Articles

Written by Katren Tyler, MD Clinical Professor of Emergency Medicine, Medical Director of Physician Wellness, Age-Friendly Emergency Department Physician Lead, Geriatric EM Fellowship Director, Vice Chair for Geriatric Emergency Medicine and Wellness, UC Davis.

Reprinted with permission from “Systems and Departmental Responses to Fatigue Management” SAEM Pulse, Nov-Dec, p50, Copyright 2022 by Society for Academic Emergency Medicine.

Many of us started our ​EM​ careers as bright-eyed​,​ twenty-somethings who had no problems with shift work, working ​multiple overnight shifts​ and rapid schedule ​transitions​.  And frankly, this is ​reasonably ​easy to keep up in our 30​’​s as well, even as our external responsibilities get more complex. And then your 40​’​s happens. 

Ludicrously, I have done two residencies in Emergency Medicine – one in Australia and one in the USA.  But in this regard, I am a​ ​bona fide expert – in my adult life, I ​have ​never not been a shift worker. As a resident in Australia, I spent more than 20 weeks in a year on a rotating night-float shift schedule and loved it. Night shifts: I used to love them. I was a night owl and proud of it. Until I didn’t and wasn’t. 

I don’t like night shifts anymore. I ​understand​ that we are a 24/7/365 ​business​. But now, in my 50’s, I am at my best early in the morning ​– the circadian opposite of being a nocturnist​  Night shifts are, without a doubt, my highest risk for a cognitive error at work, and I don’t think I am alone.   

Chronotypes are how sleep researchers describe your chronobiology. Your chronotype reflects your individual preference for going to sleep at night and getting up in the morning.  As much as possible, you should estimate your chronotype when you are free of the external responsibilities of your life​​ – work, kids, pets, all the business of modern life temporarily aside – ideally when you are on a vacation or at least on a non-work weekend.  For the most part, researchers classify chronotypes as early, intermediate, and late.  Sleep researchers recommend that we should try and make your work schedule match your chronotype. Obviously, this is a challenge in our specialty. For many people, our chronotype gets earlier as we get older and our tolerance for late and night shifts is reduced.   

In healthcare, we place most of the responsibility for coping with shift work on the individual healthcare worker. System and department wide responses to the impacts of shift work as we age, or experience other physiologic challenges are limited. My call to arms for fatigue management systems is that our lack of protections for shift workers are also likely harming our patients, and that surely makes it a systems issue. 

​​​​​We know that shift work is a burden for emergency physicians and their families in terms of circadian desynchronization and fatigue. The evidence is ​clear​: shift work, especially night shifts, get harder as we get older; night shifts are associated with short-term cognitive impairment across all industries. Moreover, longer periods of duty, especially longer night shifts, are associated with short​–​term cognitive impairment and increased errors across all industries​.​ 

System suggestions: 

We have known for decades that sleep deprivation can be as serious as alcohol intoxication. It is unacceptable to be inebriated at work.  ​Yet we​ idealize and reward​ being exhausted​ in medicine. We have socialized and normalized fatigue in medicine for decades, recent changes notwithstanding.  

Healthcare in general, and ​EM​ in particular, has not acknowledged the cognitive load and patient safety risks of shift work.  There are very little systemic protections for physicians after training, and honestly, not that many protections during residency. We do not systemically evaluate if individuals tolerate shift work. Even if we acknowledge differences, we almost always put the responsibility on the individual. Multiple studies in healthcare and in other industries show people make more cognitive errors the longer that they have been awake. It will not surprise you to learn that other industries, especially the airline industry and some manufacturing industries have made stronger commitments to fatigue management than medicine has.  Sleep is the only way to reverse sleepiness. Fatigue management systems promote a shared responsibility between the employee and the system.  Sequelae of shift work include social jetlag / circadian desynchronization, cognitive impairment, and sleep disruption. Suggestions for protecting healthcare shift workers, and their patients, include evaluating the risks to ourselves and our patients, including pregnancy outcomes in health care workers, chronotype scheduling, access to sleep clinics, breaks on night shifts or extended shifts, access to food and water including cafeteria access, and the availability of call rooms or rideshare options.  Driving home after a night shift is a significant risk for motor vehicle crashes. We have work to do on the systemic role of sleep and aging physicians; most literature acknowledges sleep deteriorates with age, especially in shift workers. 

Departmental suggestions: 

As people age, our chronotype typically gets earlier, meaning we generally need to go to sleep earlier and wake up earlier​. We typically experience ​this change starting in our mid 40’s.  If you are lucky, you have some late chronotypes on your faculty.  Physiologically, late chronotypes can tolerate later shifts, including night shifts, with more sleep before and between night shifts.  Late chronotypes may struggle with early morning shifts.  Some individuals keep the same sleep-wake patterns they had when they were younger, are better able to tolerate shift work as they get older and are referred to as healthy shift workers. 

