harm caused by an intimate partner or ex-partner. There are few studies describing interpersonal violence (IPV) among physicians. Our study describes IPV experienced by U.S. physicians. METHODS: This was a multicenter survey administered to 4 physician groups in 2015 to 2016. In total 400 respondents returned survey results. Measures included current IPV, childhood abuse, mental health, professional role, and demographics. RESULTS: IPV was reported by 24% of respondents. The most frequent abuses reported were: verbal (15%), physical (8%) followed by sexual abuse (4%) and stalking (4%). Logistic regression model found that IPV was more likely to be reported by older participants (aged 66-89), those who experienced childhood abuse, working less than full time, and had been diagnosed with a personality disorder. Women and Asian Americans reported slightly higher IPV rates. CONCLUSIONS: Our study has implications for both medical education and intervention development. Universal screening and education that addresses clinical implications when treating peers who experience IPV are needed. Workplace interventions that consider unique physician characteristics and experiences are needed, as well as programs that support sustained recovery. This is the first survey to our knowledge that confirms that physicians experience IPV at a rate consistent or higher than the national level. We developed a standardized instrument to assess IPV in male and female physicians at various career stages. We also identified significant predictors that should be included in IPV screening of potential physician victims.

Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey.

OBJECTIVES: We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California. METHODS: We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact. RESULTS: We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control. CONCLUSIONS: In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care.

International, multicenter evaluation of a new D-dimer assay for the exclusion of venous thromboembolism using standard and age-adjusted cut-offs.

INTRODUCTION: We sought to determine the test characteristics of an automated INNOVANCE D-dimer assay for the exclusion of pulmonary embolism (PE) and deep venous thrombosis (DVT) in emergency department (ED) patients using standard and age-adjusted cut-offs. METHODS: Cross-sectional, international, multicenter study of consecutive patients with suspected DVT or PE in 24 centers (18 USA, 6 Europe). Evaluated patients had low or intermediate Wells PE or DVT scores. For the standard cut-off, a D-dimer result <500 ng/ml was negative. For the age adjusted cut-off, we used the formula: Age (years) ∗ 10. The diagnostic standard was imaging demonstrating PE or DVT within 3 months. We calculated test characteristics using standard methods. We also explored modifications of the age adjustment multiplier. RESULTS: We included 3837 patients and excluded 251. The mean age of patients evaluated for PE (n = 1834) was 48 ±â€¯16 years, with 676 (37%) male, and 1081 (59%) white. The mean age of evaluated for DVT (n = 1752) was 53 ±â€¯16 years, with 710 (41%) male, and 1172 (67%) white. D-dimer test characteristics for PE were: sensitivity 98.0%, specificity 55.4%, negative predictive value (NPV) 99.8%, positive predictive value (PPV) 11.4%, and for DVT were: sensitivity 92.0%, specificity 44.8%, NPV 98.8%, PPV 10.3%. Age adjustment increased specificity (59.6% [PE], 51.1% [DVT]), but increasing the age-adjustment multiplier decreased sensitivity without increasing specificity. CONCLUSIONS: INNOVANCE D-dimer is highly sensitive and can exclude PE and DVT in ED patients with low- and intermediate- pre-test probability. Age-adjustment increases specificity, without increasing false negatives.

Deciding to lead: a qualitative study of women leaders in emergency medicine.

