Disparities in the Use of Chemical and Physical Restraints in the Emergency Department by Race/Ethnicity.

BACKGROUND: Restraints are often utilized in the emergency department (ED) to prevent patients from injuring themselves or others while managing their agitation in order to deliver appropriate medical care. Chemical and physical restraints are ordered at the discretion of the medical provider and typically employed after reasonable verbal de-escalation has been attempted. While health inequities and racial bias in medicine and healthcare have been well-established, information on the differences in the selection and use of restraints by race and ethnicity are scarce. METHODS: This retrospective cohort study utilized national data from HCA Healthcare ED and inpatient database with patient visits from 2016 to 2019 to evaluate the relationships between race and ethnicity and the utilization of restraints in the ED. Associations are reported using linear and logistic regression analyses. RESULTS: The study population included 12,229 unique ED admissions for patients 16 and older with diagnoses of aggression or agitation who had either chemical or physical restraints used. There was no statistically significant difference when comparing Black or other race to White patients and the type of restraint used. Hispanic patients received 0.206 fewer doses of chemical restraints compared to White patients (p = 0.008, 95% C.I. [-0.359, -0.053]) and were slightly less likely to receive physical restraints compared with White patients (p = 0.044, 95% C.I. [0.467, 0.989]), but there was no difference between use of physical restraint and Black or other patients compared to White patients. CONCLUSIONS: In this national sample of agitated and/or aggressive ED patients who were restrained, Hispanic patients were slightly less likely to receive physical restraints and received fewer doses of chemical restraints than White patients. There were no differences between Black or other patients compared to White patients in restraint type, number of doses of chemical restraint or time to application of either restraint type. This suggests that physicians apply the use of chemical restraints to agitated and aggressive ED patients based on factors that are not  associated with race and ethnicity.

Racial disparities in patients hospitalized for COVID-19.

BACKGROUND: The COVID-19 pandemic has demonstrated the significance of health disparities across populations with older adults and minoritized groups being disproportionately affected. Data during the COVID-19 pandemic demonstrated higher infection rates, hospitalization rates, morbidity, and potentially greater mortality in Black, Hispanic, and Native Americans compared to Whites. METHODS: This is a retrospective cohort study of de-identified patient data from 178 hospitals across the United States. Outcome variables were the length of stay, in-hospital mortality, disease severity, and discharge disposition. Outcomes were stratified by sex and racial groups. RESULTS: Of 45,360 patients, 22% were Black, 35% were Hispanic, 37% were White, and 6% were Other. The overall mortality rate was 15% across all groups but was 17% for White patients, 10% for Black patients, 14% for Hispanic patients, and 15% for patients categorized as Other. However, White patients have higher median age on admission (71 years) compared to Blacks (60 years), Hispanics (57 years), and Other (61 years). Race remained statistically significant in a multivariable model that included age, sex, and race. 6484 patients required ICU admission, intubation, and hemodynamic support. This burden was disproportionate across racial groups, with 15.6% of Blacks and 13.9% of non-Blacks having such critical disease (p < 0.0001, z-test for proportions). CONCLUSIONS: In this national study of admitted patients with COVID-19, White patients admitted were older on average compared to other racial/ethnic groups and had a higher mortality rate compared to non-Whites hospitalized for COVID-19. Black patients were significantly more likely to require admission to the ICU, mechanical ventilation, and hemodynamic support. These COVID-19 health disparities highlight the importance of addressing social and structural determinants of health.

Perceptions of Advocacy in High School Students: A Pilot Study.

