A guide to caring for patients who identify as transgender and gender diverse in the emergency department.

Through a review of current research, standards of care, and best practices, this paper serves as a resource for emergency physicians (EPs) caring for persons who identify as transgender and gender diverse (T/GD) in the emergency department (ED). Both patient- and physician-based research have identified existent potential knowledge gaps for EPs caring for T/GD in the ED. T/GD have negative experiences related to their gender identity when seeking emergency medical care and may even delay emergency care for fear of discrimination. Through the lens of cultural humility, this paper aims to address potential knowledge gaps for EPs, identify and reduce barriers to care, highlight gender-affirming hospital policies and protocols, and improve the care and experience of T/GD in the ED.

How Should Clinicians Express Solidarity With Asylum Seekers at the US-Mexico Border?

Migrants along the US-Mexico border have been subjected to transnational violence created by international policy, militaristic intervention, and multinational organizational administration of border operations. The COVID-19 pandemic compounded migrants' vulnerabilities and provoked several logistical and ethical problems for US-based clinicians and organizations. This commentary examines how the concept of transnational solidarity facilitates analysis of clinicians' and migrants' shared historical and structural vulnerabilities. This commentary also suggests how actions implemented by one organization in Tijuana, Mexico, could be scaled more broadly for care of migrants and asylum seekers in other transnational health care settings.

Los migrantes en la frontera entre EE. UU. y México han sufrido violencia transnacional por parte de la policía internacional, la intervención militar y la administración organizativa multinacional de las operaciones fronterizas. La pandemia de la COVID-19 agravó las vulnerabilidades de los migrantes y provocó varios problemas logísticos y éticos para los médicos y las organizaciones estadounidenses. Este comentario examina de qué manera el concepto de solidaridad transnacional facilita el análisis de los médicos y las vulnerabilidades históricas y estructurales compartidas de los migrantes. También, sugiere cómo las acciones implementadas por una organización en Tijuana, México, podrían aplicarse a mayor escala para la atención de los migrantes y solicitantes de asilo en otros entornos de atención médica transnacional.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future.

OBJECTIVES: The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas. METHODS: A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult). RESULTS: A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout. CONCLUSIONS: Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

Beyond border health: Infrastructural violence and the health of border abolition.

Most existing approaches to border health focus on identifying the social determinants that produce ill health and health disparities among migrants, including language barriers, documentation status, and trauma associated with migration. Attention to these kinds of problems can lead to policy and clinical changes that indeed help improve quantitatively measurable outcomes for patients. However, these approaches usually ignore the larger historical and political framework that determines the determinants - the underlying infrastructure of ill health, or what we term the infrastructural determinants of health. In this paper, we outline specific infrastructures involving race, political economy, history, and most importantly, borders themselves, that lay the foundations for border illness. We examine the plans, histories, policies, and peoples involved in building the conditions for migration, particularly out of the Northern Triangle, including forces of colonialism, US imperialism, neoliberalism, and border militarization. In place of a tacit acceptance of the modern system of borders, we argue for border abolition as a vital but underused treatment in the repertoire of medical intervention. Outlining the rights of people to stay and to move, and drawing on lessons from the prison abolition movement, we offer policies and practices towards a 'no borders' system that privileges liberatory solidarity with migrants by explicitly challenging global infrastructures that drive displacement. In doing so, we offer an emergent framework for a medical border abolition that treats both the causes and symptoms of a widespread global sickness.

An Emergency Medicine Virtual Clerkship: Made for COVID, Here to Stay.

INTRODUCTION: Safety concerns surrounding the coronavirus 2019 pandemic led to the prohibition of student rotations outside their home institutions. This resulted in emergency medicine (EM)-bound students having less specialty experience and exposure to outside programs and practice environments, and fewer opportunities to gain additional Standardized Letters of Evaluation, a cornerstone of the EM residency application. We filled this void by implementing a virtual clerkship. METHODS: We created a two-week virtual, fourth-year visiting clerkship focused on advanced medical knowledge topics, social determinants of health, professional development, and professional identity formation. Students completed asynchronous assignments and participated in small group-facilitated didactic sessions. We evaluated the virtual clerkship with pre- and post-medical knowledge tests and evaluative surveys. RESULTS: We hosted 26 senior medical students over two administrations of the same two-week virtual clerkship. Students had a statistically significant improvement on the medical knowledge post-tests compared to pre-tests (71.7% [21.5/30] to 76.3% [22.9/30]). Students reported being exposed to social determinants of health concepts they had not previously been exposed to. Students appreciated the interactive nature of the sessions; networking with other students, residents, and faculty; introduction to novel content regarding social determinants of health; and exposure to future career opportunities. Screen time, technological issues, and mismatch between volume of content and time allotted were identified as potential challenges and areas for improvement. CONCLUSION: We demonstrate that a virtual EM visiting clerkship is feasible to implement, supports knowledge acquisition, and is perceived as valuable by participants. The benefits seen and challenges faced in the development and implementation of our clerkship can serve to inform future virtual clerkships, which we feel is a complement to traditional visiting clerkships even though in-person clerkships have been re-established.

