Implementation of dedicated social worker coaching for emergency medicine residents - Lessons learned.

Emergency medicine training is associated with high levels of stress and burnout, which were exacerbated by the COVID-19 pandemic. The pandemic further exposed a mismatch between trainees' mental health needs and timely support services; therefore, the objective of our innovation was to create an opportunity for residents to access a social worker who could provide consistent coaching. The residency leadership team partnered with our graduate medical education (GME) office to identify a clinical social worker and professionally-trained coach to lead sessions. The project was budgeted at an initial cost of $15,000 over 1 year. Residents participated in 49 group and 73 individual sessions. Post implementation in 2021, we compared this intervention to all other wellness initiatives. Resident response rate was 80.88% (n = 55/68) and median interquartile range (IQR) score of the initiative was 2 (1 = detrimental and 4 = beneficial) versus 3.79 (3.69-3.88) the median IQR of all wellness initiatives. A notable number, 22%, rated the program as detrimental, which could be related to summary comments regarding ability to attend sessions, lack of session structure, loss of personal/educational time, and capacity of the social worker to relate with them. Summary comments also revealed the innovation was useful, with individual sessions preferred to group sessions. Application of a social worker coaching program in an emergency medicine residency program appears to be a feasible novel intervention. Lessons learned after implementation include the importance of recruiting someone with emergency department/GME experience, orienting them to culture before implementation and framing coaching as an integrated residency resource.

Development of a clinical prediction instrument to estimate risk of initial violent injury.

BACKGROUND: Interpersonal violent injury is a public health crisis, disproportionately affecting young people of color. We aimed to evaluate associations between sociobehavioral predictors and first-time violent injury, and to develop a predictive risk score for violent injury. METHODS: We performed a retrospective case-cohort study of adolescents aged 12-18 years. Multivariable logistic regression was used to estimate associations between 35 candidate variables and interpersonal first-time violent injury resulting in an emergency department (ED) visit. Multiple imputation was used to account for missing values and a risk score was developed by multiplying regression coefficients by 10 to generate a composite tool to predict initial violent injury (IVI). Discrimination and calibration were assessed using 10-fold cross validation. RESULTS: 19,210 adolescents were included, 276 (1.4%) as victims of IVI. The final model, the Initial Violent Injury Risk Prediction Tool (IVI-RPT), included: age, fight within the prior year, trouble with the law, and alcohol use. IVI-RPT scores were categorized as: 0-7 (low risk), 8-16 (moderate), and 17-26 (high), and IVI prevalence was 0.8% (95% confidence interval [CI]: 0.6%, 0.9%), 2.5% (95% CI: 1.9%, 3.1%), and 5.3% (95% CI: 4.1%, 6.6%), respectively. The area under the receiver operating characteristic curve was 0.70 (95% CI: 0.66, 0.73), while the slope of the calibration curve was 1.1 (95% CI: 0.9, 1.2). CONCLUSIONS: We developed a promising clinical prediction instrument, the IVI-RPT, that categorizes individuals into risk groups with increasing probabilities of violent injury. External validation of this tool is required prior to clinical practice implementation.

Understanding the makeup of a growing field: A committee on trauma survey of the national network of hospital-based violence intervention programs.

BACKGROUND: Among Hospital Based Violence Intervention programs (HVIPs), little is known about variation in services provided, funding sources, or populations served. STUDY DESIGN: Twenty-eight member programs of Health Alliance for Violence Intervention participated in a survey administered by the American College of Surgeons Committee on Trauma. Questions were quantitative and qualitative. For qualitative analysis, questions pertaining to the domains were assessed for common themes and assessed across all subject domains. RESULTS: All programs enroll patients injured by community violence, some by intimate partner violence (IPV), trafficking, and rarely by child or elder abuse. Programs with more funding (≥$300,000 per year) were more likely federally, state, or city funded. Lower funded programs (≤$300,000 per year) were funded by foundations or philanthropy. In both qualitative and quantitative analysis, barriers to starting or sustaining HVIPs included funding, and lack of risk reduction and mental health resources. Successful programs had stable funding, adequate staffing, and buy in from hospitals and staff. CONCLUSION: HVIPs serve diverse populations in variable models. There is opportunity to expand the reach of HVIPs, and the experience if existing programs is an invaluable resource.

Trauma-Informed Care for Violently Injured Patients in the Emergency Department.

