Understanding Perceived Appreciation to Create a Culture of Wellness.

OBJECTIVE: To fully address physician burnout, academic medical centers need cultures that promote well-being. One observed driver of a culture of wellness is perceived appreciation. The authors identified several contributors to perceived appreciation among faculty at a large, metropolitan academic institution through use of a novel survey. METHODS: The authors surveyed clinical faculty in five departments: psychiatry, emergency medicine, internal medicine, thoracic surgery, and radiology. Two open-ended response questions assessed sources of perceived and lack of perceived appreciation in narrative form. The authors also collected data on gender and department identity. Grounded theory methodology was used to analyze the narrative responses and design thinking to brainstorm specific recommendations based on the main themes identified. RESULTS: A total of 179 faculty respondents filled out the survey for an overall response rate of 29%. Major drivers of perceived appreciation were patient and families (42%); physician, trainee and non-physician colleagues (32.7%); chairs (10%); and compensation (3.3%). Major drivers of perceived lack of appreciation were disrespect for time and skill level, including inadequate staffing (30%); devaluation by a physician colleague, chief of one's service or the chair (29%); poor communication and transparency (13%); and patient and family anger (6%). CONCLUSIONS: Opportunities to improve perceived appreciation include structured communication of patient gratitude, community building programs, top of licensure initiatives and accountability for physician wellness, and inclusivity efforts from organizational leaders.

The State of Point-of-Care Teleultrasound Use for Educational Purposes: A Scoping Review.

Bedside ultrasound has been shown to change and direct patient management in the emergent setting. Demand, use, and diagnostic potential of point-of-care ultrasound (POCUS) has continually increased throughout the years. The ongoing COVID-19 pandemic and physical distancing have necessitated further POCUS innovation. With the advent of affordable portable ultrasound devices, teleultrasound teaching has become a more viable method of POCUS education, especially in resource-limited settings. Here, we provide a scoping review of the current state of teleultrasound, specifically its use for educational purposes.

Longitudinal accuracy analysis of ultrasound performed during a four-year emergency medicine residency.

BACKGROUND: The objective of this study was to analyze patterns of point-of-care ultrasound (POCUS) performance over 4 years of emergency medicine (EM) residency. Specifically, we aimed to study how accuracy and adherence to standards of scanning changed by postgraduate year (PGY). METHODS: This was a retrospective observational study of resident-performed POCUS at an academic emergency department over 6 years. We reviewed records of POCUS scans performed by PGY-1 to -4 residents that had been collected for quality assurance purposes. Data that were collected about EM residents' performance included the total number and type of scans per year, rate of technically limited scans (TLS), and accuracy on interpreting ultrasound images. Resident performances in each year (PGY-1 to -4) were independently evaluated and reported. RESULTS: During a 6-year period, 137 different EM residents performed 50,815 ultrasound scans. The median number of scans was 177 for PGY-1, 124 for PGY-2, 118 for PGY-3, and 76 for residents in PGY-4. The accuracy of scan interpretations were high across all PGY levels (>97%), but slight degradation was observed as residents progressed through residency. The TLS rate increased from 4.7% among PGY-1s to 13.6% as PGY-4s. CONCLUSIONS: In this large cohort of POCUS studies by EM residents, POCUS accuracy rates decreased and rates of TLS significantly increased as residents progressed through residency.

Prospective validation of the bedside sonographic acute cholecystitis score in emergency department patients.

BACKGROUND: Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients. METHOD: This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points. RESULTS: 153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%-96.9%), and a specificity of 67.5% (95% CI 58.2%-75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%-100%) and specificity of 35% (95% CI 26.5%-44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%-61.9%) and specificity of 95.7% (95% CI 90.3%-98.6%). CONCLUSION: A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.

Point-of-care Ultrasound in Morbidity and Mortality Cases in Emergency Medicine: Who Benefits the Most?

