White House Budget eliminates EMSC funding

The White House released it’s budget proposal recently and it features a series of cuts to federal spending. While presidential budgets are not law and many lawmakers have already called it “Dead on Arrival”, it does set priorities for budget negotiations moving forward. One cut relevant to pediatric emergency medicine is the elimination of funding for the Emergency Medical Services for Children (EMSC) program. The AAP and ACEP both oppose eliminating EMSC and the following is the call to action released by the AAP Section on Emergency Medicine.


Recently, President Donald Trump released his fiscal year 2018 budget proposal, which eliminated funding for the EMSC program. The Academy issued a statement opposing the overall budget proposal and today joined with several other organizations to speak out against the president’s recommendation to defund EMSC.

While the budget proposal does not become law, it sets a dangerous precedent and is a reflection of President Trump’s funding priorities.

As a pediatrician with expertise in this field, you understand the importance of children having access to emergency services, equipment and medications that are designed and dosed specifically for them. It is critical that Congress hears directly from you about the need to fully fund the EMSC program.

For more than 30 years, the EMSC program has improved the quality, capability and outcomes of pediatric emergency care, including in pre-hospital EMS systems and hospital emergency departments. The president’s budget would mean devastating consequences for this progress.

There are two ways for you to take action:

  • Contact your members of Congress: To contact your members of Congress and urge them to support full funding for the EMSC program, click on the “Take Action” button above or go to federaladvocacy.aap.org and click on “Fully Fund the Emergency Medical Services for Children Program” in the Advocacy Action Center. There, you will find a template email to guide your outreach.
    • We’ve also included talking points below if you would prefer to call your members of Congress. You can find your representative and senators by going to House.gov and “Find Your Representative” and Senate.gov and “Find Your Senators.” The Washington, DC Office contact information will be on their websites.
  • Share messages on social media: Use #EMSCDay to share messages on Twitter about the importance of the EMSC program. Sample tweets below:
    • On #EMSCDay, Congress should fund EMSC, the only federal program focused on improving emergency care for children: http://ow.ly/lXeh30bYHNm
    • EMSC is especially important during mass casualty events involving children, like this week’s bombing in England. #EMSCDay
    • On #EMSCDay we oppose President Trump’s budget proposal to eliminate EMSC, which provides pediatric emergency care: http://ow.ly/lXeh30bYHNm

Your voice is essential in these efforts. Thank you for taking advocacy action to support the EMSC program.

Talking points:

  • As a pediatrician and a member of the American Academy of Pediatrics, I urge you to support the Emergency Medical Services for Children (EMSC) program by fully funding the program for fiscal year 2018.
  • President Donald Trump’s FY 2018 budget proposal, which eliminates funding for the program, would have devastating consequences for the progress that has been made to improve pediatric emergency care in the United States.
  • For more than 30 years, the EMSC program has worked to improve the quality of care children receive, no matter where they live or require treatment. Children are not just little adults-emergency services and equipment like ventilation and airway equipment, defibrillators and life-saving drugs need to be sized and dosed especially for children.
  • The EMSC program has improved the quality, capability and outcomes of pediatric emergency care, including in pre-hospital EMS systems and hospital emergency departments. In addition, it funds critical research to improve substance use screening, such as opioid dependency, and screening for suicidality that may be linked to substance use or mental health disorders.
  • We may not know when or how an emergency will occur, but thanks to EMSC, our nation’s ambulances, EMS personnel and emergency departments are better equipped and trained to treat children.
  • I urge you to reject the president’s proposal and fully fund the EMSC program in FY 2018 so that children and adolescents continue to have the emergency medical support they need, the moment they need it.
  • Thank you for all you do for children.

Applying for PEM: Know before you go

Maybelle Kou, MD is the PEM fellowship director at INOVA Children’s Hospital and a member of the AAP Society on Emergency Medicine Program Directors Committee. She addresses the basics of applying.

So I’m interested in applying to Pediatric Emergency Medicine (PEM) Fellowships. Where do I start?

There are currently about 75 ACGME accredited PEM fellowships in North America with new programs developing yearly.

The Emergency Medicine Resident Association published a fellowship guide in 2016 that provides background. The Society of Academic Emergency Medicine also has a fellowship program directory here.

Since it can be confusing to apply, here are some other FAQ to demystify the PEM fellowship application process:

How do I find all the programs?

In ERAS, you will find two lists of PEM fellowships. The heading “pediatrics” or “emergency medicine” denotes the ACGME affiliated primary residency program it is attached to.

