Military trainees can accurately measure optic nerve sheath diameter after a brief training session

Abstract Background Identification of elevated intracranial pressure is important following traumatic brain injury. We assessed the feasibility of educating military trainees on accurately obtaining optic nerve sheath diameter measurements using a brief didactic and hands-on training session. Optic nerve sheath diameter is a noninvasive surrogate marker for elevated intracranial pressure, and may be of value in remote military operations, where rapid triage decisions must be made without access to advanced medical equipment. Methods Military trainees with minimal ultrasound experience were given a 5-min didactic presentation on optic nerve sheath diameter ultrasound. Trainees practiced optic nerve sheath diameter measurements guided by emergency physician ultrasound experts. Trainees then measured the optic nerve sheath diameter on normal volunteers. Following this, a trained physician measured the optic nerve sheath diameter on the same volunteer as a criterion standard. An average of three measurements was taken. Results Twenty-three military trainees were enrolled. A mixed design ANOVA was used to compare measurements by trainees to those of physicians, with a mean difference of − 0.6 mm (P = 0.76). A Bland-Altman analysis showed that the degree of bias in optic nerve sheath diameter measures provided by trainees was very small: d = − 0.004 for the right eye and d = − 0.007 for the left eye. Conclusion This study demonstrates that optic nerve sheath diameter measurement can be accurately performed by novice ultrasonographers after a brief training session. If validated, point-of-care optic nerve sheath diameter measurement could impact the triage of injured patients in remote areas.https://deepblue.lib.umich.edu/bitstream/2027.42/146752/1/40779_2018_Article_189.pd

Today’s advanced is tomorrow’s basic

https://deepblue.lib.umich.edu/bitstream/2027.42/145431/1/13089_2018_Article_100.pd

Feasibility study of advanced focused cardiac measurements within the emergency department

Abstract Background This study aims to compare the increased time needed to perform advanced focused cardiac measurements in the emergency department, including diastolic heart failure evaluation via E/E′, and cardiac output with LVOT/VTI. Patients with pertinent cardiopulmonary symptoms in the emergency department had a focused cardiac ultrasound performed by the emergency department ultrasound team. The ability to obtain basic cardiac windows, evaluate for effusion, systolic ejection fraction, and right-sided heart pressures were recorded. Advanced measurements, along with time to obtain all images and the training level of the provider, were recorded. Results Fifty-three patients were enrolled. Basic focused cardiac windows were able to be obtained in 80% of patients. The average 4-window focused cardiac ultrasound took 4 min and 49 s to perform. Diastolic measurements were able to be obtained in 51% of patients, taking an average of 3 min and 17 s. Cardiac output measurements were able to be obtained in 53% of patients, taking an average of 3 min and 8 s. Conclusion The ability to obtain these images improved with increasing level of training. Performing both cardiac output and diastolic measurements increased the time with bedside ultrasound by 6 min and 25 s, and were able to be obtained in slightly over half of all ED patients.https://deepblue.lib.umich.edu/bitstream/2027.42/143847/1/13089_2018_Article_93.pd

A National Point‐of‐Care Ultrasound Competition for Medical Students

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146850/1/jum14670_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146850/2/jum14670.pd

A Perfect Storm: Tyrosine Kinase Inhibitor-Associated Polymorphic Ventricular Tachycardia

BACKGROUND: Oral tyrosine kinase inhibitors (TKIs) are becoming increasingly common in oncology practice due to ease of administration and patient preference. This class of medications is relatively unknown to emergency physicians. CASE REPORT: Here we present a case of electrical storm (ES) thought to be associated with ibrutinib, a TKI. The ES was unabated despite antidysrhythmic therapy and electrical cardioversion, and was treated with supportive care, which eventually included the use of extracorporeal membrane oxygenation. This patient had no risk factors or apparent causes of recurrent ventricular tachycardia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ES has not previously been described with ibrutinib, but may be associated with off-target effects of the drug

