Resident Academic Day 2022

Carolinas Medical Center Department of Emergency Medicine

Resident Academic Day

June 9, 2022

Resident Academic Day 2022

CMC Department of Emergency Medicine Thursday, June 9, 2022 Medical Education Building • 3rd Floor Conference Room

Schedule 8:00 am

Welcome & Introductions

Mike Gibbs, MD and Mike Runyon, MD

8:10 am

2022 Resident Academic Day Address

8:30 am

Shane Ali, MD – Optimizing Prognosis of Clinical Deterioration for Intermediate-Risk Pulmonary Embolism: Results from a Large Registry

8:45 am

Travis Barlock – Trends in Emergency Department Opioid Prescribing in Atrium Health: A Retrospective Review 2017-2021

9:00 am

Matthew Cravens, MD – Effect of Stress Inoculation Training on Objective Measures of Stress in Paramedic Students

9:15 am

Kelsey Lena Craver, MD – Stress Inoculation Training to Improve Performance of EMS Trainees

Jo Anna Leuck, MD

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

Daniel Escobar, MD – Duration of SARS-CoV-2 Sero-Positivity with Introduction of Vaccinations in a Large Longitudinal Sero-Surveillance Cohort- the COVID-19 Community Research Partnership

10:00 am

Clare Gunn, MD – Cardiovascular Adverse Drug Reactions (ADRs) Associated With 4-Aminoquinolone (4-AQ) Drug Therapy During the COVID-19 Pandemic

10:15 am

Forrest Turner, MD – Perceptions, Availability and Practice Patterns of Vasopressors for Septic Shock in Tanzania

10:30 am

Oriane Longerstaey, MD – Content Validation of Needs Assessment Survey for Remote Education Initiative in Tanzania

10:45 am

Charles Harris III, MD – Implementation of Specialty Based US Application Recommendations as Requirements for Emergency Medicine Residency Graduation ------------------------------------- Break @ 11:00 am -----------------------------------------------

11:15 am

Mark Kastner, MD – Cardiac Safety Monitoring Protocol Effectiveness for Use of 4Aminoquinolones in SARS-CoV-2 Treatment

11:30 am

Clay Long, MD – Brain Venography Performance Following the Pause of Ad.26.COV2.S COVID-19 Vaccine Administration

11:45 am

Rachel Plate, MD – Virtual/In-Person Experience for Resident Supervision (VIPERS): A Qualitative Study

12:00 pm

Neha Ray, MD – Sensitivity of Three Distinct Imaging Findings for Type A Aortic Dissection

12:15 pm

Andrew Yde, MD – Evaluation of Neurological Outcome after Code Cool Target Temperature Change to 37°C

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 CMC Department of Emergency Medicine Visiting Professor

Jo Anna Leuck, MD Dr. Jo Anna Leuck is the inaugural curricular dean for the Texas Christian University School of Medicine (TCU SOM) in Fort Worth, Texas. TCU features an innovative medical school curriculum that produces Empathetic Scholars®, physicians who care for the whole patient and also have the leadership and problem-solving skills to address the challenges and inequities in the healthcare system. Dr. Leuck specializes in curricular innovation, including the use of novel modalities and technologies, longitudinal integrated clerkships, and the use of design thinking in medical education. Prior to TCU, Dr. Leuck served as the Vice Chair and Program Director for the Department of Emergency Medicine at John Peter Smith Health System (JPS) and helped start their residency program. She began her career at Carolinas Medical Center, where she implemented a simulation-based curriculum for learners throughout the institution. Dr. Leuck has two children and loves to travel and cheer for TCU football in her spare time.

Go Frogs! .

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Optimizing Prognosis of Clinical Deterioration for Intermediate-Risk Pulmonary Embolism: Results from a Large Registry S. Ali, A. Trautmann, P. Hambright, B. Lambert, S. Bradford, N. Wellinsky, T. Mathis, N. O’Connell, A. Weekes

Background and Objectives: There is limited information regarding specific demographics or laboratory and imaging characteristics that are associated with subsequent early clinical deterioration in intermediate-risk PE patients in (ED). We sought to determine clinical features of intermediate-risk PE patients at presentation associated with subsequent clinical deterioration within days.

Methods: Between 2017 to 2020, we enrolled intermediate-risk ED patients from 7 regional emergency departments. Primary composite outcome includes death, cardiac arrest, hypotension with vasopressor support, rescue respiratory intervention (intubation, positive pressure ventilation, or high flow oxygen use), or extracorporeal oxygenation.

After performing descriptive statistics and univariate tests for each predictor variable of interest by the primary composite outcome (t-test for continuous variables; chi-square tests for categorical variables), we used Random Forest (RF) and LASSO Logistic Regression (LR) to develop prediction models for the primary outcome, and compared models using Sensitivity, Specificity, Positive predictive value, Negative Predictive Value and Receiver Operating Characteristics (AUC). We trained each model using 70% of the data and validated it on 30%. From the RF model, we provide the top 20 most important variables.

