PloS oneAnnemieke E Boendermaker, Gideon H P Latten, Jelle T Prins, Kiki M J M H Lombarts, Paul L P Brand
BACKGROUND AND IMPORTANCE: Emergency medicine physicians (EMPs) work in a dynamic and challenging environment, with high risk of burnout. The prevalences of work engagement, burnout and the intention to leave among Dutch EMP have not been studied before. This study aims to evaluate the adherence to the Dutch Society of Emergency Physicians (DSEP/NVSHA) workforce recommendations, and the association between these recommendations and signs of burnout, work engagement and the intention to leave the profession. METHODS: Cross-sectional online survey based study among all Dutch EMPs in 2019. Two main outcomes, the prevalences of burnout and work engagement, were assessed using the Dutch version of the Maslach Burnout Inventory and the Utrecht Work Engagement Scale. A third main outcome, the intention to leave, was assessed by three self-developed questions. The correlations between the adherence to twelve workforce recommendations and these three main outcomes were assessed using SPSS. MAIN RESULTS: 295 EMPs participated (response rate 56%, 68% female, median age 39 years). Fifty-five respondents (18.5%) met the criteria for burnout. On work engagement, 29 (16.6%) respondents scored low to extremely low (i.e., the 25th groups' percentile) and 97 (32.9%) respondents scored high to extremely high (i.e., the groups' 75th percentile). Intention to leave the profession was high with 22-29%. Higher adherence to the workforce recommendations was significantly associated with all three main outcomes, as were five out of twelve separate recommendations. CONCLUSIONS: To ensure a sustainable future in which EMPs are protected from burnout symptoms, supported in their work, and where disproportionate job turnover is minimized, it is crucial these results are met with decisive action. Hospital management must address the unique challenges and risks providing excellent 24/7 emergency care presents. Workforce guidelines are designed to proactively create a more sustainable work environment. This study underscores the necessity of its implementation and creates a foundation for future research.
Emergency medicine Australasia : EMAAnne-Maree Kelly, Michael Eburn
Emergency clinicians may be asked by relevant authorities to provide statements, usually in criminal proceedings or for coroners' courts. These are statements of fact, not of opinion. Understanding the purpose and requirements of each statement type is essential to inform structure and content. Relevant information needs to be communicated in a clear and structured way. This article provides an overview of these statement types, their purpose and requirements, and some suggestions regarding format and style.
Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTESAbdul Samet Sahin, Aynur Sahin, Vildan Ozer, Ozgen Gonenc Cekic, Selçuk Akturan, Bilge Delibalta, Emily Kiernan, Ebru Turhal, Sinan Pasli, Yunus Karaca, Melih …
BACKGROUND: Toxic terrorism is a rare but potentially catastrophic threat that can result in mass casualties and overwhelm healthcare systems. Effective management of such incidents requires specialized clinical competencies and preparedness that may be underemphasized in standard emergency medicine training. This study aimed to assess emergency medicine residents' competencies in toxic terrorism preparedness and emergency medical management using a structured simulation-based examination. METHODS: Emergency medicine residents working in the emergency departments of two tertiary university hospitals in Trabzon participated in a simulation-based clinical assessment. The examination comprised five realistic, fully immersive objective structured clinical examination (OSCE) stations designed to evaluate diagnostic decision-making and treatment planning in toxic terrorism scenarios. Each station was scored using standardized checklists developed by medical toxicologists. Factors associated with improved performance were also examined. RESULTS: Although 33.3% of participants successfully passed the botulism scenario (Station 3), no participant successfully completed all five stations. The radiation exposure scenario (Station 2) was the most challenging. Higher performance was significantly associated with having more than 24 months of residency training, prior chemical, biological, radiological, and nuclear (CBRN) training, and previous exposure to simulation-based education. CONCLUSION: These findings suggest that current training may not adequately prepare emergency medicine residents to manage toxic terrorism incidents. Incorporating standardized simulation-based assessments, such as OSCEs, into residency curricula may help identify training gaps and improve preparedness for low-frequency, high-impact events.
Perspectives on medical educationLaura F Sartori, Bjorn K Watsjold, Katherine Wu, Lanelle Quzack, Jonathan S Ilgen, Joseph J Zorc, Lara Varpio
PURPOSE: Practice variation across physicians is commonly attributed to idiosyncratic tendencies. What factors contribute to physicians' practice variation in the disposition of children with asthma exacerbation? How do metrics demonstrating variation impact physicians and learners? METHODS: In this social constructivist qualitative study, we interviewed 11 Pediatric Emergency Medicine attendings, purposively sampling across a spectrum of acute asthma exacerbation admission rates. Participants reflected on their recent care of patients with asthma, how they assess patients, and how they determine disposition. They were shown a de-identified funnel plot demonstrating disposition rates across the physician group and reflected on the 1) quality of the metric and 2) impact on practice. We used reflexive thematic analysis to describe patterns across the data that addressed the study's research questions. RESULTS: Participants cited factors at the patient, caregiver, clinical care team, clinical environment, and personal practice levels that might result in variation. Participants framed the ability to weigh these sometimes competing factors as a reflection of patient-centered care. But when presented with a group-level data display, participants were surprised by the variation, valued seeing how they practiced compared to peers, and sometimes expressed a willingness to alter their practices to be "nearer the mean." CONCLUSIONS: Some variation in care may be driven by physician adaptive expertise, which is not fully captured through metric-driven nomothetic data. Though metrics are fundamental to understanding practice patterns, decontextualized aggregations of data may risk minimizing, or even framing as deviant, the expertise exercised by physicians when they weigh multiple factors in decision-making.
BMJ openAbid Ali Jamali, Shahan Waheed, Faisal W Ismail, Shiyam S Tikmani, Ahmed Raheem
INTRODUCTION: Up to 40% of major complications during airway management result from human factors. Through human factors such as planning, effective communication, strong leadership and clear role allocation within the team, smooth airway securement can be facilitated and the risk of complications reduced. Simulation-based teaching provides real-time situations and allows healthcare workers and learners to identify, refine and improve their technical and non-technical skills. This study aims to evaluate the effect of simulation-based human factors training on airway management among healthcare providers working in the emergency department of a tertiary healthcare setting in a low- and middle-income country. METHODS AND ANALYSIS: This will be a quasi-experimental study with a pre-post design to infer the impact of simulation-based human factors training among emergency medicine healthcare providers on paediatric airway management. The study will be conducted at the Centre of Innovation in Medical Education, Aga Khan University Hospital, Karachi. Participants will include emergency department healthcare providers who meet the inclusion criteria and are selected through purposive non-probability sampling. A total of 74 participants will be enrolled. Data will be analysed using Stata. Descriptive statistics will be presented as frequencies and percentages for categorical variables and as means with SD or medians with IQRs for continuous variables as appropriate. Changes in first-pass intubation success and time to secure the airway (≤30 vs >30 s) following the intervention will be assessed using McNemar's test. Changes in TEAM, CTS and NASA-TLX scores will be evaluated using a paired t-test. Generalised Estimating Equations will be used to identify factors associated with airway management outcomes, with results reported as adjusted ORs and 95% CIs. A p-value <0.05 will be considered statistically significant. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Aga Khan University Ethical Review Committee (ERC: 2026-12851-41186). Written informed consent will be obtained from all participants, and participation will be voluntary. Findings will be disseminated through thesis submission, conference presentations and peer-reviewed publications.
Frontiers in public healthWeidi Wang, Zhipeng Fang
BACKGROUND: Large language models (LLMs) are reshaping medical education. OBJECTIVE: To examine whether learning approach-AI-assisted, textbook-based, or blended-was associated with diagnostic accuracy for acute abdominal conditions among emergency interns. METHODS: We reviewed 720 clinical decisions by 72 emergency interns at a tertiary center over 12 months. Interns were classified into three groups: textbook-based (n = 27), AI-assisted (n = 21), and blended (n = 24). Propensity score matching with pair-stratified GEE addressed selection bias and clustering. RESULTS: Diagnostic accuracy was 73.0% (textbook), 82.4% (AI-assisted), and 87.1% (blended) (p < 0.001). Blended learning showed the largest advantage over textbook (adjusted OR = 3.21, 95% CI: 1.87-5.51, p < 0.001), followed by AI-assisted (adjusted OR = 1.68, 95% CI: 0.99-2.85, p = 0.053). Matched analyses confirmed the benefit for blended learning (p = 0.011). Subgroup analyses suggested larger effects for severe cases (OR = 4.92) and atypical presentations (OR = 3.85), with an E-value of 5.88 supporting robustness against unmeasured confounding. CONCLUSION: Blended learning combining AI tools with traditional resources showed the strongest association with diagnostic accuracy, suggesting that integrated rather than exclusive approaches may better support clinical reasoning in emergency training.
