Wellness Section Newsletter - June 2009, Vol 13, #1
Vicken Y. Totten, MD, FACEP
This is the first issue of the new cycle. We have a new co-editor to introduce: Brian O’Neal from North Carolina. There are articles on eating and weight, on the effects on health effects of shift work, and the meeting minutes from Scientific Assembly. One recurring theme was "Sound Health" and the ill effects of noise on us during our conferences. Please write back and tell us what you think. We welcome letters to the editor.
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Brian O’Neal, MD
I would like to introduce myself as a new assistant editor of this newsletter. I am a current second year resident at UNC Hospital in North Carolina. I am honored and excited to be a part of this organization that I think has so much to offer our exciting, but at times, stressful profession. I come from a family of physicians ranging in specialty from OB/GYN to Family Medicine. And although I see their dedication, I also see the stress and conflict they face with hours, insurance companies, and their allegiance to excellence. I hope to contribute to helping physicians better handle the stress of our daily lives so that we can continue to do in this profession what we set out to do….help others.
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Wellness Section membership as of 6/12/09 = 122
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Wellness Offerings at Scientific Assembly in Chicago
Lori Weichenthal, MD, FACEP
Wellness opportunities for physicians abounded at this year’s Scientific Assembly, and I am not just talking about the amount of walking it took to get from one end of the convention hall to the other!
The ACEP wellness booth continued to be a very prominent offering that allows physicians to assess their level of well-being. Hundreds of people each day stopped by the booth in the exhibit hall to have their blood pressure, body fat index and blood chemistries checked. Vaccinations were also available and there was the chance to take a burn out questionnaire. Wellness related resources and written materials were also available.
Other options for maintaining balance in the sometimes chaotic environment of the Scientific Assembly included a daily early morning guided meditation and yoga class. The room used for these offerings was also available for the rest of the day to give conference attendees a quiet place to be away from the bustle and noise of the convention center. Another place of reprieve from the main conference was the Parents with Infants Lounge. This room created a space for people to care for the needs of their small children.
Finally, the Well-being Committee and Wellness Section provided a list to all attendees in their registration packet to help people be informed of the wellness options available at the Scientific Assembly and in Chicago. The list included wellness related courses, the opportunities described above, exercise options in the surrounding area and healthy eating choices in Chicago. Probably one of the best exercise options was the beautiful trail on Lake Michigan that could be accessed from the convention center. It was a wonderful place to walk, run or just take in the breath taking views during breaks.
The plan is to continue to provide these opportunities to all conference attendees at Scientific Assemblies to come. We hope to see you in Boston in October!
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CAUTION: The Whooping Cough is Back!
Mitchell B. Cordover, MD, FACEP
When we think of emergency physician wellness, the threat of infectious disease does not immediately come to mind. Most of us are reassured that universal precautions and the recent innovations in safety needles will protect us from the usual suspects. The majority of us are immunized against Hepatitis B and tested yearly for the rare case of tuberculosis. But what if there was an infectious disease that was spread by respiratory droplets, is increasing logarithmically in the community and had a transmission rate of as much as 90%? What if it often took 8-10 weeks to recover and had a 15-30 percent complication rate? The average victim loses a week of work or more. Now consider that if you brought it home to your kids, there is a 25% incidence of secondary pneumonia for toddlers and a significant rate of death in infants. We are not talking about the movie "Outbreak." Its pertussis and its back with a vengeance.
At it’s height in the 1930’s and 1940’s, pertussis was reported in around a quarter of a million Americans during its cyclic 3-5 year epidemic cycle. This was probably significantly underreported. In that pre-antibiotic era, it was widely feared as the "Whooping cough" and its mortality rate made it one of the great scourges of children. When the pertussis vaccine came into wide use in the 1940’s, and especially after World War II, the incidence dropped to less than 1 case per 100,000 population. Since humans are the only known reservoir of the disease, public heath officials talked about having conquered it.
As time went on, however, the immunity conferred by the vaccine proved to last only about 5-10 years. Booster shots for adolescents and adults were not considered feasible on a wide scale because the reactions to the original viral vaccine and even to the subsequent acellular vaccine were too common and too bothersome. By 2002, there were more than 25,000 reported cases of pertussis and the CDC believes that there is 90-95% under reporting. And it’s not a temporary situation. By 2006, the rate had risen to 5.2 reported cases per 100,000 population, and probably twice that in reality. That’s a 5 to 10 fold increase. Eight cases out of ten are in adolescents and adult, and that includes us. It is the only vaccine-preventable disease currently on the rise.
The real risk to ED doctors and their families is that the first week of pertussis looks like any viral syndrome, and it is misdiagnosed as such. But the Bordetella pertussis bacteria it is transmitted during this as well as the subsequent stages.
