RESIDENT ACADEMIC DAY PROGRAM 2020

Carolinas Medical Center Department of Emergency Medicine

Resident Academic Day

June 18, 2020

Resident Academic Day 2020 CMC Department of Emergency Medicine Thursday, June 18, 2020 Medical Education Building • 3rd Floor Conference Room

Schedule 8:00 am

Welcome & Introductions

Mike Gibbs, MD, and Mike Runyon, MD

8:10 am

2020 Resident Academic Day Address

8:30 am

Jessica Hoglund, MD – Test Characteristics of a Five Element Cortical Screen for Identifying Anterior Circulation Large Vessel Occlusion Ischemic Strokes

8:45 am

Austin Costa, MD - Physicians’ Comfort Level and Use of Ketamine Increases Following an Agitation/Ketamine Educational Protocol

9:00 am

Angela Rombola, MD - Non-Fatal Strangulation Victims in the Emergency Department: Photographic Evidence of Injuries

9:15 am

Jennifer Potter, MD - Case Series: Hyperdense Basilar Artery Identified on Unenhanced Head CT in Three Cases of Pediatric Basilar Artery Occlusion

Malika Fair, MD, MPH, FACEP

---------------------------------------- Break @ 9:30 am ----------------------------------------------9:45 am

Nicholena Richardson, MD - Evaluation of Non-Fatal Strangulation Victims in the Emergency Department: Practice Variability Among Healthcare Workers

10:00 am

Jeremy Driscoll, MD - Prospective Observational Study Comparing Persons Under Investigation For COVID-19 At Community Paramedicine Units To Those At Regional Emergency Departments

10:15 am

Jesse Blake Bauer, MD - Focusing Rapid Electrocardiogram Screening Criteria: Fever and ST Segment Myocardial Infarctions

10:30 am

Robert Kregg Laundon, MD - Implementing a Global Health Curriculum for Emergency Medicine and Pediatric Residents

10:45 am

Colin O’Neill, MD – Assessment of Physician Financial Literacy and Satisfaction ------------------------------------- Break @ 11:00 am -----------------------------------------------

11:15 am

Ethen Ellington, MD - Virtual Reality CPR Training Improves Knowledge Acquisition of Critical Tasks

11:30 am

Christopher Gardner, MD - Right Ventricular Dysfunction Measurements in Pulmonary Embolism with Subsequent Acute Clinical Deterioration

11:45 am

Francisco Javier Andrade, MD – Development and Implementation of an Intensive Pediatric Point-of-Care Ultrasound (PoCUS) Curriculum in Guatemala

12:00 pm

Sean Murray, MD – Assessment of a Novel Ultrasound Workshop: Teaching Emergency Medicine Residents to Detect Ascending Aorta Pathology with Bedside Ultrasound

12:15 pm

Logan Stark, MD – Improvement in Comfort and Knowledge in POCUS in Testicular Torsion Following Lecture and Hands On Training

CMC Department of Emergency Medicine

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Resident Academic Day 2020

Resident Academic Day 2020 CMC Department of Emergency Medicine Visiting Professor

Malika Fair, MD, MPH, FACEP

Malika Fair, MD, MPH is the Senior Director for Health Equity Partnerships and Programs at the Association of American Medical Colleges (AAMC). In this role, Dr. Fair develops programs and initiatives to enhance institutional, faculty, and student learning in diversity & inclusion, equity, and population health. Dr. Fair serves as the Principal Investigator for the Centers for Disease Control and Prevention (CDC) Cooperative Agreement with the AAMC which seeks to strengthen collaboration between the disciplines of academic medicine and public health. She also co-leads the AAMC Accelerating Health Equity, Advancing through Discovery (AHEAD) initiative which seeks to identify, evaluate, and disseminate effective and replicable AAMC-member institution practices that improve community health and reduce health inequities. Dr. Fair oversees the Office of Community Engagement that seeks to develop strategic partnerships with community agencies to improve the health of local residents as well as assist medical schools and teaching hospitals with their community engagement efforts.

Dr. Fair is an Assistant Clinical Professor and practicing physician in the Department of Emergency Medicine of The George Washington University. Prior to her current position, Dr. Fair served as the Clerkship Director of Emergency Medicine and the Co-Director of the Health Policy Track for The George Washington University School of Medicine and Health Sciences. She also served as the Co-Principal Investigator of the Beyond Flexner Study and an investigator for the Medical Education Partnership Initiative (MEPI) in The George Washington University Milken Institute School of Public Health.

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Dr. Fair serves as Vice Chair of the Board of Directors for the Not-For-Profit Hospital Corporation (United Medical Center) and on the Advisory Board of the Griffith Leadership Center within the University of Michigan School of Public Health and Department of Health Management and Policy. In 2019, Dr. Fair was selected to be included in the 40 Under 40 Leaders in Minority Health by the National Minority Quality Forum.

Dr. Fair completed her residency training and chief residency at Carolinas Medical Center in Charlotte, NC. She received her medical and Master of Public Health degrees from the University of Michigan and Bachelor of Science from Stanford University.

