Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle.

INTRODUCTION: Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS: This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS: A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION: Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Is Covid-19 community level testing effective in reaching at-risk populations? Evidence from spatial analysis of New Orleans patient data at walk-up sites.

BACKGROUND: This paper evaluates the increase in coverage and use of Covid-19 testing services for vulnerable and hard-to-reach populations through the introduction of community-based walk-up sites in New Orleans, LA. While most GIS work on Covid-19 testing coverage and access has used census tract or ZIP code aggregated data, this manuscript is unique in that it uses individual level demographics and exact addresses to calculate distances actually traveled by patients. METHODS: We used testing data recorded for 9721 patients at 20 sites operating in May-June 2020. The dataset includes detailed age, race and ethnicity, and testing results as well as the exact address of each individual. Using GIS, we estimated changes in testing coverage for minority neighborhoods and calculated the actual distance covered by individuals. Logistic regression and multivariate linear regression were used to identify socio-demographic variables associated with distance travelled to and used of nearest testing site. We used a secondary dataset from drive-through sites to evaluate change in coverage at the census tract level for the metropolitan area. RESULTS: Walk-up sites significantly increased testing availability in New Orleans, and specifically in minority neighborhoods. Both African Americans and Asians were more likely (14.7 and 53.0%) to be tested at the nearest walk-up site. They also covered shorter distances to get tested. Being elderly was also significantly and positively associated with testing at the nearest site. Hispanics, however, were not associated with increased proximity to and use of nearest sites, and they traveled an additional 0.745 km to get tested. Individuals who tested positive also travelled significantly longer distances to obtain a test. CONCLUSIONS: Walk-up sites increased testing availability for some vulnerable populations who took advantage of the sites' proximity, although inequalities appear at the metropolitan scale. As cities are planning community vaccination campaigns, mobile, walk-up sites appear to improve both coverage and accessibility for hard-to-reach populations. With adequate technical (vaccine dose refrigeration) and messaging (addressing reticence to immunization) adaptations, they could constitute a key complementary approach to health facility points of delivery.

Fifteen Years After Katrina: Paving the Way for Health Care Transformation.

Following the devastation of the Greater New Orleans, Louisiana, region by Hurricane Katrina, 25 nonprofit health care organizations in partnership with public and private stakeholders worked to build a community-based primary care and behavioral health network. The work was made possible in large part by a $100 million federal award, the Primary Care Access Stabilization Grant, which paved the way for innovative and sustained public health and health care transformation across the Greater New Orleans area and the state of Louisiana.

Stop the Bleed Training: Rescuer Skills, Knowledge, and Attitudes of Hemorrhage Control Techniques.

BACKGROUND: Bystanders play a significant role in the immediate management of life-threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to evaluate the efficacy of STB training for rescuers from different backgrounds. We hypothesized that STB training would be appropriate to increase skills and knowledge of bleeding control techniques for all providers, regardless of level of medical training. STUDY DESIGN: Course participants anonymously self-reported confidence in six major areas. A five-point Likert scale was used to quantitate participant's self-reported performance. Results were stratified into medical rescuers (MR) and LRs. Students' ability to perform STB skills were objectively assessed using an internally validated 15-point objective assessment tool. Data were pooled and analyzed using Student's t-test and chi-Squared test with P < 0.05 considered significant. Results are presented as average with standard deviation (SD) unless otherwise stated. RESULTS: A total of 1974 participants were included in the study. Precourse confidence was lowest for both groups in management of active severe bleeding and ability to pack a bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core areas measured (P < 0.001). The most significant increases were reported in the two previous areas of lowest precourse confidence-management of active severe bleeding-LRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001-and ability to pack a bleeding wound-LR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD 0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated combined 99.3% proficiency on postcourse objective assessments. CONCLUSIONS: This study provides quantitative evidence that Stop the Bleed training is effective, with both LRs and MRs demonstrating improved confidence and skill proficiency after a 1-h course. Future program development should focus on building a pool of instructors, continued training of LRs, and determining how often skills should be recertified.

