Emergency Medicine Commons^™

Building A Virtual Community Of Practice For Medical Students: The Global Emergency Medicine Student Leadership Program, Ashley Pickering, Andrés Patiño, Stephanie C. Garbern, Dania Abu-Jubara, Alexandra Digenakis, Anthony Rodigin, Michaela S. Banks, Kimberly Herard, Stacey Chamberlain, Elizabeth L. Devos

School of Medicine Faculty Publications

Virtual communities of practice (VCoPs) facilitate distance learning and mentorship by engaging members around shared knowledge and experiences related to a central interest. The American College of Emergency Physicians and Emergency Medicine Residents’ Association's Global Emergency Medicine Student Leadership Program (GEM‐SLP) provides a valuable model for building a VCoP for GEM and other niche areas of interest. This VCoP facilitates opportunities for experts and mentees affiliated with these national organizations to convene regularly despite barriers attributed to physical distance. The GEM‐SLP VCoP is built around multiple forms of mentorship, monthly mentee‐driven didactics, academic projects, and continued engagement of program graduates …

A Survey Of Delirium Self-Reported Knowledge And Practices Among Emergency Physicians In The United States, Anita N. Chary, Adriane Lesser, Sharon K. Inouye, Christopher R. Carpenter Md, Msc, Amy R. Stuck, Maura Kennedy

Journal of Geriatric Emergency Medicine

Objective: This study aimed to evaluate United States emergency physicians’ self-reported knowledge and practices regarding the detection, prevention, and management of delirium, a common and deadly syndrome that disproportionately affects older emergency department (ED) patients. Knowledge and practices of the broader emergency physician community about these priority topics in geriatric emergency medicine are understudied.

Design: Electronic self-administered online survey

Setting: United States

Participants: One-hundred ninety-seven emergency physicians of the American College of Emergency Physicians Emergency Medicine Practice Research Network

Measures: Descriptive statistics were generated from survey responses.

Results: Of 734 physicians in the research network who were sent the …

Emergency Medicine Journal Club, David Gibbs, Dylan Norton

Advances in Clinical Medical Research and Healthcare Delivery

In this column, we provide a brief review of important papers recently published that relate to the field of Emergency Medicine. The goal is to provide the busy clinician a bullet-like summary of the study, focusing on the research question, methods, results, limitations, and bottom line interpretation.

The Influence Of Hospital Site On Emergency Physician Press Ganey Scores, Dietrich Jehle, Brian Doherty, Lexus Dickson, Melville C. O'Brien, Casey Wilson, Scott Gutovitz

HCA Healthcare Journal of Medicine

Background

The use of physician satisfaction scores to evaluate emergency medicine physicians’ performance and compensation is controversial. Prior studies have shown that the clinical environment may influence scores. This study compared satisfaction scores for the same physician at different emergency departments (ED). Differences in their individual score may indicate the ED environment could be as important as the physician’s interaction.

Methods

Press Ganey satisfaction scores were obtained for physicians at three EDs—Grand Strand, South Strand and North Strand—between July 2018 and June 2019. Included physicians worked at all 3 facilities and had at least 6 patient satisfaction surveys at each …

Mindfulness In The Emergency Department (Med): An Asynchronous Learning Course To Practise Mindfulness And Resilience In The Emergency Room Of Low Resource Setting, Syed Maaz Salahuddin, Shahan Waheed

Department of Emergency Medicine

Owing to the fast-paced, stressful, and frequent crucial rapid decisions that trigger cognitive exhaustion, emergency physicians are especially vulnerable to burnout. Mindfulness practices have been defined in the literature and it focuses on the well-being and resilience. Mindfulness is characterised as the ability to use tools and expertise to mentally respond to environmental problems to fulfil psychological needs. To overcome burnout, a self-directed learning course was developed for emergency physicians that will include learning goals on mindfulness, peer group discussions and tasks, role playing and practising meditation exercises. It would concentrate on the foundations of mindfulness and resilience, learning and …

