Perspectives of Emergency Medicine Physicians on Hidradenitis Suppurativa Care.

Introduction: Hidradenitis suppurativa (HS) is a chronic skin condition that often requires acute care during periods of flares, with many patients visiting the emergency department over 5 times before receiving a proper diagnosis. However, little is known about emergency medicine (EM) providers' experiences and knowledge of HS management. Methods: In this study, an anonymous survey was distributed to EM providers to identify knowledge and practice gaps in HS care. Results: The results showed that most respondents lacked confidence in HS diagnosis and management, especially in knowing available treatment options and managing patients with moderate to severe HS. Attendings were more confident than non-attendings in diagnosing and managing HS, and providers who saw more HS patients per month were more confident in referring patients to appropriate specialists. Over 80% of respondents referred HS patients to dermatology, which is an important initial step in HS management. Conclusion: The study highlights the importance of educating EM providers in HS recognition, timely referral to dermatology, and initial management to improve quality of life among patients and mitigate disease progression.

Pharmacy Calls for Prescription Clarification at an Academic Emergency Department.

BACKGROUND: Approximately two-thirds of patients discharged from an emergency department (ED) are prescribed at least one medication. Prescription clarification by outpatient pharmacies for ED patients can lead to delays for patients and added workload. OBJECTIVES: This study aims to describe prescriptions requiring clarification prior to being dispensed by an outpatient pharmacy for patients recently discharged from an ED. METHODS: This study was conducted at an urban, 61-bed academic ED. Prescription clarification forms were used to identify common causes for outpatient pharmacies to contact the ED to clarify prescriptions prior to dispensation. Clarification types were reviewed and classified. Descriptive statistics were used to present the classification types. RESULTS: There were 1278 documented calls to the ED for prescription clarification that were classified as clarification of directions for use (611, 47.7%), insurance or affordability issues (182, 14.2%), dose (172, 13.4%), medication availability (126, 9.8%), lost or missing prescription (93, 7.3%), patient allergy or adverse event (62, 4.8%), duplication in therapy (17, 1.3%), and clarification of medication ordered (17, 1.3%). When grouped into provider, system, or patient-related issues, provider issues were noted to be most frequent clarifications (862 clarifications, 67.3%), followed by system issues (325 clarifications, 25.4%), and finally, patient-related issues (93 clarifications, 7.3%). CONCLUSIONS: Clarification of directions for use, insurance or affordability issues, and clarification of the dose were the most common reasons that outpatient pharmacies contacted an ED regarding a prescription for a recently discharged patient.

The Effects of Leadership Curricula With and Without Implicit Bias Training on Graduate Medical Education: A Multicenter Randomized Trial.

PURPOSE: To determine whether a brief leadership curriculum including high-fidelity simulation can improve leadership skills among resident physicians. METHOD: This was a double-blind, randomized controlled trial among obstetrics-gynecology and emergency medicine (EM) residents across 5 academic medical centers from different geographic areas of the United States, 2015-2017. Participants were assigned to 1 of 3 study arms: the Leadership Education Advanced During Simulation (LEADS) curriculum, a shortened Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum, or as active controls (no leadership curriculum). Active controls were recruited from a separate site and not randomized to limit any unintentional introduction of materials from leadership curricula. The LEADS curriculum was developed in partnership with the Council on Resident Education in Obstetrics and Gynecology and Council of Residency Directors in Emergency Medicine as a novel way to provide a leadership toolkit. Both LEADS and the abbreviated TeamSTEPPS were designed as six 10-minute interactive web-based modules.The primary outcome of interest was the leadership performance score from the validated Clinical Teamwork Scale instrument measured during standardized high-fidelity simulation scenarios. Secondary outcomes were 9 key components of leadership from the detailed leadership evaluation measured on 5-point Likert scales. Both outcomes were rated by a blinded clinical video reviewer. RESULTS: One hundred ten obstetrics-gynecology and EM residents participated in this 2-year trial. Participants in both LEADS and TeamSTEPPS had statistically significant improvement in leadership scores from "average" to "good" ranges both immediately and at the 6-month follow-up, while controls remained unchanged in the "average" category throughout the study. There were no differences between LEADS and TeamSTEPPS curricula with respect to the primary outcome. CONCLUSIONS: Residents who participated in a brief structured leadership training intervention had improved leadership skills that were maintained at 6-month follow-up.

