It’s not a mystery that college kids go to parties, drink fruity jungle juice, and do keg stands. What is more concerning is how many of those kids might let their friend “sleep off” a fall or landing on their side. As clinicians, we know this can be dangerous. Anyone under the influence of one too many rum and sodas does not have great insight and may not realize that falling from a height could lead to devastating injuries. This happens cringingly often, but does not have the spotlight or common knowledge amongst teenagers and early 20-somethings. Until now.
Rachael Fiege was your typical Indiana girl. She was outgoing and a friend to many. She had been a good student and star soccer player during high school. On her second night of college at IU, she and her friends went to their first college party. They knew to stay together and look out for each other throughout the night. She and her girlfriends were having a great time until she tumbled down a flight of stairs. Able to shake it off, Rachael’s friends encouraged her to lie down on the couch, checking on her a few times during the party. It wasn’t until the morning they realized she was no longer breathing. Her mother and critical care physician, Dr. Angie Fiege received the worst possible phone call any parent could ever hear. Her beautiful, vibrant daughter had died of an intracranial hemorrhage.
Rachael’s legacy has led to an important, expanding program, Rachael’s First Week (RFW). Angie started this with donations left in her daughter’s name, initially creating the program to inform high school seniors and college students in a non-confrontational that it’s ok to call 911 if you’re worried about a friend. Thanks to the Lifeline Law, if you’re under 21 and intoxicated and need to go to the hospital, you can dial 911 for you or your friend…and not see the inside of a jail cell. Angie started off small, gathering a few of Rachael’s friends and emergency medicine residents and students from IU, and went to her high school to have the first ever session. Now, RFW has reached out to thousands of high school and college students including other schools around Indianapolis, Indiana University, Marion University, and Butler University. The message is always well received.
“ Rachael’s First Week challenges young men and women to think about the choices they make, and always look out for each other, even strangers. The program encourages a change in culture from approaching college with risk-taking behaviors to one of fun using common sense and caring for friends and strangers alike.”
The format allows for anonymous questions to be sent in via text messaging, which really allows for candid discussion. They also cover drug use and suicide through text polling, and often there’s as many as one third of the students who have considered suicide, which is eye opening and heart breaking. Through the program, they provide resources and let the students know what to do in these tricky situations. Lives have already been saved, and more will be in the future. Already, there are six events scheduled for the spring. If you are interested in helping, donating, or for more information please go to rachaelsfirstweek.com.
Numerous opportunities are coming up to volunteer with RWF February through May 2018.
By Ashley Satorius-Rutz, MD Emergency Medicine 2nd year resident
This post represents an individual resident’s reflection on current events and does not primarily represent the views of IUSM EM nor does it intend to provide expert level resources or facts on the matter, though a fair assessment of readily available information was attempted in writing this post.
Just past midnight on July 28th, 2017 an unexpected twist took place in the Senate chamber as Senator John McCain broke from Republican party lines and voted no for a “skinny repeal” on Obamacare, joining the other Republican senators Susan Collins of Maine and Lisa Murkowski of Alaska (and many Democrats) who steadfastly opposed healthcare reform in this manner. This effectively terminated the bill which would have dismantled parts of Obamacare and according to the U.S. Congressional Budget Office would have led to 16 million additional Americans becoming uninsured in 10 years and health insurance companies estimating rate increases for coverage. This was the stripped down version of a larger repeal and replace bill BRCA proposed by senators but also that met opposition and failed to pass voting earlier this month.
John McCain made it clear that he was not protecting Obamacare but that he wanted real health care reform that would not have happened in the form of the skinny bill in the following statement,
“While the amendment would have repealed some of Obamacare’s most burdensome regulations, it offered no replacement to actually reform our health care system and deliver affordable, quality health care to our citizens,” he said. “The Speaker’s statement that the House would be ‘willing’ to go to conference does not ease my concern that this shell of a bill could be taken up and passed at any time.”
