Rapid Cycle Deliberate Practice Training for Simulated Cardiopulmonary Resuscitation in Resident Education.

Background: Simulation-based medical education has been used in medical training for decades. Rapid cycle deliberate practice (RCDP) is a novel simulation strategy that uses iterative practice and feedback to achieve skill mastery. To date, there has been minimal evaluation of RCDP vs standard immersive simulation (IS) for the teaching of cardiopulmonary resuscitation to graduate medical education (GME) learners. Our primary objective was to compare the time to performance of Advanced Cardiac Life Support (ACLS) actions between trainees who completed RCDP vs IS. Methods: This study was a prospective, randomized, controlled curriculum evaluation. A total of 55 postgraduate year-1 internal medicine and emergency medicine residents participated in the study. Residents were randomized to instruction by RCDP (28) or IS (27). Stress and ability were self-assessed before and after training using an anonymous survey that incorporated five-point Likert-type questions. We measured and compared times to initiate critical ACLS actions between the two groups during a subsequent IS. Results: Prior learner experience between RCDP and IS groups was similar. Times to completion of the first pulse check, chest compression initiation, backboard placement, pad placement, initial rhythm analysis, first defibrillation, epinephrine administration, and antiarrhythmic administration were similar between RCDP and IS groups. However, RCDP groups took less time to complete the pulse check between compression cycles (6.2 vs 14.2 seconds, P = 0.01). Following training, learners in the RCDP and IS groups scored their ability to lead and their levels of anticipated stress similarly (3.43 vs 3.30, (P = 0.77), 2.43 vs. 2.41, P = 0.98, respectively). However, RCDP groups rated their ability to participate in resuscitation more highly (4.50 vs 3.96, P = 0.01). The RCDP groups also reported their realized stress of participating in the event as lower than that of the IS groups (2.36 vs 2.85, P = 0.01). Conclusion: Rapid cycle deliberate practice learners demonstrated a shorter pulse check duration, reported lower stress levels associated with their experience, and rated their ability to participate in ACLS care more highly than their IS-trained peers. Our results support further investigation of RCDP in other simulation settings.

Infective Endocarditis Presenting With Non-ST Elevation Myocardial Infarction: A Case Report.

Infectious endocarditis (IE) is a rare disease characterized by infection of the endocardial surface of the heart. IE predominately involves the left-sided valves; however, right-sided valvular IE has increased in incidence with intravenous drug use. Treatment of IE is centered on targeted antibiotic therapy and management of complications, including septic embolization, which can affect all of the major arterial beds. Acute coronary syndrome secondary to septic embolization can be difficult to identify and carries an increased risk of morbidity and mortality. Care is further complicated by a lack of formal guidelines from any organization to inform management. We present a case of Staphylococcus hominis endocarditis complicated by coronary artery embolization and non-ST elevation myocardial infarction at the time of presentation to the emergency department, followed by a discussion of available treatment modalities.

Feasibility of a Multifaceted Social Emergency Medicine Curriculum for Emergency Medicine Residents.

INTRODUCTION: Emergency physicians are in a unique position to impact both individual and population health needs. Despite this, emergency medicine (EM) residency training lacks formalized education n the social determinants of health (SDoH) and integration of patient social risk and need, which are core components of social EM (SEM). The need for such a SEM-based residency curriculum has been previously recognized; however, there is a gap in the literature related to demonstration and feasibility. In this study we sought to address this need by implementing and evaluating a replicable, multifaceted introductory SEM curriculum for EM residents. This curriculum is designed to increase general awareness related to SEM and to increase ability to identify and intervene upon SDoH in clinical practice. METHODS: A taskforce of EM clinician-educators with expertise in SEM developed a 4.5-hour educational curriculum for use during a single, half-day didactic session for EM residents. The curriculum consisted of asynchronous learning via a podcast, four SEM subtopic lecture didactics, guest speakers from the emergency department (ED) social work team and a community outreach partner, and a poverty simulation with interdisciplinary debrief. We obtained pre- and post- intervention surveys. RESULTS: A total of 35 residents and faculty attended the conference day, with 18 participants completing the immediate post-conference survey and 10 participants completing the two-month delayed, post-conference survey. Post-survey results demonstrated improved awareness of SEM concepts and increased confidence in participants' knowledge of community resources and ability to connect patients to these resources following the curricular intervention (25% pre-conference to 83% post-conference). In addition, post-survey assessment demonstrated significantly heightened awareness and clinical consideration of SDoH among participants (31% pre-conference to 78% post-conference) and increased comfort in identifying social risk in the ED (75% pre-conference to 94% post-conference). Overall, all components of the curriculum were evaluated as meaningful and specifically beneficial for EM training. The ED care coordination, poverty simulation, and the subtopic lectures were rated most meaningful. CONCLUSION: This pilot curricular integration study demonstrates feasibility and the perceived participant value of incorporating a social EM curriculum into EM residency training.

