The effect of a point-of-care ultrasound curriculum on PAs in emergency medicine.

ABSTRACT: To address identified learning gaps among physician associates/assistants (PAs) working with point-of-care ultrasound (POCUS) in our ED, we designed and implemented a longitudinal POCUS curriculum. This curriculum introduced the 12 main POCUS applications for emergency medicine with presession educational assignments and in-person learning sessions. We used the Kirkpatrick framework of evaluation to develop our metrics of measurement. To examine the effect of the curriculum, pre- and postcurriculum surveys were completed and use of POCUS before, during, and after the curriculum period was monitored. Our results showed the curriculum increased confidence and knowledge of POCUS applications and significantly increased the use of POCUS clinically by PAs. Formal, on-the-job POCUS education for postgraduate PAs is a vital adjunct to informal clinical learning for PAs in emergency medicine to gain POCUS skills.

The utility of an online discussion board for reflective writing in an emergency medicine rotation.

Background: Narrative analysis and reflection have been found to support professional identity formation (PIF) and resilience among medical students. In the emergency department, students have used reflective practice to process challenging clinical experiences, such as ethical dilemmas or moral distress. An online discussion board, however, has not been described as a curricular component of emergency medicine (EM) rotations. The objective of this educational innovation was to support medical students in an EM clinical rotation via an online discussion board for reflecting on and debriefing clinical experiences with faculty and peers. Methods: Fifty-two medical students enrolled in the pass/fail EM elective between May 13, 2019, and October 30, 2020. Each cohort of six students took part in a cohort-specific discussion using the Canvas learning management system. Students were encouraged to post about any observations, reflections, or emotions after their shifts. Faculty course directors responded to each post using concepts of debriefing, coaching, and trauma-informed teaching. Results: Over 18 months, 49 of 52 (94%) students participated in the discussion board. Of 346 total posts, half were by students, and the other half were faculty responses. Students posted 3.27 times each, on average. Students rarely raised questions about scientific knowledge content, fact-based aspects of patient care, or specific skills. Rather, they often posted about intensely affective reactions to experiences that left them with complex emotions. Upon review of posts by the course directors, the majority (54%) of students' posts contained a range of affective responses. Students appreciated faculty responses and supported each other in their written responses to peers. Conclusions: An online discussion board can be used successfully for asynchronous reflective practice to debrief clinical experiences during an EM rotation, if designed incorporating faculty and peer support using trauma-informed teaching principles to bolster well-being and PIF.

Telemedicine Use by Older Adults in a COVID-19 Epicenter.

BACKGROUND: In early 2020, New York City was the epicenter of the Coronavirus disease 2019 (COVID-19) pandemic in the United States. Older adults were at especially high risk. Telemedicine (TM) was used to shift care from overburdened emergency departments (EDs) to provide health care to a community in lockdown. TM options presented unique challenges to our diverse older adult population, including visual, hearing, cognitive, and language limitations. OBJECTIVE: Our objective was to evaluate the use of TM during the peak of the pandemic in New York City. METHODS: We conducted a retrospective chart review of patients 65 years and older evaluated remotely via TM during our pandemic surge. Chart extraction was performed by six emergency physicians. Outcomes included demographics, technical limitations, rates of ED referral, and 30-day mortality. RESULTS: During the study period, a total of 140 encounters were reviewed. The mean age was 73 years. Overall, 20% of patients in the cohort were emergently referred to the ED. Use of TM by this age cohort increased 20-fold as compared with a similar time frame pre-pandemic. ED referral was highest in those over 75 (45.9% > 75 years). Forty-three percent used family to assist. Thirty-day mortality was 7%. CONCLUSION: TM use by older adults grew substantially at our institution during our initial COVID-19 surge. The same-day emergent referral rate and mortality rate reflect the high acuity represented in this cohort and points to the need for telehealth providers that are trained in triage and emergency medicine with a knowledge of local resource availability.

Organophosphate Ester Transport, Fate, and Emissions in Toronto, Canada, Estimated Using an Updated Multimedia Urban Model.

