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Neuroscience

The Cerebellum’s Role in Human Cognitive Evolution – Neuroscience News

Summary: New research reveals the cerebellums significant role in the evolution of human cognitive functions. The study mapped the genetic development of cerebellar cells in humans, mice, and opossums, uncovering both ancestral and unique cellular characteristics.

Key findings include the increased proportion of specific Purkinje cells in humans, potentially linked to higher cognitive functions, and the identification of over 1,000 genes with varying activity profiles across species, some related to neurodevelopmental disorders.

Key Facts:

Source: Heidelberg University

The evolution of higher cognitive functions in human beings has so far mostly been linked to the expansion of the neocortex a region of the brain that is responsible, inter alia, for conscious thought, movement and sensory perception.

Researchers are increasingly realizing, however, that the little brain or cerebellum also expanded during evolution and probably contributes to the capacities unique to humans, explains Prof. Dr Henrik Kaessmann from the Center for Molecular Biology of Heidelberg University.

His research team has together with Prof. Dr Stefan Pfister from the Hopp Childrens Cancer Center Heidelberg generated comprehensive genetic maps of the development of cells in the cerebella of human, mouse and opossum.

Comparisons of these data reveal both ancestral and species-specific cellular and molecular characteristics of cerebellum development spanning over 160 million years of mammalian evolution.

Although the cerebellum, a structure at the back of the skull, contains about 80 percent of all neurons in the whole human brain, this was long considered a brain region with a rather simple cellular architecture, explains Prof. Kaessmann.

In recent times, however, evidence suggesting a pronounced heterogeneity within this structure has been growing, says the molecular biologist.

The Heidelberg researchers have now systematically classified all cell types in the developing cerebellum of human, mouse and opossum. To do so they first collected molecular profiles from almost 400,000 individual cells using single-cell sequencing technologies. They also employed procedures enabling spatial mapping of the cell types.

On the basis of these data the scientists noted that in the human cerebellum, the proportion of Purkinje cells large, complex neurons with key functions in the cerebellum is almost double that of mouse and opossum in the early stages of fetal development.

This increase is primarily driven by specific subtypes of Purkinje cells that are generated first during development and likely communicate with neocortical areas involved in cognitive functions in the mature brain.

It stands to reason that the expansion of these specific types of Purkinje cells during human evolution supports higher cognitive functions in humans, explains Dr Mari Sepp, a postdoctoral researcher in Prof. Kaessmanns research group Functional evolution of mammalian genomes.

Using bioinformatic approaches, the researchers also compared the gene expression programmes in cerebellum cells of human, mouse and opossum. These programmes are defined by the fine-tuned activities of a myriad of genes that determine the types into which cells differentiate in the course of development.

Genes with cell-type-specific activity profiles were identified that have been conserved across species for at least about 160 million years of evolution.

According to Henrik Kaessmann, this suggests that they are important for fundamental mechanisms that determine cell type identities in the mammalian cerebellum. At the same time, the scientists identified over 1,000 genes with activity profiles differing between human, mouse and opossum.

At the level of cell types, it happens fairly frequently that genes obtain new activity profiles. This means that ancestral genes, present in all mammals, become active in new cell types during evolution, potentially changing the properties of these cells, says Dr Kevin Leiss, who at the time of the studies was a doctoral student in Prof. Kaessmanns research group.

Among the genes showing activity profiles that differ between human and mouse the most frequently used model organism in biomedical research several are associated with neurodevelopmental disorders or childhood brain tumours, Prof. Pfister explains. He is a director at the Hopp Childrens Cancer Center Heidelberg, heads a research division at the German Cancer Research Center and is a consultant paediatric oncologist at Heidelberg University Hospital.

The results of the study could, as Prof. Pfister suggests, provide valuable guidance in the search for suitable model systems beyond the mouse model to further explore such diseases.

The research results were published in the journal Nature. Also participating in the studies apart from the Heidelberg scientists were researchers from Berlin as well as China, France, Hungary, and the United Kingdom. The European Research Council financed the research. The data are available in a public database.

Author: Ute Mueller-Detert Source: Heidelberg University Contact: Ute Mueller-Detert Heidelberg University Image: The image is credited to Neuroscience News

Original Research: Closed access. Cellular development and evolution of the mammalian cerebellum by Henrik Kaessmann et al. Nature

Abstract

Cellular development and evolution of the mammalian cerebellum

The expansion of the neocortex, a hallmark of mammalian evolution, was accompanied by an increase in cerebellar neuron numbers. However, little is known about the evolution of the cellular programs underlying cerebellum development in mammals.

