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BACKGROUND The Society for Academic Emergency Medicine Board of Directors convened a Task Force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The Task Force surveyed academic emergency department (ED) Chairs and Residency Program Directors. METHODS The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member Chairs and their respective Residency Program Directors (PDs) in 2021. We surveyed 125 Chairs with their self-identified PDs. The survey sampled hiring, state independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. RESULTS Of the AACEM-member Chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast track settings, 80% work in the main ED and 54% in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents report that APPs manage high-acuity patients without attending involvement. Two-thirds of Chairs believe that APPs contribute positively to the quality of patient care, while 44% believe APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. CONCLUSIONS APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic emergency department within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.

Background Acute pancreatitis (AP) is a common presentation in the emergency department (ED). Severity of pancreatitis is an important consideration for ED clinicians making admission judgments. Validated scoring systems can be a helpful tool in this process. Objective The aim of this review is to give a general outline on the subject of AP and compare different criteria used to predict severity of disease for use in the ED. Discussion This review updates the classifications and scoring systems for AP and the relevant parameters of each. This article assesses past and current scoring systems for AP, including Ranson criteria, Glasgow criteria, Acute Physiology and Chronic Health Evaluation II (APACHE II), computed tomography imaging scoring systems, Bedside Index of Severity in Acute Pancreatitis (BISAP) score, Panc 3, Harmless Acute Pancreatitis Score (HAPS), and the Japanese Severity Score. This article also describes the potential use of single variable predictors. Finally, this article discusses risk factors for early readmission, an outcome pertinent to emergency physicians. These parameters may be used to risk-stratify patients presenting to the ED into mild, moderate, and severe pancreatitis for determination of appropriate disposition. Conclusion Rapid, reliable, and validated means of predicting patient outcome from rapid clinical assessment are of value to the emergency physician. Scoring systems such as BISAP, HAPS, and single-variable predictors may assist in decision-making due to their simplicity of use and applicability within the first 24 h.

Social media has become a staple of everyday life among over one billion people worldwide. A social networking presence has become a hallmark of vibrant and transparent communications. It has quickly become the preferred method of communication and information sharing. It offers the ability for various entities, especially residency programs, to create an attractive internet presence and “brand” the program. Social media, while having significant potential for communication and knowledge transfer, carries with it legal, ethical, personal, and professional risks. Implementation of a social networking presence must be deliberate, transparent, and optimize potential benefits while minimizing risks. This is especially true with residency programs. The power of social media as a communication, education, and recruiting tool is undeniable. Yet the pitfalls of misuse can be disastrous, including violations in patient confidentiality, violations of privacy, and recruiting misconduct. These guidelines were developed to provide emergency medicine residency programs leadership with guidance and best practices in the appropriate use and regulation of social media, but are applicable to all residency programs that wish to establish a social media presence. [West JEmerg Med. 2014;15(1):26–30.]

We present the case of a 32-year-old woman who presented to the emergency department with a witnessed cardiac arrest. She was otherwise healthy with no cardiac risk factors and had undergone an uneventful repeated cesarean section 3 days priorly. The patient underwent defibrillation, out of ventricular fibrillation to a perfusing sinus rhythm, and was taken to the catheterization laboratory where coronary angiography findings showed spontaneous dissection of the left anterior descending artery. The patient received a total of 6 stents during her hospital stay and was eventually discharged in good condition. Spontaneous coronary artery dissection is a rare entity with a predilection for pregnant or postpartum women. Early diagnosis and treatment are key for survival, and when identified early, mortality is good. [West J Emerg Med. 2011;12(4):567–570.]

Background Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS) are integral parts of emergency resuscitative care. Although this training is usually reserved for residents, introducing the training in the medical student curriculum may enhance acquisition and retention of these skills. Objectives We developed a survey to characterize the perceptions and needs of graduating medical students regarding BLS, ACLS, and PALS training. Methods This was a study of graduating 4 th -year medical students at a U.S. medical school. The students were surveyed prior to participating in an ACLS course in March of their final year. Results Of 152 students, 109 (71.7%) completed the survey; 48.6% of students entered medical school without any prior training and 47.7% started clinics without training; 83.4% of students reported witnessing an average of 3.0 in-hospital cardiac arrests during training (range of 0–20). Overall, students rated their preparedness 2.0 (SD 1.0) for adult resuscitations and 1.7 (SD 0.9) for pediatric resuscitations on a 1–5 Likert scale, with 1 being unprepared. A total of 36.8% of students avoided participating in resuscitations due to lack of training; 98.2%, 91.7%, and 64.2% of students believe that BLS, ACLS, and PALS, respectively, should be included in the medical student curriculum. Conclusions As per previous studies that have examined this topic, students feel unprepared to respond to cardiac arrests and resuscitations. They feel that training is needed in their curriculum and would possibly enhance perceived comfort levels and willingness to participate in resuscitations.

