Kharmene L. Sunga

Compassion fatigue is similar in emergency medicine residents compared to other medical and surgical specialties.

Introduction Compassion fatigue (CF) is the emotional and physical burden felt by those helping others in distress, leading to a reduced capacity and interest in being empathetic towards future suffering. Emergency care providers are at an increased risk of CF secondary to their first responder roles and exposure to traumatic events. We aimed to investigate the current state of compassion fatigue among emergency medicine (EM) resident physicians, including an assessment of contributing factors. Methods We distributed a validated electronic questionnaire consisting of the Professional Quality of Life Scale with subscales for the three components of CF (compassion satisfaction, burnout and secondary traumatic stress), with each category scored independently. We collected data pertaining to day- versus night-shift distribution, hourly workload and child dependents. We included residents in EM, neurology, orthopedics, family medicine, pediatrics, obstetrics, and general surgery. Results We surveyed 255 residents, with a response rate of 75%. Of the 188 resident respondents, 18% worked a majority of their clinical shifts overnight, and 32% had child dependents. Burnout scores for residents who worked greater than 80 hours per week, or primarily worked overnight shifts, were higher than residents who worked less than 80 hours (mean score 25.0 vs 21.5; p=0.013), or did not work overnight (mean score 23.5 vs 21.3; p=0.022). EM residents had similar scores in all three components of CF when compared to other specialties. Secondary traumatic stress scores for residents who worked greater than 80 hours were higher than residents who worked less than 80 hours (mean score 22.2 vs 19.5; p=0.048), and those with child dependents had higher secondary traumatic stress than those without children (mean score 21.0 vs 19.1; p=0.012). Conclusion CF scores in EM residents are similar to residents in other surgical and medical specialties. Residents working primarily night shifts and those working more than 80 hours per week appear to be at high risk of developing compassion fatigue. Residents with children are more likely to experience secondary traumatic stress.

A multifaceted intervention for patients with anaphylaxis increases epinephrine use in adult emergency department.

BACKGROUND Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines. OBJECTIVE To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine autoinjectors, and to measure the effect on anaphylaxis guideline adherence. METHODS A cohort study was conducted from April 29, 2008, to August 9, 2012. Adult patients in the ED who were diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up, and incidence of biphasic reactions were evaluated. RESULTS The study included 202 patients. The median age of the patients was 45.3 years (interquartile range, 31.3-56.4 years); 139 (69%) were women. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs 33%; odds ratio [OR] 2.05 [95% CI, 1.04-4.04]) and admitted to the ED observation unit (65% vs 44%; OR 2.38 [95% CI, 1.23-4.60]), and less likely to be dismissed home directly from ED (16% vs 29%, OR 0.47 [95% CI, 0.22-1.00]). Eleven patients (5%) had a biphasic reaction. Of these, 5 (46%) had the biphasic reaction in the ED observation unit; 1 patient was admitted to the intensive care unit. Six patients (55%) had reactions within 6 hours of initial symptom resolution, of whom 2 were admitted to the intensive care unit. CONCLUSIONS Significantly higher proportions of patients with anaphylaxis received epinephrine and were admitted to the ED observation unit after introduction of epinephrine autoinjectors and order set implementation. Slightly more than half of the biphasic reactions occurred within the recommended observation time of 4 to 6 hours. Analysis of these data suggests that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.

Diagnostic utility of the genital Gram stain in ED patients

OBJECTIVE The study aimed to determine the diagnostic usefulness of the genital Gram stain in an emergency department (ED) population. METHODS A linked-query of an urban, tertiary-care, university- affiliated hospital laboratory database was conducted for all completed Chlamydia trachomatis and Neisseria gonorrhoeae DNA probes, Trichomonas vaginalis wet preps, and genital Gram stains performed on ED patient visits between January and December 2004. Positive criteria for a Gram stain included greater than 10 white blood cells per high-power field, gram-negative intracellular/extracellular diplococci (suggesting N gonorrhoeae), clue cells (suggesting T vaginalis), or direct visualization of T vaginalis organisms. DNA probes were used as the gold standard definition for N gonorrhoeae and C trachomatis infection. RESULTS Of 1511 initially eligible ED visits, 941 were analyzed (genital Gram stain and DNA probe results both present), with a prevalence of either C trachomatis or N gonorrhoeae of 11.4%. A positive genital Gram stain was 75.7% sensitive and 43.3% specific in diagnosing either C trachomatis and/or N gonorrhoeae infection, and 80.4% sensitive and 32.2% specific when the positive cutoff was lowered to more than 5 white blood cells/high-power field. No Gram stains were positive for T vaginalis (with 47 positive wet mounts), and clue cells were noted on 117 Gram stains (11.6%). CONCLUSION Gram stains in isolation lack sufficient diagnostic ability to detect either C trachomatis or N gonorrhoeae infection in the ED.