The Homeless Hospital Liaison Program: An Interprofessional Program to Improve Students' Skills at Facilitating Transitions of Care for Patients Experiencing Homelessness.

PROBLEM: Traditional medical school curricula lack specific training on caring for individuals experiencing homelessness, and the literature suggests that medical students' attitudes toward these individuals become increasingly negative during medical school. APPROACH: To increase discharge planning support for individuals experiencing homelessness, the Homeless Hospital Liaison (HHL) program was developed at the University Medical Center New Orleans in January 2017-May 2017. Student liaisons are recruited from all 4 years of medical school and a graduate-level social work program. Liaisons administer a social needs questionnaire to assess patients' connections to services and identify gaps in care, coordinate with hospital social workers to avoid duplicating work, coordinate with the medical team, help patients complete any needed documentation or applications for social benefits, provide patients with referrals to outpatient resources, and provide patients assistance with a variety of basic needs. OUTCOMES: As of December 2017, HHL has trained 70 students (65 medical students and 5 social work students) to serve as liaisons and has enrolled 99 patients. For the majority of these patients, student liaisons were able to facilitate successful referrals to community-based services. NEXT STEPS: Future directions of the HHL program include developing a formal, staffed consult service at the hospital (e.g., the HHL program was awarded hospital funding for 2 full-time staff in the summer of 2019, which will increase the HHL's capacity); assessing the program's effect on student knowledge, attitudes, and proficiency related to individuals experiencing homelessness and/or interprofessional collaboration; and assessing the impact of the program on patients' experiences.

Efficacy of Medical Students as Stop the Bleed Participants and Instructors.

OBJECTIVE: The Stop the Bleed (STB) program trains lay rescuers to identify and control life-threatening bleeding. Recently, medical students were allowed to become coinstructors. The aim of this study was to assess the efficacy of medical student course participation as both learners and instructors. No previous study to date has provided a critical objective assessment of medical student learners and educators of STB courses. STUDY DESIGN: Participants anonymously self-reported pre- and postcourse confidence in 6 major skill areas using a 5-point Likert scale. At the end of the course, students' ability to perform STB skills was assessed using an internally validated 15-point objective assessment tool. SETTING: Two US medical schools (Tulane University School of Medicine and Louisiana State University in New Orleans) which represent private and state institutions, respectively. PARTICIPANTS: A total of 423 medical students were enrolled in the course. A pilot group of medical students volunteered to be instructors and their ability to effectively teach the course was objectively assessed. RESULTS: Overall precourse confidence was highest in holding pressure on a wound and lowest in identification of severe active bleeding. Postcourse participant confidence increased significantly in all 6 core areas, including confidence to teach hemorrhage control skills to others. Objective assessment of medical students by STB instructors found 72.4% of medical students achieving perfect scores on their skill proficiency assessments. An assessment of 48 medical student instructors found that all students were able to proficiently serve as instructors. CONCLUSIONS: This study demonstrates that medical students can effectively master STB skills and can also serve as competent course instructors. Future program development should focus on continued training of medical students and their involvement as instructors to help increase the availability of STB courses.

Evaluating the Patient with Right Upper Quadrant Abdominal Pain.

Right upper quadrant (RUQ) pain is among the most common complaints in the emergency department. The differential diagnosis is broad and includes gastrointestinal (GI) and non-GI causes for pain. Evaluation of patients requires a combination of history, physical examination, laboratory testing, and diagnostic imaging. This article details the anatomy and physiology of the right upper abdomen and approach to the history and physical examination of the most common diseases encountered in the emergency department. "Can't miss," non-GI diagnoses are discussed. Best practices of laboratory and imaging, and treatment of most common diagnoses of RUQ pain are reviewed.

Council of Emergency Medicine Residency Directors' standardized letter of recommendation: the program director's perspective.