Ultrasound Utility in the Diagnosis of a Morel-Lavallée Lesion

Morel-Lavallée lesions are uncommon injuries that can be associated with significant comorbidities if not detected early. Rapid diagnosis in the Emergency Department could significantly improve patient outcomes. We describe the diagnosis of such a lesion through the use of ultrasound imaging in the Emergency Department to utilize a fast, cost-effective imaging technique that does not subject the patient to radiation exposure. Our patient received surgical consultation but improved with conservative management. Ultrasound findings associated with this lesion do not require specialized equipment and should be considered when evaluating soft tissue lesions using point of care ultrasound

Effect of a longitudinal preclinical point-of-care ultrasound course on medical student performance

Background and Objectives: Undergraduate medical educators have incorporated point of care ultrasound training (POCUS) to enhance specific components of basic science medical curricula. Literature on objective outcome data on curriculum efficacy is limited. Our study aims to address this deficit by comparing the preclinical performance of medical students participating in a POCUS curriculum to those who did not. We hypothesized that POCUS would improve scores in sections with clear ultrasound (US) applications but not in other areas where the US curriculum was not as well matched. Methods: At our institution the curriculum is divided into blocks by organ system. Students were offered a voluntary longitudinal POCUS course that was paired with organ system blocks and the exam performance of those enrolled in the curriculum was retroactively compared to those who did not participate. Multivariate linear regression analyses were used to evaluate the relationship between participation in the POCUS course and exam performance in cardiovascular, gastroenterology, and neurology blocks. Results were controlled for gender, MCAT score, and science versus non-science undergraduate degree. Grades in organ blocks were assigned independently by faculty not involved in this project. Results: We compared 51 students who completed the curriculum to 127 who did not participate from the same medical school class. Students who participated in the curriculum had a higher mean cardiovascular anatomy exam score (92.1 vs 88.5, p \u3c 0.05) but this difference was not seen with cumulative cardiovascular block scores. No statistically significant differences in anatomy practical or cumulative exam scores were seen with the gastroenterology or neurology blocks. Conclusion: Medical students enrolled in a longitudinal POCUS curriculum demonstrated improved performance in cardiovascular anatomy exam scores. Our study failed to demonstrate a significant difference in performance in two other organ system sequences within the curriculum. These results suggest that ultrasound education may be most beneficial in specific aspects of undergraduate medical education where the connection between organ system material and US application is strongest. Future directions include evaluating the differences in student performance in the musculoskeletal block, as well as analysis of differences in USMLE scores between participants and non-participants

Anything but Shadowing! Early Clinical Reasoning in Emergency Department Improves Clinical Skills

Introduction: Transitioning from the pre-clinical environment to clerkships poses a challenge to students and educators alike. Students along with faculty developed the Clinical Reasoning Elective (CRE) to provide pre-clinical students exposure to patients in the emergency department and the opportunity to build illness scripts and practice clinical skills with longitudinal mentorship in a low-stakes environment before entering clerkships. It is a voluntary program. Each year, the CRE has received overwhelming positive feedback from students. The objective of this study is to determine if the CRE improved students’ clinical skills and reported comfort in their skills.  Methods: We examined the relationships between students’ self-reported participation in the CRE and their individual scores on a comprehensive clinical assessment (CCA) at the end of the pre-clerkship period. A total of 178 students took the CCA exam in 2016. Of these, 113 participated in the CRE and 65 did not. Seven students who participated in CRE did not complete the exit survey and were omitted from analysis. We performed unstandardized regressions and dichotomous (participants/nonparticipants) comparisons of means with t-tests. Survey of student reactions was collected.  Results: Participants completed an average of 10 sessions over the course of the program (range=1-20). Involvement in the CRE was associated with significantly increased scores on Abdominal History; Pulmonary Physical Exam; Overall History-Taking; Overall Communication; and Overall Physical Exam (p<0.05). Nearly all students (97%) reported that the program offered opportunities to enhance clinical skills, increased their comfort with patients, and better prepared them for their clinical years. Conclusion: There were measurable improvements in clinical skills performance for students who participated in CRE. As many schools seek to incorporate early clinical exposure to their curricula, this program provides a successful framework to provide meaningful clinical exposure to real patients that also shows objective benefits to students’ clinical skills.

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