Staffing Patterns of Non-ACGME Fellowships with 4-Year Residency Programs: A National Survey.

Introduction: Emergency medicine (EM) is one of few specialties with variable training lengths. Hiring a three-year graduate to continue fellowship training in a department that supports a four-year residency program can lead to conflicts around resident supervision. We sought to understand hiring and clinical supervision, or staffing, patterns of non-Accreditation Council for Graduate Medical Education (ACGME) fellowships hosted at institutions supporting four-year residency programs. Methods: We performed a web-based, cross-sectional survey of non-ACGME fellowship directors (FD) hosted at institutions supporting four-year EM residency programs. We calculated descriptive statistics. Our primary outcome was the proportion of programs with four-year EM residencies that hire non-ACGME fellows graduating from three-year EM residencies. Results: Of 119 eligible FDs, 88 (74%) completed the survey. Seventy FDs (80%) indicated that they hire graduates of three-year residencies. Fifty-six (80%) indicated that three-year graduates supervise residents. Most FDs (74%) indicated no additional requirements exist to supervise residents outside of being hired as faculty. The FDs cited department policy, concerns about quality and length of training, and resident complaints as reasons for not hiring three-year graduates. A majority (10/18, 56%) noted that not hiring fellows from three-year programs negatively impacts recruitment and gives them access to a smaller applicant pool. Conclusion: Most non-ACGME fellowships at institutions with four-year EM programs recruit three-year graduates and allow them to supervise residents. This survey provides programs information on how comparable fellowships recruit and staff their departments, which may inform policies that fit the needs of their learners, the fellowship, and the department.

Understanding clerkship experiences in emergency medicine and their potential influence on specialty selection: A qualitative study.

Objectives: The specialty of emergency medicine (EM) is experiencing a significant decrease in student interest. In addition, women are historically underrepresented within the specialty at all levels of training and practice. We sought to understand how clinical experiences and perceptions of EM influence specialty selection by medical students, particularly women. Methods: Using a constructivist grounded theory approach, we analyzed semistructured interviews with senior medical students who considered EM as a specialty. We used purposive sampling to recruit from diverse learning environments and represent a variety of experiences. Participants reflected on their specialty selection process and experiences in EM including their perceived acceptance in the work environment. Results: Twenty-five medical students from 11 geographically diverse schools participated. A total of 68% (17/25) identified as women. The majority (21/25, 84%) planned on applying to EM residency. We identified four major themes: (1) distressing interpersonal interactions with patients and the ED care team negatively affect students; (2) EM culture includes behaviors that are perceived as exclusionary; (3) beliefs about the attributes of an ideal EM physician and the specialty itself have a gendered nature; and (4) ease of access to mentors, representation, and early exposure to EM environment increased interest in specialty. Conclusions: Our participants express that EM causes challenges for students to accept the norms of behavior in the field, which is an essential element in joining a group and professional identity formation. In addition, we raise concern that gendered perceptions and language may send exclusionary environmental cues that may negatively impact recruitment of a diverse physician workforce.

Pediatric Takotsubo cardiomyopathy resulting from clonidine overdose.

Takotsubo cardiomyopathy is a syndrome characterized by localized apical dysfunction of the left ventricle. It is rarely seen in pediatric patients, but can carry significant morbidity and mortality. While most commonly associated with psychosocial stressors or physical exertion, a growing number of cases are being attributed to medications. We describe a case of a six-month-old male diagnosed with Takotsubo cardiomyopathy in the setting of an accidental clonidine overdose. The patient presented with altered mental status and hypertension. In the course of his broad workup, cardiac dysfunction was indicated by bedside ultrasound in the Emergency Department. The classic apical dyskinesis was seen on a follow-up, cardiology-based echocardiogram. The patient responded to high-dose naloxone and only briefly required an epinephrine infusion. His symptoms resolved in a few days and serial echocardiograms showed a return to normal LV function. Rates of pediatric clonidine overdoses are increasing in the setting of changing prescribing practices. Our case illustrates some key features of the clinical presentation, as well as demonstrates a rare sequelae to this common toxic exposure. To our knowledge, this is the first reported pediatric case of Takotsubo cardiomyopathy secondary to a clonidine overdose.

Myocarditis Following mRNA COVID-19 Vaccine.

ABSTRACT: A growing number of adolescents are being diagnosed with acute myocarditis following mRNA COVID-19 vaccinations. This case describes an adolescent who presented to the emergency department with chest pain and tachycardia following the Pfizer-BioNTech COVID-19 vaccination. Point-of-care ultrasound was performed prior to the return of laboratory studies and revealed depressed left ventricular systolic function. Point-of-care ultrasound may be a tool used to rapidly diagnose or risk stratify patients with potential post-COVID-19 vaccine myocarditis.

Unilateral acrokeratoelastoidosis--second reported case.

Acrokeratoelastoidosis (AKE) is a rare disease that manifests as wartlike papules along the dorsal palmar junction. It is characterized by orthohyperkeratosis in the horny layer and elastorrhexis in the reticular dermis. Both sporadic and familial cases following autosomal dominant inheritance have been reported. Currently, no effective treatments exist for AKE, which can have a significant cosmetic impact. Here we present the second reported case of unilateral AKE in a 5-year-old African American girl and hypothesize that the mechanism for the unilateral nature of AKE in this patient is genetic mosaicism.

D-dimer and exhaled CO2/O2 to detect segmental pulmonary embolism in moderate-risk patients.

RATIONALE: Pulmonary embolism (PE) decreases the exhaled end-tidal ratio of carbon dioxide to oxygen (etCO(2)/O(2)). OBJECTIVES: To test if the etCO(2)/O(2) can produce clinically important changes in the probability of segmental or larger PE on computerized tomography multidetector-row pulmonary angiography (MDCTPA) in a moderate-risk population with a positive D-dimer. METHODS: Emergency department and hospitalized patients with one or more predefined symptoms or signs, one or more risk factors for PE, and 64-slice MDCTPA enrolled from four hospitals. D-dimer greater than 499 ng/ml was test(+), and D-dimer less than 500 ng/ml was test(-). The median etCO(2)/O(2) less than 0.28 from seven or more breaths was test(+) and etCO(2)/O(2) greater than 0.45 was test(-). MDCTPA images were read by two independent radiologists and the criterion standard was the interpretation of acute PE by either reader. PE size was then graded. MEASUREMENTS AND MAIN RESULTS: We enrolled 495 patients, including 60 (12%) with segmental or larger, and 29 (6%) with subsegmental PE. A total of 367 (74%) patients were D-dimer(+), including all 60 with segmental or larger PE (posterior probability 16%). The combination of D-dimer(+) and etCO(2)/O(2)(+) increased the posterior probability of segmental or larger PE to 28% (95% confidence interval [CI] for difference of 12%, 3.0-22%). The combination of D-dimer(+) and etCO(2)/O(2)(-) was observed in 40 patients (8%; 95% CI, 6-11%), and none (0/40; 95% CI, 0-9%) had segmental or larger PE on MDCTPA. No strategy changed the prevalence of subsegmental PE. CONCLUSIONS: In moderate-risk patients with a positive D-dimer, the et etCO(2)/O(2) less than 0.28 significantly increases the probability of segmental or larger PE and the etCO(2)/O(2) greater than 0.45 predicts the absence of segmental or larger PE on MDCTPA.