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Articles In Press

Review Article (Limit 4000 words)

Performance of Intra-arrest Echocardiography: A Systematic Review

Introduction: Intra-arrest transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have been introduced in adult patients with cardiac arrest (CA). Whether the diagnostic performance of TTE or TEE is superior during resuscitation is unclear. We conducted a systematic review following PRISMA guidelines.

Methods: We searched databases from PubMed, Embase, and Google Scholar and evaluated articles with intra-arrest TTE and TEE in adult patients with non-traumatic CA. Two authors independently screened and selected articles for inclusion; they then dual-extracted study characteristics and target conditions (pericardial effusion, aortic dissection, pulmonary embolism, myocardial infarction, hypovolemia, left ventricular dysfunction, and sonographic cardiac activity). We performed quality assessment using the Quality Assessment of Diagnostic Accuracy Studies Version 2 criteria.

Results: A total of 27 studies were included: 14 studies with 2,145 patients assessed TTE; and 16 with 556 patients assessed TEE. A high risk of bias or applicability concerns in at least one domain was present in 20 studies (74%). Both TTE and TEE found positive findings in nearly one-half of the patients. The etiology of CA was identified in 13% (271/2,145), and intervention was performed in 38% (102/271) of patients in the TTE group. In patients who received TEE, the etiology was identified in 43% (239/556), and intervention was performed in 28% (68/239). In the TEE group, a higher incidence regarding the etiology of CA was observed, particularly for those with aortic dissection. However, the outcome of those with aortic dissection in the TEE group was poor.

Conclusion: While TEE could identify more causes of CA than TTE, sonographic cardiac activity was reported much more in the TTE group. The impact of TTE and TEE on the return of spontaneous circulation and further survival was still inconclusive in the current dataset.

  • 1 supplemental ZIP

Systematic Review (Limit 4000 words)

Ultrasound Performed by Emergency Physicians for Deep Vein Thrombosis: A Systematic Review

Introduction: Point-of-care ultrasound (POCUS) performed by emergency physicians (EP) has emerged as an effective alternative to radiology department ultrasounds for the diagnosis of lower extremity deep vein thrombosis (DVT). Systematic reviews suggested good sensitivity and specificity overall for EP-performed POCUS for DVT diagnosis, yet high levels of heterogeneity were reported.

Methods: In this systematic review and meta-analysis, we aimed to provide the most up-to-date estimates of the accuracy of EP-performed POCUS for diagnosis of DVT and to explore potential correlations with test performance. We performed systematic searches in MEDLINE and Embase for original, primary data articles from January 2012–June 2021 comparing the efficacy of POCUS performed by EPs to the local standard. Quality Assessment of Diagnostic Accuracy Studies-2 for individual articles are reported. We obtained summary measures of sensitivity, specificity, and their corresponding 95% confidence intervals (CI) using bivariate mixed-effects regression models. We performed meta-regression, subgroup, and sensitivity analyses as planned in the protocol CRD42021268799 submitted to PROSPERO.

Results: Fifteen publications fit the inclusion criteria, totaling 2,511 examinations. Pooled sensitivity and specificity were 90% (95% CI 82%–95%) and 95% (CI 91%–97%), respectively. Subgroup analyses by EP experience found significantly better accuracy for exams performed by EP specialists (93%, CI 88%–97%) vs trainees (77%, CI 60%–94%). Specificity for EP specialists (97%, CI 94%–99%) was higher than for trainees (87%, CI 76%–99%, P = 0.01). Three-point compression ultrasound (CUS) was more sensitive than two-point CUS but was only statistically significant when limited to EP specialists (92% vs 88%, P = 0.07, and 95% vs 88%, P = 0.02, respectively).

Conclusion: Point-of-care ultrasound performed by emergency physicians is sensitive and specific for the diagnosis of suspected DVT when performed by trained attending EPs. Three-point compression ultrasound examination may be more sensitive than two-point CUS.

  • 2 supplemental ZIPs

Educational Advances (Limit 4000 words)

Space Ultrasound: A Proposal for Competency-based Ultrasound Training for In-flight Space Medicine

Space travel has transformed in the past several years. Given the burgeoning market for space tourism, in-flight medical emergencies are likely to be expected. Ultrasound is one of the few diagnostic and therapeutic modalities available for astronauts in space. However, while point-of-care ultrasound (POCUS) is available, there is no current standard of training for astronaut preparation. We suggest an organized and structured methodology by which astronauts should best prepare for space with the medical equipment available on board. As technology continues to evolve, the assistance of other artificial intelligence and augmented reality systems are likely to facilitate training and dynamic real-time needs during space emergencies.

Summary: As space tourism continues to evolve, an organized methodology for POCUS use is advised to best prepare astronauts for space.

Original Research (Limit 4000 words)

Usability of the 4Ms Worksheet in the Emergency Department for Older Patients: A Qualitative Study

Introduction: Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework—what matters, medications, mentation, mobility—has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED).Weaimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients’ goals of care and 2) use of the worksheet was feasible in the ED. Methods: We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January–June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories. Results: A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively. Conclusion: We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients’ underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.

  • 1 supplemental PDF

Analysis of Anonymous Student Narratives About Experiences with Emergency Medicine Residency Programs

Background: Academic emergency medicine (EM) communities have viewed anonymous online communities (AOC) such as Reddit or specialty-specific “applicant spreadsheets” as poor advising resources. Despite this, robust EM AOCs exist, with large user bases and heavy readership. Insights about applicants’ authentic experiences can be critical for applicants and program leadership decision-making. To date, there are no EM studies to qualitatively assess EM AOC narratives during the application cycle. Our goal was to perform a qualitative analysis of students’ EM program experiences through a publicly available AOC.