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Resident Academic Day 2020

Test Characteristics of a Five Element Cortical Screen for Identifying Anterior Circulation Large Vessel Occlusion Ischemic Strokes Jessica Hoglund, MD, Dale Strong, BS, Jeremy Rhoten, BSN, Brenda Chang, MS, MPH, Rahul Karamchandani, MD, Connell Dunn, BS, Hongmei Yang, PhD, Andrew W Asimos, MD

Objective: Stroke severity screens typically include the cortical signs Field cut, Aphasia, Neglect, Gaze preference, and Dense hemiparesis (FANG-D). The accuracy and reliability of these signs, when assessed by Emergency Physicians (EPs), to identify patients with Anterior Circulation Large Vessel Occlusion (ACLVO) Acute Ischemic Stroke (AIS) is unknown. We hypothesized that a novel screen, the FANG-D screen, when applied by EPs would be sensitive and reliable for identifying ACLVO AIS. Methods: We conducted a prospective cohort study enrolling consecutive patients with suspected AIS presenting within 4.5 hours of last known well to the ED. EPs performed the FANG-D screen prior to, and blinded to the results of, imaging. The imaging standard was defined as an unenhanced Computed Tomography (CT) for identifying hemorrhage, and CT Angiography for identifying large vessel occlusion (LVO). ACLVO was defined as an occlusion of the internal carotid artery, the middle cerebral artery, or its first branch. A convenience sample of patients had a duplicate FANG-D screen performed by a second EP to assess interobserver agreement.

Results: We performed 608 FANG-D assessments on 491 patients, of whom 64 (10%) had an ACLVO. FANG-D had a sensitivity of 91% (CI 81-96%) and a specificity of 35% (CI 31-39%) for identifying ACLVO. Interobserver agreement was tested on 133 patients, and was substantial, with a Fleiss’ Kappa of 0.77 (CI 0.64-0.88).

Conclusions: The FANG-D screen is a sensitive test for identifying ACLVO when performed by EPs and demonstrates substantial interrater reliability.

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Resident Academic Day 2020

Physicians’ Comfort Level and Use of Ketamine Increases Following an Agitation/Ketamine Educational Protocol Austin T. Costa, MD1, Natalie R. Wood MD2, Kathryn T. Kopec DO1 1

Atrium Health’s Carolinas Medical Center, Charlotte, NC, Memorial Regional Medical Center, Mechanicsville, VA, Richmond, Virginia,

2

Background: Agitated patients pose a significant threat to both themselves and healthcare workers. Ketamine has been demonstrated to be successful in the control of agitated patients in the prehospital setting, however, it is often underutilized in the emergency department (ED).

Objective: We performed an observational study to assess whether physicians’ comfort level and reported use of ketamine increased following the initiation of an agitation/ketamine protocol.

Methods: The study was conducted at a single, urban, level 1 trauma center ED. The protocol was developed as an educational guideline for physicians, covering recommended dose ranges, administration routes, and timing of ketamine and other commonly used sedatives for agitated patients. Survey questions assessed physician comfort level (5-point Likert scale) and usage of ketamine for agitation. Content validity (clarity and relevance) of the survey items was assessed by 5 attending emergency medicine physicians. Surveys were sent to all 109 emergency medicine attendings, fellows, residents, and interns on staff prior to and approximately 10 months following the protocol initiation. Comparisons between groups were performed using the Chi square or Fisher’s exact test for proportions and the Mann-Whitney U test for continuous variables. Two-sided p-values < 0.05 were considered significant.

Results: Of the 109 physicians surveyed, 35 (32.1%) and 68 (62.4%) responded to the pre- and post-protocol survey, respectively. There was no significant difference between the level of training in the pre- and post-protocol survey groups (p = 0.34). Comfort level with using ketamine increased following the protocol when compared to pre-protocol (4 vs. 3, difference 1 [95% CI 0-1], p = 0.02). The proportion of physicians who reported frequency of ketamine use as “none” decreased in the 10-month period following the protocol compared to their pre-protocol reported use (29.4% vs. 48.6%). All groups who reported ketamine use once or more had an increase in administration frequency (p=0.04).

Conclusion: Physician comfort level and reported use of ketamine for agitation increased following initiation of an agitation/ketamine protocol. Identifying areas of need for novel drug use and creating educational protocols can help physician comfort level and usage. Further studies needed to assess direct changes in practice and application in other clinical settings.

CMC Department of Emergency Medicine

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Resident Academic Day 2020

Non-Fatal Strangulation Victims in the Emergency Department: Photographic Evidence of Injuries Angela Rombola, MD1, Jessica Salzman, MD1, Nicholena Richardson, MD1, Danielle Dragoo, MD1 1

Atrium Health’s Carolinas Medical Center, Charlotte, NC

Study Objective: Victims of intimate partner violence (IPV) who are strangled are at the highest risk for future homicide. Emergency providers’ documentation may be the only evidence available for future legal proceedings. Photographs can provide supportive evidence of grave bodily injury needed for successful prosecution of perpetrators. We therefore sought to determine the incidence of photographic injuries obtained from a cohort of non-fatal strangulation victims presenting to a tertiary care level-one trauma center.

Methods: We performed a retrospective review of non-fatal strangulation victims who presented to the Emergency Department of a tertiary care level-one trauma center.

Inclusion criteria: non-fatal strangulation IPV victims identified by Domestic Violence Healthcare Project (DVHP) consultations from July 2018 to June 2019. Exclusion criteria: patients under age 18 and absence of consent to photograph injuries. Victims’ photographs were reviewed for specific external injuries including abrasions, contusions, lacerations, ligature marks, and petechial hemorrhages. Injuries were further characterized by anatomical location: head, face, posterior auricular, neck, supraclavicular, chest, abdomen, back, genitourinary, extremities, and other.

Results: 101 strangulation cases were identified. All patients had documented physical injuries. 49.5% consented to having photographs taken of their injuries. Of the patients photographed, 84% had injuries to the head and/or neck, and 76% had photographic evidence of additional traumatic injuries to their chest, abdomen, back, genitourinary, and extremities.

