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With little FDA oversight, melatonin supplements vary widely in … – STAT

With little FDA oversight, melatonin supplements vary widely in ... - STAT

WASHINGTON Consumers turning to melatonin gummies to get some help falling asleep might be getting a lot more help than they bargained for, according to a new study published Tuesday in the Journal of the American Medical Association.

Researchers tested the melatonin concentration in more than two dozen gummy dietary supplements that recently launched and that were available at mainstream retailers like Amazon and Walmart. Nearly all of the products had more than 10% more melatonin than advertised. One product was even three times more powerful than the label suggested.

The study underscores the Food and Drug Administrations lax regulation of melatonin supplements, and natural products more generally. The agency does not review supplements before they hit the market like it does for prescription drugs.

The study is the perfect example of why the FDA needs to do a better job overseeing dietary supplements, according to Stephen Ostroff, a former FDA official who served as both acting commissioner and deputy commissioner of the agencys food program.

Ostroff was reluctant to criticize the FDA for the current situation, and instead argued that the agency needs more money and legal authority to police the growing supplement market.

The new studys lead author, Pieter Cohen, an associate professor of medicine at Harvard Medical School, was less forgiving. While he acknowledged the FDAs current legal authority to regulate supplements is weak, he argued the agency shares some of the blame for not enforcing its existing supplement rules.

We have an inactive FDA, he said. The industry knows that if they put whatever they want to in these melatonin products theres going to be no consequences.

In a statement, the FDA promised to review the findings of the paper, and said it takes product quality concerns, including under- or over-potent products, seriously. However, the agency underscored that it does not have the authority to approve dietary supplements before they are marketed, and firms have the primary responsibility to make sure their products are not adulterated or misbranded before they are distributed.

Large amounts of the substance have also been shown to have adverse effects in children, prompting an exponential increase in poison control calls in recent years, adding to the researchers alarm.

However, one dietary supplement lobbying group argued that variability in strength of the gummies studied is to be expected, and is often purposefully done by manufacturers to ensure they do not degrade overtime and thereby run afoul of the FDAs rules. Dietary supplements are required to demonstrate they contain 100% of the listed ingredient until their expiration date, and thus manufacturers will put an overage in to start to be sure that six months from now that when that consumer buys the product, theyre still getting 100% of whats on the label, according to Steve Mister, the CEO of the Council for Responsible Nutrition.

The new study is not the first to find quality issues with melatonin supplements. A 2017 study found that the strength of melatonin supplements sold in Canada was also unreliable. That study also found several products containing undeclared amounts of the drug serotonin, which the newly published study did not find.

Mister conceded that he did share concerns about two of the products studied one which included no melatonin and another that included more than 300% of the advertised amount. He maintained, however, that there is absolutely nothing in this study that should alarm consumers.

However, the report is likely to prompt debate about the potential risks associated with the increasingly popular sleep aid.

A 2022 study found that melatonin use among U.S. adults more than quintupled from 1999 and 2018, and the number of adults taking high doses more than tripled from 2005 to to 2018.

Theres scant information available about the highest melatonin dose consumers can safely take. One of the only recommendations comes from Health Canada, which recommends no more than 10 milligrams per day.

Two of the products studied would provide users more than that daily maximum in just one recommended serving, according to the study.

This is something that we should be concerned about, said Jocelyn Cheng, a senior director at the drugmaker Eisai and a spokesperson for the American Academy of Sleep Medicine. In general [melatonin] is construed as being safe, but in high quantities we just dont have enough data to say with certainty that it would be safe.

Theres also increasing evidence that melatonin supplements are landing children in the hospital.

A report published last June found that pediatric melatonin-related calls to poison control centers spiked by 530% from 8,337 in 2012 to 52,563 in 2021, and that 4,097 children were hospitalized as a result.

Cohen argued in an interview that the extra-high potency of the products may help explain the recent spike in poison control calls.

Having something that [contains] 50% more melatonin could be the difference between whether [a child needs] to go to the emergency room or you just rest it off at home, he said.

The dietary supplement lobby, however, argued that the new studys focus on children raises a false alarm, because manufacturers typically warn that their products are not meant for children, and most calls to the poison control center were the result of accidental ingestion.

Its a misleading comparison to look at scenarios where kids, for example, got their hands on an entire bottle of adult gummies and became ill after eating multiple servings, versus having slightly more of an ingredient in a single serving that, if taken as directed, would pose no harm, Mister said.

The JAMA study did not name each product individually, but STATs review of the database used to identify the products did reveal that many products included a disclaimer they were not meant for kids. It did appear, however, that certain products bearing that disclaimer also appeared marketed to parents.

One product, for example, included a warning on the back of the bottle indicating it was not meant for people under 18, but the Amazon listing for the product also included a photo advertisement of a mother kissing a young boy good night.

Sarah Ash Combs, an emergency medicine physician at Childrens National Hospital, said the study raises the question of why melatonin and other supplements are sold as gummies in the first place.

What worries me about things being put into gummy form is if you get a hold of that and youre a little kid, youre going to chow down on it, Combs said. It continues to be problematic to me that we put dietary supplements [that are] unregulated by the FDA, such as melatonin in a form that is attractive to kids.

Combs added that she was surprised by the variability in strength of products, and it should be a signal to parents considering using melatonin to help their kids sleep that they should try other remedies like limiting screen time and maintaining a bedtime routine before reaching for melatonin. She added that if a parent still thinks their child needs melatonin that they should talk to their doctor first.

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Burns, how bad is the patient? About Wallace’s Rule of Nine – Emergency Live International

Burns, how bad is the patient? About Wallace's Rule of Nine - Emergency Live International

Dealing with an emergency scenario involving the possibility of severe burns results in a certain speed of assessment.

It is therefore important for the rescuer to be equipped with some basic knowledge that will enable him/her to correctly frame the burn victim.

Measuring the initial surface area of the burn is important for estimating fluid resuscitation requirements since patients with severe burns will experience massive fluid loss due to the removal of the skin barrier.

This tool is only used for second- and third-degree burns (also referred to as partial-thickness and full-thickness burns) and assists the provider in the rapid assessment to determine severity and fluid requirements.

The Rule of Nine has proven to be the algorithm most frequently recited by physicians and nurses to estimate burn surface area in numerous studies.[1][2][3]

The Rule of Nines estimation of burnt body surface area is based on assigning percentages to different areas of the body.

The entire head is estimated at 9% (4.5% for front and back).

The entire torso is estimated at 36% and can be further divided into 18% for the front and 18% for the back.

The front part of the trunk can be further subdivided into thorax (9%) and abdomen (9%).

The upper extremities total 18% and then 9% for each upper extremity. Each upper extremity can be further subdivided into anterior (4.5%) and posterior (4.5%).

The lower limbs are estimated at 36%, 18% for each lower limb.

Again this can be further subdivided into 9% for the anterior aspect and 9% for the posterior aspect.

