"Trauma to the Eye"-A Low Fidelity Resident Teaching Module for Identifying and Treating a Retrobulbar Hematoma.

Introduction: A retrobulbar hematoma (RH) is a serious time-dependent diagnosis due to its potential for permanent damage of the optic nerve, resulting in blindness. Emergency medicine (EM) physicians face the challenge of recognizing this time-sensitive injury and treating it before irreversible damage occurs. Due to its relative infrequency in the emergency department, residents may not have adequate experience in recognizing and treating RH. Methods: This educational intervention outlined a simulated scenario that we developed to educate EM residents to diagnose RH and perform an emergent lateral canthotomy and cantholysis (LCC). Participating residents were asked to obtain a history and perform a physical examination that was consistent with a 34-year-old patient presenting with pushing behind the eye suggesting RH. Once residents made a diagnosis, they practiced performing an emergent LCC on a low-fidelity task trainer supplemented with a novel checklist. The residents completed an assessment questionnaire before and after the teaching module to measure the educational intervention's effectiveness. Results: Learners' scores significantly improved in the ability to recognize and treat RH (12%, p < .001), in confidence in performing the procedure (18%, p < .001), but did not significantly decrease in stress (-10%, p = .058). The intervention was effective in improving preparedness, with all participants indicating that they felt more prepared to treat RH compared to before the educational intervention. Discussion: This educational intervention is a successful resource that can decrease cases of preventable blindness by improving EM residents' ability to recognize and treat RHs.

Ice-man Down: Using Simulation to Practice the Safe Extrication of Collapsed Hockey Players in a Confined Space.

Sporting event emergencies are common among both spectators and players, with unique sets of challenges associated with patient extrication in unfamiliar and chaotic environments. It is critical for sports physicians and trainers to deliberately train and prepare for emergent situations with limited resources during athletic events. One of the most difficult, yet commonly encountered challenges is determining when and how to safely remove an injured player's helmet and sporting equipment, particularly if a spinal injury is highly suspected. We created a high-fidelity simulation case to practice the safe extrication of a hockey player who collapses on the bench in the player's box, a space-restricted environment. The patient is a 25-year-old male hockey player who becomes unresponsive after a syncopal episode in the player's box, and subsequently transferred to a medical center for further evaluation. Critical actions include extrication of the player at the scene, diagnosis of syncope, placement of the unconscious player on a backboard with cervical-spine precautions, removal of the player's faceguard, removing the player off the ice, checking the electrocardiogram and glucose level, and transferring the player to a controlled environment. The learning objectives were to identify, evaluate, and manage the reversible causes of syncope, and demonstrate appropriate techniques for the optimal removal of sports equipment. Learner assessment was based on participation in the scenario and debriefing learners after the simulation. Post-simulation debriefing revealed that participants highly appreciated practicing not-so-commonly encountered hockey-related emergencies. Athletic trainers and emergency providers were able to effectively practice their management of the unresponsive hockey player. The participants were also able to deliberately practice their teamwork and communications skills with their peers. Learning points include proper c-spine immobilization techniques in a tight space and indication for gear-removal in an unconscious patient. As hockey continues to gain popularity, this simulation case will prepare athletic trainers and emergency providers to better address the reversible causes for syncope in hockey players, as well as safely and effectively extricate injured players from space-limiting sporting environments.

Rapid response team activations within 24 hours of admission from the emergency department: an innovative approach for performance improvement.

