RESIDENTS AS INTERVIEWERS: A COMPARISON OF RESIDENT AND FACULTY EVALUATIONS OF EMERGENCY MEDICINE RESIDENCY APPLICANTS.

BACKGROUND: Interviews are an integral component of the residency selection process. Many programs use current residents as interviewers in addition to faculty. Although the reliability of interview scores between faculty members has been examined, little is known about the reliability between resident and faculty interviewers. OBJECTIVE: This study evaluates the reliability of residents as interviewers compared with faculty. METHODS: A retrospective analysis of interview scores from the 2020-2021 application cycle was performed at an emergency medicine (EM) residency program. Each applicant participated in five separate one-on-one interviews led by four faculty members and one senior resident. Interviewers assigned applicants a score from 0 to 10. Consistency between interviewers was measured using the intraclass correlation coefficient (ICC). Generalizability theory was used to measure variance components including applicant, interviewer, and rater type (resident vs. faculty) and their impact on scoring. RESULTS: There were 250 applicants interviewed by 16 faculty members and 7 senior residents during the application cycle. The mean (SD) interview score given by resident interviewers was 7.10 (1.53) and the mean (SD) score given by faculty was 7.07 (1.69). There was no statistically significant difference between the pooled scores (p = 0.97). Reliability between interviewers was good to excellent (ICC = 0.90; 95% CI 0.88-0.92). The generalizability study showed most score variance was attributable to applicant characteristics and only 0.6% was attributable to interviewer or rater type (resident vs. faculty). CONCLUSIONS: There was strong concordance between faculty and resident interview scores indicating reliability of EM resident scoring compared to faculty.

Cold-atom shaping with MEMS scanning mirrors.

We demonstrate the integration of micro-electro-mechanical-systems (MEMS) scanning mirrors as active elements for the local optical pumping of ultra-cold atoms in a magneto-optical trap. A pair of MEMS mirrors steer a focused resonant beam through a cloud of trapped atoms shelved in the F = 1 ground-state of 87Rb for spatially selective fluorescence of the atom cloud. Two-dimensional control is demonstrated by forming geometrical patterns along the imaging axis of the cold atom ensemble. Such control of the atomic ensemble with a microfabricated mirror pair could find applications in single atom selection, local optical pumping, and arbitrary cloud shaping. This approach has significant potential for miniaturization and in creating portable control systems for quantum optic experiments.

CRYOGLOBULINEMIC VASCULITIS.

BACKGROUND: Cryoglobulinemia is a hematologic condition characterized by the presence of immunologic proteins in the blood, resulting from underlying malignancy to chronic viral processes. The recognition of this condition is critically vital, as patients can first present to the emergency department as their initial manifestation of disease. CASE REPORT: We present a case of cryoglobulinemia, discuss the clinically important types, their presentations, and then emergent complications that can be encountered in the emergency setting. Why Should an Emergency Physician Be Aware of This? Cryoglobulinemia comes in two clinically significant types, both of which can be indicative of an underlying hematologic malignancy, autoimmune, or viral process. The presentation can appear dramatic and can also mimic severe critical illness, for example, meningococcemia. Recognition and appropriate disposition is crucial for the best patient outcome.

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.

Mock Oral Board Examinations via Web-based Video Teleconferencing in the Era of COVID-19.

Owing to infection control measures necessitated by the COVID-19 pandemic, many educational didactic components within residency programs have needed to adapt to virtual formats. We describe and evaluate the transition of an in-person mock oral board certification examination to an entirely virtual format. Oral board cases consisting of two single cases and one triple case were adapted to a virtual format using a Web-based video teleconferencing platform. Faculty examiners underwent 20-minute training sessions prior to the examination. Both resident examinees and faculty examiners completed postexamination surveys. The system usability scale (SUS) was used to assess the usability of the new format by the faculty examiners. Fifteen resident examinees completed the mock virtual oral board examination with eight faculty examiners. All faculty members completed the postexamination survey. The mean (±SD) SUS score was 90.6 (±11.5) out of a maximum of 100. Eleven of 15 (73%) resident examinees completed the postexamination survey. All respondents agreed or strongly agreed that examiner instructions were easy to understand and that examiners were adept at using the Web-based platform. Some technical issues were encountered including audio difficulties for some examiners. Respondents were split regarding personal preference for virtual or in-person mock oral board formats. Utilizing video teleconferencing software to provide a virtual, Web-based alternative to in-person mock oral board examination was feasible, and the virtual format was shown to have high usability despite minimal training time for experienced faculty examiners.

A primer on proning in the emergency department.

Historically, the prone position was used almost exclusively in the ICU for patients suffering from refractory hypoxemia due to acute respiratory distress syndrome (ARDS). Amidst the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, however, this technique has been increasingly utilized in settings outside of the ICU, particularly in the emergency department. With emerging evidence that patients diagnosed with COVID-19 who are not intubated and mechanically ventilated may benefit from the prone position, this strategy should not be isolated to only those with critical illness. This is a review of the pertinent physiology and evidence supporting prone positioning along with a step-by-step guide meant to familiarize those who are not already comfortable with the maneuver. Placing a patient in the prone position helps to improve ventilation-perfusion matching, dorsal lung recruitment, and ultimately gas exchange. Evidence also suggests there is improved oxygenation in both mechanically ventilated patients and those who are awake and spontaneously breathing, further reinforcing the utility of the prone position in non-ICU settings. Given present concerns about resource limitations because of the pandemic, prone positioning has especially demonstrable value as a technique to delay or even prevent intubation. Patients who are able to self-prone should be directed into the ''swimmer's position'' and then placed in reverse Trendelenburg position if further oxygenation is needed. If a mechanically ventilated patient is to be placed in the prone position, specific precautions should be taken to ensure the patient's safety and to prevent any unwanted sequelae of prone positioning.