The groin is estimated at 1%.[4][5]

The Rule of Nine functions as a tool for assessing the second- and third-degree total body surface area (TBSA) in burn patients.

Once the TBSA is determined and the patient is stabilised, fluid resuscitation can often begin with the use of a formula.

The Parkland formula is often used.

It is calculated as 4 ml intravenous (IV) fluid per kilogram of ideal body weight per TBSA percentage (expressed as a decimal) over 24 hours.

Due to reports of excessive resuscitation, other formulas have been proposed such as the modified Brooke formula, which reduces IV fluid to 2 ml instead of 4 ml.

After establishing the total volume of resuscitation with intravenous fluids for the first 24 hours, the first half of the volume is administered in the first 8 hours and the other half is administered in the next 16 hours (this is converted to an hourly rate by dividing half of the total volume of 8 and 16).

The 24-hour volume time starts at the time of the burn.

If the patient presents 2 hours after the burn and fluid resuscitation has not been started, the first half of the volume should be administered in 6 hours with the remaining half of the fluids being administered as per protocol.

Fluid resuscitation is very important in the initial management of second- and third-degree burns comprising more than 20 per cent of TBSA as complications of renal failure, myoglobinuria, haemoglobinuria and multi-organ failure may occur if not treated aggressively early.

Mortality has been shown to be higher in patients with TBSA burns greater than 20% who do not receive appropriate fluid resuscitation immediately after injury.[6][7][8]

The Rule of Nine can best be used in patients weighing more than 10 kilograms and less than 80 kilograms if defined by BMI as less than obese.

For infants and obese patients, special attention should be paid to the following:

Patients defined as obese by BMI have disproportionately large trunks compared to their non-obese counterparts.

Obese patients have closer to 50% TBSA of the trunk, 15% TBSA for each leg, 7% TBSA for each arm and 6% TBSA for the head.

Android-shaped patients, defined as a preferential distribution of trunk and upper body adipose tissue (abdomen, chest, shoulders and neck), have a trunk that is closer to 53% TBSA.

Patients with gynoid shape, defined as preferential distribution of adipose tissue in the lower body (lower abdomen, pelvis and thighs), have a trunk that is closer to 48% TBSA.

As the degree of obesity increases, the degree of underestimation of TBSA involvement of the trunk and legs increases when adhering to the Rule of Nine.

Infants have proportionally larger heads that alter the surface contribution of other major body segments.

A Rule of Eight is best for infants weighing less than 10 kg.

This rule imposes approximately 32% TBSA for the patients trunk, 20% TBSA for the head, 16% TBSA for each leg and 8% TBSA for each arm.

Despite the efficiency of the Rule of Nine and its penetration into surgical and emergency medicine specialities, studies show that at 25% TBSA, 30% TBSA and 35% TBSA, the percentage of TBSA is overestimated by 20% compared to computer-based applications.

An overestimation of the TBSA burned can lead to excessive resuscitation with intravenous fluids, giving the possibility of volume overload and pulmonary oedema with increased cardiac demand.

Patients with pre-existing comorbidities are at risk of acute cardiac and respiratory decompensation and should be monitored in the intensive care unit (ICU) during the aggressive phase of fluid resuscitation, preferably in a burn centre.[9][10]

Studies have found that after examining the fully undressed patient, the percentage of TBSA can be determined by the Rule of Nine within minutes.

Several studies found in a review of the literature stated that the patients palm, excluding the fingers, accounted for approximately 0.5 per cent TBSA and that verification was detected with computer-based applications.

The inclusion of the fingers in the palm accounted for approximately 0.8% TBSA.

The use of the palm, which is the basis on which the Rule of Nine was established, is considered more appropriate for smaller second- and third-degree burns.

It has been noted that the more training a specialist has, the lower the overestimation, especially on minor burns.

Due to the inherent nature of error in human burn assessment even in rule setting, computer-based applications available for smartphones are produced to minimise over- and underestimation of TBSA rates.

The applications use standardised sizes of small, medium and obese male and female models.

Applications are also moving towards measurements of newborns.

These computer applications are experiencing variability in the reporting of TBSA rates of up to 60 per cent overestimation of the burned surface up to 70 per cent underestimation.

Intravenous fluid resuscitation guided by the Rule of Nine is only valid for patients with a TBSA percentage above 20% and these patients should be transported to the nearest trauma centre.

With the exception of special areas, such as the face, genitals and hands, which must be seen by a specialist, transfer to major trauma centres is only necessary for more than 20% TBSA burns.

The American Burn Association (ABA) has also defined criteria for which patients should be transferred to a burn centre.

Once fluid resuscitation has begun, it is important to identify whether appropriate perfusion, hydration and renal function are present.

Resuscitation derived from the Rule of Nine and intravenous fluid formula (Parkland, Brooke modified, among others) should be carefully monitored and adjusted as these initial values are guidelines.

The management of severe burns is a fluid process that requires constant monitoring and adjustments.

Lack of attention to detail can lead to increased morbidity and mortality as these patients are critically ill.

The Rule of Nine, also known as Wallaces Rule of Nine, is a tool used by healthcare professionals to assess the total body surface area (TBSA) involved in burn patients.

The measurement of the initial burn surface area by the healthcare team is important for estimating fluid resuscitation requirements because patients with severe burns have massive fluid losses due to the removal of the skin barrier.

The activity updates healthcare teams on the use of the Rule of Nine in burn victims that will produce better outcomes for patients. [Level V].

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Class of 2023 President’s Engagement and Innovation Prize Winners – University of Pennsylvania

Class of 2023 President's Engagement and Innovation Prize Winners - University of Pennsylvania

Class of 2023 Presidents Engagement and Innovation Prize Winners

On April 21, Penn President Liz Magill announced the recipients of the 2023 Presidents Engagement and Innovation Prizes. Awarded annually, the prizes empower Penn students to design and undertake post-graduation projects that make a positive, lasting difference in the world. Each prize-winning project will receive $100,000, as well as a $50,000 living stipend per team member. The prizes are the largest of their kind in higher education. All prize recipients collaborate with a Penn faculty mentor.

Two seniors and one December 2022 graduate were named recipients of the 2023 Presidents Engagement Prize. They are Seungwon (Lucy) Lee for Communities for Childbirth, and Kenneth Pham and Catherine Chang for Act First. Gabriella Daltoso, Sophie Ishiwari, Gabriela Cano, Caroline Amanda Magro, and Tifara Eliana Boyce have received the Presidents Innovation Prize for their project, Sonura.

This years Presidents Engagement and Innovation Prize recipients are fueled by a desire to make a differencein their community, across the country, and around the world, said PresidentMagill. Communities for Childbirth, Act First, and Sonura embody an inspiring blend of passion and purpose. They are addressing consequential challenges with compelling solutions, and their dedication and smarts areexemplary. I congratulate them and wish them success as they launch and grow their ventures.

