Advocacy Workshop: Diversity and Inclusion in the ED

The US population continues to become more diverse but we still have racial and ethnic disparities in health care. How do you care for patients from different racial and ethnic backgrounds in the ED? Do these differences matter in healthcare or do we treat all patients with the same protocol? What biases do you bring with you that you might not be aware of? Are there ways to address these issues and bring greater understanding for you and your patients?

In October 2015, the Advocacy Track hosted a Diversity and Inclusion Workshop led by Amanda Bonilla, Assistant Director for Social Justice Education at IUPUI. We sought to discuss what the physician social responsibility is in regards to using inclusive language, understanding privilege, cultural and ethnic differences, and micro-aggressions.

We had good turnout with residents, faculty, and medical students in attendance.

Some of the critical topics covered included:

  • Bias we may have against people with different backgrounds
  • Understanding micro-aggressions
  • Recognizing the spectrum of diversity
  • Inclusive language

Why is this discussion so important to Emergency Medicine?

We want to enhance the professional development of all EM faculty and residents with respect to culturally competent medical care. The biggest reason to have this discussion in the emergency department is that we see patients from all walks of life and often provide their first impression of the hospital or hospital system. We broke into small groups and explored common stereotypes for racial, gender, religious and ethnic groups. This helped us to identify positive and negative biases we are aware of and how they affect our perspectives. Once we broke this down, we were able to further identify micro-aggressions and their effect on our practices.

As providers we want to give the best care we can, and that includes treating people fairly. Also, the better we understand our patients’ ethnic, cultural and religious identities the better care we can advise.

A sincere thank you to everyone who participated in this important conversation and our guest leader Amanda Bonilla!

Submitted by Tendi Warren, MD, PGY3 IUEM

Rachael’s First Week – Franklin Community High School

RFW Franklin 3RFW Franklin 1

On April 22, the Rachael’s First Week team held a presentation for Franklin Community High School in Franklin, IN. For those of you not familiar with Rachael’s First Week, it is a program designed to help high school seniors navigate the difficult transition from high school to young adulthood and college. Several hundred seniors gathered in the auditorium for the presentation and their responses have been overwhelmingly positive. Emergency medicine residents, Drs. Sarah Hemming-Meyer and Alex Rhea discussed safety tips, potential risks and ways to stay safe next year, but Rachael’s friends were the ones that were able to make students appreciate the reality of their vulnerability. These college students discussed their experience with Rachael’s death and also lessons they have learned over the last two years that they wish they had known before.

Rachael’s First Week is an ever-expanding program that has been able to interact with over one thousand students in live presentations and one thousand more via social media outlets. At Franklin, the students were, for the first time, able to interact via polling software allowing them to ask questions anonymously, an outlet necessary to inquire about sensitive subjects. Please watch the wonderful segment on Channel 8 highlighting this day. The next presentation will be at Zionsville High School on May 22. If you’re interested in helping out with Rachael’s First Week please contact Alex Rhea (rarhea@iu.edu) for more details.  Follow Rachael’s First Week on twitter: @Rachaels1stWeek

Link for Channel 8: http://wishtv.com/2015/04/23/campaign-expands-to-warn-more-students-of-college-dangers/

Special thanks to the Trauma NPs and IU ED RNs for their attendance and support for RFW.

Submitted By:  Alex Rhea, PGY-3 IUEM

Emergency Medicine Legislative Day 2015

Legislative day 1

IUEM Residents attended the annual Emergency Medicine Legislative Day at the Indiana Statehouse, organized by Emily Fitz (PGY3 EM Chief Resident and INACEP Resident Representative) and Lindsay Weaver (Emergency Medicine Associate Professor). Throughout the day, several legislators from both the house and senate stopped by to discuss issues in healthcare with the residents.

Dr. Tim Brown (Chair of Ways and Means), Dr. Jennifer Walthall (Deputy State Health Commissioner), and Dr. Heidi Dunniway (President of the ISMA) also participated by sharing their thoughts and individual experiences in advocating for patients through healthcare policy. It was enlightening to hear the extent of their dedication and passion for advocacy, and the ways in which a physician can become a leader in their field.

