Evidence Based Scarce Resource Allocation During the COVID-19 Pandemic: A Case Study of Bamlanivimab Administration in the Emergency Department.

Background: Patients presenting for emergency department (ED) evaluation may be appropriate for treatment with monoclonal antibodies for mild to moderate COVID-19. While many sites have implemented infusion centers for these agents, EDs will continue to evaluate these patients where appropriate identification and efficient infusion of eligible patients is critical. Objectives: Patients receiving bamlanivimab in the EDs of an academic medical center are described. The primary objective was to describe operational metrics and secondary objectives reported clinical outcomes. Methods: Patients receiving bamlanivimab and discharged from the ED were included from November 16, 2020 to January 16, 2021 in the retrospective, observational cohort. Primary outcome was adherence to institutional criteria. Secondary outcomes included ED visit metrics, clinical characteristics, and return visits within 30 days. Risk factors for return visits were assessed with regression. Results: One hundred nineteen patients were included. Most (71%) were diagnosed with COVID-19 during the ED visit and median symptom duration was 3(IQR 2-5) days. Median number of risk factors for progression to severe disease was 2 (IQR 1-2). Thirty percent had a documented abnormal chest x-ray. Institutional criteria adherence was 99.2%. Median time from ED room to bamlanivimab was 4 (IQR 3.1-5.2) hours. Thirty patients had return visit within 30 days; 19 were COVID-19 related. Two multivariable regression models were analyzed for COVID-19 related return visit. Characteristics on ED presentation were considered in Model I: male gender (OR 3.01[0.97-9.31]), age (per 10 years) (OR 1.49[1.05-2.12]), African-American race (OR 3.46[1.09-11.06]), and symptom duration (per day) (OR 1.34[1.05-1.73]). Model II included labs and imaging acquired in ED. In Model II, age (per 10 years) (OR 1.52[1.07-2.16]) and abnormal CXR (OR 5.74[1.95-16.9]) were associated with COVID-19 related return visits. Conclusions: Administration of bamlanivimab to ED patients can be done efficiently, with the potential to reduce COVID-19 related return visits. Age and abnormal imaging were independent predictors of COVID-19 return visits.

Effects of the COVID-19 pandemic on medical students: a multicenter quantitative study.

BACKGROUND: The COVID-19 pandemic disrupted the United States (US) medical education system with the necessary, yet unprecedented Association of American Medical Colleges (AAMC) national recommendation to pause all student clinical rotations with in-person patient care. This study is a quantitative analysis investigating the educational and psychological effects of the pandemic on US medical students and their reactions to the AAMC recommendation in order to inform medical education policy. METHODS: The authors sent a cross-sectional survey via email to medical students in their clinical training years at six medical schools during the initial peak phase of the COVID-19 pandemic. Survey questions aimed to evaluate students' perceptions of COVID-19's impact on medical education; ethical obligations during a pandemic; infection risk; anxiety and burnout; willingness and needed preparations to return to clinical rotations. RESULTS: Seven hundred forty-one (29.5%) students responded. Nearly all students (93.7%) were not involved in clinical rotations with in-person patient contact at the time the study was conducted. Reactions to being removed were mixed, with 75.8% feeling this was appropriate, 34.7% guilty, 33.5% disappointed, and 27.0% relieved. Most students (74.7%) agreed the pandemic had significantly disrupted their medical education, and believed they should continue with normal clinical rotations during this pandemic (61.3%). When asked if they would accept the risk of infection with COVID-19 if they returned to the clinical setting, 83.4% agreed. Students reported the pandemic had moderate effects on their stress and anxiety levels with 84.1% of respondents feeling at least somewhat anxious. Adequate personal protective equipment (PPE) (53.5%) was the most important factor to feel safe returning to clinical rotations, followed by adequate testing for infection (19.3%) and antibody testing (16.2%). CONCLUSIONS: The COVID-19 pandemic disrupted the education of US medical students in their clinical training years. The majority of students wanted to return to clinical rotations and were willing to accept the risk of COVID-19 infection. Students were most concerned with having enough PPE if allowed to return to clinical activities.

Asymptomatic Sustained Polymorphic Ventricular Tachycardia in a Patient with a Left Ventricular Assist Device: Case Report and what the Emergency Physician Should Know.

