Objectives:The serratus anterior plane block (SAPB) is an effective ultrasound-guided regional anesthesia technique for anterolateral rib fracture pain. Formal SAPB training in emergency medicine remains limited, contributing to inconsistent adoption and procedural confidence. This study evaluated whether a simulation-based curriculum improves emergency physicians' confidence, knowledge, retention, and simulated procedural competency. Methods:A prospective educational intervention was conducted at an urban academic center. Participants completed pre- and post-curriculum surveys assessing SAPB knowledge, procedural confidence, and barriers. Survey content was developed using a three-round Delphi process by emergency medicine ultrasound and simulation experts. The curriculum included didactic teaching and four simulation stations addressing consent, ultrasound-guided in-plane technique, anatomy, and SAPB performance using task trainers. Procedural competency was assessed using an ACEP-guidelines-based checklist. Pre- and post-curriculum outcomes were analyzed using paired t-tests (p < 0.05). Results:Thirty-six physicians participated, including attendings (19.4%), fellows (8.3%), and residents (72.2%) distributed evenly across PGY1 to PGY4 levels. Two participants (5.6%) had prior ultrasound fellowship training and 5 (13.9%) had previously performed a SAPB. Self-reported confidence increased significantly following the curriculum (1.81 ± 1.09 vs. 4.00 ± 0.72; p < 0.001), as did willingness to perform the block (3.31 ± 1.60 vs. 4.53 ± 0.70; p < 0.001). All participants achieved simulated procedural competency and demonstrated improved knowledge scores following the curriculum (p < 0.001). Five clinical bedside SAPBs were performed during the first 6 months following training. Among 32 participants (88.9%) completing the 4-6-week follow-up, mean cumulative knowledge scores were 92.9% ± 11.7 immediately after training and 90.9% ± 10.3 at follow-up. Reported barriers to SAPB performance included time constraints, patient refusal, and limited availability of appropriate patients. Conclusions:A simulation-based curriculum improved emergency physicians' self-reported confidence and knowledge regarding the SAPB, while supporting short-term stability of knowledge performance. These findings highlight the value of simulation as a scalable pathway to standardize ultrasound-guided regional anesthesia training and facilitate future evaluation of SAPB adoption in emergency medicine.

Objectives: To compare the effectiveness of tabletop exercises (TTX) and high-fidelity in-person simulations (IPS) in improving knowledge, confidence, and perceived preparedness in disaster medicine among emergency medicine residents. Methods: A prospective, randomized educational intervention was conducted across 2 urban emergency medicine residency programs. Sixty-three residents were randomized to TTX or IPS groups. Each group completed a preintervention knowledge and confidence assessment, participated in their assigned exercise based on a simulated mass casualty incident (MCI), and underwent a structured debrief. Postintervention surveys assessed change in knowledge and self-reported comfort levels. A paired 2-tailed Student's t-test was utilized to compare results. Statistical significance was defined as P < 0.01. Results: Both groups demonstrated increased self-reported confidence and knowledge regarding management of MCIs. TTX participants showed higher median post-test scores (77.4%, N = 38) compared to IPS participants (67.4%, N = 25). Results were not statistically significant (P = 0.079). Conclusions: TTX is an effective modality for disaster medicine education, with outcomes comparable to IPS. While TTX may better align with knowledge-based assessments, IPS remains essential for practicing real-time decision-making under stress. Combining these 2 modalities may provide both the knowledge base and psychological duress required for robust disaster scenario training.

There is a need for high-quality disaster training in lower income communities that bear an increasing burden of MCIs. Tabletop exercises (TTX) are low-fidelity, low-cost training methods consisting of facilitator-moderated, discussion-based activities. Simulation education (SIM) is a high-fidelity modality mimicking psychological stress, muscle memory and cognitive load of an MCI. These represent economical training strategies which are standardizable across different regions, developing disaster management skills for first responders. This study compares the effectiveness of TTX and SIM in building knowledge for Emergency Physicians (EPs) involved in MCIs and increasing comfort in managing disaster scenarios. 64 EPs were randomly assigned to a 1-hour session of TTX or SIM on MCIs and completed assessments testing knowledge and self-perceived comfort levels. Simulation and Disaster Medicine faculty members subsequently moderated debriefing sessions. TTX participants (N=38) had median knowledge scores of 71% compared to 57% in SIM participants (N=25). TTX participants’ comfort level in dealing with MCIs after the education sessions showed a median comfort level of 5/5 compared to 3/5 in SIM participants. TTX showed an average change in comfort level of 2.13 (SD 1.53) pre- and post-education sessions compared to 1.68 (SD 1.38) in the SIM group, with no statistically significant difference between the groups. Both modalities increased comfort level in managing MCIs, although participants in TTX performed better on the post-exercise assessment. This data suggests TTX may be an efficacious cost-effective strategy to increase knowledge and comfort in preparing staff for MCIs.