Methods: This was a qualitative analysis of a publicly available, time-stamped, user-locked AOC dataset: “Official 2020–2021 Emergency Medicine Applicant Spreadsheet.” We extracted and then de-identified all data from selected sub-sheets entitled “Virtual Interview Impressions” and “Rotation Impressions.” Four investigators used constant comparative method to analyze the data inductively, and they subsequently met to generate common themes discussed by students. Preliminary thematic analysis was conducted on a random sample of 37/183 (20%) independent narratives to create the initial codebook. This was used and updated iteratively to analyze the entire narrative set consisting of 841 discrete statements. Finally, two unique codes were created to distinguish whether the identified sub-themes, or program attributes, were likely “modifiable” or “non-modifiable.”

Results: We identified six major themes: living and working conditions; interpersonal relationships; learning experiences, postgraduate readiness, and online/virtual supplements. Common sub-themes included patient population (13%); resident personality (7%); program leadership personality (7%); relationship with faculty/leadership (6%); geography (4%); practice setting (4%); program reputation (4%), and postgraduate year-3 experiences (4%). Modifiable sub-themes outnumbered non-modifiable sub-themes, 60.7% to 39.3%.

Conclusion: In this analysis of selected medical students’ narratives in an AOC, the majority of identified themes represented topics that may serve as external feedback for EM residency programs and their clerkships. Selective use of AOCs may set a precedent for future program assessments by applicants and inform program leadership of important programmatic elements in the eyes of applicants. It elucidates important themes in their interactions or learning experiences with programs and creates opportunities for learner-centric program improvement.

National Characteristics of Emergency Care for Children with Neurologic Complex Chronic Conditions

Introduction: Most pediatric emergency care occurs in general emergency departments (GED), where less pediatric experience and lower pediatric emergency readiness may compromise care. Medically vulnerable pediatric patients, such as those with chronic, severe, neurologic conditions, are likely to be disproportionately affected by suboptimal care in GEDs; however, little is known about characteristics of their care in either the general or pediatric emergency setting. In this study our objective was to compare the frequency, characteristics, and outcomes of ED visits made by children with chronic neurologic diseases between general and pediatric EDs (PED).

Methods: We conducted a retrospective analysis of the 2011–2014 Nationwide Emergency Department Sample (NEDS) for ED visits made by patients 0–21 years with neurologic complex chronic conditions (neuro CCC). We compared patient, hospital, and ED visits characteristics between GEDs and PEDs using descriptive statistics. We assessed outcomes of admission, transfer, critical procedure performance, and mortality using multivariable logistic regression.

Results: There were 387,813 neuro CCC ED visits (0.3% of 0–21-year-old ED visits) in our sample. Care occurred predominantly in GEDs, and visits were associated with a high severity of illness (30.1%highest severity classification score). Compared to GED visits, PED neuro CCC visits were comprised of individuals who were younger, more likely to have comorbid conditions (32.9% vs 21%, P < 0.001), and technology assistance (65.4% vs. 45.9%) but underwent fewer procedures and had lower ED charges ($2,200 vs $1,520, P < 0.001). Visits to PEDs had lower adjusted odds of critical procedures (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI] 0.62–0.87), transfers (aOR 0.14, 95% CI 0.04–0.56), and mortality (aOR 0.38, 95% CI 0.19–0.75) compared to GEDs.

Conclusion: Care for children with neuro CCCs in a pediatric ED is associated with less resource utilization and lower rates of transfer and mortality. Identifying features of PED care for neuro CCCs could lead to lower costs and mortality for this population.

  • 1 supplemental ZIP

Diagnostic Accuracy of a Handheld Ultrasound vs a Cart-based Model: A Randomized Clinical Trial

Introduction: Numerous studies have demonstrated the accuracy of point-of-care ultrasound (POCUS). Portable, handheld devices have expanded the clinical scope of POCUS at a fraction of the cost of traditional, cart-based models. There is a paucity of data assessing the diagnostic accuracy of portable devices. Our objective in this study was to compare the diagnostic accuracy of a portable device with a cart-based model.

Methods: This was an institutional review board-approved, observational, prospective, randomized clinical trial (NCT05196776) of a convenience sample of adult patients who presented to a university-based health system. Patients who required a cardiac, lung, renal, aorta, or biliary POCUS were randomized to a portable device or to a cart-based model. We hypothesized that the cart-based model would have a 90% diagnostic accuracy vs 70% for the handheld device. To detect a 20% difference, the sample size was calculated to be 98, with 49 patients randomized to each arm. We used standard 2x2 tables to calculate test characteristics with 95% confidence intervals (CI).

Results: A total of 110 patients were enrolled, with 56 patients randomized to the cart-based model and 54 to the handheld device. The sensitivity, specificity, and diagnostic accuracy of the cart-based vs handheld were 77.8% (40–97.2) vs 92.9% (66.1–99.8), 91.5% (79.6–97.6) vs 92.3% (79.1–98.4%), and 89.3% (78.1–96) vs 92.5% (81.8–97.9), respectively.

Conclusion: The diagnostic accuracy of a portable, handheld device is similar to that of a cart-based model.

Stage B Heart Failure Is Ubiquitous in Emergency Patients with Asymptomatic Hypertension

Introduction: Hypertension is the leading risk factor for morbidity and mortality throughout the world and is pervasive in United States emergency departments (ED). This study documents the point prevalence of subclinical heart disease in emergency patients with asymptomatic hypertension.

