phd in emergency medicine

Training the Physician-Scientist in Emergency Medicine

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Emergency medicine (EM) residency training prepares graduates to practice acute care medicine in high-volume emergency departments. Graduates may seek additional subspecialty clinical training in critical care medicine, emergency medical services, hospice and palliative medicine, medical toxicology, neurocritical care, pain medicine, pediatric emergency medicine, or undersea and hyperbaric medicine. From research into the social determinants of health and health services research to basic or mechanistic science, EM has broad research focus. There are multiple pathways available to become an independent researcher:

Physician Scientist Training Pathways (PSTP) – PSTPs are mentored research programs that are integrated with clinical residency training.  PSTPs are generally best suited to trainees that have substantial prior research experience, such as graduation from an MSTP program, prior Ph.D. training, or other significant prior dedicated research training. The typical model prolongs EM residency, but some models function as a built-in fellowship after clinical residency.

The purpose of this pathway is to integrate substantial research experience with clinical practice, thereby promoting clinically relevant hypothesis-driven research.  The overall goal at completion of these programs is to create independent physician-scientists who will be 1) competitive for NIH or equivalent funding, 2) dedicated to a research career, 3) adept in clinical practice, and 4) current or future leaders in academic EM.

EM PSTPs are characterized by the following:

• Integrated research experience during clinical years, such as research rotations, grand rounds, seminars, and grant writing courses.
• Continued clinical experience during research years, if applicable.
• Dedicated mentorship from independently funded physician-scientists to guide trainees in independent project design throughout the duration of the entire PSTP experience.
• Funded by institutional training grants such as T32 grants (in emergency medicine or related disciplines).
• Material and financial support for research during residency.

Research Fellowships – Another common pathway for research training in EM is research fellowships. These provide 1-3 years of additional research training following EM residency. Research fellowships are diverse, many offer the opportunity to obtain a graduate degree (i.e., MS, MA, MPH, or MHS) and all provide a focused, mentored research experience that encompasses various aspects of experimental design, epidemiology, clinical trials, or other focused research areas. Those entering a research fellowship may be new to EM research, or applicants may have significant prior research experience. Similar to PSTPs, the goal of these fellowships is to produce independent EM researchers who will change the practice of EM, be competitive for career-level funding, mentor students and residents, and continue to work clinically.  

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When I was in college, I was in a premed “bubble” a lot of the time. I took many of my courses and labs alongside hundreds of other aspiring physicians. I would see the same people throughout my academic day, and sometimes even outside of the lecture hall. Because of this, I unintentionally overheard conversations […]

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We have 3 emergency medicine PhD Projects, Programmes & Scholarships

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emergency medicine PhD Projects, Programmes & Scholarships

Knowledge support to support clinicians to manage mental health medication in general practice, phd research project.

PhD Research Projects are advertised opportunities to examine a pre-defined topic or answer a stated research question. Some projects may also provide scope for you to propose your own ideas and approaches.

Funded PhD Project (UK Students Only)

This research project has funding attached. It is only available to UK citizens or those who have been resident in the UK for a period of 3 years or more. Some projects, which are funded by charities or by the universities themselves may have more stringent restrictions.

The Architecture of Future Healthcare Environments

Self-funded phd students only.

This project does not have funding attached. You will need to have your own means of paying fees and living costs and / or seek separate funding from student finance, charities or trusts.

Computational modelling of the human blood-brain barrier to tackle multidrug resistance and neurodegenerative disorders (molecular dynamics/deep generative learning/AI)

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Emergency Medicine

Disaster fellowship.

The mission of the Disaster Medicine Fellowship is to develop fellows with the skills necessary to become academic leaders of disaster preparedness, management, and response.

The program includes focus on disaster preparedness and response at the hospital, state, and federal level, emergency public health and disaster didactics in the field and the classroom, mentorship, and the development of research skills.

Program Description

• To acquire knowledge of public health and disaster-related issues through the acquisition of a Masters in Public Health (MPH) degree
• To understand key areas of disaster management and humanitarian response
• To have the ability to conduct academic and clinical research related to disaster and humanitarian response
• To develop and conduct educational activities for physicians, medical students and allied health professionals
• To learn the skills of disaster and austere medicine by integrating emergency medicine with international health and field medicine

The curriculum for the Disaster Fellowship integrates formal public health, research and teaching training with disaster-related field work. The curriculum will be divided into five specific areas:

Public Health Training

The core of the didactic curriculum involves obtaining an MPH from the Hopkins Bloomberg School of Public Health. There are many learning tracks in the school, but an emphasis is placed on the disaster/humanitarian track and epidemiology. The fellowship schedule is more flexible for applicants already with an MPH degree.

Disaster Field Work

Practical experience is a key component of the Fellowship. Fellows will spend time each year both in disaster and other austere settings as determined by events and their schedule. Field work will be arranged and coordinated by the fellow under the supervision of the Fellowship Director.

Public speaking and teaching skills are essential to leadership development. Supervised educational training will take place in lecture, bedside and scenario settings in order to develop a variety of teaching skills. Fellows are given the opportunity to teach in classes at the School of Medicine, in the residency program and as part of the Johns Hopkins Austere Medicine course.

Research will emphasize innovations in disaster science. There are a wide variety of faculty in the Schools of Medicine and Public Health to mentor fellows in research methodology and implementation. Each fellow will complete at least one research project related to their work, of sufficient quality for publication.

Clinical Emergency Medicine

Fellows work 800 clinical hours per year as faculty at one of the three core hospitals of the JHU Department of Emergency Medicine. The fellow will participate in other academic activities in the Department of Emergency Medicine, including grand rounds presentations, conferences and literature reviews.

Academic Requirements

• Fellows will be expected to produce at least 1 peer reviewed research manuscript at completion of fellowship program.
• Fellows will successfully complete an MPH degree at the Bloomberg School of Public Health.
• Fellows will successfully complete two months as teaching attending at the JHU over the two years.

Prerequisites

• Board certified or prepared in Emergency Medicine
• Ability to obtain medical license in Maryland, USA
• Ability to obtain a clinical appointment at a Johns Hopkins Hospital
• Ability to matriculate to the Bloomberg School of Public Health for a Masters in Public Health degree

Program Length

Usually July 1, but mid-year candidates can be considered

How to apply

Interested candidate should contact the Fellowship Director for more information and should provide:

• Personal Statement and CV
• 2 letters of recommendation, forwarded from the recommender
• Academic writing sample such as an essay, published paper, or poster

Fellowship Director

J. Lee Jenkins, M.D., MS

Disaster Fellowship Director Associate Professor, Department of Emergency Medicine Email: [email protected]

Dr. Jenkins is Director of the Disaster Fellowship and an Associate Professor in Emergency Medicine at the Johns Hopkins University School of Medicine. She is internationally known in disaster medicine and responder wellness. Dr. Jenkins serves as a Board Member for the World Association of Disaster and Emergency Medicine and is the previous Chair of the Department of Emergency Health Services at the University of Maryland Baltimore County.