BACKGROUND: Left ventricular assist devices (LVADs) are a viable treatment option for patients with end-stage heart failure. LVADs can improve survival, quality of life, and functional status. The indications for LVAD placement to support left ventricular function are temporary support, a bridge to transplantation, or destination therapy. CASE REPORT: A 61-year-old man with past medical history significant for advanced congestive heart failure from ischemic cardiomyopathy, status post LVAD (HeartMate II; Thoratec Corporation, Pleasanton, CA) placement 2009 as destination therapy, presented to the Emergency Department (ED) with implantable cardiac defibrillators firing four times that morning. While in the care of Emergency Medical Services, he was in ventricular tachycardia, and they gave him a bolus of amiodarone 150 mg intravenously prior to arrival in the ED. He was reportedly alert and oriented without any chest pain on arrival to the ED, where an electrocardiogram was obtained showing polymorphic ventricular tachycardia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must be familiar with the atypical presentations of potentially lethal dysrhythmias in this patient population. They must also be familiar with the major adverse events after LVAD implantation. These include device malfunction, cardiac dysrhythmias, bleeding, thromboembolism, neurological events, and infection. The causes of device malfunction can include thrombus formation with hemolysis, mechanical failure of the impeller, and driveline lead fractures with electric failure. Although time is critical in the heart failure patient with an LVAD failure or complication, expert consultation with cardiology or the LVAD specialist should occur when possible.

Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis.

BACKGROUND: Although as much as 87 % of all healthcare spending is directed by physicians, studies have demonstrated that they lack knowledge about the costs of medical care. Similarly, learners have not traditionally received instruction on cost-conscious care. OBJECTIVE: To examine medical students' perceptions of healthcare delivery as it relates to cost consciousness DESIGN: Retrospective qualitative analysis of medical student narratives PARTICIPANTS: Third-year medical students during their inpatient internal medicine clerkship MAIN MEASURES: Students completed a reflective exercise wherein they were asked to describe a scenario in which a patient experienced lack of attention to cost-conscious care, and were asked to identify solutions and barriers. We analyzed these reflections to learn more about students' awareness and perceptions regarding the practice of cost-conscious care within our medical center. KEY RESULTS: Eighty students submitted the assignment between July and December 2012. The most common problems identified included unnecessary tests and treatments (n = 69) and duplicative tests and treatments (n = 20.) With regards to solutions, students described 82 scenarios, with 125 potential solutions identified. Students most commonly used discussion with the team (speak up, ask why) as the process they would use (n = 28) and most often wanted to focus lab testing (n = 38) as the intervention. The most common barriers to high-value care included increased time and effort (n = 19), ingrained practices (n = 17), and defensive medicine or fear of missing something (n = 18.) CONCLUSIONS: Even with minimal clinical experience, medical students were able to identify instances of lack of attention to cost-conscious care as well as potential solutions. Although students identified the hierarchy in healthcare teams as a potential barrier to improving high value care, most students stated they would feel comfortable engaging the team in discussion. Future efforts to empower learners at all levels to question value decisions and to develop and implement solutions may result in improved healthcare.

Immersion Foot: A Case Report.

BACKGROUND: Immersion foot (commonly called "trench foot") was originally described in the military literature during World War I. Since that time, the emergency department (ED) has become a common setting where this injury presents. However, this topic is neglected in the emergency medicine literature. The purpose of this case report is to present trench foot in a way that is relevant to emergency physicians and to provide an up-to-date summary of the history, case reports, physiology, clinical presentation, and treatment of this injury. CASE REPORT: Here we present the case of a homeless, schizophrenic patient who presented to one Midwestern ED in January for immersion foot. Photos of the actual patient are shown to illustrate the case. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to unfamiliarity, immersion foot can go undiagnosed during assessment of patients exposed to moist environments. In addition, patients at increased risk for developing immersion foot are frequently encountered in EDs. Most importantly, the appropriate treatment for immersion foot is different than the treatment for other freezing cold injuries.

Implementation of a workshop for mass casualty incident triage training using an immersive virtual reality simulation.