Conclusion: A large percentage of non-fatal strangulation victims had photographic evidence of injury to their head and neck that could provide evidence of grave bodily harm for prosecution.

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Resident Academic Day 2020

Case Series: Hyperdense Basilar Artery Identified on Unenhanced Head CT in Three Cases of Pediatric Basilar Artery Occlusion Jennifer K. Potter, MD1; Jonathan D. Clemente, MD; Andrew W. Asimos. MD1 1

Atrium Healthâ&#x20AC;&#x2122;s Carolinas Medical Center, Charlotte, NC

Introduction: Acute basilar artery occlusion (BAO) is an easily missed diagnosis with devastating complications. Pediatric BAO is challenging to identify because in addition to vague symptoms, acute ischemic stroke can often be overlooked in differential diagnoses for children with new neurological symptoms. Typically, in children only an unenhanced head CT (UHCT) is initially performed. A case control study of BAO in adults performed in our Emergency Department found that when the Hounsfield unit (HU) density of a basilar artery exceeds 61 HU, BAO should be highly suspected.

Quantitative assessment of a HDBA on UHCT to detect BAO has never been reported in pediatric patients. This case series presents three consecutive pediatric BAO cases with a HDBA measuring greater than 61 HU on initial UHCT and confirmed BAO on CT angiography (CTA).

Methods: Two of the cases were obtained in a query of institutional diagnosis and stroke databases. The third case presented to our institution after initial IRB approval, resulting in an IRB amendment to include that case.

Cases: Three pediatric cases of BAO were identified. The children ranged in age from 8 to 14. All three presented with altered mental status and had an UHCT performed within 2 hours of presentation. Further imaging with CTA was obtained in all three cases and identified the presence of BAO. Discussion: On retrospective analysis of the initial UHCTs, a HDBA was identified in all three cases. This illustrates the importance of quantitatively examining for a HDBA as BAO can be overlooked by both neuroradiologists and emergency physicians.

Nonetheless, since the reported sensitivity of this finding is unknown in pediatric patients, if HDBA is absent after careful inspection and acute BAO remains in the differential diagnosis, CTA should be pursued.

CMC Department of Emergency Medicine

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Resident Academic Day 2020

Evaluation of Non-Fatal Strangulation Victims in the Emergency Department: Practice Variability Among Healthcare Workers Nicholena Richardson, MD1, Danielle Dragoo, MD1, Angela Rombola, MD, Jessica Salzman, MD1 1

Atrium Healthâ&#x20AC;&#x2122;s Carolinas Medical Center, Charlotte, NC

Objectives: In this retrospective study we aimed to evaluate current practice patterns when caring for victims of non-fatal strangulation within the Emergency Department at a single tertiary care, level one trauma center. We evaluated the significance of historical features and physical exam findings which might influence decisions to order CT Angiography (CTA) of the neck when evaluating victims of non-fatal strangulation.

Methods: We performed a retrospective chart review of non-fatal strangulation victims who presented to a level one tertiary care center in Charlotte, North Carolina from July 2018 to June 2019.

Patients were selected by reviewing all consults that had been placed with a Domestic Violence Healthcare Project (DVHP) advocate in which the victim disclosed strangulation. DVHP is an institution specific advocacy lead response team that provides services for victims of intimate partner violence.

Results: The only historical feature that proved to be significant and increased the likelihood that a CTA of the neck was ordered was loss of consciousness. Additionally, if the patient complained of neck pain, pain or difficulty with swallowing, difficulty breathing or hoarseness at the time of evaluation, they were more likely to have had a CTA of the neck.

All of our patients had some form of visible injury documented on their exam. When specifically evaluating those signs more likely to be the result of strangulation, only those that had documented contusions to the head and neck or ligature marks were more likely to have undergone CTA of the neck.

Conclusions: Our study highlights practice variability among healthcare workers caring for victims of non-fatal strangulation in the Emergency Department. Standardized documentation is currently lacking which impedes the ability to collect reliable data required to create predictive models for evidence-based imaging recommendations.

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Resident Academic Day 2020

Prospective Observational Study Comparing Persons Under Investigation For COVID-19 At Community Paramedicine Units To Those At Regional Emergency Departments S. Tyler Constantine1, David Callaway, Jeremy N. Driscoll, Stephanie Murphy, and Anthony Weekes1 1

Atrium Health’s Carolinas Medical Center, Charlotte, NC

Background: The early phase of the COVID-19 pandemic required an agile testing strategy to address both screening and testing of potential patients with COVID-19 while limiting patient exposures in local Emergency Departments (EDs). We deployed mobile integrated health/community paramedicine (MIH/CP) testing sites to provide screening, testing and community outreach.

Objectives: The primary objective was to monitor the census of patients seen at MIH/CP sites during the COVID-19 pandemic compared to Persons Under Investigation (PUIs) tested across Atrium Health EDs. The secondary objectives were to determine the proportion of PUIs who tested positive for COVID-19 with that of our regional EDs and compare the demographics of cohorts seen.

Methods: This is a prospective observational report of the implementation of MIH/CP test sites in our healthcare system’s early response to the COVID-19 pandemic in March 2020. The number of patients and their associated demographics are reported here as raw data. This data was compared to PUIs seen across 20 Atrium Health EDs during this same timeframe.

Results: Between March 15 – April 15, 2020, our MIH/CP test sites evaluated 4342 patients who were pre-screened for COVID-19 testing while all Atrium Health EDs tested 4882 PUIs. Of these, 401 patients (9.2%) at MIH/CP sites had positive test results while 346 patients (7%) tested positive at AH EDs. The average age of COVID-19 positive patients was higher at AH ED compared to the MIH/CP sites. Despite the smaller population size tested, African Americans had more than twice the positivity rate of COVID-19 compared to Caucasians at both the MIH/CP and AH ED sites respectively (11.1% vs 5.1% and 15.3% vs 6.8%, P <0.0001).

