A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis.

OBJECTIVE: To determine the utility of a prehospital sepsis screening protocol utilizing systemic inflammatory response syndrome (SIRS) criteria and end-tidal carbon dioxide (ETCO2). METHODS: We conducted a prospective cohort study among sepsis alerts activated by emergency medical services during a 12 month period after the initiation of a new sepsis screening protocol utilizing ≥2 SIRS criteria and ETCO2 levels of ≤25 mmHg in patients with suspected infection. The outcomes of those that met all criteria of the protocol were compared to those that did not. The main outcome was the diagnosis of sepsis and severe sepsis. Secondary outcomes included mortality and in-hospital lactate levels. RESULTS: Of 330 sepsis alerts activated, 183 met all protocol criteria and 147 did not. Sepsis alerts that followed the protocol were more frequently diagnosed with sepsis (78% vs 43%, P < .001) and severe sepsis (47% vs 7%, P < .001), and had a higher mortality (11% vs 5%, P = .036). Low ETCO2 levels were the strongest predictor of sepsis (area under the ROC curve (AUC) of 0.99, 95% CI 0.99-1.00; P < .001), severe sepsis (AUC 0.80, 95% CI 0.73-0.86; P < .001), and mortality (AUC 0.70, 95% CI 0.57-0.83; P = .005) among all prehospital variables. Sepsis alerts that followed the protocol had a sensitivity of 90% (95% CI 81-95%), a specificity of 58% (95% CI 52-65%), and a negative predictive value of 93% (95% CI 87-97%) for severe sepsis. There were significant associations between prehospital ETCO2 and serum bicarbonate levels (r = 0.415, P < .001), anion gap (r = -0.322, P < .001), and lactate (r = -0.394, P < .001). CONCLUSION: A prehospital screening protocol utilizing SIRS criteria and ETCO2 predicts sepsis and severe sepsis, which could potentially decrease time to therapeutic intervention.

Racial disparities in patients hospitalized for COVID-19.

BACKGROUND: The COVID-19 pandemic has demonstrated the significance of health disparities across populations with older adults and minoritized groups being disproportionately affected. Data during the COVID-19 pandemic demonstrated higher infection rates, hospitalization rates, morbidity, and potentially greater mortality in Black, Hispanic, and Native Americans compared to Whites. METHODS: This is a retrospective cohort study of de-identified patient data from 178 hospitals across the United States. Outcome variables were the length of stay, in-hospital mortality, disease severity, and discharge disposition. Outcomes were stratified by sex and racial groups. RESULTS: Of 45,360 patients, 22% were Black, 35% were Hispanic, 37% were White, and 6% were Other. The overall mortality rate was 15% across all groups but was 17% for White patients, 10% for Black patients, 14% for Hispanic patients, and 15% for patients categorized as Other. However, White patients have higher median age on admission (71 years) compared to Blacks (60 years), Hispanics (57 years), and Other (61 years). Race remained statistically significant in a multivariable model that included age, sex, and race. 6484 patients required ICU admission, intubation, and hemodynamic support. This burden was disproportionate across racial groups, with 15.6% of Blacks and 13.9% of non-Blacks having such critical disease (p < 0.0001, z-test for proportions). CONCLUSIONS: In this national study of admitted patients with COVID-19, White patients admitted were older on average compared to other racial/ethnic groups and had a higher mortality rate compared to non-Whites hospitalized for COVID-19. Black patients were significantly more likely to require admission to the ICU, mechanical ventilation, and hemodynamic support. These COVID-19 health disparities highlight the importance of addressing social and structural determinants of health.

Disaster day: a simulation-based competition for educating emergency medicine residents and medical students on disaster medicine.

BACKGROUND: Disaster medicine is a growing field within the specialty of emergency medicine, but educational training typically focuses on hospital drills or other educational strategies, such as didactics, simulation, or tabletop exercises. With the success of gamification in other medical education applications, we sought to investigate if a novel gamified curricular innovation would lead to improved test performance and confidence in the ability to manage a real mass casualty incident (MCI). METHODS: This was a prospective observational study of medical students and emergency medicine residents who participated in a 4-h simulation-based competition consisting of 4 unique stations. Each station had learning objectives associated with the content taught. Learners completed a pre-event survey, followed by participation in the competitive gamification event, and subsequently completed a post-event survey. Differences between pre- and post-event responses were matched and analyzed using paired and unpaired t tests for medical knowledge assessments, the Mann-Whitney U test for perceptions of confidence in the ability to manage an MCI event, and descriptive statistics provided on perceptions of the effectiveness of this educational strategy. RESULTS: We analyzed data from 49 learners with matched (and unmatched) pre- and post-event survey responses. There was a statistically significant increase in medical knowledge assessment scores in both unmatched group means and available matched data (47 to 69%, p < 0.01, and 50 to 69%, p < 0.05). Self-reported confidence in the ability to handle an MCI scenario also significantly increased (p < 0.01). Finally, 100% of respondents indicated they "agreed" or "strongly agreed" that the event was an effective education tool for disaster preparedness and training. CONCLUSIONS: In this study, we found that learners perceived a novel gamification event as an effective educational tool, which led to improved learner knowledge and self-reported confidence in the ability to manage a real MCI.

