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Emergent thoracotomy is a rare but high-stakes procedure for trauma patients. Emergency medicine residents are expected to perform this procedure after graduation, but few get the opportunity to perform it, leading to suboptimal performance and patient morbidity and mortality. Previous low-cost thoracotomy trainers revolve around modifying an existing costly thoracotomy task trainer or bear limited resemblance to actual landmarks and anatomy. This study attempts to bridge this gap by creating a low-cost model with supplies found at most home improvement/craft stores that is more anatomically accurate. We constructed a low fidelity model, which residents ultimately found to be helpful in mastering this rare procedure, and after the training session, they reported a greater level of comfort and familiarization with the procedure.

Simultaneous bilateral central retinal vein occlusion (CRVO) is a rare presentation that warrants consideration of an underlying hyperviscosity state. Increased serum viscosity can lead to the hematologic emergency of leukostasis with resultant vascular obstruction and hypoxic tissue damage. The following case demonstrates the first case of bilateral CRVO in a young adult secondary to acute lymphoblastic leukemia (ALL). A 23-year-old female presented to the emergency department (ED) with two days of worsening bilateral blurry vision and bitemporal headache. Her ocular exam was significant for bilateral intraretinal hemorrhages consistent with CRVO with chest radiograph demonstrating widened mediastinum with perihilar lymphadenopathy and serologic testing revealing ALL with blast crisis. The patient was subsequently admitted to the oncology service for induction chemotherapy. Patients with new headache and bilateral vision changes should prompt a thorough neurological and ophthalmologic exam to assess for underlying systemic pathologies. Concurrent bilateral CRVO is a rare but specific finding for systemic hyperviscosity syndrome, blood dyscrasia, polycythemia, or other serious illness. Early recognition and treatment of the underlying condition can prevent further vision loss and overall morbidity and mortality.

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease or pseudogout is an idiopathic articular disease that predominantly affects elderly patients. It is caused by a systemic deposition of calcium pyrophosphate (CPP) crystals in the articular and hyaline joint cartilage. The majority of cases present as chronic arthritis, but a subset of CPPD can present as rapid onset of sharp pain and joint swelling, posing a diagnostic challenge. We present a case of a 64-year-old man with a history of hypertension, urologic cancer, and gout presenting to the emergency department (ED) with a sudden-onset, severe stabbing right shoulder pain radiating to the neck and upper back. On ED arrival, he was mildly hypotensive, afebrile, diaphoretic, and uncomfortable, causing concern for aortic dissection. His exam was significant for limited shoulder range of motion; his sensation, strength, and distal pulses were intact and equal in bilateral upper extremities. His plain films showed multilevel cervical degenerative disc disease and facet arthrosis and right glenohumeral osteoarthritis without fracture or malalignment. A computed tomography (CT) angiogram was negative for vascular anomalies. Throughout his ED stay, his pain was refractory to medication, and he developed a new fever, prompting a targeted shoulder ultrasound; this revealed large glenohumeral effusion, and synovial analysis revealed CPP crystals without organism growth. This case illustrates an unusual acute CPPD attack that mimicked an aortic dissection. Emergency physicians should recognize both common and uncommon presentations for chronic disease processes in maintaining a broad differential diagnosis and delivering quick, targeted treatment.

Bartonella henselae is a relatively uncommon pathogen that can present as a serious disease in immunocompromised patients. We present a case of a 76-year-old man with stable chronic lymphocytic leukemia (CLL) who presented to the emergency department (ED) with an onset of right axillary lymphadenitis after recovering from a recent cat bite on the ipsilateral finger. Doppler ultrasound demonstrated an irregular, circumscribed 5cm x 4cm, hypoechoic mass with mild vascular flow consistent with an enlarged abnormal lymph node. The patient was diagnosed with cat scratch disease and discharged on oral antibiotics with spontaneous drainage of the purulent materials in subsequent outpatient oncology visits. This case highlights the classic presentation of this rare disease in an immunocompromised patient with feline contact. Early antibiotics should be considered for at-risk and immunocompromised patients due to low sensitivity and specificity for Bartonella serologic tests. CLL can also present with similar progressive lymphadenopathy with severe systemic symptoms and extranodal involvement that requires emergent oncologic interventions and diagnostic vigilance.

