Emergency Medicine Attending Physicians Research Articles

Modification of an Airway Training Mannequin to Teach Engagement of the Hyoepiglottic Ligament.

This airway trainer modification is designed to instruct all levels of training in emergency medicine in order to familiarize trainees with airway anatomy and obtain superior views of the glottic inlet. During intubation with a standard geometry laryngoscope, such as the Macintosh blade, placement of the distal end of the blade within the vallecula and engagement of the median glossoepiglottic fold, also referred to as the midline vallecular fold (MVF), has long been championed by experts in airway management for its ability to improve glottic inlet visualization. This notion was further supported by the recent publication of a retrospective video review by Driver et al.1 Unfortunately, airway anatomy, including engagement of the MVF, does not receive the emphasis it deserves during intubation training of emergency medicine residents. Emergency physicians often have limited time to perform complete airway examinations, but a sound recognition and appreciation of the laryngeal inlet can serve as a roadmap to optimal laryngoscopy.2Recent advancements in airway education emphasize visualization of airway anatomy with review of video laryngoscopy (VL) recordings to identify routine VL errors in vallecula manipulation, such as failure to engage the MVF. 3 Simulation can continue to play an essential role in enhancing trainees' airway skills. Current airway trainers lack functional fidelity components, such an engageable MVF, resulting in a missed opportunity to teach airway skills and anatomy in a safe and controlled setting.4, 5 To address these concerns, we modified an existing airway task trainer with the addition of a simulated MVF to expose trainees to airway anatomy and adequate MVF engagement resulting in epiglottic elevation. By the end of this education session, participants should be able to:Identify relevant airway anatomy during intubation, including base of the tongue, epiglottis, midline vallecular fold, anterior arytenoids.Appreciate the value of a stepwise anatomically guided approach to intubation.Become familiar with the midline vallecular fold and underlying anatomy, including the hyoepiglottic ligament, and how proper placement of the laryngoscope can result in improved glottic visualization. The TrueCorp AirSim airway task trainer was modified with the addition of a simulated MVF. Prior to the modification described here, there were no dynamic trainers with the functional fidelity needed to teach trainees how to engage the MVF with proper placement of the distal tip of the laryngoscope. Once the trainer was created, learners are introduced to relevant anatomy through the initial lecture to unsure baseline knowledge. During the lecture, videos and images are reviewed to demonstrate the importance of an anatomical roadmap to successful intubation. Learners then practiced with the modified task trainer to gain hands-on experience with laryngoscope placement and improved glottic visualization. A short verbal debriefing was performed at the end of the skills session to address any remaining questions. Pre- and post-simulation surveys were completed by attendees of a weekly didactic session, ranging from medical students, PGY 1-4 emergency medicine residents, and emergency medicine attending physicians. Pre- and post-simulation familiarity with airway anatomy and comfortability with MVF engagement was assessed using a 5-point Likert scale. Twenty-six participants ranging from medical students to attending physicians completed a pre- and post-simulation survey. Overall, feedback from leaners was positive. Learners were excited to learn new airway management techniques and requested an expansion of current airway curriculum based on the success of this implementation. This modified task trainer places an emphasis on teaching airway anatomy to trainees with the addition of functional fidelity by adding an engageable element providing the trainee with feedback on successful placement of the laryngoscope. This simple and cost-effective modification can add value to existing airway management curriculums by serving as a visual cue of airway anatomy and instructing trainees on proper placement of the laryngoscope. Our results showed participants experienced increased comfort with airway anatomy recognition and engagement of MVF for difficult intubations. Participants found the trainer effective with the simulated MVF resulting in glottic elevation and recommended this for future simulation. Participants were eager to learn additional airway techniques to improve their laryngoscopy skills, suggesting an area of growth for emergency medicine didactic curriculums. Airway, midline vallecular fold, anatomy, difficult airway, education.

"I am the doctor": gender-based bias within the clinical practice of emergency medicine in Canada-a thematic analysis of physician and trainee interview data.