Conclusions: In our healthcare system, we pivoted the traditional MIH/CP model to rapidly initiate remote drive-through testing for COVID-19 in pre-screened individuals.

This model allowed us to test patients with suspected COVID-19 patients away from traditional healthcare sites and mitigate exposure to healthcare workers and other patients. It also appears that there are persisting disparities amongst patients with COVID-19, which may include race, socioeconomic status, and/or medical comorbidities.

CMC Department of Emergency Medicine

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Resident Academic Day 2020

Focusing Rapid Electrocardiogram Screening Criteria: Fever and ST Segment Myocardial Infarctions Jesse B. Bauer1, William Kerns II1, Michael S. Runyon1, David A. Pearson1 1

Atrium Health’s Carolinas Medical Center, Charlotte, NC

Background: Throughout hospital systems, rapid electrocardiogram (ECG) acquisition and interpretation by emergency physicians have become standard of care for patients presenting with symptoms suggestive of ST-segment-elevation myocardial infarction (STEMI). This results in frequent interruptions to physician workflow and disruption of other patient care tasks. We hypothesize that fever can be incorporated into rapid ECG protocols to make these clinical tools more efficient.

Objectives: The goal of this study was to evaluate the prevalence of fever in patients presenting with STEMI in a large health care system that utilizes a rapid emergency department (ED) ECG clinical tool.

Methods: We conducted a retrospective analysis of patients who met STEMI criteria and were entered into a health system STEMI registry from July 2017 through June 2018. A trained observer used explicitly defined variables to review the electronic medical record to document each patient’s initial temperature. The primary outcome (initial recorded temperature ≥ 100.4º F) is presented as a proportion and the associated 95% confidence interval.

Results: 569 (97%) had complete data for analysis, including 160 (28%) whose initial temperature was recorded after cardiac catheterization. The median age of our study population was 60 yrs with an interquartile range of 17 yrs and 71% were male. None of the 569 patients had an initial recorded temperature ≥ 100.4º F (0%, 95% CI: 0 – 0.6%).

Conclusions: In our population of 569 patients meeting STEMI criteria, none had fever at the time of their initial temperature measurement. Future studies are warranted to determine whether patients presenting with symptoms suggestive of STEMI can be safely streamlined by excluding those with fever.

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Resident Academic Day 2020

Implementing a Global Health Curriculum for Emergency Medicine and Pediatric Residents Robert Kregg Laundon MD1; Michael Runyon MD, MPH1; Erin Noste MD 1

Atrium Healthâ&#x20AC;&#x2122;s Carolinas Medical Center, Charlotte, NC

Background: The Intensive Global Health Course uses a didactic curriculum augmented by group learning, individual projects, and simulation to educate residents at Carolinas Medical Center in Charlotte, NC. Faculty from the Departments of Emergency Medicine and Pediatrics created a robust global health educational program for residents enrolled in their residencyâ&#x20AC;&#x2122;s global health track.

Objectives: 1. Increase comfort in working in resource limited settings.

2. Become more familiar with tropical infectious diseases, vaccine preventable diseases, malnutrition, and other pathologies not commonly encountered in our normal practice setting in Charlotte.

3. Develop an understanding of the basics of humanitarian aid, including designing and maintaining refugee camps as well as the type of medical care and resources that are needed.

4. Receive exposure to the different careers within global medicine though academics and working for non-governmental organizations (NGOs).

Methods: The curriculum consists of 2.5 weeks of education using multiple modalities including didactic lecture, case discussion, group activities, journal clubs, and several simulation sessions. Additionally, another educational session focuses on a half-day session on refugee health and have participants designing their own refugee camps using minimal standards outline in the SPHERE Handbook. The curriculum includes a pre and post course test, as well as SurveyMonkey.com feedback forms for all educational sessions, allowing for specific feedback on all activities. All participants were required to take the pre and post course test, but only those who completed 90% of the course were considered for analysis.

Results: The pre-course test mean score was 49.3%, ranging from 38.7% to 58.1%, reflecting an overall lack of confidence in the global health areas of infectious diseases, malnutrition, toxicology, and the other areas of medicine discussed in the educational objectives. The post-course test mean score was 72.4%, ranging from 69.4% to 80.7%, (P<0.0002). This demonstrated strong, statistically significant improvement in knowledge gained by the residents who completed the course.

Conclusions: The statistical analysis highlights a markedly significant difference between the tested knowledge of global health related questions after the course. Every single resident improved their scores after the course, thus demonstrating its effectiveness. Our global health curriculum resulted in quantifiable acquisition of global health related knowledge with focus on the topics discussed previously in this paper.

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Resident Academic Day 2020

Assessment of Physician Financial Literacy and Satisfaction Colin O’Neill, MD1; Michael Runyon, MD1 Dept. of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC

1

Objective: Assess physician financial literacy and health at the medical school, residency, and attending level.

Methods: Anonymous cross-sectional survey was distributed to attendings and residents in the Atrium Health CMC Emergency department and University of North Carolina medical students rotating at Atrium Health. The survey consists of 20 questions on finance to establish general level of knowledge and 18 questions about financial saving, spending, debt, and educational level.

