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Health care revolves around trust. Patients are often in a position that gives them no other choice than to trust the people taking care of them. Educational programs thus have the responsibility to develop physicians who can be trusted to deliver safe and effective care, ultimately making a final decision to entrust trainees to graduate to unsupervised practice. Such entrustment decisions deserve to be scrutinized for their validity. This end-of-training entrustment decision is arguably the most important one, although earlier entrustment decisions, for smaller units of professional practice, should also be scrutinized for their validity. Validity of entrustment decisions implies a defensible argument that can be analyzed in components that together support the decision. According to Kane, building a validity argument is a process designed to support inferences of scoring, generalization across observations, extrapolation to new instances, and implications of the decision. A lack of validity can be caused by inadequate evidence in terms of, according to Messick, content, response process, internal structure (coherence) and relationship to other variables, and in misinterpreted consequences. These two leading frameworks (Kane and Messick) in educational and psychological testing can be well applied to summative entrustment decision-making. The authors elaborate the types of questions that need to be answered to arrive at defensible, well-argued summative decisions regarding performance to provide a grounding for high-quality safe patient care.

Debriefing framework and approach inform a number of factors, including participant group and learning needs, type of predetermined learning objectives, and those debriefing points that emerge from the discussion. Although general principles for healthcare debriefing exist, special considerations apply for emergency care settings. In emergency medicine, debriefings should highlight the unique logistic and cognitive demands on individuals as well as interprofessional, multi-disciplinary teams. One size does not fit all, and debriefing approach for various components of any one simulation scenario are not mutually exclusive. For emergency settings, aspects about individual thought processes, teamwork, and systems issues may be relevant for a single debriefing session. Debriefing is an essential element of healthcare simulation and the information summarized here helps educators develop and implement an informed strategy.

The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does"). The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how"); however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Miller's conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the "does" level. Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of "doing" in practice (the "does" level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level "trusted" to the apex of Miller's pyramid.

Introduction Core temperatures (Tcore) are often invasive, and can be underutilized. Peripheral temperatures are easier to obtain, but are often less accurate. A zero-heat-flux thermometer (ZHF) is a non-invasive method to obtain core temperatures (TZHF), and has been accurate when compared to Tcore in the operating room. We aimed to determine whether TZHF accurately and reliably measures Tcore in emergency department (ED) patients when compared to rectal, bladder or esophageal temperatures. Methods We conducted a prospective observational quality improvement project, with concurrent TZHF and Tcore measurements. The primary outcome was whether one device detected a fever (≥38.1 °C) when the other device did not. Unadjusted linear regression was used to determine the relationship between temperature differences between devices. Results 268 patients were included. Mean temperatures were 36.6 °C for Tcore and 36.3 °C for TZHF. 16 of 52 patients with fever identified by Tcore were not detected by TZHF, 13 with an infectious etiology. The mean temperature difference between Tcore and TZHF increased as the patient's temperature increased; the difference was 0.2 °C in afebrile patients, but 0.7 °C in febrile patients. Conclusion While we found overall concordance between Tcore and TZHF, the ZHF did not detect fever in 25% of patients presenting with fever of infectious origin. Measurements between Tcore and TZHF varied more as temperatures increased, with TZHF consistently reporting lower values. Although more study is needed, these findings call into question the use of TZHF in the ED where detection of fever frequently guides patient evaluation and management.

Background: There is limited data on the safety and efficacy of a novel high-definition mapping catheter with 16 equidistant electrodes (Advisor HD Grid). We describe procedural details for the treatment of complex atrial arrhythmias and associated outcomes using this novel catheter design. Methods and Results: The HD Grid was employed for patients with clinically relevant arrhythmia using the EnSite Precision™ electroanatomic mapping system. AVRT and typical flutter cases were excluded. Major procedural complications were defined as bleeding, stroke or TIA, sepsis, and death from any cause, whereas minor complications were defined as no changes to the length of hospital stay or to the expected management of the patient. Recurrence was defined as sustained tachycardia after 3 months post-procedure. Consecutive patients attending for the treatment of paroxysmal atrial fibrillation (66), persistent atrial fibrillation (38), atrial tachycardia (29), and atypical flutter (18) were included, resulting in a final inclusion of 142 patients and 151 procedures. Eighty-four patients (55.3%) received general anesthetic and intracardiac echocardiography was used in 23 (15.1%). Long term follow-up was available in 150/151 procedures, mean 185.2±134.3 days; 32 patients (21.3%) documented recurrence. Three (2.0%) patients experienced complications within 30-days of the procedure including acute tamponade (1), TIA (1) and stroke (1) and 1 (0.7%) died from complications of septic arthritis 183 days post-procedure. Conclusion: The novel HD Grid differs significantly in design and handling compared to the traditional multielectrode catheters. Our data report procedural outcomes in line with contemporary clinical expectations with low complication and recurrence rates.