While women comprise about half of current Canadian medical students and physicians, only 31% of emergency medicine physicians identify as women and women trainees are less likely to express interest in emergency medicine compared to men. Gender-based bias continues to negatively impact the career choice, progress, and well-being of women physicians/trainees. Although instances of gender-based bias are well documented within other medical specialties, there remains a gap in the literature addressing the role of gender specific to the Canadian emergency medicine clinical environment. Using a qualitative study with a thematic analytical approach, participants were purposively and snowball sampled from a cross-section of centers across Canada and included emergency medicine attending physicians and trainees. A thematic analysis using an inductive and deductive approach was undertaken. All data were double coded to improve study trustworthiness. Descriptive statistics were used to characterize the study population. Thirty-four individuals (17 woman-identifying and 17 man-identifying) from 10 different institutions across 4 provinces in Canada participated in the study. Six themes were identified: (1) women experience gender bias in the form of microaggressions; (2) women experience imposter syndrome and question their role in the clinical setting; (3) more women provide patient care to women patients and vulnerable populations; (4) gender-related challenges with family planning and home responsibilities affect work-life balance; (5) allyship and sponsorship are important for the support and development of women physicians and trainees; and (6) women value discussing shared experiences with other women to debrief situations, find mentorship, and share advice. Gender inequity in emergency medicine affects women-identifying providers at all levels of training across Canada. Described experiences support several avenues to implement change against perceived gender bias that is focused on education, policy, and supportive spaces. We encourage institutions to consider these recommendations to achieve gender-equitable conditions in emergency medicine across Canada.

Comparing Direct and Video Laryngoscopy Skills Between Resident and Attending Emergency Physicians.

Introduction Advances in airway technology, in particular video laryngoscopy, are forcing attending emergency medicine physicians to master and maintain innovative airway skills. This study compares intubation times and other airway outcomes between resident and attending physicians using direct and video laryngoscopy in a mannequin model. Methods Fifty emergency medicine resident and attending physicians were asked to intubate a mannequin, using direct laryngoscopy, a C-MAC standard geometry blade, and a GlideScope hyperangulated blade. Intubation times, intubation success and accuracy, Cormack-Lehane grades, and the physician's opinion of the ease of the intubation were recorded for each intubation. Results Second-year residents had significantly quicker intubation times than attending physicians with all 3 intubation modalities. They also outperformed the interns when using the C-MAC standard geometry blade and had faster intubation times compared to third-year residents using direct laryngoscopy. When using the GlideScope hyperangulated blade, all 3 years of residents had lower intubation times compared to attending physicians and they were more accurate with endotracheal tube placement. Unlike the second-year residents, the third-year residents were not faster at direct laryngoscopy compared to the attending physicians. Conclusion Second-year residents outperformed their resident counterparts and the attending physicians with improved intubation times. Nontraditional intubation techniques associated with the GlideScope hyperangulated blade must be learned, practiced, and maintained by attending physicians, which is reflected in their longer intubation times compared to the residents. In addition, DL skills can deteriorate among resident physicians if they are not used on a regular basis.

Prognostic Performance of Bedside Lung Ultrasound Score (LUSS) and ROX Index in Hypoxemic Respiratory Failure Due to COVID-19

