Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Chest pain is the second most common chief complaint for patients undergoing evaluation in emergency departments (ED) in the United States. The American Heart Association recommends immediate physician interpretation of all electrocardiograms (ECG) performed for adults with chest pain within 10 minutes to evaluate for the finding of ST-elevation myocardial infarction (STEMI). The ECG machines provide computerized interpretation of each ECG, potentially obviating the need for immediate physician analysis; however, the reliability of computer-interpreted findings of “normal” or “otherwise normal” ECG to rule out STEMI requiring immediate intervention in the ED is unknown.

Methods: We performed a prospective cohort analysis of 2,275 ECGs performed in triage in the adult ED of a single academic medical center, comparing the computerized interpretations of “normal” and“otherwise normal” ECGs to those of attending cardiologists. ECGs were obtained with a GE MAC 5500 machine and interpreted using Marquette 12SL.

Results: In our study population, a triage ECG with a computerized interpretation of “normal” or “otherwise normal” ECG had a negative predictive value of 100% for STEMI (one-sided, lower 97.5% confidence interval 99.6%). None of the studied patients with these ECG interpretations had a final diagnosis of STEMI, acute coronary syndrome, or other diagnosis requiring emergent cardiac catheterization.

Conclusion: In our study population, ECG machine interpretations of “normal” or “otherwise normal” ECG excluded findings of STEMI. The ECGs with these computerized interpretations could safely wait for physician interpretation until the time of patient evaluation without delaying an acute STEMI diagnosis.

Introduction: Identification of patients not meeting catheterization laboratory activation criteria by electrocardiogram (ECG) but who would benefit from early coronary intervention remains challenging in the emergency department (ED). The purpose of this study was to evaluate whether emergency physician (EP)-performed point-of-care transthoracic echocardiography (POC TTE) could help identify patients who required coronary intervention within this population.

Methods: This was a retrospective observational cohort study of adult patients who presented to two EDs between 2018–2020. Patients were included if they received a POC TTE and underwent diagnostic coronary angiography within 72 hours of ED presentation. We excluded patients meeting catheterization laboratory activation criteria on initial ED ECG. Ultrasound studies were independently reviewed for presence of regional wall motion abnormalities (RWMA) by two blinded ultrasound fellowship-trained EPs. We then calculated test characteristics for coronary intervention.

Results: Of the 221 patient encounters meeting inclusion criteria, 104 (47%) received coronary intervention or coronary artery bypass grafting (CABG) referral. Overall prevalence of RWMA on POC TTE was 35% (95% confidence interval [CI] 29–42%). Presence of RWMA had 38% (95% CI 29–49%) sensitivity and 68% (95% CI 58–76%) specificity for coronary intervention/CABG referral. Presence of “new” RWMA (presence on EP-performed POC TTE and prior normal echocardiogram) had 43% (95%CI 10–82%) sensitivity and 93% (95% CI 66–100%) specificity for coronary intervention/CABG referral. The EP-performed POC TTE interpretation of RWMA had 57% (95% CI 47–67%) sensitivity and 96%(95% CI 87–100%) specificity for presence of RWMA on subsequent cardiology echocardiogram during the same admission.

Conclusion: Presence of RWMA on EP-performed POC TTE had limited sensitivity or specificity for coronary intervention or referral to CABG. The observed specificity appeared to trend higher in subjects with a prior echocardiogram demonstrating absence of RWMA, although a larger sample size will be required to confirm this finding. The EP-performed POC TTE RWMA had high specificity for presence of RWMA on subsequent cardiology echocardiogram. Further evaluation of the diagnostic performance of new RWMA on EP-performed POC TTE with a dedicated cohort is warranted.

Background: Providing adequate paralysis and appropriate sedation is challenging in patients with obesity during rapid sequence intubation (RSI). Pharmacokinetic parameters play an important role in dosing of rocuronium due to low lipophilicity. Rocuronium may be dosed based on ideal body weight (IBW). Current guidelines do not offer recommendations for dosing in the setting of obesity. Dosing depends on clinician preference based on total body weight (TBW) or IBW.

