Journal of Education and Teaching in Emergency Medicine

ABSTRACT: 

Audience: This oral board case is intended to be used with senior emergency medicine residents.

Introduction: Pericarditis and myocarditis are two disease entities that refer to inflammation of the pericardium and the myocardium. In clinical practice, when they occur together the term myopericarditis is used. Myopericarditis is a disease etiology that is uncommonly encountered in the emergency department (ED). Pericarditis accounts for 0.2% of all cardiovascular admissions and myopericarditis is even more rare with an unknown exact incidence. These pathologies can present with a wide spectrum of complaints varying from a simple case of chest pain to more severe hypotensive pulmonary edema, cardiogenic shock, and cardiac arrest. Since these pathologies primarily affect the younger patient population, they require careful consideration by the Emergency Physician (EP) as well as a systematic comprehensive approach to managing these critically ill patients. The majority of cases are of idiopathic origin; however, the causes of pericarditis are divided into infectious and noninfectious, with infectious cases primarily resulting from viral infections. Causes of myocarditis, on the other hand, can be divided into infectious, immune-mediated, and toxic. Although myopericarditis is a rare disease, its high acuity makes it an important case to enhance the educational experience of emergency medicine residents and their associated faculty. 

Educational Objectives: At the end of this oral board session, learners will be able to: 1) Demonstrate the ability to evaluate and treat a somnolent and hypoxic patient, 2) Identify a critical airway situation and manage it with a holistic approach, 3) Interpret the history, physical examination, ECG, and chest x-ray findings and discuss the list of differential diagnoses, 4) Identify a state of cardiogenic shock induced by myopericarditis and treat it appropriately, 5) Assess the presence of pericardial effusion and cardiac tamponade utilizing bedside echocardiography. 

Educational Methods: This is an oral board case and is implemented in a face-to-face setup or virtually on multiple available technological modalities. 

Research Methods: This oral mock code was developed for senior emergency medicine residents to prepare for their oral board exams. Each session lasted approximately 25 minutes, with 10 minutes for the case and 15 minutes for debriefing. The case, initially designed as myopericarditis-induced pulmonary edema progressing to shock and rhabdomyolysis, was later simplified because it was challenging for residents to identify all the elements within the time allotted. Positive feedback indicated the case was educational and beneficial, though extending the case duration to 15 minutes was recommended. Performance was assessed using the Accreditation Council for Graduate Medical Education (ACGME) core competencies with a scoring scale of 1 – 8, with 1 – 4 being unacceptable performance and 5 – 8 being acceptable. Efficacy was determined by case completion and participation in structured debriefing. Immediate verbal feedback and a post-session Likert-scale survey further supported its educational value. The case is also adaptable for simulation-based group learning. 

Results: Five senior residents (three PGY4 and two PGY3) completed the oral case, achieving an average score of 6.01/8, with only one resident completing all critical actions. The most commonly missed intervention was administering aspirin or ibuprofen, and none considered advanced circulatory support despite persistent hypotension. The case was rated highly for educational value (5/5), all of them reported that it increased their medical knowledge, and it was similar to real-life scenarios. Some also noted it increased their confidence level and the case difficulty was rated as moderate  (3/5) by the majority of the residents. 

Discussion: The educational content of this case is effective because it is multifaceted and requires consideration of multiple factors during both the approach and management. These elements produce an excellent case for discussion, practice, and examination. Points learned while implementing the case were that, 1) its degree of difficulty is more suitable for senior rather than junior learners because it involves a critically ill patient with multiple simultaneous issues to be managed, 2) it requires a well-rounded and systematic approach to achieve all critical actions, and 3) the appropriate prompts should be utilized to cover all aspects in the allotted 15 minutes for the case. 

Topics: Myopericarditis, pulmonary edema, cardiogenic shock, sepsis, septic shock.

