Where Arizona EM research is presented.

Authors

Josephine Valenzuela Jacquelyn Pearlmutter Levi Filler Carl Mitchell Gabriel Zdrale Paul Kang Ashkon Mahmoudi Christopher Borowy

Introduction

In 2023, the American College of Emergency Physicians (ACEP) guidelines moved ultrasound-guided nerve blocks from an advanced to a core application, recommending that all emergency medicine residents demonstrate competency during training. Existing curricula are limited by short duration or reliance on learner self-confidence rather than objective skill assessment. This study evaluated the performance of emergency medicine residents on a simulated ultrasound-guided nerve block task before and after implementation of a year-long nerve block curriculum.

Methods

This IRB-approved retrospective study evaluated 41 residents in a three-year emergency medicine residency program. The curriculum consisted of four one-hour sessions incorporating didactics, demonstration, and hands-on scanning. Performance on a simulated nerve block task was evaluated with a modified Regional Anesthesia Procedural Skills (RAPS) assessment, which included a 17-item procedural checklist, a global competency evaluation, and a total score. Three fellowship-trained faculty independently scored the assessments. Pre- and post-curriculum scores were compared using the Wilcoxon signed-rank test. Interrater variability was assessed using the Kruskal-Wallis test. Residents not available due to leave or other excused absences during the study period were excluded.

Results

Forty-one out of 45 residents completed both assessments. Post-curriculum mean scores were significantly higher than pre-curriculum mean scores across all three parts of the RAPS assessment, including the checklist (6.95 ± 2.77 vs 11.8 ± 2.2, p<0.001), global evaluation (15.6 ± 5.5 vs 23.2 ± 4.8, p<0.001), and total (22.5 ± 7.4 vs 35.0 ± 6.6, p<0.001). Inter-rater analysis demonstrated significant disagreement only in pre-curriculum global and total scores (p<0.003 and p<0.002).

Discussion

This study demonstrates that implementation of a longitudinal, year-long ultrasound-guided nerve block curriculum was associated with significant improvement in emergency medicine resident performance on a simulated nerve block task. Residents showed substantial gains across all components of the modified Regional Anesthesia Procedural Skills (RAPS) assessment, including procedural checklist completion, global competency evaluation, and total performance score. These findings support the effectiveness of a structured, longitudinal educational approach in developing procedural competence in ultrasound-guided regional anesthesia. The transition of ultrasound-guided nerve blocks from an advanced to a core application in the 2023 ACEP ultrasound guidelines underscores the need for residency programs to adopt curricula that ensure objective competency rather than reliance on self-reported confidence or limited exposure. Prior educational interventions in emergency medicine have often consisted of brief workshops or single-session training, which may improve learner confidence but have demonstrated variable impact on objective skill acquisition. In contrast, the curriculum evaluated in this study provided repeated exposure over time, integrating didactic instruction, faculty demonstration, and hands-on scanning practice. The observed improvements across all assessment domains suggest that repeated, spaced training may be critical for developing durable procedural skills in ultrasound-guided nerve blocks. Notably, improvement was observed not only in checklist-based procedural steps but also in global competency assessments, which reflect higher-order skills such as image optimization, needle control, and overall procedural flow. These findings suggest that the curriculum facilitated both technical skill acquisition and procedural fluency, which are essential for safe and effective performance in the clinical environment. The use of a validated assessment framework adapted from the RAPS tool further strengthens the educational rigor of this study by providing an objective measure of performance rather than subjective learner perception. Interrater analysis demonstrated acceptable agreement among faculty raters for post-curriculum assessments, with significant disagreement observed only in pre-curriculum global and total scores. This variability may reflect the inherent difficulty in assessing novice learners, where performance is more heterogeneous and subjective interpretation of competency may vary between raters. As learners progressed and performance improved following the curriculum, scoring appeared to converge, suggesting increased clarity and consistency in observed procedural competence. This study has several limitations. First, performance was assessed in a simulated environment, which may not fully translate to clinical competence or patient outcomes. Second, this was a single-institution study with a modest sample size, potentially limiting generalizability to other residency programs with different resources or patient populations. Third, the retrospective design precludes direct comparison with alternative educational models, and long-term skill retention beyond the study period was not assessed. Additionally, while a modified RAPS tool was used, further validation of this adapted assessment in the emergency medicine setting may be warranted. Despite these limitations, this study provides meaningful evidence that a longitudinal, objective, simulation-based nerve block curriculum can significantly improve resident performance and help meet updated national training expectations. Future research should focus on evaluating clinical translation of these skills, assessing long-term retention, and exploring the impact of such curricula on patient-centered outcomes such as analgesic efficacy and opioid utilization. As ultrasound-guided nerve blocks become an expected competency for graduating emergency medicine residents, structured longitudinal training with objective assessment should be considered a foundational component of residency education.

Conclusion

A year-long nerve block curriculum significantly improved emergency medicine resident performance on a simulated nerve block task. These findings support the use of a longitudinal curriculum with objective performance assessment to meet updated national training recommendations.

Authors

Iman Khan BS, Kayla Keith BS, Avani Reddy BS, Grayson Hughes BS, Ghid Bahoo MA Nguyen Tran BS, Levi Jensen MA, Iman Khan BS, C Preston Allen BS, John Ashurst DO Affiliations Midwestern University, Glendale, AZ

Introduction

In March 2020, coronavirus disease 2019 (COVID-19) disrupted traditional healthcare delivery and significantly altered emergency department (ED) utilization patterns in the United States. ED visits declined by 41-63% in multiple states during early pandemic surges, while hospital admission rates from the ED increased, suggesting higher patient acuity among those who presented (Jeffrey et al., 2020). Similar trends were observed in Arizona, where overall ED visits decreased, but the proportion of high-acuity cases increased (Ghaderi et al., 2022). During this period, telehealth rapidly expanded as a mechanism to support remote triage, symptom screening, and outpatient management. Evidence suggests that telemedicine in the ED setting can improve diagnostic concordance, reduce re-consultation rates, and shorten throughput times in non-critical cases (Ahmed et al., 2024). Hence, telehealth delivery emerged as a potential surge mitigation tool and care diversion strategy within emergency medicine. However, the ability to benefit from telehealth depends on patient awareness, digital access and technological literacy. Older adults and marginalized populations may face structural barriers related to age, race, and gender that limit telehealth utilization. This study examines demographic differences in telehealth awareness and digital access among Medicare beneficiaries during the COVID-19 pandemic and explores potential implications for ED use.

Methods

This retrospective cross-sectional study analyzed publicly available data from the Medical Current Beneficiary Survey (MCBS) COVID-19 Supplement, which includes telephone survey data from Summer 2020, Fall 2020, and Winter 2021 in response to the COVID-19 pandemic. Telehealth awareness, availability, modality and measures of digital access were analyzed. Associations with age, gender, and race/ethnicity were assessed using unweighted Pearson chi-square tests, with statistical significance defined as p < 0.05. Findings were interpreted in the context of emergency care access and system strain during the pandemic.

Results

Significant differences in telehealth awareness, modality, accessibility, and digital access were observed across age, race/ethnicity, and gender. Age demonstrated the strongest and most consistent associations. Older beneficiaries were significantly less likely to report awareness of telehealth services, less likely to have access to video-based telehealth, and more likely to rely on telephone-only services (all p <0.001). Older age groups also reported lower rates of computer ownership, reduced internet access, and greater difficulty operating video and audio modalities (all p values < 0.001). White beneficiaries were more likely to report telehealth availability and access to video modalities compared to Black and Hispanic beneficiaries (p <0.001). While pre-pandemic telehealth modality preferences did not differ by race or ethnicity, substantial differences in digital access emerged during the pandemic, including disparities in device ownership and internet availability. Gender-associated differences were statistically significant for several variables, including telehealth awareness and device ownership, but were smaller in magnitude compared to age and race/ethnicity.

Discussion

This study demonstrates significant disparities in telehealth awareness, video access, and digital readiness among Medicare beneficiaries, with older adults and racial/ethnic minorities demonstrating the greatest limitations. Age showed the strongest and most consistent association with reduced telehealth capacity. These findings suggest that telehealth expansion did not uniformly benefit all populations. Older beneficiaries, those at risk for severe illness, were often the least equipped to utilize virtual medical services. In the context of emergency medicine, unequal digital readiness may have influenced patterns of care-seeking behavior during the pandemic, potentially limiting access to early triage or outpatient evaluation for certain groups. These disparities represent structural barriers rather than individual patient choice. Addressing digital inequities among older adults and racial/ethnic minorities may be necessary to ensure that telehealth functions as an equitable extension of emergency and outpatient care during future public crises.

Conclusion

This study identifies significant demographic disparities in telehealth awareness, access, and digital readiness among Medicare beneficiaries during the COVD-19 pandemic. Older adults exhibited the greatest limitations in video modalities, internet access, and digital ownership, with racial and ethnic disparities in telehealth availability and device ownership also evident. These findings suggest that rapid telehealth expansion did not equitably reach populations at highest clinical risk. Unequal digital readiness among vulnerable populations may influence access to early evaluation and triage during public health crises. Efforts to strengthen emergency care delivery and system reliance should incorporate targeted strategies to improve digital access and literacy among older adults and underserved populations to ensure equitable integration of telehealth into acute care pathways.

Authors

Yana Nemanova, BS, Rylee Johnson, BS, Jacqueline Neff, BBA, Tyrus Nelson, BS, Diana Lalitsasivimol, PhD, Anthony Santarelli, PhD, John Ashurst, DO, EdD, MS, FACEP, FACOEP

Introduction

The American Academy of Pediatrics (AAP) and the Choosing Wisely Campaign recommend against the use of corticosteroids, bronchodilators, epinephrine, nebulized hypertonic saline, and antibacterial medications in management of uncomplicated viral respiratory illnesses. Despite the guidelines, these interventions are still utilized unnecessarily. This study aims to evaluate adherence to current guidelines in a rural emergency department and assess the impact of non-adherent care on the length of stay, cost, and patient outcomes.

Methods

A retrospective cohort study was conducted of patients aged 0–5 years diagnosed in the emergency department with bronchiolitis or viral upper respiratory infection in the dates between October 1, 2022, and March 31, 2025. Patients were categorized by adherence versus non-adherence to current guidelines. Outcomes were compared between groups.

Results

A total of 1,021 patients were included. Treatments that were recommended against were administered in 22% of cases. These were associated with a significantly longer length of stay in the emergency department, averaging 43.3 additional minutes (p<0.05), and higher total charges, averaging $196 more per patient (p<0.05). There were no significant differences in return visits within 72 hours or 30 days between adherence groups.

Discussion

The use of treatments outside of the current guidelines prolonged ED stay and escalated total patient costs. This further emphasizes the need for stronger adherence to evidence-based management. By minimizing low-value interventions, emergency providers can enhance efficiency and reduce financial burdens imposed by these interventions, while maintaining safe and patient-centered care.

Conclusion

Despite the evidence-based recommendations, approximately 1 in 5 pediatric patients with viral respiratory illnesses received advised against interventions. These were not shown to provide any clinical benefit, as demonstrated by lack of significant difference in short-term representation rates, and thus can be considered low-value interventions that result in operational burden. Future efforts should focus on provider education and institutional quality improvement measures to promote consistent adherence to national guidelines.

Authors

Timothy Vosler BS, Jacqueline Neff BBA, Tyrus Nelson, BS, Diana Lalitsasivimol, PhD, Anthony Santarelli, PhD, John Ashurst, DO, EdD, MS, FACEP, FACOEP

Introduction

The Infectious Diseases Society of America (IDSA), and American College of Gastroenterology (ACG) provides recommendations for stool sample collection via evidence based guidelines.These guidelines state to collect stool samples only in patients with high-risk features, including fever, bloody or mucoid stools, severe abdominal pain, immunocompromised status, or relevant epidemiological exposures. Routine testing in low-risk cases is discouraged due to low diagnostic yield and unnecessary healthcare costs. Despite these guidelines being in place, the over-utilization of stool sample collection may contribute to unnecessary healthcare resources being used, increasing healthcare costs for the hospital as well as the patient and prolonged emergency department stay. This retrospective chart review evaluated stool testing practices in adult patients presenting to a rural academic hospital Emergency Department. Variables included presenting symptoms, testing indications, provider characteristics, and diagnostic outcomes. The goal is to assess adherence to guideline-based indications and identify patterns of over-utilization. Findings will inform targeted quality improvement strategies to improve diagnostic stewardship and reduce unnecessary testing in emergency care.

Methods

Following institutional review board approval, a retrospective cohort of patients of all ages who were diagnosed in the emergency department with acute diarrhea (ICD-10 code R19.7) between (5/8/2024 - 9/24/2025) were reviewed. Data abstraction of demographics, diagnostic compliance, triage visits, patient outcomes, past medical history, treatment, ED length of stay, total hospital charges, and patient representation within 72 hours and 30 days. Patients were stratified based on adherence vs non-adherence to guidelines with comparisons made to assess clinical and financial impact

Results

A total of 217 patients were included in the analysis, with 116 females (53.5%), 101 males (46.5%). Overall diagnostic guideline adherence was 79.26% (172/217). The type of diagnostic non-adherence was predominately patients who were not tested when indicated (68.89%, 31/45) with 31.11% (14/45) were tested when not indicated (p<0.05). Patients with an immunocompromised status and patients with prior C. Diff infections were shown to be the most likely to be under-tested. When guidelines were not adhered to the patients increased cost was stay was demonstrated to be a median of 380$ along with an increased length of stay of 66.5 minutes (p<0.05). Guideline adherence showed a reduction in likelihood of representation due to unresolved diarrhea in 72hours by 18.5x (p<0.05). Guidelines adherence also showed that it reduced the likelihood of representation due to unresolved diarrhea in 30 days by 4.8x (p<0.05).