Results: We received a total of 65 responses, 32 (49%) residents, 25 (38%) faculty, and 9 (14%) medical students. The majority (55%) were married. Median household income for each group was $0-25,000 for medical students, $50,000-75,000 residents, and $300,000-350,000 for faculty. The mean quiz score was 50±19%, with the faculty doing significantly better (58±14%) than the residents (46±19%, p=0.04) and medical students (39±22%, p=0.02). The comparison of resident to medical student scores revealed no significant difference, p=0.54. The mean financial satisfaction was 6.0±2.5 on a 10-point scale. Faculty respondents had a higher mean satisfaction (7.5±1.7) compared with both residents (5.5±2.3, p=0.006) and medical students (4±2.7, p=0.0004). There was not significant difference in financial satisfaction between residents and medical students.

Nearly half (48%) of residents had more than $200,000 in student loans and more than a quarter (26%) have mortgages with median cost of $212,500-262,500.

Conclusion: Residents and medical students demonstrated lower financial literacy and wellness than attendings. Medical trainees might benefit from a financial literacy curriculum in medical school or residency.

CMC Department of Emergency Medicine

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Resident Academic Day 2020

Virtual Reality CPR Training Improves Knowledge Acquisition of Critical Tasks Ethen Ellington, MD1; Andrew Kitchen, MD1; Benjamin Covell, MD1; Michele Birch, MD2,3; Heather Tarantino, MD2,4; Mark Bullard, MD, MS-HPEd1,5; Michael Runyon, MD, MPH; David Pearson, MD, MS, MBA1; Catherine Wares, MD1,2 Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center; University of North Carolina School of Medicine - Charlotte Campus; 3Department of Family Medicine, Carolinas Medical Center – Atrium Health; 4Department of Internal Medicine, Carolinas Medical Center – Atrium Health; 5Carolinas Simulation Center, Carolinas Medical Center – Atrium Health 1

2

Background: Virtual reality (VR) has emerged as a novel immersive training platform.

Given that traditional simulation-based cardiac arrest resuscitation training is time and resource intensive, we examined whether VR training improved resuscitation knowledge acquisition amongst a group of clinicians at varying levels of training.

Methods: This pre- and post-test study was conducted at a 900-bed level 1 cardiac resuscitation center. Eligible participants included 42 EM residents, 33 EM attendings, and 26 third-year medical students. The training module consisted of five minute shockable and non-shockable cardiac arrest scenarios filmed using a GoPro 360° Camera Rig and viewed with either Samsung Gear VR headsets plus Samsung Galaxy S6 smartphones or Oculus Go all-in-one VR headsets. Participant knowledge of 12 critical resuscitative tasks was assessed before and after VR training. A group of expert clinicians rated the content validity (clarity and relevance) of each of the critical tasks.

Pre- and post-test performance was compared using the Wilcoxon signed rank test.

Results: Of 101 eligible clinicians, 97 participated in VR training, and 86 (85%) had complete paired pre- and post-test data, including 32 residents, 28 EM attendings, and 26 students. Median pre- and post-test scores were 83% (IQR 75-92%) and 100% (IQR 92- 100%), respectively. The median difference in post-test scores was 13% (95%CI 817%); p<0.0001.

The VR training platform was well tolerated and easy to use. Participants agreed or strongly agreed that VR was a good way to learn (96%), enjoyed the experience (96%), and were satisfied with the VR platform as a learning tool (96%). Also, 96% of learners felt there was the perception of a three-dimensional space, 83% felt immersed, and 94% reported good visual-sensory tolerance.

Conclusion: In this pre-and post-test analysis, knowledge acquisition of critical resuscitation skills improved after VR training for all learners. VR is a feasible alternative to traditional cardiac arrest resuscitation training. Future studies should directly compare the two modalities and examine long-term knowledge retention.

CMC Department of Emergency Medicine

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Resident Academic Day 2020

Right Ventricular Dysfunction Measurements in Pulmonary Embolism with Subsequent Acute Clinical Deterioration Chris Gardner MD1, Denise N. Fraga MD MPA1, Vitaliy Belyshev MD1, William Bost MD1, Jaron D. Raper MD, Melanie Hogg MS1, Michael Runyon MD MPH1, Daniel Troha MD1, Anthony J. Weekes MD MSc1 1

Atrium Health’s Carolinas Medical Center, Charlotte, NC

Background: The American Society of Echocardiography provides normal reference values for RV measurements taken on adults without cardiac or pulmonary diseases.

Currently there are no disease specific RV measurement guidelines. In pulmonary embolism (PE), right ventricular dysfunction raises the concern about PE severity and subsequent clinical deterioration. Biomarker and echocardiographic measurements of RV pressure, dilatation and systolic dysfunction in PE are not yet defined.

Primary objective: to determine echocardiographic measurements in PE patients with suspected RV dysfunction (RVD) by CT or biomarker criteria. Secondary objective: to determine differences of biomarkers and echocardiographic measurements between outcome groups, with primary outcome predefined as composite of death, respiratory failure, hypotension, dysrhythmias or reperfusion intervention within five days.

Methods: This ongoing prospective observational study at 6 regional EDs with a response team for submassive PE patients, who had urgent echocardiography performed per protocol. Extractors reviewed the EMR for predefined outcomes of clinical deterioration within subsequent 5 days of hospitalization. We used descriptive univariate analyses for the cohort and Mann Whitney U-test for outcome group differences.