She is fellowship trained in Disaster Medicine and served as the Assistant Chief of Service and the Disaster Control Physician for the Johns Hopkins Hospital. Dr. Jenkins developed the PhD Concentration in Emergency Services at UMBC and the Johns Hopkins Medical School’s first course in Disaster Medicine and Emergency Public Health. She has received the Clinician Scientist Award at Johns Hopkins Hospital for her work in triage during hospital crowding.

View full profile

Fellowship Faculty

• Associate Director, Critical Event Preparedness and Response (CEPAR)
• Associate Professor of Emergency Medicine

Expertise: Emergency Medicine

J Lee Lee Jenkins, MD

Research Interests: Decision making, Disaster Medicine, Emergency medical services, Hospital disaster preparedness, Triage

Gabe D. Kelen, MD

• Director, Department of Emergency Medicine
• Professor of Emergency Medicine

Research Interests: Disaster Health, Emergency Medicine, Emerging Infections

Additional Information

Learn more on the Center for Refugee and Disaster Response website.

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Welcome to the Division of Research in the Department of Emergency Medicine at Weill Cornell Medicine!

Our division is working to advance and influence emergency care through innovation and research. We are acutely aware of the ever-increasing complexity of emergency medicine, its expanding role in the health of individuals and societies, and the rising expectations of our patients and policymakers.  As a group of emergency medicine researchers, we believe that carefully designed research can push the boundaries of Emergency Medicine and prepare us for the next iteration of emergency medicine. 

Broadly, we are interested in inventing, improving, and implementing clinical interventions that improve outcomes for acutely ill individuals, enhancing the effective use of current and new technologies in and outside of the hospital, and find innovative strategies for positively impact population and public health.

We are expanding our research infrastructure and significantly enhance our academic and scholarly productivity. To achieve our vision, we are looking to partner with individuals and groups who share our enthusiasm for emergency care research. 

With locations throughout New York City, our department offers a research environment and opportunities rarely available in Emergency Medicine. Our presence in Brooklyn, Queens and Upper and Lower Manhattan allows us to conduct cutting-edge research amongst diverse patient populations. We are engaged in ongoing joint research projects with multiple departments in the Medical College, and frequently partner with some of the top hospitals and academic institutions in the area, including the Hospital for Special Surgery, Memorial Sloan Kettering, and Rockefeller University.

We have several faculty members with NIH research funding for domestic and international work. To learn more, please contact [email protected] .

Sincerely, 

Junaid Razzak, MBBS, PhD, FACEP Vice Chair, Research Department of Emergency Medicine

About Our Division

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Dr. radhika sundararajan’s research applies culture to care.

July 31, 2024

Guide to WCM Department of Emergency Medicine at the 2024 SAEM Meeting

April 23, 2024

Mailing Address New York-Presbyterian Hospital Weill Cornell Medical Center Department of Emergency Medicine 525 E. 68th St., Box 179 New York, NY 10065

Office of the Chair Emergency Medicine 525 E. 68th St., M-130 New York, NY 10065 (212) 746-0780

Residency Office 530 E. 70th St., M-127 New York, NY 10021 (212) 746-0892 [email protected]

Research Office 525 E. 68th St., M-130 New York, NY 10065 [email protected]

Division of Emergency Critical Care

The Stanford Emergency Critical Care (ECC) program focuses on resuscitation, early interventions, and optimizing transitions of care for critically ill patients in the ED and throughout Stanford Hospital. The program is a collaboration between nurses and dual-trained ECC faculty physicians at Stanford who attend in both the medical-surgical ICUs.

The goal of the innovative ECC program at Stanford is to transform early interventions for the critically ill through excellence in education, scientific discovery, and patient-centered care.

CRITICAL CARE FELLOWSHIP

Two critical care fellowship pathways are available at Stanford for graduates of an EM residency: Internal Medicine-CCM and Anesthesia-CCM. 

Stanford CCM Fellowship 

Patient Care

EMERGENCY CRITICAL CARE

ECC faculty are dual-boarded emergency intensivists who provide dedicated specialty care to critically ill patients in the ED, regardless of ICU bed availability. Learn more.

ECC faculty also serve as attending physicians in the medical-surgical ICUs at Stanford Hospital, the primary teaching services for Stanford residents and CCM fellows.

The ECC research group has published on severity of illness scores adapted for use in the emergency department, as well as the impact of ECC nurses and ECC physicians on outcomes among the critically ill.

MULTI-CENTER CLINICAL TRIALS

Stanford ECC faculty participate at the national level in multi-center clinical trials focused on early interventions in critical illness, including as part of the NIH-funded PETAL and SIREN networks.

The Stanford Emergency Medicine Residency offers special preparation for a career in critical care as part of the Advanced Clinical and Career Enrichment Line (ACCEL) Program. All ECC faculty participate in mentoring EM residents interested in pursuing critical care fellowship training, and partner with residents to host “critical care day,” a half-day of hands-on teaching focused on critical care topics for all EM residents. 

Stanford has a long tradition of multidisciplinary training in critical care - our first EM-trained fellow graduated in 1996! Today, ECC faculty are involved in all aspects of the critical care fellowships at Stanford, including as co-director of the critical care ultrasound curriculum and as assistant program director for the internal medicine-CCM fellowship. 

Two pathways are available at Stanford for graduates of an EM residency: Internal Medicine-CCM and Anesthesia-CCM. 

Learn more 

CONTINUING MEDICAL EDUCATION

ECC faculty help lead CME efforts not only for physicians but also for nurses and respiratory therapists working in critical care. Recent CME offerings include training at ACEP and SCCM annual meetings and the Stanford Respiratory Care Symposium. Local and national courses vary from year to year.

ECC RNs are dual ED/ICU-trained nurses who are staffed 24/7 and are primarily responsible for overseeing the care of critically ill patients in the ED. As partners, ECC physicians and ECC nurses work very closely to provide exceptional care for critically ill patients in the ED. Learn more

Department of Emergency and Disaster Health Systems

College of arts, humanities, and social sciences, emergency management.

The Emergency Management pathway includes courses in disaster health, catastrophes, and system design.

Concentration Committee:

Dr. Lauren Clay (Emergency and Disaster Health Systems), Dr. Lucy Wilson* (Emergency and Disaster Health Systems) *designated primary advisor

Downloadable PDF:  PhD Degree Audit (Emergency Management)

Required public policy core courses (18 credits required).

