Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department.

STUDY OBJECTIVE: Inappropriate antibiotic prescribing for acute respiratory tract infections is a common source of low-value care in the emergency department (ED). Racial and socioeconomic disparities have been noted in episodes of low-value care, particularly in children. We evaluated whether prescribing rates for acute respiratory tract infections when antibiotics would be inappropriate by guidelines differed by race and socioeconomics. METHODS: A retrospective cross-sectional analysis of adult and pediatric patient encounters in the emergency department (ED) between 2015 and 2023 at 5 hospitals for acute respiratory tract infections that did not require antibiotics by guidelines. Multivariable regression was used to calculate the risk ratio between race, ethnicity, and area deprivation index and inappropriate antibiotic prescribing, controlling for patient age, sex, and relevant comorbidities. RESULTS: A total of 147,401 ED encounters (55% pediatric, 45% adult) were included. At arrival, 4% patients identified as Asian, 50% as Black, 5% as Hispanic, and 23% as White. Inappropriate prescribing was noted in 7.6% of overall encounters, 8% for Asian patients, 6% for Black patients, 5% for Hispanic patients, and 12% for White patients. After adjusting for age, sex, comorbidities, and area deprivation index, White patients had a 1.32 (95% confidence interval, 1.26 to 1.38) higher likelihood of receiving a prescription compared with Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race and ethnicity, had a 0.74 (95% confidence interval, 0.70 to 0.78) lower likelihood of receiving a prescription. CONCLUSION: Our results suggest that although overall inappropriate prescribing was relatively low, White patients and patients from wealthier areas were more likely to receive an inappropriate antibiotic prescription.

Applying the Prism Model to design arts and humanities medical curricula.

The arts and humanities (A&H) play a fundamental role in medical education by supporting medical learners' development of core competencies. Like all medical curricula, those integrating the A&H are more likely to achieve the desired outcomes when the learning domains, goals, objectives, activities, and evaluation strategies are well-aligned. Few faculty development programs focus on helping medical educators design A&H curricula in a scholarly manner. The Prism Model, an evidence-based tool, supports educators developing A&H medical curricula in a rigorous way for maximum impact. The model posits that the A&H can serve four pedagogical functions for medical learners: 1) skill mastery, 2) perspective taking, 3) personal insight, and 4) social advocacy. Although this model has been described in the literature, no practical guidance exists for medical educators seeking to apply it to the development of a specific curriculum. This paper provides a step-by-step demonstration of how to use the Prism Model to design an A&H curriculum. Beginning with the first step of selecting a learning domain through the final step of curriculum evaluation, this paper helps medical educators apply the Prism Model to develop A&H curricula with intentionality and rigour to achieve the desired learning outcomes.

Social determinants of health associated with hemodialysis non-adherence and emergency department utilization: a pilot observational study.

BACKGROUND: Dialysis patients who miss treatments are twice as likely to visit emergency departments (EDs) compared to adherent patients; however, prospective studies assessing ED use after missed treatments are limited. This interdisciplinary pilot study aimed to identify social determinants of health (SDOH) associated with missing hemodialysis (HD) and presenting to the ED, and describe resource utilization associated with such visits. METHODS: We conducted a prospective observational study with a convenience sample of patients presenting to the ED after missing HD (cases); patients at local dialysis centers identified as HD-compliant by their nephrologists served as matched controls. Patients were interviewed with validated instruments capturing associated risk factors, including SDOH. ED resource utilization by cases was determined by chart review. Chi-square tests and ANOVA were used to detect statistically significant group differences. RESULTS: All cases visiting the ED had laboratory and radiographic studies; 40% needed physician-performed procedures. Mean ED length of stay (LOS) for cases was 17 h; 76% of patients were admitted with average LOS of 6 days. Comparing 25 cases and 24 controls, we found no difference in economic stability, educational attainment, health literacy, family support, or satisfaction with nephrology care. However, cases were more dependent on public transport for dialysis (p = 0.03). Despite comparable comorbidity burdens, cases were more likely to have impaired mobility, physical limitations, and higher severity of pain and depression. (p < 0.05). CONCLUSIONS: ED visits after missed HD resulted in elevated LOS and admission rates. Frequently-cited SDOH such as health literacy did not confer significant risk for missing HD. However, pain, physical limitations, and depression were higher among cases. Community-specific collaborations between EDs and dialysis centers would be valuable in identifying risk factors specific to missed HD and ED use, to develop strategies to improve treatment adherence and reduce unnecessary ED utilization.

