Current Issue: Volume 17 Issue 3 Archives - The Western Journal of Emergency Medicine

Endemic Infections

Identify-Isolate-Inform: A Tool for Initial Detection and Management of Zika Virus Patients in the Emergency Department

Volume 17, Issue 3, May 2016
Kristi L. Koenig, MD et al.

First isolated in 1947 from a monkey in the Zika forest in Uganda, and from mosquitoes in the same forest the following year, Zika virus has gained international attention due to concerns for infection in pregnant women potentially causing fetal microcephaly. More than one million people have been infected since the appearance of the virus in Brazil in 2015. Approximately 80% of infected patients are asymptomatic. An association with microcephaly and other birth defects as well as Guillain-Barre Syndrome has led to a World Health Organization declaration of Zika virus as a Public Health Emergency of International Concern in February 2016. Zika virus is a vector-borne disease transmitted primarily by the Aedes aegypti mosquito. Male to female sexual transmission has been reported and there is potential for transmission via blood transfusions. After an incubation period of 2–7 days, symptomatic patients develop rapid onset fever, maculopapular rash, arthralgia, and conjunctivitis, often associated with headache and myalgias. Emergency department (ED) personnel must be prepared to address concerns from patients presenting with symptoms consistent with acute Zika virus infection, especially those who are pregnant or planning travel to Zika-endemic regions, as well as those women planning to become pregnant and their partners. The identify-isolate-inform (3I) tool, originally conceived for initial detection and management of Ebola virus disease patients in the ED, and later adjusted for measles and Middle East Respiratory Syndrome, can be adapted for real-time use for any emerging infectious disease. This paper reports a modification of the 3I tool for initial detection and management of patients under investigation for Zika virus. Following an assessment of epidemiologic risk, including travel to countries with mosquitoes that transmit Zika virus, patients are further investigated if clinically indicated. If after a rapid evaluation, Zika or other arthropod-borne diseases are the only concern, isolation (contact, droplet, airborne) is unnecessary. Zika is a reportable disease and thus appropriate health authorities must be notified. The modified 3I tool will facilitate rapid analysis and triggering of appropriate actions for patients presenting to the ED at risk for Zika.

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Societal Impact on Emergency Care

Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements

Volume 17, Issue 3, May 2016
Nadia Zuabi, BS et al.

Introduction: The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 was enacted
to prevent hospitals from “dumping” or refusing service to patients for financial reasons. The statute
prohibits discrimination of emergency department (ED) patients for any reason. The Office of the
Inspector General (OIG) of the Department of Health and Human Services enforces the statute.
The objective of this study is to determine the scope, cost, frequency and most common allegations
leading to monetary settlement against hospitals and physicians for patient dumping.
Methods: Review of OIG investigation archives in May 2015, including cases settled from
2002-2015 (https://oig.hhs.gov/fraud/enforcement/cmp/patient_dumping.asp).
Results: There were 192 settlements (14 per year average for 4000+ hospitals in the USA).
Fines against hospitals and physicians totaled $6,357,000 (averages $33,435 and $25,625
respectively); 184/192 (95.8%, $6,152,000) settlements were against hospitals and eight against
physicians ($205,000). Most common settlements were for failing to screen 144/192 (75%) and
stabilize 82/192 (42.7%) for emergency medical conditions (EMC). There were 22 (11.5%) cases
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of inappropriate transfer and 22 (11.5%) more where the hospital failed to transfer. Hospitals failed
to accept an appropriate transfer in 25 (13.0%) cases. Patients were turned away from hospitals
for insurance/financial status in 30 (15.6%) cases. There were 13 (6.8%) violations for patients in
active labor. In 12 (6.3%) cases, the on-call physician refused to see the patient, and in 28 (14.6%)
cases the patient was inappropriately discharged. Although loss of Medicare/Medicaid funding is
an additional possible penalty, there were no disclosures of exclusion of hospitals from federal
funding. There were 6,035 CMS investigations during this time period, with 2,436 found to have
merit as EMTALA violations (40.4%). However, only 192/6,035 (3.2%) actually resulted in OIG
settlements. The proportion of CMS-certified EMTALA violations that resulted in OIG settlements
was 7.9% (192/2,436).
Conclusion: Of 192 hospital and physician settlements with the OIG from 2002-15, most were
for failing to provide screening (75%) and stabilization (42%) to patients with EMCs. The reason
for patient “dumping” was due to insurance or financial status in 15.6% of settlements. The vast
majority of penalties were to hospitals (95% of cases and 97% of payments). Forty percent of
investigations found EMTALA violations, but only 3% of investigations triggered fines.

