Podcasts about jeff once

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department. Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression? Nachi: That would certainly be all of our listeners! Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval? Show More v Nachi: Again, just about all of our listeners I’m sure! Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes? Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in. Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University. Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside. Jeff: Quite the team, from a variety of backgrounds. Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt. Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23% Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode. Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable. Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions. Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest. Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks. Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning. Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes. Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD. Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder. Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself. Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.” Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt. Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan. Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%. Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers... Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients. Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men. Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older. Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression. Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide. Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US. Nachi: That’s an incredible amount and much more than I would have guessed. Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals. Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often. Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods. Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another. Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study. Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation. Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality. Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization. Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations. Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions. Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations. Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings. Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise. Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality - how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide. Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt. Jeff: In one study, using this tool doubled the number of suicide-risk cases detected. Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener. Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit. Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it? Jeff: Great question - It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations. Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical. Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression. Nachi: And as you said, we would mention it a few times -- In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression. Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here. Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease. Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing. Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy - urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility. Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility. Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management. Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion. Nachi: That wraps up testing. Let’s move on to treatment. Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable. Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes. Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do. Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling). Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary. Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do. Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts. Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means. Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend. Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths. Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means. Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time. Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling. Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline. Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations. Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there. Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up - perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan. Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though... Nachi: Let’s talk first about special populations - the only one we will discuss this month is military veterans. Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms. Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population. Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death. Nachi: And this is in no way meant to be a knock-on VA ED docs - they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care. Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed. Nachi: Let’s talk controversies and cutting-edge topics from this issue. Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality. Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting. Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression. Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future. Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition. Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED. Jeff: The next controversy is a big one - alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated. Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide. Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED. Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment. Jeff: Very important point - in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines. Nachi: Moving on to the next topic - let’s discuss post discharge patient contact. Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%. Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact. Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors. Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance. Jeff: The last cutting-edge topic to discuss is telepsychiatry. Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner - offering quick psychiatric care to those that never had access. Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated. Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations. Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold. Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches. Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making. Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization. Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed. Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible. Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls. Risk factors for major depression include female gender, young or old age, being divorced or widowed, black or Hispanic ethnicity, poor social support, and substance abuse. The strongest predictor for suicide-related outcomes is history of prior suicidal ideation or suicide attempt. When evaluating a patient with depressive symptoms, try to identify potential secondary causes, as this may influence your management strategy. When assessing for depression, perform a complete history and consider underlying medical causes that may be contributing to their presentation. Consider serum testing for the patient’s psychiatric medications if the medications have known toxic effects. 1. Routine serum testing and urine toxicology testing are not recommended for psychiatric patients presenting to the emergency department. Imaging of the brain should not be ordered routinely in depressed or suicidal patients. Depression places patients at a significantly increased risk for alcohol abuse and dependence. In addition to providing appropriate follow up resources to your depressed patients, emergency clinicians should consider making a brief follow up telephone call to the patient. Telepsychiatry may improve access to mental health providers and allow remote assessment and care from the ED. Suicide risk assessment tools such as C-SSRS, SAFE-T, and ICARE2 can help when deciding on disposition from the ER. It may be necessary to hold a patient against their will if they are at immediate risk of self-harm. Though not routinely administered in the ED for this purpose, psychotropic medications, such as ketamine, have proven helpful in acute depressive episodes. Patients who are actively suicidal should be admitted to a psychiatric observation unit or inpatient psychiatric unit. Nachi: So that wraps up Episode 28! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report) 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book) 15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients) 16. Centers for Disease Control and Prevention. Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects) 97. Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized controlled trial; 24 participants) 100. Griffiths JJ, Zarate CA, Rasimas J. Existing and novel biological therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic that is ripe for review this time of year. We’re talking Influenza… Diagnosis and Management. Nachi: Very appropriate as the cold is settling in here in NYC and we’re already starting to see more cases of influenza. Remember that as you listen through the episode, the means we’re about to cover one of the CME questions for those of you listening at home with the print issue handy. Jeff: This month’s issue was authored by Dr. Al Giwa of the Icahn School of Medicine at Mount Sinai, Dr. Chinwe Ogedegbe of the Seton Hall School of Medicine, and Dr. Charles Murphy of Metrowest Medical Center. Nachi: And this issue was peer reviewed by Dr. Michael Abraham of the University of Maryland School of Medicine and by Dr. Dan Egan, Vice Chair of Education of the Department of Emergency Medicine at Columbia University. Jeff: The information contained in this article comes from articles found on pubmed, the cochrane database, center for disease control, and the world health organization. I’d say that’s a pretty reputable group of sources. Additionally, guidelines were reviewed from the american college of emergency physicians, infectious disease society of america, and the american academy of pediatrics. Nachi: Some brief history here to get us started -- did you know that in 1918/1919, during the influenza pandemic, about one third of the world’s population was infected with influenza? Jeff: That’s wild. How do they even know that? Nachi: Not sure, but also worth noting -- an estimated 50 million people died during that pandemic. Jeff: Clearly a deadly disease. Sadly, that wasn’t the last major outbreak… fifty years later the 1968 hong kong influenza pandemic, H3N2, took between 1 and 4 million lives. Nachi: And just last year we saw the 2017-2018 influenza epidemic with record-breaking ED visits. This was the deadliest season since 1976 with at least 80,000 deaths. Jeff: The reason for this is multifactorial. The combination of particularly mutagenic strains causing low vaccine effectiveness, along with decreased production of IV fluids and antiviral medication because of the hurricane, all played a role in last winter’s disastrous epidemic. Nachi: Overall we’re looking at a rise in influenza related deaths with over 30,000 deaths annually in the US attributed to influenza in recent years. The ED plays a key role in outbreaks, since containment relies on early and rapid identification and treatment. Jeff: In addition to the mortality you just cited, influenza also causes a tremendous strain on society. The CDC estimates that epidemics cost 10 billion dollars per year. They also estimate that an epidemic is responsible for 3 million hospitalized days and 31 million outpatient visits each year. Nachi: It is thought that up to 20% of the US population has been infected with influenza in the winter months, disproportionately hitting the young and elderly. Deaths from influenza have been increasing over the last 20 years, likely in part due to a growing elderly population. Jeff: And naturally, the deaths that we see from influenza also disproportionately affect the elderly, with up to 90% occurring in those 65 or older. Nachi: Though most of our listeners probably know the difference between an influenza epidemic and pandemic, let’s review it anyway. When the number of cases of influenza is higher than what would be expected in a region, an epidemic is declared. When the occurrence of disease is on a worldwide spectrum, the term pandemic is used. Jeff: I think that’s enough epidemiology for now. Let’s get started with the basics of the influenza virus. Influenza is spread primarily through direct person-to-person contact via expelled respiratory secretions. It is most active in the winter months, but can be seen year-round. Nachi: The influenza virus is a spherical RNA-based virus of the orthomyxoviridae family. The RNA core is associated with a nucleoprotein antigen. Variations of this antigen have led to the the 3 primary subgroups -- influenza A, B, and C, with influenza A being the most common. Jeff: Influenza B is less frequent, but is more frequently associated with epidemics. And Influenza C is the form least likely to infect humans -- it is also milder than both influenza A or B. Nachi: But back to Influenza A - it can be further classified based on its transmembrane or surface proteins, hemagglutinin and neuraminidase - or H and N for short. There are actually 16 different H subtypes and 9 different N subtypes, but only H1, H2, H3, and N1 and N2 have caused epidemic disease. Jeff: Two terms worth learning here are antigen drift and anitgen shift. Antigen drift refers to small point mutations to the viral genes that code for H and N. Antigen shift is a much more radical change, with reassortment of viral genes. When cells are infected by 2 or more strains, a new strain can emerge after genetic reassortment. Nachi: With antigen shift, some immunity may be maintained within a population infected by a similar subtype previously. With antigen drift, there is loss of immunity from prior infection. Jeff: The appearance of new strains of influenza typically involves an animal host, like pigs, horses, or birds. This is why you might be hear a strain called “swine flu”, “equine flu”, or “avian flu”. Close proximity with these animals facilitates co-infection and genetic reassortment. Nachi: I think that’s enough basic biology for now, let’s move on to pathophysiology. When inhaled, the influenza virus initially infects the epithelium of the upper respiratory tract and alveolar cells of the lower respiratory tract. Viral replication occurs within 4 to 6 hours. Incubation is 18 to 72 hours. Viral shedding is usually complete roughly 7 days after infection, but can be longer in children and immunocompromised patients. Jeff: As part of the infectious process and response, there can be significant changes to the respiratory tract with inflammation and epithelial cell necrosis. This can lead to viral pneumonia, and occasionally secondary bacterial pneumonia. Nachi: The secondary bacterial pathogens that are most common include Staph aureus, Strep pneumoniae, and H influenzae. Jeff: Despite anything you may read on the internet, vaccines work and luckily influenza happens to be a pathogen which we can vaccinate against. As such, there are 3 methods approved by the FDA for producing influenza vaccines -- egg-based, cell-based, or recombinant influenza vaccine. Once the season’s most likely strains have been determined, the virus is introduced into the medium and allowed to replicate. The antigen is then purified and used to make an injection or nasal spray. Nachi: It isn’t easy to create vaccines for all strains. H3N2, for example, is particularly virulent, volatile, and mutagenic, which leads to poor prophylaxis against this particular subgroup. Jeff: In fact, a meta-analysis on vaccine effectiveness from 2004-2015 found that the pooled effectiveness against influenza B was 54%, against the H1N1 pandemic in 2009 was 61%, and against the H3N2 virus was 33%. Not surprisingly, H3N2 dominant seasons are currently associated with the highest rates of influenza cases, hospitalizations, and death. Nachi: Those are overall some low percentages. So should we still be getting vaccinated? The answer is certainly a resounding YES.. Despite poor protection from certain strains, vaccine effectiveness is still around 50% and prevents severe morbidity and mortality in those patients. Jeff: That’s right. The 2017-2018 vaccine was only 40% effective, but this still translates to 40% less severe cases and a subsequent decrease in hospitalizations and death. Nachi: But before we get into actual hospitalization, treatment, and preventing death, let’s talk about the differential. We’re not just focusing on influenza here, but any influenza like illness, since they can be hard to distinguish. The CDC defines “influenza-like illness” as a temperature > 100 F, plus cough or sore throat, in the absence of a known cause other than influenza. Jeff: Therefore, influenza should really be considered on the differential of any patient who presents to the ED with a fever and URI symptoms. The differential when considering influenza might also include mycoplasma pneumoniae, strep pneumoniae, adenovirus, RSV, rhinovirus, parainfluenza virus, legionella, and community acquired MRSA. Nachi: With the differential in mind, let’s move on to prehospital care. For the prehospital setting, there isn’t much surprising here. Stabilize and manage the respiratory status with all of your standard tools - oxygen for those with mild hypoxia and advanced airway maneuvers for those with respiratory distess. Jeff: Of note, EMS providers should use face masks themselves and place them on patients as well. As community paramedicine and mobile integrated health becomes more common, this is one potential area where EMS can potentially keep patients at home or help them seek treatment in alternate