Results: In 12 months, we enrolled 176 PE patients (goal 280). Echocardiography was performed on average within 8.3 hours after CT confirmation. Sixty-two (35%) patients had the primary outcome of clinical deterioration. Medians for all patients were: brain natriuretic peptide (BNP) 127 (48-297); troponin 0.06 (0.03-0.17); RV basal diameter (cm) 4.3 (3.8-4.8); LV basal diameter (cm) 4.2 (3.7-4.6); RV: LV ratio 1 (0.9-1.2); RV systolic pressure (mmHg) 47 (35-57); TAPSE (cm) 1.7 (1.4-2) ; systolic excursion velocity S' (cm/s) 11.0 (8.1-13.4); TAPSE/RVSP ratio 0.04 (0.02-0.05). Outcome positive versus outcome negative group median differences were: BNP 89 (CI: 26 to 183); troponin 0.02 (CI: 0 to 0.05); RV base 0.2 (CI: 0 to 0.5); LV base -0.3 (CI: -0.5 to 0); RV:LV ratio 0.1 (0 to 0.2); RVSP 1 (CI: -4.9 to 6); TAPSE -0.2 (CI: -0.4 to 0); S’ -1.5 (CI: -2.7 to -0.2); TAPSE/RVSP ratio -0.01 (CI: -0.01 to 0).

Conclusions: ED PE with suspected RVD by CT or biomarkers had increased RV diastolic basal diameter above the ASE normal reference range, RV: LV ratio. Those with subsequent clinical deterioration within five days had significantly increased BNP and troponin, increased RV:LV ratio, decreased LV basal diameter and reduced systolic function (TAPSE and S’) Increased RV basal diameter trended toward significance.

CMC Department of Emergency Medicine

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Resident Academic Day 2020

Development and Implementation of an Intensive Pediatric Point-of-Care Ultrasound (PoCUS) Curriculum in Guatemala Francisco J. Andrade Jr. MD1, Denise Fraga MD1, Kathryn Lupez, MD 1

Atrium Health’s Carolinas Medical Center, Charlotte, NC

Objective: To evaluate the feasibility and impact of an intensive pediatric ultrasound course in a resource-limited setting by assessing participants’ knowledge retention, skill acquisition, and ultrasound machine usage.

Methods: This was a retrospective cohort study of 51 pediatricians with minimal experience in ultrasound who completed a 4-day intensive ultrasound course. Half of the participants completed the course in July 2018 and the other half completed it in April 2019. The physicians were tracked for 16 months. An ultrasound pre-test was administered prior to the course which assessed experience and barriers to ultrasound usage. Upon course completion, each participant completed an imaged-based written test and an Objective Structured Clinical Examination (OSCE). Participant long-term knowledge retention was reassessed with an image based written test at 4, 8, and 16 months depending on the cohort. Additionally, ultrasounds performed in the Pediatric Intensive Care Unit (PICU) were documented.

Results: Data was available for 50/51 (98%) participants. Forty-eight participants reported no formal training in ultrasound while only three reported more than 10 hours of training. Barriers to ultrasound use included lack of experience with ultrasound or uncertainty about image acquisition and interpretation. Before the ultrasound course, the group 1 and group 2 pre-test mean scores were 31.8% (CI 95% 26.44 – 37.10) and 38.5% (CI 95% 32.75-44.25%), respectively. For group 1 the mean scores on the posttest, 4-month follow-up, and 16-month follow-up were 89.5% (95% CI 86.93 – 92.15%); 77% (95% CI 71.15 to 82.85%); and 75% (95% CI 67.03 – 82.97). A paired sample ttest analysis was performed at each time period following the course with significant improvement in written test scores for the immediate post-test (P<0.001), 4 month follow up (P<0.001), 8 month follow up (P<0.001), and 16 month follow up (P<0.001) compared to the pre-test scores. OSCE test scores for trauma (E-FAST), echocardiography, and vascular access were 92%, 90% and 98%, respectively. A total of 614 ultrasound studies were documented during a 22-month period showing ultrasound was primarily used for cardiac evaluation (N=233;37%), vascular access (N=187; 30%), or FAST exams (N=102; 16%).

Conclusions: PoCUS training in Guatemala led to knowledge retention even after 16 months but indicated a statistically significant decay in knowledge at 4 months suggesting that refresher teaching, whether virtual or in person, should start earlier than 4 months. Interestingly, there was no difference in test scores between the 4 month and 16-month follow-up visits suggesting that knowledge retention plateaued with no further decrease in scores.

CMC Department of Emergency Medicine

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Resident Academic Day 2020

Assessment Of A Novel Ultrasound Workshop: Teaching Emergency Medicine Residents To Detect Ascending Aorta Pathology With Bedside Ultrasound Sean Murray, MD.1, Margaret Lewis, MD.1 Anthony Weekes, MD1., Andre Williams, PhD1 1

Atrium Health-Carolinas Medical Center, Charlotte, NC

Background: Acute aortic dissection (AAD) is a feared but fairly rare condition. CT Angiogram has become the most common method to evaluate for AAD. This has led to significant costs, contrast and radiation exposure to patients for a diagnosis that is unlikely to be present. Bedside ultrasound in the hands of an expert ultrasonographer is an emerging tool for the detection of AAD and does not have the same cost and risk as a CT scan. This, of course, raises the question of what constitutes a skilled ultrasonographer?

Objectives: We hypothesized that by delivering an educational module centered around evaluation of the aortic root to residents at our residency program, we could significantly increase their ability to detect ascending aortic pathology.

Methods: This was a prospective study using pre/post skills assessment to determine the overall efficacy of an ultrasound educational intervention. Residents were asked to review 30 ultrasound clips and answer a qualitative question related to each one: Does the aortic root like widened? Residents were then asked to review the same series of echocardiogram images, make and record a measurement of the aortic root, and answer an additional four questions related to each one: Is the aortic root widened?; Is a pericardial effusion present?; Is a dissection flap present?; Do these findings represent concern for ascending aortic Pathology? Following this, a presentation was delivered at the residency weekly didactic conference. Residents then completed a posttest consisting of the same clips in the pretest. Their results were compared to an ultrasound facultyâ&#x20AC;&#x2122;s answers who completed the same test.