Objectives: In this study we performed non-inferiority analysis to compare the intubation conditions, duration of paralysis, and incidence of new-onset tachycardia or hypertension after intubation in obese patients requiring RSI in the emergency department (ED).

Methods: This was a single-center, prospective, observational study. Eligible for enrollment were adultpatients with a TBW ≥30% IBW or body mass index ≥30 kilograms per meters squared who presented to the ED requiring RSI with the use of rocuronium. Rocuronium was dosed according to intubating physicians’ preference. Physicians completed a survey assessing intubation conditions. Height and weight used for the calculation of the dose, the dose of rocuronium, time of administration, and time of muscle function recovery were recorded. Endpoints assessed included grading of view during laryngoscopy, first-past success, and duration of paralysis.

Results: In total, 96 patients were included, 54 in TBW and 42 in IBW. The TBW cohort received a mean of 1 milligram per kilogram (mg/kg) compared to 0.71 mg/kg in the IBW group. Excellent intubation conditions were observed in 68.5% in the TBW group and 73.8% in the IBW group. The non-inferiority analysis for relative risk of excellent intubation was 1.12 (P = 0.12, [90% CI 0.80–1.50]).

Conclusion: Non-inferiority analysis suggests that IBW dosing provides similar optimal intubation conditions when compared to TBW dosing, but the noninferiority comparison did not reach statistical significance. This study was unable to show statistical non-inferiority for IBW dosing.

Introduction: The point-of-care lung ultrasound (LUS) score has been used in coronavirus 2019 (COVID-19) patients for diagnosis and risk stratification, due to excellent sensitivity and infection control concerns. We studied the ratio of partial pressure of oxygen in arterial blood to the fraction of inspiratory oxygen concentration (PO2/FiO2), intubation rates, and mortality correlation to the LUS score.

Methods: We conducted a systematic review using PRISMA guidelines. Included were articles published from December 1, 2019–November 30, 2021 using LUS in adult COVID-19 patients in the intensive care unit or the emergency department. Excluded were studies on animals and on pediatric and pregnant patients. We assessed bias using QUADAS-2. Outcomes were LUS score and correlation to PO2/FiO2, intubation, and mortality rates. Random effects model pooled the meta-analysis results.

Results: We reviewed 27 of 5,267 studies identified. Of the 27 studies, seven were included in the intubation outcome, six in the correlation to PO2/FiO2 outcome, and six in the mortality outcome. Heterogeneity was found in ultrasound protocols and outcomes. In the pooled results of 267 patients, LUS score was found to have a strong negative correlation to PO2/FiO2 with a correlation coefficient of −0.69 (95% confidence interval [CI] −0.75, −0.62). In pooled results, 273 intubated patients had a mean LUS score that was 6.95 points higher (95% CI 4.58–9.31) than that of 379 non-intubated patients. In the mortality outcome, 385 survivors had a mean LUS score that was 4.61 points lower (95% CI 3.64–5.58) than that of 181 non-survivors. There was significant heterogeneity between the studies as measured by the I2 and Cochran Q test.

Conclusion: A higher LUS score was strongly correlated with a decreasing PO2/FiO2 in COVID-19 pneumonia patients. The LUS score was significantly higher in intubated vs non-intubated patients with COVID-19. The LUS score was significantly lower in critically ill patients with COVID-19 pneumonia that survive.

Introduction: Big data and improved analytic techniques, such as triple exponential smoothing (TES), allow for prediction of emergency department (ED) volume. We sought to determine 1) which method of TES was most accurate in predicting pre-coronavirus 2019 (COVID-19), during COVID-19, and post-COVID-19 ED volume; 2) how the pandemic would affect TES prediction accuracy; and 3) whether TES would regain its pre-COVID-19 accuracy in the early post-pandemic period.

Methods: We studied monthly volumes of four EDs with a combined annual census of approximately 250,000 visits in the two years prior to, during the 25-month COVID-19 pandemic, and the 14 months following. We compared the accuracy of four models of TES forecasting by measuring the mean absolute percentage error (MAPE), mean square errors (MSE) and mean absolute deviation (MAD), comparing actual to predicted monthly volume.