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Treatment Protocol Assessment

Prospective Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk Elderly Fall Patients

Volume 17, Issue 3, May 2016
John Tran, MD et al.

Introduction: The National Emergency X-radiography Utilization Study (NEXUS) criteria are used
extensively in emergency departments to rule out C-spine injuries (CSI) in the general population.
Although the NEXUS validation set included 2,943 elderly patients, multiple case reports and the
Canadian C-Spine Rules question the validity of applying NEXUS to geriatric populations. The
objective of this study was to validate a modified NEXUS criteria in a low-risk elderly fall population
with two changes: a modified definition for distracting injury and the definition of normal mentation.
Methods: This is a prospective, observational cohort study of geriatric fall patients who presented
to a Level I trauma center and were not triaged to the trauma bay. Providers enrolled nonintoxicated
patients at baseline mental status with no lateralizing neurologic deficits. They
recorded midline neck tenderness, signs of trauma, and presence of other distracting injury.
Results: We enrolled 800 patients. One patient fall event was excluded due to duplicate
enrollment, and four were lost to follow up, leaving 795 for analysis. Average age was 83.6 (range
65-101). The numbers in parenthesis after the negative predictive value represent confidence
interval. There were 11 (1.4%) cervical spine injuries. One hundred seventeen patients had midline
tenderness and seven of these had CSI; 366 patients had signs of trauma to the face/neck, and
10 of these patients had CSI. Using signs of trauma to the head/neck as the only distracting injury
and baseline mental status as normal alertness, the modified NEXUS criteria was 100% sensitive
(CI [67.9-100]) with a negative predictive value of 100 (98.7-100).
Conclusion: Our study suggests that a modified NEXUS criteria can be safely applied to lowrisk
elderly falls.

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Practice Variability

Quality Improvement Initiative to Decrease Variability of Emergency Physician Opioid Analgesic Prescribing

Volume 17, Issue 3, May 2016
John Burton, MD, et al.

Introduction: Addressing pain is a crucial aspect of emergency medicine. Prescription opioids
are commonly prescribed for moderate to severe pain in the emergency department (ED);
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unfortunately, prescribing practices are variable. High variability of opioid prescribing decisions
suggests a lack of consensus and an opportunity to improve care. This quality improvement (QI)
initiative aimed to reduce variability in ED opioid analgesic prescribing.
Methods: We evaluated the impact of a three-part QI initiative on ED opioid prescribing by
physicians at seven sites. Stage 1: Retrospective baseline period (nine months). Stage 2:
Physicians were informed that opioid prescribing information would be prospectively collected and
feedback on their prescribing and that of the group would be shared at the end of the stage (three
months). Stage 3: After physicians received their individual opioid prescribing data with blinded
comparison to the group means (from Stage 2) they were informed that individual prescribing
data would be unblinded and shared with the group after three months. The primary outcome was
variability of the standard error of the mean and standard deviation of the opioid prescribing rate
(defined as number of patients discharged with an opioid divided by total number of discharges
for each provider). Secondary observations included mean quantity of pills per opioid prescription,
and overall frequency of opioid prescribing.
Results: The study group included 47 physicians with 149,884 ED patient encounters. The
variability in prescribing decreased through each stage of the initiative as represented by the
distributions for the opioid prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46%
reduction, p<0.01), and Stage 3 mean 8% (60% reduction, p<0.01). The mean quantity of pills
prescribed per prescription was 16 pills in Stage 1, 14 pills in Stage 2 (18% reduction, p<0.01),
and 13 pills in Stage 3 (18% reduction, p<0.01). The group mean prescribing rate also decreased
through each stage: 20% in Stage 1, 13% in Stage 2 (46% reduction, p<0.01), and 8% in Stage
3 (60% reduction, p<0.01).
Conclusion: ED physician opioid prescribing variability can be decreased through the systematic
application of sharing of peer prescribing rates and prescriber specific normative feedback.

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Critical Care

Anticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016

Volume 17, Issue 3, May 2016
Steve Christos, DO, MS et al.

Anticoagulation is the mainstay of medical treatment, prevention and reduction of recurrent venous thromboembolism, stroke prevention in patients with non-valvular atrial fibrillation, and it reduces the incidence of recurrent ischemic events and death in patients with acute coronary syndrome. Options for anticoagulation have been steadily increasing. Physicians need to be aware of the clinical profile of anticoagulation agents, reversal agents and treatment strategies in the face of major bleeding.

