Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates.

OBJECTIVES: In the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time. METHODS: We conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021-June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends. RESULTS: The response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%-39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%-100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%-91%). Eighty-five percent (95% CI, 77%-92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%-85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%-23%) report an average of 1 complication annually. CONCLUSIONS: All programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.

The Status of Women in Emergency Ultrasound Fellowships: A Potential Light for the Future of Gender Inclusion in Academic Medicine.

BACKGROUND: The objective of this study is to investigate gender differences in the percentage of men and women who have completed an Emergency Ultrasound (EUS) fellowship over a four-year period. Secondary objectives of this study include evaluation of the career paths and accomplishments of women who have recently completed an EUS fellowship. We will also be assessing program characteristics as reported by the program directors. METHODS: This was an online survey of all EUS fellowship programs in the United States. Programs were excluded if they were not in existence before July 2020. The survey took place between September 16, 2021, and December 5, 2021. The study was approved by the appropriate institutional review board. Emergency Ultrasound fellowship programs and their respective program directors were identified from a list of participating programs created by the Society of Clinical Ultrasound Fellowships. The survey questions were divided into the following categories: program demographics, questions regarding the program's recent fellowship classes, and questions relating to the program director's perspective on gender and fellowship. RESULTS: This study utilized a convenience sample, from a roster of 109 programs, with a response rate of 67% by program directors. There was no significant difference in the percentage of men and women who have completed an EUS fellowship over a four-year period. No graduates who identified as transgender or non-binary/gender non-conform were reported. The majority of female fellows (65%) completed a research/scholarly project during their fellowship year (65%) and have held or currently hold a leadership position at their institution (60.3%). When program directors were asked if they felt women were equally represented in EUS fellowship programs, 24 (34.3%) respondents said yes, 18 (25.7%) said no, and 28 (40%) were not sure. When asked if they felt there were barriers that specifically prevented women from pursuing a fellowship, 28 (40%) said yes, 24 (34.3%) said no, and 18 (25.7%) were not sure. CONCLUSION: There does not exist a significant difference in the percentage of males and females who have completed an EUS fellowship over a four-year period. Completion of an EUS fellowship may provide women the opportunity to participate in research and receive awards for their accomplishments. It may also serve as a pipeline to academic medicine and leadership roles.

Number Needed to Scan: Evidence-Based Point-of-Care Ultrasound (POCUS).

Interest and enthusiasm, regarding the use of point-of-care ultrasound (POCUS), continues to grow among clinicians in multiple medical specialties. Ultrasound machines technology has advanced to allow for smaller, even handheld machines. Integration of automated imaging technology has made these machines more user-friendly. However, one of the concerns with the widespread availability of POCUS is the overuse and misuse of this technology. In order to maximize the clinical impact of POCUS, this manuscript seeks to discuss a novel concept called the "Number needed to scan" (NNS). The NNS is an expression of the number of POCUS examinations needed to be performed to attain a benefit to the patient or to prevent an adverse outcome of a procedure. NNS serves a dual purpose: it can help clinicians understand the magnitude of clinical impact when they apply POCUS, and it can help clinicians explain this magnitude in layman terms to their patients. In this manuscript, we have focused our NNS calculations on landmark articles in three major categories: change in management; safety and accuracy; and catching a missed diagnosis. As clinicians seek to be good stewards of POCUS, NNS should be a concept used to consider which patients will be most likely to benefit from a clinician performed ultrasound.

The Feasibility of Blinding Residency Programs to USMLE Step 1 Scores During GME Application, Interview, and Match Processes.

BACKGROUND: With the recent announcement that Step 1 score reporting will soon change to pass/fail, residency programs will need to reconsider their recruitment processes. OBJECTIVE: We (1) evaluated the feasibility of blinding residency programs to applicants' Step 1 scores and their number of attempts throughout the recruitment process; (2) described the selection process that resulted from the blinding; and (3) reviewed if a program's initial rank list, created before scores were known, would be changed before submission for the Match. METHODS: During the 2018-2019 and 2019-2020 recruitment seasons, all programs at a single sponsoring institution were invited to develop selection criteria in the absence of Step 1 data, and to remain blinded to this data throughout recruitment. Participating programs were surveyed to determine factors affecting feasibility and metrics used for residency selection. Once unblinded to Step 1 scores, programs had the option to change their initial rank lists. RESULTS: Of 24 residency programs, 4 participated (17%) in the first year: emergency medicine, neurology, pediatrics, and psychiatry. The second year had the same participants, with the addition of family and community medicine and radiation oncology (n = 6, 25%). Each program was able to determine mission-specific qualities in the absence of Step 1 data. In both years, one program made changes to the final rank list. CONCLUSIONS: It was feasible for programs to establish metrics for residency recruitment in the absence of Step 1 data, and most programs made no changes to final rank lists after Step 1 scores were known.

