Concept of virtual research scribes in clinical research in emergency medicine.

BACKGROUND: Due to the unique nature of working in the field of emergency medicine (EM), physicians often find it difficult to engage in research and scholarly activity while also working clinical shifts. Barriers to engaging in both academic and clinical work include lack of time, resources, and incentives. EM physicians are familiar with the concept of scribes working alongside them in the emergency department, and there are multiple papers published that examine and advocate for their benefits. OBJECTIVES: This paper aims to introduce the concept of virtual research scribes in clinical research in EM to offer physicians an opportunity to alleviate the burdens of balancing clinical work and academia simultaneously. METHODS: A research scribe is a student who is interested in healthcare and research and aids the PI in literature reviews and manuscript writing and editing, completely remotely. Six research scribes were hired in a pilot program to test their efficacy in a clinical research setting. The scribes were assigned tasks including manuscript writing and editing, performing literature reviews, and writing newsletters. RESULTS: The six research scribes in the pilot program proved to be beneficial for time management, collaboration, and editing in the research and scholarly process. The remote nature of the program allowed for flexibility in scheduling on both the PI and scribe's behalf. CONCLUSION: By utilizing a research scribe in their academic career, EM physicians can increase efficiency and productivity in scholarly work.

The Effect of Athletic Chest Protectors on the Performance of Manual and Mechanical CPR: A Simulation Study.

OBJECTIVES: Sudden cardiac arrest is a leading cause of death in athletes. Although athletes wear various athletic chest protectors (ACPs) to prevent commotio cordis (CC), cardiac arrest cases still occur. Although it is established that cardiopulmonary resuscitation (CPR) quality affects outcome, little research has evaluated the effect of ACPs on CPR compressions quality. This study aimed to observe whether: (1) ACPs impact depth, rate, and hand positioning of both bystander and LUCAS CPR. (2) LUCAS devices affect CPR performance compared with traditional compressions. METHODS: An observational, prospective, convenient sample of 26 emergency medicine residents performed CPR on a high-fidelity Laerdal mannequin, which recorded real-time performance data. Baseline CPR for 1- and 2-minute cycles, CPR on a mannequin wearing the ACP, and ACP removal time was recorded. LUCAS CPR performance was measured at baseline and over the ACP. RESULTS: Bystander CPR had a statistically significant difference in both hand placement and compression rate for baseline versus ACP compressions (85% vs 57%, P < 0.05; 138 vs 142, P < 0.05, respectively), but not in compression depth (51.08 vs 50.05 mm, P = 0.39). LUCAS CPR had no significant difference in CPR performance. Bystander versus LUCAS CPR had a significant difference in compression rate (138 vs 101, P < 0.01), but not in depth or hand placement. CONCLUSIONS: Athletic chest protectors significantly impacted hand placement during bystander CPR, which may diminish CPR quality. Considering ACP removal required only 5.4 seconds, removing the ACP before standard CPR may improve quality.

Milky White Urine After Relief of Urinary Retention.

BACKGROUND: Chyluria is a rare condition where chyle is excreted into the urine. Clinically, most patients manifest with intermittent passage of milky urine. Patients may also present with dysuria, urinary frequency, urgency, retention, or with the sequelae of chronic malnutrition. CASE REPORT: We present a 55-year-old African American man who presented to the emergency department complaining of milky white urine, dysuria, decreased urine output, and suprapubic abdominal pain once a day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients may present to the emergency department complaining of milk-colored urine, hematuria, urinary retention, or the sequelae of malnutrition. Initial evaluations should include laboratory investigations of common causes of chyluria and the severity of the potential malnutrition. If the patient presents with urinary retention, after relieving the obstruction in the emergency department, assessment for clot/chyle burden and likelihood of recurrence of urinary retention should be performed by urology. Arrangements for proper outpatient follow-up should be made if the disease manifestations are not severe enough to warrant admission.

Extreme event medicine: considerations for the organisation of out-of-hospital care during obstacle, adventure and endurance competitions.

Obstacle, adventure and endurance competitions in challenging or remote settings are increasing in popularity. A literature search indicates a dearth of evidence-based research on the organisation of medical care for wilderness competitions. The organisation of medical care for each event is best tailored to specific race components, participant characteristics, geography, risk assessments, legal requirements, and the availability of both local and outside resources. Considering the health risks and logistical complexities inherent in these events, there is a compelling need for guiding principles that bridge the fields of wilderness medicine and sports medicine in providing a framework for the organisation of medical care delivery during wilderness and remote obstacle, adventure and endurance competitions. This narrative review, authored by experts in wilderness and operational medicine, provides such a framework. The primary goal is to assist organisers and medical providers in planning for sporting events in which participants are in situations or locations that exceed the capacity of local emergency medical services resources.