Emergency care for transgender and gender-diverse children and adolescents.

Transgender and gender-diverse (TGD) youth may present to the emergency department with a range of medical problems and health concerns. Some of these may be directly related to their gender identity, but the vast majority are not. While gender diversity is not considered a mental illness, TGD youth are at increased risk for suicide, anxiety, depression, and other psychological conditions, as well as family rejection, homelessness, food insecurity, and poverty. Lack of knowledge and cultural competency among emergency clinicians can create a barrier to effective care. This issue will review relevant terminology, epidemiology, and clinical best practices. It will help emergency clinicians understand common gender-affirming practices and recognize possible complications.

Characterizing injury at a tertiary referral hospital in Kenya.

INTRODUCTION: Injury accounts for more than 5.8 million deaths globally with an increasing burden in the developing world. In Kenya, trauma is one of the top 10 leading causes of death. However, no formal continuous injury surveillance systems are in place to inform injury prevention, pre-hospital care or emergency department management. The aim of this study was to implement a hospital-based trauma registry to characterize high acuity injuries presenting to a private tertiary, teaching and referral hospital in Kenya. METHODS: From January to December 2015, data was prospectively collected at a private tertiary, teaching and referral hospital in Nairobi, Kenya. Patients presenting with a traumatic injury for the first time who were admitted to the hospital for at least 48 hours were included in the study. Basic information pertaining to demographics, details of the injury, pre-hospital care and transport, hospital-based management, length of stay and disposition were collected. An injury severity score (ISS) was calculated on each patient and stratified by the mechanism of injury. Descriptive statistics and multivariate logistic regression were used to analyze data and assess risk factors associated with injury severity. RESULTS: There were 101 patients included in the study, the majority of whom were 30 to 39 years of age and male (63%). Seventy-one per cent of patients had a preexisting medical condition with hypertension (26%) and diabetes (13%) being the most common. The most common mechanism of injury was fall (46%) followed by road traffic incidents (RTI) (32%). Most injuries took place at home (43%). Most RTI were caused by cars (63%), with the driver being the most frequently injured (38%). The most common mode of arrival to the emergency department was by private car (72%). The median time between the accident and arrival at the emergency department was 1hr 10 minutes. The majority of the patients had injuries to one area (83%) with the extremities/bony pelvis (72%) being the most common. The median Injury Severity Score was 5 (range 1-34) with the majority (90%) classified as minor injuries (ISS<12). The highest severity of injury as determined by ISS was seen in gunshot wounds. CONCLUSIONS: Injured patients in Kenya showed concordance with prior studies looking at injury prevalence in the developing world when looking at demographics and place of injury. However, differences were found when looking at the mechanism of injury, with falls surpassing road traffic incidents. A delayed presentation to the hospital was also noted in this patient population. Given the rate of traumatic injuries in Kenya and their contribution to morbidity, mortality and overall healthcare costs, there is a need to implement formal trauma registries in all major hospitals in Kenya to generate more data that can be used to improve injury prevention, the overall trauma system and enhance training and preparedness.

Assessing the impact of an emergency trauma course for senior medical students in Kenya.

INTRODUCTION: Ninety percent of all injury-related deaths occur in low- and middle-income countries. The WHO recommends short, resource-specific trauma courses for healthcare providers. Studies show that teaching trauma courses to medical students in developed countries leads to significant increases in knowledge and skill. High costs hinder widespread and sustained teaching of these courses in low-income countries. METHODS: A two-day trauma course was designed for students at Moi College of Health Sciences in Eldoret, Kenya. Participants underwent pre- and post-course written and simulation testing and rated their confidence in 21 clinical scenarios and 15 procedures pre- and post-course using a five point Likert scale. A subset of the students was re-evaluated nine months post-course. Using the paired t-test, mean written, simulation and confidence scores were compared pre-course, immediately post-course and nine months post-course. RESULTS: Twenty-two students were enrolled. Written test score means were 61.5% pre-course and 76.9% post-course, mean difference 15.5% (p < 0.001). Simulation test score means were 36.7% pre-course and 82.2% post-course, mean difference 45.5% (p < 0.001). Aggregate confidence scores were 3.21 pre-course and 4.72 post-course (scale 1-5). Ten out of 22 (45.5%) students were re-evaluated nine months post-course. Results showed written test score mean of 75%, simulation score mean of 61.7%, and aggregate confidence score of 4.59 (scale 1-5). Mean differences between immediate post- and nine months post-course were 1.6% (p = 0.75) and 8.7% (p = 0.10) for the written and simulation tests, respectively. CONCLUSION: Senior Kenyan medical students demonstrated statistically significant increases in knowledge, skills and confidence after participating in a novel student trauma course. Nine months post-course, improvements in knowledge skills and confidence were sustained.