Introduction: Recruiting a physician to a rural area is expensive. However, it is even more costly and devastating to the community when a practitioner leaves. Our team aimed to identify factors that may influence physicians' decisions to remain in a rural community, as well as those that may cause them to leave, and to gather real-world perspectives on what is needed to improve their community's health. Methods: This case study used a 13-item survey with multiple-choice and narrative response options, which was sent to physicians in rural areas throughout New Mexico, USA. It incorporated both qualitative and quantitative data. The first 10 questions were demographic indicators. The remaining questions assessed what drew respondents to the area, and why, or why not, they would consider leaving this location. Short-answer responses were categorized as intrinsic or extrinsic and then grouped into common themes. Results: We achieved a response rate of 33.4%. Physicians were primarily drawn to practice in rural New Mexico for extrinsic reasons, with geographic location being the most common cause, followed by financial incentives. There were no intrinsic reasons for remaining. Conclusions: In New Mexico, 32 of the 33 counties are considered medically underserved. Retaining physicians to practice in these areas is vital. This case study demonstrates that the intrinsic motivations that initially draw physicians to practice in these rural areas may be overpowered by the extrinsic factors influencing their decision to leave.

BACKGROUND:Health care professionals are in a unique position to enact health-related social change. Medicine is subject to regulation at the organizational, local, state, and national levels. Federal laws apply to physicians throughout the US; as such, federal policy affects physician practice intentions similarly. However, there is little research on state-level engagement in the political process and none on the participation by family medicine physicians. METHODS:This article examines the nature of physician civic engagement at the state level. Data were gathered and analyzed as part of the 2023 Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) survey of Family Medicine educators and practicing physicians. We used nonparametric statistics (Kruskal-Wallis tests) to analyze ordinal variables. Categorical variables were analyzed using χ2 tests. We used multivariable ordinal logistic regression to assess the joint effects of participant characteristics on study outcomes and to adjust for potential confounding. RESULTS:The policy question section of the survey received 709 responses, a response rate of 21%. Our results show a lack of civic engagement, including less than a third voting in state elections and only 4% making financial contributions to political campaigns. Seventeen percent of respondents reported considering relocating due to state health policies. For all questions, we observed variations by geographical region and gender. CONCLUSIONS:Our findings provide a timely analysis of family medicine physician participation in the political process, the effect of specific health policies, and how these policies are comparatively received among family medicine physicians in the United States.

IntroductionForeign body airway obstruction (FBAO) is a life-threatening condition. We aimed to quantify the impact of bystander FBAO interventions on survival and neurological outcomes.MethodsWe conducted a Japan-wide prospective, multi-center, observational study including all FBAO patients who presented to the Emergency Department from April 2020 to March 2023. Information on bystander FBAO interventions was collected through interviews with emergency medical services personnel. Primary outcomes included 1-month survival and favorable neurologic outcome defined as Cerebral Performance Category 1 or 2. We performed a multivariable logistic regression and a Cox proportional hazards modeling to adjust for confounders.ResultsWe analyzed a total of 407 patients in the registry who had the median age of 82 years old (IQR 73 to 88). The FBAO incidents were often witnessed (86.5%, n = 352/407) and they intervened in just over half of the cases (54.5%, n = 192/352). The incidents frequently occurred at home (54.3%, n = 221/407) and nursing home (21.6%, n = 88/407). Common first interventions included suction (24.8%, n = 101/407) and back blow (20.9%, n = 85/409). The overall success rate of bystander interventions was 48.4% (n = 93/192). About half (48.2%, n = 196/407) survived to 1-month and 23.8% patients (n = 97/407) had a favorable neurological outcome. Adjusting for pre-specified confounders, bystander interventions were independently associated with survival (hazard ratio, 0.55; 95% CI, 0.39 to 0.77) and a favorable neurological outcome (adjusted OR, 2.18; 95% CI, 1.23 to 3.95).ConclusionBystander interventions were independently associated with survival and favorable neurological outcome, however, they were performed only in the half of patients.

