UMEM Educational Pearls - By Kevin Semelrath

Category: Administration

Title: Pulse Oximetry's Color Bias

Keywords: pulse oximetry, skin pigmentations (PubMed Search)

Posted: 6/15/2024 by Kevin Semelrath, MD (Updated: 7/22/2024)
Click here to contact Kevin Semelrath, MD

This article shows us that even things we think of as objective measures in medicine may actually perpetuate systemic biases.  

The study evaluated controlled hypoxemia in a group of volunteers.  Traditional pulse ox devices measured falsely elevated pulse ox readings in participants with dark skin pigmentation and low tissue perfusion.  It suggested different types of devices that may have improved accuracy in patients with darker skin pigmentation, but the underlying problem still exists.

Bottom line, this goes to prove what we have taught, never rely on a single value to reassure yourself of the patient's status, always take into account the bigger picture.

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This study is out of the American University of Beirut, Lebanon, and courtesy of our own Mazen El Sayed!

Many patients of Muslim faith will observe fasting during the month of Ramadan, with no food, water, oral of IV medication taken from sunrise to sunset

This study showed a lower daily ED volume than during non Ramadan months, however did show a higher length of stay during Ramadan.

It also found an increase in mortality rates during Ramadan (OR 2.88) and 72 hour ED bounce-backs (OR 1.34)

Be sensitive and aware of the needs of your patients of Muslim faith during this holy month of fasting.

Ramadan Kareem

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This study was a retrospective review of restraint use at a level 1 trauma center in the Midwest.

It found the following were factors in a patient encounter associated with an increased risk of restraint usage:

  • drug or alcohol intoxication (highest OR)
  • American Indian race
  • male gender
  • Medicaid or self pay insurance
  • dx of bipolar disorder, psychosis

This study found a decreased OR of restraint use with Black or Hispanic race, which was in contrast to other studies

This was a single center, retrospective study, so it was already limited in what it could tell us.  In addition, they didn't see  the reason for the restraints being ordered in the first place. Nonetheless, it does show that people in certain marginalized groups have a higher likelihood of ending up in restraints.  Please think twice when ordering restraints in the ED, especially for behavioral reasons

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This disturbing study out of the UK details the prevelance of sexual harassment, sexual assault and rape within the hospital environment.  

Overall it's clear that women surgeons in this study were the victims and witnesses of sexual violcence at a substantially higher rate than men.  89% on women report being witnesses of sexual harassment and 63% being the victim of it; 30% of women report being the victim of sexual assault, and 35% report being witness to it; and most concerning 0.8% of women report being raped by a colleague, with 1.9% being witness to it.

The study also asked respondents about their faith in higher organizations' (the Royal Colleges and the General Medical Council) ability to respond to these issues.  For women, the percentage of people who felt that there was an adequate response was only between 15-30 percent.

There is a huge and persistent gap between men and women both witnessing and experiencing sexual harassment and assault at work.  Everyone has a responsibility to immediately interrupt any form of sexual harassment or assault, no matter how inocuous it may seem to the perpertrator, in order to provide an environment we can all thrive in.

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Since the switch from fee for service to value based care in the US, there has been a marked push to improve our documentation to expand our MDM and differential considerations.  We are all here becoming adept at the medical documentation (thanks Dr. Adler!), but may not be adequately documenting our patients' social determinants of health using the social Z codes, a subset of ICD-10 coding language

This study wanted to look at the overall prevelance of social Z code utilization.  They used the Nationwide Emergency Department Sample (NEDS), a nationwide database of ED visits, to look at this particular documentation.  They examined 35 million (!) ED visits and found that only 1.2% had any social Z code included in the documentation.  Given how many resources are linked to a verified (eg documented) need, this raises the idea that if Z codes are better documented, this may lead to increased funding for things like food, housing and transportation insecurities.

Limitations- the authors only examined the ED visits for ICD-10 codes, they didn't specifically look at the notes themselves which may have contained SDOH information.  They also found that the social Z codes were more often documented in visits coded for mental health diagnoses, potentially indicating bias.  There is also the concern that patients may not want the social z codes included, given the stigma around things like homelessness.

Overall, social Z code documentation could potentially unlock better resources for our patients by documenting a specific need in a population.  More will come as documentation continues to evolve.

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Substance use disorder is now known to be a function of brain disease and not a moral failure.  Patients with substance use disorder are highly complex and often use the ED at a higher frequency than those without the disorder.  However, these patients are also frequently the target of implicit bias and stigmatizing behavior from the healthcare team that can lead to worsened outcomes.  Add on top of that a racial disparity, and we can see how this group of patients can have really bad health outcomes.

This study looked at the length of time to treatment of patients with SUD, to see if there was a difference within this group based on racial or ethnic differences. It did find that black patients with SUD did wait on average 35% longer in the ED before being seen or treated.  This difference was statistically significant.

While this study wasn't designed to identify the causes of such a disparity, it does raise concern for implicit bias being in effect among not only the healthcare workers, but ingrained into the healthcare systems themselves.

Patient's with SUD are a vulnerable group of patients, and black patients with SUD are experiencing a disparity in time to treatment.  This should remind us all to seek out ways to remove these biases and disparities from the systems where we work.

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Category: Misc

Title: Care for Transgender and Gender Diverse Patients

Keywords: DEI, transgender, gender nonbinary, gender diverse (PubMed Search)

Posted: 6/17/2023 by Kevin Semelrath, MD
Click here to contact Kevin Semelrath, MD


While transgender and gender diverse individuals make up a minority of the US population (approx 1.4 million individuals), they are unfortunately the victim of a large amount of discrimination in our society.  A seemingly overwhelming number of laws are being passed this year specifically targeting this group, including how they can access health care. As emergency physicians, it is our duty to not only understand and care for these patients with excellent and compassionate care, but advocate for them in places of power.

This is a qualitative study that looked at the experiences of transgender and gender nonbinary (TGN) patients seeking care in EDs in Arkansas.  They researchers performed structured interviews with 9 TGN patients who had received care in various EDs in the state.  It identified several themes in their experiences:

 1. Systems and structural issues- these included the patients' legal document and EHR gender prounouns not matching their gender identity, intake forms not having a place for patients' pronouns and chosen name, and confidentiality issues when calling patients from the waiting room using their deadname

2. Interactions with clinical staff- while many of the patients did have some positive interactions with the ED staff, there were several significant issues identified.  Patients experienced misgendering, either intentional or unintentional, as well as inappropriate questions about patient anatomy that was not related to the presenting complaint, and other harmful behavior such as being stared out by staff, and delays or refusal of care

3. Perceptions of clinical knowledge- many of the subjects reported having to educate the ED clinicans regarding transgender health care issues. This influenced their desire to return for care to those EDs


We are all responsible for treating all of our patients with dignity and respect, even if we don't fully understand their own journey. And remember pride started as a riot and became a revolution!

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