Results: Agreement between ultrasound faculty and residentâ&#x20AC;&#x2122;s when qualitatively assess aortic root width both prior to (K = 0.52 improved to K=0.71) and after measuring (K=0.53, improved to K=0.61) improved following the educational presentation, however, not to statistical significance. Agreement when detecting pericardial effusion and dissection flap did not change following the intervention. Agreement regarding whether findings were concerning for ascending aortic pathology did improve following the educational material (K=0.34, improved to 0.48). However, again, these results were not statistically significant. Similarly, when measuring the aortic root, agreement between residents and expert faculty did improve, though not with statistical significance.

Conclusions: The delivery of a thirteen slide PowerPoint presentation to the residents of Carolinas Medical Center Emergency Medicine Residency resulted in improvement of the residentsâ&#x20AC;&#x2122; ability to qualitatively determine whether an aortic root was dilated as well as their ability to measure it, though neither did so with statistical significance

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Improvement in Comfort and Knowledge in POCUS in Testicular Torsion Following Lecture and Hands On Training Logan Stark MD1; Lindsey Chaudoin MD1 1

Atrium Health’s Carolinas Medical Center, Charlotte, NC

Background: Testicular torsion is a time sensitive emergency as viability decreases with time from onset with 6 hours demarcating higher levels of viability. Physical findings and scoring such as the TWIST score can help identify high risk patients but the majority need ultrasound for diagnosis. POCUS has the potential of decreasing delay in urology consultation.

Objectives: The goal of this study was to assess baseline comfort and knowledge in point of care ultrasound in testicular torsion and evaluate how this changed after lecture and hands on practice.

Methods: This was a prospective study of emergency medicine residents, pediatric emergency medicine fellows and emergency medicine attendings who attended weekly conference at Carolinas Medical Center during January 2020. Comfort and knowledge with point of care ultrasound in testicular torsion was measured with a pretest and changes after didactic and hands on training were recorded with a posttest and follow up test.

Results: Included were 7 interns, 8 second years, 8 third years, 5 pediatric emergency medicine fellows, 3 attendings. 21 completed the follow up test. Comfort in general POCUS and POCUS in testicular ultrasound were recorded on a Likert scale (scale of 15 with a score of 1 being “very uncomfortable” and 5 being “very comfortable”).

Participants had a strong background in POCUS as seen in the average baseline comfort in general POCUS of 3.9 (3.5-4.4) with attendings the highest at 4.7 (1-5) and interns the lowest at 2.7 (1.4-4.2) Despite this, overall average comfort level for POCUS in testicular ultrasound was low at 1.3 (1-1.5). Following the intervention this increased to 2.9 (2.6-3.3) on the immediate posttest and continued to increase to an average of 3.4 (2.9-3.9) on the follow up test. Participants were also eager to use POCUS in testicular torsion with the reported likelihood of using POCUS in testicular ultrasound improving from an overall average baseline of 2.0 (1.6-2.4) to an average of 3.9 (3.7-4.2) immediately after the intervention and an average of 3.2 (2.6-3.7) on the follow up test.

Baseline knowledge in POCUS in testicular torsion was an overall 70% (63%-76%). This improved in the immediate posttest in all groups to an overall average of 93% (88%97%). Participant showed retention of knowledge with an overall average of 82% (77%86%) on the follow up test.

Conclusion: Didactic and hands on training can lead to increased comfort and knowledge in POCUS in testicular torsion.

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Resident Academic Day 2020 CMC Department of Emergency Medicine Graduatesâ&#x20AC;&#x2122; Destinations - Chief Residents

Jesse Blake Bauer, MD

Jessica Hoglund, MD

Tallahassee Memorial Healthcare Tallahassee, FL

Carolinas Medical Center Charlotte, NC

Robert Kregg Laundon, MD

Sean Murray, MD

Georgia Emergency Medicine Specialists Savannah, GA

Apollo MD Union County, NC

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Resident Academic Day 2020 CMC Department of Emergency Medicine Graduates’ Destinations - Residents

Javier Andrade, MD

Austin Costa, MD

Jeremy Driscoll, MD

Ethen Ellington, MD

Ultrasound Fellowship University of Arizona Tuscan, AZ

CaroMont Regional Medical Center Gastonia, NC

Scottsdale Emergency Associates Scottsdale, AZ

Atrium Union Union County, NC

Colin O’Neill, MD

Jennifer Potter, MD

CaroMont Regional Medical Center Gastonia, NC

PEM Fellowship Wake Forest Baptist Health Winston-Salem, NC

Nicholena Richardson, MD

Christopher Gardner, MD Mid-Atlantic Emergency Medical Associates Charlotte, NC

Angela Rombola, MD Baylor Scott & White Health – Baylor University Dallas, TX

PEM Fellowship Carolinas Medical Center Charlotte, NC

Logan Stark, MD EMPros.

