Does Inclusion of Emergency Medicine (EM) Residents in ECG Screening for STEMI Change the Time to Catheterization Lab Activation?

BACKGROUND: Emergency medicine physicians must rapidly obtain and interpret an electrocardiogram (ECG) to quickly identify life-threatening cardiac emergencies such as ST-elevation myocardial infarction (STEMI). Although ECG interpretation is a critical component of residency education, few high-powered studies exploring the accuracy of resident ECG interpretation exist. OBJECTIVES: This study aims to evaluate whether or not the inclusion of Third Year Emergency Medicine Resident ECG interpretations is noninferior to attending-only ECG interpretations in regard to time to STEMI activation. METHODS: This was a retrospective noninferiority study of STEMI activation times before and after the inclusion of Third Year Emergency Medicine Resident resident ECG interpretations into the workflow at an academic, urban tertiary care center between November 2020 and April 2022, excluding prehospital activations. The primary outcome was the proportion of successful STEMI activations initiated within 5 minutes of ECG completion. An absolute decrease of 10% between groups was chosen as the noninferiority margin. RESULTS: In the attending-only group, 26 (66.7%) cases resulted in successful STEMI activations compared to 31 cases (77.5%) in the combined group. The proportion of successful STEMI activations did not differ with resident screening, X 2 = 1.15, P = 0.28. The absolute difference between groups' successful activations was an increase of 11%, which lies within the noninferiority margin (+11%, 95% confidence interval, -8.68% to 30.7%). Average times to STEMI activation in the attending-only and combined groups were 7.59 minutes (Standard Deviation [SD], 10.19) and 5.13 minutes (SD, 6.95), respectively. Average door-to-balloon times for those undergoing Percutaneous Coronary Intervention were 72.74 minutes (SD, 20.76) in the attending-only group and 89.90 minutes (SD, 67.74) in the combination group. Two sample t-test showed no statistically significant difference between the 2 groups for average time to STEMI activation (difference = 2.46 minutes, 95% CI, -1.46 to 6.38) and average door-to-balloon time (difference = 17.16, 95% CI, -39.73 to 5.41). CONCLUSION: The inclusion of emergency medicine PGY-3 residents in the ECG screening workflow is noninferior to attending-only interpretation of ECGs with regard to STEMI activation time.

American Value.

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Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting.

BACKGROUND: Patients intubated in the prehospital setting require quick and definitive confirmation of endotracheal (ET) tube placement upon arrival to the emergency department (ED). Direct and adjunct strategies exist, but each has limitations and there is no definitive gold standard. The utility of bronchoscopy in ED intubation has been studied, but scant literature exists on its use for ET tube confirmation. This study aims to assess effectiveness, ease and speed with which ET tube placement can be confirmed with disposable fiberoptic bronchoscopy. METHODS: Emergency medicine residents recruited from a 3-year urban residency program received 5 minutes of active learning on a simulation mannequin using a disposable, flexible Ambu aScope interfaced with a monitor. With residents blinded, the researcher randomly placed the ET tube in the trachea, esophagus or right mainstem. Residents identified ET tube position by threading the bronchoscope through the tube and viewing distal anatomy. Each resident underwent 4 trials. Accuracy, speed and perceptions of difficulty were measured. RESULTS: Residents accurately identified the location of the ET tube in 88 out of 92 trials (95.7%). The median time-to-guess was 7.0 seconds, IQR (5.0-10.0). Average perceived difficulty was 1.6 on a scale from 1-5 (1 being very easy and 5 being very difficult). No tubes were damaged or dislodged. CONCLUSION: While simulation cannot completely replicate the live experience, fiberoptic bronchoscopy appears to be a quick and accurate method for ET tube confirmation. Further studies directly comparing this novel approach to established practices on actual patients are warranted.

Environmental impact of metal and metalloid leaching from highway marking glass beads.

Recently, metals and metalloids have been observed at elevated concentrations in glass beads imported to the US. Average total concentrations in imported batches ranged from 103 to 683 mg kg(-1) for As, 62 to 187 mg kg(-1) for Sb, and 23 to 179 mg kg(-1) for Pb. The labile fraction associated with the glass beads resulted in leached concentrations as great as 538 µg L(-1) for As, 1092 µg L(-1) for Pb, and 160 µg L(-1) for Sb. Sequential extraction was conducted as well to better understand the form of metals and metalloids associated with the glass beads. Only 0.23% of As, 3.40% of Pb, 2.37% of Ba, and 1.92% of Mn were extracted in the exchangeable (As, Mn, and Ba) and the oxidizable forms (Pb), whereas greater than 97% of metals and metalloids present were associated with the glass matrix. Nonparametric statistics were applied to test total concentrations that resulted in exceedances in the groundwater quality criteria. Results demonstrated that the As, Pb, and Sb limits were exceeded for 98%, 58%, and 15% of the samples tested respectively suggesting a potential environmental impact to groundwater used as a drinking water source.