The Use of Point-of-Care Ultrasound for Arthrocentesis Among Emergency Medicine Residents.

INTRODUCTION: The objective of this study is to determine if EM resident physicians are able to successfully utilize POCUS to perform an arthrocentesis in the ED. This is a retrospective review of ED patients who received an ultrasound-guided or ultrasound-assisted arthrocentesis performed in the ED over a 6-year period by an EM resident physician. METHODS: This was a retrospective review of ED patients who received an ultrasound-guided or ultrasound-assisted arthrocentesis performed in the ED over a 6-year period by an EM resident physician. An ED POCUS database was reviewed for POCUS examinations where an arthrocentesis was performed. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and the impact of the POCUS study on patient care and disposition. RESULTS: A total of 101 POCUS examinations of patients were included in the final analysis. The POCUS examinations and procedures were performed by 59 different EM residents at various levels of training. Overall, 92.1% (93/101) of the procedures were successful. When assessing for image quality, 98/101 (97%) had recognizable structures at minimum. The majority of the patients (84/101, 83.2%) received additional imaging of the affected joint. In the minority of cases (23/101, 22.8%), the ultrasound-assisted approach was utilized, while 78/100 (77.2%) utilized the ultrasound-guided approach. For the studies that utilized the ultrasound-guided approach, the quality of needle visualization was determined to be "good" 40/78 (51.3%). CONCLUSION: EM resident physicians are able to utilize POCUS to perform an arthrocentesis in the ED. Further research is encouraged to determine whether having residents utilize POCUS to perform an arthrocentesis has a significant impact on outcomes and patient care.

Can ultrasound novices develop image acquisition skills after reviewing online ultrasound modules?

BACKGROUND: Point-of-care ultrasound is becoming a ubiquitous diagnostic tool, and there has been increasing interest to teach novice practitioners. One of the challenges is the scarcity of qualified instructors, and with COVID-19, another challenge is the difficulty with social distancing between learners and educators. The purpose of our study was to determine if ultrasound-naïve operators can learn ultrasound techniques and develop the psychomotor skills to acquire ultrasound images after reviewing SonoSim® online modules. METHODS: This was a prospective study evaluating first-year medical students. Medical students were asked to complete four SonoSim® online modules (aorta/IVC, cardiac, renal, and superficial). They were subsequently asked to perform ultrasound examinations on standardized patients utilizing the learned techniques/skills in the online modules. Emergency Ultrasound-trained physicians evaluated medical students' sonographic skills in image acquisition quality, image acquisition difficulty, and overall performance. Data are presented as means and percentages with standard deviation. All P values are based on 2-tailed tests of significance. RESULTS: Total of 44 medical students participated in the study. All (100%) students completed the hands-on skills evaluation with a median score of 83.7% (IQR 76.7-88.4%). Thirty-three medical students completed all the online modules and quizzes with median score of 87.5% (IQR 83.8-91.3%). There was a positive association between module quiz performance and the hands-on skills performance (R-squared = 0.45; p < 0.001). There was no statistically significant association between module performance and hands-on performance for any of the four categories individually. In all four categories, the evaluators' observation of the medical students' difficulty obtaining views correlated with hands-on performance scores. CONCLUSIONS: Our study findings suggest that ultrasound-naïve medical students can develop basic hands-on skills in image acquisition after reviewing online modules.

Point of Care Ultrasound in Pyogenic Tenosynovitis: A Case Report.

Pyogenic tenosynovitis is caused by hematogenous spread of infection or trauma with direct inoculation of a tendon sheath. Symptoms and clinical examination findings associated with pyogenic tenosynovitis may be confused with superficial soft tissue infections, however management plans between pyogenic tenosynovitis and superficial soft tissue infection vary significantly. In patients with pyogenic tenosynovitis, operative intervention and subsequent irrigation and debridement offer a definitive therapy. Bedside ultrasound helps clinicians inspect the involved tendon sheath and may help assisting diagnosis of pyogenic tenosynovitis. In this case report, we described three cases, where point of care ultrasound was used to assist the diagnosis of pyogenic tenosynovitis, to accelerate consultation, and to expedite operative intervention.