Many departments have night shift crews and incentivize the night shift: the night shift crews should be incentivized as much as possible in time or money.   

In our department, for some years, we have been able to opt out of night shifts at 55, and recently lowered the age to opt out of night shifts to 50 years of age.  This earlier opting out of night shifts at age 50 added 2-3 nights shifts per year to those faculty less than 40. 

Pregnancy: 

​​​Pregnancy is a common physiologic challenge faced by healthcare workers and the health systems that employ them. Pregnancy outcomes are worse in shift workers and those working longer than a standard 40-hour week. It is harder to protect the first trimester because schedules are often in place before people know they are pregnant, but protecting the third trimester and ​parental ​leave periods should be more ​​straightforward than many ​EDs​ make it.  Our department has adjusted our shift requirements for pregnant faculty so that there are no required night shifts in the third trimester, and no clinical shifts in the emergency department after 36 weeks’ gestation.  As a department, we do have the option of telemedicine if pregnant faculty need to keep working clinical hours. Our health system provides 90 days of pregnancy leave for all faculty. 

Moving forward, we should think about how we collectively protect ourselves and each other from the impacts of shift work – for ourselves, for our colleagues and for our patients. 

IEPC is proud to present the 2022 Speaker Series! This free speaker series has welcomed leaders in the field to cover timely and engaging topics that are important to independent emergency physicians. The sessions precede each monthly conference call and are open to all IEPC members and those who may be interested in joining.

Fall 2022 sessions include:

• July 25 – Andrew Young, MD, MPH, Medical Consultant, CA Dept. of Health Care Services to present Medi-Cal Update: State Initiatives to Improve Quality of Care
• August 22 – Peter Viccellio, MD, FACEP, Associate CMO, University Hospital to present Making Room for Patients – ED Turnaround Times
• September 19 – James Keaney, MD MPH FAAEM to discuss Institute for Justice in Emergency Medicine
• October 24 – Laura Wooster, ACEP Associate Director, Public Affairs and Jeffrey Davis ACEP Director of Regulatory Affairs to share ACEP updates
• UPCOMING November 28 – Andrew Selesnick to discuss the Anthem Lawsuit

This series is presented on the fourth Monday of the month January – November. Advance registration is required and can be completed by registering through the monthly email invitation. After registering, you will receive a confirmation email containing information about joining the meeting.

Andrew Fenton, MD
IEPC member

IEPC thanks California ACEP and National ACEP for advocacy work on the injustice of Anthem Blue Cross denying payment of emergency services. Here is the link to an Op Ed by Dr Fenton published in MedPage Today. The bad behavior by Anthem has not stopped, but we will continue to demand justice.

Roneet Lev, MD
IEPC Executive Director

SB 864 Tyler’s Law was signed by Governor Newsome in September, 2022. Starting January 1, 2023, all hospitals in California must include fentanyl whenever a urine drug screen is ordered.

Tyler visited a emergency department in California and was assured that his drug screen was negative. Tyler’s mother Juli asked the emergency physician if the drug test included fentanyl and was given false reassurance. The emergency doctor did not realize that an opiate drug screen does not cover synthetic opioids such as fentanyl.

Juli Shamesh, Roneet Lev and Senator Melisssa Melendez are three mothers who came together
with difference expertise to carry and pass this law.

Tyler’s law does not require drug testing, it just requires fentanyl to be included along with THC, Methamphetamine, Benzodiazepines, or whatever the hospital is currently including. The fentanyl reagent costs 75 cents, a minimal financial investment. The California ACEP website includes a fentanyl testing tool kit to teach hospital laboratories how to test for fentanyl.

Here are some ways a positive fentanyl test can affect your clinical interaction with patients.

1. Inform your patient of their positive test. Some patients knowingly use fentanyl, but others may think they are using methamphetamine, cocaine, Xanax, Adderall, Marijuana, or something else. When you tell your patients that they tested positive for fentanyl,
   they may go home and act upon that information. They may dispose of counterfeit pills saving other people or decide to make a change in their life.
2. Provide a prescription for naloxone to the patient, family or friends. Anyone who uses drugs, any drugs, should have naloxone. Naloxone only works for opioids, but fentanyl has infected a vast part of all drugs and therefore is indicated. Just like giving antibiotics to STD partners, you should give naloxone to family and friends who use drugs.
3. A positive test for fentanyl is an opportunity to talk about addiction treatment. Patient may have an opioid use disorder and warrant connection to Medication Assistant Treatment. If not addicted to opioids, they may warrant treatment for substance use disorder. Starting this conversation in the emergency department can make a big impact, especially coming from the doctor.
   • New story from OC Register
   • Fox LA – California becomes 1st in US to include fentanyl testing in ER
   • High Truths on Drugs and Addiction Podcast #99 will feature the 3 Moms who helped pass Tyler’s law.