Discussion

This retrospective chart review evaluated adherence to IDSA and ACG guideline-based stool testing in adult patients with acute diarrhea presenting to a rural emergency department. While overall adherence was high, over 20% of cases deviated from guidelines, most commonly due to under-testing in high-risk populations, including immunocompromised patients and those with prior C. difficile infection. Guideline non-adherence was associated with increased emergency department length of stay, higher hospital charges, and greater likelihood of return visits within 72 hours and 30 days. Although causality cannot be inferred, these findings highlight opportunities to improve diagnostic stewardship, reduce unnecessary resource utilization, and enhance patient outcomes through improved guideline adherence.

Conclusion

Of the 217 acute diarrhea cases reviewed from the rural Emergency Department 20.7% of cases were shown to deviate from diagnostic guidelines. Deviating from the diagnostic guidelines led to an increased length cost of stay as well as increased length of stay, Most of the instances of guideline non-adherence indicate under-testing (31 patients making up 14.2% of total patients reviewed). When deviating from diagnostic guidelines the likelihood of patient representation within 72hours and 30 days is increased. Increasing diagnostic compliance leads to a reduction in costs to patients as well as a decreased likelihood of patient representation.

Authors

Brianna Robles, MS3, University of Arizona College of Medicine – Tucson Edgar Ivan Melendrez Alvarado, MS3, University of Arizona College of Medicine – Tucson

Introduction

Introduction Transthoracic echocardiography (TTE) is frequently used during cardiac arrest to evaluate for reversible causes; however, image acquisition often requires interruption of chest compressions and may be limited by patient habitus, mechanical ventilation, or ongoing resuscitative efforts. Interruptions in cardiopulmonary resuscitation (CPR) are associated with worse outcomes, highlighting the need for diagnostic tools that do not compromise CPR quality. Transesophageal echocardiography (TEE) has emerged as an alternative imaging modality that allows continuous, high-quality cardiac visualization during active chest compressions. This focused review examines existing literature comparing TEE and TTE during cardiac arrest and explores the implications of TEE use for diagnosis, CPR quality, and resuscitation management in emergency medicine.

Methods

Methods A focused narrative review of the literature was performed using published emergency medicine and critical care studies evaluating the use of TEE during adult cardiac arrest. Articles were identified that described feasibility, image quality, CPR interruption time, identification of reversible causes, and impact on clinical decision-making. Observational studies, feasibility studies, and narrative reviews conducted in emergency department, intensive care unit, and prehospital settings were included. Studies focusing on pediatric populations or non-arrest indications were excluded. Findings were synthesized to assess the comparative utility of TEE versus TTE during cardiac arrest.

Results

Results Across multiple studies, TEE consistently demonstrated superior image quality compared to TTE during cardiac arrest, particularly during ongoing chest compressions. Unlike TTE, TEE allowed continuous visualization of cardiac activity without requiring pauses in CPR, reducing interruptions associated with pulse checks and diagnostic imaging. TEE improved identification of reversible causes of cardiac arrest, including cardiac tamponade, massive pulmonary embolism, severe hypovolemia, and mechanical cardiac activity consistent with pulseless electrical activity rather than true asystole. Additionally, TEE enabled real-time assessment of chest compression effectiveness, allowing providers to identify suboptimal hand positioning and adjust compression location or depth to improve forward blood flow. Several studies reported that TEE findings directly altered resuscitation management, including initiation of thrombolytic therapy, pericardiocentesis, escalation to extracorporeal cardiopulmonary resuscitation, and decisions regarding continuation or termination of resuscitative efforts. While survival and neurologic outcomes were inconsistently reported, process-of-care improvements were consistently observed.

Discussion

Discussion The existing literature suggests that TEE offers significant advantages over TTE during cardiac arrest by providing uninterrupted, high-quality cardiac imaging during active CPR. The ability to continuously visualize cardiac activity allows for improved diagnostic accuracy and optimization of CPR mechanics, addressing two critical components of high-quality resuscitation. While most available studies are observational and limited by small sample sizes, the consistency of findings across diverse clinical settings supports the feasibility and potential clinical value of TEE in cardiac arrest. Barriers to widespread adoption include the need for specialized equipment, provider training, and institutional protocols. Importantly, current evidence is insufficient to draw conclusions regarding patient-centered outcomes, emphasizing the need for prospective, multi-center studies.

Conclusion

Conclusion Transesophageal echocardiography represents a valuable adjunct to cardiac arrest resuscitation by enabling continuous cardiac visualization without interrupting chest compressions. Compared to transthoracic echocardiography, TEE improves identification of reversible causes, enhances CPR quality assessment, and may directly influence resuscitation management. While further research is needed to evaluate its impact on survival and neurologic outcomes, TEE warrants consideration for standardized implementation in emergency department cardiac arrest protocols.

Authors

Giles Knowles, DO1. Aysha Supplice, MD5, Renée J. Crawford, DO2,3; Ted Swing, PhD4, Steve McCalley, BSN, RN5, Vinay Vaidya, MD4, Ifat Krase, MD2,3, Cindy S. Bauer, MD2,3, Cherisse Mecham, MD1, Kaleena Patel, MD1 Division of Emergency Medicine/Urgent Care, Phoenix Children’s, Phoenix, AZ, USA Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA Division of Allergy and Immunology, Phoenix Children’s, Phoenix, AZ, USA Graduate Medical Education, Phoenix Children’s, Phoenix, AZ, USA Medical Informatics, Phoenix Children’s, Phoenix, AZ, USA Division of Pediatrics, Phoenix Children’s, Phoenix, AZ, USA

Introduction

Anaphylaxis is a life‑threatening condition for which intramuscular (IM) epinephrine is the recommended first‑line treatment and should be given at the first sign of anaphylaxis. Delays in epinephrine administration are associated with increased hospitalizations, biphasic reactions, and fatalities. Literature also supports shorter observation times after epinephrine in low-risk populations and selective use of adjunct medications. Across three pediatric emergency departments (EDs), we identified significant variability in recognition and management of anaphylaxis. This QI project was a collaborative effort between the ED and institutional Allergy team with a primary aim to improve treatment of anaphylaxis by reducing time from patient check-in to receiving IM epinephrine (TTE) to less than 30 minutes within 8 months. Our secondary aims included reducing post-epinephrine observation time (obs time), ED length of stay (LOS), and adjunct medication use by 25% over the same time frame. Counterbalance measures included ventricular arrhythmias and ED bounce backs.

Methods

This was an institutional IRB exempt QI project using Plan–Do–Study–Act (PDSA) cycles in one academic and two community pediatric EDs. Baseline data were collected for the two months preceding intervention (1/1/25-3/3/25) and included all patients that received IM epinephrine in the ED with a diagnosis of anaphylaxis. Outcomes were then tracked longitudinally across 3 PDSA cycles from 3/3/25 to 11/20/25: (1) development of a standardized pathway, (2) department education, (3) implementation of a standardized anaphylaxis order set.

Results

Median TTE improved from 41.5 minutes at baseline to 34 minutes after PDSA 3 with an 18.1% reduction. Median obs time after IM epinephrine decreased from 265.5 minutes at baseline to 206 minutes in PDSA 3 with a 22.41% reduction. Median LOS for patients who received IM epinephrine decreased from 318 minutes to 252 minutes, with a 20.8% reduction. Adjunct medications were prescribed in 80% of baseline encounters compared to 71.6% in PDSA 3 (10.5% reduction), with a shift from first- to second generation antihistamines and reduced steroid and famotidine use. No ventricular arrhythmias or ED bounce backs were observed.

Discussion

Improvement was seen in TTE with a median reduction of 7,5 minutes or 18.1%. Factors that may limit our improvement include diagnostic uncertainty (e.g., isolated angioedema versus anaphylaxis), contributing to delayed treatment. Observation time and LOS are trending towards our 25% reduction target. Adjunct medication use decreased but did not meet the targeted reduction; however, prescribing patterns shifted toward guideline-concordant therapies. Limitations include reliance on retrospective chart review, staff turnover, and need for ongoing education. Generalizability may be limited in non-pediatric EDs or lower-resource settings.

Conclusion

This QI initiative improved multiple aspects of pediatric anaphylaxis management across academic and community EDs, achieving meaningful reductions in TTE, observation time, ED length of stay, and adjunct medication use in patients who received IM epinephrine for presumed anaphylaxis in the ED. However, continued efforts are needed to consistently meet our targets with each of these goals.

Authors

Brianna Robles, 3rd year medical student - The University of Arizona Tera Henson, Clinical Research Manager Joshua B Gaither, MD Mary Knotts, MD Philipp Hannan, MD Rachel Munn, DO Tyrel Fisher, MD Jocelyn Robinson, MD Reese Byerrum, MD Brianna Dolana, MD Amber D Rice, MD

Introduction

Ventricular fibrillation with low amplitude electrical activity can be difficult to distinguish from asystole in the prehospital environment. Factors such as monitor settings, electrode placement, and signal artifact may contribute to rhythm misclassification. Because defibrillation is the definitive treatment for ventricular fibrillation, failure to recognize this rhythm may adversely affect patient outcomes. Conversely, the potential harm of a single defibrillation attempt in true asystole is believed to be low. This quality improvement initiative evaluated whether implementation of a single diagnostic shock (SDS) protocol for patients initially identified as asystole could improve resuscitation outcomes across three urban and suburban EMS agencies operating within a single regional EMS system.

Methods

This prospective quality improvement project was conducted within a single regional EMS system encompassing three urban and suburban EMS agencies. Adult patients with non-traumatic out of hospital cardiac arrest and an initial monitor interpretation of asystole were included. Exclusion criteria included traumatic arrest, documented do-not-resuscitate orders, or age under 18 years. The SDS protocol allowed paramedics to deliver one biphasic defibrillation early in resuscitation when rhythm uncertainty persisted, followed immediately by cardiopulmonary resuscitation. Outcomes following protocol implementation (January–December 2024) were compared with a pre-implementation cohort (January–December 2023). The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included survival to emergency department arrival, hospital admission, and survival to hospital discharge.

Results

A total of 766 patients met inclusion criteria, with 404 patients in the pre-implementation group and 362 patients in the post-implementation group. Implementation of the SDS protocol was not associated with a statistically significant difference in ROSC (OR 0.88, 95% CI 0.59–1.30). Similarly, no significant differences were observed in survival to hospital admission (OR 0.70, 95% CI 0.47–1.04) or survival to hospital discharge (OR 0.81, 95% CI 0.34–1.93). Measures of CPR quality remained unchanged between groups.

Discussion

Despite a physiologically plausible rationale, use of a single diagnostic shock did not result in improved resuscitation or survival outcomes among patients initially identified as asystole. These findings suggest that either misclassification of fine ventricular fibrillation is uncommon or that a single early defibrillation is insufficient to meaningfully alter outcomes at the system level. Broader resuscitation factors, including early rhythm assessment and overall resuscitation quality, may have a greater impact on patient survival.

Conclusion

In this multi-agency EMS quality improvement initiative, implementation of a single diagnostic shock protocol for patients with presumed asystole did not improve ROSC or survival outcomes. While the conceptual benefits of SDS remain compelling, its impact in routine prehospital practice appears limited. Larger multicenter studies may help identify patient subgroups or operational settings in which this approach could be beneficial.

Authors

Yousef Sarameh BS1, Jacob Barnard MS1, Madison Gackle BS1, Kirat Sraa BS1, Anthony Santarelli PhD1,2, Diana Lalitsasivimol PhD2, Tyrus Nelson BS2, Jacqueline Neff BBA2, John Ashurst DO, EdD, MS1,3 Affiliations: Midwestern University Arizona College of Osteopathic Medicine Kingman Regional Medical Center Office of Research and Sponsored Programs Kingman Regional Medical Center, Department of Emergency Medicine

Introduction

Pulmonary embolism (PE) is a life-threatening condition in which a blood clot blocks circulation to the lungs In the United States, an estimated 115 cases per 100,000 are reported every year, with between 100,000 to 300,000 deaths annually. PE can present with relatively non-specific symptoms making diagnosing PE a challenge, often leading to patient admission and rigorous workups. This increased utilization of resources may be problematic in a low resource setting. The advent of direct oral anticoagulants have made outpatient treatment of pulmonary embolism feasible in select low-risk patients. The simplified PE severity score (sPESI) is a clinical stratification tool that can identify such patients. Investigating patient outcomes based on sPESI scores is necessary to further validate its use and assess its potential role in optimizing resource utilization.

Methods

A retrospective chart view from 1/1/20 to 12/31/24 that includes patients presenting to the ER with Pulmonary embolism was conducted. Patients who were transferred were excluded from this study. Patients were categorized by their sPESI score (0-6). Data abstraction was conducted using a structured data abstraction tool, and statistical analysis of disposition and outcomes (length of stay, mortality, disposition, and 30-day readmittance) were conducted using binomial logistic regression, Spearman’s rank correlation, and Kruskal-Wallis tests.

Results

502 patients were included in this study with a mean age of 67.5, with 55.8% being males and 44.2% being females. 73% of patients scored with a sPESI of 0 were admitted. Length of stay differed significantly between different scores (p < 0.001, Spearman’s rho = 0.244). Pairwise comparisons between the different groups revealed statistical differences between the length of stay for a score of 0 and scores 1-3 (p <0.05). There was no difference between any other groups. There was also no statistical significance between the different sPESI scores for 30-day mortality and readmittance within 30-days. Overall, the 30-day mortality rate was 4.6%, with congestive heart failure and advanced malignancies being the primary cause.