This study describes a randomised control trial investigating whether printed leaflets or social media are more effective in increasing knowledge of the risks of sun exposure and melanoma in people aged 18-29. The study participants were 18-29-year-old university students or graduates, recruited in London. A baseline level of knowledge was measured using the Skin Cancer and Sun Knowledge questionnaire. Study participants were then randomised into either a leaflet arm or Facebook arm. Identical information was delivered through a SunSafe campaign via either posted leaflets or Facebook during a 10-day exposure window. Following this, participants repeated the Skin Cancer and Sun Knowledge questionnaire. Following the SunSafe intervention, the mean knowledge score improved in both groups to a statistically significant degree (Facebook = 1.82, leaflets = 3.04, P

Background Shift work can negatively impact an individual's health, wellness, and quality of work. Optimal schedule design can mitigate some of these effects. The American College of Emergency Physicians has published schedule design guidelines to increase wellness and longevity in the field, but these guidelines are difficult to apply to emergency medicine (EM) residents given their high shift burdens and other scheduling constraints. Little is known is known about EM resident scheduling preferences or ideal schedule design in the context of residency training. Objectives The objectives were to determine whether EM resident schedule design preferences are consistent with current scheduling guidelines for shift workers and to gather information on scheduling practices that are important to residents. Methods We surveyed residents at four allopathic EM residency programs and assessed residents' preferences on various schedule design features including shift length, circadian scheduling, night shift scheduling, and impact of schedule design on personal wellness. Results Of the 144 residents surveyed, 98% of residents felt that their shift schedule was a key factor in their overall wellness. Residents agreed with shift work guidelines regarding the importance of circadian scheduling (65% favorable), although rated the ability to request a day off and have a full weekend off as more important (84 and 78% favorable responses, respectively). Recommended guidelines promote shorter shifts, but only 24% of residents preferred 8-hour shifts compared to 57, 71, and 43% of residents preferring 9-, 10-, and 12-hour shifts, respectively. Sixty-seven percent of residents preferred their nights to be scheduled in one sequence per 4-week period, a night scheduling strategy most at odds with recommended guidelines. Conclusions Emergency medicine resident scheduling preferences are not universally consistent with shift work guidelines, likely due to the distinct circumstances of residency training. Residents identify schedule design as a significant factor in their overall wellness.

INTRODUCTION Optimal teaching and assessment methods and models for emergency airway, breathing, and hemorrhage interventions are not currently known. The University of Minnesota Combat Casualty Training consortium (UMN CCTC) was formed to explore the strengths and weaknesses of synthetic training models (STMs) versus live tissue (LT) models. In this study, we compare the effectiveness of best in class STMs versus an anesthetized caprine (goat) model for training and assessing seven procedures: junctional hemorrhage control, tourniquet (TQ) placement, chest seal, needle thoracostomy (NCD), nasopharyngeal airway (NPA), tube thoracostomy, and cricothyrotomy (Cric). METHODS Army combat medics were randomized to one of four groups: 1) LT trained-LT tested (LT-LT), 2) LT trained-STM tested (LT-STM), 3) STM trained-LT tested (STM-LT), and 4) STM trained-STM tested (STM-STM). Participants trained in small groups for 3 to 4 hours and were evaluated individually. LT-LT was the "control" to which other groups were compared, as this is the current military predeployment standard. The mean procedural scores (PSs) were compared using a pairwise t-test with a Dunnett's correction. Logistic regression was used to compare critical fails (CFs) and skipped tasks. RESULTS There were 559 subjects included. Junctional hemorrhage control revealed no difference in CFs, but LT-tested subjects (LT-LT and STM-LT) skipped this task more than STM-tested subjects (LT-STM and STM-STM; p

