This case report discusses a patient who had subtle EKG abnormalities that were indicative of a pathological amount of coronary artery disease resulting in occlusion of the right coronary artery (RCA) even though STelevation criteria for STEMI were not initially present. In the proper clinical setting, focal repolarization abnormalities in conjunction with cardiac risk factors and cardiac symptoms may indicate a high probability of a pathological amount of coronary disease that warrants emergent intervention. We report a case of a 54year-old male with cardiac risk factors and cardiac symptoms who presented to the emergency department (ED). Initial EKG, while technically abnormal, was not diagnostic. The point of care troponin was elevated at 0.10 ng/mL. Patient ultimately went to the catheterization lab where he was found to have an occlusion of the RCA and left circumflex artery which required stenting.

Audience: This suite of borescope laryngoscopes is designed to instruct emergency medicine residents and sub-interns in video-assisted airway management. Background: Skillful and confident airway management is one of the markers of a strong emergency medicine physician. 1 Video-assisted airway management is a necessary skill, particularly in the setting of difficult airways and cervical spine immobilization. 2,3 However, the idea of learning airway management "by doing" is high-risk and mistakes can have devastating implications on patient outcomes. Fortunately, high-fidelity medical simulation tools have been developed to address this dilemma, allowing a safe environment for providers to practice their airway management skills. 4, 5 These tools, while undeniably useful, are limited in their scope; they are often designed for clinical rather than educational use, and are proprietary and expensive. 6, 7 Video laryngoscopes approved for patient use are difficult to implement widely in educational settings due to cost or because they cannot be removed from a designated area. Clinical video laryngoscopy suites typically cost 2,000 -6,000 US dollars. Additionally, the video images can only be viewed on a local small screen rather than a television or projector. This means that the number of learners is limited by space around the small laryngoscope screen. These cost and space barriers may be especially pronounced in low resource or non-traditional learning environments. Educational Objectives: Using an anatomically accurate airway simulator, by the end of a 20-30-minute instructional session, learners should be able to: 1) Understand proper positioning and use the video laryngoscope with dexterity, 2) identify airway landmarks via the video screen, and 3) demonstrate ability to intubate a simulated airway. Educational Methods: We developed a low-cost borescope laryngoscope for airway simulation training. Using this device, learners should be able to identify airway landmarks and successfully intubate a simulated INNOVATIONS 2 Section break airway. The borescope laryngoscope, a novel device which employs the camera-end of a video borescope and a single-use VL blade, was used by learners during high-fidelity airway simulation. Learners were residents or medical students undergoing airway training in case-based simulation, or in airway-management procedure stations. Research Methods: The borescope laryngoscopes were used during dedicated airway training in place of their medical device counterparts. During case-based simulation sessions involving airway management, 32 residents and 20 medical students used the borescope laryngoscope. During dedicated airway management procedure stations, 12 medical students used the borescope laryngoscope. Learners were instructed to perform endotracheal intubation and fully visualize critical structures before passing the tube. Successful intubation was defined as the ability to pass the tube independently or with the help of the instructor. The borescope laryngoscope proved effective at video visualization of critical structures. Compared to official medical equipment, the VL borescope similarly allowed for visualization of a Cormack-Lehane Grade 1 view. Learners were able to visualize the airway anatomy and successfully pass the ET tube on each pass either independently or with the help of the instructor. The development of this airway-training tool was effective and less expensive than medical grade versions. Our group of learners successfully visualized essential anatomy and passed an endotracheal tube (ED tube) through the vocal cords. The borescope laryngoscope offers a comparable user experience at a much lower cost. The devices also allowed instructors to teach video laryngoscopy without depending on clinical equipment. Widespread use may allow for expansion of airway simulation training while maintaining a high-fidelity learner experience.

Audience: This case is targeted to emergency medicine residents of all levels.Introduction: Shortness of breath (SOB) is one of the top ten most common chief complaints seen in the Emergency Department, accounting for close to 10% of presenting complaints. 1 An acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a frequent culprit, accounting for roughly 15.4 million visits and 730,000 hospitalizations per year. 2 The diagnosis of treatment of mild to moderate AECOPD can be relatively uncomplicated; however, multiple factors can increase the complexity of management and pose additional challenges that the emergency physician (EP) must be prepared for.Severe AECOPD can necessitate the need for both Non-invasive positive pressure ventilator (NIPPV) such as bi-level positive airway pressure (BiPAP) as well as emergent intubation.Furthermore, managing the ventilator settings in patients with an AECOPD is far from routine, requiring an intricate understanding of pulmonary physiology. 3Educational Objectives: By the end of this simulation, learners will be able to (1) assess for causes of severe shortness of breath, (2) manage severe COPD exacerbation by administering appropriate medications, (3) identify worsening clinical status and initiate NIPPV, (4) assess the causes of hypoxia after establishing endotracheal intubation and, (5) identify indication for needle decompression and perform chest tube thoracostomy.Educational Methods: This simulation was conducted with a high-fidelity mannequin with a separate low fidelity chest tube mannequin that allowed for hands-on practice placing a chest tube.A total of 16 PGY-1 residents participated in the simulated patient encounter.Research Methods: Following the simulation and debrief session, all residents were sent a Likert scale survey via surveymonkey.comto assess the educational quality of the simulation.The survey contained the following questions; 1) Overall, this simulation was realistic and could represent a patient presentation in the Emergency Department, 2) Overall, the case contained complexity that challenged me as a learner, 3) This case helped to expand my medical knowledge, 4) I feel more confident in diagnosing and treating AECOPD, 5) I feel more confident in recognizing the indications for NIPPV and intubation, 6) This simulation offered an USER GUIDE eturn: Ca