ACEP SimBox: A Pediatric Simulation-Based Training Innovation.

Thirty million pediatric visits (<18 years old) occur across 5,000 US emergency departments (EDs) each year, with most of these cases presenting to community EDs. Simulation-based training is an effective method to improve and sustain EDs' readiness to triage and stabilize critically ill infants and children, but large simulation centers are mostly concentrated at academic hospitals. The use of pediatric simulation-based training has been limited in the community ED setting due to the high cost of equipment and limited access to content experts in pediatric critical care. We designed an innovative "off-the-shelf" simulation-based training resource, "American College of Emergency Physicians (ACEP) SimBox," that provides a free low-technology manikin along with teaching aids and train-the-trainer materials to community EDs to run a simulation drill in their own workspaces with local educators. The goal was to develop an "off-the-shelf," free, open-access, simulation-based resource to improve the readiness of community EDs to triage, resuscitate, and transfer critically ill infants as measured by presimulation and postsimulation surveys measuring opinions regarding the scenario, session experience, and most valuable aspect of the session. Between January 2018 and December 2019, 179 ACEP SimBoxes were shipped across the United States, reaching 36 of 50 states. Facilitators and participants who completed the postsimulation survey evaluated the session as a valuable use of their time. All facilitator respondents reported that the low-technology manikins, paired with their institution-specific equipment, were sufficient for learning, thus reducing costs. All participant respondents reported an increased commitment to pediatric readiness for their ED after completing the simulation session. This innovation resulted in the implementation of a unique simulation-based training intervention across many community EDs in the United States. The ACEP SimBox innovation demonstrates that an easy to use and unique simulation-based training tool can be developed, distributed, and implemented across many community EDs in the United States to help improve community ED pediatric readiness.

Advanced closed-loop communication training: the blindfolded resuscitation.

Closed-loop communication (CLC) improves task efficiency and decreases medical errors; however, limited literature on strategies to improve real-time use exist. The primary objective was whether blindfolding a resuscitation leader was effective to improve crisis resource management (CRM) skills, as measured by increased frequency of CLC. Secondary objectives included whether blindfolding affected overall CRM performance or perceived task load. Participants included emergency medicine (EM) or EM/paediatric dual resident physicians. Participants completed presurveys, were block randomised into intervention (blindfolded) or control groups, lead both adult and paediatric resuscitations and completed postsurveys before debriefing. Video recordings of the simulations were reviewed by simulation fellowship-trained EM physicians and rated using the Ottawa CRM Global Rating Scale (GRS). Frequency of CLC was assessed by one rater via video review. Summary statistics were performed. Intraclass correlation coefficient was calculated. Data were analysed using R program for analysis of variance and regression analysis. There were no significant differences between intervention and control groups in any Ottawa CRM GRS category. Postgraduate year (PGY) significantly impacts all Ottawa GRS categories. Frequency of CLC use significantly increased in the blindfolded group (31.7, 95% CI 29.34 to 34.1) vs the non-blindfolded group (24.6, 95% CI 21.5 to 27.7). Participant's self-rated perceived NASA Task Load Index scores demonstrated no difference between intervention and control groups via a Wilcoxon rank sum test. Blindfolding the resuscitation leader significantly increases frequency of CLC. The blindfold code training exercise is an advanced technique that may increase the use of CLC.

Development of a Novel Ultrasound-guided Peritonsillar Abscess Model for Simulation Training.