You can research programs on both lists, regardless of your primary specialty. Very few programs cater to EM applicants only. The ERAS site provides links to most of the program websites for more info.

How do I know which ones I can apply to? Must I apply only to programs accredited through my primary specialty? 

The short answer is no, but it is confusing. Here’s some background with apologies for the alphabet soup. You’ll want to apply to an ACGME accredited program.

  1. Fellowships gain ACGME accreditation either through the Pediatric Residency Review Committee (RRC) or the Emergency Medicine RRC. For example, if there is no onsite EM residency, a fellowship will apply for accreditation through an onsite Pediatric residency.
  2. ACGME program training requirements for Pediatric Emergency Medicine are the same regardless of Peds or EM RRC accreditation.
  3. In PEM, two regulatory boards oversee the two individual sets of applicants: the American Board of Pediatrics (ABP), and the American Board of Emergency Medicine (ABEM).
  4. All fellows completing fellowship applying for board certification in PEM do so through their primary board, regardless of the accreditation of the program where they trained.

Can I apply to programs that are accredited through the pediatric RRC if I am EM trained?

Yes. ACGME affiliation does not necessarily direct whom the program will train, e.g. there are fellowships accredited by the Pediatric RRC that train EM applicants, and fellowships accredited by the EM RRC that train pediatric applicants. This info is not available via ERAS but might be available on a program’s web page. When in doubt send a query to the program coordinator.

So why is there a difference in length of training?

The length of training is defined by the ABP and ABEM. The length of training for residents trained in pediatrics is 3 years, whereas it is 2 years for emergency medicine trained.

If your first residency is Pediatrics:

Fellowship Training length is 3 years because the ABP requires all subspecialty pediatric fellows  year to perform a year of scholarship and research.

If your first residency is Emergency Medicine:

Fellowship Training length is 2 years (ABEM requires scholarly activity during residency).

If I’m applying from EM what else should I know?

Be aware some training programs can’t offer a 2 year program for EM applicants and they are required to disclose the curriculum up front.

Don’t be put off by a program that has not yet trained an EM graduate.  Be resourceful to make sure you are getting the education you need, program directors are often willing to let you help shape your curriculum.

It’s a good idea to seek out EM trained fellows/graduates from the program who are willing to share their experiences even if there is a track record for training EM folks.

Lastly, if you are an EM applicant applying to programs that require a 3rd year, remember the third year doesn’t have to be a dealbreaker: you may have access to degree programs, such as an Masters in Public Health or Masters in Education. Also, networking from a large, established program with a solid research infrastructure is also an advantage.

Can they make me do research or a third year if the board doesn’t require it?

If the program requires research, then it is a requirement of the program and of the board. Make sure you know what you’re signing up for!

(I don’t like research. Why do I have to do research?)

Finding the right mentorship can help you channel your interests and even change your perspective about research! Be open minded about the opportunity. Even if you don’t see research in your future, a strong foundation in literature appraisal and research methodology will be helpful in your career. It is especially important if you go on to teach in an academic environment, or even in safety and quality.

Last thoughts for applicants from EM:

Remember that within PEM you can carve a niche e.g. education, prevention, EMS, ultrasound and disaster. A fellowship in PEM provides exceptional leadership training as well as an extra board certification. Many fellows go onto leadership positions both in and outside of academics.

When looking for places to train do reach out to the program leadership if you have questions, there are some hidden gems out there you may least expect.

Thanks to Anne Whitehead MD, Jessica Wall MD and Daniella Santiago-Haddock MD for input and links.

MD Cents: Food for Thought on Your Career’s Location

An interesting article was released a few weeks ago regarding the “best” and “worst” states in which to practice medicine. I’m pretty happy practicing where I do and I hope you can say the same, regardless, I was curious. You may wonder (as I did) where does your state rank for physicians and what makes a state a good place to practice?

We each have our own criteria when looking at jobs after fellowship. Some will favor compensation, some location, and some reputation of the institution. This article looks at some of those factors but also considers many items that most PEM physicians don’t count at all in their decision process.

Here is a link to the article: Best States

Surprisingly, the top three “states” are: Iowa, Minnesota, Idaho and the worst “states” are: New Jersey, DC, and New York.

In order to explain why they make these determinations let’s dig a bit into the methodology of the report and also why some of the factors they consider should be on the radar of PEM physicians when deciding where to practice.

