Journal of Education and Teaching in Emergency Medicine

Audience: This bleeding fistula model is designed to instruct emergency medicine residents and third- and fourth-year medical students on their emergency medicine rotation. 

Introduction: The prevalence of end-stage renal disease (ESRD) has increased since 2001 (808,536 people in 2021 versus 409,226 in 2001).¹ About 14% of the United States population has a decreased glomerular filtration rate (GFR), and the overall presence of ESRD in the population as of 2021 was 2,219 per million population.¹  As of 2021, 87.7% of patients receiving dialysis were on hemodialysis.² Around 60% of dialysis patients use a fistula for access.³ Patients with ESRD have a high emergency department utilization rate, and emergencies related to dialysis include hyperkalemia, volume overload, bleeding at the dialysis site, infection, aneurysm, and pseudoaneurysm .^4-9 It is important for emergency medicine (EM) physicians to be able to intervene quickly on life-threatening complications related to dialysis, including vascular access hemorrhage. There are approximately 250 deaths related to vascular access hemorrhages yearly, and it accounts for 0.4% of deaths in patients on dialysis.⁴ Patients with an initial presentation of hemorrhage from their vascular access site are also at risk for re-bleeding, and 80% of patients with bleeding die at home.¹⁰ Due to the high acuity and low occurrence (HALO) of bleeding fistulas, procedural knowledge of hemorrhage control and a thorough understanding of dialysis-related complications is paramount for EM physicians.

Educational Objectives: After using the task trainer bleeding fistula model, learners will be able to: 1) identify vascular access hemorrhage as an emergency presentation in dialysis patients; 2) execute a stepwise approach to manage a bleeding fistula; 3) demonstrate effective hemorrhage control for a patient with uncontrolled bleeding from their fistula, including choice of appropriate suture material and suturing technique; and 4) discuss pitfalls of hemorrhage control in patients with fistulas, including risks of tourniquet use and complications related to clot formation at the fistula site.  

Educational Methods: The novel bleeding fistula model was embedded within a high-fidelity simulation for learners as part of weekly EM resident didactics. Learners received a pre-brief session to the simulation case. They then participated in a simulation scenario using a high-fidelity manikin with the bleeding fistula model on the manikin’s arm. The bleeding fistula model allowed learners to progress through a stepwise approach to achieve hemorrhage control in a patient presenting with bleeding from a dialysis access site. After the simulation, learners participated in a simulation debrief, which included a procedural skills workshop. 

Research Methods: This simulation scenario and model have been used in two academic year didactic sessions to collect learner data. Across the two years, a total of thirty-two learners consisting of fourth year medical students, post-graduate year 1 (PGY-1) and PGY-2 residents have participated in the high-fidelity simulation at a Society for Simulation in Healthcare (SSH) accredited, state-of-the-art simulation center. Learners performed a self-assessment survey using a three-point Likert scale after participating in the high-fidelity simulation case. A retrospective pre- and post-simulation survey was conducted. They answered survey questions related to their confidence of identification of a bleeding fistula and knowledge of treatment of a bleeding fistula before and after the simulation. 

Results: Over two years of implementation, we had thirty-two learners participate in the simulation and use the model for demonstration of hemorrhage control of a bleeding fistula. Based on self-assessment, learners overall felt that their overall knowledge regarding hemodialysis access hemorrhage increased. Prior to the simulation, eighteen learners rated their confidence in identification of a bleeding fistula as “average,” and fourteen learners rated their confidence as “below average.” After participating in the simulation, seventeen learners rated their confidence in identifying a bleeding fistula as “above average,” and fifteen learners rated their confidence as “average.” Prior to the simulation, thirteen learners rated their knowledge of the management of bleeding fistulas as “average,” and nineteen learners rated their knowledge of the management as “below average.” After the simulation, eighteen learners rated their knowledge in the management of a bleeding fistula as “above average,” and fourteen rated their knowledge of the management as “average.” 

In the composite score, learners self-reported knowledge and confidence in managing bleeding fistulas improved. The pre-simulation score had a mean of 2.17 and a median of 2.0, increasing to a post-simulation mean of 3.31 and a median of 3.0. This difference was statistically significant (p < 0.00001), indicating a robust improvement in learners perceived comfort and knowledge following participation in the bleeding fistula simulation, hands-on task trainer, and debriefing workshop.

Discussion: This novel fistula model helped residents practice a HALO procedure that closely simulated a real bleeding fistula. The model bled akin to a real fistula, with the ability to make the bleeding pulsatile and occlude with suturing, direct pressure, and tourniquet placement. In the literature review, there are no current simulation models or task trainers to get hands-on experience with management of hemodialysis access hemorrhage. This scenario tested resident knowledge of management of dialysis emergencies, and there was a good discussion regarding the subject. Residents stated that this simulation was helpful. They learned new information and were able to get hands-on practice to reinforce that knowledge through this activity and the use of the bleeding fistula model.

Audience: This model for ocular procedural education is designed to instruct emergency medicine residents of all levels of training.