Violent traumatic injury remains a common condition treated by emergency physicians. The medical management of these patients is well described and remains an area of focus for providers. However, violently injured patients disproportionately carry a history of physical and psychological trauma that frequently affects clinical care in the emergency department. The alteration of our clinical approach, taking into consideration how a patient's previous experiences influence how he or she may perceive and react to medical care, is a concept referred to as trauma-informed care. This approach is based on 4 pillars: knowledge of the effect of trauma, recognition of the signs and symptoms of trauma, avoidance of retraumatization, and the development of appropriate policies and procedures. Using this framework, we provide practical considerations for emergency physicians in the delivery of trauma-informed care for violently injured patients.

Correction: Correction to 'Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever' [Annals of Emergency Medicine 67 (2016) 625-639.e13].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

The Impact of the 2008 Council of Emergency Residency Directors (CORD) Panel on Emergency Medicine Resident Diversity.

BACKGROUND: In 2008, the Council of Emergency Medicine Residency Directors (CORD) developed a set of recruitment strategies designed to increase the number of under-represented minorities (URMs) in Emergency Medicine (EM) residency. OBJECTIVES: We conducted a survey of United States (US) EM residency program directors to: describe the racial and ethnic composition of residents; ascertain whether each program had instituted CORD recruitment strategies; and identify program characteristics associated with recruitment of a high proportion of URM residents. METHODS: The survey was distributed to accredited, nonmilitary US EM residency programs during 2013. Programs were dichotomized into high URM and low URM by the percentage of URM residents. High- and low-URM programs were compared with respect to size, geography, percentage of URM faculty, importance assigned to common applicant selection criteria, and CORD recruitment strategies utilized. Odds ratios and 95% confidence limits were calculated. RESULTS: Of 154 residency programs, 72% responded. The median percentage of URM residents per program was 9%. Only 46% of EM programs engaged in at least two recruitment strategies. Factors associated with higher resident diversity (high-URM) included: diversity of EM faculty (high-URM) (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.1-13.0); applicant's URM status considered important (OR 4.9; 95% CI 2.1-11.9); engaging in pipeline activities (OR 4.8; 95% CI 1.4-15.7); and extracurricular activities considered important (OR 2.6; 95% CI 1.2-6.0). CONCLUSION: Less than half of EM programs have instituted two or more recruitment strategies from the 2008 CORD diversity panel. EM faculty diversity, active pipeline programs, and attention paid to applicants' URM status and extracurricular activities were associated with higher resident diversity.

Effect of Volume of Fluid Resuscitation on Metabolic Normalization in Children Presenting in Diabetic Ketoacidosis: A Randomized Controlled Trial.

BACKGROUND: The optimal rate of fluid administration in pediatric diabetic ketoacidosis (DKA) is unknown. OBJECTIVE: Our aim was to determine whether the volume of fluid administration in children with DKA influences the rate of metabolic normalization. METHODS: We performed a randomized controlled trial conducted in a tertiary pediatric emergency department from December 2007 until June 2010. The primary outcome was time to metabolic normalization; secondary outcomes were time to bicarbonate normalization, pH normalization, overall length of hospital treatment, and adverse outcomes. Children between 0 and 18 years of age were eligible if they had type 1 diabetes mellitus and DKA. Patients were randomized to receive intravenous (IV) fluid at low volume (10 mL/kg bolus + 1.25 × maintenance rate) or high volume (20 mL/kg bolus + 1.5 × maintenance rate) (n = 25 in each). RESULTS: After adjusting for initial differences in bicarbonate levels, time to metabolic normalization was significantly faster in the higher-volume infusion group compared to the low-volume infusion group (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.0-3.9; p = 0.04). Higher-volume IV fluid infusion appeared to hasten, to a greater extent, normalization of pH (HR = 2.5; 95% CI 1.2-5.0; p = 0.01) than normalization of serum bicarbonate (HR = 1.2; 95% CI 0.6-2.3; p = 0.6). The length of hospital treatment HR (0.8; 95% CI 0.4-1.5; p = 0.5) and time to discharge HR (0.8; 95% CI 0.4-1.5; p = 0.5) did not differ between treatment groups. CONCLUSIONS: Higher-volume fluid infusion in the treatment of pediatric DKA patients significantly shortened metabolic normalization time, but did not change overall length of hospital treatment. ClinicalTrials.gov ID NCT01701557.

Increasing Resident Diversity in an Emergency Medicine Residency Program: A Pilot Intervention With Three Principal Strategies.