Method: This was a prospective observational study of ED patients with asymptomatic hypertension conducted at two urban academic EDs that belong to an eight-hospital healthcare organization in New York. Adult (≥18 years of age) English- or Spanish-speaking patients who had an initial blood pressure (BP) ≥160/100 millimeters of mercury (mmHg) and second BP ≥140/90 mm Hg, and pending discharge, were invited to participate in the study. We excluded patients with congestive heart failure, renal insufficiency, and atrial fibrillation, or who were pregnant, a prisoner, cognitively unable to provide informed consent, or experiencing symptoms of hypertension. We assessed echocardiographic evidence of subclinical heart disease (left ventricular hypertrophy, and diastolic and systolic dysfunction).

Results: A total of 53 patients were included in the study; a majority were young (mean 49.5 years old,[SD 14–52]), self-identified as Black or Other (n = 39; 73.5%), and female (n = 30; 56.6%). Mean initial blood pressure was 172/100 mm Hg, and 24 patients (45.3%) self-reported a history of hypertension. Fifty patients completed an echocardiogram. All (100%) had evidence of subclinical heart disease, with 41 (77.4%) displaying left ventricular hypertrophy and 31 (58.5%) diastolic dysfunction. There was a significant relationship between diastolic dysfunction and female gender [x2 (1, n = 53) = 3.98; P = 0.046]; Black or other race [x2 (3, n = 53) = 9.138; P = 0.03] and Hispanic or other ethnicity [x2 (2, n = 53) = 8.03; P = 0.02]. Less than one third of patients demonstrated systolic dysfunction on echocardiogram, and this was more likely to occur in patients with diabetes mellitus [x2 (1, n = 51) = 4.84; P = 0.02].

Conclusion: There is a high probability that Black, Hispanic, and female patients with asymptomatic hypertension are on the continuum for developing overt heart failure. Emergency clinicians should provide individualized care that considers their unique health needs, cultural backgrounds, and social determinants of health.

Characteristics for Low, High and Very High Emergency Department Use for Mental Health Diagnoses from Health Records and Structured Interviews

Introduction: Patients with mental health diagnoses (MHD) are among the most frequent emergency department (ED) users, suggesting the importance of identifying additional factors associated with their ED use frequency. In this study we assessed various patient sociodemographic and clinical characteristics, and service use associated with low ED users (1–3 visits/year), compared to high (4–7) and very high (8+) ED users with MHD.

Methods: Our study was conducted in four large Quebec (Canada) ED networks. A total of 299 patients with MHD were randomly recruited from these ED in 2021–2022. Structured interviews complemented data from network health records, providing extensive data on participant profiles and their quality of care. We used multivariable multinomial logistic regression to compare low ED use to high and very high ED use.

Results: Over a 12-month period, 39% of patients were low ED users, 37% high, and 24% very high ED users. Compared with low ED users, those at greater probability for high or very high ED use exhibited more violent/disturbed behaviors or social problems, chronic physical illnesses, and barriers to unmet needs. Patients previously hospitalized 1–2 times had lower risk of high or very high ED use than those not previously hospitalized. Compared with low ED users, high and very high ED users showed higher prevalence of personality disorders and suicidal behaviors, respectively. Women had greater probability of high ED use than men. Patients living in rental housing had greater probability of being very high ED users than those living in private housing. Using at least 5+ primary care services and being recurrent ED users two years prior to the last year of ED use had increased probability of very high ED use.

Conclusion: Frequency of ED use was associated with complex issues and higher perceived barriers to unmet needs among patients. Very high ED users had more severe recurrent conditions, such as isolation and suicidal behaviors, despite using more primary care services. Results suggested substantial reduction of barriers to care and improvement on both access and continuity of care for these vulnerable patients, integrating crisis resolution and supported housing services. Limited hospitalizations may sometimes be indicated, protecting against ED use.

  • 1 supplemental ZIP

Rapid Cycle Deliberate Practice Training for Simulated Cardiopulmonary Resuscitation in Resident Education

Background: Simulation-based medical education has been used in medical training for decades. Rapid cycle deliberate practice (RCDP) is a novel simulation strategy that uses iterative practice and feedback to achieve skill mastery. To date, there has been minimal evaluation of RCDP vs standard immersive simulation (IS) for the teaching of cardiopulmonary resuscitation to graduate medical education (GME) learners. Our primary objective was to compare the time to performance of Advanced Cardiac Life Support (ACLS) actions between trainees who completed RCDP vs IS.

Methods: This study was a prospective, randomized, controlled curriculum evaluation. A total of 55 postgraduate year-1 internal medicine and emergency medicine residents participated in the study. Residents were randomized to instruction by RCDP (28) or IS (27). Stress and ability were self-assessed before and after training using an anonymous survey that incorporated five-point Likert-type questions. We measured and compared times to initiate critical ACLS actions between the two groups during a subsequent IS.

Results: Prior learner experience between RCDP and IS groups was similar. Times to completion of the first pulse check, chest compression initiation, backboard placement, pad placement, initial rhythm analysis, first defibrillation, epinephrine administration, and antiarrhythmic administration were similar between RCDP and IS groups. However, RCDP groups took less time to complete the pulse check between compression cycles (6.2 vs 14.2 seconds, P = 0.01). Following training, learners in the RCDP and IS groups scored their ability to lead and their levels of anticipated stress similarly (3.43 vs 3.30,(P = 0.77), 2.43 vs. 2.41, P = 0.98, respectively). However, RCDP groups rated their ability to participate in resuscitation more highly (4.50 vs 3.96, P = 0.01). The RCDP groups also reported their realized stress of participating in the event as lower than that of the IS groups (2.36 vs 2.85, P = 0.01).

Conclusion: Rapid cycle deliberate practice learners demonstrated a shorter pulse check duration, reported lower stress levels associated with their experience, and rated their ability to participate in ACLS care more highly than their IS-trained peers. Our results support further investigation of RCDP in other simulation settings.