Introduction: Ocular complaints are a common presentation to the emergency department (ED) with some studies quoting as many as two to three million ocular-related visits annually.^1,2 These complaints can range from minor issues, such as corneal abrasions, to more serious conditions that require prompt evaluation and management, such as retrobulbar hematomas.  Emergency medicine physicians are often the first-line providers assessing these complaints, so it is imperative that they feel adept in recognizing and managing these complaints.²

Despite the frequency of ocular-related visits, ophthalmologic training among emergency medicine residents is often limited. Studies have reported that residents receive less than ten hours of formal ophthalmology training throughout their residency.^2,3 One study revealed that many emergency medicine physicians in the United States are not confident in using basic ophthalmic tools, conducting eye exams, diagnosing ophthalmic complaints, or performing vision-saving procedures.² This lack of formal training makes it difficult for residents to confidently diagnose and manage ocular conditions in the emergency department, both during residency and in their future practice. On review of the literature, there have been developments of procedural models for the practice of ophthalmology skills including removal of corneal foreign bodies utilizing swine eyes, tonometry using water balloons, and lateral canthotomy using a cadaver eye.^4.5 However, cadavers can be very difficult to obtain, and expensive and swine eyes are not reusable or easy to store.

There is a need for cost-effective, hands-on, ocular training models to help bridge this learning gap and 

increase residents’ comfort with common ocular complaints and procedures – including foreign body removal, lateral canthotomy, fluorescein staining, and intraocular pressure (IOP) measurements. Integrating hands-on ocular training models into medical education can ultimately lead to better patient outcomes. 

Educational Objectives: By the end of this session, learners will be able to: 1) identify signs and symptoms of ocular emergencies, 2) appraise for indications to perform ocular procedures, 3) demonstrate procedural competence in ocular foreign body removal, fluorescein staining, lateral canthotomy, and intraocular pressure (IOP) measurements, 4) relate increased procedural confidence with ocular procedures.

Educational Methods: We developed two gelatin-based eye models that are low-cost and can be easily replicated. The first was created with Knox^® gelatin which can be easily made at home. The second was made with Humimic Medical™ synthetic gelatin which can be easily melted down and re-used. The gelatin base mimics the eye and allows for practice of foreign body removal techniques. Different concentrations of gelatin can be used to simulate different IOPs to practice IOP measurement. Fluorescein stain can be applied to the gelatin models to mimic corneal abrasions/ulcerations with use of a Woods lamp. Finally, the gelatin eye models can be placed into an existing 3D printed face model for lateral canthotomy procedural practice, utilizing rubber bands as the ligaments.⁶ Our institution provides access to a 3D printer for both students and faculty. The average total time to create all material for this ocular session was about 20 hours, though many elements of this model can be utilized multiple times. Utilizing low-cost material, the total cost of one reusable model is about 30 United States Dollars (USD).

Research Methods: Twenty-one residents, ranging from their first year of training to their third year of training, participated in the session. A pre-survey was administered to all participants (supplemental materials). The pre-survey was broken down into each ocular procedure listed above, and the participants were asked if 1) they had ever performed the procedure, 2) if they had ever consulted ophthalmology for assistance with the procedure, and 3) to rate their comfort level with the procedure using a Likert scale (1=not at all comfortable to 5=very comfortable). After completion of the session, a post-survey (supplemental materials) was administered to participants, again broken down by each ocular procedure, asking 1) to rate their comfort level with the procedure using the same Likert scale and 2) if they would plan to consult ophthalmology for assistance with the procedure in the future.

Variables were summarized using percentages and frequencies for categorical variables, and means and ranges for continuous variables were presented. Using an α-value of 0.05, a T-test for independent samples was performed to determine if a difference between comfort levels before and after each activity exists.

Results: Twenty-one participants took part in the learning session; all participants were emergency medicine residents, ranging from post-graduate year (PGY)1s to PGY-3s. Of the participants, 100% had performed fluorescein staining, 24% had performed ocular foreign body removal, 95% had performed IOP measurements utilizing a Tono-Pen,^® and 14% had performed a lateral canthotomy (all in conjunction with ophthalmology) prior to this activity. There was a statistically significant increase in self-reported comfort level with each of these procedures after the activity: for fluorescein staining, comfort level increased from 4.1 to 4.6 (p-value 0.04); for ocular foreign body removal, comfort level increased from 2.3 to 3.9 (p-value <0.01); for IOP measurements utilizing a Tono-Pen,^® comfort level increased from 4.1 to 4.8 (p-value 0.01); for lateral canthotomy, comfort level increased from 1.7 to 3.5 (p-value <0.01). Please see Table 3 for details. Resident comments included: “Great simulations,” “Helpful, want slit lamp,” “Amazing!” and “Great sims!”

Discussion: Feedback from residents was favorable, and their comfort level with each of these ocular procedures improved after the activity. We believe this tool can offer simulation of these procedures at a relatively low cost with reusable materials to improve both comfort level and procedural competence in emergency medicine residents.