Background Although evidence-based medicine (EBM) is routinely used to guide management in the emergency department, there is still considerable variation in clinical practice. Trainees may not fully appreciate the reasons for these clinical practice variations (CPVs) and may find it frustrating when they encounter them. We used areas of CPV among our faculty as the basis for resident educational sessions and assessed the perceived utility of these sessions. Methods Topics were identified when residents noticed significant variability among the faculty in their management of particular clinical presentations. Sessions were conducted by facilitator-led reviews of EBM guidelines, by faculty panel discussions of their management rationale where EBM guidelines are not available, or by pro-con debates. Residents were surveyed after the initial sessions to assess the utility of this series and changes in their understanding of CPV. Results There was a 72% response rate. The percentage of residents who were frustrated with CPV decreased from 64% to 35%; the percentage who felt that the presence of CPV enhanced their learning increased from 19% to 48%. Sixty-five percent felt that the educational series contributed to decreased frustration, 77% felt that the sessions helped them understand why CPV occurs, and 93% felt that they helped their overall learning. Conclusion Explicit discussion and exploration of CPV in an educational setting can provide multiple benefits. Trainees may gain a better understanding of why CPV occurs and of the rationale behind practice variations. Faculty may benefit from analyzing CPV to determine whether these truly represent the "art of medicine."

The acquisition and maintenance of individual competency is a critical component of effective emergency care systems. This article summarizes consensus working group deliberations and recommendations focusing on the topic "Simulation-based education to ensure provider competency within the healthcare system." The authors presented this work for discussion and feedback at the 2017 Academic Emergency Medicine Consensus Conference on "Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcomes," held on May 16, 2017, in Orlando, Florida. Although simulation-based training is a quality and safety imperative in other high-reliability professions such as aviation, nuclear power, and the military, health care professions still lag behind in applying simulation more broadly. This is likely a result of a number of factors, including cost, assessment challenges, and resistance to change. This consensus subgroup focused on identifying current gaps in knowledge and process related to the use of simulation for developing, enhancing, and maintaining individual provider competency. The resulting product is a research agenda informed by expert consensus and literature review.

Background Shoulder dystocia (SD) requires emergent intervention to prevent maternal and fetal harm, and simulation models for training can be expensive. We developed a novel, cheap and easily transportable low-fidelity simulation (LFS) model to compare to a commercially available high-fidelity simulation (HFS) model. Methods Emergency medicine residents were randomized to training on the HFS or novel LFS model. Subjects completed a pretest and a 1-week and 6-month posttest including a self-assessment and a simulated SD delivery. Results Twenty-seven of the 43 residents completed the study (63%). The number of individuals performing dangerous maneuvers at baseline was similar, 1 week after training was five in HFS and 11 in LFS (p = 0.08) groups and at 6 months was again similar between groups. Mean checklist scores for appropriate actions increased 1 week after training but returned to baseline by 6 months and were similar between groups. The rate of successful delivery, median time to successful delivery, and maximum force applied improved at 1 week and was sustained at 6 months in both groups. Conclusion Within our limited study population, we did not find a large difference in the occurrence of dangerous actions during simulated SD delivery following HFS and LFS training. Our novel and easily transportable LFS trainer, assembled for less than US$10 each, may be a useful tool to train inexperienced providers on the steps of this procedure. However, this requires further study, as does whether HFS models with force monitoring capabilities may be helpful to train providers to minimize dangerous maneuvers such as the application of excessive force.

The meaningful assessment of competence is critical for the implementation of effective competency-based medical education (CBME). Timely ongoing assessments are needed along with comprehensive periodic reviews to ensure that trainees continue to progress. New approaches are needed to optimize the use of multiple assessors and assessments; to synthesize the data collected from multiple assessors and multiple types of assessments; to develop faculty competence in assessment; and to ensure that relationships between the givers and receivers of feedback are appropriate. This paper describes the core principles of assessment for learning and assessment of learning. It addresses several ways to ensure the effectiveness of assessment programs, including using the right combination of assessment methods and conducting careful assessor selection and training. It provides a reconceptualization of the role of psychometrics and articulates the importance of a group process in determining trainees' progress. In addition, it notes that, to reach its potential as a driver in trainee development, quality care, and patient safety, CBME requires effective information management and documentation as well as ongoing consideration of ways to improve the assessment system.