PROBLEM: Much work remains to be done to align the diversity of the health care workforce with the changing racial and ethnic backgrounds of patients, especially in the field of emergency medicine. APPROACH: In academic year (AY) 2012-2013, to increase the number of underrepresented minority (URM) candidates who were interviewed and matched, the Denver Health Residency in Emergency Medicine program (DHREM) initiated a focused pilot intervention with three principal strategies: (1) a scholarship-based externship program, (2) a funded second-look event, and (3) increased involvement and visibility of URM faculty in the interview and recruitment process. OUTCOMES: One year after implementation of the pilot intervention, the percentage of URMs among all applicants invited to interview at the DHREM doubled (7.1% [20/282] in AY 2011-2012, 7.0% [24/344] in AY 2012-2013, and 14.8% [58/393] in AY 2013-2014) (95% confidence interval [CI] = 5-10, 4-11, and 11-19, respectively). Of all DHREM interviewees in AY 2013-2014, 17.6% (49/279) (95% CI = 12-23) were URMs, nearly a threefold increase from AY 2012-2013 (6.2% [14/226], 95% CI = 3-10). In AY 2013-2014, 23.5% (4/17) (95% CI = 7-50) of all new DHREM residents were URMs, compared with 5.9% (1/17) in AY 2011-2012 and 5.6% (1/18) in AY 2012-2013 (95% CI = 0-29 and 0-27, respectively). NEXT STEPS: Additional studies are needed to determine whether these results are sustainable and generalizable to other residency programs in emergency medicine and other specialties.

Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: A randomized crossover trial.

BACKGROUND: Medication dosing errors remain commonplace and may result in potentially life-threatening outcomes, particularly for pediatric patients where dosing often requires weight-based calculations. Novel medication delivery systems that may reduce dosing errors resonate with national healthcare priorities. Our goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared to conventional medication administration, in simulated prehospital pediatric resuscitation scenarios. METHODS: We performed a prospective, block-randomized, cross-over study, where 10 full-time paramedics each managed two simulated pediatric arrests in situ using either prefilled, color-coded syringes (intervention) or their own medication kits stocked with conventional ampoules (control). Each paramedic was paired with two emergency medical technicians to provide ventilations and compressions as directed. The ambulance patient compartment and the intravenous medication port were video recorded. Data were extracted from video review by blinded, independent reviewers. RESULTS: Median time to delivery of all doses for the intervention and control groups was 34 (95% CI: 28-39) seconds and 42 (95% CI: 36-51) seconds, respectively (difference=9 [95% CI: 4-14] seconds). Using the conventional method, 62 doses were administered with 24 (39%) critical dosing errors; using the prefilled, color-coded syringe method, 59 doses were administered with 0 (0%) critical dosing errors (difference=39%, 95% CI: 13-61%). CONCLUSIONS: A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by paramedics during simulated prehospital pediatric resuscitations.

Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations.

STUDY OBJECTIVE: The Institute of Medicine has called on the US health care system to identify and reduce medical errors. Unfortunately, medication dosing errors remain commonplace and may result in potentially life-threatening outcomes, particularly for pediatric patients when dosing requires weight-based calculations. Novel medication delivery systems that may reduce dosing errors resonate with national health care priorities. Our goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared with conventional medication administration, in simulated pediatric emergency department (ED) resuscitation scenarios. METHODS: We performed a prospective, block-randomized, crossover study in which 10 emergency physician and nurse teams managed 2 simulated pediatric arrest scenarios in situ, using either prefilled, color-coded syringes (intervention) or conventional drug administration methods (control). The ED resuscitation room and the intravenous medication port were video recorded during the simulations. Data were extracted from video review by blinded, independent reviewers. RESULTS: Median time to delivery of all doses for the conventional and color-coded delivery groups was 47 seconds (95% confidence interval [CI] 40 to 53 seconds) and 19 seconds (95% CI 18 to 20 seconds), respectively (difference=27 seconds; 95% CI 21 to 33 seconds). With the conventional method, 118 doses were administered, with 20 critical dosing errors (17%); with the color-coded method, 123 doses were administered, with 0 critical dosing errors (difference=17%; 95% CI 4% to 30%). CONCLUSION: A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by emergency physician and nurse teams during simulated pediatric ED resuscitations.

Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study.