Introduction: The United States lacks a national interfacility patient transfer coordination system. During the coronavirus 2019 (COVID-19) pandemic, many hospitals were overwhelmed and faced difficulties transferring sick patients, leading some states and cities to form transfer centers intended to assist sending facilities. In this study we aimed to explore clinician experiences with newly implemented transfer coordination centers. Methods: This mixed-methods study used a brief national survey along with in-depth interviews. The American College of Emergency Physicians Emergency Medicine Practice Research Network (EMPRN) administered the national survey in March 2021. From September-December 2021, semi-structured qualitative interviews were conducted with administrators and rural emergency clinicians in Arizona and New Mexico, two states that started transfer centers during COVID-19. Results: Among 141 respondents (of 765, 18.4% response rate) to the national EMPRN survey, only 30% reported implementation or expansion of a transfer coordination center during COVID-19. Those with new transfer centers reported no change in difficulty of patient transfers during COVID-19 while those without had increased difficulty. The 17 qualitative interviews expanded upon this, revealing four major themes: 1) limited resources for facilitating transfers even before COVID-19; 2) increased number of and distance to transfer partners during the COVID-19 pandemic; 3) generally positive impacts of transfer centers on workflow, and 4) the potential for continued use of centers to facilitate transfers. Conclusion: Transfer centers may have offset pandemic-related transfer challenges brought on by the COVID-19 pandemic. Clinicians who frequently need to transfer patients may particularly benefit from ongoing access to such transfer coordination services. [West J Emerg Med. 2024;25(5)758-766.]

AimThe incidence and characteristics of thiopental‐related adverse events (AEs) in elderly patients during procedural sedation and analgesia (PSA) have not been well studied. We aimed to characterize thiopental‐related AE in elderly patients during PSA and compare the incidence of AE in elderly patients with non‐elderly adults.MethodsThis is a secondary analysis of the Japanese Procedural Sedation and Analgesia Registry (JPSTAR). We included all adult patients who received thiopental for PSA in the emergency departments and excluded patients who received concomitant sedative(s) in addition to thiopental or patients with missing body weight data. We compared the incidence of AE between the non‐elderly (18–64 years) and elderly groups (≥65 years).ResultsThe JPSTAR had data on 379 patients who received thiopental for PSA and included 311 patients for analysis. Most (222/311, 71.3%) were elderly. Cardioversion was the most common reason for PSA (96.1%). The AE incidence between groups overall was similar, however, hypoxia was significantly more frequent in the elderly compared with the non‐elderly group (10.3% versus 2.2%; adjusted odds 5.63, 95% confidence interval 1.27–25.0). The initial and total doses of thiopental were significantly lower in the elderly group than in the non‐elderly group (1.95 mg/kg versus 2.21 mg/kg and 2.33 mg/kg versus 2.93 mg/kg, respectively).ConclusionsAlthough elderly patients received lower doses of thiopental, hypoxic events were significantly more frequent in this group compared with the non‐elderly patients. However, the AE incidence was similar.

