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letters TO THE EDITOR
Letters to the Editor
Have a comment about an EMN article? Like to share your views
about issues in emergency medicine? Send your letter to the editor
to emn@lww.com. Please limit your letter to 250 words and include
your full name, title, and city and state of residence or practice.
EPs Should Not Waive
Due Process Rights
Editor:
I
applaud Sandra Scott Simons,
MD, for her excellent article
“Enough!” in your May issue. (EMN
2017;39[5]:9; http://bit.ly/2p1DEyx.)
She eloquently details how a lack of
due process can have a chilling effect on emergency physicians who
are trying to advocate for themselves and the patients they serve.
Unfortunately, this problem is
pervasive in emergency medicine.
Fifty-two percent of emergency
physicians who responded to a
­survey a few years ago by the American Academy of Emergency Medicine (AAEM) said they could be
terminated without due process.
Seventy-five percent responded that
they had felt exploited at some point
in their career, and 49 percent had
considered leaving the field due to
unfair business practices. Lack of
due process is an important patient
safety issue, as well as physician
career and wellness issues.
Due process protections are expected by the Joint Commission,
and are included in most medical
staff bylaws. Many emergency physician contracts, however, include a
waiver of these due process rights.
Not surprisingly, many of the physician groups that insist on waiving
due process protections have poor
track records in workplace fairness
and patient safety. Emergency
physicians should strike out such
clauses before signing their employment contracts, and should think
twice before taking a position with
any group that is unwilling to
provide due process protections
that are commonplace among the
rest of the medical staff.
Residency programs and professional organizations should educate
their physicians on contracts and
the potential exploitation that could
occur without due process. AAEM
considers support for due process
protections to be a top advocacy
priority, and welcomes collaboration
with other emergency medicine organizations on this important topic.
Dr. Butts responds: Thank you so
much for your letter. The authors
of the article in the New England
Journal of Medicine that I referenced did not specify the ultrasound methods used to make
the diagnosis. Typically, however,
renal ultrasound relies on three
findings, in conjunction or alone:
hydronephrosis, unilateral absence
of bladder jets, or ­direct visualization of the stone. Ureteral stones
are usually difficult to visualize because the ureters are primarily
located in the retroperitoneum,
but stones within the kidney can
often be seen. These are not typically symptomatic, but they can
be an extra clue in the right clinical scenario. I’ve written previously about ultrasound for renal
stones from a how-to perspective;
you can find those articles here:
http://bit.ly/2qrwYzA, http://bit.
ly/2qyqPwC, and http://bit.ly/
2qrQzQ1.
Working in the ED
is Not Activism
Mark Reiter, MD, MBA
Nashville
Editor:
Diagnosing Renal Colic
Editor:
C
hristine Butts, MD, didn’t
mention in her column, “Ultrasound as Accurate as CT for Renal
Colic,” how one diagnoses renal
stone apart from the finding of hydronephrosis. (EMN 2017;39[5]:12;
http://bit.ly/2rYWQ2I.) Are there
other key findings on bedside
point-of-care ultrasound?
Jeremy Silver, MD
Durham, NC
D
r. Meghan Liroff’s essay is
an example of the bubbly
enthusiasm that is refreshing
in recent residency graduates
but also full of clichés and self-­
congratulation. (“A Sanctuary for
Those with Nowhere to Turn,”
EMN 2017;39[5]:32; http://bit.
ly/2p1wNFt.) During her ED shifts,
she encounters immigrants and
refugees, some from Muslim-­
majority countries. She relates to
them and shares kindnesses, and
from this she concludes that she is
an “an activist.” This is not activism;
this is doing your job. Activists don’t
sit in the ED ordering lab tests during well-paid shifts.
Dr. Liroff is pictured posing with
her hand on the heart of a woman
wearing a hijab and an abaya. The
woman has her face turned from
the camera. Dr. Liroff stated that interacting with the hijabi women led
her to declare that these women
are “awesome,” and that it has expanded her definition of feminism. I
wonder what her original, unexpanded definition was. Feminists seek
to establish social rights as well as
educational and professional rights
for women. The hijab is the symbol
of the opposite; it is a visual representation of the cultural narrative
where women must “cover up,”
suppressing self-expression and
personal development. This is not
awesome.
Dr. Liroff seems to think that
doing her job in the ED while feeling disdain for the president is
“speaking truth to power.” A political opinion is not speaking truth to
power. It is just an opinion unless
you are feeling grandiose.
To speak truth to power, Dr.
Liroff should illegally cross the border of a Muslim-majority country,
go to an ED while wearing American clothing and request care, demanding that it be paid for by the
local citizenry. After she is apprehended, she can call home for help,
or stay and give aid to other
people who have become political
prisoners. That would be awesome
activism.
Carol Fishman Ortiz, MD
Denver, CO
Continued on page 21
VIEWPOINT
tPA
Continued from previous page
mimics). The ICH rate is 2.0-4.2 percent in the small studies of stroke
that look at low NIHSS receiving IV
tPA. (Int J Stroke 2013;8[5]:293;
Med Sci Monit 2014;20:2117; Ann
Neurol 2016;80[2]:286.)
The message that “it can’t hurt”
is simply untrue. Any suggestion
that the ICH rate is nil for TIA patients suffers from small sample
size that is underpowered to draw
conclusions. IV tPA for TIA is not
FDA-approved. One must consider
the legal ramifications of using a
drug off-label if a poor outcome
is attributed to IV tPA.
Almost all of our current studies
suffer from being uncontrolled and
nonrandomized with small numbers. Pending the PRISMS data,
it is premature and scientifically
unsupported to use the new AHA
guideline to give IV tPA routinely
in mild or resolving neurological
symptoms, even when advanced
imaging reveals a lesion, including
a proximal intracranial occlusion.
When perfusion imaging reveals
small strokes, the harm appears to
outweigh any benefit.
It is not only currently unscientific to consider giving IV
tPA to patients with a clinical
­diagnosis of TIA, including the
20 percent or more of patients with
stroke mimics (with no diagnostic
evidence of clot or ischemia), it is
medically unethical because the
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Comments? Write to us at
emn@lww.com.
only possible outcome, albeit
small, is harming the patient. The
unethical nature of IV tPA for
mild or resolving neurological deficits is magnified when one is part
of a system in which the increasing
use of IV tPA has strong financial
incentives. EMN
Dr. Mosley is the
medical director for
residency education
at Wesley Emergency
Center in Wichita, KS.
Emergency Medicine News | August 2017
5
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