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Supplemental Digital Content is available in the text., Problem The COVID-19 pandemic significantly disrupted point-of-care ultrasound (POCUS) education. Medical schools and residency programs placed restrictions on bedside teaching and clinical scanning as part of risk mitigation. In response, POCUS faculty from 15 institutions nationwide collaborated on an alternative model of ultrasound education, A Distance-learning Approach to POCUS Training (ADAPT). Approach ADAPT was repeated monthly from April 1 through June 30, 2020. It accommodated 70 learners, who included 1- to 4-week rotators and asynchronous learners. The curriculum included assigned prework and learning objectives covering 20 core POCUS topics. A rotating group of 30 faculty and fellows delivered daily virtual teaching sessions that included gamification to increase learner engagement and hands-on instruction through teleguidance. After participation, faculty and learners completed anonymous surveys. Outcomes Educators reported a significant decrease in preparatory time (6.2 vs 3.1 hours per week, P < .001) dedicated to ultrasound education after implementing ADAPT. The majority of 29 learners who completed surveys felt “somewhat confident” or “very confident” in their ability to acquire (n = 25, 86.2%) and interpret (n = 27, 93.1%) ultrasound images after the intervention; the majority of 22 educators completing surveys rated the program “somewhat effective” or “very effective” at contributing to learner’s ability to acquire (n = 13, 59.1%) and interpret (n = 20, 90.9%) images. Most learners (n = 28, 96.6%) and all educators (n = 22, 100%) were “satisfied” or “very satisfied” with ADAPT as a whole, and the large majority of educators were “very likely” (n = 18, 81.8%) to recommend continued use of this program. Next Steps A virtual curriculum that pools the efforts of multiple institutions nationwide was implemented rapidly and effectively while satisfying educational expectations of both learners and faculty. This collaborative framework can be replicated and may be generalizable to other educational objectives.

Objective We describe the purpose of the Dietary Supplement Ingredient Database (DSID), the statistical methodology underlying online calculators of analytically verified supplement content estimates, and the application and significance of DSID label adjustments in nutritional epidemiology. Background and history During dietary supplement (DS) manufacturing, many ingredients are added at higher than declared label amounts, but overages are not standardized among manufacturers. As a result, researchers may underestimate nutrient intakes from DSs. The DSID provides statistical tools on the basis of the results of chemical analysis to convert label claims into analytically predicted ingredient amounts. These adjustments to labels are linked to DS products reported in NHANES. Rationale Tables summarizing the numbers of NHANES DS products with ingredient overages and below label content show the importance of DSID adjustments to labels for accurate intake calculations. Recent developments We show the differences between analytically based estimates and labeled content for vitamin D, calcium, iodine, caffeine, and omega-3 (n-3) fatty acids and their potential impact on the accuracy of intake assessments in large surveys. Analytical overages >20% of label levels are predicted for several nutrients in 50-99% of multivitamin-mineral products (MVMs) reported in NHANES: for iodine and selenium in adult MVMs, for iodine and vitamins D and E in children's MVMs, and for iodine, chromium, and potassium in nonprescription prenatal MVMs. Predicted overages of 10-20% for calcium can be applied to most MVMs and overages >10% for folic acid in the vast majority of adult and children's MVMs. Future directions DSID studies are currently evaluating ingredient levels in prescription prenatal MVMs and levels of constituents in botanical DSs. Conclusions We estimate that the majority of MVM products reported in NHANES have significant overages for several ingredients. It is important to account for nonlabeled additional nutrient exposure from DSs to better evaluate nutritional status in the United States.

