Introduction: Over 335,000 adults are hospitalized annually for proximal hip fractures, with the incidence of these injuries increasing as the population ages. Our objective in this study was to compare pain scores of patients with proximal hip fracture 30 minutes after undergoing a combined fascia iliaca plus femoral nerve block vs standard fascia iliaca block. Methods: We performed a retrospective cohort study including all isolated proximal hip fracture patients > 18 years of age who underwent regional anesthesia by ultrasound fellowship-trained emergency physicians in a community hospital emergency department between January 1, 2022– September 26, 2024. We excluded patients with distal femur fractures, those who had received additional pain medications within 30 minutes of the block, or those who could not reliably relay a pain score. The primary outcome was subjective pain scores (scale 1-10) after undergoing regional anesthesia. Results: Of 89 patients who underwent regional anesthesia for proximal hip fracture, 20 were excluded. A total of 31 fascia iliaca blocks and 38 combined blocks were performed. Patient age, weight, and pre-procedure pain scores were similar between the groups. Females were more predominant in the fascia iliaca block group (67.7% vs 42.1%; P = .03). On average, patients who received the combined block rated their post-procedure pain score 1.4 points lower than those who received a fascia block (3.8 vs 5.2/10, P = .01). This finding was consistent when controlling for sex and pre-procedure pain scores (β: 1.5; 95% CI, 0.6-2.4). Conclusion: Undergoing combined fascia iliaca plus femoral nerve block was associated with lower pain scores after 30 minutes compared to isolated fascia iliaca block in patients with proximal hip fractures. These patients may benefit from using this single-injection procedure for improved pain control.

Introduction: Non-traumatic headache is a common emergency department (ED) presentation, yet identifying intracranial causes remains challenging in the absence of neurological deficits. In this study we aimed to evaluate the incidence and predictive ability of clinical red flag signs and symptoms for intracranial pathology. Methods: We conducted a prospective, multicenter, cross-sectional study across six academic EDs with residency programs in Türkiye. We enrolled consecutive adult patients with non-traumatic headache and no neurological deficits who had cranial computed tomography (CT) at the discretion of the treating attending physician. Exclusion criteria were recent trauma, pregnancy, fever, hematologic conditions, and known intracranial pathology. We recorded clinical features using standardized forms. The primary outcome was the presence of intracranial pathology confirmed by CT or subsequent diagnosis within a one-month follow-up. Results: Of 1,522 patients, 57 (3.7%, 95% CI, 2.8-4.8) had intracranial pathology; 104 (6.8%) patients could not be reached during the one-month follow-up. The most common diagnoses were subarachnoid hemorrhage (SAH) (n = 20, 35.1%); ischemic stroke (n = 16, 28.1%); subdural hemorrhage (n = 6, 10.5%); and sinus vein thrombosis (n = 6, 10.5%). Both univariate and multivariate analyses identified that headache aggravated by physical activity (OR 5.98; 95% CI, 2.3-15.2) and age > 50 years (OR 3; 95% CI, 1.65-5.5) independently predicted the cause of the headache. For SAH, headache exacerbated by physical activity (OR 18.6; 95% CI, 5.6-62.3), and syncope (OR 5.7; 95% CI, 1.4-24.3) were independent risk factors. Notably, “sudden onset” and “worst headache ever” were not significant predictors of intracranial pathology in this cohort. The prevalence of sudden-onset headache (45%, n = 9, vs 50.3%, n = 753; P = .64) and “worst headache ever” (55%, n = 11, vs 59.4%, n = 890; P = .69) did not differ significantly between patients with and those without SAH. The odds ratios from the multivariable analyses for sudden onset (OR 1.13, 95% CI, 0.4-3.0) and “worst headache ever” (OR 1.38, 95% CI, 0.47-4.0) were not statistically significant for SAH. Conclusion: In ED patients presenting with non-traumatic headache and no focal neurological deficits, headache aggravated by physical activity is a significant indicator for any intracranial pathology causing headache and, specifically, for subarachnoid hemorrhage. While age > 50 years was associated with intracranial pathology causing headache, syncope was specifically linked to subarachnoid hemorrhage. These findings may help refine clinical decision-making for neuroimaging in this patient population.

