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"Weinstock, Michael"
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The effects of sociocultural changes on epistemic thinking across three generations in Romania
When people experience abrupt social change, from less education to more, from less technology use to more, from a homogeneous to a heterogeneous social environment, can their epistemic thinking adapt? When divergent opinions suddenly come to be valued, does epistemic thinking shift from absolute to more relativistic? We investigate whether and how these sociocultural shifts have produced changes in epistemic thinking in Romania, a country that fell from communism and started democracy in 1989. Our 147 participants were from Timisoara and fell into three groups, each experiencing the shift at a different point in their development: (i) born in 1989 or later, experiencing capitalism and democracy throughout life (N = 51); (ii) 15- to 25-years-old in 1989 when communism fell (N = 52); (iii) 45 or older in 1989 when communism fell (N = 44). As hypothesized, absolutist thinking was less frequent and evaluativist thinking, a relativistic epistemological mode, was more frequent the earlier in life a cohort was exposed to the post-communist environment in Romania. As predicted, younger cohorts experienced greater exposure to education, social media, and international travel. Greater exposure to education and social media were significant factors in the decline of absolutist thinking and the rise of evaluativist thinking across the generations.
Journal Article
System city : infrastructure and the space of flows
A radical shift is taking place in the way that society is thinking about cities, a change from the machine metaphors of the 20th century to mathematical models of the processes of biological and natural systems. From this new perspective, cities are regarded not simply as spatially extended material artefacts, but as complex systems that are analogous to living organisms, exhibiting many of the same characteristics. There is an emerging view that the design of the thousands of new cities needed for an expanding world population are to be founded on intelligent and inhabited infrastructural systems or 'flow architectures' of urban metabolisms.
Book
Building your emotional bench: How to sustain a career in emergency medicine
Pat Croskerry has defined ‘metacognition’ as the highest level of thinking, in which we monitor our own thought-making processes in order to recognize when decisions may be prone to error [1]. Confidence is elusive; how curious that it can ebb and flow not only with patient outcomes, but with hunger, fatigue, or even a harsh word from a team member or department chair. Harvest a balance between connection and distance to prevent ‘compassion fatigue’, allowing for a realistic expectation of the eventuality of the human condition.
Journal Article
Rapid outpatient evaluation for emergency department patients with intermediate risk chest pain safely reduces admissions
This study aims to assess the safety of an outpatient chest pain pathway (OCPP) for patients presenting to the emergency department (ED) with chest pain and a HEART score of 4 or 5.
This is a retrospective, observational, non‐inferiority study assessing the impact of the OCPP on the management and outcomes of ED patients with HEART score of 4 or 5. The study compared patients evaluated in the pre‐OCPP (January‒May 2018) and the post‐OCPP period (January‒October 2022). Data were collected via non‐blinded chart review. The primary outcome was the rate of acute myocardial infarction (AMI) and death in patients utilizing the OCPP compared to patients with HEART score 4 or 5 in 2018. Secondary outcomes included admission rates before and after the implementation of this pathway. Non‐inferiority of the post‐intervention study epoch for the AMI/death composite outcome was assessed via the two one‐sided tests (TOST), procedure.
After implementing the OCPP, rates of patients with ED HEART score of 4 or 5 admitted from the ED decreased from 85.1% (605/711) to 74.1% (1239/1671) in 2022. Of the 432 total patients discharged in 2022, 237 (54.6%) patients were referred to emergent cardiology follow‐up via the OCPP. The 30‐day rate of AMI/death for patients discharged via the OCPP was 0.4% (1/237), as compared to 2.2% (8/368) in 2018. When compared to rates of AMI/death for all patients with HEART score 4 or 5 in 2018, outcomes for OCPP patients were found to be non‐inferior.
The OCPP resulted in non‐inferior rates of AMI/death in patients with HEART scores of 4 or 5 as compared to usual care.
Journal Article
The Importance of Individual and Expert Knowledge Grows as Clan Identity Diminishes: The Bedouin of Southern Israel Adapt to Anthropocene Ecology
Before the Anthropocene, Bedouin communities in Southern Israel were based on a clan structure—a kin-based social network; clans were culturally and socially homogenous communities with a strong authority structure. Work consisted of subsistence activities necessary for physical survival. Group-based authority and cooperative problem solving were adaptive in this ecology. Throughout the Anthropocene, the Bedouin of Southern Israel have had to adapt to diverse urban environments, expanded educational opportunity, and exposure to media emanating from different cultures. Our study explored the implications of these ecological shifts for epistemic thinking by comparing three generations of 60 Bedouin families: adolescent girls, their mothers, and their grandmothers (N = 180). Families were evenly divided among three residence types differing in degree of urbanization and degree of population homogeneity: unrecognized Bedouin villages consisting of single clans; recognized Bedouin villages, towns, or cities, consisting of multiple clans; and ethnically diverse cities. Results: Across the generations, media exposure and formally educated parents have weakened the epistemic authority of family elders, in turn weakening clan identity. Ethnically diverse cities have weakened extended family identity. At the same time, personal knowledge and professional expertise have gained new cultural importance. These changes in epistemology and identity are adaptive in the ecological environments that have multiplied in the Anthropocene era. Local identity was strongest both in diverse cities, with their many attractions, and in unrecognized villages, where the population continues to occupy ancestral lands.
