Ageism as a Source of Global Mental Health Inequity.

Ageism manifests as stereotyping of or discrimination against people-usually older adults-because of their age. Since ageism contributes to global mental health inequity among older people, responding to their needs should be a clinical, ethical, and policy priority. This article suggests how relatively simple, low-cost, high-yield interventions can be implemented globally and domestically to improve the well-being and quality of life of older individuals.

An Ethical Anaylsis of the Arguments Both For and Against COVID-19 Vaccine Mandates for Healthcare Workers.

BACKGROUND: Since the development of the first U.S. Food and Drug Administration-approved vaccine for the prevention of serious disease and death associated with the SARS-CoV-2 virus, health care workers have been expected to comply with mandatory immunization requirements or face potential termination of employment and censure by their state medical boards. Although most accepted this mandate, there have been several who have felt this was an unnecessary intrusion and violation of their right to choose their own health care mitigation strategies, or an infringement on their autonomy and other civil liberties. Others have argued that being a health care professional places your duties above your own self-interests, so-called fiduciary duties. As a result of these duties, there is an expected obligation to do the best action to achieve the "most good" for society. A so-called "utilitarian argument." DISCUSSION: We explore arguments both for and against these mandatory vaccine requirements and conclude using duty- and consequence-based moral reasoning to weigh the merits of each. CONCLUSIONS: Although arguments for and against vaccine mandates are compelling, it is the opinion of the Ethics Committee of the American Academy of Emergency Medicine that vaccine mandates for health care workers are ethically just and appropriate, and the benefit to society far outweighs the minor inconvenience to an individual's personal liberties.

Call of Duty - What are Physicians' Obligations During Crises?

BACKGROUND: Society allows physicians the privilege and responsibility of caring for patients. Those responsibilities demand that their knowledge and technical expertise meet standards defined and policed by their colleagues, through medical societies or governmental entities. However, the fiduciary duty that patients' interests are held above those of the physicians' is an ethical precept that is tested when society is under threat. DISCUSSION: Disasters that stress society are a constant and can present themselves in a myriad of ways to include medical, meteorological, or political. Minimizing the potential damage to the quality and quantity of life of the population is dependent upon public safety personnel and health care professionals who may put their health and safety in harm's way to care for patients. These acts may be taken for granted or assumed to be part of the professional obligations of physicians and other health care workers who work at the bedside. The obligations of physicians to their patients and society may differ from those not in the medical field, and the level of risk deemed acceptable by the physician and by society should be clearly delineated. CONCLUSION: Despite the conflict between normative and descriptive ethics, in times of disaster, physicians must respond to the call of duty. This duty is contingent on the responsibility being shared with governmental agencies and health care facilities, to mitigate the risks borne by those who answer the call.

International Survey of Antiseizure Medication Use in Patients with Complicated Mild Traumatic Brain Injury: A New York Neurotrauma Consortium Study.

BACKGROUND: Seizures and epilepsy after traumatic brain injury (TBI) negatively affect quality of life and longevity. Antiseizure medication (ASM) prophylaxis after severe TBI is associated with improved outcomes; these medications are rarely used in mild TBI. However, a paucity of research is available to inform ASM use in complicated mild TBI (cmTBI) and no empirically based clinical care guidelines for ASM use in cmTBI exist. We aim to identify seizure prevention and management strategies used by clinicians experienced in treating patients with cmTBI to characterize standard care and inform a systematic approach to clinical decision making regarding ASM prophylaxis. METHODS: We recruited a multidisciplinary international cohort through professional organizational listservs and social media platforms. Our questionnaire assessed factors influencing ASM prophylaxis after cmTBI at the individual, institutional, and health system-wide levels. RESULTS: Ninety-two providers with experience managing cmTBI completed the survey. We found a striking diversity of ASM use in cmTBI, with 30% of respondents reporting no/infrequent use and 42% reporting frequent use; these tendencies did not differ by provider or institutional characteristics. Certain conditions universally increased or decreased the likelihood of ASM use and represent consensus. Based on survey results, ASMs are commonly used in patients with cmTBI who experience acute secondary seizure or select positive neuroimaging findings; we advise caution in elderly patients and those with concomitant neuropsychiatric illness. CONCLUSIONS: This study is the first to characterize factors influencing clinical decision making in ASM prophylaxis after cmTBI based on multidisciplinary multicenter provider practices. Prospective controlled studies are necessary to inform standardized guideline development.