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Critical Care

Academic Emergency Medicine Physicians’ Knowledge of Mechanical Ventilation

Volume 13, Issue 3, May 2016
Susan R. Wilcox, MD et al.

Introduction: Although emergency physicians frequently intubate patients, management of
mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical
practice. The objective of this study was to quantify EM attendings’ education, experience, and
knowledge regarding mechanical ventilation in the emergency department.
Methods: We developed a survey of academic EM attendings’ educational experiences with
ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key
teaching hospitals for seven EM residency training programs in the northeastern United States
were invited to participate in this survey study. We performed correlation and regression analyses
to evaluate the relationship between attendings’ scores on the assessment instrument and their
training, education, and comfort with ventilation.
Results: Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5%
reported receiving three or fewer hours of ventilation-related education from EM sources over the
past year and 98 (46%) reported receiving between 0-1 hour of education. The overall correct
response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors
associated with a higher score were completion of an EM residency, prior emphasis on mechanical
ventilation during one’s own residency, working in a setting where an emergency physician bears
primary responsibility for ventilator management, and level of comfort with managing ventilated
patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM
management of ventilation, as well as hours of education.
Conclusion: EM attendings report caring for mechanically ventilated patients frequently, but most
receive fewer than three educational hours a year on mechanical ventilation, and nearly half
receive 0-1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is
most strongly correlated with their self-reported comfort with mechanical ventilation.

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Anti-N-Methyl-D-Aspartate Receptor Encephalitis, an Underappreciated Disease in the Emergency Department

Volume 17, Issue 3, May 2016
Daniel R. Lasoff, MD et al.

Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis is a novel disease discovered within
the past 10 years. Antibodies directed at the NMDAR cause the patient to develop a characteristic
syndrome of neuropsychiatric symptoms. Patients go on to develop autonomic dysregulation and
often have prolonged hospitalizations and intensive care unit stays. There is little literature in
the emergency medicine community regarding this disease process, so we report on a case we
encountered in our emergency department to help raise awareness of this disease process.

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ACE-I Angioedema: Accurate Clinical Diagnosis May Prevent Epinephrine-Induced Harm

Volume 17, Issue 3, May 2016
R. Mason Curtis, MD et al.

Introduction: Upper airway angioedema is a life-threatening emergency department (ED)
presentation with increasing incidence. Angiotensin-converting enzyme inhibitor induced
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angioedema (AAE) is a non-mast cell mediated etiology of angioedema. Accurate diagnosis by
clinical examination can optimize patient management and reduce morbidity from inappropriate
treatment with epinephrine. The aim of this study is to describe the incidence of angioedema
subtypes and the management of AAE. We evaluate the appropriateness of treatments and
highlight preventable iatrogenic morbidity.
Methods: We conducted a retrospective chart review of consecutive angioedema patients
presenting to two tertiary care EDs between July 2007 and March 2012.
Results: Of 1,702 medical records screened, 527 were included. The cause of angioedema
was identified in 48.8% (n=257) of cases. The most common identifiable etiology was AAE
(33.1%, n=85), with a 60.0% male predominance. The most common AAE management strategies
included diphenhydramine (63.5%, n=54), corticosteroids (50.6%, n=43) and ranitidine (31.8%,
n=27). Epinephrine was administered in 21.2% (n=18) of AAE patients, five of whom received
repeated doses. Four AAE patients required admission (4.7%) and one required endotracheal
intubation. Epinephrine induced morbidity in two patients, causing myocardial ischemia or
dysrhythmia shortly after administration.
Conclusion: AAE is the most common identifiable etiology of angioedema and can be accurately
diagnosed by physical examination. It is easily confused with anaphylaxis and mismanaged with
antihistamines, corticosteroids and epinephrine. There is little physiologic rationale for epinephrine
use in AAE and much risk. Improved clinical differentiation of mast cell and non-mast cell mediated
angioedema can optimize patient management.

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Case Series of Synthetic Cannabinoid Intoxication from One Toxicology Center

Volume 17, Issue 3, May 2016
Kenneth D. Katz, MD, et al.

Synthetic cannabinoid use has risen at alarming rates. This case series describes 11 patients exposed to the synthetic cannabinoid, MAB-CHMINACA who presented to an emergency department with life-threatening toxicity including obtundation, severe agitation, seizures and death. All patients required sedatives for agitation, nine required endotracheal intubation, three experienced seizures, and one developed hyperthermia. One developed anoxic brain injury, rhabdomyolysis and died. A significant number were pediatric patients. The mainstay of treatment was aggressive sedation and respiratory support. Synthetic cannabinoids pose a major public health risk. Emergency physicians must be aware of their clinical presentation, diagnosis and treatment.

