Association between acculturation and sociodemographic factors and cardiovascular disease among immigrants to the United States.

OBJECTIVE: This study investigated relationships among acculturation, sociodemographic, and health characteristics of adult U.S. immigrants and cardiovascular disease. DESIGN: Secondary data analysis using population data from 1,945 immigrant participants in the 2017 National Health Interview Survey (NHIS). MEASUREMENTS: Acculturation was measured using citizenship status, number of years in the U.S., and English language proficiency. Chi-square tests and multiple logistic regression modeling were utilized. RESULTS: Approximately 4.3% of the study sample had cardiovascular disease. Compared to immigrants without U.S. citizenship, significantly higher proportion of immigrants with U.S. citizenship had cardiovascular disease (6.2% vs. 1.7%, p < .001). In the multivariable-adjusted model, compared to non-citizen immigrants, odds of cardiovascular disease were higher in immigrants with U.S. citizenship (odds ratio 3.80, 95% confidence interval 1.91, 7.56). CONCLUSION: Acculturation factors, specifically U.S. citizenship, along with sociodemographic and health risk factors were associated with increased odds of cardiovascular disease among immigrants. This study builds upon previous findings demonstrating increased acculturation including U.S. citizenship in immigrant populations is associated with increased odds of cardiovascular disease. These findings inform public health specialists and clinicians of factors to consider for cardiovascular disease risk in immigrants as they adapt to their host country.

Comparison of Three Junctional Tourniquets Using a Randomized Trial Design.

BACKGROUND: Hemorrhage remains a leading cause of death in both civilian and military settings. Of preventable deaths from hemorrhage, a significant portion occurs from junctional wounds that are not amenable to traditional extremity tourniquets. Junctional tourniquets (JTQs) can potentially provide hemorrhage control by compressing the arteries at the junction of the trunk and extremities. The FDA has cleared 3 JTQ products: The Combat Ready Clamp (CRoC®), the Junctional Emergency Treatment Tool (JETT™), and the SAM® Junctional Tourniquet (SJT). However, little is known regarding which of these JTQs is superior in application time, effectiveness in pulse elimination, effectiveness during transport, and user preference. METHODS: Active duty corpsmen (N = 49) were given standardized instruction and hands-on training with the CRoC®, JETT™, and SJT, then sequentially applied each JTQ unilaterally to a fellow study participant in a randomized order. Pulse elimination was determined by Doppler ultrasound at the dorsalis pedis immediately then reevaluated after a short transport. User preference data were collected following testing. Data were analyzed using repeated measures ANOVA and non-parametric statistics at p < 0.05. RESULTS: The CRoC® was significantly slower in application time than the JETT™ and SJT. Effectiveness was similar for CRoC®, JETT™, and SJT. Effectiveness during transport was significantly higher for SJT than for the JETT™, but no JTQ performed well during transport (24-48% effectiveness). SJT ranked first in perceived ease of use, stability, and reliability, and in user trust and overall preference. Participants provided cogent suggestions for product improvement. CONCLUSIONS: All JTQ devices performed poorly during transport. Combined, present findings highlight the potential of JTQ products for saving lives threatened by junctional wounds, but also highlight the need for specific product improvements towards fostering JTQ performance in patient transport.

Randomized Comparative Assessment of Three Surgical Cricothyrotomy Devices on Airway Mannequins.

BACKGROUND: Airway obstruction is the second leading cause of preventable battlefield death, at least in part because surgical cricothyrotomy (SC) failure rates remain unacceptably high. Ideally, SC should be a rapid, simple, easily-learned, and reliably-performed procedure. Currently, 3 SC devices meet Tactical Combat Casualty Care (TCCC) standards: The Tactical CricKit® (TCK), Control-CricTM(CC), and Bougie-assisted Technique (BAT). However, no previous studies have compared these devices in application time, application success, user ratings, and user preference. METHODS: United States Navy Corpsmen (N = 25) were provided 15 minutes of standardized instruction, followed by hands-on practice with each device on airway mannequins. Participants then performed SC with each of the 3 devices in a randomly assigned sequence. In this within-subjects design, application time, application success, participant ratings, and participant preference data were analyzed using repeated-measures ANOVA, regression, and non-parametric statistics at p < 0.05. RESULTS: Application time for CC (M = 184 sec, 95% CI 144-225 sec) was significantly slower than for BAT (M = 135 sec, 95% CI 113-158 sec, p < 0.03) and TCK (M = 117 sec, 95% CI 93-142 sec, p < 0.005). Success was significantly greater for BAT (76%) than for TCK (40%, p < 0.02) and trended greater than CC (48%, p = 0.07). CC was rated significantly lower than TCK and BAT in ease of application, effectiveness, and reliability (each p < 0.01). User preference was significantly (p < 0.01) higher for TCK (58%) and BAT (42%) than for CC (0%). Improved CC blade design was the most common user suggestion. CONCLUSION: While this study was limited by the use of mannequins in a laboratory environment, present results indicate that none of these devices was ideal for performing SC. Based on slow application times, low success rates, and user feedback, the Control-CricTM cannot be recommended until improvements are made to the blade design.