ObjectivesThe Association of American Medical Colleges Standardized Video Interview (SVI) was recently added as a component of emergency medicine (EM) residency applications to provide additional information about interpersonal communication skills (ICS) and knowledge of professionalism (PROF) behaviors. Our objective was to ascertain the correlation between the SVI and residency interviewer assessments of PROF and ICS. Secondary objectives included examination of 1) inter- and intrainstitutional assessments of ICS and PROF, 2) correlation of SVI scores with rank order list (ROL) positions, and 3) the potential influence of gender on interview day assessments.MethodsWe conducted an observational study using prospectively collected data from seven EM residency programs during 2017 and 2018 using a standardized instrument. Correlations between interview day PROF/ICS scores and the SVI were tested. A one-way analysis of variance was used to analyze the association of SVI and ROL position. Gender differences were assessed with independent-groups t-tests.ResultsA total of 1,264 interview-day encounters from 773 unique applicants resulted in 4,854 interviews conducted by 151 interviewers. Both PROF and ICS demonstrated a small positive correlation with the SVI score (r=0.16 and r=0.17, respectively). ROL position was associated with SVI score (p&nbsp

OBJECTIVES There is currently no consolidated list of existing simulation fellowship programs in emergency medicine (EM). In addition, there are no universally accepted or expected standards for core curricular content. The objective of this project is to develop consensus-based core content for EM simulation fellowships to help frame the critical components of such training programs. METHODS This paper delineates the process used to develop consensus curriculum content for EM simulation fellowships. EM simulation fellowship curricula were collected. Curricular content was reviewed and compiled by simulation experts and validated utilizing survey methodology, and consensus was obtained using a modified Delphi methodology. RESULTS Fifteen EM simulation fellowship curricula were obtained and analyzed. Two rounds of a modified Delphi survey were conducted. The final proposed core curriculum content contains 47 elements in nine domains with 14 optional elements. CONCLUSION The proposed consensus content will provide current and future fellowships a foundation on which to build their own specific and detailed fellowship curricula. Such standardization will ultimately increase the transparency of training programs for future trainees and potential employers.

Author(s): Hart, Danielle; Franzen, Douglas; Beeson, Michael; Bhat, Rahul; Kulkarni, Miriam; Thibodeau, Lorraine; Weizberg, Moshe; Promes, Susan | Abstract: Introduction: Medical education is moving toward a competency-based framework with a focus on assessment using the Accreditation Council for Graduate Medical Education Milestones. Assessment of individual competencies through milestones can be challenging. While competencies describe characteristics of the person, the entrustable professional activities (EPAs) concept refers to work-related activities. EPAs would not replace the milestones but would be linked to them, integrating these frameworks. Many core specialties have already defined EPAs for resident trainees, but EPAs have not yet been created for emergency medicine (EM). This paper describes the development of milestone-linked EPAs for EM. Methods: Ten EM educators from across North America formed a consensus working group to draft EM EPAs, using a modified Glaser state-of-the-art approach. A reactor panel with EPA experts from the United States, Canada and the Netherlands was created, and an iterative process with multiple revisions was performed based on reactor panel input. Following this, the EPAs were sent to the Council of Residency Directors for EM (CORD-EM) listserv for additional feedback.Results: The product was 11 core EPAs that every trainee from every EM program should be able to perform independently by the time of graduation. Each EPA has associated knowledge, skills, attitudes and behaviors (KSAB), which are either milestones themselves or KSABs linked to individual milestones. We recognize that individual programs may have additional focus areas or work-based activities they want their trainees to achieve by graduation; therefore, programs are also encouraged to create additional program-specific EPAs. Conclusion: This set of 11 core, EM-resident EPAs can be used as an assessment tool by EM residency programs, allowing supervising physicians to document the multiple entrustment decisions they are already making during clinical shifts with trainees. The KSAB list within each EPA could assist supervisors in giving specific, actionable feedback to trainees and allow trainees to use this list as an assessment-for-learning tool. Linking each KSAB to individual EM milestones allows EPAs to directly inform milestone assessment for clinical competency committees. These EPAs serve as another option for workplace-based assessment, and are linked to the milestones to create an integrated framework.