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Gender Differences in Emergency Department Visits and Detox Referrals for Illicit and Nonmedical Use of Opioids

Volume 17, Issue 3, May 2016
Hyeon-Ju Ryoo, BA et al.

Introduction: Visits to the emergency department (ED) for use of illicit drugs and opioids have increased in the past decade. In the ED, little is known about how gender may play a role in drug-related visits and referrals to treatment. This study performs gender-based comparison analyses of drug-related ED visits nationwide.
Methods: We performed a cross-sectional analysis with data collected from 2004 to 2011 by the Drug Abuse Warning Network (DAWN). All data were coded to capture major drug categories and opioids. We used logistic regression models to find associations between gender and odds of referral to treatment programs. A second set of models were controlled for patient “seeking detox,” or patient explicitly requesting for detox referral.
Results: Of the 27.9 million ED visits related to drug use in the DAWN database, visits by men were 2.69 times more likely to involve illicit drugs than visits by women (95% CI [2.56, 2.80]). Men were more likely than women to be referred to detox programs for any illicit drugs (OR 1.12, 95% CI [1.02–1.22]), for each of the major illicit drugs (e.g., cocaine: OR 1.27, 95% CI [1.15–1.40]), and for prescription opioids (OR 1.30, 95% CI [1.17–1.43]). This significant association prevailed after controlling for “seeking detox.”
Conclusion: Women are less likely to receive referrals to detox programs than men when presenting to the ED regardless of whether they are “seeking detox.” Future research may help determine the cause for this gender-based difference and its significance for healthcare costs and health outcomes.

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Variations in Substance Use Prevalence Estimates and Need for Interventions among Adult Emergency Department Patients Based on Different Screening Strategies Using the ASSIST

Volume 17, Issue 3, May 2016
Roland C. Merchant, MD, MPH, ScD

Introduction: Among adult emergency department (ED) patients, we sought to examine how estimates of substance use prevalence and the need for interventions can differ, based on the type of screening and assessment strategies employed.
Methods: We estimated the prevalence of substance use and the need for interventions using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in a secondary analysis of data from two cross-sectional studies using random samples of English- or Spanish-speaking 18–64-year-old ED patients. In addition, the test performance characteristics of three simplified screening strategies consisting of selected questions from the ASSIST (lifetime use, past three-month use, and past three-month frequency of use) to identify patients in need of a possible intervention were compared against using the full ASSIST.
Results: Of 6,432 adult ED patients, the median age was 37 years-old, 56.6% were female, and 61.6% were white. Estimated substance use prevalence among this population differed by how it was measured (lifetime use, past three-month use, past three-month frequency of use, or need for interventions). As compared to using the full ASSIST, the predictive value and accuracy to identify patients in need of any intervention was best for a simplified strategy asking about past three-month substance use. A strategy asking about daily/near-daily use was better in identifying patients needing intensive interventions. However, some patients needing interventions were missed when using these simplified strategies.
Conclusion: Substance use prevalence estimates and identification of ED patients needing interventions differ by screening strategies used. EDs should carefully select strategies to identify patients in need of substance use interventions.

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Undertriage of Trauma-Related Deaths in U.S. Emergency Departments

Volume 17, Issue 3, May 2016
Jenelle Holst, MD. et al.

Introduction: Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers.
Methods: This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression.
Results: We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0–46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1–37.1]) and most rural ED visits (86.4%, 95% CI [81.5–90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70–0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1–40,999) (OR 0.54, 95% CI [0.43–0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71–1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38–0.66]).
Conclusion: We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.

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Vital Signs Predict Rapid-Response Team Activation Within Twelve Hours of Emergency Department Admission

Volume 17, Issue 3, May 2016
James Walston, MD. et al.