Objective: We offered a workshop at the 2023 annual meeting of the Society for Academic Emergency Medicine to teach the Sort-Assess-Lifesaving Interventions-Treatment/Transport (SALT) triage protocol for responding to mass casualty incidents (MCIs) using an immersive virtual reality (VR) simulator. Here, we report workshop outcomes. Methods: After a 1-h didactic on the basics of triage protocols, workshop participants rotated through three skill stations at which learners learned how to use the VR headset and controllers, practiced applying SALT triage skills through a tabletop exercise, and then finally used our VR simulator for training responses to MCIs. During their encounter with VR, participants applied their new knowledge to triaging and treating the victims of an explosion in a virtual subway station. After a brief orientation, participants entered the scene to treat and triage virtual patients who had various life-threatening (e.g., acute arterial bleed, penetrating injury, pneumothorax, amputations) and non-life-threatening injuries (lacerations, sprains, hysteria, confusion). The simulator generated a performance report for each workshop attendee to be used for debriefing by a skilled facilitator. Results: Participants were mostly trainees (residents), all of whom properly initiated their encounter with global sort commands (walk and wave) to identify the most critically injured. On average, participants correctly treated 92% of 18 injuries, with all bleeding injuries being properly controlled (tourniquets or wound packing). On average, participants correctly tagged 87.7% of 11 patients, but only took the pulse of 67% of the 11 patients. Learners had difficulty with cases involving embedded shrapnel and properly tagging patients who were stable after treatments. Conclusions: Our VR simulator provided a practical, portable, reproducible training and assessment system for preparing future emergency medical systems (EMS) medical directors to teach their EMS professionals the triage and lifesaving intervention treatment skills needed to save lives.

Evaluation of high-fidelity and virtual reality simulation platforms for assessing fourth-year medical students' encounters with patients in need of urgent or emergent care.

BACKGROUND: Medical students in the U.S. must demonstrate urgent and emergent care competence before graduation. Urgent and emergent care competence involves recognizing, evaluating and initiating management of an unstable patient. High-fidelity (HF) simulation can improve urgent and emergent care skills, but because it is resource intense, alternative methods are needed. STUDY OBJECTIVE: Our primary purpose was to use program evaluations to compare medical student experiences with HF and virtual reality (VR) simulations as assessment platforms for urgent and emergent care skills. METHODS: During their emergency medicine clerkship, students at The Ohio State University College of Medicine must demonstrate on HF manikins, competence in recognizing and initiating care of a patient requiring urgent or emergent care. Students evaluated these simulations on a five-point quality scale and answered open-ended questions about simulation strengths and weaknesses. Faculty provided feedback on student competence in delivering urgent or emergent care. In 2022, we introduced VR as an alternative assessment platform. We used Wilcoxon Signed Ranks and Boxplots to compare ratings of HF to VR and McNemar Test to compare competence ratings. Comments were analyzed with summative content analysis or thematic coding. RESULTS: We received at least one evaluation survey from 160 of 216 (74.1%) emergency medicine clerkship students. We were able to match 125 of 216 (57.9%) evaluation surveys for students who completed both. Average ratings of HF simulations were 4.6 of 5, while ratings of VR simulations were slightly lower at 4.4. Comments suggested that feedback from both simulation platforms was valued. Students described VR as novel, immersive, and good preparation for clinical practice. Constructive criticism identified the need for additional practice in the VR environment. Student performance between platforms was significantly different with 91.7% of students achieving competence in HF, but only 65.5% in VR (p≤.001, odds-ratio = 5.75). CONCLUSION: VR simulation functions similarly to HF for formative assessment of urgent and emergent care competence. However, using VR simulation for summative assessment of urgent and emergent care competence must be considered with caution because students require considerable practice and acclimation to the virtual environment.

Medical students found value in using virtual reality simulation as a platform for practice and feedback in a formative assessment arrangement.Students described the virtual reality simulation as immersive and good preparation for clinical practice.Technical difficulties were common and the student learning curve for acclimating and learning how to function in the virtual environment was noteworthy.

Learner evaluation of an immersive virtual reality mass casualty incident simulator for triage training.

