Dedicated emergency department ultrasound rotation improves residents' ultrasound knowledge and interpretation skills

Background

Graduates of Emergency Medicine (EM) residency training programs are expected to be proficient in ultrasound. However, best practices for teaching residents ultrasonography has yet to be determined.

Study Objectives

To determine if a dedicated Emergency Department (ED) ultrasound rotation objectively improves residents’ EM ultrasound knowledge, interpretation accuracy, and clinical decision-making based on ultrasound findings.

Methods

EM residents completing a required ED-based ultrasound rotation were prospectively studied. Before the start of the rotation, each resident completed a 20-question pre-test. At the end of the rotation, residents completed a 20-question post-test. Both tests covered physics, trauma (focused assessment with sonography for trauma), first-trimester pregnancy, aorta, biliary, echocardiography, and vascular sonography, using a multiple-choice format. In both tests, ultrasound images were included in 11 of the 20 questions. The questions were divided into three categories: knowledge-based (8 questions), interpretation (9 questions), and clinical decision-making (3 questions), for both tests. Scores on pre-tests and post-tests were compared using a Wilcoxon signed-rank test.

Results

During the 2-year study period, 21 residents completed the rotation. The median pre-test score was 16 (interquartile range [IQR] 14.5–17), compared to a median post-test score of 19 (IQR 18–20), p < 0.001.

Conclusions

A dedicated ED ultrasound rotation improves residents’ EM ultrasound knowledge and interpretation accuracy based on ultrasound findings, as measured by improvement on ultrasound test scores.     

Prospective outcomes of pregnant ED patients with documented fetal cardiac activity on ultrasound

Background

Evaluation of rates of spontaneous abortion (SAB) may aid in counseling pregnant patients seen in the emergency department (ED). A recent chart review reported an SAB rate of 10% among ED patients with a documented intrauterine pregnancy (IUP) and cardiac activity on ultrasound. We sought to prospectively evaluate outcomes among pregnant ED patients with documented cardiac activity on ultrasound.

Methods

We prospectively enrolled a convenience sample of pregnant patients presenting to the University of Utah ED between January 1, 2008, and April 30, 2009. Ultrasound was performed during the ED visit. Patient outcomes were followed up 30 days after the ED visit. Patients were contacted by telephone or the medical record was reviewed for documentation of pregnancy status.

Results

Seventy-one patients with an IUP and documented fetal cardiac activity were enrolled. We were able to obtain 30-day follow-up information on 61 patients (85.9%). Average patient age was 26.7 years (range, 17-42 years), average reported gravida was 3.3 (range, 1-8), and average gestational age was 10 weeks. Nine patients (14.8%; 95% confidence interval, 8.7%-23.9%) either reported or had a documented SAB during the 30 days after the ED visit.

Conclusion

In this study, which represents the first prospective evaluation of ED patients with documented IUP with fetal heart tones, the rate of SAB was consistent with that reported previously for this population. These results confirm that ED patients represent a high-risk group, and additional research is needed to better characterize risk factors for SAB.     

Resident productivity as a function of emergency department volume,shift time of day,and cumulative time in the emergency department

Objectives

We sought to determine if resident productivity changed based on emergency department (ED) volume, shift time of day, or over time during a shift.

Methods

This is a retrospective review of patients evaluated in the ED by emergency medicine residents. Data were collected using the computerized tracker that provides time of physician assignment and daily volume. Regression analysis was used to determine relationship between productivity and volume as well as relationship between productivity and accumulated time in the ED. Analysis of variance was used to assess for productivity differences by shift time of day.

Results

One hundred sixty-one postgraduate year-1 (PGY-1), 264 PGY-2, and 193 PGY-3 shifts were included. PGY-1, PGY-2, and PGY-3 residents saw 0.85, 1.13, and 1.25 patients per hour, respectively. PGY-3 and PGY-2 productivity had a weak relationship to ED volume (R = 0.28, P = .03; and R = 0.36, P = .03), whereas PGY-1 productivity had a moderate relationship to ED volume (R = 0.44, P = .0001). There were no differences in productivity based on shift time of day. Accumulated time in the ED had a strongly negative relationship to productivity, with R values from −0.79 to −0.93 (P < .002 for all comparisons).