Point-of-care ultrasound stewardship.

Rapid adoption and widespread use of point-of-care ultrasound (POCUS) has impacted diagnostic testing and clinical care across medical disciplines. The benefits of POCUS must be weighed against certain pitfalls, such as the risk of misdiagnosis and false assurance. Beyond technical error in image acquisition and interpretation, an important pitfall is reliance on POCUS results without considering pre-test patient characteristics or the diagnostic accuracy of POCUS in varying clinical contexts. In this article, we introduce the concept of POCUS stewardship that emphasizes critical evaluation of clinical indications prior to performing POCUS as well as the individual patient and test characteristics of POCUS when integrating results into clinical decisionmaking. Adherence to these principles can lead to optimized POCUS application and improved patient care.

Prevalence, documentation, and communication of incidental findings in focused assessment with sonography for trauma (FAST) examinations.

BACKGROUND: As the focused assessment with sonography for trauma (FAST) examination becomes increasingly ubiquitous in the emergency department (ED), a parallel increase in incidental findings can also be expected. The purpose of this study was to determine the prevalence, documentation, and communication of incidental findings on emergency physician-performed FAST examinations. METHODS: Retrospective review at two academic EDs. Adult trauma patients undergoing FAST examinations used for clinical decision-making at the bedside were identified from an ED ultrasound image archival system. Expert sonologists reviewed ultrasound images for incidental findings, as well as electronic medical records for demographic information, mechanism of injury, type of incidental findings, documentation of incidental findings, and communication of incidental findings to the patient. RESULTS: A total of 1,452 FAST examinations were reviewed. One hundred and thirty-seven patients with incidental findings were identified (9.4%); 7 patients had an additional incidental finding. Renal cysts were most common (49/144, 34.0%), followed by pelvic cysts in women (32/144, 22.2%). While 31/144 (21.5%) incidental findings were identified and documented in the ultrasound reports or medical records by ED providers, only 6/137 (4.4%) patients were noted to be informed of their incidental findings. CONCLUSION: Incidental findings were often encountered in FAST examinations, with cysts of the kidneys and pelvis being the most common findings. A vast majority of incidental findings were not documented or noted to be communicated to patients, which can be a barrier to follow-up care.

Cadaver Models in Residency Training for Uncommonly Encountered Ultrasound-Guided Procedures.

BACKGROUND: Arthrocentesis of the ankle and elbow and brachial plexus nerve blocks are infrequently performed procedures; however, clinicians in specialties such as emergency medicine are required to be proficient in these procedures in the event of emergent or urgent necessity. OBJECTIVES: The objective of this study was to create, implement, and assess a fresh cadaver-based educational model to help resident physicians learn how to perform ultrasound-guided arthrocentesis of the ankle and elbow and ultrasound-guided regional nerve blocks. METHODS: This was a single-center cross-sectional study conducted at an academic medical center. After a brief didactic session, 26 emergency medicine residents with varying levels of clinical and ultrasound experience rotated through 4 fresh cadaver-based stations. The objective of each station was to understand the sonographic anatomy and to perform ultrasound-guided arthrocentesis or regional nerve block with hands-on feedback from ultrasound fellows and faculty. Participants were subsequently asked to complete a questionnaire which evaluated participants' experience level, opinions, and procedural confidence regarding the 4 stations. RESULTS: A total of 26 residents participated in this study. All 26 residents agreed that the cadaver model (compared with clinical anatomy) was realistic regarding ultrasound quality of the joint space, ultrasound quality of the joint effusion, ultrasound quality of nerves, tissue density, needle guidance, and artifacts. Finally, there was a statistically significant difference between mean scores for pre-simulation and post-simulation session participant procedural confidence for all 4 procedures. CONCLUSIONS: This fresh cadaver-based ultrasound-guided educational model was an engaging and well-received opportunity for residents to gain proficiency and statistically significant confidence in procedures which are uncommonly performed in clinical settings.

Management of Trazodone Overdose with Severe Hypotension.

Trazodone is a medication that possesses antidepressant, anxiolytic, and hypnotic properties. Its mechanism of action includes blockade of serotonin type 2 receptors, weak inhibition of serotonin reuptake, blockade of histamine 1 receptors, and blockade of alpha-1-adrenergic receptors. We present a case of intentional ingestion of an estimated 2500 mg of trazodone leading to persistent hypotension, requiring aggressive fluid resuscitation, pressor support, and intensive care unit admission. Complications associated with trazodone overdoses are significant and clinicians should be aware of the associated symptoms and necessary management plans necessary for such ingestions.