BMJ openCécile Bessat, Alizé Erard, Alexia Roux, Thomas Brahier, Veronique Suttels, Roland Bingisser, Markus Schwendinger, Tim Bulaty, Yvan Fournier, Vincent Della San…
OBJECTIVES: Lung ultrasound (LUS) is accurate for diagnosing pneumonia in the emergency department (ED), but standard training is time-intensive, limiting its widespread implementation. We evaluated LUS proficiency for pneumonia diagnosis and perceived adoption barriers after a short training programme. SETTING: This study was conducted in the frame of the PLUS-IS-LESS trial (Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments) (NCT05463406), a pragmatic stepped-wedge cluster-randomised clinical trial evaluating a clinical management algorithm combining LUS and procalcitonin to guide antibiotic use for lower respiratory tract infections (LRTIs) in 10 Swiss EDs. PARTICIPANTS: All medical supervisors (senior registrars and senior physicians) from the participating EDs were invited to go through the PLUS-IS-LESS LUS training programme and all those who completed the training programme were included in this study. METHODS: The training programme included an e-learning course, followed by a half-day on-site training session with theory and hands-on practice. For proficiency evaluation, a validated structured assessment of LUS skills (LUS-OSAUS) was adapted into a 32-question online quiz and five bedside LUS examinations. Success was defined as achieving a score ≥80% on both the online quiz and supervised practical assessment. Success rates were compared between physicians according to their characteristics (age, sex, medical experience, previous use of ultrasound or LUS, linguistic region of work and type of hospital) using a χ² test. A 6-month follow-up survey identified factors associated with non-certification and barriers to the clinical use of LUS for managing LRTIs. RESULTS: Of 122 trained physicians, 83 (68 %) completed both quiz and supervised LUS and 61 (50%) achieved certification. The most challenging items were pleural line assessment (83% success), recognition of consolidations (83%) and decision-making based on LUS findings (72%). Physicians <40 years had a higher success rate (p=0.009). Among those without complete certification, limited access to an ultrasound machine and low perceived added value of LUS were the main identified reasons. Lack of time was the most frequently reported barrier overall to LUS integration into ED workflows (77%). CONCLUSION: After receiving short training and focused proficiency testing, only half of physicians achieved certification, underscoring the challenges of broad LUS implementation. Limited time, equipment access and low perceived clinical value were key barriers, and integrating LUS findings into decision-making remained difficult. Ongoing support, supervision and protected time may be needed to enhance LUS adoption in EDs. TRIAL REGISTRATION NUMBER: NCT05463406.
The Journal of emergency medicineJessica C Moore, Brittany Cesar, Joshua Davis, Emma R Furlano, Zachary Repanshek, Scott G Weiner, Reuben J Strayer
BACKGROUND: Tobacco and other nicotine use remains a major public health concern, and Emergency Physicians commonly evaluate and treat patients with nicotine use disorder (NUD). However, it unfortunately remains largely untreated or undertreated in the Emergency Department setting. OBJECTIVES: To provide expert guidance for the safe and effective treatment of NUD from the Emergency Department setting. METHODS: Independent literature searches were performed regarding nicotine use. A panel of experts in Addiction Medicine, Toxicology, and Emergency Medicine reviewed and discussed the literature to develop expert consensus guidance. RESULTS: This paper discusses the available evidence and provides recommendations for the screening and treatment of NUD in the acute care setting. CONCLUSIONS: Emergency physicians have an important opportunity to meaningfully reduce morbidity and mortality for patients with NUD by starting safe and evidence-based NUD treatments. We recommend that all patients with NUD presenting to the acute care setting be offered medications for NUD as well as brief counseling on NUD, and be referred to local outpatient follow up or other available resources for continued NUD care on discharge.
Minerva anestesiologicaLinus H Kutup, Eike S Debus, Reinhart T Grundmann
BACKGROUND: The present study aimed to clarify how English-language publication activity in anesthesiology, intensive care medicine, and pain medicine has evolved in publishing countries over a 10-year period, considering not only publication volume but also scientific impact and shifting research methodologies. METHODS: A bibliometric analysis of 20,741 publications indexed in PubMed for the time periods 2008/09 and 2018/19 was performed across 30 journals. Journals were selected based on their impact factor (IF) in 2019. Publications were analyzed for total number, cumulative impact factors (CIF) - representing the sum of individual journal impact factors multiplied by the number of publications in each journal - study type, country of origin, and country output per million inhabitants. RESULTS: From 2008/09 to 2018/19, total publication volume declined by 6.9% from 10,740 to 10,001, while CIF increased by 25.4% from 42,441.2 to 53,219.1. Clinical (Observational) studies were most frequent; meta-analyses and registry studies rose markedly (216.1% and 125.3%, respectively), while experimental studies and randomized controlled trials (RCTs) declined (-51.9% and -29.7%, respectively). The United States led in both publication count (2008/09: 3,267; 2018/19: 4,250) and CIF (2008/09: 14,256.4; 2018/19: 24,421.9). When adjusted to population, smaller countries including Denmark (2008/09: 31.1; 2018/19: 80.7), Switzerland (2008/09: 23.6; 2018/19: 42.1), and the Netherlands (2008/2009: 26.3; 2018/2019: 34.9) ranked highest. Germany - the only leading country showing declining publication output at 7.0% - demonstrated a concerning trend, while China (+83.6%) and Canada (+69.4%) showed exceptional growth. CONCLUSIONS: This study identifies a decline in publication volume alongside increased citation activity in high impact anesthesiology and intensive care medicine journals, largely driven by the dominance of clinical studies and a growing prevalence of meta-analyses and registry studies, suggesting a shift in research priorities. Reduced publication numbers likely result from increasing journal selectivity and redistribution of research output toward open-access and non-specialty journals. The country ranking is dominated by the USA and other English-speaking nations, which can be attributed to the English-language literature analyzed. However, smaller nations like Denmark and Switzerland lead in population-based ranking, revealing critical insights into research infrastructure and institutional support.
Annals of emergency medicineSteven M Green, Mark G Roback, Maala Bhatt, Gary Andolfatto, Kerry Caperell, Naveen Poonai, Paul Schwartz, Jacob A Miller, Stephen Wolf, Rebecca Kriss Burger, …
Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.
Annals of emergency medicineSteven M Green, Mark G Roback, Maala Bhatt, Gary Andolfatto, Kerry Caperell, Naveen Poonai, Paul Schwartz, Jacob A Miller, Stephen Wolf, Rebecca Kriss Burger, …
Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.
Canadian medical education journalRomaisa Ismaeel, Jamie Riggs, Mary Ott, Andrew K Hall, Catherine Patocka, Andrew Petrosoniak, Adam Szulewski, Teresa Chan, Brent Thoma
BACKGROUND: The Royal College of Physicians and Surgeons of Canada's (RCPSC) Competence by Design (CBD) framework has been criticized for increasing assessment burden due to the high number of required Entrustable Professional Activity (EPA) assessments. Another contributing factor may be the inefficient design of assessment forms. We explored variability in form design to identify differences that could impact learners' and assessors' experience with CBD. METHODS: Annotated assessment forms for the 'Core 1' (C1) EPA were collected in March 2023 from all (n = 14, 100%) RCPSC emergency medicine (EM) residency programs in Canada that had implemented CBD. Forms were divided into six sections to compare their design. The variability between form sections was described relative to RCPSC recommendations on form design. RESULTS: EPA assessments were completed within six learning management systems. Variability was found throughout the form including the number of context variables, included milestones, milestone rating criteria, and text boxes for narrative feedback; phrasing of narrative feedback prompts, milestone descriptions, and entrustment score criterion; visual presentation of the entrustment score; arrangement of form components; and the components' selection format. The mandatory completion of form components was inconsistent. Some forms could be partially completed by residents. One form added a global performance rating scale. The number of clicks required to complete a form ranged from 12 to 47. CONCLUSION: We found considerable variability in the design of the EM C1 EPA assessment form. Variations that make completion more challenging could increase assessment burden. CBD programs should be aware of this and seek to optimize the design of their forms.
