PALLIATIVE MEDICINE COMPETENCY EDUCATION IN EMERGENCY MEDICINE RESIDENCY TRAINING: A SURVEY OF EMERGENCY MEDICINE EDUCATION LEADERS

Background: Emergency physicians care for patients with palliative and hospice needs. More than 75 percent of patients visit the ED in the last 6 months of life, and two-thirds of those patients die while hospitalized. Objectives: To assess hospice and palliative medicine (HPM) instruction in EM residency programs and to identify barriers and opportunities for integrating instruction in HPM into EM training. Methods: IRB-approved, cross-sectional, mixed-mode survey (web-based and paper-based) of EM residency program directors (PDs), associate PDs (APDs), and assistant PDs (aPDs) distributed to 402 subjects. Demographic variables and institutional characteristics were collected. A five-point Likert scale (1=least, 5=most) assessed Four Domains: 1 - Importance of HPM competency for senior EM residents; 2 - Senior resident skill level in HPM competencies; 3 - Effectiveness of educational methods for HPM training; and 4 - Barriers to training. Results: There was a 50 percent response rate, a 60/40 percent distribution between paper and web-based modes, and no statistical differences in demographics between groups. Most respondents identified HPM training as important and teach HPM in their programs. In Domain 1, crucial conversations (mean 4.88, SD 0.40), management of pain (4.77, 0.53), and management of the imminently dying (4.74, 0.53) had the highest mean Likert scores for importance. In Domain 2, residents were reported to be skilled in crucial conversations (4.28, 0.66), management of pain (4.17, 0.72), and management of the imminently dying (3.91, 0.88). In Domain 3, bedside teaching (4.53, 0.81), mentoring from HPM faculty (4.11, 0.97), and case-based simulation were identified as the most effective educational methods. In Domain 4, lack of HPM expertise among faculty (3.57,1.21), lack of faculty (3.42, 1.20) and resident interest in HPM (3.04, 1.20) were identified as the greatest barriers. Six competencies (withholding/withdrawal of non-beneficial interventions, management of imminently dying, HPM referrals, ethical/legal issues, spiritual/cultural issues, management of dying child) showed large differences between perceived importance and reported senior resident skill level. Conclusions: This study is the first comprehensive description of HPM competency training in EM residencies. The results provide a foundation for focused educational interventions and future research to improve HPM training for EM residents

Pseudogout Diagnosed By Point-of-care Ultrasound

A 71-year-old male presented to the emergency department (ED) for worsening right knee pain for the prior 3-4 weeks. Point-of-care ultrasound (POCUS) of the right knee showed a pseudo-double contour sign. Subsequent ultrasound-guided arthrocentesis of the knee joint was performed, and fluid studies showed the presence of calcium pyrophosphate crystals, which was consistent with pseudogout. Ultrasound for detection of calcium pyrophosphate crystals in pseudogout and chondrocalcinosis has sensitivity of 86.7% and specificity of 96.4% making POCUS a valuable tool for diagnosing crystalline-induced arthropathy in the ED

The diagnostic accuracy of the rapid ultrasound in shock (rush) exam for shock etiology : a systematic review and meta-analysis

Poster presented at the 2017 Health Sciences Research Day which was organized and sponsored by the University of Missouri School of Medicine Research Council and held on November 9, 2017.Conclusion: The RUSH performs generally well to diagnose the category of shock in patients presenting with undifferentiated shock to the ED. However, given modest –LR values for several categories (notably distributive and mixed-etiology), it is likely best employed as one component to a complete evaluation of a patient with undifferentiated shock, rather than be relied upon solely

Adverse events related to ultrasound-guided regional anesthesia performed by Emergency Physicians: Systematic review protocol

The use of ultrasound-guided regional anesthesia for pain management has become increasingly prevalent in Emergency Medicine, with studies noting excellent pain control while sparing opioid use. However, the use of ultrasound-guided regional anesthesia may be hampered by concern about risks for patient harm. This systematic review protocol describes our approach to evaluate the incidence of adverse events from the use of ultrasound-guided regional anesthesia by Emergency Physicians as described in the literature. This project will also seek to document the scope of ultrasound-guided regional anesthesia applications being performed in Emergency Medicine literature, and potentially serve as a framework for future systematic reviews evaluating adverse events in Emergency Medicine