Emergency Medicine And Covid-19: Now And Next Year, Theodore A. Christopher, Adrienne N. Christopher

Department of Emergency Medicine Faculty Papers

The COVID-19 pandemic is responsible for infecting to date more than 93 million people worldwide and causing more than 2 million deaths. That the vast majority of deaths have occurred in the United States (U.S.) can be attributed to nonadherence by Americans to basic public health mitigation strategies that are known to curtail coronavirus spread. Emergency Departments (ED’s) throughout the U.S. experienced a dramatic decrease in patient visits during the first surge of COVID-19, followed by an ED patient visit rebound to approximately 80% of pre-COVID-19 numbers, which have remained relatively stable through the current second COVID-19 surge. The pandemic …

Emergency Medicine Shift Factors Causing The Most Stress Among Emergency Medicine Residents, Mohamad Moussa, Kristen Hayden, Chia-Hao Shih, Sadik Khuder, Zayd Safadi, Connor Parsell

Journal of Wellness

Introduction: Past studies demonstrate that stress and anxiety affect emergency medicine physicians, but the causal factors identified are usually from sources outside the work shift. We attempt to show the relationship between intrinsic factors of a work shift and anxiety perceived by residents, while also examining differing gender responses.

Methods: In 2018, a cross-sectional survey of emergency medicine residents in the United States was distributed anonymously through the Emergency Medicine Residents Association. The survey consisted of demographic questions, novel questions identifying intrinsic factors, and the Generalized Anxiety Disorder 7-item (GAD-7) scale. Spearman correlation, independent t-test, and multivariate analysis of variance …

A Novel Approach To Explore Safety-I And Safety-Ii Perspectives In In Situ Simulations-The Structured What If Functional Resonance Analysis Methodology., Ralph James Mackinnon, Karin Pukk-Härenstam, Christopher S. Kennedy, Erik Hollnagel, David Slater

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVES: With ever increasingly complex healthcare settings, technology enhanced simulation (TES) is well positioned to explore all perspectives to enhance patient safety and patient outcomes. Analysis from a Safety-II stance requires identification of human adjustments in daily work that are key to maintaining safety. The aim of this paper is to describe an approach to explore the consequences of human variability from a Safety-II perspective and describe the added value of this to TES.

METHODS: The reader is guided through a novel application of functional resonance analysis methodology (FRAM), a method to analyse how a system or activity is affected …

The Necessity Of Human Factors Training In Emergency Medicine Residency: A Road Less Travelled, Abdul Ahad Chhotani, Shahan Waheed

Department of Emergency Medicine

No abstract provided.

Systematic Review On Epidemiology, Interventions And Management Of Noncommunicable Diseases In Acute And Emergency Care Settings In Kenya, Christine Ngaruiya, Annrita Kawira, Florence Mali, Faith Kambua, Beatrice Mwangi, Mbatha Wambua, Denise Hersey, Laventa Obare, Rebecca Leff, Benjamin Wachira

Emergency Medicine, East Africa

Introduction: Mortality and morbidity from Non-Communicable Diseases (NCDs) in Africa are expected to worsen if the status quo is maintained. Emergency care settings act as a primary point of entry into the health system for a spectrum of NCD-related illnesses, however, there is a dearth of literature on this population. We conducted a systematic review assessing available evidence on epidemiology, interventions and management of NCDs in acute and emergency care settings in Kenya, the largest economy in East Africa and a medical hub for the continent.

Methods: All searches were run on July 15, 2015 and updated on December 11, …

Use Of Point Of Care Ultrasound In The Emergency Department For Diagnosis Of Femoral Pseudoaneurysm, Stephen Janssen, Jeffrey Gardecki, Giovanna Finocchio

Rowan-Virtua Research Day

Iatrogenic pseudoaneurysm after puncture or intervention of the femoral artery is a rare complication of arterial surgical intervention occurring in 0.05-0.50% of diagnostic and therapeutic catheterizations and can present weeks after initial presentation. Today we present a 57-year-old gentleman 3 months status post femoral artery stent who presented with swelling to his right groin. Point of care ultrasound was used to diagnose an actively bleeding pseudoaneurysm with hematoma that ultimately led to repeat stenting. This case shows how point of care ultrasound can expedite diagnosis and intervention and is a useful tool for the emergency physician at initial presentation.