BMC emergency medicineSebastian Imach, Tobias Ahnert, Sarah Krueger, Mai Bui, Bernd A Leidel, Jenny Patricia Kehrberger, Michael Kemper, Benny Kölbel
BACKGROUND: Endotracheal intubation (ETI) remains the gold standard for emergency airway management. The performance indicator is the first-pass success rate (FPSR). Providers without routine practice in elective airway management need adapted training to gain proficiency and maintain a high level of competence. Fresh frozen cadavers (FFCs) have been shown to be effective in training and can be modified to recreate difficult airway features seen in helicopter emergency service (HEMS). METHODS: In this prospective before-and-after study, the BASELINE phase consisted of recording both the performance of 16 HEMS physicians during 60 consecutive ETIs at Cologne HEMS and the corresponding airway characteristics of the patients. FPSR-raising measures for emergency airway management were identified through a structured literature review process and compiled into a bundle-the Best Of Airway management in HEMS (BOAH) bundle. The bundle was trained on five modified FFCs representing airway characteristics of the BASELINE phase. All the HEMS physicians and eight HEMS technical crew (HEMS-TC) members who were part of the BASELINE phase completed the training with videolaryngoscopy (VL) and a bougie-first strategy. Subsequently, another continuous 60 ETIs by the same teams were evaluated (BOAH phase). The primary outcome measure was the FPSR before and after the implementation of FFC training. Second, we evaluated the duration of ETIs and the oxygen saturation (SpO2) after ETIs. RESULTS: In the BOAH phase, 61 of 63 ETIs were recorded with a complete dataset by sixteen HEMS physicians. The FPSR significantly improved from the BASELINE (76.7%, 95% CI ±10.7) to the BOAH phase (95.1%, 95% CI ± 5.4, p=.004). Lowest postintubation oxygen saturation was 83.8% ± 16.1 SD (BASELINE) vs. 88.4% ± 13.5 SD (BOAH, p=0.014), and the duration of successful ETI attempts was 34 s ± 24.1 SD in the BASELINE phase and 32 s ± 14.9 SD in the BOAH phase (p=0.41). CONCLUSION: The combination of the BOAH airway bundle and FFC-based training was associated with a higher observed FPSR and improved oxygenation outcomes when it was used on real emergency patients by non-anaesthetist-staffed HEMS crews. These results suggest that skills acquired during cadaver-based training, which included practice of a comprehensive airway bundle, can be reliably transferred to real-life missions.
This article discusses the role of emergency physicians working in both extra-hospital and hospital settings within the emergency care continuum. Based on a non-exhaustive narrative review and the example of the canton of Valais, it analyses the potential value of such versatility when embedded in a shared care network. Expected benefits mainly concern coordination, triage, information transfer and early activation of specialized pathways. These benefits should be interpreted with caution, as direct evidence of a universal clinical benefit is lacking. The transferability of such a model depends on the local context, shared training, common protocols and the availability of trained physicians.
Swiss medical weeklyEmilie Ulrich, Youcef Guechi, Ludovic Galofaro, Raphaël Bonvin, Flora Gobet, Vincent Ribordy
STUDY AIMS: Point-of-care ultrasound (POCUS) has become a key diagnostic modality in emergency departments, facilitating rapid clinical decision-making and improving patient care. Despite its benefits, POCUS adoption remains heterogeneous. Barriers reported in the literature include the absence of standardised certification pathways, limited access to training and insufficient equipment availability. This study aimed to explore barriers and enablers of successful implementation of POCUS in Swiss emergency departments. METHODS: We conducted a national, cross-sectional multicentre survey targeting medical residents from 15 category 1 emergency training centres in Switzerland. The survey included questions on POCUS usage, training, perceived barriers and facilitators. Data were analysed using descriptive statistical methods. The data collection period spanned from October 2023 to April 2024. RESULTS: A total of 165 residents participated in the survey (35.6% response rate). Of these, one-third (32%) had attended accredited POCUS training, while only 6% reported no prior ultrasound experience. Residents exhibited a positive attitude towards POCUS, with the majority recognising it as a valuable diagnostic tool and a core skill for trained emergency physicians. Key barriers to POCUS implementation in Swiss emergency departments included limited access to training, difficulties completing certification requirements and challenges in skill maintenance after initial training. Specific obstacles were unavailable courses, lack of supervision and time-consuming logbook completion. Unlike prior literature, this study did not identify doubtful attitudes towards POCUS utility, lack of a standardised national curriculum or resistance from other specialties as barriers. CONCLUSIONS: Swiss emergency medicine residents strongly support POCUS and are motivated to pursue certification. A nationally standardised training curriculum may help address some of the barriers commonly described in the literature by providing a structural advantage. However, inconsistent local implementation, limited mentorship and restricted training access hinder full integration into practice. Bridging this gap requires stronger institutional support, better awareness of certification pathways and more hands-on opportunities to ensure residents can achieve and maintain POCUS competency, ultimately advancing the quality and efficiency of emergency care in Switzerland.
Journal of graduate medical educationSharon Bord, Doug Franzen, Erin Karl, Cullen B Hegarty, Eric Shappell, Benjamin H Schnapp, Nicole M Dubosh, Caitlin Schrepel, Katherine M Hiller, Kevin Hamilto…
BACKGROUND: Residency programs are utilizing standardized letters of evaluation with increasing frequency to obtain concise and discerning information about applicants. However, letters show a narrow distribution of ratings, leading to difficulties differentiating between applicants. OBJECTIVE: To determine if choice architecture, through 2 interventions on the electronic emergency medicine Standardized Letter of Evaluation 2.0 (eSLOE 2.0), can increase the spread of ratings on letters written for emergency medicine applicants. METHODS: On the eSLOE 2.0 Part B for the 2024-2025 application cycle, radio buttons were prepopulated to a "3" on a Likert scale of 1 to 5 (rather than blank), and a pop-up message prompted letter writers to provide narrative justification for ratings of "1" (lowest) or "5" (highest). Ratings of applicants after this intervention were compared with ratings from 2 prior application cycles. RESULTS: A total of 17 727 letters (5938 from 2024-2025; 11 789 from 2022-2024) were analyzed. Post-intervention, there was a decrease in ratings of "5" across all domains in Part B, with the absolute difference in the percentage of students rated "5" ranging from -12.3% to -19.7%. There was a post-intervention increase in percentage of "3" and "4" utilization across all domains ranging from +3.9 to +11.0 and +7.2 to +11.0 respectively. Ratings of "1" and "2" remained stable post-intervention. CONCLUSIONS: Prepopulating SLOE Part B ratings to 3 out of 5 and pop-up messages prompting letter writers to justify top or bottom ratings led to a shift in the distribution of scores and a reduction in the percentage of top ratings in the 2024-2025 cycle, as compared to the prior 2 cycles.
MedEdPORTAL : the journal of teaching and learning resourcesCaroline H Lee, Thaouyen Emily Pham, Jeanne Noble
INTRODUCTION: This simulation-based curriculum aimed to improve emergency medicine residents' confidence and knowledge in applying palliative care principles in end-of-life scenarios in the emergency department. METHODS: Residents participated in 4 simulation cases: (1) an elderly patient on hospice presenting with altered mental status, whose surrogate requests full intervention despite physician orders for life-sustaining treatment (POLST) indicating do not resuscitate/do not intubate and comfort-focused goals; (2) a patient with advanced dementia and hypotension, with a 2-year-old POLST indicating "Full Code," requiring reassessment of goals of care; (3) a 3-year-old in cardiac arrest after drowning with no return of spontaneous circulation; and (4) a previously healthy 12-month-old found apneic and cyanotic with persistent arrest despite prolonged resuscitation. All cases and debriefs were performed in succession and completed in 1 hour. Critical actions included leading goals-of-care discussions, interpreting advance directives, transitioning to comfort measures, and delivering death notifications. Learning objectives focused on communication skills, symptom management, and ethical and legal considerations. Learners completed pre- and postsession surveys evaluating prior experience, self-reported confidence, and knowledge of palliative principles. RESULTS: Thirty-one residents completed both surveys. Ninety percent reported feeling more prepared to lead end-of-life discussions. Knowledge scores increased from 72.9% to 79.4%. Qualitative feedback emphasized practicing difficult conversations, clear communication at the time of death, and a desire for further training in comfort-focused care and legal frameworks. DISCUSSION: Simulation-based end-of-life education represents an effective method for preparing emergency medicine residents for complex palliative decision-making. Findings support curricular integration.
