Defining "county": A mixed-methods inquiry of county emergency medicine residency programs.

INTRODUCTION: There is no clear unified definition of "county programs" in emergency medicine (EM). Key residency directories are varied in designation, despite it being one of the most important match factors for applicants. The Council of Residency Directors EM County Program Community of Practice consists of residency program leadership from a unified collective of programs that identify as "county." This paper's framework was spurred from numerous group discussions to better understand unifying themes that define county programs. METHODOLOGY: This institutional review board-exempt work provides qualitative descriptive results via a mixed-methods inquiry utilizing survey data and quantitative data from programs that self-designate as county. UNIQUE TREATMENT ANALYSIS AND CRITIQUE: Most respondents work, identify, and trained at a county program. The majority defined county programs by commitment to care for the underserved, funding from the city or state, low-resourced, and urban setting. Major qualitative themes included mission, clinical environment, research, training, and applicant recommendations. Comparing the attributes of programs by self-described type of training environment, county programs are typically larger, older, in central metro areas, and more likely to be 4 years in duration and have higher patient volumes when compared to community or university programs. When comparing hospital-level attributes of primary training sites county programs are more likely to be owned and operated by local governments or governmental hospital districts and authorities and see more disproportionate-share hospital patients. IMPLICATIONS FOR EDUCATION AND TRAINING IN EM: To be considered a county program we recommend some or most of the following attributes be present: a shared mission to medically underserved and vulnerable patients, an urban location with city or county funding, an ED with high patient volumes, supportive of resident autonomy, and research expertise focusing on underserved populations.

Clinical Teaching: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors.

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.

Predictors of False-Negative Focused Assessment With Sonography for Trauma Examination in Pediatric Blunt Abdominal Trauma.

OBJECTIVES: This study investigated associations between patient and injury characteristics and false-negative (FN) focused assessment with sonography for trauma (FAST) in pediatric blunt abdominal trauma (BAT). We also evaluated the effects of FN FAST on in-hospital mortality and length of stay (LOS) variables. METHODS: This retrospective cohort studied children younger than 18 years between January 1, 2002, and December 31, 2013, with BAT, documented FAST, and pathologic fluid on computed tomography, surgery, or autopsy. Multivariable and bivariate analyses were used to assess associations between FN FAST and patient injury characteristics, mortality, and hospital LOS. RESULTS: A total of 141 pediatric BAT patients with pathologic free fluid were included. There were no patient or injury characteristics, which conferred increased odds of an FN FAST. Splenic and bladder injury were negatively associated with FN FAST odds ratio of 0.4 (95% confidence interval [CI], 0.2-0.8) and 0.1 (95% CI, 0-0.8). Abbreviated Injury Scale score of 4 or greater to the abdomen and extremity was negatively associated with FN FAST odds ratio of 0.1 (95% CI, 0-0.3) and 0.3 (95% CI, 0.1-0.9). There was no association between FN FAST and mortality. Patients with an FN FAST had increased hospital LOS after controlling for sex, age, and Injury Severity Score. CONCLUSIONS: Clinicians need to be cautious applying a single initial FAST to patients with minor abdominal trauma or with suspected injuries to organs other than the spleen or bladder. Formalized studies to develop risk stratification tools could allow clinicians to integrate FAST into the pediatric patient population in the safest manner possible.

A Novel Approach to Neonatal Resuscitation Education for Senior Emergency Medicine Residents.

The majority of pediatric visits occur in general emergency departments. Caring for critically ill neonates is a low-frequency but high-stakes event for emergency physicians, which requires specialized knowledge and hands-on training. We describe a novel clinical rotation for emergency medicine (EM) residents that specifically augments skills in neonatal resuscitation through direct participation as a member of the neonatal resuscitation team. The neonatal resuscitation rotation evaluation median score of 4 (interquartile range [IQR] 3,4) was higher compared to all other off-service senior resident rotations combined (median 3, IQR 3,4) for the academic year 2018-2019. Ninety-two percent of residents evaluated the curriculum change as beneficial (median 4, IQR 4,4). The neonatal resuscitation rotation was rated more favorably than the pediatric intensive care rotation (median 4 IQR 3,4 vs median 3, IQR 2, 3) at a tertiary care children's hospital during the third year. Residency programs may want to consider implementing a directed neonatal resuscitation experience as part of a comprehensive pediatric curriculum for EM residents.

Emergency Ultrasound Literature and Adherence to Standards for Reporting of Diagnostic Accuracy Criteria.

