Virtual Town Hall Meetings to Convey Emergency Medicine Residency Program Information to Students.

BACKGROUND: Applying to emergency medicine (EM) residency programs as a medical student is challenging and complicated in a normal year, but the 2020/2021 application cycle was further complicated by the COVID-19 pandemic. Due to the decrease of in-person opportunities for students to connect with residency programs, virtual "town-hall" meetings were developed. In this study our primary objective was to determine whether attendance at a virtual residency program information session improved the perceived knowledge of curriculum information and program exposure to medical students applying to an EM residency. METHODS: Four study sites hosted a total of 12 virtual events consisting of residents, faculty, or both. Standardized pre-event/post-event surveys were conducted to capture medical student perceptions before/after each of the virtual sessions. Apart from measuring the improvement in students' perceived knowledge of a program by gauging their responses to each question, we used a 10-question composite score to compare pre- vs post-event improvement among the participants. RESULTS: The pre-event survey was completed by 195 attendees, and the post-event survey was completed by 123 attendees. The median and mean composite score to this 10-question survey improved from 32.19 to 45, and 31.45 to 44.2, respectively, in the pre- to post-event survey. CONCLUSION: This study showed improvement of medical students' perceived knowledge of residency programs (reflected as increased agreement from pre- to post-event survey). The data demonstrates through question responses that students not only obtained information about the programs but also were able to gain exposure to the culture and "feel" of a program. In a non-traditional application season in which students are unable to pursue their interest in a program through audition rotations, virtual town hall events, along with other asynchronous events, may be a reasonable approach to increasing medical student understanding and awareness of a program and its culture.

Presence of Orthopedic Residency Decreases Emergency Physician's Confidence in Orthopedic Procedures.

INTRODUCTION: At present, there exists no standard orthopedic training for emergency medicine (EM) residency programs. Varying residency environments including but not limited to volume, acuity, and competing residency programs will dictate the number of orthopedic procedures a resident is exposed to, ultimately dictating a graduate's comfort level with orthopedic procedures. Our study set out to investigate further whether training alongside an orthopedic residency affects an attending physician's perceived procedural comfort. METHODS: This is a cohort study utilizing a 14-question survey distributed to an online community of EM physicians to examine the relationship between training at a residence program alongside orthopedic residents, the utility of an elective orthopedic rotation, and the overall confidence in managing closed reductions. RESULTS: EM physicians trained at a program that also hosted an orthopedic residency were more likely to train at large academic tertiary care centers (78%). Forty-two percent of these respondents felt that the presence of an orthopedic residency had a negative impact on their overall orthopedic training. The remaining 58% felt that the orthopedic residency had a positive impact on their procedural skills. In our study, the overall mean comfort level was statistically significant (p-value = 0.0024) higher in those who trained without orthopedic residents (8.78) compared to those who trained alongside an orthopedic residency (7.61). Those who had an elective orthopedic rotation found it to be more beneficial if they did the rotation with an orthopedic residency (p-value = 0.0329). Those who reported a beneficial orthopedic rotation also reported a higher level of confidence in the management of non-fracture reductions (p < 0.011, ρ = .25). CONCLUSION: Seeing as though both training and practice environments for emergency physicians vary greatly across the country, every effort should be taken to ensure graduating residents are prepared to perform orthopedic procedures without the assistance of orthopedic surgeons. Irrespective of whether a program has in-house orthopedic residents or not, EM residents should take it upon themselves to maximize their time during residency to focus on these core competencies. Graduates at the greatest risk of having low confidence are trained at academic centers that also host orthopedic programs. One should be cognizant of this while going through their EM residency.

A Missed Celiac Artery Aneurysm Leading to Rupture: A Case Report.

INTRODUCTION: Abdominal pain is a common complaint seen in the emergency department (ED). We report a case of celiac artery aneurysm (CAA) in a male patient presenting with abdominal pain to the ED on two separate occasions, approximately 24 hours apart. CASE REPORT: On the initial visit the patient was discharged with undifferentiated abdominal pain after computed tomography imaging and laboratory investigations. On the repeat visit he was found to have a rapidly expanding CAA with rupture. He became unstable requiring intubation, blood transfusions, and emergent transfer to a tertiary care center for surgical management where, unfortunately, he died hours after failed operative management. CONCLUSION: Although rare, abdominal pain caused by CAAs can rapidly progress to rupture and have a high mortality.

Radiology Training in Emergency Medicine Residency as a Predictor of Confidence in an Attending.