Background: To minimize loss of life, modern mass casualty response requires swift identification, efficient triage categorization, and rapid hemorrhage control. Current training methods remain suboptimal. Our objective was to train first responders to triage a mass casualty incident using Virtual Reality (VR) simulation and obtain their impressions of the training's quality and effectiveness.We trained subjects in a triage protocol called Sort, Assess, Lifesaving interventions, and Treatment and/or Transport (SALT) Triage then had them respond to a terrorist bombing of a subway station using a fully immersive virtual reality simulation. We gathered learner reactions to their virtual reality experience and post-encounter debriefing with a custom electronic survey. The survey was designed to gather information about participants' demographics and prior experience, including roles, triage training, and virtual reality experience. We then asked them to evaluate the training and encounter and the system's potential for training others. Results: We received 375 completed evaluation surveys from subjects who experienced the virtual reality encounter. Subjects were primarily paramedics, but also included medical learners as well as other emergency medical service (EMS) professionals. Most participants (95%) recommended the experience for other first responders and rated the simulation (95%) and virtual patients (91%) as realistic. Ninety-four percent (94%) of participants rated the virtual reality simulator as "excellent" or "good." We observed some differences between emergency medical service and medical professionals regarding their prior experience with disaster response training and their opinions on how much the experience contributed to their learning. We observed no differences between subjects with extensive virtual reality experience and those without. Conclusions: Our virtual reality simulator is an automated, customizable, fully immersive virtual reality system for training and assessing personnel in the proper response to a mass casualty incident. Participants perceived the simulator as an adequate alternative to traditional triage and treatment training and believed that the simulator was realistic and effective for training. Prior experience with virtual reality was not a prerequisite for the use of this system. Supplementary Information: The online version contains supplementary material available at 10.1186/s44247-024-00117-5.

Clinical outcomes in patients with mild to moderate coronavirus disease 2019 treated with monoclonal antibody therapy versus an untreated control cohort.

BACKGROUND: Monoclonal antibody therapy (MAT) received Food and Drug Administration (FDA) Emergency Use Authorization (EUA) for mild to moderate COVID-19 treatment in adults at a high-risk for progression to severe disease in November 2020. This study assessed the impact of MAT on clinical outcomes. METHODS: We conducted a single-center, retrospective study comparing 30-day COVID-19-related emergency department (ED) visits, admissions, and mortality in patients receiving MAT (bamlanivimab, bamlanivimab-etesevimab, or casirivimab-imdevimab) between 16 November 2020 and 19 June 2021, compared to a control group of high-risk adults diagnosed with mild to moderate COVID-19 prior to MAT availability between 16 May 2020 and 15 November 2020. Statistical analysis used logistic regression analysis with backward selection to determine the odds ratios and 95% confidence interval evaluating the relationship between clinical characteristics and outcomes. RESULTS: 1187 patients who received MAT were compared to 1103 patients not treated with MAT. Multivariable regression model adjusted for possible confounders showed patients who received MAT had lower rates of ED visits (3.2% vs 7.4%, OR = 0.46, 95% CI = 0.31-0.70, p < .001) and hospital admissions (4.3% vs 7.8%, OR = 0.42, 95% CI = 0.29-0.62, p < .001) compared to the control group. After adjusting for confounders, MAT was associated with decreased mortality (OR = 0.36, p = .035). In the MAT group, those treated within 2 days of COVID-19 diagnosis had lower mortality than those treated more than 2 days post-diagnosis (unadjusted OR = 0.152, 95% CI = 0.031-0.734, p = .019). CONCLUSIONS: Individuals treated with MAT had lower rates of 30-day COVID-19-related ED visits and hospital admissions compared to those not receiving MAT. Early MAT resulted in lower 30-day mortality compared to receipt >2 days post COVID-19 diagnosis.

Medical student self-assessment narratives: perceived educational needs during fourth-year emergency medicine clerkship.