BACKGROUND: Given the wide usage of emergency point-of-care ultrasound (EUS) among emergency physicians (EPs), rigorous study surrounding its accuracy is essential. The Standards for Reporting of Diagnostic Accuracy (STARD) criteria were established to ensure robust reporting methodology for diagnostic studies. Adherence to the STARD criteria among EUS diagnostic studies has yet to be reported. OBJECTIVES: Our objective was to evaluate a body of EUS literature shortly after STARD publication for its baseline adherence to the STARD criteria. METHODS: EUS studies in 5 emergency medicine journals from 2005-2010 were evaluated for their adherence to the STARD criteria. Manuscripts were selected for inclusion if they reported original research and described the use of 1 of 10 diagnostic ultrasound modalities designated as "core emergency ultrasound applications" in the 2008 American College of Emergency Physicians Ultrasound Guidelines. Literature search identified 307 studies; of these, 45 met inclusion criteria for review. RESULTS: The median STARD score was 15 (interquartile range [IQR] 12-17), representing 60% of the 25 total STARD criteria. The median STARD score among articles that reported diagnostic accuracy was significantly higher than those that did not report accuracy (17 [IQR 15-19] vs. 11 [IQR 9-13], respectively; p < 0.0001). Seventy-one percent of articles met ≥50% of the STARD criteria (56-84%) and 4% met >80% of the STARD criteria. CONCLUSIONS: Significant opportunities exist to improve methodological reporting of EUS research. Increased adherence to the STARD criteria among diagnostic EUS studies will improve reporting and improve our ability to compare outcomes.

Alpha Omega Alpha Honor Medical Society: A Commitment to Inclusion, Diversity, Equity, and Service in the Profession of Medicine.

With a motto of "Be Worthy to Serve the Suffering," Alpha Omega Alpha Honor Medical Society (AΩA) supports the importance, inclusion, and development of a culturally and ethnically diverse medical profession with equitable access for all. The underrepresentation of minorities in medical schools and medicine continues to be a challenge for the medical profession, medical education, and AΩA. AΩA has worked, and continues to work, to ensure the development of diverse leaders, fostering within them the objectivity and equity to be inclusive servant leaders who understand and embrace diversity in all its forms.Inclusion of talented individuals from different backgrounds benefits patient care, population health, education, and scientific discovery. AΩA values an inclusive, diverse, fair, and equitable work and learning environment for all and supports the medical profession in its work to achieve a welcoming, inclusive environment in teaching, learning, caring for patients, and collaboration.The diversity of medical schools is changing and will continue to change. AΩA is committed to continuing to work with its members, medical school deans, and AΩA chapters to assure that AΩA elections are unbiased and based on the values of AΩA and the profession of medicine in service to patients and the profession.Progress toward diversity, inclusion, and equity is more than simply checking off a box or responding to criticism-it is about being and developing diverse excellent physicians. AΩA and all those in the medical profession must continue to guide medicine to be unbiased, open, accepting, inclusive, and culturally aware in order to "Be Worthy to Serve the Suffering."

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache

This clinical policy from the American College of Emergency Physicians addressed key issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging? (2) In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications? (3) In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage? (4) In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage? Evidence was graded and recommendations were made based on the strength of the available data.

Tenecteplase utility in acute ischemic stroke patients: A clinical review of current evidence.

INTRODUCTION: Acute ischemic stroke is a leading cause of disability in the United States. Treatment is aimed at reducing impact of cerebral clot burden and life-long disability. Traditional fibrinolytic treatment with recombinant tissue plasminogen activator (tPA) has shown to be effective but at high risk of major bleeding. Multiple studies have evaluated tenecteplase as an alternative to tPA. OBJECTIVE: This review evaluates literature and utility of tenecteplase for treatment of acute ischemic stroke. DISCUSSION: Tenecteplase is modified, third generation fibrinolytic with greater specificity for fibrin bound clots. Current data in acute myocardial infarction suggest decreased bleeding events compared to alteplase. Multiple trials have investigated superiority of tenecteplase compared to tPA for treatment of acute ischemic stroke. Current guidelines designate tenecteplase as an alternative treatment for mild acute ischemic stroke patients based on recent literature. CONCLUSION: Recent emerging literature and limited recommendation guidance from governing medical societies leave many emergency medicine providers to weigh benefit versus risk of fibrinolytic therapy and tenecteplase's place in therapy. This review evaluates the available literature regarding tenecteplase and its utility in the treatment of acute ischemic stroke patients.

Journal Club in Residency Education: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors.

Journal clubs are an important tool for critically appraising articles and keeping up-to-date with the current literature. This paper provides a critical review of the literature on the design and structure of journal clubs in residency education with a focus on preparation, topic selection, implementation, and integration of technology. Recommendations for preparation include developing clearly defined goals and objectives that are agreed upon by all journal club participants; mentorship from experienced faculty members to ensure appropriate article selection, maintenance of structure, and applicability to objectives; distribution of articles to participants 1-2 weeks prior to the scheduled session with reminders to read the articles at predetermined intervals; and the use of a structured critical appraisal tool for evaluating the articles. Recommendations for topic selection include selecting a primary objective of either critical appraisal or informing clinical practice and ensuring that the articles align with the objective; involving learners in the topic- and article-selection process; and having the article selection driven by a specific clinical question. Recommendations for implementation include hosting sessions in the evening and away from the hospital environment; providing food to participants; hosting meetings on a monthly basis at regularly scheduled intervals; mandating journal club attendance; and using theories of adult learning. Recommendations for integration of technology include using previously established, effective strategies and determining the feasibility of creating an online journal club versus joining an established journal club. It is the authors' intention that after reading this paper readers will have new strategies and techniques for implementing and running a journal club at their home institutions.

