Medical Education

AEM Education and Training 09: Looking Through the Prism - Caring for LGBTQI Patients in the ED

Welcome to the ninth episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to AEM E&T Articles or Articles in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON TITLE TO ACCESS):

Looking Through the Prism: Comprehensive Care of Sexual Minority and Gender‐nonconforming Patients in the Acute Care Setting. Angela F. Jarman MD, MPH; Alyson J. McGregor MD, MA; Joel L. Moll MD ; Tracy E. Madsen MD, ScM; Elizabeth A. Samuels MD, MPH; Mollie Chesis; Bruce M. Becker MD.

LISTEN NOW: AUTHOR INTERVIEW WITH angela jarman, MD, Mph

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Angela Jarman, MD, MPH

Assistant Professor, Department of Emergency Medicine

University of California, Davis

This interview discusses a commentary in AEM E&T which synthesizes a didactic session co‐led by the SAEM Sex and Gender in Emergency Medicine Interest Group and the Academy for Diversity and Inclusion, which was presented by the authors at the SAEM 2018 annual meeting in Indianapolis, Indiana.

The National Institutes of Health have recently recognized LGBTQ (lesbian, gay, bisexual, transgender, queer) as an official health disparity and designated the Sexual and Gender Minority Research Office in an effort to support evidence‐based medical care for this underserved patient population. As the front line of medical care for the underserved, emergency medicine (EM) physicians need to be equipped with the tools to care for these patients in a culturally competent and clinically appropriate manner. EM providers must develop an understanding of their patients’ social and medical context to provide both sensitive and effective care and to teach residents and other learners. A significant number of patients who seek treatment in the emergency department define themselves as LGBTQI—lesbian, gay, bisexual, transgender, queer, or intersex. This commentary combines both affective and objective information on the importance of semantics and language, appropriate communication, and confronting our own implicit biases in caring for this vulnerable population, creating a unique perspective and paradigm for the practice of EM and a blueprint for education. 

The authors have provided this handout for further information:

https://drive.google.com/file/d/1WDyk0HcCCP3DKmgGRdom53s8LKZB5Znz/view?usp=sharing

Excerpt:

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ADDITIONAL REFERENCES:

“Don’t be a jerk” EM Pulse Podcast, Episode 9. https://ucdavisem.com/2018/07/17/dont-be-a-jerk/

http://www.transstudent.org/gender/

NIH ORWH sex/gender. Available at https://orwh.od.nih.gov/research/sex-gender.

Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual and Transgender Health Issues and Research Gaps and Opportunities. The health of lesbian, gay, bisexual, and transgender people. National Academies Press (US), Washington, DC; 2011

Clayton JA, Tannenbaum C. Reporting Sex, Gender, or Both in Clinical Research? JAMA 2016; 316(18):1863-1864

Madsen TE, Bourjeily G, Hasnain M, Jenkins MJ, Morrison MF, Sandberg K, Tong IL, Trott J. Sex- and Gender-Based Medicine: The Need for Precise Terminology. Gender and the Genome;1(3):122-28.

Schuster MA, Reisner SL, Onorato SE. Beyond bathrooms — meeting the health needs of transgender people. NEJM 2016;375:101–103.

Soc Sci Med. 2014 Feb;103:33-41. doi: 10.1016/j.socscimed.2013.06.005. Epub 2013 Jun 18.

Structural stigma and all-cause mortality in sexual minority populations. Soc Sci Med. 2014 Feb;103:33-41. doi: 10.1016/j.socscimed.2013.06.005. Epub 2013 Jun 18.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding Editors: Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities.

Bauer GR, Scheim AI, Deutsch MB, et al. Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results From a Respondent-Driven Sampling Survey. Annals of Emergency Medicine. 2014;63(6):713-720.

Brown JF, Fu J. Emergency department avoidance by transgender persons: another broken thread in the "safety net" of emergency medicine care. Annals of Emergency Medicine. 2014;63(6):721-722.

Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Available at www.transhealth.ucsf.edu/guidelines .

Chisolm-Straker M, Jardine L, Bennouna C, Morency-Brassard N, Coy L, Egemba MO, Shearer PL (2017) Transgender and gender nonconforming in emergency departments: a qualitative report of patient experiences, Transgender Health 2:1, 8-16, DOI: 10.1089/trgh.2016.0026.