Topics: Ocular procedures, lateral canthotomy, Tono-Pen,^® IOP measurement, ocular foreign body removal, fluorescein staining, Wood’s lamp.

Audience: This task trainer is designed to instruct emergency medicine (EM) resident physicians, senior medical students, and advanced practice providers. 

Introduction: While orthopedic emergencies are common, exposure to fracture management may vary depending on one’s training environment. Given that extremity bony trauma and fracture reduction techniques are listed as core content topics in the American Board of Emergency Medicine’s (ABEM) 2022 Model of the Clinical Practice of Emergency Medicine,¹ it is beneficial to practice their management in a simulated environment. Fracture reduction is particularly difficult to practice without any task trainers. Commercial fracture models are available and cost thousands of dollars which limits universal availability. This wrist fracture task trainer was developed to be a low-cost, reusable, transportable, and storable model with similar haptics to human bone and soft tissue. 

Educational Objectives: Utilizing this task trainer, learners will be able to 1) identify key anatomic structures, 2) distinguish a Colles from a Smith fracture of the radius, 3) understand fracture reduction technique using traction, translation and angulation, 4) appreciate the amount of force required for manipulation of the distal fracture fragment, and 5) gain hands-on practice using a model with similar haptics to bone and soft tissue.

Educational Methods: This task trainer is designed for practicing fracture reduction techniques in a simulated environment. Using materials that mimic similar haptics to bone and soft tissue, such as taut rubber bands for tendons and layers of socks for soft tissue, learners will need to use force to apply traction and reduce the distal fracture fragment through translation and angulation. This task trainer can be used for procedural education at the bedside or as part of small group sessions. 

Research Methods: This task trainer was used during a small group session at a training institution’s medical simulation conference. Using a Likert scale, an anonymous survey assessed learner’s confidence in the ability to reduce a fracture pre- and post-session. Free-text boxes were also provided to obtain feedback. This task trainer was also presented as a table-top innovation in an EM national conference where attendees provided verbal feedback. 

Results: This task trainer was utilized by 32 participants during a medical simulation conference (10 PGY-1 (Post Graduate Year-1), 7 PGY-2, 5 PGY-3, 3 PGY-4, 5 medical students, 1 fellow, 1 attending physician). Of these individuals, 23 participated in the anonymous survey (8 PGY-1, 6 PGY-2, 4 PGY-3, 3 PGY-4, 2 medical students). Using a Likert scale of 1 to 5 assessing learner’s confidence in fracture reduction technique before and after using this task trainer, the total mean score of the pre-session survey was 2.6 and the total mean score of the post-session survey results was 3.9. Attendees of an EM national conference who used the task trainer for hands-on practice provided verbal feedback. It was stated that its design was simple enough to replicate, it could be used for bedside teaching during a shift, and that the feel of the fracture line and technique required to reduce the fragment was realistic. It was noted that although the amount of force required was less for this model than in human practice, it was conceptually accurate. 

Discussion: The utilization of this task trainer allows learners to understand and practice the maneuvers and force needed for successful fracture reduction. The materials used in its design require the learner to manipulate the distal fracture fragment in a realistic manner. This model is a low cost, reusable, transportable, and easily storable alternative to commercial trainers and can be used in a simulated environment to improve procedural competency and confidence. 

Audience: This phantom is designed to instruct emergency medicine residents in ultrasound-guided fascia iliaca (FI) nerve blocks but could also be used for medical students and attending physicians. 

Introduction: Ultrasound-guided regional nerve blocks are increasingly used in the emergency department for pain management. The FI block, used for pain management in patients with hip fractures, have been shown to provide pain relief for up to eight hours with rare complications and to decrease need for parenteral pain medication.^1,2  It is considered best practice to train physicians in ultrasound-guided procedures such as FI blocks by using phantoms, which are objects designed to mimic human tissue and anatomy relevant to the specific ultrasound-guided procedure. Commercial trainers are available but are quite expensive with those designed to mimic femoral anatomy priced at or over $5,000 USD, and they still lack some of the anatomical landmarks useful in FI blocks.^3,4 Several lower cost FI models have been described made from a variety of perishable items including gelatin, tofu, chicken, konnyaku jelly, pork and meat glue.^5-10However, these models have the downside of limited uses due to the nature of perishable materials, and most are also lacking in block specific landmarks and durability. 

Educational Objectives: By the end of the training session using the FI phantom and bedside ultrasound, learners should be able to: 1) discuss indications, contraindications, and complications of FI blocks; 2) identify anatomy relevant to performing an FI block on ultrasound; and 3) independently perform an FI block or demonstrate proper needle position for FI block on ultrasound of the phantom.

Educational Methods: This low-cost FI block phantom was developed using ballistics gel to create the fascia layers and muscles, bungee cord for nerve, and latex balloons for vessels. Ballistics gel was also used as the base medium for the phantom. 