Discussion

Higher sPESI scores were significantly associated with increased hospital length of stay, with the difference observed between patients with scores of 0 and 1–3. Despite this, a majority of patients with an sPESI score of 0 were admitted, suggesting underutilization of outpatient management strategies. No significant association was found between sPESI score and 30-day mortality or readmission, with deaths largely attributable to underlying comorbidities rather than PE severity. These findings support the use of sPESI to identify low-risk patients who may be suitable for outpatient management while emphasizing the need for clinical judgment.

Conclusion

Pulmonary embolisms can be life threatening if not properly addressed. Our statistical analysis shows that a sPESI greater than zero is correlated with an increased length of stay. This suggests that patients with a score of zero may be appropriate candidates for outpatient treatment. The sPESI failed to predict 30-day mortality and readmittance within our patient population.

Authors

Authors: Madison Golla, BS, Jacqueline Neff, BBA, Tyrus Nelson, BS,, Diana Lalitsasivimol, PhD, Anthony Santarelli, PhD, John Ashurst, DO, EdD, MS Affiliation: Midwestern University, Arizona College of Medicine, Kingman Regional Medical Center, Office of Research and Sponsored Programs

Introduction

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening bacterial soft tissue infection that spreads along fascial planes, most commonly caused by gram-positive organisms such as Staphylococcus aureus and Group A streptococci. It carries a high mortality rate (20–80%) due to complications including sepsis and multiorgan failure. Due to NF mimicking other soft tissue infections, diagnosis is frequently delayed, increasing morbidity and mortality. Management in rural, resource-limited settings is poorly understood; therefore, this study examines patient presentation, diagnostic approaches, clinical tools, and outcomes in such environments.

Methods

A retrospective cohort study of patients aged 18 or older who presented to the Kingman Regional Medical Center (KRMC) and were diagnosed with Necrotizing fasciitis between January 1, 2019, and December 31, 2024 was conducted. Data was collected following a structured data abstraction tool and included patient demographics, comorbidities, vitals, laboratory measures/classifications, imaging results, disposition, timing of general surgery procedures, length of stay, surgically/histologically confirmation of NF cases, and patient recovery outcomes/measures. Data was analyzed using descriptive statistics. Categorical variables were assessed via the chi-squared test and continuous variables via the Kruskal-Wallis test.

Results

A total of 93 patients with suspected necrotizing fasciitis (NF) were identified, with 69.9% admitted and 30.1% transferred. The cohort was predominantly Caucasian (70.97%), non-Hispanic (86.02%), and male (70.97%), with diabetes mellitus (54.84%), peripheral vascular disease (15.05%), and congestive heart failure (9.68%) as the most common comorbidities. No demographic or clinical variables were significantly associated with patient disposition. Diagnostic evaluation demonstrated moderate sensitivity but limited specificity for both CT-detected gas formation (sensitivity 76.19%, specificity 47.06%) and LRINEC score ≥6 (sensitivity 76%, specificity 44%). Patients who underwent surgical debridement on the day of presentation were significantly less likely to require critical care interventions (21.2% vs 45.8%, p=0.048) and had lower mortality rates (8.6% vs 28.0%, p=0.046). While the number of debridements did not significantly affect ICU admission or in-hospital mortality, patients requiring multiple surgical interventions were more likely to represent within 30 days (p=0.044).

Discussion

In this cohort, commonly used diagnostic tools for NF demonstrated limited specificity, highlighting the ongoing challenge of accurately identifying NF in resource-limited settings. Importantly, early surgical intervention was associated with significantly improved clinical outcomes, including reduced need for critical care and lower mortality, underscoring the critical role of timely debridement. The lack of association between demographic or comorbid factors with patient disposition suggests that clinical decision-making may rely more heavily on disease severity and institutional resources rather than patient characteristics alone. Increased 30-day representation among patients requiring multiple debridements may reflect greater disease burden or incomplete source control, warranting closer follow-up

Conclusion

Necrotizing fasciitis remains a challenging diagnosis, with commonly used diagnostic tools demonstrating limited specificity. Early surgical debridement was associated with significantly improved outcomes in patients with suspected necrotizing fasciitis, while commonly used diagnostic tools showed limited specificity. These findings emphasize the need for high clinical suspicion and surgeon availability, particularly in resource-limited settings.

Authors

Haley Furman, MD, Creighton University Thanh "Elise" Tran, DO, Creighton University Emily Marine, University of Arizona College of Medicine Phoenix Shirley Shao, MD Valleywise Health Megan McElhinny, MD, Valleywise Health

Introduction

Opioid related ED visits and deaths in Arizona exceed the national average, underscoring the need to optimize availability of naloxone in our state. As the Emergency Department (ED) is often a primary point of contact for patients experiencing opioid use disorder (OUD), distribution of naloxone from the ED is vital in contributing to the prevention of opioid overdose. In this study, we sought to examine naloxone prescribing practices in our county ED in Phoenix, AZ to determine strategies for increasing the availability of naloxone.

Methods

This is a retrospective chart review describing naloxone prescribing practices for adult patients discharged with a diagnosis related to OUD from a large, urban hospital ED from 2018 to 2022. The primary outcome was whether patients with a disposition diagnosis code related to OUD were prescribed naloxone at discharge. Secondary outcomes included whether naloxone was dispensed for these patients from a hospital system pharmacy, and whether that naloxone was dispensed under a prescription or by statewide standing order. Data on primary outcomes, secondary outcomes, and patient demographics were analyzed with descriptive statistics to characterize patterns over time.

Results

From 2018 to 2022 the total number of opioid related encounters (12,444) exceeded unique patient encounters (8,442). Of these encounters, 6,645 included the diagnosis of OUD. Among those with a diagnosis of OUD, a minority received a prescription for naloxone (11.1%). Only 35.1% of patients who were prescribed naloxone obtained it from the pharmacy, with almost 2% accessing naloxone from a standing order. Year to year comparison of unique patients with OUD revealed an increase in OUD related visits over time, with the highest year being 2022. Patients who received a naloxone prescription significantly increased from 2018 (1.64%) to 2022 (17.9%). Patients who were dispensed naloxone varied year to year with the maximum proportion of naloxone dispensed in 2019 (47%). Patients with a diagnosis of opioid adverse events were predominantly white (79.2%), middle-aged (39.8 mean age), and English-speaking (92.8%). Males were significantly more likely to be prescribed naloxone compared to Females (p value <.001). Black/African Americans (p value .003) and Hispanic/Latino (p value <.001) patients were more likely to be prescribed naloxone. Spanish speaking patients were significantly less likely to be prescribed naloxone (p value .001).

Discussion

Most patients with an OUD diagnosis in our hospital system were not prescribed naloxone for all years, although prescription rates did increase significantly over time. While prescription rates increased, fill rates decreased from 2019 to 2022 and cannot be accounted for by standing order or over-the-counter naloxone. These findings demonstrate the significant opportunity that emergency medicine practitioners have to provide life-saving interventions (naloxone) and resources to those suffering from OUD.

Conclusion

ED prescriptions of naloxone are vital for patient distribution and ultimately opioid overdose prevention. While there has been a significant increase in availability of naloxone through over-the-counter approval from the FDA since March 2023, there remains significant opportunity for intervention in the ED to contribute to naloxone distribution and availability strategies, such as new programs including take-home naloxone from the ED.

Authors

Jacob Barnard, MS1, Madison Gackle, BS1, Kiratpreet Sraa, BS1, Yousef Sarameh, BS1, Jacqueline Neff, BBA2, Tyrus Nelson, BS2, Diana Lalitsasivimol, PhD2, Anthony Santarelli, PhD1,2, Heather Miller, RN3, Adam Dawson, DO3 John Ashurst, DO, EdD, MS1,3 Affiliations: Midwestern University, Arizona College of Medicine1, Kingman Regional Medical Center, Office of Research and Sponsored Programs2, Kingman Regional Medical Center, Department of Emergency Medicine3

Introduction

The American healthcare system has seen a 0.16% yearly increase in substance use disorder (SUD) presentations and mortality over the past two decades. Rural communities appear at significant risk with an estimated 43.7% increase in the number of presentations for care. Due to this, healthcare systems have evolved to identify patients at risk for SUD by integrating Screening, Brief Intervention, and Referral to Treatment (SBIRT) processes. SBIRT is used to identify substance use early to prevent or reduce health related consequences, disease, accidents, and injuries through an early intervention approach. Data from SBIRT initiatives can elucidate the epidemiology of substance use within communities and be used to evaluate the healthcare burden of managing and assessing patients with SUD. The objective of the study is to evaluate the epidemiology of substance use behavior in a rural southwest population and assess the frequency of emergency department (ED) bounce-backs, presentations, and costs among users and non-users.

Methods

A retrospective chart review of all patients presenting to the ED evaluated with an SBIRT process between 10/01/2024 and 06/01/2025 was conducted. Results from the National Institute on Drug Abuse (NIDA) Modified Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) for frequency of abuse for prescription drugs, illegal drugs, tobacco, and alcohol were assessed by sex and age. Individuals were identified as substance dependent if they reported using weekly or daily. To determine healthcare utilization and costs, the number of patients presenting to the ED within 72 hours and 30 days was collected, along with the total amount of ER charges billed to the patient’s insurance upon initial presentation. Data were analyzed with IBM SPSS Statistics V30, using the chi-squared test for categorical variables and the independent-samples t-test for continuous variables, based on frequency of use (daily, weekly, monthly, once, never).

Results

A total of 13,573 unique patients were evaluated with the NIDA screening tool. A total of 0.84% (113/13,573) of patients were identified as dependent upon prescription medications, 3.69% (501/13,573) upon illegal drugs, 15.83% (2,148/13,573) upon tobacco products, and 7.49% (1,016/13/573) upon alcohol. Patients dependent upon illegal drugs (4.99% vs 2.76%, p = 0.0032) and tobacco products (3.72% vs 2.71%, p = 0.0106) were more likely to bounce-back within 72 hours of initial presentation to the ED. Patients dependent upon illegal drugs (15.77% vs 11.68% p = 0.0056) were more likely to represent within 30 days following initial presentation to the ED. Patients dependent upon alcohol had a higher cost associated with their initial presentation to the emergency department than those not dependent on alcohol ($4,333 + $71.6 vs $4,039 + $19.4, p < 0.001).

Discussion

This study demonstrates that substance use dependence remains common in a rural Southwest emergency department population and is associated with increased healthcare utilization and costs. Patients reporting frequent use of illegal drugs and tobacco were more likely to return to the emergency department within 72 hours and 30 days, while alcohol dependence was associated with higher visit-related charges. These findings highlight the emergency department as a critical setting for identifying substance use behaviors and underscore the potential value of SBIRT programs to reduce repeat visits and resource strain in rural healthcare systems.

Conclusion

Substance use dependence remains a concern within rural communities and the emergency providers that serve rural communities. Given the higher rates of healthcare representation among substance users, rural EDs should consider instituting mechanisms to evaluate substance use and provide brief treatment or referral to treatment when feasible

Authors

Matthew Gue1, Raymond Gue2, John Ashurst, DO, MSC3 1Midwestern University Arizona College of Osteopathic Medicine, Glendale, Arizona, USA 2University of California, Los Angeles, Los Angeles, CA, USA 3Clinical Assistant Professor, Midwestern University Arizona College of Osteopathic Medicine, Glendale, AZ, USA; Department of Emergency Medicine, Kingman Regional Medical Center, Kingman, AZ, USA

Introduction

Videolaryngoscopes provide many key advantages over direct laryngoscopy, including an improved view of the glottis and a greater first-attempt success rate. However, videolaryngoscopy systems are costly and not as accessible in lower-income countries and hospital systems. 3D printing has revolutionized medical tools by allowing for rapid prototyping and low-cost devices. In particular, 3D-printed videolaryngoscopes have already demonstrated their clinical viability as many anesthesia providers have implemented these devices on their medical missions around the world.

Methods

The GHAVL was designed with a computer-aided design software and 3D-printed from polylactic acid filament using the Bambu Labs P2S printer. A low-cost device was developed and revised after discussion with emergency medicine physicians with more than 40 years of experience with the goal of containing excess wires and enabling single-operator use. The device was designed to integrate with an industrial endoscope camera compatible with a smartphone for viewing. Finite element analysis was conducted to determine the mechanical performance under incremental loads at the tip of the blade.

Results

The GHAVL consists of two main components: the blade/handle unit and the phone mount. The blade/handle unit was designed with a hollow handle to contain excess wires, and the two components connect via a snap-twist mechanism for rapid, reliable joining. The phone mount positions the smartphone for real-time visualization. Finite element analysis demonstrated the GHAVL blade tip displacements of 2.1mm, 4.2mm, 6.4mm, 12.7mm, 17.0mm, and 21.2mm under a load of 50N, 100N, 150N, 300N, 400N, and 500N, respectively.

Discussion

These findings suggest that the GHAVL addresses key limitations of existing 3D-printed video laryngoscopes. The GHAVL addresses excess wires through a hollow handle and allows a single operator to seamlessly view the live video footage while controlling the laryngoscope. Another benefit of this modular design is the ability to use the blade/handle unit as a standard laryngoscope without the other components, although an external light source would have to be supplied. Finite element analysis also demonstrates the device’s ability to withstand forces consistent with clinical laryngoscopy, although further strength testing is needed.

Conclusion

The GHAVL is a modular system that integrates with an industrial endoscope and smartphone to create a low-cost, single-operator videolaryngoscope. Stress testing suggests the GHAVL’s structural integrity and ability to withstand forces of up to 150N with minimal blade deformation. The GHAVL demonstrates great promise, but it still requires rigorous physical strength, sterilization, and simulation-based testing to determine its clinical applicability.

