Resident Academic Day 2024

Carolinas Medical Center Department of Emergency Medicine

June 20, 2024 Resident

Resident Academic Day 2024

CMC Department of Emergency Medicine

Thursday, June 20, 2024

Medical Education Building • 3rd Floor Conference Room

Schedule

8:00 am Welcome & Introductions Mike Gibbs, MD and Mike Runyon, MD

8:10 am 2024 Resident Academic Day Address Christopher A. Lewandowski, MD

8:30 am Thomas Blackwell, MD – Inter-rater Reliability of the Critical Area Perfusion Score (CAPS) in Basilar Artery Occlusion

8:45 am Kylee Brooks, MD – Clinical Decision-Making in the Emergency Department: A Quality Improvement Study on the Impact of Artificial Intelligence- Assisted Point-ofCare Cardiac Ultrasound - PILOT STUDY

9:00 am Sofiya Diurba, MD – Financial Literacy Among Medical Trainees

9:15 am Haley Dusek, MD – Impact of Fast Track Workflow Implementation on Length of Stay for Pediatric Emergency Department Visits Break @ 9:30 am

9:45 am Destiny Folk, MD – Depression and Associated Risk-Factors Among Emergency Medicine Interns: Results from a National Longitudinal Cohort Study

10:00 am Nathanael Franks, MD – A Cardiac Magnetic Resonance Imaging Approach Reduces Radiation Exposure in Emergency Department Patients with Acute Chest Pain

10:15 am Allison Frazure, MD – Needs Assessment Survey for High Acuity, Low Occurrence (HALO) Procedures in an Emergency Medicine Residency Program

10:30 am Aaron Frolichstein, MD – The Feedback Shift

10:45 am Parker Hambright, MD – Low Stroke Volume Predicts Deterioration in IntermediateRisk Pulmonary Embolism: Prospective Study

Break @ 11:00 am

11:15 am Douglas Maslowski, MD – Post-Cardiac Arrest Resuscitation Care Quality Improvement Initiative after Transition to 37°C Targeted Temperature

11:30 am Faith Meyers, MD – ELIRT: ECG Learning in Real-Time – Education via a Mobile Based Platform

11:45 am Steven Perry, MD – Treatment and Outcomes of High-Risk Pulmonary Embolism

12:00 pm Angela Pikus, MD – Cardiac Measurements By Artificial Intelligence Predict Clinical Deterioration in Pulmonary Embolism

12:15 pm Aaron Sherwood, MD – Variation in Opioid Administration and Prescribing in the Emergency Department for Neck or Back Pain

Resident Academic Day 2024

Visiting Professor

Christopher A. Lewandowski, MD

Christopher A. Lewandowski, MD, FACEP, FAAEM, is board-certified in Emergency and Internal medicine. He received his BS degree in Chemistry from Marquette UniversityMilwaukee in 1976 and his MD from the Medical College of Wisconsin – Milwaukee in 1982. After 2 years in the National Health service Corp, he completed residency at Henry Ford Hospital in Emergency Medicine and Internal Medicine in 1988.

Dr. Lewandowski is currently the Executive Vice Chair for Academic Affairs and the former Residency Program Director for 25 years (combing both EM/IM and EM programs) in the Department of Emergency Medicine at Henry Ford Hospital. He founded the EM/IM Combined Residency program and the EM/IM/ Critical Care programs. He is a Clinical Professor of Emergency Medicine at Wayne State University. His primary area of interest in research is in the acute treatment of Stroke and Neurological Emergencies. He was one of the original t-PA Stroke Study Investigators and remains a member of the Ford Acute Stroke Team. His ongoing research includes participation in multiple trials sponsored by NIH, the SIREN Network, StrokeNet, as well as PTSD development among trauma survivors.

Inter-rater Reliability of the Critical Area Perfusion Score (CAPS) in Basilar Artery Occlusion

TA Blackwell, RR Karamchandani, S Satyanarayana, H Yang, JD Clemente, G Defilipp, M Hazim, and AW Asimos

Introduction: Initial data suggest that for the recently derived Critical Area Perfusion Score (CAPS), a score of >3 predicts poor outcomes for acute basilar artery occlusion patients undergoing successful thrombectomy. The purpose of this study was to evaluate the inter-rater reliability of CAPS scores assigned by clinicians with a range of neuroimaging expertise.

Methods: A total of 55 acute basilar thrombosis patients from January 2017- December 2021 were included in this retrospective analysis from Atrium’s stroke registry. CAPS was assigned by 6 raters: a board-certified neuroradiologist; a board-certified neuroradiologist/neurointerventionalist; a vascular neurologist; an emergency medicine (EM) attending physician with stroke expertise; an EM resident physician; and a 4th-year medical student. The EM resident and medical student received education pertaining to the relevant neuroimaging anatomy for calculating CAPS by reviewing online modules from https://radiopaedia.org. Inter-rater reliability (IRR) was assessed across all 6 raters and for the 4 attending physicians using Light’s kappa statistic for qualitative assessment of good (≤3) versus poor (>3) CAPS. For the 2 neuroradiologists, IRR was measured using Cohen’s Kappa.

Results: A total of 55 patients, mean age 65.8 (+- 13.1) years and median NIHSS score 15.5 were included. In the IRR analysis for all 6 raters, the kappa statistic for discriminating between favorable versus unfavorable CAPS (0-3 versus 4-6) was 0.633 (95% CI 0.497-0.785, p = 0.995). The kappa for all 4 attending physicians (excluding the emergency medicine resident physician and medical student) was 0.788 (95% CI 0.6390.943).

