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Study objective Extraglottic airway devices are frequently used during cardiac arrest resuscitations and for failed intubation attempts. Recent literature suggests that many extraglottic airway devices are misplaced. The aim of this study is to create a classification system for extraglottic airway device misplacement and describe its frequency in a cohort of decedents who died with an extraglottic airway device in situ. Methods We assembled a cohort of all decedents who died with an extraglottic airway device in situ and underwent postmortem computed tomographic (CT) imaging at the state medical examiner's office during a 6-year period, using retrospective data. An expert panel developed a novel extraglottic airway device misplacement classification system. We then applied the schema in reviewing postmortem CT for extraglottic airway device position and potential complications. Results We identified 341 eligible decedents. The median age was 47.0 years (interquartile range 32 to 59 years). Out-of-hospital personnel placed extraglottic airway devices in 265 patients (77.7%) who subsequently died out of hospital; the remainder died inhospital. The classification system consisted of 6 components: depth, size, rotation, device kinking, mechanical blockage of ventilation opening, and injury. Under the system, extraglottic airway devices were found to be misplaced in 49 cases (14.4%), including 5 (1.5%) that resulted in severe injuries. Conclusion We created a novel extraglottic airway device misplacement classification system. Misplacement occurred in greater than 14% of cases. Severe traumatic complications occurred rarely. Quality improvement activities should include review of extraglottic airway device placement when CT images are available and use the classification system to describe misplacements.

Study objective Although intubation is a commonly discussed procedure in emergency medicine, the number of opportunities for emergency physicians to perform it is unknown. We determine the frequency of intubation performed by emergency physicians in a national emergency medicine group. Methods Using data from a national emergency medicine group (135 emergency departments [EDs] in 19 states, 2010 to 2016), we determined intubation incidence per physician, including intubations per year, intubations per 100 clinical hours, and intubations per 1,000 ED patient visits. We report medians and interquartile ranges (IQRs) for estimated intubation rates among emergency physicians working in general EDs (those treating mixed adult and pediatric populations). Results We analyzed 53,904 intubations performed by 2,108 emergency physicians in general EDs (53,265 intubations) and pediatric EDs (639 intubations). Intubation incidence varied among general ED emergency physicians (median 10 intubations per year; IQR 5 to 17; minimum 0, maximum 109). Approximately 5% of emergency physicians did not perform any intubations in a given year. During the study, 24.1% of general ED emergency physicians performed fewer than 5 intubations per year (range 21.2% in 2010 to 25.7% in 2016). Emergency physicians working in general EDs performed a median of 0.7 intubations per 100 clinical hours (IQR 0.3 to 1.1) and 2.7 intubations per 1,000 ED patient visits (IQR 1.2 to 4.6). Conclusion These findings provide insights into the frequency with which emergency physicians perform intubations.

Study objective: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. Methods: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. Results: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI −0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). Conclusion: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

Currently, 1 out of 6 Americans lives within a jurisdiction in which physician-assisted dying is legally authorized. In most cases, patients ingest lethal physician-assisted dying medications at home without involvement of emergency medical services (EMS) or the emergency department (ED). However, occasionally the dying process is interrupted as a result of incomplete ingestion or vomiting of medications, confusion about timing of dying trajectory, familial emotional distress, and other variables. A case is presented here of a patient who arrived by ambulance to an urban ED after ingesting physician-assisted dying medication. Stepwise analysis of communication and actions between providers (paramedics, emergency physician, and admitting physician), risk management, and family are described chronologically. This case highlights the significant distress experienced by each party, as well as key challenges and learning points. Guidance is provided to emergency providers about expectations and communication. In states with limited physician-assisted dying experience, many EMS agencies, EDs, and hospitals require comprehensive protocols to handle the complex ethical and psychosocial issues surrounding physician-assisted dying in the ED.

