Resilience-Related Resources Predict Physicians' Fatigue, Job Search Behavior, and Productivity Outcomes.

OBJECTIVE: The objective of this research was to assess the relative contribution of three resilience-related dispositional resources (trait mindfulness, core self-evaluations, and optimism) to emergency medicine physicians' fatigue, retention, and productivity. METHODS: We surveyed emergency physicians employed by a national (US) medical staffing organization. The survey included measures of work stressors, resilience resources, job search behavior, and fatigue. We linked the survey responses to objective demographic and productivity measures from the organization's records. RESULTS: A total of 371 respondents completed the survey. Multiple regression analyses demonstrated support for each of the three resilience-related resources as predictors. Relative weights analyses showed that resilience accounted for 14% and 62% of the outcome variance, whereas work demands accounted for between 32% and 56%. CONCLUSIONS: Multiple facets of dispositional resilience are important predictors of emergency medicine physicians' occupational health, retention, and productivity.

Case Series of Three Patients with Disseminated Gonococcal Infection and Endocarditis.

INTRODUCTION: The increasing incidence of Neisseria gonorrhoeae infections and emergence of cephalosporin-resistant strains means the threat of disseminated gonococcal infection and endocarditis needs to be reimagined into the differential diagnosis for patients treated in the emergency department (ED) for sexually transmitted infections and for endocarditis itself. Only 70 cases of disseminated gonococcal infection (DGI) with endocarditis had been reported through 2014.1-4 In 2019, however, an outbreak of DGI with one case of endocarditis was reported.5 This case series of three patients with DGI and endocarditis, in addition to the recent outbreak, may represent a warning sign for reemergence of this threat. CASE REPORT: We describe three cases within a recent three-year period of gonococcal endocarditis as seen and treated at our institution. These cases show divergent presentations of this insidious disease with both classical and atypical features. One case displayed a classic migratory rash with positive urine testing and a remote history of sexually transmitted infections, while another patient developed isolated culture-confirmed endocarditis with negative cervical testing and imaging, and the final case was a male patient who presented to the ED with fulminant endocarditis as the first ED presentation of infection. CONCLUSION: Secondary to an overall rise in incidence and possibly due to increasing antibiotic-resistance patterns, gonococcal endocarditis should be included in the differential diagnosis of any case of endocarditis. Reciprocally, increased vigilance should surround the evaluation of any patient for sexually transmitted diseases while in the ED for both the development of DGI and endocarditis.

Introduction to Wilderness Medicine-A Medical School Elective.

Audience: This curriculum provides a capstone experience for fourth year medical students, integrating aspects of the basic sciences and clinical skills in the care of wilderness medicine conditions. Length of Curriculum: The duration of this course is 2 weeks. Introduction: Since passage of the Wilderness Act of 1964, leading to the protection and expansion of wilderness areas, there has been steady growth in participation in outdoor recreational activities.1 Between the years of 2000 to 2009, there was a 7.5% increase in the total number of individuals participating in outdoor recreation. Notably, during this same timeline, there has also been a 7.1% increase in the total number of people participating in "nature-based outdoor recreation." 2 Acknowledging this rising interest in the outdoors, along with increasing accessibility to remote locations, it has become clear that healthcare providers must now attain the ability to both identify and treat conditions unique to these environments.In addition to discrete medical conditions unique to environmental medicine, the practice of wilderness medicine also encompasses the management of the familiar, the "bread-and-butter" medical illnesses, occurring in the unfamiliar, nonclinical environment. Management of these conditions requires both a knowledge of core life support principles and an adaptability and awareness of the non-medical factors affecting a patient's care.Wilderness Medicine also teaches core principles of austere medicine - healthcare administration in a resource-limited environment. The skills acquired in a wilderness medical course provide not only training in the wilderness setting, but also encompass medical care necessary in instances of disaster relief, terrorist events, and international medical missions.3 Additionally, management of discrete wilderness medicine conditions provides a context to review toxicologic biomechanisms and pathophysiology shared by other, more common conditions.For these myriad reasons, a wilderness medicine elective in medical school provides students with more than a divergent experience; it provides a review and expansion of core medical principles increasingly applicable to all specialties. Educational Goals: The primary objective of this course is to provide fourth year medical students an introduction to wilderness medicine. Students will be able to: explain fundamental concepts of practicing medicine in austere conditions; identify and initiate treatment for common wilderness medicine conditions; and utilize the non-medical aspects of providing care in austere environments. Educational Methods: The educational strategies used in this curriculum include a combination of lecture-based and experiential learning activities, structured through the lens of Kolb's theory of experiential learning. Core knowledge is preferentially imparted during outdoor experiential components, allowing adaptable, true-environment training. Sessions are complemented by assigned pre-reading in Auerbach's Wilderness Medicine4 textbook to create a flipped outdoor-classroom experience. In addition to a final examination, the course will include a final multi-day expedition designed to allow students an opportunity to demonstrate their wilderness medicine knowledge. The course format opens it to adaptation as a longitudinal curriculum. Finally, this course may be adapted to serve resident education purposes. Research Methods: This curriculum has been used and vetted at the authors' institutions with over 50 medical students. All individual comments were reviewed for applicability, trends noted, and the course was further refined. Student final assessment scores were reviewed to refine the content taught and clarity of assessment. Results: The current iteration of the curriculum received the following on a 5-point Likert scale by students on post-course evaluation forms: 4.91 for overall educational experience, 4.82 for curriculum effectiveness, and 5.00 for effective faculty instruction. As a result of comments, the use of the flipped-classroom model throughout the course has increased. Topics frequently encountered in spontaneous discussion due to regional importance have been included. Discussion: Overall, this course has proven both popular and successful. Due to the dynamic and divergent nature of this as a medical school course, the authors have noted increased levels of student engagement with the material. Increasing reliance on the flipped-classroom model with student-led scenarios and discussions has increased students' ability to recall and apply their knowledge to scenarios during the final expedition. The broad range of conditions included in wilderness medicine provides a unique framework to highlight the relevance of the basic medical sciences and review core medical principles. Topics: Wilderness trauma stabilization, patient transportation, acute mountain sickness, high-altitude cerebral edema, high-altitude pulmonary edema, hypothermia, frostbite, orienteering, survival skills, expedition medical kits, marine envenomation, decompression illness, plant toxidromes, snake envenomation, arthropod envenomation, high-angle rescue, search and rescue, heat illness, lightning strike, tick-related illness, disaster response, international medicine.4.

