A 75-year-old female with no prior history of bleeding disorders presented to the emergency department with spontaneous sublingual hematoma, hemarthrosis, hemotympanum, and cutaneous ecchymoses. She denied anticoagulant use, recent trauma, or underlying systemic disease. Initial laboratory findings revealed an isolated prolonged activated partial thromboplastin time (aPTT) that failed to correct with mixing studies. Factor VIII activity was markedly reduced, and the presence of factor VIII inhibitors was confirmed, leading to a diagnosis of acquired hemophilia A (AHA). Management included recombinant activated factor VII (rFVIIa) for hemostatic control, corticosteroids for immunosuppression, and weekly rituximab for inhibitor eradication. During her hospital course, serial monitoring demonstrated a decreasing inhibitor titer and improving coagulation profile. She was discharged and completed four weeks of rituximab and a steroid taper, with complete normalization of coagulation profile and inhibitor eradication within four weeks. This case underscores the importance of recognizing AHA in patients with unexplained bleeding and prolonged aPTT. Prompt diagnosis and targeted therapy are critical in reducing morbidity and mortality associated with this rare but potentially life-threatening disorder.1,2. Topics:Acquired hemophilia A, spontaneous bleeding, factor VIII inhibitors, prolonged aPTT, Bethesda assay, recombinant activated factor VII (rFVIIa), immunosuppressive therapy.
An adult female presents for chronic eye complaints refractory to outpatient ophthalmology management, as well as purpuric rash, Reynaud's symptoms, and reported nodules. She received ophthalmology and rheumatology consultations while in the emergency department (ED) and was subsequently admitted. Expedited rheumatologic workup revealed evidence of granulomatosis with polyangiitis, a rare and potentially debilitating autoimmune vasculitis. She was ultimately discharged after an eight-day hospital course on a long prednisone taper with plan for outpatient management and transition to long-term therapy. This report documents a case warranting high clinical suspicion for an undiagnosed condition in a patient with demonstrably poor access to longitudinal care and the subsequent, in-hospital diagnosis of a rare disease facilitated by ED clinician action. Topics:Granulomatosis with polyangiitis, vasculitis, autoimmune, ophthalmology, rash.
Audience:This simulation was designed primarily for emergency medicine residents and pediatric emergency medicine residents. Additionally, off-service residents, neurosurgical residents, pediatric residents, faculty, and medical students may benefit. Introduction:Ventriculoperitoneal (VP) shunts are the treatment of choice for patients suffering from hydrocephalus. Hydrocephalus affects about 125,000 patients in the United States, and 33,000 VP shunts are implanted in patients every year.1 However, these devices can malfunction and can cause complications. It is important for the emergency department physician to recognize when these devices are not functioning correctly to prevent life-threatening complications. Training for VP shunt malfunction can be variable depending upon the patient population seen by residents. Therefore, we outline a simulation for mechanical VP shunt malfunction to provide learners with exposure to this topic. Educational Objectives:The objective of this simulated case is to increase learner knowledge and develop the skills necessary to troubleshoot VP shunt malfunction. By the end of this simulation, learners should be able to: 1) review pertinent historical and physical exam points for a shunt patient, 2) recognize the signs and symptoms of VP shunt malfunction, 3) review an algorithm for diagnosing VP shunt malfunction, 4) discuss treatment for common complications of VP shunt dysfunction, and 5) recall the indications for an emergent VP shunt tap. Educational Methods:In this study, a high-fidelity mannikin with a do-it-yourself (DIY) task trainer was used in a simulated case scenario. Learners were required to recognize the signs and symptoms of shunt dysfunction, administer the appropriate treatment, and appropriately disposition the simulated patient. Research methods:Residents completed pre- and post-simulation surveys to assess their perceived knowledge and confidence regarding the diagnosis and management of VP shunt malfunction. To prevent priming or diagnostic cueing, the term "neurologic device" was used in the pre-simulation surveys. This wording may significantly limit direct comparison between pre- and post-simulation responses. Learners were also asked to provide feedback on the utility of the simulation for their future practice and usefulness of the topic. Results:Learners reported high levels of confidence in recognizing signs and symptoms of shunt dysfunction and managing complications after the simulation. Residents also reported that the case was valuable for their future clinical practice and felt as though the simulation experience was positive. Discussion:Overall, the educational content was effective. The simulation appears to be useful in addressing knowledge gaps in managing VP shunt dysfunction and may increase learner confidence. Topics:Medical simulation, ventriculoperitoneal shunt dysfunction, hydrocephalus, pediatrics, increased intracranial pressure, shunt tap, neurologic emergencies.
