Developing medical simulations for opioid overdose response training: A qualitative analysis of narratives from responders to overdoses.

Medical simulation offers a controlled environment for studying challenging clinical care situations that are difficult to observe directly. Overdose education and naloxone distribution (OEND) programs aim to train potential rescuers in responding to opioid overdoses, but assessing rescuer performance in real-life situations before emergency medical services arrive is exceedingly complex. There is an opportunity to incorporate individuals with firsthand experience in treating out-of-hospital overdoses into the development of simulation scenarios. Realistic overdose simulations could provide OEND programs with valuable tools to effectively teach hands-on skills and support context-sensitive training regimens. In this research, semi-structured interviews were conducted with 17 individuals experienced in responding to opioid overdoses including emergency department physicians, first responders, OEND program instructors, and peer recovery specialists. Two coders conducted qualitative content analysis using open and axial thematic coding to identify nuances associated with illicit and prescription opioid overdoses. The results are presented as narrative findings complemented by summaries of the frequency of themes across the interviews. Over 20 hours of audio recording were transcribed verbatim and then coded. During the open and axial thematic coding process several primary themes, along with subthemes, were identified, highlighting the distinctions between illicit and prescription opioid overdoses. Distinct contextual details, such as locations, clinical presentations, the environment surrounding the patient, and bystanders' behavior, were used to create four example simulations of out-of-hospital overdoses. The narrative findings in this qualitative study offer context-sensitive information for developing out-of-hospital overdose scenarios applicable to simulation training. These insights can serve as a valuable resource, aiding instructors and researchers in systematically creating evidence-based scenarios for both training and research purposes.

Methemoglobinemia Secondary to Babesia Microti Infection: A Novel Case Report.

BACKGROUND: Tick-borne illnesses and methemoglobinemia have not been known to occur together in humans. Few cases have been documented in various animals of methemoglobinemia secondary to tick-borne infections. CASE REPORT: A 49-year-old man with no significant medical history presented to the emergency department from an urgent care with hypoxia saturating in the mid 80s. He also reported a pruritic rash on his back and right shoulder as well as both of his lower extremities. The rash had been present for 4 days. The patient was tachycardic and hypoxic at 90% but denied shortness of breath. He had cyanosis of the lips and fingertips and multiple erythematous, raised, ovoid lesions on the right shoulder and left lower extremity. Methemoglobin levels were elevated at 26%. He was treated with methylene blue, supplemental oxygen, and empiric doxycycline with improvement in his oxygenation. A tick-borne illness panel later tested positive for Babesia microti infection. His skin lesions resolved with the above described treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Both tick-borne illnesses and methemoglobinemia are typically easily treatable with proper antimicrobial coverage and methylene blue, respectively. The current literature is bare regarding concurrent tick-borne illnesses, specifically babesiosis, and methemoglobinemia. Without knowledge and documentation of a potential link between the two conditions, hypoxia, if found to be due to methemoglobinemia, may be treated adequately, but a potentially life-threatening tick-borne illness may continue to cause damage and disease to the patient if not tested for, identified, and treated.

Evaluating rescuer performance in response to opioid overdose in a community setting: Evidence for medically appropriate process measures.

Overdose education and naloxone distribution (OEND) programs are widely accepted to reduce opioid overdose deaths. However, there is currently no validated instrument to evaluate the skills of learners completing these programs. Such an instrument could provide feedback to OEND instructors and allow researchers to compare different educational curricula. The aim of this study was to identify medically appropriate process measures with which to populate a simulation-based evaluation tool. Researchers conducted interviews with 17 content experts, including healthcare providers and OEND instructors from south-central Appalachia, to collect detailed descriptions of the skills taught in OEND programs. Researchers used three cycles of open coding, thematic analysis, and consulted currently available medical guidelines to identify thematic occurrences in qualitative data. There was consensus among content experts that the appropriate nature and sequence of potentially lifesaving actions during an opioid overdose is dependent on clinical presentation. Isolated respiratory depression requires a distinct response compared to opioid-associated cardiac arrest. To accommodate these different clinical presentations, raters populated an evaluation instrument with the detailed descriptions of overdose response skills, such as naloxone administration, rescue breathing, and chest compressions. Detailed descriptions of skills are essential to the development of an accurate and reliable scoring instrument. Furthermore, evaluation instruments, such as the one developed from this study, require a comprehensive validity argument. In future work, the authors will integrate the evaluation instrument in high-fidelity simulations, which are safe and controlled environments to study trainees' application of hands-on skills, and conduct formative assessments.

Peritonsillar Abscess Model for Ultrasound Diagnosis Using Inexpensive Materials.