Identification of gender differences in ultrasound milestone assessments during emergency medicine residency training: a pilot study.

Objectives: Prior literature suggests that incongruities between male and female resident's procedural competency may be explained by gender bias during the evaluation process. There are no known studies investigating gender differences in the assessment of ultrasound-based procedural skills among emergency medicine (EM) residents. The purpose of this study was to evaluate for gender differences in ultrasound milestone assessments among EM residents. Methods: This is a retrospective study including EM residents. Milestone assessment data were collected from a total of 3 Accreditation Council for Graduate Medical Education (ACGME) EM residency programs representing a 3-year period The outcome measures included mean milestone levels, milestone levels at baseline and graduation and differences in milestone achievement between female and male EM residents. An unpaired Student's t-test was used to compare milestone scores between female and male residents. Results: A total of 456 ultrasound milestone evaluations were collected from 91 EM residents (34 females [37%] and 57 males [63%]). No significant differences were noted in the overall mean milestone level between females (2.3±0.6) and males (2.2±0.6) (P=0.387). There were no significant differences noted in the ultrasound milestone level between females (0.8±0.6) and males (0.7±0.7) at baseline (P=0.754). Although it did not reach statistical significance (P=0.197), the increase in the mean ultrasound milestone level from baseline to graduation was greater in males (3.4±0.7) compared to females (3.1±0.7). Conclusion: Overall, there were no statistically significant differences in the mean ultrasound milestone levels between females and males. The rate of ultrasound milestone level achievement during EM residency training at our institution had a slight tendency to be higher for males than females in the observed residency programs; however, this also did not reach statistical significance. Possible gender bias while evaluating ultrasound milestone levels needs to be further studied on a larger scale.

Students Teaching Students: A Novel Solution for Teaching Procedures via Instruction on the Corpse.

INTRODUCTION: Increased faculty and resident responsibilities have led to the decreased time available for teaching clinical skills to medical students. Numerous advances in education and simulation have attempted to obviate this problem; however, documented success is lacking. Our objective was to describe a novel fresh cadaver-based, student-driven procedural skills lab and to compare the educational effectiveness of student instructors to the senior instructor (SI). METHODS: This was a prospective study performed at an academic medical center. A pilot program, "Students Teaching Students," was introduced where four trained first-year medical students (TMS) instructed 41 other untrained first-year medical students in technical procedures. This study compared the teaching evaluations of the SI with the TMS teaching equivalent procedures. Paired t-test was used to determine statistically significant changes in procedural confidence between pre- and post-training. Utilizing a post-training questionnaire, average post-training confidence improvement values and objective post-training test scores of the participants were compared between TMS and SI, using a 2 sample t-test. Statistical significance was considered as a P-value<0.05. All statistical analyses were conducted in Stata 11 (StataCorp LP, College Station, TX, USA). RESULTS: Twenty-nine out of 39 (74%) students completed the questionnaire. Both groups demonstrated a statistically significant improvement in subjective confidence level in performing each procedure when pre- and post-training scores were compared, while there was no statistically significant difference found in cognitive knowledge between the groups (p=0.73). There was no statistically significant difference in the mean confidence improvement between the SI and TMS groups for chest tube insertion (2.06 versus 1.92 respectively, p=0.587), femoral line placement (2.00 versus 1.94 respectively, p=.734) or student test score (88% versus 85% respectively). CONCLUSION: Our results demonstrate that first-year medical students well-trained in technical skills, such as our TMS, may be a valuable additional teaching resource. The Students Teaching Students procedure lab employed in this study was effective at immediately increasing first-year medical students' confidence and technical skill. First-year medical students well-trained in technical skills, such as our TMS, may be a valuable additional teaching resource.

Performance of Ultrasound-guided Peripheral Nerve Blocks by Medical Students After One-day Training Session.

