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Emergency Medicine, Health Disparities, LGBT, Patient Care, Research

Study finds ER avoidance in transgender individuals needing care

ER2Past reports have found high levels of postponing medical care in transgender and non-gender-conforming people, owing to experiences including refusal of care, harassment and violence in medical settings, and lack of provider knowledge. A 2011 committee opinion from the American Colleges of Obstetricians and Gynecologists called the consequences of inadequate treatment among this population “staggering.”

Now, Canadian research on an Ontario transgender population shows levels of emergency-room avoidance by trans people. Published online in the Annals of Emergency Medicine, the study (subscription required) examined data from surveys in 408 transgender, transsexual, or transitioned people, many of them young (16-24 years); approximately half were male-to-female and half were female-to-male.

As described in a release:

“Patients who have had trans-specific negative experiences in other parts of the health care system may defer care until they are desperate and need the ER,” said lead study author Greta Bauer, PhD, MPH, of the Schulich School of Medicine & Dentistry in London, Ontario, Canada. “The good news is that nearly three-quarters of those who needed emergency care were able to get it in the ER. The bad news is that so many still were not.”

Almost one-quarter (21 percent) of trans patients reported ever avoiding the ER due to a perception that their trans status would negatively affect such an encounter. Negative experiences specifically related to being transgender were reported by 52 percent of trans patients.

Approximately 54 percent of trans patients reported having to educate their providers “some” or “a lot” regarding trans issues.

Bauer and her colleagues noted in the paper that their work “represents a first contribution on trans experiences within emergency medicine.” More research is needed, they said, “to better understand reasons for ED avoidance and to develop strategies to overcome this.”

Previously: Documentary on LGBT veterans’ PTSD, trauma and recovery premieres tomorrowDistinction with a difference: Transgender neurobiologist picked for National Academy of Science membershipA call for more training on LGBT health issues and Affordable Care Act prohibits discrimination against transgender patients 
Photo by robnguyen01

Emergency Medicine, Patient Care, Stanford News

More than a manual: Stanford’s crisis checklist helps those working in the OR

More than a manual: Stanford's crisis checklist helps those working in the OR

emergency manualI hate forgetting things, so when I have a bit of information that I absolutely must remember, I write it down. Many people employ the same strategy, yet as my colleague Sara Wykes explains in this edition of Inside Stanford Medicine, medical professionals are often held to unrealistic standards where a list, such as mine, could be mistaken as a sign of weakness.

As David Gaba, MD, associate dean for immersive and simulation-based learning at Stanford, explains in the story, this faulty perception of medical manuals couldn’t be further from the truth. “Many of us strive to emphasize to students, trainees and experienced clinicians that their use is actually a sign of strength and wisdom and that failing to use them is a sign of weakness and perhaps hubris,” said Gaba.

That’s why a team of medical experts from the Stanford Anesthesia Cognitive Aid Group developed an emergency manual for use at Stanford hospitals and other medical facilities. From the story:

It covers protocols for 24 conditions and circumstances. Some, like how to deal with a patient’s bradycardia (a slow and unstable heartbeat), will be familiar only to medical professionals. Others, like how to handle a hospital-wide power failure, address what to do first, and thereafter, in such circumstances.

The development group examined every aspect of the emergency manual, down to details whose importance might not seem immediately obvious, including the colors, typefaces, boldfacing of words, size of pages, binding and physical placement within a working space. Over and over, the implementation team tested the manual in simulation with a full medical team, refining elements based on feedback from its users.

This iterative process provided the Stanford team with critical information that helped them make their manual more effective in an emergency setting. “We learned from simulation testing that it is not enough just to put the manual in the OR… we need to train people to use it,” said Sara Goldhaber-Fiebert, MD, lead author of an Anesthesia & Analgesia paper (subscription required) detailing the work.

“Just the act of training to use the manual promotes team building and communication, which is critical not just in emergencies, but all the time,” agreed Bryan Bohman, MD, the former chief of staff at Stanford Hospital and an anesthesiologist who contributed to the implementation of the Stanford manual.

As Wykes outlines, tangible signs of success emerged after the Stanford team finished training medical professionals to use the manual:

OR nurses requested a second copy be hung near the nursing phone. Computer and anesthesia technicians wanted copies where they work to help them anticipate equipment that might be needed during specific emergencies.

