June 2021 AMA Update

Alysa Edwards, MSIV - University of Colorado School of Medicine

EMRA MSC AMA MSS Delegate, 2021-2022

Between attending kick-boxing classes and posting memes in the “Shenanigans” GroupMe, medical students from across the country met virtually earlier this month to debate and vote on health policy issues at the American Medical Association (AMA) Medical Student Section (MSS) Meeting. This event empowers student members to help shape the policy of the AMA and their advocacy efforts at a national and local level. Students are invited to write and submit policy resolutions for consideration by the MSS. If passed the resolutions are then presented to the House of Delegates - the physician, resident, and student body of the AMA.

At the June 2021 meeting, the MSS considered 101 items covering topics ranging from lowering Medicare eligibility to age 60 and equitable COVID vaccination to medical honor society reform. Involvement in organizations like the AMA and EMRA help strengthen the influence of students and physicians in our community. Reilly Bealer, a MS3 at Elson S. Floyd College of Medicine and the 2020-2021 AMA Government Relations and Advocacy Fellow, stated that organized medicine “allows for physicians to uplift the voices and experiences of patients while working with the public and private sectors to approach issues related to health equity, medical practice, medical education and public health.” According to student doctor Bealer, medical students in particular are vital as they“bring a new set of eyes, a new way of thinking about problems and their potential solutions” as they push organizations like the AMA forward. 

Following the MSS meeting, the House of Delegates met to discuss resolutions proffered by delegations including the MSS. Often referred to as the “moral compass” of the AMA, the MSS helped introduce and adopt positions on several contentious issues including protections for protestors, racism in medicine and medical education, vaccination efforts and TRIPS waivers, as well as “excited delirium” and sedative hypnotics. The student delegates advocating for these positions tirelessly worked for adoption by cultivating support for resolutions from various physician delegations, ensuring their ideas were well-supported by evidence, and by speaking on behalf of students in front of the assembled House. Even in a virtual format, testifying in front of hundreds of residents, fellows, and attendings is no easy feat but students consistently demonstrated their passion and commitment to health policy and equity throughout the meeting.

When asked about the AMA’s new position on protections for protestors, Danielle Rivera, a MS4 at the University of New Mexico School of Medicine and co-author of the original resolution, stated that advocating for these protections is key to patients’ health and wellbeing as well as the right to free speech. She added that “as physicians in training, it is important that we advocate for our fellow citizens' ability to engage in those rights without them having to worry about risking their health and safety.” While many, including student doctor Rivera, are happy to see the steps the AMA is taking to address these issues, there are still more guidelines and practices that can be developed and implemented to better serve our patients and communities.

The Debate on Excited Delirium Syndrome and Pharmacologic Intervention

Within the field of medicine, “excited delirium” or “excited delirium syndrome” (ExDS), remains a controversial term. In 2009, ACEP published a White Paper characterizing this syndrome as “delirium, agitation, and hyperadrenergic autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness.1” However, the American Psychiatric Association and now the AMA, do not support the use of the term as a medical diagnosis2. The term has received heightened media attention in the last few years as it has been disproportionately applied to people of color in the setting of law enforcement involvement3. ACEP is expected to release a report on ExDS which may provide additional insight to the term and its use.

The treatment for ExDS, typically pharmacologic management with sedative/hypnotic and dissociative agents, has also received criticism given the potential dangers of pharmacologic intervention, particularly ketamine, in the prehospital setting. With new policy adopted in June, the AMA now opposes the use of these agents “for agitated individuals in the out-of-hospital setting when done for a law enforcement purpose and not for a legitimate medical reason4.” Emergency medicine (EM) physicians and the EM Section Council were heavily involved in the debate surrounding this policy at the AMA meeting and emphasized that pre-hospital medicine should be overseen and practiced by physician medical directors and appropriately-trained Emergency Medical Services (EMS) personnel.

Dr. Stephen Epstein, chair of the EM Section Council, encouraged the AMA to further consider the independent investigation of law enforcement agencies and EMS in the diagnosis of ExDS and use of ketamine prior to adopting official policy on investigation. Dr. Epstein and other members of the council expressed concern that such an investigation “would put nonphysicians in the position of supervising the practice of medicine5.” Of note, a recent review of 11,291 patients treated with ketamine in the pre-hospital setting reported that ketamine-related deaths occurred in only 0.07% of cases studied6. With discussion of ExDS and pharmacologic intervention taking place within organizations including the AMA, ACEP, and EMRA, there are likely to be additional studies, debates, and management guidelines of this issue in the near future.

For more AMA details, visit Highlights from the June 2021 AMA Special Meeting

1. DeBard ML, Adler J, Bozeman W, et al. White Paper Report on Excited Delirium Syndrome. /siteassets/uploads/uploaded-files/acep/clinical-and-practice-management/ems-and-disaster-preparedness/ems-resources/acep-excited-delirium-white-paper-final-form.pdf. Published September 10, 2009. Accessed June 20,2021
2. Martin L. Agree to Disagree: Excited Delirium Syndrome as Volatile as the Term Itself. Psychiatr Times. https://www.psychiatrictimes.com/view/agree-disagree-excited-delirium-syndrome-volatile-term-itself. Published May 13, 2021. Accessed June 20, 2021.
3. Budhu J, O’Hare M, Saadi A. How “excited delirium” is misused to justify police brutality. Brookings Blog Website. https://www.brookings.edu/blog/how-we-rise/2020/08/10/how-excited-delirium-is-misused-to-justify-police-brutality/. Published August 10, 2020. Accessed June 20, 2021.
4. Berg S. Out-of-hospital pharmacologic intervention by nondoctors poses risks - AMA. https://www.ama-assn.org/delivering-care/public-health/out-hospital-pharmacologic-intervention-nondoctors-poses-risks. Published June 14, 2021. Accessed June 20, 2021.
5. Fellick M. AMA: 'Excited Delirium' Not a Legitimate Medical Diagnosis” - Medscape. https://www.medscape.com/viewarticle/953051. Published June 14, 2021. Accessed June 20, 2021.
6. Fernandez AR, Bourn SS, Crowe RP, Bronsky ES, Scheppke KA, Antevy P, Myers JB. Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality. Ann Emerg Med. 2021 Jun 7:S0196-0644(21)00152-9. doi: 10.1016/j.annemergmed.2021.02.020. Epub ahead of print. PMID: 34112540.