destinations to avoid subjecting crowded ED’s to the highly contagious influenza virus. Nachi: It’s also worth noting, that most communities have strategic plans in the event of a major influenza outbreak. Local, state, and federal protocols have been designed for effective care delivery. Jeff: Alright, so now that the EMS crew, wearing proper PPE of course, has delivered the patient, who is also wearing a mask, to the ED, we can begin our ED H&P. Don’t forget that patients present with a range of symptoms that vary by age. A typical history is 2-5 days of fever, nasal congestion, sore throat, and myalgias. You might see tachycardia, cough, dyspnea, and chills too. Nachi: Van Wormer et al conducted a prospective analysis of subjective symptoms to determine correlation with lab confirmed influenza. They found the most common symptoms were cough in 92%, fatigue in 91%, and nasal congestion in 84%, whereas sneezing was actually a negative predictor for influenza. Jeff: Sneezing, really? Can’t wait to get the Press-Gany results from the sneezing patient I discharge without testing for influenza based on their aggressive sneezes! Nachi: Aggressive sneezes…? I can’t wait to see your scale for that. Jeff: Hopefully I’ll have it in next month’s annals. In all seriousness, I’m not doing away with flu swabs just yet. In another retrospective study, Monto et al found that the best multivariate predictors were cough and fever with a positive predictive value of 79%. Nachi: Yet another study in children found that the predominant symptoms were fever in 95%, cough in 77%, and rhinitis in 78%. This study also suggested that the range of fever was higher in children and that GI symptoms like vomiting and diarrhea were more common in children than adults. Jeff: Aside from symptomatology, there are quite a few diagnostic tests to consider including viral culture, immunofluoresence, rt-pcr, and rapid antigen testing. The reliability of testing varies greatly depending on the type of test, quality of the sample, and the lab. During a true epidemic, formal testing might not be indicated as the decision to treat is based on treatment criteria like age, comorbidities, and severity of illness. Nachi: We’ll get to treatment in a few minutes, but diving a bit deeper into testing - there are 3 major categories of tests. The first detects influenza A only. The second detects either A or B, but cannot distinguish between them; and the third detects both influenza A and B and is subtype specific. The majority of rapid testing kits will distinguish between influenza A and B, but not all can distinguish between them. Fluorescent antibody testing by DFA is relatively rapid and yields results within 2 to 4 hours. Jeff: Viral culture and RT-PCR remain the gold standard, but both require more time and money, as well as a specialized lab. As a result, rapid testing modalities are recommended. Multiple studies have shown significant benefit to the usefulness of positive results on rapid testing. It’s safe to say that at a minimum, rapid testing helps decrease delays in treatment and management. Nachi: Looking a bit further into the testing characteristics, don’t forget that the positive predictive value of testing is affected by the prevalence of influenza. In periods of low influenza activity (as in the summer), a rapid test will have low PPV and high NPV. The test is more likely to yield false positive results -- up to 50% according to one study when prevalence is below 5%. Jeff: And conversely, in periods of high influenza activity, a rapid test will have higher PPV and lower NPV, and it is more likely to produce a false negative result. Nachi: In one prospective study of patients who presented with influenza-like illness during peak season, rapid testing was found to be no better than clinical judgement. During these times, it’s probably better to reserve testing for extremely ill patients in whom diagnostic closure is particularly important. And since the quality of the specimen remains important, empiric treatment of critically ill patients should still be considered. Jeff: Which is a perfect segway into our next topic - treatment, which is certainly the most interesting section of this article. To start off -- for mild to moderate disease and no underlying high risk conditions, supportive therapy is usually sufficient. Nachi: Antiviral therapy is reserved for those with a predicted severe disease course or with high risk conditions like long-standing pulmonary disease, pregnancy, immunocompromise, or even just being elderly. Jeff: Note to self, avoid being elderly. Nachi: Good luck with that. Anyway, early treatment with antivirals has been shown to reduce influenza-related complications in both children and adults. Jeff: Once you’ve decided to treat the patient, there are two primary classes of antivirals -- adamantane derivatives and neuraminidase inhibitors. Oh and then there is a new single dose oral antiviral that was just approved by the FDA… baloxavir marboxil (or xofluza), which is in a class of its own -- a polymerase endonuclease inhibitor. Nachi: The oldest class, the adamantane derivatives, includes amantadine and rimantadine. Then the newer class of neuraminidase inhibitors includes oseltamavir (which is taken by mouth), zanamavir (which is inhaled), and peramivir (which is administered by IV). Jeff: Oseltamavir is currently approved for patients of all ages. A 2015 meta analysis showed that the intention-to-treat infected population had a shorter time to alleviation of all symptoms from 123 hours to 98 hours. That’s over a day less of symptoms, not bad! There were also fewer lower respiratory tract complications requiring antibiotics and fewer admissions for any cause. Really, not bad! Nachi: Zanamavir is approved for patients 7 and older -- or for children 5 or older for disease prevention. Zanamavir has been associated with possible bronchospasm and is contraindicated in patients with reactive airway disease. Jeff: Peramivir, the newest drug in this class, is given as a single IV dose for patients with uncomplicated influenza who have been sick for 2 days or less. Peramavir is approved for patients 2 or older. This is a particularly great choice for a vomiting patient. Nachi: And as you mentioned before, just last month, the FDA approved baloxavir, a single dose antiviral. It’s effective for influenza type A or B. Note that safety and efficacy have not been established for patients less than 12 years old, weighing less than 40 kg, or pregnant or lactating patients. Jeff: Unfortunately, there has been some pretty notable antiviral resistance in the recent past, moreso with the adamantane class, but recently also with the neuraminidase inhibitors. In 2007-2008, an oseltamivir-resistant H1N1 strain emerged globally. Luckily, cross-resistance between baloxavir and the adamantanes or neuraminidase inhibitors isn’t expected, as they target different viral proteins, so this may be an answer this year, and in the future. Nachi: Let’s talk chemoprophylaxis for influenza.. Chemoprophylaxis with oseltamavir or zanamavir can be considered for patients who are at high risk for complications and were exposed to influenza in the first 2 weeks following vaccination, patients who are at high risk for complications and cannot receive the vaccination, and those who are immunocompromised. Jeff: Chemoprophylaxis is also recommended for pregnant women. For postexposure prophylaxis for pregnant women, the current recommendation is to administer oseltamivir. Nachi: We should also discuss the efficacy of treatment with antivirals. This has been a hotly debated topic, especially with regards to cost versus benefit… In a meta-analysis, using time to alleviation of symptoms as the primary endpoint, oseltamavir resulted in an efficacy of 73% (with a wide 95% CI from 33% to 89%). And this was with dose of 150mg/day in a symptomatic influenza patient. Jeff: Similarly zanamavir given at 10mg/day was 62% effective, but again with a wide 95% CI from 15% to 83%. And, of note, other studies have looked into peramivir, but have found no significant benefits other than the route of delivery. Nachi: In another 2014 study by Muthuri et al., neuraminidase inhibitors were associated with a reduction in mortality -- adjusted OR = 0.81 (with a 95% CI 0.70 to 0.93). Also when comparing late treatment with early treatment (that is, within 2 days of symptom onset), there was a reduction in mortality risk with adjusted OR 0.48 (95%CI 0.41-0.56). These associations with reduction in mortality risk were less pronounced and less significant in children. Jeff: Mortality benefit, not bad! They further found an increase in mortality hazard ratio with each day’s delay in initiation of treatment up to 5 days, when compared to treatment initiated within 2 days. Nachi: But back to the children for a second -- another review of neuraminidase inhibitors in children < 12 years old found duration of clinical symptoms was reduced by 36 hours among previously healthy children taking oseltamivir and 30 hours by children taking zanamivir. Jeff: I think that’s worth summarizing - According to this month’s author’s review of the best current evidence, use of neuraminidase inhibitors is recommended, especially if started within 2 days, for elderly patients and those with comorbidities. Nachi: Seems like there is decent data to support that conclusion. But let’s not forget that these medications all have side effects. Jeff: These drugs actually tend to be well tolerated.The most frequently noted side effect of oseltamavir is nausea and vomiting, while zanamavir is associated with diarrhea. Nachi: Amazing. Let’s talk disposition for your influenza patient. Jeff: Disposition will depend on many clinical factors, like age, respiratory status, oxygen saturation, comorbid conditions, and reliability of follow up care. Admission might be needed not only to manage the viral infection, but also expected complications. Nachi: If you’re discharging a patient, be sure to engage in shared decision making regarding risks and benefits of available treatments. Ensure outpatient follow up and discuss return to er precautions. Jeff: Also, the CDC recommends that these patients stay home for at least 24 hours after their fever has broken. Nachi: With that -- Let’s summarize the key points and clinical pearls from this month’s issue J: Even though influenza vaccine effectiveness is typically only 50%, this still translates to a decrease in influenza-related morbidity and mortality. 