Organophosphate esters (OPEs), used as flame retardants and plasticizers, occur at relatively high concentrations in urban air and surface waters. We tested the hypothesis that some OPEs could be considered persistent and mobile organic compounds (PMOCs), using the poly parameter linear free energy relationship-modified Multimedia Urban Model (ppLFER-MUM) in Toronto, Canada, as a case study. Modeled air emissions of ∑6OPEs of 3300 (190-190 000) kg yr-1 were 10-100 times higher than emissions of polychlorinated biphenyls (∑5PCBs) and polybrominated diphenyl ethers (∑5PBDEs). Model results suggested that measured ∑6OPE stream concentrations of ∼2000 ng L-1 originate from emissions to urban air transferred to water mostly via precipitation. Water transport removed 7-28% of total air inputs compared to 0.1-10% for PCBs and 2-10% for PBDEs. Chlorinated OPEs were efficiently transported via surface water due to their persistence and high solubility. Loadings of ∑6OPEs to Lake Ontario from wastewater treatment plants, streams, and atmospheric deposition were 70%, 18%, and 13%, respectively, of ∑6OPE loadings of 3100 (1200-45 000) kg yr-1. Our results support the hypothesis that three chlorinated OPEs, tris(2-chloroethyl)phosphate phosphate (TCEP), tris(chloroisopropyl)phosphate (TCiPP), and tris(1,3-dichloroisopropyl)phosphate (TDCiPP), fit the profile of PMOCs due to their mobility and persistence in surface waters.

Isomers of tris(chloropropyl) phosphate (TCPP) in technical mixtures and environmental samples.

Tris(chloropropyl) phosphate (TCPP) is an environmentally abundant organophosphate ester (OPE). TCPP is comprised of four isomers with seven possible structures, eight CAS numbers, and even more common names. A review of 54 studies reporting one or more TCPP isomers confirmed that the most abundant and most often reported TCPP isomer was tris(2-chloro-1-methylethyl) phosphate, also known as tris(chloroisopropyl) phosphate (TCiPP, referred to hereafter as TCPP1). Full-scan gas chromatography-mass spectrometry (GC-MS) was used to identify the other three isomers numbered here according to their elution order on a non-polar GC column (DB-5): bis(2-chloro-1-methylethyl) (2-chloropropyl) phosphate (TCPP2), bis(2-chloropropyl)(2-chloro-1-methylethyl) phosphate (TCPP3), and tris(2-chloropropyl) phosphate (TCPP4). GC with a flame ionization detector (FID) was used to identify the relative abundances of the isomers in commercially available standards with unknown isomer composition. In technical TCPP, TCPP1-4 isomers averaged 71 ± 1, 26 ± 0.4, 3 ± 0.5, and 0.1 ± 0.02%, respectively. When these percent masses are incorporated into GC-MS quantification, response factors (RFs) for TCPP1 and TCPP2 are significantly different from TCPP3 and TCPP4, indicating that the multiple RF approach is more accurate than the commonly employed single RF method. Samples from urban streams and wastewater treatment plant (WWTP) effluent from Toronto, Canada, had isomeric ratios of TCPP1/2 that were not significantly different from a technical mixture whereas rain had a significantly different ratio indicating enrichment in the more volatile TCPP1 isomer. Reporting TCPP isomers can provide insight into sources, transport, and fate of TCPP in the environment. Graphical Abstract ᅟ.

Halogenated catechols from cycloaddition reactions of η-(2-ethoxyvinylketene)iron(0) complexes with 1-haloalkynes.

1-chloroalkynes and 1-bromohexyne undergo cycloaddition reactions with ethoxyvinylketeneiron(0) complexes to form chloro and bromocatechols. With most substituents, the halogen is incorporated ortho to the phenolic hydroxyl group regioselectively. With chloroethyne, chlorohexyne, and methyl chloropropiolate, the reverse regioselection is observed. Ab initio calculations reveal that the products are, in most cases, nearly isoenergetic, which indicates that the intermediate ketene-alkyne adduct geometry must be important in determining the product distribution.