An Exploration of Gender Bias Affecting Women in Medicine.

Women in medicine face barriers that hinder progress toward top leadership roles, and the industry remains plagued by the grand challenge of gender inequality. The purpose of this study was to explore how subtle and overt gender biases affect women physicians, physician leaders, researchers, and faculty working in academic health sciences environments and to further examine the association of these biases with workplace satisfaction. The study used a convergent mixed methods approach. Sampling from a list of medical schools in the United States, in conjunction with a list of each state's medical society, the authors analyzed the quantitative survey responses of 293 women in medicine. The authors conducted ordinary least squares multiple regression to assess the relationship of gender barriers on workplace satisfaction. Additionally, 132 of the 293 participants provided written open-ended responses that were explored using a qualitative content analysis methodology. The survey results showed that male culture, lack of sponsorship, lack of mentoring, and queen bee syndrome were associated with lower workplace satisfaction. The qualitative results provided illustrations of how participants experienced these biases. These results emphasize the obstacles that women face and highlight the detrimental nature of gender bias in medicine. The authors conclude by presenting concrete recommendations for managers endeavoring to improve the culture of gender equity and inclusivity.

Lemonade from Lemons-Using COVID Downtime to Teach Essential Telemedicine Skills.

As a result of the COVID-19 pandemic, the use of telemedicine has rapidly accelerated. Our orthopaedic department created a telemedicine educational program for residents using standardized patient scenarios. Training residents to use telemedicine will help them navigate through unforeseen issues that otherwise may have never been a consideration. This is not only useful for today's climate but also potentially for the duration of their careers.

Blind nasogastric tube advancement following sleeve gastrectomy: an animal model.

BACKGROUND: Sleeve gastrectomy is an effective surgical treatment for morbid obesity. The major technical risk of this procedure is staple line dehiscence. Some surgeons are reluctant to place a nasogastric tube (NGT) blindly due to the perceived risk of damage to the staple line. We sought to determine whether such concern was warranted. METHODS: A porcine tissue model (Animal Technologies, Inc., Tyler, TX) was used. Sleeve gastrectomy was performed using a flexible gastroscope as a guide for the Endo GIA stapler (Covidien, New Haven, CT) in an identical fashion used in our patients. The specimen was then placed in a plastic model of the thorax (VATS Trainers, LLC. Lansing, MI). The NGT was blindly advanced to 55 cm for a total of 50 passes, and to 75 cm for another 50 passes. Endoscopy with water submersion was performed to evaluate for injury or leak. RESULTS: After multiple passes of the NGT, no significant injuries, leaks, or perforations were observed to the gastric model, except for several small petechiae of the gastric mucosa, the largest measuring approximately 3 mm. None were of full thickness or penetrated the mucosa. The staple line showed no evidence of trauma. CONCLUSION: In this porcine model, blind NGT placement was not associated with significant mucosal injury or any damage to the sleeve gastrectomy staple line.

Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 institute of medicine resident duty hours recommendations.

Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous on-site supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. One recommendation from the IOM was a required 5-hour rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 Institute of Medicine resident duty hours recommendations.

BACKGROUND: Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education, the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. DISCUSSION: The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous onsite supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. CONCLUSION: One recommendation from the IOM was a required 5-h rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

Impact of outside regulatory investigation on opiate administration in the emergency department.

UNLABELLED: This study was conducted to determine whether outside regulatory investigation related to opiate prescription diversion changes the prescribing frequency of opiates in an emergency department (ED). The presence of ED administration of opiates and prescriptions for opiates on discharge were compared across a baseline period 90 days before arrest of a physician for opiate diversion, a period immediately surrounding the arrest, and a follow-up period 90 days later. At no time was there investigation of excessive opiate prescribing for patients in the ED. The likelihood of receiving opiate analgesia either in the ED or on discharge was not significantly different for patients reporting mild pain or severe pain across all three periods. Patients with moderate pain (self-reported pain scores of 4 to 6 out of 10) were less likely to receive opiates in the ED immediately after the arrest compared with the baseline period (likelihood ratio, 0.4; confidence interval, 0.2 to 0.7). Patients with moderate pain were also less likely to receive prescriptions for opiates on discharge from the ED immediately after the arrest (likelihood ratio, 0.5; confidence interval, 0.3 to 0.9). These effects had diminished by 90 days. PERSPECTIVE: This study indicates that factors outside of the provider-patient relationship influence the likelihood of receiving opiates during an ED visit. Awareness of this phenomenon might serve to reduce oligoanalgesia.