Acromioclavicular Osteomyelitis: When Simple Cellulitis Is No Longer Simple.

The objective of this case report is to highlight the importance of continued examination and evaluation to correctly diagnose and treat the rare condition of acromioclavicular osteomyelitis and associated septic arthritis. A 51-year-old diabetic male presented with right shoulder pain and overlying cellulitis without history of trauma, intravenous (IV) drug use, lacerations, prostheses or endocarditis later developed septic arthritis and osteomyelitis of the acromion and distal clavicle requiring operative management. Decision to re-image the joint using magnetic resonance imaging (MRI) with contrast after lack of symptomatic improvement was key to making the diagnosis.

Acromioclavicular Osteomyelitis: When Simple Cellulitis Is No Longer Simple.

The objective of this case report is to highlight the importance of continued examination and evaluation to correctly diagnose and treat the rare condition of acromioclavicular osteomyelitis and associated septic arthritis. A 51-year-old diabetic male presented with right shoulder pain and overlying cellulitis without history of trauma, intravenous (IV) drug use, lacerations, prostheses or endocarditis later developed septic arthritis and osteomyelitis of the acromion and distal clavicle requiring operative management. Decision to re-image the joint using magnetic resonance imaging (MRI) with contrast after lack of symptomatic improvement was key to making the diagnosis.

The A to E (ABCDE) Pit Crew Model: A Novel Approach to Team Based Care of Critical Patients in the Prehospital Setting.

Background: This study aimed to evaluate the effectiveness of a Pit Crew intervention to improve team dynamics and time to performance of critical actions in a prehospital critical care scenario. The primary outcome was successful completion of critical actions and time to completion of these critical actions. Secondary outcomes included effectiveness of communication and overall team functioning. Methods: The study was conducted with a fire-based Emergency Medical Services (EMS) system with 233 paramedics and 115 Emergency Medical Technicians (EMT). Eight EMS crews comprised of five members each were randomly selected and assigned to either the intervention or the control group. The intervention group (n=20) watched a thirty-minute video prior to the training describing the "Pit Crew Approach;" the control group (n=20) did not watch the video. Each crew was given the same simulation scenario of a pediatric patient that had overdosed on a beta-blocker. Completion of predetermined critical tasks were noted and timestamped. A survey was administered to the participants following the training to assess team dynamics and level of confidence. Results: Three outcomes were statistically significant between the two arms: The interventional group felt they themselves had a more defined role in the resuscitation in comparison to the non-interventional group (p= 0.021). The interventional group also felt that their team members had a clearer and more defined role than the nonintervention group (p= 0.018). The interventional group also felt more confident managing a beta blocker overdose than the nonintervention group (p.007). The only statistically significant secondary outcome finding was in scene departure decision: the interventional arm spent more time on-scene (p=0.031). Of note, the non-intervention group missed performing tasks more often than the interventional group and team leaders of these groups often performed task(s) while also directing the patient care. Conclusion: The Pit Crew model was developed to optimize communication and team function. Our data identified that a formal instruction of the pit crew approach to a critical care scenario improved comfort in patient care. Future studies are needed evaluate other methods of training and the effects of continued formal pit-crew training over time.

Aortic Dissection as the Culprit for Seizure.

The authors present a case of syncope that was caused by aortic dissection. As the main artery to the system circulation, aortic dissection can manifest in numerous ways. This case reminds the clinician of the high index of suspicion necessary to diagnose this potentially life-threatening problem. Indeed, the mortality rate increases 2% per hour in the first 24 hours for a type A aortic dissection, so prompt diagnosis is imperative. The diagnostic complexity in this case is compounded by the very broad differential diagnosis for both aortic dissection and syncope.

Residency Exposure to Emergency Medical Services Concepts Through Immersion, Interprofessional Collaboration and Assembly Line Education.