By the time our patient comes in complaining of a month of cough we already have what we believe is their cold. Depending on what study you believe, between 15 and 52% of adults with a cough lasting more than 14 days have pertussis. For infants less than 2 months or who have incomplete vaccinations, the risk catching this disease from us is very real. In one study, for children for whom a source of pertussis was identified, the parents or siblings were the culprit 75% of the time.
Luckily, in 2005, an adult version of the acellular pertussis vaccine was licensed. It has a lower dose of pertussis vaccine, so it confers a protective level of immunity with an acceptable level of side effects. These include local swelling, discomfort and redness at the injection site, and less commonly, a few days of low grade fever, aches and malaise. I experienced none of these myself. The vaccine is combined with diphtheria and tetanus and the combination is called Tdap.
The CDC’s Advisory Committee on Immunization Practices has recommended that Tdap replace Td, for routine immunizations. All children should get Tdap routinely at age 11 or 12, and any 18 year old who did not do so should get a Tdap booster. All non-pregnant adults less than 65 years old, and 5 years since their last Td should get immunized now. This is especially true for healthcare providers. You can safely get a booster as often as every 5 years routinely or even sooner under special circumstances. While pregnancy and nursing are not contraindications to vaccination, the CDC recommends postponing Tdap until after delivery. There are contraindications to the vaccine, like prior fever of 1050 or more with previous vaccinations, prior vaccine related Guillain-Barre syndrome, central nervous system disease, Arthus hypersensitivity to tetanus vaccine, and other signs of allergy or intolerance.
Compared to many of the challenges to physician wellness, avoiding pertussis is relatively easy. If you have not had a recent Td, get immunized. Many EDs offer the shot for free, and it will protect you, your patients and your family.
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Yoga Poses on the Go in the ED
Lori Weichenthal, MD, FACEP
Pounding the cement of the ED, lifting patients, bending in awkward positions so that you can suture people in the hallway, and many other daily experiences of working in emergency medicine can take their toll. In the next few wellness section newsletters, I will describe some simple poses, which can be performed at work, that help to keep you limber and flexible.
This issue’s pose is a modified downward facing dog (Adho Muka Svanasana). Place you hands on a wall, shoulders distance apart at the level of your chest. Spread your fingers evenly and root your hands into the wall through all four corners of your hands. Keeping these actions in your hands, walk away from the wall until your spine is extended and your legs are at a ninety degree angle to the rest of your body. Your feet should be hips distance apart. Bend your knees so that your sitz bones (ischial tuberosities) move toward the ceiling. This helps to create the natural curve in the lumbar spine. Then lengthen your spine all the way through the crown of your head. Maintaining this energetic extension, begin to straighten your knees. Hold this pose for 5-10 breaths. Enjoy.
This pose helps to strengthen the arms, legs and torso. It stretches the palms, chest, back, hamstrings and calves. Most importantly, it is a great way to energize your body and mind without having another cup of coffee.
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Running in Residency
Kevin Biese, MD
Slap, Slap, slap. The sound of my feet hitting the pavement. Another mile goes by. I hope that lady with the MI is doing OK. I hope I called the cath lab soon enough. Slap, slap, slap. And why is Dr. X always so rude on the phone??!! And I just don’t know how to make attending Y happy!! Slap, slap, slap. Mile 7 complete. Am I really good enough to make it through residency? Will it ever end? Slap, slap, slap. And my family, my wife, my friends, will they survive residency with me? This is tough. Very tough. Slap, slap, slap. Mile 15 complete. The Saturday long run is done. I am one long run closer to the marathon. I don’t know the answers to all the questions I asked during the run, but I feel good, tired, hungry, and strangely whole again.
I am not sure that running multiple marathons is a testament to mental health, but that is part of how I got through Emergency Medicine Residency. Residency felt like it would never end. At times, I was more aware of my failures than my successes. And the sedimented layers of anxiety, confusion, guilt, and inadequacy threatened to bury me at times. My family, friends, faith, and fun times all played crucial roles in seeing me through. But so did running. Running was (and is) something I could do. Residency might feel interminable, but marathons were obtainable goals. They gave me mileposts to strive for, and allowed me to feel good and highly capable when I ran past them. The runs themselves, cleared my mind, allowing me to sweat out the anxiety and frustration. (I imagine the endorphins played a role in that.) And I got to eat more yummy foods without having to get bigger scrubs.
For me, exercise is crucial to being healthy. If I do not take care of myself, how can I really be there to heal and console when my patients need me the most? I owe it to my family, my colleagues, my patients, and myself to be as whole as possible, even, and perhaps especially, during residency.