Racial and Socioeconomic Disparities in Neurotrauma: Research Priorities in the New York Metropolitan Area Through a Global Neurosurgery Paradigm.

The New York Neurotrauma Consortium (NYNC) is a nascent multidisciplinary research and advocacy organization based in the New York Metropolitan Area (NYMA). It aims to advance health equity and optimize outcomes for traumatic brain and spine injury patients. Given the extensive racial, ethnic, and socioeconomic diversity of the NYMA, global health frameworks aimed at eliminating disparities in neurotrauma may provide a relevant and useful model for the informing research agendas of consortia like the NYNC. In this review, we present a comparative analysis of key health disparities in traumatic brain injury (TBI) that persists in the NYMA as well as in low- and middle-income countries (LMICs). Examples include (a) inequitable access to quality care due to fragmentation of healthcare systems, (b) barriers to effective prehospital care for TBI, and (c) socioeconomic challenges faced by patients and their families during the subacute and chronic postinjury phases of TBI care. This review presents strategies to address each area of health disparity based on previous studies conducted in both LMIC and high-income country settings. Increased awareness of healthcare disparities, education of healthcare professionals, effective policy advocacy for systemic changes, and fostering racial diversity of the trauma care workforce can guide the development of trauma care systems in the NYMA that are free of racial and related healthcare disparities.

Addressing Moral Injury in Emergency Medicine.

BACKGROUND: Moral injury, which is described as the psychological distress that results from actions, or lack of them, that go against one's beliefs or values, has become front and center among issues facing the practice of emergency medicine. Although it predates the COVID-19 outbreak, the pandemic has played a significant role in the increased rate of burnout, and even suicide, among emergency physicians. CASE REPORTS: This paper includes several clinical vignettes to highlight incidents that may occur in the emergency department (ED) when physicians experience violations of their moral codes, leading to distress and moral injury. These scenarios explore the conflicts posed between competing bioethical principles such as beneficence, nonmaleficence, end-of-life decision-making, medical futility, respect for self-determination (autonomy), resource scarcity and triage, duty to care, and physician impairment. DISCUSSION: There are significant similarities between moral injury and post-traumatic stress disorder (PTSD), with some authors describing moral injury as a subset of PTSD. We explore these commonalities to provide coping mechanisms and mitigation strategies for those suffering from moral injury. CONCLUSION: Physicians experiencing moral injury may benefit from the many available evidence-based treatments for PTSD to identify and manage moral injury and to support patient care and personal well-being.

The Effect of Direct Oral Anti-Coagulants on Delayed Traumatic Intracranial Hemorrhage After Mild Traumatic Brain Injury: A Systematic Review.

BACKGROUND: The use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications. OBJECTIVE: Our aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI. METHODS: We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs. RESULTS: There were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH. CONCLUSIONS: This systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.

Should I Stay or Should I Go? A Bioethical Analysis of Healthcare Professionals' and Healthcare Institutions' Moral Obligations During Active Shooter Incidents in Hospitals - A Narrative Review of the Literature.

Active shooter incidents (ASI) have unfortunately become a common occurrence the world over. There is no country, city, or venue that is safe from these tragedies, and healthcare institutions are no exception. Healthcare facilities have been the targets of active shooters over the last several decades, with increasing incidents occurring over the last decade. People who work in healthcare have a professional and moral obligation to help patients. As concerns about the possibility of such incidents increase, how should healthcare institutions and healthcare professionals understand their responsibilities in preparation for and during ASI?

Novel coronavirus COVID-19: an overview for emergency clinicians

Prior to the global outbreak of SARS-CoV in 2003, HCoV-229E and HCoV-OC43 were the only coronaviruses known to infect humans. Following the SARS outbreak, 5 additional coronaviruses have been discovered in humans, most recently the novel coronavirus COVID-19, believed to have originated in Wuhan, Hubei Province, China. SARS-CoV and MERSCoV are particularly pathogenic in humans and are associated with high mortality. In this review, the epidemiology, pathophysiology, and management of the recently discovered COVID-19 are reviewed, with a focus on best practices and the public health implications.

