Right Lower Quadrant Pain in a Young Female: Ultrasound Diagnosis of Rectus Abdominis Tear.

BACKGROUND: Right lower quadrant pain in young females presents a frequent diagnostic challenge for emergency physicians, with a broad differential and several important diagnoses. Using an "ultrasound first" imaging strategy can help decrease the use of computed tomography scans, with associated savings in radiation exposure, cost, and other resource use. CASE REPORT: We report a case of right lower quadrant pain in a young woman. After her initial history and physical examination, appendicitis was the leading differential. A bedside ultrasound was performed, leading to the uncommon diagnosis of rectus abdominis muscle tear. The sonographic findings of a muscle tear include increase in size, loss of linear, homogeneous architecture, and decreased echogenicity. Making this diagnosis at the bedside using ultrasound obviated the need for further imaging, avoiding unnecessary radiation exposure, and decreasing emergency department length of stay and overall cost, while leading to a tailored treatment plan. Why Should an Emergency Physician Be Aware of This? Rectus abdominis tear is a cause of right lower quadrant pain that may mimic appendicitis and should be considered in patients with this complaint. The ability to make this diagnosis with bedside ultrasound may assist in several important patient-oriented outcomes.

Trauma patient access: the role of the emergency medical services system in North-Central West Virginia.

UNLABELLED: Trauma patients face many obstacles as they access the healthcare system in North-Central West Virginia. This study highlights some of these barriers and discusses administrative and legislative initiatives that could help mitigate the disparities that rural trauma patients face. METHODS: This is a retrospective, observational study utilizing information from the West Virginia University (WVU) MedCom Database. Trauma related Emergency Medical Services (EMS) calls from 2002 to 2011 were reviewed to determine many of the parameters of the care provided by EMS in the WVU MedCom catchment area. These 54,952 trauma related EMS contacts were reviewed to determine estimated time of arrival (ETA) at the receiving facility, level of EMS response, trauma activation criteria, time of day, and day of week of the transport. RESULTS: The mean ETA for all transports was 11.7 minutes with mean transport ETA from the most rural county, Pendleton County, being 28.4 minutes. Emergency Medical Technician-B (BLS) providers covered 23% of the calls. Emergency Medical Technician-P (ALS) providers covered 76% of the calls. West Virginia State Trauma activation criteria were met for 30% of the transports. BLS providers transported 19% of these trauma activation criteria patients and ALS providers transported 78% of these transports. CONCLUSIONS: In north-central West Virginia, there are many barriers facing the trauma patient as they access the healthcare system. Among these are extended transport times, the capabilities of the EMS provider responding, and the limitation that approximately 50% of counties have either no hospital at all or only a hospital with limited treatment capability for the trauma patient transported by EMS.

Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management.

