Case

A 14-day old female, born at 40 weeks gestational age via normal spontaneous vaginal delivery without any complications, presented to the pediatric emergency department (PED) with fever, cough and congestion for 2 days. A rectal temperature taken the day of presentation was 38.8 °C. No antipyretics were given at home. The patient had a dry cough without increased work of breathing. There was no apnea, cyanosis, diarrhea, or rash. The patient was feeding well and had at least 4 wet diapers in the last 24 hours. The baby was acting normally without lethargy.

On arrival to the PED, her vital signs were a rectal temperature 38.4 °C, heart rate 190 beats per minute, respiratory rate 50 breaths per minute, blood pressure 73/41 mm Hg and oxygen saturation was 95% on room air. On physical examination, the patient was well appearing and in no acute distress. She had nasal congestion and a mild cough. Given that the patient was <21 days of age with a documented fever, established clinical guidelines recommend a full septic evaluation, including testing of blood, urine, and cerebrospinal fluid (CSF).

In preparation for the lumbar puncture (LP) to evaluate for meningitis, the physician performed a point-of-care ultrasound (POCUS) of the patient’s spine. The POCUS of the area of interest showed the termination of the spinal cord (conus medullaris), the cauda equina, and anechoic CSF (Figures 1 and 2). The team then used a sterile marker on the baby’s back to indicate the best location for needle insertion to have the highest likelihood of success for the procedure.

POCUS Technique

To perform POCUS prior to performing an LP, a high frequency linear transducer is recommended as it allows for the best visualization of superficial structures. The static technique is used most frequently, where POCUS is used to identify landmarks and the ideal intervertebral space for the procedure, and then the space is marked on the patient’s skin with a sterile marker. The patient is positioned for the LP procedure, either in the lateral decubitus or sitting position. In sagittal view in the midline over the lumbar spine, the conus medullaris is identified (Figure 3). The LP should be performed below this level to avoid injury to the spinal cord. The sacrum is generally identified as well to note the lower limits of where the needle should be inserted, as needle insertion at this level will be low yield in regard to CSF return. Once the appropriate space(s) are identified, the midline of the spine and the levels of the spinous processes can be marked, outlining the edges of the intervertebral spaces for the LP procedure (Figure 3, 4). A transverse view can help to confirm the central location of the cord and provide information about the best area to enter the intervertebral space.¹ Color Doppler can confirm the presence of CSF and identify vasculature surrounding the spinal canal (Figure 5). It is also possible to measure the depth to the spinal canal, which may help with procedural planning (Figures 6).

Discussion

Infant LPs are commonly performed in the PED, most often as part of an evaluation of fever in neonates. Although LPs are performed regularly, the success rates are still only approximately 50-60%, regardless of the experience of the physician performing the LP.^2,3 Small anatomical spaces containing CSF, difficulty identifying landmarks, and inability to keep the patient still are just some of the reasons that infant LPs may be difficult. Traditional methods for performing an LP utilize landmark identification with palpation of the superior aspect of the iliac crest and identification of the intercristal line. The intercristal line ideally crosses the L4 vertebrae, which allows identification of the L4-L5 intervertebral space, the ideal needle insertion location for an LP. However, it has been shown that intercristal line identification of intervertebral spaces may not be accurate, and the ideal intervertebral space may not be correctly identified through palpation alone.⁴

Point-of-care ultrasound is a tool that can be used easily at the bedside to help improve success rates of LPs in the neonatal population. The infant spine does not fully ossify until approximately six months, which allows for clear ultrasound images of spinal anatomy in infants under 6 months of age. The clinician can identify key landmarks of the infant spine and spinal cord and visualize CSF to determine the best location for needle insertion. This also provides insight into intervertebral spaces to avoid such as those containing the conus medullaris or the sacrum. If there has already been an unsuccessful LP attempt, POCUS also allows visualization of any epidural hematomas that may have formed secondary to traumatic LP attempts.^5,6 POCUS is an ideal means of obtaining anatomical information in pediatric patients as it is readily available at the bedside with fast application, uses no ionizing radiation and can be taught in a relatively short amount of time.⁷

A metanalysis on pre-procedural POCUS use for infant LPs showed a calculated risk difference of 13% and an odds ratio of 2 for first time success rates. Additionally, there were fewer traumatic LPs with a risk difference of -12% and an odds ratio of 0.45.¹