ABSTRACT:

Audience: Emergency medicine residents and medical students on emergency medicine rotation

Introduction: Participating in strenuous activities during hot, humid weather places a person at risk for heat emergencies such as heat exhaustion and heat stroke.  When the environmental temperature is greater than 35 degrees Celsius (95 degrees F), the body can no longer radiate heat to the environment. When the humidity is  greater than 75%, the body can no longer use evaporation for cooling. The hot, humid environment has effectively eliminated both mechanisms to decrease body heat, and the individual is at risk for exertional heat injury.  Altered mental status that occurs during heat stroke interferes with the ability to obtain an adequate history as to the etiology of hyperthermia and altered mental status.  It is imperative that the patient receive cooling measures immediately and that supportive measures be instituted while evaluating the patient for other etiologies including trauma-related injuries.

Educational Objectives: By the end of this oral board session, examinees will be able to:  1) construct a differential to evaluate a patient with undifferentiated altered mental status and trauma, 2) recognize the signs and symptoms of heat stroke, 3) complete an evaluation of a patient with both hyperthermia and trauma, and 4) demonstrate efficient and correct treatment of a patient with hyperthermia. 

Educational Methods: This oral board case followed the standard American Board of Emergency Medicine style case in a tertiary care hospital with access to all specialists and resources needed. This case was tested using seven first-year and five second-year residents in an ACGME (Accreditation Council for Graduate Medical Education) accredited emergency medicine residency program. 

Research Methods: Immediate feedback was solicited both from the learners and from the evaluators following the debriefing session. Residents were asked to evaluate the educational value of the case using a 1-5 Likert scale (5 being excellent). Evaluators were asked to score the residents using the ACGME core competencies with a scale of 1-8, 1-4 being unacceptable and 5-8 being acceptable.

Results: Twelve residents (seven PGY-1 and five PGY-2) completed this oral board case. The average score was 5.34/8. Five residents missed zero critical actions. Six residents failed to explore other etiologies of altered mental status in the case once the temperature was requested and given.  Three residents did not complete the primary and secondary survey searching for all injuries. Only two residents did not begin appropriate cooling measures. 

The learners rated the educational value of the case as 4.8/5. Seven residents reported that the case increased their medical knowledge; five residents reported that it somewhat increased their medical knowledge. All residents rated the case as helpful in preparing to manage this medical condition.

Discussion: The educational content from this case was effective. This is a high acuity moderate occurrence case that requires an extensive differential with a thorough evaluation as well as the recognition for immediate treatment of hyperthermia. This makes this case excellent for practice and discussion for the evaluation of patients with trauma and the treatment of hyperthermia. We learned during implementation that this case has a moderate degree of difficulty but does provide practice in the area of completing a thorough primary and secondary survey and education concerning best practices for treating heat emergencies. 

Topics: Altered mental status, heat emergency, heat stroke, hyperthermia, trauma.

ABSTRACT:

Audience: Emergency medicine residents and emergency ultrasound fellows.

Introduction: Point-of-care ultrasound (POCUS) is an essential emergency medicine skill that requires hands-on practice and an understanding of anatomy in three-dimensional space. Experientially, some common POCUS challenges are identifying foreign bodies in soft tissue, recognizing nerves, and identifying lower extremity veins in relation to other anatomic landmarks. But finding novel ways to challenge and engage advanced learners who have mastered basic POCUS content can be difficult, and this was the impetus of the current gamified educational activity.  

Educational Objectives: By the end of this session, the participant will be able to: 1) evaluate and identify the nature of metallic foreign bodies using POCUS; 2) identify common emergency department fractures on X-Ray and identify relevant sonoanatomy for ultrasound-guided regional anesthesia applications relevant to those fractures; and 3) identify normal lower extremity venous POCUS sonoanatomy and demonstrate understanding of proximal versus distal anatomical location within the lower extremity venous system. 

Educational Methods: A hands-on, gamified approach was used. This approach builds on previously published escape room models to focus on the application of the three POCUS indications described above.

Research Methods: After the activity, participants filled out a standardized teaching evaluation including questions about the quality of the material presented, the degree to which they felt actively involved as learners, and free-text qualitative feedback.