“I’ve stated time and time again that one of the major failures of Obamacare was that it was rammed through Congress by Democrats on a strict-party line basis without a single Republican vote. We should not make the mistakes of the past that has led to Obamacare’s collapse, including in my home state of Arizona where premiums are skyrocketing and health care providers are fleeing the marketplace. We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people. We must do the hard work our citizens expect of us and deserve.”
The question is – – what next? And what does it matter to Emergency doctors?
Far from the stone edifices of Washington D.C. we are taking care of patients day in and day out in the Emergency departments of Indianapolis. Hundreds of thousands of visits by Hoosiers (and sometimes neighboring states since we are “the Crossroads of America) take place here every year. Do our patients care about this reform? Recent polls suggest two thirds of U.S. citizens have cooled to the idea of immediate reform and want Congress to get to other tasks. (https://www.reuters.com/article/us-usa-healthcare-poll-idUSKBN1AE0RY)
I am an Emergency doctor with a mind for trying to play my role in the medical team of the system at large; since I cannot address and change the course of every ailment our patients come to the Emergency Department for. Aside from ruling out any bad emergencies, I take time to think about what I can do to help them in the meantime, what they need to know, and what they should try next for solutions. It matters to me that I play this role and that my patients understand that when our visit ends today, we may just be scratching the surface and not be done yet. It also matters that they discover other places to get this appropriate care and planning aside from the Emergency Department.
There is a particular part of me that despairs when I see someone without health insurance, who will surely not be able to better their health on their own, and will have a much steeper if not impossible time of getting appointments with my colleagues in the outpatient and surgery world. They came to me because they had a problem, I showed that it was not an emergent problem that required hospitalization, surgery, or intervention at that second, however, their problem will likely persist and frustrate them, feeling like “no one helped.” Without access to the medical system most typically through insurance, things are not going to be looking better for them.
We see lots of patients. We have the honor of serving patients regardless of their ability to pay or their insurance status and I appreciate the equality of that. I chose to train at IUEM program for the number of patients and the variety of people I can help. Unfortunately, business can also mean ED overcrowding and physician burnout, and it seems that numbers of ED visits climb every year. That is the trend in many Emergency Departments, and providing insurance does not do what we might have expected, which is give people a better option to outpatient doctors to get their conditions under control so they can avoid coming to the ED. Instead we are seeing a growing number of ED visits since implementation of the ACA and more people gained access to health care. (http://www.annemergmed.com/article/S0196-0644(17)30319-0/fulltext)
When the board of incoming patients never clears, when the patient’s concerns and requests of you seem unreasonable, you quickly drop the Lady Liberty act, “Give me your tired, your poor, Your huddled masses yearning to breathe free…” yadda yadda. As an intern up until July 2017, I spent the last year seeing a large percentage of my patients in the lower acuity area of our emergency departments. This did not mean patients did not need help or medical attention, but that they did not need to be in shock rooms where they might get an emergent airway, trauma survey, or invasive medical procedures performed under minute to minute monitoring. The use of an Emergency department for some of the complaints seemed a bit dubious, even to me as an idealistic intern.
On the flipside, I know how the system works and I am being trained specifically to tell an emergency from non-emergency. How many years of study did it take for me to get to this position? The burden of placing the patient in determination of what an emergency is cannot be expected for the reason I mentioned before. U.S. citizens have on average a 7th or 8th grade reading level. Good luck interpreting medical literature with that reading level and while you are trying to decide if you are experiencing an emergency.
Before ACA implementation we knew as a nation we had a shortage of doctors, especially primary care doctors, surgeons, psychiatrists, which are the specialties I most acutely need the assistance of when taking care of patients in the Emergency department. (https://www.aamc.org/data/workforce/reports/439206/physicianshortageandprojections.html). We generally do not have an optimum number of providers to patients in all fields including emergency medicine. That takes more policy change and training shifts than what the ACA can provide. However, repeal also does not even begin to tackle this problem and instead offers to take away Medicaid and what small payments outpatient offices can get for seeing these patients.