In this study, we generated single-nucleus RNA-sequencing data for ~400,000 cells to trace cerebellum development from early neurogenesis to adulthood in human, mouse, and the marsupial opossum.

We established a consensus classification of the cellular diversity in the developing mammalian cerebellum and validated it by spatial mapping in the fetal human cerebellum.

Our cross-species analyses revealed a largely conserved developmental dynamics of cell type generation, except for Purkinje cells, where we observed an expansion of early-born subtypes in the human lineage.

Global transcriptome profiles, conserved cell state markers, and gene expression trajectories across neuronal differentiation show that cerebellar cell type-defining programs have been overall preserved for at least ~160 million years.

However, we also identified many orthologous genes that gained or lost expression in cerebellar neural cell types in one of the species, or evolved new expression trajectories during neuronal differentiation, indicating widespread gene repurposing at the cell type level.

Altogether, our study unveils shared and lineage-specific gene expression programs governing the development of cerebellar cells, and expands our understanding of mammalian brain evolution.

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The Cerebellum's Role in Human Cognitive Evolution - Neuroscience News

Emergency Medicine

Lisa Lincoln, M.D., Awarded Unsung Hero by New York American College of Emergency Physicians – URMC

Lisa Lincoln, M.D., Attending Physician in the Department of Emergency Medicine at Highland Hospital and Associate Professor, Department of Clinical Emergency Medicine, University of Rochester School of Medicine & Dentistry has been named a New York State Emergency Medicine Unsung Hero. This designation is awarded to physicians for their work ethic, compassion, and collegiality.

A New York State Emergency Medicine Unsung Hero goes beyond simply being the embodiment of what it means to be an emergency physician. They are a stalwart of the Emergency Department, who is deeply committed to the mission of the emergency department, their colleagues, co-workers and patients.

Emergency Medicine encompasses planning, oversight and medical direction for community emergency medical response, medical control and disaster preparedness. Emergency physicians possess a unique body of knowledge including the initial evaluation, diagnosis, treatment, coordination of care among multiple providers and disposition of patients requiring expeditious medical, surgical or psychiatric care.

"It is no secret that the current clinical practice environment in Emergency Medicine can be challenging just about every Emergency Department has issues with boarding and resources, said Timothy Lum, M.D., FACEP, Chief of Emergency Medicine for Highland Hospital. It is these challenges that allow physicians like Dr. Lincoln to demonstrate just how exceptional they are. Dr. Lincoln is a role model within our department when it comes to patient care. She possesses integrity, truly cares about patients and is unwaveringly kind, compassionate and dedicated to the provision of excellent patient care. She does this all with an unparalleled humility."

Dr. Lincoln is a Rochester native. After attending SUNY Geneseo for her undergraduate degree, Dr. Lincoln received her medical degree from the University of Rochester School of Medicine and Dentistry in 2009. She completed her Emergency Medicine residency training at the University of Rochester and was elected to be one of the Chief Residents by her peers and the Emergency Medicine faculty.

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Lisa Lincoln, M.D., Awarded Unsung Hero by New York American College of Emergency Physicians - URMC

Emergency Medicine

ER Physician Paul Mucciolo Files for Conklin’s School Board Seat, Citing Need for ‘Healthy Dose of Professionalism’ – FlaglerLive.com

Dr. Paul Mucciolo. ( FlaglerLive)

Last Updated: 6:44 p.m.

Emergency Medicine Physician Paul Mucciolo Files to Run for Conklins School Board Seat

Dr. Paul Mucciolo, an emergency-medicine physician at AdventHealth Palm Coast, picked up his two children from Indian Trails Middle School this afternoon, headed to the Supervisor of Elections office in Bunnell and declared his candidacy for the District 3 seat on the Flagler County School Board to bring back a healthy dose of professionalism to the board, he said, and to return the school district to an A-rated organization.

Mucciolo is running for the seat Colleen Conklin has held since 2000, as he did three years ago. Conklin has elected not to run again in 2024, as has Cheryl Massaro, though Massaro may not have entirely closed the door on another run.

Their departure will leave the board with the least combined elected-office experience it has had in memory, with three other board membersSally Hunt, Will Furry and Christy Chongeach having only two years on the board by then, assuming all three complete their first term.