Results: We used 53 predictor variables including measurements of vital signs, laboratory, imaging PE risk factors, and comorbidities. Of the 1747 patients within the database in REDCap (mean age 62.7 with SD of 16.05 and 48.7% male), 12.36% had a primary outcome.

While performance statistics for each model were close, the RF model outperformed the LR model with higher sensitivity (0.72 vs 0.6), higher positive predictive value (0.28 vs 0.27), higher negative predictive value (0.95 vs 0.93), and higher AUC (0.81 vs 0.78).

The top twenty predictors for five-day clinical deterioration included the lowest systolic blood pressure, lowest oxygen saturation, highest respiratory rate, and highest heart rate within three hours of arrival in the ED. Of lab work, the highest high-sensitivity troponin was a strong predictor for five-day clinical deterioration. From ultrasound imaging, the higher RV:LV basal width ratio was a top predictor for clinical deterioration in patients with intermediate risk pulmonary embolism.

Conclusion: Predictors of clinical deterioration in intermediate-risk PE were: lowest systolic Blood pressure, lowest O2 saturations, and highest respiratory rate within three hours, followed by highest high-sensitivity troponin. This information will be beneficial by allowing clinicians to provide extra attention and frequently reassess patients with intermediate-risk pulmonary embolism, as well as seek advanced treatments such as catheter-directed thrombolysis versus systemic lysis for patients with higher risk for clinical deterioration.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Trends in Emergency Department Opioid Prescribing in Atrium Health: A Retrospective Review 2017-2021 Barlock, T. Griggs, C. Walley, M. Kamath, P. and Jarrett, S.

Objectives: Describe the trends in opioid prescribing of emergency department providers in a large healthcare system from 2017 to 2021.

Methods: This was a retrospective cohort study across a large healthcare system.

Opioid prescribing rates among discharged emergency department patients were analyzed and compared among multiple emergency departments in a large healthcare system. Opioid prescriptions were tracked and analyzed through a dataset generated from the electronic medical record which included variables of provider, location, prescription, and discharge rate from the emergency department. The secondary outcome of identifying opioid prescribing patterns in relation to the STOP Act was determined through visual trends of prescribing in multiple ED’s over time. Opioid prescribing outliers were identified by the ranking the top and bottom opioid prescribing EDs over the duration of the study.

Results: Between January 2017 and December 2021, the overall trend in opioid prescription across Atrium Health was of decreasing quantity and duration. Over the 5year timeframe, there was a 76.7% reduction in total amount of opioids prescribed and a 68.3% reduction in overall opioid prescribing per discharge. The total number of prescriptions written over 5 days duration decrease 84.1%, and on a per discharge basis, 87.8%. Similarly, the total morphine milligram equivalents (MME) and MME per discharge decreased across the network by 79.9% and 72.7% respectively. The percentage of discharged patients from the ED receiving an opioid prescription decreased from 14.6% in 2017 to 6.3% in 2021. The proportion of discharged patients receiving an opioid prescription for over 5 days duration 1.25% in 2017 down to 0.15% in 2021. The prescribed MME/DC decreased from 11.7 in 2017 down to 4.4 in 2021.

Conclusions: Overall, substantial declines in opioid prescribing have been ongoing across all emergency departments within Atrium Health. There were substantial differences in opioid prescribing habits among different emergency departments, and these differences decreased over time.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Effect of Stress Inoculation Training on Objective Measures of Stress in Paramedic Students Matthew Cravens MD, Kelsey Craver, MD, Thomas Nagel BSN, Keegan Bradley MD, S. Tyler Constantine MD Background: Stress Inoculation Training (SIT) is a resiliency-building teaching model that aims to minimize hyperarousal and improve performance in stressful situations. To our knowledge, it has not been previously studied in prehospital education.

Objective: Evaluate the effect of SIT on objective measures of stress in paramedic students through heart rate monitoring.

Methods: In a cohort of paramedic students over nine months, we used the principles of SIT to educate students regarding the stress response, introduce an intervention to mitigate increased stress, and insert intentional stressors during training scenarios.

During scenarios, we collected heart rate data with wearable monitors. Students were monitored in three phases: baseline, education, and intervention. In the education phase, students were introduced to effects of acute stress on performance. The intervention phase involved prompting students to use “tactical breathing” to offset stress during scenarios. We defined “tactical breathing” as a single cycle of four seconds each of inhaling, breath-holding, and exhaling. In the intervention phase, scenarios were also altered by study design with the insertion of intentionally stressful stimuli. We hypothesized that as they gained experience, students would become less stressed over the progressive phases.

Results: Our results were not statistically significant, but changes in mean HR and HRV indices signaled that students felt less stress during scenarios in the second phase compared to the first but had increased stress during the third phase: mean HR fell 8-9 bpm after scenario termination in phases one and three, compared to 2 bpm in phase two. This trend was also reflected in the median maximum heart rate participants experienced in each phase: 126 bpm during baseline, 116 bpm in education, and 127 bpm in intervention. The additional stressors introduced in the third phase may be responsible for these changes. We present descriptive data in the third phase showing transient decrease in heart rate after “tactical breathing.”