Research Methods: Participants completed a short electronic survey following the educational session using five-point Likert scale questions to evaluate the phantom based on ultrasound image quality, anatomical accuracy, and perceived durability. An additional question asked participants if they felt more confident performing an FI block after practicing on the phantom.

Results: Twenty-four emergency medicine residents completed the training session and the post-training survey. All learners were able to successfully demonstrate proper needle placement on ultrasound for the FI block. On a five-point Likert scale, ranging from 1 (very poor) to 5 (excellent), participants rated the phantom in durability, anatomical accuracy, and ultrasound image quality. Most participants agreed that the phantom was anatomically accurate (median 4) and durable (median 4). The phantom performed the best in the category of ultrasound image quality (median 5). Most participants agreed that practicing with the phantom increased their confidence in performing FI blocks (median 4).  The phantom held up to 100 needle sticks with only mild degradation in image quality. 

Discussion: The phantom presented here effectively taught EM residents proper needle placement for an FI block since all participants were able to demonstrate appropriate needle placement. The phantom was low cost, particularly compared to commercial trainers, and held up to a large number of needle sticks. 

Audience: The intended audience for this modified TBL are resident physicians of all years, PGY1-4.

Introduction: Biological females represent 50% of the population we encounter in the emergency department (ED), and following delivery, the ED is often the main resource for postpartum patients to seek urgent/emergent care. The US is one of the most dangerous developed nations for pregnant women, with about 1/3 of pregnancy related deaths occurring in the postpartum period.^1,2 It is presumed that many of these deaths are related to lack of support or insurance for close follow up after delivery.² The three most common reasons for postpartum hospital readmission and mortality are cardiovascular related disorders (such as hypertension, eclampsia, and cardiomyopathy), hemorrhage, and infections.^2,3 While most common, those are not exhaustive, and postpartum women are at risk for many other complications, such as breastfeeding related problems, which will cause them to present to the ED. 

As the front lines for patients with limited support or access to medical care, emergency physicians (EPs) need to understand how to recognize and intervene on the common complications faced by postpartum women. It is paramount that resident physicians have adequate training to consider and treat the unique medical concerns of this vulnerable population. This team-based learning (TBL) activity will prepare resident EPs to recognize and manage common postpartum complications.  

Educational Objectives: By the end of this session learners will be able to: 1) identify the timeline in which postpartum complications typically occur, 2) discuss the specific differential diagnoses common in the postpartum period, 3) recognize risk factors for endometritis and mastitis, 4) recognize the presentation of postpartum cardiomyopathy and pituitary infarction, 5) formulate a treatment plan for postpartum endometritis including appropriate antibiotics and disposition, 6) formulate a treatment plan for mastitis including appropriate antibiotics and disposition, 7) formulate an appropriate assessment plan for pituitary infarction with appropriate disposition, and 8) formulate an appropriate treatment plan and disposition for postpartum cardiomyopathy. 

Educational Methods: This is a modified team-based learning (mTBL) activity in which learners do not have 

learner responsible content (LRC) prior to the educational session. The multiple-choice cases can be used as an individual readiness assessment test (iRAT) followed by group discussion in a group readiness assessment test (gRAT), or without an iRAT and completed in small groups as a gRAT followed by instructor feedback and summary. Following the gRAT, there is a group application exercise (GAE) with summary cases. 

Research Methods: This mTBL was evaluated by learners immediately following the educational session using a post-participation survey. A Likert scale was used to assess the learner’s perception of the effectiveness of this educational format, relevance of the content to practice as EPs, and learner engagement with the mTBL. 

Results: The post mTBL survey had a response rate of 82% with 29/35 participants completing the evaluation. Overall, the learners rated the mTBL highly with an average total score of 4.75/5 on the Likert scale. Seventy-nine percent of learners strongly agreed (5/5 on the Likert scale) that the mTBL was effective and valuable compared to other educational activities and engaged their attention. Eighty-three percent of the learners strongly agreed (5/5 on the Likert scale) that the content was relevant to their practice of emergency medicine (EM). 

Discussion: Postpartum patients are a high risk, vulnerable population who present to the ED with a wide range of concerns. It is paramount that resident physicians are prepared to medically advocate for and treat these patients appropriately. This mTBL allowed the learners to practice engaging with and discuss the complex medical conditions faced by these patients to better serve them on their next ED shift. Learners found this content very relevant and directly relatable to their daily practice. 

Audience and Type of Curriculum: This curriculum is designed for all levels of emergency medicine (EM) Residents.  The curriculum covers the appropriate anatomy, indications, contraindications, and specific steps for placement of midline catheters.

Length of Curriculum: Three one-hour sessions over a period of three months or a single three-hour session.

Introduction: Midline catheters have become more mainstream in the emergency department as a replacement for central lines. They are readily insertable into a peripheral vein and useful for access, blood draws, and medication administration, which are well known benefits of peripheral lines. They also offer long-term reliable access and are becoming more accepted for caustic medication administration, which are clear indications for central line placement. They are significantly more comfortable than a central line and may be associated with lower rates of catheter related bloodstream infections (CRBSI) when compared to peripherally inserted central catheter (PICC) lines.¹ These combined advantages have led to increasing interest in midline use in the emergency department. Unfortunately, EM residents are often not educated on the indications for midline catheters and are not trained in placing them either. We propose a midline curriculum for EM resident success in this area.