BackgroundAn ambulance traffic crash not only leads to injuries among emergency medical service (EMS) professionals but also injures patients or their companions during transportation. We aimed to describe the incidence of ambulance crashes, seating location, seatbelt use for casualties (ie, both fatal and nonfatal injuries), ambulance safety efforts, and to identify factors affecting the number of ambulance crashes in Japan.MethodsWe conducted a nationwide survey of all fire departments in Japan. The survey queried each fire department about the number of ambulance crashes between January 1, 2017, and December 31, 2019, the number of casualties, their locations, and seatbelt usage. Additionally, the survey collected information on fire department characteristics, including the number of ambulance dispatches, and their safety efforts including emergency vehicle operation training and seatbelt policies. We used regression methods including a zero-inflated negative binomial model to identify factors associated with the number of crashes.ResultsAmong the 726 fire departments in Japan, 553 (76.2%) responded to the survey, reporting a total of 11,901,210 ambulance dispatches with 1,659 ambulance crashes (13.9 for every 100,000 ambulance dispatches) that resulted in a total of 130 casualties during the 3-year study period (1.1 in every 100,000 dispatches). Among the rear cabin occupants, seatbelt use was limited for both EMS professionals (n = 3/29, 10.3%) and patients/companions (n = 3/26, 11.5%). Only 46.7% of the fire departments had an internal policy regarding seatbelt use. About three-fourths of fire departments (76.3%) conducted emergency vehicle operation training internally. The output of the regression model revealed that fire departments that conduct internal emergency vehicle operation training had fewer ambulance crashes compared to those that do not (odds of being an excessive zero -2.20, 95% CI: -3.6 to -0.8).ConclusionTwo-thirds of fire departments experienced at least one crash during the study period. The majority of rear cabin occupants who were injured in ambulance crashes were not wearing a seatbelt. Although efforts to ascertain seatbelt compliance were limited, Japanese fire departments have attempted a variety of methods to reduce ambulance crashes including internal emergency vehicle operation training, which was associated with fewer ambulance crashes.

Aim: Foreign body airway obstruction (FBAO) dueto food can occur wherever people eat, including in hospitals. We characterized in-hospital FBAO incidents and their outcomes.Methods: We searched the Japan Council for Quality Health Care nationwide in-hospital adverse events database for relevant events from 1,549 institutions. We included all patients with FBAO incidents dueto food in the hospital from January 2010 to June 2021 and collected data on the char-acteristics, interventions, and outcomes. FBAO from non-food materials were excluded. Our primary outcomes were mortality and morbidity from FBAO incidents.Results: We identified 300 patients who had a FBAO incident from food. The most common age group was 80-89 years old (32.3%, n = 97/300). One-half (50.0%, n = 150/300) were witnessed events. Suction was the most common first intervention (31.3%, n = 94/300) and resulted in success-ful removal of foreign body in 17.0% of cases (n = 16/94). Back blows (16.0%, n = 48/300) and abdominal thrusts (8.1%, n = 24/300) were less frequently performed as the first intervention and the success rates were 10.4% (n = 5/48) and 20.8% (n = 5/24), respectively. About one-third of the patients (31%, n = 93/300) died and 26.7% (n = 80/300) had a high potential of residual disability from these incidents.Conclusion: FBAO from food in the hospital is an uncommon but life-threatening event. The majority of patients who suffered from in-hospital FBAO incidents did not receive effective interventions initially and many of them died or suffered residual disability.

As rural hospitals find it difficult to staff their emergency departments with residency trained emergency physicians (EPs), we theorize residents exposed to emergency medicine practiced in rural settings during training are more likely to seek careers in these communities. However, the current availability of rural rotations among EM residencies is unknown. This investigation aimed to describe the prevalence of rural experiences offered across EM training programs and characterize both benefits and challenges of providing these experiences.

BACKGROUND AND OBJECTIVES:Health policy is more impactful for public health than many other strategies as it can improve health outcomes for an entire population. Yet in the "see one, do one, teach one" environment of medical school, most students never get past the "see one" stage in learning about the powerful tools of health policy and advocacy. The University of New Mexico School of Medicine mandates health policy and advocacy education for all medical students during their family medicine clerkship rotation. The aim of this project is to describe a unique health policy and advocacy course within a family medicine clerkship.METHODS:We analyzed policy briefs from 265 third-year medical students from April 2016 through April 2019. Each brief is categorized by the level of change targeted for policy reform: national, state, city, or university/school. Implemented policies are described.RESULTS:Slightly less than one-third of the policies (30%) relate to education, 36% advocate for health system change by addressing cost, access, or quality issues, and 34% focus on public health issues. Fourteen policies have been initiated or successfully enacted.CONCLUSIONS:This curriculum gives each medical student a health policy tool kit with immediate opportunities to test their skills, learn from health policy and advocacy experts, and in some cases, implement health policies while still in medical school. A 1-week family medicine policy course can have impact beyond the classroom even during medical school, and other schools should consider this as a tool to increase the impact of their graduates.