Author(s): Hart, Danielle; Paetow, Glenn; Zarzar, Rochelle | Abstract: Introduction: Burnout affects over 50% of all physicians. Nearly 70% of emergency physicians are affected, and it has been found to be as high as 76% in resident physicians overall. Previous wellness initiatives have yielded variable results; therefore, we looked for interventions that could potentially be effective at reversing this trend. We explored effective wellness programs originating from other industries. Our objective was to implement a corporate wellness program with previous evidence of success in other healthcare provider populations. We aimed to investigate whether this program would be effective in decreasing burnout in emergency medicine (EM) residents.Methods: This program was conducted during required EM resident conference hours from 2016-2017. The Maslach Burnout Inventory was completed before and after the series of sessions, and we collected reactions-level data following completion of the six sessions.Results: Post-intervention scores revealed a small trend toward increased emotional exhaustion and depersonalization scores, and with increased personal accomplishment scores. The overall satisfaction rating for this program was low, at 1.5 on a 5-point scale. Forty-three percent of residents stated that this intervention subjectively worsened their overall burnout, with another 39% stating it did not improve their burnout at all. A similar trend was seen for effects on wellness.Conclusion: We found that a corporate wellness intervention that had previously been shown to be successful with other types of healthcare providers did not objectively improve burnout and was subjectively perceived as paradoxically worsening burnout for many residents. This result may be related to the type of intervention chosen (individual vs. systems-focused), the design of the intervention itself, or the unique stressors faced by the resident population.

BACKGROUND Between 2010 and 2012, the Heart Rhythm team in a tertiary care hospital completed a retrospective study that found that atrial fibrillation (AF) care can be episodic and heavily reliant on hospital resources, particularly the emergency department (ED). PROBLEM Patients who attend the ED with AF are at high risk of hospital admission. APPROACH A nurse practitioner (NP) was added to the Heart Rhythm team to create a program to improve AF care after an ED visit. Telephone practice was one of the many processes created. OUTCOMES Findings revealed that 37 of 90 patients presented to the ED with AF prior to telephone contact and 7 of 90 patients did so post-telephone contact (P < .001). CONCLUSION Telephone practice led by an NP provides an opportunity to improve assessment and management of patient with AF and offers a promising cost-effective method to reduce ED visits in the AF patient population.

Children ages 9–12 years face increasing social and academic expectations that require mastery of their thoughts, emotions, and behavior. Little is known about the development of neural pathways integral to these improving capacities during the transition from childhood to adolescence. Among 234 healthy, inner-city male and female youth (speciesHomo sapiens) 9–12 years of age followed by the Columbia Center for Children's Environmental Health, we acquired diffusion tensor imaging, multiplanar chemical shift imaging, and cognitive measures requiring self-regulation. We found that increasing age was associated with increased fractional anisotropy and decreased apparent diffusion coefficient, most prominently in the frontal and cingulate cortices, striatum, thalamus, deep white matter, and cerebellum. Additionally, we found increasing age was associated with increasedN-acetyl-l-aspartate (NAA) in the anterior cingulate and insular cortices, and decreased NAA in posterior cingulate and parietal cortices. Age-associated changes in microstructure and neurometabolite concentrations partially mediated age-related improvements in performance on executive function tests. Together, these findings suggest that maturation of key regions within cortico-striatal-thalamo-cortical circuits subserve the emergence of improved self-regulatory capacities during the transition from childhood to adolescence.SIGNIFICANCE STATEMENTFew imaging studies of normal brain development have focused on a population of inner-city, racial/ethnic minority youth during the transition from childhood to adolescence, a period when self-regulatory capacities rapidly improve. We used DTI and MPCSI to provide unique windows into brain maturation during this developmental epoch, assessing its mediating influences on age-related improvement in performance on self-regulatory tasks. Our findings suggest that rapid maturation of cortico-striato-thalamo-cortical circuits, represented as progressive white-matter maturation (increasing FA and increasing NAA, Ch, Cr concentrations accompanying advancing age) in frontal regions and related subcortical projections and synaptic pruning (decreasing NAA, Ch, Cr, Glx) in posterior regions, support age-related improvements in executive functioning and self-regulatory capacities in youth 9–12 years of age.