Conclusion: We conclude that SIT is feasible to introduce to prehospital education.

Wearable heart rate monitors may be useful in the future to help students recognize the temporary effect of “tactical breathing” to decrease heart rate during moments of overwhelming stimuli or workload.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Stress Inoculation Training to Improve Performance of EMS Trainees Kelsey Lena Craver, MD; Matthew Cravens, MD; Keegan Bradley, MD; Thomas Nagel, BSN, RN, NRP; S. Tyler Constantine, MD

Background: The purpose of this study was to investigate if teaching stress-coping methods to Emergency Medical Services (EMS) trainees would improve their overall sense of performance during medical training simulations and decrease subjective stress.

Study Design: Prospective interventional study evaluating the effects of targeted stress inoculation training on performance in a simulation environment.

Methods: The cohort included 28 paramedic students enrolled at Central Piedmont Community College who completed three phases of intervention: 1. information provision; 2. skill training; 3. skill application. As part of their training, paramedic students underwent standard medical training simulations, during which we measured subjective stress and workload by utilizing STAI-6 Pre- and Post-Survey and NASA-Task Load Index Post-Survey. In module I, control pre-surveys and post-surveys were acquired when trainees practiced intravenous access, medication administration, and management of difficult airways on mannequins. In module II, education regarding the detrimental effects of stress was provided to trainees and surveys continued to be collected during scheduled simulations. In module III, battle breathing was introduced as a stress-coping technique, along with pre-planned additional stressors in the standardized simulations. Trainees practiced this stress-coping technique during simulations while surveys continued to be collected to assess their subjective stress and workload.

Results: STAI-6 Pre- and Post-Surveys showed that by module III, 61.1% of trainees felt calm compared to 40.7% of trainees in module I. Additionally, the majority of trainees felt less tense (66.7%), upset (94.4%), and worried (88.9%) by module III compared to module I. On the NASA Task Load Index Post-Survey, 61.1% of trainees felt an intensification in mental demand, temporal demand, and effort despite an overall sense of improved performance in the simulations. By module III, 66.7% of trainees felt their subjective self-assessment of performance went well compared to 53.7% of trainees in module I. Conclusion: Despite a variation in the level of participation across all three modules, the initial results of this study are promising by presenting battle breathing tactics to EMS trainees and noting a reduction in the subjective stress experienced during simulations, along with an increase in trainees who felt an overall sense of improved performance.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Duration of SARS-CoV-2 Sero-Positivity with Introduction of Vaccinations in a Large Longitudinal Sero-Surveillance Cohort- the COVID-19 Community Research Partnership Daniel A. Escobar, MD, MS; Michael Runyon, MD, MPH; Diane Uschner, PhD; Matthew Bott, BS; Iqra Munawar, MS; Ashvi Soni, MS; Michael DeWitt, MS; Austin Lyles Seals, MS; John W. Sanders, MD, MPH Background: Estimating population prevalence and incidence of SARS-CoV-2 infection remains essential for the provision of appropriate public health recommendations related to the COVID-19 pandemic. Since the introduction of vaccines and given the significant proportion of pauci-symptomatic or asymptomatic disease, properly interpreting estimates based on sero-surveillance requires an understanding of the differences in the time to detectable antibody response, duration of antibody elevation, as well as the key features following both natural SARS-CoV-2 infection and vaccination.

Methods: We examined lateral flow assays, performed in-home on fingerstick blood samples, testing for SARS-CoV-2 specific IgM and IgG to both the spike and nucleocapsid proteins. Samples were acquired longitudinally between April 2020 and October 2021 in more than 9,000 adult participants enrolled in the COVID-19 Community Research Partnership. Positive results were analyzed for association with symptoms and preceding risk factors, including previous vaccination, self-reported infection, and close contact with an individual known to have active COVID-19 infection.

Results: Amongst all participants with antibody positivity after defined risk exposure, sero-conversion for IgM and/or IgG occurred on average within about 30 days of vaccination, 50 days of self-reported infection, and 150 days of known COVID-19 infected contact. In unvaccinated participants, the four most common symptoms within 30 days prior to sero-conversion included headache (35%), fatigue (31%), muscle pain (30%), and congestion (26%). IgM sero-reversion for all participants with a positive assay occurred more rapidly than IgG sero-reversion, with a mean of 60 days (range = [1,397], median = 42) compared to a mean of 128 days (range = [1,457], median = 123 days).

