An Innovative Curriculum For Teaching Transesophageal Echocardiography (TEE) to Emergency Medicine Residents.

BACKGROUND: Focused transesophageal echocardiogram (TEE) can be a valuable tool for emergency physicians (EP) during cardiac arrest. OBJECTIVES: We sought to demonstrate the ability of emergency medicine (EM) residents without prior TEE experience to perform a simulated four-view TEE following a short, flipped conference curriculum. METHODS: This was a prospective, simulation-based study where EM residents participated in the following four-view TEE curriculum: 1 h of online content reviewed prior to a 20-min in-person lecture and 30-min hands-on practice using a TEE trainer. Each resident attended four testing sessions over an 8-week period and performed a total of 25 TEE scans. Each TEE scan was graded in real time using a 10-point checklist by a TEE-credentialed EP. Interrater reliability of the checklist was calculated using the kappa coefficient (κ). A random sample of 10% of the TEE scans were reviewed by a TEE expert using a standard ultrasound 1-5 scale for image acquisition quality, with a "3" considered to be satisfactory. Residents completed an online pretest and posttest. RESULTS: Twenty-four residents participated. Mean pre- and posttest scores were 52% (SD 16) and 92% (SD 12), respectively. Mean TEE scores using the 10-point checklist after sessions one and four were 9.4 (SD 0.4) and 9.7 (SD 0.3), respectively. Mean time to complete each TEE scan after sessions one and four were 118.1 (SD 28.3) and 57.1 (SD 17.0) s, respectively. The κ for the checklist was 1. The median score for the image acquisition review was 3 (interquartile range 3-4). CONCLUSIONS: This simplified flipped conference curriculum can train EM residents to competently perform TEE in a simulated environment.

Using High Sensitivity Troponins to Rule Out Acute Coronary Syndrome and Lower Admission Rates.

Chest pain is a common complaint encountered by Emergency Medicine physicians in the emergency department (ED). History taking, electrocardiograms, and cardiac biomarkers are the mainstays of the evaluation process of patients who present to the ED with symptoms of an acute coronary syndrome. Cardiac troponin is the primary biomarker used for the diagnosis of acute myocardial infarction. In January 2017, high sensitivity cardiac troponins (hs-cTns) were approved for use in the United States. These markers have increased sensitivity and can more rapidly detect myocardial injury, making them very useful in the ED. However, despite improved sensitivity, elevations in hs-cTn can occur in a large number of patients who are not currently experiencing an acute myocardial infarction. As a result, it is important that clinicians understand the value of serial cardiac biomarker measurements and how to incorporate hs-cTn levels below the limit of detection into clinical decision-making. A large percentage of these low-risk patients end up having negative cardiac work-ups. This article will include a discussion on how to utilize common risk stratification tools in the ED to identify cohorts of patients suitable for discharge without additional testing. ED physicians must understand the limitations and benefits of hs-cTn levels and how to incorporate the information obtained from these biomarkers into risk scores in order to strengthen disposition decisions and safely discharge patients from the ED.