2. The CDC defines influenza-like illness as a temperature > 100 F with either cough or sore throat, in the absence of a known cause other than influenza. 3. When influenza is suspected in the prehospital setting, patients and providers should wear face masks to avoid spreading the virus. 4. In the emergency department, standard isolation and droplet precautions should be maintained for suspected or confirmed infections. 5. The most common symptoms of influenza in adults are cough, fatigue, nasal congestion, and fever. Sneezing is a negative predictor in adults. 6. In children, the most common presenting symptoms are fever, cough, and rhinitis. Vomiting and diarrhea is also more common in children than adults. 7. Rapid testing and identification results in decreased delays in treatment and management decisions. 8. During peak flu season, clinical judgement may be as good as rapid testing, making rapid testing less necessary. J: Rapid testing may be more beneficial in times of lower disease prevalence. 10. Empiric treatment of critically ill patients should be considered even if rapid testing is negative. J: For mild to moderate disease and no underlying high-risk conditions, supportive therapy is usually sufficient. 12.For more ill patients or those at substantial risk for complications, consider antiviral treatment. 13.Oseltamivir is approved for patients of all ages, and reduces the length of symptoms by one day. 14.When treating influenza, peramivir is an ideal agent for the vomiting patient. 15.Baloxavir is a new single-dose antiviral agent approved by the FDA in October 2018. It works in a novel way and is effective for treatment of influenza A and B. 16.Chemoprophylaxis with oseltamivir or zanamivir should be considered in patients who are immunocompromised or patients who are at elevated risk for complications and cannot receive the vaccination. 17.Consider oseltamivir as post exposure prophylaxis in pregnant women. 18.Neuraminidase inhibitors are associated with decreased duration of symptoms and complications, especially if started within 2 days of symptom onset. J: So that wraps up episode 23 - Influenza: Diagnosis and Management in the Emergency Department. N: Additional materials are available on our website for Emergency Medicine Practice subscribers. For our subscribers: be sure to go online to get your CME credit for this issue, which includes 3 pharmacology CME credits. J: Also, for our NP and PA listeners, we have a special offer this month: You can get a full year of access to Emergency Medicine Practice for just $199--including lots of pharmacology, stroke, and trauma CME--and so much more! To get this special deal, go to www.ebmedicine.net/APP. Again, that’s www.ebmedicine.net/APP. N: If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. J: And the address for this month’s credit is ebmedicine.net/E1218. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!    

In partnership with State Services for the Blind of Minnesota we are proud to present, PACER Center – Champions for Children with Disabilities:  A Visit with pACER’s National Bullying Prevention Center Director Julie Hertzog Julie helped start the Bullying Prevention Center back in 2006 and is a recognized National Leader in Bullying Prevention. She has been featured on CNN, NBC Nightly News with Brian Williams, Time for Kids, PEOPLE, Family Circle and The Huffington Post. Julie sits down with Jeff Thompson of Blind Abilities in the first of a series of podcasts in partnership with PACER Center and State Services for the Blind. Be sure to check out our upcoming Pacer Center podcast featuring the Simon Technology Center and how innovations and opportunities are being created every day and every way. From the web: PACER Center enhances the quality of life and expands opportunities for children, youth, and young adults with all disabilities and their families so each person can reach his or her highest potential. PACER operates on the principles of parents helping parents, supporting families, promoting a safe environment for all children, and working in collaboration with others. With assistance to individual families, workshops, materials for parents and professionals, and leadership in securing a free and appropriate public education for all children, PACER’s work affects and encourages families in Minnesota and across the nation. You can find out more about PACER Center on the web at www.Pacer.org And PACER’s national Bullying Prevention Center at www.Pacer.org/Bullying You can reach pACER Center by phone at 952-838-9000 You can find out more about State Services for the Blind on the web at  www.MN.Gov/Deed/SSB And by calling 651-539-2300 Live Learn Work and Play Thank you for listening! You can follow us on Twitter @BlindAbilities On the web at www.BlindAbilities.com Send us an email Get the Free Blind Abilities App on the App Store. Get the Free blind Abilities App on the Google Play Store.   Full Transcript [Music] Child 1: Bullying is hurting too many people in this world. Child 2: Sometimes I cry when I'm being bullied. Child 3: Bullying makes me feel sad, when I am bullied I try to walk away. Child 4: Sometimes they punch you in the eye, it's so bad that you could cry. Child 5: I got bullied at school. Child 6: Children leave me out of games. I don't like it at all. [Music] Jeff: State Services for the Blind of Minnesota presents "PACER Center Champions for Children with Disabilities". This episode focuses on bullying and with us today we have Julie Hertzog, director of PACERs National Bullying Prevention Center. Julie helped start the bullying prevention center back in 2006, and is a recognized national leader in bullying prevention. You can find out more about PACER Center and PACER's National Bullying Prevention Center on the web at www.PACER.org, we hope you enjoy. [Music] Jeff: Welcome to Blind Abilities, I'm Jeff Thompson. We are at the PACER Center located in Bloomington, Minnesota. We're talking to the director of PACER's National Bullying Prevention Center, Julie Hertzog. Julie, can you fill us in on what Pacer Center is all about and what you do as Director the National Bullying Prevention Center? Julie: Sure, thank you Jeff. Yes, we are in Bloomington Minnesota at Pacer Center and PACER is actually an acronym, P A C E R, and its Parents Advocacy Coalition for Educational Rights ,though that's probably outdated. We've been around since the late 70's and we, our organization began when students with disabilities were given the federal right to be included in the classroom and so that law today is called the IDEA, Individuals with Disabilities Education Act, and so we are a parent advocacy organization and what we do is help parents understand what their rights are when their child has a disability in an educational setting. People will oftentimes say, well where does your connection to bullying come in then as a disability organization? In response to that, as an organization we're here in Minnesota, so we do take a lot of calls from parents in Minnesota, and starting in, well it was around early 2000, we noticed that our staff noticed that we were taking more and more calls about kids who were involved in bullying situations and really both kids who were being bullied as well as kids who were doing the bullying, and a lot of those stories just kind of broke our hearts. We knew that we wanted to, to do something we knew we wanted to take action. And at the time bullying in early 2000, it really wasn't something that people were talking about and so PACER pioneered a lot of the education that happened around early 2000, and in 2006 we actually formed a program under the PACER umbrella called PACER's National Bullying Prevention Center. And the connection to our mission with disability is that students with disabilities are bullied two to three times more than their non-disabled peers, and at the time when we formed the National Bullying Prevention Center we knew that, we wanted to always make sure that we emphasize students with disabilities, but to really make a difference, we realized that we, we also wanted to focus on any kids who are