INTRODUCTION: The use of innovative strategies for teaching, such as flipped classroom and assembly line education, has become increasingly popular to engage learners. Residency education has been incorporating these methods to master content, develop critical skills, and improve professionalism. METHODS: We created a three-part immersion experience to teach Emergency Medical Services (EMS) concepts to emergency medicine residents. Residents participated in a mass casualty incident (MCI) in which they were tasked to triage patients and allocate resources in a hospital to treat 11 victims properly. The second portion was to manage a cardiac arrest scenario in the field with the tools our EMS colleagues had available. Lastly, they were asked to create short, high-yield lectures about topics related to EMS. RESULTS: Pre- and post-test surveys were used to assess the effectiveness of the experience in teaching residents core EMS topics. It was determined that residents not only felt more prepared for an MCI, but they also were more comfortable with their skills as a result of participating in this activity. CONCLUSION: Our study further highlights the benefits of non-traditional techniques in residency education. The use of immersion experiences was unique and overall a positive experience for learners. The techniques used in this activity allowed residents to gain confidence in more challenging topics for emergency physicians. This format could be applied to many more topics in the future as an innovative education technique.

A Simulated Scenario to Improve Resident Efficiency in an Emergency Department.

Introduction Multitasking is a core competency in emergency medicine. Simulation has been shown to be an effective method of education, which allows learners to prepare for real-world challenges in a controlled environment. Methods In this study, trainees were given a scenario that simulated the experience of managing two patient encounters within a time metric while addressing interruptions that take place in a typical ED. Residents were evaluated using an internally developed scoresheet, which assessed task-switching abilities, documentation skills, and adherence to door to disposition time metric. Residents were asked to evaluate their experience with a survey. Results All the participants reported that they would translate some of the skills learned to their daily clinical practice. Five out of six residents reported improvements in their skills as a result of the task-switching training. The following three common themes were pervasive in the debrief discussion: (1) the residents felt the added pressure of the door-to-disposition metric, (2) the objectives of the simulation did not fit within their pre-constructed concept of a successful simulation equating to establishing the correct diagnosis, and (3) the interruptions were very realistic. Discussion Emergency physicians are interrupted approximately every 9-14 minutes, and this number increases with the number of patients being managed simultaneously. By developing a safe, simulated training environment, we sought to transfer key strategies for improving focus and learning to prioritize while also helping them to identify how certain pressures and interruptions affected their stress levels and concentration.

Physician-Perceived Barriers to Treating Opioid Use Disorder in the Emergency Department.

Objective We aimed to assess physicians' perceptions of barriers to starting medication-assisted treatment (MAT) in the Emergency Department (ED), views of the utility of MAT, and abilities to link patients with opioid use disorder (OUD) to MAT programs in their respective communities. Methods This was a cross-sectional survey study of American emergency medicine (EM) physicians with a self-administered online survey via SurveyMonkey (Survey Monkey, San Mateo, California). The survey was emailed to the Council of Residency Directors in Emergency Medicine (CORD) listserv and HCA Healthcare affiliated EM residency programs' listservs. Attendings and residents of all post-graduate years participated. Questions assessed perceptions of barriers to starting OUD patients on MAT, knowledge of the X-waiver, and knowledge of MAT details. Statistics were performed with JMP software (SAS Institute Inc., Cary, NC) using the two-tailed Z-test for proportions. Results There were 98 responses, with 33% female, 55% resident physicians, and an overall 17% response rate. Residents were more eager to start OUD patients on MAT (71% vs 52%, p=0.04) than attendings but were less familiar with the X-waiver (38% vs 73%, p=0.001) or where community outpatient MAT facilities were (21% vs 43%, p=0.02). Conclusion Barriers in the ED were identified as a shortage of qualified prescribers, the lengthy X-waiver process, and the poor availability of outpatient MAT resources. EM residents showed more willingness to prescribe MAT but lacked a core understanding of the process. This shows an area of improvement for residency training as well as advocacy among attendings.

Kids Really Are Just Small Adults: Utilizing the Pediatric Triangle with the Classic ABCD Approach to Assess Pediatric Patients.

Pediatric altered mental status is a commonly feared presentation of children in both the emergency department and prehospital setting. Given the usual difficulties we face when treating children, utilizing systematic tools can help us to remain thorough and consistent when evaluating any given child. By using a standardized method of evaluation and diagnosis, first responders and emergency physicians can set aside their worries of mismanagement and provide adequate care to children with undifferentiated altered mental status. This article reviews one of the many approaches toward assessing children's clinical status, walks through the elements that comprise it, and examines how it can be used to make emergency providers more confident.

Development of an interactive curriculum and trainee-specific preparedness plan for emergency medicine residents.

