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Item A Short History of Free Open Access Medical Education. The Past, Present, and Future(American Thoracic Society, 2020-06-03) Chan, Teresa; Stehman, Christine; Gottlieb, Michael; Thoma, Brent; Emergency Medicine, School of MedicineFree Open Access Medical education (FOAM) has taken the emergency medicine and critical care worlds by storm in the past decade. This article represents one perspective on the stages of transition for FOAM from its humble beginnings as a grassroots movement to the more recent multiauthor blogs that are described in the peer-reviewed literature. In this article, the authors describe the following four distinct waves of people within the movement, with each wave creating a new stage in the evolution of the FOAM community: Creation by the Founders, Adoption by the Enthusiasts, Structure and Formalization by the Structuralists, and Engagement and Activity by the End Users. The authors contextualize some of the phenomena that have been observed within this field and highlight challenges for the field moving forward.Item Application of a Simulation-Based Interprofessional Teamwork Assessment Tool (SITAT) to Individual Student Performance in a Team-Based Simulation(SAGE, 2021-01-01) Daulton, Brittany J; Romito, Laura; Weber, Zach; Burba, Jennifer; Ahmed, Rami A; Emergency Medicine, School of MedicineThere are a very limited number of instruments to assess individual performance in simulation-based interprofessional education (IPE). The purpose of this study was to apply the Simulation-Based Interprofessional Teamwork Assessment Tool (SITAT) to the individualized assessment of medicine, pharmacy, and nursing students (N = 94) in a team-based IPE simulation, as well as to explore potential differences between disciplines, and calculate reliability estimates for utilization of the tool. Results of an analysis of variance provided evidence that there was no statistically significant difference among professions on overall competency (F(2, 91) = 0.756, P = .472). The competency reports for nursing (M = 3.06, SD = 0.45), medicine (M = 3.19, SD = 0.42), and pharmacy (M = 3.08, SD = 0.49) students were comparable across professions. Cronbach's alpha provided a reliability estimate of the tool, with evidence of high internal consistency (α = .92). The interrater reliability of the SITAT was also investigated. There was moderate absolute agreement across the 3 faculty raters using the 2-way mixed model design and “average” unit (kappa = 0.536, P = .000, 95% CI [0.34, 0.68]). The novel SITAT demonstrates internal consistency and interrater reliability when used for evaluation of individual performance during IPE simulation. The SITAT provides value in the education and evaluation of individual students engaged in IPE curriculum.Item Derivation and Validation of a 4-Level Clinical Pretest Probability Score for Suspected Pulmonary Embolism to Safely Decrease Imaging Testing(JAMA, 2021-06-01) Roy, Pierre-Marie; Friou, Emilie; Germeau, Boris; Douillet, Delphine; Kline, Jeffrey Allen; Righini, Marc; Le Gal, Grégoire; Moumneh, Thomas; Penaloza, Andrea; Emergency Medicine, School of MedicineImportance: In patients with suspected pulmonary embolism (PE), overuse of diagnostic imaging is an important point of concern. Objective: To derive and validate a 4-level pretest probability rule (4-Level Pulmonary Embolism Clinical Probability Score [4PEPS]) that makes it possible to rule out PE solely on clinical criteria and optimized D-dimer measurement to safely decrease imaging testing for suspected PE. Design, setting, and participants: This study included consecutive outpatients suspected of having PE from US and European emergency departments. Individual data from 3 merged management studies (n = 11 114; overall prevalence of PE, 11%) were used for the derivation cohort and internal validation cohort. The external validation cohorts were taken from 2 independent studies, the first with a high PE prevalence (n = 1548; prevalence, 21.5%) and the second with a moderate PE prevalence (n = 1669; prevalence, 11.7%). A prior definition of pretest probability target values to achieve a posttest probability less than 2% was used on the basis of the negative likelihood ratios of D-dimer. Data were collected from January 2003 to April 2016, and data were analyzed from June 2018 to August 2019. Main outcomes and measures: The rate of PE diagnosed during the initial workup or during follow-up and the rate of imaging testing. Results: Of the 5588 patients in the derivation cohort, 3441 (61.8%) were female, and the mean (SD) age was 52 (18.5) years. The 4PEPS comprises 13 clinical variables scored from -2 to 5. It results in the following strategy: (1) very low probability of PE if 4PEPS is less than 0: PE ruled out without testing; (2) low probability of PE if 4PEPS is 0 to 5: PE ruled out if D-dimer level is less than 1.0 μg/mL; (3) moderate probability of PE if 4PEPS is 6 to 12: PE ruled out if D-dimer level is less than the age-adjusted cutoff value; (4) high probability of PE if 4PEPS is greater than 12: PE ruled out by imaging without preceding D-dimer test. In the first and the second external validation cohorts, the area under the receiver operator characteristic curves were 0.79 (95% CI, 0.76 to 0.82) and 0.78 (95% CI, 0.74 to 0.81), respectively. The false-negative testing rates if the 4PEPS strategy had been applied were 0.71% (95% CI, 0.37 to 1.23) and 0.89% (95% CI, 0.53 to 1.49), respectively. The