Audience:This simulation is intended for emergency medicine residents, PGY 1-4. Introduction:Postpartum hemorrhage (PPH) is defined as cumulative blood loss ≥1000 mL or any postpartum bleeding with signs of hypovolemia within 24 hours of delivery. Post-abortion hemorrhage (PAH) has no single universally adopted numeric definition but clinically is defined as excessive bleeding following spontaneous or induced abortion that results in hemodynamic instability, need for transfusion, hospital admission, or procedural intervention. Due to its rarity, PAH may be underrecognized and thus is the target of this simulation. The emergency department is the country's reproductive health safety net. With the decline of labor and delivery units and on-call, in-house OB/GYN consultants, emergency clinicians must be equipped to recognize and manage these cases.1 Effective management of these cases includes uterotonic medications and uterine tamponade devices like the Bakri balloon.2 There is mixed evidence on the use of Bakri balloons for post-abortion hemorrhage, with some hospitals moving towards vacuum-assisted devices (e.g. JADA).3 However, they have remained relevant in non-OB settings and institutions with limited obstetrical support.4-6 This simulation aims to address a gap in training for PAH for emergency medicine residents, focusing on the placement of the Bakri balloon. Educational Objectives:By the end of this simulation, learners should be able to: 1) recognize signs of post-abortion hemorrhage, 2) manage hemorrhage using appropriate physical maneuvers, uterotonic medications, and specialist consultation, 3) demonstrate proper placement of a Bakri balloon. Educational Methods:This single-center, high-fidelity simulation was conducted at a tertiary care academic center. Simulation was chosen as the best way to teach this topic because it allows a psychologically safe environment to practice a scenario which involves high-level critical thinking and fine-motor skills that would otherwise degrade under stress during a real patient encounter. Research Methods:Pre- and post-simulation surveys were administered, including Likert-scale questions on comfort with the management and procedures included, and a multiple-choice knowledge assessment. Twenty-eight individuals completed the pre-simulation learner evaluation, and 31 completed the post-simulation learner evaluation. Likert-scale data was treated as ordinal (1 = strongly disagree, 5 = strongly agree) and analyzed using the Mann-Whitney U Test. The multiple-choice knowledge assessment was analyzed using a paired T-test. Results:The simulation included 29 emergency medicine residents, four MS3 students, four MS4 students, and three junior EM PA fellows. This case was used eight times during the session. The simulation lasts approximately 20 minutes. There were statistically significant improvements across all measures. On a 5-point Likert scale, comfort in placing a Bakri balloon increased from 2.35 to 3.97 (U = 82, z = 5.34, P < 0.01); comfort in managing postpartum/abortion hemorrhage rose from 3.11 to 3.90 (U = 197, z = 3.59, P < 0.01), and recognition of hemorrhage signs increased from 3.96 to 4.39 (U = 278, z = 2.36, P = 0.02). Mean scores on the multiple-choice knowledge assessment improved from 55.79% to 90.52% (t(18) = -5.23, P < 0.001) pre- and post-intervention. Discussion:This simulation successfully addressed the gap in the educational materials available to address the learning of the recognition and management of PPH/PAH, including the placement of intrauterine balloon devices. The simulation increased learners' comfort in managing PAH and placing Bakri balloons. While effective for immediate skills/knowledge acquisition, this is a high-acuity, low-occurrence procedure that requires repetition and deliberate practice for more durable learning. Topics:Postpartum hemorrhage, post-abortion hemorrhage, Bakri balloon, uterine tamponade, simulation training.
Audience:This clinical decision-making (CDM) case is intended for emergency medicine (EM) residents of all levels. Introduction:About 700,000 patients every year in the United States experience an acute ischemic stroke.1 Morbidity and mortality from an ischemic stroke may be limited from timely diagnosis and acute management, including specialist involvement, appropriate blood pressure control, and evaluation for possible thrombolytic therapy. EM residents should be familiar with stroke management principles whether they work in an academic, community, or rural setting. Educational Objectives:By the end of this clinical decision-making case, learners will be able to: 1) demonstrate familiarity with the CDM case format and case play, 2) describe important historical information to obtain when suspecting an acute stroke, 3) outline key diagnostic tests to rule out other causes of acute neurologic deficits, 4) outline acute management strategies for acute ischemic stroke, 5) propose an appropriate disposition plan for patients with an acute ischemic stroke. Educational Methods:This is a clinical decision-making boards case as outlined by the American Board of Emergency Medicine (ABEM). Each learner was paired with one instructor for the case, a scoring checklist by the instructor was used, structured debriefing time was incorporated into the assessment, and learners were given the opportunity to provide qualitative feedback after the case. Research Methods:Each CDM case session lasted approximately 25 minutes, with 15 minutes for the case and 10 minutes for debriefing and feedback. A 26-point critical action checklist was developed to evaluate each learner's performance, with each point reflecting an equally weighted item. Learners then provided verbal feedback on the cases to the examiners at the conclusion of their assessments. Results:Thirty-nine categorical emergency medicine residents participated as learners for this clinical decision-making session, including 10 third-year residents, 12 second-year residents and 17 first-year residents. The average overall score was 17.3 of 26 possible points. Performance with respect to postgraduate year (PGY) is as follows: 17.7 for PGY-3s, 18.8 for PGY-2s, and 15.9 for PGY-1s. One resident had a perfect score. Discussion:Performance of our learners varied and unexpectedly, our second-year residents outperformed our third-year residents. This is likely due to our PGY-2 learners being responsible for the primary care of stroke patients in our department, which makes their identification and management of acute ischemic stroke patients likely more recently retrievable. Topics:Emergency medicine, neurology, acute ischemic stroke.