Intubation Efficiency and Perceived Ease of Use of Video Laryngoscopy vs Direct Laryngoscopy While Wearing HazMat PPE: A Preliminary High-fidelity Mannequin Study

INTRODUCTION Management of contaminated patients in the decontamination corridor requires the use of hazardous material (HazMat) personal protective equipment (PPE). Previous studies have demonstrated that HazMat PPE may increase the difficulty of airway management. This study compared the efficiency of video laryngoscopy (VL) with traditional direct laryngoscopy (DL) during endotracheal intubation (ETI) while wearing HazMat PPE. METHODS Post-graduate year (PGY) 1-3 Emergency Medicine residents were randomized to VL or DL while wearing encapsulating PPE. Video laryngoscopy was performed using the GlideScope Cobalt AVL video laryngoscope. The primary outcome measure was time to successful ETI in a high-fidelity simulation mannequin. Three time points were utilized in the analysis: Time 0 (blade at lips), Time 1 (blade removed from lips after endotracheal tube placement), and Time 2 (bag valve mask [BVM] attached to endotracheal tube). Secondary outcome measures were perceived ease of use and feasibility of VL and DL ETI modalities. RESULTS Twenty-one of 23 (91.3%) eligible residents participated. Mean time to ETI was 10.0 seconds (SD=5.3 seconds) in the DL group and 7.8 seconds (SD=3.0 seconds) in the VL group (P=.081). Mean times from blade insertion until BVM attachment were 17.4 seconds (SD=6.0 seconds) and 15.6 seconds (SD=4.6 seconds), respectively (P=.30). There were no unsuccessful intubation attempts. Seventeen out of 20 participants (85.0%) perceived VL to be easier to use when performing ETI in PPE. Twelve out of 20 participants (60%) perceived DL to be more feasible in an actual HazMat scenario. CONCLUSION The time to successful ETI was not significantly different between VL and DL. Video laryngoscopy had a greater perceived ease of use, but DL was perceived to be more feasible for use in actual HazMat situations. These findings suggest that both DL and VL are reasonable modalities for use in HazMat situations, and the choice of modality could be based on the clinical situation and provider experience.

Gender Distribution Among American Board of Medical Specialties Boards of Directors

Since 1995, women have comprised more than 40% of all medical school graduates. However, representation at leadership levels in medicine remains considerably lower. Gender representation among the American Board of Medical Specialties (ABMS) boards of directors (BODs) has not previously been evaluated. Our objective was to determine the relative representation of women on ABMS BODs and compare it with the in-training and in-practice gender composition of the respective specialties. The composition of the ABMS BODs was obtained from websites in March 2016 for all Member Boards. Association of American Medical Colleges and American Medical Association data were utilized to identify current and future trends in gender composition. Although represented by a common board, neurology and psychiatry were evaluated separately because of their very different practices and gender demographic characteristics. A total of 25 specialties were evaluated. Of the 25 specialties analyzed, 12 BODs have proportional gender representation compared with their constituency. Seven specialties have a larger proportion of women serving on their boards compared with physicians in practice, and 6 specialties have a greater proportion of men populating their BODs. Based on the most recent trainee data (2013), women have increasing workforce representation in almost all specialties. Although women in both training and practice are approaching equal representation, there is variability in gender ratios across specialties. Directorship within ABMS BODs has a more equitable gender distribution than other areas of leadership in medicine. Further investigation is needed to determine the reasons behind this difference and to identify opportunities to engage women in leadership in medicine.

An In Situ Simulation-Based Training Approach to Active Shooter Response in the Emergency Department

ABSTRACTWith an increased number of active shooter events in the United States, emergency departments are challenged to ensure preparedness for these low frequency but high stakes events. Engagement of all emergency department personnel can be very challenging due to a variety of barriers. This article describes the use of an in situ simulation training model as a component of active shooter education in one emergency department. The educational tool was intentionally developed to be multidisciplinary in planning and involvement, to avoid interference with patient care and to be completed in the true footprint of the work space of the participants. Feedback from the participants was overwhelmingly positive both in terms of added value and avoidance of creating secondary emotional or psychological stress. The specific barriers and methods to overcome implementation are outlined. Although the approach was used in only one department, the approach and lessons learned can be applied to other emergency departments in their planning and preparation. (Disaster Med Public Health Preparedness. 2019;13:345-352).

Developing and Implementing a Multi-Source Feedback Tool to Assess Competencies of Emergency Medicine Residents in the United States

Multisource feedback (MSF) has potential value in learner assessment, but has not been broadly implemented nor studied in emergency medicine (EM). This study aimed to adapt existing MSF instruments for emergency department implementation, measure feasibility, and collect initial validity evidence to support score interpretation for learner assessment.