OBJECTIVES: Performance improvement programs in emergency medicine (EM) have evolved beyond peer reviews of referred cases and now encompass a large set of quality metrics that are measured proactively. However, peer review of cases continues to be an important element of performance improvement, and selection of cases tends to be driven by an ad hoc referral process based on concerns about problems with care in the emergency department (ED). In the past decade, there has been widespread hospital adoption of rapid response teams (RRTs) that respond to patients who decline clinically to reduce adverse outcomes. In an effort to cast a wider net, to take a more systematic approach, and to avoid "blind spots" from individual variability in criteria for referring cases, the institution instituted a new process for selecting cases for ED peer review based on RRT activations within 24 hours of admission from the ED. The hypothesis was that a formal process for review of these activation cases would increase the number of cases for peer review. METHODS: This was a prospective, observational study conducted from July 1, 2012, to June 30, 2013, at an urban, academic medical center with an EM residency program. A new automated monthly report was created, capturing all RRT activations within 24 hours of admission from the ED. All events were reviewed by three physicians from the ED performance improvement committee to examine for systems issues, individual provider issues, or both, that might yield opportunities for improvement. Cases with potential opportunities were reviewed by the full ED performance improvement committee. Cases were classified according to the indication for response team activation using the system outlined by the U.S. Agency for Healthcare Research and Quality. RESULTS: During the study period 61,814 patients were treated in the ED, and 13,067 were admitted to inpatient status. Thirty-two RRT activations within 24 hours of admission from the ED occurred among these admitted patients, representing 0.24% of admissions (95% confidence interval [CI] = 0.16% to 0.33%). Of the 32 cases, only one was also referred independently for ED performance improvement review via the traditional ad hoc process. During the same period of time, 85 cases were referred to the ED performance improvement committee via the traditional ad hoc referral process. Thus, the RRT cases added an additional 31 cases, or 36.5%, to the 85 cases reviewed in ED performance improvement. Of the 32 cases, two were determined by the performance improvement committee to have individual provider factors in their ED care, which contributed to the clinical decline triggering the response teams; none had system factors. Most of the response team activations were for neurologic changes (n = 13) and respiratory status changes (n = 12). In two cases there was long-term morbidity or mortality related to the team activation event; in neither of these cases were ED system or individual provider factors judged to have contributed. CONCLUSIONS: The review of RRT activations within 24 hours of admission from the ED significantly supplemented the typical ad hoc referral system for peer review of cases, highlighting cases that likely would not have received attention within the ED. This novel and unique case review process revealed opportunities for education and performance improvement. This and other systematic approaches to case detection may be useful adjuncts to traditional case referrals for review.

Social media guidelines and best practices: recommendations from the Council of Residency Directors Social Media Task Force.

Social media has become a staple of everyday life among over one billion people worldwide. A social networking presence has become a hallmark of vibrant and transparent communications. It has quickly become the preferred method of communication and information sharing. It offers the ability for various entities, especially residency programs, to create an attractive internet presence and "brand" the program. Social media, while having significant potential for communication and knowledge transfer, carries with it legal, ethical, personal, and professional risks. Implementation of a social networking presence must be deliberate, transparent, and optimize potential benefits while minimizing risks. This is especially true with residency programs. The power of social media as a communication, education, and recruiting tool is undeniable. Yet the pitfalls of misuse can be disastrous, including violations in patient confidentiality, violations of privacy, and recruiting misconduct. These guidelines were developed to provide emergency medicine residency programs leadership with guidance and best practices in the appropriate use and regulation of social media, but are applicable to all residency programs that wish to establish a social media presence.

Google Internet searches on residency applicants do not facilitate the ranking process.

BACKGROUND: Information used by program directors (PDs) to evaluate and rank residency applicants is largely limited to the Electronic Residency Application Service and the interview day. The Internet represents a potential source of additional data on applicants. Recent surveys reveal that up to 90% of United States (US) companies are already using the Internet to post jobs and to screen candidates. However, its use in residency applicant evaluation is not well studied. OBJECTIVE: We hypothesize that the Internet, through the use of a Google search, will provide useful information to PDs in ranking applicants. METHODS: This prospective observational study was completed by six Accreditation Council for Graduate Medical Education-accredited Emergency Medicine residency programs. After the interview process, programs formed their rank order list in their usual fashion. Then participating programs performed a Google search on applicants from their list. A standardized search was used and information reviewed was limited to the first two Google pages. The main outcome measure was change in an applicant's status on the rank order list. Change in status was based on the judgment of the individual program's PD. RESULTS: A total of 547 applicants were reviewed. The time for review of information was 4,386 min total and a mean of 7.2 min per resident. Position on the rank order list was changed for three applicants; two moved up on the list and one moved down. Four programs made no changes. No applicants were removed. CONCLUSIONS: The Internet, through the use of a Google search, did not appear to provide useful information in a time-effective manner to PDs in ranking applicants.