Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial.

STUDY OBJECTIVE: Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores. METHODS: In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison. RESULTS: All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66). CONCLUSION: Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.

The development of an educational workshop to reframe and manage professional conflict via a sex and gender lens.

Background: Conflict is inevitable in the emergency department, and conflict resolution is an essential skill for emergency providers to master. Effective conflict management can optimize patient care and enhance professional satisfaction. To communicate effectively in high-stress, high-impact situations, sex- and gender-based differences need to be considered. Methods: Nine resident, fellow, junior, and senior faculty members of the Academy for Women in Academic Emergency Medicine collaborated to design a 4-h workshop. The focus was on professional communication and conflict resolution in emergency medicine (EM), with special attention on how sex and gender can influence these processes. Results: The final educational workshop utilized a variety of formats focused on communication and effective conflict resolution including: traditional didactics, facilitated small groups with case-based learning, expert panel discussion, and an experiential learning session. The consideration of how sex- and gender-associated factors might contribute additional complexity or challenges to conflictual interactions were interwoven into each session to highlight alternative vantage points. Conclusions: Effective conflict resolution is an important skill for success in EM. We developed a workshop that went beyond typical communication-based programming to consider how sex- and gender-related factors influence communication and conflict resolution.

Sex- or Gender-specific Differences in the Clinical Presentation, Outcome, and Treatment of SARS-CoV-2.

This review describes the sex and gender differences in COVID-19 presentation, treatment, and outcomes. We discuss the differences between the sexes in susceptibility to infection, the role of sex chromosomes on the body's immunologic response and the influence of hormones on the body's response to the virus. Additionally, the sex differences in clinical and laboratory presentation, complications of infection and outcomes, as well as differences in response to treatment and prevention are reviewed.

Engaging Emergency Medicine Influencers in Sex- and Gender-based Medicine: Lessons Learned from the Sex and Gender Interest Group in Emergency Medicine and the SAEM Jeopardy Game.

The Sex and Gender in Emergency Medicine (SGEM) interest group of the Society of Academic Emergency Medicine (SAEM) was established to increase research and to disseminate knowledge about the influence of sex and/or gender in acute care medicine and on patient outcomes. To help facilitate these goals, over the past 4 years, SGEM has created, delivered, and honed a Jeopardy-like scientific quiz game for the annual SAEM national meeting. Here we describe the SAEM Jeopardy Game's development, implementation, evolution, and outcomes as well as our targeted approach to access and engage emergency medicine stakeholders in its participation.

Incorporating Sex and Gender-based Medical Education Into Residency Curricula.

BACKGROUND: Emergency medicine (EM) residents do not generally receive sex- and gender-specific education. There will be increasing attention to this gap as undergraduate medical education integrates it within their curriculum. METHODOLOGY: Members of the Sex and Gender in Emergency Medicine (SGEM) Interest Group set out to develop a SGEM toolkit and pilot integrating developed components at multiple residency sites. The curriculum initiative involved a pre- and posttraining assessment that included basic demographics and queries regarding previous training in sex-/gender-based medicine (SGBM). It was administered to PGY-1 to -4 residents who participated in a 3-hour training session that included one small group case-based discussion, two oral board cases, and one simulation and group debriefing. ANALYSIS: Components of the developed toolkit (https://www.sexandgenderhealth.org) were implemented at four unique SGEM Interest Group member residency programs. Residents (n = 82/174, 47%) participated; 64% (n = 49) were male and 36% (n = 28) were female. Twenty-six percent (n = 21) of the residents reported that they had less than 1 hour of training in this domain during residency; 59% (n = 48) reported they had 1 to 6 hours and 16% (n = 13) reported they had >6 hours. The average preassessment score was 61% and postassessment was 88%. After training, 74% (n = 60) felt that their current practice would have benefited from further training in sex-/gender-based topics in medicine during medical school and 83% (n = 67) felt their clinical practice would have benefited from further training in this domain during residency. IMPLICATIONS: The majority of EM residents who participated in this training program reported that they had limited instruction in this domain in medical school or residency. This initiative demonstrated a method that can be emulated for the incorporation of SGBM educational components into an EM residency training educational day. After training, the majority of residents who participated felt that their current practice would have benefited from further training in sex- and gender-based topics in residency.

Producing a successful PeRLs video.

Academic Emergency Medicine publishes selected peer-reviewed videos that present state-of-the-art research, practice, and evidence in the field of emergency medicine. These videos are referred to as peer-reviewed lectures (PeRLs). This commentary reviews considerations for creating, filming, and producing high-quality PeRLs videos.

Prospective comparison of helical CT of the abdomen and pelvis without and with oral contrast in assessing acute abdominal pain in adult Emergency Department patients.