The school districtstop administrative staff has also lost experienced hands and is led by first-year Superintendent LaShakia Moore, with additional administrative losses ahead. Moore expects to have a deputy superintendent by early next year. That would not necessarily be a problem in an organization moored to a functioning board. But that has not been the case, as a member of the public put it to the board this afternoon at the beginning of a workshop.

Ive been coming to these meetings a long time. But for the past year, which coincides probably with three new members of the board, what I dont seem to see or understand or perceive is that the board has spent any time in the last year thinking about kids, Mike Cocchiola told the board before enumerating the boards various firings and going after anything with a rainbow on it, for your own personal convictions. It seems to me that youre spending more time and more taxpayer money attacking cultural issues, and not once that I hear, especially the new members, say lets do something for the kids.

Mucciolo hadnt heard the commentit was delivered around the same time that the doctor was leaving the supervisors office, three floors up from where he wasbut seemed to echo it. Im trying to get Flagler schools and mainly the school board back on track to try to get the students and parents first, then the staff, then the support staff, and then the the board actually last, he said. The board should be there to serve, to serve the students and to give them the best possible education that they can get.

He does not want the operations of the school board to control so much of the agenda, as it has for the past few years, often at the detriment of other priorities. Flagler should be back to an A school [district], it should never lost the designation, he said. We have to look at why its not an A school and make sure that we dedicate the resources to bring whatever area needs attention up to par in order to earn that designation. He added: I would like there to be more of a business like attitude, a healthy dose of professionalism, and what I would like to really see happen is to open the doors more to our community. That is what is going to benefit our children, benefit our businesses, benefit our district in generalby having a closer relationship with the educational opportunities and businesses in the community.

Mucciolo carries a heavy workload. He practices emergency medicine full time, serves as the medical director at AdventHealth Palm Coast and AdventHealth Palm Coast Parkway (both the north and south campuses of the hospital), and at the International Speedway, where AdventHealth is the exclusive healthcare provider. My demands are many but the flexibility in my scheduling affords me the ability to attend meetings, to take phone calls, to meet with people. So, while I do have a heavy load, I can adjust it in order to accommodate additional demands, Mucciolo said.

He and his wife Christy moved to Palm Coast in 2008. He was in emergency medicine with Halifax Health before switching to AdventHealth in 2015. Why emergency medicine? The variety of the job. I get to see it all, he said. And its a privilege to be able to care for people who are at their worst. Its their worst moment, and its an honor to help people put their trust in you to try to help them. The current school board may not be such a leap from the emergency room.

He is now one of two candidates for the District 3 seat. Nicole Durenberger, a relatively new arrival in Flagler County, initially filed for a Palm Coast City Council seat, withdrew, then filed for School Board. (Like County Commission candidates, School Board candidates are elected according to districts. The candidates must live in the district they represent. But voters from across the county cast ballots for candidates regardless of district. The races are ostensibly non-partisan, but in todays ideologically polarized campaigns, most voters pay attention to a candidates registration and the local political parties overtly politicize non-partisan races.)

Mucciolo has been following the school board since before his first campaign. He ran against Conklin three years ago. Conklin won in a three-way race (she took 52 percent of the vote to Mucciolos 35, with a third candidate taking the balance of the votes) Mucciolo, a Republican, and Conklin, a Democrat, then essentially became colleagues as Mucciolo appeared on a virtual town hall Conklin organized during the Covid pandemic to counter the effects of unscientific information and tamp down some o the hysteria surrounding recommended safety measures at the time, in school and elsewhere.

Paul and I had an opportunity to work together during Covid, Conklin said this evening, after a boar workshop. I relied on his expertise and it was clear to me that he was greatly focused on the success of all students. I believe hes disassociated himself from those who thought they may have been able to influence him. He is very much his own man.

I cant fill her seat, Mucciolo said of Conklin. With that depth and length of experience and the breadth of experience, Im coming in new. It has some disadvantages because I have to uncover a lot of things and look behind the doors that we dont see now, because Im not active on the board. But it has an advantage of bringing some fresh perspectives. And the thing to do is to carry on the good work. She has worked tirelessly for the students and the teachers. And what Ive noticed from her is that shes very open to listening. And I think thats where its most importantthat we listen to our students. We listen to the teachers, and we listened to the community, and I would like to carry forth that quality more than anything, and the dedication to making sure that everyones needs are met when there are difficult times like Covid or an economic downturn.

