Originally, the puerperium was defined as the period of confinement during and just after birth; ... more Originally, the puerperium was defined as the period of confinement during and just after birth; it is now generally accepted to mean the 6 weeks after delivery. The puerperium has also been referred to as “the fourth trimester.” This period is marked by multiple physiologic changes (Table 123.1) as the woman returns to the prepregnant state, including healing physically from any trauma during delivery, and adjusts to the many physiologic and psychologic demands involved in caring for a newborn. Just as in pregnancy, when there are so many physiologic changes, the potential exists for the normal healing process to go awry and emergencies to occur. Certain significant changes in the physiology of the coagulation system during pregnancy persist past delivery and into the puerperium, including major changes in the coagulation and fibrinolytic system, as well as a reduction in venous blood flow in the deep venous system. Combined, these alterations increase the thrombotic potential in near-term and immediate postpartum patients. A pregnant patient around term and immediately postpartum has significant increases in factors I, V, VII, IX, X, and XII; von Willebrand factor antigen; and ristocetin cofactor activity. The endogenous anticoagulants protein C and antithrombin remain unchanged throughout pregnancy, but levels of protein S are reduced. Fibrinolytic activity is impaired during pregnancy as a result of placentally derived plasminogen activator inhibitor type II and pregnancy-induced increases (approximately threefold) in endothelial and hepaticderived inhibitor of plasminogen activator type I. These changes rapidly return to normal following delivery. During normal pregnancy there is a significant reduction in blood flow to the deep venous system, as well as an increase in diameter of the major leg veins. These changes do not occur evenly in both legs. Studies of patients in the puerperium have reported greater diameter and slower blood flow in the left common femoral vein than in the right. These differences are manifested clinically; in nonpregnant patients, the left leg was affected in 55% of cases of DVT, whereas in pregnancy the • The most common infection after childbirth is a genital tract infection. • Because lochia will contaminate a clean-catch specimen in the first 4 to 8 weeks postpartum, urine should be obtained by catheterization in the immediate postpartum period to rule out a urinary tract infection. • In the immediate postpartum period, an acute abdomen may not be manifested as abdominal rigidity on examination because of laxity of the abdominal wall tissue at this time. • Leukocytosis cannot be used to help differentiate an infection in the first 2 weeks postpartum because of the physiologic leukocytosis that occurs during pregnancy and delivery. • Fever is the most important criterion for the diagnosis of postpartum metritis. KEY POINTS
Journal of the American College of Emergency Physicians Open, Apr 1, 2023
ObjectiveIncome fairness is important, but there are limited data that describe income equity amo... more ObjectiveIncome fairness is important, but there are limited data that describe income equity among emergency physicians. Understanding the magnitude of and factors associated with income differences may be helpful in eliminating disparities. This study analyzed the associations of demographic factors, training, practice setting, and board certification with emergency physician income.MethodsWe distributed a survey to professional members of the American College of Emergency Physicians. The survey included questions on annual income, educational background, practice characteristics, gender, age, race, ethnicity, international medical graduate status, type of medical degree (MD vs DO), completion of a subspecialty fellowship, job characteristics, and board certification. Respondents also reported annual income. We used linear regression to determine the respondent characteristics associated with reported annual income.ResultsFrom 45,961 members we received 3407 responses (7.4%); 2350 contained complete data for regression analysis. The mean reported annual income was $315,306 (95% confidence interval [CI], $310,649 to $319,964). The mean age of the respondents was 47.4 years, 37.4% were women, 3.2% were races underrepresented in medicine (Black, American Indian, or Alaskan Native), and 4.8% were Hispanic or Latino. On linear regression, female gender was associated with lower reported annual income; difference −$43,565, 95% CI, −$52,217 to −$34,913. Physician age, degree (MD vs DO), underrepresented racial minority status, and underrepresented ethnic minority status were not associated with annual income. Fellowship training was associated with lower income; Accreditation Council for Graduate Medical Education (ACGME) program difference −$30,048; 95% CI, −$48,183 to −$11,912, non‐ACGME‐program difference −$27,640, 95% CI, −$40,970 to −$14,257. Working at a for‐profit institution was associated with higher income; difference $12,290, 95% CI, $3693 to $20,888. Board certification was associated with higher income; difference, $43,267, 95% CI, $30,767 to $55,767.ConclusionsThis study identified income disparities associated with gender, practice setting, fellowship completion, and American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certification.
ImportancePrior studies have revealed gender differences in the milestone and clinical competency... more ImportancePrior studies have revealed gender differences in the milestone and clinical competency committee assessment of emergency medicine (EM) residents.ObjectiveTo explore gender disparities and the reasons for such disparities in the narrative comments from EM attending physicians to EM residents.Design, Setting, and ParticipantsThis multicenter qualitative analysis examined 10 488 narrative comments among EM faculty and EM residents between 2015 to 2018 in 5 EM training programs in the US. Data were analyzed from 2019 to 2021.Main Outcomes and MeasuresDifferences in narrative comments by gender and study site. Qualitative analysis included deidentification and iterative coding of the data set using an axial coding approach, with double coding of 20% of the comments at random to assess intercoder reliability (κ, 0.84). The authors reviewed the unmasked coded data set to identify emerging themes. Summary statistics were calculated for the number of narrative comments and their c...