Indiana’s Insurance Program HIP 2.0
I am relieved for the near future that this round of health care reform will not proceed without more deliberation and hopefully bipartisan and policy expert input. Lots of questions must be resolved. I understand that part of the opposition to leaving the ACA intact involves the increasing insurance premiums and decreased choice available on state exchanges. Indiana, which has a Medicaid waiver to run its own Medicaid expansion program called HIP 2.0 was discussed as a possible example of nationwide Medicaid reform at the 2017 ACEP Leadership and Advocacy conference in D.C. Despite being touted as a success, this program is not without its issues, outside policy researchers found that the monthly payments or “skin in the game” notion that patients must contribute to stay active in the program confused and often locked them out of care for a time period.
“One-third of eligible individuals who apply are not enrolled because they haven’t made a premium payment… Around 30,000 people… had been found eligible in the past 60 days but hadn’t enrolled at all. HIP 2.0’s premiums are deterring significant numbers of eligible low-income people from enrolling… For many people, the cost wasn’t the biggest obstacle. Rather, 84 percent of people who were bumped from HIP Plus to HIP Basic for nonpayment said they had been confused about the payment process and the program in general.” (https://www.theatlantic.com/business/archive/2016/12/medicaid-and-mike-pence/511262/?utm_source=atlgp)
Another obstacle facing our own state, and many others, is that costs of insurance premiums are increasing and less insurance companies are participating in the exchange which negates competitive pricing options. In 2018 in Indiana only two insurers will continue to participate in Obamacare exchanges, whether this changes now that legislation to gut Obamacare has failed thus far, we will see. (https://www.ibj.com/articles/64327-only-two-insurers-to-offer-obamacare-plans-in-indiana-next-year?v=preview) Insurance markets and incentives go way beyond my level of understanding and I hope that as a state we have the right people at the table to turn back this trend for Hoosiers and propose ways to improve this moving forward.
Future for EM and American Health Care
I stand in favor of providing access and working to make the system more preventative than reactionary when providing Americans with health care. I welcome debate, education, and well-thought out ideas about how to make this system better as an Emergency resident and physician providing medical care to my fellow people. In summary and in agreement with the following, I include the most recent statement about health care reform from President of American College of Emergency Physicians, Becky Parker, MD, FACEP:
“We have expressed concerns throughout this process regarding the devastating impact some of the repeal proposals under consideration could have had. Looking ahead, we now urge lawmakers on both sides of the aisle to work together to address the serious problems that still exist involving the health insurance market. These solutions must include appropriate protections for the tens of millions of emergency medical patients that go to emergency departments each year.
Guaranteed coverage for emergency medical care must continue to be protected by federal law. Patients should be able to seek and receive emergency care when and where it is needed, without fear that their insurance company will not cover it. In addition, when patients have insurance plans with unreasonably high deductibles, they often delay medical care until the problem becomes a life-threatening emergency.
Policymakers, lawmakers, business leaders, physicians and health care experts must work together to help improve a health care system that benefits every American.” (http://newsroom.acep.org/2017-07-28-ACEP-Statement-on-Future-Health-Care-Legislation)
Reflection by Jennica Siddle, MD MPH, 2nd year Emergency Medicine Resident
IUEM has had a long and fruitful relationship with the Central Indiana Bicycling Association (https://www.cibaride.org/) and this year was no different! We stayed busy at several volunteer opportunities to make children safer and parents more educated about helmet and bike safety in Indianapolis. Assisted by grants that CIBA acquired we managed to hand out thousands of helmets to protect the gourds, noggins, or craniums of many Indy youth.
On April 30th, our volunteers and partners handed out 2,750 helmets at the Children’s Museum of Indianapolis. Each kid’s head was measured and then trained volunteers adjusted the helmets to ensure a good fit. We had a good 30 some volunteers representing IU Emergency medicine and Pediatric residencies, nursing staff from Methodist Emergency department, Indianapolis Metro Police Department, and of course, CIBA to make the event a success.
We hope all the kids had a very active and safe summer with their new shiny helmets!