Conclusion: With a community containing both vaccinated and unvaccinated individuals along with pauci-symptomatic or asymptomatic infections, the true prevalence of SARSCoV-2 infection may be difficult to assess. Being able to associate common risk factors collectively with expected time to IgM and IgG sero-conversion and subsequent seroreversion could prove to be a useful tool in differentiating suspected true natural infection from vaccination. Additionally, it is important to note that the currently available vaccinations approved for use in the United States elicit a humoral response specifically to the SARS-CoV-2 spike protein. This understanding may motivate future estimations to preferentially use rapid and cost-effective lateral flow assay designs that qualitatively detect separately for antibodies produced against nucleocapsid and spike proteins to further differentiate natural infection from response to vaccination.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Cardiovascular Adverse Drug Reactions (ADRs) Associated With 4Aminoquinolone (4-AQ) Drug Therapy During the COVID-19 Pandemic Clare Gunn, MD1, Mark Kastner, MD1, Ann-Jeannette Geib, MD1, Christine Murphy, MD1, Satish Misra, MD2, William Kerns, MD1, Kathryn T Kopec, DO1 1

2

Carolinas Medical Center, Atrium Health, Charlotte, NC, USA Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC, USA

Background: During the SARS-CoV-2 pandemic, 4-aminoquinolone (4-AQ) drugs (chloroquine, hydroxychloroquine) were granted emergency use approval (EUA) as antivirals from 3/28/2020 to 6/15/2020. 4-AQ drugs have serious adverse effects including hypotension, dysrhythmias, and prolonged QTc. Their benefit-risk ratio as a treatment for SARS-CoV-2 was unknown, especially when used in conjunction with additional QTc-prolonging medications.

Hypothesis: We assessed the demographics, dose, duration, and cardiovascular adverse drug reactions (ADRs) of 4-AQ in the treatment of COVID-19 patients within a large healthcare system.

Methods: This IRB-approved retrospective chart review used a standardized data abstraction form and included patients greater than 18 years old that received 4-AQ therapy for confirmed COVID-19 from 3/1/2020 - 6/15/2020. Patients were identified through pharmacy distribution records. Patients were excluded if they received 4-AQ for other medical indications. Descriptive analysis and Chi square were performed.

Results: A total of 155 COVID-19 patients received at least one hydroxychloroquine dose, none received chloroquine. Eighty-two (53%) patients were male, and the median age was 60 years. One-hundred three patients (66%) received additional QTc prolonging drugs. Ninety-one patients (58%) completed the 10-dose course, while 64 patients (42%) did not. There were 67 patients (44%) that experienced cardiovascular events: hypotension 62 (93%), dysrhythmias 23 (34%). Of these 67 patients, 57 (85%) were co-prescribed a QTc prolonging medication and 19 (33%) developed dysrhythmias.

The proportion of patients with dysrhythmias was similar between 4-AQ alone and 4-AQ plus other QTc prolonging drugs (Chi Square p > 0.09). Among patients co-prescribed a QTc prolonging medication, 66 (64%) of 103 patients completed therapy. In this subset, cardiovascular ADRs occurred in 37 patients (57%), including hypotension in 36/37 (97%) and dysrhythmias in 8/37 (22%). Prolonged QTc resulted in 4-AQ cessation in 7/64 patients with incomplete treatment courses. During the study period, there were 107 recorded deaths of hospital inpatients with COVID-19 with 28 of those being treated with HCQ. The proportion of deaths among those treated with HCQ was significantly greater than among those who did not receive this medication (p = 0.02).

Conclusion: Cardiovascular ADRs were prevalent in patients receiving 4-AQ drug therapy when used as COVID-19 treatment.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Perceptions, Availability and Practice Patterns of Vasopressors for Septic Shock in Tanzania Forrest Turner, MD – Emergency Medicine Resident, Carolinas Medical Center Said Kilindimo MD, MMed, FCEM (SA), FCICM (India) – Emergency Physician and Intensivist – MUHAS Vivian Mlawi MD, MMed – Pediatric Intensivist, Jakaya Kikwete Cardiac Institute Raya Musa MD, MMed – Emergency Physician, MNH Hendry Sawe, MD, MMed, MBA – Assistant Professor Emergency Medicine, MUHAS Adeline Dozois, MD – Assistant Professor Emergency Medicine, Carolinas Medical Center Background: Sepsis carries a disproportionately high mortality in Sub-Saharan Africa (SSA). Current international guidelines for adult and pediatric patients with septic shock advocate for fluid boluses during initial resuscitation, up to 60 mL/kg, followed by vasopressors if there is ongoing concern for hypoperfusion. Emerging data suggest patients in SSA who receive large fluid boluses may have increased mortality, and that earlier administration of vasopressors may have clinical benefit. Little data exists on the availability, general use and perceptions of vasopressors in Tanzania and other countries in SSA, limiting an understanding of the feasibility of this strategy. Our objective was to describe current patterns and attitudes towards vasopressor use in Tanzania, including availability and barriers toward administration.

Methods: We conducted a cross-sectional web-based survey of clinical staff (physicians and nurses) in hospitals throughout Tanzania. Results were summarized with descriptive statistics.