While the static use of POCUS prior to LP is most used for pediatric patients, POCUS can be used dynamically as well. For the dynamic technique, POCUS is used during the LP procedure to directly visualize the needle entering the intervertebral space. There is some data on the dynamic technique from the neonatal intensive care unit (NICU). Data from the NICU has shown the dynamic technique to be beneficial and more successful than palpation alone. In a retrospective study of 17 infants in the NICU where dynamic ultrasound-guided LPs were performed, the first attempt success rate was 65% and overall success rate was 100%.⁸

Using POCUS allows the clinician to have more information before beginning an invasive procedure, increases success rates, lowers traumatic LPs and, ultimately, is safer for the patient. This may also help alleviate the stress for families during the procedure as well.

Case Conclusion

The patient continued to be well appearing. Acetaminophen was given for fever. In addition to checking blood work and urine, an LP was performed successfully after POCUS was performed, and clear CSF was collected. The CSF white blood cell count was 0/uL and the red blood cell count was 5/uL (reference range 0-10/uL), indicating that the lumbar puncture was atraumatic. The CSF meningitis/encephalitis PCR panel was negative. The respiratory pathogen PCR panel was positive for respiratory syncytial virus. The patient was admitted to the pediatric hospital inpatient unit for observation until all cultures were negative and then discharged home the following day with supportive care and prompt follow-up with her primary care physician.

Indications

• Pre-procedural guidance for LP
• Prior failed LP attempts using the traditional landmark approach
• Evaluate for epidural hematomas secondary to traumatic LPs

Technique

• Place the patient in the lateral decubitus or sitting position.
• Use a high frequency linear transducer in the sagittal orientation over the midline of the patient’s lumbar back to identify the spinal column. Slide the transducer to position the targeted intervertebral space on the center of the ultrasound machine’s screen.
• With a sterile marker, make a mark on the patient’s skin on both sides of the transducer at its center to show the location of the targeted intervertebral space.
• Rotate the transducer into the transverse orientation and slide it left or right to put the center of the spinal canal in the center of the ultrasound machine’s screen.
• With a sterile marker, make a mark on the patient’s skin above and below the midline of the transducer to show the location of the midline of the spinal canal.
• Lift the transducer off of the patient’s skin and then use the sterile marker to draw lines connecting the marks, so to make an plus sign on the back to guide needle placement.

Pitfalls and Limitations

• Most commonly, the static technique is used in pediatrics. Dynamic guidance can be used with the same ultrasound transducer but would require more advanced instruction and sterile ultrasound probe covers.
• The spinal cord and CSF can only be visualized on POCUS in young infants, as the spine ossifies around 6 months of age and will limit the ability to visualize the spinal canal.
• This is an extra step to a procedure and may lengthen the procedural time.
• POCUS prior to LP has a learning curve and may be especially helpful to expert sonologists performing the procedure.

Jeffrey Thompson, MD FACEP
Assistant Professor, Emergency Medicine
SUNY at Buffalo

A Normal Krausian Distribution

No, that’s not a typo; I did mean Krausian. You’ve never heard that term? OK, I made it up, but it is how I describe myself and my medical practice. For this column, I would like to take the personal privilege of paying tribute to the late Dr. Richard Krause, my residency program director and mentor whose leadership and teaching had a profound impact on my career and on the way I practice medicine. Dr. Krause served as PD of the University at Buffalo EM residency from its founding in 1994 until he stepped back from the position in 2008.

I first met Dr. Krause when I was a third-year medical student rotating at our trauma center, and I was terrified of him. He was known to be somewhat gruff toward medical students and that was apparent right from the beginning. I worked with him a couple times during the rotation and during those shifts I was sometimes “banished” to fast track, grilled about my decision to order a CBC, and told not to write in the chart. Granted, these were different times in medical education, and those experiences were not entirely out of place. I remember finishing some of those shifts and questioning whether I was cut out for emergency medicine, and whether I would want to train in Buffalo. But during that month, I watched the way he interacted with his residents; the way he mentored them, joked around with them, and encouraged them to work hard. I saw an excellent physician with strong clinical acumen whose clinical diagnostic skills I wished to emulate, and I realized that behind a somewhat rough and imposing exterior was a doctor who cared about the well-being of his patients and a leader invested in the education of his trainees.