Bystander Assistance for Trauma Victims in Low- and Middle-Income Countries: A Systematic Review of Prevalence and Training Interventions.

OBJECTIVE: Lack of organized prehospital care may contribute to the disproportionate burden of trauma-related deaths in low- and middle-income countries (LMICs). The World Health Organization (WHO) recommends bystander training in basic principles of first aid and victim transport; however, prevalence of bystander or layperson assistance to trauma victims in LMICs has not been well-described, and organized reviews of existing evidence for bystander training are lacking. This systematic review aims to 1) describe the prevalence of bystander or layperson aid or transport for trauma victims in the prehospital setting in LMICs and 2) ascertain impacts of bystander training interventions in these settings. METHODS: A systematic search of OVID Medline, Cochrane Library, and relevant gray literature was conducted. We included 1) all studies detailing prevalence of bystander-administered aid or transport for trauma victims in LMICs and 2) all randomized controlled trials and observational studies evaluating bystander training interventions. We extracted study characteristics, interventions, and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: Sixty-two studies detailed prevalence of bystander transport and aid. Family members, police, and bus or taxi drivers commonly transported patients; a majority of patients, up to >94%, received aid from bystanders. Twenty-four studies examined impacts of training interventions. Only one study looked at transport interventions; the remainder addressed first aid training. Interventions varied in content, duration, and target learners. Evidence was generally of low quality, but all studies demonstrated improvements in layperson knowledge and skills. Five studies reported a mortality reduction. CONCLUSIONS: Heterogeneity in data reporting and outcomes limited formal meta-analysis. However, this review shows high rates of bystander involvement in prehospital trauma care and transport in LMICs and highlights the need for bystander training. Bystander training in these settings is feasible and may have an important impact on meaningful outcomes such as mortality. Categories of involved bystanders varied by region and training interventions should be targeted at relevant groups. "Train the trainer" models appear promising in securing community engagement and maximizing participation. Further research is needed to examine the value of bystander transport networks in trauma.

Accuracy and Reliability of Emergency Department Triage Using the Emergency Severity Index: An International Multicenter Assessment.

STUDY OBJECTIVE: We assess accuracy and variability of triage score assignment by emergency department (ED) nurses using the Emergency Severity Index (ESI) in 3 countries. In accordance with previous reports and clinical observation, we hypothesize low accuracy and high variability across all sites. METHODS: This cross-sectional multicenter study enrolled 87 ESI-trained nurses from EDs in Brazil, the United Arab Emirates, and the United States. Standardized triage scenarios published by the Agency for Healthcare Research and Quality (AHRQ) were used. Accuracy was defined by concordance with the AHRQ key and calculated as percentages. Accuracy comparisons were made with one-way ANOVA and paired t test. Interrater reliability was measured with Krippendorff's α. Subanalyses based on nursing experience and triage scenario type were also performed. RESULTS: Mean accuracy pooled across all sites and scenarios was 59.2% (95% confidence interval [CI] 56.4% to 62.0%) and interrater reliability was modest (α=.730; 95% CI .692 to .767). There was no difference in overall accuracy between sites or according to nurse experience. Medium-acuity scenarios were scored with greater accuracy (76.4%; 95% CI 72.6% to 80.3%) than high- or low-acuity cases (44.1%, 95% CI 39.3% to 49.0% and 54%, 95% CI 49.9% to 58.2%), and adult scenarios were scored with greater accuracy than pediatric ones (66.2%, 95% CI 62.9% to 69.7% versus 46.9%, 95% CI 43.4% to 50.3%). CONCLUSION: In this multinational study, concordance of nurse-assigned ESI score with reference standard was universally poor and variability was high. Although the ESI is the most popular ED triage tool in the United States and is increasingly used worldwide, our findings point to a need for more reliable ED triage tools.