Conclusions

Resident productivity is not strongly linked to volume or time of day. If specific times have statistically higher volume, they should be staffed with larger numbers of residents. In addition, emergency medicine resident productivity declines reliably over shift time. Therefore, scheduling should be adjusted to create larger shift overlaps to aid in smoother patient flow.     

Fetal outcomes in first trimester pregnancies with an indeterminate ultrasound

Background

Pregnant women commonly present to the Emergency Department (ED) for evaluation during their first trimester. These women have many concerns, one of which is the viability of their pregnancy and the probability of miscarriage.

Study Objectives

We sought to determine fetal outcomes of women with an indeterminate ultrasound who present to the ED during the first trimester of pregnancy.

Methods

A retrospective analysis of consecutive ED patient encounters from December 2005 to September 2006 was performed to identify patients who were pregnant and who had an indeterminate transvaginal ultrasound performed by an emergency physician or through the Radiology Department during their ED visit. Demographic data, obstetric/gynecologic history, and presenting symptoms were recorded onto a standardized patient chart template designed to be used for any first trimester pregnancy. Outcomes (spontaneous abortion, ectopic pregnancy, and 20-week gestation) were determined via computerized medical records.

Results

During the study timeframe, a total of 1164 patients were evaluated in the ED during the first trimester of their pregnancy; 359 patients (30.8%) met inclusion criteria and had a diagnosis of indeterminate ultrasound. Outcome data were obtained for 293 patients. Carrying the pregnancy to ≥20 weeks occurred in 70 patients (23.9%). Spontaneous abortion occurred in 193 women (65.9%), and 30 women (10.2%) were treated for an ectopic pregnancy. Total fetal loss incidence was 89.2% in patients presenting with any vaginal bleeding, compared to 34.7% in patients with pain only.

Conclusion

Indeterminate ultrasounds in the setting of first trimester symptomatic pregnancy are indicative of poor fetal outcomes. Vaginal bleeding increased the risk of fetal loss. These data will assist emergency physicians in counseling women in the ED who are found to have an indeterminate ultrasound.     

Hypotension after medical termination of pregnancy: think outside of the uterus

Background

Under usual circumstances, an ectopic pregnancy would not be generally considered in the initial differential diagnosis of shock after voluntary termination of pregnancy.

Objective

To present a rare case of a young woman with shock after voluntary termination of pregnancy due to undiagnosed ectopic pregnancy with concealed hemorrhage.

Case Report

A 37-year-old woman presented to the Emergency Department (ED) 3 days after termination of pregnancy with clinical features of shock. The patient had some evidence of infection and was initially managed as a case of septic shock secondary to possible complication of recent termination of pregnancy. Subsequent work-up led to suspicion of internal bleeding, and ruptured ectopic pregnancy was confirmed and managed successfully.

Conclusion

Ruptured ectopic pregnancy can present with a wide range of symptoms and under variable circumstances. Recognition of subtle signs of hemorrhage and consideration of the diagnosis of ruptured pregnancy in the ED will lead to early diagnosis and appropriate management.     

Fetal loss in symptomatic first-trimester pregnancy with documented yolk sac intrauterine pregnancy

Background

The possibility of spontaneous miscarriage is a common concern among pregnant women in the emergency department (ED).

Objective

This study sought to determine fetal outcomes for women following ED evaluation for first-trimester abdominopelvic pain or vaginal bleeding who had an intrauterine pregnancy (IUP) on ultrasound before a visible fetal pole (“yolk sac IUP”).

