ResidentOfficial Publication of the Emergency Medicine Residents’ Association April/May 2019 VOL 46 / ISSUE 2 Wilderness Toxins Excited Identifying Dangers Delirium in the ED US-Guided Subclavian Access Prehospital Stroke Alert Spring Award Winners & New Leaders I WORK FOR ENVISION PHYSICIAN SERVICES BECAUSE ... THEY ARE MY HOME AWAY FROM HOME REBECCA PARKER, MD, FACEP EMERGENCY MEDICINE Reasons to Choose Us Physician-led practices supported by fellow physicians within our local, regional and national level infrastructure Best-in-class professional development and leadership programs with long-term career pathways Collegial environment that strengthens clinical engagement and encourages work-life balance Long-term, stable contracts with facilities offering a multitude of practice types, ranging from academic and community hospitals to rural and urban settings Transparent compensation structure and flexible scheduling with full-time, part-time and travel team options Earn up to 2,500/month in your senior year with our Earn While You Learn Program (site and specialty specific) 844.307.1218 EVPS.com/EMRA2019 Unsafe Nursing Ratios Incapacitate EDs, Endanger Patients Tommy Eales, DO executives, who argue that fixed ratios approval before a health care organization Editor-in-Chief, EM Resident leave minimal flexibility in scheduling may qualify to receive reimbursements Indiana University around variation in patient volume and from Medicare and Medicaid. @tommyeales acuity. Simply stated, standardized nurse- The Joint Commission does not t’s the evening surge at a busy ED to-patient ratios cost more.7 explicitly require reporting of nurse-to- where all beds are occupied. Several To date, 14 states have passed patient staffing ratios, though this metric admitted patients — including 2 I legislation regarding nurse staffing. could satisfy a portion of the qualification critically ill — are waiting for rooms The regulatory language trends toward assessment should the data be presented. upstairs. A quick glance reveals a full ambiguity, leaving much to the discretion In the category of nurse staffing standards, waiting room with multiple potentially of hospital administrators. Only 7 states the Joint Commission requires reporting sick patients. Then, 2 new patients arrive require that hospitals internally monitor on a minimum of 4 metrics from a list via EMS. Each will require immediate any nurse staffing metrics at all, let alone focused on patient outcomes. Of the 4 stabilizing interventions. If nursing nurse-to-patient ratios. metrics, 2 must involve “human resource resources were not already overwhelmed, Minnesota law avoids the concept indicators” such as overtime use. The they now will be. In the blink of an eye, this setup has of self-monitoring altogether and simply other 2 must involve “clinical or service 10 created one of the most high-risk practice mandates that each hospital’s Chief indicators” such as patient falls. environments in emergency medicine. Yet, Nursing Officer develops a staffing plan So, who exactly is keeping track of few emergency physicians would recognize “with input from others.” As previously nursing ratios? Outside of a small minority it as such or even think twice about it. mentioned, nurse executives are the of states, the answer is simple — no one. After all, it’s just another day. largest opponents to standardized ACEP’s current policy on nurse But consider this: Decreasing the staffing ratios. staffing is similar to ENA and ANA policy nurse-to-patient ratio immediately Massachusetts law requires ICUs to statements. The American Academy of increases the frequency of medication be staffed with nurses at a ratio of either Emergency Medicine takes it a step further errors and all-cause mortality for all 1:1 or 1:2, depending on the stability of and advocates for a 1:3 maximum nurse- patients in the ED — not only the critically the patient. However, there is no specific to-patient ratio with protected triage ill ones who just arrived.1-4 mention of critically ill patients in the ED and charge nurse roles for higher acuity 11,12 In fact, there is strong evidence to or patients admitted to the ICU who are departments. suggest that protected emergency nursing boarding in the ED. The regulation does As a young specialty, emergency ratios are key not only for patient safety, not mention nurse-to-patient ratios in any medicine has the unique ability to rapidly but also for departmental efficiency.5,6 other specialties. adopt evidence-based practices and make So, why is it controversial to ask that EDs California remains the only state with a changes to better care for our patients. In provide adequate nursing staffing? legally defined minimum nurse-to-patient this, emergency physicians must