vulnerable to bullying and whether that was a student with a disability, are being bullied based on their disability, on their race, their religion, their weight, their gender, we wanted to be inclusive. But we also didn't want to focus just on the kids who are being bullied, we wanted to really engage, we knew to make a difference, we wanted to engage the entire community, so we wanted to be speaking to schools, we want to be speaking to teachers, and and parents, and the students themselves because at that time we had adopted the tagline, the end of bullying begins with you, and we knew that we wanted to really have a community conversation about this. That it wasn't about saying that, you know, schools need to fix this, or teachers need to fix this, or the kids need to fix it, it was really about all of us working together. And so that is the background on the National Bullying Prevention Center and how we got started. Jeff: You mentioned something that really struck me as it's more than just one person, it well, it is about one person, what I'm getting at is, it's a community, it's the family, and the communication that happens between all of them that will help solve this. Julie: Yeah for so long we talked about some of those misperceptions that we had about bullying or some of those stereotypes that we had about bullying and if you think back to early 2000, I remember when I first started working on this and again I've been on this project since its origin and there was so many statements such as boys will be boys, yeah, meaning that it was justified because they were boys, that it was okay for them to fight, that's just the way it was. Of course, we've all heard that universal one, sticks and stones will break your bones, but words will never hurt you. We know that that is not true, that bullying is not only about physical, it's about emotional, and you know through the years we've had kids say some really poignant things like, words are like weapons, or words will break your heart, and we know that that emotional bullying has just as much effect on students and probably lives inside them much longer even than the physical bullying has. There's also other stereotypes and misperceptions out there that have rationalized bullying for so long such as, you know, just fight back, or you know, kids have also been blamed for why the behaviors happening to them and parents or adults have said to kids, well if you didn't act that way, bullying wouldn't happen to you. And so those are all things that in early 2000, just those stereotypes allowed bullying behavior to perpetuate because we were silent, so when a child was reaching out to us and we were saying things back to them like, well what did you do to make that happen? Really what we were doing is shutting down the conversation and any options that they had to make it stop. Or even when kids would tell an adult that someone else was being bullied, you know our response was, don't be a tattletale. And so again if we're so long what has happened is our society allowed the behavior to perpetuate not, not intentionally but, there was also that statement of, bullying is just a natural part of growing up, I mean those, those were all rationalizations for the behavior for so long. But I will say around you know in that early kind of mid-2000's that people really started recognizing the incredibly negative impact that bullying had, not only short term, but also long term. And there was a couple things that happened at that time in that, the results of the advent of social media at that time. I can remember saying that in 2006 that the Internet is the new bathroom wall, meaning that bullying used to be limited to the school or you know, possibly the neighborhood and kids could go home and escape that, well maybe except for that occasional phone call that they would get or something, but they were really able to, you know, go back home and remove themselves from it. But with social media it became their, you know with the evolution of technology also became the evolution to bully, and so kids were vulnerable to bullying 24 hours a day, and I think that that was one of the reasons that bullying really was put on kind of that national dialogue and also there was a recognition that kids because of things like self-harm, things like depression, anxiety, we began to recognize that there was medical things happening with our kids that were the result of being bullied, and also their you know, the suicide ideation, and suicide attempts, became part of the dialogue as well. So those two things really kind of started to put bullying much more in the public radar and also, they turned a lot of those stereotypes around and we recognize that bullying was a very serious issue for our kids. Jeff: You mentioned in the beginning that educating parents and giving them tools to deal with some of the stuff that comes with, I mean mostly parents in my situation that I know, they didn't choose to become a parent of a child with disabilities, and where do they go for that so, that's what PACER was basically built on. Julie: Absolutely and Jeff I'll just share too that I am the parent of a young man who was born with Down syndrome, who was also nonverbal, he has a feeding tube, a pacemaker, some really significant medical issues and so, it was David who, he was three when I started here at PACER, and he's now 21, and it was thinking about those vulnerabilities of kids that really inspired our, my work here, and also the work of others, in that so much of bullying happens because someone is not able to defend themselves against it, and so it was about how do we educate parents to raise kids who are self-advocates? How do we educate parents to be advocates for their own children? You know and I think back, and again I'll just reference back to 2000, so often when kids would tell their parents that they were being bullied, I think the first response from parents from majority of parents was, oh just ignore it, it'll go away, and you know, and that came from a really good place, and I think parents hoped that by ignoring it, it would stop, but we know from history that just ignoring it does not make a go away, in fact it usually gets worse, and and I remember kids, there was some kids who jokingly when we were talking to them for the focus groups and everything else and they said, well what if I would tell my parents to just ignore their annoying boss? Would that be a solution to the situation? And I remember there was another kid he said, What if I told my parents just to ignore their bills? Would their bills just go away? And so, you know we'd say that, and we realized that, how ineffective that response was, but that was the only thing we had at that time, and we know now that there's so many more solutions. And since 2000 now, every state across the nation has a law about bullying, and bullying prevention in schools, and legislators focused on the school environment when creating those laws. So, we now know that parents and kids have rights and within every state about what can happen if they're being bullied and those weren't in place before, and we also teach parents just how they could be supportive of their child. So instead of being that dismissive, just ignore it, we help them understand how important it is to talk through it and let them know that they're not alone, that we're getting, that you're gonna as a parent, you're gonna be there to help them learn how to advocate their way through it, and I would say to Jeff, that you know, I think for my own son even, self-advocacy skills were so important for him and being a child who's nonverbal, one of the things that we taught him how to do is, if, if you're not feeling comfortable, first thing we want you to do is find a teacher, and we had that written into his IEP, and even from there we continued developing more strategic options for him. Jeff: So, when I was on the website for the National Bullying Prevention Center, I noticed there's some videos and it just wasn't a collection of videos, they were broken down into young children, teens, and you know it even led to what you're talking about educating adults. Can you tell us a little bit about those videos? They really impacted me because it brought me back to the realization that, I may have been part of, not may have, I was part of bullying a little bit and I was bullied, and it just it doesn't go away really, because it all came back to me pretty vivid, pretty, it was all there. Child 7: It makes me cry after school. Child 8: We are different in many different ways, size, shape, and color. Child 9: I have been bullied so I know how it feels to everyone going through a hard time out in the world. Several child voices: Tall, short, skinny, or round, tall, short, skinny, or round, you have a voice, so make a sound. never meant to be the same. Child 10: You have to care because there are other people in the world besides you that have feelings. Child 11: Bullying can prevent good in the world and make the bad go in the world. Child 12: It's not nice to bully, it's better to be a friend. Julie: Yeah absolutely, and you bring up such a good point to Jeff in that, one of the decisions we made very early on was to recognize that any student within the same day can play multiple roles in