Introduction: Rapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration marked by decline in vital signs. Traditionally emergency department (ED) disposition is partially based on the patients’ vital signs (VS) at the time of hospital admission. We aimed to identify which patients will have RRT activation within 12 hours of admission based on their ED VS, and if their outcomes differed.
Methods: We conducted a case-control study of patients presenting from January 2009 to December 2012 to a tertiary ED who subsequently had RRT activations within 12 hours of admission (early RRT activations). The medical records of patients 18 years and older admitted to a non-intensive care unit (ICU) setting were reviewed to obtain VS at the time of ED arrival and departure, age, gender and diagnoses. Controls were matched 1:1 on age, gender, and diagnosis. We evaluated VS using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all patients. Our study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational studies.
Results: A total of 948 patients were included (474 cases and 474 controls). Patients who had RRT activations were more likely to be tachycardic (odds ratio [OR] 2.02, 95% CI [1.25–3.27]), tachypneic (OR 2.92, 95% CI [1.73–4.92]), and had lower oxygen saturations (OR 2.25, 95% CI [1.42–3.56]) upon arrival to the ED. Patients who had RRT activations were more likely to be tachycardic at the time of disposition from the ED (OR 2.76, 95% CI [1.65–4.60]), more likely to have extremes of systolic blood pressure (BP) (OR 1.72, 95% CI [1.08–2.72] for low BP and OR 1.82, 95% CI [1.19–2.80] for high BP), higher respiratory rate (OR 4.15, 95% CI [2.44–7.07]) and lower oxygen saturation (OR 2.29, 95% CI [1.43–3.67]). Early RRT activation was associated with increased healthcare utilization and worse outcomes including increased rates of ICU admission within 72 hours (OR 38.49, 95%CI [19.03–77.87]), invasive interventions (OR 5.49, 95%CI [3.82–7.89]), mortality at 72 hours (OR 4.24, 95%CI [1.60–11.24]), and mortality at one month (OR 4.02, 95%CI [2.44–6.62]).
Conclusion: After matching for age, gender and ED diagnosis, we found that patients with an abnormal heart rate, respiratory rate or oxygen saturation at the time of ED arrival or departure are more likely to trigger RRT activation within 12 hours of admission. Early RRT activation was associated with higher mortality at 72 hours and one month, increased rates of invasive intervention and ICU admission. Determining risk factors of early RRT activation is of clinical, operational, and financial importance, as improved medical decision-making regarding disposition would maximize allocation of resources while potentially limiting morbidity and mortality.

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Trauma Triage and Trauma System Performance

Volume 17, Issue 3, May 2016
Gary Johnson, MD

Trauma systems seek to provide complex medical care at the correct time and the correct place. During the past four decades numerous articles have been published that validate trauma systems from many points of view. Achievements of trauma systems include improvement in mortality and morbidity, efficiencies of care, and economic outcomes. Prehospital policy execution is intrinsic to trauma system performance. Trauma system criteria are relatively standardized. However, flexibility in emergency medical service (EMS) decision-making is commonly allowed. These decisions have major impacts on resource allocation, trauma center utilization, and patient outcome.

In this edition, Holst, et al1 reviewed adult emergency department (ED) trauma deaths as reported in the 2010 National Emergency Department Sample. They recorded the association of these deaths to trauma or non-trauma center designation, as well as geographic and patient demographics including rural vs urban site, gender, and patient income data. They found that one half of all trauma ED deaths nationally and one third of ED urban trauma patients died in non-trauma centers. Both elderly trauma deaths and deaths due to falls more frequently occurred in non-trauma centers. Like most studies describing trauma system performance, this is a retrospective review taken from a large database. Therefore, causation of outcome cannot be directly attributed to undertriage. However, the magnitude of the non-trauma center death rate merits further investigation.

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Inadequate Sensitivity of Laboratory Risk Indicator to Rule Out Necrotizing Fasciitis in the Emergency Department

Volume 17, Issue 3, May 2016
Elizabeth Burner, MD et al.

Necrotizing fasciitis (NF) is a life-threatening infection with high mortality. Because NF can be misdiagnosed as a less lethal mimic, such as cellulitis and abscess, efforts have been made to identify clinical features that could help clinicians accurately diagnose NF and avoid delays to surgical debridement.1 Prior retrospective studies have shown certain laboratory values, particularly an extremely elevated leukocyte count and a low sodium concentration, are associated with NF.2 These abnormal values might help clinicians distinguish NF from less severe soft-tissue infections. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed in a large cohort of admitted patients to identify patients at higher risk for NF.3 Patients are assigned a LRINEC score based on serum sodium, glucose, creatinine, c-reactive protein (CRP), leukocyte count and hemoglobin. Scores range from 0 to 13; a score 6 or greater was associated with a high risk of NF, and a score of 8 or greater with a very high risk.

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Ten Tips for Engaging the Millennial Learner and Moving an Emergency Medicine Residency Curriculum into the 21st Century

Volume 17, Issue 3, May 2016
Shannon Toohey, MD et al.