Temporal artery and axillary thermometry comparison with rectal thermometry in children presenting to the ED.

BACKGROUND: Accurate temperature readings, often obtained rectally, are an important part of the initial evaluation of pediatric patients in the Emergency Department. Temporal artery thermometry (TAT) is one way to noninvasively measure temperature. We sought to compare the accuracy of axillary and temporal artery temperatures compared to rectal. METHODS: This prospective study included children age 0-36months presenting to the Emergency Department of a large military treatment facility. Rectal, axillary, and temporal artery temperatures were obtained. Test characteristics (sensitivity, specificity, NPV, PPV) were reported. The effect of cutoff values 99.9°F, 100.4°F, and 102.2°F on test characteristics were also evaluated. RESULTS: The sensitivities of axillary and temporal artery thermometry to detect rectal fever is 11.5% and 61.5% respectively. Cutoff values did not significantly alter test characteristics. In this study, temporal artery thermometry was 0.2°C lower than rectal temperature, axillary measurement was 0.9°C below the reference standard. Mean temperature difference in the febrile group between TAT and rectal thermometry was >0.5°C compared with a mean temperature difference 0.05°C in afebrile patients. CONCLUSION: The findings of our study do not support using axillary thermometry to screen pediatric patients for fever in the emergency department. TAT cannot be recommended as a rectal thermometry replacement where height and duration of fever are used in pediatric disease prediction models. TAT may have a role in screening for fever in the appropriate pediatric patient population like primary orthopedic or trauma presentations where the balance between device precision, data capture and patient comfort may favor use of TAT.

Acute lobar nephronia: a case report and literature review.

BACKGROUND: Patients with fever, vomiting, and abdominal pain commonly present to the emergency department, often generating a broad differential diagnosis. We describe the first reported case in the emergency medicine literature of acute lobar nephronia (ALN). OBJECTIVES: To describe the presentation, evaluation, and management of acute lobar nephronia. CASE REPORT: A healthy 27-year-old woman presented after 18 h of fever to 39.94°C (103.9°F), nausea, vomiting, and severe right-sided abdominal pain. Despite a normal urinalysis, a contrasted computed tomography scan of the abdomen and pelvis demonstrated right perinephric stranding, which was initially interpreted as pyelonephritis. A staff over-read the following day by a radiology body specialist confirmed "likely developing abscess," consistent with the diagnosis of acute lobar nephronia. CONCLUSION: A normal urinalysis may move clinicians to dismiss a nephrogenic or urologic process. ALN is considered a midpoint in the spectrum of upper urinary tract infections between acute pyelonephritis and intrarenal abscess. Diagnosis may be difficult, and inpatient management, sometimes prolonged, is the norm.

The Impact of Progressive Simulation-Based Training on Tourniquet Application.

The Advanced Combat Medical Experience (ACME) is a progressive simulation-based training held for second-year medical students at the Uniformed Services University (USU). This study explored the impact of participating in ACME on students' tourniquet application skills. A panel of emergency medicine physician experts developed an assessment to evaluate the participants' performance. Trained raters then scored students' tourniquet application performance before and after participating in ACME. We conducted a Wilcoxon signed-rank test to detect any significant difference in the participants' pretest and posttest ratings as well as time it took them to apply the tourniquet. Our results indicated a significant difference in the pre- and posttest ratings of students as well as the time it took them to apply the tourniquet. This study confirms the effectiveness of progressive simulation-based education for teaching TCCC skills to military medical trainees.