absolute reductions in imaging testing were -22% (95% CI, -26 to -19) and -19% (95% CI, -22 to -16) in the first and second external validation cohorts, respectively. The 4PEPS strategy compared favorably with all recent strategies in terms of imaging testing. Conclusions and relevance: The 4PEPS strategy may lead to a substantial and safe reduction in imaging testing for patients with suspected PE. It should now be tested in a formal outcome study.Item Inhaled nitric oxide to control platelet hyper-reactivity in patients with acute submassive pulmonary embolism(Elsevier, 2020-03-01) Kline, Jeffrey A.; Puskarich, Michael A.; Pike, Jonathan; Zagorski, John; Alves, Nathan J.; Emergency Medicine, School of MedicineBackground: We test if inhaled nitric oxide (NO) attenuates platelet functional and metabolic hyper-reactivity in subjects with submassive pulmonary embolism (PE). Methods: Participants with PE were randomized to either 50 ppm NO + O2 or O2 only for 24 h with blood sampling at enrollment and after treatment; results were compared with healthy controls. Platelet metabolic activity was assessed by oxygen consumption (basal and uncoupled) and reactivity was assessed with agonist-stimulated thromboelastography (TEG) and fluorometric measurement of agonist-stimulated cytosolic [Ca++] without and with pharmacological soluble guanylate (sGC) modulation. Results: Participants (N = 38 per group) were well-matched at enrollment for PE severity, comorbidities as well as TEG parameters and platelet O2 consumption. NO treatment doubled the mean plasma [NO3-] (P < 0.001) indicating successful delivery, but placebo treatment produced no change. After 24 h, neither TEG nor O2 consumption parameters differed significantly between treatment groups. Platelet cytosolic [Ca++] was elevated with PE versus controls, and was decreased by treatment with cinaciguat (an sGC activator), but not riociguat (an sGC stimulator). Stimulated platelet lysate sGC activity was increased with PE compared with controls. Conclusions: In patients with acute submassive PE, despite evidence of adequate drug delivery, inhaled NO had no major effect on platelet O2 consumption or agonist-stimulated parameters on TEG. Pharmacological activation, but not stimulation, of sGC effectively decreased platelet cytosolic [Ca++], and platelet sGC activity was increased with PE, confirming the viability of sGC as a therapeutic target.Item Development and implementation of a point of care ultrasound curriculum at a multi-site institution(Springer, 2021-02-21) Russell, Frances M.; Herbert, Audrey; Ferre, Robinson M.; Zakeri, Bita; Echeverria, Valerie; Peterson, Dina; Wallach, Paul; Emergency Medicine, School of MedicineIn 2014, over 60% of medical schools were incorporating point of care ultrasound (POCUS) into their curriculum. Today, over 6 years later, many more schools are teaching POCUS or are in the planning stages of implementing a POCUS curriculum. In 2019, the AAMC reported that 53 schools or over one-third of US medical schools have multi-site campuses for undergraduate medical education. Implementation of a POCUS educational initiative at a multi-site campus presents unique challenges for teaching a uniform curriculum statewide. This article will discuss the POCUS curriculum and implementation process at a large multi-site institution.Item Effect of metabolic syndrome on mean pulmonary arterial pressures in patients with acute pulmonary embolism treated with catheter-directed thrombolysis(Elsevier, 2020-03-01) Stewart, Lauren K.; Beam, Daren M.; Casciani, Thomas; Cameron, Scott J.; Kline, Jeffrey A.; Emergency Medicine, School of MedicineBackground: Metabolic syndrome (MetS) has been associated with a procoagulant and hypofibrinolytic state. Current data exploring the role of MetS in venous thromboembolism (VTE) are limited. The objective was to measure the prevalence of MetS in patients with acute PE receiving catheter-directed thrombolysis (CDT) and to investigate its effect on mean pulmonary arterial pressure and overall treatment success. Methods: We used a 3-year prospective registry of ED patients with acute PE with severity qualifying for activation of a PE response team (PERT). All patients had CDT with catheter-measured mPAP and angiography. The presence or absence of MetS components were extracted from chart review based on the following criteria: 1. body mass index (BMI) >30 kg/m2; 2. diagnosed hypertension; 3. diabetes mellitus (including HbA1c >6.5%) and; 4. dyslipidemia (including triglycerides >150 mg/dL or high-density lipoprotein <40 mg/dL). Results: Of the 134 patients, 85% met the criteria for at least one of four MetS components, with obesity being most common, present in 71%. Results demonstrated a positive concordance between the number of criteria for MetS and MPAP, both pre- and post-fibrinolysis, as pressures tended to increase with each additional MetS criterion. Multivariate regression analysis determined age (-), BMI (+) and hypertension (+) to be significant independent predictor variables for mPAP. Conclusions: MetS was common in patients with more severe manifestations of PE and was associated with higher mPAP values both at diagnosis and following treatment with CDT.Item Functional testicular torsion secondary to an incarcerated inguinal hernia in a 4-month old: complete recovery at 18-hours(Oxford University Press, 2021-02-16) Taylor, Gregory M.; Strachan, Christian C.; Emergency Medicine, School of MedicineOne of the most common urological emergencies