During her reflections on advocacy and resident impact on health policy, Dr. Jen Walthall aptly described, “residents are adorable but ruthless” in creating positive change in the legislative arena, and if “you are not at the table, then you are on the table.”

At this time, the Indiana legislation is considering the following bills:

  • Naloxone prescriptions for lay people (abusers, family and friends)
  • Needle Exchange Programs
  • Funding for more Residency spots in Indiana
  • Programs to enroll prisoners in Medicaid Prior to Release so they can get mental health medications
  • Increase in Medicaid coverage for psychiatric medications and inpatient detoxification

Dr. Lindsay Weaver reflected on the following recent legislation. “A bill that would increase malpractice caps was defeated earlier this year.  However, it is expected that the malpractice law will continue to be under attack over the next several years.  Thankfully, being at the statehouse and showing interest year after year will give us a voice in this debate.”

Several presentation were prepared and given by IUEM residents:

Emily Fitz, EM PGY3, Chief Resident:  “Legislative Day Overview”

  • 6th year of the program
  • Put together and run by IUEM residents
  • Sponsored by INACEP and IUEM
  • Our collaborations have brought about real change. Examples include the – Lifeline Law and Narcan for first responders

Sarah Hemming-Meyer, EM PGY2:  “Mental Health”

  • Mental health affects everyone- 1/4 adults, 1/10 children, 26% homeless and >50% inmates
  • Access to Care is directly related to Funding-HIP 2.0 expansion of Medicaid will have provide services to some people, but more funding is needed
  • We support the currently bills that are at this house & senate–Bill 1448 & Bill 1269
  • B1448–widening Medicaid coverage for approved FDA drugs with aid with substance withdrawal and inpatient detoxification
  • B1269–Department of Corrections become POA and assist inmates with Medicaid application not only while in prison and when released to ensure proper medications and support for inmates with mental illness.
  • National shortage of providers- increase funding for loan reimbursement, psych residency spots to increase # of psychiatry providers.

Kyle Yoder, EM/Pediatrics PGY5, Chief Resident:  “Prudent Lay Person” 

  • “Emergencies” are defined by the patient, not the doctor‬
  • A layperson cannot be expected to be able to differentiate a serious medical condition masquerading as a common medical condition
  • As emergency medicine doctors, we sometimes practice outside of the scope of our “medical specialty” because we are the only medical access for a portion of the population and because we took an oath to do what’s best for our patients

Rob Cantor, EM PGY3:  “Opiate Abuse and the Heroin Epidemic”

  • Opioid abuse is becoming an epidemic issue affecting our city, state and country.  Americans comprise <5% of the world’s population yet we consume ~80% of the world’s opioid supply.  120 people die in the U.S. every day from an opioid drug overdose.
  • Opioid abuse does not discriminate.  It affects all socioeconomic classes and ages, and being unemployed/homeless are not good predictors of abuse.
  • Recent increased restrictions on opioid prescribing has had several unintended consequences.  This includes a worsening heroin epidemic as well as HIV outbreaks in select communities as a result of increased intravenous drug abuse.
  • Senate Bill 406 (SB406), if passed, would allow physicians to prescribe Naloxone OTC without examining the patient for whom the drug is intended.  It would also allow for family/friends/first responders to administer this medication to individuals experiencing an expected opioid-related overdose.  We support passage of this bill which, when used in conjunction with current 911 Good Samaritan laws, can help save lives.
  • We have several goals looking towards the future.  We request continued support for state-side databases such as INSPECT.  We need additional funding for addictions counselors and facilities across the state.  We need improved resources and treatment options for individuals with mental health.  Our vision is to better identify patients who have a high risk of opioid abuse/addiction/overdose so that they can be treated appropriately either in chronic pain programs, with addiction specialists, or in various opioid clinics around the state.

David Hillhouse, EM PGY3:  “Malpractice and Increasing Residency Positions”

  • 1/4 of our residents choose to stay in IN
  • Opening up more residency spots will also keep good physicians in IN
  • A big reason residents choose to stay is because the malpractice laws are favorable (medical review board especially)
  • Maintaining the malpractice environment will keep physicians from leaving and will encourage more new physicians to come to IN

The following residents attended Legislative Day to meet their legislators and support their colleagues: Kailyn Kahre-Sights, Alex Rhea, Kara Reynolds, Beth Beard, Kyra Reed, and Dan Elliot.  Thanks also to Dr. Frank Messina, (Staff Emergency Medicine MD at Eskenazi), who was in attendance and reflected, “I think that it is important that we be involved at the level decisions are made.”