Educational Goals: The purpose of this curriculum is to teach emergency medicine residents how to place and utilize midline catheters.

Educational Methods: The educational strategies used in this curriculum include written and skills assessments as well as in-person lectures, and asynchronous learning. Specifically, there is a pre- intervention and post-intervention knowledge assessment as well as a pre- and post-skills assessment and skills check list. The knowledge assessments are conducted using written multiple-choice exams, and the skills curriculum evaluation is performed with task trainers and instructor feedback.

Research Methods: Educational content was evaluated by learners via online survey. Efficacy of the 

educational content was assessed using scores and feedback from the written pre- and post-intervention examinations and procedural skills assessments.

Results: Thirty-nine residents completed the study curriculum. Overall, we found the written exam score improved from pre- to post-intervention by roughly 5% (75% to 80% on average). The time to midline placement from tourniquet to vessel catheterization was significantly improved from pre-intervention at 7 minutes, 32 seconds to post-intervention at 5 minutes, 0 seconds.  The post-curriculum survey taken by participants demonstrated an increased self-reported likelihood of placing a midline on a patient and improved self-reported core knowledge. However, self-reported clinical skills did not improve significantly.

Discussion: The intent of our midline curriculum was to improve EM resident knowledge regarding line usage, placement, and confidence in using them in practice. The EM residents’ knowledge, ability to place, and self-reported intent to use midlines more often was improved based on our pre/post written, skills assessments and our feedback sessions. This project was well received and will hopefully result in more midline placement in the emergency department which should benefit learners, nurses, and patients.

This case report highlights the clinical complexities of diagnosing and managing appendicitis complicated by appendicoliths in a 44-year-old female patient. Appendicitis is a common cause of acute abdominal pain, with imaging playing a crucial role in diagnosis. The patient presented with symptoms of right lower quadrant pain, nausea, vomiting, and chills that were initially misattributed to menstrual cramps. Diagnostic evaluation revealed multiple appendicoliths via computed tomography (CT), and the decision for laparoscopic appendectomy was based on the imaging results and clinical presentation. Intraoperative findings showed gangrenous but non-perforated appendicitis. The patient's postoperative recovery was uneventful, with successful symptom resolution. This case highlights the importance of considering appendicitis in the differential diagnoses for acute abdominal pain in females, particularly with overlapping gynecological symptoms. The high sensitivity of CT imaging for appendicitis and the necessity of timely surgical intervention in cases involving appendicoliths are discussed. Multimodal imaging and prompt surgical management are vital for favorable outcomes in complicated appendicitis cases.

Sarcoidosis is a multisystem inflammatory disease characterized by non-caseating granulomas, primarily affecting the lungs but also involving other organs such as the skin, eyes, and heart.¹ Due to its variable presentation, diagnosing sarcoidosis in the emergency department (ED) can be challenging. We report a case of a 28-year-old African American female presenting with acute dyspnea on exertion, significant weight loss, and multiple cutaneous nodules. Her diagnostic workup revealed hypercalcemia, diffuse pulmonary nodules, and extensive lymphadenopathy on imaging. Biopsy of her eyelid lesions confirmed non-caseating granulomas, leading to a diagnosis of sarcoidosis. She was initiated on high-dose steroids and evaluated for further immunologic therapy. Sarcoidosis presents a diagnostic challenge due to its nonspecific symptoms, often mimicking more common conditions.² Early recognition in the ED is critical to prevent disease progression. This case underscores the importance of considering sarcoidosis in patients with unexplained systemic symptoms and highlights the need for a multidisciplinary approach to management.

Rashes are a common presentation in the emergency department (ED) and can signify a wide variety of underlying conditions. Early recognition of serious dermatologic rashes in the acute care setting is essential in improving patient outcomes. Here we describe the case of a 69-year-old female with a medical history of cirrhosis with ascites, chronic kidney disease (CKD) secondary to immunoglobulin A (IgA) nephropathy, and hypertension who presented to the ED with a chief complaint of foot pain with an associated rash. On examination, she had tender purpura with bilateral symmetric pedal edema. Initial work up in the ED was significant for mildly elevated inflammatory markers. Given the concern for vasculitis, dermatology was consulted; punch biopsy confirmed IgA vasculitis. The patient was subsequently admitted for acute renal injury and started on corticosteroids. After a week-long inpatient stay, she was discharged home in stable condition. This case highlights the importance of maintaining a broad differential diagnosis for purpuric rashes, recognizing when specialty consultation is warranted, and understanding the pathophysiologic interplay between IgA vasculitis, liver cirrhosis, and IgA nephropathy.  