Assessing perceptions and attitudes of advocacy in adolescent populations is an important area of research. Previous studies have shown that advocacy programs in high schools are well-received and help promote health advocacy. This pilot study took place at the University of Central Florida College of Medicine Health Leaders Summer Academy hosted by medical students of the Student National Medical Association. A one-hour interactive workshop was administered to high school students interested in the healthcare field. Pre- and post-survey data were collected to assess participants' perceptions, methods, and barriers to engaging in advocacy. A total of 29 students were included in this study. Results indicated that students' definitions of advocacy changed after completing the workshop, as a higher percentage of students indicated that they practiced advocacy (pre-survey, 82.76% versus post-survey, 95.45%). There was a statistically significant difference in perceptions of the importance of advocacy in the student's future career (pre-survey, 3.82 versus post-survey, 4.15, p = .035). Social media was the most effective and common form of advocacy used (post-survey 72.73%). The most common barrier to practicing advocacy was a lack of education on a particular topic (31.82% post-survey). Overall, the workshop increased participants' interest in engaging in advocacy. Future directions include expanding the study to a larger population sample throughout the Orlando community and researching the use of social media as a tool for advocacy.

Health Equity in Medicine.

Description Healthcare disparities exist when, due to racial, ethnic, or gender identity differences linked to social, economic or environmental factors, certain populations lack equitable access to quality healthcare and insurance coverage. Such disparities across history carry profound future implications that we have only begun to contemplate as a profession. This special issue of the HCA Healthcare Journal of Medicine examines the critical issue of health equity in medicine and how the medical community can advance health equity through inclusive behavior and interactions in clinical and educational settings, and our communities.

Identifying, Addressing, and Eliminating Microaggressions in Healthcare.

Description Microaggressions are pervasive throughout society, including in healthcare and academic institutions. They are often unconscious but accumulate over time, and they negatively impact the recipients' productivity and achievement by creating a sense of inadequacy as well as a lack of belonging. We outline several evidence-based strategies and teaching frameworks that institutions and training programs can adopt to reduce the prevalence and impact of microaggressions against trainees from historically marginalized groups, and that can promote psychological safety for everyone.

A Simulated Scenario to Improve Resident Efficiency in an Emergency Department.

Introduction Multitasking is a core competency in emergency medicine. Simulation has been shown to be an effective method of education, which allows learners to prepare for real-world challenges in a controlled environment. Methods In this study, trainees were given a scenario that simulated the experience of managing two patient encounters within a time metric while addressing interruptions that take place in a typical ED. Residents were evaluated using an internally developed scoresheet, which assessed task-switching abilities, documentation skills, and adherence to door to disposition time metric. Residents were asked to evaluate their experience with a survey. Results All the participants reported that they would translate some of the skills learned to their daily clinical practice. Five out of six residents reported improvements in their skills as a result of the task-switching training. The following three common themes were pervasive in the debrief discussion: (1) the residents felt the added pressure of the door-to-disposition metric, (2) the objectives of the simulation did not fit within their pre-constructed concept of a successful simulation equating to establishing the correct diagnosis, and (3) the interruptions were very realistic. Discussion Emergency physicians are interrupted approximately every 9-14 minutes, and this number increases with the number of patients being managed simultaneously. By developing a safe, simulated training environment, we sought to transfer key strategies for improving focus and learning to prioritize while also helping them to identify how certain pressures and interruptions affected their stress levels and concentration.

Apnea and Diffuse Alveolar Hemorrhage Caused by Cocaine and Heroin Use: A Case Report.

INTRODUCTION: Drug overdose represents a growing reason for emergency department visits and hospitalizations in the United States. Co-ingestion of multiple substances is also on the rise, and toxidromes can be seen from any of multiple drugs in a single patient. CASE REPORT: We present a case of diffuse alveolar hemorrhage secondary to cocaine abuse in a patient who was apneic and unresponsive after heroin overdose. The patient responded to supportive care and was discharged with complete return to physical and mental baseline. CONCLUSION: Clinicians must be vigilant for any number of concomitant toxidromes when a patient is brought in with complications following drug overdose.

Hyperkalemic Emergency: When You Have Taken a Few Too Many KCl Tablets.

Hyperkalemia is a common clinical problem that varies significantly in severity and indications for treatment. Hyperkalemic emergency exists when there are clinical signs or symptoms, including cardiac conduction abnormalities. The combination of nebulized albuterol and insulin with glucose is most effective for managing clinically significant hyperkalemia. Prompt recognition of hyperkalemic emergency, immediate interventions to lower extracellular potassium, and involvement of multiple disciplines (including critical care and nephrology) are essential to addressing this life-threatening presentation.