Background: Noninvasive ventilation, mainly helmet CPAP, was widely used during the COVID-19 pandemic, even outside of intensive care units. Both the ROX index and the LUS score (LUSS) have been proposed as tools to predict negative outcomes in patients with hypoxemia treated with noninvasive ventilation (NIV) outside of ICUs. We aim to evaluate whether the combination of LUSS with the ROX index improves the predictive performance of these indices in patients with hypoxemia due to COVID-19 pneumonia, treated with NIV outside of ICUs. Methods: This is a monocentric prospective observational study conducted at the university teaching hospital Fondazione IRCCS San Gerardo dei Tintori (Monza, Italy) from February to April 2021. LUSS and ROX were collected at the same time in noninvasively ventilated patients outside of the ICU. An LUS exam was performed by 3 emergency medicine attending physicians with at least 5 years' experience in point-of-care ultrasonography using a 12-zone system. To evaluate the accuracy of the prognostic indices in predicting a composite outcome (endotracheal intubation and mortality), ROC curves were used. A logistic multivariable model was used to explore the predictors of the composite outcome of endotracheal intubation and in-hospital mortality. An unadjusted Kaplan-Meier analysis was used to explore the association with the composite outcome of survival without invasive mechanical ventilation at the 30-day follow-up by stratifying the 3 indices by their best cut-offs. Results: A total of 79 patients were included in the statistical analysis and stratified into 2 groups based on the presence of a negative outcome, which was reported in 24 patients out of 79 (30%). A great proportion of patients (66 patients-84%) were treated with helmet CPAP. All three indices (LUSS, ROX and LUSS/ROX) were independently associated with negative outcomes in the multivariable analyses. Although the comparison between the AUROC of LUSS or ROX versus LUSS/ROX did not reveal a statistically significant difference, we observed a trend toward a higher accuracy for predicting negative outcomes using the LUSS/ROX index as compared to using LUSS. With the Kaplan-Maier approach, all three indices stratified by the best cut-off reported a significant association with the outcome of 30-day survival without mechanical ventilation. Conclusions: A multimodal noninvasive approach that combines ultrasound (i.e., LUSS) and a bedside clinical evaluation (i.e., the ROX index) may help clinicians to predict outcomes and to identify patients who would benefit the most from invasive respiratory support.

Coaching the coach: A randomized controlled study of a novel curriculum for procedural coaching during intubation.

Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation. Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis. Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice. This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice.

If the machine says "Normal" on the ECG, can I put the patient in the waiting room?: a study on the reliability of ECG software classification

Background: Electrocardiograms (ECGs) are one of the most basic and fundamental screening tools used in the emergency department (ED). Previous studies have shown machine diagnosis of ECG to be unreliable, the ECG machine does provide a simpler classification of: 1- Normal, 2- Otherwise normal, 3- Borderline, and 4- Abnormal printed on the ECG. We aim to investigate if machine classification could be used reliably as a screening test for triage. Methods: This cross-sectional study was conducted from 1 to 14 June 2019 of ED at King Abdullah Medical Complex using electronic medical records. The ECGs were put into sets of 25 traces/set and then presented to 21 board-certified emergency medicine attending physicians (EMPs) to assess and decide on one of the actions: Put in the waiting area, see in triage, or admit immediately. The responses were analyzed for inter-subject correlation coefficient kappa (k). Results: Of the 3,149 patients, 452 had ECGs done from which 200 ECGs were chosen at random. The inter-subject correlation coefficient was found to be 0.315 ± 0.187 denoting a fair to moderate correlation. From the ECG traces classified as "Normal" by the ECG machine, only 46% ended up in the waiting room. While almost 15% were admitted immediately to an ED bed. In contrast, 27% of those labeled as "Abnormal" ended up in the waiting room, while 44% were admitted to an ED bed. Conclusion: The machine classification of the ECG traces unfortunately failed remarkably to predict the EMP's decision. As such, the assessment of the attending EMP remains a necessary and essential part of the assessment.

Gender Differences in Emergency Medicine Attending Physician Comments to Residents: A Qualitative Analysis