The objective of this study is to present an algorithm for improving the safety and effectiveness... more The objective of this study is to present an algorithm for improving the safety and effectiveness of transitions of care (ToC) in the emergency department (ED). This project was undertaken by the Council of Emergency Medicine Residency Directors (CORD) Transitions of Care Task Force and guided by the six-step Kern model for curriculum development. A targeted needs assessment in survey form was designed using a modified Delphi method among the CORD ToC Task Force. The survey was designed for four subgroups within the ED: emergency medicine (EM) residency program directors, EM academic chairpersons, EM residents, and EM nurses. Members from nationally recognized EM organizations assisted in the development of each respective survey, including the Academic Affairs Committee of the American College of Emergency Physicians, the leadership of the Emergency Medicine Residents' Association (EMRA), and the leadership of Emergency Nurses Association (ENA). The surveys contained questions about current handoff practices and asked participants to rate the importance of key logistical and informational parameters within a ToC. Survey validity was achieved through content validity, item analysis, format familiarity, and electronic scoring. The surveys of program directors and academic chairpersons were distributed through the CORD listserv, the resident survey was distributed via EMRA correspondents, and the nurse survey was distributed through the ENA listserv. Following survey collection, the ToC Task Force convened and used the data to assess handoff practices and deficiencies. The Task Force developed recommendations for a ToC algorithm that was then piloted by medical educators in their institutions. These educators shared their experiences with senior department members in a phone interview. This informant feedback was used to address deficiencies in the algorithm and finalize the recommendations from the CORD Task Force. The surveys for program directors (n = 147), academic chairpersons (n = 99), residents (n = 194), and nurses (n = 902) were electronically scored. Handoff education in the form of structured workshops or classes was typically not offered, with only 10.9% of residents and 9.0% of nurses reporting that they received such training. The majority (93.9%) of EM academic chairpersons stated that assessments of handoff proficiency were not conducted within their programs. Computerized handoff was the most popular assistive tool among all surveyed groups. Handoff parameters that were rated as "important" and "extremely important" included uninterrupted time and space to perform the handoff, identification of…
This study aimed to assess practices in emergency department (ED) handoffs as perceived by emerge... more This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.
Introduction: Although the Accreditation Council for Graduate Medical Education mandates structur... more Introduction: Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution. Methods: We conducted a national survey at 33 emergency medicine residency programs evaluating residents’ perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text ...
Originally, the puerperium was defined as the period of confinement during and just after birth; ... more Originally, the puerperium was defined as the period of confinement during and just after birth; it is now generally accepted to mean the 6 weeks after delivery. The puerperium has also been referred to as “the fourth trimester.” This period is marked by multiple physiologic changes (Table 123.1) as the woman returns to the prepregnant state, including healing physically from any trauma during delivery, and adjusts to the many physiologic and psychologic demands involved in caring for a newborn. Just as in pregnancy, when there are so many physiologic changes, the potential exists for the normal healing process to go awry and emergencies to occur. Certain significant changes in the physiology of the coagulation system during pregnancy persist past delivery and into the puerperium, including major changes in the coagulation and fibrinolytic system, as well as a reduction in venous blood flow in the deep venous system. Combined, these alterations increase the thrombotic potential in near-term and immediate postpartum patients. A pregnant patient around term and immediately postpartum has significant increases in factors I, V, VII, IX, X, and XII; von Willebrand factor antigen; and ristocetin cofactor activity. The endogenous anticoagulants protein C and antithrombin remain unchanged throughout pregnancy, but levels of protein S are reduced. Fibrinolytic activity is impaired during pregnancy as a result of placentally derived plasminogen activator inhibitor type II and pregnancy-induced increases (approximately threefold) in endothelial and hepaticderived inhibitor of plasminogen activator type I. These changes rapidly return to normal following delivery. During normal pregnancy there is a significant reduction in blood flow to the deep venous system, as well as an increase in diameter of the major leg veins. These changes do not occur evenly in both legs. Studies of patients in the puerperium have reported greater diameter and slower blood flow in the left common femoral vein than in the right. These differences are manifested clinically; in nonpregnant patients, the left leg was affected in 55% of cases of DVT, whereas in pregnancy the • The most common infection after childbirth is a genital tract infection. • Because lochia will contaminate a clean-catch specimen in the first 4 to 8 weeks postpartum, urine should be obtained by catheterization in the immediate postpartum period to rule out a urinary tract infection. • In the immediate postpartum period, an acute abdomen may not be manifested as abdominal rigidity on examination because of laxity of the abdominal wall tissue at this time. • Leukocytosis cannot be used to help differentiate an infection in the first 2 weeks postpartum because of the physiologic leukocytosis that occurs during pregnancy and delivery. • Fever is the most important criterion for the diagnosis of postpartum metritis. KEY POINTS
Journal of the American College of Emergency Physicians Open, Apr 1, 2023