Nursing Perceptions of the Emergency Severity Index as a Triage Tool in the United Arab Emirates: A Qualitative Analysis.

INTRODUCTION: With emergency department crowding becoming an increasing problem across the globe, nursing triage to prioritize patients receiving care is ever more important. ESI is the most common triage system used in the United States and is increasingly used worldwide. This qualitative study that explores emergency nursing perceptions of the ESI identifies strengths, weaknesses, and barriers to implementation of the ESI internationally. METHODS: We conducted a cross-sectional qualitative analysis using semistructured interviews of 27 emergency triage nurses. Content analysis was performed by 2 independent coders, using NVivo software to identify and analyze important themes. RESULTS: Interview coding revealed 7 core themes related to use of the ESI (frequencies indicated in parentheses): ease of use (90), speed and efficiency (135), patient safety (12), accuracy and reliability (30), challenging patient characteristics (123), subjectivity and variability (173), and effect of triage system on team dynamics (100). Intercoder agreement was excellent (Cohen's unweighted kappa = 0.84). Subjectivity and variability in ESI score assignment consistently emerged in all interviews and included variability in number and use of resources, definition of "high risk," nursing experience, and subjectivity in pain assessment. DISCUSSION: Although emergency nurses perceive the ESI as easy to use, there are concerns about the subjectivity and variability inherent in the ESI that can lead to a functional lack of triage and a burden of undifferentiated ESI level 3 patients. These limitations in separating critically ill patients and in stratifying patients based on anticipated required resources points to the need for improvement in the ESI algorithm or a more objective triage system that can predict patient outcomes.

Impact of nutrition interventions on pediatric mortality and nutrition outcomes in humanitarian emergencies: A systematic review.

OBJECTIVES: Malnutrition contributes to paediatric morbidity and mortality in disasters and complex emergencies, but summary data describing specific nutritional interventions in these settings are lacking. This systematic review aimed to characterise such interventions and their effects on paediatric mortality, anthropometric measures and serum markers of nutrition. METHODS: A systematic search of OVID MEDLINE, Cochrane Library and relevant grey literature was conducted. We included all randomised controlled trials and observational controlled studies evaluating effectiveness of nutritional intervention(s) on defined health outcomes in children and adolescents (0-18 years) within a disaster or complex emergency. We extracted study characteristics, interventions and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: A total of 31 studies met inclusion criteria. Most were conducted in Africa (17), during periods of conflict or hunger gaps (14), and evaluated micronutrient supplementation (14) or selective feeding (10). Overall study quality was low, with only two high and four moderate quality studies. High- and medium-quality studies demonstrated positive impact of fortified spreads, ready-to-use therapeutic foods, micronutrient supplementation, and food and cash transfers. CONCLUSION: In disasters and complex emergencies, high variability and low quality of controlled studies on paediatric malnutrition limit meaningful data aggregation. If existing research gaps are to be addressed, the inherent unpredictability of humanitarian emergencies and ethical considerations regarding controls may warrant a paradigm shift in what constitutes adequate methods. Periodic hunger gaps may offer a generalisable opportunity for robust trials, but consensus on meaningful nutritional endpoints is needed.

Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality.

STUDY OBJECTIVES: The shock index (SI), defined as the ratio of HR to systolic BP, has been studied as an alternative prognostic tool to traditional vital signs in specific disease states and subgroups of patients. However, literature regarding its utility in the general ED population is lacking. Our main objective was to determine the probability of admission and inpatient mortality based on the first measured SI at initial presentation in the general adult ED population in our tertiary care centre. METHODS: A retrospective chart review of all adult patients (≥18 years old) presenting to the ED at our tertiary care centre over a 12-month period was conducted. Likelihood ratios (LRs) were calculated in order to determine the optimal SI cut-off for predicting hospital admission and inpatient mortality. RESULTS: We reviewed 58 336 ED patient encounters occurring between 1 October 2012 and 30 September 2013. SI >1.2 was associated with a large increase in the likelihood of hospital admission, with a positive LR (+LR) of 11.69 (95% CI 9.50 to 14.39) and a moderate increase in the likelihood of inpatient mortality with a +LR of 5.82 (95% CI 4.31 to 7.85). SI >0.7 and >0.9, the traditional 'normal' cut-offs cited in the literature, were only associated with minimal to small increases in the likelihood of admission and inpatient mortality. CONCLUSIONS: In our single-centre study, the initial SI recorded in the ED shows promise as a clinical metric in the general adult ED population, increasing the probability of both hospital admission and inpatient mortality, specifically at a threshold of SI >1.2.

