Browsing by Subject "Emergency Medicine"
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Item Clinical Ultrasound Is Safe and Highly Specific for Acute Appendicitis in Moderate to High Pre-test Probability Patients(eScholarship, 2018-05) Corson-Knowles, Daniel; Russell, Frances M.; Emergency Medicine, School of MedicineIntroduction: Clinical ultrasound (CUS) is highly specific for the diagnosis of acute appendicitis but is operator-dependent. The goal of this study was to determine if a heterogeneous group of emergency physicians (EP) could diagnose acute appendicitis on CUS in patients with a moderate to high pre-test probability. Methods: This was a prospective, observational study of a convenience sample of adult and pediatric patients with suspected appendicitis. Sonographers received a structured, 20-minute CUS training on appendicitis prior to patient enrollment. The presence of a dilated (>6 mm diameter), non-compressible, blind-ending tubular structure was considered a positive study. Non-visualization or indeterminate studies were considered negative. We collected pre-test probability of acute appendicitis based on a 10-point visual analog scale (moderate to high was defined as >3), and confidence in CUS interpretation. The primary objective was measured by comparing CUS findings to surgical pathology and one week follow-up. Results: We enrolled 105 patients; 76 had moderate to high pre-test probability. Of these, 24 were children. The rate of appendicitis was 36.8% in those with moderate to high pre-test probability. CUS were recorded by 33 different EPs. The sensitivity, specificity, and positive and negative likelihood ratios of EP-performed CUS in patients with moderate to high pre-test probability were 42.8% (95% confidence interval [CI] [25-62.5%]), 97.9% (95% CI [87.5-99.8%]), 20.7 (95% CI [2.8-149.9]) and 0.58 (95% CI [0.42-0.8]), respectively. The 16 false negative scans were all interpreted as indeterminate. There was one false positive CUS diagnosis; however, the sonographer reported low confidence of 2/10. Conclusion: A heterogeneous group of EP sonographers can safely identify acute appendicitis with high specificity in patients with moderate to high pre-test probability. This data adds support for surgical consultation without further imaging beyond CUS in the appropriate clinical setting.Item Does Length of Emergency Medicine Training Matter for Leadership Skills in Pediatric Resuscitation? A Pilot Study(2023-04-28) Schoppel, Kyle; Keilman, Ashley; Fayyaz, Jabeen; Padlipsky, Patricia; Diaz, Maria Carmen G.; Wing, Robyn; Hughes, Mary; Franco, Marleny; Swinger, Nathan; Whitfill, Travis; Walsh, BarbaraBackground The majority of pediatric patients in the United States (US) are evaluated and treated at general emergency departments (GEDs) that are often ill prepared for pediatric patients. Despite rotating at large pediatric hospitals, during training Emergency Medicine (EM) residents care perform few pediatric resuscitations. It is possible that discrepancies in length of EM residency training may allow for variable exposure to pediatric patients, critical resuscitations, and didactic events. The goal of this study was to compare leadership skills of EM residents graduating from 3 vs. 4-year programs during simulated pediatric resuscitations using a previously validated leadership assessment tool, the Concise Assessment of Leader Management (CALM). Methods This was a prospective, multicenter, simulation-based cohort pilot study that included graduating 3rd- and 4th-year EM resident physicians from 6 EM residency programs. We measured leadership performance across three simulated pediatric resuscitations using the CALM tool and compared leadership scores between the 3rd- vs. 4th-year resident cohorts. We also correlated leadership to self-efficacy scores. Results Forty-seven residents (24 3rd-year residents and 23 4th-year residents) participated. Out of a total possible CALM score of 66, residents from 3-year programs scored 45.2 [SD ± 5.2], 46.8 [SD ± 5.0], and 46.6 [SD ± 4.7], whereas residents from 4-year programs scored 45.5 [SD ± 5.2], 46.4 [SD ± 5.0], 48.2 [SD ± 4.3] during the sepsis, seizure and cardiac arrest cases respectively. The Total Leadership Score (TLS) for the 3-year cohort was 46.2 [SD ± 4.8] vs. 46.7 [ SD ± 4.5] (p = 0.715) for the 4-year cohort. Conclusions These data suggest there may be no difference in leadership skills between 3rd- vs 4th-year EM residents in our study cohort. This pilot study provides the basis of future work that will assess a larger multicenter cohort with the hope to obtain a more generalizable dataset.Item Establishing a Low-Resource Simulation Emergency Medicine Curriculum in Nepal(Association of American Medical Colleges, 2020-07-15) Wang, Alfred; Saltarelli, Nicholas; Cooper, Dylan; Amatya, Yogendra; House, Darlene R.; Emergency Medicine, School of MedicineIntroduction High-fidelity medical simulation is widely used in emergency medicine training because