INTRODUCTION: At present, there exists no standardized curriculum for the interpretation of plain film radiography for emergency medicine (EM) training programs that have been adopted by an accrediting body. Education geared towards plain film interpretation is highly variable and institutionally specific. This highly variable education is dependent upon institutional resources, availability of real-time radiology interpretations, formalized radiology instruction, in addition to self-directed study. Furthermore, it is unclear whether the presence of a radiology residency program at the same institution will positively or negatively impact the radiographic education of the EM resident. In a community practice setting, EM providers may encounter several scenarios in which they must rely on their own independent interpretations during radiology coverage gaps. The goal of this study was to assess whether the amount of formal radiology training correlates with the confidence in the interpretation of radiographs following residency graduation early in a junior attending's career. METHODS: A survey study with 14 questions was distributed to EM attendings utilizing social media. Over a two-month period, 218 responses were obtained and statistical analysis was performed utilizing a chi-square test. Three survey questions with multi-variable answers were compressed into two variables for statistical analysis. RESULTS: Only 30% of survey participants indicated universal radiology coverage; 30% also responded that they did not feel prepared to interpret plain film radiographs upon residency completion. There were four statistically significant factors associated with higher confidence in interpreting radiographs upon residency graduation. Physicians were more likely to feel confident in reading radiographs if they (1) graduated from a program with no radiology residency present, (2) if their residency was located in a non-tertiary training facility, (3) if most of their radiograph learning occurred on shift and (4) if they made clinical decisions based on their own interpretations frequently. 40% of physicians reported they were more confident currently in interpreting radiographs than when they first completed residency. CONCLUSION: Steps should be taken to ensure that graduating residents are being prepared to interpret plain film radiographs as many providers will be required to do so independently in future practice. Emphasis should be focused towards on-shift teaching of these skills. Graduates at greatest risk of lower confidence train at large tertiary care centers with concomitant training of radiology residents. By emphasizing on off-shift strategies for the interpretation of plain film radiographs, residents will build confidence and develop the ability to perform these necessary skills early in one's career.

Disseminated Intravascular Coagulation With Purpura Fulminans Presentation of Acute Promyelocytic Leukemia.

A 47-year-old male presented to the emergency department with 12 hours of nausea, vomiting, abdominal pain, and a widespread skin eruption with mottled, irregular, purpuric lesions with subsequent rapid decompensation. Laboratory analysis revealed thrombocytopenia, bandemia, elevated metamyelocytes, abnormal coagulation panel, decreased fibrinogen, elevated fibrin split products, renal dysfunction, bacterial rods, dohle bodies, and toxic granulation. Acute promyelocytic leukemia (APML) was confirmed via bone marrow biopsy, flow cytometry, and fluorescence in situ hybridization analysis. Disseminated intravascular coagulation (DIC) may be the initial presentation of APML. When treated promptly, APML can achieve high remission rates; however, conditions such as DIC continue to increase mortality requiring early recognition to improve survival rates.

Synergistic Bradycardia from Beta Blockers, Hyperkalemia, and Renal Failure.

BACKGROUND: Bradycardia is a common vital sign encountered in the emergency department. These patients are often hemodynamically stable and require no emergent intervention. On occasion, bradycardia can cause hemodynamic instability, and there are established treatment pathways involving atropine, ionotropic and vasopressive infusions, and eventual mechanical pacing, if necessary. However, these pathways fail to account for the many and varied causes of bradycardia and their treatment. CASE REPORT: A 24-year-old man presented to our emergency department with syncope caused by symptomatic bradycardia. This was caused by a largely unrecognized synergistic bradycardia resulting from renal failure, AV nodal blocker use, and hyperkalemia. Our patient's worsening renal failure caused accumulation of both potassium and beta blocker, which resulted in bradycardia and hypotension, in turn worsening renal failure secondary to poor renal perfusion and potentiating his hyperkalemia and beta blocker toxicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: There is a growing number of cases that suggest this is an underrecognized synergistic and potentially lethal mechanism of hemodynamically unstable bradycardia and the treatment falls outside of typical algorithms for handling bradycardia. Understanding the multiple causes of these patients' hemodynamically unstable bradycardia allows for maximal medical management and can prevent unnecessary invasive management for these patients.

Antidepressant-like pharmacological profile of a novel triple reuptake inhibitor, (1S,2S)-3-(methylamino)-2-(naphthalen-2-yl)-1-phenylpropan-1-ol (PRC200-SS).

Due to the putative involvement of dopaminergic circuits in depression, triple reuptake inhibitors are being developed as a new class of antidepressant, which is hypothesized to produce a more rapid onset and better efficacy than current antidepressants selective for serotonin or norepinephrine neurotransmission. (1S,2S)-3-(Methylamino)-2-(naphthalen-2-yl)-1-phenylpropan-1-ol (PRC200-SS), a new triple reuptake inhibitor, potently bound to the human serotonin, norepinephrine, and dopamine transporters with K(d) values of 2.3, 0.63, and 18 nM, respectively. Inhibition of serotonin, norepinephrine, and dopamine uptake by PRC200-SS was also shown in cells expressing the corresponding transporter (K(i) values of 2.1, 1.5, and 61 nM, respectively). In vivo, PRC200-SS dose-dependently decreased immobility in the forced-swim test in rats and in the tail-suspension test in mice, models predictive of antidepressant activity, with effects comparable with imipramine. These results in the behavioral models did not seem to result from the stimulation of locomotor activity. Consistent with the in vitro data and behavioral effects, peripheral administration of PRC200-SS (5 and 10 mg/kg i.p.) significantly increased extracellular levels of serotonin and norepinephrine in the medial prefrontal cortex, and of serotonin and dopamine in the core of nucleus accumbens, with reduction of levels of 3,4-dihydroxyphenylacetic acid, homovanillic acid, and 5-hydroxyindoleacetic acid compared with levels for saline control. Furthermore, PRC200-SS self-administration, which was used as a marker of abuse liability, was not observed with rats. Therefore, it seems that PRC200-SS may represent a novel triple reuptake inhibitor and possess antidepressant activity.