Pediatric Outcomes of Emergency Medical Services Non-Transport Before and During the COVID-19 Pandemic

Introduction: Pediatric patients account for 6–10% of emergency medical services (EMS) activations in the United States. Approximately 30% of these children are not transported to an emergency department (ED). Adult data in the literature reports higher hospitalization and complications following non-transport. Few studies discuss epidemiology and characteristics of pediatric non-transport; however, data on outcome is limited. Our primary aim was to determine outcomes of non-transported children within our urban EMS system before and during the COVID-19 pandemic. Our secondary objective was to explore reasons for non-transport.

Methods: This was a prospective, descriptive pilot study. We compared EMS data for September 2019 (pre-COVID-19) to September 2020 (pandemic). Included were children aged 0–17 years who activated EMS and did not receive transport to the primary hospital for the EMS capture area. We defined outcomes as repeat EMS activation, ED visits, and hospital admissions, all within 72 hours. Data was obtained via electronic capture. We used descriptive statistics to analyze our data, chi square for categorical data, stepwise logistic regression, and univariate logistic regression to test for association of covariates with non-transport.

Results: There were 1,089 pediatric EMS activations in September 2019 and 780 in September 2020. Non-transport occurred in 633 (58%) in September 2019 and 412 (53%) in September 2020. Emergency medical services was reactivated within 72 hours in the following: 9/633 (1.4%) in 2019; and 5/412 (1.2%) in 2020 (P = 0.77). Visits to the ED occurred in 57/633 (9%) in 2019 and 42/412 (10%) in 2020 (P = 0.53). Hospital admissions occurred in 10/633 (1.5%) in 2019 and 4/412 (0.97%) in 2020 (P = 0.19). One non-transported patient was admitted to the intensive care unit in September 2020 (<1%) and survived. Hispanic ethnicity, age >12 years, and fever were associated with repeat EMS activation. The most common reason for non-transport in both study periods was that the parent felt an ambulance

was not necessary (47%).

Conclusion: In our system, non-transport of pediatric patients occurred in >50% of EMS activations with no significant adverse outcome. Age >12 years, fever, and Hispanic ethnicity were more common in repeated EMS activations. The most common reason for non-transport was parents feeling it was not necessary. Future studies are needed to develop reliable EMS guidelines for pediatric non-transport.

Simulation Improves Emergency Medicine Residents’ Clinical Performance of Aorta Point-of-Care Ultrasound

Purpose: Using point-of-care ultrasound (POCUS) to diagnose abdominal aortic aneurysm (AAA) is an essential skill in emergency medicine (EM). While simulation-based POCUS education is commonly used, the translation to performance in the emergency department (ED) is unknown. We investigated whether adding case-based simulation to an EM residency curriculum was associated with changes in the quantity and quality of aorta POCUS performed by residents in the ED.

Methods: A case-based simulation was introduced to resident didactics at our academic, Level I trauma center. A case of undifferentiated abdominal pain was presented, which required examination of an ultrasound phantom to diagnose an AAA, with a hands-on didactic. We compared the quantity, quality, and descriptive analyses of aorta POCUS performed in the ED during the four months before and after the simulation.

Results: For participating residents (17/32), there was an 86% increase in total studies and an 80%increase in clinical studies. On an opportunity-adjusted, per-resident basis, there was no significant difference in median total scans per 100 shifts (4.4 [interquartile range (IQR) 0–15.8 vs 8.3 [IQR] 3.3–23.6, P = 0.21) or average total quality scores (3.2 ± 0.6 vs 3.2 ± 0.5, P = 0.92). The total number of limited or inadequate studies decreased (43% vs 19%, P = 0.02), and the proportion of scans submitted by interns increased (7% vs 54%, P =<.001).

Conclusion: After simulation training, aorta POCUS was performed more frequently, and ED interns contributed a higher proportion of scans. While there was no improvement in quantity or quality scores on a per-resident basis, there were significantly fewer incomplete or limited scans.

Development and Validation of a Scoring Rubric for Editorial Evaluation of Peer-review Quality: A Pilot Study

Introduction: Despite the importance of peer review to publications, there is no generally accepted approach for editorial evaluation of a peer review’s value to a journal editor’s decision-making. The graduate medical education editors of the Western Journal of Emergency Medicine Special Issue in Educational Research & Practice (Special Issue) developed and studied the holistic editor’s scoring rubric (HESR) with the objective of assessing the quality of a review and an emphasis on the degree to which it informs a holistic appreciation for the submission under consideration.

Methods: Using peer-review guidelines from several journals, the Special Issue’s editors formulated the rubric as descriptions of peer reviews of varying degree of quality from the ideal to the unacceptable. Once a review was assessed by each editor using the rubric, the score was submitted to a third party for blinding purposes. We compared the performance of the new rubric to a previously used semantic differential scale instrument. Kane’s validity framework guided the evaluation of the new scoring rubric around three basic assumptions: improved distribution of scores; relative consistency rather than absolute inter-rater reliability across editors; and statistical evidence that editors valued peer reviews that contributed most to their decision-making.

Results: Ninety peer reviews were the subject of this study, all were assessed by two editors. Compared to the highly skewed distribution of the prior rating scale, the distribution of the new scoring rubric was bell shaped and demonstrated full use of the rubric scale. Absolute agreement between editors was low to moderate, while relative consistency between editor’s rubric ratings was high. Finally, we showed that recommendations of higher rated peer reviews were more likely to concur with the editor’s formal decision.

Conclusion: Early evidence regarding the HESR supports the use of this instrument in determining the quality of peer reviews as well as its relative importance in informing editorial decision-making.