Introduction: Anemia is common in the emergency department (ED). Physicians often rely on inspecting conjunctival pallor or other body parts for gestalt estimates. We aimed to evaluate the validity and reliability of physician gestalt for anemia detection and examine the impact of clinical experience and incorporating images of multiple body parts on physician gestalt-based anemia detection. Methods: Prospective observational study in the ED at an academic medical center between January–November 2023. Using convenience sampling, we included patients ≥ 18 years with recent laboratory hemoglobin (Hgb) measurements. We used a smartphone to capture the images of the patient’s conjunctiva, palm, and fingernails. Five board-certified attending emergency physicians (two junior, two mid-level, and one senior) reviewed the patient images and provided gestalt predictions of Hgb levels and anemia likelihood on a 1-10 scale. Two pairs of physicians evaluated the same set of patient images to assess reliability. Anemia was defined as Hgb < 13.1 grams per deciliter (g/dL) for men and < 11.0 g/dL for women, according to our laboratory standard. Results: We enrolled a total of 100 patients (mean age 67 years; 45% male). Of these, 59 (59%) had anemia and 41 (41%) did not. The correlation coefficients between physicians’ predicted Hgb levels and actual Hgb levels were only moderate (0.31, 0.41, and 0.40 for junior, mid-level, and senior physicians, respectively; P < .05 for all). Although not statistically significant, the mid-level physicians’ gestalt had the highest area under the receiver operating characteristic curve (0.78), followed by senior- (0.74) and junior physicians (0.72). The impact of incrementally adding images of other body parts to conjunctiva was small (mean changes in anemia likelihood <1 on a 1-10 scale). The agreement on predicted Hgb levels between the paired physicians was high (0.71 for junior physicians, 0.67 for mid-level physicians, P < .001 for both). Conclusion: Physician gestalt demonstrated moderate validity and moderate-to-high reliability for anemia detection. Adding images other than conjunctiva did not improve the performance of physician gestalt. However, the clinical experience did matter slightly in detecting anemia.

Introduction: Effective disaster response in healthcare depends on coordinated strategies that maintain access to critical supplies across institutions. During Hurricane Helene in September 2024, a major intravenous (IV) fluid shortage caused by the destruction of a manufacturing plant exposed the vulnerability of centralized supply chains. Our objective in this study was to evaluate the impact of a multisite IV fluid conservation initiative on ordering patterns, cost, and environmental outcomes across three emergency departments (ED). Methods: We conducted a retrospective study evaluating large-volume, IV fluid-bolus orders placed before, during, and after the critical shortage. Interventions included an interruptive alert in the electronic health record, clinician education, and workflow adjustments. Our primary outcome measure was the number of IV fluid-bolus orders placed during each period. Secondary outcomes included total fluid volume administered, total cost of fluids, estimated carbon dioxide emissions, and the proportion of ED encounters involving fluid administration. Results: During the pre-shortage period, 24,251 IV fluid-bolus orders were placed across 41,752 ED encounters (41.8%). Orders dropped to 18,692 during the critical shortage across 39,840 encounters (30.8%), reflecting a 22.9% relative reduction. In the post-shortage period, 23,911 orders were placed across 40,967 encounters (39.6%), remaining slightly below baseline. Estimated cost savings during the shortage period totaled $27,202, with a projected annual savings of $108,808. Carbon dioxide emissions dropped by 3.1 metric tons—the equivalent of avoiding the use of over 349 gallons of gasoline. Conclusion: Emergency department-based conservation strategies were associated with measurable reductions in IV fluid use, cost, and environmental impact. Further validation is needed to understand their impact on clinical outcomes and healthcare system resilience.