BACKGROUND: The educational needs of medical students in the 4th-year of training are not well defined in the literature. PURPOSE: The specific aim of this investigation is to characterize the perceived educational needs of 4th-year medical students during an Emergency Medicine clerkship. METHODS: This was a thematic analysis of informed self-assessment narratives. The writings were performed by medical students during an Emergency Medicine clerkship from July 2010 through May 2011. Themes and subthemes that emerged were assessed for frequency of occurrence. RESULTS: Qualitative analysis of 203 narratives revealed 13 themes and 55 subthemes. Patient care (50%), history taking (44%), and physical examination (29%) were the themes most commonly noted as strengths. Medical decision making/plan of care (44%), differential diagnosis (37%), presentation skills (32%), and knowledge base (27%) were the themes most commonly noted as weaknesses. All themes were described as strengths by some students and weaknesses by others; however, trends were apparent in the analysis. CONCLUSIONS: Fourth-year medical students rotating on an Emergency Medicine clerkship perceive an educational need to improve medical decision making/plan of care. Self-assessment narratives reveal trends in strengths and weaknesses but also highlight the importance of recognizing students as unique learners with individualized needs.

A tiered mentorship program improves number of students with an identified mentor.

BACKGROUND: Mentorship is critical to professional development and academic success. Unfortunately, only about 40% of medical students can identify a mentor. While group mentorship has been evaluated - the concept of a specialty specific, tiered group mentorship program (TGMP) has not. In the latter, each member of the group represents a unique education or professional level. PURPOSE: The purpose of this study was to investigate the ability of a specialty-specific, tiered group mentorship program to improve mentorship for students interested in emergency medicine. METHODS: Groups consisted of faculty members, residents, 4th-year students pursuing a career in Emergency Medicine, and junior (MS1, MS2, and MS3) medical students (13 total groups). Students completed confidential electronic surveys before and after completion of the program. RESULTS: Of 126 students, 85 completed the Course Evaluation Survey. At program onset, 11.4% of 1st-year students, 41.7% of 2nd-year students, 50% of 3rd-year students, and 28% of the total students could identify a mentor. After completion, 68.6% of 1st years, 83.3% of 2nd years, 90% of 3rd years, and 77.6% of the total reported they could identify a mentor. Faculty were rated most important members followed by the 4th-year student. CONCLUSION: A tiered group mentorship program improved the ability of students to identify a mentor. Students identified mentoring relationships from individuals at various professional levels.

Fishhook removal: case reports and a review of the literature.

BACKGROUND: Fishhook injuries are common among people who fish for recreation, but can be encountered in anyone who has handled a fishhook. They represent a unique challenge for Emergency Physicians who seek to remove them without causing further tissue damage from the barbed nature of the hook. OBJECTIVE: Our aim was to discuss the techniques available to providers in the removal of a barbed fishhook by illustrating actual cases seen in the Emergency Department. CASE REPORTS: We present two cases of patients with fishhook injuries. We discuss the proper assessment of these injuries. We describe techniques for removing a barbed hook from a patient's skin and offer images to guide management. CONCLUSIONS: Understanding the unique nature of fishhook injuries and awareness of techniques to manage them are essential to the practicing Emergency Physician.

Faculty prefer continuity with medical students in the emergency department.

INTRODUCTION: The aim of this investigation was to better understand emergency medicine (EM) faculty opinions as they relate to continuity with students. METHODS: This was a prospective cohort study of faculty supervising students completing an EM clerkship. Student schedules were aligned to maximise continuity with faculty. Faculty completed surveys prior to the start of the study and again at the end of the study period. RESULTS: Faculty generally indicated a favourable opinion regarding continuity with students. Significant change was noted in two survey questions from pre- to post-intervention: faculty reported higher motivation to teach and felt the students' learning experience was better with improved continuity. CONCLUSION: EM faculty express theoretical optimism regarding the value of improved continuity between teacher and learner. This positive sentiment persisted after actual experience with students on a shift allocation model that aligns faculty and student schedules.

Cervical Spinal Immobilization: A Head-to-Head Comparison of a One-Step Spray-on Foam Splint Versus Structural Aluminum Malleable Splint Immobilization.