OBJECTIVES: The standardized letter of evaluation (SLOE) was created in 1997 to provide residency program directors (PDs) with a summative evaluation that incorporates normative grading (i.e., comparisons to peers applying to emergency medicine [EM] training). Although the standard letter of recommendation (SLOR) has become increasingly popular and important in decision-making, it has not been studied in the past 12 years. To assess the SLOR's effectiveness and limitations, the perspective of EM PDs was surveyed in this study. METHODS: After validation of the questionnaire by 10 retired PDs, the survey was sent to the PD of each of the 159 EM residencies that existed at that time. The survey was circulated via the Council of Emergency Medicine Residency Directors' (CORD) listserv from January 24, 2013, to February 13, 2013. Weekly e-mail reminders to all PDs served to increase participation. RESULTS: A total of 150 of 159 PDs (94.3%) completed the questionnaire. Nearly all respondents (149 of 150; 99.3%) agreed that the SLOR is an important evaluative tool and should continue to be used. In the application process, 91 of 150 (60.7%) programs require one or more SLORs, and an additional 55 (36.7%) recommend but do not require a SLOR to be considered for interview. When asked to identify the top three factors in deciding who should be interviewed, the SLOR was ranked first (139 of 150; 92.7%), with EM rotation grades ranked second (73 of 150; 48.7%). The factors that were most often identified as the top three that diminish the value of the SLOR in order were 1) "inflated evaluations" (121 of 146; 82.9%), 2) "inconsistency between comments and grades" (106 of 146; 72.6%), and 3) "inadequate perspective on candidate attributes in the written comments" and "inexperienced authors" (60 of 146; 41.1% each). CONCLUSIONS: The SLOR appears to be the most important tool in the EM PD's armamentarium for determining which candidates should be interviewed for residency training. Although valuable, the SLOR's potential utility is hampered by a number of factors, the most important of which is inflated evaluations. Focused changes in the SLOR template should be mindful that it appears, in general, to be successful in its intended purpose.

Operation CeaseFire-New Orleans: an infectious disease model for addressing community recidivism from penetrating trauma.

BACKGROUND: CeaseFire, using an infectious disease approach, addresses violence by partnering hospital resources with the community by providing violence interruption and community-based services for an area roughly composed of a single city zip code (70113). Community-based violence interrupters start in the trauma center from the moment penetrating trauma occurs, through hospital stay, and in the community after release. This study interprets statistics from this pilot program, begun May 2012. We hypothesize a decrease in penetrating trauma rates in the target area compared with others after program implementation. METHODS: This was a 3-year prospective data collection of trauma registry from May 2010 to May 2013. All intentional, target area, penetrating trauma treated at our Level I trauma center received immediate activation of CeaseFire personnel. Incidences of violent trauma and rates of change, by zip code, were compared with the same period for 2 years before implementation. RESULTS: During this period, the yearly incidence of penetrating trauma in Orleans Parish increased. Four of the highest rates were found in adjacent zip codes: 70112, 70113, 70119, and 70125. Average rates per 100,000 were 722.7, 523.6, 286.4, and 248, respectively. These areas represent four of the six zip codes citywide that saw year-to-year increases in violent trauma during this period. Zip 70113 saw a lower rate of rise in trauma compared with 70112 and a higher but comparable rise compared with that of 70119 and 70125. CONCLUSION: Hospital-based intervention programs that partner with culturally appropriate personnel and resources outside the institution walls have potential to have meaningful impact over the long term. While few conclusions of the effect of such a program can be drawn in a 12-month period, we anticipate long-term changes in the numbers of penetrating injuries in the target area and in the rest of the city as this program expands. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Medical student education in emergency medicine: do students meet the national standards for clinical encounters of selected core conditions?