A qualitative study of medical educators' perspectives on remediation: Adopting a holistic approach to struggling residents.

INTRODUCTION: During residency, some trainees require the identification and remediation of deficiencies to achieve the knowledge, skills and attitudes necessary for independent practice. Given the limited published frameworks for remediation, we characterize remediation from the perspective of educators and propose a holistic framework to guide the approach to remediation. METHODS: We conducted semistructured focus groups to: explore methods for identifying struggling residents; categorize common domains of struggle; describe personal factors that contribute to difficulties; define remediation interventions and understand what constitutes successful completion. Data were analyzed through conventional content analysis. RESULTS: Nineteen physicians across multiple specialties and institutions participated in seven focus groups. Thirteen categories emerged around remediation. Some themes addressed practical components of remediation, while others reflected barriers to the process and the impact of remediation on the resident and program. The themes were used to inform development of a novel holistic framework for remediation. CONCLUSIONS: The approach to remediation requires comprehensive identification of individual factors impacting performance. The intervention should not only include a tailored learning plan but also address confounders that impact likelihood of remediation success. Our holistic framework intends to guide educators creating remediation plans to ensure all domains are addressed.

Number of Weeks Rotating in the Emergency Department Has a Greater Effect on Ultrasound Milestone Competency Than a Dedicated Ultrasound Rotation.

OBJECTIVES: Ultrasound (US) is vital to modern emergency medicine (EM). Across residencies, there is marked variability in US training. The "goal-directed focused US" part of the Milestones Project states that trainees must correctly acquire and interpret images to achieve a level 3 milestone. Standardized methods by which programs teach these skills have not been established. Our goal was to determine whether residents could achieve level 3 with or without a dedicated US rotation. METHODS: Thirty-three first- and second-year residents were assigned to control (no rotation) and intervention (US rotation) groups. The intervention group underwent a 2-week curriculum in vascular access, the aorta, echocardiography, focused assessment with sonography for trauma, and pregnancy. To test acquisition, US-trained emergency medicine physicians administered an objective structured clinical examination. To test interpretation, residents had to identify normal versus abnormal findings. Mixed-model logistic regression tested the association of a US rotation while controlling for confounders: weeks in the emergency department (ED) as a resident, medical school US rotation, and postgraduate years. RESULTS: For image acquisition, medical school US rotation and weeks in the ED as a resident were significant (P = .03; P = .04) whereas completion of a US rotation and postgraduate years were not significant. For image interpretation, weeks in the ED as a resident was the only significant predictor of performance (P = .002) whereas completion of a US rotation and medical school US rotation were not significant. CONCLUSIONS: To achieve a level 3 milestone, weeks in the ED as a resident were significant for mastering image acquisition and interpretation. A dedicated US rotation did not have a significant effect. A medical school US rotation had a significant effect on image acquisition but not interpretation. Further studies are needed to best assess methods to meet US milestones.

Test Characteristics of Emergency Physician-Performed Limited Compression Ultrasound for Lower-Extremity Deep Vein Thrombosis.

BACKGROUND: The current literature suggests that emergency physician (EP)-performed limited compression ultrasound (LCUS) is a rapid and accurate test for deep vein thrombosis (DVT). OBJECTIVE: Our primary objective was to determine the sensitivity and specificity of LCUS for the diagnosis of DVT when performed by a large heterogeneous group of EPs. METHODS: This was a prospective diagnostic test assessment of LCUS conducted at two urban academic emergency departments. The scanning protocol involved compression at the common femoral, superficial femoral, and popliteal veins. Patients were eligible if undergoing radiology department ultrasound of the lower extremity with moderate or high pretest probability for DVT, or low pretest probability for DVT with a positive d-dimer. The enrolling EP performed LCUS before radiology department ultrasound of the same lower extremity. Sensitivity, specificity, and associated 95% confidence intervals (CIs) were calculated with the radiologist interpretation of the radiology department ultrasound as the criterion standard. RESULTS: A total of 56 EPs enrolled 296 patients for LCUS, with a median age of 50 years and 50% female. Fifty (17%) DVTs were identified by radiology department ultrasound, and another five (2%) cases were deemed indeterminate. The sensitivity and specificity of EP-performed LCUS was 86% (95% CI 73-94%) and 93% (95% CI 89-96%), respectively. CONCLUSIONS: A large heterogeneous group of EPs with limited training can perform LCUS with intermediate diagnostic accuracy. Unfortunately, LCUS performed by EPs with limited ultrasound training is not sufficiently sensitive or specific to rule out or diagnose DVT as a single testing modality.