9. Annas GJ: Judging Medicine. Clifton, New Jersey, Humana Press, 1988, p 331-333. 10. Veatch RM: Problems with institutional review hoards: Inconsistency.
JAMA 1982;248:179-180. 11. Benson PR: The social control of human biomedical research: An overview and review of literature. Soc Sci Med 1989;29:1-12.
Emergency Medicine Education and the HIV Epidemic The spread of human immunodeficiency virus (HIV} infection has already reached epidemic proportions and continues to expand. As of February 1989, more than 87,000 Americans had been diagnosed with acquired immune deficiency syndrome (AIDS).1 The US Public Health Service projects that there will be 365,000 diagnosed cases of AIDS and 263,000 cumulative deaths by 1992; from 1 to 1.5 million Americans are currently infected with HIV.2 Much has been written about the effect of the HIV epidemic on both undergraduate education and specialty education programs. Within emergency medicine, there are several levels at which the HIV epidemic poses a challenge to our education programs and both undergraduate and graduate trainees.
OCCUPATIONAL RISK Apprehensions regarding occupational transmission of HIV infection are a legitimate issue in emergency medicine education because students and residents assigned to the emergency department are on the front line in dealing with acute presentations of illness in an undifferentiated patient population. Patients often present with little time to undertake universal precautions, and treatment often requires extensive exposure to various body fluids. Furthermore, recent epidemiologieal work and clinical experience show that many ED patients are unaware of their seropositivity. Many students and residents may not be comfortable with the assimilation of personal risk into the conduct of their professional responsibilities at its extreme (ie, if high rates of nosocomially acquired HIV infection become a reality among ED personnel). The potential exists for the competitiveness of emergency medicine, as either a career choice or an elective educational experience, to suffer compared with other alternatives.
PREHOSPITAL CARE ISSUES Prehospital care issues in emergency medicine pertaining to the HIV epidemic are primarily twofold. First, standards and precautions in prehospital care may undergo change secondary to increasing numbers of HIV-positive patients requiring invasive prehospital intervention (eg, IV therapy, tamponade of bleeding, airway intervention, ventilation). Second, actual or potential liability of emergency medical services (EMS) systems and indirect liability to municipalities and national or state agencies that sponsor EMS systems may ultimately result in limitation or abolishment of the use of prehospital systems for the education of medical students and emergency medicine resi19:7 July 1990
dents. In addition, students and residents, fearing the acquisition of HIV infection, may choose not to participate in these educational activities.
PATIENT ISSUES Issues pertaining directly to undergraduate and graduate programs exist at several levels. HIV patients with acute complications may be both time and labor intensive, thus adding to often overwhelming ED caseloads and potentially diluting resident exposure to other types of cases as the epidemic expands in the 1990s. The uneasiness of physicians with these patients' lifestyles or prognoses (or often the outright rejection of HIV-positive patients by physicians) must be addressed in programs. This negativism may increase as AIDS patients lose their perception as "innocent victims" and are seen instead as suffering from a self-inflicted disease resulting from unsafe sexual or IV drug practices. Both the increased clinical caseload and the negativism toward AIDS patients have the potential to affect the quality of emergency medicine training programs. Further, the competitiveness of residency training programs in EDs with high volumes of HIV-related cases may suffer, in much the same way that the competitiveness of internal medicine training programs in such endemic areas have suffered. Lastly, an adequate but not overwhelming amount of didactic teaching must be devoted to the issues that arise in the care of these patients.
MORAL OBLIGATIONS The moral obligation for emergency physicians to care for HIV-infected patients must be acknowledged in our training programs and in our educational goals and objectives. If medicine in general (and emergency medicine in particular) is a profession and not a trade, devotion to moral ideals of selflessness, commitment to serving the ill, and acceptance of an element of personal risk in duty to patients {particularly during epidemics) are assumed and time honored. Medicine is a moral enterprise, and demonstration of this precept by faculty to residents and students in the care of these patients is incumbent. Our students must see emergency medicine practitioners on the front line with these patients, having resolved their tensions with their own personal risks in favor of the resultant benefits to emergently ill HIV patients. Similarly, e m e r g e n c y medicine residency programs must collectively clarify their own attitudes and approaches toward their HIV-infected patient population. Institutions must establish policies and procedures and de-
Annals of Emergency Medicine
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EDITORIALS
vote resources toward the myriad number of issues that surround infection control, nosocomially acquired infection, financial compensation, and curricular alteration for HIV-positive physicians. Many recommendations pertaining to these issues must be considered by academic emergency physicians. As with other emergency medicine diseases, HIV-related illness and treatment issues that arise with these patients should be incorporated into our bedside and didactic teaching programs. The impact of AIDS care on emergency medicine education should be discussed at all levels: among faculty for policy initiative, with resident applicants, and with students at the beginning of rotations. Accurate information on HIV-positive caseload, clinical protocols and expectations, and transmission risks should be given to applicants, and the attractiveness of "low-HIV" caseloads should not be touted. Competence in the practice of infection control should be taught, and equipment availability to undertake universal precautions should be ensured in
148/831
all EDs. Finally, adequate health, life, and disability insurance coverages should be instituted for housestaff, and adequate (preferably 24-hour) availability of counseling and referral programs for occupational exposures (and possible prophylactic antiviral therapy) should be available. Many of these issues and recommendations are valid independent of the HIV epidemic. Perhaps this epidemic will hasten both the resolution of these issues and the implementation of many of these recommendations in our academic centers. Louis S Binder, M D D e p a r t m e n t of Emergency Medicine Texas Tech University Health Sciences Center at E1 Paso 1. Centers for Disease Control: AIDS Weekly Surveillance Report. Febru-
ary 20, 1989. 2. Centers for Disease Control: Report to 7he White House Domestic Policy Council. July 26, 1988.