Our next event was the Indy Criterium Bicycle Festival on July 8 where we again fitted and provided a large number of bike helmets for Indy kids with CIBA. What a fun event, held right in the heart of downtown on the circle! (http://www.indycrit.org/festival)
In the process of volunteering we also got to cheer on one of our Riley Pediatric Emergency Dept. attending physicians, Greg Faris. IU held their own in the racing of the Indiana Pacer bike-share bikes, the yellow ones you see downtown meant for more casual cruising. Alas, victory was just out of reach. However, we were certainly pleased with the knowledge that hundreds of children would have a safer summer for the volunteer work we were able to provide.
We look forward to being involved again next year and maybe seeing IU bring home a win on the cruisers!
If you are interested in knowing whether your bike helmet is fitted correctly, check out this quick 30 second tutorial. We found that lots of helmets put on by the kids or parents left much of the forehead unprotected.
And if you are on the fence about whether helmets are worthwhile, take a look at some literature from 1994 …
“Wearing a helmet reduced the risk of head injury by 63% (95% confidence interval 34% to 80%) and of loss of consciousness by 86% (62% to 95%).”
Effectiveness of bicycle helmets in preventing head injury in children: case-control study
BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6922.173 (Published 15 January 1994)
The advocacy track hosted Kim Irwin from the Health By Design association on Nov. 29th to talk about Urban Planning. The general message of our meeting addressed the importance of sidewalks and adequate pedestrian options in Indianapolis and how they have gone about projecting and planning for these needs. It is an issue I find important in my personal life and for my medical professional life. I also get excited by the idea that the place I live can perpetually improve and that we can make it better and enjoy it as a community. So I was pleased to learn about and support the message of Health By Design which forms coalitions of stakeholders and groups that have more power and resources to change the City of Indianapolis for the better.
When I moved to Indy I deliberately chose to live downtown near the Cultural Trail and the Monon Trail because I liked the walkability for outdoor exercising, historical sightseeing, access to a grocery store, and frequenting restaurants and shops all by foot. I was lucky to be able afford to rent in this up and coming area. As it turns out I’m not so unique, according to Ms. Irwin’s presentation my preferences are fairly typical of my demographic: educated, white, and on the older edge of the Millenial generation which has latched on to more minimalist, pedestrian, and community hub living styles than preceding generations. I get to choose where to live, how to get around with plenty of options available to me, and mainly decide to walk recreationally rather than for practical transport to and from work. However, the purpose of Health By Design is not for young yuppies who like to powerwalk to get their next latte (for the record, I do not power walk), it is also about equitable options for people who require public transit, public places, and pedestrianism for their way of life. Regardless of whether you use walking for recreation or necessity, having sidewalks that people can safely ambulate on enriches the lives of everyone.
There are many areas of Indianapolis that walking as an easy and viable mode of transportation is hard. Arterial roads with high traffic and high speeds, long intervals between cross walks, lack of sidewalks, lack of pedestrian protection to cross at traffic lights, areas of greater crime, and general lack of lighting and visibility all contribute to walking being difficult or unsafe. Our heavily car reliant culture has not only changed our priorities in how cities plan transportation between areas of town but it also has influenced people’s perception of norms and socioeconomic class when it comes to getting around. Hopefully, social patterns will change over time to greater appreciate walking and exercise.
In the Emergency Department I see improved walkability as affecting my patients two fold. First, sedentary lifestyles have harmed people chronically and second, a decent amount of trauma comes from pedestrians put in unsafe conditions whether they are assaulted by others, intoxicated, and/or because they are struck by vehicles. After a few shifts it is not a far stretch to understand how Indianapolis received the dubious title of “Least Healthy Metro City in the Country” in 2016 (http://www.theindychannel.com/news/local-news/indy-named-least-healthy-metro-city-in-the-country). While walking wasn’t directly measured in this study it is likely related: Indy Metro area came in below target for physical activity in 30 days, meeting CDC aerobic activity guidelines, aerobic strength guidelines, and below target numbers in parks and recreational centers, as well as the typical variables like rates of obesity, coronary vascular disease, diabetes, and death as well as others. However, addressing these issues from within the ED does not work. It takes a larger community to affect change outside the hospital.