Electrical storm: A focused review for the emergency physician.

BACKGROUND: Electrical storm is a dangerous condition presenting to the Emergency Department that requires rapid diagnosis and management. OBJECTIVE: This article provides a review of the diagnosis and management of electrical storm for the emergency clinician. DISCUSSION: Electrical storm is defined as ≥3 episodes of sustained ventricular tachycardia, ventricular fibrillation, or shocks from an implantable cardioverter defibrillator within 24 h. Patients may present with a wide array of symptoms. Initial evaluation should include an electrocardiogram with a rhythm strip and continuous cardiac monitoring, a medication history, assessment of hemodynamic stability, and identification of potential triggers. Management includes an antiarrhythmic and a beta blocker. Refractory patients may benefit from double-sequential defibrillation or more invasive procedures such as intra-aortic balloon pumps, catheter ablation and extracorporeal membrane oxygenation for critically ill patients. These patients will typically require admission to an intensive care unit. CONCLUSION: Electrical storm is a condition associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the evaluation and management of these patients.

Screening Electrocardiograms in Cocaine-Positive Chest Pain-Free Psychiatric Patients Requiring Medical Screening.

BACKGROUND: The current practice at a large urban academic emergency department (ED) is to obtain screening electrocardiograms (ECGs) as part of the medical screening on all psychiatric patients who test positive for cocaine. OBJECTIVE: We sought to examine the impact of an ECG in the medical screening of chest pain-free psychiatric patients who test positive for cocaine. METHODS: An institutional review board-approved retrospective chart review from January 2014 to December 2015 was performed on charts of adult ED patients requiring medical screening before transfer to a psychiatric facility. Patients who tested positive for cocaine on urine drug screens were included in this study. Patients with chest pain or those who did not have an ECG recorded were excluded. Outcomes evaluated included disposition and subsequent cardiac work-up. RESULTS: One thousand nine hundred sixty-eight ED patients were identified who tested positive for cocaine on a urine toxicology screen, and 853 met the inclusion criteria. ECGs were normal in 812 patients (95% [95% confidence interval 93-96%]) and abnormal in 41 patients (5% [95% confidence interval 4-7%]). Of 41 patients with abnormal ECGs, 4 were admitted for cardiac work-up. Two patients had positive troponin values in the ED, 2 had cardiology consultations, and 3 had further cardiac stress testing, all of which were negative or nondiagnostic. No cardiac catheterizations were performed. CONCLUSIONS: Most ED patients with recent cocaine use but without chest pain have a normal ECG. Of the minority with an abnormal ECG, no cases of acute myocardial ischemia or infarction were identified.

Utilizing Analytics to Identify Trends in Residency Program Website Visits.

Introduction Most medical residency training programs maintain websites to provide content for audiences including current residents, prospective residents, and medical students. This study seeks to characterize when and how a residency program website is being accessed in order to identify the primary audiences to provide appropriate and timely content. Methods The authors examined website analytics at a large urban Accreditation Council for Graduate Medical Education (ACGME)-accredited post-graduate year (PGY)1-PGY4 emergency medicine residency training program website. Analytics were performed from July 1, 2016 to June 30, 2018 with daily traffic cataloged along with referral sources, page views, and device type used to access the website. The top five dates by daily traffic were further analyzed with daily traffic trends during the residency interview season. Results There was an average of 45.8 unique visitors daily with 261.5 daily page views. Computer (67.2%), mobile device (29.6%), and tablet (3.1%) were the most common devices used for viewing. The most popular content areas by page-view were "people" (68,987 visits), "home" (38,569), "clinical curriculum" (35,556), and "medical students" (14,461). The five most-visited dates were all related to application processes including the opening of the Visiting Student Application Service (VSAS), the Electronic Residency Application Service (ERAS), and Match Day. During the interview season, peak visits occurred the dates immediately preceding interview dates. Conclusion Residency program websites appear to be accessed most commonly by medical students and prospective residency applicants. Website managers should take the needs of these audiences into account and provide appropriate content to maximally inform prospective residency program candidates.

Impact of Resident-Paired Schedule on Medical Student Education and Impression of Residency Programs.

INTRODUCTION: Clinical rotations in emergency medicine (EM) can be challenging for medical students because of the lack of continuity with attending physicians. To overcome this challenge, institutions have started to match a student's schedule with that of a resident, referred to as "paired shifts." We sought to pilot and compare two schedule formats for fourth-year medical students (MS4) - a resident-paired shifts (RPS) and a traditional resident-unpaired shifts (RUS) schedule. METHODS: This prospective, crossover trial included MS4s rotating in the emergency department over four consecutive four-week blocks. Each MS4 was assigned two weeks using the RUS schedule and two weeks with the RPS schedule, alternating the format order each month. At the end of the rotation students were anonymously surveyed regarding the differences in learning experience, their ability to showcase their knowledge and clinical skills, and familiarity with the residency program with the two formats. RESULTS: The response rate was 47 of 58 students (84%). Respondents indicated that RPS resulted in more teaching time (64.6% RPS vs 8.3% RUS), a better overall educational experience (68.8% RPS vs 8.3% RUS), and a greater ability to showcase their medical knowledge (52.1% RPS vs 6.3% RUS). Additionally, students felt that the program was better able to evaluate them (66.7% RPS vs 10.4% RUS) and they were better able to better evaluate the program (66.7% RPS vs 6.3% RUS) in the RPS format. CONCLUSIONS: When compared to traditional RUS during an MS4 rotation, a RPS format provided students with the perception of an improved learning experience, ability to showcase knowledge, and familiarity with the residency program without sacrificing teaching from attending physicians.