MedicineMerve Ağaçkiran, Sinan Önder, Ümit Can Yürekli, İlter Ağaçkiran
Emergency medicine specialists often pursue subspecialty training worldwide. In Türkiye, subspecialization in critical care medicine was introduced in March 2024, with the first entrance examination for subspecialty training in medicine (YDUS) examination having been conducted on December 15, 2024 by the Measurement, Selection, and Placement Center. Medical applications of artificial intelligence (AI), particularly GPT-4 Omni (GPT-4o), GPT-4, and Gemini-Advanced, have garnered considerable attention. This study aimed to evaluate the performance of these AI models in answering emergency medicine YDUS questions, marking the first assessment of the role of AI in this examination. The performance of 3 AI models (GPT-4, GPT-4o, and Gemini-Advanced) on questions from the emergency medicine YDUS examination was evaluated. The examination included 60 multiple-choice questions, of which 10% were publicly available. Questions were classified as clinical or factual. Responses of the AI models were analyzed using Cochran Q test as the omnibus test, with exact Bonferroni-adjusted McNemar tests for pairwise comparisons where applicable. No significant differences in the correct responses for both clinical and factual questions were observed between each AI model (P values: GPT-4o, 1.000; Gemini-Advanced, .554; and GPT-4, 1.000). GPT-4o significantly outperformed Gemini-Advanced in clinical (92.6% vs 70.4%) and factual questions (90.9% vs 78.8%) (P values: clinical, .021; factual, .039). A comparison of the overall performance showed an omnibus significant difference (P = .001); however, post hoc pairwise comparisons revealed that only GPT-4o (91.7%) significantly outperformed Gemini-Advanced (75%), whereas GPT-4 (88.3%) did not show a statistically significant difference from Gemini-Advanced after adjustment. This study found that both GPT-4o and GPT-4 significantly outperformed Gemini-Advanced in answering Turkish emergency medicine YDUS questions. While GPT-4o achieved the highest numerical accuracy, there was no statistically significant difference between GPT-4o and GPT-4. Both models demonstrated high accuracy in this examination dataset. Although these findings highlight their potential as supplementary learning tools, strong examination performance does not establish clinical readiness or definitive educational usefulness. Gemini-Advanced exhibited weaker performance but frequently advised expert consultation. However, this study did not formally evaluate ethical behavior, safety, or the appropriateness of these refusals.
MedicineEvren Ekingen, Mete Ucdal, Ercan Koca, Saniye Baladura
BACKGROUND: Emergency medicine has experienced growth as a research discipline, with psychiatric emergencies representing an area of expansion. The increasing volume of psychiatric presentations to emergency departments necessitates analysis of scientific output in this domain. This study examines publication trends, geographic distribution, and thematic priorities in psychiatric emergency medicine research over the past decade. METHODS: We conducted a bibliometric analysis of articles published between January 2014 and December 2023. Data were extracted from the Web of Science Core Collection database using the search terms "Emergency Medicine" AND "Psychiatry." Analysis included publication trends, geographic distribution, journal metrics according to Bradford Law, keyword frequency analysis, and thematic mapping. Statistical analyses employed IBM SPSS Statistics 25 and bibliometric software. RESULTS: The analysis identified 862 publications authored by 5111 individuals from 67 countries. Annual publication volume increased from 52 articles in 2014 to 126 articles in 2023. The United States contributed 488 publications (56.7%), followed by Turkey (46 publications, 5.3%), Canada (44, 5.1%), Australia (40, 4.7%), and Iran (33, 3.8%). Four core journals accounted for 37.0% of publications: American Journal of Emergency Medicine (117 articles), Pediatric Emergency Care (75), Academic Emergency Medicine (66), and Journal of Emergency Medicine (61). Mean citation rate was 11.5 per article. Keyword analysis identified 6 primary research themes: pediatric psychiatric emergencies, substance use, suicide and self-harm, consultation models, emergency department management, and geriatric psychiatric emergencies. Temporal analysis revealed increased research focus on vulnerable populations including children and older adults after 2017. CONCLUSION: Psychiatric emergency medicine research demonstrated consistent growth over the decade studied. Publication output was concentrated geographically, with limited international collaboration. Research priorities evolved toward pediatric and geriatric populations. Findings provide insight into current research landscape and may inform future research directions and resource allocation in psychiatric emergency care.
Frontiers in public healthTingting Fan, Tianle Gao, Wan Tang, Qian Xu, Xingyou Wang, Qiaoli Su, Qingguo Lyu
BACKGROUND: Emergency medicine education occurs in high-acuity, interruption-prone, and time-constrained environments, where learners must develop rapid clinical reasoning, effective communication, procedural competence, and reliable documentation skills. Large language models (LLMs) are increasingly being explored in health-professions education. This narrative review synthesizes emerging applications, major risks, and implementation pathways for LLMs in emergency medicine education. METHODS: A structured narrative review was conducted using PubMed, Web of Science Core Collection, China National Knowledge Infrastructure (CNKI), and Wanfang Data. The search period extended from January 1, 2023, to April 10, 2026. English and Chinese search blocks combined terms related to LLMs or generative artificial intelligence, emergency medicine or emergency care contexts, and education, training, simulation, assessment, communication, documentation, or implementation. After duplicate removal, title and abstract screening, and full-text review, 48 English-language studies and 5 Chinese-language studies were included. Eligible records addressed emergency medicine or emergency medical services education, simulation or virtual-patient applications, formative assessment and feedback, documentation or discharge communication, or governance issues relevant to educational use in emergency settings. RESULTS: LLMs showed potential across multiple educational domains in emergency medicine, including just-in-time tutoring, resource generation, case drafting, simulation and virtual-patient rehearsal, formative feedback support, examination and competency-assessment support, documentation and discharge communication coaching, and educator workflow support. Potential benefits included more timely feedback, broader access to structured teaching resources, repeated rehearsal of low-frequency high-acuity scenarios, and greater consistency in communication training. Translation into routine educational practice remains constrained by hallucination, context mismatch with local protocols, automation bias, limited relational authenticity in AI-mediated interaction, privacy and cybersecurity concerns, multilingual inequity, uncertain validity of AI-assisted assessment, and uneven faculty readiness. CONCLUSION: LLMs hold substantial promise for strengthening emergency medicine education, particularly in areas requiring rapid language-based support, structured feedback, scalable case generation, and communication rehearsal. Current evidence supports phased adoption, local grounding in institutional protocols, secure workflows, explicit faculty oversight, and evaluation of educational, operational, and governance outcomes. This review proposes a pragmatic framework for the integration of LLMs into emergency medicine education.
In order to evaluate the effectiveness of the "Script Killing" teaching method and the traditional teaching method in enhancing the learning outcomes of emergency medicine resident trainees during the standardized training period, from May to October 2024, we recruited 30 resident physicians from the emergency department of Zhengzhou People's Hospital as the research subjects and randomly divided them into Group A and Group B. The experiment adopted a crossover design: the first stage (6 weeks) - Group A received traditional lecture-based teaching, while Group B received immersive Script Killing" teaching; the second stage (6 weeks) - the two groups exchanged teaching intervention methods. The assessment contents included satisfaction surveys, theoretical knowledge tests, practical skill evaluations, and patient-doctor evaluations. The experimental results were analyzed using SPSS 22.0 to adjust for confounding factors. The results showed that the satisfaction of the "Script Killing" group was significantly higher (P < 0.05), the theoretical scores were better (P < 0.05), and the practical performance was also better (P < 0.05), while there was no significant difference in the traditional teaching group. No statistical differences were observed in patient-doctor feedback. These preliminary findings suggest that the "Script Killing" teaching method may effectively enhance the clinical operational abilities and learning satisfaction of emergency medicine trainees. Although limited by a small sample size and single-center design, this approach shows promise as a beneficial supplement to standardized residency training, warranting further validation in larger cohorts.