Audience: The targeted audience for this simulation is Emergency Medicine (EM) residents. Medical students, advanced practice providers, and staff physicians could all also find educational merit in this scenario. Background: Cardiovascular disease is the leading cause of death in the United States according to the CDC.1 Coronary artery disease caused 375,000 deaths 2021 alone, and about 5% of all adult patients have a prior history of coronary artery disease.2 Furthermore, chest pain itself is a common chief complaint encountered in the ED, with nearly 8 million visits annually occurring throughout the United States, with 10-20% of those patients ultimately being diagnosed with an acute coronary syndrome3, including ST-elevation myocardial infarction (STEMI). Given this, it is essential that EM residents are well prepared to care for all patients presenting with chest pain, regardless of the acute care or emergency setting.Throughout their training, most EM residents typically learn and evaluate patients at a large tertiary or quaternary medical center with 24-hour catheterization laboratory availability. For patients presenting with electrocardiogram (EKG) findings consistent with STEMI, the standard of care is for the patient to undergo cardiac catheterization and stent placement within 90 minutes of arrival. Unfortunately, only half of patients living in rural areas have a cardiac catheterization-capable facility available to them within a 60-minute driving radius, making it difficult for those patients to undergo cardiac catheterization within the desired time frame.4 These patients remain candidates for thrombolytic therapy, but given infrequent opportunities to learn about and deploy thrombolytic agents during residency training, graduating EM residents may be unfamiliar with indications, dosing, and contraindications before they begin practice. Furthermore, the recent EM workforce data suggests that although there may be an oversupply of 8,000 emergency physicians by 2030, robust practice opportunities for emergency physicians remain in rural settings.5 Although historically EM graduates have not selected rural areas for practice, with only approximately 8% of emergency physicians practicing in rural areas,6 it is likely that given the opportunities present and perceived saturation in many non-rural settings, more EM graduates will pursue practice in a rural setting. With these changing practice dynamics in mind, this simulation provides the opportunity for residents and medical students to experience the management of a STEMI in the rural setting, with a focus upon the indications, contraindications, dosing, and disposition of a patient receiving thrombolytics. Educational Objectives: By the end of this simulation, learners will be able to:Diagnose ST elevation myocardial infarction accurately and initiate thrombolysis in the rural setting without timely access to cardiac catheterization.Engage the simulated patient in a shared decision-making conversation, clearly outlying the benefits and risks of thrombolysis.Identify the indications and contraindications for thrombolysis in ST elevation myocardial infarction.Arrange for transfer to a tertiary care center following completion of thrombolysis. Educational Methods: This scenario is a simulated encounter in a rural emergency department setting requiring the diagnosis of a STEMI, a discussion with the patient regarding the risks and benefits of thrombolysis prior to administration, administration of thrombolysis, and transfer of patient to a higher level of care. Research Methods: The educational content of this simulation as a teaching instrument was evaluated by the learner utilizing an internally developed survey after case completion. This survey was reviewed for precision of language and assessment of learning objectives by our simulation faculty and other members of our West Virginia University Emergency Medicine Department of Medical Education. The learner was asked to specify any prior experience with rural STEMI management as well as quantify via a five-point Likert Scale, where 1 = very uncomfortable and 5 = very comfortable, their level of comfort with thrombolysis before and after the scenario as well as their comfort with having a shared decision-making conversation with patients with regards to thrombolysis. Learners were also asked to rank the helpfulness of this simulation in preparing them for administering thrombolytics for STEMI in a rural setting on a five-point Likert scale, where 1 = not helpful and 5 =very helpful. An open response section was also provided to allow learners the opportunity to comment directly on any aspect of the simulation. Results: Data was collected anonymously from 16 PGY1-3 resident learners via surveys with a 100% response rate. Overall, the feedback received regarding the simulation was positive. There was a low average comfort level with administering thrombolytics and having a shared decision-making conversation regarding administering thrombolytics. There was a high average rating of the helpfulness of this simulation in preparing residents for this conversation as well as managing STEMIs in a rural setting. Subjective comments regarding the simulation were universally positive. Discussion: The management of STEMI in the rural emergency department differs significantly from the environment in which many EM residents train. As a leading cause of death in the United States, STEMI management is a vital component of EM resident education. Although the concept of thrombolysis in the rural setting is discussed, the opportunity for real-world experience in its execution is often limited despite many graduates ultimately working in rural emergency departments. This simulation sought to provide a realistic patient encounter to promote familiarity and comfort in the identification, patient discussion and execution of thrombolysis in the treatment of a STEMI. The educational content was shown to be effective via learner survey completion.

Hospitalizations of older patients with human immunodeficiency virus in the United States.

BACKGROUND: Older adults represent a growing percentage of the United States (US) population living with human immunodeficiency virus (HIV). The Emergency Department plays an integral role in the identification and initial evaluation and treatment of patients with HIV. OBJECTIVE: We sought to estimate the number of hospitalizations of older adults (age ≥ 50 years) with HIV in the United States from 2000 to 2006 and compare features of this population to younger adults with HIV. Clinical and demographic characteristics of the younger cohort (19-49 years) and two older cohorts (ages 50-64 and ≥ 65 years) were examined and compared. METHODS: Data from the Nationwide Inpatient Sample was used to compare the three groups of HIV-positive patients. Comparisons between the most common discharge diagnoses and primary procedures were also made. RESULTS: Older adults with HIV constitute almost one quarter of the hospitalizations of adults with HIV. Older adults with HIV were more likely to be male, have a significantly higher average hospital charge, and have a longer length of stay than younger adults with HIV. Pneumonia and fluid and electrolyte disorders were common diagnoses among all three age cohorts. CONCLUSIONS: Older HIV patients were more likely to die during hospitalization compared with younger adults with HIV and older adults without HIV. Admissions for older HIV patients almost doubled during the study period and future studies should examine whether this is due to aging of the current HIV population or new infections.