Keynote address: Toward a pragmatic model for community consultation in emergency research.

Under the Final Rule enacted in 1996 by the United States Food and Drug Administration and Office of Health and Human Services, community consultation and public notification are required when emergency research is to be conducted in the absence of prior informed consent by subjects. There is a dearth of published recommendations concerning the degree to which communities must be aware of the existence and parameters of a study for which informed consent might not be obtained prior to enrollment. It is argued that effective community consultation requires empirical measurement of the dynamics of community, and that ordinary notions of community may not capture the populations at greatest risk or those who might for other reasons figure most prominently in community consultation. A pragmatic approach to community consultation would establish benchmarks for such measures, and it is argued that such an approach is possible given the correct empirical measures.

The effect of practitioner characteristics on patient pain and embarrassment during ED internal examinations.

UNLABELLED: The objective was to determine if practitioner characteristics influence patients' pain and embarrassment during an emergency department (ED) internal pelvic examination (IPE). This prospective, comparative study was performed in an urban, university teaching hospital ED with an annual census of 64,000. The study population consisted of a convenience sample of patients who required an IPE as part of her ED evaluation. Information gathered included patient age and final diagnosis, as well as examiner gender and level of training (LOT). Immediately after IPE, the patient was asked to rate both pain and embarrassment of the examination using a previously validated 100-mm visual analog scale (VAS). Finally, each subject was asked to indicate her practitioner gender preference for IPE. The influence of examiner gender and LOT on patient pain and embarrassment was assessed using a t-test or ANOVA with significance defined as P <.05. A total of 278 subjects completed the study (mean age 27.7 +/- 10.5 years, range 13 to 70 years). The mean pain and embarrassment scores were 29.7 and 17.5 respectively. Examiner gender, examiner LOT and patient age did not predict pain and embarrassment scores. Overall, 173 (62%) patients had no practitioner gender preference, whereas 93 (34%) preferred women and 11 (4%) preferred men. CONCLUSION: Examiner characteristics do not influence either the pain or the embarrassment associated with IPE in the ED.

Parental report of child restraint device use in an emergency department population.

To survey parents regarding use of child restraint devices (CRD) and knowledge of CRD recommendations, parents of children < or = 14 years of age presenting to an emergency department (ED) provided demographic data and answered questions regarding the family's restraint use and their understanding of CRD recommendations. Three hundred thirteen adults completed surveys, providing data on 541 children. Decreasing restraint use was reported with advancing child age. Parental restraint use remained constant. Demographics were similar. Optimal infant CRD position was not identified by 27%. Incorrect answers were associated with single parents, lower income, less education, and older child age. Only 41% identified the age for mandatory car seat use. Most identified the safest vehicle position for any child. No variables were associated with correct answers. In conclusion, CRD use decreases with increasing child age. In this study, many parents were unaware of CRD recommendations.

Midazolam syrup as a premedication to reduce the discomfort associated with pediatric intravenous catheter insertion.

This randomized, double-blind, placebo-controlled study evaluated midazolam syrup for reducing discomfort from intravenous placement in children 9 months to 6 years. Parents and observers rated the child's discomfort by using visual analogue scales. Median parents' pain scores were significantly lower in the midazolam than the placebo group (P =.002). Midazolam effectively reduces discomfort associated with intravenous insertion.

Nebulized fentanyl for relief of abdominal pain.

OBJECTIVE: To compare the efficacies of nebulized vs. intravenous fentanyl for the relief of abdominal pain. METHODS: This randomized, double-blind, double-placebo-controlled study compared nebulized and intravenous fentanyl (1.5 micro g/kg). Group I received intravenous fentanyl and nebulized saline. Group II received nebulized fentanyl and intravenous saline. Pain scores were measured at baseline and at 15 and 30 minutes after the study drug, using a 100-mm visual analog scale. Thirty minutes after the study drug, the subjects were offered rescue medication. The groups were compared for changes in pain scores at 30 minutes (primary outcome, t-test), changes in pain scores at 15 minutes (t-test), and need for rescue medication (Fisher's exact test). Significance was defined as p < 0.05. RESULTS: Fifty subjects (24 group I, 26 group II) were enrolled. The groups were similar with respect to mean baseline pain (72 mm group I, 74 mm group II) and demographics. A statistically significant difference in changes in pain scores at 15 minutes favoring group I (25 mm vs. 10 mm, p = 0.005) was not evident by 30 minutes (25 mm vs. 16 mm, p = 0.24). The groups were not different with respect to need for rescue medication (50% in group I compared with 69% in group II, p = 0.25). CONCLUSIONS: Nebulized fentanyl provides comparable analgesia to that of intravenous fentanyl.