Beyond diversity and inclusion: Developing a research agenda for anti-racism in emergency medicine education.

Background: Addressing racism in emergency medicine education is vital for providing optimal training and assessment of physicians in the specialty, developing physicians with the skills necessary to advocate for their patients, and recruiting and retaining a diverse group of physicians. To form a prioritized research agenda, the Society of Academic Emergency Medicine (SAEM) conducted a consensus conference at the annual meeting in May 2022 on addressing racism in emergency medicine, which included a subgroup on education. Methods: The education workgroup worked on summarizing the current literature on addressing racism in emergency medicine education, identifying critical knowledge gaps, and creating a consensus-driven research agenda for addressing racism in emergency medicine education. We used a nominal group technique and modified Delphi to develop priority questions for research. We then distributed a pre-conference survey to conference registrants to rate priority areas for research. During the consensus conference, group leaders provided an overview and background describing the rationale for the preliminary research question list. Attendees were then involved in discussions to help modify and develop research questions. Results: Nineteen questions were initially selected by the education workgroup as potential areas for research. The education workgroup's next round of consensus building resulted in a consensus of ten questions to be included in the pre-conference survey. No questions in the pre-conference survey reached consensus. After robust discussion and voting by workgroup members and attendees at the consensus conference, six questions were determined to be priority research areas. Conclusions: We believe recognizing and addressing racism in emergency medicine education is imperative. Critical gaps in curriculum design, assessment, bias training, allyship, and the learning environment negatively impact training programs. These gaps must be prioritized for research as they can have adverse effects on recruitment, the ability to promote a safe learning environment, patient care, and patient outcomes.

Faculty Development for Academic Emergency Physicians: A Focus Group Analysis.

OBJECTIVES: The objective is to explore academic emergency medicine physicians' exposure to and needs regarding faculty development. METHODS: We conducted a prospective qualitative study of Society for Academic Emergency Medicine members in 2018 using focus groups selected by convenience and snowball sampling. One facilitator ensured representative engagement and responses were transcribed in real-time by an assistant after obtaining verbal consent. Results were analyzed using a grounded theory approach with a constructivist perspective. Thematic analysis was refined using the constant comparative method. RESULTS: Sixteen physicians participated in the focus groups, representing a diverse group of perspectives. Six themes emerged about unmet needs in faculty development: knowledge and skills, relationships, specific programs or resources, and professional benefits. CONCLUSIONS: Members of a national academic society identified three areas of focus important to developing academicians in emergency medicine: content for faculty developers, relationship-building among members, and support from the organization as a "professional home." Academic societies can use this to guide future programming.

An Assessment of Management Strategies for Adult Patients with Foreign-Body Sensation in the Neck.

OBJECTIVES: Patients come to the emergency department (ED) for the evaluation of foreign-body sensation in the neck. Given the dearth of clinical studies for this complaint, these patients are treated subjectively by different providers. We aim to propose a treatment approach that results in the timely diagnosis and removal of foreign bodies by comparing the common radiologic studies used in the ED for this complaint, determining the utility of consults, and providing an approach that minimizes length of stay. METHODS: We conducted a retrospective cohort study of adults between January 2014 and December 2015 presenting to LIJ and NSUH EDs with a chief complaint of foreign-body sensation in the pharynx, larynx, or esophagus. Fifty unique cases were studied. Consultations with ear, nose, and throat (ENT) and/or gastrointestinal, any imaging studies used, and time until discharge from the hospital were the primary exposures studied. The time for each diagnostic path for successful removal of a foreign body was compared for each case. RESULTS: Three common diagnostic approaches were identified. The most common pathway (six cases) had an ENT consult for removal of the foreign body, with an average time to discharge of 188 min. Another common pathway (four cases) began with a neck X-ray followed by an ENT consult, with an average time of 327 min. The third common approach (6 cases) involved no imaging studies or consults, with an average time of 166 min. Neck X-ray (20 cases) was found to have a sensitivity of 43% and a specificity of 83%. The sensitivity of neck computed tomography (CT) (15 cases) had a sensitivity of 91% and a specificity of 50%. Chest X-ray (15 cases) was found to have a sensitivity of just 17%. Chest CT (3 cases) had a sensitivity of 67%. CONCLUSION: Based on our data, we recommend that an attempt to localize the foreign body be completed by the emergency physician. If an initial attempt does not resolve the sensation, an ENT consult to remove the possible object should be initiated. Only after failure by ENT should radiological imaging be considered.