Prior studies have revealed gender differences in the milestone and clinical competency committee assessment of emergency medicine (EM) residents. To explore gender disparities and the reasons for such disparities in the narrative comments from EM attending physicians to EM residents. This multicenter qualitative analysis examined 10 488 narrative comments among EM faculty and EM residents between 2015 to 2018 in 5 EM training programs in the US. Data were analyzed from 2019 to 2021. Differences in narrative comments by gender and study site. Qualitative analysis included deidentification and iterative coding of the data set using an axial coding approach, with double coding of 20% of the comments at random to assess intercoder reliability (κ, 0.84). The authors reviewed the unmasked coded data set to identify emerging themes. Summary statistics were calculated for the number of narrative comments and their coded themes by gender and study site. χ2 tests were used to determine differences in the proportion of narrative comments by gender of faculty and resident. In this study of 283 EM residents, of whom 113 (40%) identified as women, and 277 EM attending physicians, of whom 95 (34%) identified as women, there were notable gender differences in the content of the narrative comments from faculty to residents. Men faculty, compared with women faculty, were more likely to provide either nonspecific comments (115 of 182 [63.2%] vs 40 of 95 [42.1%]), or no comments (3387 of 10 496 [32.3%] vs 1169 of 4548 [25.7%]; P < .001) to men and women residents. Compared with men residents, more women residents were told that they were performing below level by men and women faculty (36 of 113 [31.9%] vs 43 of 170 [25.3%]), with the most common theme including lack of confidence with procedural skills. In this qualitative study of narrative comments provided by EM attending physicians to residents, multiple modifiable contributors to gender disparities in assessment were identified, including the presence, content, and specificity of comments. Among women residents, procedural competency was associated with being conflated with procedural confidence. These findings can inform interventions to improve parity in assessment across graduate medical education.

238 A Comparison of Sengstaken-Blakemore Tube Insertion Performance Between Academic Emergency Medicine Attending and Resident Physicians

Sengstaken-Blakemore (SB) tube insertion is a rare but potentially life-saving skill used to manage emergent upper gastrointestinal bleeding. Although SB tube insertion is part of the emergency medicine (EM) curriculum, no widespread, objective standard exists to ensure competency. Moreover, practicing physicians have infrequent opportunities for application in the clinical environment. Therefore, variable skills in placing an SB tube may be observed. Our primary objective was to compare SB tube insertion performance between academic EM attending and resident physicians.

160 Emergency Medicine Attending Physician Performance of Pigtail and Thoracostomy Tube Insertion in a Simulated Environment

Emerging evidence suggests that attending physicians demonstrate variable performance of some bedside procedures. The primary objective of this study was to assess emergency medicine attending physician performance of pigtail and tube thoracostomy insertion in a simulated environment. Secondary objectives were to evaluate: 1) if a simulation-based mastery learning intervention improved performance, and 2) for potential correlations between baseline performance and participant comfort level or recent reported clinical experience.

Improving Compliance with the CMS SEP-1 Sepsis Bundle at a Community-Based Teaching Hospital Emergency Department.

INTRODUCTIONThe Centers for Medicare & Medicaid Services (CMS) designed Hospital Quality Initiatives (HQI) to assure delivery of quality health care for institutions receiving Medicare payments. Like many teaching institutions, the SEP-1 compliance rates at McLaren Oakland in Pontiac fluctuated monthly and were not achieving institutional target expectations.METHODSThe project team designed a Sepsis Macro and a Sepsis Order Set in the electronic medical record system. The project team also implemented an educational initiative targeted at emergency medicine resident and attending physicians. The educational initiative instructed emergency medicine resident and attending physicians in the metrics measured in the SEP-1 bundle as well as how to properly use the newly designed Sepsis Macro and Sepsis Order Set.RESULTSAfter implementation of the Sepsis Macro and Sepsis Order Set, the overall compliance with the SEP-1 bundle improved from 57% to 62%, above national averages and at the institutional target expectations. However, there were not statistically significant differences (p = 0.562) between the compliance rate before and after program implementation (Pre = 57% (SD = 0.27); 95% CI: 0.29 - 0.85); Post= 62% (SD = 0.11); 95% CI: 0.55 - 0.70). After program implementation the SEP-1 compliance rate was met in 82% of the months in comparison with 50% of the months in the pre-intervention (p = 0.28).CONCLUSIONSAlthough not achieving statistical significance, this intervention demonstrated that simple, cost-effective measures of education and standardization in documentation and order entry in EMR’s can improve clinically significant compliance to CMS HQI metrics in community-based teaching institutions.

Interrater agreement of the HEART score history component: A chart review study.