Influenza in the emergency department: 2020 update

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for influenza and the available resources to guide management. This comprehensive review outlines the classification of influenza viruses, influenza pathophysiology, the identification of high-risk patients, and the importance of vaccination, with an update on the 2019-2020 influenza season. Seasonal variations of influenza are discussed, as well as the rationale for limiting testing during periods of high prevalence. Differences between strains of influenza are discussed, as well as the challenges in achieving optimal vaccine effectiveness. Recommendations for use of the currently available oral, intranasal, and intravenous antiviral treatments are provided, as well as utilizing shared decision-making with patients regarding risks and benefits of treatment.

Influenza: diagnosis and management in the emergency department.

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for influenza and the available resources to guide management. This comprehensive review outlines the classification of influenza viruses, influenza pathophysiology, the identification of high-risk patients, and the importance of vaccination. Seasonal variations of influenza are discussed, as well as the rationale for limiting testing during periods of high prevalence. Differences between strains of influenza are discussed, as well as the challenges in achieving optimal vaccine effectiveness. Recommendations for use of the currently available oral, intranasal, and intravenous antiviral treatments are provided, as well as utilizing shared decision-making with patients regarding risks and benefits of treatment.

Do Out-of-Hospital Cardiac Arrest Patients Have Increased Chances of Survival When Transported to a Cardiac Resuscitation Center?

Background Patients suffering from an out-of-hospital cardiac arrest are often transported to the closest hospital. Although it has been suggested that these patients be transported to cardiac resuscitation centers, few jurisdictions have acted on this recommendation. To better evaluate the evidence on this subject, a systematic review and meta-analysis of the currently available literature evaluating the association between the destination hospital's capability (cardiac resuscitation center or not) and resuscitation outcomes for adult patients suffering from an out-of-hospital cardiac arrest was performed. Methods and Results PubMed, EMBASE , and the Cochrane Library databases were first searched using a specifically designed search strategy. Both original randomized controlled trials and observational studies were considered for inclusion. Cardiac resuscitation centers were defined as having on-site percutaneous coronary intervention and targeted temperature management capability at all times. The primary outcome measure was survival. Twelve nonrandomized observational studies were retained in this review. A total of 61 240 patients were included in the 10 studies that could be included in the meta-analysis regarding the survival outcome. Being transported to a cardiac resuscitation center was associated with an increase in survival (odds ratio=1.95 [95% confidence interval 1.47-2.59], P<0.001). Conclusions Adult patients suffering from an out-of-hospital cardiac arrest transported to cardiac resuscitation centers have better outcomes than their counterparts. When possible, it is reasonable to transport these patients directly to cardiac resuscitation centers (class II a, level of evidence B, nonrandomized). Clinical Trial Registration URL : www.crd.york.ac.uk/PROSPERO/ . Unique identifier: CRD 42018086608.

The return of an old nemesis: Survival after severe tricyclic antidepressant toxicity, a case report.

Tricyclic antidepressants (TCAs) were first approved by the Food and Drug Administration (FDA) for use as antidepressants in the 1950s. Although their function as an antidepressant in the U.S. has largely been replaced by newer and safer alternatives, they are still prescribed for various conditions, including chronic pain and intractable depression. We will discuss a case of a TCA overdose presenting with generalized tonic-clonic seizures and multiple recurrent cardiac arrests. This is a case of a 34 year-old female who was brought in by Emergency Medical Services (EMS) with generalized tonic clonic seizure, status post intentional ingestion of multiple drugs. Her vital signs were: Temperature-38.8 °C, Heart Rate-140 beats per minute, Respiratory Rate (RR)-25 breaths per minute, Blood Pressure (BP)-139/77 mmHg, Oxygen Saturation (SaO2)-99% on 100% nonrebreather facemask (NRB). Her electrocardiogram (EKG) showed a widened ventricular tachyarrhythmia and she was immediately given an ampule of sodium bicarbonate. Over the span of the subsequent 2 h, she had recurrent pulseless ventricular tachycardic arrest 5 times in the emergency department (ED). After 5 days of further stabilization, the patient had a subsequent complete recovery with normal neurological function at discharge from the medical unit. In the ED it is imperative that we understand the now uncommon presentation of a TCA overdose in order to initiate immediate treatment. It is also important to understand the optimal treatment choices in patients that presents with TCA toxicity, especially arrhythmias that are refractory to initial treatment choices. Overall, severe TCA poisoning is often fatal; however, we demonstrated that with high quality resuscitative efforts, despite multiple arrests, survival to discharge with normal neurological outcome is possible.