Lower-Third Standardized Letters of Evaluation in Emergency Medicine: Does Gender Make a Difference in Match Outcome?

Objective The purpose of this study was to determine whether gender influences the likelihood of receiving a lower-third global assessment (GA) on the standardized letter of evaluation (SLOE) submitted as part of the emergency medicine (EM) application process as well as the impact of gender on ultimate match outcomes for applicants receiving a lower-third GA ranking. Our hypothesis was that female applicants with a lower-third GA ranking have a higher risk of not matching. Methods We conducted a retrospective cohort study evaluating U.S.-based allopathic applicants to a single EM residency program in the Mid-Atlantic region during the 2017-2018 and 2018-2019 match cycles. GA SLOE rankings and gender for all applicants were extracted and compared to the National Resident Matching Program (NRMP) data for each applicant on match outcome. Comparative analyses were conducted between gender and SLOE GA rankings in order to obtain an odds ratio (OR) of gender and match outcomes. Results A total of 2,017 SLOEs were reviewed from 798 applicants in the 2018 and 2019 EM match cycles. Overall, 716 (90%) applicants successfully matched in EM, with 82 (10%) applicants failing to match into EM; 277 students had at least one lower-third GA ranking. For all applicants, having at least one lower-third GA ranking was associated with a significant risk of not matching (OR: 0.20; 95% CI: 0.12-0.34). Of the 277 students with at least one lower-third GA ranking, 85 (31%) were female and 192 (69%) were male. Of the female applicants with a lower-third GA ranking, 15 (18%) failed to match in EM, and 39 (20%) of the males failed to match in EM. For applicants with a lower-third GA ranking, female gender alone was not associated with a significantly increased risk of not matching (OR: 1.18; 95% CI: 0.61-2.21). Conclusions Female applicants receive a lower-third GA ranking less frequently than their male counterparts. One or more lower-third rankings on the GA significantly reduced an applicant's chances of matching into an EM program. For those with a lower-third GA ranking, female gender alone does not significantly increase the risk of not matching into EM.

Does the Medical Student Performance Evaluation Change the Decision to Invite Residency Applicants?

INTRODUCTION: Although emergency medicine (EM) residency program directors (PD) have multiple sources to evaluate each applicant, some programs await the release of the medical student performance evaluation (MSPE) to extend interview offers. While prior studies have demonstrated that MSPE content is variable and selectively positive, no prior work has evaluated the impact of the MSPE on the likelihood to invite (LTI) applicants for a residency interview. This study aimed to evaluate how information in the MSPE impacted LTI, with the hypothesis that changes in LTI would be relatively rare based on MSPE review alone. METHODS: We conducted a prospective, observational study analyzing applications to three EM residency programs during the 2019-2020 match cycle. Reviewers assessed applications and rated the LTI on a five-point Likert scale where LTI was defined as follows: 1 = definitely no; 2 = probably no; 3 = unsure; 4 = probably yes; and 5 = definitely yes. The LTI was recorded before and after MSPE review. A change in LTI was considered meaningful when it changed the overall trajectory of the applicant's likelihood to receive an invitation to interview. RESULTS: We reviewed a total of 877 applications with the LTI changing ≥1 point on the Likert scale 160 (18.2%) times. The LTI was meaningfully impacted in a minority of applications - 48 total (5.5 %, p< 0.01) - with only 1 (0.11%) application changing from 1 or 2 (definitely/probably no) to 4 or 5 (probably/definitely yes) and 34 (3.8%) changing from 3 (unsure) to 4 or 5 (probably/definitely yes). Thirteen (1.5%) applications changed from 4 or 5 (probably/definitely yes) to 3 (unsure or probably/definitely no). CONCLUSION: Review of the MSPE resulted in a meaningful change in LTI in only 5.5% of applications. Given the time required for program leadership to review all parts of the variably formatted MSPEs, this finding supports a more efficient application review, where the PD's focus is on succinct and objective aspects of the application, such as the Standardized Letter of Evaluation.