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ER Physician Paul Mucciolo Files for Conklin's School Board Seat, Citing Need for 'Healthy Dose of Professionalism' - FlaglerLive.com

Emergency Medicine

Are First-Year Emergency Medicine Residents Still Behind on Level 1 Care-Based Milestones? – Cureus

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Are First-Year Emergency Medicine Residents Still Behind on Level 1 Care-Based Milestones? - Cureus

Emergency Medicine

UAB researchers awarded $1 million to study ways to reduce emergency department overcrowding – University of Alabama at Birmingham

The research teams goal is to create a customizable solution that can be applied across various health care settings to reduce overcrowding in emergency departments.

Abdulaziz Ahmed, Ph.D. and Bunyamin Ozaydin, Ph.D.A group of University of Alabama at Birmingham researchers have been awarded $1 million to develop and implement solutions to reduce emergency department overcrowding.

This is definitely a significant topic and an important societal problem, said Abdulaziz Ahmed, Ph.D., associate professor in the UAB School of Health Professions and associate scientist in the Center for Clinical and Translational Science. We are all excited to be tackling something that can be so impactful for so many people.

The research will use artificial intelligence, machine learning and health information technology to analyze the full capacity protocol in managing patient flow in the ED and beyond. The FCP consists of multiple levels, each triggered by specific criteria. When a level is activated, various interventions can be implemented to address ED crowding.

Currently, most hospitals adopt a reactive approach, waiting until the ED is crowded before deploying resources to mitigate the issue. In contrast, this project aims to leverage AI and machine learning to transform the FCP into a proactive protocol that anticipates crowding using different AI models.

This is a problem facing every health system around the world. There is not one universal protocol, Ahmed said. Plus, not every hospital even has an FCP.

Bunyamin Ozaydin, Ph.D., who has extensive system development experience in the UAB Marnix E. Heersink School of Medicine Department of Anesthesiology, emphasizes that ED overcrowding is not solely an ED problem but rather a hospital wide issue affecting patient flow.

After leaving the operating room, surgical patients go into post-op or ICU, then some go to inpatient units, and those are the same destinations for admitted ER patients, Ozaydin said. That is why were looking at this more holistically and looking at more of the overall hospital patient flow.

Shortly after joining the HSA department, Ahmed gave a presentation at the CCTS, where he discussed the research he conducted, predicting ED admission disposition at the time of triage. His work was to be a possible solution to reduce boarding time and consequently reduce overcrowding.

Ahmed connected with James Booth, M.D., associate vice chairman of the UAB Department of Emergency Medicine and interim chief medical information officer of the UAB Health System, about the impracticality of focusing solely on anticipating patient outcomes without considering the use or lack of use of an FCP. After extensive discussion, they agreed to collaborate and proposed shifting from reactive strategies to proactive solutions.

In the simplest terms, we decided to use AI and machine learning to leverage reactive FCP and make it proactive, Ahmed said. We plan to use a deep learning model to predict different patient flow measures across the hospital and then package all these models to feed data automatically into a decision support system, which is a dashboard that can be integrated with the set of tools the patient flow management team utilizes.

The team will focus on the conceptualization and development of the process and procedures in the first two years of the grant. During this time, the UAB team will study the effectiveness and feasibility of proactive FCP that is supported by AI.

The models are the engine of the car, but an engine alone doesnt get you there you have to build a car that is actually drivable, said Ozaydin, who holds a masters degree in electrical engineering and a doctoral degree in computer engineering. For that, we need a substantial system with input interfaces, output interfaces, user requirements, user interfaces and more built around the models.

The proactive FCP simulation will compare the system prediction model outcomes with the reactive outcomes to evaluate the effectiveness of the proactive FCP before its full implementation. Once the models reach a certain maturity level, they will be launched live.

During the last three years of the study, they will focus on establishing a proof-of-principle by implementing their models at three hospitals. The selection of multiple sites will enable them to generalize the system as much as possible and to study configuration settings specific to a particular organization.

We will do the customization for the first site, and then we will do it at the other sites so we can understand what parameters need to be generalized, which will help us better understand how our solution can be implemented at any given hospital, Ozaydin said. There are many very complex processes in health care that could be improved. Our project further signifies the importance of AI in positively impacting everyones lives and how it can be used to tackle many problems across health care.