what we call a bullying situation, and that you may be that young person, you're on a bus riding to school and someone might be throwing, you know, wads of paper at the back of your head over and over and everybody's laughing. So you're that person that's targeted by bullying on the bus and so you can imagine how that feels, that vulnerability, you're on the bus and you get to school and there's all sorts of emotions you're feeling, you're, you know you might be feeling anger, you might be feeling fear, you might be feeling sad, and then you get off that bus and you walk into school and you see a kid by a locker and for whatever reason you just decide to push that kid because you know that you can, and you you push that kid, you've now taken on that role of the kid who's doing the bullying. The next hour you might be witnessing a similar situation you know, in your own classroom, and so to just be labeling kids as a bully, or as a victim, or as you know, somebody who sees it, it wasn't strategic for us. We realized that this is the root of all bullying, it's a social issue. It's a very social issue and by us allowing the behavior to continue to happen without anybody saying anything about it is why it was perpetuated for so long, and I think it's about, we say bullying is about behavior, and so our kids, they're about behaviors, they're not about labels, and what we really want to do is be educating them, and Jeff you mentioned those videos and I think that, again in today's culture, and our evolution, the way we absorb information, we thought it was so important to be offering everybody a variety, so everything from being able to read information, to listen to information, to have access to videos, and you know, and we do a lot of interactive stuff as well. The video series we wanted to touch a parent audience because we want to be giving them a little bit different information than what we would give our kids. So, we actually do have three different websites. We have the National Bullying Prevention Center which we consider our portal page, and that's really for our adult audience, and then we also have two age-appropriate websites. One is called Teens Against Bullying and that is for middle and high school students, and the second is called Kids Against Bullying, which is for elementary school students, so we present to information that that's age-appropriate on those sites through a variety of dissemination, so everything from reading, to interaction on the website, to videos. Jeff: Yeah that was really interesting because I think the ones for kids had animated drawings, it actually described what was going to be on there and said drawings that the kids did, and then their voices, so it really brings it home, and when you witness, or you hear that kids voice, and the tones in their voice, it really like, you can feel it and you mentioned something about everyone's kind of a participant in it. Either your bullying, your target, or you're a bystander. Julie: Yeah and you know, bullying doesn't affect just that kid who's being bullied because when we think about, we like to talk about bullying on a continuum, so if you take a hundred students and you'd line them up, there's gonna be ten students who are frequently targeted by bullying, there's gonna be ten students who maybe are doing the bullying, but that leaves these eighty kids in-between who probably you know might experience bullying a little bit, or might participate in groups, but they're also that 80 percent that sees it happening and you know Jeff I'll tell you universally from talking to kids for, for the past almost twenty years, that group doesn't like it, they don't like what they see, but what they've never had in the past is that they didn't feel empowered to do something about it. You know it goes back to maybe one of those kids in that group was the one that went and told a teacher when they saw a bully and when they were met with, don't be a tattletale, you know what does that do, it shuts them down, they're not going to go back again and say something about it, and so again, it's about making that cultural shift to really engage that 80% to be what we call advocates. It goes back to our PACER model of advocacy, and we say it's advocacy for self, and advocacy for others, and so really giving that that group the dialogue and the tools about, what do you say if you see a bullying situation? And I think that 80% is so important for our kids with disabilities to because the majority of bullying is happening outside the adult's world, and so it's happening in places like a bus where there's not adults, you know, the one person who's on a bus is the bus driver, and what are they doing, they're facing the other way of where all these kids are sitting behind them. And so bullying also happens online, in places where adults aren't, you know that's why so many social media sites that adults are using, kids aren't, because they want to be in a world of their own choosing, and interacting with each other. And so if you think about it, it becomes extremely important for this peer group, this, these bystanders to be empowered to do and say something about bullying, and especially for those who aren't able to stop it on their own. And there's also a really powerful statistic that almost 60% of bullying situations will stop when a peer intervenes and that peer invention becomes so much more powerful than anything in an adult could ever do because just as kids who bully have a lot of power, the peers can take that power away in that situation by saying, you know, we don't accept this, this is not what our school is about, we're better than this, and we've found that that it's extremely effective. [Music] Jeff: It's cool to be kind. [Laughter] Julie: Yeah you know you want to say something, it's cool to be kind sounds really cool to us as adults, but we like to frame it a little bit different for kids and, and especially you know, I think our elementary school students, things like that still resonate with them, you can go with that, some of those really very simple messages. Life gets a lot more complicated for our middle and high school students and how that empathy is, how do you tap into that natural empathy that kids have, because most people don't want to see another person be hurt, but they don't want to put themselves in that situation where they themselves might next become the target, or they get in trouble for sometimes intervening, and so you, you want to really make the payoff, you want to make the trade-off worth their investment of intervening and taking that risk. Jeff: Yeah that group mentality, those eighty students, is it cool to be part of the cool group, that the group is doing this, or is it cool, and I think because of PACER and you know the states passing the laws about bullying that the youth now is starting to realize that it's okay, and cool, those to step out step in, and be part of the conversation part of the solution to bullying. Julie: Absolutely, and Jeff again, my son David, I remember when he was going into middle school and again, you know everybody has their individual vulnerabilities and for him, it was not being able to tell us if he was in a bullying situation he just he wouldn't have that ability to do that and we wouldn't know, and so one of the things that we wrote into his IEP at that time was about training kids to be his advocates. So, at that time, we selected four young people who I knew were already allies of David and these weren't popular kids, they weren't the student council kids, they were they were kids I just knew who had empathy and who cared. We gave them the training to look out for David because we knew that they would know about bullying long before any of the adults would and those students were amazing, and they had such incredible, just their own self-worth and their self-confidence was brought up so much by learning those advocacy skills for David that they shared it with friends and they told people how much you know, this meant to them being part of you know, being delegated with this responsibility, and so that model quickly expanded within my son's school, that advocacy model and they became known as peer advocates. And so, what we did is we continued to train students about what to do if they saw somebody in a bullying situation, how they could intervene, what kind of support they could provide for David, and we also provided an adult mentor that they could go to. So that they could you know, share if there was something that was beyond what they could handle. And that model was incredibly effective, and it became known as the peer advocacy model, and it's still in place at that school today and I know we also have information about it on PACER's website. Yeah there's a great video on there, there's the toolkit, there's statistical data, and there's also a way that you can start it within your own school as well. Jeff: And that's what that toolkits about right? Julie: We have several toolkits on the website, but there's a peer advocacy toolkit on the website that really explains that model in more detail. Jeff: In my world of disability with the blindness and vision loss and difficulty in reading the printed word, self-advocacy is an important skill to develop because typically the