Study objectivesThis study investigated the interrater reliability of the history component of the HEART (history, electrocardiogram, age, risk, troponin) score between physicians in emergency medicine (EM) and internal medicine (IM) at 1 tertiary‐care center.MethodsWe conducted a retrospective, secondary analysis of 60 encounters selected randomly from a database of 417 patients with chest pain presenting from January to June 2016 to an urban tertiary‐care center. A total of 4 raters (1 EM attending, 1 EM resident, 1 IM attending, and 1 IM resident) scored the previously abstracted history data from these encounters.The primary outcome was the interrater agreement of HEART score history components, as measured by kappa coefficient, between EM and IM attending physicians. Secondary outcomes included the agreement between attending and resident physicians, overall agreement, pairwise percent agreement, and differences in scores assigned.ResultsThe kappa value for the EM attending physician and IM attending physician was 0.33 with 55% agreement. Interrater agreement of the other pairs was substantial between EM attending and resident but was otherwise fair to moderate. Percent agreement between the other pairs ranged from 48.3% to 80%. There was a significant difference in scores assigned and the subgroup in which there was disagreement between the raters demonstrated significantly higher scores by the EM attending and resident when compared to the IM attending.ConclusionThis study demonstrates fair agreement between EM and IM attending physicians in the history component of the HEART score with significantly higher scores by the EM attending physician in cases of disagreement at 1 tertiary‐care center.

An exploratory investigation of the measurement of cognitive load on shift: Application of cognitive load theory in emergency medicine.

Emergency physicians often experience a high cognitive load (CL) due to the inherent nature of working in acute care settings. CL has traditionally been measured in educational studies but has not been well studied in the clinical environment. Emergency medicine attending physicians and residents working in an academic urgent care center completed psychometric questionnaires while on shift to measure overall CL, intrinsic cognitive load (ICL), extraneous cognitive load (ECL), and acute stress. Data regarding the patient load, patient acuity, and the number of patients in the waiting room were also collected. Correlational analysis and simple linear regression were used to evaluate predictors of CL on shift. Forty-two questionnaires were completed (26 by attending physicians, 16 by residents). Attending physicians carried a significantly higher patient load compared to residents (p<0.001). No differences in mean overall CL, ICL, ECL, and acute stress were observed between attending physicians and residents. Bivariate analysis demonstrated associations between ICL, ECL, acute stress, and overall CL in attending physicians. In residents, acute stress was the only variable associated with overall CL and the number of high-acuity patients was associated with ICL. Factors influencing reported CL during clinical work are different between attending emergency physicians and residents. Further study to appreciate the impact of these differences is required and may help educators elucidate strategies to better manage CL, thereby improving clinical performance and potentially improving patient care.

Procedural Competency in Academic Emergency Medicine Attending Physicians: How Is Competency Maintained and Evaluated by Academic Institutions in the US?

IntroductionThere have been numerous studies examining the minimum graduation requirements for resident training of procedural skills within Emergency Medicine programs; however, how academic medical centers in the United States maintain Emergency Medicine attending procedural skill competency has not been explored.ObjectivesThe aim of this study was to examine the processes in place to evaluate and track the procedural skills practices of Emergency Medicine attending physicians at academic institutions in the US.MethodsAn exploratory cross-sectional survey was sent to all 39 ACGME-accredited Emergency Medicine programs in the US through a REDCap survey in 2020. Survey items inquired about the current methods in place to maintain competence on 13 procedural skills performed by Emergency Medicine providers.ResultsThe survey response rate was 26.9%. The majority of programs did not have a process in place to evaluate procedural skills at the time of initial appointment (74.3%), and almost half of participating programs reported no formalized process during employment (51.3%). Institutions reported no minimum required number for the following procedures: dislocation reduction, intraosseous placement, lateral canthotomy, lumbar puncture, paracentesis, pericardiocentesis, thoracentesis, transvenous cardiac pacing, and tube thoracostomy. For central venous access, cricothyrotomy, endotracheal intubation, and procedural sedation, 25.6% or less of institutions had minimum annual requirements.ConclusionThis study summarized the current methods in place to assess Emergency Medicine attending procedural skills at US academic institutions and demonstrated that the majority of programs lack a formalized method to assess attending procedural competency. Further research is needed to determine the value and benefit of different methods available for procedural skill competency assessment. It is believed that preventing procedural skill decay in attending physicians by a standardized process has the potential to improve patient outcomes, reduce costs and complication rates, and improve physician self-esteem, well-being, and confidence.