The 2023 prize recipientsselected from an applicant pool of 76will spend the next year implementing the following projects:

Seungwon (Lucy) Lee for Communities for Childbirth:Ms. Lee, a neuroscience major in the College of Arts and Sciences, is CEO and co-founder of Communities for Childbirth, an international organization that empowers maternal and child health in Jinja, Uganda. With the support of the Presidents Engagement Prize, Ms. Lee will create a community-based referral system that provides efficient transportation to health facilities and patient-hospital communication during obstetric emergencies. Ms. Lee is mentored by Lisa D. Levine, the Michael T. Mennuti Associate Professor in Reproductive Health in the Perelman School of Medicine.

Kenneth Pham and Catherine Chang for Act First:Mr. Pham, a chemistry major in the College of Arts and Sciences, and Ms. Chang, a December 2022 CAS graduate, willexpand on an idea started through Penns Medical Emergency Response Team (MERT) to provide critical first-aid training to high school students in Philadelphia, including opioid reversal, CPR, and bleeding prevention. Mr. Pham is a former MERT administrative director and Ms. Chang is a former MERT general board member. They are mentored by Joshua Glick, an assistant professor of emergency medicine in the Perelman School of Medicine.

Gabriella Daltoso, Sophie Ishiwari, Gabriela Cano, Caroline Amanda Magro, and Tifara Eliana Boyce for Sonura:Ms. Daltoso, Ms. Ishiwari, Ms. Cano, Ms. Magro, and Ms. Boyce are bioengineering majors in the School of Engineering and Applied Science. Their startup, Sonura, is developing a beanie that promotes the cognitive and socioemotional development of newborns in the NICU by protecting them from the auditory hazards of their environments while fostering parental connection. The Sonura beanie is composed of a frequency-dependent filter and a mobile application. The Sonura team is mentored by Brian Halak, a lecturer in the engineering entrepreneurship program.

We are very proud of the wide-ranging curiosity and passionate commitment to improving the world that characterize our great Penn students said Interim Provost Beth A. Winkelstein. These three exciting projects provide creative, innovative solutions that will shape the future of areas from cognitive development of newborns to childbirth in Africa to first-aid training here in Philadelphia. We are deeply grateful to the committees that worked tirelessly to review this years exceptional applicants, as well as to the Center for Undergraduate Research and Fellowships and the outstanding faculty advisors who worked closely with these students to develop their visionary ideas.

The prizes are supported by Trustee Emerita Judith Bollinger and William G. Bollinger, in honor of Ed Resovsky; Trustee Emerita Lee Spelman Doty and George E. Doty, Jr.; Trustee Emeritus James S. Riepe and Gail Petty Riepe; Trustee David Ertel and Beth Seidenberg Ertel; Trustee Ramanan Raghavendran; Wallis Annenberg and the Annenberg Foundation; and an anonymous donor.

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ADHD in Medical Learners and Physicians | AMEP – Dove Medical Press

ADHD in Medical Learners and Physicians | AMEP - Dove Medical Press

Plain Language Summary

Attention Deficit Hyperactivity Disorder (ADHD) is a condition characterized by functionally impairing levels of poor focus and/or hyperactive-impulsive behavior. While initially thought of as a childhood disorder, studies have shown that in 60% of cases, symptoms persist into adulthood. It affects 3% to 5% of adults. This perspective piece aims to highlight the occurrence of ADHD in medical learners (ie, medical students and residents) and practicing physicians. It reviews what has been published about the prevalence of ADHD in these groups, why the rates in residents and practicing physicians may be higher than what has been reported in the scientific literature, the consequences of untreated ADHD in these groups, and a potentially helpful, innovative educational tool to help medical learners and physicians with ADHD with an important aspect of their training and practice the reading of scientific articles. Dr. Ims team concludes that although it has received less attention in the scientific literature than depression, anxiety, and burnout in medical learners and physicians, ADHD has numerous and significant consequences for these individuals that can have a negative effect on medical training, practice, and ultimately patient care. This makes it imperative to support medical learners and physicians with ADHD via evidence-based treatments, program-based accommodations, and innovative educational tools.

The multiple challenges, physical and emotional, associated with pursuing a career in the medical profession are well-documented.1,2 Recent studies have documented significant rates of depression, anxiety, psychological distress, and burnout among medical students,35 with some research noting higher rates of these conditions among medical students (58% depression, 27.233.8% anxiety, 49.6% burnout) compared to age-matched population samples.68 Significant rates of depression, anxiety, and burnout have also been reported among medical residents (7% to 47% depression,915 18% to 56% anxiety,918 and 37% to 85% burnout)9,1114,19 and practicing physicians (22% to 40% depression,6,9 44% anxiety,9 and 37% to 73% burnout).6,9

While increasing attention has been appropriately paid to these concerning levels of depression, anxiety, and burnout in medical students, residents, and practicing physicians, comparatively little attention has been devoted to the occurrence of symptoms of attention deficit hyperactivity disorder (ADHD) in medical learners and physicians. ADHD is a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.20 Symptoms of ADHD can include not seeming to listen when spoken to, easy distractibility, forgetfulness, making careless mistakes in work or school, procrastination, difficulty sustaining attention, difficulty completing tasks, excessive fidgetiness or restlessness, impulsivity, becoming easily bored or impatient, and blurting out answers or interrupting others.20 Although originally conceptualized as a childhood disorder, research has shown that ADHD persists in up to 60% of adults who experienced symptoms as children.21 Evidence from genetic, neuroimaging, and neurological studies reveals difficulty in executive functioning in ADHD associated with lack of availability of dopamine and norepinephrine in the prefrontal cortex.2225

The purpose of this perspective piece is to highlight the occurrence of ADHD in medical learners and physicians, including its reported prevalence in these groups, why reported rates may reflect underestimates, consequences of untreated symptoms, accommodation-based interventions to date, and a potentially helpful innovative educational tool to assist with a vital aspect of their medical training and practice.

While several studies have reported on the prevalence of ADHD in medical students,2632 some of these studies focused primarily on the non-medical use of prescription stimulants rather than on ADHD per se,3032 and the published literature on ADHD in medical residents and practicing physicians is scant. For example, for medical students, disability-related registry data from the Association of American Medical Colleges (AAMC) suggest an ADHD prevalence of 0.9% to 1.4%,4,26 while other studies, mostly employing self-report methodology, have reported prevalence rates of 3.5%,27 4.5%,28 5.5%,30 9%,31 12.7%,32 and 24.4%.29 For medical residents, rates of ADHD are largely unknown; one survey of emergency medicine residency program directors33 noted that 3 of 4644 (0.06% of) residents were known by program directors to have ADHD. Another study, also a cross-sectional survey of emergency medicine residency program directors,34 noted that 4 of 104 programs reported having one or more residents with known disability due to ADHD. For practicing physicians, data from the 2019 AAMC National Sample Survey of Physicians indicate a prevalence of ADHD of 0.32%.35

At first glance, the lower reported rates of ADHD in medical learners (particularly residents) and practicing physicians compared to published rates of depression, anxiety, and burnout in these groups and compared to ADHD prevalence estimates of 3% to 5% in the general adult population36,37 - may seem intuitive, since having ADHD would ostensibly constitute a significant barrier to successfully completing the rigorous level of focused study, clinical rotations, scholarly activities, and other tasks necessary to complete medical training. In essence, then, it could be argued that medical residents and practicing physicians represent a sample that is pre-selected not to have ADHD.

