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Objectives: Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment., Methods: This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents., Results: There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM., Conclusions: EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training., (© 2016 by the Society for Academic Emergency Medicine.)

Spermatic cord anesthesia block (SCAB) is a useful technique for providing anesthesia to males with scrotal pain. This technique has been described and published in the urology and anesthesia literature for more than 40 years. Initially described as a blind injection, anesthesia of the spermatic cord provides pain control to the scrotal contents. The technique can easily be performed under ultrasound guidance by emergency physicians and should be considered a useful option when seeking to provide pain relief to male patients with scrotal pain., Competing Interests: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

The influence of using ofloxacin in place of ciprofloxacin on hospital fluoroquinolone expenditures, total antimicrobial expenditures, and susceptibility of Pseudomonas aeruginosa to fluoroquinolones was studied. Hospitals with fluoroquinolone expenditures of at least $1 per occupied bed per year were administered annual surveys covering the years 1993 through 1996. The two most recent consecutive years of data were compared among hospitals that used ciprofloxacin as their primary fluoroquinolone during both years (group 1), hospitals whose ofloxacin purchases increased from accounting for < or =25% of total fluoroquinolone expenditures during year 1 to accounting for >25% during year 2 (group 2), and hospitals whose ofloxacin purchases accounted for at least 25% of total fluoroquinolone expenditures for both years (group 3). A total of 109 hospitals were included in the study. Most hospitals spent more on fluoroquinolones and total antimicrobials in year 2 than year 1. Group 3 hospitals had a significant increase in expenditures for fluoroquinolones and non-fluoroquinolone antipseudomonal antimicrobials. Group 2 hospitals did not realize antimicrobial cost savings and had higher rates of Pseudomonas aeruginosa resistance than hospitals that used ciprofloxacin. Whether a hospital changed its pattern of ciprofloxacin and ofloxacin purchasing was not significantly associated with expenditures for fluoroquinolones, nonfluoroquinolone antimicrobial agents, or all antimicrobials. Susceptibility of P. aeruginosa to ciprofloxacin was lower in hospitals with greater proportions of ofloxacin use. Individual hospital, ciprofloxacin expenditures, and study year were found to be predictive of P. aeruginosa susceptibility to ciprofloxacin among all pooled hospitals.

Hospital expenditures on antimicrobial drugs, antimicrobial management practices, and the effects of these practices were studied. A survey on institutional budget, size, and staffing; intensive care unit drug costs and use evaluations; and pharmacy expenditures, including antimicrobial costs, for 1993 and 1994 was sent to 122 hospitals. The written survey was followed by telephoned questions regarding each institution's antimicrobial management and expenditures, and any perceived link between the two. Hospitals were grouped by size and type, data were normalized to costs per occupied bed and costs per occupied bed per case mix index, and averages for each size category were calculated for general institutional information and expenses per antimicrobial. Eighty-eight institutions (72%) responded. Although 61% to 74% of the respondents used an antimicrobial formulary to restrict drug choices and control costs, average total antimicrobial expenses increased by more than $300 per occupied bed between 1993 and 1994. Only 7% of the institutions saw decreased costs of $500 or more per occupied bed. The most common reasons for these decreases were restructuring of pricing contracts and implementation of educational programs. The replacement of one formulary alternative with another led to increases in the use of antimicrobials other than the replacement drug and often did not produce savings. The replacement of one formulary antimicrobial with another led more to costshifting than to overall savings.