Blunt cerebrovascular injury (BCVI) is defined as blunt traumatic injury to the carotid or vertebral vessels. Although rare, understanding risk factors and management of possible complications is vital in the emergency department (ED) setting since BCVI is associated with ischemic stroke and potential for poor neurologic outcome or death. In this case, a 27-year-old female patient presented with headache following a motor vehicle collision. Computed tomography angiography (CTA) of the neck revealed a right internal carotid artery dissection. Despite the injury, the patient was largely asymptomatic besides headache and discharged on acetylsalicylic acid (ASA) 81 mg to prevent stroke. Follow-up CTA one week later revealed worsening of the carotid dissection and a new vertebral artery dissection. The patient was admitted and received a diagnostic cerebral angiogram that elucidated the extent of her vascular injuries. The patient was discharged on ASA 325 mg and was followed for 27 months with no further neurological symptoms. Blunt cerebrovascular injury is a potentially life-threatening, yet often underrecognized, injury that occurs in the carotid or vertebral arteries. It is most often associated with high-energy trauma. Up to 80% of patients with BCVI are initially asymptomatic, and effective screening is important for timely diagnosis. Computed tomography angiography is the preferred choice for initial screening and diagnosis of BCVI. Treatment may involve surgical repair, endovascular intervention, and antithrombotic therapy. Topics:Blunt cerebrovascular injury (BCVI), carotid artery dissection, vertebral artery dissection, computed tomography angiography (CTA), case report.
Audience:This auricular hematoma task trainer is designed to instruct emergency medicine (EM) residents, fellows, and medical students. Otolaryngology trainees may also benefit from this simulator. Introduction:Auricular hematomas are relatively infrequent but require timely intervention to prevent complications such as infection, cartilage necrosis, or permanent ear deformity ("cauliflower ear").1 Although these injuries make up only a small part of all otologic complaints in the emergency department, they are one of the most frequent ear injuries in contact sports, with wrestlers, boxers, and rugby players being the most at-risk.2 Not only can they occur in sports, one urban level I trauma review found 42% of auricular hematoma presentations were due to interpersonal violence or assault,3 making timely drainage a core skill now listed in the 2022 Model of the Clinical Practice of Emergency Medicine.4 EM residents often have limited opportunities to gain hands-on experience with this procedure in a controlled learning environment, with a low reported baseline confidence level highlighting a persistent training gap.5 Traditional models are expensive and single-use, with each one costing up to $60-100.6 This innovation was developed to address a training gap by providing a simple, affordable, and reproducible task trainer that enables learners to practice landmark identification, drainage, and post-procedure care of auricular hematomas with confidence. Educational Objectives:By the end of this session, learners will be able to: 1) identify the landmarks used to drain auricular hematomas, 2) demonstrate the ability to numb, incise, and drain an auricular hematoma, and 3) review methods for applying dressings to auricular hematomas. Educational Methods:Residents were given a five-minute in-person demonstration of how an auricular hematoma is drained using one of the models. They were then able to walk through the steps of incising, draining, and dressing the ear themselves using material found in the emergency department. The EMRAP instructional video was reviewed by the attending conducting the demonstration prior to teaching.7. Research Methods:Eleven participants were instructed to incise and drain an auricular hematoma. The Michigan Standard Simulation Experience Scale (MiSSES) was used for anonymous feedback on the task trainer immediately after the simulation. Participants scored the simulator in five categories: Self-efficacy, fidelity, educational value, teaching quality, and the overall rating on a 5-point Likert scale, 1 = Strongly Disagree, 5 = Strongly Agree. The scale is a freely available, validated subjective-assessment tool created at the University of Michigan to standardize the evaluation of simulation-based education. In the scale, there are six domains for evaluation, and they demonstrated good internal consistency at initial psychometric testing.8 Variables were summarized using the mean and standard deviation. Results:The eleven participants were composed of 7 PGY 1 EM residents and 4 EM attendings. They all completed the simulation and filled out the MiSSES form. Of the residents, none had any previous experience with auricular hematoma drainage. Of the attendings, all had done one previously, but none more than 3. Using the MiSSES, the model received an overall positive rating of 5.0. The highest rating was on teaching quality (5.0) and educational value (5.0). For fidelity, the trainer received a 4.9/5. Discussion:Overall, the residents felt that this simulation was a good training tool for auricular hematoma, which is a lower occurrence but time-sensitive procedure. We created a reusable and cheap simulator model that scored high in a standard simulator's assessment survey. Topics:Auricular hematoma, incision and drainage, cauliflower ear.
This case report highlights a unique presentation of a prosthetic joint infection. A 63-year-old female presented to the emergency department for right knee pain after falling three months earlier, shortly after a total knee arthroplasty. On exam, she was found to have a chronically dehisced wound with exposure of her femur, prosthetic, and overlying cellulitis. She was started on intravenous antibiotics and admitted to the orthopedic surgery service for an above-the-knee amputation. Her unusually delayed presentation and repeated refusal of operative management were heavily influenced by social determinants of health, including polysubstance use, lack of caregiver support, and housing instability." This uncommon presentation of chronic dehiscence and prosthetic joint infection provides an opportunity to review the management of prosthetic joint infections compared to native joint septic arthritis, how socioeconomic factors drive patient outcomes, and a discussion on medical capacity. Topics:Wound dehiscence, chronic dehiscence, prosthetic joint infection, septic joint, total knee arthroplasty, social determinants of health, medical capacity.