INTRODUCTION: Cervical spine immobilization in a low-resource environment is difficult secondary to limited equipment, prolonged transportation, and secondary complications. A structural aluminum malleable (SAM) splint is commonly utilized because of its availability and multipurpose intention. A one-step spray-on foam immobilization technique (Fast Cast) has been shown to be effective in lower-extremity splinting. The aim of this study was to demonstrate the ability of the Fast Cast to effectively immobilize the cervical spine in a head-to-head comparison against the SAM splint. We hypothesized that there would be no difference in surgeon scoring between Fast Cast and SAM splints for the immobilization of the cervical spine. METHODS: This was a cadaveric experimental comparative study that compared a SAM splint versus Fast Cast for the immobilization of an unstable cervical spine. Each of the three cadaveric specimens had a corpectomy without fixation performed. A board-certified emergency medicine physician specialized in disaster medicine performed all SAM immobilizations. An orthopedic surgeon performed Fast Cast immobilizations. Each method of immobilization was done on each cadaver. Lateral fluoroscopic imaging was taken before and after immobilization and after log roll/gravity stress. Five board-certified orthopedic surgeons served as graders to independently score each splint. A 5-point Likert scale based on 10 splinting criteria (50 total points possible) was utilized to evaluate cervical spine immobilization. The lead statistical analyst was blinded to the immobilization groups. The statistical significance was assessed via a Wilcoxon signed-rank test and chi-square Fisher's exact test with significance between groups set at α < .05. Inter-rater reliability of the Likert scale results was assessed with the interclass correlation coefficient. RESULTS: Inter-rater reliability for the current Likert scale in the evaluation of cervical spine stabilization was good (interclass correlation coefficient = 0.76). For the cumulative Likert scale score, Fast Cast (32 [28-34]) exhibited a higher total score than SAM (44 [42-47]; P < .01). Likewise, Fast Cast exhibited a greater likelihood of higher Likert scores within each individual question as compared to SAM (P ≤ 0.04). In 100% of cases, raters indicated that Fast Cast passed the gravity stress examination without intrinsic loss of reduction or splinting material, whereas 33% of SAM passed (P < .01). In 100% of cases, raters indicated that Fast Cast passed the initial radiographic alignment following immobilization, whereas 66% of SAM passed (P = .04). In 100% of cases, raters indicated that Fast Cast passed radiographic alignment after the gravity stress examination, whereas 47% of SAM passed (P < .01). CONCLUSION: The Fast Cast exceeded our expectations and was shown to be rated not equivalent but superior to SAM splint immobilization for the cervical spine. This has significant clinical implications as the single-step spray-on foam is easy to transport and has multifaceted applications. It also eliminates pressure points and circumferential wrapping and obstruction to airway/vascular access while immobilizing the cervical spine and allowing for radiographic examination. Further studies are needed for human use and application.

First Responder Virtual Reality Simulator to train and assess emergency personnel for mass casualty response.

As mass casualty incidents continue to escalate in the United States, we must improve frontline responder performance to increase the odds of victim survival. In this article, we describe the First Responder Virtual Reality Simulator, a high-fidelity, fully immersive, automated, programmable virtual reality (VR) simulation designed to train frontline responders to treat and triage victims of mass casualty incidents. First responder trainees don a wireless VR head-mounted display linked to a compatible desktop computer. Trainees see and hear autonomous, interactive victims who are programmed to simulate individuals with injuries consistent with an explosion in an underground space. Armed with a virtual medical kit, responders are tasked with triaging and treating the victims on the scene. The VR environment can be made more challenging by increasing the environmental chaos, adding patients, or increasing the acuity of patient injuries. The VR platform tracks and records their performance as they navigate the disaster scene. Output from the system provides feedback to participants on their performance. Eventually, we hope that the First Responder system will serve both as an effective replacement for expensive conventional training methods as well as a safe and efficient platform for research on current triage protocols.

The impact of two clinical shift allocation models on student experiences in an emergency medicine clerkship.