Authors

Chris Thompson, DO, MHA Creighton University East Valley Emergency Medicine (CUEVA) Emergency Medicine, PGY-2 Josh Burton, DO Creighton University East Valley Emergency Medicine (CUEVA) Emergency Medicine Attending Physician

Introduction

Granulomatosis with polyangiitis (GPA) is a systemic necrotizing vasculitis affecting small- and medium-sized vessels, classically involving the respiratory tract and kidneys. Cardiac involvement occurs in up to 61% of GPA patients when assessed by cardiac MRI, though it often remains subclinical. Conduction system abnormalities represent a rare but potentially life-threatening manifestation, caused by granulomatous lesions within the conduction system or arteritis of the atrioventricular nodal artery. We present a case of complete atrioventricular (AV) block as the initial presentation of previously undiagnosed GPA in a healthy middle-aged adult.

Methods

Not Applicable

Results

A 45-year-old male with no past medical history presented to the emergency department with syncope and bradycardia. He reported three episodes of intermittent bradycardia with subsequent syncope prior to arrival, unrelated to exertion or positional changes. He denied chest pain, shortness of breath, or constitutional symptoms. On examination, he was diaphoretic and anxious with a heart rate of 40 bpm, blood pressure 149/65 mmHg, and oxygen saturation 99% on supplemental oxygen. Cardiac examination revealed bradycardia with faint peripheral pulses. Laboratory evaluation showed leukocytosis (WBC 14.0) with neutrophilia (84.4%), normal electrolytes, creatinine 1.11 mg/dL, and troponin 11 ng/L. Electrocardiogram demonstrated complete AV block with a ventricular rate of approximately 40 bpm. During evaluation, the patient became acutely symptomatic, stating "Hey Doc, I'm going down" before near-syncope with heart rate dropping to 18 bpm. Transcutaneous pacing was initiated with immediate improvement. Atropine was avoided given its limited efficacy in infranodal blocks. The patient was transitioned to transvenous pacing, followed by permanent dual-chamber pacemaker implantation. Subsequent genetic and serologic testing revealed a new diagnosis of GPA.

Discussion

This case highlights GPA as a rare but important etiology of complete AV block in young patients without traditional risk factors. In GPA, cardiac conduction abnormalities result from granulomatous inflammation directly affecting the AV node or vasculitis of the nodal artery. Cardiac involvement is an independent risk factor for mortality in GPA patients. Despite immunosuppressive therapy, permanent pacemaker implantation is often required for complete AV block in this population. Emergency physicians should consider systemic inflammatory conditions in the differential diagnosis of unexplained complete heart block, particularly in younger patients without structural heart disease or typical risk factors.

Conclusion

Complete AV block may be the initial manifestation of GPA. Early recognition of this association enables timely diagnosis and appropriate management, including both cardiac pacing and immunosuppressive therapy.

Authors

Madison Gackle, BS, Midwestern University, Arizona College of Osteopathic Medicine Kiratpreet Sraa, BS, Midwestern University, Arizona College of Osteopathic Medicine Yousef Sarameh, BS, Midwestern University, Arizona College of Osteopathic Medicine Jacob Barnard, MS, Midwestern University, Arizona College of Osteopathic Medicine Jacqueline Neff, BBA, Kingman Regional Medical Center, Office of Research and Sponsored Programs Tyrus Nelson, BS, Kingman Regional Medical Center, Office of Research and Sponsored Programs Diana Lalitsasivimol, PhD, Kingman Regional Medical Center, Office of Research and Sponsored Programs Anthony Santarelli, PhD, Kingman Regional Medical Center, Office of Research and Sponsored Programs Derek Meeks, DO, Kingman Regional Medical Center, Emergency Department John Ashurst, DO, EdD, MS, Midwestern University, Arizona College of Osteopathic Medicine, Kingman Regional Medical Center, Emergency Department

Introduction

Skin and soft tissue infections (SSTI) occur due to a breach in the skin barrier, allowing for bacteria to enter and cause infection. SSTIs present clinically to the emergency department (ED) as cellulitis, folliculitis, necrotizing fasciitis, skin abscesses, and more. Of these, abscesses and cellulitis are the most common with standard treatment encompassing either incision and drainage (I&D) and/or treatment with antibiotics. However the guidelines for treatment type, duration, and antibiotic use vary by differing guidelines.

Methods

A retrospective chart review of patients aged 18 or older who were diagnosed with abscess, cellulitis, or a combination of both as part of their ED work-up between January 1, 2020, and December 31, 2024 was conducted. Data collected included baseline demographics, laboratory values associated with the index visit to the ED, antibiotic treatments, re-presentations to the ED, and hospital admissions due to SSTIs. Treatment compliance was compared to recommendations by the Emergency Physician Resident’s Association (EMRA), Infectious Disease Society of America (IDSA), American Academy of Family Physicians (AAFP), University of California, San Francisco (UCSF), and Stanford guidelines. Categorical variables were assessed via the chi-squared test and continuous variables via the Kruskal-Wallis test.

Results

A total of 600 cases were included in the analysis with 75.5% (453/600) with a clinical presentation of cellulitis, 13.7% (82/600) cases of abscesses, and 10.8% (65/600) cases of abscess and cellulitis. The median age of the sample was 53 years (IQR: 27.5), with the sample containing 59.5% (357/600) male and 40.5% (243/600) female. Overall treatment compliance was 41% (246/600) with EMRA, 48.7% (292/600) with IDSA, 39.7% (56/141) with AAFP, 8.7% (52/597) with UCSF, and 36.8% (211/574) with Stanford. Compliance increased between 2020 and 2024 by 22.5% with EMRA (p=0.001), 15.5% with IDSA (p=0.044), 34.4% with AAFP (p<0.001), 3.6% with UCSF (p=0.180), and 19.9% with Stanford (p=0.003). There was no difference between re-presentation rate between patients treated compliant or not with the EMRA (p=0.256), IDSA (p=0.186), AAFP (p=0.454), and Stanford (p=0.497) guidelines. Patients treated compliantly with UCSF were more likely to re-present (p=0.014).

Discussion

Compliance to IDSA was the most likely compliance, despite overall compliance still remaining suboptimal. This could have been related to the overall brevity of the guidelines. Patients treated compliantly to the UCSF guidelines were more likely to represent, most likely due to overall underdosing in comparison to the other guidelines. Compliance over the 5 year evaluation did yield overall improvement to the guidelines. This is most likely due to coming out of the pandemic and more towards prior practice patterns.

Conclusion

Despite established clinical guidelines, overall treatment compliance remained low across all of the guidelines analyzed. However, compliance rates with clinical treatment guidelines at a community ED are not always indicative of patient re-presentation to the ED.

Authors

Alexandria Foster DO, Lindsay Williams DO, Jordan Hilton DO, Geoff Comp DO

Introduction

Single-use epinephrine auto-injectors limit anaphylaxis care in wilderness settings. We evaluated EpiPen Jr. mechanics and redosing feasibility (0.15 mg/0.3 mL). Disassembly is described; risks include dosing inaccuracy and pediatric safety concerns. Further study is needed.

Methods

Background: Anaphylaxis requires IM epinephrine; 7.7% need repeat dosing. Single-use auto-injectors (EpiPen 0.3 mg; EpiPen Jr 0.15 mg) limit management of refractory reactions, particularly in pediatric patients in austere wilderness environments.Carrying multiple epinephrine auto-injectors is safest for refractory anaphylaxis, but wilderness constraints have led to off-label extraction methods that remain unapproved and unstudied in pediatric populations.

Results

Epipen Deconstruction: In remote emergencies, trained providers may disassemble a pediatric EpiPen Jr as a last-resort for persistent anaphylaxis, ensuring sterile technique, correct dosing, and EMS coordination. Both EpiPen and EpiPen Jr deliver 0.3 mL per injection, but the EpiPen contains 0.3 mg (1 mg/mL) and the Jr 0.15 mg (0.5 mg/mL). Both use a glass-barrel syringe with a white plunger, black rubber tip, and attached needle. After initial use, additional doses can be manually withdrawn by inverting the syringe, adding air, returning it needle-down, and depressing the plunger to ensure accurate dosing. Non-expired devices should contain clear liquid.

Discussion

Pediatric Considerations: In remote emergencies, trained providers may disassemble a pediatric EpiPen Jr as a last-resort for persistent anaphylaxis, ensuring sterile technique, correct dosing, and EMS coordination. Both EpiPen and EpiPen Jr deliver 0.3 mL per injection, but the EpiPen contains 0.3 mg (1 mg/mL) and the Jr 0.15 mg (0.5 mg/mL). Both use a glass-barrel syringe with a white plunger, black rubber tip, and attached needle. After initial use, additional doses can be manually withdrawn by inverting the syringe, adding air, returning it needle-down, and depressing the plunger to ensure accurate dosing. Nonexpired devices should contain clear liquid.

Conclusion

Research gaps include safety, dosing accuracy, and residual epinephrine stability. Validated extraction methods, wilderness guidelines, and training are needed. In austere settings, even partial epinephrine is better than none for delayed care. ***Additional Comment: The outline of our paper/poster is fairly niche and doesn't quite follow the prompts that are outlined in this form. ***

Authors

Adan Escamilla - first author. Arron McMurray - second author. John Ashurst, DO - last/senior author. Midwestern University Arizona College of Osteopathic Medicine.

Introduction

Air pollution is a well-established trigger of acute exacerbations in chronic obstructive pulmonary disease (COPD). Arizona presents a unique exposure environment characterized by desert particulate matter, ozone, hazardous air pollutants (HAPs), and recurrent wildfire activity. However, population-level evidence linking ambient air quality to COPD morbidity in this setting remains limited, particularly at the statewide scale.

Methods

We evaluated associations between ambient air quality and COPD emergency department (ED) visits, hospitalizations and mortalities across Arizona counties from 2005–2022 (except wildfire data which was 2005-2015). Annual county-level COPD ED visit, hospitalization, and mortality counts were obtained from state health data and normalized per 100,000 population. Exposure measures included EPA-modeled annual concentrations of selected HAPs, exceedance metrics for PM₂.₅, PM₁₀, and ozone from the Air Quality System, and wildfire burn acreage. Negative binomial regression with population offsets was used for count outcomes, with complementary linear and nonparametric analyses for visit rates.

Results

Across Arizona counties (2005–2022), annual air quality metrics were not positively associated with COPD outcomes. In negative binomial mixed models, wildfire burn acreage was not associated with COPD ED visits (p > 0.50). PM₁₀ exceedance percentage showed statistically significant inverse associations with COPD ED visits (IRR = 0.87 per 10-percentage-point increase, p < 0.001), while hospitalizations were non-significant and mortality was borderline inverse (p = 0.087). Ozone exceedance days were inversely associated with ED visits (IRR = 0.93 per 10 days, p = 0.036) and hospitalizations (p = 0.014). Associations with 1,3-butadiene were inconsistent across outcomes. At this resolution, the available data were insufficient to demonstrate statistically significant associations between annual air quality metrics and COPD ED visits, hospitalizations, or mortality.

Discussion

N/A

Conclusion

Despite strong mechanistic and clinical evidence that air pollution precipitates COPD exacerbations, our findings suggest that annual, county-level surveillance data are insufficiently granular to detect these acute exposure–response relationships. The absence of detectable associations may reflect temporal and spatial exposure misclassification rather than true null effects. These results highlight a critical limitation of current public health monitoring systems and underscore the need for higher-resolution environmental and health data—particularly short-term exposure metrics aligned with acute clinical outcomes—to adequately quantify pollution-related COPD burden in regions with complex air quality profiles such as Arizona.

Authors

Elise Bouchal, Mark Moroz, Berit Lubben

Introduction

Gangrene is a form of tissue necrosis that results from ischemia or bacterial infection. It is a potentially life-threatening condition that often requires urgent clinical intervention. This case of advanced bilateral dry gangrene secondary to peripheral vascular disease highlights the complex, chronic progression of this condition, including discussion of independent risk factors, psychological impact, and complexities in management.

Methods

N/A

Results

We present a 53-year-old woman with a history of peripheral vascular disease who presented to the emergency department (ED) complaining of severe bilateral lower extremity pain. She was found to have advanced dry gangrene of both legs with severe stenosis and occlusions in multiple lower extremity arteries. She had presented twice to the ED within the prior month with progressive necrosis; and had left against medical advice at both of these encounters after the possibility of amputation was discussed. On her third ED presentation, she was admitted to the hospital and underwent a right above the knee and left below the knee amputation.

Discussion

This patient presented with various risk factors for peripheral vascular disease including end stage renal disease (ESRD), atherosclerosis, hypertension, and type 2 diabetes mellitus that predisposed her to gangrene (Nandakumar et al., 2024). Additionally, the patient’s recent CABG surgery with a poorly healed incision at the harvest site, presented a significant factor to the progression of the bilateral gangrenous necrosis. The patient had several episodes of leaving against medical advice (AMA) after amputation was discussed, highlighting the complexity of the psychological and social factors that may not be immediately apparent. This highlights the importance of patient informed consent, as well as factors including socioeconomic and insurance status, that may play into a patient leaving AMA.

Conclusion

The bilateral nature of the gangrene and the patient’s history of severe stenosis and occlusions in multiple lower extremity arteries emphasize the muli-factorial effect of the patient’s pre-existing conditions and her CABG, culminating in amputation. Despite not managing chronic conditions, Emergency physicians should be wary when a patient with a similar history presents to the emergency room. The patient ultimately elected for successful amputation, however, consistent access to care and management of several chronic diseases including ESRD and atherosclerosis might have improved outcomes.