A 49-year-old male presented to the emergency department (ED) with bilateral knee pain that began after a mechanical fall down several steps. He states that he fell in such a way that both knees were flexed while he was in the air, which he described as a "flying prayer" position, and he landed with all his weight onto his flexed knees. He did not immediately seek medical care but instead wore knee braces and used crutches to ambulate. This resulted in multiple other falls due to persistent pain and lack of mobility. He was seen at an outside facility prior to presenting to our ED and was reportedly diagnosed with severe arthritis based on x-ray imaging and told he may have a minor quadriceps tendon injury. No other imaging was performed at that time. Due to continued pain, he presented to our ED where we utilized point-of-care ultrasound (POCUS) which revealed the presence of bilateral full-thickness quadricep muscle and tendon tears. He was treated with surgical repair of his quadriceps tendons and had an uncomplicated postoperative course. This case report highlights the importance of ultrasound in diagnosing musculoskeletal injuries and improving patient outcomes. We also summarize POCUS findings that emergency physicians can use to diagnose quadriceps muscle and tendon tears. Topics:Point-of-care ultrasound (POCUS), musculoskeletal ultrasound, tendon rupture, fall. Hines J, et al. A Case Report of Rare Bilateral Quadriceps Tendon Rupture Diagnosed by Point of Care.
Audience:This guided small group exercise is suitable for medical students who have completed basic lectures on electrocardiogram (EKG) interpretation. This activity was created for use within a third year required Emergency Medicine (EM) clerkship but can be implemented in other undergraduate medical education settings as well. Introduction:Electrocardiogram (EKG) interpretation is poorly understood by medical students,1 and trainees display a concordant lack of confidence in their interpretation skills which can carry into fourth year of medical school and residency.2,3,4 Improving learner confidence and competence in identification of arrhythmias is of paramount importance to improve patient care.5,6 Our workshop targets the recognition and management of dangerous arrhythmias frequently seen in the Emergency Department. Educational Objectives:By the end of this session, learners will be able to: 1) identify common tachyarrhythmias and pulseless rhythms using EKGs, 2) differentiate stable from unstable tachyarrhythmias based on hemodynamics, symptoms, and EKG findings in acutely ill ED patients, 3) apply appropriate critical resuscitative actions to manage stable tachyarrhythmias, unstable tachyarrhythmias, and pulseless rhythms during emergency department resuscitations, in accordance with ACLS (Advanced Cardiopulmonary Life Support) principles, and 4) construct a rapid, ED-focused decision-making algorithm to guide the identification and management of tachyarrhythmias and pulseless rhythms. Educational Methods:Learners participated in an interactive EKG workshop interspersed with lectures, EKG interpretation exercises, and case-based learning activities. During the workshop, students constructed a tachyarrhythmia and pulseless algorithm that will enable students in the future to identify and manage sinus tachycardia, supraventricular tachycardia (SVT), atrial fibrillation ( A fib ), atrial flutter, ventricular fibrillation (VF) and ventricular tachycardia (VT). Students collaborated in small groups, receiving real-time feedback from the facilitator on all activities. Research Methods:Since this curriculum was designed for research purposes, learners completed a pre-test prior to starting this session and a post-test once the session concluded. This EKG pre/post-test was developed alongside the workshop curriculum to address the concerns identified in the needs assessment. The test was validated through testing on PGY1-3 EM residents. Confidence was assessed using Likert-scales of 1 (not at all confident) to 5 (extremely confident). Retention was assessed four weeks after completing the workshop using the same post-test. This study was Institutional Review Board (IRB) exempt. Results:Pre and post-test results were analyzed for 69 students that were divided across four cohorts. Students averaged a pre-test score of 74% and post-test score of 87.75%. This post-test score was maintained at the four-week reassessment with an average score of 86% (24.6% response rate).Confidence was measured by defining Likert scores of 1-3 as being "not confident" and 4-5 as "confident." On the pre-test, student confidence in identifying ventricular tachycardia was 52%, identifying a shockable rhythm 38%, and identifying features of instability 16%. On the post-test, student's confidence in identifying ventricular tachycardia rose to 96%, shockable rhythms to 93%, and features of instability to 90%. Discussion:Active small-group EKG workshops enhance learners' confidence and competence in recognizing and managing clinically significant arrhythmias in the emergency department. This learning exercise has become a staple of our required third-year EM clerkship and continues to show high learner satisfaction. Topics:EKG, arrythmias, tachyarrhythmia, atrial fibrillation, ventricular tachycardia, PEA, asystole, ventricular fibrillation, atrial flutter, supraventricular tachycardia, undergraduate medical education, learner confidence, learner competence.