STUDY OBJECTIVE:Extraglottic airway devices are frequently used during cardiac arrest resuscitations and for failed intubation attempts. Recent literature suggests that many extraglottic airway devices are misplaced. The aim of this study is to create a classification system for extraglottic airway device misplacement and describe its frequency in a cohort of decedents who died with an extraglottic airway device in situ.METHODS:We assembled a cohort of all decedents who died with an extraglottic airway device in situ and underwent postmortem computed tomographic (CT) imaging at the state medical examiner's office during a 6-year period, using retrospective data. An expert panel developed a novel extraglottic airway device misplacement classification system. We then applied the schema in reviewing postmortem CT for extraglottic airway device position and potential complications.RESULTS:We identified 341 eligible decedents. The median age was 47.0 years (interquartile range 32 to 59 years). Out-of-hospital personnel placed extraglottic airway devices in 265 patients (77.7%) who subsequently died out of hospital; the remainder died inhospital. The classification system consisted of 6 components: depth, size, rotation, device kinking, mechanical blockage of ventilation opening, and injury. Under the system, extraglottic airway devices were found to be misplaced in 49 cases (14.4%), including 5 (1.5%) that resulted in severe injuries.CONCLUSION:We created a novel extraglottic airway device misplacement classification system. Misplacement occurred in greater than 14% of cases. Severe traumatic complications occurred rarely. Quality improvement activities should include review of extraglottic airway device placement when CT images are available and use the classification system to describe misplacements.

Compared to intubation with a cuffed endotracheal tube, extraglottic airway devices (EGDs), such as laryngeal mask airways, are considered less definitive ventilation conduit devices and are therefore often exchanged via endotracheal intubation (ETI) prior to obtaining CT images. With more widespread use and growing comfort among providers, reports have now described use of EGDs for up to 24 h including cases for which clinicians obtained CT scans with an EGD in situ. The term EGD encompasses a wide variety of devices with more complex structure and CT appearance compared to ETI. All EGDs are typically placed without direct visualization and require less training and time for insertion compared to ETI. While blind insertion generally results in functional positioning, numerous studies have reported misplacements of EGDs identified by CT in the emergency department or post-mortem. A CT-based classification system has recently been suggested to categorize these misplacements in six dimensions: depth, size, rotation, device kinking, mechanical blockage of the ventilation opening(s), and injury from EGD placement. Identifying the type of EGD and its correct placement is critically important both to provide prompt feedback to clinicians and prevent inappropriate medicolegal problems. In this review, we introduce the main types of EGDs, demonstrate their appearance on CT images, and describe examples of misplacements.

INTRODUCTION:Foreign body airway obstruction (FBAO) is a major public health issue worldwide. In 2017, there were more than 5000 fatal choking cases in the USA alone, and it was the fourth leading cause of preventable injury-related death in the home and community. In Japan, FBAO is the leading cause of accidental death and with almost 9000 fatalities annually. However, research on FBAO is limited, particularly on the impact of a foreign body (FB) removal manoeuvres by bystanders. The primary objective of this study is to determine the impact of bystander FB removal manoeuvres on 1 month neurological outcome. Our secondary objectives include (1) evaluating the efficacy of a variety of FB removal manoeuvres; (2) identifying risk factors for unsuccessful removal and (3) evaluating the impact of time intervals from incidents of FBAO to FB removal on neurological outcome.METHODS AND ANALYSIS:We will conduct a nationwide multi-centre prospective cohort study of patients with FBAO who present to approximately 100 emergency departments in both urban and rural areas in Japan. Research personnel at each participating site will collect variables including patient demographics, type of FB and prehospital variables, such as bystander FB removal manoeuvres, medical interventions by prehospital personnel, advanced airway management and diagnostic findings. Our primary outcome is 1 month favourable neurological outcome defined as cerebral performance category 1 or 2. Our secondary outcomes include success of FB removal manoeuvres and complications from the manoeuvres. We hypothesise that bystander FB removal manoeuvres improve patient survival with a favourable neurological outcome.ETHICS AND DISSEMINATION:This study received research ethics approval from Nippon Medical School Hospital (B-2019-019). Research ethics approval will be obtained from all participating sites before entering patients into the registry. The study was registered at the University Hospital Medical Information Network (UMIN) Clinical Trials Registry.TRIAL REGISTRATION NUMBER:UMIN 000039907.