In their methodology they give a score to several factors:

  1. Physicians average annual wages
  2. Physicians average annual starting monthly wage
  3. Hospitals per capita
  4. Insured population rate
  5. Primary care provider shortage
  6. Projected elderly share of the population
  7. Current physician competition
  8. Projected physician competition
  9. Number of CME credits required
  10. Presence of interstate medical licensure compact law
  11. Quality of public hospital systems
  12. Punitiveness of the state medical board
  13. Malpractice award payout per capita
  14. Annual malpractice liability insurance rate

As you can see they take many factors into consideration. Some of them we often think of like salary and the quality of the health system we are joining but many are unique (and some don’t apply to the PEM physician at all like the elderly population rate). For instance, I did not consider the insured population rate, the presence or lack of a primary care physician shortage, or the punitiveness of the state medical board in my decision to practice in Indiana. Many of these are directly related to your finances, hence the examination of this article on this blog.

Let’s dive in a bit. The factors that arguably can make your job help or a hinder your financial future include factors that directly affect your compensation and factors that effect the chance you will get sued potentially taking away financial resources.

The authors assign a 0-100 score to each state based on the 14 factors listed above. The first 10 make up the opportunity and compensation factors where a state can score up to 70 points and the last 4 make up the medical environment factor where a state can score up to 30 points.

As you would imagine, several different states lead in different categories and none is all “good” or “bad.” For instance, Indiana ranks #1 in physician compensation and in the top 5 for malpractice insurance premiums, whereas New York is in the bottom 5 for annual wage, competition, malpractice awards and insurance rates. Given this it isn’t hard to see why some states ranked lower than others.

One important caveat is that compensation rankings in this article were adjusted for cost of living. This makes it easy to see why a relatively high wage would be ranked higher in a place like Indiana than say, California or New York as the cost of living is much more on the coasts. Also, more desirable locations attract people, physicians included so this inevitably leads to more competition (and higher physician density) decreasing the score for some of the same locales that have lower adjusted compensation for the cost of living. This proves a double whammy to certain states.

Other important factors that have nothing to do with physician density are the punitiveness of medical boards (sorry New Mexico, Ohio, Delaware, Louisiana and Wyoming), the amount of malpractice awards (lowest in North Dakota, Minnesota, Wisconsin, Texas and North Carolina), and the cost of malpractice insurance (condolences New York, DC, Michigan, Illinois, West Virginia). Malpractice insurance is cheaper where malpractice awards are relatively lower and this is often partly due to the presence of tort reform laws. These awards also cause a double hit to certain states, as it seems that many states with high desirability, geographically speaking, also have more punitive environments for physicians and any mistakes they might make.

Overall, I found this article interesting and it raised a couple of points that I think are pertinent to PEM physicians looking for a new/first job. Namely, the state practice environment depends on more than just whether there is an ocean/good climate/mountains present and that a PEM job seeker should consider physician density, the state medical board, and the malpractice climate along with more traditional considerations like salary when they make their decisions.

What do you think about the article? Did you consider the malpractice environment in your future practice site when thinking about your current job? Do you think the score is faulty or how would you change the scoring system to rank states in your opinion?

Epinephrine or Dopamine? Results may shock you

Andrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t in the room that day, we’re going to be counting them down over here over the next few weeks.

Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock

Ventura AM1, Shieh HH, Bousso A, et al. Critical Care Medicine. 2015.

Unmet Needs Addressed

Sepsis results in high rates of mortality. That is a problem. While some diagnostic and treatment guidelines for pediatric sepsis exist, some areas remain debatable. One of those debates is what is the best first-line vasoactive infusion for children with fluid-refractory shock?

Methods

  • Single center, prospective, randomized, double-blind trial in a pediatric ICU in São Paulo, Brazil
  • Children 1 month to 15 years old who met clinical criteria for fluid-refractory septic shock were screened for eligibility
  • Exclusion: Children receiving vasoactive drug(s) before hospital admission, known cardiac disease, prior study enrollment during same hospital stay, DNR
  • Data were collected between 2009-2013
The study defined fluid-refractory shock as:

Clinical signs of hypo-perfusion

  • Abnormal heart rate for age
  • Altered/decreased mental status
  • Altered capillary refill time (>2 seconds or flash)
  • Diminished or impalpable or bounding peripheral pulses
  • Mottled cool extremities
  • Urine output <1ml/kg/hr

DESPITE fluid bolus of at least 40 ml/kg

They compared various doses of epinephrine (0.1, 0.2, and 0.3 mcg/kg/min) and dopamine (5, 7.5, and 10 mcg/kg/min) via a PIV or intraosseous line.

Main Results

There were 120 children with fluid-refractory septic shock studied.

Check out the Kaplan-Meyer for epinephrine versus dopamine.