  • 3 supplemental ZIPs

User Experience of Access to Sexual Assault Nurse Examiner and Emergency Contraception in Emergency Departments in the United States: A National Survey

Background: Despite the prevalence of sexual assault presentations to emergency departments (ED) in the United States, current access to sexual assault nurse examiners (SANE) and emergency contraception (EC) in EDs is unknown.

Methods: In this study we employed a “secret shopper,” cross-sectional telephonic survey. A team attempted phone contact with a representative sample of EDs and asked respondents about the availability of SANEs and EC in their ED. Reported availability was correlated with variables including region, urban/rural status, hospital size, faith affiliation, academic affiliation, and existence of legislative requirements to offer EC.

Results: Over a two-month period in 2019, 1,046 calls to hospitals were attempted and 960 were completed (91.7% response rate). Of the 4,360 eligible hospitals listed in a federal database, 960 (22.0%) were contacted. Access to SANEs and EC were reported to be available in 48.9% (95%confidence interval [CI] 45.5–52.0) and 42.5% (95% CI 39.4–45.7) of hospitals, respectively. Access to EC was positively correlated with SANE availability. The EDs reporting SANE and EC availability were more likely to be large, rural, and affiliated with an academic institution. Those reporting access to EC were more likely to be in the Northeast and in states with legislative requirements to offer EC.

Conclusion: Our results suggest that perceived access to sexual assault services and emergency contraception in EDs in the United States remains poor with regional and legislative disparities. Results suggest disparities in perceived access to EC and SANE in the ED, which have implications for improving ED practices regarding care of sexual assault victims.

Education Special Issue - Brief Research Report (Limit 1500 words)

Staffing Patterns of Non-ACGME Fellowships with 4-Year Residency Programs: A National Survey

Introduction: Emergency medicine (EM) is one of few specialties with variable training lengths. Hiring a three-year graduate to continue fellowship training in a department that supports a four-year residency program can lead to conflicts around resident supervision. We sought to understand hiring and clinical supervision, or staffing, patterns of non-Accreditation Council for Graduate Medical Education (ACGME) fellowships hosted at institutions supporting four-year residency programs.

Methods: We performed a web-based, cross-sectional survey of non-ACGME fellowship directors (FD) hosted at institutions supporting four-year EM residency programs. We calculated descriptive statistics. Our primary outcome was the proportion of programs with four-year EM residencies that hire non-ACGME fellows graduating from three-year EM residencies.

Results: Of 119 eligible FDs, 88 (74%) completed the survey. Seventy FDs (80%) indicated that they hire graduates of three-year residencies. Fifty-six (80%) indicated that three-year graduates supervise residents. Most FDs (74%) indicated no additional requirements exist to supervise residents outside of being hired as faculty. The FDs cited department policy, concerns about quality and length of training, and resident complaints as reasons for not hiring three-year graduates. A majority (10/18, 56%) noted that not hiring fellows from three-year programs negatively impacts recruitment and gives them access to a smaller applicant pool.

Conclusion: Most non-ACGME fellowships at institutions with four-year EM programs recruit three-year graduates and allow them to supervise residents. This survey provides programs information on how comparable fellowships recruit and staff their departments, which may inform policies that fit the needs of their learners, the fellowship, and the department.

  • 2 supplemental ZIPs

Changes in Residency Applicant Cancellation Patterns with Virtual Interviews: A Single-site Analysis

Background: Residency programs transitioned to primarily virtual interviews due to the COVID-19 pandemic. This shift raised questions regarding expectations and patterns of applicant cancellation timeliness. The purpose of this study was to examine changes in applicant cancellations after transitioning to virtual interviews.


Methods: This was a retrospective cohort study of interview data from a three-year emergency medicine residency at a tertiary-care academic medical center. Using archived data from Interview Broker, we examined scheduling patterns between one in-person (2019–2020) and two virtual interview cohorts (2020–2021 and 2021–2022). Our outcomes were the overall cancellation rates relative to interview slots as well as the proportion of cancellations that occurred within 7 or 14 days of the interview date.


Results: There were 453 interview slots and 568 applicants invited. Overall, applicants canceled 17.1%of scheduled interviews. Compared with in-person interviews, applicants canceled significantly fewer virtual interviews (in person: 40/128 (31.3%), virtual year 1: 22/178 (12.4%), virtual year 2: 15/143 (10.5%), P = 0.001). Conversely, applicants canceled significantly more virtual interviews within both the 14-day threshold (in person: 8/40 (20%), virtual year 1: 12/22 (55.5%), virtual year 2: 12/15 (80%), P < 0.001) and the 7-day threshold (in person: 0/40 (0%), virtual year 1: 3/22 (13.6%), virtual year 2: 4/15 (26.7%), P = 0.004).


Conclusion: While limited, at our site, changing to a virtual interview format correlated with fewer cancellations overall. The proportion of cancellations within 14 days was much higher during virtual interview seasons, with most cancellations occurring during that time frame. Additional studies are needed to determine the effects of cancellation patterns on emergency medicine recruitment.

Virtual Interviews and the Pediatric Emergency Medicine Match Geography: A National Survey

Introduction: Virtual interviews (VI) are now a permanent part of pediatric emergency medicine (PEM) recruitment, especially given the cost and equity advantages. Yet inability to visit programs in person can impact decision-making, leading applicants to apply to more programs. Moreover, the cost advantages of VI may encourage applicants to apply to programs farther away than they might otherwise have been willing or able to travel. This could create unnecessary strain on programs. We conducted this study to determine whether PEM fellowship applicants would apply to a larger number of programs and in different geographic patterns with VI (2020 and 2021) as compared to in-person interviews (2018 and 2019).