Point-of-care Echocardiogram as the Key to Rapid Diagnosis of a Unique Presentation of Dyspnea: A Case Report.

INTRODUCTION: Dyspnea is commonly evaluated in the emergency department (ED).The differential diagnosis is broad. Due to the large volume of dyspneic patients evaluated, emergency physicians (EP) will encounter uncommon diagnoses. Early, liberal application of point-of-care ultrasound (POCUS) may decrease diagnostic error and improve care for these patients. CASE REPORT: We report a 48-year-old male presenting to the ED with cough and progressively worsening dyspnea for 11 months after multiple healthcare visits. Using POCUS, the EP was immediately able to diagnose a severe dilated cardiomyopathy (DCM) with left ventricular thrombus. CONCLUSION: Given that non-ischemic DCM is one of the most common etiologies of heart failure, often presenting with respiratory symptoms, POCUS is key to rapid diagnosis and, along with modalities such as electrocardiography and chest radiograph, should be standard practice in the workup of dyspnea, regardless of age or comorbidities.

What do you do if your relief comes to work intoxicated: An Impaired Provider Scenario.

Audience: The primary audience for this simulation exercise is emergency medicine (EM) residents, although it could be more broadly applied to all provider groups, including medical students, advanced practice providers, and faculty physicians. Introduction: Over the course of their professional careers, approximately 10-15% of physicians will misuse or abuse alcohol or drugs.1 Unfortunately, Emergency Physicians (EPs) are not immune to this phenomenon, and although EPs make up only 4.7% of the active physician workforce,2 they are over-represented in samples of physicians referred to physician health programs (PHPs) for substance use disorder.3 Despite this increased prevalence, when EPs were referred to a PHP by themselves, family, or colleagues, 84% of them completed the program and were practicing medicine 5 years later,3 which makes recognition and referral of the impaired physician an important step to provide the treatment needed for recovery and ultimately for return to practice. Given the prevalence of substance use disorder in EPs, it is not surprising that the 2019 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements in Emergency Medicine stipulate that "residents and faculty members must demonstrate an understanding of their personal role in the recognition of impairment, including from illness, fatigue, and substance use, in themselves, their peers, and other members of the health care team."4 Furthermore, the common program requirements also outline that each residency program must have "designated individuals responsible for reporting impaired providers in accordance with each institution's policies as well as being knowledgeable in the resources available to said provider."4 Despite these requirements, there are no best practices available to outline how residency programs can effectively teach trainees how to recognize and report the impairment. This simulation scenario is intended to provide an opportunity for learners to recognize an impaired colleague in a clinical setting, remove them from the clinical care environment, and notify the appropriate contacts, such as a Program Director, Department Chair, or nursing supervisor. To our knowledge, this is the first described simulation scenario where learners develop competency in recognizing and reporting the impaired provider. Objectives: By the end of this simulation, learners will be able to: 1) Identify potential impairment in the form of alcohol intoxication in a physician colleague; 2) demonstrate the ability to communicate effectively with the colleague and remove them from the patient care environment; 3) discuss the appropriate next steps in identifying long-term wellness resources for the impaired colleague; and 4) demonstrate understanding of the need to continue to provide care for the patients by moving the case forward. Educational Methods: This scenario is a simulated encounter taking place in the emergency department (ED) where the patient is a trauma activation who is not critically ill; the learner's confederate colleague in the scenario arrives for sign-out smelling of alcohol and appearing intoxicated. The learner will need to both provide care for the injured patient while addressing their colleague's impairment and safely removing them from the patient care area. Research Methods: The effectiveness of this simulated scenario as a teaching instrument was evaluated utilizing an internally developed evaluation survey that is part of the standard simulation curriculum at West Virginia University (WVU). The survey consisted of questions both regarding the effectiveness of the instructors as well as of the simulation, rated on a Likert scale. Learners were given the opportunity to answer free response questions where they were asked to reflect upon their experience, including the strengths of the experience and any identified opportunities for improvement. Results: Using a standard Likert scale, learners completing the impaired provider simulation scenario reviewed the effectiveness of the simulation and instructors very positively, with the vast majority of learners scoring all aspects of the scenario either as a 4 or 5. The free response answers were universally positive with many participants considering the experience very useful for training on a topic that is not frequently taught in other portions of the formal didactic curriculum. Discussion: While it is fortunately rare to encounter a colleague who is acutely intoxicated by alcohol or drugs and to simultaneously be responsible for providing patient care, it is important that learners are provided with formal instruction on how to recognize impairment and navigate the potentially difficult conversation with the impaired provider to ensure patient safety. This simulated scenario provides a realistic curricular instrument that could be implemented in any EM training program. Topics: Substance abuse; impaired provider; impaired provider reporting policies; professionalism; patient safety; provider safety.