Perceptions of the Emergency Medicine Resident Selection Process by Program Directors Following the Transition to a Pass/Fail USMLE Step 1.

Background: Beginning January 26th, 2022, the National Board of Medical Examiners transitioned scoring of the United States Medical Licensing Examination (USMLE) Step 1 from a 3-digit score to pass/fail. In the past, the Step 1 score has been weighted heavily by program directors (PDs) as one of the most important metrics when assessing medical student's competitiveness. Objective: The objective of this study was to evaluate the perceptions of emergency medicine (EM) PDs on the transition to a pass/fail USMLE Step 1 exam, and to elicit the opinions of EM PDs on the USMLE examinations' ability to predict resident performance. Methods: A survey consisting of ranking and multiple-choice questions was sent to EM PDs. The multiple-choice questions were asked to determine EM PDs level of confidence in the ability of Step 1 and Step 2 Clinical Knowledge (CK) to predict a student's ability to succeed in residency. The ranking questions focused on assessing each program's current resident selection practices in comparison to expected selection criteria changes following a transition to pass/fail Step 1. R studio and MATLAB were used for statistical analysis, and a P value <0.05 was considered significant. Results: The survey was completed by 57 (20.21%) EM PDs. When asked if Step 1 and Step 2 CK are accurate predictors of a resident's ability to perform clinically within EM, only 10.5% of PDs answered 'yes' to Step 1 being predictive, compared to 31.6% for Step 2 CK. Regarding selection criteria, the top quartile of attributes (standardized letters of evaluation [1st], away rotations [2nd], clerkship grades [3rd] and Step 2 CK score [4th]) remained the same following the transition. Conclusion: Our results indicate that the top quartile of attributes might remain the same, despite most PDs agreeing that Step 2 CK is a better predictor of a resident's performance.

Necrotizing Mediastinitis Following Dental Extraction: A Case Report.

INTRODUCTION: Necrotizing mediastinitis is a rare complication following a dental procedure. It is frequently lethal and requires prompt diagnosis with advanced imaging, administration of broad-spectrum antimicrobials, and early surgical consultation. CASE REPORT: A 19-year-old, otherwise healthy male presented to the emergency department with chest pain, muffled voice, and facial and neck swelling six days following dental extraction. He was found to have a retropharyngeal abscess causing necrotizing mediastinitis and septic shock. The patient was started on broad-spectrum antimicrobials, required 10 surgical procedures, and experienced a prolonged hospitalization. CONCLUSION: Consider necrotizing mediastinitis in patients presenting with chest pain and signs of retropharyngeal infection after dental procedures. Prompt imaging, antimicrobial therapy, and surgical consultation is critical in treating this frequently fatal disease.

Evaluation of Emergency Medicine Residency Programs' use of social media in the setting of the COVID-19 pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic significantly affected the ability of residency programs and applicants to interact using traditional methods of in-person interviews and visiting rotations. We examined the social media presence of emergency medicine (EM) residency training programs and how programs responded to the COVID-19 pandemic. METHODS: The Electronic Residency Application Service (ERAS) identified EM residency programs that participated in the 2021 match. Programs were reviewed for the presence of a website and social media accounts on Twitter, Instagram, and Facebook, as well as foundation date. Data were collected after the ERAS application deadline. RESULTS: All programs, except one, had some sort of online presence. A total of 258 websites and 476 social media accounts were identified. The majority of programs maintained an account on Twitter (75%), Instagram (61%), or Facebook (38%). Most Twitter and Facebook accounts were established before the onset of the COVID-19 pandemic. However, 46% of Instagram accounts were created after March 1, 2020. During 2020, there was a 34% increase in total social media account development, higher than in previous years. CONCLUSION: EM residency training programs have a robust online presence. Account development continued to grow in 2020, after the onset of the COVID-19 pandemic, and growth on Instagram was noted to be substantial. Interactions through online platforms may supplement the residency application process, but their efficacy is unclear.

Does QBank participation impact in-training examination performance?