BACKGROUND: Establishing a core curriculum for undergraduate Emergency Medicine (EM) education is crucial to development of the specialty. The Clerkship Directors in Emergency Medicine (CDEM) National Curriculum Task Force recommended that all students in a 4(th)-year EM clerkship be exposed to 10 emergent clinical conditions. OBJECTIVES: To evaluate the feasibility of encountering recommended core conditions in a clinical setting during a 4(th)-year EM clerkship. METHODS: Students from three institutions participated in this ongoing, prospective observation study. Students' patient logs were collected during 4-week EM clerkships between July 2011 and June 2012. De-identified logs were reviewed and the number of patient encounters for each of the CDEM-identified emergent conditions was recorded. The percentage of students who saw each of the core complaints was calculated, as was the average number of core complaints seen by each. RESULTS: Data from 130 students at three institutions were captured; 15.4% of students saw all 10 conditions during their rotation, and 76.9% saw at least eight. The average number of conditions seen per student was 8.4 (range of 7.0-8.6). The percentage of students who saw each condition varied, ranging from 100% (chest pain and abdominal pain) to 31% (cardiac arrest). CONCLUSIONS: Most students do not encounter all 10 conditions during patient encounters throughout a 4-week EM rotation, although most have exposure to at least eight. Certain conditions are far less likely than others to be encountered, and may need to be taught in a nonclinical setting.

Experience with the core curricular elements for international emergency medicine fellowships.

BACKGROUND: The number of international emergency medicine (IEM) fellowships available in the US has grown dramatically since the inception of subspecialty training in 1994 Bayram et al. (Acad Emerg Med 17:748-757, 2010). These fellowships vary according to their curricular structure, intensity of fellow exposure and requirements for program completion. The variety of fellowship structures may have negative connotations for graduates from its fellowships and reflect upon the translatability of their skill sets.The recent article "Core Curricular Elements for International Emergency Medicine Fellowships" Alagappan and Holliman (Emerg Med Clin 23(1):1-10, 2005) was designed as a curricular development tool and enumerates seven foci within the broad field of IEM. OBJECTIVES: The authors of this article describe their experience using this curriculum development tool. Individual experiences in each of the seven categories described in the "Core Curricular Elements" article were identified and undertaken within the typical 2-year training period. DISCUSSION: A curricular structure is described that integrates exposure to all seven areas along with the Master's of Public Health (MPH) degree, the clinical component and the academic component thematic to existing fellowships. Benefits of this curriculum include increased exposure to multiple areas of IEM, potential for greater standardization and increased translatability of skill set. Disadvantages include superficial exposure to areas of IEM and potentially decreased travel time. CONCLUSION: The result is a plausible curriculum where fellows would gain exposure to more areas of IEM than they may have otherwise while still earning their MPH, working clinical shifts and carrying out academic fellowship requirements. The authors conclude that this structure allows fellowships to continue drawing on their strengths, provides a more well-rounded fellowship experience and increases structure without requiring standardization.

Medical students' perceptions of an emergency medicine clerkship: an analysis of self-assessment surveys.

BACKGROUND: No studies have been performed that evaluate the perceptions of medical students completing an emergency medicine (EM) clerkship. Given the variability of exposure to EM in medical schools nationwide, assessment of the student rotation may inform the structure and content of new and existing clerkships, particularly in relation to student's acquisition of the core competencies. OBJECTIVES: To investigate whether undergraduate medical students rotating through an EM clerkship improved their understanding and abilities in core content areas and common procedural skills; to evaluate whether improvement was affected by rotation length. METHODS: All students participating in an EM clerkship over a 12-month period were asked to complete an anonymous voluntary pre- and post-rotation survey. Confidence with patient assessment, diagnosis, and management plans; trauma and medical resuscitations; formal and informal presentations; basic procedure skills and understanding of the modern practice of EM were self assessed using a Likert scale. Group mean scores on each question on the pre- and post-clerkship surveys were calculated and compared. The mean scores on each survey item, both pre- and post-clerkship, were compared between 2- and 4-week clerkship rotation groups. RESULTS: Two hundred thirty-nine students participated in the rotation during the 12 months of the study. One hundred sixty-one (161), or 67.4%, completed the pre-rotation survey, and 96 (40.2%) completed the post-rotation survey. Overall, students showed significant mean gains in confidence with initial patient assessment, diagnosis, and management plans (p < 0.01, 0.02, <0.01) and with basic procedure skills (p < 0.01 for all). Students completing a 2-week rotation did not differ significantly from f4week rotators in confidence levels, except in the area of formal presentation skills (p = 0.01), where the 4-week students demonstrated a statistically significant advantage. The 2-week clerkship participants were significantly less confident in all procedures except EKG interpretation, splinting, and venipuncture (p = 0.28, 0.22, 0.05). Regardless of rotation length, students generally felt they had sufficient exposure to patients and opportunities for hands-on learning and practice, and overwhelmingly would recommend the EM clerkship to a fellow student, regardless of their chosen specialty. CONCLUSIONS: Medical students show significant gains in confidence with acute care knowledge, disease management, and procedure skills after completion of an EM clerkship. Although a 4-week clerkship may be preferable to expose students to the widest variety of patients and procedures, all students can benefit and improve in core competencies after an EM undergraduate experience.