A Standardized Patient Experience: Elevating Interns to Expected Level of Clinical Competency.

INTRODUCTION: Medical students transition to intern year with significant variability in prior clinical experience depending on their medical school education. This leads to notable differences in the interns' ability to perform focused histories and physical exams, develop reasoned differentials, and maximize care plans. Providing a foundational experience for these essential skills will help to establish standardized expectations despite variable medical school experiences. METHODS: During an orientation block, interns participated in a standardized patient experience. Interns were presented with three common chief complaints: abdominal pain; chest pain; and headache. Faculty observed the three patient encounters and provided immediate verbal and written feedback to the interns based on a standardized grading rubric. RESULTS: All residents that participated "agreed" or "strongly agreed" that the experience was a meaningful educational experience. 90% of the interns reported the experience would change their clinical practice. Additionally, 75% of residents survyed one year after the experience felt the experience changed their clinical practice. Faculty felt the learning experience allowed them to address knowledge gaps early and provide early guidance where needed. CONCLUSION: This article describes an emergency medicine residency program's effort to provide a foundational experience for interns in evaluating emergency department patients. The intent was to "level the playing field" and establish "good habits" early in intern year with the realization that prior experiences vary significantly in July of intern year.

Do Emergency Medicine Residency Graduates Feel Prepared to Manage Closed Fractures After Training?

OBJECTIVES: Fractures comprise 3% of all emergency department (ED) visits. Although emergency physicians are often responsible for managing most of the initial care of these patients, many report a lack of proficiency and comfort with these skills. The primary objective was to assess how prepared recent emergency medicine (EM) residency graduates felt managing closed fractures upon completion of residency. Secondary objectives included whether residency training or independent practice contributed most to the current level of comfort with these procedures and which fractures were most commonly reduced without orthopedic consultation. METHODS: An anonymous online survey was sent to graduates from seven EM residency programs over a 3-month period to evaluate closed fracture reduction training, practice, and comfort level. Each site primary investigator invited graduates from 2010 to 2014 to participate and followed a set schedule of reminders. RESULTS: The response rate was 287/384 (74.7%) and included 3-year (198/287, 69%) and 4-year (89/287, 31%) programs. Practice in community, academic, and hybrid ED settings was reported by 150/287 (52.3%), 64/287 (22.3%), and 73/287 (25.4%), respectively. It was indicated by 137/287 (47.7%) that they reduce closed fractures without a bedside orthopedic consultation greater than 75% of the time. The majority of graduates felt not at all prepared (35/287, 12.2%) or somewhat prepared (126/287, 43.9%) upon residency graduation. Postresidency independent practice contributed most to the current level of comfort for 156/287 (54.4%). The most common fractures requiring reduction were wrist/distal radius and/or ulna, next finger/hand, and finally, ankle/distal tibia and/or fibula. CONCLUSIONS: Although most recent graduates feel at least "somewhat" prepared to manage closed fractures in the ED, most felt that independent practice was a greater contributor to their current level of comfort than residency training. Recent graduates indicate that fracture reduction without orthopedic consultation is common in today's clinical practice. This survey identifies common fractures requiring reduction which EM residencies may wish to consider prioritizing in their emergency orthopedic curricula to better prepare their residents for independent clinical practice.