ObjectiveIncome fairness is important, but there are limited data that describe income equity amo... more ObjectiveIncome fairness is important, but there are limited data that describe income equity among emergency physicians. Understanding the magnitude of and factors associated with income differences may be helpful in eliminating disparities. This study analyzed the associations of demographic factors, training, practice setting, and board certification with emergency physician income.MethodsWe distributed a survey to professional members of the American College of Emergency Physicians. The survey included questions on annual income, educational background, practice characteristics, gender, age, race, ethnicity, international medical graduate status, type of medical degree (MD vs DO), completion of a subspecialty fellowship, job characteristics, and board certification. Respondents also reported annual income. We used linear regression to determine the respondent characteristics associated with reported annual income.ResultsFrom 45,961 members we received 3407 responses (7.4%); 2350 contained complete data for regression analysis. The mean reported annual income was $315,306 (95% confidence interval [CI], $310,649 to $319,964). The mean age of the respondents was 47.4 years, 37.4% were women, 3.2% were races underrepresented in medicine (Black, American Indian, or Alaskan Native), and 4.8% were Hispanic or Latino. On linear regression, female gender was associated with lower reported annual income; difference −$43,565, 95% CI, −$52,217 to −$34,913. Physician age, degree (MD vs DO), underrepresented racial minority status, and underrepresented ethnic minority status were not associated with annual income. Fellowship training was associated with lower income; Accreditation Council for Graduate Medical Education (ACGME) program difference −$30,048; 95% CI, −$48,183 to −$11,912, non‐ACGME‐program difference −$27,640, 95% CI, −$40,970 to −$14,257. Working at a for‐profit institution was associated with higher income; difference $12,290, 95% CI, $3693 to $20,888. Board certification was associated with higher income; difference, $43,267, 95% CI, $30,767 to $55,767.ConclusionsThis study identified income disparities associated with gender, practice setting, fellowship completion, and American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certification.
ImportancePrior studies have revealed gender differences in the milestone and clinical competency... more ImportancePrior studies have revealed gender differences in the milestone and clinical competency committee assessment of emergency medicine (EM) residents.ObjectiveTo explore gender disparities and the reasons for such disparities in the narrative comments from EM attending physicians to EM residents.Design, Setting, and ParticipantsThis multicenter qualitative analysis examined 10 488 narrative comments among EM faculty and EM residents between 2015 to 2018 in 5 EM training programs in the US. Data were analyzed from 2019 to 2021.Main Outcomes and MeasuresDifferences in narrative comments by gender and study site. Qualitative analysis included deidentification and iterative coding of the data set using an axial coding approach, with double coding of 20% of the comments at random to assess intercoder reliability (κ, 0.84). The authors reviewed the unmasked coded data set to identify emerging themes. Summary statistics were calculated for the number of narrative comments and their c...
The objective of this study is to present an algorithm for improving the safety and effectiveness... more The objective of this study is to present an algorithm for improving the safety and effectiveness of transitions of care (ToC) in the emergency department (ED). This project was undertaken by the Council of Emergency Medicine Residency Directors (CORD) Transitions of Care Task Force and guided by the six-step Kern model for curriculum development. A targeted needs assessment in survey form was designed using a modified Delphi method among the CORD ToC Task Force. The survey was designed for four subgroups within the ED: emergency medicine (EM) residency program directors, EM academic chairpersons, EM residents, and EM nurses. Members from nationally recognized EM organizations assisted in the development of each respective survey, including the Academic Affairs Committee of the American College of Emergency Physicians, the leadership of the Emergency Medicine Residents' Association (EMRA), and the leadership of Emergency Nurses Association (ENA). The surveys contained questions about current handoff practices and asked participants to rate the importance of key logistical and informational parameters within a ToC. Survey validity was achieved through content validity, item analysis, format familiarity, and electronic scoring. The surveys of program directors and academic chairpersons were distributed through the CORD listserv, the resident survey was distributed via EMRA correspondents, and the nurse survey was distributed through the ENA listserv. Following survey collection, the ToC Task Force convened and used the data to assess handoff practices and deficiencies. The Task Force developed recommendations for a ToC algorithm that was then piloted by medical educators in their institutions. These educators shared their experiences with senior department members in a phone interview. This informant feedback was used to address deficiencies in the algorithm and finalize the recommendations from the CORD Task Force. The surveys for program directors (n = 147), academic chairpersons (n = 99), residents (n = 194), and nurses (n = 902) were electronically scored. Handoff education in the form of structured workshops or classes was typically not offered, with only 10.9% of residents and 9.0% of nurses reporting that they received such training. The majority (93.9%) of EM academic chairpersons stated that assessments of handoff proficiency were not conducted within their programs. Computerized handoff was the most popular assistive tool among all surveyed groups. Handoff parameters that were rated as "important" and "extremely important" included uninterrupted time and space to perform the handoff, identification of…
This study aimed to assess practices in emergency department (ED) handoffs as perceived by emerge... more This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.
Introduction: Although the Accreditation Council for Graduate Medical Education mandates structur... more Introduction: Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution. Methods: We conducted a national survey at 33 emergency medicine residency programs evaluating residents’ perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text ...
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