Factors that Contribute to Resident Teaching Effectiveness

Background One of the key components of residency training is to become an educator. Resident physicians teach students, advanced practice providers, nurses, and even faculty on a daily basis. Objective The goal of this study was to identify the objective characteristics of residents, which correlate with perceived overall teaching effectiveness. Methods We conducted a one-year, retrospective study to identify factors that were associated with higher resident teaching evaluations. Senior emergency medicine (EM) teaching residents are evaluated by medical students following clinical teaching shifts. Eighteen factors pertaining to resident teaching effectiveness were chosen. Two items from the medical students' evaluations were analyzed against each factor: teaching effectiveness was measured on a five-point Likert scale and an overall teaching score (1-75). Results A total of 46 EM residents and 843 medical student evaluations were analyzed. The ACGME milestones for systems-based practice (p = 0.02) and accountability (p = 0.05) showed a statistically significant association with a rating of "five" on the Likert scale for teaching effectiveness. Three other ACGME milestones, systems-based practice (p = 0.01), task switching (p = 0.04), and team management (p = 0.03) also showed a statically significant association of receiving a score of 70 or greater on the overall teaching score. Conclusion Residents with higher performance associated with system management and accountability were perceived as highly effective teachers. USMLE and in-service exams were not predictive of higher teaching evaluations. Our data also suggest that effective teachers are working in both academic and community settings, providing a potential resource to academic departments and institutions

Emergency Physicians Are Able to Detect Right Ventricular Dilation With Good Agreement Compared to Cardiology

Objective Focused cardiac ultrasound (FOCUS) is a useful tool in evaluating patients presenting to the emergency department (ED) with acute dyspnea. Prior work has shown that right ventricular (RV) dilation is associated with repeat hospitalizations and shorter life expectancy. Traditionally, RV assessment has been evaluated by cardiologist-interpreted comprehensive echocardiography. The primary goal of this study was to determine the inter-rater reliability between emergency physicians (EPs) and a cardiologist for determining RV dilation on FOCUS performed on ED patients with acute dyspnea. Methods This was a prospective, observational study at two urban academic EDs; patients were enrolled if they had acute dyspnea and a computed tomographic pulmonary angiogram without acute disease. All patients had an EP-performed FOCUS to assess for RV dilation. RV dilation was defined as an RV to left ventricular ratio greater than 1. FOCUS interpretations were compared to a blinded cardiologist FOCUS interpretation using agreement and kappa statistics. Results Of 84 FOCUS examinations performed on 83 patients, 17% had RV dilation. Agreement and kappa, for EP-performed FOCUS for RV dilation were 89% (95% confidence interval [CI] 80–95%) and 0.68 (95% CI 0.48–0.88), respectively. Conclusions Emergency physician sonographers are able to detect RV dilation with good agreement when compared to cardiology. These results support the wider use of EP-performed FOCUS to evaluate for RV dilation in ED patients with dyspnea

Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage

Introduction: Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary. Methods: We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure. Results: A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44-0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74-93). Conclusion: This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure

Teaching Seasoned Doctors New Technology: An Intervention to Reduce Barriers and Improve Comfort With Clinical Ultrasound

Introduction: Although clinical ultrasound (CUS) is a core skill that is a requirement for emergency medicine (EM) residency graduation, only a fraction of EM practitioners who trained prior to this requirement are certified in CUS. The objective of the study was to implement a CUS workshop for practicing EM physicians, identify barriers to utilization, and assess comfort with the machine, obtaining and interpreting images, and incorporating CUS into clinical practice. Methods: This was a prospective descriptive cohort study of EM physician faculty who participated in an interactive 5-hour CUS workshop intervention that introduced four core CUS modalities via didactics and hands-on scanning stations. Pre- and post-surveys were administered to identify barriers to utilization and assess perceived comfort with CUS using a 5-point Likert scale. Results were analyzed using Fisher's exact and paired t-tests. Results: Thirty-five EM physicians participated with a 100% survey response rate. Only five of the physicians were ultrasound certified at the time of the workshop. On average, physicians were 16 years post-residency. Prior to the workshop, 29% had minimal ultrasound experience and 43% had not performed more than 50 ultrasounds. In the pre-course survey, every physician expressed at least one barrier to CUS utilization. Post-workshop, physicians felt significantly more comfortable using the ultrasound machine (p=0.0008), obtaining and interpreting images (p=0.0009 and p=0.0004), and incorporating CUS into clinical practice (p=0.002). Conclusion: This workshop is an effective tool to expose practicing physicians to core concepts of CUS, improve their comfort level, and reduce barriers to ultrasound utilization