La Medicina del lavoroEkim Sağlam Gürmen, Mustafa Yorgancıoğlu, Hasan Demirbaş
BACKGROUND: Shift-based work schedules may disrupt circadian rhythm and adversely affect sleep and stress regulation among healthcare workers. Emergency physicians are particularly exposed to high-intensity workloads and prolonged 24-hour shifts, which can increase occupational strain. Methods: This study was conducted between April and December 2024 in a tertiary emergency department. Participants wore a smartwatch continuously for 30 days to record sleep architecture and heart rate variability-based stress indicators. Physiological parameters obtained during 24-hour shifts and at home were compared. Analyses were performed across four professional-experience groups. RESULTS: Sleep duration, deep sleep percentage, deep sleep continuity score, breathing quality score, and overall sleep score were lower during 24-hour shifts, whereas light sleep percentage, nighttime awakenings, and stress levels were higher (all p < 0.001). Physicians with greater professional experience had longer sleep duration and lower stress levels during 24-hour shifts compared with early-career residents. Multiple linear regression analysis indicated that professional experience was the only independent predictor of stress levels during shifts. CONCLUSIONS: Shift work in emergency medicine is associated with impaired sleep quality and increased physiological stress. Professional experience appears to mitigate stress responses but does not fully restore sleep quality. These findings support the need for targeted occupational strategies, including optimized workload distribution and structured support for early-career physicians, to improve well-being and ensure patient safety in high-intensity clinical environments.
BMC emergency medicineP Hilbert-Carius, H Wrigge, K Zur Nieden, B Stichert, A Großstück, Michael Lautenschläger
BACKGROUND: Traumatic haemorrhage is one of the most common causes of death in patients with injuries. Targeted pre-hospital haemostasis can reduce morbidity and mortality. The use of tourniquets is advisable for external bleeding in the extremities that cannot be treated with compression or wound packing. There are recommendations for the use of tourniquets. Little is currently known about the level of training and frequency of use of various professional groups of potential tourniquet users. METHODS: A regional cross-sectional online survey was conducted on the level of training, frequency of use, and adherence to guidelines for tourniquets among various pre-hospital professional groups (emergency medical technician- EMT, advanced emergency medical technician-AEMT, Paramedical, Helicopter Emergency Medical Services-Technical Crew member-HEMS-TC, pre-hospital physician), to get a regional convenience sample. To obtain an overview of the level of training and use of tourniquets among various professional groups, we conducted a regional online survey on ground-based emergency medical services in the region of Halle/Northern Saale District in Saxony-Anhalt, as well as on helicopter emergency medical services in the Halle/Leipzig metropolitan region. The different professional groups were compared with regard to theoretical and practical training, frequency of use, and adherence to the existing guidelines. RESULTS: 178 participants (74% male, 26% female) took part and answered the questionnaire. Among respondents who reported professional group were 47% pre-hospital physicians, 32% paramedics, 9% EMT, 7% HEMS-TCs, 4% AEMT. Statistically significant differences were found in theoretical education, with the lowest rate of education in the EMT group (67%) and the highest rate in the paramedic group (96%). When comparing theoretical education of all the emergency medical service personnel (91%) against the pre-hospital physicians (73%), it was significantly higher in the emergency medical service personnel group. No differences were found in practical training or frequency of use. Physicians had a significant higher adherence to the guidelines for location for applying a tourniquet. CONCLUSION: In addition to theoretical education, no statistically significant differences were detected in this regional sample in terms of practical training or frequency of use. With regard to adherence to existing guidelines, physicians had a significantly higher adherence for location for applying a tourniquet. Standardized training and periodic refresher education may help ensure consistent tourniquet knowledge and application across prehospital professional groups.
Military medicineEric S Weinstein, Jacques Mather, Drew Delp, Sherri Tschida, Sean Murphy, Amila Ratnayake, Paul Amoroso, Serhii Tertyshnyi, Barclay Stewart, Hannah B H Wild
INTRODUCTION: Actors in conflict, those in asymmetric warfare, conducting criminal activity or participating in paramilitary training activities may possess explosive ordnance. For various reasons this ordnance can misfire resulting in failure to detonate and become impaled or embedded in those near an intended target. The management of the patient with an impaled or embedded unexploded ordnance (eUXO) is a high impact event with the potential to cause death of those in proximity and destruction of the health care facility. The probability of this event is low with less than 50 cases reported in the literature. The objective of this study is to use a modified Delphi approach to produce statements to develop treatment guidelines of the eUXO patient in low-resource settings without explosive ordnance disposal team (EOD) assets. MATERIALS AND METHODS: Fifty-three statements were derived from authoritative texts and a PRISMA-Scoping review through an iterative process by the authors. Included experts rated their agreement with each statement on a 7-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤1. Statements attaining consensus after the first and subsequent rounds moved to the final report. Statements that did not attain consensus moved to the next round and this process repeated for 3 rounds. The remaining statements did not attain consensus. The University of South Florida Institutional Review Board determined that this study met the criteria for exemption. RESULTS: After the 37 experts first, 35 experts second, and 33 experts third round, 29 statements attained consensus, and 24 statements did not attain consensus. CONCLUSIONS: Although agreement was reached on key safety, transport, and training principles, uncertainties remain on how best to weigh clinical priorities to manage an eUXO patient to reduce the risk of detonation without available EOD assets in low-resource settings.
Annals of emergency medicineYvette Calderon, Barry Knapp, Felix K Ankel, Ted Gaeta, Lynne Holden, Derek Linklater, Zeno St Cyr, Ernest Wang, Melissa Barton, Andrew R Trotter, Kevin Jolder…
The American Board of Emergency Medicine gathers extensive background information on Accreditation Council for Graduate Medical Education-accredited emergency medicine residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2026 annual report on the status of physicians training in Accreditation Council for Graduate Medical Education-accredited emergency medicine training programs in the United States.
Academic emergency medicine : official journal of the Society for Academic Emergency MedicineEllen Shank, Jennifer Whitlock, Matthew Lopas, Amy Zeidan, Theresa Cheng
Emergency departments (EDs) are increasingly sites of interaction between clinicians and federal immigration authorities. Recent shifts in federal enforcement policy have intensified these encounters. Patients now more frequently arrive in custody, accompanied by immigration enforcement officers who may assert control over communication, decision-making, or access to patients. These circumstances introduce challenges for maintaining standard clinical practice. Clinicians may encounter situations in which patient confidentiality, informed consent, and independent medical judgment are difficult to operationalize in the presence of immigration enforcement officers. In addition to impacts on patient care, these encounters may contribute to clinician moral injury and distress, particularly when emergency medicine (EM) clinicians feel pressured to compromise patient privacy, deviate from standard practices, or navigate conflicts between enforcement priorities and patient care priorities. Uncertainty regarding institutional policy and the appropriate limits of immigration enforcement authority may exacerbate tensions related to liability and compliance. For patients, disruptions in care and delays in treatment may increase the risk of adverse outcomes. In response to these urgent concerns, the National Immigration Law Center (NILC), a leading advocacy organization in U.S. immigration, has developed Advocating On Behalf of Patients in ICE Custody: A Resource for Health Care Providers and Medical Staff, a national resource guide outlining practical considerations for clinicians and healthcare institutions caring for patients in immigration custody. In this commentary, we build on this resource to provide practical, bedside-oriented guidance for EM clinicians when interacting with immigration enforcement officers or caring for patients in immigration custody. We examine the implications of immigration enforcement within healthcare settings while articulating a path forward that protects patient rights, clinical integrity, and the ethical foundations of medical practice. The following highlights clinical questions that EM clinicians may have when caring for patients in immigration custody or interacting with immigration enforcement officials in hospital settings.