For all raters, agreement (kappa coefficient, 95% CI) for individual scores for cerebellum, pons and midbrain/thalamus were: 0.81 (0.73 - 0.89); 0.73 (0.63 - 0.84) and 0.418 (0.29 - 0.57) respectively. For four attending physicians, kappas were 0.885 (0.807 - 0.968) 0.904 (0.813 - 0.999) 0.528 (0.356 - 0.735). For two neuroradiologists, kappas were 0.909 (0.810 - 1.010) 0.866 (0.715 - 1.02) 0.68 (0.422 - 0.97)

Conclusion: Across all readers, there was moderate agreement for discriminating between favorable versus unfavorable CAPS (0 -3 versus 4-6), but when novice readers were excluded, agreement improved into the substantial range. Among the brain regions included in CAPS, agreement was the lowest for scoring the midbrain and thalamus.

Clinical Decision-Making in the Emergency Department: A Quality Improvement Study on the Impact of Artificial Intelligence-Assisted Pointof-Care

Cardiac Ultrasound - PILOT STUDY

Belyshev, V, Brooks, K, Bayonnet, B, Doris, C, Tayal, V

Background: Point-of-care cardiac ultrasound is crucial in the emergency department (ED) for rapid assessment of critically ill patients. Advanced ultrasound assessments may require additional training and time. Artificial intelligence (AI)-assisted cardiac ultrasound offers promise in enhancing proficiency and streamlining clinical decisionmaking.

This pilot study evaluates how AI-assisted cardiac ultrasound affects clinical decisionmaking (diagnosis, treatment, disposition) and confidence of decision-making in the ED.

Methods: Emergency physicians at Carolinas Medical Center used the Mindray TEX ultrasound machine with AI features for cardiac ultrasound. Participants completed a questionnaire post-ultrasound, assessing AI's impact on decision-making and confidence in decisions. Data collected anonymously and analyzed descriptively.

Results: In this preliminary analysis, eight emergency physicians participated. None had high confidence in manual advanced data collection. With AI assistance, all obtained at least one advanced data point, however, diastolic dysfunction assessment remained inconclusive in 71% of cases. Diagnosis was impacted in 25% of cases, with an increase confidence of diagnosis in 62.5% of cases. Management/treatment was affected in 37.5% of cases (primarily fluid administration) with increased confidence in decision in 75% of cases. Disposition was affected 25% of cases with an increase in the confidence of disposition decision in 75% of cases. Overall, AI assisted ultrasound data did not affect clinical decision making in most cases but did increase provider confidence in all realms of clinical decision making in the majority cases.

Conclusion: AI-enhanced ultrasound bolstered confidence, potentially serving as an educational tool for less proficient ultrasonographers. While not directly altering decisionmaking in most cases, it enhanced confidence levels.

Financial Literacy Among Medical Trainees

Sofiya Diurba, MD and Michael Runyon, MD

Introduction: Physician job satisfaction, productivity, and levels of burnout are affected by personal finances and financial wellbeing. Financial literacy is not a standard part of undergraduate or graduate medical education. We sought to determine the financial literacy, behaviors, and attitudes of intern residents starting residency at one academic hospital system and compare to previously published data of groups of similar individuals.

Methods: We administered a cross-sectional, anonymous, web-based survey to a convenience sample of first year residents at Carolinas Medical Center. We used a 52question survey validated from prior research (Ahmad 2017) assessing financial literacy in a 20-question financial knowledge quiz, followed by questions about debt, savings, financial planning, and attitudes towards finances such as risk tolerance. Questions about risk tolerance and financial satisfaction were graded on a Likert scale (1=lowest, 10=highest).

Results: The survey was sent to 81 new intern residents at Carolinas Medical Center and 43 individuals responded (53%). The average score on the financial knowledge quiz was 44.2% (SD = 18.6, range of 10% to 100%) and there were no differences by specialty (p=0.67). A higher test score was associated with higher financial satisfaction (p=0.006) and with increased willingness to take financial risks (p=0.03). Only half of respondents (51.2%) have a 3-month emergency fund; however most (95.3%) could come up with $2,000 in an emergency. Similar to prior studies of residents, but lower than the general population, a fifth of respondents (20.9%) carry credit card debt that they won’t pay off at the end of the month. Two thirds of respondents carry student loan debt (67.4%) and of those that do, most (82.7%) carry over $150,000 in student loan debt. Over half of respondents (55.8%) reported saving some amount of money for retirement, however most of those that have saved, saved less than $25,000. Most (83.3%) of those residents who have saved for retirement have done so through an employer sponsored retirement plan. Most residents reported not having any financial planning in medical school (79.1%), and few read financial books (23.3%), blogs (9.3%), or listed to finance podcasts (4.7%).

Conclusion: First year residents of various specialties beginning their training at Carolinas Medical Center have low financial literacy, high debt, and minimal savings. Having higher financial literacy is associated with higher financial satisfaction, thus inventions to improve residents’ financial literacy are an important potential target to improve long-term physician well being and burn out.

Impact of Fast Track Workflow Implementation on Length of Stay for Pediatric Emergency Department Visits

Haley L. Dusek MD,1 S. Chad Scarboro MD1,2

1. Atrium Health Carolinas Medical Center 2. Atrium Health Levine Children’s Hospital

Introduction: Overcrowding has affected both adult and pediatric emergency departments across the country and led to increased length of stay in the emergency department (ED). In pediatric emergency departments, increased volume has been associated with an increase in low acuity ED visits. To target increased length of stay in a busy pediatric emergency department, an interdisciplinary team developed and trialed a novel paramedic driven fast track workflow for low acuity patients named “Supertrack.” We predicted a decrease in median total length of stay for ED patients with Supertrack implementation.