Legislative Day 2

Thank you to Dr. Emily Fitz and Dr. Lindsay Weaver for organizing a successful Legislative Day, and also to everyone for your participation and for representing Emergency Medicine in Indiana!

Submitted by Kyra Reed, PGY-3 EM/Pediatrics

Advocacy Workshop: Death and Dying in the ED

“There is a dignity in dying that doctors should not dare to deny.” – Unknown

Palliative Care Workshop 1

How do you respond when a family member pleas, “do everything”, for a dying patient?  What do you do for a patient with profound dyspnea at the end of life?  Did you know that hospice bereavement services are available to families of deceased patients even if the patient was never in hospice?

In February 2015, the Advocacy Track hosted a Palliative Care Workshop led by Dr. Lindsay Weaver, Assistant Professor of Clinical Emergency Medicine and Palliative Care Medicine. There was a tremendous turn out for the workshop, and included representation from multiple hospitals and a wide variety of specialties/fields – RNs, faculty/resident EM MDs, NPs, SWs, CMs, CNAs, hospice representatives, and palliative care experts.

A few of the critical topics related to death and dying in the ED were covered, including:

  • Withdrawal and end of life of care in the ED
  • Code status discussions in the ED
  • Hospice resources/information
  • Discussing the results of the palliative care needs assessment
  • Aiding in the development of an action plan for end of life care in our EDs

Why is this discussion so important, and how does it relate to emergency medicine?  

As Dr. Weaver aptly stated in her powerpoint, “The Emergency Department is the safety net for the acutely and chronically seriously ill. As the population ages, ED visits for crisis events in the setting of serious, chronic illness are likely to increase. Initiating end of life conversations in the ED allow for a more patient centered, quality of life centered focus that may save the patient from unwanted procedures, avoidance of unnecessary admissions, integration into resources such as palliative care sooner, and decreased overall cost to patients and families that does not ultimately improve end of life care.

Palliative Care Workshop 3

Individual patient cases were discussed in small groups, each illuminating key points in caring for patients at the end of life. The overwhelming theme was communication. Taking the time to discuss options with patients and families with the other team members (RNs, CMs, SWs) can prove to be the major factor in providing optimal care. The consensus was that we should start these conversations in the ED, because what we do has a snowball effect for the patient’s management/testing/procedures in the hospital.

What limitations or barriers exist to limit our ability as providers to achieve this in the ED?

  • Common responses include TIME. Conversations about end of life take time, and this can be a limited commodity in the ED during a bustling shift. However, sharing with your colleagues in the department that you are going to have a conversation with a family is OK. Some thoughts were to have secretaries hold pages for 10 minutes during this time, and to make a call-back list when you are finished. We often do not like to ask for help, but in some situations, this can prove to be the difference between intubation, central lines, arterial lines, vasopressors, and a week or more on the ventilator, when perhaps all the patient or family really wants is the option to go home with hospice or focus primarily on pain control and do it well.
  • Another concern was provider/RN comfort and perceived time required in providing medications for comfort. There seems to be a educational gap regarding goals of comfort measures in the department, because it is not performed often.
  • Furthemore, lack of documentation and medico-legal concerns are another factor.

Solutions we discussed to improve Palliative Care in the ED:

  • Creating an order set for withdrawal of care/comfort measures in the ED
  • Identifying a quiet place in the ED to provide comfort care and/or arrange services, for example, the observation unit
  • A bereavement resource basket filled with information for families who have a loved one pass in the ED
  • Resource handout available in the ED for easy reference for providers
  • Educating staff/residents/RNs/ancillary staff on medications used for comfort measures
  • Carrying out discussions and plan of care in the presence of the entire team, if possible, including MDs, RNs, chaplain, SW/CM to ensure communication is consistent
  • Holding pages from secretaries and asking fellow ED colleagues for help while you have this important conversation uninterrupted

Some of the above solutions are actively being implemented in the Methodist ED, and other sites are also being considered.