“Having the manual is reassuring, especially when you’re going through these catastrophic events… There’s always a certain part of you that wonders, ‘Have I thought of everything?” said second-year resident at Stanford Jason Johns.

The Stanford emergency manual can be downloaded for free here.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: What health-care providers can learn from the nuclear industrySully Sullenberger talks about patient safety and A closer look at Stanford’s simulation technology
Photo by Norbert von der Groeben

Emergency Medicine, Health Policy, Imaging, Pregnancy, Research, Stanford News

Studying the best approach to diagnosing appendicitis in pregnant women

Studying the best approach to diagnosing appendicitis in pregnant women

OLYMPUS DIGITAL CAMERAWhen it comes to pregnant women, managing abdominal pain and diagnosing appendicitis can be a tricky proposition for doctors. Current practice includes an ultrasound followed by further imaging if the diagnosis remains unclear, but some providers and patients are hesitant to use one common imaging tool – a CT scan. That’s because of its use of radiation, and its possible risk to the fetus.

Zachary Kastenberg, MD, is a general surgery resident at Stanford and reports that he and his colleagues encounter this issue relatively frequently in the emergency department. “We often find ourselves guiding expecting mothers and fathers through difficult, anxiety-provoking decisions with minimal evidence to support differing practitioner perspectives,” he recently told me, noting that acute appendicitis is the most common cause of non-obstetric surgery in pregnant women.

Kastenberg said he wanted to help “influence the management and diagnosis of abdominal pain in pregnant women and to inform practitioners regarding the relative risks of abdominal imaging and fetal radiation during pregnancy.” And so he and colleagues performed a comprehensive cost-effectiveness analysis of the diagnostic strategies for appendicitis during pregnancy. Using a computer-based model, the researchers examined the costs and short- and long-term risks of the interventions, and various quality-of-life measures across the lifetime of a cohort of 25-year-old mothers-to-be and their fetuses.

What the researchers found was that in the vast majority of cases, preoperative imaging is the most prudent choice for managing pregnant women with suspected appendicitis. They also determined that magnetic resonance imaging (MRI) – which doesn’t involve radiation – is the most cost-effective diagnostic strategy, and that CT – even when taking into consideration the potential risks of radiation-associated childhood cancer – is a cost-effective option when MRI isn’t available. The latter finding is particularly important for those hospitals (usually smaller or rural ones) that don’t have an MRI machine or access to skilled MRI interpretation at night or on weekends.

Kastenberg acknowledged that patients may still experience anxiety associated with radiation exposure. But he says he hopes the analysis “will give physicians the confidence to guide patients through an educated discussion of the risks and benefits of preoperative imaging, including CT, when confronted with this difficult clinical situation.”

Kastenberg is a post-doctoral fellow in Stanford’s Center for Health Policy and the Center for Primary Care and Outcomes Research. The research appears in the October issue of the Journal of Obstetrics and Gynecology.

Photo by Daquella Manera

Emergency Medicine, Patient Care, Public Safety, Stanford News

Ready for anything: Emergency responders refine protocols in simulated explosion at Stanford Stadium

Ready for anything: Emergency responders refine protocols in simulated explosion at Stanford Stadium

12947-drill_victims_ffPlanning and practice are two mainstays of any emergency response team. That’s why Stanford routinely conducts emergency drills such as a simulated explosion at Stanford Stadium last week. ”Rather than waiting for something you have to lean in and anticipate,” Palo Alto Police Chief Dennis Burns said in a Stanford Report story.

The two-hour drill simulated what it might be like if an explosion resulting in mass casualties occurred in Stanford Stadium. The event helped Stanford Hospital and police test their ability to coordinate a large emergency response effort with volunteers and more than 20 agencies from Santa Clara and San Mateo counties. “The exercise itself confirmed for us what works well and what needs to be fine tuned,” said Stanford Police Chief Laura Wilson.