Introduction  Ultrasound-guided peripheral nerve blocks (USGPNB) are performed by various specialists and are excellent, non-addicting pain control techniques. Alternative pain management approaches are needed to combat opiate abuse. Medical students should be aware of alternative pain management therapies before they begin clinical practice. Objective  Our objective was to determine if medical students can identify peripheral nerves under ultrasound and perform a USGPNB after a one-day hands-on training session. Methods  This was a cross-sectional study at an academic medical center. The study participants were third-year medical students with minimal prior ultrasound experience. Students were given an introductory lecture highlighting the opiate epidemic and benefits of USGPNB prior to the workshop. The one-day hands-on educational workshop consisted of learning basic sonographic anatomy, indications for USGPNB, and practicing needle guidance under ultrasound guidance. After the educational workshop, students' procedural competency was assessed by ultrasound-trained emergency medicine clinicians. Results  A total of 94 participants were included in this study. The average pre-test score was 68.4% (95% confidence interval [CI]; 65.4% to 71.4%). After the one-day educational workshop, the post-test score was 92.8% (95% CI; 90.8% to 94.8%). The average hands-on evaluation score was 84.4% (95% CI; 81.6% to 87.3%). All students agreed that this educational session is a good start to learning about USGPNB, and they felt comfortable identifying the peripheral nerves using ultrasound. On a confidence scale of one (low) through 10 (high), 83% (95% CI; 75.9% to 90.15%) rated their confidence as ≥6. All except one student either agreed that this educational session helped them understand how USGPNB could be integrated into acute pain management. The majority (84% [95% CI; 77% to 91%]) agreed that the session will change how they manage patients' acute pain in their future medical practice. Conclusion  Medical students can learn the sonographic anatomy of peripheral nerves and techniques of USGPNB after a one-day educational session.

Variants of Erythema Multiforme: A Case Report and Literature Review.

Erythema multiforme is an acute skin condition characterized by targetoid lesions and occurs most frequently in young adults, particularly males. There are two variants of this condition, one with mucosal involvement, termed erythema multiforme major, and one without mucosal involvement, known as erythema multiforme minor. Due to the similarities in clinical and histological findings, it was previously believed that erythema multiforme major was indistinguishable from Steven-Johnson syndrome (SJS). However, evidence suggests these are two distinct diseases with a different etiology. It is important for clinicians to readily identify the difference between erythema multiforme from SJS, as the prognosis and mortality rate vary significantly between the two disorders.

Point-of-care Ultrasound Evaluation of Tibial Avulsion Fractures.

It can be difficult to diagnose a tibial avulsion fracture based on physical examination alone as findings are often non-specific. Emergency physicians will usually opt for radiography as their initial imaging modality, which has several disadvantages in evaluating tibial avulsion fractures. The objective of this case series is to describe the utility of point-of-care ultrasound (POCUS) in the evaluation of tibial avulsion injuries. A 15-year-old male presented to the emergency department (ED) after sustaining a left knee injury while playing soccer. The clinician had a high suspicion for patellar tendon involvement. A POCUS exam revealed a cortical irregularity and interruption of the left proximal tibia. The patellar tendon was found attached to an avulsed bony portion. Findings were consistent with a tibial tuberosity avulsion fracture. The patient was admitted and scheduled for surgery the following day. Our second case is a 31-year-old male who presented to the ED with a complaint of left knee pain after a 10-foot fall from a ladder. A POCUS exam revealed a bony avulsion over the anterior tibia that was not noted on the initial radiography read by radiology. His patellar tendon showed no evidence of rupture. This led to prompt consultation with orthopedics who evaluated the patient in the ED. Radiographs were reviewed again and it appeared that there was a missed anterior tibial spine fracture. The patient was placed in a knee immobilizer and discharged with instructions to follow up with orthopedics for outpatient surgery. The use of POCUS in the evaluation of these patients led to prompt diagnosis of tibial avulsion injuries, which led to early consultation and appropriate patient management. POCUS allows for expedited diagnosis and appropriate management of patients with tibial avulsion injuries.

"Flipped classroom" for academic and career advising: an innovative technique for medical student advising.

INTRODUCTION: Career advising for medical students can be challenging for both the student and the adviser. Our objective was to design, implement, and evaluate a "flipped classroom" style advising session. METHODS: We performed a single-center cross-sectional study at an academic medical center, where a novel flipped classroom style student advising model was implemented and evaluated. In this model, students were provided a document to review and fill out prior to their one-on-one advising session. RESULTS: Ninety-four percent (95% CI, 88%-100%) of the medical students surveyed felt that the advising session was more effective as a result of the outline provided and completed before the session and that the pre-advising document helped them gain a better understanding of the content to be discussed at the session. CONCLUSION: Utilization of the flipped classroom style advising document was an engaging advising technique that was well received by students at our institution.