Diagnostic accuracy of transthoracic echocardiography for the identification of proximal aortic dissection: a systematic review and meta-analysis.

This systematic review and meta-analysis evaluated the performance of transthoracic echocardiography (TTE) for diagnosis of proximal aortic dissections based on the identification of specific sonographic features. A systematic literature search of major databases was conducted on human studies investigating the diagnostic accuracy of TTE for proximal aortic dissection. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of studies was evaluated using Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were gathered for the following sonographic findings: intimal flap, tear, or intramural hematoma; enlargement of aortic root or widening of aortic walls; aortic valve regurgitation; or pericardial effusion. Sensitivity, specificity, diagnostic odds ratio, number needed to diagnose values, and likelihood ratios were determined. Fourteen studies were included in our final analysis. More than half of the included studies demonstrated low risk of bias. The identification of intimal flap, tear, or intramural hematoma was shown to have an exceptional ability as a diagnostic tool to rule in proximal aortic dissections. TTE should be considered during the initial evaluation of patients presenting to the emergency department with suspected proximal aortic dissection. Positive sonographic findings on TTE may aid in rapid assessment, coordination of care, and treatment of individuals awaiting advanced imaging.

Simultaneous Bilateral Ovarian Torsion in a Transgender Patient.

Ovarian torsions are a diagnostic challenge in the emergency room that result in significant morbidity when missed. Ovarian torsions have a low incidence and can present with atypical and variable symptoms. As such, recognition of ovarian torsion is a key skill that emergency clinicians must master. Typically, ovarian torsion is a unilateral finding but there have been cases of bilateral torsions noted previously in the literature. These rare cases tend to have higher morbidity making it even more important to recognize. This case is unique in that it was a transgendered patient developing synchronous bilateral ovarian torsions, which, to our knowledge, has not been previously described in the literature. This case illustrates the potential for unique presentations of this condition. We advise a high index of suspicion until more data, both objective and subjective gestalt, is known.

Analyzing the effect of interview time and day on emergency medicine residency interview scores.

BACKGROUND: When it comes to scheduling interviews, medical students may wonder if they need a strategy to increase their likelihood of matching. Previous studies examined the temporal effects of the residency interview on overall match rate; however, there are additional factors that affect the match process, including board examination scores and letters of recommendation. Only few studies have examined the effect interview time of day has on match success. The current study examines the impact date and time of interview during the interview season have on candidates' respective interview scores. METHODS: Interview data over a three-year period (i.e., three interview cycles) was examined at a PGY-1-3, ACGME-accredited EM residency program in Philadelphia. Date of interview and time of day of interview (i.e., morning versus afternoon) was examined. A linear regression analysis was performed to determine if there is a statistically-significant difference in overall interview scores based on date during the interview season and time of day. RESULTS: There is no statistically-significant effect of time of day or date on residency interview scores. CONCLUSIONS: Our findings are congruent with other studies on the temporal effects of residency interviews on overall match rate. Findings should provide reassurance to students scheduling interviews, as time slots have not been found to have a significant relationship with overall interview score. Future studies should more holistically analyze the residency application process.

Management of Poisoned Patients: Implementing a Blended Toxicology Curriculum for Emergency Medicine Residents.