Open fractures represent high acuity injuries requiring rapid evaluation and management for optimal outcomes. In this report, we discuss a patient presenting with an open fracture of the proximal phalanx of the right thumb with interphalangeal (IP) joint dislocation. The patient reported that the injury occurred in the setting of trauma from catching a cricket ball, experiencing immediate severe pain and bleeding. Key interventions in the emergency department included rapid x-ray evaluation of the injury, administration of cefazolin and tetanus vaccine, pain control, covering the exposed bone in moist gauze, and involvement of the hand surgery team for bedside irrigation and reduction. He underwent open reduction and internal fixation of the fracture the next day. He was followed in the hand clinic and was doing well at the 12-week appointment. In summary, we report on an open fracture and dislocation of the proximal phalanx of the thumb secondary to a traumatic cricket injury. Early mobilization of the surgical team and adjunctive prophylaxis with cefazolin and updated tetanus were key measures in the emergency department for achieving optimal outcomes.

Primary adrenal insufficiency is a rare disease characterized by deficient production of glucocorticoids with or without a deficiency of mineralocorticoids and adrenal androgens.¹ This disease can present as a range of symptoms provoking a visit to the emergency department (ED). In this case, we present a 40-year-old female who reported tongue and gingival discoloration, unintentional weight loss, and skin hyperpigmentation. The patient was evaluated by an endocrinologist in the ED, received a dose of steroids in the ED, and discharged home with a prescription for steroids. This case report illustrates the distinctive tongue discoloration seen in primary adrenal insufficiency, highlighting the need for early recognition in the emergency setting to enable prompt and appropriate management.

Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of assisted reproductive technology (ART). Here, we present the case report of a 30-year-old female undergoing infertility treatment who presented to the emergency department (ED) with nausea and vomiting, abdominal distention, and shortness of breath. On physical exam, she had notable ascites. Computed tomography (CT) of the abdomen and pelvis and pelvic ultrasound (US) revealed significant ascites and enlarged ovaries with multiple cysts. She was diagnosed with severe OHSS and admitted to obstetrics and gynecology (OBGYN) service for five days where she underwent intravenous (IV) hydration and paracentesis. This case report reviews the clinical presentation, categorization, management, and prevention of OHSS and provides examples of imaging findings consistent with the condition.

Open globe injury is defined as a full-thickness injury through all anatomical layers of the eye. Prolapse or herniation of the iris may be observed at presentation of an open globe injury, and iris prolapse is not well represented in the literature. This case report details the case of a 48-year-old male presenting with three hours of right eye pain after sustaining a traumatic injury due to a foreign body. Examination of the right eye revealed a 2 mm x 1 mm laceration to the 4-5 o'clock position with iris prolapse and plugging. The affected eye also revealed a teardrop-pupil with associated corectopia in the inferonasal direction and a 2 mm hyphema. The patient was diagnosed with a globe rupture and underwent same-day surgical intervention. This report emphasizes the use of fluorescein eye exams and explains the rationale against the measurement of intraocular pressures or removal of an obvious foreign body. The care provided represents strict adherence to the principles of management in ocular trauma and a positive outcome in which a patient’s vision and visual acuity were relatively maintained.

Sinonasal carcinoma is a rare malignancy that often presents with nonspecific symptoms, making early diagnosis challenging. Delayed recognition can lead to disease progression and worse outcomes. This case report emphasizes the importance of early identification, prompt imaging, and multidisciplinary management. A 73-year-old male with a history of anemia and hypertension presented with progressive facial swelling, 20-pound weight loss, and vision loss in the left eye over two months. Initially misdiagnosed with bacterial sinusitis, his symptoms persisted. Examination revealed a proptotic left eye and a large obstructive nasal mass. Computed tomography (CT) and MRI (magnetic resonance imaging) demonstrated a destructive sinonasal mass with skull base and intracranial extension. A biopsy confirmed sinonasal carcinoma, and the patient was started on chemoradiation therapy due to the inoperability of the tumor.

This case underscores the importance of recognizing red flag symptoms such as persistent facial swelling and neurological deficits. Multimodal imaging played a critical role in diagnosis. The literature suggests sinonasal carcinoma is often diagnosed late, reinforcing the need for early suspicion and specialist referral. Sinonasal carcinoma should be considered in patients with persistent facial or nasal symptoms. Timely imaging, biopsy, and interdisciplinary care are essential for optimizing outcomes.

A 14-year-old female patient presented to the pediatric emergency department (ED) with chief complaints of abdominal pain, vomiting, and unintentional weight loss. A palpable abdominal mass was noted on exam, prompting a computed tomography (CT) scan which revealed a gastric bezoar that had fragmented, leading to intermittent and spontaneously resolving small bowel obstruction. The patient underwent surgical removal of the bezoar for definitive management.

This report highlights a novel case of spontaneous bezoar fragmentation and its associated imaging findings. Because this phenomenon represents the description of a rare occurrence, the goal is to enhance the emergency medicine providers’ understanding of an uncommon cause of abdominal masses and small bowel obstruction (SBO). 