Results: In the 23 months prior to COVID-19, the overall average MAPE across four forecasting methods was 3.88% ± 1.88% (range 2.41–6.42% across the four ED sites), rising to 15.21% ± 6.67%during the 25-month COVID-19 period (range 9.97–25.18% across the four sites), and falling to 6.45% ± 3.92% in the 14 months after (range 3.86–12.34% across the four sites). The 12-month Holt-Winter method had the greatest accuracy prior to COVID-19 (3.18% ± 1.65%) and during the pandemic (11.31% ± 4.81%), while the 24-month Holt-Winter offered the best performance following the pandemic (5.91% ± 3.82%). The pediatric ED had an average MAPE more than twice that of the average MAPE of the three adult EDs (6.42% ± 1.54% prior to COVID-19, 25.18% ± 9.42% during the pandemic, and 12.34% ± 0.55% after COVID-19). After the onset of the pandemic, there was no immediate improvement in forecasting model accuracy until two years later; however, these still had not returned to baseline accuracy levels.

Conclusion: We were able to identify a TES model that was the most accurate. Most of the models saw an approximate four-fold increase in MAPE after onset of the pandemic. In the months following the most severe waves of COVID-19, we saw improvements in the accuracy of forecasting models, but they were not back to pre-COVID-19 accuracies.

Introduction: Interruptions that occur during sign-out in the emergency department (ED) may affect workflow, quality of care, patient safety, errors in documentation, and resident education. Our objective in this study was to determine the frequency and classification (emergent vs non-emergent, in-person vs phone call) of interruptions that occur during emergency medicine (EM) resident sign-out before and after the institution of a group sign-out process involving residents and attending physicians.

Methods: A convenience sample of sign-out observations between EM residents were observed and coded between April–December 2021. We excluded sign-out observations of pediatric patients (<18 years of age) and observations not conducted in the main ED. Collected data included number of patients signed out during each observation; total duration in minutes for each observation; total number of interruptions during each observation; and type of interruption (emergent vs non-emergent, in-person vs phone call). We further stratified data before and after the institution of a group sign-out process (July 2021).

Results: We performed data analysis on 58 individual and 65 group sign-out observations, respectively. Although the total number of patients signed out, the total duration of sign-outs observed, mean number of patients signed out per minute, and mean duration of sign-out per observation were more for the group sign-out aggregate compared with the individual sign-out aggregate, the total number of interruptions (44 vs 73, P = 0.007), number of interruptions per minute (0.05 vs 0.16, P < 0.001), total number of non-emergent interruptions (38 vs. 67, P = 0.005), and total number of in-person interruptions (14 vs 44, P < 0.001) was less in the group sign-out compared with the individual sign-out totals.

Conclusion: Based on our sample, although the total duration of group sign-out with both residents and an attending was longer than individual resident-to-resident sign-out, the total number of interruptions, number of interruptions per minute, total number of non-emergent interruptions, and total number of in-person interruptions was less in the group sign-out. Group sign-out may be an option to limit the negative effects of interruptions in the ED.

Introduction: Consideration of the cost of care and value in healthcare is now a recognized element of physician training. Despite the urgency to educate trainees in high-value care (HVC), educational curricula and evaluation of these training paths remain limited, especially with respect to emergency medicine (EM) residents. We aimed to complete a needs assessment and evaluate curricular preferences for instruction on HVC among EM residents.

Methods: This was a qualitative, exploratory study using content analysis of two focus groups including a total of eight EM residents from a single Midwestern EM residency training program. Participants also completed a survey questionnaire.

Results: There were two themes. Within the overall theme of resident experience with and perception of HVC, we found five sub-themes: 1) understanding of HVC focuses on diagnosis and decision-making; 2) concern about patient costs, including the effects on patients’ lives and their ability to engage with recommended outpatient care; 3) conflict between internal beliefs and external expectations, including patients’ perceptions of value; 4) approach to HVC changes with increasing clinical experience; and 5) slow-moving, political discussion around HVC. Within the overall theme of desired education and curricular design, we identified four sub-themes: 1) limited prior education on HVC and health economics; 2) motivation to receive training on HVC and health economics; 3) desire for discussion-based format for HVC curriculum; and 4) curriculum targeted to level of training. Respondents indicated greatest acceptability of interactive, discussion-based formats.