Dr. James Keaney, Emergency
Physician, Author The Rape of
Emergency Medicine

The sole purpose of the Institute for Justice in Emergency Medicine (IJEM) is to decolonize the nation’s emergency departments from the rapacious slumlords posing as Wall Street-traded corporations known as contract management groups (CMGs), hedge funds and pseudodemocracies offering so-called services which front for the imposition of unnecessary third-party middlemen. These exploitationists are not only toxic to emergency physician well-being and resiliency but also constitute a public-health detriment to the communities in which the hospitals are located.

We propose a federal lawsuit against the Centers for Medicare and Medicaid for violation of the original intent of the Medicare Act of 1965 passed by both houses of Congress and signed into law by President Lyndon Johnson. The current transmutation or misallocation of Medicare-approved, clinically generated fees by bedside emergency physicians into vast administrative wealth for nonclinical work-and-make-work provides zero-point-zero real benefit to the American patients or to the clinical emergency physicians. Moreover, it constitutes a public health detriment to the communities in which the hospitals are located.

This is the central premise of the lawsuit; Institute for Justice in Emergency Medicine (IJEM) versus United States Secretary of Health and Human Services.

The gross violation of the original intent of the Medicare Act of 1965 is the diverting of taxpayer money which is specifically designated to pay bedside physicians to provide healthcare to the “Joe-the-Plumbers” and “Rosie the Riveters” of America to corporations providing emergency medical care according to the dictums of Bernie Madoff rather than the Oaths of Hippocrates and Maimonides. Tens of millions of dollars of Medicare money is being wasted on slick advertisements by CMGs to send scores of men in crisp blue suits with red ties and women in well accessorized Saks Fifth Avenue outfits to traipse all over the nation trying to outwit and capsize stable independent emergency medicine groups knowing full well the CMGs gumbo of doctors and their “Kulture” offer nothing but profits for the mothership with staggering commissions for themselves. This phenomenon of Mad Men marketing is undermining quality emergency medical care.

Sixty years of “separate but equal” didn’t work but ended up with Brown v Board of Education; sixty-five years of communism collapsed with the fall of the Berlin Wall; 45 years of CMGs hasn’t worked now requiring IJEM v HHS.

Currently, the attempts to reverse engineer the current perverse system which provides maximum passive income for a few shareholders and speculative hedge-funders have not been fruitful. The neurosurgeons who clip the most aneurysms and remove the most brain tumors have the highest income but the emergency physicians seeing the fewest emergencies make the most money. In the upside-down world of EM, making incremental changes is like Waiting for Godot. The medical crime of the century is happening before our eyes. And, in only one specialty. We need to reweigh the payment system for the benefit of patients and clinical physicians. A single court order would change the system into a civilized delivery of emergency medical care overnight which, indeed, was the original intent of the congressional act.

Methamphetamine (meth) is the number one killer in San Diego County among those using drugs, and a significant driver of violence in the community. Nationwide, meth is the fastest growing drug of abuse, representing over 798,000 annual emergency department (ED) visits, with deaths increasing 14-fold since 2015 (32,856 deaths in 2021 alone), yet no therapeutics are available. There is an urgent need for a safe rapidly acting antidote for methamphetamine.

With support from the National Institute on Drug Abuse (NIDA), Cambridge, MA-based Clear Scientific (www.clearsci.com) is developing an antidote for meth for use in the ED. This small molecule therapeutic, CS-1103, reverses meth intoxication by sequestering it in the plasma compartment and removing it from the central nervous system effect site. The now ‘inactive’ meth is eliminated from the body by filtration in the kidney. Rapid sequestration and clearance of meth reverses its effects. This mechanism of action is similar to Sugammadex (BRIDION®), a reversal agent for neuromuscular blockade. Unlike antibody-based treatments, CS-1103 not only binds harmful substances, but also rapidly removes them from the body – “Remove the Cause, Remove the EffectTM”. CS-1103 is formulated for intravenous injection for use in the ED.

In nonclinical studies, CS-1103 was highly effective in lowering the level of meth and rapidly reversing its toxic effects. CS-1103 has an excellent safety profile in Good Laboratory Practice (GLP) studies with rapid clearance and has been produced at scale under Current By Clear Scientific Good Manufacturing Practice (cGMP).

It is anticipated that the Phase 1 and 2/3 Clinical Trials will be completed in 2023 and 2024, respectively, with availability to ED physicians by late 2024.

For more information, please listen to the discussion between Dr. Roneet Lev and the Clear Scientific team on the High Truths podcast [Episode 91 September 19,2022].