A sincere thank you to everyone who participated in this important conversation, particularly to our guest speakers, our resident leaders Amber Fouts (EM PGY-2) and Anar Desai (EM PGY-3), and to our faculty leader/presenter, Dr. Lindsay Weaver.

Submitted by: Kyra Reed, PGY-3 EM/Pediatrics

IUEM Christmas Family 2014

Christmas Family IUEM 2014 group

Each year, the Emergency Medicine/Pediatrics Residency and the Advocacy Team through Indiana University Emergency Medicine Program takes part in the United Way Christmas Service. The United Way pairs volunteers or groups with an underserved family in the community, with the goal being to provide gifts to a family that otherwise would be unable to do so. Volunteers are given the names, ages, sizes of clothes/shoes, and the desired gifts for each family member.

This year, the Advocacy Team provided gifts to a family of seven – five children (ages 1, 6, 11, 14, 17) and two parents. We are excited to share that well over $500 in donations were provided from the IUEM Residency Program! Volunteers helped wrap gifts and deliver them a few days before Christmas to the family. Shoes, clothes, winter coats, family games, a basketball, and a variety of Ninja Turtles toys were just a few examples of the gifts provided to the family. During delivery, the family was ecstatic about the donations, and extremely thankful. The mother shared that with a family member currently in hospice, they are going through a financial and emotional rough patch, and without the donations, they would have not been able to celebrate the holidays at all this year. The children stated happily that they plan on sending hand drawn thank you cards to the residency. Look at those smiles!

Christmas Family IUEM 2014 kids

Christmas Family IUEM 2014, wrap

Christmas Family IUEM 2014 wrap 2

Thank you everyone for your generous donations and for those that helped wrap and deliver the gifts! We look forward to continuing this annual tradition.

More about the Christmas Service:  http://www.uwci.org/programs/united-christmas-service

Submitted by:  Kyra Reed, PGY-3 Emergency Medicine/Pediatrics

Infant Mortality Summit 2014

Kyra Reed, PGY3 Emergency Medicine/Pediatrics

infant socks mort conference

“Preventing infant death is EVERYONE’s responsibility”.
This recurrent message from the 2014 Infant Mortality Summit resonated deeply with the audience as we gazed upon the 654 pairs of infant socks arranged on the stage. These socks represent the number of infants that do not survive to see their first birthday in Indiana each year. The issue surrounding infant mortality is multifaceted and complex, spanning a variety of socioeconomic, cultural, and geographic lines. The goal of the summit was to educate on facts, inspire, share innovative ideas/solutions, and to bring together resources to combat this public health concern in Indiana.

Reflecting on the conference, this message definitely included Emergency Medicine in my mind. We can all strive to find a teachable moment or provide a small intervention with families in the ED, such as information on safe sleep, injury prevention, and coping with parental stress. This just might save a life.

A few highlights from the summit:

infant mort summit safe sleep book

Charlie’s Kids Foundation is an organization created in memory of Charlie, son of Maura and Sam Hanke, who died from SIDsS in 2010. The book above, “Sleep Baby, Safe and Snug”, was written to educate families about safe sleep through vivid illustrations. Each page displays the AAP’s guidelines for safe sleep and early literacy in a creative and beautiful way. Perhaps a future project could be to pass out books to parents/guardians/foster parents of infants from the ED? Find out more: http://charlieskids.org/

Non-accidental trauma is an unfortunate reality, and this is part of what we see in the ED. Dr. David Olds with the Nurse-Family Partnership found that with the institution of home visiting nurse programs, the incidence of NAT and pediatric injuries substantially decreased.

— CVS announced that all tobacco products have been removed from their shelves. A win in the effort to decrease smoking rates.