Discussion: We conducted a targeted needs assessment for HVC among EM residents. We identified broad interest in the topic and limited self-reported baseline knowledge. Curricular content may benefit from incorporating resident concerns about patient costs and conflict between external expectations and internal beliefs about HVC. Curricular design may benefit from a focus on interactive, discussion-based modalities and tailoring to the learner’s level of training.

Background: Emergency medicine (EM) resident training is guided by the American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (EM Model) and the EM Milestones as developed based on the knowledge, skills, and abilities (KSA) list. These are consensus documents developed by a collaborative working group of seven national EM organizations. External experts in geriatric EM also developed competency recommendations for EM residency education in geriatrics, but these are not being taught in many residency programs. Our objective was to evaluate how the geriatric EM competencies integrate/overlap with the EM Model and KSAs to help residency programs include them in their educational curricula.

Methods: Trained emergency physicians independently mapped the geriatric resident competencies onto the 2019 EM Model items and the 2021 KSAs using Excel spreadsheets. Discrepancies were resolved by an independent reviewer with experience with the EM Model development and resident education, and the final mapping was reviewed by all team members.

Results: The EM Model included 77% (20/26) of the geriatric competencies. The KSAs included most of the geriatric competencies (81%, 21/26). All but one of the geriatric competencies mapped onto either the EM Model or the KSAs. Within the KSAs, most of the geriatric competencies mapped onto necessary level skills (ranked B, C, D, or E) with only five (8%) also mapping onto advanced skills (ranked A).

Conclusion: All but one of the geriatric EM competencies mapped to the current EM Model and KSAs. The geriatric competencies correspond to knowledge at all levels of training within the KSAs, from beginner to expert in EM. Educators in EM can use this mapping to integrate the geriatric competencies within their curriculums.

Introduction: Timely diagnosis of patients affected by an emerging infectious disease plays a crucial role in treating patients and avoiding disease spread. In prior research, we developed an approach by using machine learning (ML) algorithms to predict serious acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection based on clinical features of patients visiting an emergency department (ED) during the early coronavirus 2019 (COVID-19) pandemic. In this study, we aimed to externally validate this approach within a distinct ED population.

Methods: To create our training/validation cohort (model development) we collected data retrospectively from suspected COVID-19 patients at a US ED from February 23–May 12, 2020. Another dataset was collected as an external validation (testing) cohort from an ED in another country from May 12–June 15, 2021. Clinical features including patient demographics and triage information were used to train and test the models. The primary outcome was the confirmed diagnosis of COVID-19, defined as a positive reverse transcription polymerase chain reaction test result for SARS-CoV-2. We employed three different ML algorithms, including gradient boosting, random forest, and extra trees classifiers, to construct the predictive model. The predictive performances were evaluated with the area under the receiver operating characteristic curve (AUC) in the testing cohort.

Results: In total, 580 and 946 ED patients were included in the training and testing cohorts, respectively. Of them, 98 (16.9%) and 180 (19.0%) were diagnosed with COVID-19. All the constructed ML models showed acceptable discrimination, as indicated by the AUC. Among them, random forest (0.785, 95% confidence interval [CI] 0.747–0.822) performed better than gradient boosting (0.774, 95% CI 0.739–0.811) and extra trees classifier (0.72, 95% CI 0.677–0.762). There was no significant difference between the constructed models.

Conclusion: Our study validates the use of ML for predicting COVID-19 in the ED and demonstrates its potential for predicting emerging infectious diseases based on models built by clinical features with temporal and spatial heterogeneity. This approach holds promise for scenarios where effective diagnostic tools for an emerging infectious disease may be lacking in the future.