Methods

A retrospective chart review of consecutive ED charts from December 2005 to September 2006 identified patients with a yolk sac IUP. Demographic data, obstetric/gynecologic history, and presenting symptoms were obtained. Outcomes were determined via computerized records. Fetal loss was diagnosed by falling β-human chorionic gonadotropin or pathology specimen. Live birth was diagnosed by viable fetus at 20-week ultrasound or delivery.

Results

A total of 131 patients were enrolled in this study. Of these, 14 were lost to follow-up (12%), leaving 117 patient encounters. Of the 117 women, 82 carried their pregnancies to at least 20-week gestation. Thirty-five patients miscarried. Fetal loss rate by chief complaint were as follows: 8 of 46 patients presenting with pain only, 14 of 34 presenting with vaginal bleeding only, and 13 of 37 with both vaginal bleeding and pain.

Conclusion

Seventy percent of women diagnosed with a yolk sac IUP in the ED carried their pregnancy to at least 20 weeks. The remaining women (30%) experienced fetal loss. Vaginal bleeding (with or without pain) increased the rate of fetal loss compared with women with pain only. These data will assist the emergency physician in counseling women with symptomatic first-trimester pregnancies.     

Evaluating the Effect of Emergency Residency Training on Productivity in the Emergency Department

Background

Resident productivity, defined as patients seen per unit time, is one measure that is used to assess the performance and educational progress of residents in the emergency department (ED). One published study suggested that emergency residency training (EM) does not improve productivity compared with that in other specialties, including internal medicine (IM).

Objectives

This study assesses how EM and IM trainees perform in the ED and illustrates how resident productivity changes through the academic year.

Methods

A retrospective review of attending physicians and residents working 8-h shifts in the higher acuity zone of a large-volume, tertiary, academic health care center was performed for July 2009, October 2009, January 2010, and April 2010. The total number of patients seen primarily and admitted during each shift was recorded. ED volume was approximated by the number of patients seen by the attending physician, and acuity was approximated by admission rate. A mixed model regression assessed the impact of year and type of residency training (e.g., EM1, EM2, IM1, and IM2), ED volume, and acuity on resident productivity (number of patients per shift). The study was granted waiver of informed consent by our institutional review board.

Results

We reviewed 936 shifts. After adjusting for acuity and ED volume, the EM1 group had a significant increase in patients per shift over the year, from 6.11 in July to 10.3 in April (p < 0.001). No other group increased productivity significantly.

Conclusions

The first EM training year leads to a significant change in productivity that separates EM from IM residents. This contradicts the previous assertion that non-EM residents have the same productivity as EM residents in the ED.     

Near-Miss in Focused Lower-Extremity Ultrasound for Deep Venous Thrombosis

Background

Focused, proximal compression ultrasound (FPCUS) is a commonly used point-of-care study in the Emergency Department (ED). Pelvic vein deep venous thrombosis (DVT) is a rare presentation, and Emergency Physicians need to be aware of the limitations and pitfalls of FPCUS.

Objective

A case of external iliac vein DVT diagnosed in the ED is presented, with a focus on subtle signs seen during FPCUS that led to the diagnosis and additional ultrasound techniques to aid in appropriate point-of-care diagnosis.

Case Report

We describe a patient who presented with lower-extremity pain and was subsequently diagnosed with external iliac DVT. A FPCUS study by Emergency Physicians was performed and demonstrated subtle findings that led to further investigation and appropriate diagnosis.

Conclusion

Emergency physicians using FPCUS in the evaluation of lower-extremity pain or swelling need to be aware of the pitfalls, limitations, and advanced techniques to avoid misdiagnosis while evaluating for DVT.     

A Brief Educational Intervention Is Effective in Teaching the Femoral Nerve Block Procedure to First-Year Emergency Medicine Residents

Background

Hip fractures are a painful condition commonly encountered in the emergency department (ED). Older adults in pain often receive suboptimal doses of analgesics, particularly in crowded EDs. Nerve blocks have been utilized by anesthesiologists to help control pain from hip fractures postoperatively. The use of nerve stimulator with ultrasonographic guidance has increased the safety of this procedure.