— The afternoon breakout sessions also proved equally enlightening. A variety of important topics were covered, including approaches to addressing infant safe sleep, pregnancy and prescription drug abuse, delayed cord clamping in premature infants, smoking cessation in pregnancy, infant mortality in Burmese Chin population, strategies to address disparities in rural areas, postpartum contraception in urban adolescents, breastfeeding improvement strategies, simulation for obstetric/neonatal emergencies to improve outcomes in rural areas, and innovative technological mobile applications to improve education and access to resources. Some specifics from the sessions I attended:

Reducing Infant Mortality in a Vulnerable Burmese Chin Population, with Panel Discussion
– Burmese refugees represent the largest proportion of immigrants to Indianapolis, and numbers are increasing drastically every year
– Culture: Pregnancy is expected shortly after marriage. A larger family represents the strength of the family and provides increased support in times of need.
– Mothers often feel that prenatal vitamins lead to maternal weight gain, which results in large infants and therefore a high risk delivery
– Thus, providers need to encourage vitamin use and nutrition while explaining benefits
– Little to no prenatal care available in home country, all health costs paid out of pocket. No insurance, no blood banks. Most deliveries occur in the home with the assistance of female elder of the community.
– Initial screening for refugees upon arrival to U.S.: CMP, CBC, Hep A/B, UA, UPT, TB, syphilis, HIV
– Ways the community is attempting to improve education include: Educational programs on nutrition, health, and navigating healthcare in U.S., going to apartment communities where large number of Burmese live to provide resources
– Currently, group is working on providing genetic counseling and mental health resources
– Suicide risk in this population 4 times higher than general population

Wabash Valley Healthy Moms and Babies Initiative
RHIC picture
– Rural Health Innovation Collaborative (RHIC) in Terre Haute, IN: Learn more http://therhic.org/index.php
– “It’s about connecting people out of their silos,” explains Stephanie Laws, Executive Director of RHIC.
– Goal is to learn from communities and identify priorities of the community
– Striving to promote development of community-based prevention and intervention strategies
– It is a broad spectrum of community participation that leads to sustainability
– Rural culture often does not support asking for help, which impacts health
– Enacting Community Health Advocacy Leaders (evalueLEAD) for Pregnancy Peer Support Program, which creates social networks to provide emotional and instructional support for mothers
– The importance of community leaders in identifying issues and promoting change is undeniable
– The project has observed the immense power that social determinants have in overall health

Training Rural Providers to Save Infants Using Simulation
sim baby
– Large number of OB units throughout rural Indiana are closing
– Many residents of rural Indiana travel >30miles to access care
– Now have increasing number of deliveries occurring in rural EDs
– This is a low volume yet high risk situation for providers, mothers, and infants in this setting
– RHIC created simulation center to train rural providers for these OB/neonatal emergencies in order to reduce infant mortality
– Simulation scenarios are also brought to rural EDs unannounced to assess preparedness and what resources are needed for these situations
– Most rural providers have never seen an OB/neonatal emergency or it has been >9mo since being involved
– Critical Access Hospitals are eager to learn, and this training has been implemented successfully
– More about http://therhic.org/index.php/simcenter

Overall, a moving and educational conference. Thank you to the Indiana State Department of Health, Summit Speakers, and Breakout Session Speakers/Panelists for all of your hard work and inspirational comments!

On Back Pain and the Discipline of Empathy

Samuel Locoh-Donou is an IUEM PGY-2 resident and part of the IUEM Avocacy Track.

“Let ME tell you how to do this dance, doc. First, I want an American doctor who speaks good English and who knows what he is doing. Second, I want my brother to get an MRI today, instead of a goddamned rectal exam. Nobody is getting a rectal exam! I have a slipped disk, so I know how you guys operate. Always trying to line your pockets by billing for unnecessary procedures!”

How did we get here? I recall vividly an angry man standing in front of me, eyes blazing, with his index finger pointed in my face. He must have been in his late 50’s, and had tobacco stains in his beard and moustache, and a hunting cap screwed on his head. His brother, who actually was my patient, was resting on the ER room’s bed, in his mechanic dark blue overalls, looking very uncomfortable with the unexpected turn of events.

I was in shock. Over the course of my clinical training, I had yet had to encounter this level of disrespectful and prejudiced speech. In the space of two seconds, this family member had made allusions to my ethnicity, my accent, and my treatment plan in a way that made my blood instantly boil. This was new for me. My experience as a healthcare practitioner in this country has always been a very positive one. My French accent and a bit formal English vocabulary (conditioned by my schooling in the British system) was generally welcomed with an initial wide-eyed curious surprise on behalf of my patients, quickly replaced by a smile and a heartfelt, mindful conversation on what brought them to the hospital.