Daytona Beach, FL

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Resident Academic Day 2020 CMC Department of Emergency Medicine Resident Award Recipients JOHN A. MARX OUTSTANDING SENIOR RESIDENT AWARD 1994 1995 1996 1996 1997 1998 1999 1999 2000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Jeffrey A. Kline, MD John T. DiPasquale, MD Craig A. Meek, MD Daniel M. Roberts, MD David A. Caro, MD Sean R. Sue, MD Joanne Oaks, MD Jennifer Isenhour, MD Tony Seupaul, MD Frances Eizember, MD Brent Myers, MD Alan E. Jones, MD Jennifer Gehring, MD Bret Nicks, MD Jim Fiechtl, MD Benjamin Davis, MD Gretchen Roe, MD Danielle Turner-Lawrence, MD Bijal Shah, MD Mike Puskarich, MD Liza Rosenman, MD Mike Koehler, MD Jackie Davis, MD Katharine Modisett, MD Daniel Troha, MD Kathryn West, MD Blake Johnson, MD Jaron Raper, MD Kathryn Lupez, MD

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Resident Academic Day 2020 CMC Department of Emergency Medicine Resident Award Recipients DARREN BEAN OUTSTANDING TEACHING BY A RESIDENT AWARD 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Simong S. Youmans, MD Bruce B. Marshall, MD Joel L. Moll, MD Tony Yuan, MD Chris Thomson, MD Alan Heffner, MD Desiree La Charite, MD Darren Bean, MD, and Nael Hasan, MD Charles Staples, MD Josh Simmons, MD Dave French, MD Keith Pochick, MD Richard Graham, MD JoAnna Leuck, MD Harland Hayes, MD Shiloh Gilbert, MD Dustin Calhoun, MD Brittany Murray, MD Katie Sprinkel, MD Jonathan Bronner, MD Karina Reyner, MD Joshua Robertson, MD Catherine Lounsbury, MD Enola Okonkwo, MD Russell Trigonis, MD

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Resident Academic Day 2020 CMC Department of Emergency Medicine Resident Award Recipients OUTSTANDING RESIDENT RESEARCH ACHIEVEMENT AWARD 1994 1995 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Jeffrey A. Kline, MD David W. Templeton, MD Tamara M. Ardans, MD Andrew D. Perron, MD Kirk Mahon, MD Mark Courtney, MD Chris Moore, MD Alan E. Jones, MD Mike Runyon, MD Michael T. Fitch, MD, PhD Lyn Aborn, MD Christopher Crean, MD Patrick Oâ&#x20AC;&#x2122;Malley, MD, and Melinda Threlkeld, MD Danielle Turner-Lawrence, MD John Garrett, MD, and Anne Daul, MD Mike Puskarich, MD, and Maria Glenn, MD Dustin Calhoun, MD Daren Beam, MD, and Omayra Marrero, MD James Cao, MD Greg Zahn, MD, and Andrew Wyman, MD Daniel Troha, MD Angela Johnson, MD and Gregory Thacker, MD Blake Johnson, MD Adeline Dozois, MD Kathryn Lupez, MD

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Resident Academic Day 2020 CMC Department of Emergency Medicine Faculty Award Recipients

OUTSTANDING ACADEMICIAN - Faculty Award 2004 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Chris Tomazewski, MD Andrew Asimos, MD Lee Garvey, MD Mike Runyon, MD Jeff Kline, MD Sean Fox, MD Randy Cordle, MD Catherine Wares, MD David Callaway, MD Mike Runyon, MD David Pearson, MD Anthony Weekes, MD Anthony Weekes, MD Maria Pelucio, MD

EXEMPLAR - Faculty Award 2008 2009 2010 2012 2013 2014 2015 2016 2017 2018 2019

Dave Pearson, MD Andrew Asimos, MD Jennifer Isenhour, MD Vivek Tayal, MD JP McBryde, MD Anthony Weekes, MD Mike Gibbs, MD Lee Garvey, MD Chris Griggs, MD David Callaway, MD Erin Noste, MD

OUTSTANDING TEACHER - Faculty Award 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Jayne Batts, MD Vivek Tayal, MD Michael Roshon, MD John Marx, MD Vivek Tayal, MD JP McBryde, MD William Tsai, MD Jeffrey Hyland, MD Sean Fox, MD Jayme Woodson, MD Emily MacNeill, MD Randy Cordle, MD

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2013 2014 2015 2016 2017 2018 2019

Mike Gibbs, MD Andrew Asimos, MD Sean Fox, MD Tyson Cook, MD Danielle Dragoo, MD Dalton Cox, MD Kathryn West, MD

CMC Department of Emergency Medicine

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Resident Academic Day 2020 CMC Department of Emergency Medicine Visiting Professors: 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Judd E. Hollander, MD – University of Pennsylvania William H. Cordell, MD, Professor – Indiana University Frank Counselman, MD – Eastern Virginia Medical School Jill Baren, MD – University of Pennsylvania School of Medicine James L. Scott, MD – George Washington University Michael Gibbs, MD – Maine Medical Center James Hoestra, MD – Wake Forest University Katherine L. Heilpern, MD – Emory University School of Medicine Charles B. Cairns, MD, Professor & Chair – UNC Chapel Hill William Barsan, MD, Professor & Chair– University of Michigan Medical School Edward C. Jaunch, MD, MS , PACEP, FAHA – Medical University of South Carolina Andrew D. Perron, MD, FACEP, FACSM – Maine Medical Center Tony Seupaul, MD, Professor & Chair – University of Arkansas for Medical Science Alan Jones, MD – University of Mississippi Medical Center Jeffrey W. Runge, MD FACEP Joe Lex, MD, FACEP, MAAEM, FIFEM – Temple University School of Medicine David Mark Courtney, MD, MSCI - Feinberg School of Medicine at Northwestern Leon L. Haley Jr., MD, MHSA, FACEP – University of Florida Health Jacksonville “Tony” Seupaul, MD - Professor and Chair - University of Arkansas

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