Methods: Retrospective health records review.

A 12-week control period (4/18-7/4/2022) was compared to the implementation period (4/18-7/4/2023). The primary outcome was median length of stay (LOS), as total time in the department. Secondary outcomes included ED LOS for low acuity patients (ESI 4 &5), median wait time (time to provider evaluation), and rate of left without being seen (LWBS).

Results: 14,636 visits were included (7282 in the implementation period, 7354 in the control period). Median total length of stay was significantly lower for the implementation period v. the control period (217 v. 235 min, interquartile range (IQR) 179 v. 193, p<0.01). Length of stay for low acuity patients (ESI 4&5) was 140 minutes for the implementation period (IQR 109), versus 162 minutes for the control period (IQR 137) (p <0.001). Median wait time was 33 minutes for the implementation period (IQR 44) versus 39 minutes for the control period (IQR 67) (p<0.001). Left without being seen decreased from 5% to 1.7% for the implementation period (p<0.001).

Conclusions: Our Supertrack workflow significantly decreased median length of stay, as well as wait time, and rates of left without being seen in the pediatric ED. Paramedics played a critical role in the throughput of patients. A paramedic driven fast track workflow is accessible to many emergency departments and can improve length of stay and wait times for ED patients.

Depression and Associated Risk Factors Among Emergency Medicine Interns: Results from a National Longitudinal Cohort Study

Destiny D. Folk MD, Cortlyn Brown MD, Carrie C. Bissell MD, Lauren A. Fowler PhD

Objective: Despite depression being common in residents, there are no published studies on the prevalence and risk factors for depression in emergency medicine (EM) interns. Our objectives were to explore the prevalence of depression among EM interns and to identify risk factors for depression including sleep, work hours, rotation type, race, ethnicity, sex, and age.

Methods: The Intern Health Study is a national longitudinal cohort study on intern mental health in all specialties. Secondary analysis was performed for EM interns only in this study. Data were collected from 2007 to 2021 and study participants completed a pre– intern year baseline survey and quarterly surveys throughout intern year, which included demographics and information on depressive symptoms, work hours, sleep, and rotation specifics. Depression severity was objectified using the Patient Health Questionnaire (PHQ9) with scores of 10 and higher meeting criteria for moderate to severe depression.

Results: A total of 1123 EM interns completed all surveys. The prevalence of moderate to severe depression among EM interns before starting internship was 4.8%. At Months 3, 6, 9, and 12 of the intern year, the prevalence of moderate to severe depression was 17.8%, 20.5%, 20.8%, and 18.8%, respectively. PHQ9 scores were significantly higher at Month 3 of intern year compared to pre–intern year, but there were no differences at subsequent time points during intern year (p< 0.001). Females were more likely to have PHQ9 scores of 10 or above at all time points (p< 0.001). Clinical rotation type had a significant effect on PHQ9 scores, with intensive care unit rotations having a significantly higher PHQ9 score than other rotations (p< 0.001). Pearson's correlation revealed significant weak positive correlations between work hours and PHQ9 at each time point (r= 0.195, 0.200, 0.202, 0.243) and significant weak negative correlations between sleep hours and time off with PHQ9 (−0.162, −0.223, −0.180, −0.178; all p< 0.001).

Conclusion: Many EM interns experience moderate to severe depression. Female EM interns are more likely to be depressed than male interns. Numerous factors influence depression scores for interns, many of which are modifiable.

A Cardiac Magnetic Resonance Imaging Approach Reduces Radiation Exposure in Emergency Department Patients with Acute Chest Pain

Cedric Lefebvre MD; Anna C. Snavely PhD; Nathanael J. Franks MD; Robin R. Kiehl MD; Nicklaus P. Ashburn MD, MS; Michael W. Supples MD, MPH; Simon A. Mahler MD, MS; Chadwick D. Miller MD, MS

Background: Patients presenting to the Emergency Department (ED) with chest pain who have an indeterminate (detectable to mildly elevated) troponin are often further evaluated with tests that use ionizing radiation. We hypothesized that patients initially evaluated with stress cardiac magnetic resonance (CMR) imaging receive less ionizing radiation through one-year of followup than those initially evaluated with invasive angiography.

Methods: We conducted a secondary analysis of the CMR-IMPACT trial, which randomized adult patients at 4 U.S. sites (9/2013-7/2018) with a contemporary troponin of 0.006-1.0 ng/mL to either CMR imaging or invasive angiography. Cumulative radiation exposure from coronary computed tomography angiography, nuclear medicine stress imaging, cardiac catheterization, and percutaneous coronary intervention was assessed from index through one-year using validated radiation dose estimates. Radiation doses at index and one-year were compared between arms using linear regression adjusted for the stratification factors of initial troponin and known coronary artery disease in both intention to treat (ITT) and per protocol (PP) populations.

Results: During the study period, 312 patients were enrolled, with 156 randomized to each arm (CMR vs. invasive angiography). In the ITT analysis, patients in the CMR arm had less radiation exposure at index compared to patients in the invasive angiography arm (4.7±5.7 mSv vs. 7.8±5.8 mSv; p<0.001). However, the difference in radiation exposure was not maintained at one-year (7.5±10.9 mSv vs. 9.5±8.4 mSv; p=0.06). In the PP analysis, patients receiving CMR (N=102) had less radiation exposure than those receiving invasive angiography (N=104) at index (3.5±5.1 mSv vs. 9.3±3.7 mSv; p<0.001) and one-year (5.8±10.9 mSv vs. 11.2±8.1 mSv; p<0.001).