Cryptococcal meningitis is a systemic infection that can be seen in immunosuppressed patients. Altered mental status, somnolence, and obtundation are warning signs of poor prognosis or advanced disease processes. We present a 23-year-old female with a past medical history significant for human immunodeficiency virus (HIV) obtained via vertical transmission who presented to the emergency department (ED) with a gradual onset of worsening headache over 10 days, with blurry vision, photophobia, nausea and vomiting, and progressive memory lapses. Her blood tests, chest plain radiograph, and non-contrast brain computed tomography (CT) were normal. In the ED, she developed a fever of 102°F and became more confused and agitated, with interspersed screaming and yelling. A lumbar puncture (LP) showed elevated white blood cell count and was positive for Cryptococcus neoformans; an opening pressure was unable to be obtained due to patient agitation. Despite prompt intravenous antibiotics and antifungal medications, her short, but tenuous hospital course involved declining mental status, requiring intubation and multiple therapeutic lumbar punctures, with an elevated opening pressure of up to 55 cm H2O. The patient suffered global ischemic encephalopathy and died on hospital day two. This case highlights the rapid decompensation of a young immunocompromised patient with cryptococcal meningitis, as well as the importance of early disease management and consultation to neurology and neurosurgery services. An important paradigm difference for emergency medicine (EM) physicians in the management of increased intracranial pressure (ICP) in patients with cryptococcal meningitis is avoiding acetazolamide, mannitol, and steroids and considering the indication for neurosurgical interventions for severe cryptococcal meningitis.

Introduction Previous studies have shown that risk attitudes and tolerance for uncertainty are significant factors in clinical decision-making, particularly in the practice of defensive medicine. These attributes have also been linked with rates of physician burnout. To date, the risk profile of emergency medicine (EM) physicians has not yet been described. Our goal was to examine the risk profile of EM residents using a widely available risk tolerance and attitude assessment tool. Methods First-, second-, and third-year residents of Thomas Jefferson University Hospital’s EM residency program completed the commercially available, unmodified Risk Type Compass, a validated instrument offered by Multi-Health Systems (MHS Inc, New York, USA). Scored reports included information on residents’ risk type (one of eight personality types that reflect their temperament and disposition); risk attitudes (domains where residents are more likely to engage in risky behaviors); and an overall risk tolerance indicator (RTi) (a numerical estimate of risk tolerance). RTi scores are reported as means with 95% confidence intervals (CIs). Results There was no significant change in RTi scores in residents across different years of their post-graduate year (PGY) training. PGY-one residents trended towards risk aversion; PGY-two residents were more risk-taking; and PGY-three residents scored in the middle. Conclusion Our pilot assessment of risk types in EM residents highlighted shifts across the years of training. Variations between members of each PGY cohort outweighed any outright differences between classes with regards to absolute risk tolerance. There was an increase in the frequency of health and safety risk-taking attitude with higher PGY class, and this was also the risk attitude that was the prominent domain for resident risk tolerance. The study was limited by sample size and single cross-sectional evaluation.

Medical simulation competitions have become an increasingly popular method to provide a hands-on “gamified” approach to education and training in the health professions. The most well-known competition, SimWars, consists of well-coordinated teams that are tasked with completing a series of mind-bending clinical scenarios in front of a live audience through ‘bracket-style’ elimination rounds. Similarly, challenging hazards amidst observational simulation (CHAOS) in the emergency department (ED) is another novel approach to gamification in both its structure and feel. Conducted at the Council of Emergency Medicine Resident Directors (CORD) 2018 National Assembly in San Antonio, Texas, instead of assigning premeditated teams, it placed random Emergency Medicine (EM) faculty, residents, and medical students together in teams to test them on a variety of fundamental EM content areas. Additionally, the event incorporated multiple levels within each round, allowing the inclusion of additional information to be shared with participants to support “switching gears,” as is typical for teams working in the ED and augmenting the perceived level of “chaos.” To assess this pilot project, formal quantitative and qualitative feedback was solicited at the end of the session. Quantitative evaluation of the intervention was obtained through an eight-item questionnaire using a five-point Likert-type scale from 19 of the 20 enrolled participants (95% response rate). Responses were generally positive with an overall course rating score of 4.45 out of 5 (SD +/- 0.62). Qualitative feedback revealed that learners enjoyed performing procedures and networking with their EM colleagues. The majority of residents (95%) recommend the activity be integrated into subsequent conferences. Areas for improvement included shorter cases and minimizing technical malfunctions. CHAOS in the ED was a successful pilot study that incorporated gamification as a means to deploy simulation-based training at a national emergency medicine conference in a community of simulation educators. Future studies should focus on incorporating learners’ feedback into subsequent CHAOS iterations and reducing overhead costs to increase its adoption by both regional and national audiences.

Publishing a manuscript in an academic journal represents more than just 'promotional currency.' It provides the opportunity to provoke debate, share your experiences, and challenge the status quo on provider practices. Writing a manuscript relies on collaboration and shared responsibility from a research team, which can often challenge mentors as they supervise and guide its development. While there are numerous online resources and peer-reviewed journal articles on 'How to write a scientific article,' we aim to tackle an even larger and overarching theme that transcends specific journal categories, writing styles, and citation formatting. In order to guide new researchers in navigating the expansive ocean of scientific publications, we collected, reviewed, and revised 11 tips based on multiple focus-group discussions with junior and senior researchers to determine common barriers for publishing manuscript. The goal is to help mentors and mentees navigate the research and publication processes. The tips include: 1) recognizing leadership styles; 2) initiating the groundwork; 3) establishing backup plans; 4) making a deadline; 5) courting the editor; 6) determining authorship; 7) finding personal incentives; 8) writing what you know; 9) sharing with caution; 10) following directions; and 11) Consider open-access journals.