Objectives

We instituted a pilot study to assess the ability of Emergency Medicine (EM) resident physicians to effectively perform this procedure after a didactic and demonstration session.

Methods

First-year EM residents from three urban training programs underwent a 1-h didactic and hands-on training session on the femoral nerve block (FNB) procedure. A written pretest was used to assess baseline knowledge; it was administered again (with test items randomized) at 1 and 3 months post training session. A critical actions checklist (direct observation of procedure steps via simulated patient encounter) was used to assess the residents after the training session and again at 3 months.

Results

A total of 38 EM residents were initially evaluated. Thirty-three successfully completed 1-month and 3-month written test evaluations; 30 completed all written and direct observation evaluations. The mean written pretest scores were 66% (SD 9); post-test 92% (SD 5), 1-month 74% (SD 8), and 3-month 75% (SD 9). After initial training, 37 of 38 (97%) residents demonstrated competency (completing ≥ 15 of 19 critical actions) in the FNB procedure determined via direct observation. At 3 months, 25 of 30 residents (83%) continued to retain 85% of their initial critical action skills, and 3 of 30 (10%) saw an improvement in their proficiency.

Conclusion

A 1-h training and demonstration module yielded high competency rates in residents performing critical actions related to the FNB; these skills were well maintained at 3 months. An ongoing study will attempt to correlate this competency with procedures performed on patients.     

Emergency ultrasound diagnosis of ovarian hyperstimulation syndrome: case report

Background

Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED).

Objectives

OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography.

Case Report

We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles.

Conclusions

This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.     

Diagnosis of Megaureter by Point-of-Care Ultrasound

Background

Presentation of congenital megaureter in adult life is rare; patients usually become symptomatic in childhood.

Case Report

A 32-year-old man presented to the Emergency Department (ED) with dyspnea, tongue swelling, and a rash, which he attributed to amoxicillin he had taken shortly prior to onset of symptoms. He was hypotensive on arrival to the ED. To further evaluate the hypotension, point-of-care ultrasound of the heart, lungs, and abdomen were performed while treatment for anaphylaxis was initiated. Ultrasound examination did not identify a cause for hypotension, but the treating physician noted an anechoic structural abnormality posterior to the bladder, suggestive of megaureter. The patient responded well to treatment of anaphylaxis; further history and diagnostic imaging subsequently confirmed a diagnosis of congenital megaureter.

Conclusion

We report an unusual case of congenital megaureter, identified by point-of-care ultrasound performed to evaluate hypotension. Clinicians performing limited ultrasound examinations must be attentive to incidental findings that will require follow-up.     

The effect of ED crowding on education

Objective

We studied if emergency department (ED) crowding affects the quality of resident and medical student education on individual patient encounters.

Methods

We performed a cross-sectional study of a ED faculty-learner interactions over a 5-week period in an academic ED. Research assistants administered surveys to residents and senior medical students assessing attending physicians on 4 domains (teaching, clinical care, approachability, and helpfulness) using a scale (ER score for teaching on individual patients) validated for use during ED rotations. Each domain was assessed on a 5-point scale with a highest score of 20 representing superb/outstanding. We tested the association between measures of ED crowding (waiting room number, occupancy, number of admitted patients, and patient-hours) at the time of assessment with the ER score and individual domain scores using correlation coefficients and regression analysis with clustering on the attending physician.

Results

Forty-three residents (22 ED, 21 non-ED) and 3 medical students assessed 34 attending physicians in 352 separate encounters. Median ER score was 16/20 (interquartile range, 12-16). Emergency department crowding levels and ER scores on individual patients were not significantly correlated, nor were ED crowding and individual domains. In the adjusted analysis, ED crowding was not associated with an ER score of 16 or higher, nor was any ED crowding measure associated individual assessments of teaching, clinical care, approachability, or helpfulness.

Conclusion

Emergency department crowding is not associated with the quality of education on individual patients.     