Midgut volvulus is a rare finding in adults, especially those without a known history of congenital gastrointestinal abnormalities. This is a case of a 78-year-old man who presented to the Emergency Department (ED) with two weeks of intermittent, postprandial abdominal bloating and pain. His examination was notable for tachycardia and mild abdominal distention. On computed tomography angiography (CTA), he was found to have midgut volvulus and underwent emergent exploratory laparotomy with Emergency General Surgery (EGS) where his bowel was found to be twisted clockwise around the mesentery. This case report highlights the diagnosis and treatment of a patient with the relatively uncommon diagnosis of midgut volvulus. In this report, we describe the patient's presentation, important imaging findings, and key management principles for midgut volvulus. Topics:Volvulus, Midgut volvulus, abdominal pain.
Audience:The target audience for this video is any provider who is likely to experience patient death. We have demonstrated this method to medical students, residents, and faculty and across departments and disciplines of health care including physician assistants and nurses. Introduction:Emergency medicine (EM) physicians frequently encounter patient death, requiring effective coping strategies. Brief mindfulness practices, including focused breathing, can promote emotional regulation and reduce perceived stress. These techniques are particularly relevant in acute care settings where rapid cognitive and emotional transitions are required.1 While techniques such as "The Pause"-a moment of silence after death-have been proposed, their impact remains understudied. 2-4 In addition to the Pause Method, many physicians at our institution utilize the "Three-Breath Guided Meditation" technique, a structured deep-breathing exercise designed to help reduce stress. This study aimed to assess EM physicians' perceived ability to process patient death, explore coping strategies, and evaluate the effectiveness of both "The Pause" and the "Three-Breath Method." Educational Objectives:After watching the video, proposed viewers should be able to: 1) describe the Three-Breath technique, and its potential impact on healthcare providers' ability to manage stress and process patient death, 2) evaluate the effectiveness of the Three-Breath guided meditation in improving emotional reconciliation and reducing stress for emergency medicine physicians, and 3) demonstrate the Three-Breath technique and implement it into their own practice. Educational Methods:Emergency medicine residents and faculty were invited via email to watch a 4-minute instructional video on the Three-Breath Technique. This video lecture was made available asynchronously, and participants were encouraged to watch the video at a time that was suitable to them. Research Methods:Emergency medicine residents and attending physicians completed a mixed-methods questionnaire on their coping abilities after patient death. The survey included baseline experiences, coping practices, comfort levels, and the 4-minute instructional video. Responses were analyzed using descriptive statistics, Spearman's correlation for continuous variables, and thematic analysis of free-text data. Results:Of 79 invited EM physicians, 49 responded (62%), including 39% attendings and 61% residents (median age 33.5 years, 53% male, 47% female). A weak correlation was found between training level and perceived ability to process death (r=0.27), with attending physicians reporting greater comfort (mean = 4.45) than residents (mean = 3.75). Perceived ability to process death moderately correlated with comfort returning to work (r=0.55). Overall, 59% used the Pause or Three-Breath techniques, and 94% reported comfort coping after patient death. Discussion:Physicians' comfort in processing patient death increases with training level, with attendings feeling more prepared than residents. Most providers use the Pause1-3 or Three-Breath Method and report comfort in coping. However, the study's single-institution scope, modest sample size, and reliance on self-reported data may limit generalizability. Future efforts should be expanded to additional specialties and emphasize flexibility and individualized strategies to support emotional well-being in clinical practice.The Three-Breath guided meditation technique, as an extension of The Pause,2-4 is being widely adopted by physicians at one US academic institution and may enhance physicians' ability to process patient death, promoting emotional reconciliation and stress reduction in high-pressure healthcare environments. Topics:Physician coping with patient death, coping strategies, novel coping strategy, emotional resilience.