BACKGROUND: Performance on the annual in-training examination (ITE) for emergency medicine (EM) residents has been shown to correlate with performance on the American Board of Emergency Medicine (ABEM) qualifying examination. As such, significant planning is often committed to ITE preparation, from an individual resident and a residency program perspective. Online specialty-specific question banks (QBanks) represent a popular medium for ITE preparation; however, the impact of QBanks on ITE performance is unclear. We sought to assess the impact of QBank participation on EM resident ITE performance. METHODS: ITE and QBank performance results were collated over 2 academic years, 2019 and 2020, from a 3-year EM residency program. The QBank was provided as a self-study option in 2019 and incorporated as a mandatory component of the curriculum in 2020. ITE raw scores and percentile rank for training level scores were compared with performance on the QBank, including QBank average performance score as well as number of QBank questions completed. The Pearson correlation coefficient was used to measure association between ITE performance and QBank correlates. Additional descriptive demographics, to include gender, PGY level, and USMLE step 1 and 2 scores were also considered. RESULTS: Sixty-two sets (30 residents in 2019, 32 residents in 2020) of ITE performance data and QBank correlates were included. Overall, raw ITE scores and number of QBank questions completed were found to have a significant, positive correlation, (r(60) = 0.34, p < 0.05); correlation was stronger for 2019 (r[28] = 0.39, p < 0.05) compared to 2020 (r[30] =0.25, p = 0.16). Overall, ITE percentile rank for training level scores were also found to have a significant, positive correlation with number of QBank questions completed (r(60) = 0.35, p < 0.05); correlation was again stronger for 2019 (r(28) = 0.42, p < 0.05) compared to 2020 (r(30) = 0.29, p = 0.12). Finally, ITE percentile rank for training level correlated positively with QBank average performance (as a percentage), albeit weakly, and was not found to be significant overall (r[60] = 0.20, p = 0.16); in this instance, 2019 did not show a correlation (r[28] =0.12, p = 0.54); however, 2020 did (r[30] =0.55, p < 0.05). Academic year 2020 raw ITE scores also demonstrated a significant correlation with QBank average performance (r[30] = 0.66, p < 0.0001) while 2019 did not (r[28] = 0.08, p = 0.68). CONCLUSION: Participation and engagement in a QBank are associated with improved EM resident performance on the ABEM ITE. Utilization of a QBank may be an effective mode of ITE preparation for EM residents.

Community-acquired pneumonia in the emergency department.

As recommendations for the diagnosis, treatment, and disposition of patients with community-acquired pneumonia continue to evolve, this issue reviews the current evidence and guidelines for managing these patients in the emergency department. The various clinical decision aids are compared, as they assist in determining the level of inpatient care required and allow for a greater proportion of patients to be treated successfully as outpatients. A clinical pathway for emergency department management delineates optimal antibiotic regimens based on severity, comorbidities, and risk factors.

Emergency department-based interventions affecting social determinants of health in the United States: A scoping review.

BACKGROUND: Social determinants of health (SDoH) have significant implications for health outcomes in the United States. Emergency departments (EDs) function as the safety nets of the American health care system, caring for many vulnerable populations. ED-based interventions to assess social risk and mitigate social needs have been reported in the literature. However, the breadth and scope of these interventions have not been evaluated. As the field of social emergency medicine (SEM) expands, a mapping and categorization of previous interventions may help shape future research. We sought to identify, summarize, and characterize ED-based interventions aimed at mitigating negative SDoH. METHODS: We conducted a scoping review to identify and characterize peer-reviewed research articles that report ED-based interventions to address or impact SDoH in the United States. We designed and conducted a search in Medline, CINAHL, and Cochrane CENTRAL databases. Abstracts and, subsequently, full articles were reviewed independently by two reviewers to identify potentially relevant articles. Included articles were categorized by type of intervention and primary SDoH domain. Reported outcomes were also categorized by type and efficacy. RESULTS: A total of 10,856 abstracts were identified and reviewed, and 596 potentially relevant studies were identified. Full article review identified 135 articles for inclusion. These articles were further subdivided into three intervention types: a) provider educational intervention (18%), b) disease modification with SDoH focus (26%), and c) direct SDoH intervention (60%), with 4% including two "types." Articles were subsequently further grouped into seven SDoH domains: 1) access to care (33%), 2) discrimination/group disparities (7%), 3) exposure to violence/crime (34%), 4) food insecurity (2%), 5) housing issues/homelessness (3%), 6) language/literacy/health literacy (12%), 7) socioeconomic disparities/poverty (10%). The majority of articles reported that the intervention studied was effective for the primary outcome identified (78%). CONCLUSION: Emergency department-based interventions that address seven different SDoH domains have been reported in the peer-reviewed literature over the past 30 years, utilizing a variety of approaches including provider education and direct and indirect focus on social risk and need. Characterization and understanding of previous interventions may help identify opportunities for future interventions as well as guide a SEM research agenda.