• PUBL 600:Research Methodology
• PUBL 603: Theory and Practice of Policy Analysis
• PUBL 604:Statistical Analysis  Or an equivalent graduate-level statistics course from an accredited university
• PUBL 609: Doctoral Research Seminar

Choose two of the following:

• ECON 605:  Benefit-Cost Evaluation
• ECON 611: Advanced Econometric Analysis I (Fall)
• ECON 612: Advanced Econometric Analysis II (Spring)
• EDHS 691*: Business Development and Strategic Planning
• EDHS 720*: Emergency Health Services Quality Assessment
• PUBL 607: Statistical Applications in Evaluation Research
• PUBL 608: Applied Multivariate Regression – An Introduction
• PUBL 611: Casual Inference in Program Evaluation
• SOCY 619: Qualitative Methods in Social Research

Other methodological/analytic courses recommended by track advisor(s)

Required Public Policy Disciplinary Foundation Courses (9 credits required)

• PUBL 601:Political and Social Context of the Policy Process
• SOCY 606: Social Inequality and Social Policy

Choose one of the following:

• PUBL 602: Microeconomics for Public Policy (formerly ECON 600)
• ECON 601: Microeconomic Analysis

Required Emergency Health Core Courses (9 credits required)

• EDHS 630: Issues Analysis and Proposal Writing
• EDHS 640: Introduction to High-Performance EDHS
• EDHS 642: Event-Driven Resource Deployment

Emergency Management Electives (12 credits required)

Choose four of the following:.

• EDHS 632: Disaster Health Services
• EDHS 633: Refugee Health Services
• EDHS 634: Disaster Mitigation
• EDHS 636: Disaster Response
• EDHS 637: Disaster Recovery
• EDHS 638: Disaster Preparedness
• EDHS 639: Catastrophe Preparation and Response
• PUBL 613: Managing Public Organizations
• PUBL 623: Governmental Budgeting

Other elective courses recommended by track advisor(s)

*Can count towards either a Public Policy Elective OR an Emergency Health Elective – not both

Other courses taught at UMBC and sister institutions within the University System of Maryland may be relevant to the Emergency Services Concentrations. Before registering for any such courses, approval from an advisor is required.

Total Required Credits: 48

Doctoral Dissertation Research (18 credits required)

• PUBL 899: Doctoral Dissertation Research (See “a” below)

All Ph.D. candidates must register for a minimum of 18 semester hours of doctoral dissertation research. Guidelines for writing and defending dissertations are available on the Public Policy Graduate Student Group site . Copies of proposals and dissertations are available for inspection in the Graduate Student Reading Room.

Browse a list of completed dissertations from previous students. For a full list of theses and dissertations, visit the database search on UMBC’s Library page (database search requires UMBC login).

Other Degree Requirements

a) Ph.D. Dissertation (PUBL 899, 9 credits per semester)

1) Committee formed

2) Topic Approved (proposal defense)

3) Final Dissertation defense

b) Recommended for degree

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Public Health Practice, DrPH (Emergency Preparedness)

Doctor of Public Health Degree in Public Health Practice with a Concentration in Emergency Preparedness

The online Doctor of Public Health Program (DrPH) in Public Health Practice with a concentration in Emergency Preparedness provides high-level problem solving and critical thinking knowledge and skills that can be used in preparing for and responding to emergencies.

Total Credits

Cost Per Credit

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Students in the DrPH program gain skills to:

• Formulate solutions to challenges from complex disasters.
• Evaluate need and implement an Area Command or a Multiagency Coordination Center (MAC).
• Organize and manage a command structure to support an expanding event.
• Construct an exercise program for an agency or organization.
• Conduct a tabletop exercise, functional exercise and full-scale exercise.

Courses focus on the concepts inherent to leadership and the management of complex events in Emergency Preparedness through the phases of prevention, protection, response and recovery, to prepare students for high level leadership positions both in public health and healthcare. Additional courses such as Exercise Development and Managing Complex Incidents provide essential strategies to prepare their organization/community for a disaster, as well as how to operate in a leading role during a disaster response.

DrPH students also work with leaders in public health practice during practicum experiences providing the opportunity to apply academic knowledge in a practice setting and complete a practice-based dissertation consistent with an advanced practice designed to influence programs, policies or systems addressing public health.

The DrPH in Public Health Practice degree prepares students to work as a leader or administrator in a variety of practice-based settings with the public, private or academic sectors. DrPH graduates advance programs, policies and systems to improve population health in the United States and globally.

The DrPH in Public Health Practice differs substantially from a PhD, focusing on preventing disease or injury and improving the health within a specific community. Graduates are expected to occupy leadership positions having a major influence on achieving important broad-reaching public health objectives in communities. A PhD degree focuses on the skills needed to make research-based contributions to the field of public health contributing to generalizable knowledge.

Additional Program Information

For up-to-date application, course and licensure information, visit the campus program page.

The University of Nebraska Medical Center trains more health professionals than any other institution in the state. UNMC’s scientists and clinicians are at the leading edge of discovering new medical breakthroughs, transforming lives across the state and around the world.

UNMC has come together with its primary clinical partner, Nebraska Medicine, on a set of core values, which include focusing on the educational learner, research scope and prominence, clinical excellence, community engagement. Diversity, equity and inclusion, economic development, as well as organizational culture and leadership.

Career Outlook

According to the United States Bureau of Labor Statistics, employment of emergency management directors is projected to grow 4% from 2019 to 2029. The importance of preparing for and minimizing the risk from emergencies will sustain demand and employment opportunities for emergency management directors. These workers will be needed to help businesses and organizations continue to provide essential services during and after emergencies.

Examples of careers with a DrPH include:

• Health department director
• Health policy advisor
• Public health program director
• Community health manager

Finance Your Education

The University of Nebraska offers some of the most affordable tuition rates in the region, particularly for our online programs. Explore the array of funding options to finance your education in a way that makes sense for you.

Online tuition rates are calculated by credit hour and college offering the course and, because the University of Nebraska is a public institution supported by Nebraska taxpayers, Nebraska residents may receive a lower tuition rate than out-of-state students.

Cost Per Credit

In-State	Out-of-State
$626.85	$626.85
Note: Campuses may charge additional fees; see the  for more details.

If you are a college student considering transferring courses, an adult returning to college or a high school student with college credit, Transfer Nebraska is for you.

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Apply to PhD in Epidemiology

Application requirements.

The GEOHealth-MENA program offers a PhD in Epidemiology, with a focus on environmental and occupational health (EOH), at the Faculty of Health Sciences (FHS) of the American University of Beirut (AUB) . The program is accredited by the Council on Education for Public Health (CEPH).

Applications are open now for the Fall semester of AY 2024-2025. Accepted applicant shall start in August 2024.

Who can apply to the GEOHealth-MENA PhD Program?

Who is eligible.

To be eligible for admission to the PhD in Epidemiology program, a candidate must:

• Hold a master’s degree in Epidemiology or in a relevant discipline such as public health, nursing, statistics and health informatics, pharmacy, biological sciences and others, from AUB or other recognized institution of higher learning.
• Have an outstanding cumulative average, acceptable to the appropriate faculty graduate committee. A minimum cumulative course average of 85 over 100, or its equivalent, is required for admission
• Demonstrate evidence of high interest in EOH
• Have achieved a minimum score of 1,000 on the Graduate Record Exam (GRE) general component.
• Demonstrate English proficiency as stipulated in the University Graduate Catalogue for requirement for admission into PhD studies
• An interview in person will be undertaken by the PhD Program committee for applicants who meet the minimum admission requirements

Important Note

• Applicants must apply for graduate admission through the AUB online graduate admissions portal .
• Official transcripts and certified copies of degrees and certificates from previous universities
• Official GRE scores on the general component
• Demonstrate English proficiency, as stipulated in the University Graduate Catalogue for admission into PhD studies​
• Letters of recommendation (a minimum of three letters)
• Personal statement outlining interest in the program of stud​y including research interests and experience
• An updated CV​
• Application Fees ($50)
• Applicants must submit personal statement that clearly explains one’s interest in EOH and addresses future plans for a career in this field to [email protected] and/or [email protected] .
• Interviews : Selected applicants may be invited for a video interview by the selection committee.