Background:With a rise in mass casualty incidents, training in hemorrhage control using tourniquets has been championed as a basic-and lifesaving-procedure for bystanders and medical professionals alike. The current standard for training is in-person (IP) courses, which can be limited based on instructor availability. Virtual reality (VR) has demonstrated the potential to improve the accuracy of certain medical tasks but has not yet been developed for hemorrhage control. The objective of this study was to evaluate the efficacy of a VR hemorrhage trainer in learner retention of tourniquet application when compared to traditional IP instructor teaching among a cohort of emergency medicine residents practicing in a Level I trauma center. Methods:This was a prospective, observational study of 53 emergency medicine residents at an inner-city program. Participants were randomly assigned to either the control or the VR group. On Day 0, all residents underwent a training session (IP vs. VR) for the proper, stepwise application of a tourniquet, as defined by the American College of Trauma Surgeons. Each participant was then assessed on the application of a tourniquet by a blinded instructor using the National Registry Hemorrhage Control Skills Lab rubric. After 3 months, each resident was reevaluated on the same rubric, with subsequent data analysis on successful tourniquet placement (measured as under 90 s) and time to completion. Results:Of the 53 participants, the IP training group had an initial pass rate of 97% (28/29) compared to 92% (22/24) in the VR group (p = 0.58). On retention testing, the IP training group had a pass rate of 95% (20/21) compared to 90% (18/20) in the VR group (p = 0.62). Stratifying the success of tourniquet placement by level of resident training did not demonstrate any statistically significant differences. Conclusions:In this pilot study of emergency medicine residents, we found no significant differences in successful hemorrhage control by tourniquet placement between those trained with VR compared to a traditional IP course among emergency medicine residents. While more studies with greater power are needed, the results suggest that VR may be a useful adjunct to traditional IP medical training.

Introduction: Wellens’ syndrome represents an important, at times overlooked, spectrum of left anterior descending (LAD) coronary artery occlusion, spontaneous reperfusion, and impending reocclusion. Once considered pathognomonic for a thromboembolic coronary event, an increasing number of clinical scenarios have been demonstrated to result in pseudo-Wellens’ syndrome, each requiring unique forms of assessment and management. Case Report: We describe two clinical presentations in which myocardial bridging (MB) of the LAD led to clinical and electrophysiologic presentations of a pseudo-Wellens’ syndrome. Conclusion: These reports represent a rare cause of pseudo-Wellens’ syndrome attributed to MB of the LAD. Transient ischemia secondary to myocardial compression of the traversing LAD leads to intermittent angina and electrocardiogram changes that are typical in patients presenting with Wellens’ syndrome secondary to an occlusive coronary event. As with other previously reported pathophysiologic mechanisms that have been shown to mimic Wellens’ syndrome, myocardial bridging should be considered in patients presenting with a pseudo-Wellens’ syndrome.

INTRODUCTION:Over the last several decades simulation, in both graduate and undergraduate emergency medicine education, has continued to develop as a leading and highly effective teaching modality. Limited research exists to evaluate the efficacy of low-fidelity (table-top) simulation, as compared to high-fidelity standards, as it relates to medical knowledge learning outcomes. We sought to assess the efficacy of a low-fidelity simulation modality in undergraduate emergency medicine education, based on quantitative medical knowledge learning outcomes.METHODS:A prospective, randomized, crossover-control study comparing objective medical knowledge learning outcomes between simulation modalities. Analysis was designed to evaluate for the statistical equivalence of learning outcomes between the two cohorts. This was done by comparing a calculated 95% confidence interval (CI) around the mean difference in post-test scores, between experimental and control modalities, to a pre-established equivalence margin.RESULTS:Primary outcomes evaluating student performance on post-test examinations demonstrated a total cohort CI (95% CI, -0.22 and 0.68). Additional course-subject subgroup analysis demonstrated non-inferior CIs with: Shortness of Breath (95% CI, -0.35 and 1.27); Chest Pain (95% CI, -0.53 and.94); Abdominal Pain (95% CI, -0.88 and 1.17); Cardiovascular Shock (95% CI, -0.04 and 1.29). Secondary outcome analysis was done to evaluate medical knowledge acquisition by comparing the difference in pre and post-test examination between the cohorts. CI of the full cohort ranged from (95% CI, -0.14 and 0.96).CONCLUSION:The student's performance on quantitative medical-knowledge assessment was equivalent between the high-fidelity control and low-fidelity experimental simulation groups. Analysis of knowledge acquisition between the two groups also demonstrated statistical equivalence.