Methods: We conducted an anonymous national survey of all PEM fellows comparing two cohorts: current fellows who interviewed in-person (applied in 2018/2019) and fellows who underwent VIs in 2020/ 2021 (current fellows and those recently matched in 2021). The study took place in March–April 2022. Questions focused on geographic considerations during interviews and the match. We used descriptive statistics, chi-square and t-tests for analysis.

Results: Overall response rate was 42% (231/550); 32% (n = 74) interviewed in person and 68% (n = 157) virtually. Fellows applied to a median of 4/6 geographic regions (interquartile range 2, 5). Most applied for fellowship both in the same region as residency (216, 93%) and outside (192, 83%). Only the Pacific region saw a statistically significant increase in applicants during VI (59.9% vs 43.2%, P = 0.02). There was no statistical difference in the number of programs applied to during in-person vs VI (mean difference (95% confidence interval 0.72, −2.8 – 4.2). A majority matched in their preferred state both during VI (60.4%) and in-person interviews (65.7%). The difference was not statistically significant (P = 0.45).

Conclusion: While more PEM fellowship applicants applied outside the geographic area where their residency was and to the Pacific region, there was no overall increase in the number of programs or geographic areas PEM applicants applied to during VI as compared to in-person interview seasons. As this was the first two years of VI, ongoing data collection will further identify trends and the impactof VI.

  • 2 supplemental ZIPs

Brief Research Report (Limit 1500 words)

Enroller Experience and Parental Familiarity of Disease Influence Participation in a Pediatric Trial

Introduction: Acquiring parental consent is critical to pediatric clinical research, especially in interventional trials. In this study we investigated demographic, clinical, and environmental factors associated with likelihood of parental permission for enrollment in a study of therapies for diabetic ketoacidosis (DKA) in children. Methods: We analyzed data from patients and parents who were approached for enrollment in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) trial at one major participating center. We determined the influence of various factors on patient enrollment, including gender, age, distance from home to hospital, insurance status, known vs new onset of diabetes, glycemic control (hemoglobin A1c), DKA severity, gender of the enroller, experience of the enroller, and time of enrollment. Patients whose parents consented to participate were compared to those who declined participation using bivariable and multivariable analyses controlling for the enroller. Results: A total of 250 patient/parent dyads were approached; 177 (71%) agreed to participate, and 73 (29%) declined. Parents of patients with previous episodes of DKA agreed to enroll more frequently than those with a first DKA episode (94.3% for patients with 1-2 previous DKA episodes, 92.3% for > 2 previous episodes, vs 64.9% for new onset diabetes and 63.2% previously diagnosed but no previous DKA). Participation was also more likely with more experienced enrollers (odds ratio [95% confidence interval] of participation for an enroller with more than two years’ experience vs less than two years: 2.46 [1.53, 3.97]). After adjusting for demographic and clinical factors, significant associations between participation and both DKA history and enroller experience remained. Patient age, gender, distance of home from hospital, glycemic control, insurance status, and measures of DKA severity were not associated with likelihood of participation. Conclusion: Familiarity with the disease process (previously diagnosed diabetes and previous experience with DKA) and experience of the enroller favorably influenced the likelihood of parental permission for enrollment in a study of DKA in children.

Bridging the Gap: Evaluation of an Electrocardiogram Curriculum for Advanced Practice Clinicians

Background: Training programs for advanced practice providers (APP) often have significant variability in their curriculum, including electrocardiogram (ECG) education. Despite limitations in formal ECG training, APPs in the emergency department (ED) may be the first practitioner to interpret an ECG. Foundations of Emergency Medicine (FoEM) offers free, open-access curricula that are widely used for resident education. We sought to improve APP ECG interpretation skills by implementing the FoEM ECG I course.

Methods: This was a single-site, pre- and post-intervention study of 23 APPs at our high-acuity, urban ED. In the fall of 2020, APP learners enrolled in a FoEM ECG I course led by faculty and senior resident instructors. The course consisted of six virtual, small-group, active-learning ECG workshops. Participants completed a 15-question multiple-choice test before, immediately after, and six months post-intervention to quantify knowledge acquisition. Additionally, a pre- and post-intervention knowledge, attitudes, and practices survey was administered on ECG interpretation skills and to evaluate the course. We evaluated change in ECG knowledge scores using a Wilcoxon signed-rank test. Changes in self-assessed knowledge were evaluated using an ordinal logistic mixed-effects regression.

Results: A total of 23 APPs enrolled in the course. Knowledge assessments showed APPs improved from the pre-test (median 9/15, interquartile range [IQR] 7–11) to the post-test (median 12/15, IQR 10–13; P = 0.001). Test scores did not significantly change from the post-test to the delayed post-test (median 12/15, IQR 12–13; P = 0.30). Respondents’ subjective rating of their skill did not significantly change (P = 0.06). Respondents reported no change in their likelihood of approaching an attending when uncertain of the correct interpretation of an ECG (P = 0.16). Overall, 91% were satisfied with the course and 96% agreed that the course difficulty was appropriate.

Conclusion: The FoEM ECG course provided a standardized curriculum that improved APP knowledge for interpreting ECGs. Despite this, the course did not alter APPs’ willingness to approach physicians for guidance with interpretation of abnormal ECGs. These findings may inform expansion of this concept for other programs who desire formalized APP ECG education.

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Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans

Introduction: A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED.

Methods: We performed a retrospective analysis of all CT imaging completed at an urban, tertiary care ED from May 1–July 31, 2021. During that period, 5,685 CTs were performed on 4,344 patients, with a median time from CT order to completion of 108 minutes (Quartile 1 [Q1]: 57 minutes, Quartile 3 [Q3]: 182 minutes, interquartile range [IQR]: 125 minutes). Outliers were defined as studies that took longer than 369 minutes to complete (Q3 + 1.5 × IQR). We systematically reviewed outlier charts to determine factors associated with delay and identified five factors: behaviorally non-compliant or medically unstable patients; intravenous (IV) line issues; contrast allergies; glomerular filtration rate (GFR) concerns; and delays related to imaging protocol (eg, need for IV contrast, request for oral and/or rectal contrast). We calculated confidence intervals (CI) using the modified Wald method. Inter-rater reliability was assessed with a kappa analysis.