Audience: This curriculum is appropriate for emergency medicine residents PGY 1-3 as a toxicology curriculum. Length of Curriculum: The intent is to run this curriculum over one week. Introduction: Toxicology is an important part of the emergency medicine (EM) curriculum and defined in the Council of Residency Directors (CORD) 2019 Model of Clinical Practice of Emergency Medicine as a key area of core content expected to be mastered by graduating EM seniors.1 Unfortunately, programs may not have time in their schedules for a dedicated toxicology curriculum, and residents may not have time to learn this important subject outside of conference didactics. Many emergency medicine programs have mandatory toxicology rotations, as many as 66% according to a 2018 study, with an additional 22% of EM programs offering an elective.2 At our institution, we have limited toxicology faculty available for instruction, and until now have only been able to incorporate occasional lectures into regular conference didactics, prompting our development of a new approach. Developing an asynchronous curriculum allows more dedicated time to study toxicology for our learners and allows greater flexibility for our limited toxicology faculty to teach during a synchronous component. Several asynchronous toxicology curricula have been developed previously.3,4 There have also been several novel synchronous toxicology curricular innovations for introduction during regular conference didactics.5,6 While some learners can benefit from asynchronous learning alone, it has been shown that having synchronous components in distance learning can be very important for improving learning experience and improving deep understanding rather than surface learning.7 Here we propose a one-week, blended asynchronous and synchronous rotation in toxicology that aims to give learners a foundation in important core toxicological concepts that they can implement on shift in the Emergency Department. Educational Goals: The goal of this curriculum is to introduce EM residents to core toxicology concepts and to reinforce toxicology principles through a multimodal approach that leads to increased confidence in the management of poisoned patients on shift. Educational Methods: The educational strategies used in this curriculum include: 1) Online asynchronous modules for each day of the week consisting of free open access medical education (FOAMed) articles, instruction on core topics, and daily quizzes. The content was created, organized, and published utilizing Articulate Rise 360 8 as a learning management system (LMS) but could easily be adapted to other LMS platforms, such as Google Classroom. The majority of educational content used to build the modules was based on Rosen's Emergency Medicine Concepts and Clinical Practice. (5th editions). 2) A virtual simulation session reviewing toxicology cases with a faculty member. Cases were initially oral boards style cases but were later adapted to independent learning sessions utilizing pre-made Full-Code 9 scenarios. This could likely be adapted to other platforms such as in-person simulation for institutions without Full Code subscriptions. 3) A virtual discussion and question & answer board review session with a staff toxicologist. Research Methods: Following completion of the course, residents were encouraged to fill out a survey developed by the writer of the course designed to assess their thoughts about the course, their confidence in recognizing toxidromes as well as their comfort in the medical management of the poisoned patient. This survey was developed in-house and utilized a Likert scale and was administered on Google Forms. In an effort to promote honest feedback, residents were made aware that submissions were anonymous and email information was not collected. Results: Of the 22 participating residents (PGY1-3), 15 responded to our survey for a response rate of 68%. Overall, resident responses to the course were favorable. All participants except for one answered that they were "satisfied" or "very satisfied" with the course; the respondent who did not mark "satisfied" or "very satisfied" marked the option labeled "neutral." Similarly, 93% (14/15) of respondents "agreed" or "strongly agreed" that they would recommend this course to a colleague, and 86% (13/15) "agreed" or "strongly agreed" that the course was a valuable use of their time.Resident responses also indicated an increased confidence in both the recognition of toxidromes and the management of poisoned patients. The majority of respondents (9/15) indicated that their perceived confidence in recognizing toxidromes improved after completion of the course; the remainder, except for one, remarked the same level of confidence before and after completing the course. The resident who had a decline in their confidence said they were "confident" in recognizing toxidromes prior to the course and "somewhat confident" after the course. Unsurprisingly, perceived confidence in the medical management of toxicology patients improved for 87% (13/15) of respondents after having taken the course, with 2 respondents noting the same level of confidence before and after taking the course.Lastly, multiple residents wrote in the free-response section that the toxicology rotation had been directly helpful to them when managing various toxidromes with real cases in the emergency department. For example, one response noted that they had since managed both a tricyclic antidepressant and a calcium channel blocker overdose, which they felt more comfortable with after completing the course. Another resident wrote about the experience of having a pediatric patient suffering from an ingestion of both acetaminophen and aspirin who was placed on a bicarbonate drip. Discussion: This blended synchronous and asynchronous approach to a toxicology course was a success with the residents. Based on our survey responses, the majority of the residents felt this was a valuable educational experience. Many of the residents commented on times after the course where they were directly able to apply the knowledge learned from the modules, which was also encouraging. While COVID limitations kept our synchronous aspects virtual, these were also successful with the residents. While we had initially used oral boards style cases for the simulation session, we had found that engagement with learners during these sessions was not as high as we had hoped. We subsequently switched to using the virtual simulation platform Full Code.8 The learners seemed to enjoy these cases much more with having more visual stimulus during the cases. It was also less work on the part of the faculty to have pre-written toxicology cases to use and lab values/imaging results a click away. However, for institutions without a Full Code subscription, oral boards style cases or in person simulation would be a worthwhile alternative. Additionally, video conference sessions with our toxicology faculty members were helpful for the residents to go over the information they had learned in a question-and-answer format.Regarding the synchronous aspect of the course, having written the modules ahead of time, it was very easy to upload into an LMS. We particularly found Articulate Rise7 to be helpful as an LMS, especially with integrating some interactive elements into each module. However, this could easily be adapted into any LMS your institution prefers, or even into slideshow software. Topics: General approach to poisoned patient, gastric decontamination, dialysis in toxicology, acetaminophen overdose (od), salicylate od, carbon monoxide poisoning, pediatric toxicology considerations, alcohol withdrawal, toxic alcohols, beta blocker od, calcium channel blocker od, tca od, serotonin syndrome, opiate od, body packers vs stuffers, marijuana, synthetic cannabinoids, gamma hydroxybutyric acid (ghb) od; cocaine toxicity, inhalant abuse, spider envenomations, snake envenomations, marine envenomations, mushroom toxicities, organophosphate poisoning.