Audience: This low-cost peritonsillar abscess model is intended for the education of emergency medicine and otolaryngology residents and advanced care practitioners of all training levels. Introduction: With incidence rates as high as 124 per 100,000 in the 14-21 age range, peritonsillar abscesses (PTA) are one of the more common head and neck soft tissue infections encountered in the emergency department.1 Peritonsillar abscesses can present to the emergency department in critically ill patients with the dangers of airway compromise and further local spreading. Emergency medicine (EM) residents need practice to properly identify and to minimize procedural complications such as perforation of nearby vessels, aspiration pneumonitis, and airway compromise. A major tool used in the emergency department that can help prevent complications is the use of ultrasound, which the Accreditation Council for Graduate Medical Education (ACGME) requires residents to become proficient at.2 Historically, computed tomography (CT) scanning to diagnose along with blind drainage has been the method of choice. With a sensitivity of 95.2%, intraoral ultrasound can minimize both radiation and procedure related complications.3 The current simulators available come at significant capital expenditure and do not provide high-fidelity ultrasound experience. Here we design and implement a low-cost trainer for residents to use ultrasound to diagnose and drain a PTA. Educational Objectives: By the end of this instructional session learners should be able to: 1) identify and discuss the indications, contraindications, and complications associated with peritonsillar abscesses, 2) properly identify and measure a PTA through ultrasound, and 3) competently perform ultrasound-guided peritonsillar abscess drainage on a simulator and remove fluid. Educational Methods: This PTA model utilizes task trainers designed from Styrofoam wig heads. An airway was modeled using readily available wood shop tools and balloons filled with a fluid mixture containing coconut lotion, water, and fragrance beads, which were inserted into the airway. This unique mixture within the balloons creates a realistic echogenicity of an abscess with loculations. With emergency medicine clinical faculty guidance and the use of ultrasound, learners are able to identify a peritonsillar abscess and subsequently demonstrate drainage of fluid with a needle and syringe. Research Methods: This PTA model was tested with a group of 36 emergency medicine residents. Optional, anonymous post surveys were completed by 17 residents. A 5-point Likert Scale was used to assess utility of this model. Results: The majority of users agreed the model provides a realistic image of the disease for diagnosis by ultrasound with a score of 3.6 and felt more comfortable identifying and draining peritonsillar abscesses with scores of 3.7 and 3.6 respectively. Learners' surveys revealed the session was useful and improved their knowledge with both scoring 3.8. No critical feedback was given by learners or instructors. The efficacy of the content was assessed by evaluators observing proper ultrasound, procedure set up, and drainage of PTA. Discussion: This inexpensive model to expose residents to proper PTA drainage was effective considering learners' high response to post-procedure survey scales. The results of our pilot implementation showed this model has utility in teaching ultrasound guided identification and drainage of PTA's. With minimal build and optimized instruction time, we can improve residents' comfort in performing this procedure and allow for important simulation experience in a safe, controlled environment. Topics: Simulation, emergency medicine, peritonsillar abscess, otolaryngology.

Aortic dissection presenting as isolated lower leg ischemia.

BACKGROUND: Aortic dissections that present only with symptoms of lower extremity ischemia are rare. Few case reports exist documenting this phenomenon. OBJECTIVES: We report an unusual case of aortic dissection presenting as unilateral lower extremity pain. CASE REPORT: A 56-year-old man presented with left lower extremity pain of 1 h duration. He had no associated complaints. Doppler imaging revealed decreased flow in the left iliac artery, thus, initial treatment with anticoagulation was begun for presumptive obstruction. Subsequent imaging with arteriography revealed a Stanford type A/DeBakey type 1 aortic dissection. This was confirmed by computer-assisted tomography angiography, and the patient was taken to surgery for repair. CONCLUSION: It is important to consider the connection between lower extremity symptoms and possible aortic dissection.

Clinical confounder: an incarcerated appendix masquerading as epididymitis.

BACKGROUND: Acute appendicitis can have various unusual presentations. Detection of this entity is often confounded by its presence in the company of symptoms consistent with distinctly different etiologies. OBJECTIVES: This article highlights an extremely rare presentation of appendicitis. CASE REPORT: The case of a man presenting to an urban Emergency Department complaining of scrotal swelling and pain is discussed. On surgical exploration, the patient's symptomatology was diagnosed as acute appendicitis within an Amyand hernia. CONCLUSION: Appendicitis can sometimes be a challenging diagnosis. Thorough examination and maintenance of a wide differential diagnosis with common complaints can assist the emergency physician in reaching the correct diagnosis.