Rapid Dissemination of a COVID-19 Airway Management Simulation Using a Train-the-Trainers Curriculum.

The most effective way to train clinicians to safely don and doff personal protective equipment (PPE) and perform aerosol-generating procedures (AGPs), such as intubations, is unknown when clinician educators are unavailable, as they have been during the COVID-19 pandemic. Proper PPE and airway management techniques are critical to prevent the transmission of respiratory illnesses such as COVID-19. In March 2020, the authors implemented a structured train-the-trainers curriculum to teach PPE techniques and a modified airway management algorithm for suspected COVID-19 patients. A single emergency medicine physician trainer taught 17 subsequent emergency medicine and critical care physician trainers the proper PPE and airway management techniques. The initial trainer and 7 of the subsequent trainers then instructed 99 other emergency medicine resident and attending physicians using in situ simulation. Trainers and learners completed retrospective pre-post surveys to assess their comfort teaching the material and performing the techniques, respectively. The surveys demonstrated a significant increase in the trainers' comfort in teaching simulation-based education, from 4.00 to 4.53 on a 5-point Likert scale (P < .005), and in teaching the airway management techniques through simulation, from 2.47 to 4.47 (P < .001). There was no difference in the change in comfort level between those learners who were taught by the initial trainer and those who were taught by the subsequent trainers. These results suggest that the subsequent trainers were as effective in teaching the simulation material as the initial trainer. Work is ongoing to investigate clinician- and patient-specific outcomes, including PPE adherence, appropriate AGP performance, complication rate, and learners' skill retention. Future work will focus on implementing similar train-the-trainers strategies for other health professions, specialties, and high-risk or rare procedures.

Point-of-Care Ultrasound Findings in Multisystem Inflammatory Syndrome in Children: A Cross-Sectional Study.

Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 is a novel pediatric condition with significant morbidity and mortality. The primary objective of this investigation was to describe the point-of-care ultrasound (POCUS) findings in patients evaluated in the emergency department (ED) who were diagnosed with MIS-C. A retrospective cross-sectional study was conducted including patients <21-years-old who had POCUS performed for clinical care in a pediatric ED and were diagnosed with MIS-C. Point-of-care ultrasound studies were performed by pediatric emergency medicine attending physicians or fellows. Data abstracted by chart review included patient demographics, clinical history, physical examination findings, diagnostic test results, the time POCUS studies and echocardiograms were performed, therapies administered, and clinical course after admission. For the 24 patients included, 17 focused cardiac ultrasound, 9 lung POCUS, 7 pediatric modified rapid ultrasound for shock and hypotension, 1 focused assessment with sonography for trauma, 1 POCUS for suspected appendicitis, and 1 ocular POCUS were performed by 13 physicians. Point-of-care ultrasound identified impaired cardiac contractility in 5 patients, large intraperitoneal free fluid with inflamed bowel in 1 patient, and increased optic nerve sheath diameters with elevation of the optic discs in 1 patient. Trace or small pericardial effusions, pleural effusions, and intraperitoneal free fluid were seen in 3 patients, 6 patients, and 4 patients, respectively. This study demonstrates the spectrum of POCUS findings in MIS-C. Prospective studies are needed to help delineate the utility of incorporating POCUS into an ED management pathway for patients with suspected MIS-C.

Barriers to point-of-care ultrasound utilization during cardiac arrest in the emergency department: a regional survey of emergency physicians.

