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Introduction: The emergency physician (EP) workforce has been a recent focus after a workforce projection predicted a surplus of EPs by 2030. A previous study of Iowa emergency departments (EDs) demonstrated wide variability in ED staffing patterns and attributed it to the lack of EP job candidates. With the recent increase in emergency medicine (EM) residency positions, the objectives of this study were to understand how Iowa ED physician staffing has changed in regard to presence of board-certified EPs and what operational differences in Iowa EDs may be associated with staffing to provide insight into what may be occurring in other predominantly rural states., Methods: An electronic and telephone survey of nonfederal Iowa EDs was conducted using a structured data collection instrument. Responses were collected from a leadership representative at each facility (medical director or nurse manager). The data collection included both objective staffing data and Likert-style questions about reasons for staffing and operational practices. We obtained hospital characteristics from the American Hospital Association and directly compared these results to a similar Iowa study conducted in 2013. Summary data were presented as counts and percentages, and physician staffing was compared between critical-access hospitals (CAHs) and non-CAHs. CAHs represent a type of rural hospital in the rural setting., Results: Responses from 113 of 116 (97%) Iowa EDs were recorded. Of responding EDs, 19 (17%) were staffed exclusively by EM residency-trained and/or EM board-certified physicians (EPs), 72 (66%) were staffed by a combination of EPs and non-EPs (physicians who completed a residency other than EM), 19 (17%) were staffed exclusively by non-EPs, and 52 (46%) were staffed either fully or at times by advanced practice providers (APPs) without in-house supervision. In the subgroup of CAHs, only three (4%) staff only EPs, compared with 16 (42%) of non-CAHs (difference 38%, 95% confidence interval [CI] 24.6%-51.2%). Providers staffing CAHs were more likely than those at non-CAHs (88% vs. 63%, difference 25%, 95% confidence interval [CI] 9.5%-40.2%) to have responsibilities outside the ED, the most common being inpatient cardiac arrest management (n = 84, 74%). The most common reason for hiring EPs was the quality of care they provide (n = 47, 58%), and the most common reason for hiring non-EPs was low availability of EPs (n = 56, 70%). Compared to the 2013 Iowa ED workforce study, the proportion staffed by EPs only were similar (increased by 5.5%, 95% CI -14.7% to 3.7%) and by non-EPs only was similar (decreased by 10.5%, 95% CI -0.4% to 21.3%). EDs staffed solely by APPs decreased from decreased by 13.2% (95% CI 0.3%-26.2%) to 47% in 2023., Conclusions: Iowa EDs are predominantly staffed by non-EPs, and this remains unchanged despite a decade of increasing EM residency positions nationally. There remains a significant disparity between CAHs and non-CAHs. This study demonstrates that EM residency position increases have not penetrated rural Iowa EDs, where there remains both a substantial shortage and desire for EP staffing., (© 2025 Society for Academic Emergency Medicine.)

Objective: The purpose of this study was to investigate the efficacy of hyperangulated video laryngoscopy (HAVL) versus standard geometry video laryngoscopy (SGVL) in the simulated prehospital environment using a manikin. There is consensus that video laryngoscopy (VL) can be very useful in the emergency department when difficult intubations are predicted. Emergency medical service (EMS) providers are also often faced with difficult, rapidly deteriorating airway management situations that not only involve patient and operator factors but also include challenging unique environmental factors, such as nonoptimized positions in transport vehicles (eg, helicopters and ambulances) or at ground level or entrapped positions. To our knowledge, there has never been a study purposefully investigating the efficacy of hyperangulated geometry versus standard geometry VL techniques in the prehospital environment., Methods: A single-center, randomized controlled crossover trial was performed using attending physician helicopter EMS providers. Physicians were randomized to perform 5 HAVL or SGVL intubations followed by the subsequent technique. Intubations were performed on ground level and then repeated in the helicopter with the first location also randomized. A manikin airway management trainer was used to simulate intubation in each environment. The time to intubation (primary outcome) as well as first-pass success and the Cormack-Lehane view were recorded for each attempt. Qualitative data were also obtained for physician preference and perceived difficulty., Results: There was no statistically significant difference in the time to intubation with HAVL versus SGVL (ground: 15.02 vs. 14.88 seconds, P = .86; helicopter: 16.11 vs. 16.14 seconds, P = .93). First-pass success was 100% for both techniques in both scenarios. More Grade 1 views were obtained with HAVL (147/150 vs. 134/150). Moreover, most physicians preferred HAVL overall and felt that HAVL required less force (9/15 grounded manikin and 10/15 helicopter manikin) and led to the best chance for first-pass success (11/15 grounded manikin and 10/15 helicopter manikin)., Conclusion: The results of this study are limited because of the static and highly favorable anatomy of a manikin versus the variability and often difficult anatomy of individual patients. Our results suggest that both techniques are efficacious when the patient is both on the ground or in the helicopter, although provider preference does seem to vary., (Published by Elsevier Inc.)

We investigated how the occurrence and severity of the main neuropathological types of traumatic brain injury (TBI) influenced the severity of disability after a head injury. Eighty-five victims, each of whom had lived at least a month after a head injury but then died, were studied. Judged by the Glasgow Outcome Scale (GOS), before death 35 were vegetative, 30 were severely and 20 were moderately disabled. Neuropathological assessment showed that 71 (84%) victims had sustained cerebral contusions, 49 (58%) had diffuse axonal injury (DAI), 57 (67%), had ischemic brain damage (IBD), 58 (68%) had symmetrical ventricular enlargement, and in 47 (55%) intracranial pressure (ICP) had been increased. Thirty-five (41%) had undergone evacuation of an intracranial hematoma. Brainstem damage was seen in only 11 (13%). Analysis (χ(2) test for trends) of the relationship between these features and outcome showed that findings of DAI, raised ICP, thalamic damage, or ventricular enlargement (all p<0.005), and IBD (p=0.04) were associated with an increasingly worse outcome. Conversely, moderate or severe contusions (p=0.001) were increasingly associated with better outcomes, and evacuation of a hematoma was associated (p=0.001) with outcomes likely to be better than vegetative. We conclude that diffuse or multifocal neuropathological patterns of TBI from primary axonal injury or secondary ischemic damage are most likely to be associated with the most severely impaired outcomes after a head injury.