Dr. Krause practiced what I consider to be common sense, practical medicine. If it didn’t make sense to do something – order a test, give a treatment, admit a patient, even if it was the latest trend – why do it? How would we use the result? What if something was abnormal – would we be prepared to address the abnormality? We quickly learned that if the test would not change our management or we were not willing to address incidental abnormalities, we probably should not order the test. I never got the sense that he was pushing back just to be critical. Rather, he was trying to put us through the mental gymnastics to make sure we could justify the time and expense of a workup, and by so doing understand the medicine and medical system more wholistically. He convincingly argued that the CBC was the most useless, overordered lab test in all of medicine, and I still think twice before clicking that order! [Hmm, I wonder what he would think of lactate today…] Nevertheless, when working on shift with Dr. Krause, critical thinking and reflective practice were expected and cookbook medicine was discouraged. Do what the patient needs; nothing more, nothing less.

As I said earlier, even though I was very intimidated by Dr. Krause as a student, I came to realize that he was Papa Bear to his residents. He fiercely defended us and our department in the hospital and the university. This is not surprising as his career included those early years when EM was developing as a new specialty and had to prove itself in the house of medicine. Whether on shift or behind the scenes, he was willing to go to battle on behalf of our residency and, more importantly, on behalf of our ED patients. He taught us how to navigate the challenges of an admitting service pushing back or a condescending surgeon belittling us and our department. At the same time, he carried high expectations of his residents and demanded that we be every bit as good as any other resident in any program. I worked hard, not because I feared him, but because I respected him and wanted to meet his expectations. Truth be told, much of my motivation during residency was making sure I didn’t disappoint Dr. Krause!

Throughout my training and early in my career, I was fortunate to have many great mentors who shaped who I am today, but it is Dr. Krause who had the greatest impact on my practice of emergency medicine. During my last conversation with him a couple years ago, I told him that I often use the term Krausian to describe my practice pattern and style: I hold high expectations for my trainees, I am thoughtful (and have been described as parsimonious) in my workups, and don’t shy away from necessary confrontation when patient care and resident needs are at stake. He responded that there were things he would do differently if given the chance, but appreciated the sentiment, nonetheless. And while I am a slightly softer version of Dr. Krause (times have changed, after all), I continue to describe myself as Krausian with pride as it represents the legacy of a great educator and clinician who shaped the residency in Buffalo and the people who have come through it. Whether or not you ever met him or worked with him, I invite you to join me in paying tribute to Dr. Krause and, in his memory, maybe order one less CBC on your next shift!

Reflections of a Graduating Emergency Medicine Resident

As my time as a resident comes to a close over the next couple of months, I am finding myself reflecting on the people I’ve met, the experiences I’ve had, and the lessons I’ve learned. All of this has shaped me into the emergency medicine physician I am today.

I have learned from some of the best teachers – both my patients and my colleagues. Each one of my attendings is an expert in emergency medicine, and each one of them practices in a slightly different way. There are attendings that have training in a variety of different fellowships (ultrasound, EMS, sports medicine, administration…) and they practice in a wide variety of settings (large academic centers to suburban, stand-alone emergency departments). These experiences have shaped the way that they practice, and the collective time spent with all of my attendings has shaped the way that I approach my own patient encounters.

Throughout residency, I have been incredibly fortunate to be a member of The American College of Emergency Physicians. ACEP was first introduced to me as an intern, when my program sponsored the entire intern class to attend the NY ACEP Scientific Assembly at The Sagamore on Lake George. Over the past 3 years, I have come to learn that ACEP is more than a gathering once a year; it is the body that sets forth the clinical standards, education, advocacy, and professional development for our entire profession. Being a member of this organization not only provides personal opportunities, but helps to advance the profession as a whole.

Advocacy can mean many things in different situations. On a single shift, you can find yourself advocating for a patient by discussing their case with a consultant or hospitalist. From a broader perspective, there are countless opportunities to influence policy – on a hospital level, on a state level, and on a national level (and ACEP has opportunities for this!). As you gain expertise, your voice becomes that much more powerful – as you see the challenges that your patients face on a day-to-day basis as they interact with the healthcare system, you have the opportunity to amplify their voices.

