Medicine and Health Sciences Commons^™

Challenging Hazards Amidst Observational Simulation In The Emergency Department: Advancing Gamification In Simulation Education Through A Novel Resident-Led Skills Competition., Nicholas Salerno, Dimitrios Papanagnou, Md, Priyha Mahesh, Kaitlin M Bowers, Scott H Pasichow, Sara Paradise, Xiao Chi Zhang

Department of Emergency Medicine Faculty Papers

Medical simulation competitions have become an increasingly popular method to provide a hands-on "gamified" approach to education and training in the health professions. The most well-known competition, SimWars, consists of well-coordinated teams that are tasked with completing a series of mind-bending clinical scenarios in front of a live audience through 'bracket-style' elimination rounds. Similarly, challenging hazards amidst observational simulation (CHAOS) in the emergency department (ED) is another novel approach to gamification in both its structure and feel. Conducted at the Council of Emergency Medicine Resident Directors (CORD) 2018 National Assembly in San Antonio, Texas, instead of assigning premeditated teams, it …

A Three-Dimensional Printed Low-Cost Anterior Shoulder Dislocation Model For Ultrasound-Guided Injection Training., Zachary Risler, Mark A. Magee, Jacob M. Mazza, Kelly Goodsell, Arthur K. Au, Resa E. Lewiss, Robert S. Pugliese, Bon Ku

Department of Emergency Medicine Faculty Papers

Anterior shoulder dislocations are the most common, large joint dislocations that present to the emergency department (ED). Numerous studies support the use of intraarticular local anesthetic injections for the safe, effective, and time-saving reduction of these dislocations. Simulation training is an alternative and effective method for training compared to bedside learning. There are no commercially available ultrasound-compatible shoulder dislocation models. We utilized a three-dimensional (3D) printer to print a model that allows the visualization of the ultrasound anatomy (sonoanatomy) of an anterior shoulder dislocation. We utilized an open-source file of a shoulder, available from embodi3D® (Bellevue, WA, US). After …

Low-Cost, Low Fidelity Meat Model To Teach Ultrasound Guided Nerve Blocks, Morgan Oakland, Shruti Chandra, Carl Alsup

Department of Emergency Medicine Faculty Papers

Audience: The target audience of this workshop is emergency medicine residents; however, it is appropriate for all level of learners from medical students to faculty.

Introduction: Pain control is a major focus in the emergency department. Regional anesthesia is a rapidly growing alternative to opioid analgesia or procedural sedation. Nerve blocks are useful in many procedures and are relevant to some of our most common chief complaints. Ultrasound guided regional anesthesia has been shown to be highly successful with minimal complications, and has been shown to reduce the need for supplemental anesthesia such as sedation and narcotics.¹ Ultrasound guidance …

Gamification Of Hospital Utilization: Incorporating Cost-Consciousness In Daily Practices., Peter J Tomaselli, Dimitrios Papanagnou, Md, Jonathan E Karademos, Elizabeth Teixeira, Xiao Chi Zhang

Department of Emergency Medicine Faculty Papers

Healthcare costs in the United States have skyrocketed over the past decade, contributing to an estimated $750 billion in wasteful spending annually. Despite the demand to improve residency education on value-based, cost-conscious healthcare, there is no consensus on how to best teach this practice. Traditional lectures have failed to demonstrate enduring change in clinical practice patterns, provider attitudes, and reductions in hospital expenditures. We sought to evaluate whether gamification is an effective pedagogical tool to teach cost-consciousness to emergency medicine (EM) residents by creating a 60-minute interactive session based on the popular gameshow, the Price is Right. Costs and associated …

Myocardial Dysfunction After Out-Of-Hospital Cardiac Arrest: Predictors And Prognostic Implications., Yuan Yao, Nicholas James Johnson, Sarah Muirhead Perman, Vimal Ramjee, Anne Victoria Grossestreuer, David Foster Gaieski