OBJECTIVES: To create an interactive mass casualty incident (MCI) curriculum for emergency medicine residents and to integrate them into the hospital disaster response, thereby creating a "trainee-specific emergency preparedness plan." METHODS: We created an interactive MCI curriculum and "trainee-specific emergency preparedness plan" for emergency medicine residents. The curriculum consisted of lectures, a small focus group, a triage activity, and the designation of a resident disaster champion to collaborate with hospital leadership to implement a "trainee-specific emergency preparedness plan" for the upcoming hospital disaster drill. RESULTS: Residents gave positive feedback on the new curriculum and retained information from the education. All resident teams accurately triaged at least 78% of the disaster scenarios. The residents also created a "trainee-specific emergency preparedness plan" for the upcoming hospital disaster drill, utilizing principles they learned from their MCI lessons. By allowing the residents to have an active role in the design and implementation of the new resident integrated disaster management plan, there was a general consensus of increased interest and retention of what was learned, as well as an increased comfort level in participating in MCI scenarios. Residents did not feel cursory to the planning; they became a part of the planning and felt more involved. Through this exercise, residents were able to give feedback to the hospital leadership that further shaped the disaster response plan. We also found that integration of the emergency medicine residents into the hospital response doubled the amount of active physicians available. CONCLUSION: An interactive-based MCI curriculum is more engaging and may foster more retention than the traditional lecture approach. Resident involvement in the hospital disaster response is paramount as more hospitals are becoming teaching hospitals and mass casualty incidents are inevitable.

Ruptured Hepatic Artery Aneurysm.

Aneurysmal ruptures are a life-threatening pathology, and while the aorta is the principal location, any aneurysmal rupture can be fatal. Most result from chronic diseases, such as hypertension, diabetes, and vasculitis. Nevertheless, a rupture can result in acute decompensation and must be recognized and addressed quickly to limit morbidity and mortality. The authors describe a case of a 66-year-old female who presented to the emergency department (ED) for abdominal pain and syncope. Even though imaging did not explicitly show the specific site of rupture of the hepatic artery, the positive Rapid Ultrasound for Shock and Hypotension (RUSH) exam and aortic dissection on computed tomography angiography along with her clinical picture (hypotension, abdominal pain, decreased capillary refill, grey skin) raised our suspicions for critical pathology. Exploratory laparotomy revealed a ruptured hepatic artery aneurysm. Her hospital course was complicated by ischemic necrosis of the gallbladder, spleen, and liver, requiring cholecystectomy, splenectomy, and partial hepatectomy, but she was discharged to rehabilitation and expected to make a recovery. This case displays the importance of using ultrasonography early to aid in expedited diagnosis and treatment as well as maintaining a high suspicion for vascular pathology in the setting of hemorrhagic shock.

Assembly Line Education: A Novel Educational Technique for Today's Learners.

Background Education is undergoing a transformation. The traditional passive lectures are failing to capture and inspire the new generation of learners who value more active and collaborative learning techniques. Objective We sought to create a novel educational technique to integrate into our curriculum that would be more personalized, employ more active learning and collaboration, and allow for an effective assessment of resident strengths and weaknesses. Discussion We created a monthly assembly line education academic half-day that evolved to replace one of the typical in-classroom didactics each month. Faculty run small-group simulation rooms, procedure workshops, competitive ultrasound, and wellness stations through which residents and medical students rotate. Conclusion This novel education technique resulted in a more personalized approach that increased resident interest, sparked the creation of a very popular MedEd-Simulation elective, and allowed the faculty to gain a better sense of resident strengths and deficiencies.

Radial Head Dislocation with Elbow Subluxation in an Adult.

Isolated radial head subluxation without fracture, commonly referred to as "nursemaid's elbow," is one of the most common pediatric upper extremity injuries. Radial head dislocation without an associated fracture is rarely seen in adults. They are usually associated with ulnar fractures or an elbow dislocation. We present a case of an adult female presenting with a radial head dislocation and an elbow subluxation sustained while dressing, which was successfully reduced using the techniques commonly used to reduce nursemaid's elbow in pediatric patients.

Comparing Quick Sequential Organ Failure Assessment Scores to End-tidal Carbon Dioxide as Mortality Predictors in Prehospital Patients with Suspected Sepsis.

INTRODUCTION: Early identification of sepsis significantly improves outcomes, suggesting a role for prehospital screening. An end-tidal carbon dioxide (ETCO2) value ≤ 25 mmHg predicts mortality and severe sepsis when used as part of a prehospital screening tool. Recently, the Quick Sequential Organ Failure Assessment (qSOFA) score was also derived as a tool for predicting poor outcomes in potentially septic patients. METHODS: We conducted a retrospective cohort study among patients transported by emergency medical services to compare the use of ETCO2 ≤ 25 mmHg with qSOFA score of ≥ 2 as a predictor of mortality or diagnosis of severe sepsis in prehospital patients with suspected sepsis. RESULTS: By comparison of receiver operator characteristic curves, ETCO2 had a higher discriminatory power to predict mortality, sepsis, and severe sepsis than qSOFA. CONCLUSION: Both non-invasive measures were easily obtainable by prehospital personnel, with ETCO2 performing slightly better as an outcome predictor.