Physiologic Fidelity as a Domain in Assessing Mixed Reality Trauma Simulation.

INTRODUCTION: Mixed reality has been used in trauma and emergency medicine simulation for more than a decade. As mixed reality potential in trauma simulation continues to expand, so too does the need to validate it as a surrogate for real-life emergency scenarios. Validation of these simulations can occur by measuring fidelity, or the degree to which a computing system can reproduce real-world experiences. After performing a literature review, we determined that most fidelity assessments of trauma and emergency simulations focus on how the user subjectively experiences the simulation. Although subjective user assessment is an important component of determining fidelity, we pose an introductory three-part framework that may assess mixed reality trauma simulation more adequately. MATERIALS AND METHODS: A literature review was conducted using Google Scholar, PubMed, and the Uniformed Services University PowerER search database. Relevant articles were assessed to identify how studies measured fidelity in trauma simulation. We then designed the three-part framework to aid researchers in assessing the fidelity of mixed reality trauma simulations. RESULTS: The domains we determined to best assess mixed reality emergency simulation are as follows:1. Continue assessing fidelity via subjective user assessments. This allows the researcher to know how real the simulation looked and felt to the user based on their individual report.2. Determine whether the trauma simulation changes the medical decision-making capacity of the user. If the user's decision-making capacity changes with a stress-inducing trauma simulation versus a non-stress-inducing simulation, then the stress-inducing trauma environment would be approaching greater fidelity.3. Study the domain of our newly proposed concept: physiologic fidelity. We define physiologic fidelity as the degree to which the simulation elicits a measurable, autonomic response independent of observed emotion or perceived affect. Recreating objective autonomic arousal may be the best way to ensure a trauma simulation reaches fidelity. CONCLUSION: We propose a methodology to assess mixed reality trauma simulation fidelity. Once fidelity is more fully known to the researcher and the simulation user, adjustments can be made to approach reality more closely. Improved simulators may enrich the preparedness of both junior and senior learners for real-life emergencies. We believe assessing the three domains using the Wide Area Virtual Experience at the Val G. Hemming simulation center in Bethesda, MD, will validate mixed reality-trauma simulators as invaluable surrogates for real-life emergency scenarios and ultimately contribute to improved clinical outcomes for clinicians and their patients.

Medical Students' Professional Identity Formation During Operation Bushmaster.

INTRODUCTION: The role of the military medical officer is complex, as it encapsulates officer, physician, and leader. Professional identity formation is therefore essential for military medical students and junior military physicians to successfully execute the responsibilities of the military medical officer in their future careers. Because little is known regarding best practices for professional identity formation training for military physicians, this study explored the ways in which medical students conceptualized the complex roles of the military medical officer during a medical field practicum. MATERIALS AND METHODS: Guided by the phenomenological tradition of qualitative research, we interviewed 15 fourth-year medical students twice regarding their understanding of the role of the military medical officer, as they progressed through a 5-day high-fidelity military medical field practicum, Operation Bushmaster. Our research team then analyzed the interview transcripts for emerging themes and patterns, which served as the results of this study. RESULTS: The following themes emerged from the data regarding the participants' conceptualization of the military medical officer: (1) the scope of the role of the military medical officer; (2) the intersecting identities of the military medical officer; and (3) the adaptable role of the military medical officer in an operational environment. As they progressed through the medical field practicum, the participants articulated a clear understanding of the vast and complex nature of the military medical officer's intersecting roles as officer, physician, and leader in austere and often unpredictable environments. At the end of the medical field practicum, the participants expressed confidence in carrying out their roles as military medical officers during their future deployments. CONCLUSIONS: This study provided an in-depth understanding of the participants' conceptualization of the military medical officer. The participants described how the medical field practicum provided them with opportunities to experience first-hand and therefore better understand the roles of the military medical officer while leading a health care team in an operational environment. As a result, high-fidelity medical field practicums like Operation Bushmaster appear to be an effective tool for facilitating professional identity formation.

The Impact of Operation Bushmaster on Medical Student Decision-making in a High-Stress, Operational Environment.