Since clear and accurate communication is essential in times of crisis, this emergency drill was also used by Stanford’s Office of University Communications to assess their protocol for conveying critical information to the media, patient’s loved-ones, and the Stanford community. From the report:

Kathy Harris, a public safety program manager who planned the exercise, said the components of the drill were identified long before the Boston Marathon emergency and the Asiana Airlines crash at San Francisco International Airport. The scenario was designed to test multiple procedures, including the need to change the command post in the middle of a response and to react to an unstable situation. “This was not a reaction to anything but part of our routine pro-active emergency planning,” she said.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Plane crash creates unexpected learning environment for medical students“Preparation is everything:” More on how Stanford and Packard got ready for the Asiana crashAfter the plane crash: Inside the command center with Stanford Hospital’s chief of staffBehind-the-scenes look at treating SFO plane-crash survivors and “Everyone came together right away:” How Stanford response teams treated SFO plane-crash victims
Photo by L.A. Cicero

Emergency Medicine, Medical Education, Stanford News

Plane crash creates unexpected learning environment for medical students

Plane crash creates unexpected learning environment for medical students

The emergency department (ED) is a major gateway of the hospital, where unexpected illnesses are triaged and vague complaints are teased out. I especially appreciate the specialty because emergency physicians know how to initially evaluate just about any kind of patient who shows up at the door. Although I knew EDs were used to dealing with unexpected patient flow, what I didn’t fully appreciate until recently was that top hospitals like Stanford are also well-versed in mobilizing for massive unexpected illness or injury – and the subsequent onslaught of dozens, or even hundreds, of patients without appointments.

Expecting a loud, chaotic scene, I instead walked in on a machine made of well-rehearsed professionals

“We have a busload of wounded passengers on the way, ETA 15 minutes,” the loudspeaker crackled, as I arrived on my shift in the emergency department on July 6. Asiana Airlines flight 214 had just crash landed at SFO, and the Stanford ED had already initiated “Code Triage.” This activates a set of multi-team hospital protocols to respond to a mass casualty event. Expecting a loud, chaotic scene, I instead walked in on a machine made of well-rehearsed professionals. From triage to trauma assessment, the hands on deck made disaster response look more like business as usual.

I was quickly put to work and assisted with about a dozen patients with a chief complaint of “Airplane Crash,” and through a Mandarin or Korean interpreter performed a crash-focused history and physical exam. Using bedside ultrasound I also helped check for traumatic internal bleeding, which helped show us who needed to go to the O.R. immediately. While most victims were stable enough to be released same day, a common injury pattern spoke to how violently the plane tossed and tumbled passengers. The most serious injuries appeared to affect those in the rear of the aircraft, presenting with head lacerations; these reflected the catastrophic trauma resulting from the loss of the plane’s tail section.

As skeletal imaging revealed, other patients were primarily victims of the massive torsional and deceleration forces generated when the plane spun and lurched to a halt. This spinal jarring led to vertebral fractures and even paralysis. The majority, however, described similar patterns of left-sided body pain, likely from being flung into the armrest while wearing a lap belt.

In addition to the incredible response by the Stanford ED and commitment of the staff who worked those extra hours, I was truly impressed by the larger regional disaster planning efforts taken in advance of this tragedy. It underscores why disaster medicine is a medical specialty of its own and how emergency medical system (EMS) is part of the fabric of local government and the community. I was lucky to be a part of something that most physicians won’t see in their career and to have experienced it alongside our nation’s leaders in the field.

Mike Hoaglin is a fourth-year visiting medical student who plans to pursue emergency medicine.

Previously:“Preparation is everything:” More on how Stanford and Packard got ready for the Asiana crash, After the plane crash: Inside the command center with Stanford Hospital’s chief of staff, Behind-the-scenes look at treating SFO plane-crash survivors and “Everyone came together right away:” How Stanford response teams treated SFO plane-crash victims

Emergency Medicine, Public Safety, Stanford News

“Preparation is everything:” More on how Stanford and Packard got ready for the Asiana crash

"Preparation is everything:" More on how Stanford and Packard got ready for the Asiana crash

blog crash pic 5 ed

“Preparation is everything,” said Stanford’s chief of trauma and critical care surgery, David Spain, MD, when I asked him about the breathtaking response by the Stanford and Lucile Packard Children’s hospital staff who helped care for the influx of Asiana Airlines crash victims July 6.