Their preparation for this work has already begun, and they are excited for the future. Although it will take time to see and then implement results, they firmly believe this is a strong step forward. They see their work as having the potential to help many patients soon. Even more importantly, they hope it can provide much needed insight to practitioners and other researchers for many years to come.

Ahmed, contact principal investigator; Ozaydin, multi-principal investigator; and Eta S. Berner, Ed.D., co-investigator; in the UAB Department of Health Administration, along with Booth, co-investigator in the Department of Emergency Medicine, are the investigators of a five-year grant awarded by the Agency for Healthcare Research and Quality.

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UAB researchers awarded $1 million to study ways to reduce emergency department overcrowding - University of Alabama at Birmingham

Emergency Medicine

Doctors on (video) call: Rural medics get long-distance help in treating man gored by bison – News-Medical.Net

Rural medics who rescued rancher Jim Lutter after he was gored by a bison didn't have much experience handling such severe wounds.

But the medics did have a doctor looking over their shoulders inside the ambulance as they rushed Lutter to a hospital.

The emergency medicine physician sat 140 miles away in a Sioux Falls, South Dakota, office building. She participated in the treatment via a video system recently installed in the ambulance.

"I firmly believe that Jim had the best care anyone has ever received in the back of a basic life support ambulance," said Ed Konechne, a volunteer emergency medical technician with the Kimball Ambulance District.

The ambulance service received its video system through an initiative from the South Dakota Department of Health. The project, Telemedicine in Motion, helps medics across the state, especially in rural areas.

Telehealth became commonplace in clinics and patients' homes during the covid-19 pandemic emergency, and the technology is starting to spread to ambulances. Similar programs recently launched in regions of Texas and Minnesota, but South Dakota officials say their partnership with Avel eCare a Sioux Falls-based telehealth company appears to be the nation's only statewide effort.

Lutter, 67, and his wife, Cindy, are among the 12 residents of Gann Valley, a town just east of the Missouri River in central South Dakota. They operate a hunting lodge and ranch, where they raise more than 1,000 bison.

Last December, Lutter went to check on a sick bison calf. The animal was in the same pen as Bill, a 3-year-old bull that was like a family pet.

"We raised him from a tiny little calf, and I always told everybody he thinks Im his mother. He just followed me everywhere," Lutter recalled. Lutter climbed into the pen and saw Bill calmly walk toward him.

What does Chuck Norris say? Always expect the unexpected.' Well, I didn't do that. I didn't expect the unexpected," he said.

The bison suddenly hooked Lutter with his horns, repeatedly tossed him in the air, and then gored him in the groin. Lutter thought he was going to die but somehow escaped the pen and found himself on the ground, bleeding heavily.

"The red snow was just growing," he said.

Lutter couldn't reach his cellphone to call 911. But he managed to climb into a front-end loader, similar to a tractor, and drove a few miles to the house of his brother Lloyd.

Jim Lutter's pain didn't kick in until his brother pulled him out of the loader and into a minivan. Lloyd called 911 and began driving toward the ambulance base, about 18 miles away.

Rural ambulance services like the one in Kimball are difficult to sustain because insurance reimbursements from small patient volumes often aren't enough to cover operating costs. And they're largely staffed by dwindling ranks of aging volunteers.

That's left 84% of rural counties in the U.S. with at least one "ambulance desert," where people live more than 25 minutes from an ambulance station, according to a study by the Maine Rural Health Research Center.

Konechne, the volunteer medic, was working his regular job as a hardware store manager when a dispatcher came onto his portable radio with a call for help. He hustled two blocks to the Kimball fire station and hopped into the back of an ambulance, which another medic drove toward Gann Valley.

Lloyd Lutter and the ambulance driver both pulled over on the side of the country road once they saw each other coming from opposite directions.

"I opened the side door of the van where Jim was and just saw the look on his face," Konechne said. "Its a look Ill never forget."

Rural medics often have less training and experience than their urban counterparts, Konechne said. Speaking with a more experienced provider via video gives him peace of mind, especially in uncommon situations. Konechne said the Kimball ambulance service sees only about three patients a year with injuries as bad as Jim Lutter's.

Katie DeJong was the emergency medicine physician at Avel eCare's telehealth center who took the ambulance crew's video call.

"What? A bison did what?" DeJong remembers thinking.

After speaking with the medics and viewing Lutter's injuries, she realized the rancher had life-threatening injuries, especially to his airway. One of Lutter's lungs had collapsed and his chest cavity was filled with air and blood.