In June 2023, the Supreme Court declared that there was no longer a right to abortion under the federal constitution. This decision has allowed states to promulgate different restrictions on abortion, many of which implicate the practice of emergency medicine. An abortion is defined as a “medical intervention provided to individuals who need to end the medical condition of pregnancy” and includes care such as termination of an ectopic pregnancy and induction of labor for previable preterm premature rupture of membranes—interventions that emergency physicians either perform or rely on the assistance of consultants to perform. State bans on abortion must be evaluated against duties under the Emergency Medical Treatment and Labor Act, a federal law that preempts state law. In this paper we examine the conflict between state and federal law as it applies to emergency abortion care and describe how emergency physicians can continue caring for patients.

Introduction: We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients.

Methods: We performed a retrospective case control study from June 1–August 31, 2019 (pre-program) to September 24, 2019–January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables.

Results: A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P < 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P < 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41–0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14–0.50).

Conclusion: Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients.

Introduction: We conducted this systematic review to identify emergency department (ED) relevant recommendations in current guidelines for care of transgender and gender-diverse (TGD)people internationally.

Methods: Using PRISMA criteria, we did a systematic search of Ovid Medline, EMBASE, and CINAHL and a hand search of gray literature for clinical practice guidelines (CPG) or best practice statements (BPS) published until June 31, 2021. Articles were included if they were in English, included medical or paramedical care of TGD populations of any age, in any setting, region or nation, and were national or international in scope. Exclusion criteria included primary research studies, review articles, narrative reviews or otherwise non-CPG or BPS, editorials, or letters to the editor, articles of regional or individual hospital scope, non-medical articles, articles not in English, or if a more recent version of the guideline existed. Recommendations relevant to ED care were identified, recorded, and assessed for quality using the AGREE-II and AGREE-REX criteria. We performed interclass correlation coefficient for interrater reliability. Recommendations were coded for the relevant point of care while in the ED (triage, registration, rooming, investigations, etc.).

Results: We screened 1,658 unique articles, and 1,555 were excluded. Of the remaining 103 articles included, seven had recommendations relevant to care in the ED, comprising a total of 10 recommendations. Four guidelines and eight recommendations were of high quality. They included recommendations for testing, prevention, referral, and provision of post-exposure prophylaxis for HIV, and culturally competent care of TGD people.

Conclusions: This is the most comprehensive review to date of guidelines and best practices statements offering recommendations for care of ED TGD patients, and several are immediately actionable. There are also many opportunities to build community-led research programs to synthesize and inform a comprehensive dedicated guideline for care of TGD people in emergency settings.

Introduction: People without reliable access to healthcare are more likely to be diagnosed with late-stage cancer that could have been treated more effectively if diagnosed earlier. Emergency departments (ED) may be a novel place for cancer screening education for underserved patients. In this study we sought to determine patient characteristics and barriers to cancer screening for those patients who presented to a large, academic safety-net ED and were overdue for breast, cervical, and colorectal cancer screening since the coronavirus 2019 (COVID-19) pandemic.

Methods: Adult ED patients eligible for at least one cancer screening based on US Preventive Serivces Task Force guidelines completed a web-based survey. We examined the association of demographic characteristics and having a personal physician with being overdue on screening using chi-square or the Fisher exact test for categorical variables and t-tests for continuous variables.

Results: Of 221 participants, 144 were eligible for colorectal, 96 for cervical, and 55 for breast cancer screening. Of eligible patients, 46% (25/55) were overdue for breast cancer screening, 43% (62/144) for colorectal, and 40% (38/96) for cervical cancer screening. There were no significant characteristics associated with breast cancer screening. Being overdue for cervical cancer screening was significantly more likely for patients who were of Asian race (P = 0.02), had less than a high school diploma (P = 0.01), and were without a routine checkup within the prior five years (P = 0.01). Overdue for colorectal cancer screening was associated with patients not having insurance (P = 0.04), being in their 40s (P = 0.03), being Hispanic (P = 0.01), and not having a primary care physician (P = 0.01). Of 97 patients overdue for at least one screening, the most common barriers were cost (37%), lack of time (37%), and lack of knowledge of screening recommendations (34%). Only 8.3% reported that the COVID-19 pandemic delayed their screening.

Conclusion: The ED may be a novel setting to target patients for cancer screening education. Future work that refers patients to free screening programs and primary care physicians mayhelp improve disparities in cancer screening and cancer mortality rates for underserved populations.