BACKGROUND: The aim of this study is to highlight career paths of senior women leaders in academic emergency medicine (EM) to encourage younger women to pursue leadership. METHODS: This was a qualitative study using semi-structured interviews with female EM leaders. We interviewed 22 recognized female leaders selected using criterion-based sampling and a standardized script of open-ended questions derived from the Intelligent Career Model. Questions were related to job purpose, skills, and networking. Interviews were transcribed verbatim and three trained reviewers analyzed transcripts following grounded theory principles and using Dedoose®. Researchers used an iterative process over several meetings to produce the final set of codes and themes. RESULTS: Our iterative process identified four themes: women leaders made an intentional decision to pursue opportunities to influence emergency medicine, women sought out natural mentors and sponsors to facilitate career development, women leaders intentionally planned their out of work life to support their leadership role, and an important focus for their work was to help others achieve excellence. CONCLUSIONS: Our study provides insights from senior female leaders in EM; supporting the value of women pursuing leadership. There is a widely acknowledged need to diversify leadership and support gender-specific needs to develop women leaders in medicine. Becoming a woman leader in EM means making intentional decisions and taking risks. Leaders found benefits in natural mentors and sponsors. Those relationships have power to change the trajectory of emerging women leaders by identifying and reinforcing potential. Work/life balance remains an area which requires intentional planning. Woman leaders encourage succession planning and corroborate the need for increasing the percentage of women leaders to benefit the organizational culture. Leadership in academic medicine is changing with reorientation of a largely autocratic, vertically oriented hierarchy into a more democratic, consensus-driven, and horizontally organized management structure which should complement the strengths women bring to the leadership table.

Healthcare students interprofessional critical event/disaster response course.

OBJECTIVE: Numerous disasters confirm the need for critical event training in healthcare professions. However, no single discipline works in isolation and interprofessional learning is recognized as a necessary component. An interprofessional faculty group designed a learning curriculum crossing professional schools. DESIGN: Faculty members from four healthcare schools within the university (nursing, pharmacy, allied health, and medicine) developed an interdisciplinary course merging both published cross-cutting competencies for critical event response and interprofessional education competencies. SETTING: Students completed a discipline-specific online didactic course. Interdisciplinary groups then participated in a 4-hour synchronous experience. This live course featured high-fidelity medical simulations focused on resuscitation, as well as hands-on modules on decontamination and a mass casualty triage incorporating moulaged standardized patients in an active shooter scenario. PARTICIPANTS: Participants were senior students from allied health, medicine, nursing, and pharmacy. MAIN OUTCOME MEASURES: Precourse and postcourse assessments were conducted online to assess course impact on learning performance, leadership and team development, and course satisfaction. RESULTS: Students participated were 402. Precourse and postcourse evaluations showed improvement in team participation values, critical event knowledge, and 94 percent of participants reported learning useful skills. Qualitative responses evidenced positive response; most frequent recurring comments concerned value of interprofessional experiences in team communication and desire to incorporate this kind of education earlier in their curriculum. Students demonstrated improvement in both knowledge and attitudes in a critical event response course that includes interprofessional instruction and collaboration. Further study is required to demonstrate sustained improvement as well as benefit to clinical outcomes.

Effect of Educational Debt on Emergency Medicine Residents: A Qualitative Study Using Individual Interviews.

STUDY OBJECTIVE: In 2001, less than 20% of emergency medicine residents had more than $150,000 of educational debt. Our emergency medicine residents anecdotally reported much larger debt loads. Surveys have reported that debt affects career and life choices. Qualitative approaches are well suited to explore how and why such complex phenomena occur. We aim to gain a better understanding of how our emergency medicine residents experience debt. METHODS: We conducted individual semistructured interviews with emergency medicine residents. We collected self-reported data related to educational debt and asked open-ended questions about debt influence on career choices, personal life, future plans, and financial decisions. We undertook a structured thematic analysis using a qualitative approach based in the grounded theory method. RESULTS: Median educational debt was $212,000. Six themes emerged from our analysis: (1) debt influenced career and life decisions by altering priorities; (2) residents experienced debt as a persistent source of background stress and felt powerless to change it; (3) residents made use of various techniques to negotiate debt in order to focus on day-to-day work; (4) personal debt philosophy, based on individual values and obtained from family, shaped how debt affected each individual; (5) debt had a normative effect and was acculturated in residency; and (6) residents reported a wide range of financial knowledge, but recognized its importance to career success. CONCLUSION: Our emergency medicine residents' debt experience is complex and involves multiple dimensions. Given our current understanding, simple solutions are unlikely to be effective in adequately addressing this issue.