However, five factors warrant consideration before presuming that rates of ADHD among medical residents and practicing physicians are sufficiently negligible to obviate concern about this diagnosis in these groups. First, it is possible that a significant number of medical residents and practicing physicians with a confirmed diagnosis of ADHD do not report having this diagnosis out of fear of being stigmatized or scrutinized by colleagues or supervisors, or because of concern about legal or licensing ramifications.38,39 Second, many medical residents and practicing physicians, despite long experiencing symptoms of ADHD, may not seek formal evaluation and treatment for these symptoms, either because of lack of recognition by themselves, family members, or friends that these symptoms represent ADHD (eg, symptoms are exclusively attributed to personality traits or are dismissed because the individual was accepted into medical school) or an internal belief that as a future or current medical provider, having a neurodevelopmental disorder warranting treatment is unacceptable.3941 Third, even when medical residents and practicing physicians do seek evaluation and treatment for ADHD, they may face resistance by mental health providers to diagnosing and treating the condition due to cognitive and affective biases on the part of psychiatrists about prescribing medications like stimulants.42,43 Fourth, as with many mental health conditions, significant inter- and intra-individual variability affects assessment of severity and functional impairment of ADHD symptoms,44 and many medical residents and practicing physicians, prior to medical training, may have compensated for ADHD symptoms by relying on strong intellectual ability, the flexibility of teachers/professors, the support of significant others, and selected areas of study or activities that either provide a level of structure protective against academic, athletic, or social floundering, or are sufficiently void of tight deadlines and/or the need to regularly prioritize or multi-task that goals are achieved successfully despite the presence of inattentive symptoms.38,40 These compensatory mechanisms then become challenged when the volume and complexity of material to be learned and applied increase dramatically during medical training.38,44,45 Finally, although varying across studies, reported prevalence rates of ADHD in medical students27,28,3032 are comparable to rates in the general adult population, making a precipitous drop (on the order of 1015 times less) in such rates among residents and practicing physicians difficult to reconcile.

The consequences of experiencing untreated ADHD symptoms, while not extensively studied for medical learners and providers, are likely numerous and significant for these groups, if we extrapolate from general studies in adults with ADHD.21,37,46 These conceivably include difficulty engaging in effective and efficient study, poor academic performance,47 tardiness for or absence from clinical duties (due to forgetfulness or disorganization),43 poor sleep (due to inefficient completion of coursework, poor time management, and baseline sleep difficulties associated with having ADHD),44 relationship difficulties (due to inattentive or impulsive symptoms causing conflicts or less dedicated free time),21 secondary anxiety,21 secondary depression,21 and increased substance use as a means to manage poor focus, sleep deprivation, or stress.21 Moreover, one study found that medical students with ADHD (among other cognitive/learning disabilities), compared with matched cohort controls, had lower United States Medical Licensing Examination (USMLE) Step 2 scores, were less likely to graduate on time, and were less likely to match into a residency program on their first attempt.48 Ultimately, untreated ADHD symptoms in medical learners and providers have the potential to adversely impact patient care, if knowledge and skills critical to serving as a competent physician are not mastered (for students and residents), if careless mistakes are made in the process of performing procedures, interpreting test results, or prescribing medications (in the case of residents and practicing providers), or if associated depression, anxiety, substance abuse, or burnout hinder sufficient motivation, concentration, energy, and persistence to provide medical care.

Research suggests that even when adults are properly diagnosed and treated for ADHD, over time about half of them discontinue treatment (specifically stimulant medications, the first-line treatment for ADHD), with the most common reason being lack of perceived effectiveness.49,50 This underscores the need to not only increase awareness of the possibility that symptoms of ADHD may adversely impact the lives of some medical learners and providers, but to develop effective, durable interventions to support these individuals during and after their medical training.

Accommodation-based interventions for medical students and residents with ADHD, guided by interpretations of the Americans with Disabilities Act (ADA) of 1990 and subsequent Americans with Disabilities Amendments Act (ADAAA) of 2008, have been reported or suggested in the literature to include task management strategies (such as detailed instruction and templates for guiding task completion), environmental modifications (such as quiet, distraction-free environments for testing, learning, charting, or phone calls), and self-management strategies (such as frequent reorientation to tasks, pacing of workflow, use of timers and alarms to help with time management, and scheduling explicit time each day to organize tasks using tools like checklists and filing systems).21,51 Other accommodation-based strategies have included direct daily feedback to residents regarding time management, task prioritization, and areas for improvement, review of daily task lists by residents, guidance by the resident to staff members as to when and how to provide instruction and non-urgent teaching, assistance by faculty for residents to develop a comprehensive reading plan, time allowance by faculty for residents personal health-care appointments, and coordination between residents care providers, program supervisors, and residents regarding helpful accommodations and any changes in these over time.52

While these accommodations have likely provided significant benefit to medical students and residents struggling with ADHD, little to no mention is made in the literature about one particular task area that is a crucial part of medical training and practice, and likely an area of challenge for learners and physicians with ADHD: the reading of scientific articles.

Scientific article reading and application of information contained therein has long been part of training and practice in many disciplines, including medicine. At the medical student level, it may receive less emphasis compared to textbooks, course packs, and pocket reference guides, but the practice may gain more salience during clinical rotations, when attending physicians either ask medical students about their knowledge of the literature in a given area or provide brief teaching points during rounds that reference recently published studies. At the resident level, scientific article reading becomes more important, as two of the general competencies that residents are expected to demonstrate based on the Accreditation Council for Graduate Medical Education (ACGME) guidelines,53 medical knowledge and practice-based learning and improvement, require that residents appraise and evaluate scientific evidence and demonstrate knowledge about established and evolving biomedical, clinical, and cognatesciences and the application of this knowledge to patient care, respectively.21 These skills can practically come into play when residents staff cases with attending physicians, during which time there is discussion about evidence-based approaches to patient care and any recent changes in the relevant evidence base. For practicing physicians, scientific article reading is often required to meet continuing medical education (CME), self-assessment, and cognitive component requirements for board re-certification as dictated by the American Board of Medical Specialties.54 It is also an integral part of conducting research, which, for physicians in academic settings, is either a requirement of employment (for tenure track faculty) or a partial requirement for promotion (for clinical or instructional track faculty).