Defining and improving the role of emergency medical services in Cape Town, South Africa.

INTRODUCTION: Low and middle income countries bear a disproportionate burden of paediatric morbidity and mortality. South Africa, a middle income country, has unacceptably high mortality in children less than 5 years of age. Many factors that contribute to the child mortality rate are time sensitive and require efficient access to emergency care. Delays and barriers within the emergency medical services (EMS) system increase paediatric morbidity and mortality from time sensitive illnesses. METHODS: This study is a qualitative evaluation of the prehospital care system for paediatric patients in Cape Town, South Africa. A purposive sample of healthcare personnel within and interacting with the EMS system were interviewed. A structured interview form was used to gather data. All interviews were audio recorded and transcribed; two independent reviewers performed blinded content analysis of the transcribed script. RESULTS: 33 structured interviews were conducted over a 4 week period. Eight broad themes were identified during coding, including: access, communication, community education, equipment, infrastructure, staffing, training and triage. Subcategories were used to identify areas for targeted intervention. Overall agreement between the two independent coders was 93.36%, with a κ coefficient of 0.69. CONCLUSIONS: The prehospital system is central to delivering time sensitive care for paediatric patients. In a single centre middle income setting, communication barriers between dispatch personnel and medical facilities/EMS personnel were deemed to be a high priority intervention in order to improve care delivery. Other areas for targeted interventions should include broadening the advanced life support provider base and introducing basic medical language in dispatch staff training.

Hypokalemia causing rhabdomyolysis in a patient with short bowel syndrome.

BACKGROUND: Rhabdomyolysis, usually in the setting of trauma or drug use, is frequently seen in the emergency setting, and often leads to hyperkalemia at presentation. Hypokalemia, however, is a potentially underrecognized cause of rhabdomyolysis. CASE REPORT: We present a case of rhabdomyolysis likely due to hypokalemia in the setting of short bowel syndrome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although less common, hypokalemia can be a significant cause of rhabdomyolysis via its effects on muscle. This scenario should be considered in the differential diagnosis of patients at risk for hypokalemia who present with weakness. Rapid recognition of this relationship and rapid correction of hypokalemia may prove very important in preventing the deleterious effects of rhabdomyolysis.

Bringing abstract concepts to life: A health humanities-based approach to teaching social determinants of health.

Background: To address health inequities, emergency physicians must understand the structural underpinnings of health disparities, including social determinants of health (SDoH), and must critically reflect on the integration of SDoH into clinical practice. SDoH education should include reflective knowledge acquisition, while incorporating systemic sociohistorical forces and individual factors, such as bias, which propagate inequities but are rarely emphasized in graduate medical education (GME). The health humanities (HH), an inclusive transdisciplinary field combining arts, humanities, and social justice, may represent a novel unexplored approach toward incorporating SDoH in GME. Methods: We sought to implement and evaluate a GME HH-based curriculum focused on SDoH. An interprofessional team applied Kern's framework to create a longitudinal HH curriculum integrating narrative medicine and visual thinking strategies with evidence-based practices for addressing SDoH in clinical practice. This curriculum was implemented for 52 residents in an EM program in 2019-2020; sessions were initially held in the classroom and community and then virtually during the COVID-19 pandemic. Objectives included encouraging (1) critical thinking about SDoH, (2) engagement with patients and communities, (3) self-reflection, and (4) translation of SDoH to patient care. Descriptive statistics and a constructivist paradigm were applied to results of a postcurriculum survey and focus group, respectively. Results: A curriculum evaluation survey completed by 32/52 residents (61.5%) revealed agreement (75%-90%) that objectives were met. 93.1% of respondents thought humanities were important in residency training. Qualitative analysis of a focus group with 10 participants revealed additional impacts on individual growth, transformation of departmental culture, and transformation of patient care. Curriculum implementation was inexpensive and relied on interprofessional collaboration. Conclusions: The HH represent a promising collaborative framework for integrating SDoH in GME and may inspire transformation of learners' attitudes and practices in EM, though clinical impacts still need to be established.