Kim presented the magnificent work that Health By Design has put into the initiative, Indy WalkWays, which is a collaborative partnership between Health by Design, the City of Indianapolis, the Marion County Public Health Department, the American Planning Association – Indiana Chapter and the Indiana Public Health Association. This initiative takes into account a number of factors to create an informed and improved Pedestrian Plan relevant to Indianapolis’ needs for greater walkability. It created a data driven algorithm and geographical information system (GIS) map to prioritize where Indianapolis should invest first for the biggest impact in improved walkability. This is necessary because unfortunately the need outstrips the funding. Right now, the cost of building an improved sidewalk network needed along Indianapolis’ arterial streets would be at least $750 million while the current annual budget is only $50 million for ALL city-funded transportation.
The scoring factors they used to weight GIS areas are Health, Safety, Equity, Comfort, Demand, and City Priorities. The image included at the end is the amalgamation of these maps came from their informative Pedestrian Plan available on their website (http://indywalkways.org/wp-content/uploads/2015/10/Indianapolis_Pedestrian-Plan_DRAFT_web_Pages.pdf). It is evident that their scoring system places heavier emphasis on safety, health, and equity for underserved communities which I appreciate. Ms. Irwin spent some time showing us each GIS layer individually which is also available in the Pedestrian Plan online. Health was notably worse in the near East-side of Indy extending to the eastern edge of the county. Access to grocery stores and parks was poor. Overweight, obesity, diabetes and heart disease rates were high. This area also suffered a density of pedestrian collisions. My own anecdotal observations have been that this is where some of our worst traumas like gunshot wounds come from. The equity GIS map illustrated the areas that are most dependent on city-funded transit for the majority of their trips, calculated from areas high in concentration of elderly, disabled, minorities, households without cars, limited English speaking, and poverty in a swath along the southeast and northwest. The safety GIS layer also showed more than 50% of pedestrian-vehicle collisions occurring in the heart of downtown which surprised me since this is the area I frequently run and bike. Ultimately, this comes together to form many high priority Tier 1 areas in downtown Indianapolis that would benefit from urban investment.
A final piece of Kim Irwin’s presentation that I found interesting was the concept of not blaming the pedestrian for collisions that occur. This challenges our propensity in the medical field to point to a pedestrian’s choices to be irresponsible or drunk when they were injured so badly. According to WalkWays “No matter how you look at the data, every traffic fatality is preventable and unacceptable” because with proper planning and engineering human error can nearly be eliminated. For example, just reducing vehicle speed down from 40 mph by 10 or 20 mph in a collision with a pedestrian you improve mortality 50 and 90%, respectively. “Vision Zero” is a lofty goal to end all pedestrian fatalities adopted in other major metropolitan areas. The city of Indianapolis has not yet committed to this but WalkWays still advocates for city planning to keep safe non-motorized transportation in mind. The side effects of sedentariness and questionable life choices leading to trauma are problems that I cannot easily address quickly in a shift but I can remind myself based off of this talk how we can work to make things better in this city in the long run.
I appreciated the chance to attend this talk and lift my head out of the Emergency Department fugue. It reminded me why I was excited to live in my new neighborhood when I moved here. I have absolutely taken advantage of the strides Indy has taken to improve its livability, which are the fruits of investments made years before I ever came here. It re-inspired the nerdy, community oriented, and policy driven part of myself (like Leslie Knope the fictional character in the TV show Parks and Rec). I hope I can participate in Indy WalkWays events that may happen this spring. I reflected on the fact that especially in the Emergency department where our empathy and patience is continually stretched, judgment and blame will sometimes creep into the background of my impression of patients and the societal issues they deal with are often complex and beyond their control. I could probably not walk a day in the shoes of many of my difficult patients’ lives so I’m thankful that an Indy group like Health By Design exists to make this walk easier.
Submitted by Jennica Siddle, MD PGY-1
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
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 (firstname.lastname@example.org) for more details. Follow Rachael’s First Week on twitter: @Rachaels1stWeek
Special thanks to the Trauma NPs and IU ED RNs for their attendance and support for RFW.
Submitted By: Alex Rhea, PGY-3 IUEM