Introduction: Historically, there have been no systematic programs for teaching peer review, leaving trainees to learn by trial and error. Recently, a number of publications have advocated for programs where experienced reviewers mentor trainees to more efficiently acquire this knowledge.

Objective: Our goal was to develop an introductory learning experience that intentionally fosters peer-review skills.

Methods: The Council of Residency Directors in Emergency Medicine (CORD) offered education fellowship directors the opportunity to mentor their fellows by reviewing submitted manuscript(s) supplemented by educational material provided by their journal. Reviews were collaboratively created. The decision letter that was sent to manuscript authors was also sent to the mentees; it included all reviewers’ and editor’s comments, as feedback. In 2022, fellows received a post-experience survey regarding prior experiences and their perspectives of the mentored peer-review experience.

Results: From 2020–2022, participation grew from 14 to 30 education fellowships, providing 76 manuscript peer reviews. The 2022 survey-response rate of 87% (20/23) revealed that fellows were inexperienced in education scholarship prior to participation: 30% had authored an education paper, and 10% had performed peer review of an education manuscript. Overall, participants were enthusiastic about the program and anxious to participate the following year. In addition, participants identified a number of benefits of the mentored experience including improved understanding of the scholarship process; informing fellows’ scholarly pursuits; improved conceptualization of concepts learned elsewhere in training; and learning through exposure to scholarship.

Conclusion: This program’s early findings suggest that collaboration between academic societies and interested graduate medical education faculty has the potential to formalize the process of learning peer review, benefitting all involved stakeholders.

Introduction: Despite the inclusion of both diagnostic and procedural ultrasound and regional nerve blocks in the original Model of the Clinical Practice of Emergency Medicine (EM), there is no recommended standardized approach to the incorporation of ultrasound-guided regional anesthesia (UGRA) education in EM training.

Methods: We developed and implemented a structured curriculum for both EM residents and faculty to learn UGRA in a four-hour workshop. Each Regional Anesthesia Anatomy and Ultrasound Workshop was four hours in length and followed the same format. Focusing on common UGRA blocks, each workshop began with an anatomist-led cadaveric review of the relevant neuromusculoskeletal anatomy followed by a hands-on ultrasound scanning practice for the blocks led by an ultrasound fellowship-trained EM faculty member, fellow, or a postgraduate year (PGY)-4 resident who had previously participated in the workshop. Learners identified the relevant anatomy on point-of-care ultrasound and reviewed how to conduct the blocks. Learners were invited to complete an evaluation of the workshop with Likert-scale and open-ended questions.

Results: In the 2020 academic year, six regional anesthesia anatomy and ultrasound workshops occurred for EM faculty (two sessions, N = 24) and EM residents (four sessions, N = 40, including a total of five PGY4s, 10 PGY3s, 12 PGY2s, and 13 PGY1s). Workshops were universally well-received by both faculty and residents. Survey results found that 100.0% of all responding participants indicated that they were “very satisfied” with the session. All were likely to recommend this session to a colleague and 95.08% of participants believed the session should become a required component of the EM curriculum.

Conclusion: The use of UGRA is increasing, and and it critical in EM. An interdisciplinary approach in collaboration with anatomists on an interactive, nerve block workshop incorporating both gross anatomy review and hands-on scanning was shown to be well-received and desired by both EM faculty and residents.

Background: Trauma team leadership is a core skill for the practice of emergency medicine (EM). In this study our goal was to explore EM residents’ perception of their trauma leadership skill development through formal and informal processes and to understand factors that may impact the development and implementation of trauma leadership skills.

Methods: Using qualitative semi-structured interviews, we explored the leadership experiences of 10 EM residents ranging from second to fourth postgraduate year. Interviews were conducted between July 26–October 31, 2019 and were audio-recorded, transcribed, and de-identified. We analyzed data using qualitative content analysis.

Results: Residents discussed three main themes: 1) sources of leadership development; 2) challenges with simultaneously assuming a dual leader-learner role; and 3) contextual factors that impact their ability to assume the leadership role, including the professional hierarchy in the clinical environment, limitations in the physical environment, and gender bias.