"I don't want to be the squeaky wheel": Addressing bias as a leader in emergency medicine.

BACKGROUND: Implicit bias poses a barrier to inclusivity in the health care workforce and is detrimental to patient care. While previous studies have investigated knowledge and training gaps related to implicit bias, emergency medicine (EM) leaders' self-awareness and perspectives on bias have not been studied. Using art to prompt reflections on implicit bias, this qualitative study explores (1) the attitudes of leaders in EM toward implicit bias and (2) individual or structural barriers to navigating and addressing bias in the workplace. METHODS: Investigators facilitated an hour-long workshop in May 2022 for those with leadership positions in the Society for Academic Emergency Medicine (SAEM), a leading national EM organization, including 62 attending physicians, eight residents/fellows, and four medical students. The workshop utilized arts-based methods to generate a psychologically supportive space to lead conversations around implicit bias in EM. The session included time for individual reflection, where participants used an electronic platform to respond anonymously to questions regarding susceptibility, fears, barriers, and experiences surrounding bias. Two independent coders compiled, coded, and reviewed the responses using an exploratory constructivist approach. RESULTS: A total of 125 responses were analyzed. Four major themes emerged: (1) acceptance that bias exists; (2) individual barriers, including fear of negative reactions, often due to power dynamics between respondents and other members of the ED; (3) institutional barriers, such as insufficient funding and unprotected time committed to addressing bias; and (4) ambiguity about defining and prioritizing bias. CONCLUSIONS: This qualitative analysis of reflections from an arts-based workshop highlights perceived fears and barriers that may impact EM physicians' motivation and comfort in addressing bias. These results may help guide interventions to address individual and structural barriers to mitigating bias in the workplace.

Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review.

OBJECTIVE: The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting. METHODS: This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step-down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism. RESULTS: A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta-analysis. CONCLUSIONS: High-level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking.

Transformative experiences at art museums to support flourishing in medicine.

PURPOSE: We implemented and evaluated a hybrid 4-week arts-based elective for clinical medical students to support flourishing. MATERIALS AND METHODS: Five students participated in early 2022. Twelve sessions occurred in-person at art museums and other cultural centers, and five occurred online. Sessions incorporated varied arts-based learning activities, including Visual Thinking Strategies, a jazz seminar, and a mask-making workshop. We evaluated the course via weekly reflective essays, interviews 6 weeks after the course, and pre-post surveys that included four scales with clinical relevance: capacity for wonder (CfW), tolerance for ambiguity (TFA), interpersonal reactivity index, and openness to diversity. RESULTS: Qualitatively, the course helped learners: 1) reconnect with individual characteristics and interests that had been neglected during medical education; 2) better appreciate others' perspectives; 3) develop identities as physicians; and 4) engage in quiet reflection, renewing their sense of purpose. Quantitatively, pre-post mean totals increased for the CfW (32.0 [SD 6.8] vs 44.0 [SD 5.7], p=.006) and TFA scales (16.4 [SD 5.2] vs 24.2 [SD 6.9], p=.033). CONCLUSIONS: This elective facilitated learners' connecting with themselves, others, and their profession with improvement in clinically-relevant measures. This provides further evidence that arts-based education can foster professional identity formation and be transformative for students.

Antiracism in Health Professions Education Through the Lens of the Health Humanities.