The Application Of Point-Of-Care Ultrasound In Ed Intubations And Airway Access: A Systematic Review, Frank Wheeler, James Espinosa, Alan Lucerna, Jeffrey Gardecki

Rowan-Virtua Research Day

Intubation is an essential procedure performed on a routine basis in the emergency room. Unsuccessful intubations are associated with deleterious outcomes. A systematic review was performed to investigate the accuracy of point of care ultrasound (POCUS) in successful Endotracheal Tube (ET) tube confirmation, utilizing ultrasonography, identification of the cricothyroid membrane utilizing ultrasound, and dynamically during use of ultrasonography in the process of intubation. This review demonstrated high sensitivity and specificity for ultrasound confirmation of ET tube placement, high success rate in ultrasound-guided intubation, and lower than expected accuracy in identifying the cricothyroid membrane. Ultrasonography should be considered for ET tube …

Case Report: The Value Of Vigilance And Iterative Evaluations With An Uncooperative Patient In The Emergency Department, Duwayne Campbell

Rowan-Virtua Research Day

Discussion

A Flexible and Vigilant Approach: The initial presenting information from EMS could have led to anchoring bias. A flexible approach led to new information, which led to interative testing.

Iterative physical examination. There are cases, as seen in this case report, where the physical examination was unreliable or even impossible. Iterative evaluations ultimately led to appropriate imaging and accurate diagnosis.

Iterative testing: In the case presented, the radiologist reported a finding as being present on a prior CXR; however, given the patient’s clinical presentation, further imaging studies were necessary.

Access To Point-Of-Care Ultrasound In Maine Emergency Departments, Christina N. Wilson, Campbell Belisle Haley

Journal of Maine Medical Center

Introduction: Point-of-care ultrasound (POCUS) is an essential tool in emergency medicine. We evaluated access to bedside ultrasound machines and characterized POCUS use in Maine emergency departments (EDs).

Methods: We conducted a cross-sectional electronic survey of all ED medical directors in Maine. The survey included questions on ED characteristics, access to ultrasound machines, POCUS use patterns, POCUS administration, and barriers to use.

Results: Thirty-four EDs were identified, and 24 medical directors completed the survey, yielding a response rate of 71%. EDs were predominantly small and rural. Only 21% identified as urban, and 54% reported less than 20 000 annual visits. Surveys …

Patient Experience In A Pediatric Emergency Department During Covid-19, Beth L. Emerson Md, Erika Setzer

Patient Experience Journal

The COVID-19 pandemic has changed many dynamics in healthcare in the United States. This study explores an increase in patient experience (PE) scores in a pediatric emergency department. Visits were analyzed before and after March 8, 2020, corresponding with the first local case of COVID-19. Changes in the patient population and characteristics of survey responders were analyzed. Overall, the number of daily visits decreased (113 vs 36/day) and survey response rate decreased (3.7 vs 2.8%, p = 0.03), but PE scores increased (87.21 to 93.73, p = 0.002). Comparatively, an increase in patients with higher acuity levels by Emergency Severity …

Telemedicine In The Emergency Department In The Era Of Covid-19: Front-Line Experiences From 2 Institutions, Joel M. Hamm, Chris Greene, Michael T. Sweeney, Setareh Mohammadie, Linda B. Thompson, Eric Wallace, Walter Schrading

Emergency Medicine Faculty Publications

During the COVID-19 pandemic, one of the major changes that has occurred in emergency medicine is the evolution of telemedicine. With relaxation of regulatory and administrative barriers, the use of this already available technology has rapidly expanded. Telemedicine provides opportunity to markedly decrease personal protective equipment (PPE) and reduce healthcare worker exposures. Moreover, with the convenience and availability of access to medical care via telemedicine, a more fundamental change in healthcare delivery in the United States is likely. The implementation of telemedicine in the emergency department (ED) in particular has great potential to prevent the iatrogenic spread of COVID-19 and …