Ocular Thermal Burn Injury in the Emergency Department.

We present a case of an ocular thermal burn from a cooking accident where vegetable oil splashed into the patient's face. The emergency department evaluation and management of ocular thermal burns is discussed. Prompt evaluation, copious irrigation, and consultation with ophthalmology are recommended. Teaching points are highlighted.

Assembly Line Education: A Novel Educational Technique for Today's Learners.

Background Education is undergoing a transformation. The traditional passive lectures are failing to capture and inspire the new generation of learners who value more active and collaborative learning techniques. Objective We sought to create a novel educational technique to integrate into our curriculum that would be more personalized, employ more active learning and collaboration, and allow for an effective assessment of resident strengths and weaknesses. Discussion We created a monthly assembly line education academic half-day that evolved to replace one of the typical in-classroom didactics each month. Faculty run small-group simulation rooms, procedure workshops, competitive ultrasound, and wellness stations through which residents and medical students rotate. Conclusion This novel education technique resulted in a more personalized approach that increased resident interest, sparked the creation of a very popular MedEd-Simulation elective, and allowed the faculty to gain a better sense of resident strengths and deficiencies.

Medical students and metrics: seven techniques for a win-win situation.

BACKGROUND: The authors present seven winning strategies for maintaining a rich academic environment for learners while working in a busy emergency department with expected productivity metrics. METHODS: This is a descriptive paper based on existing literature and on the authors' experience. RESULTS: Winning strategies to improve ED throughput while also supporting the mission of medical education and improving the learning environment for students include the following: (1) attending first, (2) provider in triage, (3) mobile workstations, (4) patient education, (5) bedside patient presentations, (6) dedicated teaching resident, and (7) thoughtful scheduling. CONCLUSIONS: The authors present seven practical strategies that are portable to many settings.

Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review.

Spontaneous bacterial peritonitis (SBP) has a high mortality rate; early antimicrobial therapy is essential for improving patient outcomes. Given that cirrhotic patients are often coagulopathic, the perceived risk of bleeding may prevent providers from performing a paracentesis and ruling out this potentially deadly disease. We examine the pathophysiology and risk factors for SBP, and current guidelines for its diagnosis and treatment. We then review the time-sensitive nature of performing a paracentesis, and the current controversies and contraindications for performing this procedure in patients at risk for SBP. Cirrhotic patients with ascites and clinical suspicion for SBP-abdominal pain or tenderness, fever or altered mental status-should have a diagnostic paracentesis. Although most patients with cirrhosis and liver dysfunction will have prolonged prothrombin time, paracentesis is not contraindicated. Limited data support platelet administration prior to paracentesis if <40,000-50,000/µL. Timely antimicrobial therapy includes a third-generation cephalosporin for community-acquired infection; nosocomial infections should be treated empirically with a carbapenem or with piperacillin-tazobactam, or based on local susceptibility testing. Patients with gastrointestinal (GI) hemorrhage should receive ceftriaxone prophylactically for GI hemorrhage. SBP has a high mortality rate. Early diagnosis and antimicrobial therapy are essential for improving patient outcomes. Cirrhotic patients with ascites with clinical suspicion for SBP, abdominal pain or tenderness, altered mental status or fever should have a diagnostic paracentesis performed prior to admission unless platelets <40,000-50,000/µL.

Socially-assigned race, healthcare discrimination and preventive healthcare services.