Results: We identified a total of 182 outliers (4.2% of total patients). Fifteen (8.2%) cases were excluded for CT time-stamp inconsistencies. Of the 167 outliers analyzed, 38 delays (22.8%, 95% confidence interval [CI] 17.0–29.7) were due to behaviorally non-compliant or medically unstable patients; 30 (18.0%, 95% CI 12.8–24.5) were due to IV issues; 24 (14.4%, 95% CI 9.8–20.6) were due to contrast allergies; 21 (12.6%, 95% CI 8.3–18.5) were due to GFR concerns; and 20 (12.0%, 95% CI 7.8–17.9) were related to imaging study protocols. The cause of the delay was unknown in 55 cases (32.9%, 95%CI 26.3–40.4).

Conclusion: Our review identified both modifiable and non-modifiable factors associated with significantly delayed CT in the ED. Patient factors such as behavior, allergies, and medical acuity cannot be controlled. However, institutional policies regarding difficult IV access, contrast administration in low GFR settings, and study protocols may be modified, capturing up to 42.6% of outliers.

Novel Scoring Scale for Quality Assessment of Lung Ultrasound in the Emergency Department

Introduction: The use of a reliable scoring system for quality assessment (QA) is imperative to limit inconsistencies in measuring ultrasound acquisition skills. The current grading scale used for QA endorsed by the American College of Emergency Physicians (ACEP) is non-specific, applies irrespective of the type of study performed, and has not been rigorously validated. Our goal in this study was to determine whether a succinct, organ-specific grading scale designed for lung-specific QA would be more precise with better interobserver agreement.

Methods: This was a prospective validation study of an objective QA scale for lung ultrasound (LUS) in the emergency department. We identified the first 100 LUS performed in normal clinical practice in the year 2020. Four reviewers at an urban academic center who were either emergency ultrasound fellowship-trained or current fellows with at least six months of QA experience scored each study, resulting in a total of 400. The primary outcome was the level of agreement between the reviewers. Our secondary outcome was the variability of the scores given to the studies. For the agreement between reviewers, we computed the intraclass correlation coefficient (ICC) based on a two-way random-effect model with a single rater for each grading scale. We generated 10,000 bootstrapped ICCs to construct 95% confidence intervals (CI) for both grading systems. A two-sided one-sample t-test was used to determine whether there were differences in the bootstrapped ICCs between the two grading systems.

Results: The ICC between reviewers was 0.552 (95% CI 0.40–0.68) for the ACEP grading scale and 0.703 (95% CI 0.59–0.79) for the novel grading scale (P < 0.001), indicating significantly more interobserver agreement using the novel scale compared to the ACEP scale. The variance of scores was similar (0.93 and 0.92 for the novel and ACEP scales, respectively).

Conclusion: We found an increased interobserver agreement between reviewers when using the novel, organ-specific scale when compared with the ACEP grading scale. Increased consistency in feedback based on objective criteria directed to the specific, targeted organ provides an opportunity to enhance learner education and satisfaction with their ultrasound education.

Images in Emergency Medicine (Limit 500 words)

Evolving Paralysis after Motor Vehicle Collision

Case Presentation An 85-year-old male presented to the emergency department after a motor vehicle collision and developed progressive neurological deficits.  CT imaging demonstrated epidural thickening from C2-C7, and MRI was notable for a cervicothoracic epidural hematoma.  The patient underwent emergent decompression with a favorable outcome. Discussion Cases of traumatic spinal epidural hematomas are rarely seen in the emergency department.  These are part of a small subset of operative neurological emergencies that benefit from urgent operative intervention.

A Strange Twist

Case presentation. A 16-year-old female presented to the emergency department with a four-day history of right lower quadrant abdominal pain for several hours. The patient was afebrile and physical examination was notable for isolated tenderness in the right lower quadrant. Ultrasound and computed tomography demonstrated an adnexal cystic structure. Pelvic magnetic resonance imaging was ordered to better characterize the pathology. Discussion. Isolated fallopian tube torsion is an uncommon entity requiring prompt surgical intervention. Recognition and appropriate management are essential.

Nail gun injury of the trachea and spinal cord

Case Presentation A 26-year-old man was impaled by a nail after a nail gun accident. He was fully conscious with weakness and loss of sensation in the extremities. Cervical computed tomography showed a 9-cm long nail penetrating the spinal cord. The nail was removed 6 hours after the incident. The neurological deficits gradually improved, and at the 3-month follow-up, the patient had completely recovered from muscle weakness. Discussion The present case showed a favorable neurological course, which was be attributable to the fact that the cervical spinal cord injury did not involve the corticospinal tracts and anterior horn.