Simulation-Based Mastery Learning Compared To Standard Education For Discussing Diagnostic Uncertainty With Patients In The Emergency Department: A Randomized Controlled Trial., Danielle M. Mccarthy, Rhea E. Powell, Kenzie A. Cameron, David H. Salzman, Dimitrios Papanagnou, Amanda Doty, Benjamin E. Leiby, Katherine Piserchia, Matthew R. Klein, Xiao C. Zhang, William C. Mcgaghie, Kristin L. Rising

Department of Pharmacology and Experimental Therapeutics Faculty Papers

BACKGROUND: Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications.

METHODS: The trial is a multicenter, two-arm randomized controlled trial designed to …

“Trauma To The Eye” – A Low Fidelity Module For Identifying Retrobulbar Hematoma And Practicing Lateral Canthotomy & Cantholysis, Jared Raikin, Dimitrios Papanagnou, Md, Ronald Hall, Md

Phase 1

Purpose: A retrobulbar hematoma (RH) can cause preventable blindness due to damage of the optic nerve. Due to its relative infrequency in the emergency department, Emergency Medecine (EM) residents have limited experience in recognizing and treating a RH. This paper outlines a simulated scenario that was developed to improve EM residents knowledge in diagnosing a RH and performing an emergent lateral canthotomy and cantholysis (LCC).

Methods: This module used a low fidelity task trainer and case vignette created for EM residents to practice recognizing a RH and perfroming a LCC. Participants took an assessment questionnaire before and after the teaching …

Development Of An Outpatient Palliative Care Protocol To Monitor Fidelity In The Emergency Medicine Palliative Care Access Trial., Corita R. Grudzen, Abigail M. Schmucker, Deborah J. Shim, Aminat Ibikunle, Jeanne Cho, Frank R. Chung, Susan E. Cohen

Student Papers, Posters & Projects

Introduction: Palliative care is recommended for patients with life-limiting illnesses; however, there are few standardized protocols for outpatient palliative care visits. To address the paucity of data, this article aims to: (1) describe the elements of outpatient palliative care that are generalizable across clinical sites; (2) achieve consensus about standardized instruments used to assess domains within outpatient palliative care; and (3) develop a protocol and intervention checklist for palliative care clinicians to document outpatient visit elements that might not normally be recorded in the electronic heath record.

Methods: As part of a randomized control trial of nurse-led telephonic case management …

An Evaluation Of Risk Attitudes And Risk Tolerance In Emergency Medicine Residents., Carlos Rodriguez, Nishad A Rahman, Kory London, Robin Naples, Simran Buttar, Xiao Chi Zhang, Hyunjoo Lee, Joshua Rudner, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

Introduction Previous studies have shown that risk attitudes and tolerance for uncertainty are significant factors in clinical decision-making, particularly in the practice of defensive medicine. These attributes have also been linked with rates of physician burnout. To date, the risk profile of emergency medicine (EM) physicians has not yet been described. Our goal was to examine the risk profile of EM residents using a widely available risk tolerance and attitude assessment tool. Methods First-, second-, and third-year residents of Thomas Jefferson University Hospital's EM residency program completed the commercially available, unmodified Risk Type Compass, a validated instrument offered by Multi-Health …

Defining And Measuring Quality In Acute Paediatric Trauma Stabilisation: A Phenomenographic Study., Ralph James Mackinnon, Karin Pukk-Härenstam, Ulrica Von Thiele Schwarz, Christopher S. Kennedy, Terese Stenfors

Manuscripts, Articles, Book Chapters and Other Papers

Objectives: Trauma is the leading cause of death in children. The lack of an accepted definition of what constitutes a high-quality stabilisation of a traumatically injured child has limited the evaluation of direct interventions in simulation-based education and service-delivery models to improve trauma care. The aim of this study was to create a framework that delineates quality by exploring the perceptions of the multi-disciplinary team providing and improving this initial care.

