We appreciate the opportunity to respond to the letter to the editor in reference to our prior publications1,2 and to clarify the concerns raised. It seems that we, the authors of the original article, and the author(s) of the most recent letter to the editor have common ground on many of the issues presented. We believe that all emergency patients should be cared for by emergency physician-led teams. We agree that the training of our physician residents cannot be compromised.
We believe the letter to the editor by Tsyrulnik et al1 clarifying the initial manuscript “Implementation of a Physician Assistant Emergency Medicine Residency Within a Physician Residency” from December 2020 is an important marker and acknowledgment of a deep-rooted workforce issue that will plague emergency medicine (EM) for the entirety of its future. It also only scratches the surface. Indeed, in the aftermath of the EM workforce reports by the American Academy of Emergency Medicine (AAEM), and more recently the American College of Emergency Physicians, the AAEM Resident and Student Association is now advocating for an end to all postgraduate training programs for non-physician practitioners (NPP).2
As the novel coronavirus 2019 (COVID-19) has rapidly become a global pandemic, emergency physicians worldwide play essential roles in the frontline management of critically ill patients with COVID-19. In emergency airway management, video laryngoscopes (VL) are recommended over direct laryngoscopy to minimize healthcare worker exposure to aerosolized particles.1 However, the VL may be too expensive or unavailable in resource-limited settings, where it is needed to protect the limited number of healthcare providers. We, therefore, reintroduce the idea of creating a low-cost VL from the direct laryngoscope (DL) and a low-cost (approximately $8) smartphone borescope, which is widely available to purchase online. The borescope camera should be secured at the same level as the light sources of the Macintosh blade for the optimal view (Figure, Video). Previous studies of such “Do-It-Yourself” (DIY) VL demonstrated an improved glottic view and increased ease of use in simulated settings for novices and may be comparable to the commercial VL for experienced intubators.2,3 Moreover, if the capability exists, the disposable blade could be produced from 3D printing.2
The rapid global spread of coronavirus disease of 2019 (COVID-19) has resulted in considerable emotional and physical distress in a time of limited medical resources. As healthcare systems have been pushed to the brink, advanced care planning and end-of-life life discussions are of the utmost importance. Palliative care is at a unique vantage point to help treat symptomology and provide guidance. Due to resource limitations, we aim to outline pressing, palliative care needs from a critical care and emergency medicine standpoint.
We first want to thank Peters and colleagues for their interest in our work. They bring up two notable points in discussing our study.
We utilized three-lead Nasiff CardioHolter monitors to assess physiologic parameters. The raw data was downloaded directly from Holter monitors using Nasiff software and then reviewed by study authors to ensure quality data was obtained. While there was some motion artifact throughout the shift, the majority of the data was reliable with discernible QRS complexes in one of the three leads. We did not quantify the amount of artifact in each reading. This data was then analyzed using the provided software. When designing the study, we felt that a three-lead Holter, although less convenient and comfortable, would afford us additional data over pulse rate sensors. We do acknowledge as a limitation that we cannot account for all data obscured by artifact as we cannot control how the software decides to analyze and provide specific summary measures.
We were very interested to read the manuscript by Janicki and colleagues, and we are grateful for their contribution to the literature.1 We agree that stress is a major problem for emergency physicians.2 But we had two concerns with the study design.
With interest we read the review article by Valiuddin et al. about the neurological implications of coronavirus disease 2019 (COVID-19) (neuro-COVID).1 The authors listed ischemic stroke, transverse myelitis, seizures, acute hemorrhaghic necrotising encephalopathy (AHNE), acute disseminated encephalo-myelitis (ADEM), posterior reversible encephalopathy syndrome (PRES), myasthenia, and sinus venous thrombosis as central nervous system (CNS) manifestations, and hyposmia/hypogeusia, Guillain-Barré syndrome, facial palsy, ophthalmoparesis, and neuropathy, as peripheral nervous system (PNS) manifestations of COVID-19.1 We have the following comments and concerns.
The COVID-19 pandemic has been a significant catalyst for change in medical education and clinical care. The traditional model of bedside clinical teaching in required advanced clerkships was upended on March 17, 2020, when the Association of American Medical Colleges recommended removing medical students from direct patient care to prevent further spread of the disease and also to help conserve scarce personal protective equipment (PPE). This created unique challenges for delivering a robust, advanced emergency medicine (EM) clerkship since the emergency department is ground zero for the undifferentiated and potentially infected patient and has high demand for PPE. Here, we describe the development, application, and program evaluation of an online-based, virtual advanced EM curriculum developed rapidly in response to the COVID-19 pandemic.
We thank Drs. Megarbane and Schicchi for their thoughtful comments on our manuscript and efforts to highlight pertinent in vitro and in vivo literature. As stated in our manuscript, we agree that aggressive supportive care is the mainstay of treatment for acute chloroquine and hydroxychloroquine toxicity, including management of the airway with appropriate ventilation, if necessary.
We would like to comment on Lebin and LeSaint’s overview of chloroquine/hydroxychloroquine (CQ/HoCQ) toxicity and management.1 The authors focused on the indications and administration modalities of hypertonic sodium bicarbonate, diazepam, and epinephrine. Surprisingly, they did not consider the role and indications of tracheal intubation and mechanical ventilation, while representing the mainstay of treatment.