At my short white coat ceremony at the start of medical school, my aunt (a retired nurse) jokingly gave me some excellent advice. As we posed for pictures with family and friends, she pulled me aside and said “be nice to the nurses!”. Nurses are the backbone of not only the emergency department, but the entire hospital and healthcare system. Every shift throughout residency, I have worked with nurses that have taught me invaluable lessons. I hope I have lived up to my aunt’s advice throughout my time as a resident.

The other week, I had a quadriplegic patient in the emergency department. After we ruled out any surgical emergencies, he had a simple request – he wanted a ginger ale. I have had countless patients request drinks in the past, but this patient’s inability to use his arms presented an opportunity to spend an extra second with him in his examination room as I held the drink up to his mouth. This simple act allowed me to pause and reflect on his experience and barriers that caused his presentation in the emergency department in the first place. You are never too busy – get your patient a ginger ale.

Appreciate your patients and colleagues – they are your best teachers. Join a professional society. Advocate for your patients. Be nice to the nurses. Grab your patient a ginger ale. Through it all, remember that practicing emergency medicine is a privilege and it is the best job in the world.

Removing the “Pebbles”: A Simple Strategy to Improve the Clinical Learning Environment in Emergency Medicine

Pediatric Stroke: The Great Masquerader

A 13-year-old male accompanied by his mother presents from home for vomiting. The history and physical exam are benign with a non-tender, soft abdomen. Zofran is given, and the patient tolerates oral intake without issue. The patient states that he is feeling better. Shared decision making is done with the mother for discharge and pediatrician follow up if symptoms return or worsen. He stands to walk out when you notice an unsteady gait. The patient feels nauseous again and vomits. With these new findings, lab work, and imaging is ordered. The radiologist calls for a critical finding: cerebellar infarction.

Recognition & Impact

Pediatric stroke can often present similar to the case above. Oftentimes, nonspecific symptoms that mimic benign conditions like migraines, Todd’s paralysis, toxic ingestions, and metabolic derangements. These conditions tend to be more common and can mask strokes. The average time to diagnosis from symptom onset of a stroke is approximately 22 hours.¹ Early recognition and intervention in the emergency department (ED) is critical to overall prognosis and improvement in patient outcomes.

A stroke is defined as a clinical syndrome of global or focal disturbance in brain function lasting more than 24 hours or brain tissue death with no other cause.² Strokes can be classified into two main types: ischemic and hemorrhagic. Ischemic strokes result from a loss of perfusion within an arterial or venous vascular territory, leading to parenchymal injury.³ In contrast, hemorrhagic strokes involve non-traumatic bleeding within the intracerebral, intraventricular, or subarachnoid spaces.⁴ An additional category of pediatric stroke, not addressed in this article, is perinatal stroke, which occurs between 20 weeks of gestation and the first week of neonatal life.⁵

Although a routine part of adult emergency medicine, stroke in the pediatric patient is not as prevalent, estimated to be at 2.4 per 100,000 children.⁶ Despite its low prevalence, the mortality rate for pediatric stroke is approximately 25%.⁷ Among children who experience a stroke, about 25% will have a recurrent stroke.⁷ Additionally, more than 75% of children develop long-term neurological deficits following an acute ischemic stroke.³ Morbidity is greater in children, as they live with stroke-related disabilities longer than adults.

Screening Tools

The first step in pediatric stroke management is prompt identification. Screening tools can assist clinicians, particularly in ambiguous cases. The BEFAST-S exam (Balance, Eyes, Facial Symmetry, Arm Weakness, Speech, Time, Seizure) may be used during triage or initial assessment to raise suspicion for stroke.⁸ This tool is adapted from the adult BEFAST scale, with the addition of seizure to better capture common pediatric presentations. While it demonstrates high sensitivity for stroke detection, its specificity remains low.⁸ Additionally, a pediatric version of the National Institutes of Health (NIH) Stroke Scale has been developed for patients aged 2–18 years and has shown high validity and reliability in this population.⁹