Conclusion: CMR was associated with decreased radiation exposure compared to invasive angiography. These findings suggest that a CMR-based risk stratification strategy may reduce iatrogenic radiation exposure.

Needs Assessment Survey for High Acuity, Low Occurrence (HALO) Procedures in an Emergency Medicine Residency Program

Allison Frazure MD , Bryant Allen MD

Introduction: High acuity, low occurrence (HALO) procedures are critical interventions in emergency medicine and trauma care. Due to their infrequent nature, residents often have limited experience with these procedures, potentially impacting their confidence and competency. This study aimed to evaluate the educational, curriculum, simulation, and real-life experience needs of residents at a single center, 3-year emergency medicine residency training program regarding HALO procedures.

Methods: A needs assessment survey for HALO procedure education was developed and distributed to emergency medicine residents at a single center, 3-year emergency medicine residency training program to identify gaps and areas for improvement, with the goal of informing the creation of a new curriculum to enhance resident training.

Results: There were 31 respondents to the needs assessment survey. According to the survey respondents, current educational conference time has provided some instruction on pericardiocentesis, but little on cricothyroidotomy, lateral canthotomy, and thoracotomy, and virtually none on resuscitative hysterotomy, REBOA placement, DPL, or ECMO cannulation. Simulation experiences were reported to be more frequent for cricothyroidotomy and pericardiocentesis but were notably sparse for the other procedures. The effectiveness of current educational methods was met with neutral responses from 67% of residents, with only 33% finding them adequate. Eighty-four percent of respondents felt that there was no structured method for teaching HALO procedures, and 100% of respondents agreed that implementing a recurrent review or curriculum would be beneficial.

Conclusions: The needs assessment survey reveals significant areas for improvement regarding HALO procedural training. Development of a structured curriculum that includes regular, hands-on workshops and frequent, realistic simulation exercises, along with increased opportunities for supervised real-life practice should lead to improved resident competency and confidence in performing HALO procedures, potentially enhancing patient care outcomes in emergency and trauma settings

The Feedback Shift

Aaron Frolichstein MD, Bryant Allen MD, Sean M. Fox MD

Background: Feedback from faculty is essential to the growth of residents in an emergency medicine program. Various methods for delivering this feedback have been explored in the literature, though these do not always reliably deliver significant or actionable feedback. The goal of this project is to provide residents and faculty a means to exchange feedback in a more consistent and actionable manner.

Methods: Over a three-month time frame residents and attendings were sent an automated text message at the end of their clinical shifts that utilized a 10 point Likert scale to assess for perceptions on the quality of feedback both given and received. This data was collected via red cap and twilio messaging systems and stored for future analysis. This initial three-month data collection. Served as the control prior to the implementation of a” feedback shift" in which residents and faculty were educated that they would be prompted with text messages prior to their shift encouraging directly observed patient encounters and standardized feedback at the end of every shift. Faculty and residents were once again sent at 10-point Likert scale to assess their perceptions on the quality of feedback both given and received.

Results: Over the time the study was conducted we were able to collect 98 surveys from residents that were “not primed”, meaning there was no message sent prior to the shift to either faculty or resident. We collected 93 surveys in which both the residents and faculty were primed prior to the shift and successfully completed the survey at the end of the shift as well. The average rating of feedback from the resident standpoint on non primed shifts was 6.66, the average rating on feedback from residents on prime shifts was 8.99. Utilizing an unpaired T test we found a statistical significance with a P value of .0001.

Conclusion: Based on our quantitative and qualitative data, residents seem to prefer a more structured approach to post shift feedback. Text prompts both reminded and helped facilitate feedback exchange from attendings to residents but how to sustainably implement this model is up for debate.

Low Stroke Volume Predicts Deterioration in Intermediate-Risk

Pulmonary Embolism: Prospective Study

Anthony J Weekes MD, MSc1, Parker Hambright MD1, Ariana Trautmann MD1, Shane Ali MD1, Angela Pikus MD1, Nicole Wellinsky BS1, Sanjeev Shah MD2, Nathaniel O’Connell PhD3

1 Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, North Carolina, USA

2 Atrium Health Sanger Heart and Vascular Institute, North Carolina, USA

3 Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA

Introduction: Prognosis and management of patients with intermediate-risk pulmonary embolism (PE) is challenging. We investigated if stroke volume may be used to identify the subset of this population at increased risk of clinical deterioration or PE-related death. Our secondary objective was to compare echocardiographic measurements of patients who received escalated interventions vs. anticoagulation monotherapy.

Methods: We selected patients with intermediate-risk PE, who had comprehensive echocardiography within 18 hours of PE diagnosis and before any escalated interventions, from a PE registry populated by 11 emergency departments. Echocardiographers measured right ventricle (RV) size, tricuspid annular plane systolic excursion (TAPSE), and stroke volume (SV) using velocity time integral (VTI) by left ventricular (LV) outflow tract Doppler or 2D method of discs (MOD). The primary outcome was a composite of PE-related death, cardiac arrest, catecholamine administration for sustained hypotension, or emergency respiratory intervention during the index hospitalization. Secondary outcome was escalated intervention with reperfusion or extracorporeal membrane oxygenation therapy.