Author(s): Nadir, Nur-Ain; Hart, Danielle; Cassara, Michael; Noelker, Joan; Moadel, Tiffany; Kulkarni, Miriam; Sampson, Christopher; Bentley, Suzanne; Naik, Neel; Hernandez, Jessica; Krzyzaniak, Sara; Lai, Steven; Podolej, Gregory; Strother, Christopher | Abstract: Introduction: Resident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR).Methods: We conducted a literature search on SBR practices using the terms “simulation,” “remediation,” and “simulation based remediation.” We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM.Results: Faculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved.Conclusion: Simulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

Title of Document: A QUALITATIVE ANALYSIS OF MIDDLE SCHOOL ADMINISTRATORS’ PERCEPTIONS OF CYBERBULLYING Danielle Moore, Doctor of Education, 2018 Directed by: Dr. Stephanie Timmons-Brown, College of Education With the increase in students’ use of technology—and subsequently social media, email, and texting—schools have seen a marked increase in instances of cyberbullying. The aim of this study was to explore six middle schools’ implementation of a district cyberbullying policy in one school system. Each of the six schools had documented incidents of cyberbullying in the most recent schools years. The researcher collected data, through one-on-one interviews with principals and administrative designees who managed student cyberbullying incidents, in order to address the following research questions: (1) How do administrators approach and process cyberbullying incidents? (2) What are administrators’ perceptions of how cyberbullying impacts the learning environment? (3) What strategies have middle school administrators employed to reduce cyberbullying incidents? The participants noted that cyberbullying negatively affected the learning environment for schools, created unsafe spaces that impeded student learning, and monopolized the time of administrators. Most notably, the results indicate that although schools address incidents of cyberbullying with the district policy in mind, they do not always document or report the incidents to district leaders, as the policy requires. As a result, the district may be unknowingly underreporting cyberbullying incidents to the state. Based on these findings, the researcher recommended that the school district consider streamlining the process by which school administrators document cyberbullying investigations and results, strengthen efforts to educate parents about how to monitor their students’ social media use, and provide middle schools with research-based prevention programs to support their efforts to address cyberbullying.

There are multiple techniques for face-mask (FM) ventilation. To our knowledge, the one-handed vs. two-handed C-E technique has been compared in children and adults, but no studies have compared the various two-handed methods.To compare the effectiveness of mask seal using three different FM techniques on a model intended to simulate difficult FM ventilation and measure ventilation performance.This was a prospective randomized study of health care providers. A standard airway-training mannequin was modified to produce variable airway resistance and allow measurements of ventilation volume and pressure. Each subject performed FM ventilation for 3 min per technique (30 breaths) in a randomized order. Median exhaled tidal volume and proximal peak flow pressure were determined and compared.Seventy subjects were enrolled. Both two-handed ventilation techniques were more effective than the one-handed technique by both volume and pressure measurements. The one-handed C-E technique yielded a median volume of 428.4 mL, vs. the two-handed C-E technique with 550.8 mL, and the two-handed V-E technique with 538 mL (p0.001). Peak pressure measurements revealed a median of 54.6 cm H2O for the one-handed C-E technique, 66 cm H2O for the two-handed C-E technique, and 66.6 cm H2O for the two-handed V-E technique (p0.001). There was not a difference between the various two-handed techniques.This model for FM ventilation is able to differentiate the efficacy of FM techniques. Both two-handed ventilation methods were superior to one-handed ventilation, both of which should perhaps be included in airway training for health care providers.