A Workshop to Reflect on Personal Resilience in Emergency Medicine Residents: Applying the Connor-Davidson Resilience Scale, Visual Explorer, and the Critical Incident Questionnaire to Support Introspection.

Burnout among emergency medicine (EM) residents is gaining increasing attention. The authors designed a workshop to assess EM residents' resilience using a validated scale to prompt personal reflection. The workshop then shifted to peer-to-peer conversations and sharing using images from Visual Explorer (VE) to further reflect on resilience. Overall, resident resilience scores were below those of the US general population, with post-graduate year (PGY)-2 year residents having the lowest scores. The workshop was well received by residents; data from the Critical Incident Questionnaire (CIQ) suggested that residents felt engaged during discussion of the images. Further study is needed to assess the correlation between resilience scores and burnout.

Effective Use of Virtual Gamification During COVID-19 to Deliver the OB-GYN Core Curriculum in an Emergency Medicine Resident Conference.

Introduction Coronavirus disease 2019 (COVID-19) has challenged medical educators on continuing to provide quality educational content in a virtual setting. The objective of this module was to create a gamified review of core obstetric and gynecology (OB-GYN) topics that residents would find educational and informative. Methods The game created was modeled after the TV show "So You Think You Can Dance?", with a warm-up and several rounds of rapid-fire OB-GYN questions and cases, eliminating teams to a final face-off. The residents were given a post-session survey to determine their attitudes and learning towards this virtual conference approach. Results Based on the post-session survey, the majority of the residents found this activity to be educational, entertaining, engaging, and better than the traditional lecture format. Conclusion This initial attempt at migrating gamification, a core component of our live conferences, into the new virtual arena, was well-received by learners as effective, educational, and engaging. This style of gamification can be incorporated into residency programs at other institutions currently limited to virtual platforms to boost resident education and engagement.

Making the Cut: Implementing a Low Cost, Low Fidelity Simulation Model for Teaching Emergency Thoracotomy Procedure.

Emergent thoracotomy is a rare but high-stakes procedure for trauma patients. Emergency medicine residents are expected to perform this procedure after graduation, but few get the opportunity to perform it, leading to suboptimal performance and patient morbidity and mortality. Previous low-cost thoracotomy trainers revolve around modifying an existing costly thoracotomy task trainer or bear limited resemblance to actual landmarks and anatomy. This study attempts to bridge this gap by creating a low-cost model with supplies found at most home improvement/craft stores that is more anatomically accurate. We constructed a low fidelity model, which residents ultimately found to be helpful in mastering this rare procedure, and after the training session, they reported a greater level of comfort and familiarization with the procedure.

Preparing Osteopathic Students for the Single Graduate Medical Education Accreditation System: Evaluating Factors for Match Success in Emergency Medicine.

INTRODUCTION: With the development of and progression toward a single graduate medical education accreditation system combining the current Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) residency programs, the total number of students competing for the same postgraduate training spots will continue to rise. Given this increasing competition for emergency medicine (EM) residency positions, understanding factors that contribute to match success is important to ensure a successful match for osteopathic medical students. METHODS: Our anonymous survey to evaluate factors that led to a successful match was sent out to residents in current ACGME-, AOA-, and dually-accredited programs via the AOA program director listserv and the Council of Residency Directors (CORD) e-mail listserv in 2017. RESULTS: We had 218 responses. Responses showed that osteopathic graduates had less affiliation with EM residencies, their home institutions provided less information regarding standardized letters of evaluations (SLOE), and that successful osteopathic graduates seemed to learn about them while on EM elective rotations. These students also had less direct EM mentorship and were generally unsatisfied with the level of mentorship available. Osteopathic graduates in current ACGME programs were also more likely to have taken the United States Medical Licensing Examination compared to their AOA resident counterparts. CONCLUSION: Osteopathic medical schools can improve their graduates' chances of successfully matching in EM by establishing mentorship programs and educating their students early about SLOEs.