Food insecurity is a commonly underrecognized social determinant of health and is a risk factor for severe, though uncommon, nutritional deficiencies. This report describes a 60-year-old male with a history of asthma and housing instability who presented to the emergency department (ED) for shortness of breath and was found to have classic findings of vitamin C deficiency, colloquially known as scurvy. Examination revealed diffuse wheezing, poor dentition with palatal ecchymosis, and a perifollicular rash with scattered bruising on his bilateral lower extremities. Due to financial struggles, he was experiencing food and housing insecurity, with a diet primarily composed of processed carbohydrates. Laboratory studies revealed anemia, hypoalbuminemia, and severely low levels of vitamins C and B6. He was admitted for management of his asthma exacerbation and treatment of his nutritional deficiencies with vitamin supplementation, electrolyte repletion, and dietary support. Upon discharge, he was placed in a nearby shelter with financially accessible follow-up care, food bank resources, and multivitamin prescriptions. At follow-up three weeks later, his dermatologic findings had resolved.

This case highlights the importance of a thorough physical examination and detailed social history in the ED to avoid missing subtle yet clinically significant diagnoses. It underscores the need for early recognition and treatment of nutritional deficiencies, particularly in vulnerable populations. Furthermore, it demonstrates the value of accessible follow-up care in supporting the management of nutritional deficiencies and promoting long-term recovery.

Audience: This activity is designed as a team building capstone exercise for new interns to review important content from intern orientation at an emergency medicine residency program. 

Introduction: Medical students matriculate into residency with various backgrounds, medical knowledge base, and personalities. As they orient themselves into their respective specialties, interns are commonly taught using lectures and slide decks with varied and unclear effectiveness.^1,2 It has been recommended that intern orientation should incorporate active learning, such as simulation as well as a collaborative environment to bolster retention and encourage teamwork.^1,3Escape rooms are becoming increasingly popular in medical education as an adjunct to traditional lecture-based learning that encourages collaboration amongst learners.⁴ We embraced this modality to create a capstone and teambuilding experience for our new interns that was delivered at the completion of our intern orientation activities. Topics taught in our intern orientation include resuscitation of the critically ill patient, airway management, acute coronary syndromes, EKG reading, basic ultrasound, stroke care, and foundational pediatric topics.  In this activity, an escape room is used to recall and apply topics learned during the emergency medicine intern orientation, while also promoting teamwork and camaraderie amongst a new intern cohort. 

Educational Objectives: By the end of this small group exercise, learners will be able to: 

1. Identify first, second, and third-degree heart block on a 12-lead ECG.
2. Recognize STEMI pattern on a 12-lead ECG. 
3. Categorize appropriate images that make up an EFAST exam for a trauma patient. 
4. Recall the proper management of a tension pneumothorax. 
5. Identify an organized approach to emergency department rapid-sequence intubation (RSI).
6. Recognize acute otitis media (AOM).
7. Locate the appropriate antibiotic and pediatric dose to treat acute otitis media via the Harriet Lane Handbook.
8. Demonstrate how to apply evidence-based guidelines to a clinical case of neonatal pediatric fever.
9. Recall common clinical findings of basilar skull fracture.
10. Identify important concepts in the management of stroke syndromes.
11. Recognize vital sign abnormalities that could indicate sepsis.
12. Review important concepts related to the management of septic patients. 

Educational Methods: The use of game-based learning or gamification has become increasingly popular within medical education as a form of active learning.⁵ There is a growing body of literature among health care professionals highlighting improvement in participants' skills and learning through games as well as the ability of this method in encouraging peer education and socialization.^6-8 Escape rooms are a form of game-based learning employing various puzzles and settings specifically designed to meet educational objectives in an active learning environment.⁹ Recently, literature has shown that escape rooms can be an instrument to foster relationships amongst co-workers in addition to facilitating improved learning outcomes via active learning.¹⁰

We developed an escape room to review and solidify important content from our intern orientation as well as to encourage teamwork and camaraderie on the last day of orientation. The intern class was divided into three teams, each with four participants. Each team selected their own team name and were informed during a pre-briefing that they would only be able to escape intern orientation by completing all six stations. A facilitator at each station timed the teams. The team with the fastest time was deemed the winner which was announced after a short debrief of the activity. 

Research Methods: All interns who participated in the escape room completed an anonymous online survey after the activity. The survey was designed to solicit feedback on the effectiveness of the activity in reviewing material taught during orientation as well as overall satisfaction with the escape room experience measured as a recommendation to continue the activity in the future. 

Results: All twelve (100%) interns that attended the escape room completed the post participation survey. Ninety-two percent (11/12 interns) thought the activity was moderately to extremely effective in reviewing the content delivered during intern orientation and 100% (12/12 interns) recommended we continue the escape intern orientation activity for future classes. Representative free response comments soliciting general feedback on the activity included “Great event, do it again. Very interactive and fun.” As well as “Great activity to tie in all that we learned this month. Very creative and clever! Also, a great team building opportunity as well.”