INTRODUCTION: Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferentiated patient in the emergency department (ED). Our primary objective in this study was to determine the perceived impact of POCUS in high-risk cases presented at emergency medicine (EM) morbidity and mortality (M&M) conferences. Additionally, we sought to identify in which types of patients POCUS might be most useful, and which POCUS applications were considered to be highest yield. METHODS: This was a retrospective survey of cases submitted to M&M at an EM residency program that spans two academic EDs, over one academic year. Postgraduate year 4 (PGY) residents who presented M&M cases at departmental sessions were surveyed on perceived impacts of POCUS on individual patient outcomes. We evaluated POCUS use and indications while the POCUS was used. RESULTS: Over the 12-month period, we reviewed 667 cases from 18 M&M sessions by 15 PGY-4 residents and a supervising EM attending physician who chairs the M&M committee. Of these cases, 75 were selected by the M&M committee for review and presentation. POCUS was used in 27% (20/75) of the cases and not used in 73% (55/75). In cases where POCUS was not used, retrospective review determined that if POCUS had been used it would have "likely prevented the M&M" in 45% (25/55). Of these 25 cases, the majority of POCUS applications that could have helped were cardiac (32%, 8/25) and lung (32%, 8/25) ultrasound. POCUS was felt to have greatest potential in identifying missed diagnoses (92%, 23/25), and decreasing the time to diagnosis (92%, 23/25). Patients with cardiopulmonary chief complaints and abnormal vital signs were most likely to benefit. There were seven cases (35%, 7/20, 95% CI 15-59%) in which POCUS was performed and thought to have possibly adversely affected the outcome of the M&M. CONCLUSION: POCUS was felt to have the potential to reduce or prevent M&M in 45% of cases in which it was not used. Cardiac and lung POCUS were among the most useful applications, especially in patients with cardiopulmonary complaints and in those with abnormal vital signs.

Visual Estimation of Tricuspid Annular Plane Systolic Excursion by Emergency Medicine Clinicians.

INTRODUCTION: Tricuspid annular plane systolic excursion (TAPSE) is an established echocardiographic marker of right ventricular (RV) systolic function. The objective of this study was to evaluate whether emergency clinicians can visually estimate RV function using TAPSE in a set of video clips compared to a reference standard M-mode measurement. METHODS: Emergency clinicians were shown a five-minute educational video on TAPSE. Participants then viewed 20 apical four-chamber point-of-care ultrasound (POCUS) echocardiography clips and recorded their estimate of TAPSE distance in centimeters (cm), as well as whether TAPSE was normal (>1.9 cm), borderline (1.5-1.9 cm), or abnormal (<1.5 cm). We calculated sensitivity, specificity, and overall accuracy of visual TAPSE categorization using M-mode measurement as the criterion standard. Participants also reported their comfort with assessing TAPSE on a five-point Likert scale before and after participation in the study. RESULTS: Among 70 emergency clinicians, including 20 postgraduate year 1-4 residents, 22 attending physicians, and 28 physician assistants (PA), the pooled sensitivity and specificity for visual assessment of TAPSE was 88.6% (95% confidence interval, 85.4-91.7%) and 81.6% (95% CI, 78.2-84.4%), respectively. The sensitivity and specificity for the clips in which the measured TAPSE was <1.5 cm or >1.9 cm was 91.4% (95% CI, 88.4-94.3%) and 90.8% (95% CI, 87.7-93.9%), respectively. There was no significant difference in sensitivity (p = 0.27) or specificity (p = 0.55) between resident and attending physicians or between physicians and PAs (p = 0.17 and p = 0.81). Median self-reported comfort with TAPSE assessment increased from 1 (interquartile range [IQR] 1-2) to 3 (IQR 3-4) points after participation in the study. CONCLUSION: A wide range of emergency clinicians demonstrated fair accuracy for visual estimation of TAPSE on previously recorded POCUS echocardiography video clips. These findings should be considered hypothesis generating and warrant validation in larger, prospective studies.

A randomized trial of ultrasound-guided peripheral IV catheter placement in difficult access patients using a guidewire approach.

OBJECTIVE: The purpose of this pilot study was to investigate whether use of a guidewire improves successful placement of ultrasound-guided peripheral IVs (PIV) in difficult intravenous access patients in the emergency department (ED). METHODS: This was an unblinded, prospective, randomized trial performed by emergency medicine (EM) clinicians at a single academic ED. Eligible participants were randomized to ultrasound-guided PIV placement with or without the use of a guidewire. PIV access was obtained using the Accucath™ 20 gauge × 5.7 cm catheters by way of deployment or non-deployment of the guidewire. Primary outcome measure was first-pass success rate and secondary outcomes included number of attempts, complication rates, and clinician reported ease of insertion. RESULTS: Seventy patients were enrolled and 69 were included in the final analysis. Thirty-four participants were randomized to use of guidewire and 35 to no guidewire. First-pass success rates were similar with and without guidewire use, 47.1% vs. 45.7%, (p = 0.9). There were no differences found in median number of attempts between the two techniques, 2 (IQR 1-2) vs 2 (IQR 1-2), (p = 0.60). The complication rates were similar, 15% vs. 29% (p = 0.25). Clinicians reported no difference in ease of insertion between methods on a 5-point Likert Scale, mean 2.6 vs 2.7 (p = 0.76). DISCUSSION: In this pilot study comparing ultrasound-guided PIV placement in ED patients using an integrated guidewire versus no guidewire, there was no significant difference in first-pass success, number of attempts, or complication rates. This study provides preliminary data for further investigations.