Introduction
Millennial learners are changing the face of residency education because they place emphasis on technology with new styles and means of learning. While research on the most effective way to teach the millennial learner is lacking, programs should consider incorporating educational theories and multimedia design principles to update the curriculum for these new learners. The purpose of the study is to discuss strategies for updating an emergency medicine (EM) residency program’s curriculum to accommodate the modern learner.
Discussion
These 10 tips provide detailed examples and approaches to incorporate technology and learning theories into an EM curriculum to potentially enhance learning and engagement by residents.
Conclusion
While it is unclear whether technologies actually promote or enhance learning, millennials use these technologies. Identifying best practice, grounded by theory and active learning principles, may help learners receive quality, high-yield education. Future studies will need to evaluate the efficacy of these techniques to fully delineate best practices

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Survey of Individual and Institutional Risk Associated with the Use of Social Media

Volume 17, Issue 3, May 2016
Manish Garg, MD, et al.

Introduction: Residents and faculty in emergency medicine (EM) residency programs might
be unaware of the professional and legal risks associated with the use of social media (SM).
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The objective of this study was to identify and characterize the types and reported incidence of
unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal
and institutional risks.
Methods: This multi-site study used an 18-question survey tool that was distributed electronically
to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine
Residency Directors (CORD), and the residents of 14 EM programs during the study period May
to June 2013.
Results: We received 1,314 responses: 772 from residents and 542 from faculty. Both
groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use
by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents
reported posting of one of the following by a resident peer or nursing colleague: identifiable
patient information (26%); or a radiograph, clinical picture or other image (52%). Residents
reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%),
and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by
NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph,
clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted
images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or
inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued
reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were
more likely to post photos of their resident peers or nursing colleagues in an intoxicated state
than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and
identifiable patient information (p=0.0004) than were residents.
Conclusion: EM residents and faculty members cause and encounter HRTPE frequently while
using SM; these events present significant risks to the individuals responsible and their associated
institution. Awareness of these risks should prompt responsible SM use and consideration of
CORD’s Social Media Task Force recommendations.

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Impact of Doximity Residency Rankings on Emergency Medicine Applicant Rank Lists

Volume 17, Issue 3, May 2016
William J. Peterson, MD, et al.

Introduction: This study investigates the impact of the Doximity rankings on the rank list choices
made by residency applicants in emergency medicine (EM).
Methods: We sent an 11-item survey by email to all students who applied to EM residency
programs at four different institutions representing diverse geographical regions. Students were
asked questions about their perception of Doximity rankings and how it may have impacted their
rank list decisions.
Results: Response rate was 58% of 1,372 opened electronic surveys. This study found that a
majority of medical students applying to residency in EM were aware of the Doximity rankings prior
to submitting rank lists (67%). One-quarter of these applicants changed the number of programs
and ranks of those programs when completing their rank list based on the Doximity rankings
(26%). Though the absolute number of programs changed on the rank lists was small, the results
demonstrate that the EM Doximity rankings impact applicant decision-making in ranking residency
programs.
Conclusion: While applicants do not find the Doximity rankings to be important compared to other
factors in the application process, the Doximity rankings result in a small change in residency
applicant ranking behavior. This unvalidated ranking, based principally on reputational data rather
than objective outcome criteria, thus has the potential to be detrimental to students, programs, and
the public. We feel it important for specialties to develop consensus around measurable training
outcomes and provide freely accessible metrics for candidate education.

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Emergency Medicine Resident Perceptions of Medical Professionalism

Volume 17, Issue 3, May 2016
Joshua Jauregui, MD, et al.

Introduction: Medical professionalism is a core competency for emergency medicine (EM)
trainees; but defining professionalism remains challenging, leading to difficulties creating
objectives and performing assessment. Because professionalism is dynamic, culture-specific, and
often taught by modeling, an exploration of trainees’ perceptions can highlight their educational
baseline and elucidate the importance they place on general conventional professionalism
domains. To this end, our objective was to assess the relative value EM residents place on
traditional components of professionalism.
Methods: We performed a cross-sectional, multi-institutional survey of incoming and graduating
EM residents at four programs. The survey was developed using the American Board of Internal
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Medicine’s “Project Professionalism” and the Accreditation Council of Graduate Medical Education
definition of professionalism competency. We identified 27 attributes within seven domains: clinical
excellence, humanism, accountability, altruism, duty and service, honor and integrity, and respect
for others. Residents were asked to rate each attribute on a 10-point scale. We analyzed data
to assess variance across attributes as well as differences between residents at different training
levels or different institutions.
Results: Of the 114 residents eligible, 100 (88%) completed the survey. The relative value
assigned to different professional attributes varied considerably, with those in the altruism domain
valued significantly lower and those in the “respect for others” and “honor and integrity” valued
significantly higher (p<0.001). Significant differences were found between interns and seniors for
five attributes primarily in the “duty and service” domain (p<0.05). Among different residencies,
significant differences were found with attributes within the “altruism” and “duty and service”
domains (p<0.05).
Conclusion: Residents perceive differences in the relative importance of traditionally defined
professional attributes and this may be useful to educators. Explanations for these differences are
hypothesized, as are the potential implications for professionalism education. Because teaching
professional behavior is taught most effectively via behavior modeling, faculty awareness of
resident values and faculty development to address potential gaps may improve professionalism
education.