Risk Factors

Risk factors for pediatric stroke are numerous and diverse, encompassing a wide range of diseases and conditions. High-risk factors include vasculopathies, such as Moyamoya disease, vasculitis, and fibromuscular dysplasia as well as coagulopathies including factor V Leiden mutation, protein C or S deficiency, and antiphospholipid antibody syndrome.^4,10,11 Anatomical vascular abnormalities, such as vascular malformations and aneurysms, also contribute to increased risk.^4,10,11 In addition, cardiac conditions including patent foramen ovale (PFO), arrhythmias, and structural abnormalities such as rheumatic heart disease can lead to cardioembolic stroke.²

A notable and common risk factor for pediatric stroke is sickle cell disease (SCD). Approximately 10% of children with SCD will experience a symptomatic stroke by the age of 18, and up to 30% will have a “silent” stroke without immediate clinical symptoms.¹² SCD is unique in that its management differs substantially from standard stroke protocols. As the proportion of sickled red blood cells increases, so does the risk of thromboembolism and impaired cerebral perfusion. Consequently, treatment focuses on blood transfusion or exchange transfusion to reduce the concentration of sickled cells in circulation.¹³

Common conditions and medications encountered in everyday clinical practice can also serve as risk factors for stroke. Infections such as meningitis and encephalitis may predispose patients to stroke.¹⁴ Additionally, oral contraceptive use is associated with an increased risk of stroke, with risk rising alongside higher doses and longer duration of use.¹⁵ The sheer number and diversity of stroke risk factors can make identification challenging, reinforcing the importance of including stroke in our differential diagnosis.

Imaging

Imaging in the adult patient consists of a stroke protocol computed tomography (CT) which includes a non-contrast CT head, CT perfusion, and CT angiography of the head and neck. This amount of radiation exposure is acceptable considering the risk of missing a stroke. However, this becomes complicated in pediatrics as the relative radiation exposure is much greater and has a greater likelihood of causing cancer.¹⁶ Despite this, pediatric strokes are difficult to spot on clinical exams and oftentimes present with transient symptoms that can only be diagnosed with advanced imaging.²

Magnetic resonance imaging (MRI) is considered the modality of choice for acute pediatric stroke, recommended by both the American Heart Association (AHA) and the American Stroke Association (ASA).⁵ It is highly sensitive and can identify stroke mimics without ionizing radiation.¹⁷ MRI is not available in every institution, takes a significantly longer time to obtain images, and often requires procedural sedation.¹⁷ Abbreviated MRI protocols have been proposed to reduce scan time and minimize sedation requirements, but their availability remains variable and institution dependent (Mirsky).

In contrast, CT is readily available and can be performed rapidly, making it an acceptable alternative in cases of MRI unavailability or patient instability.⁵ A non-contrast CT has poor sensitivity for early arterial ischemic strokes but has excellent sensitivity for hemorrhagic stroke and potential mimics like intracerebral mass.⁹ There is no universally accepted door-to-imaging time within pediatric stroke, but most pediatric stroke centers have set a goal of 60 minutes (Harrar).

Management

Unlike adult strokes which are protocolized and well-researched, pediatric stroke lacks cohesive protocols and evidence-based management. For those physicians who work at an academic center with pediatric neurology, early consultation is critical as their recommendations can guide management and fill in the gaps where protocols do not exist (Klucka). The AHA and ASA recommend a hospital-wide pediatric stroke code pathway that can allocate resources and intervention on a system-based approach (Fierro).

There are only 41 major pediatric stroke centers in the country, meaning the vast majority of emergency departments that treat these patients are community-based.¹⁸ Management of this condition should always prioritize airway, breathing, and circulation while minimizing further injury. Supportive measures like adjusting the head of the bed are simple yet effective. The head of the bed should be flat in ischemic strokes to increase cerebrovascular flow and raised to 30 degrees in hemorrhagic stroke to reduce intracerebral pressure.⁵

There exists no randomized control trial or large-scale research on pediatric thrombolysis versus thrombectomy. The overall data to intervene or not is limited and debated. The Thrombolysis in Pediatric Stoke (TIPS), the largest trial conducted to date to evaluate the safety of tissue plasminogen activator (TPA) in children, suffered from poor enrollment and could not establish definitive treatment guidelines.¹⁹ However, it did provide a framework for TPA administration that mimicked adult thrombolysis including a window of 4.5 hour from last known well, the same dosage (0.9 mg/kg), and the same form of administration (10% of total push over 1 minute followed by the rest over 60 minute infusion).¹⁹ Observational data showed that the risk of spontaneous intracerebral hemorrhage after TPA administration was lower than expected but still required intensive neurological checks.²⁰ These patients require pediatric intensive care settings for ongoing care.