Necessity of fire department response to the scene of motor vehicle crashes.

The purpose of this study was to identify how often fire department (FD) response to the scene of motor vehicle crashes (MVCs) is necessary for rescue and fire suppression. A retrospective review of MVCs between January 1, 1997 and December 13, 2000 occurring in a suburban municipality (population 79,000, 13 FDs) was conducted. Data abstracted included the total number of reported MVCs, MVCs with personal injury (PIAC), MVCs to which the FD responded, MVCs requiring any extrication, MVCs requiring extensive extrication, and MVCs requiring fire suppression. Data were analyzed using descriptive statistics. A total of 14,450 MVCs occurred during the study period. Two thousand ninety-five (14.5%) resulted in personal injury. The FD responded to 198 MVCs (9.5% of PIAC). Twenty-four (1.1% of PIAC) required simple door release. Fourteen (0.7% of PIAC) required more extensive extrication. No MVC required fire suppression. During this study period, specialized equipment and personnel were rarely needed for patient extrication from MVCs in this municipality. At no time was fire suppression required. Routine FD response to MVCs for purposes of extrication or fire suppression is not warranted in this emergency response system. A prospective study, including a cost analysis, should be undertaken to further clarify the role of FD response to MVCs.

Prevalence of traumatic brain injury in an ED population.

The objective of this study was to determine prevalence of traumatic brain injury (TBI) in an emergency department (ED) population. Questionnaires were administered to patients in an urban, university, trauma center ED. All respondents provided demographics; patients reporting TBI were asked age at injury, if they experienced loss of consciousness (LOC), mechanism, or if medical attention was sought. Five hundred one patients completed the survey. Forty-one percent reported TBI; 23% had TBI with LOC. Mean age at injury was 21.5 years. Mechanism was evenly distributed among sports, assaults, falls, and motor vehicle crashes (MVC). Medical attention was sought for 61% of injuries. Men were more likely to report TBI (P <.001). Medical attention was more likely if MVC or LOC and less likely in sports-injured patients (all P <.01). Twenty-five percent of patients with TBI sustained repeat injury by the same mechanism. Prevalence of TBI in this population is high. Many occur by mechanisms that potentially are preventable.

Socioeconomic and health status differences between depressed and nondepressed ED elders.

The objective of the study was to describe differences in demographics, medical conditions, and social situation between depressed and nondepressed elderly emergency department (ED) patients. We studied a prospective convenience sample of English-speaking ED patients greater-than-or-equal 65 years, without altered mental status, obvious dementia or delirium, participating in a depression screening study during an ED visit for a nonpsychiatric complaint. Demographics were collected. Research personnel administered the Geriatric Depression Scale (GDS), the Folstein Mini-Mental State Examination and a health questionnaire. A total of 103 subjects were enrolled. GDS identified 33 patients (32%) with DEP. DEP patients were more likely to report the following: lower income, lower education level, more medical conditions, less independence, assisted living, and poorer overall health than ND patients. A third of these elderly ED patients report symptoms consistent with depression. There are significant differences in socioeconomic characteristics, health status, and functional ability. Future depression studies should focus on elders with these characteristics.

Validation of a brief screening tool to detect depression in elderly ED patients.

Although depression is the most common psychiatric disorder in the elderly, it is often unrecognized by physicians. The objective of the study was to assess the utility of a 3-question screening instrument (ED-DSI) to detect depression among elderly emergency department (ED) patients. We used a prospective convenience sample of English-speaking ED patients >or=65yr. Patients were excluded for being too ill to participate, having obvious dementia, or acute changes in mentation. A physician administered the ED-DSI. Trained research personnel blinded to ED-DSI answers then administered the 30 question Geriatric Depression Scale (GDS). The ED-DSI was considered positive if the patient answered yes to one or more questions and subjects were considered depressed when the GDS score was >or=10. ED-DSI was compared to GDS using contingency tables. A total of 103 subjects were enrolled. Average age was 75 years and subjects were predominately female (66%) and white (85%). GDS identified 33 patients (32%) as depressed. Of these, 26 were correctly identified by ED-DSI giving an ED-DSI sensitivity of 79% (95%CI (65%, 93%)) specificity of 66% (95%CI (54%, 78%)) and a negative predictive value of 87% (95%CI (79%, 95%)). The 3-question ED-DSI is a useful tool to detect depression in this population of ED patients.