PURPOSE: This prospective study compares the agreement of nonenhanced helical computed tomography (NECT) with oral contrast-enhanced computed tomography (CECT) in Emergency Department (ED) patients presenting with acute abdominal pain. MATERIALS AND METHODS: One hundred eighteen patients presenting to the ED with acute abdominal pain undergoing CT were enrolled over a 13-month period using convenience sampling. Exclusion criteria included acute trauma, pregnancy, unstable patients, and patients suspected of having urinary calculi. Patients were scanned helically using 5-mm collimation before and approximately 90 min after oral contrast administration. Both exams were prospectively interpreted by different attending radiologists in a blinded fashion using an explicit data sheet specifying the presence or absence of 28 parameters relating to various common diagnoses. RESULTS: The 118 patients had a mean age of 49 years, a male: female ratio of 7:13, and a median height, weight, and BMI of 166 cm, 80 kg, and 29, respectively. The most common indications for the study included appendicitis (32%) and diverticular disease (12%). Pain maximally localized to the right lower quadrant in 37% and the left lower quadrant in 21%. There were 21 patients that had significant disagreement of interpretations between NECT and CECT resulting in a simple agreement of 79% (95% CI: 70-87%). For specific radiologic parameters, agreement ranged from 77 to 100%. A post hoc agreement analysis was subsequently performed by two radiologists and only five paired scans were identified as discordant between the NECT and CECT. For only one of these patients did both radiologists agree that there was a definite discordant result between the two studies. A final unblinded consensus review demonstrated that much of the disagreement between the interpretations was related to interobserver variation. CONCLUSION: There is 79% simple agreement between NECT and CECT in diagnosing various causes of acute abdominal pain in adult ED patients. Post hoc analysis indicates that a significant portion of the discordance was attributable to interobserver variability. This data suggests that NECT should be considered in adult ED patients presenting with acute abdominal pain.

How reliable are pain scores? A pilot study of 20 healthy volunteers.

INTRODUCTION: Pain scales such as the 100-MM Visual Analog Scale and the 10-point Numeric Rating Scale are used to describe pain intensity. The Visual Analog Scale and the Numeric Rating Scale provide accurate descriptors for a patient's perceived level of pain. But how accurate or reliable is a patient's perception of pain? METHODS: To test the relationship between the intensity of the pain stimulus and pain perception, we devised an experiment using a convenience sample of 20 healthy adult volunteers. A cutaneous nerve stimulator delivered a series of shocks of increasing intensity to the individual via a pediatric EKG electrode. The participants indicated their threshold for "intolerable pain." With use of this same level of stimulus in subsequent shocks, the participants, blinded to the amount of stimulus, were then asked to rate each shock as either "the same," "a little less," or "a little more" than the baseline stimulus. They then recorded their VAS score for each stimulus. RESULTS: "Intolerable pain" varied widely between 8 mm to 73 mm; likewise, the level of stimulus that produced this pain ranged from 4 to 9. Once a person's threshold of "intolerable pain" had been reached, 49% of the subsequent shocks were perceived as different, even though the stimulus was exactly the same. DISCUSSION: This experiment showed that (1) given the same intensity of pain stimulus, different persons have different perceptions of pain; and (2) the same intensity of pain stimulus, given to the same person repeatedly, does not result in the same self-report of pain intensity.

Patient encounter time intervals in the evaluation of emergency department patients requiring abdominopelvic CT: oral contrast versus no contrast.

The aim of the study was to assess various time intervals during patient encounters involving unenhanced (NECT) versus oral-contrast-enhanced (CECT) abdominopelvic (A/P) CT performed in the emergency department (ED) on adult patients presenting with acute abdominal pain. Computerized patient order entry and administrative data as well as scans themselves were retrospectively evaluated at a high-volume (107,000 visits per annum) regional medical center urban ED for a period of 30 consecutive days. All adult patients who had CT of abdomen and pelvis for abdominal pain during the 30 days of the study period were included. Data collected included demographic information, time of registration, time of first encounter in the ED, time of CT order, clinical indication for scan, time of scan, time of disposition (i.e., discharge or admit), and final disposition. Patients were excluded if they were less than 16 years old, pregnant, or met criteria for major trauma and evaluation in the trauma suite. Patients were also excluded from analysis if they received more than one scan on the same day (3 patients). Of 183 patients, 102 underwent NECT and 81 CECT. Some of the patients who underwent NECT had urinary colic. Among patients who did not have urinary colic there is a statistically significant difference in the median time intervals between: (1) patient arrival in the ED and evaluation by a physician (NECT 57 min, CECT 84 min, P<0.001); (2) patient exam by the physician and the time the A/P CT was ordered (NECT 35 min, CECT 63 min, P<0.01); (3) receipt of the CT order and the time of the scan (NECT 104 min, CECT 172 min, P<0.001); and (4) time of arrival in ED and disposition (NECT 358 min, CECT 599 min, P<0.001). There are significant time interval differences between CECT and NECT during patient encounters involving adults presenting with abdominal pain to the ED. The differences are greater than the amount of time allotted for opacification of small bowel (90 min). Baseline data such as these may prove useful in assessing the efficacy of scan techniques and improving resource utilization.

Does morphine change the physical examination in patients with acute appendicitis?

The objective of this study was to determine if judicious dosing of morphine sulfate can provide pain relief without changing important physical examination findings in patients with acute appendicitis. We conducted a prospective, randomized, double-blind crossover design. Patients scheduled for appendectomy were randomized to two groups. Group A received 0.075 mg/kg intravenous morphine sulfate and 30 minutes later received placebo. The sequence of medication was reversed in group B. Patients were examined by a surgical resident and an EM attending before and after receiving medication. Six explicit physical examination findings were documented as absent, indeterminate, or present. Physicians were also asked if they felt overall examination findings had changed after medication. Patient's visual analog scale (VAS) was recorded before each medication and at study completion. Thirty-four patients were enrolled and full data were available for 22 patients. Neither morphine nor placebo caused a significant change in individual examination findings. Three patients in both groups were judged to have a change in their examination after medication. The median change in VAS was 20 mm after morphine and 0 mm after placebo (P =.01). In this pilot study, patients with clinical signs of appendicitis were treated with morphine and had significant improvement of their pain without changes in their physical examination.