Though point-of-care ultrasound (POCUS) is recognized as a useful diagnostic and prognostic intervention during cardiac arrest (CA), critics advise caution. The purpose of this survey study was to determine the barriers to POCUS during CA in the Emergency Department (ED). Two survey instruments were distributed to emergency medicine (EM) attending and resident physicians at three academic centers in the South Florida. The surveys assessed demographics, experience, proficiency, attitudes and barriers. Descriptive and inferential statistics along with Item Response Theory Logistic Model and the Friedman Test with Wilcoxon Signed Rank tests were used to profile responses and rank barriers. 206 EM physicians were invited to participate in the survey, and 187 (91%) responded. 59% of attending physicians and 47% of resident physicians reported that POCUS is performed in all their cases of CA. 5% of attending physicians and 0% of resident physicians reported never performing POCUS during CA. The top-ranked departmental barrier for attending physicians was "No structured curriculum to educate physicians on POCUS." The top-ranked personal barriers were "I do not feel comfortable with my POCUS skills" and "I do not have sufficient time to dedicate to learning POCUS." The top-ranked barriers for resident physicians were "Time to retrieve and operate the machine" and "Chaotic milieu." While our study demonstrates that most attending and resident physicians utilize POCUS in CA, barriers to high-quality implementation exist. Top attending physician barriers relate to POCUS education, while the top resident physician barriers relate to logistics and the machines. Interventions to overcome these barriers might lead to optimization of POCUS performance during CA in the ED.

Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study.

Dyspnea is the second leading cause of US emergency department (ED) visits and an independent predictor of morbidity and mortality1 in older adult patients aged ≥65 years. Unfortunately, the diagnosis of the cause of dyspnea presents diagnostic challenges to emergency physicians2-4 that disproportionately affects older adults.5 One in 5 dyspneic older adults experience missed diagnosis in the ED2 and 21% are treated for ≥1 pneumonia, acute exacerbation of chronic obstructive pulmonary disease [COPD], and acute exacerbation of heart failure [HF].5 Importantly, some may have multiple causes of their dyspnea but accurate diagnosis remains critical.

412 A Survey of the Perception of Emergency Medicine Residents and Attending Physicians on the Effect of Sign-Out on Safety and Efficiency

412 A Survey of the Perception of Emergency Medicine Residents and Attending Physicians on the Effect of Sign-Out on Safety and Efficiency

Maxillofacial Trauma Management During COVID-19: Multidisciplinary Recommendations.

Maxillofacial Trauma Management During COVID-19: Multidisciplinary Recommendations.

Entrustable Professional Activities: Do General Surgery Residents Trust Them?

The American Board of Surgery has initiated a pilot study to investigate the incorporation of Entrustable Professional Activities (EPAs) into the training of general surgery residents (GSR). Limited data exist on perception of EPAs by GSR. We aimed to assess the impact of EPAs on GSR for 2 included program topics: inguinal hernia and general surgery consultation. A 21-question, cross-sectional, Likert scale survey was distributed to 64 GSR at an urban university hospital to assess perceptions and apprehensions regarding EPA implementation. The Mann-Whitney U test was used to analyze differences in responses between junior residents (PGY 1-3) and senior residents (PGY 4-5), and by gender of respondent, α = 0.05. Forty-one (64%) GSR completed surveys. Approximately one-half of respondents had "faint to some" knowledge about EPAs. Fifty-seven percent of GSR were "moderately to highly concerned" about being assessed by attending surgeons with whom they did not have a prior relationship. Additionally, concerns were raised about being assessed by attending surgeons who may have observed their patient interaction only in part. Most GSR expressed "little to no concern" about impact of EPAs to potentially increase workload, the view of their program director as to their clinical competency, or American Board of Surgery plans to use collected data. Forty-two percent GSR in PGY 1 to 3 were "moderately to highly" concerned about impact on progression to the next year of residency, whereas senior GSR had "little to no concern." Most GSR (57%) expressed "moderate to high" concern about emergency medicine attending physicians evaluating them. Similar themes regarding EMA evaluation were identified in the comments section of the survey. EPAs are intended to be a major part of GSR's competency-based assessment and advancement. More work needs to be done to alleviate concerns as to who should provide assessments, as well as in defining how EPAs will be used to assess clinical competency.