Three times a charm a case of repeat appendicitis status post two prior appendectomies.

BACKGROUND: Appendicitis is defined as the bacterial proliferation and inflammation of the vermiform appendix, typically caused by a fecalith . There have been a few cases reported in the literature of recurrent appendicitis status post an appendectomy, however there has been no reported case of a recurrence status post two prior appendectomies. We would like to present the first case of recurrent appendicitis status post two prior appendectomies. CASE REPORT: A 32year old otherwise healthy male presented to the ER on 8/27 with right lower quadrant pain and no other symptoms. His initial triage vital signs were within normal limits. Of note patient had an appendectomy on 8/15/17 and a repeat appendectomy on 8/22/17 for recurrent appendicitis. Other than the RLQ abdominal pain, the patient's review of systems and physical examination were unremarkable. Patient's WBC was 7.5 and lactate was 1.4. A CT of the abdomen/pelvis showed a 1.3cm inflamed appendix. Patient was admitted to the Surgery service on IVF and IV antibiotics. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Appendicitis should continue to be on an emergency physician's differential for a patient with RLQ pain even when the patient has had a prior appendectomy. Appropriate management in the ER can lead to improved treatment, timely surgical consultations and decreased complications.

Primary Adrenal Failure in the Emergency Department.

BACKGROUND: Primary adrenal failure is considered to be an extremely rare disease presenting in the ED, with an incidence reported to be as low as 50 cases per 1,000,000 persons (Klauer, 2017). I would like to present a case of a young man who presented to the ED, with what I suspected to be this rare entity. CASE REPORT: A 26year old otherwise healthy male presented to our ED with complaints of weakness, nausea, vomiting, and hiccups of 1.5-day duration. He also complained of lightheadedness, describing it as if he was going to pass out. Other than slight tachycardia (100) and darkened skin, his physical exam, ROS, PMH, Family and Social History, were all unremarkable. His sodium returned at 111, and he was later noted to become more confused in the ED prompting the emergent use of Hypertonic Saline. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Albeit a rare disease entity, EPs need to keep this life threatening disease process in the back of their minds when presented with a patient with vague symptoms such as weakness or fatigue, electrolyte abnormalities and darkening of their skin.

Late onset postpartum preeclampsia 3 months after delivery.

Preeclampsia is defined by the American College of Obstetrics and Gynecology (ACOG) as "the occurrence of new onset hypertension plus new-onset proteinuria" [1]. Up-to-Date elaborates a little further on this by defining preeclampsia as "the new onset of hypertension and proteinuria, or hypertension and end-organ dysfunction with or without proteinuria, after 20 weeks of gestation in a previously normotensive woman. It may also develop postpartum. Severe hypertension or signs/symptoms of end-organ injury represent the severe end of the disease spectrum" [2] In 2013, the American College of Obstetricians and Gynecologists removed proteinuria as a key component in the diagnosis of preeclampsia. They also removed massive proteinuria (previously, 5 g/24 hours) and fetal growth restriction as possible features of severe disease. They found that were was a poor correlation in many outcomes between massive proteinuria and fetal growth restriction when managed similarly, with or without preeclampsia as a diagnosis. Oliguria was also removed as a characteristic of severe disease. [3] There have been several cases reported in the literature as well as by Obstetricians citing the incidence of preeclampsia occurring upwards of 6 to even 12 weeks postpartum. We hope to demonstrate what we believe to be a case of postpartum preeclampsia at 89 days postpartum.