Objectives: Immediate ischemic stroke treatment improves outcomes and early alteplase administration is recommended for patients within window. We implemented stroke guidelines through a neuro-resuscitation initiative (NRI) and hypothesized that the intervention would decrease times to assessment and treatment. Methods: We analyzed quality assurance data for EMS and triage patients arriving to our academic emergency department with suspected ischemic stroke to compare outcomes 12 months before to 6 months after initiative implementation at an academic certified primary stroke center in the U.S.Southwest. We examined four time-based outcomes: neurology at bedside, CT head without contrast, CT head angiogram, and alteplase administration. We summarized times with median and IQR values and compared pre and post times to event (in minutes) with Wilcoxon rank sum tests and Kaplan-Meier survival curves. Results: We identified 203 EMS (83 pre, 120 post) and 66 (11 pre, 55 post) triage Stroke Alert patients. We observed decreased times for all outcomes in both the EMS and triage samples: however, only those in the EMS sample were significant. In the EMS sample, neurology at bedside median times decreased from 20 min to 2 min (p < 0.001); median minutes to Cr head without contrast decreased from 16 min to 9 min (p < 0.001); median minutes to Cr head angiogram decreased from 71 min to 21 min (p = 0.007); and, median minutes to alteplase decreased from 72 min to 49.5 min (p = 0.04). Conclusions: An academic ED led stroke care initiative streamlined evaluation and care with significantly shortened times to all four events. (C) 2020 Elsevier Inc. All rights reserved.

Procedural sedation and analgesia (PSA) is performed for a variety of indications in emergency departments (EDs). Although the practice of PSA in the ED is somewhat unique from other clinical areas, there is currently no guideline for this practice in Japan. Policy statements and guidelines for PSA have been published in Europe and North America. These guidelines suggest first evaluating patients carefully before performing PSA, and then deciding on target sedative level and choice of medications. Patient evaluation requires a combination of continuous visual observation by trained medical staff to assess the depth of sedation and respiration with noninvasive measurements of blood pressure, continuous electrocardiography monitoring, and pulse oximetry. Sedative selection should be based on its characteristics, peak time, effectiveness, and risks. It is important to administer sedatives and analgesics in small, incremental doses while keeping a close eye on the patient's reaction to avoid adverse events (AEs) until the planned sedation level is reached. Further, additional attention is needed for special populations such as pediatric and elderly patients. PSA is a key element for patient-centered care in emergency medicine. In this manuscript, we review the available evidence for PSA in the EDs, including guidelines for evaluation, monitoring, pharmacology, AEs, and special populations such as pediatric and elderly patients.