Introduction: The concept of commensality, the act of eating together, is as old as humanity and has been extensively explored in the social sciences and humanities. We sought to assess whether an interdepartmental commensality program would improve cross-departmental familiarity, willingness to engage in scholarly discussions, and enhance collaborative efforts. Methods: A program was established to arrange dinners for emergency department (ED) faculty with six other departments, after which participants were surveyed about their thoughts on the dinner’s impact. Our primary outcome measure was change in perceived familiarity with interdepartmental colleagues. Secondary outcomes included willingness to engage in academic discussion and perceived likelihood of future collaboration. A program was established to arrange dinners between the ED and six other departments (obstetrics and gynecology, neurology, psychiatry, internal medicine, otolaryngology, and ophthalmology), followed by a post-event survey. Results: A total of 55 of 81 participants responded to the survey (response rate 67.9%). We found significant increases in familiarity with colleagues (2 pre- to 4/5 post-intervention, P < .001), willingness to discuss academic issues (4 to 5/5, P < .001), and anticipated collaborations (2 to 5/5, P < .001). Conclusion: An interdepartmental commensality program initiated by an institution’s department of emergency medicine can potentially improve interdepartmental collaboration, familiarity, and discussions.

Introduction: Early recognition and referral are critical to minimizing morbidity and mortality in acute stroke, but evaluation and referral processes differ worldwide. In this systematic review we examined the accuracy of recognition tools, referral patterns, outcomes, and factors affecting efficiency in primary and emergency care settings. Methods: Following PRISMA 2020 guidelines, we searched PubMed, Scopus, Web of Science, and Cochrane Library for studies published January 2003–December 2025. Eligible studies included randomized controlled trials, cohort, case-control, cross-sectional, and large case series (> 30 patients) involving adults with acute ischemic or hemorrhagic stroke. Risk of bias was assessed using Cochrane Risk-of-Bias 2 (RoB) and RoB in non-standardized studies-I. We extracted data on diagnostic accuracy, referral pathways, outcomes, and systemic factors. Results: We identified 206 papers, of which 33 studies met our inclusion criteria. Recognition tools such as Face, Arms, Speech, Time (FAST); Recognition of Stroke in the Emergency Room, the Cincinnati Prehospital Stroke Scale, and National Institutes of Health Stroke Scale showed good pooled sensitivity (79-95%) but variable specificity (52-84%). Newer technologies, including the PreHospital Ambulance Stroke Test, FAST-ED, and artificial intelligence (AI)-based models, showed promise but need validation. Referral strategies such as emergency medical services prenotification, dispatcher triage, and mobile stroke units reduced prehospital delays. Seven studies reported onset-to-door times 12-22 minutes faster and 7-12% increase in reperfusion eligibility. Increased referral efficiency was associated with a reduction in mortality of approximately 8-12% and improvements in functional independence of 10-15%, with persistent disparities reported in resource-limited settings. Conclusion: Early recognition and referral improve outcomes in patients with acute stroke. Structured tools and system-level interventions reduce mortality, while AI and mobile stroke units show promise. Strengthening referral systems and adopting cost-effective triage strategies may support equitable implementation, particularly in low-resource settings, as addressing systemic and geographic barriers is critical for equitable stroke care.

Introduction: The Standardized Letter of Evaluation (SLOE) is a core component of emergency medicine (EM) residency applications, designed to assess clinical performance, professionalism, and leadership potential. While its utility in selecting residency candidates is well established, its association with future leadership roles, such as chief resident, remains unclear. Identifying early indicators of leadership potential could inform both recruitment and resident development efforts. In this study we aimed to evaluate whether medical students’ SLOEs are associated with subsequent selection as chief residents, offering insight into the SLOE’s potential to forecast future leadership within EM. Methods: We conducted a retrospective review of 243 de-identified SLOEs from 101 residents at a single urban, academic EM residency program between 2015–2021; 21 residents (20.8%) went on to hold chief resident roles between 2018–2024. The SLOEs were numerically scored across 10 groups. We excluded SLOEs lacking quantitative ratings or written for non-core EM rotations. Results: Chief residents scored significantly higher than non-chief residents in three of 10 evaluated domains following Bonferroni correction for multiple comparisons: teamwork (P = .002), overall comparison to EM applicants from prior years (P = .003), and anticipated rank-list placement (P = .004). No significant differences were found in domains such as clinical reasoning, communication skills, or commitment to EM. Sex distribution among chief residents was approximately equal, minimizing concerns for confounding. Conclusion: The Standardized Letter of Evaluation may offer limited but meaningful insight into future leadership potential in EM. Traits such as teamwork, self-directed learning, and perceived autonomy may distinguish future chief residents even prior to matriculation. However, traditional academic indicators alone may not identify those who ultimately assume leadership roles. These findings underscore the need for structured leadership development opportunities for all residents, regardless of early SLOE evaluations. Future research should explore whether intentional cultivation of leadership competencies throughout training can better support residents in achieving roles such as chief resident and beyond.