Use of a Refresher Course Increases Confidence in Point-of-Care Ultrasound Skills in Emergency Medicine Faculty.

Introduction All practicing emergency medicine (EM) physicians need to maintain a skillset in emergency ultrasound (US) after their initial training. EM physicians in academic practice may be supervising trainees performing ultrasound applications that they aren't comfortable with. This study investigates the effectiveness of a US refresher course. The hypothesis was that a series of short courses would increase confidence in performing and supervising US applications. Methods Nine basic emergency ultrasound applications were taught over the course of one year by ultrasound fellowship-trained EM faculty in a simulation center at a single academic institution. Each session included 30-minutes of didactics/image review and 30-minutes of hands-on practice on normal volunteers and was followed by an anonymous questionnaire evaluating comfort level performing and supervising the ultrasound application before and after the course using a Likert scale from 1 "not at all confident" to 5 "very confident". Results Thirty-six of 60 EM physicians participated in at least 1 of the 9 sessions (median 3, interquartile range 2-4). Faculty who attended had a median of 10 (interquartile range 7-15) years in practice and 61% work at both academic and community sites. For all sessions combined, confidence in performing US increased from a mean score on the Likert scale of 3.3 to 4.4 (difference 1.1, confidence interval (CI) (0.94, 1.29), p < 0.001) and confidence in supervising trainees increased from a mean of 3.4 to 4.5 (difference 1.1, CI (0.88, 1.23), p < 0.001). The largest increases were seen in musculoskeletal (MSK), nerve, and pelvic applications and the least increase was seen with the session focused on intravenous access, but confidence was increased in all sessions. Physicians in practice ≥10 years increased in confidence in performing and supervising the applications by 1.4 (CI (1.11, 1.60), p < 0.001) and 1.3, (CI (1.01, 1.49), p < 0.001), respectively. Physicians in practice <10 years increased 0.8 (CI (0.57, 1.03), p < 0.001) and 0.8 (CI (0.55, 1.05), p < 0.001), respectively. Conclusion An emergency ultrasound refresher course for EM physicians at a single institution improved self-reported confidence in both performing and supervising trainees in all applications reviewed. Those in practice ≥10 years showed the largest increases.

Correlation of OSCE performance and point-of-care ultrasound scan numbers among a cohort of emergency medicine residents.

BACKGROUND: Point-of-care ultrasound (POCUS) is an important clinical tool for a growing number of medical specialties. The current American College of Emergency Physicians (ACEP) Ultrasound Guidelines recommend that trainees perform 150-300 ultrasound scans as part of POCUS training. We sought to assess the relationship between ultrasound scan numbers and performance on an ultrasound-focused observed structured clinical examination (OSCE). METHODS: This was a cross-sectional cohort study in which the number of ultrasound scans residents had previously performed were obtained from a prospective database and compared with their total score on an ultrasound OSCE. Ultrasound fellowship trained emergency physicians administered a previously published OSCE that consisted of standardized questions testing image acquisition and interpretation, ultrasound machine mechanics, patient positioning, and troubleshooting. Residents were observed while performing core applications including aorta, biliary, cardiac, deep vein thrombosis, Focused Assessment with Sonography in Trauma (FAST), pelvic, and thoracic ultrasound imaging. RESULTS: Twenty-nine postgraduate year (PGY)-3 and PGY-4 emergency medicine (EM) residents participated in the OSCE. The median OSCE score was 354 [interquartile range (IQR) 343-361] out of a total possible score of 370. Trainees had previously performed a median of 341 [IQR 289-409] total scans. Residents with more than 300 ultrasound scans had a median OSCE score of 355 [IQR 351-360], which was slightly higher than the median OSCE score of 342 [IQR 326-361] in the group with less than 300 total scans (p = 0.04). Overall, a LOWESS curve demonstrated a positive association between scan numbers and OSCE scores with graphical review of the data suggesting a plateau effect. CONCLUSION: The results of this small single residency program study suggest a pattern of improvement in OSCE performance as scan numbers increased, with the appearance of a plateau effect around 300 scans. Further investigation of this correlation in diverse practice environments and within individual ultrasound modalities will be necessary to create generalizable recommendations for scan requirements as part of overall POCUS proficiency assessment.

Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department.

BACKGROUND: Emergency physicians frequently encounter patients with acute small bowel obstructions (SBO). Although computed tomography (CT) imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique. METHODS: We evaluated the accuracy of ultrasound performed in the ED by a variety of providers (physicians with various levels of training, physician assistants) compared to CT imaging in 47 patients with suspected SBOs. RESULTS: Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis. CONCLUSION: Ultrasound can play an important role in the identification of small bowel obstructions in ED patients.

Ten Strategies for Optimizing Ultrasound Instruction for Group Learning.

Ultrasound use is rapidly increasing in clinical care and as an educational modality. While there is widespread interest in training health-care professionals to incorporate ultrasound into their daily practice, there are few resources available to guide instructors in the design of impactful and efficient training sessions. We present 10 practical strategies to optimize the educational value of ultrasound workshops for any audience.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience.

INTRODUCTION: Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. METHODS: This was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey. RESULTS: All first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum. CONCLUSION: POCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school.

Evaluation of the Aortic Arch from the Suprasternal Notch View Using Focused Cardiac Ultrasound.

BACKGROUND: The suprasternal notch view (SSNV) is an additional echocardiographic view not routinely used by emergency physicians (EPs) performing focused cardiac ultrasound (FOCUS). OBJECTIVE: This pilot study determined the ease and self-perceived accuracy of the SSNV as performed by EPs. Additionally, we assessed the accuracy of FOCUS including the SSNV in thoracic aortic measurements compared to chest CT angiography (CTA). METHODS: This was a prospective, observational, pilot study of adult patients undergoing chest CTA. Thoracic aortic measurements were recorded at the sinus of Valsalva, sinotubular junction, and ascending aorta at its widest diameter in the parasternal long axis (PSL) view and SSNV. EPs rated ease of acquisition and self-perceived accuracy of thoracic aorta measurements. Two blinded radiologists performed thoracic aortic CTA measurements at predefined locations corresponding to the ultrasound measurements. RESULTS: Of the 79 patients (median age 57 years) enrolled, the SSNV was obtained in 97% of cases. EPs rated the ease of obtaining the SSNV as "easy" in 64.5% of cases and "very difficult" in 7.6% of cases. The mean difference between ultrasound (FOCUS plus SSNV) and CTA measurements were 1.2 mm (95% limits of agreement -2.9 to 5.3) at the sinus of Valsalva, 1.0 mm (95% limits of agreement -5.5 to 3.6 mm) at the sinotubular junction, 0.8 mm (95% limits of agreement -6.2 to 4.6 mm) at the proximal ascending aorta, and 0.6 mm (95% limits of agreement -2.8 to 4.0) at the aortic arch. CONCLUSIONS: Our findings suggest that the SSNV is an easily attainable and accurate view of the thoracic aorta that can be obtained by EPs in the majority of ED patients.

Point-of-care ultrasonography for the diagnosis of small bowel obstruction in the emergency department.

Small bowel obstruction (SBO) is a common cause of acute abdominal pain presenting to the emergency department (ED). Although the literature is limited, point-of-care ultrasonography (POCUS) has been found to have superior diagnostic accuracy for SBO compared to plain radiography; however, it is rarely used in North America for this. We present the case of a middle-aged man who presented with abdominal pain where POCUS by the emergency physician early in the hospital course expedited the diagnosis of SBO and led to earlier surgical consultation. The application of POCUS for SBO is easily learned and applied in the ED. POCUS for SBO may obviate the need for plain radiography and expedite patient care.

Positive FAST without hemoperitoneum due to fluid resuscitation in blunt trauma.

BACKGROUND: The focused assessment with sonography in trauma (FAST) examination is an important screening tool in the evaluation of blunt trauma patients. OBJECTIVES: To describe a case of a hemodynamically unstable polytrauma patient with positive FAST due to fluid resuscitation after blunt trauma. CASE REPORT: We describe a case of a hemodynamically unstable polytrauma patient who underwent massive volume resuscitation prior to transfer from a community hospital to a trauma center. On arrival at the receiving institution, the FAST examination was positive for free intraperitoneal fluid, but no hemoperitoneum or significant intra-abdominal injuries were found during laparotomy. In this case, it is postulated that transudative intraperitoneal fluid secondary to massive volume resuscitation resulted in a positive FAST examination. CONCLUSION: This case highlights potential issues specific to resuscitated trauma patients with prolonged transport times. Further study is likely needed to assess what changes, if any, should be made in algorithms to address the effect of prior resuscitative efforts on the test characteristics of the FAST examination.