Lower-Third SLOE Rankings Impede, But Do Not Prevent, A Match in Emergency Medicine Residency Training.

OBJECTIVE: Emergency medicine program directors (PD) value the standardized letter of evaluation (SLOE) as the most important aspect of a residency application when making both invitation and ranking decisions. This study aims to determine whether the presence of any lower-third in either SLOE global assessment (GA) question impacted the ability of an applicant to match into EM. We hypothesized that any lower-third ranking would be associated with increased odds of not matching into EM. METHODS: We conducted a retrospective cohort study evaluating allopathic applicants from medical schools in the United States (US allopathic applicants) to a single EM residency program during the 2018/2019 match cycles. GA SLOE rankings from all applications were tabulated and compared to the applicant's National Resident Matching Program (NRMP) match outcome. Comparative analyses were conducted between SLOE groupings and odds ratios (OR) were calculated. RESULTS: A total of 2,017 SLOEs from 781 US allopathic applicants were analyzed during the study period. Of the total, 277 (35%) applicants in our sample had any lower-third GA ranking, which significantly decreased an applicant's odds of matching in EM by 79% (OR 0.21, 95% CI, 0.12-0.34). Having more than one lower-third GA ranking did not further statistically decrease the odds of a successful EM match (OR 0.60, 95% CI 0.31-1.17). As a secondary finding of the study, results demonstrate that those applicants having no lower-third GA rankings had a nearly 5 times increased odds of an EM match (OR 4.84, 95% CI, 2.91-8.03). CONCLUSION: Having any lower-third GA ranking significantly reduced an applicant's chances of matching into an EM program. Faculty advisors should be aware of the increased risk of not matching for any applicant with any lower-third GA ranking and advise students appropriately, while maintaining the integrity of the SLOE and not divulging the confidential information contained within.

Evaluation of Gender Differences in Ultrasound Milestone Evaluations During Emergency Medicine Residency Training: A Multicenter Study.

OBJECTIVES: Prior literature has demonstrated incongruities among faculty evaluation of male and female residents' procedural competency during residency training. There are no known studies investigating gender differences in the assessment of procedural skills among emergency medicine (EM) residents, such as those required by ultrasound. The objective of this study was to determine if there are significant gender differences in ultrasound milestone evaluations during EM residency training. METHODS: We used a stratified, random cluster sample of Accreditation Council for Graduate Medical Education (ACGME) EM residency programs to conduct a longitudinal, retrospective cohort analysis of resident ultrasound milestone evaluation data. Milestone evaluation data were collected from a total of 16 ACGME-accredited EM residency programs representing a 4-year period. We stratified milestone data by resident gender, date of evaluation, resident postgraduate year, and cohort (residents with the same starting date). RESULTS: A total of 2,554 ultrasound milestone evaluations were collected from 1,187 EM residents (750 men [62.8%] and 444 women [37.1%]) by 104 faculty members during the study period. There was no significant overall difference in mean milestone score between female and male residents [mean difference = 0.01 (95% confidence interval {CI} = -0.04 to 0.05)]. There were no significant differences between female and male residents' mean milestone scores at the first (baseline) PGY1 evaluation (mean difference = -0.04 [95% CI = -0.09 to 0.003)] or at the final evaluation during PGY3 (mean difference = 0.02 [95% CI = -0.03 to 0.06)]. CONCLUSIONS: Despite prior studies suggesting gender bias in the evaluation of procedural competency during residency training, our study indicates that there were no significant gender-related differences in the ultrasound milestone evaluations among EM residents within training programs throughout the United States.