A Critically Ill Influenza A-Positive Patient With Spontaneous Pneumomediastinum, Superimposed Bacterial Pneumonia, and Bilateral Pneumothoraces.

Influenza most often causes a febrile viral syndrome inclusive of pulmonary irritation with cough, shortness of breath, and congestion. However, severe infection can also occur, causing significant viral pneumonia with Type 1 respiratory failure. and rare but life-altering complications such as pneumomediastinum, secondary bacterial pneumonia, acute respiratory distress syndrome (ARDS), viremia, and death. This was a case of a 20-year-old male with no significant past medical history who presented to the emergency department with shortness of breath and chest discomfort and was found to have Influenza A with Type I respiratory failure requiring High Flow Nasal Cannula (HFNC) and extensive pneumomediastinum, superimposed bacterial pneumonia, and bilateral pneumothoraces. It is possible that complications secondary to influenza A infections could be under-reported due to the extremely high prevalence of the viral infection in this country. In addition, complicated pneumomediastinum from Influenza infection is sparsely documented in young adult males and children, but its clinical course can be dramatic enough to include life-altering complications. This case should serve as a reminder to all emergency medicine providers that when evaluating unstable Influenza A patients, various tests should be considered on a case-by-case basis to risk-stratify the likelihood of emergent pathology.

Effectiveness of a virtual reality trainer for retention of tourniquet application skills for hemorrhage control among emergency medicine residents.

Background: With a rise in mass casualty incidents, training in hemorrhage control using tourniquets has been championed as a basic-and lifesaving-procedure for bystanders and medical professionals alike. The current standard for training is in-person (IP) courses, which can be limited based on instructor availability. Virtual reality (VR) has demonstrated the potential to improve the accuracy of certain medical tasks but has not yet been developed for hemorrhage control. The objective of this study was to evaluate the efficacy of a VR hemorrhage trainer in learner retention of tourniquet application when compared to traditional IP instructor teaching among a cohort of emergency medicine residents practicing in a Level I trauma center. Methods: This was a prospective, observational study of 53 emergency medicine residents at an inner-city program. Participants were randomly assigned to either the control or the VR group. On Day 0, all residents underwent a training session (IP vs. VR) for the proper, stepwise application of a tourniquet, as defined by the American College of Trauma Surgeons. Each participant was then assessed on the application of a tourniquet by a blinded instructor using the National Registry Hemorrhage Control Skills Lab rubric. After 3 months, each resident was reevaluated on the same rubric, with subsequent data analysis on successful tourniquet placement (measured as under 90 s) and time to completion. Results: Of the 53 participants, the IP training group had an initial pass rate of 97% (28/29) compared to 92% (22/24) in the VR group (p = 0.58). On retention testing, the IP training group had a pass rate of 95% (20/21) compared to 90% (18/20) in the VR group (p = 0.62). Stratifying the success of tourniquet placement by level of resident training did not demonstrate any statistically significant differences. Conclusions: In this pilot study of emergency medicine residents, we found no significant differences in successful hemorrhage control by tourniquet placement between those trained with VR compared to a traditional IP course among emergency medicine residents. While more studies with greater power are needed, the results suggest that VR may be a useful adjunct to traditional IP medical training.

In Situ Simulation as a Quality Improvement Tool to Identify and Mitigate Latent Safety Threats for Emergency Department SARS-CoV-2 Airway Management: A Multi-Institutional Initiative.

BACKGROUND: In situ simulation has emerged as a powerful quality improvement (QI) tool in the identification of latent safety threats (LSTs). Following the first wave of SARS-CoV-2 at an urban epicenter of the disease, a multi-institutional collaborative was formed to integrate an in situ simulation protocol across five emergency departments (EDs) for systems improvement of acute airway management. METHODS: A prospective, multi-institutional QI initiative using two Plan-Do-Study-Act (PDSA) cycles was implemented across five EDs. Each institution conducted simulations involving mannequins in acute respiratory failure requiring definitive airways. Simulations and systems-based debriefs were standardized. LSTs were collected in an online database, focused on (1) equipment availability, (2) infection control, and (3) communication. RESULTS: From June 2020 through May 2021, 58 of 70 (82.9%) planned simulations were completed across five sites with 328 unique individual participants. Overall LSTs per simulation (7.00-4.69, p < 0.001) and equipment LSTs (3.00-1.46, p < 0.001) decreased from cycle 1 to cycle 2. Changes in mean LSTs for infection control and communication categories varied among sites. There was no correlation between total LSTs or any of the categories and team size. Number of beds occupied was significantly negatively correlated with total and infection control LSTs. CONCLUSION: This study was unique in simultaneously running a structured in situ protocol across numerous diverse institutions during a global pandemic. This initiative found similar categories of threats across sites, and the protocol developed empowered participants to implement changes to mitigate identified threats.