parents are what becomes a personís advocate to make, ensure that they're receiving services, or they seek, come to PACER's to learn how to be their advocate in a sense, but then there's a point where the parent will assign chores, or wean them into responsibilities and self-advocacy because they're going to transition from high school to college to the workplace and having that skill set is very important. I was glad to see in the bullying that you guys mentioned self-advocacy. Julie: Yeah, I would say with self-advocacy in bullying, the one important nuance there, is that, we want to make sure that we're not putting full responsibility upon the student to stop it themselves because if they could have stopped it themselves they would have already done that. But what we do say is that self-advocacy is very important and that'll help you get your power back in this situation because I think so much about being bullied, you start to feel powerless, you start to feel like you don't have any options, so in doing that self-advocacy piece is really powerful, and in the world of disability too, it's important to note a couple things, that you have either your IEP, or your 504 that you can be writing those goals and objectives right into, and we've seen parents and teachers get incredibly creative with that. So everything from identifying an adult that a young person can go to if they need help in a bullying situation, and, and that advice, because that isn't always readily available in the school, and so writing that right into your plan is very important, or you know, we've seen other situations where students can leave class five minutes early just because if a hallway is really busy and they're getting bumped around you know, quote-unquote by accident, when we really know it's not by accident that it's on purpose, you know maybe for a short period of time they want to leave class early just to make sure that, that it's not happening, but ultimately we want that behavior to stop in the hallway and for it not to be happening so that they can be included with their peers. But the other important piece is that there's not a federal law about bullying, so every state has a law, but at the federal level there's a law on harassment. So, the distinction between that is that if the bullying is based on an individual's disability, or their race, or their religion, or their gender, or their national origin, then it reaches a threshold of harassment, and at that time the Department of Education as well as the office for civil rights are looking at those scenarios too, so there are some protections in place when the bullying is based on an individual's disability. Child 13: I push myself and yet it is never enough. Child 14: It's never enough. Child 13: And it's hard to ask for what I need. Child 15: I wish others could see that I may not be tough on the football field. Child 16: Or deal with social events very well, but I am a dependable friend. Child 17: It is hard to be understood. Jeff: You mentioned harassment and bullying and you thinking about all the definitions as they're defined in whether a dictionary, you know Webster would say, but it seems like they all blur together, it's a little blurry like conflict harassment, bullying, can you talk just a little bit about that? Julie: Sure I'll give a quick 101 on a definition of bullying, and again Jeff, you know like you say it's, it's somewhat nebulous, and so I'll go back to, if you're listening to this, this recording in the state of Minnesota, Minnesota's definition of bullying in the schools might be much different than how California legislation defines it, or legislation in Pennsylvania, but there are some common hallmarks that I'm gonna mention as far as what defines bullying. So, the first would be that there has to be the intent to hurt, harm, or humiliate, and that can be either emotionally or physically. So, everything from a push, a shove, to name-calling/gossip, so there's that intentionality to hurt, harm, humiliate. The second is is that, the act is typically repeated, instead of you know, but often you know, if it's of significance it can be a one-time act, and I'll use the illustration of say for example if somebody's on social media and they say something really inflammatory and it reaches the an audience of a thousand people immediately, to me that may be a single act, but because it's reaching a thousand people it would definitely hit that threshold of bullying. The third is there's this power imbalance, and again this is, this is I, you know, the imbalance of power up, with that in quotations because it sounds very lofty, but what it is is when a person has either more physical or social power, so everything from you know, so a larger person being much more intimidating to someone else, to a person of smaller stature, but it can also be social power you know, so often we hear it's the quote-unquote the cool kids who are bullying, and so they have much more social cachet then the person that they're bullying. But that imbalance of power can also be about groups, because so often with bullying there's a group mentality and you know, against one person, and it's awfully hard to have power in that situation as an individual versus a group. And the fourth one is that the person is not able to defend themselves, because we see a lot of times people act inappropriately, but it's when, when that person is, feels vulnerable, and they're not able to stop what is happening to them without the help of someone else. The distinction between bullying conflict and harassment then, so with harassment, it has all those hallmarks of bullying, but it's also, and again we're looking at the legal definitions based on legislation, and so the distinction with harassment is that it has all the hallmarks of bullying, but it's also based on an individual's disability, gender, race, religion, national origin, and so the legal, that's the legal definition. And at the interesting nuance to is just to understand what the difference is between conflict and bullying because I think that's very important with our kids, is that we want to let them know, that to have a disagreement, to have an argument, that's a natural part of just life, and it's going to happen through through life, and the distinction of when conflict crosses over into that threshold of bullying is when one person feels unsafe, they no longer feel safe in that disagreement, and also that most conflict will stop when the person realizes how much they're hurting the other person, and so those are really those those distinctions. Jeff: Yeah, I remember there's something saying, guided by empathy that someone does then, retreat or realize they're doing, they're harming someone, they actually realize it, and some people just don't. Julie: Yeah and they'll usually though, they'll be an apology or just an acknowledgement of, hey I guess you know, we've, we've crossed a line here that's not comfortable for someone, for the other person. Jeff: I think the, one of the biggest things you know I, I knew I was coming here to talk about bullying and so I you know, looked at the website and I talked to a couple people about it, and I reflected some things in my past, and I just am grateful that the children today in schools and stuff have the opportunity to be part of the conversation that you and PACER are doing, the bullying prevention, are doing, that there is a conversation that people can join in on. Julie: Yeah one of the I think important parts about our websites is that we wanted to make it not only educational, but we also want it to be aspirational and inspirational and you do that through the sharing of stories, and so if you do go on our website, one of our primary hub and navigation just lists stories, and that's true in all three of our web sites, whether it's for our kids, teens, or adults because we need to understand that impact that bullying has, and I think it's so, it's so easy to say, oh you know it's horrible what happened to somebody, but when you read their their personal story, and you understand the impact that it had for that person, literally about them maybe not wanting to get up and go to school because they couldn't face another day, it's important to know that, and it's those stories and the sharing of stories that really changes lives. And so we wanted to have a way that people could interact and so story sharing is one of those, we also have a nice feature called I care because dot dot dot, where individuals can go on there and fill out why this topic matters to them, and again those are very poignant, and very telling, and also just that kind of that aspirational piece is that, we want the opportunity for anyone to get involved and we realized that we're a small staff so PACER overall has a staff of almost seventy people but on our bullying prevention project there's only three of us, so there's three of us within PACER and we obviously have an infrastructure that supports us, but one of the things that we knew is that the only way we could make change with such a small staff was to really have people who wanted to get invested within every community and that's really what we found is whether it's kids, whether it's parents, or teachers, or even community members, we want to give them tools so that