Applicants must be accepted by BOTH AUB graduate programs and GEOHealth-MENA admissions committees.

GEOHealth-MENA seeks to form a cohort of trainees that is rich in diversity of ethnic backgrounds, prior training, and gender representation. The program is open to those with basic science, public health, and clinical interests.. The process for trainee selection is as follows:

• Official GRE scores on the general component (GRE IS WAIVED FOR APPLICATIONS 2022)
• Demonstrate English proficiency, as stipulated in the University Graduate Catalogue for admission into PhD studies
• Personal statement outlining interest in the program of study including research interests and experience
• An updated CV
• Applicants must submit personal statement that clearly explains one’s interest in EOH and addresses future plans for a career in this field to [email protected] .
• Interviews: Selected applicants may be invited for a video interview by the selection committee.

For questions regarding AUB and your application to the Faculty of Health Sciences, please check out the AUB Graduate Admissions Website .

For all further questions please reach out by email to [email protected] or [email protected] .

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Online Doctoral Degree Doctor of Emergency Management

The Doctor of Emergency Management (DEM) prepares students with the knowledge and skills needed for careers in contemporary emergency management roles, emphasizing theoretical and practical leadership components. As students become practitioners in the field, they learn to analyze data, design evidence-based research, integrate theoretical frameworks, and make professional recommendations to solve some of the most complex challenges in the emergency management field.

Doctoral Dissertation

Doctoral students are required to complete a dissertation and defend their research before a committee and University representatives, which may take place at a distance through audio/visual means. No degree shall be awarded without majority of committee approval. Information regarding this capstone doctoral requirement is published in the Dissertation Handbook.

Graduates will successfully complete a minimum of 61 semester hours and dissertation research courses as outlined below.

Multiple factors, including prior experience, geography and degree field, affect career outcomes. CSU does not guarantee a job, promotion, salary increase, eligibility for a position, or other career growth.

Degree at a Glance

• Number of Credits  
• Maximum Transfer Credits  
• Tuition Per Credit *  
• Next Start Date  
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Program Summary

Program description, learning outcomes.

Upon completion of the program, students should be able to do the following:

Concentration

Concentration outcomes, ready to get started.

For more information regarding courses outside the recommended course of study, view the full course listing . ( * Indicates recommended course of study. )

Major Requirements

credit hours

Major Requirements – Group {{group}}

Course Number	Course Title	Credit Hours
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Major Courses

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Concentration Courses

12 credit hours

To fulfill the General Concentration for this degree, student may choose any 5000-6000 level course not used to satisfy program requirements. Student can review all available courses at our full course listing. Students are strongly encouraged to speak to their academic advisor prior to choosing general concentration course options.

General Education

The following courses indicated by * are recommended to satisfy General Education Requirements .

{{subject}} — {{hours}} required hours

Course Number	Course Title	Credit Hours
	{{ CourseHours }}

To fulfill open electives, students may choose any course not used to satisfy program requirements, taking into consideration the degree program upper-level requirements. Students can review all available courses at our  full course listing. Students are strongly encouraged to speak to their academic advisor prior to choosing open elective options.

Program Electives

Program Electives

Dissertation Requirements

To satisfy the requirements of the Doctor of Emergency Management, students must complete a minimum of 15 hours of dissertation/research hours. Doctor of Emergency Management students should communicate regularly with their dissertation chair regarding the completion of these hours.

Tuition Rates

Our goal is to provide the strongest online academic programs at an affordable rate. On average, our tuition is less than half the cost of our competitors.

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Course Type	Tuition Rate Per Credit Hour
Undergraduate	$270
Graduate	$349
Doctoral	$545

* Rates are per credit hour. Most courses are three (3) credit hours. Tuition and fees are payable in U.S. funds. Tuition rates are subject to change. CSU’s tuition rate for associate, bachelor’s and master’s courses is $250 per credit hour for all active-duty military members using tuition assistance except those who are using a Learning Partner discount. The lower rate is offered to keep the tuition rate at the DoD cap of $250. † CSU Learning Partners receive a tuition discount that is applied to the full tuition rate.

Tuition reports include tuition and required fees per academic year for full time beginning students. Source: U.S. Department of Education College Affordability and Transparency Center, National Center for Education Statistics, Integrated Postsecondary Education Data System (IPEDS), Winter 2021-2022, Student Financial Aid component.

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Doctor of Philosophy (PhD) in Emergency and Protective Services

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Earn a doctorate degree in Emergency and Protective Services, advance both scholarly research and your career

The rapid infusion of new technology, material, and human interactions in every setting is creating new challenges for Emergency and Protective Service professionals in every environment.  The pressures to identify, plan and implement response requirements, for emergencies where life, property or the environment is at risk while preventing injuries and death to both emergency responders and the general public is greater now than at any time in the past. 

Capitol Technology University’s online PhD program in emergency and protective services is designed for current professionals in the field who desire to elevate their skills to the highest level and contribute to the body of knowledge in the field. 

While completing the program, students will already be helping to advance the industry through the creation of new knowledge and ideas. Through this research-based, online doctorate, students engage quickly in research and publishing without the limitations inherent in traditional coursework models. Graduates will be prepared for a variety of leadership roles in emergency and protective services, or for teaching roles in higher education.

As a doctoral student in emergency and protective services at Capitol Tech, you’ll enter the program with a research idea and at least a committee chair. After enrollment, you’ll work with your chair and research committee to further develop your research proposal. You’ll then work independently to produce a meaningful body of original research of publishable quality. In the process, you’ll also gain valuable insight into the legal, political, ethical, and social dimensions of your field of study.

This is a research based doctorate PhD degree where you will be assigned an academic supervisor almost immediately to guide you through your program and is based on mostly independent study through the entire program. It typically takes a minimum of two years but typically three years to complete if a student works closely with their assigned academic advisor. Under the guidance of your academic supervisor, you will conduct unique research in your chosen field before submitting a Thesis or being published in three academic journals agreed to by the academic supervisor.  If by publication route it will require original contribution to knowledge or understanding in the field you are investigating.

As your PhD progresses, you move through a series of progression points and review stages by your academic supervisor. This ensures that you are engaged in a process of research that will lead to the production of a high-quality Thesis and/or publications and that you are on track to complete this in the time available. Following submission of your PhD Thesis or accepted three academic journal articles, you have an oral presentation assessed by an external expert in your field.

Why Capitol?

Learn around your busy schedule

Program is 100% online, with no on-campus classes or residencies required, allowing you the flexibility needed to balance your studies and career.