Results: Forty-nine providers completed the survey, who represented 17 different hospitals throughout Tanzania (two national hospitals, 12 regional hospitals, and three district hospitals). Most respondents (98%) said they had some access to vasopressors, however all respondents from district hospitals and 30% of those from regional hospitals had access to vasopressors <50% of the time. All respondents noted barriers to vasopressor administration, most commonly lack of availability (55.1%), followed by lack of comfort or knowledge (42.8%). Vasopressors were generally perceived to be safe and helpful for treating septic shock.

Conclusions: Nearly all Tanzanian clinicians reported that they had some access to vasopressors to treat septic shock, however for most vasopressors were not consistently available. In addition to lack access, lack of comfort with vasopressors was also reported as a barrier to administration. Our findings suggest that ensuring adequate supply of these generally low-cost medications and education in their use would improve sepsis care in many Tanzanian hospitals.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Content Validation of Needs Assessment Survey for Remote Education Initiative in Tanzania Oriane Longerstaey, MD; Adeline Dozois, MD; Michael Gibbs, MD; Breanna Lorenzen, MD; Michael Runyon, MD; Humphrey Godwin, MD; Raya Mussa, MD, MMed Alphonce Simbila, MD, MMed Background: Historically, global health projects have involved in-person work to develop educational initiatives and research projects. A limited understanding of the local population and resources available can limit the efficacy of didactics given by faculty from other institutions. There is limited data on how these limitations can be addressed. As part of a larger study to implement a remote lecture initiative between Carolinas Medical Center (CMC) and Muhimbili National Hospital (MNH), the goal of this study was to create and validate a needs assessment tool to guide lecture development.

Methods: Two study authors familiar with the Tanzanian hospital and residency program derived two surveys for Tanzanian residents and faculty. Questions from each survey were evaluated by an expert panel consisting of two faculty members and one resident from each institution. Each item was rated from 1 to 4 for clarity and relevance respectively. We calculated a content validity index (CVI) for each item using the proportion of experts who rated it as valid. Items with a CVI of less than 0.8 were revised and resubmitted to the panel. A CVI for each instrument was calculated using the same method.

Results: 20 of 26 items in the initial resident survey were clear with a CVI >0.8, and 25 of 26 items were relevant with a CVI >0.8. One item was deemed not relevant and removed from the survey. For the faculty survey, 10 of 12 items received a CVI > 0.8 for clarity and all questions received relevance CVI > 0.8. Five questions from the resident survey and two from the faculty survey were deemed relevant but unclear. They were subsequently rewritten and sent back to experts for rating. They all achieved a CVI>0.8.

The total CVI for each survey was 1.

Conclusion: Using a team-based approach, we derived and validated a needs assessment tool to guide the creation of didactics that can be delivered to target audiences in a different practice setting. This validated tool is an important step in the creation and evaluation of a process to develop locally appropriate content and could be replicated by other groups planning similar initiatives.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Implementation of Specialty Based US Application Recommendations as Requirements for Emergency Medicine Residency Graduation Charles Harris III, MD; Vivek Tayal, MD

Objectives: Ultrasound (US) is a standard element of practice in emergency medicine (EM) residency training. The American College of Graduate Medical Education (ACGME) has established guidelines for US in residents set to 150 quality-assured (QA) US scans to achieve one of the competencies required for graduation from an American EM residency in different milestones. These guidelines are without specification in the distribution of the 150 ultrasounds amongst 12 American College of Emergency Physician (ACEP) specific core US applications. This could lead to training with uneven utilization of a few applications and failure to establish parity of US training. Some of these requirements may have the goal of reaching a total number of ultrasounds but may neglect some of the lesser utilized bedside ultrasounds depending on US privileges at that institution. Our residency program US curriculum was revised to allow achievement of the 150 scans but as well to establish a more even distribution of core US applications based on the ACEP 2016 US Guidelines.

Methods: Retrospective study assessing 4 years of graduating residents pre (n=56 from 2012-2015) and post (n=58 from 2016-2019) completed, acceptable US numerical examinations of the new US curriculum requirements. 11 separate applications (excluding bowel as application requirement was not established at the time) were evaluated by quantifying the median number of QA US studies performed as well as total number of US performed of all 11 applications. Medians with IQR were calculated with Wilcoxon rank sum test with P <0.05 representing statistically significant findings.

Results: After implementation, statistically significant (p < 0.05) increases in US applications were found for biliary (pre 14.50 [9.00, 21.00] vs post 27.00 [25.00, 29.00]), cardiac (38.00 [29.75, 52.75] vs 78.50 [56.25, 97.50]), DVT (9.00 [6.00, 14.50] vs 27.50 [25.25, 30.00]), urinary tract (17.00 [13.00, 25.00] vs 29.00 [25.25, 33.00]), ocular (6.00 [2.00, 10.25] vs 26.00 [25.00, 28.00]), and thoracic (10.00 [2.00, 19.25] vs 29.00 [26.00, 32.75]). Total US performed had also increased (468.50 [403.75, 538.00] vs 637.50 [577.50, 687.00]) Conclusion: Introducing ACEP specialty specific requirements for residency US curriculum creates more parity of ultrasound training. It also allows learners to perform more total ultrasounds giving them more hands-on learning with a probe to become more comfortable with applications that are not often required during clinical shifts.