Authors

Colleen Leu-Turner, MD Creighton of Phoenix Arizona EM Residency Elise Tran, DO Creighton of Phoenix Arizona EM Residency Brett Armstrong, DO Creighton of Phoenix Arizona EM Residency Geoff Comp, DO Creighton of Phoenix Arizona EM Residency

Introduction

The preparedness of the medical team in emergent situations is paramount to facilitate the best probability of a favorable outcome for patients. In training facilities, there is a constant influx of new interns thrust into unfamiliar environments with expectations of seasoned learners. While simulation training is necessary for mastering the steps of a procedure, these environments vary in design and layout from the trauma bays in the emergency department where the resident works. The unfamiliarity and non-uniformity of these environments in stressful situations can lead to delays in various stages, most notably gathering supplies, affecting procedure preparedness, and intern confidence. In a practice session, learners will have dedicated non-patient care time in the emergency department trauma bay to practice gathering these supplies for various procedures using a tangible reference, as they might in a real scenario. The session aims to help learners feel more comfortable and confident in quickly gathering supplies in an unfamiliar location for these critical procedures.

Methods

This educational session equips learners with the resources to practice gathering supplies and preparing for emergent procedures outside a simulated session, which often does not mirror the trauma bay where learners are expected to perform quickly and accurately. 22 residents from the intern class participated in the learning sessions. Pre/post-event educational surveys with a 10-point modified Likert scale, ranging from “strongly disagree” (0) to “strongly agree” (10), were collected to assess learners' comfort with the steps and their ability to gather supplies. No control group. All participants will complete a pre- and post-event survey. All data was de-identified.

Results

Attendees of the sessions were asked to complete a Likert scale from 0 to 10 in a pretest and a post-test, using the same questions regarding comfort with various critical procedures. Twenty-three pretests were completed, and 22 post-tests were completed with a post-test completion rate of 100%. These scores were analyzed using a Wilcoxon signed-rank test to compare the pre- and post-test scores. Post-intervention improvement averaged 67.68 points, resulting in a 51.9% increase in rated comfort among interns, with each question having a p-value of 0.001.

Discussion

The trauma orientation session provided a novel, meaningful learning experience that improved learners’ comfort with finding supplies for critical procedures in an unfamiliar environment. This design can be utilized and modified for any environment or learner level to introduce an individual before adding pressure from a time-sensitive critical procedure. While simple in design, it provides a framework to support new learners as they grow in an otherwise daunting and overwhelming environment.

Conclusion

This orientation session aims to aid the learner in the early stages of training by providing a tangible written reference and simulated scavenger hunt for the most common procedures performed in the emergency department trauma bay, while creating a low stress environment for familiarizing themselves. Our study supports that learners benefited from an educational session that made them feel more confident in preparedness for these critical procedures.

Authors

Josephine Valenzuela, MD, Valleywise Health, valenzuelaje@gmail.com Christopher Borowy, DO, Valleywise Health, Christopher_Borowy@dmgaz.org Paul Kang, MS, MPH, Creighton University School of Medicine, paulkang@creighton.edu Carlos Gonzalez, BS, Creighton University School of Medicine, cag29808@creighton.edu Andrew Keown, MD, Creighton University School of Medicine, andrewkeown@creighton.edu

Introduction

National recommendations suggest emergency medicine (EM) residents perform 25–50 supervised point-of-care ultrasound (POCUS) studies per core application to achieve proficiency, though these thresholds lack validation. This study examines echocardiography learning curves within an EM residency.

Methods

This was an IRB–approved, retrospective review of POCUS echocardiography studies performed by a single EM residency class (n=16). Exclusion criteria included patients < 18 years old, cardiac arrest cases, procedure-related or interrupted studies, patient-intolerance terminations, and attending-performed studies. Two ultrasound fellowship-trained EM faculty independently and blindly scored each image using the Rapid Assessment of Competency in Echocardiography (RACE) scale. Multivariable logistic regression models assessed the association between image volume and achieving a satisfactory RACE score across five cardiac views, adjusting for postgraduate year and clustering by resident identifier using generalized estimating equations. Interrater reliability was evaluated with Cohen’s kappa.

Results

A total of 576 ultrasounds comprising 2,282 images were analyzed. For simpler views, such as the inferior vena cava, odds of achieving a satisfactory score plateaued near 25 images, while more complex views, such as the apical four-chamber, plateaued near 40 images. Most views demonstrated decreased proficiency beyond plateau, suggesting potential skill perishability. Interrater reliability was high across all views (Cohen’s kappa >0.70).

Discussion

Emergency medicine resident echocardiography image acquisition proficiency varies by cardiac view, with simpler views plateauing after approximately 25 images and more complex views after approximately 40 images. Performance declined beyond these plateaus, suggesting that POCUS skills may be perishable without ongoing reinforcement. These findings challenge volume-based competency thresholds and support a shift toward view-specific, competency-based assessment models.

Conclusion

EM resident echocardiogram image acquisition proficiency varies by view, plateauing at 25 to 40 images, after which performance may decline, suggesting that POCUS skills are perishable. This study additionally provides external validation for a previously established echocardiography image acquisition scoring scale.

Authors

Cody Petrie, MD, C.A.Q.S.M. Aaron Thomas, M.D. Connor Q. O'Hare, M.D. Jacquelyn Pearlmutter, DO

Introduction

Blunt laryngeal trauma is a rare but potentially life-threatening condition, especially in contact sports such as hockey. Injuries may range from minor mucosal contusions to complex cartilage fractures with airway compromise necessitating tracheostomy. Prompt recognition and immediate referral to the emergency department are critical to acute preventing airway complications and long-term sequelae. We report a case of a thyroid cartilage fracture with associated pneumomediastinum in a young athlete, managed conservatively with favorable outcome.

Methods

A 22-year-old male hockey player presented to the emergency department immediately following an in-game collision in which he sustained a direct elbow strike to his anterior neck. He reported anterior neck pain, throat pain, and hoarseness after the direct blow. Initial Vitals: Blood Pressure: 117/62 mmHg Heart Rate: 59 bpm Oxygen Saturation: 98% on room air Pertinent physical exam: - Hoarse voice with painful speech - No stridor, no respiratory distress, or no pulsatile neck mass. No pooling of secretions - No crepitus or ecchymosis appreciated externally CTA Head and Neck: Demonstrated extensive pneumomediastinum extending into the retroperitoneal space. Irregularity of the right lateral trachea at the level of the thyroid and irregularity of the right thyroid cartilage consistent with a non-displaced fracture. Esophogram: - No extraluminal contrast to suggest esophageal perforation. Outcome: The patient was admitted to the otolaryngology team for close airway monitoring and medical management. His treatment regimen included: IV Dexamethasone 10 mg every 8 hours IV Unasyn (ampicillin/sulbactam) for prophylactic coverage to prevent superimposed bacterial infection IV Protonix 40mg Acetaminophen, oxycodone, ondansetron, and compazine as needed for symptom control Supportive care included: Voice rest Avoidance of coughing or straining Head-of-bed elevation to 30 degrees The patient remained hemodynamically stable without signs of airway compromise. No surgical intervention was required. He was discharged on hospital day three with outpatient ENT follow-up.

Results

At two-week follow-up, the patient reported complete resolution of symptoms. He was cleared to resume non-contact exercise and advised to avoid contact sports for at least four weeks. He is expected to make a full recovery.

Discussion

Laryngeal trauma in athletes is rare but may be underrecognized due to subtle presentations. Although our patient experienced a favorable recovery with conservative management, laryngeal fractures are associated with a significant risk of morbidity and mortality, particularly when diagnosis or intervention is delayed. These injuries are rare, especially in athletes, but the potential complications underscore the need for prompt recognition and immediate referral to the emergency department. Symptoms of respiratory distress, hoarseness, stridor, and loss of laryngeal prominence after blunt laryngeal trauma should prompt immediate emergency department evaluation. The most urgent concern in laryngeal trauma is airway compromise. Progressive edema, hematoma formation, or displacement of cartilage fragments can narrow the airway, sometimes hours after the initial injury, leading to delayed respiratory collapse. Stridor, dyspnea, and acute airway obstruction are classic warning signs; however, even subtle symptoms, such as hoarseness or odynophagia, may herald underlying instability. For this reason, many authors advocate for early airway monitoring and at least 24 hours of observation in any patient with a confirmed laryngeal fracture. Thyroid cartilage fractures, particularly those associated with pneumomediastinum, warrant a thorough airway assessment and necessitate imaging and laryngoscopy. Beyond the acute period, long-term sequelae should be recognized. Malalignment of fractured cartilage can cause chronic airway stenosis, resulting in persistent stridor or exertional dyspnea. Injuries to the vocal folds, cricoarytenoid joints, or recurrent laryngeal nerve may produce permanent dysphonia or aphonia, profoundly affecting communication and quality of life. Aspiration is another concern, as impaired glottic closure predisposes patients to recurrent aspiration pneumonia. In severe cases, tracheostomy dependence may be required. Additional complications arise from associated injuries and tissue disruption. Mucosal lacerations can result in granulation tissue formation and scarring, further distorting airway anatomy. Air leak syndromes—including subcutaneous emphysema, pneumomediastinum, and even pneumothorax—have been described, particularly when fractures are accompanied by mucosal tears or tracheal disruption. These findings not only complicate management but may signal deeper injury requiring surgical exploration. Outcomes are strongly linked to the timing of diagnosis and treatment. Patients who have been identified earlier for acute complications and managed appropriately, whether conservatively or operatively, experienced significantly improved functional outcomes. In the context of sports-related trauma, where injuries may initially appear minor, this case reinforces the importance of a high index of suspicion. Any athlete presenting with hoarseness, anterior neck pain, or subtle voice changes following blunt trauma should undergo airway evaluation in the emergency department. Early referral and multidisciplinary assessment are critical, as timely intervention minimizes the risk of both acute airway compromise and long-term morbidity. While displaced fractures or significant mucosal injuries may require surgical repair—options include mini-plate fixation, wire cerclage, ultrasonic pins, or endolaryngeal stents—most minor injuries can be managed conservatively. There is no standardized treatment protocol, and decisions are guided by injury severity, airway status, and symptomatology. Our case underscores the importance of early imaging and laryngoscopy in athletes with persistent voice changes or neck pain after blunt trauma, even in the absence of stridor or external findings.

Conclusion

This case illustrates a rare presentation of a thyroid cartilage fracture with pneumomediastinum in a young athlete, managed conservatively with excellent outcomes. It highlights the need for high clinical suspicion, early airway evaluation, and individualized management in sports-related neck trauma.

Authors

Chris Salvino, MD - Saint Francis Health System Kylie Salvino - Creighton University School of Medicine David M Notrica, MD - Phoenix Children’s Hospital

Introduction

Rapid-onset hypoxia is a critical risk during rapid sequence intubation (RSI), especially in paralyzed, apneic patients. Despite adjuncts like nasal cannulas, oxygen desaturation often occurs within 60 seconds. The Turbo® O₂ Cap is a novel FDA Class I device designed to mitigate this risk by delivering high-flow oxygen directly to the glottic area during intubation.

Methods

Study design and ethics This study was conducted at Absorption Systems California, LLC (ASC), a Pharmaron Company. The protocol was approved by the ASC Institutional Animal Care and Use Committee (IACUC protocol 22C627Q1) and complied with the National Research Council Guide for the Care and Use of Laboratory Animals and AVMA guidelines. Device description The Turbo® O₂ Cap is a disposable device that attaches to a standard 15-mm endotracheal tube connector and delivers up to 15 L/min of 100% oxygen near the glottic inlet. It allows simultaneous stylet use and incorporates redundant pressure-relief valves. Animal model Three adult Yorkshire pigs (65–85 kg) were acclimatised for at least five days. Animals were sedated with telazol and xylazine and maintained under deep anaesthesia with isoflurane. Neuromuscular paralysis was achieved using intravenous succinylcholine. Experimental protocol Each animal underwent four apnoeic cycles: two control cycles and two test cycles, yielding twelve total cycles. Animals were not pre-oxygenated. Following paralysis, an endotracheal tube was positioned proximal to the vocal cords without tracheal advancement. Control cycles received no oxygen. Test cycles received 15 L/min oxygen via the Turbo® O₂ Cap. Oxygen saturation was monitored until SpO₂ reached 75% or fifteen minutes elapsed. Animals were then intubated and ventilated to baseline saturation before subsequent cycles. Data collection and statistical analysis The primary endpoint was maintenance of SpO₂ ≥94% for fifteen minutes. Fisher’s exact test compared outcomes between control and test cycles. Arterial blood gases (PaO₂, PaCO₂, pH) were collected during one test cycle per animal and summarised descriptively.

Results

All animals remained haemodynamically stable throughout the study. In every control cycle, SpO₂ declined rapidly below 75% within one minute of paralysis. In contrast, all test cycles maintained SpO₂ ≥94% for the full fifteen minutes. This difference was statistically significant (p = 0.0022). Arterial blood-gas analysis during test cycles demonstrated persistently elevated PaO₂ values throughout apnoea. PaCO₂ increased progressively, accompanied by a gradual decrease in pH to approximately 7.2 by fifteen minutes.

Discussion

This preclinical study demonstrates that targeted oxygen delivery at the glottic inlet can prevent hypoxaemia for fifteen minutes during complete apnoea under neuromuscular paralysis. By contrast, apnoea without supplemental oxygen resulted in profound desaturation within one minute. The mechanism appears diffusion-driven. Delivering high-flow oxygen millimetres from the glottic opening minimises ambient air entrainment and establishes a steep oxygen gradient, facilitating passive alveolar oxygen diffusion in the absence of ventilation. Rising PaO₂ values during apnoea support this mechanism. Carbon dioxide accumulation and acidaemia observed during apnoea were expected physiological consequences and were not primary efficacy or safety endpoints. The study was not designed to define acceptable thresholds for hypercapnia or acidosis.^11,12 Limitations include the small sample size and limited arterial blood-gas sampling. Further preclinical and clinical studies are warranted to define optimal clinical use.

Conclusion

In this porcine model, a novel endotracheal-tube oxygenation device prevented hypoxaemia for fifteen minutes during complete apnoea under neuromuscular paralysis. These findings provide proof of concept that sustained apnoeic oxygenation may be achievable during difficult or prolonged airway management and support further clinical investigation.