Study objective Resuscitative thoracotomy is a time-sensitive, lifesaving procedure that may be performed by emergency physicians. The left anterolateral thoracotomy (LAT) is the standard technique commonly used in the United States to gain rapid access to critical intrathoracic structures. However, the smaller incision and subsequent limited exposure may not be optimal for the nonsurgical specialist to complete time-sensitive interventions. The modified bilateral anterior clamshell thoracotomy (MCT) developed by Barts Health NHS Trust clinicians at London’s Air Ambulance overcomes these inherent difficulties, maximizes thoracic cavity visualization, and may be the ideal technique for the nonsurgical specialist. The aim of this study is to identify the optimal technique for the nonsurgical-specialist-performed resuscitative thoracotomy. Secondary aims of the study are to identify technical difficulties, procedural concerns, and physician preferences. Methods Emergency medicine staff and senior resident physicians were recruited from an academic Level I trauma center. Subjects underwent novel standardized didactic and skills-specific training on both the MCT and LAT techniques. Later, subjects were randomized to the order of intervention and performed both techniques on separate fresh, nonfrozen human cadaver specimens. Success was determined by a board-certified surgeon and defined as complete delivery of the heart from the pericardial sac and subsequent 100% occlusion of the descending thoracic aorta with a vascular clamp. The primary outcome was time to successful completion of the resuscitative thoracotomy technique. Secondary outcomes included successful exposure of the heart, successful descending thoracic aortic cross clamping, successful procedural completion, time to exposure of the heart, time to descending thoracic aortic cross-clamp placement, number and type of iatrogenic injuries, correct anatomic structure identification, and poststudy participant questionnaire. Results Sixteen emergency physicians were recruited; 15 met inclusion criteria. All participants were either emergency medicine resident (47%) or emergency medicine staff (53%). The median number of previously performed training LATs was 12 (interquartile range 6 to 15) and the median number of previously performed MCTs was 1 (interquartile range 1 to 1). The success rates of our study population for the MCT and LAT techniques were not statistically different (67% versus 40%; difference 27%; 95% confidence interval –61% to 8%). However, staff emergency physicians were significantly more successful with the MCT compared with the LAT (88% versus 25%; difference 63%; 95% CI 9% to 92%). Overall, the MCT also had a significantly higher proportion of injury-free trials compared with the LAT technique (33% versus 0%; difference 33%; 95% CI 57% to 9%). Physician procedure preference favored the MCT over the LAT (87% versus 13%; difference 74%; 95% CI 23% to 97%). Conclusion Resuscitative thoracotomy success rates were lower than expected in this capable subject population. Success rates and procedural time for the MCT and LAT were similar. However, the MCT had a higher success rate when performed by staff emergency physicians, resulted in less periprocedural iatrogenic injuries, and was the preferred technique by most subjects. The MCT is a potentially feasible alternative resuscitative thoracotomy technique that requires further investigation.

Study objective Factors associated with intraosseous (IO) catheterization are not well described. Our objective is to identify factors associated with the attempt and timing of IO catheterization in a pediatric emergency department (ED) resuscitation setting. Methods We completed a video-based, case-control study (1:3 ratio) of children undergoing IO catheterization in the resuscitation area of a high-volume, academic, pediatric ED. We selected 8 independent factors a priori for analysis: younger than 2 years, Glasgow Coma Scale score less than 8, cardiopulmonary resuscitation (CPR), parent or caregiver presence, physician team leader with greater than 5 years of pediatric ED experience, 2 or more IO-catheterization-capable staff, ultrasonographically trained nurse vascular access team presence, and resuscitation occurring during the evening (4 pm to midnight) or overnight (midnight to 8 am) shift. We fit linear regression models to analyze for associations with IO access attempts and timing. Results One hundred fourteen patients were enrolled; 40 encounters involved IO catheterization (35.1%). Only CPR was associated with IO catheterization (odds ratio 39.0; 95% confidence interval 12.5 to 121.6). Mean time to IO attempt was shorter with CPR (3.2 versus 14.2 minutes) and longer with vascular access team presence (23.5 versus 3.4 minutes) or caregiver presence (10.5 versus 2.6 minutes). Of resuscitations that achieved peripheral intravenous access, only 1 (1.1%) did so in less than 90 seconds. Conclusion CPR was the only factor associated with IO access attempts, whereas providers may have been more hesitant to attempt IO catheterization with vascular access team or caregiver presence. Future studies should include a larger, multicenter sample and use qualitative methods to explore reasons for IO catheterization hesitancy, especially in the nonarrest scenario.

Study objective Decisionmaking is influenced by the environment in which it takes place. The objective of our study was to explore the influence of the specific features of the emergency department (ED) environment on decisionmaking. In this paper, we specifically report on the way emergency physicians use their knowledge of their collaborators to make their decisions. Methods We conducted a qualitative study on emergency physicians recruited in 3 French hospitals. Physicians were equipped with a microcamera to record their clinical activity from their "own-point-of-view perspective." Semistructured interviews, based on viewing the video, were held with each physician after an actual clinical encounter with a patient. They were then analyzed thematically, using constant comparison and matrices, to identify the central themes. Results Fifteen expert emergency physicians were interviewed. Almost all of them reported using their knowledge of other health care professionals to assess the seriousness of the patient's overall condition (sometimes even before his or her arrival in the ED) to optimize the patient's treatment and to anticipate future care. Conclusion Emergency physicians interact with many other health care workers during the different stages of the patient's management. The many ways in which experts use their knowledge of other health care professionals to make decisions puts traditional conceptions of expert knowledge into perspective and opens avenues for future research.

Consultations with specialist services occur with regularity in the emergency department (ED). Emergency physician interactions with consultants in the ED offer an amazing opportunity for collegial patient care but can also present a number of challenges. Navigating the consultation process requires effective communication skills that are considered a core competency within the Accreditation Council for Graduate Medical Education, as well as the CanMEDS frameworks of the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. Because of time pressure, environmental complexities, patient acuity, and the fast pace of the ED, learning this skill can be challenging for trainees and is something many attending physicians will struggle with at times. It has been established that trustworthiness and familiarity are 2 key components within the referral-consultation process. Both components rely on reputation, which creates a challenge in a training environment in which one's knowledge base and clinical acumen is a constant work in progress. Moreover, poor communication contributes to problematic patient care and decreased patient satisfaction. Knowing this, we believe it is imperative that residents be formally trained in this important skill. In this article, we introduce and highlight the most recent advances in standardized approaches to the referral-consultation process, including the 5C (contact, communicate, core question, collaborate, close the loop), PIQUED (prepare, identify, question, urgency, educational modifications, debrief), and CONSULT (contact courteously, orient, narrow question, story, urgency, later, thank you) models. Common roadblocks and complicating factors involved in resident-consultant interaction are also reviewed, ending with best-practice recommendations for consultants involved in resident education, as well as free open access medical education resources.