DeJong called the emergency department at the hospital in Wessington Springs 25 miles from Gann Valley to let its staff know how to prepare. Get ready to insert a chest tube to clear the area around his lungs, she instructed. Get the X-ray machine ready. And have blood on standby in case Lutter needed a transfusion.

DeJong also arranged for a helicopter to fly Lutter from the rural hospital to a Sioux Falls medical center, where trauma specialists could treat his wounds.

Konechne said he was able to devote 100% of his time to Lutter since DeJong took care of taking notes, recording vital signs, and communicating with the hospitals.

Nurse practitioner Sara Cashman was working at the emergency department in Wessington Springs when she received the video call from DeJong.

"It was nice to have that warning so we could all mentally prepare," Cashman said. "We could have the supplies that we needed ready, versus having to assess when the patient got there."

A doctor inserted a tube into Lutter's chest to drain the blood and air around his lungs. Medics then loaded him into the helicopter, which flew him to the Sioux Falls hospital where he was rushed into surgery. Lutter had a fractured collarbone, 16 broken ribs, a partially torn-off scalp, and a 4-inch-deep hole near his groin.

The rancher stayed in the hospital for about a week and compared his painful wound-packing regimen near his groin to the process of loading an old-fashioned rifle.

"That's exactly what it was. Like packing a muzzleloader and you take a rod, let's poke that in there," Lutter said. "That was just a lot of fun."

The video technology that helped save Lutter had only recently been installed in the ambulance after Telemedicine in Motion launched in fall 2022. The program is financed with $2.7 million from state funds and federal pandemic stimulus money.

The funding pays for Avel eCare employees to provide and install video equipment and teach medics how to use it. The company also employs remote health care professionals who are available 24/7.

So far, 75 of South Dakota's 122 ambulance services have installed the technology, and an additional 18 plan to do so. The system has been used about 700 times so far.

Avel's contract ends in April, but the company hopes the state will extend Telemedicine in Motion into a third year. Once the state funding ends, ambulance services will need to decide if they want to start paying for the video service on their own. Patients wouldn't be charged extra for the video calls, said Jessica Gaikowski, a spokesperson for Avel eCare.

This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF - the independent source for health policy research, polling, and journalism.

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Doctors on (video) call: Rural medics get long-distance help in treating man gored by bison - News-Medical.Net

Emergency Medicine

SPOHN RESIDENTS: Vote to determine the future of residency program – KRIS 6 News Corpus Christi

CORPUS CHRISTI, Texas The Nueces County Hospital District Board of Managers will consider a deal Friday that would keep the Christus Spohn Emergency Medicine Residency Program intact at least for the next six years.

As KRIS 6 News has previously reported, Spohn announced in October that it would be phasing out that program by 2026.

That program is a three-year learning opportunity in the hospital's emergency department for residents at the Texas A&M School of Medicine. The program allows residents to practice in any emergency care environment.

Following that announcement, doctors and community members began protesting that decision and said the termination of the program would be detrimental to healthcare in the Coastal Bend. They also said program impacts would be felt almost immediately.

READ MORE: Audio recording reveals Christus Spohn ER staff concerns post-residency cancellation READ MORE: Physicians fear community will suffer without Christus Spohn's Emergency Medicine Residency

The deal, which the board of managers will consider today, is the second to come before the Hospital District's governing body after the first was rejected.

The new agreement, which requires a vote of the board of managers, has been termed "monumental" by public officials.

As KRIS 6 News previously reported, this agreement includes payments by the Hospital District to Christus Spohn at up to $21 million over the next six years to maintain this program.

It also includes a requirement that Spohn maintain not only the program but also the support staff and materials needed for the program.

KRIS 6 News reporter Makaylah Chavez will be at this 12:30 p.m. meeting and will bring updates on this developing story.

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SPOHN RESIDENTS: Vote to determine the future of residency program - KRIS 6 News Corpus Christi

Emergency Medicine

DO Book Club: Code Gray: Death, Life and Uncertainty in the ER – The DO

Welcome back to The DO Book Club!

Very rarely, I come across a book that captures the essence of my professional experience as an emergency physician. As an avid reader and reviewer, I have read several medical memoirs that came close. They tend to be compilations of the most moving (and awful) experiences in the lives of the physicians and staff of the emergency department.