What can COVID-19 teach us about patient satisfaction in the emergency department? A mixed-methods approach.

OBJECTIVE: The current study explored improved patient satisfaction scores at a single emergency department (ED) during the early phase of the COVID-19 pandemic (March to May 2020). METHODS: A mixed-methods design, integrating qualitative and quantitative data analyses, was employed to explore a total of 289 patient satisfaction survey ratings and 421 comments based on care that took place in the ED during the initial phase of the COVID-19 epidemic. This allowed for comparisons to a more typical time period in the ED along with the emergence of novel categories of influence. RESULTS: The ED census was 31% lower during 2020 (COVID-19) than the previous year, and a significantly greater percentage of patients in 2020 indicated that they would "definitely recommend" the ED compared with 2019. Wait time was mentioned in >40% of dissatisfied patient comments in 2019 but <20% of dissatisfied patient comments in 2020. General negative comments were proportionately greater than general positive comments in 2019, whereas in 2020 the reverse pattern held. Other categories did not differ significantly across 2019 and 2020. CONCLUSIONS: The general circumstances surrounding the early stages of the COVID-19 pandemic included a lower census in the ED and higher reported satisfaction among patients. A comparison of the content of patient comments revealed less concern about wait times and a more positive overall view toward receiving care during the first 3 months of the pandemic.

Dedicated area within the emergency department versus an outside dedicated area for evaluation and management of suspected coronavirus disease 2019.

BACKGROUND: The circumstances of the coronavirus disease 2019 pandemic necessitated an alternate operations strategy for efficient patient management. Alternate care sites were a viable option for managing emergency department (ED) surge in previous epidemics and disasters. OBJECTIVE: This study describes the development of an alternate care site and evaluates efficiency by comparing key performance indicators between an ad hoc nested respiratory evaluation unit (NRU) within the ED and an alternate care site outside the ED. METHODS: This was a cohort study of 2 care models in the same ED during 2 different time periods. As coronavirus disease 2019 surged in March 2020, potential treat-and-release patients with fever or respiratory symptoms were triaged to a dedicated ED area (NRU). As ED volume grew, these low-acuity patients were triaged to an ACS. We compared ED length of stay, elopement, and left without being evaluated rates and ED recidivism between the 2 care models: NRU patients presented to the ED from March 16, 2020, to March 31, 2020, and ACS patients presented from April 1, 2020, to April 15, 2020. Continuous variables were compared using independent t test or Mann-Whitney test. Categorical variables were compared using χ2 test. RESULTS: There were 414 NRU patients and 146 alternate care site patients with no significant differences in sex or age. The mean ED length of stay was shorter for alternate care site patients: 155 versus 45 minutes (P < 0.01). Elopement and left without being evaluated rates were higher in the NRU. There was no significant difference in ED recidivism between groups: 10% versus 6% (P = 0.15). CONCLUSIONS: An alternate care site provided an efficient resource for the evaluation of patients with fever or respiratory symptoms during the coronavirus disease 2019 pandemic.

Cardiac tamponade as a delayed presentation of Neisseria meningitidis infection in a 5-month-old infant.

This is a case of a 5-month-old female infant diagnosed with primary meningococcal pericarditis. Pericarditis is a well-recognized but uncommon complication of meningococcal infection. Primary meningococcal pericarditis, defined as purulent pericarditis without any clinical evidence of disseminated meningococcemia, meningitis, or other foci of meningococcal infection, is exceedingly rare, with only 21 reported cases since the first case was reported in 1939. This case report of primary meningococcal pericarditis is the youngest case and only the second case reported in an infant in the English literature to date.

Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States.