Results: Our test group including emergency ultrasound fellows and senior emergency medicine residents successfully completed the escape room. Three of the four participants (75%) completed the evaluation; 3/3 (100%) rated the escape room as exceeded expectations for actively involving learners and qualitatively reported that the activity was “fun,” “interactive,” “engaging,” and “innovative.”

Discussion: We found that using an escape room format for POCUS education was effective and engaging. However, it is important to note that small details in the escape room design may have large impacts on the ability of the learners to complete the activity and meet the educational goals. Overall, we found that this activity was effective and fun for both learners and educators. 

Topics: Point-of-care ultrasound (POCUS), team building, foreign body identification, ultrasound image review, lower extremity venous, ultrasound-guided regional anesthesia.

ABSTRACT:

Audience: Emergency medicine residents of all years of training

Introduction: Ultrasound guided peripheral nerve blocks (USGPNBs) provide adequate analgesic management by targeting specific nerves while limiting systemic effects. Utilizing this form of analgesia can decrease the use of procedural sedation and/or systemic pain management, which can pose inherent risks such as need for continuous monitoring and airway compromise. Nerve blocks require both training and specialized equipment to perform. This workshop aimed to evaluate resident comfort and familiarity with these blocks before and after completing specialized training sessions focusing on serratus anterior, posterior tibial, median, ulnar, and radial USGPNB. Ultrasound training for most residents is a longitudinal experience that often includes dedicated ultrasound scanning shifts and encouragement to include ultrasound into daily practice, however, the utility of ultrasound workshops in teaching nerve blocks has up until this point been explored very little and therefore under-utilized.

Educational Objectives: After completing this small group workshop, the resident should be able to: 1) recognize the indications for the serratus anterior plane block, the posterior tibial block and the ulnar, median, and radial nerve blocks and the anatomical locations that would benefit from these blocks, 2) identify proper probe selection and placement, in addition to patient positioning, in order to perform these blocks, as well as anesthetic choice and dosing, 3) demonstrate knowledge of anatomical landmarks and areas to avoid evidenced by probe placement and positioning, 4) describe the steps to perform these nerve blocks, and 5) demonstrate knowledge of contraindications to these blocks as well as potential complications of these procedures and how to mitigate them.

Educational Methods: This workshop was held in a small group format that was set up in multiple stations. Each station started with a short didactic presentation followed by USGPNB simulation on standardized patients.

Research Methods: Pre-workshop surveys were conducted via Qualtrics to assess familiarity with the indications and mechanics for conducting UGPNBs. Following the workshop, the survey was repeated as a post-workshop assessment, where residents were given the opportunity to assess their comfort with the indications for these blocks and their confidence in the steps taken to perform them. They also gave feedback on the workshop design and content.

Results: Overall, residents reported more comfort with these blocks based on survey results. Pre-workshop survey responses contained widespread levels of comfort in all aspects of these blocks including knowledge pertaining to indications, probe selection, anatomical regions that would benefit from anesthetic, anatomical landmarks, areas to avoid, anesthetic choice, contraindications, and complications and their respective management. Following the workshop, all participants voiced increased knowledge and confidence, answering that they somewhat or strongly agreed with comfortability in all of the above areas 93-100% of the time.

Discussion: Small group workshops that utilize standardized patients (SPs) and concise didactic presentations are effective ways to teach emergency medicine residents how to confidently perform UGPNBs.

Topics: Nerve block, ultrasound, small group, workshop, resident, local anesthesia.

ABSTRACT:

Audience: This small group curriculum is geared toward medical students and residents of all levels of training in emergency medicine programs.