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Introducing a Fresh Cadaver Model for Ultrasound-guided Central Venous Access Training in Undergraduate Medical Education

Volume 17, Issue 3, May 2016
Ryan Miller, BS et al.

Introduction: Over the past decade, medical students have witnessed a decline in the
opportunities to perform technical skills during their clinical years. Ultrasound-guided central
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venous access (USG-CVA) is a critical procedure commonly performed by emergency medicine,
anesthesia, and general surgery residents, often during their first month of residency. However, the
acquisition of skills required to safely perform this procedure is often deficient upon graduation from
medical school. To ameliorate this lack of technical proficiency, ultrasound simulation models have
been introduced into undergraduate medical education to train venous access skills. Criticisms of
simulation models are the innate lack of realistic tactile qualities, as well as the lack of anatomical
variances when compared to living patients. The purpose of our investigation was to design and
evaluate a life-like and reproducible training model for USG-CVA using a fresh cadaver.
Methods: This was a cross-sectional study at an urban academic medical center. An 18-point
procedural knowledge tool and an 18-point procedural skill evaluation tool were administered
during a cadaver lab at the beginning and end of the surgical clerkship. During the fresh cadaver
lab, procedure naïve third-year medical students were trained on how to perform ultrasoundguided
central venous access of the femoral and internal jugular vessels. Preparation of the fresh
cadaver model involved placement of a thin-walled latex tubing in the anatomic location of the
femoral and internal jugular vein respectively.
Results: Fifty-six third-year medical students participated in this study during their surgical
clerkship. The fresh cadaver model provided high quality and lifelike ultrasound images despite
numerous cannulation attempts. Technical skill scores improved from an average score of 3 to 12
(p<0.001) and procedural knowledge scores improved from an average score of 4 to 8 (p<0.001).
Conclusion: The use of this novel cadaver model prevented extravasation of fluid, maintained
ultrasound-imaging quality, and proved to be an effective educational model allowing third-year
medical students to improve and maintain their technical skills.

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Population Health Research Design

Authorship Trends of Emergency Medicine Publications over the Last Two Decades

Volume 17, Issue 3, May 2016
Richard Lammers, MD, et al.

Introduction: With the recent merger of the American Osteopathic Association (AOA) and
the Accreditation Council for Graduate Medical Education (ACGME) a heightened pressure for
publication may become evident. Our objective was to determine whether there was a gap in the
type of both medical degree designation and advanced degree designation among authorship in
three United States-based academic emergency medicine journals.
Methods: We reviewed the Journal of Emergency Medicine, Academic Emergency Medicine and
Annals of Emergency Medicine for the type of degree designation that the first and senior authors
had obtained for the years 1995, 2000, 2005, 2010 and 2014.
Results: A total of 2.48% of all authors held a degree in osteopathic medicine. Osteopathic
physician first authors contributed to 3.26% of all publications while osteopathic physician senior
authors contributed 1.53%. No statistical trend could be established for the years studied for
osteopathic physicians. However, we noted an overall trend for increased publication for allopathic
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services to the University of California and delivers a dynamic
research platform to scholars worldwide.
senior authors (p=0.001), allopathic first authors with a dual degree (p=0.003) and allopathic
senior authors with a dual degree (p=0.005). For each journal studied, no statistical trend could
be established for osteopathic first or senior authors but a trend was noted for allopathic first
and senior authors in the Journal of Emergency Medicine (p-value=0.020 and 0.006). Of those
with dual degrees, osteopathic physicians were in the minority with 1.85% of osteopathic first
authors and 0.60% of osteopathic senior authors attaining a dual degree. No statistical trend could
be established for increased dual degree publications for osteopathic physicians over the study
period, nor could a statistical trend be established for any of the journals studied.
Conclusion: Very few osteopathic physicians have published in the Journal of Emergency
Medicine, Academic Emergency Medicine or Annals of Emergency Medicine over the last two
decades. Despite a trend for increased publication by allopathic physicians in certain journals,
there appears to be no trend for increased publication of osteopathic physicians in emergency
medicine.