While the specific content of scientific articles varies based on medical specialty, subspecialty, journal featuring the article, writing style of the author(s), and other factors, these articles generally have several features in common that may pose challenges for medical learners and physicians with ADHD. First, scientific articles are often lengthy, typically spanning several pages. It is well-documented that individuals with ADHD struggle with sustained attention, particularly with subject matter that is experienced as more mundane and not personally stimulating (eg, a resident or faculty member needing to read an article that is outside their area of subspecialty interest).20 Second, scientific articles are typically written in the third person style, which avoids use of I or you pronouns, providing less immediate engagement for readers in general and becoming problematic for individuals with ADHD, who are more inclined to become easily bored due to under-release of dopamine and norepinephrine in the prefrontal cortex.2225 Third, scientific articles frequently contain jargon or concepts that are not immediately comprehensible to readers who are unfamiliar with the particular subject matter of those articles. Neuropsychological studies have shown that adults with ADHD exhibit poorer performance on tasks higher in complexity or time requirements, as would characterize the reading of scientific articles containing jargon or concepts needing clarification via looking up of such terminology;55 moreover, recent studies have suggested impaired reading comprehension abilities in ADHD, with particular difficulty picking out main ideas from material that is read.56 Fourth, scientific articles are presented, with rare exceptions, in small-font text format with minimal illustrations. Neuropsychological studies have revealed that adults with ADHD struggle with tasks requiring use of verbal memory (responsible for encoding much of information presented in written form), focused attention, sustained attention, and abstract verbal problem solving with working memory.57 As a result, it has been recommended that individuals with ADHD have information presented to them in multimodal (eg, visual and auditory) forms and in a well-structured and highly interesting way in order to engage interest, avoid waning of attention, and enhance encoding and consolidating of memory processes.58 Most of these methods of information presentation are not provided by scientific articles.

Given the likely aforementioned numerous challenges associated with reading scientific articles for medical learners and physicians with ADHD, and the already heavy demands on time, concentration, energy, and sleep for medical learners and providers in general (making timely, consistent, and thorough reading of scientific articles challenging), we propose the development of an innovative educational tool for presenting relevant information from scientific articles. This consists of a 5-minute recorded video summary in which an engaging speaker presents the relevant information from a scientific article using a brief PowerPoint (Microsoft Corporation, Redmond, Washington, United States)59 presentation shared using videoconferencing (eg, Zoom [Zoom Video Communications, Incorporated, San Jose, California, United States])60 technology. Use of a limited number of slides, underlining, bolding, and graphics when possible are employed to highlight the salient aspects of the visually presented information, and regular eye contact, engaged facial expression, variable vocal tone, and insertion of periodic commentaries similarly are used to de-monotonize verbally expressed material. Information is thus presented in both written and oral form, providing visual and auditory engagement of the learner, while keeping the session brief to prevent waning of attention over time. The recording would be captured in a video file that can be easily accessed from the learners desktop computer, laptop computer, smartphone, or other electronic device, and can be listened to (without being viewed) while exercising, driving, or engaging in other activities for convenience. The recording can be paused, stopped, re-wound, and re-played at the learners convenience (eg, to clarify content that may have been missed the first time, or to review particularly complex material), in line with the benefit of repeating presentation of instructions or other information to individuals with ADHD to address forgetfulness, distractibility, or difficulty following through. The video summary, while brief, would allow presentation of information on study limitations, discussion points, and other material that would not typically be captured in article abstracts.

One might question how the 5-minute video summary (5MVS) differs from the use of video abstracts offered by some scientific journals. Key differences include: (1) Video abstracts provide a video summary of the background, methods, results, and conclusions of the article being presented a visual form of the article abstract, as the title implies. The 5MVS, however, includes not only these elements of the article, but discussion of the strengths and limitations of the article via commentaries designed to enhance reader engagement. The longer duration of the 5MVS (five minutes) compared to video abstracts (typically one to three minutes) facilitates this inclusion of additional information. (2) Video abstracts are typically presented by the author(s) of the featured article, to provide an overview of the research from the standpoint of the authors, who presumably are in the best position to describe the context, motivation, and intent behind the study. The 5MVS, on the other hand, is presented by a physician who is not one of the articles authors, providing potentially greater objectivity in disseminating the articles findings, particularly with use of commentaries on the strengths and limitations of the article, as noted above. (3) While both video abstracts and the 5MVS can be viewed by any medical learner or physician, the 5MVS is specifically designed to help medical learners or physicians with ADHD through intentional use of visual enhancements (such as text bolding, underlining, italicizing, coloring, and use of easy-to-follow pictures and schematics), engaged facial affect, variation in vocal pitch/tone, and insertion of periodic commentaries, with the goal of capturing and maintaining attention through multiple modes of information presentation. (4) Video abstracts are customarily offered by the scientific journals featuring the articles on which the video abstracts are based, as a means of enhancing reader interest in the articles featured, whereas the 5MVS would be made available independent of an articles particular journal affiliation, with the goal of providing readers with ADHD an avenue to process and retain the important content of scientific articles more effectively and efficiently.

The effectiveness of the 5MVS tool could be assessed via real-time and cumulative approaches. Real-time approaches could entail including a limited number (eg, three) of multiple choice questions at the end of the 5MVS designed to assess understanding, retention, and application of the material presented, with responses by each individual viewer (including percent correctly answered) tracked and recorded in a central database, akin to how retention of material from maintenance of certification articles is assessed and tracked by the American Board of Medical Specialties.54 Cumulative approaches could involve, for example, assigning a group of residents with ADHD six articles to read in four weeks; half of the residents would have access to 5MVSs of these articles, and half would not (all residents would have access to the full-length articles, which could feature topics relevant to the medical field but unlikely to have been previously read by the residents). The two resident groups could be matched on demographic, specialty, ADHD severity, comorbid psychiatric and learning conditions, and other variables. At the end of the six weeks, the residents would take a multiple-choice quiz designed to assess understanding, retention, and application of material from the six articles. Those who had access to the 5MVSs could then be compared to those who did not in terms of quiz scores.

One might question the utility of the 5MVS in terms of helping medical learners and physicians to critically appraise scientific literature, rather than merely read it. Two points are noteworthy here: (1) The 5MVS includes commentaries by the presenter regarding the strengths and limitations of the article, to both increase engagement of the viewer as well as encourage the viewer to critically evaluate the articles findings; and (2) The 5MVS is not intended to replace other approaches aimed at encouraging medical learners and physicians to critically assess scientific literature, including the use of journal clubs, workshops, clinical and methodological critiques, listserv discussions, and other approaches.61,62 That stated, to the extent that some of these approaches utilize articles or other formats that may lend themselves to video summarization (eg, workshops, clinical and methodological critiques), the 5MVS could prove valuable in helping medical learners and physicians with ADHD improve their development of critical appraisal skills.

