Pain Medicine Education in Emergency Medicine Residency Programs.

Background Pain is a common complaint in the emergency department (ED), yet there is a lack of robust pain curricula in emergency medicine (EM) residency programs. In this study, we investigated pain education in EM residencies and various factors related to educational development. Methodology This was a prospective study collecting online survey results sent to Program Directors, Associate Program Directors, and Assistant Program Directors of EM residencies in the United States. Descriptive analyses with nonparametric tests were performed to investigate relationships between these factors, including educational hours, level of educational collaboration with pain medicine specialists, and multimodal therapy utilization. Results The overall individual response rate was 39.8% (252 out of 634 potential respondents), representing 164 out of 220 identified EM residencies with 110 (50%) Program Directors responding. Traditional classroom lectures were the most common modality for the delivery of pain medicine content. EM textbooks were the most common resource utilized for curriculum development. An average of 5.7 hours per year was devoted to pain education. Up to 46.8% of respondents reported poor or absent educational collaboration with pain medicine specialists. Greater collaboration levels were associated with greater hours devoted to pain education (p = 0.01), perceived resident interest in acute and chronic pain management education (p < 0.001), and resident utilization of regional anesthesia (p = <0.01). Faculty and resident interest in acute and chronic pain management education were similar to each other and high on the Likert scale, with higher scores correlating to greater hours devoted to pain education (p = 0.02 and 0.01, respectively). Faculty expertise in pain medicine was rated the most important factor in improving pain education in their programs. Conclusions Pain education is a necessity for residents to adequately treat pain in the ED, but remains challenging and undervalued. Faculty expertise was identified as a factor limiting pain education among EM residents. Collaboration with pain medicine specialists and recruitment of EM faculty with expertise in pain medicine are ways to improve pain education of EM residents.

Away Rotation Applications in Emergency Medicine: Medical Student Behaviors, Outcomes, and Stressors.

BACKGROUND: Completing an emergency medicine (EM) away rotation is integral to matching successfully into an EM residency program. The demand for EM away rotations (ARs) drives students to submit numerous applications without evidence-based recommendations to guide stakeholders on the approach or number to submit. OBJECTIVES: We conducted a survey study of EM-bound fourth-year medical students to gain insight into their AR application experiences, outcomes, and perceptions. METHODS: We distributed a 40-item questionnaire to EM applicants in Fall 2018 via e-mail through the Clerkship Directors in Emergency Medicine, Council of Residency Directors in EM, and Emergency Medicine Residents' Association listservs. Responses were evaluated using quantitative and qualitative analysis. Primary outcomes were the number of AR applications submitted and AR offers received by students. Secondary outcomes were students' self-assessment of their competitiveness, differences in AR application numbers by degree type, sources of student advising, and student perceptions of the AR application process. RESULTS: There were 253 respondents, consisting of 192 allopathic (MD) and 61 osteopathic (DO) medical students, who met the inclusion criteria, representing about 10% of the applicant pool. On average, students submitted 13.97 applications (95% confidence interval [CI] 11.59-16.35), received 3.25 offers (95% CI 3.01-3.49), and accepted 2.22 offers (95% CI 2.08-2.36). DO candidates submitted twice as many applications as MD candidates while experiencing a similar rate of offers received. Peer influence (n = 154, 61%), peer online advising networks (n = 83, 33%), and self-assessment (n = 114, 45%) were the most often reported causes of increased applications; cost (n = 104, 41%) and geographic limitations (n = 114, 45%) were the most often reported causes of decreased applications. Open-response analysis revealed frustration with lack of standardization (n = 44, 29.5%), insufficient transparency on available positions (n = 37, 24.8%), limited communication (n = 30, 20.1%), and cost (n = 12, 8.1%). CONCLUSIONS: This study showed that, as a whole, students received one away rotation offer for every four to five applications submitted. It clarified factors contributing to increased EM away rotation application submissions and associated stressors inherent in the application experience. Our findings offer insights to inform advising recommendations. They also suggest that stakeholders consider standardizing the process and improve communication over spot availability and application status.

Availability of Emergency Medicine Away Rotations.