While reporting a story on the response for today’s Inside Stanford Medicine, it became apparent just how well the staff had prepared.

In the past year, they’ve participated in two large-scale mass-casualty exercises: One, an active-shooter scenario, was a statewide effort; the other, an earthquake scenario, was a joint training with Stanford University, Stanford University School of Medicine, Santa Clara County and Palo Alto.

Maybe most fortuitously, just last month as part of a Stanford Office of Emergency Management training program, every emergency department nurse completed training for triaging disaster casualties, and then on June 14, just three weeks before the crash, emergency management program managers Eric Giardini and Laura Harwood ran a simulation with the whole emergency department of “code triage” — exactly the scenario faced after the plane crash.

When I talked about that simulation with Brandon Bond, the administrative director of the emergency management office, he told me how valuable it proved to be: “They set up the patient triage system in the ambulance bay, deployed the triage disaster supplies as well as simulated patient triage. Every component that the team had exercised last month was utilized during the event July 6.”

Previously: After the plane crash: Inside the command center with Stanford Hospital’s chief of staffBehind-the-scenes look at treating SFO plane-crash survivors“Everyone came together right away:” How Stanford response teams treated SFO plane-crash victims
Photograph, of medical teams receiving patients at the Marc and Laura Andreessen Emergency Department, by Brandon Bond

Emergency Medicine, In the News, Patient Care, Podcasts, Stanford News

After the plane crash: Inside the command center with Stanford Hospital’s chief of staff

After the plane crash: Inside the command center with Stanford Hospital's chief of staff

Earlier today, we shared a video that provides a behind-the-scenes look at our emergency teams’ response to Saturday’s plane crash. Now, in a 1:2:1 podcast, Stanford’s Ann Weinacker, MD, provides even more details from Saturday morning: how officials here mobilized to establish a command center and initiate code triage, bringing together cross-functional teams from emergency, trauma, operations, security and others to coordinate the expected surge of patients. Among the things Weinacker shares in this 26-minute interview is the sense of calm and organization she arrived to at the hospital, and the uncertainties she and her colleagues later felt as they waited for patients to arrive:

It concerned us that we didn’t always knew who was coming or how many people were coming or what the extent of their injuries might be. We would get word that an ambulance was coming with several people or a bus was coming with 15 people… At one point we had heard what was being reported on the news, that there were 60 people unaccounted for; that of course caused a lot of anxiety for us in our minds. Are these people severely injured? Are they deceased? We didn’t really know what the situation was or how many of those people we would be getting.

Weinacker is chief of staff at Stanford Hospital & Clinics and a professor of critical care medicine at the medical school.

Previously: Behind-the-scenes look at treating SFO plane-crash survivors and “Everyone came together right away:” How Stanford response teams treated SFO plane-crash victims

Emergency Medicine, In the News, Stanford News

Behind-the-scenes look at treating SFO plane-crash survivors

View more videos at: http://nbcbayarea.com.

It’s been several days since the crash of Asiana Airlines Flight 214, and NBC Bay Area offers a look back at how Stanford and Lucile Packard Children’s Hospital emergency teams handled the rush of survivors. As reporter Marianne Favro describes, “it came down to two things: training and timing.”

Previously: “Everyone came together right away:” How Stanford response teams treated SFO plane-crash victims

Emergency Medicine, Global Health, Infectious Disease, Public Health, Stanford News

Factoring in the environment: A report from Stanford Medicine magazine

Factoring in the environment: A report from Stanford Medicine magazine

summer 13 cover blogIt’s right before our eyes: The water we drink, the air we breathe, our neighborhood — in other words, our environment — can make or break our health. This simple truth gnawed at Pulitzer Prize-winning investigative reporter/Stanford medical alum Sheri Fink, MD, PhD, as Hurricane Sandy approached New York City last fall.

As she writes in the new issue of Stanford Medicine magazine, a collaboration with the Stanford Woods Institute for the Environment:

The images of the hurricane spinning toward my city, and the knowledge that thousands of New York’s most fragile residents would be left in its path, in facilities that were not hardened to withstand significant flooding or power outages, made my stomach sink.