Cricothyrotomy is a rare but crucial procedure in the armamentarium of the emergency physician. The infrequency with which it is performed has led to a reliance on models, simulators, and animals in resident education, but each of these methods has unique drawbacks. Using recently deceased patients as teaching tools has a long history in medicine, though controversy surrounds whether, how, and from whom consent ought to be obtained. Recent studies have shown that families expect to be asked for permission and often will grant it, even for invasive procedures such as cricothyrotomy. Obtaining consent maintains the integrity of the relationship among the physician, the deceased, the family, and the community and need not prohibit performing procedures on the newly dead for the purpose of resident education. Thus, a balanced approach to resident instruction that incorporates the use of the deceased in addition to other methods of instruction seems both prudent and feasible.

Study objective We sought to characterize and understand the residents' perspective on how professionalism develops through pediatric emergency medicine experiences. Methods Qualitative methods (freelisting—listing words associated with professionalism—and semistructured interviews) were conducted with senior emergency medicine and pediatric residents about their experiences rotating in the emergency department of a large, urban, tertiary care, freestanding children's hospital. All senior residents were eligible, with purposive sampling to maximize demographic variability. Saliency (importance) of words was analyzed with Smith S scores and consensus analysis. Interviews were conducted until content saturation was achieved; transcripts were coded by independent investigators to reach thematic consensus. Results Twenty-five interviews (36% emergency, 64% pediatrics) were conducted. Common words associated with professionalism were "respect," "compassion," "empathy," and "integrity"; however, residents did not share a common consensus. The framework for how residents described the development of their professionalism includes observations, interactions, and environment. Examples include resident observation of role models; interactions with patients, families, and coworkers; self-reflection; and the unique environment of the ED. Residents believed that role modeling was the most influential factor. Few reported receiving sufficient observation by attending physicians during their interactions with patients and most reported receiving little direct feedback on their professionalism. Residents' descriptions of professionalism crossed multiple Accreditation Council for Graduate Medical Education (ACGME) competencies. Conclusion Residents displayed high variability in their understanding of professionalism, which was frequently at variance with the corresponding ACGME competency definition. The resident perspective and understanding of professionalism may usefully inform refinements in ACGME milestones and entrustable professional activities.

Study objective Out-of-hospital care is becoming more complex, thus placing greater reliance on the cognitive abilities of paramedics to manage difficult situations. In adapting to the challenges in their work, paramedics develop expertise. We study the cognitive strategies used by expert paramedics to contribute to understanding how paramedics and the EMS system can adapt to new challenges. Methods We conducted a "staged-world" cognitive task analysis to explore paramedics' handling of cognitive challenges related to sense-making and to resource and task management. A mixed-fidelity simulation was used to present paramedics with 2 challenging scenarios: a pulmonary embolism initially presenting as a myocardial infarction and a 2-person shooting with limited resources available. Results Participants were 10 paramedics, 6 more experienced and 4 less experienced. Analysis involved comparing the performance of the 2 groups to identify strategies associated with expertise. The more experienced paramedics made more assessments, explored a wider variety of presumptive diagnoses, and identified the pulmonary embolism earlier. They switched attention between the 2 shooting victims more, used their emergency medical technician–basic level partners more, and provided more advanced level care for both patients. Their patients arrived at the emergency department more prepared for specialized emergency care. Conclusion Our findings correspond to general cognitive attributes of expertise: greater cue gathering and inferential reasoning, and more functional and strategic thinking. These results suggest potential areas and methods to facilitate development of expertise, as well as ways to better support use of expertise. Future studies should expand on these findings through larger sample sizes and more complex scenarios.

Study objective We seek to provide current, comprehensive, and physician-level data for critical procedures performed in a high-volume pediatric emergency department (ED). Methods We conducted a retrospective study of all critical procedures performed in the ED of a tertiary care pediatric institution. Data were collected from written records of resuscitative care provided. The primary outcome measure was the cumulative frequency of each critical procedure during 12 consecutive months. Additional outcome measures included the number of critical procedures performed by pediatric emergency medicine faculty and fellows and a description of the other physician types performing each procedure. Results Two hundred sixty-one critical procedures were performed during 194 patient resuscitations, which represented 0.22% of all ED patient evaluations. Sixty-one percent of pediatric emergency medicine faculty did not perform a single critical procedure. Orotracheal intubation occurred 147 times and represented 56% of all critical procedures, yet 63% of pediatric emergency medicine faculty did not perform a single successful orotracheal intubation. Pediatric emergency medicine fellows performed a median of 3 critical procedures. Conclusion Critical procedures were rarely performed in a large, academic pediatric ED. Pediatric emergency medicine faculty are at significant risk for skill deterioration, and pediatric emergency medicine fellows are unlikely to achieve competence in the performance of critical procedures if clinical exposure is the sole basis for the attainment and maintenance of skill.