it mirrors the fast-paced environment of the emergency department (ED). However, simulation is not common in emergency medicine training programs in lower-resourced countries as cost, availability of resources, and faculty experience are potential limitations. We initiated a simulation curriculum in a low-resource environment. Methods We created a simulation lab for medical officers and students on their emergency medicine rotation at a teaching hospital in Patan, Nepal, with 48,000 ED patient visits per year. We set up a simulation lab consisting of a room with one manikin, an intubation trainer, and a projector displaying a simulation cardiac monitor. In this environment, we ran a total of eight cases over 4 simulation days. Debriefing was done at the end of each case. At the end of the curriculum, an electronic survey was delivered to the medical officers to seek improvement for future cases. Results All eight cases were well received, and learners appreciated the safe learning space and teamwork. Of note, the first simulation case that was run (the airway lab) was more difficult for learners due to lack of experience. Survey feedback included improving the debriefing content and adding further procedural skills training. Discussion Simulation is a valuable experience for learners in any environment. Although resources may be limited abroad, a sustainable simulation lab can be constructed and potItem Gaps in Pediatric Emergency Medicine Education of Emergency Medicine Residents: A Needs Assessment(2023-04-28) Schoppel, Kyle; Spector, Jordan; Okafor, Ijeoma; Church, Richard; Deblois, Katy; Della-Guistina, David; Kellogg, Adam; MacVane, Casey; Pirotte, Matthew; Snow, David; Hays, Geoffrey; Connelly, Haley; Sheng, AlexanderBackground Greater than 90% of pediatric patients in the United States (US) are evaluated and treated at community-based emergency departments (EDs). Yet, recent data shows emergency medicine (EM) attending physicians have minimal exposure to critically ill pediatric patients and perform few pediatric critical procedures. Evidence suggests mortality outcomes may be worse for critically ill pediatric patients treated at centers not designated as a children’s hospital and/or centers without pediatric trauma designation. Part of the variability in clinical care may be due to the considerable heterogeneity in pediatric emergency medicine (PEM) education provided to emergency medicine (EM) resident physicians. Limited previous data has shown that EM residency program directors report deficiencies in PEM education and suboptimal confidence in resident ability to perform critical pediatric procedures. Research Question Identify perceived gaps in current PEM education provided to EM residents physicians. Methodology This was a prospective, survey-based, descriptive cohort study. We surveyed a representative cohort of recently graduated EM attending physicians (less than 5 years) from 9 institutions across the US. Surveys were sent via email and were de-identified. Responses were reported and themes analyzed. Results 167 responses were obtained from 521 eligible participants (37%). Most respondents trained at urban academic medical centers (90.4%). Most reported satisfaction with engagement by PEM faculty during residency (89.1%). Non-emergency pediatric rotations varied with proportions as follows: pediatric intensive care (50.6%), pediatric wards (20.5%), neonatal intensive care unit (31.3%) and pediatric anesthesia (26.5%). Topics perceived to be adequately covered during residency included: febrile neonate, sepsis, seizure, and respiratory failure. Topics perceived to be inadequately covered included: neonatal jaundice, neonatal resuscitation, pediatric airway, and cardiac arrest. Most reported feeling uncomfortable managing neonates (40.36%) and placing chest tubes on pediatric patients (53.01%). Whereas most reported feeling comfortable performing bag-mask ventilation (88.55%). We noted a positive association between completing NICU rotations and comfort level caring for neonates and infants (p = 0.041). Conclusion/Discussion This survey-based cohort study found considerable variation in residency experiences and perceived comfort for various pediatric emergency topics. In general, participants were more comfortable managing older children. While some topics (such as respiratory failure and BVM) were reported to be covered adequately in residency, other critical aspects of pediatric emergency care (cardiac arrest, tube thoracostomy) were not. This study found that the most significant perceived deficit in PEM education to EM trainees appears to be neonatal medicine/resuscitation. Similarly, there appears to be wide variation in comfort level managing pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the US to promote future educational initiatives.Item Longitudinal Prospective Study of Emergency Medicine Provider Wellness Across Ten Academic and Community Hospitals During the Initial Surge of the COVID-19 