Thrombectomy is another treatment modality used in acute stroke management. It requires a comprehensive pediatric stroke center and is typically reserved for children with higher stroke severity scores.²¹ The modified Alberta Stroke Program Early Computed Tomography Score (modASPECTS) is an adaptation of an adult assessment tool that estimates infarct volume in ischemic stroke using MRI and helps guide decisions regarding thrombectomy.⁹ Higher modASPECTS scores have been shown to correlate with higher pediatric NIHSS scores.⁹

Conclusion

Stroke can occur at any stage of life. It has numerous risk factors that can be rare, common, obvious, and hidden. Screening tools like BEFAST-S and the pediatric NIHSS can be used as initial assessments. Imaging is vital and can include CT, MRI, or a combination depending on institutional policy. Management should focus on supportive care with advanced reperfusion therapies being considered at an institutional level. Although rare, pediatric stroke should remain on the differential diagnosis of children presenting with persistent or unexplained neurological symptoms. The mortality and morbidity of pediatric stroke can be significantly lowered with prompt diagnosis and treatment within the ED.

Food insecurity is one of the most pervasive health issues in America. It touches on people of all different backgrounds and directly impacts health outcomes. I recently had the privilege of speaking to my residency program about food insecurity and in preparing for this presentation, I learned much about how I can better address this critical social determinant of health as an emergency medicine physician.

Food insecurity is the condition of not having access to safe and sufficient food of adequate nutritional quality to meet one’s basic needs. The causes of food insecurity are plentiful and complex. These causes include housing instability, lack of geographical access to quality food, unemployment and underemployment, discrimination, stress, and trauma. In New York State, more than 1 in 10 households experience food insecurity; in New York City alone, this includes 1.4 million people. While lower socioeconomic status and racial and ethnic minority groups experience higher rates of food insecurity, it affects a wide range of demographics. In New York City, 67 percent of food pantry users are employed, and more than 40 percent of college students at two universities report inadequate food availability.

From a physician perspective, food insecurity has significant ramifications on our patients’ health outcomes. It is linked to an increased risk of diet-related diseases including cardiovascular disease, diabetes, and certain cancers. Furthermore, it is an independent predictor of poor health. Limited access to nutritionally adequate food creates a vicious cycle for our patients—a nutritionally poor diet can lead to an exacerbation of chronic disease, which can then lead to increased health care expenditures. This in turn results in fewer resources patients have available to spend on obtaining quality food, thus exacerbating food insecurity.

How can we as physicians combat food insecurity for at-risk patients? One of the most impactful things we can do is something we already do every shift: talk with and listen to our patients. As emergency medicine physicians, we are uniquely positioned to establish trust with our patients in a relatively short amount of time. We often ask our patients some form of the question, “Do you have a safe place to stay?” So why not add, “Do you feel you have enough food at home?” Asking this question may encourage them to confide in us about a need they may be too embarrassed to discuss otherwise. Establishing this line of query as practice in the emergency department shows the community we serve that the community’s food security is a priority, engendering trust in the department and the hospital. I now ask about food security more regularly and have been pleasantly surprised with how often this leads to follow-up questions from my patients. When I identify patients who may have food insecurity, I add a list of local food pantries and other food resources using a dot phrase to their discharge instructions. There are several online resources that can be used to search for local food programs by region and zip code (see below).

Some health systems have their own hospital-based resources. For example, my hospital system, New York-Presbyterian, partnered with community-based organizations to develop Food Farmacy, a program that provides fresh fruits and vegetables and other ingredients to patients experiencing food insecurity. Pregnant or postpartum patients who have access to a kitchen and screen positive for food insecurity are eligible to receive twice-monthly deliveries for six months through Food Farmacy. Food Farmacy staff also assist participants with obtaining SNAP benefits and addressing other non-food-related needs. While many Food Farmacy participants are captured through primary care clinics, patients can be referred to this valuable resource directly from our emergency department. I encourage you to learn about any resources at your institution that provide food and longitudinal support to patients experiencing food insecurity and how you can help patients access these resources.