Results: Of 370 intermediate-risk PE patients (mean age 64.0 ± 15.5 years, 38.1% male), 39 (10.5%) had the primary outcome. These 39 patients had lower mean SV regardless of measurement method than those without the primary outcome: SV MOD 36.2 vs. 49.9 mL, p <0.001; SV Doppler 41.7 vs. 57.2 mL, p = 0.003; VTI 13.6 vs. 17.9 cm, p = 0.003. Patients with primary outcome also had lower mean TAPSE than those without (1.54 vs. 1.81 cm, p = 0.003). Multivariable models, selecting SV as predictor, had area under the receiver operating curve of 0.8 and Brier score 0.08. The best echocardiographic predictor of our primary outcome was SV MOD (odds ratio 0.72 [0.53, 0.94], p = 0.024). Patients who received escalated interventions had significantly lower SV or surrogate measurements, greater RV dilatation, and lower RV systolic function than patients who received anticoagulation monotherapy.

Conclusion: Low SV was a predictor of clinical deterioration and PE-related death. Low SV may be used to identify a subset of intermediate-risk PE patients, who are higher risk (“intermediate-high risk”), and for whom escalated interventions should be considered.

Post-Cardiac Arrest Resuscitation Care Quality Improvement Initiative after Transition to 37°C Targeted Temperature

Doug Maslowski1, Tsai-Wei Wang2, Kathi Kraft2, Leslie London3, Alan Heffner4, Dave Pearson1

Background: The science of targeted temperature management in post-cardiac arrest care has evolved over the past two decades. Initially hypothermia was recommended but after further studies2 the evidence has favored against maintained hypothermia but rather fever avoidance may have been the benefit to the post-arrest vulnerable brain. Additionally, studies have shown post arrest hypotension can also be detrimental to post-arrest care and outcomes16, 17. After the movement towards normothermia, some hospitals noted reduced compliance with temperature goals11,12. This quality improvement initiative aimed to increase education about post arrest care, implement a new electronic health record orderset, and change nomenclature in efforts to improve post-arrest care.

Methods: Primary outcome was measurement of fever rates in post ROSC patients. Secondary outcomes tracked were vasopressor initiation, utilization of targeted temperature management devices, and ultimately neurologic outcomes in those who sustained ROSC. During the pre-intervention period a total of 150 patients contributed data for 10 months followed by a “wash-out” period for 3 months while interventions were performed. The post-intervention period occurred over 3 months to obtain comparison data.

Results: Results show statistically significant improvement in TTM device utilization (Pre 35.3%, Post 81.1%, P<0.0001). There was no significant change to fever occurrences (pre 55.3%, post 46.0%, P >0.05) or vasopressor use (pre 81.3%, post 81.1%, P>0.05). No significant difference appreciated in good neurologic outcomes (pre 32.7%, post 24.3%, P>0.05). Additionally, the demographics were similar in the pre and post cohorts except for the post cohort having 75% less individuals than the pre cohort during time of analysis (pre 150, post 37).

Conclusions: Further studies investigating timing of TTM placement in association with fever rate are recommended. Data will continue to be analyzed as more patients are enrolled into the post cardiac arrest registry at the hospital sites.

ELIRT: ECG Learning in

Faith R. Meyers MD, Catherine M. Wares MD, H. Pendell Meyers MD, Sean M. Fox MD

Introduction: The ability to accurately interpret electrocardiogram (ECG) findings is a critical skill of a competent emergency medicine provider. At our institution, an easily accessible group messaging application has been used to implement a unique, in realtime teaching modality that can be utilized for both asynchronous and synchronous learning via the ability to share ECGs in real-time along with relevant clinical context. Our objective was to investigate and describe patterns of provider use, experience, and perception of impact on education and clinical practice, with the goal of enhancing provider competence in ECG interpretation.

Method: This is a descriptive study utilizing survey data collected via REDCap from Carolinas Medical Center (CMC) Department of Emergency Medicine providers who participate in the ECG learning platform. Providers who have not used the platform were excluded. Survey questions were designed to assess participant level of training, patterns of use, opinions of educational value, implications on clinical practice, and opinions on applicability as an educational and clinical tool. Participation was voluntary. Basic descriptive analytics were performed using REDCap performed on aggregate survey responses.

Results: The survey was distributed among 132 providers, with 45 meeting inclusion criteria. Participants included PGY1 (22.2%), PGY2 (20.0%), & PGY3 (22.2%) residents, fellows (8.9%), APPs (6.7%), and attendings (20.0%). On questions utilizing a 5-point Likert scale (Excellent, Above Average, Average, Below Average, Poor), 75.6% of participants described confidence in interpreting ECGs prior to residency as “Average” or “Below Average”, with 71.1% of participants describing current confidence in interpretation as “Excellent” or “Above Average”. 95.6% described utilization of this group as an educational tool for training in interpreting ECGs as “Excellent” or “Above Average”. 86.7% of participants reported that utilization of the group has impacted their clinical practice in real time, and 97.8% felt their use would impact their future clinical practice. 91.1% of participants feel this format of learning could be applied to other facets of emergency medicine.

Conclusion: A variety of providers at all training levels utilize the mobile learning platform. Most participants felt that their confidence in interpreting ECG findings has much improved as compared to their knowledge prior to advanced training and consider this teaching modality to be an excellent/above average training tool. Many feel that use of this group has significantly impacted their clinical practice in the past, and that the educational value will continue to impact their clinical practice in the future. This training modality was highly regarded among participants as an educational and clinical tool.