Pandemic(2020-10-15) Kelker, Heather; Yoder, Kyle; Musey, Paul; Harris, Madison; Johnson, Olivia; Sarmiento, Elisa; Vyas, Punit; Henderson, Brooke; Adams, Zachary; Welch, Julie L.; Emergency Medicine, School of MedicineBackground: While the coronavirus (COVID-19) has had far-reaching consequences on society and health care providers, there is a paucity of research exploring emergency medicine (EM) provider wellness over the course of a pandemic. The objective of this study was to assess the well-being, resilience, burnout, and wellness factors and needs of EM physicians and advanced practice providers (APPs) during the initial phase of the COVID-19 pandemic. Methods: A longitudinal, descriptive, prospective cohort survey study of 213 EM physicians and APPs was performed across ten emergency departments in a single state, including academic and community settings. Participants were recruited via email to complete four weekly, voluntary, anonymous questionnaires comprised of customized and validated tools for assessing wellness (Well Being Index), burnout (Physician Work Life Study item), and resilience (Brief Resilience Scale) during the initial acceleration phase of COVID-19. Univariate and multivariate analysis with Chi-squared, Fisher’s Exact, and logistic regression was performed. Results: Of 213 eligible participants, response rates ranged from 31 to 53% over four weeks. Women comprised 54 to 60% of responses. Nonrespondent characteristics were similar to respondents. Concern for personal safety decreased from 85% to 61% (p<0.001). Impact on basic self-care declined from 66% to 32% (p<0.001). Symptoms of stress, anxiety or fear was initially 83% and reduced to 66% (p=0.009). Reported strain on relationships and feelings of isolation affected >50% of respondents initially without significant change (p=0.05 and p=0.30 respectively). Women were nearly twice as likely to report feelings of isolation as men (OR 1.95; 95%CI 1.82-5.88). Working part-time carried twice the risk of burnout (OR, 2.45; 95% CI, 1.10-5.47). Baseline resilience was normal to high. Provider well-being improved over the four-weeks (30% to 14%; p=0.01), but burnout did not significantly change (30% to 22%; p=0.39). Conclusion: This survey of frontline EM providers during the initial surge of COVID-19 found that despite being a resilient group, the majority experienced stress, anxiety, fear, and concerns about personal safety due to COVID-19, with many at risk for burnout. The sustained impact of the pandemic on EM provider wellness deserves further investigation to guide targeted interventions.Item Man with productive cough(Wiley, 2020-06-12) Pettit, Nicholas; Al‐Hader, Ahmad; Emergency Medicine, School of MedicineItem Multicenter registry of United States emergency department patients tested for SARS-CoV-2(Wiley, 2020-11-12) Kline, Jeffrey A.; Pettit, Katherine L.; Kabrhel, Christopher; Courtney, D. Mark; Nordenholz, Kristen E.; Camargo, Carlos A.; Emergency Medicine, School of MedicineThis paper summarizes the methodology for the registry of suspected COVID‐19 in emergency care (RECOVER), a large clinical registry of patients from 155 United States (US) emergency departments (EDs) in 27 states tested for SARS‐CoV‐2 from March–September 2020. The initial goals are to derive and test: (1) a pretest probability instrument for prediction of SARS‐CoV‐2 test results, and from this instrument, a set of simple criteria to exclude COVID‐19 (the COVID‐19 Rule‐Out Criteria—the CORC rule), and (2) a prognostic instrument for those with COVID‐19. Patient eligibility included any ED patient tested for SARS‐CoV‐2 with a nasal or oropharyngeal swab. Abstracted clinical data included 204 variables representing the earliest manifestation of infection, including week of testing, demographics, symptoms, exposure risk, past medical history, test results, admission status, and outcomes 30 days later. In addition to the primary goals, the registry will provide a vital platform for characterizing the course, epidemiology, clinical features, and prognosis of patients tested for COVID‐19 in the ED setting.Item Preparing Emergency Medicine Residents as Teachers: Clinical Teaching Scenarios(Association of American Medical Colleges, 2018-05-14) Humbert, Aloysius J.; Pettit, Katie E.; Turner, Joseph S.; Mugele, Josh; Rodgers, Kevin; Emergency Medicine, School of MedicineIntroduction: Preparing residents for supervision of medical students in the clinical setting is important to provide high-quality education for the next generation of physicians and is mandated by the Liaison Committee on Medical Education as well as the Accreditation Council for Graduate Medical Education. This requirement is met in variable ways depending on the specialty, school, and setting where teaching takes place. This educational intervention was designed to allow residents to practice techniques useful while supervising medical students in simulated encounters in the emergency department and increase their comfort