Implementing numerical thresholds based on ACEP US Guidelines should be considered by residency program directors.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Cardiac Safety Monitoring Protocol Effectiveness for Use of 4Aminoquinolones in SARS-CoV-2 Treatment Mark Kastner, MD1, Clare Gunn, MD1, Ann-Jeannette Geib, MD1, Christine Murphy, MD1, Annie Rominger, MD1, Satish Misra, MD2, William Kerns, MD1, Kathryn T Kopec, DO1 1

2

Carolinas Medical Center, Atrium Health, Charlotte, NC, USA Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC, USA

Background: Early in the SARS-CoV-2 pandemic, the FDA granted emergency repurposing of the 4-aminoquinolone (4-AQ) drugs as antiviral treatment options.

Adverse effects of 4-AQ drugs include prolonged QTc and dysrhythmias; therefore, our facility developed a cardiac monitoring safety protocol for the use of 4-AQs. Our study evaluated physician compliance with the cardiac safety monitoring protocol.

Methods: This study was an IRB-approved retrospective chart review of patients ³ 18 years old treated with Hydroxychloroquine (HCQ) for confirmed SARS-CoV-2 from 3/1/2020 - 6/15/2020. Patients were placed on the cardiac monitoring protocol which required a baseline ECG prior to drug initiation and telemetry strips/ECG at 4 hours following drug administration. The timing of the HCQ dose, ECG, and telemetry strip including QTc intervals were collected on a standardized data abstraction form. Two providers recorded their QT interval interpretations, and the inter-rater reliability was calculated. Compliance with the protocol was evaluated using descriptive statistics to compare the actual captured ECG and telemetry strips to the expected number.

Results: There were 150 SARS-CoV-2 patients who received at least one dose of HCQ for treatment. Physicians completed the full cardiac safety monitoring protocol in six cases (4%). Seventeen patients (11.3%) had no baseline ECG performed. One hundred and twenty-three (82%) patients lacked 4-hour telemetry/ECG performed after the second dose, three (2%) patients lacked 4-hour telemetry/ECG performed after the third dose, and one (0.66%) patient lacked 4-hour telemetry/ECG performed after the fourth dose. In our study, 15.3% of patients developed a QTc > 480 ms and 4.5% of those patients had a dose 4-6 hours prior to that QTc measurement. Inter-rater reliability between ECG reading providers was 0.64.

Conclusion: Physicians did not rigorously follow the cardiac monitoring safety protocol for SARS-CoV-2 patients treated with HCQ. Potential reasons for poor compliance include inpatient overcrowding, directives to minimize SARS-CoV-2 patient contact, insufficient staff to obtain the telemetry strip or ECG, and lack of protocol awareness.

Further investigation is warranted to (1) assess if poor safety protocol compliance resulted in adverse clinical outcome and (2) how to construct and distribute future drug safety monitoring protocols for a hospital system that will be more successful.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Brain Venography Performance Following the Pause of Ad.26.COV2.S COVID-19 Vaccine Administration Clayton V. Long,a* Jonathan D. Clemente,b Sam Singh,c Jeremy B. Rhoten,c Dale Strong,d Tanushree Prasad,e Andrew W. Asimos a a

Atrium Health’s Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC b Charlotte Radiology, PA, Charlotte, NC c Atrium Health, Information and Analytics Services, Charlotte, NC d Atrium Health Neurosciences Institute, Charlotte, NC e Clinical analytics, Atrium Health

Objective: Cases of cerebral venous thrombosis (CVT) associated with vaccine induced thrombotic thrombocytopenia (VITT) were reported following administration of the adenoviral vector COVID-19 vaccines, resulting in a pause in Ad.26.COV2.S vaccine administration in the United States, beginning on April 14, 2021. We aimed to quantify and characterize an anticipated increase in brain venograms performed in response to this pause.

Method: Brain venogram cases were retrospectively identified during the three-week period following the vaccine pause and during the same calendar period in 2019. For venograms performed in 2021, we compared COVID vaccinated to unvaccinated patients.

Results: There was a 261% increase in venograms performed between 2019 (n=26) and 2021 (n=94), compared to only a 19% increase in all radiologic studies. Fifty-seven percent of patients in 2021 had a history of COVID-19 vaccination, with the majority being Ad.26.COV2.S. All patients diagnosed with CVT were unvaccinated. COVID vaccinated patients lacked platelet or D-dimer measurements consistent with VITT. Significantly more vaccinated versus unvaccinated patients had a headache (94% vs 70%, p=0.0014), but otherwise lacked compelling CVT presentations, such as decreased/altered consciousness (7% vs 23%, p=0.036), neurologic deficit (28% vs 48%, p=0.049), and current/recent pregnancy (2% vs 28%, p=0.0003).