Omental Prolapse Through Vaginal Cuff Dehiscence

ABSTRACT A 31-year old female with a history of laparoscopic assisted vaginal hysterectomy presented by ambulance to the emergency department with acute onset of abdominal pain and a vaginal protrusion which occurred while straining to pass a bowel movement.  Physical examination was notable for a flat but slightly tender abdomen, normal bowel sounds, scant vaginal bleeding, and a 15cm long, blood-tinged mass protruding from the vagina.  A brief and unsuccessful attempt at reduction was made by the emergency physician.  Obstetrics and Gynecology was consulted, and the patient was taken to the operating DIAGNOSIS Omental prolapse through vaginal cuff dehiscence .  Following vaginal hysterectomy, the vaginal cuff is closed surgically1.  Occasionally, this site can dehisce, allowing abdominal contents to enter the vagina or protrude through the vaginal canal. Vaginal cuff dehiscence is estimated to have a rate of 0.39%. It is more commonly seen after total laparoscopic hysterectomy (1.35%) compared with laparoscopic-assisted vaginal hysterectomy, (0.28%)2. Risk factors include trauma from sexual intercourse, repetitive Valsalva maneuvers, smoking, malnutrition, anemia, diabetes, immunosuppression, and corticosteroid use2.  Cases typically present as vaginal spotting or post-coital bleeding, and occasionally pelvic pressure or protrusion2.  Most cases occur within weeks to months after the procedure, but some can present years later. Patients are at risk for infection due to exposure of peritoneal contents to vaginal and skin flora.  Management includes administration of broad-spectrum antibiotics.  Partial dehiscence can be managed with rest, but large dehiscence is usually managed surgically. This case highlights the importance of the pelvic exam in patients with vaginal bleeding and abdominal pain, and care should be taken to not mistake protruding omental tissue for prolapsed vaginal mucosa.   REFERENCES 1.     Binz NM, et al. Complications of Gynecologic Procedures. Emergency Medicine: A Comprehensive Study Guide , 9e. McGraw Hill; 2020. 2.     Clarke-Pearson D, & Geller E. Complications of Hysterectomy.  Obstetrics & Gynecology, 121 (3), 654-673; 2013.

Table of Contents

Articles in Press

Once articles have been accepted for publication but have not yet been assigned to an issue, we place them here.

Case Report (Limit 1750 words)

Pheochromocytoma: A Diagnosis Made More Difficult in the COVID-19 Era

ABSTRACT INTRODUCTION Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that secrete catecholamines. Symptoms of these tumors are related directly to catecholamine excess but can be intermittent and easily misattributed to other more common pathologies.  Identification in the Emergency Department is inherently difficult.  In the COVID-19 pandemic physicians have had to account for both the disease itself as well as associated increased prevalence of cardiac, pulmonary, and vascular complications. Such shifting of disease prevalence arguably makes rarer diseases, like pheochromocytoma, less likely to be recognized. CASE REPORT We report a case of pheochromocytoma discovered in the emergency department in a patient who presented with fatigue, tachycardia, and diaphoresis. The differential included pulmonary embolism, cardiomyopathy, congestive heart failure and infectious causes.  A broad workup was begun including serology, electrocardiogram, Computed Tomography Angiogram (CTA), and COVID-19 testing. This patient was evaluated in the winter of 2020, the local height of the COVID-19 pandemic, and was found to be positive.  A tiny retroperitoneal tumor was reported on CTA as “incidental” in the setting of multifocal pneumonia from COVID-19 infection. But further history taking discovered many years of intermittent symptoms and suggested that the tumor may be more contributory to the patient’s presentation. Subsequent MRI and surgical pathology confirmed the pheochromocytoma. CONCLUSION This case presentation highlights the importance of careful history taking, keeping a broad differential, and examining incidental findings in the context of the patient’s presentation.

Case Report: Pancreatitis, with a Normal Serum Lipase, as a Rare Post-Esophagogastroduodenoscopy Complication

Pancreatitis after Esophagogastroduodenoscopy (EGD) is not a common occurrence, particularly in the setting of a normal serum lipase. The lack of commonality may delay diagnosis and treatment in some patients presenting to the emergency department with abdominal pain after an otherwise uncomplicated procedure. This case report serves to bring awareness to this potential procedural complication and the possibility of pancreatitis with a normal serum lipase.

Takotsubo cardiomyopathy following traumatic hand amputation

Takotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease. We describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point of care ultrasound (POCUS) associated with traumatic hand amputation.  The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition ten days later. Emergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.

Hypotension unresponsive to fluid resuscitation: A Case Report

Introduction: Iron deficiency anemia is commonly seen in the emergency department, and the cause can be complex and variable.  Chronic lice infestation as the etiology of severe iron deficiency anemia has not been well studied and is mostly limited to case reports. Case Report: We present a case of a female without known medical history who presented to the emergency department for generalized weakness and was found to have severe anemia in the setting of chronic lice infestation.  This patient’s hypotension was initially unresponsive to fluid resuscitation which allowed for consideration of other etiologies of this patient’s presentation and an unusual case of severe anemia. Conclusion: Severe and chronic pediculosis can cause chronic blood loss and be an unusual and rare cause of iron deficiency anemia.  In the setting of anemia and hypotension unresponsive to fluid resuscitation, consideration should be given to early PRBC transfusion and subsequent investigation of causes of severe anemia.

Occipital Lobe Status Epilepticus; A Rare Stroke Mimic with Novel Imaging Findings: A Case Report

Introduction This case reviews a patient who presented to the emergency department (ED) with homonymous hemianopsia, a rare manifestation of partial status epilepticus of the occipital lobe.  Her initial brain computerized axial tomographic (CT) perfusion scan and magnetic resonance imaging (MRI) revealed novel findings associated with this diagnosis. Case Report A 70-year-old female presented to our ED with left visual field hemianopsia, dyskinesia, dysmetria and facial droop . Her initial diagnosis was left posterior fossa circulation cerebrovascular accident.  However, her neuroimaging indicated hypervascularity of the left occipital lobe without evidence of infarct or structural lesion. A cerebral angiogram excluded arterio-venous malformation.  Subsequently, an electroencephalogram showed left occipital lobe status epilepticus.   Conclusion Hemianopsia is a rare presentation of partial status epilepticus mimicking stroke.  Hypervascularity seen on advanced neuroimaging may have suggested this diagnosis on initial ED evaluation.