Study objective We determine the test performance characteristics for point-of-care ultrasonography performed by pediatric emergency physicians compared with radiographic diagnosis of elbow fractures and compare interobserver agreement between enrolling physicians and an experienced pediatric emergency medicine sonologist. Methods This was a prospective study of children aged up to 21 years and presenting to the emergency department (ED) with elbow injuries requiring radiographs. Before obtaining radiographs, pediatric emergency physicians performed focused elbow ultrasonography. An ultrasonographic result positive for fracture at the elbow was defined as the pediatric emergency physician's determination of an elevated posterior fat pad or lipohemarthrosis of the posterior fat pad. All patients received an elbow radiograph in the ED and clinical follow-up. The criterion standard for fracture was fracture on initial or follow-up radiographs. Results One hundred thirty patients with a mean age of 7.5 years were enrolled by 26 sonologists. Forty-three (33%) patients had a radiograph result positive for fracture. A positive elbow ultrasonographic result had a sensitivity of 98% (95% confidence interval [CI] 88% to 100%), specificity of 70% (95% CI 60% to 79%), positive likelihood ratio of 3.3 (95% CI 2.4 to 4.5), and negative likelihood ratio of 0.03 (95% CI 0.01 to 0.23) for fracture. The interobserver agreement (κ) was 0.77. The use of elbow ultrasonography would reduce radiographs in 48% of patients but would miss 1 fracture. Conclusion Point-of-care ultrasonography is highly sensitive for elbow fractures, and a negative ultrasonographic result may reduce the need for radiographs in children with elbow injuries. Elbow ultrasonography may be useful in settings in which radiography is not readily accessible or is time consuming to obtain.

Study objective Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience. Methods We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival. Results During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival. Conclusion Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival.

Stress experienced by emergency medical providers during the resuscitation of critically ill or injured patients can cause cognitive and technical performance to deteriorate. Psychological skills training offers a reasonable and easily implemented solution to this problem. In this article, a specific set of 4 performance-enhancing psychological skills is introduced: breathe, talk, see, and focus. These skills comprise breathing techniques, positive self-talk, visualization or mental practice, and implementing a focus "trigger word." The evidence supporting these concepts in various domains is reviewed and specific methods for adapting them to the environment of resuscitation and emergency medicine are provided.

Study objective Guideline committees recommend postresuscitation debriefings to improve performance. "Hot" postresuscitation debriefings occur immediately after the event and rely on team recall. We assessed the ability of resuscitation teams to recall their performance in team-based, hot debriefings in a pediatric emergency department (ED), using video review as the criterion standard. We hypothesized that debriefing accuracy will improve during the course of the study. Methods Resuscitation physician and nurse leaders cofacilitated debriefings after ED resuscitations involving cardiopulmonary resuscitation (CPR) or intubation. Debriefing teams recorded their self-assessments of clinical performance measures with standardized debriefing forms. The debriefing form data were compared with actual performance measured by video review at 2 pediatric EDs over 22 months. CPR performance measures included time to automated external defibrillator pad placement, epinephrine administration timing, and compression pause timing. Intubation measures included occurrences of oxygen desaturation, number of intubation attempts, and use of end-tidal carbon dioxide monitoring. Results We analyzed 100 resuscitations (14 cardiac arrests, 22 cardiac arrests with intubation, and 64 intubations). The accuracy of debriefing answers was 87%, increasing from 83% to 91% between the first and second halves of the study period (7.7% difference; 95% confidence interval 0.2% to 15%). Debriefings that acknowledged an error in certain performance measures (ie, automated external defibrillator pad placement delay, multiple intubation attempts, and occurrence of oxygen desaturation) had significantly worse performance in those specific measures on video review. Conclusion Teams in postresuscitation debriefings had a higher degree of debriefing answer accuracy in the final 50 debriefings than in the first 50. Teams also distinguished various degrees of resuscitation performance.

Study objective Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r=0.92) and residents (r=0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment.

Study objective We use medical students' reflections to deepen understanding of professionalism in the emergency department (ED), including the ideals that students wish to model and the lapses they hope to avoid. Methods Fourth-year students in a mandatory ED clerkship were required to write 2 narrative reflections during the month. The authors conducted a qualitative analysis to determine professionalism themes. Results Sixty-one of 150 student reflections contained professionalism themes. Positive behaviors included compassion, tension between respecting diversity and respecting other core values, and balance between patient-centered care and effective care. In addition, the students wrote about commitment to excellent medical care and ethical principles. Many students struggled with how to deal with patients who might be "drug seekers" and when to prescribe narcotics. They were concerned about the balance of compassion, often noting differences in the patients' backgrounds compared with their own. On the other hand, many students observed unprofessional behaviors. Particularly concerning were the absence of compassion, physicians lying, and a lack of teamwork. Students reflected on how their own professional behavior could improve according to their experiences in the ED. Conclusion Students' reflective narratives are a rich source of information about good professional behavior, as well as threats to professionalism. Their experiences shaped the students' perceptions of emergency medicine and its values. Such reflections may constitute an important resource for faculty, student, and resident development.