Dealing with the difficult student in emergency medicine.

Dealing with a student who is perceived as difficult to work with or teach is inevitable in any academic physician's career. This paper will outline the basic categories of these difficulties pertinent to Emergency Medicine rotations in order to facilitate appropriate identification of problems. Strategies for evaluation and reporting of the difficult student are presented. Remediation, based on the type of difficulty, is addressed. Timeliness of reporting, evaluation, and feedback are invaluable to allow for appropriate assessment of the outcome of the remediation plan.

Sexual assault victims in the emergency department: analysis by demographic and event characteristics.

The objective of this study was to analyze demographic and event characteristics of patients presenting to the Emergency Department (ED) for evaluation after sexual assault, using a Sexual Assault Nurse Examiner standardized database. Data were prospectively collected as part of the Sexual Assault Nurse Examiner program at an urban teaching hospital. This study reviewed all ED patient records with a complaint of sexual assault between January 1, 2000 and December 31, 2004. Data were collected on 1172 patients; 92.6% were women, with a mean age of 27 years. The sample was 59.1% black, 38.6% white, and 2.3% "Other." Black victims of sexual assault were significantly more likely to be young (25 years or less) than Whites. Over half (54%) reported involvement of drugs or alcohol during the event. Fifty-three percent knew their assailant(s), and black and young patients were significantly more likely to know the perpetrator(s). Threats of force were common (72.4% of sample), and multiple assailants were uncommon (18.1% of sample). Physical evidence of trauma was present in more than half (51.7%), with increased rates among Whites and older persons. Multivariate analysis showed that race, age, threats, and substance use during the event were independent risk factors for evident trauma on physical examination. Survivors of sexual assault who present to the ED are overwhelmingly female, relatively young, often know the perpetrator of the event, and are likely to be threatened and show signs of physical trauma. Differences between patients according to demographic and event characteristics may have important implications for ED management and treatment plans.

Male victims of partner violence: prevalence and accuracy of screening tools.

The objective of this study was to determine the accuracy of two brief surveys for detection of male victims of intimate partner violence (IPV) in the Emergency Department (ED). This study was conducted prospectively in an urban, teaching hospital over 6 weeks; all men triaged to the acute care portion of the ED were eligible for enrollment. Exclusion criteria included age less than 18 years, refusal, altered mental status, or condition requiring lifesaving intervention. Data included demographics, Revised Conflict Tactics Scale (CTS2) score, and scores on two brief surveys of IPV: the HITS ("Hurt/Insult/Threaten/Scream") scale and the Partner Violence Screen (PVS). The CTS2 uses previously validated population scores for female to male psychological aggression and physical assault. Neither the HITS nor the PVS has been validated for use in the ED for detecting male victims of IPV. There were 116 men approached for enrollment; nearly half completed all surveys. Mean age was 41.8 years, and the sample was 73% African-American and 20% white. Thirty-nine percent had positive scores on the psychological aggression portion of the CTS2, whereas 20% had positive scores on the physical assault subscale. Comparing the HITS and PVS to both the psychological and physical portions of the CTS2 resulted in sensitivities of 30-45% and specificities of 83-88%. False negative rates on the two brief surveys ranged from 14-33%, and negative predictive values and positive likelihood ratios were low. Neither the HITS nor the PVS accurately screens male victims of IPV in the ED. Further research is needed to develop a valid, brief screening test to identify male victims of IPV in an acute setting. (c) 2006 Elsevier Inc.