A 64-year-old man, who underwent a stent placement in his left external iliac vein 5 days prior, presented to the Emergency Department complaining of acute-onset shortness of breath. He denied any chest pain or leg swelling. Initial vital signs revealed a blood pressure of 115/70 mm Hg, heart rate of 130 beats/min, respiratory rate of 18 breaths/min, and O2 saturation of 92%, improving to 99–100% with nasal cannula and non-rebreather oxygen at flush rate (>40 L/min). Electrocardiogram revealed sinus tachycardia at 132 beats/min, poor R-wave progression, and ST depressions in V4–V6. A point-of-care cardiac ultrasound scan revealed a dilated right ventricle, septal bowing from the right side into the left side, and a ∼3-cm thrombus in transit visualized in the right atrium and right ventricle (see Figure 1 and Videos 1–4, available online). Shortly thereafter, the patient started to become more lethargic as his respiratory rate increased to 36 breaths/min and his blood pressure trended down to a systolic pressure in the 80s. A repeat ultrasound scan revealed no clot in the right atrium, and worsening McConnell's sign (Figure 2, Videos 5–8, available online). The patient was given tissue plasminogen activator (tPA) 50 mg for a presumed massive pulmonary embolism (PE), with improvement in vitals and mental status prior to being admitted to the cardiac care unit. Figure 2Repeat point-of-care ultrasound scan revealed no visualized thrombus in the right atrium/ventricle, right atrial/ventricular dilatation, and a McConnell's sign (arrow). View Large Image Figure Viewer Download Hi-res image

PURPOSE:To quantify the frequency of patient noncompliance in an urban radiation oncology department and identify predictors of noncompliance.METHODS AND MATERIALS:We identified patients treated with external beam radiation therapy (RT) with curative intent in our department from 2007 to 2012 for 1 of 7 commonly treated malignancies. Patients who missed 2 or more scheduled RT appointments were deemed "noncompliant." An institutional database was referenced to obtain clinical and demographic information for each patient, as well as a quantitative estimate of each patient's socioeconomic status. Logistic regression was used to identify factors associated with RT noncompliance.RESULTS:A total of 2184 patients met eligibility criteria. Of these, 442 (20.2%) were deemed "noncompliant." On multivariate analysis, statistically significant predictors of noncompliance included diagnosis of head-and-neck, cervical, or uterine cancer, treatment during winter months, low socioeconomic status, and use of a long treatment course (all P<.05).CONCLUSION:This is the first large effort examining patient noncompliance with daily RT. We have identified demographic, clinical, and treatment-related factors that can be used to identify patients at high risk for noncompliance. These findings may inform future strategies to improve adherence to prescribed therapy.

Proceedings: AACR 101st Annual Meeting 2010‐‐ Apr 17‐21, 2010; Washington, DC High intensity focused ultrasound (HIFU) is a non-invasive ablative treatment that induces rapid temperature elevation in tissues in the focal zone, resulting in instantaneous coagulative necrosis. Previous studies by us demonstrated that repeated cycles of nonablative low energy focused ultrasound (LOFU), administered 1 day prior to ablative HIFU, induce antitumoral imunity. We hypothesized that LOFU modulates phenotypic changes in the tumor cell surface, resulting in enhanced antigen presentation and phagocytosis by dentritic cells (DC) and increased susceptibility to cytotoxic T cell (CTL) attack. In this study, we optimized the LOFU regimen based on immunomodulatory changes in tumor cells and cytotoxicity. Three murine tumor cell lines, Panc-2, RM-1, and E. G7 (OVA+) were exposed to LOFU using the Phillips therapy and imaging probe system, operated at 1 MHz, 100% duty cycle and 0-4 watts acoustic power for 1.5 seconds. Cells were harvested (6, 24, 48h and day 7) for detection of cell surface expression of MHC-I, Calreticulin, FAS and cytoplasmic HSP70 by flow cytometry and HSP70 ELISA of cell lysates. Phagocytosis assay was performed by coculturing marrow-derived DCs or JAWS-II cells with CellTracker-labeled LOFU-treated tumor cells, followed by flow cytometric detection of engulfed tumor cells. DC activation was analyzed by CD80, CD86, MHC-II and CD40 flow cytometry. T-cell activation was analyzed by coculturing OVA-specific splenocytes with LOFU-treated OVA+ E. G7 cells, followed by measurement of IFN-gamma secretion in culture supernatant by ELISA. Finally, C57BL/6 mice bearing palpable RM-1 tumors were treated with LOFU (weekly for 3wks) and sacrificed at 4th wk and tumor specific T cell response was assessed by IFN-gamma ELISPOT. Tumor cells treated with LOFU had significant upregulation of intracellular HSP70 (peak at 24hrs, 13.4±5.8 fold) and marginal cell killing (15.6±4.4%) at 3W acoustic power. Further studies were performed with LOFU at 3W. LOFU induced translocation of cytoplasmic calreticulin on the cell surface (50-79.5% at 24 hr). Immature DCs phagocytosed LOFU-treated tumor cells (10-16.3%), followed by induction of cell surface CD80, CD86 and MHC-II expression (2-3 fold induction) indicating increased activation. There was a 2-3-fold upregulation of surface expression of HSP70 and FAS in LOFU-treated E. G7 cells, resulting in enhanced OVA-specific CTL-mediated cytotoxicity. Finally, a significant increase in tumor specific T cells (0.1-0.3%) was observed in the splenocytes from mice with LOFU-treated RM-1 tumors. Control mice with untreated tumors had no detectable tumor-specific T cells. These results demonstrate a potent tumor specific immune response induced by non-ablative LOFU. Further studies are warranted to augment LOFU/HIFU-induced antitumoral immunity for the treatment of recurrent and metastatic cancer. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 5630.