Authors

Merlyn York, BS, Madison Gackle, BS, Kayla Keith, BS, Tushar Tejpal, BHSc, John Ashurst, DO, EdD, MS Affiliation: Arizona College of Osteopathic Medicine, Midwestern University

Introduction

Title: Assessing characteristics of completed, withdrawn, and terminated clinical trials of the resuscitative endovascular balloon occlusion of the aorta procedure Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure used to control and stabilize intra-abdominal hemorrhage in emergency settings. REBOA application has been increasing in recent years, however, clinical trial outcomes assessing REBOA have been variable, with many trials being terminated. Understanding the factors that influence the outcomes and completion of these trials, is essential for guiding future research and improving procedural efficacy.

Methods

A retrospective cohort of all REBOA-related trials from ClinicalTrials.gov was obtained by searching for “REBOA”, "Resuscitative endovascular balloon occlusion of the aorta”, “Endovascular Aortic Balloon Occlusion”, and “Endovascular Balloon Aortic Occlusion”. Trials were categorized as "Completed" or "Discontinued." Discontinued trials were further sub-classified as "Terminated" or "Withdrawn". Variables analyzed include intervention classification, sponsor, phase grouping, funding type, study type, study design, enrollment estimates (median [IQR]), and published results. Categorical variables were assessed via the chi-squared test and continuous variables via the Mann-Whitney U test.

Results

A total of fifteen REBOA clinical trials were identified that met the inclusion criteria, ten of which were completed, and five either terminated/withdrawn. No differences were identified between the interventions used in completed versus terminated/withdrawn trials (p=0.248), funding type (p=0.075), or study type (p=0.714). There was also no significance between completed (n=5) versus terminated or withdrawn (n=3) trials between phase grouping (p=0.4105), allocation (p=0.851), or interventional model (p=0.851). All industry-funded trials (n=2) were terminated, while all government-funded trials (n=2) were completed. Completed trials had a median of 25.5 (IQR: 15-150) versus terminated or withdrawn at 0 (IQR: 0-14, p=0.0168). Of the completed trials, 8 published an abstract or manuscript, whereas none of the terminated/withdrawn trials did.

Discussion

Although no statistically significant differences were found between completed and terminated clinical trials, potential trends were found that could help to inform future REBOA research studies. Government-funded studies were much more likely to be completed and published, suggesting greater access to infrastructure and participant recruitment. Conversely, industry-funded studies were more frequently terminated and characterized by low enrollment, suggesting potential problems related to study design, recruitment, or funding allocation. Additionally, many of the other studies were funded by academic institutions, which play an important role in advancing REBOA research.

Conclusion

These findings suggest an association between industry funding and lower enrollment with termination of REBOA clinical trials. In contrast, government-funded trials were more likely to reach completion and publish their findings. These trends highlight potential feasibility challenges, and future directives could focus on the funding source and recruitment strategies as a means of predicting the completion of the clinical trials.

Authors

Ryan Adkins, DO, Associate Program Director, Creighton University East Valley Arizona Sara Dimeo, MD, Program Director, Creighton University East Valley Arizona Chris Thompson, DO, Resident, Creighton University East Valley Arizona

Introduction

Gamification, the application of game design elements to non-game contexts, has improved engagement in medical education. However, it is rarely applied to administrative responsibilities such as faculty evaluations, academic coursework, conference attendance, and procedural logging—tasks critical for resident development but often driven by extrinsic motivation. This pilot project introduces a gamification curriculum to enhance participation in these "administrative hygiene" activities and explore residents' intrinsic and extrinsic motivators.

Methods

Residents participated in a longitudinal gamification curriculum and were placed into balanced teams (“families”). Monthly leaderboards, longitudinal points and end of year rewards supported ongoing engagement. Points were tracked using simple automated spreadsheets to minimize faculty and coordinator workload. Administrative task completion, semiannual surveys using the Work Extrinsic and Intrinsic Motivational Scale (WEIMS), and qualitative data from focus groups and one-on-one interviews.

Results

Residents demonstrated strong compliance with key administrative hygiene tasks, including documented procedures per block (18.8 per resident), faculty evaluation completion (87%), conference attendance (89%), and academic task engagement (83%). Mid-year survey data using the Work Extrinsic and Intrinsic Motivation Scale (WEIMS) showed a positive Self-Determination Index (SDI) of 8.4, reflecting a supportive and motivating learning environment. Qualitative feedback indicated increased interaction, enthusiasm, and engagement with content throughout the gamification curriculum. Residents expressed that while games enhanced motivation and accountability, they preferred simpler structures that avoided overly complex rules or scoring systems.

Discussion

This pilot project shows that gamifying administrative hygiene tasks can meaningfully improve resident engagement, consistency, and motivation. High completion rates across faculty evaluations, conference attendance, procedure logging, and academic tasks indicate that the structure effectively reinforced accountability while reducing coordinator workload. Importantly, the positive Self-Determination Index (SDI 8.4) suggests that the curriculum fostered not only compliance but also a supportive motivational climate. Residents reported greater enjoyment, interaction, and teamwork, aligning with educational literature indicating that simple, intuitive game frameworks strengthen intrinsic motivation. Feedback highlighted that clarity and simplicity of game rules are essential, reinforcing the value of keeping gamification accessible and low-burden for both residents and faculty.

Conclusion

Gamifying administrative hygiene tasks is a promising, low-cost strategy that enhances resident motivation, improves task completion, and strengthens team culture. This model is scalable, easy to implement, and adaptable to other programs seeking to improve administrative consistency while supporting intrinsic motivation. Continued evaluation across larger cohorts and multiple academic years will help define its long-term sustainability and broader impact on residency culture and performance.

Authors

Aubrey Bethel, MD; Ryan Adkins, DO; Sara P. Dimeo, MD, MPH

Introduction

The new American Board of Emergency Medicine (ABEM) certifying examination will commence in 2026 as an in-person examination. In preparation for this, Dignity Health-East Valley Emergency Medicine Residency launched an innovative simulation curriculum that encompassed these topics. The development of the curriculum was grounded in Kolb's experiential learning theory, which includes four stages: experience, reflection, conceptualization, and experimentation to solidify learning of skills and concepts. The purpose of this study was to evaluate the residents’ confidence in approaching the different certifying exam content topics.

Methods

During six dedicated simulation didactic times, residents had a 40 minute session dedicated to the new oral board format. The cases were written using the Journal of Education and Teaching - Emergency medicine 4 updated certification exam templates. The residents received training on six different content areas: clinical decision making (CDM), prioritization, reassessment and troubleshooting (R/T), difficult conversations, managing conflict and patient centered communication (PCC) Residents were consented and randomly assigned a study number and filled out pre- confidence level surveys based on their confidence with preparing for the new oral boards. A likert scale was used from 1-5, 1=Not at all confident, 5 = Very confident. One week before the simulation content, residents watched a video from the ABEM website to review the specific format and reflect on a similar real-world experience. Residents performed the simulation in teams of 2-4, with one ‘hot seat’ resident, one resident grading with the attending, and the remaining residents observing. After completing the in-person case session, the residents filled out a post-confidence level survey. The pre-and post- results were then compared.

Results

3 of the 6 content areas have been performed and surveyed - CDM, R/T, and PCC. Of the responding residents, there is improvement in confidence levels. CDM improved from a mean of 1.69 to 2.85(p= 0.001), PCC improved from 2 to 4.14 (p= 0.001), and R/T from a 2 to 2.83 (p=0.092).

Discussion

Resident confidence has improved in the specific areas significantly, however participation in the post-surveys has declined. Initially, 15 of the 16 consented residents filled out the pre-survey. 13 residents completed the post- CDM survey, 8 completed post-PCC , and 6 post- R/T survey. The R/T survey was not statistically significant, and the factors for this are unclear.

Conclusion

By integrating the new oral certifying exam content into regularly scheduled didactics, residents are reporting an improvement in confidence for taking the new certifying exam, however retaining resident participation to complete the post- surveys remains a focus of concern.

Authors

Aubrey Bethel, MD; Vivienne Ng, MD, MPH

Introduction

Superficial soft-tissue abscesses are a frequent chief complaint in any emergency department, with up to 3.2 % of patients presenting with this issue.(1) The preferred method for treatment is incision and drainage (I&D) because antibiotics alone are often insufficient.(2,3) There are two common methods for draining abscesses. The first is a single linear incision over the length of the abscess that is either left open or packed with gauze which is removed 24-48 hours later.(4) The second is the loop technique, which uses two smaller parallel incisions with a sterile rubber or plastic tube threaded through them and tied into a circle.(5,6) While abscess drainage is a common procedure for surgical and sub-surgical specialties, it is not often taught in medical schools or to residency prior to performing in the patient care setting. Frequently, this is due to the to lack of access to affordable commercial task trainers, which range in cost from $19.99 up to device.(7,8) Other published $171.00 per single use low-cost task trainers require cadavers or are more time intensive or require creative set up.(9) This nipple cover task trainer gives a realistic feel for anesthetizing and incising abscesses using affordable material and requires minimal preparation time. Even centers with limited simulation capabilities can create and use this task trainer because it uses material that is readily available.

Methods

Educational Methods: The abscess task trainers were fabricated using pre-made nipple covers, plastic wrap, and unscented hand lotion. The nipple covers come with a sticky backside that adhere to plastic wrap. The plastic wrap is then filled with hand lotion and folded to prevent leakage. The nipple covers can then be anesthetized and incised. The time to fabricate each abscess was approximately one to two minutes. Research Methods: Eight PGY-1 emergency medicine residents completed a pre-simulation survey evaluating their confidence in draining an abscess using a five-point Likert scale (1=strongly disagree, 5 = strongly agree). Residents observed the instructor demonstrate the procedure, and then they performed two abscess drainages on separate nipple covers, one using a single linear incision and the other the loop technique. After the simulation, the resident confidence levels were re-assessed using the same five-point Likert scale. Residents were also asked to rate the fidelity of the task trainer, compared to a real abscess (1= strongly disagree, 5 = strongly agree)

Results

Residents reported an increase in their mean confidence in draining an abscess, with an increase from the pre-simulation score of 3.5 to 4.875 (p=0.0038). Residents also felt that the model was realistic, with a mean score of 4.875. Every resident recommended using this model for future learners.

Discussion

To create the nipple cover task trainer, minimal preparation time and resources are required, making this a simulation that can be replicated in even resource-sparse residency or medical student programs. In the future, comparing this task trainer with a commercially available task trainer would be beneficial to improve task trainer fidelity.

Conclusion

Overall, this affordable and simple task trainer was well received by the learners and improved beginner confidence with a frequently performed procedure. With minimal preparation time and resources, this nipple cover task trainer can be used to teach residents how to anesthetize, incise, drain, and pack abscesses.

Authors

Laura Bailey, BSN, William Shaffer MS3, Aubrey Bethel, MD

Introduction

Auricular hematomas are relatively infrequent but require timely intervention to prevent complications such as infection, cartilage necrosis, or permanent ear deformity (“cauliflower ear”). (1) Although these injuries make up only a small part of all otologic complaints in the emergency department, they are one of the most frequent ear injuries in contact sports, with wrestlers, boxers, and rugby players being the most at-risk. (2) Not only can they occur in sports, one urban level-I trauma review found 42% of auricular hematoma presentations were due to interpersonal violence or assault (3), making timely drainage a core skill now listed in the 2022 Model of the Clinical Practice of Emergency Medicine. (4) EM residents often have limited opportunities to gain hands-on experience with this procedure in a controlled learning environment, with a low reported baseline confidence level highlighting a persistent training gap. (5) Traditional models are expensive and single-use, with each one costing up to $60-100. (6) This innovation was developed to address a training gap by providing a simple, affordable, and reproducible task trainer that enables learners to practice landmark identification, drainage, and post-procedure care of auricular hematomas with confidence.

Methods

Residents were given a 5 minute in-person demonstration of how an auricular hematoma is drained using one of the models. They then were able to walk through the steps of incising, draining and dressing the ear themselves using material found in the emergency department. 11 participants were instructed to incise and drain an auricular hematoma. The Michigan Standard Simulation Experience Scale (MiSSES) template was used for anonymous feedback on the task trainer immediately after the simulation. Participants scored the simulator in five categories: Self-efficacy, fidelity, educational value, teaching quality, and the overall rating on a 5-point Likert scale. 1 = Strongly Disagree, 5 = Strongly Agree. MiSSES is a freely available, validated subjective-assessment tool created at the University of Michigan to standardize evaluation of simulation-based education. MiSSES contains six domains for evaluation and demonstrated good internal consistency at initial psychometric testing. Variables were summarized using the mean and standard deviation. I also have 'creation of the auricular hematoma model' on the poster with pictures: The auricular hematoma model was created by using a purchased silicone ear and inserting a 20 gauge IV catheter through the helix at the triangular fossa (1.) cutting out a copy of the internal ear from a sheet of silicone (2.) and then adhering that with silpoxy to the outside of antihelix and concha to create an internal hematoma reservoir.(3) An IV J-loop, stopcock and syringe is attached to administer the hematoma. (4)

Results

This simulation was performed during regular didactic time during an hour of ‘round robin’ style teaching. Residents came to the table in groups of 2-4 and had 20 minutes to view the demonstration and perform the procedure themselves. They used a #15 blade, hemostat, and 4x4’s with various bolster dressings. Immediately after the 20 minutes, residents were asked to fill out the MiSSES survey. 7 PGY 1 EM residents and 4 EM attendings completed the simulation and filled out the MiSSES form (Table 1). Of the residents, none had any previous experience with auricular hematoma drainage. Of the attendings, all had done one previously, but none more than 3. Using the MiSSES, the model received an overall positive rating of 5.0. The highest rating was on teaching quality (5.0), and educational value (5.0) (Table 2). For fidelity, the trainer received a 4.9/5.