Finally, I encourage you to support your local community food programs through volunteering and donations. There are hundreds of food pantries, soup kitchens, and mobile food distribution sites in New York City, and many more across the rest of the state. One of my hospitals is closely affiliated with two different food programs: 1) Community Impact’s Ford Hall Food Pantry that provides food to over 30,000 people a year and 2) Community Lunch, a program that serves weekly hot meals to over 10,000 people a year. I now regularly refer patients to both via the list of resources I give them at discharge. Like almost all community food programs, these programs regularly need and appreciate volunteers and donations. I fully recognize the demands on our time from both personal and professional obligations as emergency medicine physicians. However, for me, carving out a small amount of time to volunteer at a food pantry is a way for me to give back to my community and further care for my patients (Figure 1).

Food insecurity is an important, but underdiscussed, determinant of health. It is vital we recognize its prevalence and the resources we have available to address it. Know the resources available at your institution and your community. Ask your patients about their access to safe and nutritious food. If possible, support your local community food programs by volunteering and donating. Everything you do matters and has great impact.

Resources for Finding Community Food Programs

• Feeding America

https://www.feedingamerica.org/find-your-local-foodbank

• New York Department of Health

https://www.health.ny.gov/prevention/nutrition/hpnap/regional_foodbank_map.htm

• FoodFinder

https://foodfinder.us/

• City Harvest (New York City)

https://www.cityharvest.org/

Jen Goebel, DO
Director of Wellness, Emergency Medicine
Attending Physician, South Shore University Hospital/Northwell Health

Workplace Efficiency as a Driver of Well-Being

Workplace efficiency is a critical and often underrecognized determinant of clinician well-being. The Stanford Model of Occupational Well-Being¹ emphasizes that burnout is driven largely by organizational and system-level factors rather than individual resilience alone. A core domain of this model, Efficiency of Practice, highlights how inefficient workflows, administrative burden, poor communication, and misaligned roles undermine professional fulfillment and contribute directly to burnout. Conversely, well-designed systems that allow clinicians to practice at the top of their license support both well-being and high-quality care.

Organizational well-being frameworks reinforce the importance of shifting from individual-focused wellness efforts toward structural and operational solutions. Improving efficiency through workflow redesign, appropriate staffing, functional technology, and meaningful clinician involvement in decision-making reduces daily friction while strengthening engagement, psychological safety, and retention. Investments in efficiency also signal that clinician time, expertise, and well-being are valued by the organization.

Guided by these principles, the Emergency Department at South Shore University Hospital/Northwell Health launched a pilot initiative focused on workplace efficiency as a pathway to improving staff well-being. A multidisciplinary work group was established, including attending physicians, emergency medicine residents, advanced care practitioners, nursing staff, nursing assistants, unit clerks, and operational partners, to identify frontline department workflow challenges and prioritize improvement opportunities. A Microsoft Forms survey was distributed to all ED staff and received 129 responses (41% response rate). The survey captured perceived workflow challenges and proposed solutions, along with standardized measures of job satisfaction, teamwork, burnout, and leadership support from Mini Z Questions.

Using survey findings and ongoing frontline feedback during monthly meetings, the group identified key pain points, including diagnostic testing delays and equipment and supply accessibility. Specific areas of focus include timely electrocardiogram acquisition, urine collection processes, and ensuring essential supplies are consistently available within the department. Two focused subgroups were formed to conduct deeper analyses of these issues, develop targeted interventions, and identify measurable outcomes. A regular monthly cadence is used to review progress, gather feedback, and refine proposed solutions.

This pilot represents a practical application of organizational well-being theory, translating the Stanford framework into action through front line staff-led, data-informed system redesign. By intentionally aligning workplace efficiency with clinician well-being, this initiative demonstrates how operational improvements can serve as sustainable, system-level strategies to strengthen workforce engagement, professional fulfillment, and quality of care.

References

1. Bohman, B. D., Makowski, M. S., Wang, H., Menon, N. K., Shanafelt, T. D., & Trockel, M. T. (2025). Empirical Assessment of Well-Being: The Stanford Model of Occupational Well-Being. Academic medicine : journal of the Association of American Medical Colleges, 100(8), 960–967. https://doi.org/10.1097/ACM.0000000000006025