Proven academic excellence

Study at a university that specializes in industry-focused education in technology fields, with a faculty that includes many industrial and academic experts.

Expert guidance in doctoral research

Capitol’s doctoral programs are supervised by faculty with extensive experience in chairing doctoral dissertations and mentoring students as they launch their academic careers. You’ll receive the guidance you need to successfully complete your doctoral research project and build credentials in the field. 

Key Faculty

Vice President

Dissertation Chair

Fire Chief, City of Oakland, CA

Degree Details

This program may be completed with a minimum of 60 credit hours, but may require additional credit hours, depending on the time required to complete the dissertation/publication research. Students who are not prepared to defend after completion of the 60 credits will be required to enroll in RSC-899, a one-credit, eight-week continuation course. Students are required to be continuously enrolled/registered in the RSC-899 course until they successfully complete their dissertation defense/exegesis.

The student will produce, present, and defend a doctoral dissertation after receiving the required approvals from the student’s Committee and the PhD Review Boards.

Prior Achieved Credits May Be Accepted

Doctor of Philosophy - 60 credits

(Prerequisite: None)	6
(Prerequisite: EPS-800)	6
(Prerequisite: EPS-810)	6
(Prerequisite: EPS-820)	6
(Prerequisite: EPS-830)	6
(Prerequisite: EPS-840)	6
(Prerequisite: EPS-900)	6
(Prerequisite: EPS-910)	6
(Prerequisite: EPS-920)	6
(Prerequisite: EPS-930)	6

Educational Objectives:

• Students will integrate and synthesize alternate, divergent, or contradictory perspectives or ideas fully within the field of emergency and protective services.
• Students will present scholarly work on emergency and protective services via appropriate communication channels.
• Students will demonstrate advanced knowledge and competencies in emergency and protective services.
• Students will analyze existing theories to draw data-supported conclusions in emergency and protective services.
• Students will execute a plan to complete a significant piece of scholarly research in emergency and protective services.
• Students will evaluate the legal, social, economic, environmental, and ethical impact of actions within emergency and protective services and demonstrate advanced knowledge and competency to integrate the results in the leadership decision-making process.

Learning Outcomes:

Upon graduation:

• Graduates will evaluate the legal, social, economic, environmental, and ethical impact of actions within emergency and protective services and demonstrate advanced knowledge and competency to integrate the results in the leadership decision-making process.
• Graduates will demonstrate the highest mastery of traditional and technological techniques of communicating ideas effectively and persuasively.
• Graduates will evaluate complex problems, synthesize divergent/alternative/contradictory perspectives and ideas fully, and develop advanced solutions to emergency and protective services challenges.
• Graduates will contribute to the body of knowledge in the study of emergency and protective services.

Tuition & Fees

Tuition rates are subject to change.

The following rates are in effect for the 2024-2025 academic year, beginning in Fall 2024 and continuing through Summer 2025:

• The application fee is $100
• The per-credit charge for doctorate courses is $950. This is the same for in-state and out-of-state students.
• Retired military receive a $50 per credit hour tuition discount
• Active duty military receive a $100 per credit hour tuition discount for doctorate level coursework.
• Information technology fee $40 per credit hour.
• High School and Community College full-time faculty and full-time staff receive a 20% discount on tuition for doctoral programs.

Find additional information for 2024-2025 doctorate tuition and fees.

Need more info, or ready to apply?

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Programme co-convenors: Dr Willem Stassen    and Mr Wesley Craig

This research degree is offered by dissertation only. Candidates will be required to undertake an advanced, approved research project under the guidance of a supervisor, indicating successful training in methods of research.  The PhD degree is not regarded as a basis for registration as a specialist with the Health Professions Council of South Africa, but can be registered as an additional qualification.

Please note: Admission requirements are subject to amendment based on new requirements of the Department of Education. Applicants for research degrees are required to submit a research proposal with their application. Prospective applicants are advised to contact the Division directly in order to present their research idea prior to completing an application.

APPLICATION PROCESS?

It is unlikely that your application will be successful if you have not consulted with the PhD lead, Dr Willem Stassen, prior to the application.  You will also require an approved summary for your research project.  You can submit a summary for approval to the emergency medicine division research committee (EMDRC).  Progression to proposal and registration will not be supported until the summary has passed the EMDRC summary stage. In order to facilitate the development of your PhD idea and summary, a compulsory three-month, bootcamp will take place at the beginning of every year. Once this has been successfully completed, you will be eligible for registration on the PhD programme. Hereafter, you will be required to sign a memorandum of understanding with your supervisors and start working on your proposal.  The expectation is that you successfully achieve ethical approval for your study within a year.  As a research degree, it is expected that students wishing to apply for the PhD have an understanding of basic research concepts and principles.  Although this is not a requirement, prospective students may be required by the EMDRC to demonstrate sufficient knowledge of the scientific method by passing a research methodology competency test.  Alternatively prospective students can enrol on either one of the following courses

• UCT MPhil's research methodology module (see below)
• The Understanding Clinical Research: Behind the Statistics online course from Coursera
• A notable exception is planned qualitative research which is not covered in these research methodology courses.  The Qualitative Research Methods online course from Coursera is recommended instead of the two research courses listed above

Once the EMDRC has approved your summary and the PhD coordinator has given you the go-ahead you can formally register.   Apply online using the course code for the PhD: FCE7064W

Upon completion of this degree (minimum 2 years, normally between 3 and 5 years), you are expected to function as an independent researcher. We are dedicated to capacity-building in academic emergency medicine. For this reason, PhD candidates will be encouraged to undertake a series of courses or seminars to bolster their learning throughout the PhD journey.

The PhD degree is awarded in recognition of high quality, original research and is conventionally assessed based on a dissertation. In addition to this, it is now possible to include publications on which you were the first author into your PhD. It is however not possible to obtain a PhD exclusively on the basis of published articles.

With regard to the date of submission of the dissertation, the number of copies to be submitted, as well as the further requirements with which students have to comply in order to graduate, the general provisions for doctorates will apply as stipulated by the University. For more information please consult the  UCT doctoral page

Julie Kafka, PhD, MPH Assistant Professor, Emergency Medicine

• MPH, University of North Carolina at Chapel Hill (2018)
• PhD, University of North Carolina at Chapel Hill (2022)
• BA, Colby College (ME) (2012)
• University of Washington Program, Firearm Injury and Policy Research Program (2024)

Recognition & Awards

• Dean's Distinguished Dissertation Award in the Social Sciences, University of North Carolina (2023)
• Travel Award, National Research Conference on Firearm Injury Prevention (2022)
• Lyndon Haviland Scholarship, American Public Health Association (2020)
• Jamie Kimble Scholarship for Courage, Jamie Kimble Foundation (2019)
• Honoree, inductee, Delta Omega Honorary Society in Public Health (2018)

Research Interests

Publications.