STUDY OBJECTIVE: We evaluate the diagnostic accuracy of clinical decision rules and physician judgment for identifying clinically important traumatic brain injuries in children with minor head injuries presenting to the emergency department. METHODS: We prospectively enrolled children younger than 18 years and with minor head injury (Glasgow Coma Scale score 13 to 15), presenting within 24 hours of their injuries. We assessed the ability of 3 clinical decision rules (Canadian Assessment of Tomography for Childhood Head Injury [CATCH], Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE], and Pediatric Emergency Care Applied Research Network [PECARN]) and 2 measures of physician judgment (estimated of <1% risk of traumatic brain injury and actual computed tomography ordering practice) to predict clinically important traumatic brain injury, as defined by death from traumatic brain injury, need for neurosurgery, intubation greater than 24 hours for traumatic brain injury, or hospital admission greater than 2 nights for traumatic brain injury. RESULTS: Among the 1,009 children, 21 (2%; 95% confidence interval [CI] 1% to 3%) had clinically important traumatic brain injuries. Only physician practice and PECARN identified all clinically important traumatic brain injuries, with ranked sensitivities as follows: physician practice and PECARN each 100% (95% CI 84% to 100%), physician estimates 95% (95% CI 76% to 100%), CATCH 91% (95% CI 70% to 99%), and CHALICE 84% (95% CI 60% to 97%). Ranked specificities were as follows: CHALICE 85% (95% CI 82% to 87%), physician estimates 68% (95% CI 65% to 71%), PECARN 62% (95% CI 59% to 66%), physician practice 50% (95% CI 47% to 53%), and CATCH 44% (95% CI 41% to 47%). CONCLUSION: Of the 5 modalities studied, only physician practice and PECARN identified all clinically important traumatic brain injuries, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.

Traumatic intracranial injury in intoxicated patients with minor head trauma.

OBJECTIVES: Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. METHODS: This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. RESULTS: A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. CONCLUSIONS: In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury.

Validation of rules to predict emergent surgical intervention in pediatric trauma patients.

BACKGROUND: Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC). STUDY DESIGN: We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated. RESULTS: There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively. CONCLUSIONS: Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.

Use of kiosks and patient understanding of opt-out and opt-in consent for routine rapid human immunodeficiency virus screening in the emergency department.

OBJECTIVES: The objective was to evaluate patient acceptance and understanding of nontargeted opt-out and opt-in rapid human immunodeficiency virus (HIV) screening using computerized kiosks in the emergency department (ED). METHODS: This study was a prospective quasi-experiment in an urban hospital with an annual ED and urgent care census of 120,000 visits. During medical screening, patients 13 years and older were offered rapid HIV screening using kiosks and opt-out consent (October 2009) or opt-in consent (December 2009). Random time blocks were used to administer structured surveys to evaluate patient understanding of the testing process. RESULTS: During the opt-out phase, 6,602 were offered testing, and of these 3,993 (61%) did not opt-out and 886 (13%) completed screening. During the opt-in phase, 5,781 were offered testing, and of these 930 (16%) opted-in and 389 (7%) completed screening (absolute difference = 6%, 95% confidence interval [CI] = 5% to 8%). During the opt-out phase, 330 patients completed the survey. Of these, 201 (61%) did not opt-out, but 108 (54%, 95% CI = 47% to 61%) responded that they had not been informed about an HIV test. Of the 84 patients who had been informed, 32 (38%, 95% CI = 28% to 49%) responded that they had not agreed to an HIV test. During the opt-in phase, 416 completed the survey. Of these, 80 (19%) agreed to testing and two (3%, 95% CI = 0.3% to 9%) responded that they had not been informed about an HIV test. Of the 74 patients who had been informed, only two (3%, 95% CI = 0.3% to 9%) responded that they had not agreed to an HIV test. CONCLUSIONS: Computerized kiosks can be successfully used to perform nontargeted rapid HIV screening in EDs. However, when using this approach, patient understanding of opt-in consent is significantly better than opt-out consent.

The Denver Seizure Score: anion gap metabolic acidosis predicts generalized seizure.