Electron spin resonance investigation of H2(+), HD(+), and D2(+) isolated in neon matrices at 2 K.

Various isotopologues of nature's simplest molecule, namely H(2)(+), HD(+), and D(2)(+), have been isolated in neon matrices at 2 K for the first time and studied by electron spin resonance (ESR). Over many years, hundreds of matrix isolation experiments employing a variety of deposition conditions and ion generation methods have been tried to trap the H(2)(+) cation radical in our laboratory. The molecule has been well characterized in the gas phase and by theoretical methods. The observed magnetic parameters for H(2)(+) in neon at 2 K are: g(∥) ≈ g(⊥) = 2.0022(1); A(iso)(H) = 881(7) MHz; and A(dip)(H) = 33(3) MHz. Reasonable agreement with gas phase values of the isotropic hyperfine interaction (A(iso)) is observed; however, the neon matrix dipolar hyperfine interaction (A(dip)) is noticeably below the gas phase value. The smaller matrix value of A(dip) is attributable to motional averaging of the H(2)(+) radical in the neon matrix trapping site--an occurrence that would prevent the full extent of the hyperfine anisotropy from being measured for a powder pattern type ESR sample.

Prevalence of bicycle helmet use by users of public bikeshare programs.

STUDY OBJECTIVE: Public bikeshare programs are becoming increasingly common in the United States and around the world. These programs make bicycles accessible for hourly rental to the general public. We seek to describe the prevalence of helmet use among adult users of bikeshare programs and users of personal bicycles in 2 cities with recently introduced bikeshare programs (Boston, MA, and Washington, DC). METHODS: We performed a prospective observational study of adult bicyclists in Boston, MA, and Washington, DC. Trained observers collected data during various times of the day and days of the week. Observers recorded the sex of the bicycle operator, type of bicycle, and helmet use. All bicycles that passed a single stationary location in any direction for a period of between 30 and 90 minutes were recorded. RESULTS: There were 43 observation periods in 2 cities at 36 locations; 3,073 bicyclists were observed. There were 562 (18.3%; 95% confidence interval [CI] 16.4% to 20.3%) bicyclists riding shared bicycles. Overall, 54.5% of riders were unhelmeted (95% CI 52.7% to 56.3%), although helmet use varied significantly with sex, day of use, and type of bicycle. Bikeshare users were unhelmeted at a higher rate compared with users of personal bicycles (80.8% versus 48.6%; 95% CI 77.3% to 83.8% versus 46.7% to 50.6%). Logistic regression, controlling for type of bicycle, sex, day of week, and city, demonstrated that bikeshare users had higher odds of riding unhelmeted (odds ratio [OR] 4.4; 95% CI 3.5 to 5.5). Men had higher odds of riding unhelmeted (OR 1.6; 95% CI 1.4 to 1.9), as did weekend riders (OR 1.3; 95% CI 1.1 to 1.6). CONCLUSION: Use of bicycle helmets by users of public bikeshare programs is low. As these programs become more popular and prevalent, efforts to increase helmet use among users should increase.

Victims of violence.

I HAVE just read Pat McCollum's review of the book, Domestic Violence: The Essential Guide by Greta McGough, which appears in October's Emergency Nurse.

Nurses must not feel obliged to help in an emergency.

I read the article in which lecturer in law Marc Cornock clarifies the professional and legal aspects of intervening in an emergency (career development July 6). He points out that professional regulators have moved away from the idea that healthcare professionals can be off-duty when they are asked to assist a member of the public.

First aid article further confuses a complicated issue.

Articles such as 'Introduction to the nurse's role in providing first aid' (art&science September 30) do notassist or educate the nursing community on their duties and obligations. They serve only to confuse the issues.

Your letters.

Care pathways for domestic violence Devising a care pathway for detecting and managing domestic violence, as highlighted in the news pages of last month's Emergency Nurse, will present quite a challenge.