Residency training programs and medical institutions could provide training of interested providers (perhaps residents and faculty with a passion for teaching) in the construction and implementation of the 5MVSs, incorporating the aforementioned elements to optimize the educational experience for all learners, including those with ADHD. One potential barrier to this would be time constraints on the part of busy residents and faculty physicians. This might be addressed by providing a certain percentage of protected time for residents and/or faculty members to devote to the creation of this tool for learners. Another potential barrier could be technology constraints, although most academic institutions currently have the capability of employing videoconferencing technology, and current costs associated with acquiring such technology do not appear prohibitive for most organizations.63 It would also be important to achieve an acceptable balance between making a presentation stimulating and engaging (through use of visual techniques, tone of voice, insertion of commentaries, and other methods as above) and maintaining objectivity in how scientific information is presented, so as not to inadvertently introduce bias in presentation of the material.

While receiving less published attention than depression, anxiety, and burnout, untreated ADHD in medical learners and physicians has numerous and significant consequences that can adversely impact training, practice, and ultimately patient care. Standard, first-line treatments for ADHD (ie, stimulant medications) provide benefit, but nearly half of adults with ADHD discontinue treatment over time due to lack of perceived effectiveness, and accommodation-based interventions, while helpful and important, do not specifically address a crucial facet of medical training and practice the reading of scientific articles. We propose an innovative educational tool for helping medical learners and physicians with ADHD acquire relevant information from scientific articles, taking into account constraints imposed by the disorder and learning approaches that are more likely to be effective in light of these challenges. Future research should examine both the perceived effectiveness of this tool among medical learners and providers with ADHD who have used it and objective data (using validated measures of information comprehension, retention, and conceptual application) comparing the effectiveness of this tool with standard approaches to the reading of scientific articles. As noted by Duong and Vogel (2022),39 a growing community of physicians is challenging the notion that neurodivergence (defined as having a neurodevelopmental condition such as ADHD that may produce challenges functioning in a neurotypical society but may also offer strengths) is incompatible with a medical career, particularly if individuals with these conditions are properly supported via evidence-based treatments, program-based accommodations, and innovative educational tools.

The authors report no conflicts of interest in this work.

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I’m an ER pediatrician. Here are 7 things I never let my kid do – TODAY

I'm an ER pediatrician. Here are 7 things I never let my kid do - TODAY

Kids will be kids, and accidents happen, but certain activities carry more risk than others. Injury is still the leading cause of death for children and teens in the United States, according to the U.S. Centers for Disease Control and Prevention, and unfortunately, many of these are preventable.

We spoke to pediatricians who are also parents about things theyd never let their children do because of the heightened risk of injury or death, and how to make sure your child is as safe as possible.

Motor vehicle crashes are a leading cause of unintentional injury and death in the U.S., per the CDC. Children should always be in the backseat with the proper restraints, the experts note.

This means using the appropriate size and type of restraints whether thats a car seat, booster seat, seatbelt for their age, height and weight, Dr. Brent Kaziny, medical director of emergency management at Texas Childrens Hospital, tells TODAY.com.

While it may be obvious to buckle up younger children, parents also need to be vigilant about school-aged children and preteens, the experts say.

Even if a child seems large enough to ride in the passenger seat, stick to this hard and fast rule. My kids will not ride in the front seat before the age of 13, which is the recommended age that kids can move to the front, Dr. Katie Lockwood, a primary care pediatrician at Childrens Hospital of Philadelphia, tells TODAY.com.

The (front) airbags are potentially dangerous to children, whose skeletons are still developing and arent the right size to be in the front, says Lockwood, adding airbags can cause rib fractures, punctured lungs and injuries to the head, neck and spine.

No matter how much pressure kids put on their parents because their friends ride in the front, Lockwood stresses that 12-year-olds and younger go in the back, no matter how short the drive.

Unfortunately, the highs of this beloved backyard accessory may not be worth the lows. Some trampolines are riskier than others, the experts say.

Dr. Ee Tay, apediatric emergency medicine specialist at Hassenfeld Childrens Hospital at NYU Langone, tells TODAY.com that public trampolines or trampoline parks are out of the question for her kids. Theres just so many broken bones and orthopedic injuries, says Tay, adding that the uncontrolled environment and greater number of kids increases the risk of collisions and falls.

It depends on the weight of the child, how hard they can bounce, how high they can jump, if theres another child next to them. ... Its just very unpredictable, says Tay. Other trampoline-associated injuries include lacerations, concussions and spinal injuries.

While he does see many trampoline injuries, Kaziny says he thinks there are ways to do it safely. Trampolines that are in-ground or have enclosure nets are safer, and parents should always supervise trampoline sessions, minimize the number of kids jumping at once, and make sure there aren't significant differences in age or weight among kids, says Kaziny. (The same applies to bounce houses.)

The American Academy of Orthopaedic Surgeons recommends children under 6 do not use trampolines at all, and the American Academy of Pediatrics recommends children only use them in supervised training programs for gymnastics or other sports.

My kids will never, ever go on an ATV. ... They are so dangerous, says Tay, adding that the all-terrain vehicles cause many preventable accidents among children. This applies to both riding and driving ATVs, though most are built for just one person.

Motor sports have become increasingly popular in the U.S., and ATV-related injuries are on the rise, TODAY.com previously reported.

ATVs do not require any training or a license, Tay points out, and children often dont have the ability to properly judge speed or distance. They just kind of go at it, says Tay. The heavy machines can also flip easily.

Although ATVs do come in youth sizes, Kaziny says he commonly sees parents get an ATV that the child won't outgrow too quickly. The child ends up being on something thats really not age appropriate ... from a size and power perspective, says Kaziny.

The AAP recommends that no one under the age of 16 ride or operate an ATV, and that this is the most effective way to reduce ATV-associated injury or death.

If parents choose to let their child ride an ATV, Kaziny recommends making sure it is age-appropriate, the child is wearing a helmet and other protective equipment, and that they follow safety measures.

Drowning is another leading cause of unintentional injury among children. More children ages 1 to 4 die from drowning than any other cause of death (per the CDC), says Lockwood, adding that these often occur in swimming pools but also bathtubs (especially among infants) and natural water sources.

The experts encourage parents to teach their children how to swim as early as possible but even after kids learn, parents should remain vigilant and set rules.

As kids get older and they know how to swim, they have increased confidence," which can lead kids to take more risks, such as swimming alone, Lockwood says. So it's important to remember your child can still drown, even if they know how to swim.

I teach my kids from a young age not to swim alone and that they should always have an adult whos watching them, Lockwood continues. She stresses parents should ensure there is always one designated and sober "water watcher."

Even if the child is swimming in their own pool at home, the experts warn that tragedies can happen. Its shocking how quickly a kid can end up getting themselves in trouble if youre not really paying attention, says Kaziny. He recommends that all home pools should have child-resistant barriers, like locking gates.