Esophageal Intubation of an Infant.

A 68-day-old former 30-week infant presented with listlessness, apnea and bradycardia. The patient was intubated for airway protection. After intubation, breath sounds were auscultated bilaterally and a Pedi-Cap carbon dioxide detector had color change from purple to yellow. A nasogastric tube (NGT) was placed and a post-procedural chest radiograph was obtained (Figure). Figure Infant with endotracheal tube in the esophagus; nasogastric tube present in the stomach. White arrow indicates endotracheal tube tip. Black arrow indicates low lung volumes. There are several features of esophageal intubation: low lung volumes, esophageal and gastric distention despite NGT placement and juxtaposition of the endotracheal tube (ETT) relative to the NGT.1–2 Other findings of esophageal intubation not seen here are identification of the ETT distal to the carina or outside of the tracheal-bronchial air column.3 Due to high success rates of endotracheal intubation in the emergency department,4–5 these findings are rare and may be overlooked. In this case, misleading clinical evidence was obtained through auscultation of bilateral breath sounds, visualization of endotracheal tube condensation, positive change on the carbon dioxide colorimeter and post-procedural hemodynamic and oxygenation stability. Previous literature, however, has demonstrated false-positive colorimetric change from swallowed air with pre-intubation positive pressure ventilation,6–7 hence the importance of radiographic identification of ETT location. In this patient, esophageal intubation was recognized after continuous capnography revealed absence of waveform.

Board #244 - Program Innovation A Novel Evaluation Tool for Testing Emergency Medicine Level 1 Milestones Through Simulation During Intern Orientation (Submission #7599)

Objectives In 2012 the Accreditation Council of Graduate Medical Education and the American Board of Emergency Medicine jointly announced the introduction of the Emergency Medicine Milestones Project (EMMP). The EMMP serves as “a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency”1 and is intended to be an instrument for benchmarking, evaluation and promotion of the learner towards proficient performance. The EMMP has five different levels of expected learner achievement, with Level 1 Milestones (L1Ms) demonstrating criteria required of an incoming resident. We describe the development and implementation of a simulation-based tool for incoming interns with the purpose of assessing L1Ms achievement. Secondary goals were to reduce intern anxiety surrounding transition to residency, increase familiarity with the simulation-based educational environment, outline our program’s expectations for clinical performance at the intern level and increase aptitude in the evaluation and management of common presentations in emergency department patients. Description During the four-hour simulation and debriefing, interns were individually exposed to scenarios integrating high-fidelity manikins, standardized patients and task trainers. Cases consisted of a pediatric febrile seizure requiring a medical interpreter; acute appendicitis in a female of child bearing age; multi-factorial altered mental status needing airway protection; forearm laceration with foreign body visible on ultrasound. Cumulatively the scenarios tested 16 L1Ms: emergency stabilization (PC1), focused history/physical (PC2), diagnostic studies (PC3), diagnosis (PC4), pharmacotherapy (PC5), observation/reassessment (PC6), disposition (PC7), multi-tasking (PC8), approach to procedures (PC9), airway management (PC10), anesthesia/acute pain management (PC11), ultrasound (PC12), wound management (PC13), professional values (PROF1), patient centered communication (ICS1), team management (ICS2). For each intern we graded L1Ms attainment using a standardized observation matrix. We obtained evaluation and feedback from participants through an anonymous online survey. Pilot performance of the tool occurred July 2012. The instrument was refined based on survey data and delivered again July 2013, after which we used assessment scores for formative categorization of L1Ms achievement. Conclusion Of the eight interns who completed the July 2013 orientation session, five were able to demonstrate all L1Ms assigned to their scenarios. Two interns failed to achieve one L1M each (consistently asking for drug allergies and determining the necessity of diagnostic studies, respectively). One intern was unable to demonstrate three L1Ms (performing and communicating a reliable history and physical, determining the necessity of diagnostic studies and describing basic resources available for the care of the emergency department patient). The 37.5% failure of L1Ms achievement is consistent with previous literature. 2 To date 16 residents have completed the orientation and have rated the course to be highly valuable by incorporating cases that met their learning needs and were clinically relevant to their practice. The 2013 L1Ms simulation orientation was able to identify areas of improvement for individual interns at the beginning of residency and allow for early remediation. We anticipate that this will be an annual occurrence for our program. Future directions include continued development of efficacy metrics and comparison of simulated Milestones achievement with clinical evaluations and patient outcome measures. References 1. The Emergency Medicine Milestones Project. Available at: https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/EmergencyMedicineMilestones.pdf. Accessed April 23, 2014. 2. Bond M, Cassara M, Doty C, Weizberg M. Have first year emergency medicine residents achieved level 1 on care-based milestones? SAEM Annual Meeting Abstracts. Acad Emerg Med 2014;21:S219-220. Disclosures None