BACKGROUND: Medical students on Emergency Medicine (EM) clerkships are traditionally assigned work shifts in a manner that provides a mix of daytime, evening, overnight, and weekend shifts. Whether or not this shift allocation model provides the optimal educational experience remains unclear. PURPOSE: The purpose of this study was to compare the impact of two different shift allocation models on the student's clerkship experience. Specifically, we set out to compare the traditional shift allocation model to a novel model designed to maximize teacher-learner continuity. METHODS: This was a prospective, crossover, cohort study of medical students participating in an EM clerkship at one institution from January 1 through April 31, 2010. All students completed 2 weeks of shifts under the "traditional shift model" and 2 weeks of shifts under the "continuity-based shift model." In the latter, the guiding principle of student shift allocation was continuity between teacher and learner. Students completed coded surveys after each 2-week block that were later matched and analyzed using 2-way ANOVAs with 1 repeated measure. In addition, all students participated in a semistructured group interview at the completion of both blocks. The interviews were recorded, transcribed, and analyzed using qualitative methods. Themes and subthemes that emerged were assessed for frequency of occurrence. RESULTS: Eighteen medical students consented to participate. Students rated the continuity-based shift model higher on all 10 survey items. However, only the items that asked specifically about "faculty"-faculty teaching, faculty interaction, frequency and quality of faculty feedback-were rated significantly higher when students worked under the continuity-based shift model. Qualitative analysis of group interviews revealed 6 major themes and 16 subthemes. Students described feedback (N = 16/117) and the teacher-learner relationship (N = 21/117) as superior under the continuity-based shift model. CONCLUSIONS: Changes in shift allocation affects student experience in an EM clerkship. A shift allocation model that maximizes the continuity between teacher and learner is perceived by students to improve feedback and the teacher-learner relationship.

How we use social media to supplement a novel curriculum in medical education.

BACKGROUND: The millennial learner is reliant on technology to gain knowledge. Social media in the form of Twitter and Facebook provide a unique way to reach these learners. AIMS: To demonstrate a supplement to a curriculum using "push technology" via Twitter and Facebook to deliver educational content to mobile devices. METHODS: A curriculum consisting of high-yield ultrasound concepts was developed and posted to Twitter @EDUltrasound daily. Followers received tweets "pushed" directly to their mobile devices. Following the year-long program, followers were surveyed regarding the program's effectiveness. To determine the ways in which tweets were reaching users, followers were categorized demographically. RESULTS: Daily "tweets" were posted each morning beginning on July 1, 2010. By the end of the year, there were 87 followers on Twitter and 78 on Facebook. The majority of followers (55.6%) had not previously used Twitter. The majority of followers (88.9%) found Twitter user-friendly, while most (81.5%) found the information useful. CONCLUSIONS: Due to ease of use and widespread applicability, Twitter and Facebook are excellent applications of "push technology" as a means to deliver educational content. This pilot project demonstrates the potential of social media to both supplement and enhance traditional educational methods.

Emergency Preparedness and Disaster Response: There's an App for That 2.0.

INTRODUCTION: In disaster response, smartphone applications (or apps) are being used by the layperson, emergency first responders, and health care providers to aid in everything from incident reporting to clinical decision making. However, quality apps are often diluted by the overwhelming number of apps that exist for both the lay public and first responders in the Apple iTunes (Apple Inc.; Cupertino, California USA) and Google Play (Google LLC; Mountain View, California USA) stores. HYPOTHESIS/PROBLEM: A systematic review of disaster response apps was originally completed in 2015; a follow-up review was completed here to evaluate trends and explore novel apps. METHODS: A search of the Apple iTunes and Google Play stores was performed using the following terms obtained from PubMed (National Center for Biotechnology Information; Bethesda, Maryland USA) Medical Subject Headings Database: Emergency Preparedness; Emergency Responders; Disaster; Disaster Planning; Disaster Medicine; Bioterrorism; Chemical Terrorism; Hazardous Materials; and the Federal Emergency Management Agency (FEMA [Washington, DC USA]). After excluding any unrelated apps, a working list of apps was formed and categorized based on topics. Apps were categorized by intended user (first responders or the public) and sub-categorized by topic for discussion. Sub-categories included News/Information, Reference/Education, Weather/Natural Disasters, Travel/Navigation, and Communication/Reunification. RESULTS: A search of the Apple iTunes store revealed 394 unique apps and was narrowed to 342 based on relevance to the field and availability on the iPhone. A search of the Google Play store yielded 645 unique applications and was narrowed to 634 based on relevance. Of note, 49 apps appeared in both app stores using the search terms. An aggregate 927 apps from the Apple iTunes and Google Play stores were then critically reviewed by the authors. Apps were sub-categorized based on intended audience, layperson or first responder, and sorted into one of five disaster response categories. Two apps were chosen for discussion from each of the five sub-categories. The highest quality apps were determined from each group based on relevance to emergency preparedness and disaster response, rating, and number of reviews. CONCLUSION: After comparisons with the 2015 article, many new apps have been developed and previously described apps have been updated, highlighting that this is a constantly changing field deserving of continued analysis and research.