My 55-year old male patient had actually come in for back pain, like one of the thousand others who walk into our emergency room every day with the same complaint. He worked as a mechanic, and had developed instant back pain 3 days ago when bending over the hood of a truck he had been working on. His symptoms included lumbar pain so severe that he could not sleep at night, as well as shooting pains radiating from his lumbar area into his L. calf. He had no history of recent back trauma, IV drug abuse, cancer, or chronic steroid usage. When I asked about cauda equina symptoms, he denied saddle anesthesia, but endorsed 3 recent episodes of urinary incontinence and 2 episodes of weakness in his bilateral lower extremities that had caused his legs to buckle at the knees. The patient was unable to tell if his legs gave away because of pain or because of pure weakness. His past medical history was positive for hypertension and hyperlipidemia. He had undergone hernia repair surgery in the past, and smoked 1.5 pack of cigarettes a day.

My patient was clearly uncomfortable, but pleasant and calm during the interview. As I proceeded to the clinical examination, his brother walked into the room and sat silently on a chair in the furthest corner, watching us warily. Since it is my habit to acknowledge every person in the room, I greeted the family member, and earned a grunt for a response. As I focused back on my clinical examination, it struck me that my patient was very tender to palpation in the paraspinal lumbar areas, and had difficulty with proximal and distal bilateral lower extremity strength testing. When I asked why he was weak, he said he was actually too in pain to move. His lower extremity sensation and reflexes were normal. Given his story of urinary incontinence and the findings of weakness (possibly due to pain), I decided to check for a rectal tone for my own peace of mind. I explained to the patient what I wanted to do, and the reasoning behind a thorough physical exam for the type of symptoms he was having. The patient flat out refused, and the brother erupted from his corner with his index finger pointed to me.

I maintained an attitude as professional as possible, attempted to explain the indications for an emergency MRI and the required physical exam components to precede the actual MRI, but every single word I calmly uttered only further aggravated the family member. He screamed that he wanted a different doctor for his brother, so I excused myself and stepped out of the room. I closed the door with shaking hands as I tried to quell the anger storming inside. My female staff ended the visit after walking in the room alone and getting a better history of the episodes of urinary incontinence (more related to inability to get to the bathroom in time) and lower extremity weakness more related to pain than actual weakness. The patient was discharged with pain control, return precautions, and a physical therapy referral.

As I reflected on this incident in the following days, I realized that the outburst directed at me by the angry family member was actually rooted in the love the man had for his brother, and a fear that his brother would have to suffer unnecessarily because of perceived inadequate care. Since no man is perfect, the family member’s emotions could not be detached from his personal socio-cultural canvas, and his perception of a different skin tone and accent in a healthcare provider only heightened a sense of unfamiliarity and insecurity already ignited by a loved one’s suffering. I came to terms with my initial feelings of anger and indignation, by applying to my patient’s brother the same principles of empathy I apply with all my difficult patients.

According to a 2007 study, the development of clinical empathy by physicians is key in managing difficult patient-physician encounters, and clinical empathy was defined as the ability for physicians to be emotionally engaged during conflicts with patients. In a nutshell:

– Physicians should accurately acknowledge their feelings and negative emotions as they occurred;
– Physicians should take the time to consider the meaning of their negative feelings and how they may relate to the patients’ feelings;
– Physicians should attempt to discern the emotional issues that underlie the patients’ negative reactions;
– Physicians should be sensitive to the patients’ body language, as the patients’ nonverbal cues will require the provider to adjust their own nonverbal signals accordingly;
– Finally physicians should accept patients’ criticism and negative feedback without falling in the trap of getting defensive.

I believe that the disciplined application of these key principles to not only patients, but patients’ families as well, is a healthy technique for healthcare providers to engage in a conflictual conversation with emotional intelligence and without compromising themselves. The discipline of clinical empathy goes beyond the simple doctor-patient relationship, as a provider is also engaged in some type of therapeutic communication with a patient’s loved ones. And this is the challenging beauty of the art of medicine.

J. Halpern, “Empathy and Patient–Physician Conflicts,” Society of General Internal Medicine 22 (2007): 696–700