Conclusion: We found a dramatic increase in brain venograms performed following publicity of rare COVID-19 vaccine associated CVT cases, with no CVTs identified in vaccinated patients. Clinicians should carefully consider if brain venogram performance is indicated in COVID-19 vaccinated patients lacking thrombocytopenia and D-dimer elevation, especially without other compelling CVT risk factors or symptoms.

CMC Department of Emergency Medicine

14

Resident Academic Day 2022

Virtual/In-Person Experience for Resident Supervision (VIPERS): A Qualitative Study Rachel Plate, MD1; Bryant Allen, MD1; Sean Fox, MD1 1

Department of Emergency Medicine, Atrium Health Carolinas Medical Center

Background: Prior to the COVID-19 global pandemic, in-person attending supervision of resident physicians was required in Emergency Medicine training programs. In March 2020, the ACGME allowed telemedicine to be incorporated into EM residency training programs, including for the supervision of resident-directed patient care. Perceptions surrounding resident education, professional development, and attending physician provision of entrustment had not yet been assessed when emergency medicine residents were supervised virtually.

Methods: This was a qualitative study conducted at a single academic emergency department after deploying virtual supervision of resident-directed patient care and operations management in a low acuity area of the emergency department. Semistructured focus groups were conducted with resident and attending physicians who experience virtual supervision at least one time. Authors used constant comparative method and open coding to inductively develop themes encountered in the focus groups.

Results: Resident autonomy was perceived by both attending and resident physicians to increase during periods of virtual supervision. Educational opportunities were present, though different, when virtual supervision was utilized. Resident and attending perceptions of these opportunities often diverged. A trusting clinical relationship between attendings and residents was necessary from the outset of virtual supervision for success.

Conclusions: Virtual supervision was described as successful in providing educational opportunities for residents and increased resident autonomy. It worked best when there was previously established trust between both parties. Additional studies could further delineated the effect of virtual supervision on patient-safety and operations-based outcomes and usefulness in other ED settings.

CMC Department of Emergency Medicine

15

Resident Academic Day 2022

Sensitivity of Three Distinct Imaging Findings for Type A Aortic Dissection Neha Ray, MD1; Courtney Owens, MD1; John Frederick, MD2; John Childress, MD3, Mike Gibbs, MD1; Margaret Lewis, MD1 1

Department of Emergency Medicine, Atrium Health Carolinas Medical Center 2 Division of Cardiovascular Surgery, Sanger Heart and Vascular Institute 3 Department of Radiology, Atrium Health Carolinas Medical Center

Stanford Type A aortic dissections are rare but life-threatening emergencies. They are commonly misdiagnosed and have a high in-hospital mortality. CT angiography has high sensitivity for detection of type A aortic dissections but requires transport out of the resuscitation bay and time to complete. A sensitive bedside test to rapidly screen for the presence of aortic dissection is desirable.

Objective: To identify the sensitivity of three distinct CT imaging findings that can be evaluated with point-of-care ultrasound using patients with known Type A aortic dissections: (1) dilated ascending aorta, (2) presence of pericardial effusion, and (3) dissection flap extending to the level of the celiac artery takeoff.

Methods: : A retrospective chart review was performed to identify Type A aortic dissections using a surgical repair database. Each patient’s CT chest angiography was then independently reviewed by 2 emergency medicine physicians to evaluate for the presence of the above imaging findings. Sensitivity of these imaging findings was calculated. Inter-reviewer reliability was assessed between the two reviewers as well as with radiology documentation, when available.

Results: 240 charts were reviewed, and 166 patients were identified to meet inclusion criteria. Presence of a dilated ascending aorta (dilated aortic root and/or mid-ascending aorta) was 0.85 (CI 0.79-0.90). The sensitivity of a pericardial effusion was 0.20 (CI 0.14-0.27) and for a dissection flap extending to the level of the celiac artery takeoff was 0.58 (CI 0.51-0.66). The overall sensitivity of one or more of these findings was 0.94 (CI 0.90-0.98). The correlation coefficient between the first and second reviewer was 0.71 for aortic root measurement and 0.65 for mid-ascending aorta measurement. The kappa value between the first and second reviewer was 0.50 for presence a pericardial effusion and 0.65 for extension of dissection flap to the level of the celiac artery takeoff.

Conclusion: The above study demonstrates high sensitivity for detection of a Type A aortic dissection using 3 distinct imaging findings. Further studies are needed to examine methods to improve inter-reviewer reliability and to examine if these imaging findings can be accurately identified by emergency medicine physicians with the use of point-of-care ultrasound.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Evaluation of Neurological Outcome after Code Cool Target Temperature Change to 37°C Andrew Yde MD, TsaiWei Wang MS, Kathi Kraft RN, David Pearson MD MS MBA

Objectives: Recent evidence suggests no difference in neurological outcome in postcardiac arrest patients with a fever avoidance strategy as opposed to mild hypothermia therapy3. Hospitals within the Greater Charlotte Region of Atrium Health recently changed guidance for post-cardiac arrest targeted temperature management to 37C from 33C-36C. The objective of this study is to assess the impact on survival and neurological outcome of this institutional guideline change.