they could be part of the conversation. I think an important evolution you know, what you've heard me talk about what bullying was like in 2000 and where we are now in 2018 is that when we started in 2000 we really needed to be educating people about why do you need to care about this topic of bullying, and then you know, and the reasons were is because it had such a negative impact on her kids, everything from them not wanting to go to school, to also having these physical symptoms of depression and anxiety. You know I think the majority of our society now understands that, that bullying is is not acceptable, but now we need to beware. What are we going to do about it and what behaviors do we want to replace it with and so our conversation has continued to evolve to, we are together against bullying but we're also United for attributes such as kindness, because again you can't go wrong with kindness, and the world just needs a lot more of it. But we also started talking about the concepts of inclusion and acceptance, and we chose those two very purposefully. Inclusion because so often our students with disabilities are not included, you know traditionally they're not included in a classroom setting, they're not included in peer groups, they're not included in friendships, and so to be having active conversations about that we felt was really important. And the other values of kindness, inclusion, and acceptance, and I think so often bullying is about people's differences and in thinking about it, so often what somebody is bullied about is really what makes them unique and valuable to society and I'll just use my own that I, I'm five-eleven now, and I think I was five-eleven back in sixth grade and though I was teased about height and, but really that's what I value, and I think in blind or visually impaired community, and again Jeff, you can probably speak to this, but it's probably your uniqueness that you value about yourself. And so one of the things that we want to do is to say that acceptance is about who somebody is and things that they cannot change, but it's also probably what really they value most about themselves as well, and even my son with Down syndrome, I think what people value about him is his disability because of what he brings to a community, because of his uniqueness, and how he approaches life because of this disability. Jeff: I'm so glad to be part of this conversation because I'm just reflecting back and you talked about acceptance, like when I first lost my eyesight there was a period of time there where I was like, hmm, I didn't know what I didn't know, and I was like kind of lost, so vulnerability at that point until I was able to accept my blindness, my visual impairment, then I could deflect comments or just things like that so, Julie what suggestions would you have for someone who may be experiencing bullying? Julie: Sure, and I'm gonna look at this through the lens of we really focus on students in K through 12, and the first thing I always want to tell anyone who's in that age range and/or their parents is to know that, especially if you are experiencing bullying, that you're not alone, and and I say that Jeff because, one of the things we so commonly hear from individuals is that they feel like they're the only ones that are going through this experience. And you're not alone, in that people are here for you, and if you are being bullied, absolutely as a young person reach out to somebody and let them know, because you have the right to do that, you have the right to be safe at school, you have the right to feel safe online, and so in talking to a parent it's not a show of weakness, it's a show of strength, and I think it takes incredible courage if you are being bullied to just show up to school every day, and so use that courage and translate it into action by talking to an adult and then figure out what you want to do to, to advocate to make it better, and part of advocacy is telling somebody and letting them help you through a plan, and you know whatever that plan may be, make it unique to you, that fits your needs. And for adults, if you find out that your child is being bullied number one listen to them, and let them talk through it because it's a very emotional thing, and you as a parent are going to be experiencing a lot of emotion if you find out that your child is being bullied. Everything from why didn't I know about this before to why didn't they tell me before, but the most important thing you can do is be supportive and the 2nd thing is to go in and find out what your rights are, you know be calling us, or be emailing us, or going online and in finding out what your rights are because your child does have the right to be safe at school, I think that's, that's just of primary importance in of advocate. Jeff: I don't know this one will make the podcast, but as you're talking there I was thinking, do kids who bully ever come forward and wonder why they're doing it? Julie: Yeah absolutely and it's a great question and, and again, I can only speak [inaudible] from the kids that we that we have communicated with, but we've heard where kids go on our website and we actually have a checklist on there especially for our young kids and it's called, do you bully? And they go on there and they read through those behaviors and they, they read through it, and they say, wow I'm doing that, and they don't realize the impact that they've had on another person through their actions, and so we need to be teaching our kids about what appropriate behaviors are, and if you as a parent find out that your kid is, is showing those bullying behaviors, absolutely be having that conversation with them and saying how can we redirect what you're doing? And teaching them how to have empathy for others, such an important piece, and, and I don't think most kids would identify themselves as quote/unquote a bully, and so that's where it's particularly important for adults to be acknowledging those behaviors and saying what can we do to redirect them? Jeff: Once again thank you so much for all this information, there's just a wealth of information that I was able to tap into, I'm going on to the website and talking to you, and you know even this podcast people are gonna be listening, and it's just, sometimes you feel like you're in a vacuum in life, you're isolated from it like, what do I know about bullying in a sense that do I have the answers, but with the conversation going on, and the website and stuff people can get connected to each other and share, especially their parents because they're the ones if they know about it, they're the ones that can do stuff too, and it's just great resource. Can you tell people how they can get to your website? Julie: Absolutely, you go to PACER, again P A C E R, is that acronym that I talked about way back at the beginning and it's PACER.org, and that'll get you to PACER's primary website, and then to reach the National Bullying Prevention Center you would put in PACER.org slash bullying. Jeff: Well that's easy enough, well Julie thank you so much for carrying on this conversation that we all need, and I don't think just because I'm in the blindness community, and bullying doesn't have boundaries, so opening it up to so much, most of our podcasts deal with blindness and stuff but we can't hide from bullying because it it does exist, so thank you very much. Julie: Thank you Jeff and thank you listeners! Child 18: Sometimes we are just told to deal with it. Child 19: Sometimes I don't think I'm any different from other teenagers. Child 20: We kind of all struggle to be understood. Child 21: But yeah, I struggle. Child 22: Emotionally and intellectually, it's sad when people are insulted and made fun of because they have something they're born with and cannot help but have. Child 23: If only others could see, I have so much to offer. Child 24: I would like to encourage kids of my generation... Child 25: Well, really everyone.... Child 26: To be more kind each other.... Child 27: To be more kind to each other...... Child 28: To be more kind to each other. Child 29: Think about how good it feels when someone comes to help you when you least expect it. Child 30: We are all trying to fit in. Child 31: We are all trying to fit in. Child 32: We are all trying to figure life out. Child 33: We are all trying to figure life out. [Music] Jeff: Be sure to check out PACER's Center Champions for Children with Disabilities and PACER's National Bullying Prevention Center on the web at www.pacer.org, and check out State Services for the Blind in Minnesota at www.mn.gov/deed/ssb. Live, learn, work, and play. And a big thank you goes out to Chee Chau and Steven Letnes for their beautiful music. You can find Chee Chau on Twitter at lcheechau, and Stephen Letnes at stephenletnes.com. For more podcast with the blindness perspective, check us out on the web at www.blindabilities.com, on twitter at BlindAbilities, and download the free Blind Abilities app from the app store, and on Google Play, that's two words, Blind Abilities. You can also enable the Blind Abilities Skill on your Amazon device, just say enable Blind Abilities. And from Pacer Center, State Services for the Blind, and Blind Abilities, Thanks for listening, we hope you enjoyed, and until next time, bye bye! [Music]