Burnout among Japanese emergency medicine physicians: A multicentric questionnaire study.

Objective: Burnout negatively affects the wellness and performance of emergency physicians (EPs). This study aimed to clarify the actual prevalence of burnout and its associated factors among Japanese EPs. Methods: We conducted a cross-sectional questionnaire study of selected 27 Japanese emergency departments (EDs). We examined the Maslach Burnout Inventory-Human Services Survey score and its associations with ED-level- and EP-level factors in a multivariable analysis. Results: A total of 267 EPs (81.9%) completed survey. Of these, 43 EPs (16.1%) scored severe emotional exhaustion (EE), 53 (19.8%) scored severe depersonalization (DP), and 179 (67.0%) scored severe personal accomplishment (PA), and 24 (8.9%) scored severely in all three domains. In our multivariable analysis, emergency medical service centers were associated with severe PA scores (odds ratio [OR], 10.56; 95% confidence interval [CI], 1.78-62.66; p = 0.009). A 3 to 6 hour-sleep period was associated with severe EE scores (OR, 2.04; 95% CI, 1.04-3.98; p = 0.036), and EPs in their 20s were associated with severe DP scores (OR, 7.37; 95% CI, 1.41-38.38; p = 0.018). Conclusion: Our results suggest that 8.9% of Japanese EPs are in higher degrees of burnout. In particular, Japanese EPs scored more severely on PA. To avoid burnout in Japanese EPs, it is important to improve the working environment by ensuring more than 6 h of sleep, providing more support for young EPs, and taking effective action to combat low EP self-esteem.

A case of reexpansion pulmonary edema and acute pulmonary thromboembolism associated with diffuse large B-cell lymphoma treated with venovenous extracorporeal membrane oxygenation.

A 37-year-old man diagnosed with diffuse large B-cell lymphoma two weeks previously, visited our emergency department with sudden dyspnea. He had a severe respiratory failure with saturated percutaneous oxygen at 80% (room air). Chest radiography showed a large amount of left pleural effusion. After 1000 mL of the effusion was urgently drained, reexpansion pulmonary edema (RPE) occurred. Despite ventilator management, oxygenation did not improve and venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated in the intensive care unit. The next day, contrast-enhanced computed tomography showed a massive thrombus in the right pulmonary artery, at this point the presence of pulmonary thromboembolism (PTE) was revealed. Fortunately, the patient's condition gradually improved with anticoagulant therapy and VV-ECMO support. VV-ECMO was successfully discontinued on day 4, and chemotherapy was initiated on day 8. We speculated the following mechanism in this case: blood flow to the right lung significantly reduced due to acute massive PTE, and blood flow to the left lung correspondingly increased, which could have caused RPE in the left lung. Therefore, our observations suggest that drainage of pleural effusion when contralateral blood flow is impaired due to acute PTE may increase the risk of RPE. .

Factors associated with successful rescue intubation attempts in the emergency department: an analysis of multicenter prospective observational study in Japan.

AIM: It remains unclear whether physicians should change intubation approaches after the failed first attempt. We aimed to determine the rescue intervention approaches associated with a higher success rate at the second attempt in the emergency department (ED). METHODS: We analyzed the data from a prospective, multicenter, observational study - the second Japanese Emergency Airway Network Study. The current analysis included all patients who underwent emergency intubation from February 2012 through November 2017. We defined a rescue intubation attempt as a second intubation attempt with any change in intubation approaches (i.e., change in methods, devices, or intubators) from the failed first attempt. The outcome measure was second-attempt success. RESULTS: Of 2,710 patients with a failed first attempt, 43% underwent a second intubation attempt with changes in intubation approach (i.e., rescue intubation). Rescue intubation attempts were associated with a higher second-attempt success rate compared to non-rescue intubation attempts (adjusted odds ratio [OR], 1.78; 95% confidence interval [CI], 1.50-2.12). The rescue intubation approaches associated with a higher second-attempt success were changes from non-rapid sequence intubation (RSI) to RSI (adjusted OR, 2.04; 95% CI, 1.12-3.75), from non-emergency medicine (EM) residents to EM residents (adjusted OR, 2.02; 95% CI, 1.44-2.82), and from non-EM attending physicians to EM attending physicians (adjusted OR, 2.82; 95% CI, 2.14-3.71). CONCLUSIONS: In this large multicenter study, rescue interventions were associated with a higher second-attempt success rate. The data also support the use of RSI and backup by EM residents or EM attending physicians to improve the airway management performance after a failed attempt in the ED.

Advancing emergency airway management practice and research.

Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first-pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well-designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.

Emergency airway management by resident physicians in Japan: an analysis of multicentre prospective observational study.

AIM: To examine the success rates of emergency department airway management by resident physicians in Japan. METHODS: We conducted an analysis of a multicentre prospective registry (Japanese Emergency Airway Network Registry) of 13 academic and community emergency departments in Japan. We included all patients who underwent emergency intubation performed by postgraduate year 1 to 5 transitional or emergency medicine residents (resident physicians) between April 2010 and August 2012. Outcome measures were success rates by the first intubator, and by rescue intubator, according to the level of training. RESULTS: We recorded 4,094 intubations (capture rate, 96%); 2,800 attempts (2,800/4,094; 68%; 95% confidence interval (CI), 67%-70%) were initially performed by resident physicians. Overall success rate on the first attempt was 63% (1,767/2,789; 95%CI, 61%-64%); the rate improved over the first 3 years of training before reaching a plateau (P trend < 0.001). Success rate by the first intubator was 78% (2,185/2,800; 95%CI, 76%-79%); the rate steadily improved as level of training increased (P trend < 0.001). Of 597 failed intubation attempts by the first intubator, 41% (247/597; 95%CI, 37%-45%) of rescue attempts were performed by resident physicians. Success rate on the first rescue attempt was 76% (187/247; 95%CI, 70%-81%), and success rate by first rescue intubator was 89% (220/247; 95%CI, 85%-93%). These rates on rescue attempts steadily improved as level of training increased (both P trend < 0.001). Intubations were ultimately successful in 2,778 encounters (99.6%). CONCLUSION: In this multicentre study characterizing emergency airway management across Japan, we observed that emergency department intubations were primarily managed by resident physicians with acceptably high success rates overall.