OBJECTIVES To evaluate observer agreement using qualitative goal-directed echocardiographic criteria for right ventricular (RV) dysfunction prognostication in submassive pulmonary embolism (PE). METHODS Two emergency physicians and 2 cardiologists independently reviewed 31 packets of goal-directed echocardiographic video clips consisting of at least 3 windows obtained by emergency physicians from normotensive patients with PE. Nine packets were repeated to assess for intraobserver agreement. Right ventricular dysfunction criteria on goal-directed echocardiography were as follows: RV enlargement was present, with a right-to-left ventricular basal diameter ratio of 1.0 or higher and blunting of the apex of the RV in 2 or more different windows; RV systolic dysfunction was present if the tricuspid annulus moved toward the apex 10 mm or less and there was RV free wall hypokinesis; and septal deviation was present with any flattening or deviation of the ventricular septum toward the left ventricle. RESULTS Among the 4 participants, there was 83.9% agreement on the presence or absence of RV enlargement (κ = 0.84), 74.2% agreement on the presence or absence of RV systolic dysfunction (κ = 0.69), and 71.0% agreement on the presence or absence of septal deviation (κ = 0.59). Intraobserver agreement was 100% for each RV dysfunction variable for each observer (κ = 1.0). CONCLUSIONS Agreement was substantial for both severe RV enlargement and RV systolic dysfunction and moderate for septal deviation. Right ventricular dysfunction assessment with qualitative goal-directed echocardiographic criteria is reproducible for PE risk stratification.

Introduction Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography. Methods We performed a literature search and report clinical experience to provide an introduction to CEUS and describe its current applications for point-of-care indications. Results The uses of CEUS include several applications highly relevant for emergency medicine, such as solid-organ injuries, actively bleeding hematomas, or abdominal aortic aneurysms. Compared with CT as the preeminent advanced imaging modality in the emergency department, CEUS is low cost, radiation sparing, repeatable, and readily available. It does not require sedation, preprocedural laboratory assessment, or transportation to the radiology suite. Conclusions CEUS is a promising imaging technique for point-of-care applications in pediatric and adult patients and can be applied for patients with allergy to CT contrast medium or with impaired renal function. More high-quality CEUS research focusing on accuracy, patient safety, health care costs, and throughput times is needed to validate its use in emergency and critical care settings.

Introduction: The goal of this study was to characterize current practices in the transition of care between the emergency department and primary care setting, with an emphasis on the use of the electronic medical record (EMR). Methods: Using literature review and modified Delphi technique, we created and tested a pilot survey to evaluate for face and content validity. The final survey was then administered face-to-face at eight different clinical sites across the country. A total of 52 emergency physicians (EP) and 49 primary care physicians (PCP) were surveyed and analyzed. We performed quantitative analysis using chi-square test. Two independent coders performed a qualitative analysis, classifying answers by pre-defined themes (inter-rater reliability > 80%). Participants’ answers could cross several pre-defined themes within a given question. Results: EPs were more likely to prefer telephone communication compared with PCPs (30/52 [57.7%] vs. 3/49 [6.1%] P < 0.0001), whereas PCPs were more likely to prefer using the EMR for discharge communication compared with EPs (33/49 [67.4%] vs. 13/52 [25%] p < 0.0001). EPs were more likely to report not needing to communicate with a PCP when a patient had a benign condition (23/52 [44.2%] vs. 2/49 [4.1%] p < 0.0001), but were more likely to communicate if the patient required urgent follow-up prior to discharge from the ED (33/52 [63.5%] vs. 20/49 [40.8%] p = 0.029). When discussing barriers to effective communication, 51/98 (52%) stated communication logistics, followed by 49/98 (50%) who reported setting/environmental constraints and 32/98 (32%) who stated EMR access was a significant barrier. Conclusion: Significant differences exist between EPs and PCPs in the transition of care process. EPs preferred telephone contact synchronous to the encounter whereas PCPs preferred using the EMR asynchronous to the encounter. Providers believe EP-to-PCP contact is important for improving patient care, but report varied expectations and multiple barriers to effective communication. This study highlights the need to optimize technology for an effective transition of care from the ED to the outpatient setting.

