Teaching emergency medicine residents health equity through simulation immersion.

OBJECTIVE: Our aim was to conduct a large, case-based diversity, equity, and inclusion (DEI) simulation exercise with a goal to improve the DEI pillars of cultural and structural awareness for residents. METHODS: Utilizing data resulting in poor health outcomes, the top eight themes were utilized, and via a modified Delphi approach, a diverse group of faculty developed representative cases. A mass simulation effort was organized with the assistance of our local simulation office. Twenty residents in groups of two to three rotated through all scenarios. Each resident group was allotted 15 min for each scenario. After each case, resident teams received feedback from standardized patients and a debrief together with the simulation directors. Pre- and postsimulation surveys were developed and distributed to residents. RESULTS: Twenty residents completed the simulation. Eighteen completed a pre- and postsimulation survey. Every resident rated the overall usefulness of this activity as a 5.0 on a scale of 1 to 5 with 5 being the highest score. All cases demonstrated an improvement in the residents perceived confidence on a 9-point Likert scale. All residents reported improved understanding of key concepts in health care disparities as related to race/ethnicity, homelessness, LGBTQIA, and their own biases. The largest improvement was seen in the overarching theme of "difficult conversations" with a presimulation survey mean of 3.9 and postsimulation survey mean of 6.5 (delta = +2.6, 95% confidence interval = 1.9 to 3.3, p < 0.01). CONCLUSIONS: Emergency medicine residency programs must fulfill their obligation to DEI efforts and national requirements while ensuring competency clinically. Mass simulation exercises are a way to incorporate this training. This preliminary data shows promise for a solution and can be easily duplicated. Diversity, health equity, inclusivity, and cultural humility can be effectively taught by an innovative mass simulation effort.

Paravertebral block associated with decreased opioid use and less nausea and vomiting after reduction mammaplasty.

BACKGROUND: In light of data finding that postoperative pain, nausea, and vomiting worsen outcomes, a renewed emphasis has been placed on optimizing the perioperative period. Use of preoperative paravertebral block (PVB) has been shown to reduce opioid administration and postoperative nausea and vomiting (PONV) in many surgical populations, though its role in reduction mammaplasty remains undefined. Therefore, we seek to evaluate PVB as an adjunct to general anesthesia (GA) for reduction mammaplasty. MATERIALS AND METHODS: We reviewed records for patients who underwent reduction mammaplasty at our institution from 2010 to 2015. Patients were categorized into two groups: GA alone and GA + PVB (GA with PVB adjunct). Demographic information, opioid administration, phase I/II pain scores, presence of PONV, and anesthesia time were analyzed. Analysis was performed using t-tests and Fisher's exact test, with P-values less than 0.05 statistically significant. RESULTS: We identified 264 patients meeting criteria: 209 (79%) received GA alone and 55 (21%) received GA + PVB. Intraoperative opioid administration were lower for GA + PVB patients (morphine equivalent of 44 mg versus 35 mg, P = 0.019), though there was no difference in postoperative opioid administration (P = 0.915). Phase I and II pain scores were significantly lower for those receiving PVB (2.9 versus 3.9, P = 0.012, and 3.0 versus 4.2, P = 0.001, respectively). GA + PVB was associated with less PONV (14% versus 33%, P = 0.007) and longer anesthesia times (271 min versus 236 min; P = 0.001). CONCLUSIONS: By improving pain control and reducing PONV, factors known to be associated with poor patient satisfaction and inferior outcomes, PVB is an attractive anesthetic adjunct in elective breast surgery.