Implementation of a COVID-19 Vaccine Emergency Department Education Program for Underserved Communities.

Background The COVID-19 pandemic has provided an opportunity for significant reflection on our public health response as providers. Throughout the past two years, we learned that administration of COVID-19 vaccines, rapidly and widely across all communities, has been key to halting the spread of the virus. One significant challenge in promoting a large-scale immunization program is the threat of vaccine hesitancy. A general mistrust in healthcare providers exists across the country, especially in underrepresented minority (URM) communities. Objective This study aims to determine reasons for vaccine hesitancy in an urban emergency department and to provide targeted education on the safety and efficacy of the COVID-19 vaccines to patients. Methods An interprofessional quality improvement team was assembled to develop an educational intervention addressing COVID-19 vaccine safety for vaccine-eligible patients receiving treatment in the emergency department at an urban community hospital where over 70% of patients identify as URM. A survey was conducted to elucidate patients' concerns surrounding the COVID-19 vaccine. Upon completion of the survey, up-to-date safety information and education targeting their surveyed concerns were provided by trained medical students. A follow-up survey was conducted to assess the impact of education on patients' attitudes toward the vaccine. Surveys were developed using standardized scoring systems from the Oxford coronavirus explanations, attitudes, and narratives survey (OCEANS) II study and the Kaiser Foundation. Hesitancy scores before and after education were tabulated to assess the effectiveness of targeted education in improving vaccine hesitancy. Results Patients cited a variety of concerns surrounding the COVID-19 vaccine. The three most common reasons for declining vaccines were potential side effects (67.3% were concerned or extremely concerned), the belief that COVID-19 vaccines are neither effective nor safe (64.5% were concerned to extremely concerned), and the risk of developing COVID-19 infection from the vaccine itself (38.8% were concerned to extremely concerned). This information was used to address these concerns directly with patients, answer questions, clarify information, and encourage patients to get vaccinated. Through this education program, vaccine hesitancy scores improved by an average of 29% indicating an increased likelihood of patients who would get vaccinated in the future. Of patients receiving education, 38% agreed to sign up for a vaccine appointment during the intervention. Conclusion The emergency department often serves vulnerable patient populations. As such, its role in public health in these communities cannot be underestimated. This quality improvement project is a novel method that can be used to develop and implement public health education programs to address specific community needs in the emergency department. These results show that a multidisciplinary healthcare team can provide a measurable change in attitudes about vaccine safety with directed education in the emergency department that can help address vaccine hesitancy in the future.

Medical student professionalism narratives: a thematic analysis and interdisciplinary comparative investigation.

BACKGROUND: Professionalism development is influenced by the informal and hidden curriculum. The primary objective of this study was to better understand this experiential learning in the setting of the Emergency Department (ED). Secondarily, the study aimed to explore differences in the informal curriculum between Emergency Medicine (EM) and Internal Medicine (IM) clerkships. METHODS: A thematic analysis was conducted on 377 professionalism narratives from medical students completing a required EM clerkship from July 2008 through May 2010. The narratives were analyzed using established thematic categories from prior research as well as basic descriptive characteristics. Chi-square analysis was used to compare the frequency of thematic categories to prior research in IM. Finally, emerging themes not fully appreciated in the established thematic categories were created using grounded theory. RESULTS: Observations involving interactions between attending physician and patient were most abundant. The narratives were coded as positive 198 times, negative 128 times, and hybrid 37 times. The two most abundant narrative themes involved manifesting respect (36.9%) and spending time (23.7%). Both of these themes were statistically more likely to be noted by students on EM clerkships compared to IM clerkships. Finally, one new theme regarding cynicism emerged during analysis. CONCLUSIONS: This analysis describes an informal curriculum that is diverse in themes. Student narratives suggest their clinical experiences to be influential on professionalism development. Medical students focus on different aspects of professionalism depending on clerkship specialty.