Methods: Interviews were conducted with 36 experienced UK trauma team members and governance administrators (clinical directors to executive board level), from three standard UK trauma units. This study used …

Emergency Medicine Palliative Care Access (Empalla): Preliminary Data From A Multi-Center Randomized Controlled Trial, Abigail M. Schmucker, Ba, Deborah J. Shim, Bs, Corita R. Grudzen, Md, Mshs, Jeanne Cho, Mph, Keith Goldfeld, Drph

Phase 1

Introduction: Emergency department (ED)-initiated palliative care has been shown to improve patient-centered outcomes in older adults with serious illnesses, but the optimal modality for providing such interventions is unknown. The EMPallA trial compares nurse-led, telephonic case management with specialty, outpatient palliative care on: 1) patient quality of life (QOL); 2) healthcare utilization; 3) loneliness and symptom burden; and 4) caregiver strain, QOL, and bereavement.

Objective: Summarize preliminary demographic and QOL data for the EMPallA cohort.

Methods: A pragmatic, parallel, two-arm randomized controlled trial is enrolling 1350 ED patients across 9 EDs over 3 years to compare the effectiveness of palliative …

Retrospective Review Of The Patient Cases At A Major Trauma Center In Nairobi, Kenya And Implications For Emergency Care Development, Julie Saleeby, Justin G. Myers, Karen Ekernas, Katherine Hunold, Ali Wangara, Alice Maingi, Peyton Wilson, Vincent Mutiso, Sarah Zamamiri, Daniel Bacon, Wes Davis, John Suder, Yash Agrawal, Ogar Ogar, Ian B.K. Martin, Stephen Dunlop

Faculty & Staff Scholarship

Introduction

Low- and middle-income countries (LMICs) are continuing to experience a “triple burden” of disease - traumatic injury, non-communicable diseases (NCDs), and communicable disease with maternal and neonatal conditions (CD&Ms). The epidemiology of this triad is not well characterised and poses significant challenges to resource allocations, administration, and education of emergency care providers. The data collected in this study provide a comprehensive description of the emergency centre at Kenya's largest public tertiary care hospital.

Methods

This study is a retrospective chart review conducted at Kenyatta National Hospital of all patient encounters over a four-month period. Data were collected from financial …

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 …

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 …

Improving Medical And Endovascular Management For Acute Ischemic Stroke Through Multidisciplinary Education And Simulation, Richard F. Schmidt, Md, Megan Margiotta, Md, Elan Miller, Md, Robin D'Ambrosio, Bsn, Scrn, Robin Dharia, Md, Maria Aini, Md, Diana Tzeng, Md, Fred Rincon, Md, Pascal Jabbour, Md, Nabeel Herial, Md

House Staff Quality Improvement and Patient Safety Conference (2016-2019)

Primary goals:

1. Reduce door to treatment times (both DTN and DTP) to meet and exceed existing guidelines metrics.
2. Educate residents about acute stroke management, including national guidelines and new institutional protocols to improve efficiency during stroke alerts.

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 …

Optimal Scene Time To Achieve Favorable Outcomes In Out-Of-Hospital Cardiac Arrest: How Long Is Too Long?, Glenn Goodwin, Dyana Picache, Brian J. Louie, Nicholas Gaeto, Tarik Zeid, Paxton P. Aung, Sonu Sahni

Touro College of Osteopathic Medicine (New York) Publications and Research

Despite advances in resuscitation science and public health, out-of-hospital cardiac arrest (OOHCA) cases have an average survival rate of only 12% nationwide, compared to 24.8% of cases occurring in hospital. Many factors, including resuscitation interventions, contribute to positive patient outcomes and have, therefore, been studied in attempts to optimize emergency medical services (EMS) protocols to achieve higher rates of return of spontaneous circulation (ROSC) in the field. However, no consensus has been met regarding the appropriate amount of time for EMS to spend on scene.