Journal Article
Cost variation and revisit rate for adult patients with asthma presenting to the emergency department
Asthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care.
We sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation.
We used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering.
In 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371–980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18–1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00–1.00).
Hospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.
Journal Article
Teaching Tracheostomy Tube Changes: Comparison of Operant Learning Versus Traditional Demonstration
Objective Tracheostomy tube change is a multistep skill that must be performed rapidly and precisely. Despite the critical importance of this skill, there is wide variation in teaching protocols. Methods An innovative operant conditioning teaching methodology was employed and compared to traditional educational techniques. Medical student volunteers at a tertiary care academic institution (Albert Einstein College of Medicine) were recruited and randomly distributed into 2 groups: operant vs traditional (control). Following the educational session, each group was provided with practice time and then asked to perform 10 tracheostomy tube changes. Performance was recorded and scored by blinded raters using deidentified video recordings. Results The operant learning group (OLG) demonstrated greater accuracy in performing a tracheostomy tube change than the traditional demonstration group. Twelve of 13 operant learners performed the skill accurately each time compared to 3 of 13 in the traditional group (P = 0.002). The median lesson time was longer for the OLG (535 seconds) than for the traditional group, (200 seconds P < 0.001). The average time per tracheostomy change was not significantly different between the 2 groups (operant learners mean 7.1 seconds, traditional learners mean 7.5 seconds, P = 0.427). Discussion Although the operant conditioning methodology necessarily requires a greater time to teach, the results support this methodology over traditional learning modalities as it enhances accuracy in the acquired skill. Operant learning methodology is under consideration for other skills and education sessions in our program. Future steps include the application and adaptation of this education model to students and residents in other settings and fields. Implications for Practice Operant learning is effective for teaching multistep skills such as tracheostomy tube changes with decreased error rates.
Journal Article
Syncope on presentation is a surrogate for submassive and massive acute pulmonary embolism
There are conflicting data regarding the prognostic value of syncope in patients with acute pulmonary embolism (APE).
We retrospectively reviewed data of 552 consecutive adults with computed tomography pulmonary angiogram-confirmed APE to determine the correlates and outcome of the occurrence of syncope at the time of presentation.
Among 552 subjects with APE (mean age 54years, 47% men), syncope occurred in 12.3% (68/552). Compared with subjects without syncope, those with syncope were more likely to have admission systolic blood pressure<90mmHg (odds ratio (OR) 5.788, P<0.001), and an oxygen saturation<88% on room air (OR 5.560, P<0.001), right ventricular dilation (OR 2.480, P=0.006), right ventricular hypokinesis (OR 2.288, P=0.018), require mechanical ventilation for respiratory failure (OR 3.152, P=0.014), and more likely to receive systemic thrombolysis (OR 4.722, P=0.008). On multivariate analysis, syncope on presentation was an independent predictor of a massive APE (OR 2.454, 95% CI 1.109–5.525, P=0.03) after adjusting for patients' age, sex, requirement of antibiotics throughout hospitalization, peak serum creatinine, admission oxygen saturation<88% and admission heart rate>100bpm. There was no difference in mortality in cases with APE with or without syncope (P=0.412).
Syncope at the onset of pulmonary embolization is a surrogate for submassive and massive APE but is not associated with higher in-hospital mortality.
Journal Article
High-Risk Patient Refusals in the Prehospital Setting—Clinical and Legal Considerations
When emergency medical service (EMS) arrives on the scene, it is estimated that patients end up declining treatment and/or transport around 5% to 10% of the time. When a patient is suspected of having a life-threatening emergency and declines care, these cases are deemed “high-risk refusals,” as the subsequent delay in treatment drastically increases the risk of morbidity and mortality, as well as the legal risk for all those involved. These cases warrant careful consideration and deliberate training, not only among EMS professionals and EMS medical directors but also among any in-hospital physicians providing online medical oversight. To mitigate the risk associated with high-risk refusals, EMS systems and emergency departments should have standardized policies and guidelines in place for managing these cases, just as with any other complex, high-risk procedure. State statutes should be referenced and ideally legal counsel should be consulted when developing these guidelines. Checklists and quick references are recommended, and calling online medical supervision should be strongly encouraged. EMS medical directors should also routinely review high-risk refusal charts and include these cases in their ongoing quality improvement and quality assessment efforts.
Journal Article