Drug abuse is a common problem and growing concern in the United States, and over the past decade, novel or atypical drugs have emerged and have become increasingly popular. Recognition and treatment of new drugs of abuse pose many challenges for health care providers due to lack of quantitative reporting and routine surveillance, and the difficulty of detection in routine blood and urine analyses. Furthermore, street manufacturers are able to rapidly adapt and develop new synthetic isolates of older drugs as soon as law enforcement agencies render them illegal. In this article, we describe the clinical and adverse effects and purported pharmacology of several new classes of drugs of abuse including synthetic cannabinoids, synthetic cathinones, salvia, desomorphine, and kratom. Because many of these substances can have severe or life-threatening adverse effects, knowledge of general toxicology is key in recognizing acute intoxication and overdose; however, typical toxidromes (e.g., cholinergic, sympathomimetic, opioid, etc.) are not precipitated by many of these agents. Medical management of patients who abuse or overdose on these drugs largely consists of supportive care, although naloxone may be used as an antidote for desomorphine overdose. Symptoms of aggression and psychosis may be treated with sedation (benzodiazepines, propofol) and antipsychotics (haloperidol or atypical agents such as quetiapine or ziprasidone). Other facets of management to consider include treatment for withdrawal or addiction, nutrition support, and potential for transmission of infectious diseases.

Simulation-based mastery learning (SBML) improves procedural skills among medical trainees. We employed an SBML method that includes an asynchronous knowledge acquisition portion and a hands-on skill acquisition portion with simulation to assess senior medical student performance and retention of the following 6 core clinical skills: (a) ultrasound-guided peripheral intravenous placement, (b) basic skin laceration repair, (c) chest compressions, (d) bag-valve mask ventilation, (e) defibrillator management, and (f) code leadership.Seven emergency medicine (EM) faculty members developed curricula, created checklists, and set minimum passing standards (MPSs) to test mastery of the 6 skills. One hundred thirty-five students on an EM clerkship were pretested on all 6 skills, viewed online videos asynchronously followed by a multiple choice computer-based skill-related quiz, received one-on-one hands-on skill training using deliberate practice with feedback, and were posttested until MPS was met. We compared pretest and posttest performance. We also retested, unannounced, a convenience sample (36%) of students from 1 to 9 months postintervention to assess skill retention.All students passed each quiz. The percentage of students who reached each MPS increased significantly (P0.001) from pretest to posttest for all 6 clinical skills. Ninety-eight percent of the students scored at or above the MPS when retested 1 to 9 months later. There was no significant decrease in mean score for any of the 6 skills between posttest and retention testing.Simulation-based mastery learning using a substantial asynchronous component is an effective way for senior medical students to learn and retain EM clinical skills. This method can be adapted to other skill training necessary for residency readiness.

Purpose Current examination techniques do not detect the wide clinical variability of the flexor digitorum superficialis (FDS). Modification of current examination techniques may be necessary to detect anomalies and lead to more accurate diagnosis. We examined 500 subjects using an expansion of current techniques to elicit the range of variations in FDS function discernable on clinical examination. Methods FDS function was evaluated by asking subjects to flex the finger of interest while all other fingers were held fully extended at the metacarpophalangeal and interphalangeal joints. Isolated flexion at the proximal interphalangeal (PIP) joint indicated independent FDS function. Obligatory flexion at the distal interphalangeal (DIP) joint indicated flexor digitorum profundus (FDP) activity. Because FDS activity could not be evaluated if concurrent FDP activity was present, these fingers were designated as having FDP substitution. Difficulty isolating PIP joint flexion suggested connections to adjacent FDS or FDP, prompting the examiner to serially release adjacent fingers while observing for improvement in PIP or DIP range of motion. Results Independent FDS function was most consistently present in the ring and middle fingers, less so in the index finger, and least in the small finger. Variations included FDP substitution or connections to flexor tendons in 1 or 2 adjacent fingers with or without evidence of FDP substitution. Absent FDS function cannot be presumed in any subject based solely on clinical examination of a single digit. Conclusions Current examination techniques are inadequate to discern among the multiple variations of FDS function. An expanded examination technique is recommended for accurate diagnosis of FDS function following flexor tendon injury.