I dont let my kids ride anything with wheels without wearing a helmet, says Lockwood. This includes bikes, scooters, skateboards, rollerblades and hoverboards.

"Kids have a disproportionately large head compared to their body, so theyre more likely than adults to fall and hit their head," explains Lockwood. Resulting injuries range from bumps and lacerations to concussions and severe brain bleeds that cause permanent damage.

Tay agrees: There are too many injuries that we see in the ER for something that can be very easily prevented with (head) protection.

Children should also wear helmets while skiing, snowboarding, ice skating, horseback riding and during water sports. "If they make a helmet for it, you should wear one," says Kaziny.

Lockwood encourages parents to remind children that no matter how good they are at something, accidents happen and other people can cause crashes.

"I also try to model that good behavior by always wearing a helmet myself," adds Kaziny.

Parents can prevent a lot of ER visits by teaching kids how to behave appropriately around animals, especially ones they do not know.

We have a rule at my house. ... If we see an animal we want to interact with, that we do it in a safe and controlled way and make sure the owner is OK with it, says Kaziny.

Children may feel more confident approaching animals if they have pets at home, but Kaziny recommends teaching kids about boundaries with animals. For example, a child cant kiss or hug any dog because they do this to their own dog.

One of the common types of injuries that we see is when the child gets right up in the animal's face then the child gets bitten on their face, says Tay, adding that she also sees bites occur when children approach an animal while it is eating.

"I would not let my kids go to someones house without verifying if they own guns, and if they do that theyre safely stored," says Lockwood. Safely stored means they are locked in a safe and out of reach of children which is especially important as kids get older and hang out without parental supervision, she explains.

Firearm injury has now exceeded motor vehicle collision injury as a cause of child mortality, Dr. MarcAuerbach, professor of pediatrics and emergency medicine at Yale School of Medicine, tells TODAY.com. Unfortunately we have seen a large number of both unintentional firearm injuries and in the older child or teenage population, related to suicide or homicide."

Fortunately, firearm-related injuries and deaths in children are preventable, says Kaziny. Families that own firearms should always practice firearm safety and store them appropriately, and parents should feel empowered to ask about firearms in any home their child will be.

Auerbach also encourages parents to have early conversations with children so they can really understand how dangerous and life-threatening firearms can be.

Caroline Kee

Caroline Kee is a health reporter for TODAY Digital. She previously worked for Healthline and Buzzfeed News.

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Over 550 Emergency Medicine Positions Unfilled in This Year’s Match – Medpage Today

Over 550 Emergency Medicine Positions Unfilled in This Year's Match - Medpage Today

In this year's Match, 555 positions in emergency medicine went unfilled -- more than double the 219 unfilled positions last year and only 14 unfilled spots in the 2021 Match, according to preliminary data.

This year's data were shared across social media but not officially by the National Resident Matching Program (NRMP), and most of the spots will likely be filled in the Supplemental Offer and Acceptance Program (SOAP). Nonetheless, emergency medicine physicians are concerned about the recent trend.

"It's a radical change," said Robert McNamara, MD, chair of emergency medicine at Temple University in Philadelphia and chief medical officer of the American Academy of Emergency Medicine (AAEM). "If you go back 3 or 4 years, emergency medicine was one of the most competitive specialties."

The reasons for the jump in unfilled positions -- the exact spots and programs were also posted on social media -- are multifactorial, according to a joint statement from several emergency medicine groups published on the American College of Emergency Physicians (ACEP) website. Reasons include workforce projections, increased clinical demands, emergency department boarding, economic challenges, the COVID-19 pandemic, the corporatization of medicine, and others.

"It's still a great profession, we just don't have the narrative we did 15 to 20 years ago," said Ryan Stanton, MD, an emergency medicine physician in Lexington, Kentucky, and an ACEP board member. "It's a negative narrative. We hear about struggles with payers, and threats of continued cuts. Students listen to that."

McNamara placed special emphasis on workforce issues -- in particular, a study by ACEP that warned of future challenges with emergency physician oversupply -- and on the increasing involvement of corporate entities.

"Emergency medicine residents always have among the highest debt of any specialty," McNamara said. "They have a strong sense of social justice and often don't come from privileged backgrounds ... so they're likely to accumulate debt."

Residents carrying a lot of debt who suspect they won't be able to get a job when they graduate may be deterred from entering the specialty, he noted.

Additionally, fewer graduates are finding placement with physician-owned groups, and instead more are working for corporate entities, which can impact physician autonomy, he added.

"Doctors who work for these companies don't like it," McNamara said. "They're burning out. They get treated like a money-making machine, like a cog in the wheel. ... Emergency medicine is a 24/7/365 specialty, and with the nature of the things we see, you can't do a difficult specialty long-term if you feel someone is taking advantage of you."

Facilities have created more emergency medicine residency spots in recent years, he pointed out, noting that, in a way, the specialty is a victim of its own success. "Once you attract talented doctors, you want more," he said. "Some hospitals say, wow, they have an emergency medicine residency, I want one too. We just created too many."

He said it's not just corporations pushing to create new positions, but academic centers as well.

Stanton was particularly concerned about the creation of new residency positions. "There are no guardrails on the number of programs, whether they're produced by HCA or the expansion of academic programs," he said. "You can open up a residency program as long as you meet ACGME [Accreditation Council for Graduate Medical Education] criteria."

"A residency program is not a cost-effective staffing strategy. It is an educational opportunity," he added. "Any program expanding simply to find a cheap workforce is doing it for the wrong reasons."

Bryan Carmody, MD, of Eastern Virginia Medical School in Norfolk, who posts frequently about Match data, noted in a blog post last fall that even while emergency medicine residency positions are up -- they more than doubled in the past 15 years -- the number of applicants took a significant dip last year, and fell again in this year's Match cycle.

"Regardless of why, the what is clear," Carmody wrote. "There are unquestionably fewer emergency medicine applicants. So the next question is, if you care about emergency medicine, what -- if anything -- should you do about it?"

In the joint statement, ACEP, AAEM, and others noted that they convened a Match Task Force to identify the factors that have led to the increase in unfilled positions, and to develop a strategy to mitigate the crisis.

"Although these are challenging results, emergency medicine remains a vibrant and appealing specialty for many, with almost 2,500 new trainees already joining the emergency medicine family," the group wrote.

McNamara said there are no easy solutions. "We have to restore emergency medicine to a practice where physicians can enjoy the job," he said. "It's not going to be good for a while."

Kristina Fiore leads MedPages enterprise & investigative reporting team. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Send story tips to k.fiore@medpagetoday.com. Follow

Libyas Emergency Medicine and Support Center serves the people affected by the Turkeys Stricken Areas – EIN News

Libyas Emergency Medicine and Support Center serves the people affected by the Turkeys Stricken Areas - EIN News

LIBYA, TRIPOLI, March 14, 2023 /EINPresswire.com/ -- The Emergency Medicine and Support Center (EMSC) is a specialist center responsible for the provision of humanitarian assistance, medical care, and relief aid to people affected by war and natural disasters, in addition to the treatment of wounded victims and providing healthcare to all with impartiality.