Department of Emergency Medicine Faculty Papers

We aim to determine the incidence of early myocardial dysfunction after out-of-hospital cardiac arrest, risk factors associated with its development, and association with outcome. A retrospective chart review was performed among consecutive out-of-hospital cardiac arrest (OHCA) patients who underwent echocardiography within 24 h of return of spontaneous circulation at three urban teaching hospitals. Our primary outcome is early myocardial dysfunction, defined as a left ventricular ejection fraction < 40% on initial echocardiogram. We also determine risk factors associated with myocardial dysfunction using multivariate analysis, and examine its association with survival and neurologic outcome. A total of 190 patients achieved ROSC and underwent echocardiography within 24 h. Of these, 83 (44%) patients had myocardial dysfunction. A total of 37 (45%) patients with myocardial dysfunction survived to discharge, 39% with intact neurologic status. History of congestive heart failure (OR 6.21; 95% CI 2.54-15.19), male gender (OR 2.27; 95% CI 1.08-4.78), witnessed arrest (OR 4.20; 95% CI 1.78-9.93), more than three doses of epinephrine (OR 6.10; 95% CI 1.12-33.14), more than four defibrillations (OR 4.7; 95% CI 1.35-16.43), longer duration of resuscitation (OR 1.06; 95% CI 1.01-1.10), and therapeutic hypothermia (OR 3.93; 95% CI 1.32-11.75) were associated with myocardial dysfunction. Cardiopulmonary resuscitation immediately initiated by healthcare personnel was associated with lower odds of myocardial dysfunction (OR 0.40; 95% CI 0.17-0.97). There was no association between early myocardial dysfunction and mortality or neurological outcome. Nearly half of OHCA patients have myocardial dysfunction. A number of clinical factors are associated with myocardial dysfunction, and may aid providers in anticipating which patients need early diagnostic evaluation and specific treatments. Early myocardial dysfunction is not associated with neurologically intact survival.

Epigenetics In Ovarian Cancer: Premise, Properties, And Perspectives., Qilian Yang, Yuqing Yang, Nianxin Zhou, Kexin Tang, Wayne Bond Lau, Bonnie Lau, Wei Wang, Lian Xu, Zhengnan Yang, Shuang Huang, Xin Wang, Tao Yi, Xia Zhao, Yuquan Wei, Hongjing Wang, Linjie Zhao, Shengtao Zhou

Department of Emergency Medicine Faculty Papers

Malignant ovarian tumors bear the highest mortality rate among all gynecological cancers. Both late tumor diagnosis and tolerance to available chemical therapy increase patient mortality. Therefore, it is both urgent and important to identify biomarkers facilitating early identification and novel agents preventing recurrence. Accumulating evidence demonstrates that epigenetic aberrations (particularly histone modifications) are crucial in tumor initiation and development. Histone acetylation and methylation are respectively regulated by acetyltransferases-deacetylases and methyltransferases-demethylases, both of which are implicated in ovarian cancer pathogenesis. In this review, we summarize the most recent discoveries pertaining to ovarian cancer development arising from the imbalance of histone acetylation …

Neurosyphilis: A Simulation Case For Emergency Medicine Residents., Chana Rich, Dimitrios Papanagnou, David Curley, Xiao Chi Zhang

Department of Emergency Medicine Faculty Papers

Neurosyphilis is a dangerous and increasingly more prevalent sexually transmitted infection of the central nervous system caused by the bacterium Treponemapallidum that can present during the advanced stages of the disease (tertiary syphilis). Health care providers must remain vigilant in screening for syphilis in patients with high-risk behaviors as a delay in diagnosis and treatment may lead to symptom progression and debilitating sequelae years later. To date, there have been no published simulation case studies on neurosyphilis. This simulation case, based on a real patient encounter, is written for emergency medicine residents to diagnose and manage a patient …

Cardiac-Derived Ctrp9 Protects Against Myocardial Ischemia/Reperfusion Injury Via Calreticulin-Dependent Inhibition Of Apoptosis., Dajun Zhao, Pan Feng, Yang Sun, Zhigang Qin, Zhengbin Zhang, Yanzhen Tan, Erhe Gao, Wayne Bond Lau, Xin-Liang Ma, Jian Yang, Shiqiang Yu, Xuezeng Xu, Dinghua Yi, Wei Yi

Department of Emergency Medicine Faculty Papers

Cardiokines play an essential role in maintaining normal cardiac functions and responding to acute myocardial injury. Studies have demonstrated the heart itself is a significant source of C1q/TNF-related protein 9 (CTRP9). However, the biological role of cardiac-derived CTRP9 remains unclear. We hypothesize cardiac-derived CTRP9 responds to acute myocardial ischemia/reperfusion (MI/R) injury as a cardiokine. We explored the role of cardiac-derived CTRP9 in MI/R injury via genetic manipulation and a CTRP9-knockout (CTRP9-KO) animal model. Inhibition of cardiac CTRP9 exacerbated, whereas its overexpression ameliorated, left ventricular dysfunction and myocardial apoptosis. Endothelial CTRP9 expression was unchanged while cardiomyocyte CTRP9 levels decreased after simulated …

Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model., Robert Strony, Jennifer R. Marin, John Bailitz, Anthony J. Dean, Mike Blaivas, Vivek Tayal, Chris Raio, Rachel Liu, Aimee Woods, Michael Zwank, Matthew Fields, Alyssa Abo, Stan Wu, Tarina Kang, Teresa Liu, Megan Leo, Courtney Smalley, Jerry Chiricolo, Mikaela Chilstrom, Resa E. Lewiss

Department of Emergency Medicine Faculty Papers

Clinical ultrasound (CUS) is integral to the practice of an increasing number of medical specialties. Guidelines are needed to ensure effective CUS utilization across health systems. Such guidelines should address all aspects of CUS within a hospital or health system. These include leadership, training, competency, credentialing, quality assurance and improvement, documentation, archiving, workflow, equipment, and infrastructure issues relating to communication and information technology. To meet this need, a group of CUS subject matter experts, who have been involved in institution- and/or systemwide clinical ultrasound (SWCUS) program development convened. The purpose of this paper was to create a model for SWCUS …

Variability Of Extracorporeal Cardiopulmonary Resuscitation Utilization For Refractory Adult Out-Of-Hospital Cardiac Arrest: An International Survey Study., Patrick J. Coppler, Benjamin S. Abella, Clifton W. Callaway, Minjung Kathy Chae, Seung Pill Choi, Jonathan Elmer, Won Young Kim, Young-Min Kim, Michael Kurz, Joo Suk Oh, Joshua C. Reynolds, Jon C. Rittenberger, Kelly N. Sawyer, Chun Song Youn, Byung Kook Lee, David F. Gaieski

Department of Emergency Medicine Faculty Papers

Objective: A growing interest in extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue strategy for refractory adult out-of-hospital cardiac arrest (OHCA) currently exists. This study aims to determine current standards of care and practice variation for ECPR patients in the USA and Korea.

Methods: In December 2015, we surveyed centers from the Korean Hypothermia Network (KORHN) Investigators and the US National Post-Arrest Research Consortium (NPARC) on current targeted temperature management and ECPR practices. This project analyzes the subsection of questions addressing ECPR practices. We summarized survey.

Results: Overall, 9 KORHN and 4 NPARC centers reported having ECPR programs and had complete …

A Curious Researcher's Guide On Successfully Publishing Scientific Manuscripts., Xiao Chi Zhang, Alexander H Tran, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

Publishing a manuscript in an academic journal represents more than just 'promotional currency.' It provides the opportunity to provoke debate, share your experiences, and challenge the status quo on provider practices. Writing a manuscript relies on collaboration and shared responsibility from a research team, which can often challenge mentors as they supervise and guide its development. While there are numerous online resources and peer-reviewed journal articles on 'How to write a scientific article,' we aim to tackle an even larger and overarching theme that transcends specific journal categories, writing styles, and citation formatting. In order to guide new researchers in …

Ice-Man Down: Using Simulation To Practice The Safe Extrication Of Collapsed Hockey Players In A Confined Space., Meryl Abrams, Dimitrios Papanagnou, Carlos Rodriguez, Joshua Rudner, Hyunjoo Lee, Simran Buttar, Ronald V Hall, Xiao Chi Zhang

Department of Emergency Medicine Faculty Papers

Sporting event emergencies are common among both spectators and players, with unique sets of challenges associated with patient extrication in unfamiliar and chaotic environments. It is critical for sports physicians and trainers to deliberately train and prepare for emergent situations with limited resources during athletic events. One of the most difficult, yet commonly encountered challenges is determining when and how to safely remove an injured player's helmet and sporting equipment, particularly if a spinal injury is highly suspected. We created a high-fidelity simulation case to practice the safe extrication of a hockey player who collapses on the bench in the …

A Novel Approach To Debriefing Medical Simulations: The Six Thinking Hats., Xiao Chi Zhang, Hyunjoo Lee, Carlos Rodriguez, Joshua Rudner, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