Discussion: Intern orientation is a necessary, high-yield time for new doctors to learn foundational specialty and hospital specific topics.¹¹ As educators are being challenged to move away from traditional classroom lecturing, gamification has emerged within medical education as an active learning tool to increase engagement, promote team building, provide immediate feedback, and make content more interesting.¹² Escape rooms fall within a constructivist theory of learning because participants are challenged to incorporate existing knowledge to draw conclusions, ultimately unlocking their “escape.”¹³

Further, intern orientation is also a time of social gathering and team building. Because camaraderie is connected to wellbeing, it is highly valued in emergency medicine residencies.¹⁴ When interns matriculate into their residencies, social interactions are encouraged among the group. In our escape room activity, gamification is used to enhance social interaction in a way that encourages relationship building and teamwork. This is important as cohesiveness amongst the resident group is a key factor for their success in residency.¹⁵

Audience: This small group session is intended for emergency medicine residents, medical students, and faculty.

Introduction: Improvisational techniques offer a novel and effective approach to teaching relationship-centered communication (RCC) and enhancing learner feedback in emergency medicine (EM).¹ Improvisational theater (improv) is a form of spontaneous performance where all things or most things are made up on the spot. The “yes, and” principle—accepting a partner’s idea ("yes") and building upon it ("and")—reflects core improv values such as affirmation, spontaneity, active listening, and empathy, all of which contribute to psychologically safe learning environments.¹ It is an engaging practice that can foster creativity, build confidence, and enhance communication and social skills. Improv helps participants become more adaptable, attuned to emotional tone, and comfortable with uncertainty. These are critical elements of high-quality interpersonal feedback.^2,3,4

In the fast-paced EM setting, where teaching and supervision often occur in real time, the ability to deliver concise, respectful, and actionable feedback is essential. Improv-based learning provides a low-stakes space to explore tone, content, and delivery without fear of error. Prior studies demonstrate that improv improves communication performance, team collaboration, and confidence in difficult conversations.^5,6 This module builds on that foundation by integrating structured feedback models and core RCC principles with improvisational exercises, allowing participants to refine skills through play, reflection, and peer interaction. As EM continues to emphasize communication and professionalism milestones, improv offers a compelling adjunct to traditional faculty or resident development by combining emotional literacy, interpersonal skills, and educational theory in a single interactive format.

Educational Objectives: By the end of this session, learners will be able to improve relationship-centered communication (RCC): 1) define “yes, and” and its role in RCC, and 2) demonstrate active listening and responsiveness using improvisational techniques such as “yes, and,” gift-giving, establishing scene, and callbacks. They will also be able to improve learner feedback: 1) define “yes, and” and its role in learner feedback, 2) review three evidence-based feedback models through a “yes, and” lens,  and 3) practice improv techniques and deliver structured feedback in real-time peer scenarios using improvisational techniques such as “yes, and,” gift-giving, establishing scenes, and callbacks.

Educational Methods: Using Kern’s six-step approach, this curriculum was designed to address gaps in relationship-centered communication (RCC) and feedback skills among emergency medicine residents.^7,8,9,10 The first two workshops focused on RCC, linking improvisational principles to patient communication through the Three-Function Model, which emphasizes building relationships, understanding the patient’s perspective, and collaborating on care decisions. Sessions incorporated facilitator discussions, a video clip from Whose Line Is It Anyway? and small-group improv exercises. The third workshop targeted feedback skills for Graduate Medical Education (GME) leadership, introducing concepts such as “yes, and,” credible feedback, and evidence-based models, and included interactive activities like the “Red Ball” exercise and improv-based learner scenarios to reinforce effective communication and feedback practices.  

Research Methods: A post-intervention survey with a 5-point Likert scale was administered immediately after all three sessions via Google Forms. Participants were asked about the structure of the activity, length, engagement, relevance to practice, and the facilitator's skill. Open-response questions included:

“Describe a specific moment during the improv session that stood out to you.” 

“How did it impact your understanding or approach to feedback or communication?” 

“How do you see the skills learned today translating to your future clinical practice?” 

“How likely are you to use “yes, and” in your communication with colleagues and patients?” 

 “What challenges did you encounter when applying improv techniques during this session?” Thematic analysis of reflective prompts was performed. 

Results:  Fifty-two learners participated and responded to the post-intervention survey. This included a 5-point Likert scale and open-response questions administered for all three sessions. Respondents rated highly (4 or 5 on Likert scale) the activity structure (96.1%), length (84.3%), engagement (100%), relevance to practice (92.3%), and facilitator skill (88.5%). Thematic analysis of free-text answers revealed themes of “enjoyment/engagement,” “connection to patient care,” “applying improv to feedback,” and “openness to future application.” 

Discussion:  This applied improvisation curriculum provided an effective modality to practice RCC and feedback skills among EM learners and faculty. High engagement, relevance to practice, and strong facilitator impact highlight this effectiveness. The thematic analysis findings underscore the value of connecting improv techniques to patient care and feedback delivery.