Study objective Although often the focus of quality improvement efforts, emergency medical services (EMS) advanced airway management performance has few national comparisons, nor are there many assessments with benchmarks accounting for differences in agency volume or patient mix. We seek to assess variations in advanced airway management and conventional intubation performance in a national cohort of EMS agencies. Methods We used EMS data from ESO Solutions, a national EMS electronic health record system. We identified EMS emergency responses with attempted advanced airway management (conventional intubation, rapid sequence intubation, sedation-assisted intubation, supraglottic airway insertion, and cricothyroidotomy). We also separately examined cases with initial conventional intubation. We determined EMS agency risk-standardized advanced airway management and initial conventional intubation success rates by using mixed-effects regression models, fitting agency as a random intercept, adjusting for patient age, sex, race, cardiac arrest, or trauma status, and use of rapid sequence or sedation-assisted intubation, and accounting for reliability variations from EMS agency airway volume. We assessed changes in agency advanced airway management and initial conventional intubation performance rank after risk and reliability adjustment. We also identified high and low performers (reliability-adjusted and risk-standardized success confidence intervals falling outside the mean). Results During 2011 to 2015, 550 EMS agencies performed 57,209 advanced airway management procedures. Among 401 EMS agencies with greater than or equal to 10 advanced airway management procedures, there were a total of 56,636 procedures. Median reliability-adjusted and risk-standardized EMS agency advanced airway management success was 92.9% (interquartile range 90.1% to 94.8%; minimum 58.2%; maximum 99.0%). There were 56 advanced airway management low-performing and 38 high-performing EMS agencies. Among 342 agencies with greater than or equal to 10 initial conventional intubations, there were a total of 37,360 initial conventional intubations. Median reliability-adjusted and risk-standardized EMS agency initial conventional intubation success was 77.3% (interquartile range 70.9% to 83.6%; minimum 47.1%; maximum 95.8%). There were 64 initial conventional intubation low-performing and 45 high-performing EMS agencies. Conclusion In this national series, EMS advanced airway management and initial conventional intubation performance varied widely. Reliability adjustment and risk standardization may influence EMS airway management performance assessments.

Study objective We assess accuracy and variability of triage score assignment by emergency department (ED) nurses using the Emergency Severity Index (ESI) in 3 countries. In accordance with previous reports and clinical observation, we hypothesize low accuracy and high variability across all sites. Methods This cross-sectional multicenter study enrolled 87 ESI-trained nurses from EDs in Brazil, the United Arab Emirates, and the United States. Standardized triage scenarios published by the Agency for Healthcare Research and Quality (AHRQ) were used. Accuracy was defined by concordance with the AHRQ key and calculated as percentages. Accuracy comparisons were made with one-way ANOVA and paired t test. Interrater reliability was measured with Krippendorff's α. Subanalyses based on nursing experience and triage scenario type were also performed. Results Mean accuracy pooled across all sites and scenarios was 59.2% (95% confidence interval [CI] 56.4% to 62.0%) and interrater reliability was modest (α=.730; 95% CI .692 to .767). There was no difference in overall accuracy between sites or according to nurse experience. Medium-acuity scenarios were scored with greater accuracy (76.4%; 95% CI 72.6% to 80.3%) than high- or low-acuity cases (44.1%, 95% CI 39.3% to 49.0% and 54%, 95% CI 49.9% to 58.2%), and adult scenarios were scored with greater accuracy than pediatric ones (66.2%, 95% CI 62.9% to 69.7% versus 46.9%, 95% CI 43.4% to 50.3%). Conclusion In this multinational study, concordance of nurse-assigned ESI score with reference standard was universally poor and variability was high. Although the ESI is the most popular ED triage tool in the United States and is increasingly used worldwide, our findings point to a need for more reliable ED triage tools.

Study objective Current recommendations indicate that emergency physicians should activate cardiac catheterization laboratory personnel by a single page for ST-segment elevation myocardial infarction (STEMI) patients. We assessed the accuracy of emergency physician cardiac catheterization laboratory activations, angiographic findings, outcomes, and treatment times among patients with and without STEMI. Methods We classified the appropriateness and outcomes of consecutive emergency physician STEMI pages between June 2006 and September 2008. Emergency physician activations of the cardiac catheterization laboratory were classified according to the findings of the initial ECG compared with cardiology interpretation for the presence of STEMI and presence of coronary disease. Results During a 27-month period, emergency physician activation of the cardiac catheterization laboratory occurred 249 times. There were 188 (76%) patients with a true STEMI, of whom 13 did not receive emergency angiography. Of the 37 (15%) patients who had ECG findings meeting STEMI criteria and who ultimately did not have myocardial necrosis and underwent emergency angiography, 12 had significant disease and 5 had revascularization performed. Eleven patients had ECGs concerning for but not meeting STEMI criteria; all had emergency angiography (n=11) or received a diagnosis of non-STEMI (n=6). Only 13 patients were considered as having received unnecessary cardiac catheterization laboratory activations (5.2%) in which emergency angiography was not performed and myocardial infarction was excluded. Conclusion A significant number of emergency physician STEMI cardiac catheterization laboratory activations are for patients who did not meet standard STEMI criteria. However, most had ECG findings and symptoms that lead to emergency angiography, had significant disease, or were diagnosed with non-STEMI. Only a small percentage of patients received unnecessary cardiac catheterization laboratory activations. Our findings support current recommendations for emergency physician cardiac catheterization laboratory activation for potential STEMI patients.