Conclusion: This study describes the complex factors and experiences that contribute to the development and implementation of trauma team leadership skills in EM residents. This includes three primary sources of leadership development, the dual role of leader and learner, and various contextual factors. Research is needed to understand how these factors and experiences can be leveraged or mitigated to improve resident leadership training outcomes.

Introduction: The platelet-to-lymphocyte ratio (PLR) is associated with the inflammatory response in various diseases. However, studies on the use of the PLR for the prognosis of elderly patients with severe trauma are lacking. In this study, we examined the relationship between the PLR and in-hospital mortality in elderly patients with severe trauma.

Methods: This retrospective observational study included elderly (≥65 years) patients who were admitted for severe trauma (as defined by an Injury Severity Score [ISS] ≥ 16) between January–December 2022. We conducted multivariate analysis to assess the association between the PLR and in-hospital mortality using logistic regression of relevant covariates. We also performed receiver operating characteristic curve analysis to examine the prognostic performance of the PLR forin-hospital mortality.

Results: Among the 222 patients included in the study, the in-hospital mortality rate was 19.4% (43). The PLR of non-survivors was lower than that of survivors (62.1 vs 124.5). The areas under the curve (AUC) of the Glasgow Coma Scale (GCS) score ≤12, ISS, hemoglobin level, and PLR for predicting in-hospital mortality were 0.730 (95% confidence interval [CI] 0.667–0.787), 0.771 (95% CI 0.710–0.824), 0.657 (95% CI 0.591–0.719), and 0.730 (95% CI 0.667–0.788), respectively. The AUC of the PLR was not significantly different from that of GCS score ≤12 and ISS for predicting in-hospital mortality. Multivariate analysis showed that the PLR was independently associated with in-hospital mortality (odds ratio: 0.993; 95% CI 0.987–0.999).

Conclusion: Low platelet-to-lymphocyte ratio is independently associated with in-hospital mortality in elderly patients with severe trauma.

Introduction: Pulmonary embolism (PE) is an imperative diagnosis to make given its associated morbidity. There is no current consensus in the initial workup of pregnant patients suspected of a PE. Prospective studies have been conducted in Europe using a pregnancy-adapted YEARS algorithm, which showed safe reductions in computed tomography pulmonary angiography (CTPA) imaging in pregnant patients suspected of PE. Our objective in this study was 1) to measure the potential avoidance of CTPA use in pregnant patients if the pregnancy-adapted YEARS algorithm had been applied and 2) to serve as an external validation study of the use of this algorithm in the United States.

Methods: This study was a single-system retrospective chart analysis. Criteria for inclusion in the cohort consisted of keywords: pregnant; older than 18; chief complaints of shortness of breath, chest pain, tachycardia, hemoptysis, deep vein thromboembolism (DVT), and D-dimer—from January 1, 2019– May 31,2022. We then analyzed this cohort retrospectively using the pregnancy-adapted YEARS algorithm, which includes clinical signs of a DVT, hemoptysis, and PE as the most likely diagnosis with a D-dimer assay. Patients within the cohort were then subdivided into two categories: aligned with the YEARS algorithm, or not aligned with the YEARS algorithm. Patients who did not receive a CTPA were analyzed for a subsequent diagnosis of a PE or DVT within 30 days.

Results: A total of 74 pregnant patients were included in this study. There was a PE prevalence of 2.7% (two patients). Of the 36 patients who did not require imaging by the algorithm, seven CTPA were performed. Of the patients who did not receive an initial CTPA, zero were diagnosed with PE or DVT within a 30-day follow-up. In total, 85.1% of all the patients in this study were treated in concordance with the pregnancy-adapted YEARS algorithm.

Conclusion: The use of the pregnancy-adapted YEARS algorithm could have resulted in decreased utilization of CTPA in the workup of PE in pregnant patients, and the algorithm showed similar reductions compared to prospective studies done in Europe. The pregnancy-adapted YEARS algorithm was also shown to be similar to the clinical rationale used by clinicians in the evaluation of pregnant patients, which indicates its potential for widespread acceptance into clinical practice.