We thank the authors for their insights and for sharing this case. The authors describe a patient who was intubated with the endotracheal tube (ETT) located at the tip of the carina, thereby allowing for bilateral lung sliding, while placing the ETT at risk of converting to a mainstem intubation.
In the recent edition of the Western Journal of Emergency Medicine, Gottlieb and colleagues discuss point of care ultrasound (POCUS) confirmation of intubation.1 Up to 25% of intubations using the classic formula of endotracheal tube (ETT) depth equal to three times the ETT diameter are inappropriately positioned,2 and 35–60% of mainstem intubations are missed by auscultation.1 Therefore, chest radiograph (CXR) has traditionally been used for confirmation of appropriate ETT placement.
We thank the authors for their interest in our article, and for highlighting some important limitations of our work. 1 We are grateful for the opportunity to address these concerns further.
Regarding the authors’ first concern, indeed we already acknowledge in our limitations section that many of our patients did not receive continuous cardiac monitoring, and asymptomatic events could have been missed. While the clinical importance of asymptomatic self-terminating dysrhythmias is debatable, this question has fortunately been addressed by the DORM II investigators, who prospectively studied patients receiving droperidol for acute behavioral disturbance in multiple Australian emergency departments (ED). All patients in that study were initially treated in a critical care bed and attached to a cardiac monitor. When available, continuous ECG recordings were later analyzed, no patients had dysrhythmias, and while QT prolongation was observed the investigators found it was frequently due to causes other than droperidol. 2 We believe the incidence of such transient asymptomatic dysrhythmias in our study is likely miniscule.
We read with interest the recent article discussing QT prolongation and torsade des pointes (TdP) and droperidol.1 The paucity of readily available antipsychotics and antiemetics that are not associated with QT prolongation makes selection of an appropriate pharmaceutical challenging in ideal situations and decidedly complex when confronted with an agitated, delirious, or intoxicated patient.
We read with interest the article by Rebecca Karb et al1 titled “Homeless shelter characteristics and prevalence of SARS-CoV-2,” published in the Western Journal of Emergency Medicine. We appreciated the authors focusing on people experiencing homelessness, a population that has been particularly impacted by the recent coronavirus disease 19 (COVID-19) pandemic and that is more at risk of contracting COVID-19 for specific environmental and individual characteristics.2
We, the authors of the paper: “Implementation of a Physician Assistant Emergency Medicine Residency Within a Physician Residency” (West J Emerg Med. 2020 Dec 14;22(1):45–8) would like to address concerns raised by members of the emergency medicine (EM) community. Our article describes the successful implementation of a physician assistant (PA) training program within the existing framework of an EM residency. This article was submitted as a “brief educational advance.” It is a description of the logistics of our program and was not powered to draw any statistical conclusions on the limited data of an evaluation tool lacking validation, as was pointed out in the limitations. It does not support or suggest the equivalence of physician graduates of a 3- or 4-year residency in emergency medicine with PA training program graduates. As such, it does not seek to equate the two programs or the skills of their respective graduates, but instead to describe a successful interprofessional educational collaboration.
We agree fully that “reciprocal liking” may be an important causal factor behind some of the mismatch between student behavior and theoretically ideal Match behavior. Indeed, it likely explains why programs and applicants go out of their way to communicate liking for one another despite official National Resident Matching Program (NRMP) policy discouraging communications…
We would like to thank the authors for exploring students’ understanding of the National Residency Match Program (NRMP) algorithm,1 as it is both complex and potentially confusing. In their paper, the authors make significant value judgments about what should and should not affect an applicant’s rank list. They make assumptions about what an optimal match would be for applicants and assert that a program’s opinion of an applicant is not a reason to change a preference for one residency over another. An applicant’s perceived competitiveness based on program reputation alone should not dissuade them from ranking highly a very competitive program, as the NRMP algorithm prioritizes applicants’ preferences over those of programs. However, if an applicant has some evidence that a certain program thinks especially highly of them, we believe that bit of data may suggest how a program views their fit with the residency. Programs should be cautious when alerting applicants about their relative rank list positions as applicants may interpret that as a guarantee. Ranking an applicant highly may not necessarily mean they are guaranteed to match, but rather in a position to match based on data from previous match years.
The COVID-19 pandemic has generated enhanced focus on the safety of healthcare providers and efforts to mitigate the risks of viral transmission.1 Reports of previous viral epidemics have described substantially increased risk to providers performing laryngoscopy and tracheal intubation in patients infected with the virus.
Emergency Physicians provide ongoing care to psychiatric patients beyond the confines of a standard emergency room visit. Often, when we identify patients who need specialty psychiatric care, patients board in the emergency department awaiting acceptance and transfer to an outside facility. Even in cases where it has taken multiple days to complete the transfer, it has been unclear how to properly obtain reimbursement for this care. We discuss a new coding clarification that may provide a pathway to improve part of this situation.
We appreciate the discussion outlined by Merelman et al. regarding the important role ketamine has in emergency airway management, 1 and agree with the sentiment that ketamine may be preferable to other agents in many different clinical scenarios.
We appreciate the response to our manuscript “Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine” and value the authors’ perspectives, both competing and complementary.