Does emergency physician empathy reduce thoughts of litigation? A randomised trial.

BACKGROUND: We hypothesised the addition of brief empathetic statements to physician-patient interaction might decrease thoughts regarding litigation. METHODS: We enrolled a convenience sample of adults in our emergency department (ED) waiting room into a randomised, double-blind controlled trial. Subjects watched videos of simulated discharge conversations between physicians and patient actors; half of the videos differed only by the inclusion of two brief empathetic statements: verbalisations that (1) the physician recognises that the patient is concerned about their symptoms and (2) the patient knows their typical state of health better than a physician seeing them for the first time and did the right thing by seeking evaluation. After watching the video subjects were asked to score a five-point Likert scale their thoughts regarding suing this physician in the event of a missed outcome leading to lost work (primary outcome), and four measures of satisfaction with the physician encounter (secondary outcomes). RESULTS: We enrolled and randomised 437 subjects. 213 in the empathy group and 208 in the non-empathy group completed the trial. Sixteen subjects did not complete the trial due to computer malfunction or incomplete data sheets. Empathy group subjects reported statistically significant less thoughts of litigation than the non-empathy group (mean Likert scale 2.66 vs 2.95, difference -0.29, 95% CI -0.04 to -0.54, p=0.0176). All four secondary measures of satisfaction with the physician encounter were better in the empathy group. CONCLUSIONS: In this study, the addition of brief empathetic statements to ED discharge scenarios was associated with a statistically significant reduction in thoughts regarding litigation. CLINICAL TRIAL REGISTRATION: NCT01837706.

Intimate Partner Violence Experienced by Physicians: A Review.

BACKGROUND: Physicians play a significant role in screening for domestic violence. However, little information is available about the prevalence of physicians who experience intimate partner violence (IPV) or the implications for their clinical practice. National surveys indicate a potential prevalence of 16% for sexual abuse and 32% for abuse by an intimate partner. This extrapolates to more than 395,000 potential physician victims, the majority of which are women. METHODS: We conducted a systematic review of IPV and physician victims from 1990 to 2014 that included peer-reviewed journals, trade books, and dissertations that referenced physician victims. RESULTS: We identified 17 publications; nine quantitative studies, four first-person accounts, one qualitative study, and a qualitative dissertation that included two physician subjects. Two case studies of victimized physicians were identified in trade books. Quantitative results noted that women reported higher prevalence for all experiences of violence [childhood exposure (6%-32%), adult IPV exposure (7%-24%)] than men (6%-10%). CONCLUSIONS: This review highlights the need for improved understanding of physician experience with IPV, and development of physician-sensitive resources and treatment approaches. Contributions and limitations are provided for each publication. IPV exposure impacts clinical practice, including reticence to consistently screen patients. Lower reported prevalence may be related to extreme stigma among physicians that may prevent their reporting and help seeking, but more research is needed. We provide recommendations for clinical practice, education, and future research.

Comparison of the finger counting method, the Broselow tape and common weight estimation formulae in Filipino children after Typhoon Haiyan.

OBJECTIVES: We sought to evaluate commonly used paediatric weight estimation techniques in a sample of children in the Philippines. METHODS: We prospectively collected age, height and weight data for a sample of 207 children aged 1-9 years seen during a medical aid trip. Weights were estimated using the finger counting method, the Broselow method and four formulae. Bland-Altman analysis was performed to evaluate agreement with measured weight. RESULTS: Mean difference and range of agreement in kilograms were as follows: 0.6 (95% CI 0.1-1.1) and 14.9 (95% CI 13.1-16.7) for the Broselow method; 1.1 (95% CI 0.5-1.7) and 17.3 (95% CI 15.2-19.3) for the traditional APLS formula; 3.1 (95% CI 2.4-3.7) and 18.6 (95% CI 16.4-20.8) for the finger counting method; 4.0 (95% CI 3.2-4.8) and 23.1 (95% CI 20.3-25.8) for the updated APLS method; 5.1 (95% CI 4.4-5.8) and 21.1 (95% CI 18.6-23.6) for the Luscombe formula; and 5.3 (95% CI 4.5-6.1) and 22.5 (95% CI 20-25.2) for the Best Guess formulae. CONCLUSIONS: The Broselow tape and the traditional APLS formula performed best in our sample. The finger counting method also outperformed newer weight estimation formulae. 'Updated' age-based formulae created recently in developed countries should not be used in disaster relief efforts in the Philippines. Caution should be used when applying these formulae to other developing countries and in disaster response.