OBJECTIVES: Residency directors in emergency medicine (EM) have been placing increased value on the Standardized Letter of Evaluation to evaluate the escalating numbers of residency applications received each year. This has placed added significance on EM away rotations (ARs). We sought to determine the overall availability of ARs in EM. METHODS: We surveyed clerkships sites at the end of 2018-2019 application season. The survey requested data about maximum rotation spots available, actual number of students that rotated, and data about application processing and rotation offer decision making. RESULTS: We received 190 responses, of which 129 (49% of 262 clerkship sites surveyed) provided data regarding available positions and student rotators. A total of 3,472 ARs were completed at the responding sites. The average capacity ratio (CR; maximum available AR spots divided by AR completed by students) for responding sites was 1.57. AR availability varied by time and geography. Most AR positions were filled during peak season (CR = 1.22); however, many went unfilled outside of this time frame (CR = 2.41). Geographic data showed some locations had significant unfilled AR availability. CONCLUSIONS: Our survey data show that there are at least 1.5 AR positions per applicant. Students can be reasonably expected to complete one AR and, in select cases, a second. CR during peak season indicates nearly saturated AR positions. Flexibility of rotation timing and tools to link open AR positions with students needing to complete a rotation will help optimize filling available AR positions. Continued effort in application advising from home clerkships and processes to ensure equitable distribution of AR positions among students will help ensure interested students obtain a position.

Implementation of a Medical Education Rotation for Senior Emergency Medicine Residents.

Audience and type of curriculum: This medical education (MedEd) rotation is designed for post graduate year 3 (PGY-3) residents. Length of curriculum: The rotation runs over one month for each PGY-3. Introduction: Resident physicians have teaching responsibilities during and after training. These responsibilities expand beyond teaching medical students and junior residents to include teaching advanced practice providers, nursing colleagues, and prehospital personnel.1 The need for formal teaching curricula in graduate medical education is recognized, but practical examples are lacking.2. Educational Goals: Our objectives were to provide our senior residents with exposure to various aspects of the field of MedEd, to further develop their teaching skills and to encourage them to consider a career in academic emergency medicine. Educational Methods: The educational strategies used in this curriculum include: 1) clinical shifts supervising small groups of medical students with dedicated faculty supervision, 2) a structured simulation-based medical student teaching activity where the resident is able to provide feedback and teach medical students, 3) a MedEd project, 4) required readings that cover a variety of topics including education theory, curriculum design, and feedback, 5) case-based didactic presentation at our monthly case conference, and 6) one hour of postgraduate year 1 (PGY-1) small group facilitation focusing on fundamentals of emergency medicine. Research Methods: PGY-3 residents completed an online survey prior to residency graduation. The timing of the survey was purposefully delayed to the end of the academic year to allow the residents time to practice techniques they learned during their MedEd rotation. Results: Thirteen residents (93%) completed a survey. Five residents (38%) reported that the rotation had "some" or more impact on their career decision. The other 8 residents reported "almost no impact" or "a little bit of impact." Ten residents (77%) reported that they would "sometimes," "often," or "almost always" use the teaching techniques they learned during the rotation. The highest rated activities were simulation-based teaching and dedicated clinical teaching shifts. Confidence with bedside teaching improved after the session, with a median confidence before the session of 3/5 (moderately confident; IQR 2-3) and a median confidence after the session of 4/5 (quite confident; IQR 3-4, p=0.006). Discussion: Our MedEd rotation improved teaching confidence but had low impact on career decision. Residents rated the interactive, faculty-supervised components of the rotation highest. We recommend that programs interested in instituting a MedEd rotation first trial the rotation as an elective and utilize established formal teaching activities. Topics: Medical Education, resident physician, medical student teaching, simulation, academic medicine.

COVID-19: A Driver for Disruptive Innovation of the Emergency Medicine Residency Application Process.

The coronavirus disease (COVID-19) pandemic has had a significant impact on undergraduate medical education with limitation of patient care activities and disruption to medical licensing examinations. In an effort to promote both safety and equity, the emergency medicine (EM) community has recommended no away rotations for EM applicants and entirely virtual interviews during this year's residency application cycle. These changes affect the components of the EM residency application most highly regarded by program directors - Standardized Letters of Evaluation from EM rotations, board scores, and interactions during the interview. The Council of Residency Directors in Emergency Medicine Application Process Improvement Committee suggests solutions not only for the upcoming year but also to address longstanding difficulties within the process, encouraging residency programs to leverage these challenges as an opportunity for disruptive innovation.

Calming Troubled Waters: A Narrative Review of Challenges and Potential Solutions in the Residency Interview Offer Process.

The rising numbers of residency applications along with fears of a constrained graduate medical education environment have created pressures on residency applicants. Anecdotal evidence suggests substantial challenges with the process of offering residency interviews. This narrative review is designed to identify and propose solutions for the current problems in the process of offering residency interviews. We used PubMed and web browser searches to identify relevant studies and reports. Materials were assessed for relevance to the current process of distributing residency interviews. There is limited relevant literature and the quality is poor overall. We were able to identify several key problem areas including uncertain timing of interview offers; disruption caused by the timing of interview offers; imbalance of interview offers and available positions; and a lack of clarity around waitlist and rejection status. In addition, the couples match and need for coordination of interviews creates a special case. Many of the problems related to residency interview offers are amenable to program-level interventions, which may serve as best practices for residency programs, focusing on clear communication of processes as well as attention to factors such as offer-timing and numbers. We provide potential strategies for programs as well as a call for additional research to better understand the problem and solutions.