Methods: In this retrospective, pre- vs post-cohort, multi-hospital study, we included out-of-hospital cardiac patients successfully resuscitated and admitted to an ICU at each receiving Level 1 Cardiac Arrest Center (Carolinas Medical Center, Atrium Health Pineville, and Atrium Health Cabarrus, Cleveland) and enrolled in the Code Cool clinical pathway. The intervention was the guideline change to target temperature of 37C. The pre-intervention cohort included patients with target temperature of 33C or 36C enrolled from June 30, 2014 to July 1, 2021. The post-intervention cohort included patients with target temperature of 37C enrolled during July 12, 2021 to April 30, 2022.

The primary outcome was good neurological outcome based on Cerebral performance Category (CPC) scale of 1 or 2 at time of discharge. Secondary outcomes included survival to hospital discharge, incidence of fever within 72 hours from ROSC, and hospital length of stay (LOS) in the post-intervention cohort.

Results: There were 1215 patients vs 137 patients (mean age 57 vs 58 years, male 64 vs 58%, witnessed 78.6% vs 72.3%, shockable arrests 48.6% vs 41.6%) in the pre- vs post-intervention cohorts. The pre-intervention population had more hypertension, hyperlipidemia, coronary artery disease, and vasopressor use. There was no difference in good neurological outcome (40.1% vs. 36.2%, p=0.35) or survival to hospital discharge (42% vs 69%, p=0.31) in the pre- vs post-intervention cohorts. In the postintervention cohort, there less use of an external cooling device, cold intravenous fluids, and paralytics compared to the pre-cohort (P<0.0001) with 38.6% of patients experiencing fever within 72 hours. There was no difference in mean hospital LOS (9.8 vs 10.4 days, p=0.57).

Conclusions: There was no difference in survival or good neurological outcome after changing target temperature to 37C from 33C/36C. Given the small post-intervention sample size compared to the pre-intervention cohort and varying comorbidities, further assessment is warranted. However, a notable incidence of fever after institutional guideline change to 37C targeted temperature with significant decrease in cooling device utilization warrants further consideration whether strict adherence to routine cooling device use for all post-arrest patients is required for fever prevention.

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 CMC Department of Emergency Medicine Graduates’ Destinations - Chief Residents

Travis Barlock, MD

Matthew Cravens, MD

Swedish Medical Center Englewood, CO

Critical Care Fellowship Maine Medical Center Portland, ME

Clare Gunn, MD

Mark Kastner, MD

Sky Ridge Medical Center Denver, CO

ApolloMD at Atrium Union Monroe, NC

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 CMC Department of Emergency Medicine Graduates’ Destinations - Residents

Shane Ali, MD

Kelsey Lena Craver, MD

Daniel Escobar, MD

Charles Harris III, MD

St. David’s South Austin Medical Center Austin, TX

PEM Fellowship Wake Forest Baptist Winston-Salem, NC

Mercy Hospital Northwest Arkansas Rogers, AR

Medical Center of Aurora Denver, CO

Clay Long, MD

Oriane Longerstaey, MD

Rachel Plate, MD

Neha Ray, MD

ApolloMD at Atrium Union Monroe, NC

Global Health Fellowship Brown University Providence, RI

Mercy Hospital Springfield, MO

Mission Hospital Ashville, NC

Forrest Turner, MD

Andrew Yde, MD

Advent Health Waterman Tavares, FL

ApolloMD at Atrium Union Monroe, NC

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 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 2020 2021

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 and Carly A. Cox MD Kathryn Lupez, MD Jessica Hoglund, MD Elizabeth Olson, MD

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 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 2020 2021

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 Robert Kregg Laundon, MD Gabriela Rivera-Camacho, MD

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 CMC Department of Emergency Medicine Resident Award Recipients JEFFREY A. KLINE 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 2020 2021

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 O’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 Jessica Hoglund, MD Alyssa Thomas, MD, MPH

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 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 2020 2021

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 Kathryn Kopec, DO Cathy Wares, MD

EXEMPLAR - Faculty Award 2008 2009 2010 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

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 Jessica Salzman, MD Brandon Fetterolf, DO

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 CMC Department of Emergency Medicine Faculty Award Recipients OUTSTANDING TEACHER - Faculty Award 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

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 Mike Gibbs, MD Andrew Asimos, MD Sean Fox, MD Tyson Cook, MD Danielle Dragoo, MD Dalton Cox, MD Kathryn West, MD Denise Fraga, MD Harvey P. Meyers, MD

CMC Department of Emergency Medicine

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Resident Academic Day 2022

Resident Academic Day 2022 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 2020 2021

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 Malika Fair, MD, MPH, FACEP – The George Washington University Jeffrey Kline, MD - Wayne State University School of Medicine

CMC Department of Emergency Medicine

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Resident Academic Day 2022

CMC Department of Emergency Medicine

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Resident Academic Day 2022