• Kafka, J.M., Schleimer, J.P., Toomet, O., Chen., K, Ellyson, A.M. & Rowhani-Rahbar, A. “Measuring interpersonal firearm violence: Natural language processing (NLP) methods to address limitations in criminal charge data.” Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocae082
• Kafka, J.M., Rivara, F., Ross, R., & Rowhani-Rahbar, A. (2024). “Research needs related to firearm rights restoration.” Injury Epidemiology, 11(1). https://doi.org/10.1186/s40621-023-00482-1
• Kafka JM, Fliss MD, Trangenstein PJ, McNaughton Reyes L, Pence BW, Moracco KE. Detecting intimate partner violence circumstance for suicide: development and validation of a tool using natural language processing and supervised machine learning in the National Violent Death Reporting System. Inj Prev. 2023 Apr;29(2):134-141. PubMed PMID: 36600568
• Houang ST, Kafka JM, Choi SK, Meanley SP, Muessig KE, Bauermeister JA, Hightow-Weidman LB. Co-occurring Epidemic Conditions Among Southern U.S. Black Men Who Have Sex with Men in an Online eHealth Intervention. AIDS Behav. 2023 Feb;27(2):641-650. PubMed PMID: 35986818
• Kafka, J. M., Moracco, K.E., Pence, B.W., Trangenstein, P.J., Fliss, M.D. & McNaughton Reyes, L. (2023). “Intimate partner violence and suicide mortality: A cross-sectional study using machine learning and natural language processing of suicide data from 43 states.” Injury Prevention. dx.doi.org/10.1136/ip-2023-044976
• Kafka, J. M., Moracco, K.E., Graham, L., AbiNader, M.A., Fliss, M.D. & Rowhani-Rahbar. (2023). “Intimate partner violence circumstances for fatal violence in the US.” JAMA Network Open. doi:10.1001/jamanetworkopen.2023.12768
• Graham LM, Kafka JM, AbiNader MA, Lawler SM, Gover-Chamlou AN, Messing JT, Moracco KE. Intimate Partner Violence-Related Fatalities Among U.S. Youth Aged 0-24 Years, 2014-2018. Am J Prev Med. 2022 Apr;62(4):529-537. PubMed PMID: 34876319
• Boggs JM, Kafka JM. A Critical Review of Text Mining Applications for Suicide Research. Curr Epidemiol Rep. 2022;9(3):126-134. PubMed PMID: 35911089

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Delayed Bleeding: The Silent Risk for Seniors

Robert D. Glatter, MD; Richard D. Shih, MD; Christina L. Shenvi, MD, PhD, MBA

Authors and Disclosures

Disclosure: Robert D. Glatter, MD, has disclosed no relevant financial relationships. 

Disclosure: Richard D. Shih, MD, has disclosed the following relevant financial relationships:   Received research grant from: The Florida Medical Malpractice Joint Underwriting Association Grant for Safety of Health Care Services (Grant RFA #2022-01: The Geriatric Emergency Department Fall Injury Prevention [The GREAT FALL]. Principal Investigator: Shih RD; 07/01/2022 to 06/30/2025)

Disclosure: Christina L. Shenvi, MD, PhD, MBA, has disclosed the following relevant financial relationships:  Serve(d) as a consultant for: American College of Emergency Physicians; Institute for Healthcare Improvement  Serve(d) as a speaker or a member of a speakers bureau for: AstraZeneca; CurvaFix (spoke to their staff about geriatric falls)

This discussion was recorded on August 2, 2024. This transcript has been edited for clarity. 

Robert D. Glatter, MD: Hi. I'm Robert Glatter, medical advisor for Medscape Emergency Medicine. Today, we'll be discussing the results of a new study published in The Journal of Emergency Medicine , looking at the incidence of delayed intracranial hemorrhage among older patients taking preinjury anticoagulants who present to the emergency department (ED) with blunt head trauma .

Joining me today is the lead author of the study, Dr Richard Shih, professor of emergency medicine at Florida Atlantic University. Also joining me is Dr Christina Shenvi, associate professor of emergency medicine at the University of North Carolina (UNC) Chapel Hill, with fellowship training in geriatric emergency medicine. 

Welcome to both of you.

Richard D. Shih, MD: Thanks, Rob. 

Christina L. Shenvi, MD, PhD, MBA: Thanks. Pleasure to be here. 

ICH Study Methodology

Glatter: It's a pleasure to have you. Rich, this is a great study and targeted toward a population we see daily in the emergency department. I want you to describe your methodology, patient selection, and how you went about organizing your study to look at this important finding of delayed intracranial hemorrhage, especially in those on anticoagulants.

Shih: This all started for our research team when we first read the 2012 Annals of Emergency Medicine paper . The first author was Vincenzo Menditto, and he looked at a group of patients that had minor head injury , were anticoagulated, and had negative initial head CTs. 

There were about 100 patients, of which about 10 of them did not consent, but they hospitalized all these patients. These were anticoagulated, negative-first head CTs. They hospitalized the patients and then did a routine second CT at about 24 hours. They also followed them for a week, and it turned out a little over 7% of them had delayed head CT. 

We were wondering how many delayed intracranial hemorrhages we had missed because current practice for us was that, if patients had a good physical exam, their head CT was normal, and everything looked good, we would send them home.

Because of that, a number of people across the country wanted to verify those findings from the Menditto study. We tried to design a good study to answer that question. We happen to have a very large geriatric population in Florida, and our ED census is very high for age over 65, at nearly 60%. 

There are two Level I trauma centers in Palm Beach County. We included a second multicenter hospital, and we prospectively enrolled patients. We know the current state of practice is not to routinely do second CTs, so we followed these patients over time and followed their medical records to try to identify delayed bleeding. That's how we set up our methodology.

Is It Safe to Discharge Patients With Trauma After 24 Hours?

Glatter: For the bulk of these patients with negative head CTs, it's been my practice that when they're stable and they look fine and there's no other apparent, distracting painful trauma, injuries and so forth, they're safe to discharge. 

The secondary outcome in your study is interesting: the need for neurosurgical intervention in terms of those with delayed intracranial hemorrhage.

Shih: I do believe that it's certainly not the problem that Menditto described, which is 7%. There are two other prospective studies that have looked at this issue with delayed bleeding on anticoagulants . Both of these also showed a relatively low rate of delayed bleeding , which is between like 0.2% and 1.0%. In our study, it was 0.4%. 

The difference in the studies is that Menditto and colleagues routinely did 24-hour head CTs. They admitted everybody. For these other studies, routine head CT was not part of it. My bet is that there is a rate of delayed bleeding somewhere in between that seen in the Menditto study and that in all the other studies.

However, talking about significant intracranial hemorrhage, ones that perhaps need neurosurgery, I believe most of them are not significant. There's some number that do occur, but the vast majority of those probably don't need neurosurgery. We had 14 delayed bleeds out of 6000 patients with head trauma. One of them ended up requiring neurosurgery, so the answer is not zero, but I don't think it's 7% either. 

Glatter: Dr Shenvi, I want to bring you into the conversation to talk about your experience at UNC, and how you run things in terms of older patients with blunt head trauma on preinjury anticoagulants.