Simulation has become a standard training method in emergency medicine (EM). Specifically, post-simulation debriefings offer participants the opportunity for reflection while exposing their knowledge and practice gaps. The educational yield of these debriefings, however, is contingent on the debriefer's skills. Without professional development, faculty and educators may not be equipped with supportive debriefing strategies. We propose the Six Thinking Hats (6TH), originally developed by Edward de Bono (1970) as a debriefing framework to support effective, high-yield debriefing conversations. The six colored hats represent six unique approaches to critical thinking. The white hat represents the facts; the green hat, creativity and …

Reversible Cerebral Vasoconstriction Disorder In A Patient With A Chief Complaint Of Headache., Simran Buttar, Anuja Trivedi, Dimitrios Papanagnou, Md

Department of Emergency Medicine Faculty Papers

As emergency medicine physicians, we have formulated an approach to managing patients with a chief complaint of headache that starts with considering the story the patient relays in the context of a wide differential. Here we will describe a case that presented to our emergency department in hopes to broaden your differential. Reversible cerebral vasoconstriction syndrome (RCVS), well described in the neurology literature, is characterized by severe headaches that may or may not be accompanied by neurological symptoms and is definitively diagnosed by diffuse constriction of cerebral arteries on cerebral angiogram. Here we present a case of a patient who …

Integrating Telehealth Emergency Department Follow-Up Visits Into Residency Training., Dimitrios Papanagnou, Danica Stone, Shruti Chandra, Phillip Watts, Anna Marie Chang, Judd E. Hollander

Department of Emergency Medicine Faculty Papers

Introduction: Given the rapid expansion of telehealth (TH), there is an emerging need for trained professionals who can effectively deliver TH services. As there is no formal TH training program for residents, the Department of Emergency Medicine (DEM) at Thomas Jefferson University (TJU) developed a pilot training program for senior post-graduate-year three (PGY-3) residents that exposed them to TH practices. The objective of the study was to determine the feasibility of developing a resident-led, post-Emergency-Department (ED) visit TH follow-up program as an educational opportunity to 1) address patient satisfaction; and 2) expose senior residents to TH delivery.

Methods: During …

Validation Of An Icd Code For Accurately Identifying Emergency Department Patients Who Suffer An Out-Of-Hospital Cardiac Arrest., Shelby K. Shelton, Steve B. Chukwulebe, David F. Gaieski, Benjamin S. Abella, Brendan G. Carr, Sarah M. Perman

Department of Emergency Medicine Faculty Papers

AIM: International classification of disease (ICD-9) code 427.5 (cardiac arrest) is utilized to identify cohorts of patients who suffer out-of-hospital cardiac arrest (OHCA), though the use of ICD codes for this purpose has never been formally validated. We sought to validate the utility of ICD-9 code 427.5 by identifying patients admitted from the emergency department (ED) after OHCA.

METHODS: Adult visits to a single ED between January 2007 and July 2012 were retrospectively examined and a keyword search of the electronic medical record (EMR) was used to identify patients. Cardiac arrest was confirmed; and ICD-9 information and location of return …

The Rna Binding Protein Sorbs2 Suppresses Metastatic Colonization Of Ovarian Cancer By Stabilizing Tumor-Suppressive Immunomodulatory Transcripts., Linjie Zhao, Wei Wang, Shuang Huang, Zhengnan Yang, Lian Xu, Qilian Yang, Xiu Zhou, Jinjin Wang, Qiuhong Shen, Chenlu Wang, Xiaobing Le, Min Feng, Nianxin Zhou, Wayne Bond Lau, Bonnie Lau, Shaohua Yao, Tao Yi, Xin Wang, Xia Zhao, Yuquan Wei, Shengtao Zhou

Department of Emergency Medicine Faculty Papers

BACKGROUND: Ovarian cancer constitutes one of the most lethal gynecologic malignancies for females. Currently, early detection strategies and therapeutic options for ovarian cancer are far from satisfactory, leading to high diagnosis rates at late stages and disease relapses. New avenues of therapy are needed that target key processes in ovarian cancer progression. While a variety of non-coding RNAs have been proven to regulate ovarian cancer metastatic progression, the functional roles of RNA-binding proteins (RBPs) in this process are less well defined.