Treatment and Outcomes of High-Risk

Embolism

Anthony J. Weekes, MD, MSc1*, Kelly L. Goonan, MPH1, Fernanda Calienes Cerpa, MD1, Parker L. Hambright, MD1, Angela M. Pikus, MD1, Steven M. Perry, MD, MSc1†, R. Dalton Cox, MD1†, Nicole Wellinsky , BS1†, Nathaniel S. O’Connell, PhD2

1 Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, North Carolina, USA

2Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston- Salem North Carolina, USA

Objective: Determine differences in outcomes and treatment among high-risk pulmonary embolism (PE) subgroups.

Methods: We examined death, major bleeding, clinical deterioration, and treatment choice among patients with intermediate- and high-risk PE at regional emergency departments (EDs). We compared outcomes for all patients and high-risk subgroups by catastrophic status and conducted multivariable analyses to report odds ratios (ORs) for predictor associations with death and bleeding.

Results: Among 2027 PE registry patients, 337 of 1863 (18.1%) intermediate-risk and 108 of 164 (65.9%) high-risk patients had advanced interventions. Outcomes for catastrophic (n = 117) versus non-catastrophic high-risk patients (n = 47): death (43 [35%] vs. 6 [12.8%]), bleeding (41 [35%] vs. 7 [14.9%]), clinical deterioration (111 [94.9%] vs. 16 [34.0%]), and anticoagulation monotherapy (27 [23.1%] vs. 28 [59.6%]). Predictors of death were catastrophic high-risk (2.64 [1.28, 5.45]), mechanical ventilation (31.7 [17.6, 57.1]), and immediate advanced intervention (3.42 [1.48, 7.7]). For high-risk PE only, mechanical ventilation had an OR of 4.35 (1.83, 10.34). Predictors of bleeding included extracorporeal membrane oxygenation (ECMO 48.6 [2.9, 809]), surgical embolectomy (12.5 [2.2, 69.8]), mechanical ventilation (4.0 [2.45, 6.6]), immediate advanced intervention (3.3 [1.9, 5.8]), metastatic cancer (1.99 [1.13, 3.48]), and white race (0.63 [0.43, 0.91]). For high-risk PE only, ECMO had an OR of 51.0 (92.9, 897).

Conclusions: High-risk patients had significantly poorer outcomes than intermediaterisk patients, especially if catastrophic high-risk. Neither high-risk subgroup independently predicted death nor bleeding but mechanical ventilation independently predicted both. ECMO was strongly associated with bleeding.

Cardiac Measurements By Artificial Intelligence Predict Clinical Deterioration in Pulmonary Embolism

Angela M. Pikus, MD, Parker L. Hambright, MD, Nathaniel O’Connell, PhD, Anthony J. Weekes, MD, MSc

Introduction: Most pulmonary embolism response teams (PERTs) use a radiologistdetermined right ventricle to left ventricle ratio (RV:LV) cut-off of 1.0 to risk stratify pulmonary embolism (PE) patients. Artificial intelligence (AI) can measure RV:LV, possibly improving radiologists’ workflow and risk stratification. Therefore, we sought to characterize the association of AI-derived cardiac measurements on computed tomography (CT) with acute clinical deterioration and need for advanced PE interventions.

Methods: This is a retrospective database of 1664 adult patients for whom the PERT was activated at eight affiliated emergency departments 2018–2022. We used an AI algorithm (Aidoc, Tel Aviv, Israel) on anonymized CT scans to measure RV:LV as a predictor of clinical deterioration. The primary outcome was in-hospital PE-related clinical deterioration defined as cardiac arrest, hypotension requiring vasoactive medication, or rescue respiratory interventions. Secondary outcome was advanced interventions. We used random forest (RF) and least absolute shrinkage and selection operator (LASSO) regression for multivariable analyses of all candidate variables. We determined optimal cut-offs with Youden’s index for the primary outcome.

Results: Of 1639 patients, 190 (11.6%) had clinical deterioration, and 314 (19.2%) had advanced interventions. AI analyzed 1634 CTs with 89.3% agreement with radiologists for RV:LV of 1.0 (kappa 0.36, 95% CI: 0.28, 0.43). Mean RV:LV ratios were 1.50 (0.39) vs 1.30 (0.32) for those with and without clinical deterioration and 1.62 (0.33) vs 1.35 (0.32) for those with and without advanced interventions. RV:LV (cutoff of 1.0) by AI and radiologists had 0.02 and 0.5 p-values for clinical deterioration, respectively. With adjusted LASSO, top clinical deterioration predictors were cardiac arrest at presentation, lowest systolic blood pressure, and ICU admission. RV:LV measurements were amongst top 10 predictors on RF variable importance plot. Optimal cut-off for RV:LV was 1.54 with odds ratio of 2.5 (1.85, 3.45) and area under the curve 0.6 (0.66, 0.70).

Conclusion: AI-derived RV:LV measurements of 1.5 or more on the initial CT had strong associations with in-hospital clinical deterioration and advanced interventions in a large database of intermediate- and high-risk patients with pulmonary embolism.

Variation in Opioid Administration and Prescribing

in the Emergency Department for Neck or Back Pain

Aaron Sherwood MD, Christopher Griggs MD, Daniella James MSN MBA

Objective: To study clinician and facility-level variation in ED administration of opioids as well as prescribing of opioids to patients who are discharged with primary diagnoses of neck or back pain.

Methods: This is a retrospective cohort study of data extracted from our hospital’s electronic medical record that compared clinician and facility opioid administration and prescribing rates to patients discharged from the ED with primary diagnoses of neck or back pain. We analyzed distributions of opioid administration and prescribing across clinicians and facilities and plotted cumulative distributions of clinicians’ rates to better understand the impact that individuals can have on institutional opioid prescribing metrics.