Deutsch MB, Jamison Green, Keatley J, Mayer G, Hastings J, Hall AM. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health. J Am Med Inform Assoc. 2013;20:700-703

IOM. Collecting sexual orientation and gender identity data in electronic health records: Workshop summary. Washington, DC: Institute of Medicine;2013.

James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality;2016.

Jalali S, Sauer LM. Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the Emergency Department. Annals of Emergency Medicine. 2015;66(4):417-423.

Lambda legal. Creating equal access to quality health care for transgender patients: transgender-affirming hospital policies. May 2016. Http://assets.Hrc.Org//files/assets/resources/transaffirming-hospitalpolicies-2016.Pdf?_Ga=2.179968679.225917522.1494296888-1373396650.1480810731

Samuels EA, Tape C, Garber N, Bowman S, Choo EK. “Sometimes you feel like the freak show”: A Qualitative Assessment of Emergency Care Experiences Among Trans and Gender Non-Conforming Patients. Ann Emerg Med 2017: doi:10.1016/j.annemergmed.2017.05.002.

World Professional Association for Transgender Health, Standards of Care for the Health of Transexual, Transgender, and Gender Nonconforming People 5 (7th ed.), http://www.wpath.org/uploaded_ les/140/ les/Stan- dards%20of%20Care,%20V7%20Full%20Book.pdf

Meeting Uncle Rhabdo

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THE PATIENT:

A 28 year old previously healthy male presents to the emergency department with concerns for worsening back pain that is predominantly left sided and along the lumbar spine. Two days prior to the visit he recalls a work out that consisted of many dead lifts. He also played basketball the following day and rode his bike into work, which is more activity than usual for him. He tried NSAIDs for pain control, but his pain is more intense and he noticed his urine looked brown today. He denies any fevers, history of IVDU, weight gain or loss, urinary tract infections or STDs, immunosuppression, recent spinal fracture or procedure, incontinence or retention.

PHYSICAL EXAMINATION:

144/83, 82, 37.1, 18, 98%

Gen: well appearing, no acute distress

HENT: normocephalic, MMM

CV: RRR

Pulm: CTAB

Abd: soft, nontender, nondistended

MSK: muscle spasms along the left lumbar paraspinal muscle, no midline tenderness to palpation, muscle compartments in the upper and lower extremities are soft

Neuro: L1-S5 strength 5/5 and sensation to light touch is intact

Skin: pink, warm, dry

THE COURSE:

As an experienced clinician you are able to quickly arrive at a diagnosis of rhabdomyolysis from the brief history and physical exam, but what else needs to be done? In the emergency department we need to initiate diagnostic studies to evaluate the severity of illness and help plan for an appropriate disposition. Thankfully, your history and exam reveal no red flag findings for more concerning etiologies of back pain, so your evaluation can be quite focused. The patient had lab work sent off and was provided with IVF boluses and given analgesia with marked improvement in his symptoms. He was admitted to the medical floor for continued care for the next couple days.

THE WORK UP:

CK >20,000 IU/L (labs upper limit for reporting without further analysis and quantitative estimates, normal range 20-210, remained >20,000 for 5 consecutive days) finally on day 6 CK 10, 933 IU/L

BMP: Glu 113, BUN 19, Cr 1.0 (on discharge was 0.84), Na 139, K 3.8, Cl 104, CO2 29, Ca 8.9

Urinalysis: Brown, cloudy, trace ketones, specific gravity >1.03, blood 3+, protein >300

Urine microscopic analysis: RBC none seen, WBC 3, amorphous crystals present

Urine myoglobin: >8,750 mcg/ml (normal range < 28mcg/ml)

DISCUSSION:

The key clinical manifestations of rhabdomyolysis include a triad of muscle tenderness and weakness as well as dark urine, so the triage note already had it set up on a silver platter for you. Remember, however, as with any triad in medicine this classic presentation is rare. Some studies revealed that over half of patients do not report muscle pain or weakness. Rhabdomyolysis occurs due to muscle necrosis and the release of intracellular contents into the circulation. Patients may present with a wide range of symptoms and the most concerning complications include hyperkalemia, renal failure and rarely disseminated intravascular coagulation. Patients who present with concomitant acute kidney injury tend to have worse outcomes and the mechanism of injury is primarily related to the nephrotoxic effects of myoglobin. In an acidic environment myoglobin may precipitate and subsequently damage the kidneys by obstruction of the renal tubules, cause oxidative damage and vasoconstriction.