Introduction: Among ED visits, presentation for a non-traumatic dental condition represents one of the most preventable, as 79% of these visits are considered avoidable. Our goal was to investigate the association between individual-level socioeconomic status (SES) and emergency department (ED) use for non-traumatic dental conditions. Methods: In this retrospective, pooled cross-sectional analysis we used data from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The sample included adults (≥ 18) who presented to the ED between 2017-2021 and had complete data on SES indicators (ie, income, education level, net worth, homeownership, and low-income subsidy status). The primary outcome was ED use for non-traumatic dental conditions, identified via International Classification of Diseases diagnosis codes. We used multivariate logistic regression models with marginal effects to examine the relationship between SES and ED visits, adjusted for demographics, geographic region, and disease burden. Results: Among 3,894,785 individuals, 74,685 (1.9%) had an ED visit related to non-traumatic dental conditions. Lower SES was significantly associated with increased ED visits for these conditions, with income exhibiting the strongest effect. Compared to individuals earning > $100,000 annually, those earning < $40,000 were 0.7 percentage points (1.5% vs 2.2%) more likely to visit the ED for non-traumatic dental conditions (P < .001). A dose-dependent effect was observed for the composite SES score, with individuals in the lowest SES quartile 1.3 percentage points (1.3% vs 2.6%) more likely to visit the ED compared to the highest quartile (P < .001). Conclusion: Lower socioeconomic status is associated with higher ED use for non-traumatic dental conditions, underscoring disparities in oral healthcare access. Targeted policy interventions and better integration of oral and medical healthcare systems are needed to reduce preventable ED visits.

Introduction: Gender and sex equity-promoting (GSEP) clinical research is essential to improving diversity and inclusivity in medicine. In this study we aimed to compare journal impact metrics in emergency medicine (EM) between journals that integrated gender- and sex-based considerations and those that did not. Methods: We searched the 2023 Journal Citations Report (Clarivate Analytics) for EM journals. Submission guidelines of each EM journal were examined according to the SAGER (Sex and Gender Equity in Research) guidelines and stratified as conforming or non-conforming depending on whether at least one SAGER criterion was met. Our primary outcome measure was the journal impact factor. Secondary outcome measures included other citation and influence metrics: total citations; 5-year journal impact factor; journal citation indicator; article influence score, normalized Eigenfactor score; citable items; total articles; and immediacy index. Results: Based on our classification system informed by the SAGER criteria, most journals (66%, 31/47) were classified as non-compliant. The EM journals that conformed to the sex and gender equity guidelines were rated higher than non-conforming journals across all studied journal metrics. We found that conforming journals had a significantly higher median difference (MD) than non-conforming EM journals in total citations (MD 1,586; GSEP: 3,599 vs non-GSEP: 901); 2023 2-year journal impact factor (MD 0.8; 2.3 vs 1.4); 5-year journal impact factor (MD 0.7; 2.5 vs 1.9); article influence score (MD 0.26; 0.76 vs 0.47); normalized Eigenfactor score (MD 0.79; 1.06 vs 0.26); citable items (MD 37; 103 vs 56), and total articles (MD 41; 87 vs 42). All differences were statistically significant (P < 0.05). Conclusion: Using criteria informed by the Sex and Gender Equity in Research guidelines, most EM journals (66%) were classified as non-conforming to these guidelines. This indicates a significant gap in the integration of gender- and sex-based considerations in EM research publication practices.