Results: Our facility-level analysis included 20488 encounters assigned to 596 clinicians at 27 EDs across 3 states in the southeastern United States between July 1, 2023 and March 31, 2024. 18845 of the 20488 encounters were included in our analysis of clinicians after excluding those who were assigned to less than 20 neck and back pain encounters during the study period. Across all clinicians, the average percentage of opioid administration was 35.7% with a standard deviation of 16.9% and the average percentage of opioid prescribing was 16.3% with a standard deviation of 15.8%. The median percentage of clinician opioid administration was 33.9% with an IQR of 25.2 and the median percentage of opioid prescribing was 11.1% with an IQR of 19.5, which suggests significant variability among clinicians’ practice. There were notable clinician outliers in both opioid administration and prescribing, with maximum rates of 92% and 89.3%, respectively. Cumulative distribution analysis revealed that the top 10 clinician contributors to institutional rates of opioid use were responsible for 8.7% and 15.1% of all opioids administered and prescribed, respectively. Less variability was observed between facilities, although there was still a significant range in the percentage of opioid administration, from as low as 23% to as high as 57.9%.

Conclusions: Although variation in opioid administration and prescribing between facilities exists, there was remarkable variation between clinicians, with a small number of extreme outliers responsible for a large portion of our institution-wide opioid administration and prescribing rates.

Resident Academic Day 2024

Graduates’ Destinations - Chief Residents

Kylee Brooks, MD

ApolloMD at Atrium Health Union Charlotte, NC

Haley Dusek, MD

PEM Fellowship University of Washington Seattle, WA

Sofiya Diurba, MD Cheyenne Regional Medical Center Cheyenne, WY

Steven Perry, MD

Wake Forest Emergency Providers Charlotte, NC

Resident Academic Day 2024

Department of Emergency Medicine

Graduates’ Destinations - Residents

Thomas Blackwell, MD

Wake Forest Emergency Providers Charlotte, NC

Aaron Frolichstein, MD

Skagit Valley Hospital/ Cascades Regional hospital Bellingham, WA

Destiny Folk, MD Eskenazi Health – Indiana University SOM Indianapolis, IN

Parker Hambright, MD Critical Care Fellowship University of Alabama Birmingham, AL