It’s not clear how the editors allowed this chart to use shades of grey for the lines instead of a dotted line. But it suggests that children in the dopamine group died earlier and children in the epinephrine group had an increased odds of survival (6.49). The rate of adverse events were similar.

The dopamine group had a higher percentage for hospital-associated infections compared to the epinephrine group (18/63 patients and 4/57 patients, respectively).

How Did This Make Our Top 10?

Using epinephrine as the first-line vasoactive infusion for children with fluid refractory shock was superior to dopamine. The results admittedly must be replicated.

In addition, peripheral and intraosseous lines were effectively used for early initiation of vasoactives.

Cutting out the surgeon from appendicitis?

David Mathison, MD, MBA, takes a fresh look at how we practice pediatric emergency medicine, looking to turn PEM upside down

I remember being a medical student on general surgery and drawing the short straw, the straw that meant I had to call the attending surgeon at 1am about a patient in the ED with routine appendicitis.  The surgeon answered the phone, strung off a slew of expletives, and finished with the statement, “I’m on my way.”

A decade later, that straw changed. A non-perforated appendicitis was no longer an emergency and appendectomies could be deferred to the next day after the initiation of antibiotic therapy.1 Calling the attending surgeon meant you would hear, “ok, I’ll see the patient in the morning.”
Now, we’re seeing that paradigm shift further, questioning the role of appendectomy all together. Evidence for the outpatient antibiotic treatment of acute uncomplicated non-perforated appendicitis continues to grow. What was once the most common surgical emergency of childhood may no longer be a routine surgical disease. Multi-centered randomized studies are ongoing, but appendicitis is becoming a family-physician negotiation rather than a ticket to surgery.

Non-operative management of appendicitis is not without complication. As many as 12% of patients fail within 7 days and require appendectomy. However, few patients past the short-term period have true recurrence that requires operative management.2  While we’re searching for the NNT in pediatrics and how to correctly risk stratify the non-operative options, non-operative appendicitis is becoming an increasing reality.

An antibiotic-first approach may completely change our ED approach to the patient with new-onset RLQ pain. Is it ridiculous to treat patients with clinically diagnosed uncomplicated appendicitis using PO broad-spectrum antibiotics and defer radiologic diagnosis for outpatient care?

Twenty years ago, surgeons would say that 1 out of 4 patients taken to the OR for suspected appendicitis would have a normal appendix. An evolving safety culture and medicolegal landscape demand radiographic diagnosis before operative management. I remember only one case in the past ten years where I was able to convince a surgeon that a patient had appendicitis without radiographic diagnosis. All the stars were aligned: Adolescent male patient, classic presentation, and attending walking by the room coincidentally.

Radiologic diagnosis is important before operative care to diagnose as well as rule out other disease masking RLQ symptoms. For example, the patient with undiagnosed Crohn’s disease who has ileocolic disease may present with RLQ pain. But is radiologic diagnosis so important if we are treating with antibiotics, especially if the radiologic diagnosis carries its own risk and cost? We diagnose pneumonia with a stethoscope and don’t need an ultrasound to diagnose a classic testicular torsion. While the radiologic evaluation is important, maybe it’s no longer part of the ED evaluation?

The Children’s Hospital Association advocates for ultrasound as the preferred initial modality. However many community hospitals cannot perform this test as well as a pediatric equipped facility. This results in over-utilization of CT scans or needless transports to pediatric centers. Even facilities with excellent US diagnostic technique still have high equivocal rates resulting in secondary testing. Trends to avoid ionizing radiation favor MR as a secondary modality. MRI is often not available 24 hours a day and is difficult in patients less than 8 years who may not be able to hold still.

As we approach value-based care, we have opportunity as PEM physicians to facilitate management of many acute diseases, but this may no longer be a reflexive call to a surgeon or admission. Rather, creative approaches with initiation of antibiotic therapy and outpatient surgical care coordination are the future. For example, using POC ultrasound to rule-out abscess formation followed by care coordination to follow clinical progress, arranging further radiologic testing, and managing the length of antibiotic therapy. What better opportunity to take over the management of this “surgical” disease? Time to change our thinking on appendicitis.

Who wants to take the lead?

1. Dunlop et al, Is Nonperforated Pediatric Appendicitis Still Considered a Surgical Emergency? A Survey of Pediatric Surgeons; Acad Pediatrics (12) 2012

2. Di Saverio, et al.  The NOTA Study (Non-Operative Treatment for Acute Appendicitis)  Ann Surg 2014 Jul; 260(1)