INTRODUCTION: Operation Bushmaster is a high-fidelity military medical field practicum for fourth-year medical students at the Uniformed Services University. During Operation Bushmaster, students treat live-actor and mannequin-based simulated patients in wartime scenarios throughout the five-day practicum. This study explored the impact of participating in Operation Bushmaster on students' decision-making in a high-stress, operational environment, a crucial aspect of their future role as military medical officers. MATERIALS AND METHODS: A panel of emergency medicine physician experts used a modified Delphi technique to develop a rubric to evaluate the participants' decision-making abilities under stress. The participants' decision-making was assessed before and after participating in either Operation Bushmaster (control group) or completing asynchronous coursework (experimental group). A paired-samples t-test was conducted to detect any differences between the means of the participants' pre- and posttest scores. This study was approved by the Institutional Review Board at Uniformed Services University #21-13079. RESULTS: A significant difference was detected in the pre- and posttest scores of students who attended Operation Bushmaster (P < .001), while there was no significant difference in the pre- and posttest scores of students who completed online, asynchronous coursework (P = .554). CONCLUSION: Participating in Operation Bushmaster significantly improved the control group participants' medical decision-making under stress. The results of this study confirm the effectiveness of high-fidelity simulation-based education for teaching decision-making skills to military medical students.

Medical Students' Integration of Formative Feedback During Simulation: A Grounded Theory Study.

INTRODUCTION: Formative feedback is critical for trainees' growth and development. However, there is a gap in the professional literature regarding the ways in which formative feedback affects student performance during simulation. This grounded theory study addresses this gap by exploring the ways in which medical students received and integrated ongoing formative feedback throughout a multiday, high-fidelity military medical simulation, Operation Bushmaster. MATERIALS AND METHODS: Our research team interviewed 18 fourth-year medical students in order to investigate how they processed formative feedback during the simulation. Guided by the grounded theory tradition of qualitative research, our research team used open coding and axial coding to categorize the data. We then used selective coding to determine the casual relationships between each of the categories that emerged from the data. These relationships determined our grounded theory framework. RESULTS: Four phases emerged from the data and provided a framework to delineate the process in which students received and integrated formative feedback throughout the simulation: (1) ability to self-assess, (2) self-efficacy, (3) leadership and teamwork, and (4) appreciation of feedback for personal and professional growth. The participants first focused on feedback related to their individual performance but then shifted to a teamwork and leadership mindset. Once they adapted this new mindset, they began to intentionally provide feedback to their peers, increasing their team's performance. At the end of the simulation, the participants recognized the benefits of formative feedback and peer feedback for ongoing professional development throughout their careers, signifying a growth mindset. CONCLUSIONS: This grounded theory study provided a framework for determining how medical students integrated formative feedback during a high-fidelity, multiday medical simulation. Medical educators can use this framework to intentionally guide their formative feedback in order to maximize student learning during simulation.

The development, implementation, and evaluation of a medical student peer teaching training curriculum during a high-fidelity prehospital trauma simulation.

Objectives: While peer teaching has been found to be an effective technique during simulation, no peer teaching training curriculum (PTTC) has been developed for simulation-based learning. The objective of this study, therefore, was to develop, implement, and evaluate a PTTC during a high-fidelity trauma simulation. Methods: When developing the PTTC, we combined several validated learning models for teaching and learning procedural skills. We then implemented it over 6 days in two phases: instructional (learning how to teach) and experiential (practicing teaching). Our research team conducted a qualitative evaluation to evaluate the effectiveness of the PTTC. We analyzed written self-reflections from 20 second-year medical students who completed the PTTC. Using an iterative inductive approach to data analysis, our research team first individually coded the reflection papers. We then met to define and categorize the codes into themes. Finally, we compared these themes to the PTTC's objectives to evaluate the curriculum's effectiveness. Results: The following themes emerged from the data: 1) learning through teaching; 2) self-actualization as an educator; and 3) role of physician as leader, advocate, and educator. The students described how the peer teaching experience improved their own procedural knowledge and skills. They also reported an increase in their leadership and communication skills as they effectively provided guidance and feedback to their peers, which led to their self-actualization as an educator. This self-actualization inspired the peer teachers' professional identity formation as leaders and educators in medicine. Conclusions: Based on these themes, we found our PTTC to be an effective curricular design. Our results reinforce previously described benefits to both peer teachers and learners in regard to medical knowledge and skills acquisition and furthers the academic emergency medicine community's understanding of how students' involvement as peer teachers in simulation-based education impacts their professional development.