OBJECTIVE:: To determine the most accurate predictor of central venous pressure among three point-of-care venous ultrasound techniques. DESIGN:: Cross-sectional study. SETTING:: Medical ICU in an academic medical center. PATIENTS:: Convenience sample of 67 spontaneously breathing patients who had an intrathoracic central venous catheter to allow measurement of central venous pressure. INTERVENTION:: Measurement of the internal jugular vein height to width ratio (aspect ratio), the inferior vena cava diameter, and the percent collapse of the inferior vena cava with inspiration (collapsibility index) by ultrasound. MEASUREMENTS AND MAIN RESULTS:: Complete data for analysis were available in 65 patients, as the inferior vena cava could not be visualized in two patients. A central venous pressure of 10 mm Hg was chosen a priori as a clinically significant cutoff. The range of central venous pressure values was 1-23 mm Hg with a median value of 7 mm Hg. The maximal inferior vena cava diameter correlated moderately with central venous pressure (R = 0.58), whereas the inferior vena cava collapsibility index and the internal jugular vein aspect ratio showed poor correlation (R = 0.16 and 0.21, respectively). The area under the receiver operating characteristics curve (area under the curve) to discriminate a low central venous pressure (< 10 mm Hg) was 0.91 for inferior vena cava diameter (95% confidence interval 0.84-0.98), which was significantly higher than the internal jugular vein aspect ratio (area under the curve 0.76; 95% confidence interval 0.65-0.89) or the inferior vena cava collapsibility index (area under the curve 0.66; 95% confidence interval 0.51-0.80) (p = 0.0001). An inferior vena cava diameter < 2 cm predicted a central venous pressure < 10 mm Hg with a sensitivity of 85% (95% confidence interval 69% to 94%), specificity of 81% (95% confidence interval 60% to 93%), and positive predictive value of 87% (95% confidence interval 71% to 95%). Inferior vena cava collapsibility index was not an independent predictor of central venous pressure after adjusting for inferior vena cava diameter in a multiple linear regression model. CONCLUSION:: Among spontaneously breathing patients largely without vasopressor support, the maximal inferior vena cava diameter is a more robust estimate of central venous pressure than the inferior vena cava collapsibility index or the internal jugular vein aspect ratio.

Endotracheal intubation (ETI) is an important skill for all emergency providers; our ability to train and assess our learners is integral to providing optimal patient care. The primary aim of this study was to assess the inter-rater reliability (IRR) and discriminant validity of a novel field ETI assessment tool using a checklist-derived performance score (PS) and critical failure (CF) rate.Forty-three participants (18 paramedic students, 11 paramedics, and 14 emergency physicians [EPs]) performed ETI during a simulated trauma scenario on a pseudo-ventilated cadaver. Each participant was assessed by two experienced raters. IRR was calculated using the intraclass correlation coefficient. Regarding discriminant validity, a Kruskal-Wallis test was used to analyze PSs and a χThe ETI assessment tool had excellent IRR, with an intraclass correlation coefficient of 0.94. There was a significant difference in PSs, CFs, and GRSs (p0.05) between cohorts.The novel field ETI assessment tool has excellent reliability among trained raters and discriminates between experienced ETI providers (EPs) and less experienced ETI performers using PSs, CFs, and GRSs on a fresh cadaveric model.

There are many models currently used for teaching and assessing performance of trauma-related airway, breathing, and hemorrhage procedures. Although many programs use live animal (live tissue [LT]) models, there is a congressional effort to transition to the use of nonanimal- based methods (i.e., simulators, cadavers) for military trainees. We examined the existing literature and compared the efficacy, acceptability, and validity of available models with a focus on comparing LT models with synthetic systems. Literature and Internet searches were conducted to examine current models for seven core trauma procedures. We identified 185 simulator systems. Evidence on acceptability and validity of models was sparse. We found only one underpowered study comparing the performance of learners after training on LT versus simulator models for tube thoracostomy and cricothyrotomy. There is insufficient data-driven evidence to distinguish superior validity of LT or any other model for training or assessment of critical trauma procedures.

Background Training health care providers to manage common life-threatening traumatic injuries is an important endeavor. A fresh perfused cadaveric model with high anatomic and tissue fidelity was developed to assess performance of hemorrhage and airway management skills during a simulated polytrauma scenario. Methods Fresh human cadavers were obtained within 96 hours of death. Hemorrhage from a right traumatic amputation and left inguinal wound was simulated using cannulation of the right popliteal and left femoral artery, respectively. The thoracic aorta (thoracotomy method) or external iliac arteries (Pfannenstiel method) were used for catheter access points. Lung ventilation to simulate chest rise and fall was achieved using bilateral chest tubes connected to a bag valve mask. Participants underwent a simulated nighttime field care scenario in which they attempted tourniquet placement, direct wound pressure and packing, and endotracheal intubation. Results Twenty-four donors were obtained (58-95 years old; mean, 77). There were 305 total scenarios completed using 23 cadavers (mean, approximately 13 scenarios per cadaver). The cost for acquisition and preparation of donors can be estimated at $3,611 to $9,399. Conclusion This model successfully allowed for the demonstration of hemorrhage and airway management skills with high anatomic and tissue fidelity. For the assessment of critical lifesaving skills that are nondestructive in nature, the use of a fresh perfused cadaveric model is feasible and suitable for evaluation of these procedures.