INTRODUCTION: Peritonsillar abscess (PTA) is the most common deep space infection of the head and neck presenting to emergency departments.1 No commercial PTA task trainer exists for simulation training. Thus, resident physicians often perform their first PTA needle aspiration in the clinical setting, knowing that carotid artery puncture and hemorrhage are serious and devastating complications. While several low-fidelity PTA task trainers have been previously described, none allow for ultrasound image acquisition.6-9 We sought to create a cost-effective and realistic task trainer that allows trainees to acquire both diagnostic ultrasound and needle aspiration skills while draining a peritonsillar abscess. METHODS: We built the task trainer with low-cost, replaceable, and easily cleanable materials. A damaged airway headskin was repurposed to build the model. A mesh wire cylinder attached to a wooden base was fashioned to provide infrastructure. PTAs were simulated with a water and lotion solution inside a water balloon that was glued to the bottom of a paper cup. The balloon was fully submerged with ordnance gelatin to facilitate ultrasound image acquisition, and an asymmetric soft palate and deviated uvula were painted on top after setting. PTA cups were replaced after use. We spent eight hours constructing three task trainers and used 50 PTA cups for a total cost <$110. RESULTS: Forty-six emergency medicine (EM) residents performed PTA needle aspirations using the task trainers and were asked to rate ultrasound image realism, task trainer realism, and trainer ease of use on a five-point visual analog scale, with five being very realistic and easy. Sixteen of 46 (35%) residents completed the survey and reported that ultrasound images were representative of real PTAs (mean 3.41). They found the model realistic (mean 3.73) and easy to use (mean 4.08). Residents rated their comfort with the drainage procedure as 2.07 before and 3.64 after practicing on the trainer. CONCLUSION: This low-cost, easy-to-construct simulator allows for ultrasound image acquisition while performing PTA needle aspirations and is the first reported of its kind. Educators from EM and otolaryngology can use this model to educate inexperienced trainees, thus ultimately improving patient safety in the clinical setting.

Point-of-care echocardiography in simulation-based education and assessment.

BACKGROUND: Emergency medicine milestones released by the Accreditation Council for Graduate Medical Education require residents to demonstrate competency in bedside ultrasound (US). The acquisition of these skills necessitates a combination of exposure to clinical pathology, hands-on US training, and feedback. OBJECTIVES: We describe a novel simulation-based educational and assessment tool designed to evaluate emergency medicine residents' competency in point-of-care echocardiography for evaluation of a hypotensive patient with chest pain using bedside US. METHODS: This was a cross-sectional study conducted at an academic medical center. A simulation-based module was developed to teach and assess the use of point-of-care echocardiography in the evaluation of the hypotensive patient. The focus of this module was sonographic imaging of cardiac pathology, and this focus was incorporated in all components of the session: asynchronous learning, didactic lecture, case-based learning, and hands-on stations. RESULTS: A total of 52 residents with varying US experience participated in this study. Questions focused on knowledge assessment demonstrated improvement across the postgraduate year (PGY) of training. Objective standardized clinical examination evaluation demonstrated improvement between PGY I and PGY III; however, it was noted that there was a small dip in hands-on scanning skills during the PGY II. Clinical diagnosis and management skills also demonstrated incremental improvement across the PGY of training. CONCLUSION: The 1-day, simulation-based US workshop was an effective educational and assessment tool at our institution.

Introducing a Fresh Cadaver Model for Ultrasound-guided Central Venous Access Training in Undergraduate Medical Education.