Audience and type of curriculum:This curriculum is designed to prime pre-medical-field undergraduate students with medical research concepts and skills necessary to assist Emergency Medicine (EM) residents on clinical research projects in a community hospital setting. Length of curriculum:The PRIMER lecture series should run two to three days with six hours of lecture content to be covered. Project completion and poster presentation should take 8-16 weeks depending on time constraints, resources, and project scope. Introduction:Scholarly research has taken an increasingly prominent role in both undergraduate and graduate medical education. However, researchers and clinician-teachers can be limited in productivity due to lack of funding, time, and formalized infrastructure. This can result in siloed activities, incomplete or unrealized ideas, and often make research challenging for student and resident physicians alike.1 These barriers to participating in scholarly research are further exacerbated for those in community-hospital-based residencies and community- or rural-medicine educational tracks because these facilities have further reduced access to research personnel and resources.2, 3 Simultaneously, research literacy and experience are becoming increasingly critical qualifications for admission to professional medical educational programs.4,5 Developing structured research training and mentorship for premedical students in community hospital settings can simultaneously enhance residents' research capacity and provide premedical students with critical experience and exposure needed for medical school admission. Educational Goals:The purpose of this project is to design a didactic training to provide undergraduate research assistants the necessary training to enhance resident research projects in the emergency department. Educational Methods:The educational strategies used in this curriculum include: 1) Blended learning of in-person lectures and online readings and resources implemented in a three-day workshop to provide foundational research knowledge, skills, and resources to research assistants before beginning projects, 2) Experiential learning implemented in workshops interspersed through the three-day intensive, allowing students to begin literature searches, compose IRB proposals, and develop data management and analysis plans that apply to their assigned research project, and 3) Group Learning where students develop action plans, communication, and presentation skills. Research Methods:The educational outcomes were quantitatively and qualitatively analyzed by administration of a pre- and post-test and self-evaluation using a 5-item Likert scale as well as the completion of project and presentation of poster. Average examination scores and self-evaluation scores were analyzed for trends. Learner feedback was collected concurrently with the final assessment. Results:Average pre-test and self-evaluations scores were 3.29 ± 1.11 out of 7 and 11.0 ± 1.63 out of 20, respectively. Average post-test and self-evaluation scores increased dramatically to 5.71 ± 0.95 and 17.86 ± 1.77, demonstrating student acquisition of concepts and increased confidence in their knowledge of medical research. End-of-program scores were 6.43 ± 0.53 and 17 ± 1.15, respectively, and demonstrated good concept retention and retained confidence. Discussion:The PRIMER model serves to both increase the capacity for resident-driven research in community hospital settings and provide pre-professional students with training and experience to help matriculate and succeed in medical programs. Resident physicians (PGY1-PGY4, n=15) indicated that the PRIMER program would be very helpful in designing (n=12), implementing (n=12), and completing (n=13) a research project. We were successful in implementing the program with three of four projects completed in the initial time frame planned. One project was not completed, and one contributing factor was resident vacation time. Future iterations in our program will consider the full resident schedule for the duration of the program. Research assistants feedback suggested improvements on coordinating resident schedules (vacation and graduation) with the program. We plan to implement the program two to three times each year to accommodate the overwhelming undergraduate interest and further enhance our residents' ability to ask clinically relevant research questions and explore those results in a community-based EM program. Topics:Medical research, statistics, data analysis, mentorship, data management, research ethics.
Children presenting to emergency departments who are found to have flat, round esophageal foreign bodies (FB) are often transferred to sites capable of foreign body removal. Coins are the most common FBs ingested in pediatric patients. However, button battery (BB) ingestions are a high-risk esophageal FB that can lead to severe injury. It is imperative to distinguish between these two radiographically similar objects to ensure expedited removal of BBs. The halo sign and step-off sign are characteristic of BBs. The presented case demonstrates an exception, where a coin stack (CS) mimicked a BB. A six-year-old female arrived at a tertiary care center as a transfer from an outside hospital with concern for BB ingestion. Her presenting symptoms were vomiting, gagging, and drooling. Her chest x-ray showed a radio-opaque, esophageal FB with halo and step-off signs. The circular FB was urgently removed and proved to be a nickel overlying a quarter. Due to the relative rarity of CSs and the difficulty to radiologically distinguish from high-risk BBs, CSs should be treated as BB ingestions-the FB should be removed urgently, and the final object identification should be determined operatively. Topics:Button battery, halo sign, step-off sign, coin stack, esophageal foreign body.
Acute aortic dissection (AAD) typically presents with sudden, severe chest or back pain. This case highlights an atypical painless presentation that was rapidly progressive and lethal. A 55-year-old woman presented with generalized weakness, agitation, and shortness of breath, but without pain. Initial point-of-care ultrasound (POCUS) was reassuring, but persistent agitation and emerging abdominal tenderness prompted reexamination and repeat POCUS, which revealed evidence of aortic dissection. Computed tomography angiogram (CTA) confirmed the diagnosis of a Stanford Type A dissection. Despite aggressive resuscitative efforts, the patient's condition deteriorated rapidly. This case emphasizes the importance of observant reassessment and repeating POCUS in atypical presentations of AAD because subtle clinical changes can reveal life-threatening conditions such as aortic dissection. Topics:Acute aortic dissection, abdominal aortic dissection, painless aortic dissection, atypical presentation, point-of-care ultrasound reassessment, diagnostic ultrasound.
Cerebral venous thrombosis (CVT) is an uncommon occurrence, but it carries significant morbidity.1 CVT symptoms overlap with other common emergency department conditions, and it requires a specific neuroimaging for accurate detection, making this diagnosis a significant challenge for emergency clinicians. We present a case of a 20-year-old postpartum woman with a history of a post-dural puncture headache following a spinal block with worsening headache and disequilibrium. She was found to have a cerebral venous thrombosis on non-contrast head CT and CT venogram of the head. Her course was uncomplicated with appropriate symptom control while on anticoagulation. We review her CT imaging findings and provide a brief review of the current recommendations and literature on CVT. Topics:Cerebral venous thrombosis, empty delta sign, CT venogram, headache, dural sinus thrombosis.
