"I never wanted to burn any bridges": discerning between pushing too hard and not enough in trainees' acts of professional resistance.

As trainees resist social harm and injustice in medicine, they must navigate the tension between pushing too hard and risking their reputation, or not enough and risking no change at all. We explore the discernment process by examining what trainees attend to moments before and while they are resisting to understand how they manage this tension. We interviewed 18 medical trainees who shared stories of resisting social harm and injustice in their training environments. Interviews were analyzed using open and focused coding using Vinthagen and Johansson's work, which conceptualizes resistance as a dynamic process that includes an individual's subjectivity within a larger system, the context in which they find themselves, and the interactions they have with others. We framed these acts as an individuals' attempt to undermine power, while also being entangled with that power and needing it for their efforts. When deciding on how and whether to resist, trainees underwent a cost-benefit analysis weighing the potential risk against their chances at change. They considered how their acts may influence their relationship with others, whether resisting would damage personal and programmatic reputations, and the embodied and social cues of other stakeholders involved. Trainees undergo a dynamic assessment process in which they analyze large amounts of information to keep themselves safe from potential retaliation. It is by attending to these various factors in their environment that trainees are able to keep their acts professional, and continue to do this challenging work in medical education.

'When I stood up for something it's because I felt a moral violation': Trainees' acts of resistance against social harm and injustice.

INTRODUCTION: As medical students around the world enter their chosen profession, they inherit a system that they did not design nor create, yet are still responsible for it. This system is rooted in centuries of social harm and inequity. This study examines trainees' professional acts of resistance to understand what trainees hope to accomplish in their resistance efforts, why they are resisting, and the tactics they use. METHODS: Drawing on counter-storytelling and critical theory, we collected in-depth qualitative interviews from nine medical students and nine residents/fellows across North America. Using theoretical guidance on how to study acts of resistance, data were analysed using a combination of coding techniques to understand resistors' intentions in resisting and the tactics they used to understand what, why, and how trainees were resisting. The analysis was returned to participants for member checking. RESULTS: Trainees described resisting systems of harm and injustice bequeathed to them by an older generation whose values and practices were reflective of a different time. Their motivations stemmed from deep-seated moral distress from the mistreatment of patients and learners. They hoped to re-envision medical education to be patient- and learner-centred. The tactics they chose depended on the level of power they had in the system and the extent to which they wished to have their efforts known. DISCUSSION: Trainees described intentional and deliberate acts of resistance to the social harm and injustice embedded in the broader profession to re-create the profession. Given that these acts spanned a large geographical area, this study suggests that trainees may be part of a larger social movement aimed at creating widespread change within the profession.

Osteosarcoma of the Larynx: A Case Report and Review of Literature.

The most common malignant laryngeal tumors are squamous cell carcinomas (SCCs), and other types such as sarcomas are rare. Osteosarcomas of the larynx are extremely rare within the subset of sarcomas, with very few cases reported in the literature. This cancer has a predilection for elderly males, in the sixth to eighth decades of life. Associated symptoms include hoarseness, stridor, and dyspnea. It is known to spread early and has a high rate of recurrence. We present the case of a 73-year-old male, a former smoker, who presented to the clinic with severe dyspnea and progressive hoarseness and was found to have a large exophytic mass arising from the epiglottis. A biopsy of the mass showed a poorly differentiated cancer with osteoid and new bone formation. He then underwent surgical removal of the mass, followed by radiation, and achieved clinical remission. However, a surveillance positron emission tomography (PET) scan 14 months later showed a hypermetabolic lesion in the left lung. Biopsy revealed metastatic osteosarcoma, and unfortunately, this cancer also spread to the brain. In this report, we will focus on the histological features of this rare malignancy and treatment options.

Clinical profile, outcomes and predictors of mortality in elderly patients admitted to the emergency medicine intensive care unit of a teaching hospital - A single-center registry.

AIM: Emergency intensive care of the elderly is often complicated and multifaceted. Understanding the clinical profile of elderly patients admitted in an emergency department-intensive care unit (ED-ICU) is crucial in planning health policies in geriatric emergency medicine. Thus, the aim of the study was to create a local registry of elderly people utilizing the ED-ICU services and to understand the rate and predictors of mortality. METHODS: A retrospective chart analysis was performed including all patients aged ≥60 years who had an ED-ICU admission during a 6-month period (August 2018-January 2019). A structured case record form was used to capture information such as basic demography, clinical profile, and outcomes. RESULTS: Total number of records considered for final analysis were 503. Mortality was seen in 21.07% (n = 106/503). The most common presenting complaint and cause of death was breathing difficulty (n = 48/503; 29.42%) and pneumonia (n = 41/106; 38.67%), repectively. The significant predictors of mortality [adjusted odds ratio; 95% confidence intervals; P value] were hypertension (2.195; 1.255, 3.840; 0.006), chronic liver disease (CLD) (4.324; 1.170, 15.979; 0.028), malignancy (2.854; 1.045, 7.796; 0.041), requiring noninvasive ventilation (NIV) (2.618; 1.449, 4.730; 0.001), requiring intubation (6.638; 3.705, 11.894; <0.001), and requiring vasopressors (3.583; 1.985, 6.465; <0.001). CONLUSION: Approximately one in every five elderly patients getting admitted in ED-ICU died, and respiratory illness was the common diagnosis leading to death. Those with comorbidities such as hypertension, CLD, or malignancy and those requiring NIV, intubation, or vasopressors had higher mortality.