This post contains some of the learning and reflections from Day 2 of ICEM 2022 in Melbourne (Friday).
Day 2 of ICEM22 kicked off with a session on equity, chaired by Ffion Davies.
The amazing, inspiring Mulinda Nyirenda took to the stage first to talk about social determinants of health.
Children who are born attended by healthcare professionals come from the more affluent proportion of the population and outcomes are poorer for children in rural areas. Like many other places on earth, substance abuse is prevalent in Africa (a study from Kenya was referenced, with alcohol use prevalent in 41.6% of adolescents).
She also highlighted the effect of conflict and disasters, with child mortality high in areas of conflict.
Next to speak was Kon Karapanagiotidis, founder of the Asylum Seeker Resource Centre, who talked about health equity for people seeking asylum. He outlined an ideal health system that I think we can all buy into; one that provides social and trauma informed care, that recognises and speaks to the needs of LGBTQIA+ people, that is in parallel with the right to healthcare and other basic human rights. He called for governmental accountability towards refugees, the bravest and most vulnerable members of our society, and an end to the political narrative that demonises them.
I was really proud to see Priyadarshini Marathe – whom I was fortunate to work alongside back in my days at the John Radcliffe Hospital in Oxford – take to the stage alongside Imron Subhan to talk about gender equity in emergency care.
Priya challenged a number of traditional notions around medicine, medications, resuscitation that make assumptions about patient gender – the solution, she says, is planting seeds in medical education early.
Our position is unique – we listen keenly when our patients speak, but other specialties use our department to work up patients. So we can use this power to influence the practice of other teams beyond our department.
Imron followed with the assertion that culture change is everyone’s responsibility; that gender equity and equality is not taught however we are expected to know everything about it. It’s a complicated problem across the world, with multiple factors maintaining inequity in gender across the world. The job of tackling this is huge – we need gender specific quality indicators, expertise in trans health, gender champions – and one of the works that IFEM’s group has done is the GEE (Gender Equity and Equality) workshop. Through the workshops, people are being sensitised and this is the first step towards addressing the issues.
Gregory Phillips spoke about aboriginal health issues in medical education. Interestingly, medical students do not initially recognise the need and relevance of first nations health issues – and called us to integrate teaching how to unlearn inherent biases and racism. The health effects of colonisation and racism in Australia are ongoing – racism, he assures us, is a public health issue. We need to separate the idea that our “goodness” in intent does not excuse us for the effects of our actions.
The last speaker of the morning was Gillian Schmitz, speaking on health inequities for African-American and Latin-American communities. She drew particularly upon the opportunity emergency departments have to engage in public health through screening for populations who might not as readily interact with healthcare in other settings.
The session concluded with the speakers making a series of calls to action, to address the inequity we had been thinking about and reflecting on this morning.
- Gender equity – accept that there are issues and that we may not be measuring them correctly.
- Expose your biases: do the Harvard Implicit Association Test
- Embrace diversity and uniqueness: in ubuntu, I am because we are. We are rich because of diversity
- Consider mentorship as a mutual process: we all have something to share and learn
- Recognise that hospitals are a place of great fear for migrants, refugees and even first nations people – and address racism in ourselves and our workplaces
- Accept that there is significant distrust at present; seek to understand before we are understood
- Work towards creating safe spaces for teaching, learning and challenging each other – at every educational level in healthcare
After morning tea, I headed to the Clinical and Literature Updates in Cardiology session, chaired by the awesome Louise Cullen and featuring our own Rick Body.
Steve Smith was up first up, talking about OMI diagnosis in the context of modified Sgarbossa criteria. He reminds us that we are ditching STEMI/non-STEMI in favour of OMI/nOMI (occlusion MI vs non-occlusion OMI). He took us through a case of LBBB and assessment of discordance of ST segments and T waves. If you find the Smith modified Sgarbossa criteria a bit much for your brain (I know I do), there’s a handy prompt-based assessment tool here.
Rick spoke next, taking on point-of-care high-sensitivity-troponin testing. Quicker results from diagnostic testing might be one way we can relieve overcrowding in ED, but the results have to be reliable. Combining testing with decision aids is one way to improve the reliability of our diagnostics.
Single test rule out is often prohibited by lab testing times. Previously, POC tests had a far higher limit of detection than lab troponin assays, and the sensitivity was highly variable (ranging from 68-89% across the three POC tests). However, in combination with a risk score (T-MACS in this case), the PPV was much better.
Newer POC testing options performed much more closely to the lab assay. Validation is still awaited but data is promising. There are several other barriers we need to overcome; training, disruption of care pathways (to ensure that there is a clinician to review the patient earlier than 8hrs after arrival, otherwise the benefit of streamlining care in this way is lost).
So, POC troponin testing might be coming – but we aren’t quite there yet.
Gary Mitchell talked about ECPR and the Queensland experience of introducing ECMO in cardiac arrest. The initiation of ECMO CPR is highly resource-intensive, but studies in Australia (CHEER and 2CHEER) have shown promising proportions with good neurological outcomes. Lots of advocacy in his talk for whole-team simulation in making ECMO CPR “work”, from the pre-hospital to the ED phase.
I’ve written up some ECMO stuff from the Sydney HEMS education days in these posts (1 and 2).
Cynthia Papendick rounded off the session with her talk about rapid assessment using HS troponin in the ED. She told a fascinating (and eerily relatable) story of the unanticipated change of troponin assay in her hospital, to a more sensitive assay with its potential to alter clinical management without clinicians really understanding how the new assay should be used. This was the paper that resulted from her work, finding no difference in adverse outcomes but improvements in the proportion of patients who were safely discharged from the ED.
In the afternoon concurrent, I went to the session on gender equity and development of equality systems in Emergency Medicine. Current president of IFEM, Sally McCarthy, spoke first about the current state of gender equity in EM.
She shared this paper, from internal medicine, in which senior men’s perceptions of gender equity were different from women’s and from junior men’s perceptions. Gender inequity has also been shown to exist at every level in medicine, not just among juniors. This paper showed that the longstanding belief that by increasing the number of women in medicine we could also naturally increase the number of women in leadership to be false. The paper includes some interesting gender-based narratives around beliefs held regarding leadership positions, namely that men felt that leadership was their destiny and they were ordained to be leaders, whereas women often required coaxing to accept roles and were pressed into leadership. The Global Gender Gap Index showed that gender-based differences in political empowerment persist, with only 22% of the gap closed to date.
Her presentation was followed by Gayle Galletta, who discussed why gender inequality persists in developed countries. Using the US as an example, she explored how gender inequity is prevalent thoughout politics and leadership and how this directly impacts gender inequity in healthcare. The US is also the only high income country with no paid parental leave. Parental leave – not just maternity leave – is important because it also helps erase some of society’s established gender stereotypes.
Kim Hansen spoke next, on taking women to the next leadership level. ACEM’s Advancing Women in Emergency (AWE) interest group aims to support, advocate and lead, to ensure ACEM is a diverse organisation, to provide metrics, to support doctors where they are working. The gender equity solutions, she says, are opportunities for progression, longer and secure contracts, leadership, policies supporting equality, sponsorship, mentorship and support and to address discrimination.
The talks were followed by a panel discussion on gender equity; it was summarised nicely by Sue Ieraci:
The day closed with a session on equity through advocacy, with a panel discussion chaired by Rhys Ross-Browne.