The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis. Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article. The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.

Background The Next Accreditation System (NAS) is being implemented by the Accreditation Council for Graduate Medical Education with seven specialties, including Emergency Medicine (EM), which began in July 2013. The NAS represents a more structured method of accreditation, with dependence on outcomes and less emphasis on educational process. A key component of the NAS is the individual resident semiannual reporting of the Milestone proficiency levels for all sub-competencies, which are more specific areas of domain for the general competencies. All specialties are struggling to some extent with developing assessment mechanisms for the Milestones. At the heart of this struggle is the conceptualization of the Milestones themselves-descriptors of the individual. In practice, faculty assess clinical care provided to the patient by the resident. This creates difficulty for faculty to assign a resident to a specific sub-competency proficiency level when their focus has been on assessment of clinical care. Objectives The objectives of this article include the discussion of whether Entrustable Professional Activities (EPAs) could be defined and linked to milestones in a way that, once implemented, could inform Clinical Competency Committees of the Milestone proficiency reporting. Discussion EPAs are units of professional work, or clinical care that may help translate aspects of clinical care into Milestone proficiencies. This article explores EPAs in depth, and discusses how EPAs may be used within EM as one method of assigning proficiency levels to residents. Conclusions EPAs may be a useful tool to inform Milestone proficiency placement of residents. Because EPAs are based on clinical descriptions rather than individual physician descriptions, there may be less faculty development needed for Milestone sub-competency assessment.

In this 30-minute talk, the authors take an in-depth look at how to debrief high-fidelity case-based simulation sessions, including discussion on debriefing theory, goals, approaches, and structure, as well as ways to create a supportive and safe learning environment, resulting in successful small group learning and self-reflection. Emphasis is placed on the "debriefing with good judgment" approach. Video clips of sample debriefing attempts, highlighting the "dos and don'ts" of simulation debriefing, are included. The goal of this talk is to provide you with the necessary tools and information to develop a successful and effective debriefing approach. There is a bibliography and a quick reference guide in Data Supplements S1 and S2 (available as supporting information in the online version of this paper).

Background Breech presentation and delivery are important complications of labor and delivery, which, although dealt with by the emergency physician infrequently, can represent major morbidity and mortality to both the mother and fetus if techniques are not performed correctly. Objectives We aim to describe a technique for breech delivery that was used successfully when all conventional techniques had failed. To our knowledge, this technique has not been described in previous literature. Case Report A 36-year-old woman presented to an urban emergency department in active labor. The physicians were called to the triage area, and found the patient lying on the floor with a limp, cyanotic-appearing fetus delivered to the level of the mid thorax. The arms and shoulders were delivered successfully, but after all traditional maneuvers to deliver the head were unsuccessful, a novel approach was used successfully and is described in this report. Conclusion We have described a novel, seemingly safe, and effective technique to use in breech delivery when traditional techniques have failed.

In this 30-minute talk, we will briefly discuss the characteristics of the Millennial Generation and explore in depth how these characteristics relate to their ability, or inability, to learn productively in a traditional lecture-style format. This discussion will encompass both a review of the current literature and survey results from the current emergency medicine residents at Hennepin County Medical Center regarding techniques they find effective and engaging during “the lecture” or other large group educational sessions. The goal of this talk is to expand or refine the armamentarium of tools to use when designing your large-group educational sessions, to maximize the learning and retention of information for your students.

ACADEMIC EMERGENCY MEDICINE 2012; 19: 1084–1085 © 2012 by the Society for Academic Emergency Medicine Abstract In this 30-minute talk, the authors take an in-depth look at how to debrief high-fidelity case-based simulation sessions, including discussion on debriefing theory, goals, approaches, and structure, as well as ways to create a supportive and safe learning environment, resulting in successful small group learning and self-reflection. Emphasis is placed on the “debriefing with good judgment” approach. Video clips of sample debriefing attempts, highlighting the “dos and don’ts” of simulation debriefing, are included. The goal of this talk is to provide you with the necessary tools and information to develop a successful and effective debriefing approach. There is a bibliography and a quick reference guide in Data Supplements S1 and S2 (available as supporting information in the online version of this paper). The video is located here: https://vimeo.com/33991081 password is perls