BACKGROUND: The use of emergency ultrasonography (EUS) has gained much popularity in the past few decades, and is now a mainstay of diagnostic decision-making. This expanded use is now highlighting the substantial issue of individual hospitals in credentialing its emergency medicine attending physicians in EUS in the United States. This issue is also of importance as more hospitals are now requesting reimbursements for emergency ultrasounds. The objective of this study is to gain an understanding of how many emergency departments are currently credentialing its attending staff in EUS, what the internal structure and staffing are of these emergency departments, and how they are currently performing quality assurance of the ultrasounds performed. METHODS: This was a cross-sectional, web-based survey sent to 160 ACGME-accredited EM residency programs from July 2013 to November 2013. The survey consisted of 23 questions regarding: (1) number of emergency medicine attendings on staff, (2) presence of an EUS fellowship, (3) quality assurance (QA) process, and (4) current US credentialing process. RESULTS: There was a 50 % response rate. Fifty percent of the total respondents (n = 40) had an EUS fellowship program. Of the sites with an EUS fellowship, 36 had EUS fellowship-trained attendings. Of the sites without an EUS fellowship, 19 had EUS fellowship-trained faculty, p ≤ 0.0001. Sites with an EUS fellowship had a greater percentage of staff credentialed to perform EUS as compared to sites with no EUS fellowship, p = 0.0161. All sites with an EUS fellowship had EUS-credentialed attendings. In sites with an EUS fellowship, 35 conducted a formal QA of ED performed EUS scans versus 22 at sites without an EUS fellowship, p = 0.003. CONCLUSIONS: The survey results support hiring emergency attendings that have completed postgraduate training in emergency ultrasonography to aid in credentialing staff. This also seems to be helpful in completing a timelier QA of all ED ultrasounds.

The attenuation of strike acceleration with the use of safety equipment in tae kwon do.

PURPOSE: THE OBJECTIVES OF THIS STUDY INCLUDE: (1) Determination of the attenuation of strike acceleration that Tae Kwon Do sparring safety pads provide from kicks from Olympic style TKD fighters, (2) The sex and weight differentiation in acceleration achieved within the thorax model with the roundhouse kicks. METHODS: This prospective, observational study utilized 15 Olympic style fighters from an "elite" team kicking a water core heavy bag thorax model with roundhouse kicks. The model was fitted with a tri-axial accelerometer (GCDC, model X250-2) to measure g acceleration from strikes to the bag. The bag was kicked in three, 10 kick phases by all subjects: kicks without padding; kicks with hogu on heavy bag, and kicks with hogu and instep guards on feet. The g acceleration readings were recorded in all phases. RESULTS: Kolmogorov-Smirnov failed for all variables. There were 8 female subjects: median age 14 years, median weight 53.4 kg and 7 male subjects: median age 17 years, median weight 70.45 kg. The ANOVA on ranks of the acceleration from kicks against the bag achieved significance, P=0.001. Spearman rank order correlation between the weights of players and acceleration of strike against the hogu without and with insteps pads was significant, P=0.035/r=0.54 and P=0.018/r=0.59, respectively. CONCLUSION: Heavier and male subjects tend to produce more force in strikes. Protective chest guard reduces acceleration to the thorax model, but the utility of instep guards is questionable.

Comparison of Metallic Foreign-Body Removal between Dynamic Ultrasound and Static Radiography in a Pigs' Feet Model.

INTRODUCTION: We compared the immediate cosmetic outcome of metallic foreign-body removal by emergency medicine (EM) residents with ultrasound guidance and conventional radiography. METHODS: This single-blinded, randomized, crossover study evaluated the ability of EM residents to remove metallic pins embedded in pigs' feet. Before the experiment, we embedded 1.5-cm metallic pins into numbered pigs' feet. We randomly assigned 14 EM residents to use either ultrasound or radiography to help remove the foreign body. Residents had minimal ultrasound experience. After a brief lecture, we provided residents with a scalpel, laceration kit, a bedside portable ultrasound machine, nipple markers, paper clips, a dedicated radiograph technician, and radiograph machine 20 feet away. After removal, 3 board-certified emergency physicians, who were blinded to the study group, evaluated the soft-tissue model by using a standardized form. They recorded incision length and cosmetic appearance on the Visual Analog Scale. RESULTS: In total, 28 foreign bodies were removed. No significant difference in the time of removal (P = 0.12), cosmetic appearance (P = 0.96), or incision length (P = 0.76) was found. CONCLUSION: This study showed no difference between bedside ultrasound and radiography in assisting EM residents with metallic foreign-body removal from soft tissue. No significant difference was found in removal time or cosmetic outcome when comparing ultrasound with radiography.