Study objective We determine the effect of a simulation-based curriculum on fourth-year medical student test performance and satisfaction during an emergency medicine clerkship. Methods This was a randomized controlled study using a crossover design for curriculum format and an anonymous end-of-rotation satisfaction survey. Students were randomized into 2 groups. One group started the rotation with simulation and the other with group discussion. Midrotation, they each crossed over to the opposite format. All students subsequently completed the same multiple choice examination. We assessed paired samples of the number of questions missed for material taught in each format. Students rated satisfaction with a 5-point Likert scale framed as attitude toward simulation compared with group discussion. Scores ranged from 5, signifying strong agreement with a statement, to 1, signifying strong disagreement. Results Ninety students (99%) completed the multiple choice test. Significantly fewer questions were missed for material presented in simulation format compared with group discussion, with a mean difference per student of 0.7 (95% confidence interval [CI] 0.3 to 1.0; P=.006). This corresponds to mean scores of 89.8% for simulation and 86.4% for group discussion. Eighty-eight (97%) students completed the satisfaction survey. Students rated simulation as more stressful (mean 4.1; 95% CI 3.9 to 4.3), but also more enjoyable (mean 4.5; 95% CI 4.3 to 4.6), more stimulating (mean 4.7; 95% CI 4.5 to 4.8), and closer to the actual clinical setting (mean 4.6; 95% CI 4.4 to 4.7) compared with group discussion. Conclusion A simulation-based curriculum yielded measurable benefits. Students demonstrated a small improvement in learning and were more satisfied with the simulation-based curriculum compared with group discussion.

Study objective The objective of this investigation is to use a dental simulation model to compare splinting and bandaging methods for managing tooth avulsions and fractures, as measured by dentist evaluators for quality and time to complete each stabilization procedure. Methods This was a randomized crossover study comparing 3 splinting techniques for managing a traumatically avulsed tooth (periodontal pack, wire, and bondable reinforcement ribbon) and 2 bandage techniques for managing a fractured tooth (calcium hydroxide paste and light-cured composite). After viewing a Just-in-Time training video, a convenience sample of emergency physicians performed the 5 stabilization techniques on dental models containing extracted teeth embedded in clay to simulate a segment of the human dentition. Data collected included time to complete each procedure, the evaluation of dentists about whether the procedure was performed satisfactorily or unsatisfactorily, and the ranking of dentists' and participants' preferred technique. Results Twenty-five emergency physicians participated in the study: 17 residents, 2 pediatric emergency medicine fellows, and 6 attending physicians. Reported median time, as well as minimum and maximum times to complete each splinting technique for an avulsed tooth, was as follows: periodontal pack 4.4 minutes (2.5 to 6.5 minutes), wire 8.6 minutes (5.8 to 12.9 minutes), and bondable reinforcement ribbon 8.9 minutes (5.6 to 15 minutes). Median time (and minimum and maximum times) to complete each protective bandaging technique for a fractured tooth was calcium hydroxide paste 4.6 minutes (3 to 9.6 minutes) and light-cured composite 7.1 minutes (5.5 to 14.1 minutes). When asked to choose a preferred splinting and bandaging technique according to the performance of the physicians, the dentists chose the bondable reinforcement ribbon 96% (24/25) and the light-cured composite 100% (25/25) of the time. Study participants had no measurable or agreeable preference for a particular splinting or bandaging technique. Conclusion The results of this study suggest that of the stabilization procedures completed by emergency physicians, dentists preferred the bondable reinforcement ribbon for managing an avulsed tooth and the light-cured composite technique for managing a fractured tooth over the commonly taught and more frequently used procedures in emergency medicine.

Study objective We investigate the test performance of emergency physician–performed sonographic measurement of optic nerve sheath diameter for diagnosis of increased intracranial pressure. Methods Children between the ages of 0 and 18 years with suspected increased intracranial pressure were prospectively recruited from the emergency department and ICU of an urban, tertiary-level, freestanding pediatric facility. Pediatric emergency physicians with goal-directed training in ophthalmic sonography measured optic nerve sheath diameter. Images were recorded and subsequently reviewed by a pediatric ophthalmologist and an ophthalmic sonographer, both of whom were blind to the patient's clinical condition. Measurements obtained by the ophthalmic sonographer were considered the criterion standard. An optic nerve sheath diameter greater than 4.0 mm in subjects younger than 1 year and greater than 4.5 mm in older children was considered abnormal. The diagnosis of increased intracranial pressure was based on results of cranial imaging or direct measurement of intracranial pressure. Results Sixty-four patients were recruited, of whom 24 (37%) had a confirmed diagnosis of increased intracranial pressure. The sensitivity of optic nerve sheath diameter as a screening test for increased intracranial pressure was 83% (95% confidence interval [CI] 0.60 to 0.94); specificity was 38% (95% CI 0.23 to 0.54); positive likelihood ratio was 1.32 (95% CI 0.97 to 1.79) and negative likelihood ratio was 0.46 (95% CI 0.18 to 1.23). There was fair to good interobserver agreement between the pediatric emergency physician and ophthalmic sonographer (κ 0.52) and pediatric ophthalmologist (κ 0.64). Conclusion The sensitivity and specificity of bedside sonographic measurement of optic nerve sheath diameter is inadequate to aid medical decisionmaking in children with suspected increased intracranial pressure. Pediatric emergency physicians with focused training by a pediatric ophthalmologist familiar with ophthalmic sonography can measure optic nerve sheath diameter accurately.