Angela Pikus, MD Ultrasound Fellowship at CMC Charlotte, NC

Nathanael Franks, MD Mery Northwest Arkansas Rogers, AR

Douglas Maslowski, MD Wake Forest Emergency Providers Charlotte, NC

Aaron Sherwood, MD Wake Forest Emergency Providers Charlotte, NC

Frazure, MD UK King’s Daughter Medical Center Ashland, KY

Faith Meyers, MD Operational & Disaster Medicine Fellowship at CMC Charlotte, NC

Allison

Resident Academic Day 2024

CMC Department of Emergency Medicine

Resident Award Recipients

JOHN A. MARX OUTSTANDING SENIOR RESIDENT AWARD

1994 Jeffrey A. Kline, MD

1995 John T. DiPasquale, MD

1996 Craig A. Meek, MD

1996 Daniel M. Roberts, MD

1997 David A. Caro, MD

1998 Sean R. Sue, MD

1999 Joanne Oaks, MD

1999 Jennifer Isenhour, MD

2000 Tony Seupaul, MD

2000 Frances Eizember, MD

2001 Brent Myers, MD

2002 Alan E. Jones, MD

2003 Jennifer Gehring, MD

2004 Bret Nicks, MD

2005 Jim Fiechtl, MD

2006 Benjamin Davis, MD

2007 Gretchen Roe, MD

2008 Danielle Turner-Lawrence, MD

2009 Bijal Shah, MD

2010 Mike Puskarich, MD

2011 Liza Rosenman, MD

2012 Mike Koehler, MD

2013 Jackie Davis, MD

2014 Katharine Modisett, MD

2015 Daniel Troha, MD

2016 Kathryn West, MD

2017 Blake Johnson, MD

2018 Jaron Raper, MD and Carly A. Cox MD

2019 Kathryn Lupez, MD

2020 Jessica Hoglund, MD

2021 Elizabeth Olson, MD

2022 Matthew Cravens, MD

2023 Courtney Owens, MD

Resident Academic Day 2024

CMC Department of Emergency Medicine

Resident Award Recipients

DARREN BEAN OUTSTANDING TEACHING BY A RESIDENT AWARD

1995 Simong S. Youmans, MD

1996 Bruce B. Marshall, MD

1997 Joel L. Moll, MD

1998 Tony Yuan, MD

1999 Chris Thomson, MD

2000 Alan Heffner, MD

2001 Desiree La Charite, MD

2002 Darren Bean, MD, and Nael Hasan, MD

2003 Charles Staples, MD

2004 Josh Simmons, MD

2005 Dave French, MD

2006 Keith Pochick, MD

2007 Richard Graham, MD

2008 JoAnna Leuck, MD

2009 Harland Hayes, MD

2010 Shiloh Gilbert, MD

2011 Dustin Calhoun, MD

2012 Brittany Murray, MD

2013 Katie Sprinkel, MD

2014 Jonathan Bronner, MD

2015 Karina Reyner, MD

2016 Joshua Robertson, MD

2017 Catherine Lounsbury, MD

2018 Enola Okonkwo, MD

2019 Russell Trigonis, MD

2020 Robert Kregg Laundon, MD

2021 Gabriela Rivera-Camacho, MD

2022 Daniel Escobar, MD

2023 Lucas Goss, MD

Resident Academic Day 2024

Resident Award Recipients

JEFFREY A. KLINE OUTSTANDING RESIDENT RESEARCH ACHIEVEMENT AWARD

1994 Jeffrey A. Kline, MD

1995 David W. Templeton, MD

1996 Tamara M. Ardans, MD

1998 Andrew D. Perron, MD

1999 Kirk Mahon, MD

2000 Mark Courtney, MD

2001 Chris Moore, MD

2002 Alan E. Jones, MD

2003 Mike Runyon, MD

2004 Michael T. Fitch, MD, PhD

2005 Lyn Aborn, MD

2006 Christopher Crean, MD

2007 Patrick O’Malley, MD, and Melinda Threlkeld, MD

2008 Danielle Turner-Lawrence, MD

2009 John Garrett, MD, and Anne Daul, MD

2010 Mike Puskarich, MD, and Maria Glenn, MD

2011 Dustin Calhoun, MD

2012 Daren Beam, MD, and Omayra Marrero, MD

2013 James Cao, MD

2014 Greg Zahn, MD, and Andrew Wyman, MD

2015 Daniel Troha, MD

2016 Angela Johnson, MD and Gregory Thacker, MD

2017 Blake Johnson, MD

2018 Adeline Dozois, MD

2019 Kathryn Lupez, MD

2020 Jessica Hoglund, MD

2021 Alyssa Thomas, MD, MPH

2022 Neha Ray, MD

2023 Anthony James, MD

Resident Academic Day 2024

CMC Department of Emergency Medicine

Faculty Award Recipients

OUTSTANDING ACADEMICIAN - Faculty Award

2004 Chris Tomazewski, MD

2007 Andrew Asimos, MD

2008 Lee Garvey, MD

2009 Mike Runyon, MD

2010 Jeff Kline, MD

2011 Sean Fox, MD

2012 Randy Cordle, MD

2013 Catherine Wares, MD

2014 David Callaway, MD

2015 Mike Runyon, MD

2016 David Pearson, MD

2017 Anthony Weekes, MD

2018 Anthony Weekes, MD

2019 Maria Pelucio, MD

2020 Kathryn Kopec, DO

2021 Cathy Wares, MD

2022 Pendell Meyers, MD

2023 Cortlyn Brown, MD

EXEMPLAR - Faculty Award

2008 Dave Pearson, MD

2009 Andrew Asimos, MD

2010 Jennifer Isenhour, MD

2012 Vivek Tayal, MD

2013 JP McBryde, MD

2014 Anthony Weekes, MD

2015 Mike Gibbs, MD

2016 Lee Garvey, MD

2017 Chris Griggs, MD

2018 David Callaway, MD

2019 Erin Noste, MD

2020 Jessica Salzman, MD

2021 Brandon Fetterolf, DO

2022 Christyn Magill, MD

2023 Anthony Weekes, MD

Resident Academic Day 2024

CMC Department of Emergency Medicine

Faculty Award Recipients

OUTSTANDING TEACHER - Faculty Award

2001 Jayne Batts, MD

2002 Vivek Tayal, MD

2003 Michael Roshon, MD

2004 John Marx, MD

2005 Vivek Tayal, MD

2006 JP McBryde, MD

2007 William Tsai, MD

2008 Jeffrey Hyland, MD

2009 Sean Fox, MD

2010 Jayme Woodson, MD

2011 Emily MacNeill, MD

2012 Randy Cordle, MD

2013 Mike Gibbs, MD

2014 Andrew Asimos, MD

2015 Sean Fox, MD

2016 Tyson Cook, MD

2017 Danielle Dragoo, MD

2018 Dalton Cox, MD

2019 Kathryn West, MD

2020 Denise Fraga, MD

2021 Pendell Meyers, MD

2022 Jessica Hoglund, MD

2023 Bryant Allen, MD

Resident Academic Day 2024

CMC Department of Emergency Medicine

Visiting Professors:

2001 Judd E. Hollander, MD – University of Pennsylvania

2002 William H. Cordell, MD, Professor – Indiana University

2003 Frank Counselman, MD – Eastern Virginia Medical School

2004 Jill Baren, MD – University of Pennsylvania School of Medicine

2005 James L. Scott, MD – George Washington University

2006 Michael Gibbs, MD – Maine Medical Center

2007 James Hoestra, MD – Wake Forest University

2008 Katherine L. Heilpern, MD – Emory University School of Medicine

2009 Charles B. Cairns, MD, Professor & Chair – UNC Chapel Hill

2010 William Barsan, MD, Professor & Chair– University of Michigan Medical School

2011 Edward C. Jaunch, MD, MS , PACEP, FAHA – Medical University of South Carolina

2012 Andrew D. Perron, MD, FACEP, FACSM – Maine Medical Center

2013 Tony Seupaul, MD, Professor & Chair – University of Arkansas for Medical Science

2014 Alan Jones, MD – University of Mississippi Medical Center

2015 Jeffrey W. Runge, MD FACEP -

2016 Joe Lex, MD, FACEP, MAAEM, FIFEM – Temple University School of Medicine

2017 David Mark Courtney, MD, MSCI - Feinberg School of Medicine at Northwestern

2018 Leon L. Haley Jr., MD, MHSA, FACEP – University of Florida Health Jacksonville

2019 “Tony” Seupaul, MD - Professor and Chair - University of Arkansas

2020 Malika Fair, MD, MPH, FACEP – The George Washington University

2021 Jeffrey Kline, MD - Wayne State University School of Medicine

2022 Jo Anna Leuck, MD - Texas Christian University School of Medicine (TCU SOM)

2023 Andrew D. Perron, MD, FACEP – Dartmouth University