Introduction: Emergency departments serve as critical first points of contact for patients with acute health needs, often exacerbated by social determinants of health (SDoH). Incorporating SDoH awareness into emergency medicine practice is essential for addressing immediate health concerns, preventing future crises, and reducing the burden on healthcare systems. By identifying and addressing social factors, emergency providers can break cycles of recurrent emergencies, connect patients with community resources, and foster trust-based, patient-centered relationships. Training emergency medicine residents in SDoH is crucial for preparing them to provide comprehensive, equitable care to diverse populations, enhancing their ability to advocate for vulnerable groups and reduce health disparities. This simulation curriculum aims to immerse residents in scenarios that highlight SDoH impacts, equipping them with the skills to recognize, address, and provide resources for patients affected by social determinants, ultimately improving overall patient outcomes and quality of care in emergency settings.

Educational Objectives: The educational objectives of this activity are to: 1) enhance residents' understanding and recognition of (SDoH) in emergency medicine; 2) develop residents' skills in addressing SDoH within the emergency medicine setting; 3) foster a patient-centered approach that promotes health equity in emergency medicine; and 4) identify local resources available to address various SDOH.

Educational Methods: The curriculum employs a comprehensive, multi-faceted approach to educate emergency medicine residents about SDoH. It combines didactic lectures, online simulations, clinical case scenarios, debriefing sessions, and community engagement activities to provide a well-rounded learning experience.

Research Methods: Pre- and post-curriculum surveys were employed to evaluate the effectiveness of the SDoH training program for residents. These surveys assessed residents’ confidence in understanding SDoH, their ability to recognize SDoH impacts on emergency department patients, and their knowledge of related community resources and support services, before and after the curriculum. The pre-survey established a baseline, while the post-survey measured the impact of the training. Additionally, verbal feedback from residents and faculty was collected to gather insights and suggestions for improvement. This comprehensive evaluation approach aimed to ensure the curriculum's responsiveness to residents' needs and facilitate ongoing refinement of the simulation program.

Results: A comprehensive survey of 16 emergency medicine residents across various training levels achieved full participation, assessing their understanding of SDoH, recognition of SDoH impacts on patients, and knowledge of relevant community resources. Analysis of pre- and post-curriculum responses demonstrated that while residents had initial SDoH awareness, the curriculum significantly deepened their comprehension and practical application of SDoH concepts. Notably, residents showed substantial improvement in identifying SDoH effects on patients' overall health and well-being, with the most significant progress in their familiarity with SDoH-related community resources. These results highlight the curriculum's success in equipping emergency medicine residents to provide holistic, equitable care and champion health equity in their practice.

Discussion: The innovative SDoH curriculum for emergency medicine residents shows promising results in enhancing comprehensive and equitable care delivery. Utilizing diverse educational methods including lectures, simulations, case studies, and community engagement, the program effectively translates theoretical SDoH knowledge into practical skills. Significant improvements in residents' understanding, identification, and knowledge of local SDoH resources highlight the curriculum's efficacy. These outcomes indicate that the program successfully prepares residents to navigate the complex relationship between social factors and health outcomes in emergency settings, potentially fostering more patient-centered care and advancing health equity. While these initial findings are encouraging, it's important to recognize the study's limitations and consider future research opportunities to further validate and refine the curriculum's impact.

Topics: Social medicine, social determinants of health, homelessness, health literacy, limited English proficiency.

ABSTRACT:
Nonketotic hyperglycemia hemichorea is a rare neurological manifestation associated with uncontrolled diabetes mellitus. This case report presents the clinical features, diagnostic workup, and management of a 74-year-old female with hemichorea secondary to nonketotic hyperglycemia. Patient presented to the emergency department with acute onset of right leg movement that was non-purposeful and random without any associated neurological symptoms such as  paresthesias weakness, pain, or systemic symptoms. Patient’s medical history included untreated diabetes mellitus with glucose of 198 measured in the ED. Computed tomography of the and neck were unremarkable for any signs of ischemia, occlusion, hemorrhage or masses. Brain MRI without contrast showed T1 shortening within the left basal ganglia involving both the caudate nucleus and the lentiform nucleus, a radiologic finding common in nonketotic hyperglycemia hemichorea. Patient was admitted to the hospital for diabetes management. Patient’s symptoms did not completely resolve prior to discharge from the hospital but was closely monitored by her primary care doctor and neurologist; she had significant improvements in her symptoms over the subsequent year with improvement in her activities of daily living (ADLs).