RESULTS: In this study, we identify that the RBP sorbin and SH3 domain containing 2 (SORBS2) is a potent …

Trapped As A Group, Escape As A Team: Applying Gamification To Incorporate Team-Building Skills Through An 'Escape Room' Experience, Xiao Chi Zhang, Hyunjoo Lee, Carlos Rodriguez, Joshua Rudner, Teresa M Chan, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

Teamwork, a skill critical for quality patient care, is recognized as a core competency by the Accreditation Council for Graduate Medical Education (ACGME). To date, there is no consensus on how to effectively teach these skills in a forum that engages learners, immerses members in life-like activities, and builds both trust and rapport. Recreational 'Escape Rooms' have gained popularity in creating a life-like environment that rewards players for working together, solving puzzles, and completing successions of mind-bending tasks in order to effectively 'escape the room' in the time allotted. In this regard, escape rooms share many parallels with the multitasking …

Temporal Trends In Incidence, Sepsis-Related Mortality, And Hospital-Based Acute Care After Sepsis., Nathaniel Meyer, Michael O. Harhay, Dylan S. Small, Hallie C. Prescott, Kathryn H. Bowles, David F. Gaieski, Mark E Mikkelsen

Department of Emergency Medicine Faculty Papers

OBJECTIVES: A growing number of patients survive sepsis hospitalizations each year and are at high risk for readmission. However, little is known about temporal trends in hospital-based acute care (emergency department treat-and-release visits and hospital readmission) after sepsis. Our primary objective was to measure temporal trends in sepsis survivorship and hospital-based acute care use in sepsis survivors. In addition, because readmissions after pneumonia are subject to penalty under the national readmission reduction program, we examined whether readmission rates declined after sepsis hospitalizations related to pneumonia.

DESIGN AND SETTING: Retrospective, observational cohort study conducted within an academic healthcare system from 2010 …

Not Your Typical Simulation Workshop: Using Legos To Train Medical Students On The Practice Of Effective Communication., Dimitrios Papanagnou, Hyunjoo Lee, Carlos Rodriguez, Xiao Chi C Zhang, Joshua Rudner

Department of Emergency Medicine Faculty Papers

As students in the health professions transition from the classroom into the clinical environment, they will be expected to effectively communicate with their team members and their patients. Effective communication skills are essential to their ability to effectively contribute to their clinical team and the patient care they deliver. The authors propose an interactive workshop that can support students' deliberate practice of communication skills. The authors designed a simulation workshop that affords students the opportunity to practice their communication and peer-to-peer coaching skills. Using LEGOs, a one-hour workshop was conducted with medical students. Students were divided into groups of two. …

Emergency Medicine Resident Perceptions About The Need For Increased Training In Communicating Diagnostic Uncertainty., Kristin L Rising, Dimitrios Papanagnou, Danielle Mccarthy, Alexzandra Gentsch, Rhea Powell

Department of Emergency Medicine Faculty Papers

Introduction Diagnostic uncertainty is common in healthcare encounters. Effective communication is important to help patients and providers navigate diagnostic uncertainty, especially at transitions of care. This study sought to assess the experience and training of emergency medicine (EM) residents with communication of diagnostic uncertainty. Methods This was a survey study of a national sample of EM residents. The survey questions elicited quantitative and qualitative responses about experiences with and educational preparation for communication with patients in the setting of diagnostic uncertainty. Results A sample of 263 emergency medicine residents who had trained at over 87 medical schools and 37 residency …

A Novel Biosimulation Task Trainer For The Deliberate Practice Of Resuscitative Hysterotomy., Lawrence Lau, Dimitrios Papanagnou, Elaine Smith, Crystal Waters, Elizabeth Teixeira, Xiao Chi Zhang

Department of Emergency Medicine Faculty Papers

Resuscitative hysterotomy is a daunting and rarely performed procedure in the emergency department (ED). Given the paucity of clinical exposure to this intervention, resuscitative hysterotomy is an ideal opportunity for simulation-mediated deliberate practice. The authors propose a novel training program using a homegrown, realistic, simulation device as a means to practice resuscitative hysterotomy. Two high-fidelity, tissue-based task-trainer models were constructed and tested on a convenience sample of 14 emergency medicine (EM) residents. The simulated human placenta, bladder, amniotic sac, and uterus were constructed through the use of porcine skin, porcine stomach, transparent plastic bag, Foley tubing, and squid mantle, all …