Background: Health professionals need to be both person- and community oriented to improve population health. For educators to create socially accountable physicians, they must move learners from understanding social accountability as an expectation to embracing and incorporating it as an aspect of professional identity that informs medical practice. Aim: The aim of this article was to assess the degree to which medical students, preceptors and community mentors understand the concept of social accountability. Setting: The setting is the KwaZulu-Natal Province in Durban, South Africa. Methods: Using an observational design, we surveyed 332 participants, including the first- and sixth-year medical students, physician preceptors and community mentors. Results: Whilst most respondents understood social accountability as requiring an action or set of actions, it was defined by some as simply the awareness one must have about the needs of their patients, community or society at large. Some respondents defined social accountability as multi-dimensional, but these definitions were the exception, not the rule. Finally, most respondents did not identify to whom the accountable party should answer. Conclusion: Whilst the development of professional identity is seen as a process of ‘becoming’, the ability to define and understand what it means to be socially accountable is not a linear process. Assessment of this progress may start with comprehending how social accountability is understood by students when they begin their education and when they are graduating, as well as in knowing how their educators, both clinical and community, define it.

Our objective is to describe a model for process improvement evaluation that utilizes trained undergraduate student research assistants to collect provider-patient encounter data in the acute care environment. Process evaluation is imperative when making changes in a complex environment. This is especially true when the overall goal is to improve process efficiency and outcomes for critically ill and injured patients. The department of emergency medicine at the University of New Mexico uses an iterative approach to evaluate protocol changes in its Emergency Department Resuscitation Unit (EDRU), a nine-bed acute care unit internal to our emergency department. The collection of provider-patient encounter data by our student research assistants provides department leadership with evidence for assessing implementation problems and evaluating outcomes for protocol and practice changes. As part of a multi-semester course entitled Research in Acute Care, students collect data on provider-patient encounters in the EDRU on a secure electronic tool. Findings from the data collection are compiled and regularly presented to a workgroup of EM clinical faculty who in turn make recommendations on protocol revisions and continued education and training for personnel in the EDRU. In 2018, student research assistants spent over 1500 hours in the EDRU. This resulted in the collection of data on 1327 provider-patient encounters, including 26 instances of cardiopulmonary resuscitation (CPR), 418 of high acuity trauma, 112 strokes, and 164 cases of sepsis. During this same time period, the workgroup met 9 times to review findings from this and other data collections. The program has resulted in recommendations for additional training activities, identification and solutions for protocol related tools and missing equipment in the EDRU, and the identification of areas for research on patient-provider encounters. Our dynamic program is capable of meeting many of the department's process improvement data gathering needs. The program provides invaluable experience in emergency medicine to future health care professionals through clinical environment exposure and first-hand experience in quality improvement research. We will continue to adapt our data collection program as existing protocols are revised and new protocols are implemented. We hope to expand our program and its data collection capabilities through increasing student coverage in the EDRU and possibly expanding to other units in the emergency department.

Background: A socially accountable health professional education curriculum aims to produce fit-for-purpose graduates to work in areas of need. ‘Fit-for-purpose’ can be assessed by monitoring graduate practice attributes. Aim: The aim of this article was to identify whether graduates of ‘fit-for-purpose’ programmes are socially accountable. Setting: The setting for this project was all 37 district hospitals in the KwaZulu-Natal province in Durban, South Africa. Methods: We surveyed healthcare professionals working at district hospitals in the KwaZulu-Natal province. We compared four social accountability indicators identified by the Training for Health Network Framework, comparing medical doctors educated at the Nelson R. Mandela School of Medicine (NRMSM) with medical doctors educated at other South African and non-South African medical schools. In addition, we explored medical doctors’ characteristics and reasons for leaving or staying at district hospitals. Results: The pursuit of specialisation or skills development were identified as reasons for leaving in the next 5 years. Although one-third of all medical doctors reported an intention to stay, graduates from non-South African schools remained working at a district hospital longer than graduates of NRMSM or other South African schools and they held a majority of leadership positions. Across all schools, graduates who worked at the district hospital longer than 5 years cited remaining close to family and enjoyment of the work and lifestyle as motivating factors. Conclusion: Using a social accountability approach, this research assists in identifying areas of improvement in workforce development. Tracking what medical doctors do and where they work after graduation is important to ensure that medical schools are meeting their social accountability mandate to meet community needs.