The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization using a Standard Intravenous Catheter

Background

Obtaining vascular access is difficult in certain patients. When routine peripheral venous catheterization is not possible, several alternatives may be considered, each with its own strengths and limitations.

Discussion

We describe a novel technique for establishing vascular access in Emergency Department (ED) patients: the placement of a standard catheter-over-needle device into the internal jugular vein using real-time ultrasound guidance. We present a series of patients for whom this procedure was performed after other attempts at vascular access were unsuccessful. In all cases, the procedure was performed quickly and without complications.

Conclusion

Although further study of this technique is required, we believe this procedure may be a valuable option for ED patients requiring rapid vascular access.     

Resident productivity: does shift length matter?

Background

It has been established that residents are able to evaluate more patients per hour as they progress through training. However, it is unknown if shift length influences resident productivity.

Objectives

The aim of this study is to assess whether there is a difference in second-year resident productivity as a function of shift length.

Methods

This is a retrospective chart review of patients evaluated in the emergency department (ED) by second-year residents in a 65 000 volume center; 9- and 12-hour shifts were included. Nine-hour shifts provide a 1-hour overlap, such that three 9-hour shifts provide 24 hours of resident coverage. Shifts on weekly conference day were excluded. A patient was determined as having been evaluated by a resident if the resident initiated care on the patient and dictated the chart. Data were analyzed using 2-tailed t test.

Results

A total of 193 nine-hour shifts and 90 twelve-hour shifts met inclusion criteria. Residents working 12-hour shifts evaluated 1.06 patients per hour, and residents working 9-hour shifts evaluated 1.15 patients per hour (95% confidence interval, 0.031-0.151). In an ED with 120 hours of resident coverage per day, this results in 10 additional patients seen by residents working 9-hour shifts. In our department with 9 ED months in the second year of residency, this results in 180 additional patient encounters per resident during that year.

Conclusions

Shorter shift lengths appear to result in more patients evaluated per hour by second-year residents and an increase in patient encounters.     

Initiating palliative care in the emergency department

Background

In 2006, nearly a quarter of a million patients either arrived dead or died in the Emergency Department (ED). The role of palliative care (PC) in the ED is not well defined, and education of medical students and residents in the area is sparse.

Objectives

We use an illustrative case to discuss important concepts in PC for the emergency physician (EP). The reader should be able to define hospice and PC, recognize its importance in the practice of Emergency Medicine, and understand the benefits PC has for the patient, the patient’s family and caregivers, and the health care system as a whole.

Discussion

PC excels at treating pain and addressing end-of-life issues. Families and caregivers of patients benefit from PC in terms of improved personal quality of life after the patient’s death. PC is more cost-effective than traditional medical care.

Conclusion

Research on PC in the ED is sparse but it is a growing need, and the EP will need to become proficient in the delivery of PC in the ED.     

A Sedentary Job? Measuring the Physical Activity of Emergency Medicine Residents

Background

The debate on the quality of health care provided in the United States has continued to be waged as concerns have grown over the years. Stress, sleep deprivation, poor diet, and lack of exercise may lead to inadequate work performance by physicians.

Objective

This study was undertaken to determine whether Emergency Medicine (EM) residents satisfy daily recommendations for total number of steps taken per day set forth by the Centers for Disease Control and Prevention and Surgeon General in a 12-h shift.

Methods

An observational prospective cohort study was conducted between August 2009 and November 2009 at an urban Level I trauma center with an annual census of over 165,000 Emergency Department (ED) visits per year. The mean number of steps taken by EM residents during 12-h shifts was measured.

Results

Mean steps taken during a shift were 7333 (95% confidence interval 6901–7764). Only nine (9.9%) pedometer readings reached the target level of 10,000 (10 K) steps or above. A t-test was used to compare steps with the hypothesized 10 K steps target. Recordings of 10 K steps or greater were not correlated with ED sections (p = 0.60) shift (medical vs. surgical, p = 0.65) or ED census (r² < 0.0017).