stand Staffing issues have been front and ratio for all nurses. Per the regulation, by our nurse colleagues and advocate for center to nursing legislative efforts for there is always a mandatory 1:4 ratio in the safe staffing ratios. Although hospital quite some time. In fact, campaigns to ED. For critically ill patients in the ED and associations and nurse executives control establish standardized nurse-to-patient those admitted to the ICU, the maximum the budgets, everyone must work together ratios have been underway by nursing ratio is 1:2. Since passing this legislation in on this issue to keep patients safe. professional societies since the early 2004, evidence shows the trends seen with So, the next time the ED is staffing 1990s.7 The American Nurses Association dangerous nurse staffing levels are indeed nurses at an unsafe ratio, consider currently advocates for state-based reversible with mandatory staffing ratios.6 documenting it and reporting this regulations that require hospitals to create It should be noted that the California patient safety deficiency through the staffing plans individualized to each Nurses Association separated from the local incident reporting system. After nursing unit. This effort is endorsed by ANA over philosophical differences in the all, a quick post-shift email isn’t going to the Emergency Nurses Association, the late 1990s, with nurse staffing policy being increase patient mortality. largest professional society representing one of the primary issues.7 But dangerous staffing practices? emergency nurses. Both organizations stop While most states have yet to pass The evidence suggests that it might. short of supporting mandated nurse-to- legislation regarding nurse staffing, To learn more about the ongoing patient ratios.7-9 external accrediting organizations have national advocacy efforts for safe The major adversaries to standardized weighed in on the issue to various degrees. nurse-to-patient staffing ratios, visit the nurse-to-patient ratios have historically Although the Joint Commission is not a National Nurses United website at www. been hospital associations and nurse government agency, most states require its nationalnursesunited.org/ratios. ¬ References available online. April/May 2019 | EM Resident 1 RICHARD LOGUE, MD, FACEP EMERGENCY MEDICINE Featured Southern Opportunities: ■ Citrus Memorial Hospital Greater Tampa Bay, FL ■ Lawnwood Regional Medical Center Ft. Pierce, FL ■ Kendall Regional Medical Center Miami, FL ■ McLeod Medical Center - Dillon Dillon, SC ■ Ocala Regional Medical Center Ocala, FL ■ Oviedo Medical Center Greater Orlando, FL For more information, contact: 877.226.6059 [email protected] 2 EMRA | emra.org • emresident.org TABLE OF CONTENTS EDITORIAL STAFF EDITOR-IN-CHIEF Tommy Eales, DO Indiana University DEPUTY EDITOR Brian Fromm, MD 8 24 Thomas Jefferson University EMRA Continues EM Residency Programs 5 28 EDITORIAL TEAM Advocating for You! and Global Health Whitney Johnson, MD PRESIDENT’S MESSAGE Experiences UCSF-Fresno INTERNATIONAL 6 Making Sense Jeremy Lacocque, DO of Balance Billing 30 Sudden Cardiac Events Midwestern University/CCOM HEALTH POLICY and Risk Mitigation Leah McDonald, MD Wilderness Toxins Quiz for Emergency NYU/Bellevue Medical Center First Responders 8 WILDERNESS MEDICINE Clark Owyang, MD PREHOSPITAL & DISASTER Stanford Critical Care Medicine Fellow 13 Excited Delirium MEDICINE in the ED Setting Jayram Pai, MD EM Podcasting Advice TOXICOLOGY Mount Sinai 31 From Andy Little, DO Rare Occurrence of Yagnaram Ravichandran, MBBS, MD, FAAP 17 MEDICAL EDUCATION Children’s Hospital of Michigan Lemierre’s Syndrome Resilience: The Art CASE REPORT 32 Danny VanValkinburgh, MD of Picking Yourself University of Tennessee 18 Ultrasound-Guided Up After a Fall College of Medicine Subclavian Vein WELLNESS ECG Faculty Editor Cannulation Cure Sometimes, Jeremy Berberian, MD ULTRASOUND Christiana Care Health System 33 Comfort Always Updates in Prehospital OP-ED Toxicology Faculty Editor 20 Stroke Alert Identification David J. Vearrier, MD, MPH, FACMT, FAACT, FAAEM EMRA 2019 Spring Program Director, Medical Toxicology Fellowship Clinical Scenario 34 Award Recipients Drexel University PREHOSPITAL & DISASTER AWARDS MEDICINE MSC Editor Thank You for Samuel Southgate ED Management of Inborn 36 University of Connecticut 22 Errors of Metabolism a Job Well Done! LEADERSHIP PEDIATRICS How to Give Your EMRA Committees EM Resident (ISSN 2377-438X) is the bi-monthly 24 38 Primed for Progress magazine of the Emergency Medicine Residents’ Patients Bacteria Association (EMRA). The opinions herein are and Not End Up in M&M LEADERSHIP those of the authors and not of EMRA or any institutions, organizations, or federal agencies. INFECTIOUS DISEASE News & Notes 40 EMRA