Emergency department provider preferences related to clinical practice guidelines for tobacco cessation: a multicenter survey.

OBJECTIVES: The objective was to assess current emergency department (ED) provider practices and preferences for tobacco cessation interventions. The ED is an opportune place to initiate smoking cessation interventions. However, little is known about ED provider current practices and preferences for cessation counseling in the ED. METHODS: This was a survey of ED providers conducted in 2008-2009 (including physicians, nurse practitioners, physician assistants, and nurses), working at least half-time at 10 U.S. academic EDs, regarding adherence to clinical practice guidelines ("5 As") and preferences for cessation interventions/styles. Data analysis occurred in 2012-2013. RESULTS: The response rate was 64% (800 out of 1,246 completed surveys). Providers reported strongest adherence to asking about patient smoking status, followed by advising, with significant variance by clinical role. Assessing, assisting, and arranging support for patients was low overall. Most frequently used interventions were to provide patients with a list of telephone numbers for stop-smoking counseling (87%), pamphlets on smoking health risks and the benefits of stopping (85%), and referrals to the National Toll-Free Smoker's Quitline (84%). Most providers (80%) were supportive of personally conducting brief (less than 3 minutes) smoking cessation counseling sessions during the ED visit, emphasizing education and encouragement. The least appealing intervention was writing a prescription for nicotine replacement therapies or medications to stop smoking (35%). CONCLUSIONS: Interventions most likely to be used were brief and delivered with a positive tone and included referral to external resources. The logical next step is to design and test interventions that ED providers find acceptable.

Continuous IV Crotalidae Polyvalent Immune Fab (Ovine) (FabAV) for selected North American rattlesnake bite patients.

BACKGROUND: In patients bitten by North American rattlesnakes and treated with Crotalidae Polyvalent Immune Fab (Ovine) (FabAV), late hematologic abnormalities-persistent, recurrent, or late, new onset of hypofibrinogenemia, prolonged PT/INR, prolonged PTT, and/or thrombocytopenia beyond 48 h post-envenomation-are common, difficult to manage, and may result in morbidity and mortality are common, difficult to manage, and may result in morbidity and mortality. The optimal management of late hematologic abnormalities, particularly the use of further treatment with antivenom, has not been well defined. The current FabAV treatment regimen is to give antivenom as a bolus dose over a one-hour period. We describe our experience using a continuous intravenous infusion of FabAV for late hematologic effects and/or associated bleeding complications in rattlesnake envenomation. METHODS: This is a retrospective, observational case series of patients envenomated by North American rattlesnakes at three medical centers managed with a continuous intravenous infusion of FabAV for late hematologic abnormalities and/or associated bleeding complications. Indications, dilution and infusion protocols, and duration of therapy were individualized. RESULTS: Five cases were identified between July 2010 and September 2011. All patients had profound late hematologic abnormalities and/or were associated with bleeding complications. Several patients had received repeat bolus infusions of FabAV, with or without human blood products, with either inadequate or only transient beneficial response. All patients were then managed with a continuous intravenous infusion of FabAV and all appeared to respond to the continuous intravenous infusion of FabAV, titrated to effect, with cessation of progression and, in most cases, improvement in hematologic abnormalities. Rates of infusion varied from 2 to 4 vials per 24 h (mean = 3.1 ± 0.4 vials/day). The termination of FabAV infusion was between day 6 and day 14 from the time of envenomation (mean = 10 ± 3 days), after which hematologic values were normalized or were normalizing in all patients and continued to do so. DISCUSSION: The use of FabAV as a continuous intravenous infusion, particularly after the acute phase of envenomation has passed, provides a continuous source of circulating antibodies to neutralize venom components reaching circulation from tissue stores and allows natural replenishment of hematologic factors such as platelets and/or fibrinogen. This method is an efficient use of FabAV, avoiding the wasteful excess of a bolus dose, may be more effective, eliminating the potential for destruction of hematologic factors when protective antivenom levels are lost between bolus FabAV doses, and appears to be safe. Further assessments of the stability and sterility of the product during infusion are needed. The need to continue hospitalization is the major drawback, but continued observation and inpatient care may be needed for other indications (e.g. bleeding) in this subset of patients. CONCLUSIONS: A continuous intravenous infusion of FabAV between 2 and 4 vials per day, titrated to effect, and continued for 6-14 days post-envenomation appeared to be associated with reversal of late hematologic effects of rattlesnake envenomation and, when combined with indicated human blood products, control of significant bleeding. Continuous intravenous infusion of FabAV may be safer, more efficacious, and more cost-effective than observation without FabAV treatment or as-needed bolus dosing in selected patients with late hematologic abnormalities.