Conclusion

A majority of residents (90%) did not meet the target number of steps for shifts. More rigorous charting needs, overcrowding, or even spatial limitations may explain this. This warrants further investigation to determine if some daily physical activity regimens may help improve the overall well-being of EM residents.     

Focused Cardiac Ultrasound Training: How Much Is Enough?

Background

Focused transthoracic echocardiography (F-TTE) is an important tool to assess hemodynamically unstable patients in the Emergency Department. Although its scope has been defined by the American College of Emergency Physicians, more research is needed to define an optimal F-TTE training program, including assessment of proficiency.

Objective

The goal of this study was to determine the effectiveness of current standards in post-residency training to reach proficiency in F-TTE.

Methods

Fourteen staff Emergency Physicians were enrolled in a standardized teaching curriculum specifically designed to meet the 2008 American College of Emergency Physicians’ guidelines for general ultrasound training applied to echocardiography. This training program consisted of 6 h of didactics and 6 h of scanning training, followed by independent scanning over a 5-month period. Acquisition of echocardiographic knowledge was assessed by an online pre- and post-test. At the conclusion of the study, a hands-on skills test assessed the trainees’ ability to perform and interpret F-TTE.

Results

Ninety percent of trainees passed the written post-test. Two views, the parasternal long and short axis, were easily obtainable, regardless of the level of training or the number of ultrasounds completed. Other views were more difficult to master, but strong trends toward increased competency were evident after 10 h of mixed didactic and scanning training and > 45 ultrasounds.

Conclusions

A short, 12-h didactic training in F-TTE provided proficiency in image interpretation and in obtaining adequate images from the parasternal window. More extensive training is needed to master the apical and subcostal windows in a timely manner.     

Longitudinal Trends in the Treatment of Abdominal Pain in an Academic Emergency Department

Background

Abdominal pain is a top chief complaint of patients presenting to Emergency Departments (ED). Historically, uncertainty surrounded correct management. Evidence has shown adequate analgesia does not obscure the diagnosis, making it the standard of care.

Objective

We sought to evaluate trends in treatment of abdominal pain in an academic ED during a 10-year period.

Methods

We prospectively evaluated a convenience sample of patients in an urban academic tertiary care hospital ED from September 2000 through April 2010. Adult patients presenting with a chief complaint of abdominal pain were included in this study. Analgesic administration rates and times, pain scores, and patient satisfaction at discharge were analyzed to evaluate trends by year.

Results

There were 2,646 patients presenting with abdominal pain who were enrolled during the study period. Rates of analgesic administration generally increased each year from 39.9% in 2000 to 65.5% in 2010 (p value for trend <0.001). Similarly, time to analgesic administration generally decreased by year, from 116 min in 2000 to 81 min in 2009 (p < 0.001). There was no improvement in mean pain scores at discharge by year (p = 0.27) and 48% of patients during the 10-year period still reported moderate to severe pain at discharge. Patient satisfaction with pain treatment increased from a score of 7.1 to 9.0 during the study period (p < 0.005), following the trend of increase in analgesic administration.

Conclusions

In patients presenting to the ED with abdominal pain, analgesia administration increased and time to medication decreased during the 10-year period. Despite overall improvements in satisfaction, significant numbers of patients presenting with abdominal pain still reported moderate to severe pain at discharge.     

Myocardial Infarction in a Young Man Due to Coronary Artery Aneurysms after an Undiagnosed Kawasaki Disease

Background

Kawasaki disease usually affects infants and young children. It often goes unrecognized in adults due to varying symptoms and lack of definite diagnostic criteria.

Objectives

To describe the potential for acute myocardial infarction as a complication of antecedent Kawasaki Disease (KD).

Case Report

We describe a case of a 19-year-old man who presented to the Emergency Department (ED) with an acute myocardial infarction that was subsequently determined to be the result of previously untreated KD.

Conclusion

Kawasaki disease can cause coronary complications in a teenager. A high level of suspicion in the ED can help in proper management of these patients.