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Out-of-Hospital Surgical Airway Management: Does Scope of Practice Equal Actual Practice?

Volume 17. Issue 3, May 2016
Molly Furin, MD, MS et al.

Introduction: Pennsylvania, among other states, includes surgical airway management, or
cricothyrotomy, within the paramedic scope of practice. However, there is scant literature that evaluates
paramedic perception of clinical competency in cricothyrotomy. The goal of this project is to assess
clinical exposure, education and self-perceived competency of ground paramedics in cricothyrotomy.
Methods: Eighty-six paramedics employed by four ground emergency medical services agencies
completed a 22-question written survey that assessed surgical airway attempts, training, skills verification,
and perceptions about procedural competency. Descriptive statistics were used to evaluate responses.
Results: Only 20% (17/86, 95% CI [11-28%]) of paramedics had attempted cricothyrotomy, most (13/17
or 76%, 95% CI [53-90%]) of whom had greater than 10 years experience. Most subjects (63/86 or 73%,
95% CI [64-82%]) did not reply that they are well-trained to perform cricothyrotomy and less than half
(34/86 or 40%, 95% CI [30-50%]) felt they could correctly perform cricothyrotomy on their first attempt.
Among subjects with five or more years of experience, 39/70 (56%, 95% CI [44-68%]) reported 0-1 hours
per year of practical cricothyrotomy training within the last five years. Half of the subjects who were able
to recall (40/80, 50% 95% CI [39-61%]) reported having proficiency verification for cricothyrotomy within
the past five years.
Conclusion: Paramedics surveyed indicated that cricothyrotomy is rarely performed, even among those
with years of experience. Many paramedics felt that their training in this area is inadequate and did not
feel confident to perform the procedure. Further study to determine whether to modify paramedic scope of
practice and/or to develop improved educational and testing methods is warranted.

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Pilot Study to Determine Accuracy of Posterior Approach Ultrasound for Shoulder Dislocation by Novice Sonographers

Volume 17, Issue 3, May 2016.
Shadi Laham, MD, MS, et al.

Introduction: The goal of this study was to investigate the efficacy of diagnosing shoulder
dislocation using a single-view, posterior approach point-of-care ultrasound (POCUS) performed
by undergraduate research students, and to establish the range of measured distance that
discriminates dislocated shoulder from normal.
Methods: We enrolled a prospective, convenience sample of adult patients presenting to
the emergency department with acute shoulder pain following injury. Patients underwent
ultrasonographic evaluation of possible shoulder dislocation comprising a single transverse
view of the posterior shoulder and assessment of the relative positioning of the glenoid fossa
and the humeral head. The sonographic measurement of the distance between these two
anatomic structures was termed the Glenohumeral Separation Distance (GhSD). A positive GhSD
represented a posterior position of the glenoid rim relative to the humeral head and a negative
GhSD value represented an anterior position of the glenoid rim relative to the humeral head. We
compared ultrasound (US) findings to conventional radiography to determine the optimum GhSD
cutoff for the diagnosis of shoulder dislocation. Sensitivity, specificity, positive predictive value,
and negative predictive value of the derived US method were calculated.
Results: A total of 84 patients were enrolled and 19 (22.6%) demonstrated shoulder dislocation
on conventional radiography, all of which were anterior. All confirmed dislocations had a negative
measurement of the GhSD, while all patients with normal anatomic position had GhSD>0. This
value represents an optimum GhSD cutoff of 0 for the diagnosis of (anterior) shoulder dislocation.
This method demonstrated a sensitivity of 100% (95% CI [82.4-100]), specificity of 100% (95% CI
[94.5-100]), positive predictive value of 100% (95% CI [82.4-100]), and negative predictive value
of 100% (95% CI [94.5-100]).
Conclusion: Our study suggests that a single, posterior-approach POCUS can diagnose anterior
shoulder dislocation, and that this method can be employed by novice ultrasonographers, such as
non-medical trainees, after a brief educational session. Further validation studies are necessary
to confirm these findings.

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Point-of-Care Ultrasound Diagnosis of Left-Sided Endocarditis

Author Affiliation Charles W. Bugg, MD, PhD Keck School of Medicine, LAC+USC Medical Center, Department of Emergency Medicine, Los Angeles, California Kristin Berona, MD Keck School of Medicine, LAC+USC Medical Center, Department of Emergency Medicine, Los Angeles, California Supplementary information A 56-year-old male presented to the emergency department (ED) with fatigue, generalized weakness, cough without […]

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