Audience:This innovation is designed for first- and second-year medical students seeking early exposure to core procedural skills relevant to emergency medicine. Introduction:Early procedural training opportunities are limited in preclinical medical education, leaving students underprepared and lacking confidence in essential clinical skills.1 Simulation-based procedural instruction has proven effective for residents and senior students, but preclinical learners often lack similar access.2 Procedurepalooza was developed to address this gap by providing a scalable, low-cost, hands-on workshop introducing foundational procedural techniques in a supportive, high-engagement environment. Prior studies demonstrate that early procedural exposure improves confidence and skill acquisition; however, structured opportunities for preclinical learners remain limited.3. Educational Objectives:By the end of the Procedurepalooza instructional session, learners will be able to: 1) recognize appropriate clinical indications for six foundational procedural skills commonly performed in emergency and acute care medicine, including intravenous (IV) placement, suturing, splinting, point-of-care ultrasound, airway management, and electrocardiogram (ECG) interpretation, 2) demonstrate proper technique in each procedure under guided supervision, emphasizing safety and ergonomics, and 3) perform core procedural steps through repeated hands-on practice in a structured small-group environment. Educational Methods:Procedurepalooza is a half-day, multi-station workshop teaching six essential procedural skills: intravenous (IV) placement, suturing, splinting, point-of-care ultrasound, airway management, and electrocardiogram (ECG) interpretation. Learners rotate through small-group stations (6-10 students) in 20-minute intervals, guided by faculty or senior residents. The workshop is designed for adaptability across institutions, requiring only basic equipment and reusable materials. The session was conducted as a live, hands-on workshop within the preclinical curriculum using a standardized small-group rotation model.2. Research Methods:A pre- and post-event survey assessed self-reported procedural confidence across the six skills using a 5-point Likert scale. Participation was voluntary and anonymous. Quantitative analysis compared mean confidence ratings pre- and post-event. Results:Procedurepalooza has been conducted annually since 2012, consistently attracting strong student participation and faculty engagement. In one representative implementation, 148 students participated, and 102 completed both pre- and post-event surveys (70% response rate). Statistically significant improvements were observed across all procedural domains (P < 0.001). The largest gains occurred in intravenous (IV) placement (+1.80) and suturing (+1.68). Qualitative feedback emphasized the event's accessibility, supportive teaching environment, and value in preparing students for clinical rotations. Discussion:Procedurepalooza significantly improved learner confidence in procedural skills through an engaging, reproducible, and low-cost format. While this event demonstrated improved procedural confidence, prior work shows that structured skills training enhances long-term procedural performance and that simulation-based education is associated with improved patient-related outcomes. Although we did not assess downstream proficiency, the combination of increased confidence and learner engagement suggests that early procedural exposure may support future clinical skill development.4,5 Its design promotes scalability and sustainability, making it suitable for institutions seeking to enhance preclinical procedural training with limited resources. Because Procedurepalooza also introduces preclinical students to emergency medicine earlier in their training-an experience typically deferred until later clinical years-this may anecdotally increase student interest in pursuing the specialty. Topics:Procedural skills, simulation, airway management, ultrasound, suturing, medical education innovation, emergency medicine.
Audience:This simulation is intended for second-year medical students who are in the pre-clinical phase of their medical school curriculum. This case is delivered as part of a longitudinal simulation-based curriculum that aligns with concurrent didactic instruction in the cardiopulmonary systems course. Introduction:Pneumothorax is a potentially life-threatening condition that requires urgent attention and intervention, particularly in the setting of trauma.1 Traumatic pneumothorax has been reported in up to one-third of patients presenting with blunt chest wall injury.2 If left unrecognized or inadequately treated, this may progress to a life-threatening tension pneumothorax, resulting in severe respiratory compromise and obstructive shock with hemodynamic instability. Early familiarity with structured trauma assessment and recognition of time-sensitive cardiopulmonary deterioration represents a foundational skill for learners entering clinical training.This case emphasizes critical actions central to emergency medicine practice, including high-flow oxygen delivery and the use of ultrasound to guide timely procedural intervention. It is also designed to introduce medical students to fundamental principles of trauma assessment and management, which are often not directly assessed in pre-clerkship curricula.3 Prior studies have demonstrated that early exposure to simulation-based trauma training improves learner confidence and clinical preparedness,4,5 supporting the use of this structured trauma scenario. Educational Objectives:By the end of this simulation, learners will be able to: 1) obtain a focused history in the setting of recent motor vehicle accident and respiratory difficulty, 2) identify abnormal respiratory findings consistent with pneumothorax on physical exam, 3) interpret chest x-ray and point-of-care ultrasound to identify the progression of a life-threatening tension pneumothorax,4) assess for potential internal bleeding and hypovolemic shock by integrating imaging findings, vital signs, mental status, and additional components of physical examination, 5) interpret imaging and clinical findings to guide appropriate management decisions, including need for urgent procedural intervention and escalation of care, and 6) deliver a concise oral presentation to an attending physician, including key findings and management plan. Educational Methods:This case is conducted using a high-fidelity simulation environment that includes a standardized nurse, vital sign monitoring, a mannequin, and video display for diagnostic imaging (chest x-ray and point-of-care ultrasound findings). The simulation case is structured around the ABCDE (airway, breathing, circulation, disability, exposure) approach to trauma assessment, encouraging learners to prioritize stabilization during an evolving clinical presentation.6 Through this scenario, learners are guided toward integrating history-taking, physical examination findings, and point-of-care diagnostics to identify and initiate management of a traumatic pneumothorax. The case also highlights core elements of acute care management including high-flow oxygen delivery, use of ultrasound, and timely coordination of procedural intervention.This simulation was developed using the principle of instructional scaffolding, in which learners progress through a structured pathway toward key clinical objectives.7 For this case, scaffolding is operationalized through facilitator cues, prompts from confederate actors, and dynamic changes in patient status (vital signs and mannequin responses) based on learner interventions. This approach was chosen because it allows learners to make independent clinical decisions within a guided framework and enhances reproducibility of the case. Research Methods:This simulation was piloted with a group of medical students participating in a simulation-based elective curriculum. Learner performance was assessed using a structured critical actions checklist developed by the authors based on relevant literature in simulation-based assessment8 and refined by an emergency medicine physician and a simulation education specialist. The checklist was designed to capture completion of key team-based clinical actions and to facilitate targeted feedback during debriefing, consistent with established best practices in simulation-based education.8The educational efficacy of the case was evaluated through structured debriefing, facilitator observation, and post-session learner feedback. Learner comments and facilitator observations were used to refine the simulation script, standardize nurse prompts, and pace the case. Results:The learner group involved in the case pilot consisted of four pre-clerkship medical students (n=4). The learner group independently completed five of seven predefined key action items, including obtaining a focused history, performing a complete physical exam, ordering point-of-care diagnostic imaging, interpreting chest radiograph findings consistent with tension pneumothorax, and delivering a concise presentation to the attending physician. Learners required prompting from confederates to escalate oxygen delivery and recognize the need for needle decompression.Learners rated the simulation highly for clinical relevance, realism, and educational value (median of 5 on 5-point Likert scale, range 4-5). Three of four learners (75%) reported increased confidence in approaching similar scenarios and all learners (100%) reported improved understanding of FAST exam interpretation, primary trauma survey, and pneumothorax management. Discussion:This case successfully integrates clinical reasoning and team communication within a high-acuity simulation. This represents a novel addition to the medical school's simulation curriculum because it is the first scenario in the pre-clerkship program to focus on the structured primary survey and acute management of a trauma patient. Learners benefitted from the scaffolded approach to airway assessment, application of point-of-care diagnostics, and emphasis on collaborative decision-making in a high-acuity setting. Topics:Pneumothorax, trauma, ultrasound, FAST exam, respiratory distress, primary survey, acute care, medical education, simulation.
This case report highlights the rapid and sensitive diagnostic capabilities of a right upper quadrant (RUQ) ultrasound to diagnose pneumoperitoneum secondary to a hollow viscus rupture. The patient was a 55-year-old male with sudden onset epigastric and right upper quadrant pain. Symptoms were concerning for either acute cholecystitis and gastric ulcer or perforation. Immediate point of care ultrasound (POCUS) of the RUQ showed no signs of acute cholecystitis but showed concerning findings of intraabdominal free air given the enhanced peritoneal stripe sign, reverberation, and ring down artifacts. The radiologist did not note any signs of free air on the interpretation of the formal ultrasound. Eventually, the chest X-ray and computed tomography (CT) of the abdomen and pelvis showed air under the right diaphragm, fluid in the porta hepatis, and multiple foci of pneumoperitoneum. Broad spectrum antibiotics and fluid resuscitation were given. General surgery performed an emergency diagnostic laparotomy with repair of duodenal ulcer perforation. Upper gastrointestinal (GI) study on post-operative day three showed no complications, and patient has been doing well in follow-up clinic visits. In this case report, immediate recognition of signs of pneumoperitoneum would have expedited the treatment and management of the duodenal perforation. Although our emergency department was able to perform a CT scan of the abdomen and pelvis and have it read within two hours, this may not be possible in all emergency departments. Therefore, the use of POCUS in the evaluation of abdominal pain can identify potentially disastrous time-dependent pathology. It would be beneficial for emergency physicians to learn the signs of pneumoperitoneum on ultrasound since this requires emergent surgery. Topics:Hollow viscus perforation, ultrasound, pneumoperitoneum, point-of-care ultrasound (POCUS).
Open globe injury is defined as a full-thickness injury through all anatomical layers of the eye. Prolapse or herniation of the iris may be observed at presentation of an open globe injury, and iris prolapse is not well represented in the literature. This case report details the case of a 48-year-old male presenting with three hours of right eye pain after sustaining a traumatic injury due to a foreign body. Examination of the right eye revealed a 2 mm x 1 mm laceration to the 4-5 o'clock position with iris prolapse and plugging. The affected eye also revealed a teardrop-pupil with associated corectopia in the inferonasal direction and a 2 mm hyphema. The patient was diagnosed with a globe rupture and underwent same-day surgical intervention. This report emphasizes the use of fluorescein eye exams and explains the rationale against the measurement of intraocular pressures or removal of an obvious foreign body. The care provided represents strict adherence to the principles of management in ocular trauma and a positive outcome in which a patient’s vision and visual acuity were relatively maintained.