Audience: This interactive module is designed for implementation within an Emergency Medicine Residency program. The target audience is post-year-graduate one to post-year-graduate four residents, medical students, physician assistant postgraduate trainees, physician assistant students, and physician assistants. A knowledge of tickborne illness represents a critical component of infectious disease education for Emergency Medicine residents. Ticks that harbor these organisms are highly endemic to the continental United States and zoonotic infections are a critical differential diagnosis in the evaluation of patients in the Emergency Department. 1 There is significant morbidity and mortality associated with tickborne diseases, and many of the signs and symptoms can mimic other common presentations. While these illnesses can present a diagnostic challenge and coinfection does occur, treatment is generally straightforward and readily available. 2 An understanding of vectors and rates of transmission in a geographic area can foster a high clinical suspicion and ensure that effective treatment is administered. 3 Educational Objectives: After participation in this module, learners will be able to 1) list the causative agents for Lyme Disease, Babesiosis, Tularemia, Ehrlichiosis, Anaplasmosis, Tick Paralysis, Rocky Mountain Spotted Fever, and Powassan Virus, 2) identify different clinical features to distinguish the different presentations of tickborne illnesses, and 3) provide the appropriate treatments for each illness. Educational Methods: This module utilized the flipped classroom model of education for independent learning, along with small group discussion as the in-class active learning strategy. Learners independently completed pre-assigned readings and questions based on the readings. In didactics sessions, learners created an infographic of each of the tickborne illnesses. Each infographic was shared with the entire group in the final 30 minutes of the didactic session. Research Methods: Each learner completed a pre-test prior to receiving the educational preparatory materials. At the end of the session, participants completed a post-test, a Likert scale survey to evaluate the program, and a free text box to provide qualitative feedback on the session. Efficacy of the education content was determined by post-test scores. Results: Unfortunately, the pre-test file was corrupted by a virus and inaccessible, resulting in no comparison data. A post-course test of 4 questions and a Likert scale evaluation was completed by 22 participants. 72.7% of the participants felt the session increased his/her knowledge on the topic, and 59% enjoyed the format of the session. Fifty-percent of the participants missed zero post-course test questions, 27% missed one question, and 22% missed two or more questions. Comments for improvement suggested a better explanation on the use of software to create the infographics. The post-course test and evaluation suggest the session achieved positive Kirkpatrick levels I and II of evaluation, was effective, and the objectives were met. Based on comments for improvement, information on the infographic software should be provided ahead of the session. This session has become a regular part of our 18-month residency didactic curriculum.

Audience: This procedure training model is designed for all levels of emergency medicine residents. Background: Pericardiocentesis is a relatively uncommon but potentially life-saving procedure within the scope of Emergency Medicine practice. As such, the Accreditation Council for Graduate Medical Education (ACGME) designates its competency as a requirement within emergency medicine residency programs. Because of its relative rarity, simulation-based training is often utilized to fill the gaps in clinical experience during emergency medicine residency training. There have been several models of pericardiocentesis training, including gel-based models that can be purchased or constructed, 1-3 non-gel models, 4 and cadaveric models. 5 In this paper, we describe the fabrication of a high-fidelity cadaveric model and report emergency medicine resident experience with this model. Training programs can use this model to increase trainee competence and confidence with this high-acuity, low-frequency procedure. Educational Objectives: By the end of this session, residents will gain increased procedural competence and confidence with pericardiocentesis. Residents will be able to identify necessary supplies for the procedure, identify relevant surface anatomy and ultrasound views, and successfully aspirate fluid from model effusion. Educational Methods: We created a pericardial effusion in a soft prep cadaver by placing a catheter into the pericardial sac and then infusing normal saline via intravenous fluid tubing. Learners were then able to practice aspiration of pericardial fluid via landmark and ultrasound-guided approaches under observation by facilitators able to offer real-time feedback.