Topics: Nonketotic hyperglycemia hemichorea, diabetes, hemichorea.

Type IV hypersensitivity reactions are delayed, cell-mediated reactions between T cells and antigens that normally occur usually within 48 to 72 hours after exposure to an antigen. This is a case of a 51-year-old male status post left Achilles tendon repair with findings consistent with a type IV hypersensitivity reaction on post-operative day 12. The patient’s examination revealed blistered and macerated skin underneath the region of the wound closure strips and liquid skin adhesive. Wound care and debridement were initiated on post-operative day 14 by a wound care specialist. After six weeks of weekly wound care with debridement, the wound ultimately healed. Clinicians should be aware of the ability for any patient to develop a delayed type IV hypersensitivity reaction to treatment regimens, including dermatologic wound closure strips and liquid skin adhesives.

Topics: Type IV hypersensitivity reaction, wound closure strips, liquid skin adhesive.

ABSTRACT:

Audience: This low-cost task trainer is intended for the education of medical students, advanced practice providers and surgical subspecialties interns, including emergency medicine.

Introduction: Superficial soft-tissue abscesses are a frequent chief complaint in any emergency department, with up to 3.2 % of patients presenting with this issue. The preferred method for treatment is incision and drainage (I&D) because antibiotics alone are often insufficient. There are two common methods for draining abscesses. The first is a single linear incision over the length of the abscess that is either left open or packed with gauze which is removed 24-48 hours later. The second is the loop technique, which uses two smaller parallel incisions with a sterile rubber or plastic tube threaded through them and tied into a circle.

While abscess drainage is a common procedure for surgical and sub-surgical specialties, it is not often taught in medical schools or to residency prior to performing in the patient care setting. Frequently, this is due to the to lack of access to affordable commercial task trainers, which range in cost from $19.99 up to $171.00 per single use device.7,8  Other published low-cost task trainers require cadavers or are more time intensive or require creative set up.  This nipple cover task trainer gives a realistic feel for anesthetizing and incising abscesses using affordable material and requires minimal preparation time. Even centers with limited simulation capabilities can create and use this task trainer because it uses material that is readily available.

Educational Objectives: By the end of this training session, learners will be able to anesthetize an abscess, perform incision and drainage, develop manual dexterity maneuvering instruments to break up the abscess, and place packing using both the linear incision and loop techniques.

Educational Methods:  The abscess task trainers were fabricated using pre-made nipple covers, plastic wrap, and unscented hand lotion. The nipple covers come with a sticky backside that can allow adherence to plastic wrap. The plastic wrap is then filled with hand lotion and folded to prevent leakage. The nipple covers can then be anesthetized and incised. The time to fabricate each abscess was approximately one to two minutes. 

Research Methods: Eight PGY-1 emergency medicine residents completed a pre-simulation survey evaluating their confidence in draining an abscess using a five-point Likert scale (1=strongly disagree, 5 = strongly agree). Residents observed the instructor demonstrate the procedure, and then they performed two abscess drainages on separate nipple covers, one using a single linear incision and the other the loop technique. After the simulation, the resident confidence levels were reassessed using the same five-point Likert scale. Residents were also asked to rate the fidelity of the task trainer, compared to a real abscess (1= strongly disagree, 5 = strongly agree).

Results: Residents reported an increase in their mean confidence in draining an abscess, with an increase from the pre-simulation score of 3.5 to 4.875 (p=0.0038). Residents also felt that the model was realistic, with a mean score of 4.875. Every resident recommended using this model for future learners. 

Discussion: Overall, this affordable and simple task trainer was well received by the learners and improved beginner confidence with a frequently performed procedure. With minimal preparation time and resources, this nipple cover task trainer can be used to teach residents how to anesthetize, incise, drain, and pack abscesses. 

Topics: Abscess, incision and drainage, simulation, task trainer.