OBJECTIVES: Anion gap (AG) and serum bicarbonate concentration (BICARB) may help confirm a diagnosis of seizure in an unwitnessed collapse; however, little data exist to support this practice. Our objective was to assess the association between AG metabolic acidosis and generalized seizure and to derive a simple score to predict seizure. METHODS: This was a case-control study at an urban teaching hospital. Patients transported to our emergency department with witnessed loss of consciousness and final confirmed diagnoses of generalized seizure (cases) or syncope (controls) were eligible for enrollment. Multivariable logistic regression analysis was used to model associations between AG, BICARB, and seizure. RESULTS: In 49 cases and 40 controls, patients in the seizure group were more likely to have a lower median BICARB (17 [range, 14-34] vs 23 [range, 20-24], P < .0001) and a higher median AG (22 [range, 9-42] vs 13 [range, 7-21], P < .0001). The Denver Seizure Score was defined, using regression coefficient weighting, as the Δ BICARB plus twice the Δ AG [(24 - BICARB) + (2×(AG - 12))]. The score ranged from -16 to +74 and identified patients as low likelihood (score <0), moderate likelihood (score 0-20), or high likelihood (score >20), with 21% (95% confidence interval [CI], 5%-51%), 40% (95% CI, 26%-56%), and 96% (95% CI, 82%-100%) being categorized as seizure, respectively. CONCLUSIONS: Anion gap metabolic acidosis is associated with generalized seizure. A Denver Seizure Score greater than 20 predicts generalized seizure in the emergency department and may be useful for differentiating patients with unwitnessed loss of consciousness.

Postpartum preeclampsia: emergency department presentation and management.

STUDY OBJECTIVE: Postpartum preeclampsia/eclampsia is the presence of hypertension and proteinuria, with or without seizures, occurring up to 4 weeks after delivery. We describe the Emergency Department (ED) presentation, signs and symptoms, results of diagnostic studies, management, and outcome in a cohort of patients diagnosed with postpartum preeclampsia/eclampsia at our institutions, and use this to review the diagnosis and management of postpartum preeclampsia/eclampsia. METHODS: A retrospective chart review was conducted at two urban teaching hospitals. Twenty-two cases were identified via ICD-9 (International Classification of Diseases, 9(th) revision) codes of discharge diagnoses over an 8-year period. Only those patients who initially presented to an ED in the postpartum period after hospital discharge were included. A standardized data tool was used to extract demographic data, signs and symptoms of preeclampsia/eclampsia, ancillary studies previously associated with eclamptic pathology, and outcome during admission. RESULTS: Of the 22 women, over half (55%) had not been diagnosed with preeclampsia in the ante- or peripartum period. Common prodromal symptoms and signs in the postpartum presentation included headache, visual changes, hypertension, edema, proteinuria, elevated uric acid, and elevated liver function tests. All 4 patients who seized had prodromal symptoms. Women presented from 3 to 10 days postpartum (median: 5 days). Only 10 women were primiparas. Nineteen women presented with diastolic blood pressures > 90 mm, and only 3 of these had diastolic blood pressures of 110 mm Hg or greater. CONCLUSIONS: Postpartum preeclampsia/eclampsia often presents to the ED without a history of preeclampsia during the pregnancy. Further, not all women with this diagnosis who present to the ED in the postpartum period will have each of the "classic" features of this disease, including elevated blood pressure, edema, proteinuria, and hyperreflexia. This report is intended to inform emergency physicians of the presentation of preeclampsia/eclampsia in the postpartum period, including symptoms of headache, vision changes, elevated blood pressure, or seizure up to 4 weeks after delivery.

Art, Chaos, Ethics, and Science (ACES): a doctoring curriculum for emergency medicine.

ACES (Art, Chaos, Ethics, and Science) is a curriculum developed by 2 residents and a faculty mentor at the Denver Health Medical Center Emergency Medicine Residency Program. The goal of the ACES curriculum is 2-fold: (1) to discuss areas of clinical consequence typically outside the scope of the regular academic curriculum, such as ethical dilemmas and the challenges of professionalism; and (2) to encourage reflection on our roles as caregivers on a personal, public health, and political level. Each bimonthly "doctoring roundtable" session focuses on one of these goals, bringing local and national leaders in the field to the forum to enrich discussion. Attending physicians from academic and private settings within the residency, residents at all levels, rotating medical students, and, for the past year, emergency department nurses participate in the meetings. Thus far, regular voluntary participation has been the only measure of the ongoing program's success. In this descriptive article, we discuss the aim of the program, the curriculum, and how the ACES program enriches the residency's educational goals. Recent accreditation requirements for residency training programs mandate educational experiences that allow residents to demonstrate competency in professionalism and ethical principles. The ACES curriculum developed a unique niche in our residency, creating an open forum for passionate discussion of challenging clinical encounters, unpressured reflection on ethics and decisionmaking, and constructive personal and professional development.