INTRODUCTION: Over the past decade, medical students have witnessed a decline in the opportunities to perform technical skills during their clinical years. Ultrasound-guided central venous access (USG-CVA) is a critical procedure commonly performed by emergency medicine, anesthesia, and general surgery residents, often during their first month of residency. However, the acquisition of skills required to safely perform this procedure is often deficient upon graduation from medical school. To ameliorate this lack of technical proficiency, ultrasound simulation models have been introduced into undergraduate medical education to train venous access skills. Criticisms of simulation models are the innate lack of realistic tactile qualities, as well as the lack of anatomical variances when compared to living patients. The purpose of our investigation was to design and evaluate a life-like and reproducible training model for USG-CVA using a fresh cadaver. METHODS: This was a cross-sectional study at an urban academic medical center. An 18-point procedural knowledge tool and an 18-point procedural skill evaluation tool were administered during a cadaver lab at the beginning and end of the surgical clerkship. During the fresh cadaver lab, procedure naïve third-year medical students were trained on how to perform ultrasound-guided central venous access of the femoral and internal jugular vessels. Preparation of the fresh cadaver model involved placement of a thin-walled latex tubing in the anatomic location of the femoral and internal jugular vein respectively. RESULTS: Fifty-six third-year medical students participated in this study during their surgical clerkship. The fresh cadaver model provided high quality and lifelike ultrasound images despite numerous cannulation attempts. Technical skill scores improved from an average score of 3 to 12 (p<0.001) and procedural knowledge scores improved from an average score of 4 to 8 (p<0.001). CONCLUSION: The use of this novel cadaver model prevented extravasation of fluid, maintained ultrasound-imaging quality, and proved to be an effective educational model allowing third-year medical students to improve and maintain their technical skills.

Emergency medicine resident crisis resource management ability: a simulation-based longitudinal study.

BACKGROUND: Simulation has been identified as a means of assessing resident physicians' mastery of technical skills, but there is a lack of evidence for its utility in longitudinal assessments of residents' non-technical clinical abilities. We evaluated the growth of crisis resource management (CRM) skills in the simulation setting using a validated tool, the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS). We hypothesized that the Ottawa GRS would reflect progressive growth of CRM ability throughout residency. METHODS: Forty-five emergency medicine residents were tracked with annual simulation assessments between 2006 and 2011. We used mixed-methods repeated-measures regression analyses to evaluate elements of the Ottawa GRS by level of training to predict performance growth throughout a 3-year residency. RESULTS: Ottawa GRS scores increased over time, and the domains of leadership, problem solving, and resource utilization, in particular, were predictive of overall performance. There was a significant gain in all Ottawa GRS components between postgraduate years 1 and 2, but no significant difference in GRS performance between years 2 and 3. CONCLUSIONS: In summary, CRM skills are progressive abilities, and simulation is a useful modality for tracking their development. Modification of this tool may be needed to assess advanced learners' gains in performance.

Anaesthesia for a child with adrenoleukodystrophy: A case report and review of the literature.

We present a 9-year-old boy with X-linked cerebral adrenoleukodystrophy (X-linked ALD) and previous umbilical cord transplant who required general anaesthesia. An anaesthetic plan for each individual should be tailored to ensure the best possible anaesthetic care for these patients. The anaesthetic considerations include mental retardation, seizure disorder, hypotonia, liver function abnormalities, gastro-oesophageal reflux, impaired adrenocortical function and immunosuppression. Pre-operative sedation should be avoided because of hypotonia of the pharyngeal muscles. Anti-convulsants are continued, and potentially epileptogenic anaesthetic agents are avoided. The patient was intubated using a modified rapid sequence induction with a head up position of 30 degrees. Four other cases have been reported in literature. Nevertheless, there is still no established anaesthetic management for these patients, and total intravenous anaesthesia can be considered as a safe and alternative method of anaesthesia. To the best of our knowledge, this is the first reported use of total intravenous anaesthesia with propofol and remifentanil in a case of cerebral adrenoleukodystrophy, and with a favourable outcome.

Childhood Abuse and Delinquency: A Descriptive Study of Institutionalized Female Youth in Singapore.