Tip of the Iceberg: Assessing the Global Socioeconomic Costs of Alzheimer's Disease and Related Dementias and Strategic Implications for Stakeholders.

While it is generally understood that Alzheimer's disease (AD) and related dementias (ADRD) is one of the costliest diseases to society, there is widespread concern that researchers and policymakers are not comprehensively capturing and describing the full scope and magnitude of the socioeconomic burden of ADRD. This review aimed to 1) catalogue the different types of AD-related socioeconomic costs described in the literature; 2) assess the challenges and gaps of existing approaches to measuring these costs; and 3) analyze and discuss the implications for stakeholders including policymakers, healthcare systems, associations, advocacy groups, clinicians, and researchers looking to improve the ability to generate reliable data that can guide evidence-based decision making. A centrally emergent theme from this review is that it is challenging to gauge the true value of policies, programs, or interventions in the ADRD arena given the long-term, progressive nature of the disease, its insidious socioeconomic impact beyond the patient and the formal healthcare system, and the complexities and current deficiencies (in measures and real-world data) in accurately calculating the full costs to society. There is therefore an urgent need for all stakeholders to establish a common understanding of the challenges in evaluating the full cost of ADRD and define approaches that allow us to measure these costs more accurately, with a view to prioritizing evidence-based solutions to mitigate this looming public health crisis.

From the voices of people with haemophilia A and their caregivers: Challenges with current treatment, their impact on quality of life and desired improvements in future therapies.

INTRODUCTION: Haemophilia A is a chronic disease requiring frequent intravenous infusions of recombinant factor VIII. Previous studies have shown that challenges associated with current treatments may have significant impacts on quality of life (QoL) that are as important as the health outcomes conferred by the therapy. Emerging therapeutic innovations offer the potential to mitigate treatment-related challenges, and it is therefore important to develop a better understanding of patient and caregiver experiences with existing haemophilia A treatments in order to characterize the full value of new treatments. AIM: To gather firsthand perspectives from people with haemophilia A (PWHA) and caregivers on the challenges with current treatment, their impact on QoL and desired improvements in future therapies. METHODS: Qualitative insights were gathered from 20 non-inhibitor PWHA or caregivers of PWHA across Canada through one-on-one interviews; insights were further explored through focus group sessions to uncover overarching themes and prioritize issues with current treatments. RESULTS: PWHA and caregivers identified several challenges, including administration of intravenous infusions, coordination of treatment schedules and ensuring adequate medication and supplies. Participants described how these challenges impact psychosocial well-being, physical health, personal/social life and work. Alternate modes of administration and longer-lasting treatment effects were identified as desired improvements over current treatments. CONCLUSION: This study emphasizes the impact that existing haemophilia A treatments have on psychological well-being, employment opportunities and adherence to treatment regimens. These considerations may help to inform decision-making for policymakers and health systems around the true value of new therapies entering the haemophilia market.

Quantitation of the lower subscapular nerve for potential use in neurotization procedures.

OBJECT: New information regarding nerve branches of the brachial plexus can be useful to the surgeon performing neurotization procedures following patient injury. Nerves in the vicinity of the axillae have been commonly used for neural grafting procedures, with the exception of the lower subscapular nerve (LSN). METHODS: The authors dissected and measured the LSN in 47 upper extremities (left and right sides) obtained in 27 adult cadavers, and determined distances between the LSN and surrounding nerves to help quantify it for possible use in neurotization procedures. The mean diameter of the LSN was 2.3 mm. The mean length of the LSN from its origin at the posterior cord until it branched to the subscapularis muscle was 3.5 cm, and the mean distance from this branch until its termination in the teres major muscle was 6 cm. Therefore, the mean length of the entire LSN from the posterior cord to the teres major was 9.5 cm. When the LSN was mobilized to explore its possible use in neurotization, it reached the entrance site of the musculocutaneous nerve into the coracobrachialis muscle in all but three sides and was within 1.5 cm from this point in these three. In the other specimens, the mean length of the LSN distal to this site of the musculocutaneous nerve was 2 cm. The mobilized LSN reached the axillary nerve trunk as it entered the quadrangular space in all specimens. The mean length of the LSN distal to this point on the axillary nerve was 2.5 cm. Furthermore, on all but one side the LSN was found within the confines of an anatomical triangle previously described by the authors. CONCLUSIONS: The authors hope that these data will prove useful to the surgeon for both identifying the LSN and planning for potential neurotization procedures of the brachial plexus.