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A Case of a Family with Cough
Mitchell B. Cordover, MD, FACEP
A previously healthy 24 year old African American female came to the Emergency Department complaining of persistent cough and pain in her right lateral chest. The pain started suddenly during a bout of hard coughing that had become chronic. The pain increased with deep inspiration, cough, or certain movements. She had experienced "a little cold" with sneezing, mild occasional cough and a low grade fever about 3 weeks prior. But after a week the cough became worse, and was especially bad at night. She couldn’t sleep and felt exhausted. She had been seen by her private doctor and again at another ED and had been diagnosed with "asthmatic bronchitis," but the inhaler she was prescribed did not help the cough and she had never suffered from asthma before. She had been prescribed levofloxacin by her doctor along with a steroid dose pack, but he stopped the medication when she called him about heel pain.
Physical exam was unremarkable except for a persistent cough. There were no wheezes, rales, or ronchi. Her white blood cell count was 16.5k with 60% lymphocytes. Chest x-ray showed moderate hyperinflation but no acute pathology. Rib films failed to demonstrate a fracture. There was motion artifact on the film because she could not keep from coughing. Influenza swab was negative.
The patient admitted that he had come in today in part because her two young children were being seen our Pediatric area. They both had caught her cold, but the baby had developed a fever of 101degrees and was now vomiting when she coughed. Both she and her brother were coughing so hard "that their face turned blue" and her pediatrician had referred to us to rule out pneumonia. It had just gotten bad over the last 24 hours. She admitted that she had not had her children immunized for fear of possible side effects.
Mini swabs were done on the patient’s anterior nasal secretions and sent in for Bordetella pertussis PCR. It is sensitive even after the first day of upper respiratory symptoms and stays positive for up to 14 days after the cough becomes severe. This represents most of the contagious phase of pertussis. The turnaround time on this test for this facility is over 24 hours, but in many places it is over 72 hours. She was empirically put on Trimethoprim/Sulfamethoxazole. She was offered the preferred agent, Azithromycin, but she complained of gastric upset with "any of the mysins" which was presumed to include clarithromysin, and erythromycin, the only other medications indicated for pertussis. (Levofloxacin does show some in vitro activity but there is no clinical evidence of it’s efficacy against the illness.)
This is the classic story of pertussis, an infectious disease that had been very much in eclipse until the last decade. Many community practitioners are slow to consider it, considering it nearly extinct despite the nearly 28,000 reported cases per year. It is a serious respiratory illness which is extremely contagious by both respiratory droplets and hand-to-mouth transmission from contaminated surfaces. In times past, whooping cough patients were quarantined within their homes for weeks.
Pertussis evolves through three phases. The catarrhal stage is a one to two week period of mild cough, upper respiratory symptoms and low grade fever. It is rapidly followed by the paroxysmal state during which thick respiratory secretions cause bursts of coughing. A paroxysm describes many coughs in a single expiration, often followed by a gasping stridorous inspiration form which the "whooping cough" gets its name. There is a recording of this characteristic cough at www.doitforyourbaby.com/mediaplayer.html.
This phase includes post tussive vomiting and occasionally diarrhea. Fever and high white counts with absolute lymphocytosis reaching as high as 20,000 is typical. This stage can progress for 1-2 weeks and usually lasts or 2 or 3 weeks. Not infrequently it can last for 9 weeks! During the latter part of this phase, the patient does not appear ill but has 15-24 paroxysms per day, and especially at night. Older patient may fracture ribs. Young infants who are too weak, mount an effective gasp may experience significant episodes of hypoxemia. The dehydration, malnutrition and exhaustion often require inpatient intervention. At this point they have been ill for a month or more.
The final stage of pertussis demonstrates a decline in the severity of the cough, but patients have a lingering cough and enervation for weeks and often months with an increased susceptibility to subsequent infections, bronchospasm and exacerbations of their chronic conditions.
Most pertussis is among adolescents and adults, whose immune status has declined over time. However, family members below the age of 6 months will not have had a complete series of immunizations. They are far more likely to have serious sequelli and death. 63% of infants less than 12 months require hospitalization and 90 of the roughly 100 annual deaths in the US are in children younger than 4 months of age. Primary (Bordetella) and secondary pneumonia, seizures and persistent seizure disorder, asthma, subdural hematoma from cough, encephalopathy, hypoxemia and possible subsequent intellectual impairment are all well documented complications. Dehydration and malnutrition are also short term risks during the acute illness.
Because the early symptoms are hard to recognize until the patient has been contagious for a week or more, and because there is no rapid-turnaround test for whooping cough, the best public heath strategy is widespread vaccination. Healthcare centered outbreaks are well documented. Healthcare workers, and especially those exposed to children under12 months or immune compromised patients (ie, all ED doctors) are especially encouraged to renew their immunization.