Delay in Hospital Presentation Is the Main Reason Large Vessel Occlusion Stroke Patients Do Not Receive Intravenous Thrombolysis

OBJECTIVES: Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of \u3e4.5 hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT. METHODS: This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample RESULTS: Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of \u3e4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49). CONCLUSION: Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of \u3e4.5 hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants

Creation of Surge Capacity by Early Discharge of Hospitalized Patients at Low Risk for Untoward Events

Objectives: US hospitals are expected to function without external aid for up to 96 hours during a disaster; however, concern exists that there is insufficient capacity in hospitals to absorb large numbers of acute casualties. The aim of the study was to determine the potential for creation of inpatient bed surge capacity from the early discharge (reverse triage) of hospital inpatients at low risk of untoward events for up to 96 hours. Methods: In a health system with 3 capacity-constrained hospitals that are representative of US facilities (academic, teaching affiliate, community), a variety (N = 50) of inpatient units were prospectively canvassed in rotation using a blocked randomized design for 19 weeks ending in February 2006. Intensive care units (ICUs), nurseries, and pediatric units were excluded. Assuming a disaster occurred on the day of enrollment, patients who did not require any (previously defined) critical intervention for 4 days were deemed suitable for early discharge. Results: Of 3491 patients, 44% did not require any critical intervention and were suitable for early discharge. Accounting for additional routine patient discharges, full use of staffed and unstaffed licensed beds, gross surge capacity was estimated at 77%, 95%, and 103% for the 3 hospitals. Factoring likely continuance of nonvictim emergency admissions, net surge capacity available for disaster victims was estimated at 66%, 71%, and 81%, respectively. Reverse triage made up the majority (50%, 55%, 59%) of surge beds. Most realized capacity was available within 24 to 48 hours. Conclusions: Hospital surge capacity for standard inpatient beds may be greater than previously believed. Reverse triage, if appropriately harnessed, can be a major contributor to surge capacity

A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke.

Introduction: Endovascular thrombectomy (EVT) significantly improves outcomes in large vessel occlusion stroke (LVOS). When a patient with a LVOS arrives at a hospital that does not perform EVT, emergent transfer to an endovascular stroke center (ESC) is required. Our objective was to determine the association between door-in-door-out time (DIDO) and 90-day outcomes in patients undergoing EVT. Methods: We conducted an analysis of the Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry of 2,400 LVOS patients treated at nine ESCs in the United States. We examined the association between DIDO times and 90-day outcomes as measured by the modified Rankin scale. Results: A total of 435 patients were included in the final analysis. The mean DIDO time for patients with good outcomes was 17 minute shorter than patients with poor outcomes (122 minutes [min] vs 139 min, P = 0.04). Absolute DIDO cutoff times of ≤60 min, ≤90 min, or ≤120 min were not associated with improved functional outcomes (46.4 vs 32.3%, P = 0.12; 38.6 vs 30.6%, P = 0.10; and 36.4 vs 28.9%, P = 0.10, respectively). This held true for patients with hyperacute strokes of less than four-hour onset. Lower baseline National Institutes of Health Stroke Scale (NIHSS) score (11.9 vs 18.2, P = \u3c.001) and younger age (62.5 vs 74.9 years (P \u3c .001) were associated with improved outcomes. On multiple regression analysis, age (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.45-2.02) and baseline NIHSS score (OR 1.67, 95% CI 1.42-1.98) were associated with improved outcomes while DIDO time was not associated with better outcome (OR 1.13, 95% CI 0.99-1.30). Conclusion: Although the DIDO time was shorter for patients with a good outcome, this was non-significant in multiple regression analysis. Receipt of intravenous thrombolysis and time to EVT were not associated with better outcomes, while male gender, lower age, arrival by private vehicle, and lower NIHSS score portended better outcomes. No absolute DIDO-time cutoff or modifiable factor was associated with improved outcomes for LVOS. This study underscores the need to streamline DIDO times but not to set an artificial DIDO time benchmark to meet

Transformative Leadership: Emergency Physicians Lead AOA and AMA

This was a historic summer in Chicago for emergency medicine. On July 18, 2015, John W. Becher, DO, became the 119th president of the American Osteopathic Association (AOA), while a month earlier, on June 9, 2015, Steven J. Stack, MD, became the 170th president of the American Medical Association (AMA). This is the first time that emergency physicians have led the two largest professional physician organizations in the United States, and the first time that an emergency physician has led the AMA