BACKGROUND: Race and ethnicity, typically defined as how individuals self-identify, are complex social constructs. Self-identified racial/ethnic minorities are less likely to receive preventive care and more likely to report healthcare discrimination than self-identified non-Hispanic whites. However, beyond self-identification, these outcomes may vary depending on whether racial/ethnic minorities are perceived by others as being minority or white; this perception is referred to as socially-assigned race. PURPOSE: To examine the associations between socially-assigned race and healthcare discrimination and receipt of selected preventive services. METHODS: Cross-sectional analysis of the 2004 Behavioral Risk Factor Surveillance System "Reactions to Race" module. Respondents from seven states and the District of Columbia were categorized into 3 groups, defined by a composite of self-identified race/socially-assigned race: Minority/Minority (M/M, n = 6,837), Minority/White (M/W, n = 929), and White/White (W/W, n = 25,913). Respondents were 18 years or older, with 61.7% under age 60; 51.8% of respondents were female. Measures included reported healthcare discrimination and receipt of vaccinations and cancer screenings. RESULTS: Racial/ethnic minorities who reported being socially-assigned as minority (M/M) were more likely to report healthcare discrimination compared with those who reported being socially-assigned as white (M/W) (8.9% vs. 5.0%, p = 0.002). Those reporting being socially-assigned as white (M/W and W/W) had similar rates for past-year influenza (73.1% vs. 74.3%) and pneumococcal (69.3% vs. 58.6%) vaccinations; however, rates were significantly lower among M/M respondents (56.2% and 47.6%, respectively, p-values<0.05). There were no significant differences between the M/M and M/W groups in the receipt of cancer screenings. CONCLUSIONS: Racial/ethnic minorities who reported being socially-assigned as white are more likely to receive preventive vaccinations and less likely to report healthcare discrimination compared with those who are socially-assigned as minority. Socially-assigned race/ethnicity is emerging as an important area for further research in understanding how race/ethnicity influences health outcomes.

Ethical considerations for clinical photography in the global South.

Clinical photography is an important tool for teaching practitioners and field workers about the clinical manifestations of famine and undernutrition, particularly with respect to the Global South. Current international guidelines for clinical photography are not consistently applied or enforced, which has led to violations of privacy and rights, particularly for patients and victims of disaster in the Global South. Combining existing clinical photography guidelines from the North with ongoing clinical ethics debates in the South, this paper explores approaches to establishing photography guidelines throughout the world that will be sensitive to the privacy and dignities of all patients and victims of emergencies.

Late gestation increase in 11beta-hydroxysteroid dehydrogenase 1 expression in human fetal membranes: a novel intrauterine source of cortisol.

Late human gestation is associated with an increase in the concentration of cortisol (F) in the fetal circulation and amniotic fluid. It had been assumed that most of the F measured in the amniotic fluid came from the fetal adrenal gland. However, local production of F can also occur in human intrauterine tissues from inactive cortisone under the influence of the enzyme 11beta-hydroxysteroid dehydrogenase (11beta-HSD) type 1. Recent studies have shown that 11beta-HSD 1 activity is up-regulated by prostaglandins (PG) E2 and F2alpha, hormones that are produced in the fetal membranes (FM) at term. In the present study, we hypothesized that 11beta-HSD 1 expression would increase in FM during pregnancy and at labor, creating the potential for local increase in F production at term. We examined 11beta-HSD 1 expression in placenta and FM obtained during normal pregnancy from nonlaboring women [26-28 wk (n = 3); 29-30 wk (n = 3); 32-33 wk (n = 3); 35-36 wk (n = 3)] and from uncomplicated term pregnancies after elective cesarean section (n = 6). 11beta-HSD 1 expression was also examined in amnion and chorionic tissues in relation to term labor (n = 12). Immunohistochemistry and Western blot analysis were used to examine 11beta-HSD 1 localization and expression. 11beta-HSD 1 activity was also measured in microsomal fractions prepared from whole fetal membranes. At term, immunoreactive 11beta-HSD 1 expression was localized predominantly to the chorion trophoblast cells, attached decidua, and amnion epithelial cells. 11beta-HSD 1 expression in FM increased with gestational age and reflected increased enzyme reductase activity. No change in 11beta-HSD 1 expression was found in placental tissue from the same patients. There was a significant increase in 11beta-HSD 1 expression in amnion but not in chorion with the onset of labor. We suggest that increases in 11beta-HSD 1 expression/activity by intrauterine membranes during late gestation may result in increased potential for a local increase in F production and that FM should be considered as an extraadrenal source of F during late gestation. This local F production may be involved in different pathways contributing to the regulation of parturition.