The Impact of Medical School on Military Physicians' Readiness for their First Deployment.

INTRODUCTION: Military physicians receive their undergraduate medical training primarily by either attending civilian medical school, through the Armed Forces Health Professions Scholarship Program (HPSP), or by attending the Uniformed Services University (USU), a federal medical school with a military unique curriculum. The purpose of this study was to explore the perceptions of graduates from these two educational pathways regarding the impact of their medical school training on their readiness for their first deployment. MATERIALS AND METHODS: We conducted 18 semi-structured interviews with military physicians who attended civilian medical schools and USU and who had deployed within the past 2 years. The participants also completed emailed follow-up questions. The interviews were recorded and transcribed. The research team coded the interviews, extracted meaning units, and identified themes that emerged from the data. RESULTS: The following themes emerged from the data: (1) medical readiness; (2) operational readiness; (3) command interactions; and (4) role as a military physician. All of the participants perceived themselves to be prepared medically. However, the USU graduates were more confident in their ability to navigate the operational aspects of deployment. In addition, they described their ability to naturally build positive working relationships with their commanding officers and navigate their combined roles as both a physician and military officer. CONCLUSIONS: These perceptions of both the civilian medical graduates and USU graduates provide important insight to the military medical education community regarding the ways in which civilian medical schools and USU prepare students for their first deployment. This insight will help to identify any training gaps that should be filled in order to ensure that military physicians are ready for deployment.

A dignitary medicine curriculum developed using a modified Delphi methodology.

BACKGROUND: Dignitary medicine is an emerging field of training that involves the specialized care of diplomats, heads of state, and other high-ranking officials. In an effort to provide guidance on training in this nascent field, we convened a panel of experts in dignitary medicine and using the Delphi methodology, created a consensus curriculum for training in dignitary medicine. METHODS: A three-round Delphi consensus process was performed with 42 experts in the field of dignitary medicine. Predetermined scores were required for an aspect of the curriculum to advance to the next round. The scores on the final round were used to determine the components of the curriculum. Scores below the threshold to advance were dropped in the subsequent round. RESULTS: Our panel had a high degree of agreement on the required skills needed to practice dignitary medicine, with active practice in a provider's baseline specialty, current board certification, and skills in emergency care and resuscitation being the highest rated skills dignitary medicine physicians need. Skills related to vascular and emergency ultrasound and quality improvement were rated the lowest in the Delphi analysis. No skills were dropped from consideration. CONCLUSIONS: The results of our work can form the basis of formal fellowship training, continuing medical education, and publications in the field of dignitary medicine. It is clear that active medical practice and knowledge of resuscitation and emergency care are critical skills in this field, making emergency medicine physicians well suited to practicing dignitary medicine.

Control of Junctional Hemorrhage in a Consensus Swine Model With Hemostatic Gauze Products Following Minimal Training.

OBJECTIVE: Uncontrolled hemorrhage from junctional wounds that cannot be controlled by traditional tourniquets accounts for one in five preventable battlefield exsanguination deaths. Products for treating these wounds are costly and require special training. However, chemically treated gauze products are inexpensive, potentially effective, and require only minimal training. This study was designed to assess the efficacy of three hemostatic gauze products following brief training, using a consensus swine groin injury model. METHODS: After viewing a 15-minute PowerPoint presentation, without demonstration or practice, 24 U.S. Navy Corpsmen, most with little to no live tissue or hemostatic agent experience, applied one of three hemostatic agents: QuikClot Combat Gauze, Celox Trauma Gauze, or Hemcon ChitoGauze. Animals were resuscitated and monitored for 150 minutes to assess initial hemostasis, blood loss, rebleeding, and survival. Participants completed a survey before training and following testing. RESULTS: Products were similar in initial hemostasis, blood loss, and rebleeding. Twenty-three swine survived (96%). Ease of use and perceived efficacy of training ratings were high. Comfort level with application improved following training. CONCLUSIONS: Hemostatic gauze can potentially be effective for treating junctional wounds following minimal training, which has important implications for corpsmen, self-aid/buddy-aid, civilian providers, and Tactical Combat Casualty Care guidelines.