Shenvi: Thanks, Rob. I remember when this paper came out showing this 7% rate of delayed bleeding and the question was, "Should we be admitting all these people?" Partly just from an overwhelming need for capacity that that would bring, it just wasn't practical to say, "We're going to admit every patient with a negative head CT to the hospital and rescan them." That would be hundreds or thousands of patients each year in any given facility. 

The other thing is that delayed bleeds don't always happen just in the first 24 hours. It's not even a matter of bringing patients into observation for 24 hours, watching them, and rescanning them if they have symptoms. It can occur several days out. That never, in almost any institution that I know of, became standard practice. 

The way that it did change my care was to give good return precautions to patients, to make sure they have somebody with them to say, "Hey, sometimes you can have bleeding several days out after a fall, even though your CT scan here today looks perfect," and to alert them that if they start having severe headaches, vomiting, or other symptoms of intracranial hemorrhage, that they should come back. 

I don't think it ever became standard practice, and for good reason, because that was one study. The subsequent studies that Richard mentioned, pretty quickly on the heels of that initial one, showed a much lower rate of delayed ICH with the caveats that the methodology was different. 

Shift in Anticoagulants

Shenvi: One other big change from that original study, and now to Richard's study, is the shift in anticoagulants. Back in the initial study you mentioned, it was all warfarin . We know from other studies looking at warfarin vs the direct oral anticoagulants (DOACs) that DOACs have lower rates of ICH after a head injury, lower rates of need for neurosurgical intervention, and lower rates of discharge to a skilled nursing facility after an intracranial hemorrhage.

Across the board, we know that the DOACs tend to do better. It's difficult to compare newer studies because it's a different medication. It did inform my practice to have an awareness of delayed intracranial hemorrhage so that I warn patients more proactively. 

Glatter: I haven't seen a patient on warfarin in years. I don't know if either of you have, but it's all DOACs now unless there's some other reason. That shift is quite apparent.

Shih: The problem with looking at delayed bleeding for DOACs vs warfarin is the numbers were so low. I think we had 13 people, and seven were in the no-anticoagulant group. The numbers are even lower, so it's hard to say. 

I just wanted to comment on something that Dr Shenvi said, and I pretty much agree with everything that she said. Anticoagulants and warfarin, and that Menditto study, have a carryover effect. People group DOACs with warfarin similarly. When a patient is brought in, the first thing they talk about with head trauma is, "Oh, they're on an anticoagulant" or "They're not on an anticoagulant." It's so ingrained.

I believe that in emergency medicine, we're pressed for space and time and we're not as affected by that 24-hour observation. Maybe many of our surgeons will automatically admit those patients. 

I haven't seen a guideline from the United States, but there are two international guidelines. One is from Austria from 2019, and one is from Scandinavia . Both recommended 24-hour observation if you're on an anticoagulant.

There is a bit of controversy left over with that. Hopefully, as more and more of information, like in our study, comes out, people will be a little bit more clear about it. I don't think there's a need to routinely admit them. 

I do want to mention that the Menditto study had such a massive impact on everybody. They pointed out one subgroup (and it's such a small number of patients). They had seven cases of delayed bleeding; four or five of them were within that 24 hours, and a couple were diagnosed later over the next couple days.

Of those seven people, four of them had international normalized ratios (INRs) greater than 3. Of those four patients, I've heard people talk about this and recommend, "Okay, that's the subgroup I would admit." There's a toss-up with what to do with DOAC because it's very hard to tell whether there's an issue, whether there are problems with their dosing, and whatever. 

We actually recently looked at that. We have a much larger sample than four: close to 300 patients who were on warfarin. We looked at patients who had INRs below 3 and above 3, and we didn't show a difference. We still don't believe that warfarin is a big issue with delayed bleeding.

Should We Be Asking: 'Are They on Blood Thinners?'

Shenvi: One of the interesting trends related to warfarin and the DOACs vs no anticoagulant is that as you mentioned, Dr Shih, the first question out of people's mouths or the first piece of information emergency medical services gives you when they come in with a patient who's had a head injury is, "Are they on blood thinners or not?"

Yet, the paradigm is shifting to say it's not actually the blood thinners themselves that are giving older patients the higher risk for bleeding; it's age and other comorbidities.

Certainly, if you're on an anticoagulant and you start to bleed, your prognosis is much worse because the bleeding doesn't stop. In terms of who has a bleeding event, there's much less impact of anticoagulation than we used to think. That, in part, may be due to the change from warfarin to other medications.

Some of the experts I've talked to who have done the research on this have said, "Well, actually, warfarin was more of a marker for being much older and more frail, because it was primarily prescribed to older patients who have significant heart disease, atrial fibrillation , and so on." It was more a marker for somebody who is at risk for an intracranial hemorrhage. There are many changes that have happened in the past 10 years with medications and also our understanding. 

Challenges in Patient Follow-up

Glatter: That's a great point. One thing, Rich, I want to ask you about is in terms of your proxy outcome assessment. When you use that at 14 and 60 days with telephone follow-up and then chart review at 60 and 90 days (because, obviously, everyone can't get another head CT or it's difficult to follow patients up), did you find that worked out well in your prospective cohort study, in terms of using that as a proxy, so to speak? 

Shih: I would say to a certain extent. Unfortunately, we don't have access to the patients to come back to follow up all of them, and there was obviously a large number of patients in our study. 

The next best thing was that we had dedicated research assistants calling all of the patients at 14 days and 60 days. I've certainly read research studies where, when they call them, they get 80%-90% follow-up, but we did not achieve that.

I don't know if people are more inundated with spam phone calls now, or the older people are just afraid of picking up their phone sometimes with all the scams and so forth. I totally understand, but in all honesty, we only had about a 30%-35% follow-up using that follow-up pathway. 

Then the proxy pathway was to look at their charts at 60 and 90 days. Also, we looked at the Florida death registry, which is pretty good, and then finally, we had both Level I trauma centers in the county that we were in participating. It's standard practice that if you have an intracranial hemorrhage at a non–Level I trauma center, you would be transferred to a Level I trauma center. That's the protocol. I know that's not followed 100% of the time, but that's part of the proxy follow-up. You could criticize the study for not having closer to 90% actual contact, but that's the best we could do. 

Glatter: I think that's admirable. Using that paradigm of what you described certainly allows the reader to understand the difficulty in assessing patients that don't get follow-up head CT, and hardly anyone does that, as we know.

To your point of having both Level I trauma centers in the county, that makes it pretty secure. If we're going to do a study encompassing a similar type of regional aspect, it would be similar.

Shenvi: I think your proxies, to your credit, were as good as you can get. You can never get a 100% follow-up, but you really looked at all the different avenues by which patients might present, either in the death registry or a Level I center. Well done on that aspect. 

Determining When to Admit Patients for Observation

Glatter: In terms of admissions: You admit a patient, then you hear back that this patient should not have been admitted because they had a negative head CT, but you put them in anyway in the sense of delayed bleeding happening or not happening.