level with providing feedback to students. Methods: The four role-playing scenarios described here were developed for second-year residents in emergency medicine at the Indiana University School of Medicine. Residents participated in the scenarios prior to serving as a supervisor for fourth-year medical students rotating on the emergency medicine clerkship. For each scenario, a faculty member observed the simulated interaction between the resident and the simulated student. The residents were surveyed before and after participating in the scenarios to determine the effectiveness of the instruction. Results: Residents reported that they were more comfortable supervising students, evaluating their performance, and giving feedback after participating in the scenarios. Discussion: Participation in these clinical teaching scenarios was effective at making residents more comfortable with their role as supervisors of fourth-year students taking an emergency medicine clerkship. These scenarios may be useful as part of a resident-as-teacher curriculum for emergency medicine residents.Item Rapid Adaptation to Remote Didactics and Learning in GME(Wiley, 2020-09-08) Hickam, Grace; Santen, Sally A.; Cico, Stephen John; Manthey, David; Wolff, Margaret; Moll, Joel; Lambert, Alexandra; Jordan, Jaime; Haas, Mary R. C.; Emergency Medicine, School of MedicineWeekly didactic conference in emergency medicine education has traditionally united residents and faculty for learning and fostered community within the residency program. The global pandemic Coronavirus Disease-19 (COVID-19) has fueled a rapid transition to remote learning that has disrupted the typical in-person format. To maintain ACGME educational experiences and requirements for residents in a safe manner, many residencies have moved to videoconferencing platforms such as Zoom™, Teams™, and WebEX.™ Given the importance of didactic conference as a ritual, educational experience and community-building activity, most residency programs have worked to maintain an active and robust didactic conference despite the many logistical challenges. Engaging residency program members in the transition to remote learning and utilizing opportunities for innovation can help to maintain normalcy and combat isolation resulting from the loss of weekly in-person contact. Herein, we propose practical tips for optimizing remote learning for weekly emergency medicine residency didactics.Item Venous Thromboembolism and D-dimer In Patients with COVID-19(Indiana Medical Student Program for Research and Scholarship (IMPRS), 2020-12-15) Hoffer, Joshua; Stewart, Lauren; Pettit, Kate; Kline, Jeffrey A.; Department of Emergency Medicine, IU School of MedicineBackground and Hypothesis: The potential association between venous thromboembolism (VTE) and COVID-19 is an area of growing research, and methods of effective prophylaxis, detection, and treatment continue to be sought. D-dimer assays have been previously established as a highly sensitive — albeit nonspecific — test to assess patient risk of VTE, but the full clinical utility of this test in COVID-19 patients is currently not well understood. We hypothesized that, in patients presenting to the emergency department (ED) and determined to be positive for COVID-19, an elevated D-dimer value is associated with an increased 30-day incidence of VTE. Project Methods: Deidentified patient encounter data was collected and analyzed from a multicenter registry of ED patients tested for SARS-CoV-2. We measured the frequency of a positive SARS-CoV-2 test and compared the incidence of VTE between SARS-CoV-2 positive and negative patients. We also compared average D-dimer values in SARS-CoV-2 positive patients with and without VTE. Results: Of 6,445 patient encounters queried, 2,051 tested positive for SARS-CoV-2 (32%). SARS-CoV-2 positive patients had a significantly higher incidence of VTE in the 30-day follow-up period compared to SARS-CoV-2 negative patients (3.2 vs. 1.6%, p= 0.0002). D-dimer values were available for 537 of these SARS-CoV-2 patients, with an average D-dimer of 1813.83 ng/mL. The average D-dimer in SARS-CoV-2 positive patients who did develop VTE tended to be higher than those who did not develop VTE (2969 ng/mL vs. 1822 ng/mL), although this difference was not statistically significant (p=0.34). The fitted areas for binomial receiver operating characteristic curves of D-dimer for detection of VTE in patients with and without SARS-CoV-2 were 0.628 and 0.829, respectively. Conclusion and Potential Impact: We found a positive SARS-CoV-2 test to be associated with a higher incidence of VTE. However, an elevated D-dimer continues to be nonspecific for VTE in SARS-CoV-2 positive patients, and performs more poorly in SARS-CoV-2 positive patients than in negative patients. Additional clinical criteria should be identified to further guide the use of diagnostic imaging modalities and prophylactic anticoagulation in COVID-19 positive patients with suspicion of VTE.