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JAMA 1982;248:179-180. 11. Benson PR: The social control of human biomedical research: An overview and review of literature. Soc Sci Med 1989;29:1-12.
Emergency Medicine Education and the HIV Epidemic The spread of human immunodeficiency virus (HIV} infection has already reached epidemic proportions and continues to expand. As of February 1989, more than 87,000 Americans had been diagnosed with acquired immune deficiency syndrome (AIDS).1 The US Public Health Service projects that there will be 365,000 diagnosed cases of AIDS and 263,000 cumulative deaths by 1992; from 1 to 1.5 million Americans are currently infected with HIV.2 Much has been written about the effect of the HIV epidemic on both undergraduate education and specialty education programs. Within emergency medicine, there are several levels at which the HIV epidemic poses a challenge to our education programs and both undergraduate and graduate trainees.
OCCUPATIONAL RISK Apprehensions regarding occupational transmission of HIV infection are a legitimate issue in emergency medicine education because students and residents assigned to the emergency department are on the front line in dealing with acute presentations of illness in an undifferentiated patient population. Patients often present with little time to undertake universal precautions, and treatment often requires extensive exposure to various body fluids. Furthermore, recent epidemiologieal work and clinical experience show that many ED patients are unaware of their seropositivity. Many students and residents may not be comfortable with the assimilation of personal risk into the conduct of their professional responsibilities at its extreme (ie, if high rates of nosocomially acquired HIV infection become a reality among ED personnel). The potential exists for the competitiveness of emergency medicine, as either a career choice or an elective educational experience, to suffer compared with other alternatives.
PREHOSPITAL CARE ISSUES Prehospital care issues in emergency medicine pertaining to the HIV epidemic are primarily twofold. First, standards and precautions in prehospital care may undergo change secondary to increasing numbers of HIV-positive patients requiring invasive prehospital intervention (eg, IV therapy, tamponade of bleeding, airway intervention, ventilation). Second, actual or potential liability of emergency medical services (EMS) systems and indirect liability to municipalities and national or state agencies that sponsor EMS systems may ultimately result in limitation or abolishment of the use of prehospital systems for the education of medical students and emergency medicine resi19:7 July 1990
dents. In addition, students and residents, fearing the acquisition of HIV infection, may choose not to participate in these educational activities.
PATIENT ISSUES Issues pertaining directly to undergraduate and graduate programs exist at several levels. HIV patients with acute complications may be both time and labor intensive, thus adding to often overwhelming ED caseloads and potentially diluting resident exposure to other types of cases as the epidemic expands in the 1990s. The uneasiness of physicians with these patients' lifestyles or prognoses (or often the outright rejection of HIV-positive patients by physicians) must be addressed in programs. This negativism may increase as AIDS patients lose their perception as "innocent victims" and are seen instead as suffering from a self-inflicted disease resulting from unsafe sexual or IV drug practices. Both the increased clinical caseload and the negativism toward AIDS patients have the potential to affect the quality of emergency medicine training programs. Further, the competitiveness of residency training programs in EDs with high volumes of HIV-related cases may suffer, in much the same way that the competitiveness of internal medicine training programs in such endemic areas have suffered. Lastly, an adequate but not overwhelming amount of didactic teaching must be devoted to the issues that arise in the care of these patients.
MORAL OBLIGATIONS The moral obligation for emergency physicians to care for HIV-infected patients must be acknowledged in our training programs and in our educational goals and objectives. If medicine in general (and emergency medicine in particular) is a profession and not a trade, devotion to moral ideals of selflessness, commitment to serving the ill, and acceptance of an element of personal risk in duty to patients {particularly during epidemics) are assumed and time honored. Medicine is a moral enterprise, and demonstration of this precept by faculty to residents and students in the care of these patients is incumbent. Our students must see emergency medicine practitioners on the front line with these patients, having resolved their tensions with their own personal risks in favor of the resultant benefits to emergently ill HIV patients. Similarly, e m e r g e n c y medicine residency programs must collectively clarify their own attitudes and approaches toward their HIV-infected patient population. Institutions must establish policies and procedures and de-
Annals of Emergency Medicine
830/147
EDITORIALS
vote resources toward the myriad number of issues that surround infection control, nosocomially acquired infection, financial compensation, and curricular alteration for HIV-positive physicians. Many recommendations pertaining to these issues must be considered by academic emergency physicians. As with other emergency medicine diseases, HIV-related illness and treatment issues that arise with these patients should be incorporated into our bedside and didactic teaching programs. The impact of AIDS care on emergency medicine education should be discussed at all levels: among faculty for policy initiative, with resident applicants, and with students at the beginning of rotations. Accurate information on HIV-positive caseload, clinical protocols and expectations, and transmission risks should be given to applicants, and the attractiveness of "low-HIV" caseloads should not be touted. Competence in the practice of infection control should be taught, and equipment availability to undertake universal precautions should be ensured in
148/831
all EDs. Finally, adequate health, life, and disability insurance coverages should be instituted for housestaff, and adequate (preferably 24-hour) availability of counseling and referral programs for occupational exposures (and possible prophylactic antiviral therapy) should be available. Many of these issues and recommendations are valid independent of the HIV epidemic. Perhaps this epidemic will hasten both the resolution of these issues and the implementation of many of these recommendations in our academic centers. Louis S Binder, M D D e p a r t m e n t of Emergency Medicine Texas Tech University Health Sciences Center at E1 Paso 1. Centers for Disease Control: AIDS Weekly Surveillance Report. Febru-
ary 20, 1989. 2. Centers for Disease Control: Report to 7he White House Domestic Policy Council. July 26, 1988.
Annals of Emergency Medicine
19:7 July 1990