Study objective Clinical reasoning is a crucial skill for all residents to acquire during their training. During most patient encounters in pediatric emergency medicine, physicians and trainees are challenged by diagnostic, investigative, and treatment uncertainties. The Script Concordance Test may provide a means to assess reasoning skills in the context of uncertainty in the practice of pediatric emergency medicine. We gathered validity evidence for the use of a pediatric emergency medicine Script Concordance Test to evaluate residents' reasoning skills. Methods A 1-hour test containing 60 questions nested in 38 cases was administered to 53 residents at the end of their pediatric emergency medicine rotation at 1 academic institution. Twelve experienced pediatricians were part of a reference panel to establish the basis for the scoring process. Results An optimized version of the test, based on positive item discrimination data, contained 30 cases and 50 questions. Scores ranged from 48% to 82%, with a mean score of 69.9 (SD=11.5). The reliability of the optimized test (Cronbach's α) was 0.77. Performance on the test increased as the level of experience of the residents increased. The residents considered the Script Concordance Test true to real-life clinical problems and had enough time to complete the test. Conclusion This pediatric emergency medicine Script Concordance Test was reliable and useful to assess the progression of clinical reasoning during residency training.

Study objective We compare the effectiveness of an endotracheal tube introducer ("bougie") with a new fiberoptic stylet as an adjunct to direct laryngoscopy in facilitating simulated difficult tracheal intubation in a manikin. Methods Inexperienced laryngoscopists were recruited for this randomized, crossover study. After brief training, participants were randomized to first use either the bougie or fiberoptic stylet as an adjunct to direct laryngoscopy for attempted tracheal intubation of a manikin presenting a fixed, simulated, Cormack-Lehane grade IIIA view. Two attempts at tracheal intubation were allowed, each limited to 60 seconds. The participant then crossed over and used the other device. The same procedure was then repeated on a second manikin presenting a simulated Cormack-Lehane grade IIIB view. Primary outcomes were time to tracheal intubation and successful endotracheal tube placement. Results One hundred three study participants performed a total of 533 tracheal intubations for evaluation. For the Cormack-Lehane grade IIIA view, correct placement of the endotracheal tube was achieved in 101 (98%) of the fiberoptic stylet-facilitated and all 103 (100%) of the bougie-facilitated tracheal intubations. The time to successful tracheal intubation was similar for both devices (difference in mean time 1.8 seconds; 95% confidence interval [CI] −2.5 to 6.1 seconds). In the Cormack-Lehane grade IIIB view manikin, use of the fiberoptic stylet significantly increased success rate (fiberoptic stylet 98% versus bougie 9%), and a trend was observed toward a decrease in the mean time required for successful tracheal intubation compared to the bougie (fiberoptic stylet 31.0 seconds versus bougie 45.6 seconds; difference in mean time –14.6 seconds; 95% CI −31.4 to 2.3 seconds). Conclusion In a manikin model, with inexperienced clinicians, both the bougie and the fiberoptic stylet were effective in facilitating tracheal intubation of a simulated Cormack-Lehane grade IIIA view. For a Cormack-Lehane IIIB view, the fiberoptic stylet was significantly more effective than the bougie in facilitating tracheal intubation. Because a manikin model eliminates some of the barriers to use of fiberoptics in patients, further validation of fiberoptic stylet use is required in human subjects with normal and difficult airways.

Study objective Out-of-hospital endotracheal intubation is a complex intervention. One strategy for improving the quality of a complex intervention is to limit the procedure to practitioners or agencies that meet minimum procedure experience standards. The system-level influence of such limits is unknown. We seek to determine how minimum endotracheal intubation experience standards influence the number and distribution of out-of-hospital endotracheal intubations. Methods We used 2003 Pennsylvania statewide emergency medical services (EMS) data. We included endotracheal intubations that could be attributed to a valid rescuer, EMS agency, and minor civil division. We calculated the total number of endotracheal intubations performed across the state. We calculated the absolute and relative changes in total, cardiac arrest, nonarrest, pediatric, and trauma endotracheal intubation when the procedure was limited to on-scene rescuers meeting minimum endotracheal intubation experience standards, ranging from zero to 20 annual endotracheal intubations. We evaluated the same relationships when the procedure was limited to EMS agencies meeting minimum endotracheal intubation experience standards, ranging from zero to 200 annual endotracheal intubations. We evaluated these relationships with line plots and geographic information system maps. Results During the study period there were 11,771 endotracheal intubations (7,854 cardiac arrest, 3,917 non-arrest, 1,325 trauma and 561 pediatric endotracheal intubations). Limiting endotracheal intubations to rescuers with at least 3, 5, 10, and 15 endotracheal intubations per year would result in relative endotracheal intubation reductions of 12%, 32%, 79%, and 93%, respectively. Limiting endotracheal intubations to EMS agencies with at least 20, 30, 50, 100, and 150 endotracheal intubations per year would result in relative endotracheal intubation reductions of 15%, 27%, 41%, 65%, and 73%, respectively. Cardiac arrest endotracheal intubations would exhibit the largest absolute reduction. Conclusion Minimum endotracheal intubation experience standards would result in absolute and relative reductions in total and subgroup endotracheal intubations. These findings provide vital perspectives about the system-wide organization of out-of-hospital airway management.