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienneKerstin de Wit, Jasmeet Benepal, Arani Sivakumar, Natasha Clayton, Louise C F Rang, Susan A Bartels, Rodrick K Lim, Patrick M Archambault, Teresa M Chan, Sara …
BACKGROUND: Canadian emergency staff have been dealing with record patient attendances, long wait times, bed blocking, and department overcrowding. We sought to report temporal trends in Canadian emergency physician burnout, and describe the impact of emergency medicine practice on physician well-being. METHODS: We undertook a longitudinal study on Canadian emergency physician wellness that enrolled participants in April 2020. Participants were invited to 3 follow-up surveys in November 2020, September 2022, and January 2025. The primary outcomes were emotional exhaustion, depersonalization, and personal accomplishment scores. We conducted a deductive qualitative thematic analysis of the 2025 survey free-text responses by applying the framework created with our 2022 survey, to identify interconnected themes explaining burnout causes, consequences, and mechanisms that physicians use to stay in the specialty. RESULTS: The response rate to the survey was 410/615 (67%) in January 2025, from respondents in all provinces or territories in Canada except Yukon and Nunavut. Of 410 participants, 41 (10%) had left the profession. Among those who remained in emergency medicine and completed the full survey, 69/351 (20%) had taken time off emergency medicine and 170/351 (48%) had reduced their clinical hours in emergency medicine. In total, 229/351 (65%) scored either high emotional exhaustion, high depersonalization, or both. Burnout levels in 2020, 2022, and 2025 remained unchanged. Respondents pointed to a broken health care system, unrealistic societal expectations, and insurmountable workplace challenges as reasons for burnout. The consequences were physician distress and leaving the profession. Mechanisms to continue in emergency medicine were reducing work hours, modifying work roles, and changing health care institutions. INTERPRETATION: Emergency physician burnout remains high, with almost half of respondents having reduced their work hours, and 10% having left the profession. Provincial, regional, and institutional health care leaders could reduce emergency physician burnout by following EM:POWER recommendations and instituting work models that facilitate reducing clinical hours and taking time away from emergency medicine when needed.
The American journal of emergency medicineAvram Flamm, Bryan Wexler, Andrew Milsten
OBJECTIVE: Disaster Medicine (DM) is an emerging subspecialty of medicine that functions in a variety of settings ranging from hospitals to non-conventional and austere environments. DM fellowships are the primary pathway for Emergency Physicians into this field. DM fellowships have grown in the U.S., and as of March 2026, are recognized by the American Board of Medical Specialties as an ABMS-approved subspecialty. This study describes the current characteristics of U.S. based DM fellowship programs with the goal of informing ongoing subspecialty development. METHODS: An online, 59-question survey was distributed from May to June 2024 to active civilian U.S. DM fellowship program directors that were identified through the SAEM website and ACEP's Disaster Medicine Fellowship Directors listserv. The anonymous responses were collected and then analyzed using Microsoft Excel. Descriptive statistics were generated. Inactive and military-only programs were excluded. A comprehensive description of the results is presented and discussed. RESULTS: Fourteen fellowship programs were contacted and 13 (93%) completed the survey. Programs offered a median of 2 fellowship spots a year (range 1-10), 70% of which were filled. Most fellows were trained in Emergency Medicine (79%). Fellowship duration was varied: 38% offered 1-year only, and 54% offered 2-year tracks. Foreign candidates were accepted by 46% of programs; 15% accepted NPs or PAs. Most programs (92%) pay fellows, often permitting moonlighting. Didactics, simulation, and experiential learning (e.g., deployments, special operations, mass gatherings) were common, though curricular standardization was variable. Only 31% used a published curriculum. CONCLUSIONS: The 2023 Model Core Content for DM provides curricular guidance; however, DM fellowships vary significantly in structure, educational delivery, and resources. Standardization will likely increase as the specialty continues to evolve following formal subspecialty recognition.
The western journal of emergency medicineTyler Kirchberg, Robert Nolan, Spencer Tomberg
IMPORTANCE: Distal radius fractures and distal ulna fractures are common orthopedic injuries treated in emergency departments (ED). Our goal in this narrative review was to present emergency physicians with a single source that covers the evaluation and treatment of distal radius fractures and distal ulna fractures across the lifetime of our patients. There are differences in the treatment algorithms for distal radius fractures between pediatric, young adult, and geriatric patients. OBSERVATIONS: Pediatric distal radius fractures are defined by their relation to the growth plate and are influenced by the gradual calcification of the developing bone. Some pediatric distal radius fractures can heal through significant displacement, while others require anatomical reduction to limit the risk of growth arrest. For adult patients with a distal radius fracture, there are established guidelines for both appropriate reduction goals and for when operative treatment is indicated. For geriatric patients, management strategies have evolved over the last decade after multiple studies demonstrated no functional difference between operative and nonoperative management. Given this, most geriatric distal radius fractures are managed nonsurgically, which makes effective reduction in the ED important to optimize long-term wrist function. CONCLUSION AND RELEVANCE: Emergency physicians need to be well versed at both identifying fracture patterns and be knowledgeable about radiographic fracture-reduction goals. This emergency medicine-focused and illustrated narrative review will assist physicians, nurse practitioners, and physician assistants in meeting those goals. We also summarize pain management, splint molding, possible complications and follow-up considerations for emergency physicians treating patients with distal radius fractures.
The Journal of emergency medicineLindsay Fountain, Kayla Corredera-Wells, Nicholas Cozzi, Jeffrey M Goodloe, Jenny M Guido, Alyssa B Johnson, Christopher S Kang, Thomas McNally, Andrea L Neved…
BACKGROUND: In the United States, emergency clinicians are often the first to care for injured patients in the hospital setting. Current trauma clinical guidance does not consistently meet the needs of emergency clinicians caring for this population. OBJECTIVES: To better understand end-user needs, we evaluated emergency clinician priorities and preferences in accessing, interpreting, and applying trauma clinical guidance. METHODS: Emergency clinicians were recruited via email for semi-structured video conference interviews. Rapid directed qualitative analysis of interview notes and audio recordings yielded initial insights about guidance barriers and facilitators. A subsequent quantitative survey was developed and distributed via email to members of relevant professional associations. Survey results were analyzed using descriptive and inferential statistics. RESULTS: Twelve emergency clinicians participated in interviews. A total of 154 eligible participants responded to the survey. Clinicians expressed support for trauma clinical guidance overall but often find resources lacking. Barriers to guidance usage include lack of awareness, difficulty locating guidance, and cumbersome design. Clinical guidance should be objective, concise, updated, and easy-to-use at bedside. The strongest determinant of guidance usability was being quickly understood in a time-pressured situation. Clinicians prefer to access guidance through mobile applications or multi-modal channels. Rural clinicians reported additional difficulties in staffing and having resources needed to follow guidance. CONCLUSION: When developing trauma clinical guidance, the trauma community should continue to consider the variety of end users and clinical settings, including emergency clinicians. Mobile device-friendly and quickly understandable formats may be important considerations for authors of trauma clinical guidance, although further work with larger and more diverse population is needed.
JAMA network openDavid Rudolph, Kirlos Haroun, Michael Gottlieb, Susan Farrell, Yvette Calderon, Kayla Iuliucci, Lea Moujaes, Blake Denley, P Logan Weygandt
IMPORTANCE: Burnout is highly prevalent among emergency medicine (EM) residents and is associated with negative outcomes for physician well-being and patient care. Emerging evidence suggests sexual minority trainees may be at increased risk, but differences within EM residency are not well characterized. OBJECTIVE: To determine if burnout prevalence among EM residents differs by sexual orientation after adjustment for key confounders. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included US resident physicians who took the 2024 American Board of Emergency Medicine In-Training Exam (ITE) postexamination survey and answered the question on sexual orientation. EXPOSURE: Sexual minority status (heterosexual or straight and sexual minority [lesbian, gay, bisexual, queer or questioning, asexual, pansexual, or other sexual identity]), adjusted for age, gender, race and ethnicity, postgraduate training year, program length, and region. MAIN OUTCOMES AND MEASURES: The primary outcome was burnout, assessed with an abbreviated 6-item Copenhagen Burnout Inventory: internal (personal or work-related) and external (patient-related) burnout. Prevalence ratios (PRs) were estimated for burnout stratified by sexual orientation, utilizing Poisson regression with robust standard errors. RESULTS: Of 9478 residents who took the ITE, 7852 respondents (median [IQR] age, 30 [28-32] years; 4416 male [56%]; 3364 female [43%]; 56 nonbinary [1%]) were included, with 928 (12%) identifying as a sexual minority and 6924 (88%) identifying as heterosexual. Compared with heterosexual residents, sexual minority residents had higher prevalence of any burnout prevalence (431 of 803 residents [54%] vs 2786 of 5967 residents [47%]; P < .001) and internal burnout (311 of 802 residents [39%] vs 1902 of 5979 residents [32%]; P < .001). After adjustment, sexual minority status was associated with higher prevalence of internal burnout (PR, 1.12; 95% CI, 1.02-1.24) and any burnout (PR, 1.09; 95% CI, 1.01-1.17). Among sexual minority subgroups, bisexual residents had the highest adjusted prevalence of any burnout (PR, 1.17; 95% CI, 1.05-1.30), and queer residents had higher prevalence of internal burnout (PR, 1.28; 95% CI, 1.02-1.62). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of 7852 EM residents, those who identified as a sexual minority reported higher burnout, particularly internal burnout, compared with heterosexual peers. These findings indicate that targeted support for sexual minority trainees is needed to improve physician well-being, training experience, and patient care.