Discussion

The model was well received by residents and attendings. One of the issues is that it builds up pressure on the inside if more than 1 cc of fake blood placed, and can ‘explode’ violently when incised. Ensure that this procedure is done on chucks with paper towels present to help clean up the fake blood. Gloves are encouraged as the fake blood can stain hands. The ears are reusable by sealing the previous incisions with silpoxy adhesive and allowing 6 hours to dry.

Conclusion

This simulation was an excellent training tool for auricular hematoma, which is a lower occurrence but time sensitive procedure. We created a reusable and cheap simulator model that scored high in a standard simulator’s assessment survey

Authors

Addison B Smartt, B.S. - Mayo Clinic Alix School of Medicine Rochelle Kofman, B.S. - Mayo Clinic Alix School of Medicine Reginald J. Myles, B.S. - Mayo Clinic Alix School of Medicine Patrick G. Kishi, M.D. - Mayo Clinic, Department of Emergency Medicine Douglas E. Rappaport, M.D. - Mayo Clinic, Department of Emergency Medicine Kevin M. Drechsel, M.D. - Mayo Clinic, Department of Emergency Medicine

Introduction

Central retinal artery occlusion (CRAO) is a neurological and ophthalmologic emergency that presents as sudden, painless, monocular vision loss and can result in permanent blindness. Causes of CRAO can be classified as arteritic, such as in giant cell arteritis, or non-arteritic. Most cases of non-arteritic CRAO are due to embolism, commonly from atherosclerosis of the ipsilateral carotid artery. More proximal sources of embolism, such as atrial fibrillation and cardiac masses, are uncommon but can occur. Prompt recognition of CRAO is critical for vision preservation therapy and initiation of ischemic stroke diagnosis protocols.

Methods

A 66-year-old female, with a previous history of diabetes mellitus type II, hypertension, and hyperlipidemia, presented to the Emergency Department eight hours after sudden loss of central vision in the right eye. She denied any associated pain, headache, speech difficulty, unilateral weakness, and ocular trauma. On examination, she was hypertensive with a blood pressure of 174/74 and had no focal neurological deficits or cranial nerve abnormalities. No ocular erythema or injection was discovered, and a fundoscopic examination yielded poor visualization of the vessels and optic disc.

Results

An ocular point of care ultrasound (POCUS) was used to further investigate the cause of vision loss, revealing no evidence of retinal detachment, vitreous hemorrhage, or posterior vitreous detachment, but did reveal a retrobulbar spot sign (RBSS). This finding points towards an non-arteritic, embolic cause of CRAO, prompting a stroke workup including a CT angiogram. As the search for the embolic source continued, an electrocardiogram (ECG) and transesophageal echocardiogram (TEE) performed by cardiology was ordered. The ECG showed normal sinus rhythm, however the TEE revealed a highly mobile pedunculated mass attached to the mitral valve protruding into the left ventricular outflow tract during systole. The patient underwent mitral valve replacement and resection of the mass due to its cardioembolic potential, and intraoperatively the mass was confirmed to be a cardiac myxoma.

Discussion

The differential for painless, monocular vision loss can be wide, including retinal detachment, vitreous bleeding, temporal arteritis, ischemic stroke, and optic neuropathy. Ocular POCUS is a valuable screening tool for many of these etiologies, especially those with the need for prompt evaluation and management. The retrobulbar spot sign (RBSS) detected in this case report represents embolic activity in the retinal artery, with a sensitivity and specificity for embolic CRAO of 83% and 100%, respectively. These functions make ocular POCUS evaluation of monocular vision loss especially useful in emergent cases and situations where ophthalmic specialists are not immediately available. The detection of a RBSS may have an impact on treatment as well, as some evidence indicates that the presence of a RBSS predicts poor response to thrombolytic treatment. The user-dependence of ultrasound is a clear limitation; while not the definitive diagnostic tool for CRAO, it can provide timely, accurate, and inexpensive information for a time-sensitive clinical presentation.

Conclusion

In conclusion, point-of-care ultrasound is an efficient and effective diagnostic tool for the assessment of acute, painless, and monocular vision loss. The presence of a retrobulbar spot sign indicates central retinal artery occlusion, providing both diagnostic and prognostic information. Although not a definitive diagnostic tool, POCUS can narrow the differential and expedite treatment for patients with embolic CRAO.

Authors

Rochelle Kofman, B.S., Mayo Clinic Alix School of Medicine Ryan Allen, B.A., Mayo Clinic Alix School of Medicine Addison B. Smartt, B.S., Mayo Clinic Alix School of Medicine Kevin M. Drechsel, M.D., Department of Emergency Medicine, Mayo Clinic Arizona Jordan R. Pollock, M.D., M.B.A., Department of Radiology, Mayo Clinic Arizona Wayne A. Martini, M.D., Department of Emergency Medicine, Mayo Clinic Arizona Douglas E. Rappaport, M.D., Department of Emergency Medicine, Mayo Clinic Arizona

Introduction

Sternoclavicular joint (SCJ) injuries are rare and potentially life-threatening injuries due to their proximity to vital mediastinal structures. In adolescents, skeletal immaturity can add complexity to the injury due to potential involvement of the physis. A physeal fracture with displacement can appear as a dislocation on imaging, also known as pseudodislocation. Additionally, this anatomic area is difficult to visualize with plain radiographs, which can result in misdiagnosis and delayed treatment.

Methods

We present a case of a 15-year-old male athlete who presented to the Emergency Department 4 hours after sustaining a football injury, with severe right clavicular pain. Plain radiographs obtained at an outside facility as well as repeat plain radiographs at our facility showed no evidence of fracture or dislocation. The patient’s degree of pain and physical exam findings prompted further imaging with CT, ultimately revealing a physeal fracture of the medial right clavicle with posterior and superior displacement.

Results

Orthopedic and thoracic surgery teams were consulted, who recommended the patient be transferred to and evaluated by a pediatric center. The pediatric orthopedic team proceeded with immediate surgical intervention including open reduction and internal fixation. Physeal fracture with posterior superior displacement of the clavicle was confirmed intraoperatively. The operative course was uncomplicated. A full recovery was anticipated after three months.

Discussion

Sternoclavicular joint injuries in skeletally immature patients are complex and require immediate diagnosis and intervention. An unfused medial clavicular physis may make it difficult to radiographically distinguish physeal fractures from dislocations in adolescents. Plain radiographs are often unreliable in recognizing these injuries and in our case, the physeal fracture with displacement was not radiographically apparent on two separate occasions. Advanced imaging with CT revealed the diagnosis, highlighting the importance of a detailed physical exam and for physicians to maintain a high index of clinical suspicion when evaluating adolescents with high-impact trauma, even in the setting of negative plain radiographs.

Conclusion

This is a rare case of a posterior sternoclavicular joint displacement with physeal involvement in an adolescent football player; a diagnosis originally missed on initial x-rays. CT is often underutilized in emergency settings for SCJ injuries, despite the known limitations of plain radiographs in identifying posterior displacement, and the diagnosis is often missed or delayed. This case reinforces the need for early advanced imaging, even in the setting of negative plain radiographs, for prompt diagnosis and treatment of pediatric SCJ injuries.

Authors

Wallace SG¹, Higa N², Ho WH², Campbell JM¹, Okuno H², Gallitano AL¹

Introduction

The immediate early gene (IEG) Early growth response 1 (Egr1) is expressed in neurons in response to neuronal activity and plays an essential role in encoding memory of the events that triggered its expression. Egr1 is activated by the neuronal stimulation that induces hippocampal long-term potentiation (LTP), a form of synaptic plasticity associated with memory formation. Mice lacking Egr1 have deficits in LTP and in long-term memory (after 24 hours). These findings suggest that increasing levels of Egr1 may improve memory. However, standard methods used to overexpress genes in the brain do not distinguish active versus inactive neurons. Failure to replicate the specific timing and location of Egr1 expression, and disruption of the unique pattern of activated neurons that form the memory engram.

Methods

To address this problem, we created an adeno-associated virus (AAV) expressing Egr1 under control of a promoter containing multiple copies of the synaptic activity response element (SARE) isolated from the IEG Arc (activity regulated cytoskeleton associated protein) to overexpress Egr1 in active neurons. Activity-responsive overexpression was validated in vivo by injection of AAV-ESARE-Egr1 into the hippocampal dentate gyrus (DG) and exposure of mice to environmental enrichment, electroconvulsive seizure, or home cage (control). Image J was used to quantify immunofluorescent (IF) labeling. Behavioral tests performed included the non-associative place recognition test, the open field test, and contextual fear conditioning.

Results

Quantification of IF levels and counts of fluorescently labeled cells showed that AAV-ESARE-Egr1 infusion into the mouse DG results in activity-inducible overexpression of Egr1 and increasing EGR1 IF in active hippocampal DG cells by 2.8 to 9.6-fold in response to neuronal activity. In the non-associative place recognition test, mice injected with control virus demonstrated recall 24 hours following an initial exposure to a novel context when Day 1 exposure times were 6 min. or 3 min., but not following a 1 min. exposure. In contrast, AAV-ESARE-Egr1 expressing mice displayed recognition following as little as a 1 min. exposure to the environment on Day 1. In the fear-conditioning test, injected mice displayed more freezing behavior than control virus injected mice.

Discussion

We show that infusion of AAV-ESARE-Egr1 into the mouse DG results in activity-inducible overexpression of Egr1 in active hippocampal DG cells in response to neuronal stimulation. Injected mice show improved ability to recall a novel context and enhanced memory in contextual fear conditioning.

Conclusion

These results suggest that increasing activity-dependent Egr1 expression in hippocampal DG cells enhances contextual memory in mice and suggest that developing molecules that upregulate Egr1 selectively in response to neuronal activity may have therapeutic use in disorders characterized by memory deficits or decline, such as dementia or Alzheimer’s. Improved treatments could reduce the frequency of dementia patient visits to the emergency room and hospital admissions resulting from those visits

Authors

1. Andrew Holzman 2. Brennan Hand 3. Wayne A. Martini, MD 4. Douglas Rappaport, MD Affiliations: 1 and 2: Mayo Clinic Alix School of Medicine, Phoenix, USA 3 and 4: Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, USA

Introduction

We report a case of M. osloensis bacteremia in a 66-year-old male presenting with acute abdominal pain and intermittent low-grade fevers following a dental extraction. The patient was diagnosed on return to the emergency department after cultures drawn during an initial visit produced a positive result for the organism on PCR. He was discharged without complication following admission to the hospital for intravenous antibiotics. Clinically significant M. osloensis infection is rare, and we have not found other reports describing a similar presentation with this organism.

Methods

N/a

Results

N/a

Discussion

This case exhibits a clinically significant infection with M. osloensis in a patient without severe chronic disease or immunosuppression. Existing literature suggests such infections are rare, and we have not found reports implicating this organism in a similar presentation with bacteremia following a dental procedure. The patient’s dental procedure likely introduced the pathogen to the bloodstream, and we suspect chronic dysphagia and gastritis may have led to an abnormal bacterial overgrowth involving M. osloensis in the oropharynx. This patient’s outcome supports previous reports that prognosis is positive with susceptibility to ceftriaxone. We note that dental amoxicillin prophylaxis appears not to have been effective in this patient; this may not relate to the organism’s susceptibility to amoxicillin, given the limited benefit studies have found for this intervention in general [11]. We note the difficulty of ascribing this patient’s gastrointestinal symptoms directly to the organism cultured in the blood, however given their acuity following dental surgery and the response to antibiotics we feel the association, in addition to the likely source of M. osloensis bacteremia, is suggested by the clinical course in this case. Still, the difficulty of proving this association is an important limitation for the implications of this case.

Conclusion

This case highlights the importance of surveillance for rare pathogens in patients presenting with infectious symptoms. Additionally, it proposes a possible presentation of infection with M. osloensis. Continued surveillance for rare pathogens is an important element of emergency department practice and its contribution to public health.

Authors

Matthew J. Van Ligten Mayo Clinic Alix School of Medicine Arizona, Medical Student, First Author Talia Sobel, MD, Mayo Clinic Arizona Department of Women's Health Sara Shihab, MD, Mayo Clinic Arizona Department of Women's Health Andrej Urumov, MD, Mayo Clinic Arizona Emergency Medicine Cameron R. Adler, MD Mayo Clinic Arizona Department of Radiology Wayne A. Martini Jr, MD, Mayo Clinic Arizona Emergency Medicine, Senior Author

Introduction

Endometriosis is a common, chronic inflammatory disease in which ectopic endometrial tissue exists outside the uterus. It affects up to 10% of women during their reproductive years [1]. Although the exact cause is unknown, endometriosis can occur throughout abdominopelvic organs. Common symptoms include dysmenorrhea, chronic pelvic pain, and fatigue. Endometriosis presents in a wide variety of ways, with some patients being asymptomatic and others being severely disabled from the associated pain. Given that it can be asymptomatic, endometriosis can remain unnoticed until it obstructs crucial structures and leads to adverse outcomes. In a Medicaid insurance study of women with and without endometriosis, those with endometriosis had 30% more visits to the emergency department (ED), revealing that endometriosis is a commonly seen entity in the ED [2]. This case presentation is of a woman with rapidly progressive left flank pain and eventual rupture of the renal pelvis in her left kidney while she was in the ED. Subsequent intervention and evaluation showed an area of stricture thought to be caused by endometriosis. Thus, although endometriosis can be clinically silent, it can also obstruct crucial structures, making it a possible diagnosis for a myriad of symptoms and worth considering in numerous clinical situations.

Methods

This was a single case report of a patient who presented to the Mayo Clinic ED for evaluation and management. Consent was obtained prior to publication and a literature review was conducted to understand the prevalence in literature and learning points.