The etiologies of rhabdomyolysis can be broken up into four broad categories: impaired production or use of ATP, dysfunctional oxygen or nutrient delivery, increased metabolic demand exceeding capacity, and direct myocyte damage. Recently, on EM: RAP Dr. DeLaney argued that this can be further simplified into two broad categories, exertional and non-exertional. Classic cases include trauma patients who have crush injuries but can also occur with heat related illnesses such as heat exhaustion or stroke, or in cases of hyper-kinetic states. Medications implicated in this disease process include antipsychotics and statins as well as others such as illegal drugs like cocaine.

CK levels classically rise within two to twelve hours after the onset of injury and peak within three days. The level should return to baseline within ten days. The diagnosis is often considered if the CK level is above five times the upper limit of normal at presentation, roughly 1,000 IU/L. More discrete categories can also be used to differentiate mild to severe cases based on CK levels, however, it is the degree of renal impairment that likely has the greatest role on patient outcome. Emergency department management includes aggressive IVF hydration with a target urine output of approximately 250 ml/hr and attempts to identify and correct the underlying pathology. Some argue for urinary alkalinization; however, the literature is limited with regards to strong recommendations on this topic. Common electrolyte abnormalities include: hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. Disseminated intravascular coagulation can rarely be seen as a result of thromboplastin and prothrombotic agents released from damaged myocytes. Acute kidney injury is more common if the presentation includes a CK >5,000 IU/L and in cases with sepsis, acidosis, or dehydration. Ultimately, most patients do well during their hospital courses and rarely require significant interventions, but mortality may be upwards of 20% in those that present with significant kidney injury noted at the time of presentation, therefore, careful evaluation of the patient’s lab studies and admission for close observation remains the mainstay of treatment.

Faculty Reviewer: Dr. Gita Pensa

SOURCES:

  1. DeLaney, M. “Rhabdomyolysis: Part 1 Diagnosis and Treatment.” www.emrap.org March 2018, 18 (3)

  2. DeLaney, M. “Rhabdomyolysis: Part 2 Disposition.” www.emrap.org March 2018, 18 (3)

  3. Majoewsky, M. “Rhabdomyolysis: C3 Project.” www.emrap.org June 2012, 2 (6)

  4. Sauncy, H. (2017). Don’t Get Broken Up About Muscle Breakdown. In Mattu, A. Marcucci, L. et al (Eds.), Avoiding Common Errors in the Emergency Department: Second Edition (pp. 414-16). Philadelphia: Wolters Kluwer.

Mobile Applications for the ED Provider

We conducted an online survey of the approximately 200 EM providers (attendings, fellows, residents, nurse practitioners, and physician assistants) affiliated with BrownEM. The survey asked providers which medical apps they had downloaded on their mobile devices and which apps they actually used on a regular basis. Ninety-nine providers answered the survey (response rate 49.5%); the distribution of respondents was 51% attendings, 33% residents/fellows, and 16% NPs/PAsThe results of the survey are presented below, categorized by type of mobile app. Most of the apps and resources described below are widely used and highly circulated throughout the emergency medicine community. Just as in consumer mobile health, we found that although many apps are downloaded, few are used on a regular basis; on average, BrownEM providers reported that they had six medical apps downloaded on their phone, but only regularly used two. Highlighted below are the apps that providers most frequently find themselves using in day to day practice. BrownEM has no financial ties to any of these applications or their developers.

 

Just in time resources (percent of respondents using the app)

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1. Epic Haiku

(77%)

The essential companion application for the Epic EMR. The most useful feature is the ability to capture clinical images and upload them to the patient’s chart. Because sometimes a picture really is worth a thousand words.

iOS | Android

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2. UpToDate

(38%)

One of the most widely used, peer reviewed online reference sources for physicians. A great resource for a quick refresher on a topic, however much information is not necessarily important for ED management.

iOS | Android

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3. MD Calc

(26%)

An app that aggregates clinical decision rules, medical formulas, and other hard to remember checklists/criteria. Simple to use, free to download. Also available online.

iOS | Android

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4. Epocrates

(24%)