Parents’ concerns over the dire side effects of vaccination are for the most part unfounded. They should discuss the rare episodes of high fever or other significant side effects associated with the vaccine with their pediatrician. However, reluctant moms and dads can no longer depend on "herd immunity". The American Pediatric Association and the Centers for Disease Control and prevention recommend that, except for prior allergic reactions or other rare exceptions, all children be vaccinated with acellular pertussis as part of the "Dtap" combination with tetanus, and diphtheria. Shots should be scheduled for 2, 4, 6, and 15-18 months. Low grade fever or 1-2 days and local tenderness and irritation are expected at the injection site after the 4th or 5th inoculation.
Eleven and twelve year olds should get a booster of Tdap, the adult formulation which contains a lower dose of acellular pertussis vaccine. If they have not gotten their booster, wound related vaccination in the ED should be with Tdap.
Adults who have not received a Td in the last ten years should receive one dose of Tdap and boosters of Td every ten years thereafter. Pregnant women who are more than 10 years out from their last Td are approved to receive wound-related Td in the second or third trimester but otherwise should get Tdap in the immediate post partum period to avoid contracting the disease and exposing their infants. Likewise all healthcare workers with the exposures discussed should receive one dose of Tdap, even if their most recent Td was as late as two years ago.
Emergency physicians are 10 times more likely to get pertussis from an infected patient than they are to contract hepatitis C from a contaminated hollow needle stick. A single booster can prevent 2-4 months of illness and lost work and reduce the possibility of passing a potentially seriously respiratory illness to our patents. Whooping cough is back and it’s as bad as ever. We all should be fully engaged in diagnosing and treating this under-reported illness and in vaccinating our patients and ourselves against it.
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Annual Meeting Minutes
Wellness Section Meeting
October 28, 2008
Members in attendance for all or part of the meeting included: Sixteen members and guests.
Others participating for all or part of the meeting included: Alex Rosenau, DO, FACEP, Board Liaison; Rhonda Whitson, RHIMA, Marilyn Bromley, RN, Staff Liaison
- Wellness Booth Update
- Update on Task Force on the Aging Physician
- Update on the year’s activities
- Ratify Section Operational Guidelines
- Topics of discussion in coming year
- Other issues
Major Points Discussed
Dr. Julia Huber welcomed everyone to the meeting and thanked everyone for their support during her year as chair.
Update on the Wellness Booth indicated that the traffic, although steady, was not such that there were any major delays. The 100 doses of tDAP vaccine were gone the first day. There seems to be interest in obtaining this vaccine despite the fact most hospitals now administer it to staff.
Dr. Goldberg provided an update on the survey done regarding "Issues of Concern to Emergency Physicians in Pre-Retirement Years." Respondents to this survey generally viewed themselves as competent, empathic practitioners. Yet a substantial percentage of respondents acknowledged at least some degree of cognitive or physical decline. The results suggest a role for the College in endorsing practice modifications that promote career longevity and clinical competence among its senior members. A task force to address research and related issues of the aging physician has been convened. Representatives from various committees and sections with an interest in this area will have a conference call after the first of the year to discuss next steps.
The section operational guidelines had been sent electronically to the entire section for review and comment, with the note they would be ratified at the section meeting. Those in attendance discussed the operational guidelines and it was pointed out that although most of the wording was boiler plate language that was approved by the Board of Directors there had been an addition of e-voting language and it was pointed out the officers would serve for 2 years. The operational guidelines were unanimously approved.
The section members discussed the enhanced wellness opportunities for attendees of Scientific Assembly this year. The morning meditation and yoga classes, the meditation room available all day, the family room for feeding, nursing or changing diapers, the information provided to attendees on all the available wellness offerings including courses, restaurants, health clubs, and running /walking trails.
There was still concern about the decibel level of the bands at the receptions. It was suggested that those planning the meetings be made aware of ‘sound health’ and the problems the loud music causes to hearing and the ability to talk with people you may only see once a year. It was suggested that a there be an investigation into the availability of soft ear plugs for those attending the receptions. Another suggestion was that ACEP look into featuring Chamber Music and small, secluded booths at next year’s reception rather than a large room with a band.
The section noted that due to legal-insurance issues the College could not sanction running or walking events; however if groups wanted to get together before or at the end of the day that was something that they could investigate.
The section will work with other sections and committees to enhance the wellness offerings and resource hyperlinks on the wellness webpage. It was asked that a report be provided on the number of hits on the wellness page.
One member of the College in attendance at the meeting reported how grateful she was for the peer-to peer counseling services. She felt that it had been a ‘life-saver’ and the advice she received was extremely valuable. She was appreciative that she was able to have on-going dialogue with some of the members she met through this service.
Dr. Lori Weichenthal will be chair for the next 2 years. The section will be asked for a volunteer to serve as chair elect. Dr. Vicken Y. Totten and Dr. Brian O’Neal will serve as Co- Secretary Newsletter editors. Councillor will be Dr. Mitch Cordover, Alternate Councillors will be Dr. Rachelle Greenman, Dr. Lori Weichenthal and Louise Andrew.
The meeting adjourned at 5:45pm.
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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.