Student perception of high fidelity medical simulation for an international trauma life support course.

BACKGROUND: High fidelity medical simulators (HFMS) are accepted tools for health care instruction. The use of HFMS was incorporated into an International Trauma Life Support course, and course participants were surveyed regarding attitudes toward HFMS. METHODS: Course participants, including physicians, nurses, and prehospital personnel, were given pre- and post-course questionnaires measuring their confidence in knowledge and treatment of trauma resuscitation, as well as their attitudes towards the utility and realism of immersive simulation. The participants were randomly assigned to take a course examination either before or after their simulator session. RESULTS: Thirteen course participants of varying backgrounds and degrees of clinical experience were surveyed and tested. All surveyed areas improved following simulator training, including comfort level with simulation as a training method (17%), perception of the realism of HFMS (15%), and reported self-confidence in knowledge, experience and training in trauma care (27%). Test scores were improved in the post-simulation group as opposed to the pre-simulation group (86% pass rate in the post-simulation test group versus 50% pass rate in the pre-simulation test group). CONCLUSIONS: High fidelity medical simulation was accepted by medical professionals of different backgrounds and experience. Attitudes towards simulation and self-confidence improved after simulator sessions, as did test scores, suggesting improved comprehension and retention of course materials. Further testing is required to validate the findings of this small, observational study.

Antismoking advertisements for youths: an independent evaluation of health, counter-industry, and industry approaches.

OBJECTIVES: We used a validated copy test method to examine the effectiveness of 8 types of antismoking advertisements representing health, counterindustry, and industry approaches. We tested the hypothesis that health ads about tobacco victims can lower most adolescents' intent to smoke if the ads elicit disgust and anti-industry feelings rather than fear. We hypothesized null effects for adolescents with conduct disorder because of their abnormally low empathy. METHODS: Ninth-grade students from 8 California public schools (n=1725) were randomly assigned to view 1 of 9 videotapes containing a TV show with ads that included either a set of antismoking ads or a set of control ads. Participants completed baseline measures assessing personality traits and postexposure measures assessing smoking intent, feelings, beliefs, and ad evaluations. RESULTS: Ads focusing on young victims suffering from serious tobacco-related diseases elicited disgust, enhanced anti-industry motivation, and reduced intent to smoke among all but conduct-disordered adolescents. Counterindustry and industry ads did not significantly lower smoking intention. CONCLUSIONS: Sponsors of tobacco use prevention ad campaigns should consider using ads showing tobacco-related disease and suffering, not just counterindustry ads. Ads should be copy tested before airing.