The western journal of emergency medicineHannah E Miller, Claudia Tarrant, Miles Lamberson, Cate Nicholas, Katherine Dolbec
INTRODUCTION: It is not known whether skin color influences inclusion of substance use on medical students' differential diagnoses for a simulated cardiac arrest. Our objective in this study was to investigate whether the presence of a dark-skinned or light-skinned manikin in the lab correlated with their decision to include substance use on the differential as a possible cause of cardiac arrest. METHODS: In this study at a single institution, all fourth-year medical students in an emergency medicine course participated in a manikin-based cardiac arrest simulation case. The simulation sessions alternated between the use of a light-skinned and a dark-skinned manikin. Both were adult sized. After the first shock was delivered, students individually documented their differential diagnosis for the cause of the cardiac arrest on deidentified, free-text research forms. We excluded forms if they were blank, had been completed by a non-medical student, or could not be associated with the skin color of the manikin used. The primary outcome measure was how often students included substance use as a cause of cardiac arrest anywhere in their differential diagnoses. We compared the relationship between manikin skin color and the students' consideration of substance use as a cause of cardiac arrest, using the Fisher exact test. RESULTS: Of 270 eligible participants, 271 surveys were returned; 75 (27.7%) were excluded. Of the remaining 196 surveys, 96 were associated with the light-skinned and 100 with the dark-skinned manikin. Among the 100 respondents using the dark-skinned manikin, one student (1%) listed substance use as the leading diagnosis, while none (0%) of the students using the light-skinned manikin listed substance use as the leading diagnosis. In each group, only 20% of students (n = 39 total) listed substance use anywhere on the differential diagnosis (P = 1.00). CONCLUSION: Among fourth-year medical students participating in a simulated cardiac arrest, we found no correlation between manikin skin color and the inclusion of substance use on their differential for cardiac arrest. Overall, their decision to include substance use in their differentials was low regardless of skin color, suggesting the need to improve their awareness of substance use as a potential cause of cardiac arrest.
The western journal of emergency medicineEric Boccio, Daniel Levi, James Bonz, Justin Belsky, Jason D'Amore
INTRODUCTION: Emergency front-of-neck access may serve as a life-saving intervention when facing patients with difficult airways. Cricothyrotomy consists of needle and surgical techniques and is performed in approximately 0.2-0.5% of all airway management attempts. Our primary aim in this study was to compare procedural completion time and first-pass success of needle and surgical approaches to cricothyrotomy by civilian and military practitioners using a human cadaver model. METHODS: Emergency medicine (EM) attendings and residents and U.S. Air Force Pararescue specialists were randomized to perform either a needle or surgical cricothyrotomy on an unfixed human cadaver a single time following a 30-minute didactic session about both procedure types. We recorded procedural completion time, first-pass success, frequency and type of observed complications, and subject level of training. Our primary outcome measure was procedural completion time. Secondary outcome measures included first-pass success and complication rates. We used a Wilcoxon signed-rank test to compare the difference in median completion times between needle and surgical groups. We performed a Cox regression analysis to evaluate the relationship between technique and procedural completion time while adjusting for subject level of training. Chi-squared or Fisher exact tests were used to compare unadjusted first-pass success and complication frequencies between needle and surgical groups. Multivariable logistic regression analysis modeling the association between technique and first-pass success and complication events while adjusting for subject level of training was performed. RESULTS: A total of 99 subjects were enrolled, and 19 (19%), 68 (69%), and 12 (12%) were classified as EM attending, EM resident, and Pararescue specialist, respectively; 51 (52%) and 48 (48%) were randomized into the needle and surgical groups, respectively. The median time to procedural completion was shorter in the needle group than the surgical group (56.5 seconds [sec], 95% confidence interval, 54-66 sec vs 65 sec, 95% CI, 59-73 sec, respectively). The difference in median completion times was 8 sec (95% CI, -1.0 to 17 sec, P = .08). The hazard ratio comparing completion time of surgical to needle cricothyrotomy while adjusting for level of training was 1.41 (95% CI, 0.93-2.13, P = .11). First-pass success and complication rates were similar between the needle and surgical groups (94% vs 94%, P = .32, and 27% vs 33%, P = .52, respectively). The adjusted odds ratios comparing the likelihoods of first-pass success and complication between surgical and needle groups while adjusting for level of training were 1.06 (95% CI, 0.20-5.54, P = .95) and 1.40 (95% CI, 0.55-3.56, P = .48), respectively. CONCLUSION: In this study using unfixed human cadavers, needle and surgical cricothyrotomy demonstrated comparable performance regarding procedural completion time, first-pass success, and complication rates. The 8-second difference in median completion time between groups was not found to be statistically significant and is unlikely to be clinically significant given the typical oxygen reserves in an apneic patient. These findings suggest that for practitioners in civilian and military settings, both needle and surgical cricothyrotomy remain viable options for emergency front-of-neck access, assuming adequate operator-level procedural proficiency and access to necessary equipment.
The western journal of emergency medicineTravis Hase, Cindy Ndiaye, Margaret Putman
INTRODUCTION: Emergency physicians frequently care for patients with serious or terminal illnesses, yet they often lack formal palliative care training. Our primary objective was to develop a structured, multimodal palliative care curriculum for emergency medicine (EM) residents and evaluate whether this curriculum improved residents' knowledge, comfort level, and perceived application of skills to care for patients with chronic or terminal illness in the emergency department (ED). Our secondary objective was to determine whether EM residents found palliative care education important and to identify which educational modalities are most effective for acquiring palliative care knowledge and skills. METHODS: We implemented an eight-hour multimodal curriculum for EM residents at a single, large Level I trauma center (four hours of didactics, a three-hour simulated patient communication skills lab, and one hour of high-fidelity simulation). Our primary outcome was pre- and post-intervention surveys (12 questions) that assessed perceived knowledge, comfort, and skill application on five-point Likert scales. We analyzed paired responses using the Wilcoxon signed-rank test, with a P value of < .05 considered statistically significant. Effect size was calculated using Cohen d. Our secondary outcome measure was a post-intervention survey (six questions) that assessed participants' opinions on the effectiveness of the different educational methods. RESULTS: There was a 100% response rate among 41 residents from all postgraduate years 1-3. Significant improvements (P < .001) were observed in residents' self-reported abilities across all domains with large effect sizes. Median scores and interquartile ranges increased for conducting goals-of-care discussions (4 [3-4] vs 4 [4-5]), interpreting advance directives (3 [2-4] vs 4 [4-4]), managing end-of-life symptoms (3 [2-3] vs 4 [3-4]), communicating bad news (3 [2-4] vs 4 [4-4]), and coordinating with palliative or hospice teams (2 [2-3] v. 4 [4-4]). All educational modalities were rated effective, with simulation and small-group sessions preferred over lectures. CONCLUSION: A structured, multimodal palliative care curriculum significantly enhanced EM residents' perceived preparedness to manage patients with palliative care needs. Embedding didactic and simulation-based palliative training in EM residencies is both feasible and impactful, addressing critical gaps in palliative competencies and aligning with national best-practice guidelines.