Sporting event emergencies are common among both spectators and players, with unique sets of challenges associated with patient extrication in unfamiliar and chaotic environments. It is critical for sports physicians and trainers to deliberately train and prepare for emergent situations with limited resources during athletic events. One of the most difficult, yet commonly encountered challenges is determining when and how to safely remove an injured player’s helmet and sporting equipment, particularly if a spinal injury is highly suspected. We created a high-fidelity simulation case to practice the safe extrication of a hockey player who collapses on the bench in the player’s box, a space-restricted environment. The patient is a 25-year-old male hockey player who becomes unresponsive after a syncopal episode in the player’s box, and subsequently transferred to a medical center for further evaluation. Critical actions include extrication of the player at the scene, diagnosis of syncope, placement of the unconscious player on a backboard with cervical-spine precautions, removal of the player’s faceguard, removing the player off the ice, checking the electrocardiogram and glucose level, and transferring the player to a controlled environment. The learning objectives were to identify, evaluate, and manage the reversible causes of syncope, and demonstrate appropriate techniques for the optimal removal of sports equipment. Learner assessment was based on participation in the scenario and debriefing learners after the simulation. Post-simulation debriefing revealed that participants highly appreciated practicing not-so-commonly encountered hockey-related emergencies. Athletic trainers and emergency providers were able to effectively practice their management of the unresponsive hockey player. The participants were also able to deliberately practice their teamwork and communications skills with their peers. Learning points include proper c-spine immobilization techniques in a tight space and indication for gear-removal in an unconscious patient. As hockey continues to gain popularity, this simulation case will prepare athletic trainers and emergency providers to better address the reversible causes for syncope in hockey players, as well as safely and effectively extricate injured players from space-limiting sporting environments.

Teamwork, a skill critical for quality patient care, is recognized as a core competency by the Accreditation Council for Graduate Medical Education (ACGME). To date, there is no consensus on how to effectively teach these skills in a forum that engages learners, immerses members in life-like activities, and builds both trust and rapport. Recreational ‘Escape Rooms’ have gained popularity in creating a life-like environment that rewards players for working together, solving puzzles, and completing successions of mind-bending tasks in order to effectively ‘escape the room’ in the time allotted. In this regard, escape rooms share many parallels with the multitasking and teamwork that is essential for a successful emergency department (ED) shift. A pilot group of nine emergency medicine (EM) residents and one senior EM faculty member underwent a commercial escape room as part of a team-building exercise in January 2018. The escape room required participants to practice teamwork, communication, task delegation, and critical thinking to tackle waves of increasingly complex puzzles, ranging from hidden objects, physical object assembly (i.e., jigsaw puzzles), and symbol matching. Activities required members to recognize and utilize the collective experiences, skills, knowledge base, and physical abilities of the group. After the game, players underwent a structured ‘game-master’ debriefing facilitated by an employee of the commercial escape room; this was followed by a post-event survey facilitated by a faculty member, which focused on participants’ feelings, experiences, and problem-solving techniques. Escape rooms afford learners the opportunity to engage in an activity that rewards teamwork and effective leadership through experiences that directly link to specific ACGME milestones and educational learning theories. EM participants were engaged in the activity and felt that the escape room reproduced an environment analogous to the ED. The debriefing that followed the activity provided a satisfactory conclusion to the experience; but learners preferred a more organized debriefing format that provided them with constructive and specific feedback on their performance.

As students in the health professions transition from the classroom into the clinical environment, they will be expected to effectively communicate with their team members and their patients. Effective communication skills are essential to their ability to effectively contribute to their clinical team and the patient care they deliver. The authors propose an interactive workshop that can support students' deliberate practice of communication skills. The authors designed a simulation workshop that affords students the opportunity to practice their communication and peer-to-peer coaching skills. Using LEGOs, a one-hour workshop was conducted with medical students. Students were divided into groups of two. Each student took on a different role: teacher or builder. Teachers were tasked with instructing builders on how to construct a pre-made LEGO structure, not allowing builders to look at the structure. A group debriefing followed to evaluate the activity and explore the themes that emerged. Twenty first-year medical students and 25 fourth-year medical students participated in this activity. Most groups were successful in reproducing the pre-made structure. Groups that pre-briefed before building were most successful. Unsuccessful groups did not define orientation or direction in mutually understood terms, resulting in the creation of an incorrect mirror image of the structure - a common phenomenon seen during the teaching of procedures in the clinical learning environment. The workshop was well received. Students made requests to have similar sessions throughout their training to better support the development of effective communication skills. The workshop can easily be applied to other specialties to assist with procedural skills instruction or in workshops focusing on effective communication.