encountered in pediatric patients in the emergency department (ED) is the acute scrotum. We present the case of a 4-month-old male that presented to our community ED with scrotal swelling and vomiting of 16-hours duration. He was diagnosed with a functional testicular torsion from an incarcerated inguinal hernia, transferred to a hospital with pediatric urological capabilities and was taken to the operating room ~2 hours later. His hospital course was unremarkable, and he was discharged on day 3, having made a full recovery without any loss of bowel or testicle. There have only been a handful of cases in the literature of a pediatric patient presenting with a functional testicular torsion as a result of spermatic cord compression from an indirect inguinal hernia, with no reported cases of complete salvage at nearly 18 hours since symptom onset.Item Severe methemoglobinemia secondary to isobutyl nitrite toxicity: the case of the ‘Gold Rush’(Oxford University Press, 2021-02-15) Taylor, Gregory M.; Avera, Robert S.; Strachan, Christian C.; Briggs, Christian M.; Medler, Jason P.; Pafford, Carl M.; Gant, Timothy B.; Emergency Medicine, School of MedicineIsobutyl nitrite is one of the popular recreational drugs with high abuse potential that is known to cause methemoglobinemia. While inhaling this recreational drug, often referred to as a 'popper', is the typical route of administration, oral ingestion can produce a more rapid and fulminant course of methemoglobinemia. We present the case of a 69-year-old male that presented to our emergency department in extreme, life-threatening methemoglobinemia due to the ingestion of isobutyl nitrite that he obtained from an adult novelty store. The patient had a methemoglobin level above our lab cut-off of 28% and was subsequently treated with two doses of intravenous methylene blue. His hospital course was unremarkable, and he was discharged on Day 2. Methemoglobinemia is a medical emergency that requires a high index of clinical suspicion, prompt recognition, and rapid treatment.Item Septic Malleolar Bursitis in a Patient with an Ankle Electronic Monitoring Device: A Case Report(eScholarship, 2021-02) Besinger, Bart; Ryckman, Sydney; Emergency Medicine, School of MedicineIntroduction: Septic malleolar bursitis is a rare cause of ankle pain and swelling. It has been described in certain occupational and recreational activities that involve tight-fitting boots, such as figure skating. Court-ordered electronic monitoring devices are often worn on the ankle. It is not known whether these devices are a risk factor for the development of malleolar bursitis. Case report: We describe a 41-year-old male under house arrest with an electronic monitoring device on his right ankle who presented to our emergency department with several days of progressive pain and swelling over the medial malleolus. Point-of-care ultrasound revealed a thick-walled cystic structure consistent with medial malleolar bursitis. Bursal aspiration was performed. Fluid culture yielded Staphylococcus aureus. Discussion: Emergency physicians regularly see patients with ankle pain and swelling and must consider a comprehensive differential diagnosis. Septic malleolar bursitis is an uncommon but important cause of ankle pain and swelling that requires prompt diagnosis and intervention. Point-of-care ultrasonography may aid in the diagnosis. Additionally, emergency physicians should be aware of potential complications related to electronic monitoring devices.Item Success of Implementation of a System-Wide Point of Care Ultrasound (POCUS) Training and Privileging Program for Emergency Physicians(Wiley, 2022-04) Kennedy, Sarah K.; Ferre, Robinson M.; Rood, Loren K.; Nti, Benjamin; Ehrman, Robert R.; Emergency Medicine, School of MedicineObjectives Point-of-care ultrasound (POCUS) is widely used in the emergency department (ED). Not all practicing emergency physicians (EPs) 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 Department of Emergency Medicine. 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 Department of Emergency Medicine: a pediatric tertiary site, 2 tertiary academic sites, and 7 community sites. POCUS exams included aorta, cardiac, first-trimester obstetrics, and extended focused assessment with sonography in trauma. Pediatric emergency medicine faculty were taught soft tissue and thoracic ultrasound instead of aorta and obstetrics. Completion of the program required 16 hours of didactics, ≥25 quality assured ultrasound examinations by exam type and passing a series of knowledge-based exams. Descriptive statistics were calculated. Associations between physician characteristics and successfully becoming privileged in POCUS were modeled using Firth’s logistic regression. Results 176 faculty physicians were eligible. 145 (82.4%) achieved basic POCUS privileging during the study period. Different pathways were used including: 86 (48.9%) practice-based, 9 (5.1%) fellowship-based, and 82 (46.9%) residency-based. POCUS privileging was lower for those working in a community versus academic setting (OR 0.3, CI 0.1-0.9). A greater number of scans completed prior to the privileging program was associated with greater success. Conclusion Implementation of a POCUS training and privileging program can be successful in a large Department of Emergency Medicine that staffs hospitals in a large-scale healthcare system comprised of both academic and community sites. Faculty physicians with at least some prior exposure to POCUS were more successful.