Upon the instructions of His Highness, the Prime Minister of the National Unity Government, EMSC strives to provide medical care and relief aid to people affected by Turkey's stricken areas. The EMSC worked, together with the National Safety Authority, the Criminal Investigation Department, the Medical Treatment Support and Development Agency, and the Military Medicine Division, to dispatch a joint team for relief and rescue consisting of 106 medical and paramedical personnel. The team is divided into four groups and serves as humanitarian assistance.

The first group was stationed in Adana province and was assigned the task of coordinating logistics and follow-up.

The second group stationed in Jumhoriet district, Antakya, and Hatay province also contributed to rescue operations. The group recovered 69 bodies and pulled out six people alive. The location of 380 bodies was also determined, and the relevant Turkish authorities were informed.

In all duration, coordinates were provided to the authorities and were used by other foreign agencies to recover the bodies.

The third group was stationed in the Hattay Field Hospital, where first aid, advanced medical aid, resuscitation, and minor operations were provided to more than 600 cases. The group was the only one that worked hand in hand with Turkish personnel.

In addition, the fourth group conducted a field investigation of cases in camps set up for the displaced people near the epicenter of the earthquake in Jumhorit, district of Hatay Province. The group provides treatment and medication to more than 40 patients inside the aforementioned camps.

About Emergency Medicine and Support Center:

The Emergency Medicine and Support Center (EMSC) is a specialist center that provides services for the provision of humanitarian assistance, medical care, and relief aid to people affected by war and natural disasters such as flood disasters and earthquakes. Additionally, to the treatment of wounded victims and providing healthcare to all with impartiality. Consequently, the Libyan team, which consists of EMSC personnel, focuses on the treatment of Syrian cases as well as Arabic-speaking Turkish patients and other cases in general.

http://emsc.ly/

Tarek ElhamsharyEmergency Medicine and Support Centeremail us here

In rural Mississippi, E.R. staff are being trained to care for moms and deliver babies – WBHM

In rural Mississippi, E.R. staff are being trained to care for moms and deliver babies - WBHM

Two medical teams wait patiently in the hallway outside of a hospital room at theMississippi Center for Emergency Servicesat the University of Mississippi Medical Center in mid-February. Its quiet as they slip on blue gloves and consult with their team on tasks. One will help the mother. The other will receive the baby.

Dr. Tara Lewis presents todays patient and students listen carefully as she lays out the scenario, making note of the patients age, symptoms and whats missing from her chart. Then, as the patient Victoria Tubby screams through the door, they ready themselves. Its time to deliver a baby.

But this is no ordinary hospital room, and Victoria is no ordinary patient. For starters, shes not a real person. Shes a high-tech mannequin that simulates a woman in labor. She bleeds, screams and has a removable belly and placenta.

And the delivery of her baby a slippery, 5-pound doll is all part of aSTORK training simulationunderway at MCES.

As hospitals in rural Mississippi continue to cut maternal and neonatal services, residents are strapped to find options in an emergency like going into labor. The STORK programlaunchedin May to prepare paramedics and health care providers for those rising gaps in care.

Lewis, an emergency medicine physician, said the response to STORK has been overwhelmingly positive. At its creation, the plan was to teach 10 classes in a year, but demand turned it into two per month. By the end of the programs first year, more than 400 people will have attended a STORK session, whether at the MCES or at a hospital across the state.

The training had real-world effects almost immediately.

Weve had people reach out to us that we have trained that have delivered babies the next day in their E.R., Lewis said.

Giving birth in an emergency room doesnt seem ideal for most mothers, but across the Gulf States, hospitals have had todownsize, opting to preservecritical careover maternity care and leaving pregnant people to rely heavily on emergency services. Over the past year,as many as four hospitalshave suspended labor and delivery services the most recent being Singing River hospital in Gulfport, Mississippi.

We see people having to drive two to three hours to get obstetric health care in the Delta specifically, Lewis said.

Most of the Mississippi Delta qualifies as amaternity care desert, according to the latest March of Dimes report meaning there are barely any obstetric providers for mothers in the region. Mississippis poor health care system also affects babies. With only one childrens hospital in the entire state, even patients with the least critical care needs can expect to travel hundreds of miles.

Adam Bandy, whos part of the pediatric transport team at MCES, said long ambulance trips are common and his job can take him into some deeply rural areas.

Make sure you pack your lunch because were probably going to be gone for 5 to 6 hours on this trip, Bandy said. Thats a routine trip. Thats not if theres any kind of complications or if we have to provide any kind of next level of care.

Bandy points to hub cities, such as Jackson and Hattiesburg as having adequate facilities for patients, but in places like Greenwood or Gulfport, sometimes the nearest hospital with a pediatric unit isnt in the state.

Well go to Louisiana, Alabama [and] Tennessee on occasion, and we will transfer either from here to there, or we will bring them from there for resources since Jackson has the only childrens hospital in the state of Mississippi, he said.

Those resources can be hard to come by, so STORK provides each participant with a duffle bag packed with supplies to deliver a baby or stabilize a laboring mom. If the paramedic uses anything in the bag, STORK will replace it.

Bandy was present at the February STORK training, but it isnt his first time completing the course. He said its vital to keep those skills sharp. Lewis said STORK gives health care providers the opportunity to practice skills they may not use daily. The class is made up of paramedics, flight medics, and nurses, many of whom have never had to deliver a baby.

Before the simulation, students attend a lecture to learn how to stabilize a patient, stop a hemorrhage and intubate an infant emergency procedures that could mean life or death.

In the hospital room, they pay special attention to Victoria and check her and her babys vitals on a large screen. Victoria is responsive and offers feedback to her providers while they work. She can be affirming and grateful that theyve gotten the baby out, or can be difficult, yelling out dont touch me! She sometimes goes into shock, and its a scramble to then bring her back, but participants can practice as many times as they want.

She can simulate things like seizures, postpartum hemorrhage, pre-eclampsia, abnormal presentation of the baby, Lewis said. She does it all.

Students practice multiple best- and worst-case scenarios, offer fluids and medicine and support Victoria through labor. Everyone keeps a watchful eye to help her safely deliver her baby.

You can actually get your hands on it and catch a baby and do it multiple times because that repetition kind of helps educate people, helps you get that just muscle memory of what to do, Lewis said.

This story was produced by theGulf States Newsroom, a collaboration betweenMississippi Public Broadcasting, WBHMin Alabama,WWNO andWRKFin Louisiana andNPR. Support for reproductive health coverage comes fromThe Commonwealth Fund.

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Grit and Goals: DFCM Resident Dr. Hayley Wickenheiser on the … – University of Toronto