Improving physician well-being and reducing burnout using a peer-to-peer recognition program.

Background: Drivers of physician burnout include an intricate interplay between health care organizational structures, societal influences, and individual-level factors. In the traditional workforce, peer-to-peer recognition programs (PRPs) have reduced burnout by building a sense of community and effectively creating a "wellness culture." We implemented a PRP in an emergency medicine (EM) residency and determined its impact on subjective symptoms of burnout and wellness. Methods: This was a prospective, pre- and postintervention study conducted in a single residency over a 6-month period. All 84 EM residents of the program were sent a voluntary anonymized survey that included a validated instrument on wellness and burnout. A PRP was initiated. After 6 months, a second survey was distributed. The outcome of the study was to examine whether the addition of a PRP reduced burnout and improved wellness. Results: There were 84 respondents to the pre-PRP survey and 72 to the post-PRP survey. Respondents reported an improvement after the inception of the use of the PRP in two factors that contribute to a physician's wellness: feeling recognized for accomplishments at work, which improved from 45% (38/84) affirmative to 63% (45/72; 95% confidence interval [CI] 2.3%-32.4%, p = 0.025) and a comfortable and supportive work environment, which improved from 68% (57/84) to 85% (61/72; 95% CI 3.5%-29.3%, p = 0.014). There was no significant effect in the Stanford Professional Fulfillment Index (PFI) as a result of this intervention over the 6 months. Conclusions: A PRP initiative resulted in improvements in several factors that drive physician wellness but overall burnout measured by the Stanford PFI did not show any improvement over the 6-month period. A future longitudinal study examining the continuous assessment of PRP on the EM residents throughout the entire course of 4 years of residency training would be beneficial to determine if it could change burnout from year to year.

Self-reported modifying effects of resilience factors on perceptions of workload, patient outcomes, and burnout in physician-attendees of an international emergency medicine conference.

Emergency medicine has one of the highest rates of burnout of all medical specialties. Recent research has identified putative sources of burnout in emergency medicine, including stress of overnight shifts, psychological demands of handling emergency patients, and perceived poor departmental support systems. This burnout is detrimental to the quality of patient care, and thus represents an important target to simultaneously improve both physician wellness and patient outcomes. We lack consensus on the best way to combat the impacts of physician burnout in part, because we do not know the protective factors that best enable individuals to manage their burnout and be resilient to its impacts on their patient care. The goal of this study was to identify the resilience factors that have the greatest influence on the relationship between physician burnout symptoms and perceptions of workload impact on patient outcomes. We conducted a cross-sectional web-based anonymous survey of full-time attending emergency medicine physicians and measured self-reported responses about perceived impacts of workload on patient care and symptoms of burnout. Additionally, we measured resilience factor-related items (such as shift length/type, spirituality, home life, etc.), stratified the responses by level of agreement with the statements, and assessed how each impacted the relationship between burnout domains and perceived workload/patient outcomes. The level of agreement with five resilience factor statements influenced the magnitude of correlation between workload's effects on patient outcomes and burnout. These factors included personal spirituality, utility of mindfulness techniques, sleep quality, perceptions of home life, and the presence of institutional debriefing procedures. This work identified five resilience factors that may enable emergency medicine physicians to mitigate the impact of their burnout on their work and patient care. Promoting these resilience factors represent targets for institutional-level interventions to improve both physician wellness and patient outcomes.

Biofilm formation protects Escherichia coli against killing by Caenorhabditis elegans and Myxococcus xanthus.

Enteric bacteria, such as Escherichia coli, are exposed to a variety of stresses in the nonhost environment. The development of biofilms provides E. coli with resistance to environmental insults, such as desiccation and bleach. We found that biofilm formation, specifically production of the matrix components curli and cellulose, protected E. coli against killing by the soil-dwelling nematode Caenorhabditis elegans and the predatory bacterium Myxococcus xanthus. Additionally, matrix-encased bacteria at the air-biofilm interface exhibited ∼40-fold-increased survival after C. elegans and M. xanthus killing compared to the non-matrix-encased cells that populate the interior of the biofilm. To determine if nonhost Enterobacteriaceae reservoirs supported biofilm formation, we grew E. coli on media composed of pig dung or commonly contaminated foods, such as beef, chicken, and spinach. Each of these medium types provided a nutritional environment that supported matrix production and biofilm formation. Altogether, we showed that common, nonhost reservoirs of E. coli supported the formation of biofilms that subsequently protected E. coli against predation.