Shearwater Foraging in the Southern Ocean: The Roles of Prey Availability and Winds

Background Sooty (Puffinus griseus) and short-tailed (P. tenuirostris) shearwaters are abundant seabirds that range widely across global oceans. Understanding the foraging ecology of these species in the Southern Ocean is important for monitoring and ecosystem conservation and management. Methodology/Principal Findings Tracking data from sooty and short-tailed shearwaters from three regions of New Zealand and Australia were combined with at-sea observations of shearwaters in the Southern Ocean, physical oceanography, near-surface copepod distributions, pelagic trawl data, and synoptic near-surface winds. Shearwaters from all three regions foraged in the Polar Front zone, and showed particular overlap in the region around 140°E. Short-tailed shearwaters from South Australia also foraged in Antarctic waters south of the Polar Front. The spatial distribution of shearwater foraging effort in the Polar Front zone was matched by patterns in large-scale upwelling, primary production, and abundances of copepods and myctophid fish. Oceanic winds were found to be broad determinants of foraging distribution, and of the flight paths taken by the birds on long foraging trips to Antarctic waters. Conclusions/Significance The shearwaters displayed foraging site fidelity and overlap of foraging habitat between species and populations that may enhance their utility as indicators of Southern Ocean ecosystems. The results highlight the importance of upwellings due to interactions of the Antarctic Circumpolar Current with large-scale bottom topography, and the corresponding localised increases in the productivity of the Polar Front ecosystem

Mammal responses to global changes in human activity vary by trophic group and landscape

Wildlife must adapt to human presence to survive in the Anthropocene, so it is critical to understand species responses to humans in different contexts. We used camera trapping as a lens to view mammal responses to changes in human activity during the COVID-19 pandemic. Across 163 species sampled in 102 projects around the world, changes in the amount and timing of animal activity varied widely. Under higher human activity, mammals were less active in undeveloped areas but unexpectedly more active in developed areas while exhibiting greater nocturnality. Carnivores were most sensitive, showing the strongest decreases in activity and greatest increases in nocturnality. Wildlife managers must consider how habituation and uneven sensitivity across species may cause fundamental differences in human–wildlife interactions along gradients of human influence.Peer reviewe

Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage

Introduction: Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary.Methods: We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure.Results: A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44-0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74-93).Conclusion: This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure.&nbsp

Success of implementation of a systemwide point-of-care ultrasound privileging program for emergency medicine faculty

Objectives: Point-of-care ultrasound (POCUS) is widely used in the emergency department (ED). Not all practicing emergency physicians received POCUS training during residency, leaving a training gap that is reflected in POCUS privileging. The purpose of this study was to evaluate the success of meeting privileging criteria as well as associated factors, following implementation of a basic POCUS training and privileging program within a large emergency medicine department. Methods: We implemented a POCUS training and privileging program, based on national guidelines, for faculty physicians who worked at one of the following EDs staffed by the same emergency medicine department: a pediatric tertiary site, two tertiary academic sites, and seven community sites. POCUS examinations included aorta, cardiac, first-trimester obstetrics (OB), and extended focused assessment with sonography in trauma. Pediatric emergency medicine faculty were taught soft tissue and thoracic US instead of aorta and OB. Completion of the program required 16 h of didactics, ≥25 quality-assured US examinations by examination type, and passing a series of knowledge-based examinations. Descriptive statistics were calculated. Associations between physician characteristics and successfully becoming privileged in POCUS were modeled using Firth's logistic regression. Results: A total of 176 faculty physicians were eligible. A total of 145 (82.4%) achieved basic POCUS privileging during the study period. Different pathways were used including 86 (48.9%) practice-based, nine (5.1%) fellowship-based, and 82 (46.9%) residency-based. POCUS privileging was lower for those working in a community versus academic setting (odds ratio 0.3, 95% confidence interval 0.1-0.9). A greater number of scans completed prior to the privileging program was associated with greater success. Conclusions: Implementation of a POCUS training and privileging program can be successful in a large emergency medicine department that staffs hospitals in a large-scale health care system composed of both academic and community sites. Faculty physicians with at least some prior exposure to POCUS were more successful