Childhood abuse experiences appear prevalent in institutionalized children and youth, but research to date has been limited. Moreover, there is no published study that has examined the issue of childhood abuse and delinquency within institutionalized children and youth in Singapore. This study was cross-sectional in design with follow-up criminal record checks. Data were collected from multiple data sources including official records, structured clinical interviews, and self-report questionnaires on 79 adolescent female residential youth. Two thirds reported having experienced childhood abuse and a higher proportion reported having previously engaged in self-harming behaviours. Participants with multiple types of abuse reported being abused at a younger age, were more likely to be subjected to repeated physical abuse, to have overdosed on medication, and to have reported more health and sexual concerns and trauma symptomatology than those who reported either experiencing one or no previous types of abuse. Fourteen (18%) of the sample had been convicted of further criminal offences over a 6½-year follow-up. The adolescents with histories of multiple types of abuse in childhood presented with more health concerns and traumatic symptomatology, self-reported delinquency, as well as past self-harming behaviour during their institutional stay. Identification of these additionally vulnerable adolescents has important clinical implications for identification, assessment and intervention planning.

A qualitative and quantitative study of psychotherapists' congruence in Singapore.

This study explores the phenomenological world of 11 Satir-based Singaporean Chinese therapists with regard to their experience of congruence. A mixed qualitative-cum-quantitative research method was used in this study. A phenomenological methodology was used to explore (a) the phenomenological world of therapists with regard to their lived experience of congruence in their personal or inner lives, (b) how this congruence is used in psychotherapy, and (c) how therapists can enhance their level of congruence. Quantitative findings include (a) significant nonparametric correlations among the intrapersonal, interpersonal, and transpersonal levels of congruence with overall congruence; (b) significant nonparametric correlation between intrapersonal congruence and interpersonal congruence; (c) significant nonparametric correlations between overall congruence and interpersonal congruence with self-esteem and life satisfaction; and (d) significant nonparametric correlations between intrapersonal congruence and self-esteem. These results may have research and clinical implications for the practice of psychotherapy.

Sputum processing methods to improve the sensitivity of smear microscopy for tuberculosis: a systematic review.

In low-income and middle-income countries, direct (unconcentrated) sputum smear microscopy is the primary method for diagnosing pulmonary tuberculosis. The method is fast, inexpensive, and specific for Mycobacterium tuberculosis in high incidence areas. The main limitations of direct microscopy are its relatively low sensitivity, especially in individuals co-infected with HIV, and variable quality of the test in programme conditions. Thus, there is a need to identify methods to improve the sensitivity of microscopy. Physical and chemical sputum processing methods, including centrifugation, sedimentation, and bleach, have been studied and found to show promise. We did a systematic review to assess the ability of different processing methods to improve the sensitivity of microscopy. By searching many sources, we identified 83 studies. Overall, by comparison with direct smears, the results suggested that centrifugation with any of several chemical methods (including bleach) is more sensitive, that overnight sedimentation preceded by chemical processing is more sensitive, and that specificity is similar. There were insufficient data to determine the value of sputum processing methods in patients with HIV infection. Operational studies are needed to determine whether the increased sensitivity provided by processing methods is sufficient to offset their increased cost, complexity, and potential biohazards, and to examine their feasibility.

Fluorescence versus conventional sputum smear microscopy for tuberculosis: a systematic review.

Most of the world's tuberculosis cases occur in low-income and middle-income countries, where sputum microscopy with a conventional light microscope is the primary method for diagnosing pulmonary tuberculosis. A major shortcoming of conventional microscopy is its relatively low sensitivity compared with culture, especially in patients co-infected with HIV. In high-income countries, fluorescence microscopy rather than conventional microscopy is the standard diagnostic method. Fluorescence microscopy is credited with increased sensitivity and lower work effort, but there is concern that specificity may be lower. We did a systematic review to summarise the accuracy of fluorescence microscopy compared with conventional microscopy. By searching many databases and contacting experts, we identified 45 relevant studies. Sensitivity, specificity, and incremental yield were the outcomes of interest. The results suggest that, overall, fluorescence microscopy is more sensitive than conventional microscopy, and has similar specificity. There is insufficient evidence to determine the value of fluorescence microscopy in HIV-infected individuals. The results of this review provide a point of reference, quantifying the potential benefit of fluorescence microscopy, with which the increased cost and technical complexity of the method can be compared to determine the possible value of the method under programme conditions.