Fink’s article on heroics in New York City’s hospitals and nursing homes during Hurricane Sandy is part of the special report, Environmental impact: The health effect,” in this summer’s issue of the magazine, which has just been published.

Also in the issue:

  • “Water solutions:” Actor Matt Damon and engineer Gary White, co-founders of water.org, discuss how they intend to solve the global water crisis.
  • “Priming the pumps:” The tale of a trip to the slums of Dhaka that led to a radical solution for contaminated drinking water.
  • “Street smarts:” A feature on senior citizens using tablet computers developed at Stanford to wake up city officials to safety hazards in their working-class neighborhood.
  • “Close encounters:” A story on scientists who are combining data from satellite images and studies on the ground to grasp the ecology of disease-bearing pests.

This issue’s “Plus” section, featuring stories unrelated to the special report, includes:

  • “Leo and Frida:” The tale of the friendship between artist Frida Kahlo and Stanford surgeon Leo Eloesser, MD.
  • “Winnie’s tale:” The story of how a cancer treatment 30 years in the making came in the nick of time for centenarian Winnie Bazurto.

Previously: New issue of Stanford Medicine magazine asks, What do we know about blood? The money crunch: Stanford Medicine magazine’s new special reportThe data deluge: A report from Stanford Medicine magazine, Tens of thousands of children still affected by Hurricane Katrina, Pulitzer Prize-winner Sheri Fink: the final hours at New Orleans Memorial and Murky waters: A look at Memorial Medical Center after Hurricane Katrina
Illustration by Brian Cronin

Emergency Medicine, In the News, Stanford News

“Everyone came together right away:” How Stanford response teams treated SFO plane-crash victims

"Everyone came together right away:" How Stanford response teams treated SFO plane-crash victims

ambulenceI was in Wisconsin visiting family when I received the news from a friend. “Plane crash at SFO. Airport shut down,” the instant message chirped at me. “Aren’t you flying back tomorrow?” Shocked, I went online to find out exactly what happened at the airport I’ve traveled in and out of countless times.

Closer to home, I would find out later, teams of Stanford physicians, nurses, technicians, and other specialists had also heard the news and were jumping into action. Stanford Hospital and Lucile Packard Children’s Hospital were among nine hospitals in the Bay Area called on to evaluate and treat the crash victims; 55 passengers from Asiana Airlines Flight 214 were ultimately brought here.

Today, two of my colleagues provide details of what transpired Saturday afternoon:

Officials at Stanford Medicine quickly activated the hospital command center after receiving word of the incoming casualties. They initiated a “code triage,” bringing together cross-functional teams from emergency, trauma, operations, security and more to safely and efficiently coordinate the expected surge of patients.

Eric A. Weiss, MD, medical director for the Office of Emergency Management, said the mobilization was rapid. “Within 30 minutes we had admitted or discharged most of the patients who were previously being treated in the emergency department, and we mobilized over 150 health-care providers dedicated to responding to the airplane tragedy,” said Weiss, who is also an associate professor of emergency medicine at the School of Medicine…

To evaluate and treat the influx of trauma patients from the crash, the hospitals mobilized seven trauma teams with fully trained surgeons and five perioperative teams. “We also implemented our rapid admission and rapid discharge plan, plus we set up an expansive and well-staffed triage area outside the emergency department to accommodate the surge of additional patients,” Weiss said.

Of the 55 patients evaluated and treated, 11 were admitted to Stanford Hospital and seven to Packard Children’s. “The injuries were of varying degrees,” said David Spain, MD. As chief of trauma and critical care surgery at Stanford, Spain was already on site when patients started arriving by ambulance and helicopter.

Despite the severity of the situation, people on the scene report that the mood in the emergency department was calm. And the article notes it’s clear the hours of disaster planning and training paid off for the medical teams. “Everyone came together right away to deal with a rapidly evolving situation and do what they do best, which is save lives,” said Brandon Bond, administrative director of the Office of Emergency Management for the two hospitals.

Previously: Following Boston bombings, “there’s nothing else in the world I would rather do now” than go into medicine“We are not innocents:” What prepared medical professionals to treat Boston bombing victims and New Stanford Hospital team ready to mobilize for disaster relief
Photo courtesy of Brandon Bond

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