Results

A 30-year-old woman came to the ED with severe left-sided flank pain. She had a history of excision of endometriotic lesions, left ureterolysis, and ovarian cystectomy (10 months prior). She said that her pain had been gradually increasing, ultimately becoming severe and radiating to her left inguinal area. She had associated nausea and vomiting. She also said that the pain was different from past episodes of abdominal pain caused by her endometriosis. She had no infectious or urinary symptoms. She reported taking no medications. The patient had normal vital signs, and the only notable findings were tenderness in the left costovertebral angle and flank. The initial laboratory evaluation showed no signs of leukocytosis, urinary tract infection, or frank hematuria. The urinalysis showed trace protein but no elevated levels of white blood cells or bilirubin and no casts. Given her level of pain, a kidney stone was suspected, so abdominal computed tomography (CT) with contrast was ordered, which showed moderate to mild dilatation of the left renal collecting system, with the left ureter extending to the left ovary. Signs of urinary obstruction with hydronephrosis were seen on the left side (Figure 1) without any clear sign of renal pelvis rupture, but findings were suspicious for fluid accumulation in the retroperitoneum medial to the kidney, with subtle focal fluid in the perinephric fat (Figure 2). A urologist was consulted, who recommended another CT scan of the abdomen and pelvis with a delayed phase to assess for flow in the urinary collecting system. Subsequent CT imaging showed active signs of extravasation and non-opacification of the ureter due to obstruction from endometriosis (Figure 3), although the exact location of the obstruction was unclear. The patient was admitted, and a left-sided nephrostomy tube was placed to depressurize the system and to allow for appropriate urinary drainage. She improved and was discharged the next day, with plans to return for follow-up testing. Approximately 4 weeks later, a follow-up anterograde left-sided pyelogram showed signs of a distal ureteral stricture (Figure 4), and a retrograde pyelogram showed a distal stricture too tight to allow contrast flow (Figure 5) that had caused the renal pelvis rupture. Although there was clearly flow throughout the ureter on antegrade imaging, an attempt at placing a stent failed because the stricture could not be passed despite the use of multiple sizes of wires. Approximately 1 week later, the patient had renal scintography that showed delayed excretion from the left kidney into the slightly dilated collecting system, which improved substantially after she was given 20 mg of intravenous furosemide. However, no scintigraphic evidence was seen of a urodynamically significant obstruction, suggesting spontaneous resolution of the ureteral obstruction. After this, capping trials were done, during which her pain level did not increase. Ultrasonography confirmed continued urinary drainage without hydronephrosis. In additional conversations with the patient and the urology team, it was decided not to pursue complex ureteral reconstructive surgery because her pain and urinary flow had spontaneously improved substantially allowing for removal of nephrostomy tubes. She chose to restart her previously prescribed oral contraceptive medication. Close follow-up was recommended, including office visits with the Urology team at 6 weeks, 12 weeks, and 6 months as well as repeat basic metabolic panels and ultrasonography of the kidney. Ultimately within the 6 month follow up period the patient did not require any further intervention.

Discussion

Endometriosis can present with a wide variety of symptoms. ED physicians should consider this diagnosis for acute flank pain, especially for patients with known endometriosis. In this case, the patient reported severe, left-sided flank pain and was found to have left-sided costovertebral angle tenderness. Due to the fact that she was afebrile and did not have urinary symptoms it was unlikely that she had an infection. However, tenderness at the costovertebral angle in an afebrile patient is highly specific for obstructive uropathy [3], with her presentation of radiating pain from the left flank down to the groin raising a high suspicion for renal colic. Though classic teaching suggests ordering CT without contrast for renal colic, the choice was made to use IV contrast due to the patient’s history of endometriosis, concern for possible infection, and her lack of having kidney stones. Ultrasonography imaging was considered; however, kidney stones are best diagnosed on CT with or without contrast. Ultrasonography can be used effectively to screen for obstruction, particularly for those with a benign presentation and recurrent history, which can decrease CT in the ED up to 50% [4]. This patient did not have kidney stones on imaging; however, she did mild hydronephrosis of the left kidney, indicating stricture and/or obstruction. Her history of endometriosis made it the most probable cause of the obstruction and the subsequent rupture. Although endometriosis was the probable cause of her obstruction, the definitive diagnosis could only have been made with surgery. Urethral endometriosis has been reported in only 1% of patients with endometriosis [5], with the left distal ureter being the most common site of ureteral endometriosis. Treatment may include placing a stentor other surgical procedures, such as complex ureteral reconstruction if the area is fibrosed and/or too stenotic for stent placement. Thus, it is important for ED physicians to recognize that endometriosis and complications from endometriotic tissue excision carry a wide range of symptoms, making it a diagnosis to consider for female patients with acute flank pain.

Conclusion

Awareness of the various and complex presentations of endometriosis, especially for those with a history of the disease, is important for ensuring optimal outcomes for patients with acute urinary obstruction due to endometriosis. Physicians in the ED should maintain a high index of suspicion for endometriosis-related complications to facilitate timely intervention and prevent adverse outcomes for women with acute flank pain. This case showed that complications can quickly arise in otherwise healthy women and emphasized the crucial role of a patient’s history in diagnosis and treatment.

Authors

Michelle Goforth BS, Lindsay Bucklin BS, David Guttman MD, MPH UACOM-Phoenix

Introduction

Many students cite prior exposure to their specialty of choice as one of the highest contributing factors in their decision to apply for that specialty. A majority of students in another study looking at what influences medical students to choose emergency medicine as a specialty made their decision to pursue a career in emergency medicine during or after their third year of medical school. This can be challenging for some students to make this decision earlier as not all medical schools offer an emergency medicine elective during the third year nor are students guaranteed the opportunity to participate in those electives if they are available. We sought to see if having the opportunity to gain exposure to the emergency department through the personalized active learning (PAL) experience between the first and second years of medical school influenced students’ decision to choose emergency medicine as their specialty.

Methods

Ten students were paired with an emergency medicine physician mentor for the 6 week PAL program. Each student was asked to complete a pre-survey assessing their perceptions of the field of emergency medicine and their likelihood of choosing emergency medicine as a specialty. Students were then required to complete 20 hours working with their mentor in the emergency department prior to filling out the post-survey.

Results

Of the 10 students that started the program, 8 students finished the required 20 hours and completed both of the surveys. Of the respondents, 60% of the students had prior EM interactions, most commonly as shadowing. 100% of students believed that the ability to multitask was critical after shadowing. Additionally, 70% of respondents believed EM physicians had to love trauma, whereas 70% disagreed with this statement afterwards. All students felt that they had a good understanding of the flow of the emergency department after the experience, and 75% now feel prepared to begin their EM clerkship rotation. 88% of the participants would be extremely likely to recommend the EM PAL experience to another student. 100% were extremely satisfied with their PAL shadowing experience. There were 88% of participants who felt they fostered connections with EM faculty and mentors as a result of this experience. The top 3 specialties of interest stayed consistent throughout the surveys, as EM, General Surgery, and IM. The likelihood of choosing emergency medicine prior to PAL experience was 56.7% and afterwards was 63.5%.

Discussion

N/A

Conclusion

The EM PAL experience served as an impactful clinical experience for medical students, where all participants were extremely satisfied with their experience and developed stronger mentorship connections with EM faculty as a result. All participants felt they developed a foundation of emergency medicine and consistently reported emergency medicine as their top specialty of interest. The opportunity to gain exposure to EM through the PAL experience helped assist students earlier in their medical careers with the decision if emergency medicine was a good fit for residency.

Authors

Yusuke Murakami, MD/MPH Student. University of Arizona College of Medicine - Phoenix Daniel Lee, MD Student. University of Arizona College of Medicine - Phoenix Rachel Fisher, MD/MPH Student. University of Arizona College of Medicine - Phoenix Alexander Schatzki-Lumpkin, MD Student. University of Arizona College of Medicine - Phoenix Kory Johnson, PhD. Biostatistician. University of Arizona College of Medicine - Phoenix Moneesh Bhow, MD. Medical Director, Emergency Department. Banner University Medical Center - Phoenix Joyce K. Lee-Iannotti, MD. Director, Sleep Disorders Center. University of Arizona College of Medicine - Phoenix

Introduction

Previous studies have consistently demonstrated the deleterious effects of shift work, from increased likelihood of cardiovascular disease and cancer to increased rates of job-related injuries and errors. Shift-based work during non-standard hours can result in a circadian rhythm sleep dysfunction known as shift work disorder (SWD). Although healthcare professionals who work in the emergency department (ED) are among the highest risk for SWD, literature examining the prevalence of SWD in the ED is scarce. This study aimed to find the estimated prevalence of SWD in the ED by utilizing a previously validated questionnaire and to identify associated factors and mitigation strategies for SWD.

Methods

A 20-question survey was administered to ED personnel from one urban academic medical center, who were recruited via emails and fliers that provided access to a Qualtrics survey link. Survey respondents were presented with four previously validated screening questions for SWD. Additionally, they were asked questions about their position, exposure to working non-standard shifts, strategies for managing non-standard shift work, their perceptions of how this shift work has affected various personal and professional aspects of their lives, and demographic characteristics. A total of 48 respondents completed the survey. Descriptive statistics from this sample were calculated for each measure in the survey. Additionally, a series of chi-square tests, logistic regression analyses, Mann-Whitney U tests, Kruskal-Wallis H tests, and ordinal logistic regression analyses were conducted to identify potential predictors of SWD and any associations SWD had with respondents’ perceptions of their personal and professional lives.

Results

Based on the previously validated screening questions, 58% of the respondents were identified as being likely to have SWD. In addition, 71% of participants felt that working non-standard shifts had a negative impact on their physical health, while 57% reported a negative impact on their personal life. However, only 35% of individuals reported having decreased work satisfaction and 13% reported having decreased work performance. A statistically significant relationship was identified between being likely to have SWD and the odds of reporting both lower work satisfaction (p-value = 0.005) and physical health (p-value = 0.005) scores, even after controlling for other predictors of these outcomes. Additionally, one statistically significant predictor of SWD was identified, wherein the odds of being in the likely SWD category were 267% higher for those who reported increased caffeine intake to minimize the impact of working non-standard shifts (p-value = 0.034).

Discussion

Our findings suggest that the prevalence of SWD in an ED setting (58% likely SWD) is substantially higher than previously reported for shift workers in the general population (26.5%). Notably, participants perceived that working non-standard shifts had a large negative impact on several aspects of their personal lives, but had minimal impact on their work performance.

Conclusion

Based on our study, the estimated prevalence of SWD among ED workers was alarmingly high at 58%. The detrimental effects of working non-standard shifts may be a large contributor to the high burnout rate in emergency medicine. Further studies are needed to find effective strategies to mitigate the risks of shift work.

Authors

Katie Huisman ; Medical Student ; University of Arizona College of Medicine Phoenix Dalia Koujah ; Medical Student ; University of Arizona College of Medicine Phoenix Bakir Mousa ; Medical Student ; University of Arizona College of Medicine Phoenix Kory Johnson PhD ; Biostatistician II ; University of Arizona College of Medicine Phoenix Daniel Lee ; Medical Student ; University of Arizona College of Medicine Phoenix Justin Zeien MD, MPH ; Resident ; Walter Reed National Military Medical Center

Introduction

Opioid overdose is a leading cause of accidental death in the United States. Persons experiencing homelessness (PEH) face a significantly higher risk of opioid overdose and opioid-related hospital visits than low-income housed individuals, making them a high-risk population for overdose-related mortality. Overdose-related deaths associated with prehospital refusal of care pose a unique and significant challenge to pre-hospital emergency providers. Our study investigates overdose-related EMS calls amongst PEH to assess if housing status impacts transport refusal rate and treatment.

Methods

A retrospective analysis of publicly available Phoenix Fire Department EMS data from 2022-2023 was conducted regarding all encounters involving naloxone administration. The amount of naloxone administered per encounter was also recorded. The total naloxone administered was divided by the total number of calls to obtain an average for naloxone administered per call for each incident type. Data was stratified based on housing status and analyzed for doses of naloxone administered and transport refusal rate.

Results

Out of 11,486 EMS encounters involving naloxone administration, housed individuals exhibited a significantly higher refusal rate of 43.1% compared to 31.0% for PEH (OR=1.42, 95% CI: 1.34-1.50). PEH received a significantly lower average number of naloxone doses for calls labeled as “code” (3.34 vs 3.63) and “altered level of consciousness” (ALOC) (2.75 vs 2.97) (p<0.05). For other types of calls, PEH and housed individuals received naloxone doses that were not significantly different.

Discussion

Our study found that persons experiencing homelessness (PEH) in Phoenix had higher EMS transport utilization for suspected overdoses compared to housed individuals, consistent with prior studies. The reasons for higher transport rates could be due to lack of alternative forms of transportation, promise of shelter, etc., but require further investigation. It is unclear whether hospitalization after an acute opioid overdose results in decreased risk of overdose-related mortality . Other benefits to hospital care such as referrals to medication-assisted treatment, counseling, and other specialty services have shown clear benefit in the literature. These benefits support interventions to reduce transport hesitancy regardless of housing status. We also observed that PEH received similar doses of naloxone as housed individuals during opioid overdose events. Naloxone doses were significantly lower for PEH in calls relating to codes and ALOC, but this was not found to be clinically significant. This contradicts our hypothesis of a bias from prehospital emergency providers in naloxone distribution.

Conclusion

Based on our data, PEH were less likely to refuse transport and received similar doses of naloxone in incidences of opioid overdose compared to their housed counterparts. Given the complexity of PEH and challenges in delivering care and follow up, future research should focus on preventative efforts in the context of addiction and opioid misuse as well as emphasizing the importance of transport as an opportunity to engage in multidisciplinary, longitudinal care.