Racism represents a public health crisis, adversely impacting patient outcomes and health care workplace inclusivity. Dismantling racism requires transforming both racist systems and individual and collective consciousness. Focusing on antiracism in health professions education through the transdisciplinary lens of the health humanities can spur self-reflection, critical thinking, and collaboration among health professions educators and trainees to create more equitable structures of care. This article describes how the health humanities provide a powerful framework for antiracist health professions education. The authors conclude with a snapshot of an existing humanities-based antiracist curriculum, with suggestions to facilitate implementation in other settings.

Identity and uncertainty: art-mediated medical student reflections in a time of transition.

Medical education comprises intense periods of transition, which can significantly impact student well-being, as well as personal and professional development. In 2020, medical students navigating transitions from pre-clinical to clinical roles were also experiencing the historic forces of the COVID-19 pandemic and ongoing societal reckoning with systemic injustice and racism, likely heightening the usual challenges associated with these transitions. Reflection has been suggested as a tool for facilitating such transitions, and arts-mediated approaches hold promise in inspiring authentic reflection, yet they are rarely used to prompt medical student reflection. This article describes common themes in medical students' reflections on a specific period of transition during a unique moment in history, via qualitative analysis of their narrative responses to visual arts-mediated reflective prompts. The authors used a visual arts-based activity to explore medical students' hopes and concerns as they transitioned to clinical clerkships between the 2019-2020 and 2020-2021 academic years at one academic institution. Qualitative analysis using an exploratory constructivist approach revealed that students' reflections often focused on identity within three main themes: the personal self, the professional self, and the social self. Within these categories, subthemes included uncertainty and concerns focusing on medical training and knowledge, the sense of hope and value inherent to their social connections, critiques of the culture of medical education, and reflections on complicity and responsibility in racial injustice. This article not only provides a cross-sectional snapshot of the experiences of medical students during a historic moment, but also provides themes to guide discussions on training transitions and describes a low-cost, adaptable approach to facilitating deep exploration and reflection on tumultuous moments in training.

Evaluation of a Hands-On Wrist Fracture Simulator for Fracture Management Training in Emergency Medicine Residents.

Background Fractures are common in the emergency department, and fracture management training poses certain challenges. Recent emergency medicine (EM) residency graduates feel only somewhat prepared to manage fractures. In this study, our objectives were to determine the effect of introducing a wrist fracture simulator (Sawbones®) to traditional EM fracture management education and to assess resident attitudes, comfort with fracture management, and perceptions of the simulator. Methodology This six-month prospective study involved postgraduate year one residents at two academic EM programs. For convenience, each residency was considered as one test group. One residency group was deemed the traditional group (n = 10), while the other was the intervention simulator group (n = 16). Identical traditional lectures and buddy splinting workshops were provided. The simulator group received supplemental training with the Sawbones® simulator. Groups were filmed using this simulator for fracture management before the teaching sessions and at six months. Grading utilized a 27-point scale, with a subscale covering reduction. Data were collected regarding attitudes, comfort with fracture management, and perceptions of the simulator. Results In total, 26 residents participated in the study. There was no significant difference between groups at six months in overall fracture management scores (traditional group: 15.8 ± 3.1; simulator group: 15.4 ± 3.9; p = 0.92). On the subscale of fracture reduction skills, the simulator group showed significant improvement (p = 0.0078), while the traditional training group did not (p = 0.065). Both groups reported satisfaction with the simulator, improved comfort, and knowledge of fracture management. Conclusions Fracture management is an essential competency, and prior research has shown that most graduating EM residents do not feel comfortable with these skills. All participating residents in this study struggled with adequate fracture management, even after the teaching session. Our study suggests that there is a benefit to supplementing traditional training with a fracture simulator.

The Health Humanities and Emergency Medical Services (EMS): A Call to Action.

In the context of an on-going global pandemic that has demanded increasingly more of our Emergency Medical Services (EMS) clinicians, the health humanities can function to aid in educational training, promoting resilience and wellness, and allowing opportunity for self-expression to help prevent vicarious trauma.As the social, cultural, and political landscape of the United States continues to require an expanded scope of practice from our EMS clinicians, it is critical that the health humanities are implemented as not only part of EMS training, but also as part of continued practice in order to ensure the highest quality patient-centered care while protecting the longevity and resilience of EMS clinicians.