Study objective Sexual assault nurse examiner (SANE) programs have improved the quality of care for sexual assault victims. An adverse effect of these programs is reduced resident clinical exposure to victims of sexual assault. The objectives of this project are to determine the baseline level of resident competence in knowledge and management of sexual assault and to demonstrate the effectiveness of training in developing resident competence. Methods The study included 27 emergency medicine residents at an urban academic center with an active SANE program. The design included pretest, intervention, and retest at 6 months. The intervention included 8 hours of lecture, role play, and skills laboratories. Objectives were based on SANE standards. The 4 assessments were a written knowledge test, evidence collection on mannequin, standardized patient interviews, and a written emergency department note. Data were compared with paired t tests. Results Twenty-three (85%) residents completed the study. Preintervention, residents scored 56% on the written knowledge test, 63% on evidence collection, 71% on standardized patient interviews, and 66% on the written note. Residents showed significant postintervention improvements in written knowledge (improvement 24%; 95% confidence interval [CI] 20% to 27%) and evidence collection (improvement 18%; 95% CI 12% to 24%). Performance on standardized patient-based communication skills did not change after the intervention. Resident posttest scores were similar to those of SANE providers. Conclusion Emergency medicine residents training in an urban center with an active SANE program had limited knowledge and skills in the treatment of victims of sexual assault. Our multimodal educational intervention increased residents' knowledge and evidence collection skills to levels equivalent to that of experienced providers in a SANE program.

Significant evidence identifies point-of-care ultrasound (PoCUS) as an important diagnostic and therapeutic tool in resource-limited settings. Despite this evidence, local health care providers on the African continent continue to have limited access to and use of ultrasound, even in potentially high-impact fields such as obstetrics and trauma. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries, yet no current consensus exists in regard to core PoCUS competencies. The current practice of transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems fails to acknowledge the unique challenges, needs, and disease burdens of recipient systems. As emergency medicine leaders from 8 African countries, we introduce a practical algorithmic approach, based on the local epidemiology and resource constraints, to curriculum development and implementation. We describe an organizational structure composed of nexus learning centers for PoCUS learners and champions on the continent to keep credentialing rigorous and standardized. Finally, we put forth 5 key strategic considerations: to link training programs to hospital systems, to prioritize longitudinal learning models, to share resources to promote health equity, to maximize access, and to develop a regional consensus on training standards and credentialing.

This manuscript reports recommendations of the National Fourth Year Medical Student Emergency Medicine Curriculum Guide Task Force. This task force was convened by 6 major emergency medicine organizations to develop a standardized curriculum for fourth year medical students. The structure of the curriculum is based on clerkship curricula from other specialties such as internal medicine and pediatrics. The report contains a historical context, global and targeted needs assessment, goals and objectives, recommended educational strategies, implementation guidelines, and suggestions on feedback and evaluation.

Study objective Nearly all emergency medicine residency programs provide some training in emergency physician-performed ultrasonography, but the extent of emergency physician-performed ultrasonography in community emergency departments (EDs) is not known. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians. Methods A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician-performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. Twelve hundred of 5264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from Fall 2003 to Spring 2004. Results Overall response rate was 61% (684/1130). Respondents who self-reported as being academic with emergency medicine residents were excluded from further analysis (n=35). A sensitivity analysis (reported in parentheses) was performed on the key outcome question to adjust for response bias. As reported by ED directors, ultrasonography was available in the ED for use by emergency physicians at all times in 19% of EDs (12% to 28%), with an additional 15% (9% to 21%) reporting a machine available for use by emergency physicians in some capacity and 66% (51% to 80%) reporting that there was no access to a machine for emergency physician use. ED directors reported being requested or required to limit ultrasonography orders performed by radiology in 41% of EDs, with less timely access to radiology-performed ultrasonography in off hours. Of EDs with emergency physician-performed ultrasonography, the most common applications were Focused Assessment with Sonography for Trauma (FAST) examination (85%), code situation (72%), and check for pericardial effusion (67%). Of physicians performing ultrasonography, 16% stated they were currently requesting reimbursement (billing). The primary reason cited for not implementing emergency physician-performed ultrasonography was lack of emergency physician training. For the statement "emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasonography," 84% of ED directors agreed, 14% were neutral, and less than 2% disagreed. Conclusion Community ED directors continue to report barriers to obtaining ultrasonography from consultants, especially in off hours. Nineteen percent of community ED directors report having a machine available for emergency physician use at all times; however, two thirds of EDs report no access to ultrasonography for emergency physician use. A majority of community ED directors support residency training in emergency physician-performed ultrasonography.