Background Many patients present to the Emergency Department (ED) for multiple visits. Whatever the cause, assuring the highest quality of care is difficult in the ED. Objectives We sought to implement a web-based, ED-initiated, multidisciplinary program to improve patient care and reduce frequent visits to the ED. Methods The top 50 ED frequent visitors were identified and care plans were constructed. Care plans consist primarily of a summary of the patient's pertinent history and any psychosocial issues that can contribute to frequent use of the ED, and recommend treatment plans for these patients. Results During the study period, ED visits by the top 50 chronic frequent visitors ranged from 88 to 98 visits/month and 28 to 31 admissions/month. As of January 2007, the top 50 frequent visitors had 94 ED visits/month (1,129 visits/year) for 2.2% of the total census, and 31 admissions/month (372 admissions per year) for approximately 3.3% of the total admissions. Each frequent visitor has approximately 22.6 visits/year (range from 11 to 41) and 7.3 admissions/year (range from 0 to 20). By May 2008, the top 50 frequent visitors had a decrease to 88 visits/month (1,059 visits/year) and 28 admissions/month (340 admissions/year), with each frequent visitor having 21.2 visits/year and 6.8 admissions/year. Social determinants included psychiatric disease (36%), substance abuse (22%), malingering (20%), medication noncompliance (16%), and unstable housing (10%). Conclusions There was a trend toward a decrease of monthly ED visits by the top 50 ED frequent visitors, but no effect on the rate of admissions. Based on these preliminary data and the relative ease of integration into the system, this project shows the potential to begin to address the problem of chronic ED use with patient care plans.

Objective Various HIV testing models have been described, but widespread implementation has lagged. We describe a clinical HIV testing program notable for its use of conventional (nonrapid) assays, native hospital personnel, and an electronic system to aid targeted patient selection. Methods Clinical HIV testing program records and hospital emergency department (ED) and laboratory records were reviewed and linked for the period from January 2007 until November 5, 2008. Results There were 103,475 visits to the ED, for which 1,258 (1.2%) resulted in HIV testing, and 54 (4.3%) were positive for HIV antibody. Result notification was successful for 52 (96%) individuals with positive test results. After reporting to the health department, it was determined that 28 (2.2%) individuals had received a new diagnosis, of whom 89% were linked with care. Mean baseline CD4 counts for new diagnoses for periods 1 through 3, respectively, were (1) unavailable, (2) 138 cells/μL (95% confidence interval [CI] 34 to 242 cells/μL), and (3) 222 cells/μL (95% CI 119 to 325 cells/μL). Overall, mean calculated to be 180 cells/μL (95% CI 16 to 345 cells/μL). Conclusion This ED HIV testing model successfully expanded new patient identification, result notification, and linkage to care. Although this effort falls short of Centers for Disease Control and Prevention recommendations, the model can be implemented widely without external funding for parallel staffing or rapid assays.

Figure 1. Chest X-ray study showing a significantly widened mediastinum (arrows). A 53-year-old man with history of hypertension, coronary artery disease, and chronic left leg deep vein thrombosis on Coumadin (Bristol-Myers Squibb Company, Princeton, NJ) presented complaining of chest pain. The pain was dull, midsternal, gradual in onset, and rated 5/10. There was no radiation of the pain, and the patient initially said that this pain was similar to his previous cardiac pain. Review of systems was positive for mild exertional chest pain and occasional shortness of breath. Vital signs were stable and the examination was remarkable for a 2/6 systolic ejection murmur. Electrocardiogram showed right bundle branch block without ischemia. Cardiac enzymes were normal. Chest X-ray study (Figure 1) showed widened mediastinum. A computed tomography scan with angiography of the chest (Figure 2) revealed a pulmonary aneurysm with the main pulmonary artery dilatated to 71 mm and enlargement of both pulmonary arteries. An echocardiogram showed a severely dilatated right ventricle, moderate tricuspid regurgitation, and a pulmonary artery pressure of approximately 66 mm Hg, consistent with pulmonary hypertension. The patient’s pulmonary aneurysm was thought to most likely be secondary to chronic undiagnosed pulmonary embolisms causing pulmonary hypertension. His symptoms resolved, so he was medically optimized and discharged. The aneurysm has remained stable since his first visit. Pulmonary artery aneurysms are found in approximately 1 in 14,000 postmortem examinations (1). Congenital heart disease is thought to cause the majority of

Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicine's report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems' administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Children's National Medical Center, Family Voices, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.

A 40-year-old man with Hepatitis C and a history of cocaine abuse presented with multiple stages of painful rashes on his extremities and ears. On examination, the patient had several areas of purpuric macules and retiform purpura to his legs and ears (Figures 1 and 2), as well as large ulcerations with erythematous borders on bilateral lower extremities (Figure 3). Laboratory studies revealed mild leukopenia (white blood cell 3.8 K/uL), positive anti-nuclear antibody (ANA), and negative cryoglobulins. Anti-myeloperoxidase antibodies (MPO-ANCA) and anti-proteinase-3 (PR3-ANCA) were also positive. Skin biopsy revealed dermal purpura and thrombi.