It's interesting. Maybe the insurers will start looking at this in some capacity, based on your study, that because it's so infrequent that you see delayed bleeding, that admitting someone for any reason whatsoever would be declined. Do you see that being an issue? In other words, [do you see] this leading to a pattern in terms of the payers?

Shih: Certainly, you could interpret it that way, and that would be unfortunate. The [incidence of] delayed bleeding is definitely not zero. That's the first thing. 

The second thing is that when you're dealing with an older population, having some sense that they're not doing well is an important contributor to trying to fully assess what's going on — whether or not they have a bleed or whether they're at risk for falling again and then hitting their head and causing a second bleed, and making sure they can do the activities of daily life. There really should be some room for a physician to say, "They just got here, and we don't know him that well. There's something that bothers me about this person" and have the ability to watch them for at least another 24 hours. That's how I feel. 

Shenvi: In my location, it would be difficult to try to admit somebody purely for observation for delayed bleeding. I think we would get a lot of pushback on that. The reasons I might admit a patient after a fall with a negative head CT, though, are all the things that, Rob, you alluded to earlier — which are, what made them fall in the first place and were they unable to get up? 

I had this happen just this week. A patient who fell couldn't get off the ground for 12 hours, and so now she's dehydrated and delirious with slight rhabdomyolysis . Then you're admitting them either for the sequelae of the fall that are not related to the intracranial hemorrhage, or the fact that they are so debilitated and deconditioned that they cannot take care of themselves. They need physical therapy. Often, we will have physical and occupational therapists come see them in the ED during business hours and help make an assessment of whether they are safe to go home or whether they fall again. That can give more evidence for the need for admission.

Glatter: To bring artificial intelligence into this discussion, algorithms that are out there that say, "Push a button and the patient's safe for discharge." Well, this argues for a clinical gestalt and a human being to make an assessment because you can use these predictive models, which are coming and they're going to be here soon, and they already are in some sense. Again, we have to use clinical human judgment. 

Shih: I agree. 

Advice for Primary Care Physicians

Glatter: What return precautions do you discuss with patients who've had blunt head trauma that maybe had a head CT, or even didn't? What are the main things we're looking for?

Shenvi: What I usually tell people is if you start to have a worse headache , nausea or vomiting, any weakness in one area of your body, or vision changes, and if there's a family member or friend there, I'll say, "If you notice that they're acting differently or seem confused, come back."

Shih: I agree with what she said, and I'm also going to add one thing. The most important part is they are trying to prevent a subsequent fall. We know that when they've fallen and they present to the ED, they're at even higher risk for falling and reinjuring themselves, and that's a population that's already at risk.

One of the secondary studies that we published out of this project was looking at follow-up with their primary care physicians, and there were two things that we wanted to address. The first was, how often did they do it? Then, when they did do it, did their primary care physicians try to address and prevent subsequent falls?

Both the answers are actually bad. Amazingly, just over like 60% followed up. 

In some of our subsequent research, because we're in the midst of a randomized, controlled trial where we do a home visit, when we initially see these individuals that have fallen, they'll schedule a home visit for us. Then a week or two later, when we schedule the home visit, many of them cancel because they think, Oh, that was a one-off and it's not going to happen again . Part of the problem is the patients, because many of them believe that they just slipped and fell and it's not going to happen again, or they're not prone to it.

The second issue was when patients did go to a primary care physician, we have found that some primary care physicians believe that falling and injuring themselves is just part of the normal aging process. A percentage of them don't go over assessment for fall risk or even initiate fall prevention treatments or programs. 

I try to take that time to tell them that this is very common in their age group, and believe it or not, a fall from standing is the way people really injure themselves, and there may be ways to prevent subsequent falls and injuries. 

Glatter: Absolutely. Do you find that their medications are a contributor in some sense? Say they're antihypertensive, have issues of orthostasis, or a new medication was added in the last week. 

Shenvi: It's all of the above. Sometimes it's one thing, like they just started tamsulosin for their kidney stone, they stood up, they felt lightheaded, and they fell. Usually, it's multifactorial with some changes in their gait, vision, balance, reflex time, and strength, plus the medications or the need for assistive devices. Maybe they can't take care of their home as well as they used to and there are things on the floor. It's really all of the above.

'Harder to Unlearn Something Than to Learn It'

Glatter: Would either of you like to add any additional points to the discussion or add a few pearls? 

Shenvi: This just highlights the challenge of how it's harder to unlearn something than to learn it, where one study that maybe wasn't quite looking at what we needed to, or practice and prescribing patterns have changed, so it's no longer really relevant. 

The things that we learned from that, or the fears that we instilled in our minds of, Uh oh, they could go home and have delayed bleeding , are much harder to unlearn, and it takes more studies to unlearn that idea than it did to actually put it into place. 

I'm glad that your team has done this much larger, prospective study and hopefully will reduce the concern about this entity. 

Shih: I appreciate that segue. It is amazing that, for paramedics and medical students, the first thing out of their mouth is, "Are they on an anticoagulant?"

In terms of the risk of developing an intracranial hemorrhage, I think it's much less than the weight we've put on it before. However, I believe if they have a bleed, the bleeds are worse. It's kind of a double-edged sword. It's still an important factor, but it doesn't come with the Oh my gosh, they're on an anticoagulant that everybody thinks about.

Number-One Cause of Traumatic Injury Is a Fall from Standing

Glatter: These are obviously ground-level falls in most patients and not motor vehicle crashes. That's an important part in the population that you looked at that should be mentioned clearly. 

Shih: It's astonishing. I've been a program director for over 20 years, and geriatrics is not well taught in the curriculum. It's astonishing for many of our trainees and emergency physicians in general that the number-one cause for traumatic injury is a fall from standing.

Certainly, we get patients coming in the trauma center like a 95-year-old person who's on a ladder putting up his Christmas lights. I'm like, oh my God. 

For the vast majority, it's closer to 90%, but in our study, for the patients we looked at, it was 80% that fall from standing. That's the mechanism that causes these bleeds and these major injuries. 

Shenvi: That's reflective of what we see, so it's good that that's what you looked at also. 

Glatter: Absolutely. Well, thank you both. This has been a very informative discussion. I appreciate your time, and our readers will certainly benefit from your knowledge and expertise. Thank you again. 

Robert D. Glatter, MD, is an assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is a medical advisor for Medscape and hosts the  Hot Topics in EM  series . 

Richard D. Shih, MD , is a professor of emergency Medicine at the Charles E. Schmidt College of Medicine at Florida Atlantic University. His current grant funding and area of research interest involves geriatric emergency department patients with head injury and fall-related injury. He has received a number of teaching awards including the American College of Emergency Physicians National Faculty Teaching Award and the American Academy of Emergency Medicine Educator of The Year Award. 

Christina L. Shenvi, MD, PhD, MBA , is an associate professor of emergency medicine at the University of North Carolina at Chapel Hill. She is fellowship-trained in geriatric emergency medicine; has launched a geriatric emergency medicine podcast, GEMCAST; and has served on the board of governors for the American College of Emergency Physicians Geriatric Emergency Department Accreditation Program.

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