Yogaman: An Inexpensive, Anatomically-detailed Chest Tube Placement Trainer.

INTRODUCTION: Opportunities for chest tube placement in emergency medicine training programs have decreased, making competence development and maintenance with live patients problematic. Available trainers are expensive and may require costly maintenance. METHODS: We constructed an anatomically-detailed model using a Halloween skeleton thorax, dress form torso, and yoga mat. Participants in a trial session completed a survey regarding either their comfort with chest tube placement before and after the session or the realism of Yogaman vs. cadaver lab, depending on whether they had placed <10 or 10 or more chest tubes in live patients. RESULTS: Inexperienced providers reported an improvement in comfort after working with Yogaman, (comfort before 47 millimeters [mm] [interquartile ratio {IQR}, 20-53 mm]; comfort after 75 mm [IQR, 39-80 mm], p=0.01). Experienced providers rated realism of Yogaman and cadaver lab similarly (Yogaman 79 mm [IQR, 74-83 mm]; cadaver lab 78 mm [IQR, 76-89 mm], p=0.67). All evaluators either agreed or strongly agreed that Yogaman was useful for teaching chest tube placement in a residency program. CONCLUSION: Our chest tube trainer allowed for landmark identification, tissue dissection, pleura puncture, lung palpation, and tube securing. It improved comfort of inexperienced providers and was rated similarly to cadaver lab in realism by experienced providers. It is easily reusable and, at $198, costs a fraction of the price of available commercial trainers.

Infections of the Neck.

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.

A Two-Center Validation of "Patient Does Not Follow Commands" and Three Other Simplified Measures to Replace the Glasgow Coma Scale for Field Trauma Triage.

STUDY OBJECTIVE: Out-of-hospital personnel worldwide calculate the 13-point Glasgow Coma Scale (GCS) score as a routine part of field trauma triage. We wish to independently validate a simpler binary assessment to replace the GCS for this task. METHODS: We analyzed trauma center registries from Loma Linda University Health (2003 to 2015) and Denver Health Medical Center (2009 to 2015) to compare the binary assessment "patient does not follow commands" (ie, GCS motor score <6) with GCS score less than or equal to 13 for the prediction of 5 trauma outcomes: emergency intubation, clinically significant brain injury, need for neurosurgical intervention, Injury Severity Score greater than 15, and mortality. As a secondary analysis, we similarly evaluated 3 other measures simpler than the GCS: GCS motor score less than 5, Simplified Motor Score, and the "alert, voice, pain, unresponsive" scale. RESULTS: In this analysis of 47,973 trauma patients, we found that the binary assessment "patient does not follow commands" was essentially identical to GCS score less than or equal to 13 for the prediction of all 5 trauma outcomes, with slightly superior positive likelihood ratios (eg, those for mortality 2.37 versus 2.13) offsetting slightly inferior negative ones (eg, those for mortality 0.25 versus 0.24) and its graphic depiction of sensitivity versus specificity superimposing the GCS prediction curve. We found similar results for the 3 other simplified measures. CONCLUSION: In this 2-center external validation, we confirmed that a simple binary assessment-"patient does not follow commands"-could effectively replace the more complicated GCS for field trauma triage.

The San Bernardino, California, Terror Attack: Two Emergency Departments' Response.

On December 2, 2015, a terror attack in the city of San Bernardino, California killed 14 Americans and injured 22 in the deadliest attack on U.S. soil since September 11, 2001. Although emergency personnel and law enforcement officials frequently deal with multi-casualty incidents (MCIs), what occurred that day required an unprecedented response. Most of the severely injured victims were transported to either Loma Linda University Medical Center (LLUMC) or Arrowhead Regional Medical Center (ARMC). These two hospitals operate two designated trauma centers in the region and played crucial roles during the massive response that followed this attack. In an effort to shed a light on our response to others, we provide an account of how these two teaching hospitals prepared for and coordinated the medical care of these victims. In general, both centers were able to quickly mobilize large number of staff and resources. Prior disaster drills proved to be invaluable. Both centers witnessed excellent teamwork and coordination involving first responders, law enforcement, administration, and medical personnel from multiple specialty services. Those of us working that day felt safe and protected. Although we did identify areas we could have improved upon, including patchy communication and crowd-control, they were minor in nature and did not affect patient care. MCIs pose major challenges to emergency departments and trauma centers across the country. Responding to such incidents requires an ever-evolving approach as no two incidents will present exactly alike. It is our hope that this article will foster discussion and lead to improvements in management of future MCIs.