I am pleased to say that in this book, Code Gray: Death, Life and Uncertainty in the ER, author Farzon Nahvi, MD, has absolutely captured the essence of the great privilege, joy, despair and uncertainty of working in a modern urban emergency department. As an emergency physician in New York City during the early months of 2020 through the first wave of the deadly COVID-19 pandemic, Dr. Nahvi draws back the opaque curtain on what was really happening and how frontline medical staff were sharing information and trying to figure out how to treat the novel coronavirus.

Dr. Nahvis book is really two in one. The first part, entitled Prologue, was what the young doctor never expected to become part of his publication. When the epidemic of COVID-19 began, we knew hardly anything about the virus. The traditional timelines for testing evidence-based medical treatments were far too slow to be of use to the physicians, nurses and respiratory therapists faced with the first wave of afflicted patients. The author includes redacted text messages between himself and his colleagues working in the emergency departments of other cities.

In these messages, Dr. Nahvi and his colleagues describe running out of medications used to sedate before intubation, as well as shortages of personal protective equipment, IV pumps, antibiotics and ventilators. They describe the sheer ferocity and rapidity of disease progression. They discuss cases when COVID took patients before they even arrived at the hospital or intensive care unit. The author was particularly distressed over how he could accurately tell patients or their families about the terrible course and prognosis of COVID-19 that medical professionals knew so little about and were not substantially able to change.

The rapid spread of COVID-19 stressed a health care system that was already strained.

COVID-19 was not a wrecking ball, then, but a magnifying glass, wrote Dr. Nahvi. It did not break American medicine but reveal it for what it has always beenlong before the pandemic had ever hit, our experiences were challenging, strange and discomfiting. Our routine was to encounter impossible situations for which there exists no answers, and to answer them. (p. 47)

The majority of Code Gray focuses on an intense examination of one particular afternoon in the emergency department that Dr. Nahvi calls simultaneously routine and exceptional. Although he focuses on the treatment of one critically ill patient and interactions with her husband, he loops in several other patient care experiences and the difficult lessons he learned during his years of training.

One point that Dr. Nahvi explores is the universal experience that physicians have when they must deliver bad news to their patients. In painful detail, he brings in several examples from his own career and others of how physicians routinely fail in this endeavor. He notes that the softening of bad news with euphemistic language like mass instead of cancer or not doing well instead of dying only harms the patient or the family.

Ultimately, using anything but honest and frank language is not something that we do for our patients, but for ourselves, wrote Dr. Nahvi. We may believe we are softening our blows for our audience, but we know that in the end, doing so does not actually help them we do this to avoid our own discomfort. (p. 153)

COVID-19 was not a wrecking ball, then, but a magnifying glass.

Tied back to the central patient case narration, Dr. Nahvi faces the uncertainty of how to deliver the devastating news of the patients cause of death to her husband. Even exposing that one fact opens a gray area of questions and conundrums. The author presents many of the dilemmas faced by compassionate physicians and health care professionals: What can we do when the rules of the system deny treatment to some or offer no realistic care for unhoused or uninsured people in our care? How can we be honest with our patients without blaming them for their illness or injury?

When I was a medical student, many of the professors spoke about the sense of pride we would one day feel upon appreciating the awesome responsibilities that our profession entrusted us with, said Dr. Nahvi. They never once mentioned the inverse. They never mentioned the deep sense of shame we routinely feel in knowing that our profession lets so many of our patients down. (p. 175)

The professors did not know yet about the prevalence of moral injury and burnout. Dr. Nahvi knows and shares thoughtful explorations of the gray areas with his readers, not just in the abstract, but with real and relatable patient case histories from his years training in residency and as a young attending physician. For the public, much of what they read in Code Gray may be new and shocking in nature. Physicians reading the book will find themselves nodding in agreement and remembering many similar situations that they lived and worked through.

Dr. Nahvi artfully presents the trials and tribulations of the emergency department, not just the exciting narrative, but as a metaphor for life in general.

Life sometimes contains no perfect solutions and no correct courses of action, said Dr. Nahvi. We are often surrounded by unknowns, and yet we must take action. We are routinely presented with the impossible situation where there exists no right thing to do. (p. 139)

Readers will come to understand, through Dr. Nahvis detailed and lyrical prose, how uncertain the art and science of medicine actually is.

Editors note: The views expressed in this article are the authors own and do not necessarily represent the views of The DO or the AOA.

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DO Book Club: Code Gray: Death, Life and Uncertainty in the ER - The DO