All-in-one application with guidelines, pill identification, drug interaction tool, drug monographs, and more. Free app with limited features, or a premium version is available.

iOS | Android

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5. EMRA Antibiotics Guide

(20%)

The official antibiotics guide published by EMRA. The app requires a $20 investment but is updated yearly with new recommendations for drug choices. An incredibly helpful resource for when you can’t quite remember what drug to reach for or its dosing.

iOS | Android

 

Runner Ups

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WikiEM

Mobile version of the opensource, wikipedia-like encylopedia of emergency medicine. A good quick reference with the caveat of it being publicly editabe.

iOS | Android

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MedScape

Similar to Epocrates but is free and has an offline version. Good resource for pill identification, drug info, and drug interactions.

iOS | Android

Eye Chart

A simple, straightforward app for checking visual acuity at 4ft.

iOS

 

When looking at the educational resources used in our department, there is one clear winner. EM:RAP is the go-to resource used by almost every single survey respondent. A few apps are featured below that may be worth investigating as they are fun, educational, and easy to use.

Educational resources (percent of respondents using the app)

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EM:RAP

(97%)

The well-known and almost ubiquitous EM:RAP is an excellent way to keep current. With new podcasts and content published on a monthly basis it can be considered an EM staple. Paid subscription is required for the content, but the app is free.

iOS | Android

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QxRead

(17%)

A literature aggregator. Fill in your specialty, favorite journals, and areas of interest and it will pull together recent articles geared towards your interests. An amazing way to keep up with the literature. It integrates with Brown’s library system to access articles.

iOS | Android

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ECG Guide

 

(7%)

Great for refreshing yourself on ECGs findings. Has over 200 ECGs that you can be quizzed on with teaching pearls. $0.99

iOS | Android

 

Suggested Apps

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1 Minute Ultrasound

60 second video clips of the bread and butter EM ultrasound scans. Perfect for showing students or a quick refresher before going into a room.

iOS | Android

Resuscitation!

A series of interactive clinical vignettes where you must chose the correct workup, management, and disposition for an evolving patient presentation.

iOS | Android

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Figure 1

Think of this app as “Instagram for doctors” but with an educational twist. Users submit images of interesting cases for discussion. Check out our account @BrownEM

iOS | Android

 

Finally, multiple providers made suggestions for resources they find incredibly helpful but are not app based. Below is a compilation of some of the top websites, programs, resources, and organizational tools that help some of us keep it together.

Evernote – A could based platform for organizing notes, documents, and files across multiple devices.

Dropbox and Google Drive – Online cloud storage platforms that allow for the sharing of documents, images, files across computers and with other users. Essential tools for the modern EM provider.

Lexicomp – A comprehensive drug reference with information regarding dosing, efficacy, and adverse effects. Access is provided for free through Lifespan intranet. A mobile app is also available to download.

Podcasts – By now most folks have gotten a taste of the podcast life. Everybody has their favorites depending on their interests. A couple of podcasts that this author has found to be particularly high yield are:

  • Pediatric Emergency Playbook – bread and butter PediEM cases and core content
  • EMCRIT – Scott Weingart’s pride and joy, cutting edge stuff but lots of opinions
  • UltrasoundPodcast – From scanning basics to literature reviews, they have it all
  • FOAMCast – brings together the best of FOAM, new literature, and core content
  • GEL Podcast – a new ultrasound podcast discussing the evidence behind scanning
  • EM Basic – as the name implies, bread and butter EM basics
  • ED ECMO – high tech critical care brought into the world of EM

BrownEM has recently taken the plunge into the podcasting world under the guidance of Dr. Gita Pensa. Check out the BrownEM podcast here.

Twitter – with thousands of EM docs tweeting daily, there is a niche interest for everybody in the FOAMed (Free Open Access Medical Education) Twitter-verse. Critical care, airway management, wellness, education, sex and gender, ophtho, anesthesia – you name it, and somebody is tweeting about it. **Buyer beware, the veracity of some tweets cannot be guaranteed**

Blogs – the online companions to many podcasts, twitter accounts, and residency programs. Great sources of information that usually have posts on relevant and interesting topics, with useful images, original content, and amazing references.  The two most highly recommended by our providers are Life in the Fast Lane and Academic Life in Emergency Medicine

Faculty Reviewer: Megan Ranney, MD