The western journal of emergency medicineAbagayle Bierowski, Casey Morrone, Erin Hoag, Ridhima Ghei, Michael Pasirstein, Julie Blaszczak, Dimitrios Papanagnou
INTRODUCTION: The transition from resident to junior faculty in academic emergency medicine (EM) may be shaped not only by formal training and institutional policies but also by the "unwritten curriculum," a set of norms and expectations embedded in institutional culture. However, the unwritten curriculum and its potential to impact junior faculty development remains largely unexplored. Little is known about how junior faculty perceive, experience, and navigate these informal expectations, or the formal and informal structures that influence this process. In this study we aimed to explore junior faculty members' experiences with the unwritten curriculum in academic EM, with a focus on how they interpret and navigate institutional norms and identify supports and barriers encountered during their early faculty development. METHODS: Within their first five years, EM faculty at academic institutions distinct from their residency training sites completed an anonymous, iteratively developed survey designed to explore experiences with the unwritten curriculum, informed by Schlossberg's transition theory framework. The primary analytic focus was identification of themes describing how junior faculty perceive and navigate implicit institutional norms. Open-ended responses underwent thematic analysis using a structured codebook, applied by two independent reviewers with consensus-based coding and adjudication by a third when disagreements arose. RESULTS: A total of 35 junior faculty members completed the survey. All participants indicated influence of the unwritten curriculum on their professional development. Major themes identified include the unspoken importance of mentorship and peer guidance; implicit expectations and norms surrounding engagement, productivity, and visibility; work-life integration; cultural adjustment; scholarly output; and gaps in onboarding, feedback, and role clarity. Participants emphasized challenges in navigating departmental politics, understanding hierarchical nuances, and balancing unspoken expectations for committee involvement and informal social participation. Additionally, unclear feedback processes, inconsistent evaluation expectations, and cultural norms for active engagement were noted as barriers to integration and professional growth. CONCLUSION: Junior faculty in academic EM described the unwritten curriculum as a meaningful influence on their early faculty experience. Within this sample, participants highlighted mentorship, feedback transparency, and structured faculty development as potential mechanisms to support navigation of implicit expectations during the transition to junior faculty. These findings reflect individual perceptions rather than program characteristics and should be interpreted within the context of the study's scope.
The western journal of emergency medicineChigozie Chukwunyere, Jessica Heil, Matthew Salzman, Rachel Haroz
INTRODUCTION: We incorporated an 8-hour standardized substance use disorder (SUD) curriculum and X-waiver training into our emergency medicine (EM) residency. We sought to assess whether the implementation of the standardized SUD curriculum and X-waiver training affected graduated EM residents' comfort with treating SUD and prescribing practices, as well as their view of their future career paths. METHODS: Physicians who completed their EM residency at our hospital from 2016-2022 were invited to complete the survey in 2023. The primary outcome measure was the proportion of surveyed graduates who reported comfort and confidence in treating patients with SUD, measured by affirmative responses to survey items. The secondary outcome measure was the proportion of surveyed graduates reporting that participation in the SUD curriculum and X-waiver training during residency influenced their career plans, measured by affirmative responses to career-related survey items. For each outcome measure, we compared percentages of affirmative responses between physicians who completed residency prior to and after the implementation of the SUD curriculum and X-waiver training. RESULTS: Among 81 graduated EM residents invited to complete the survey, 63 (78.8%) responded. We grouped them based on whether they had completed residency prior to the addition of the standardized SUD curriculum (pre-curriculum, 2016-2017) or after (post-curriculum, 2018-2022). Of the 63 participants, 17 were pre- and 46 were post-curriculum residents. Of the pre-curriculum residents, 58.8% prescribed buprenorphine in their practice after residency, compared to 76.1% of the post-curriculum residents (Fisher exact test, P = .22, odds ratio [OR] 0.46, 95% confidence interval, 0.12-1.76). Of the post-curriculum graduates, 93.5% noted that they were better prepared to treat patients with SUDs than their peers compared to 88.2% of the pre-curriculum graduates (Fisher exact test, P = .605, OR .529, 95% CI, 0.055-6.909), and 69.6% believed the training impacted their careers professionally and increased their interest in helping patients with opioid use disorder. CONCLUSION: Overall, a greater proportion of EM graduates who had been X waiver-trained in a substance use disorder curriculm during residency training at our institution prescribed buprenorphine to their patients than those who had not undergone specific training. Although the X-waiver is no longer a requirement, our SUD curriculum and training remain relevant for buprenorphine prescribing and may offer some opportunities for EM residents to develop their careers.
The western journal of emergency medicineEric Boccio, Rachelle Perkins, James Bonz
INTRODUCTION: During endotracheal intubation, equipment setup typically includes the patient monitor fixed at the head of the bed behind the back of the operator. Inability to directly visualize the patient monitor may result in delayed recognition of desaturation. Our primary aim in this study was to measure the association between patient monitor position and the time to recognition of a desaturation event during endotracheal intubation. METHODS: We performed a randomized crossover trial of emergency medicine residents across two Accreditation Council for Graduate Medical Education-accredited programs. Subjects were asked to perform direct and video-assisted laryngoscopy once on a difficult airway trainer in a simulation. The sequence of laryngoscopy modality (direct vs video-assisted) and monitor position (head vs left vs right of bed) were randomized prior to each attempt. The simulated patient's peripheral capillary oxygen saturation (SpO2) was programmed to begin at 100% and decrease at a rate of 1% per second 10 seconds after the start of the subject's attempt. The primary outcome measure was time to operator recognition of hypoxia defined as the observed period during which the simulated SpO2 was < 90%. Secondary outcomes were operator failure to visualize a desaturation event. We rendered Kaplan-Meier curves illustrating the time to visualization of hypoxia and performed a Cox regression adjusting for laryngoscopy modality and total number of previous intubations performed. Using multivariable linear regression, we modeled the association between time to recognition of hypoxia in seconds and patient monitor position with similar adjustments. To assess differences in the number of observed failure events between study arms, we used chi-squared or Fisher exact tests. The threshold for statistical significance was a two-sided P < 0.05. RESULTS: We observed 68 attempts by 34 subjects. Twenty-two (32.5%), 22 (32.5%), and 24 (35%) intubations were performed with the monitor positioned at the head, left, and right, respectively. The median times to recognition of hypoxia were 37 seconds [sec] (95% CI, 25-86 sec) for the head, 32 sec (95% CI, 18-50 sec) for the left, and 23 sec (95% CI, 19-34 sec) for the right groups, respectively. Cox regression demonstrated hazard ratios of 2.7 and 3.2 for the left and right groups when compared to the head group, and these findings were statistically significant (P = .04 and P = 0.03, respectively). We found no statistically significant associations between time to recognition of hypoxia and laryngoscopy modality or total number of previous intubations (P = .82 and .21, respectively). Failure rates across head, left, and right groups were similar, at 36%, 59%, and 50%, respectively (P = .30). CONCLUSION: Positioning of the patient monitor at the head of the bed results in delayed visualization of desaturation events during simulated direct and video-assisted laryngoscopy across different levels of experience. Ideally, the patient monitor should be positioned on the side of the bed and within the operator's direct line of sight. Further research is warranted to assess how equipment setup may impact procedural performance, operator ergonomics, and patient safety.
Emergency medicine clinics of North AmericaAndrew Petrosoniak, Christopher Hicks
This article reframes preparation for critically ill patients as a dynamic, compounding process that spans 3 temporal phases: strategic, operational, and reflective. Using concepts such as shared mental models, psychological safety, adaptive capacity, and the 3A's prebriefing framework (anticipate, align, and adapt), the article outlines how teams can better navigate uncertainty and complexity in real time. This article describes the consequences of preparation deficit and preparation debt, and provide practical tactics for rapid appraisal, decision-making in motion, and structured reflection. Together, these strategies create a preparation architecture that enhances performance, reduces error, and strengthens team and system resilience.
INTRODUCTION: The stressors in emergency medicine and the coping strategies that can help decrease stress have not been well understood. Therefore, our aim was to explain to emergency medicine specialists the perceived stressors and useful coping strategies in the emergency departments in 2024. METHODS: The present study is a conventional qualitative content analysis with an inductive approach. Data were collected using open-ended, semi-structured individual interviews. The participants were emergency medicine specialists of all medical universities in the country. The contents were analyzed using the Graham and Longman content analysis method. RESULTS: Of 19 participants, the majority were in the 40- to 49-year age group, married, and male. The majority were assistant professors and associate professors of medicine with 10 to 19 years of work experience, who underwent virtual interviews. The participants' statements revealed three stressor categories with 15 subcategories: individual stressors, concurrent stressors, and collateral stressors. In addition, three stress-reducing coping strategies categories with 15 subcategories were extracted: active individual adaptation, treatment optimization, and receiving support. CONCLUSION: The medical field is inherently stressful, but not all stressors faced by medical professionals are individual in nature. Some stressors occur simultaneously and laterally that are not individual but organizational and environmental. The coping strategies explained were active personal adaptation, optimizing treatment, and receiving support. In other words, in addition to the need for medicine to actively resolve damaging stressors with individual self-care, medicine needs comprehensive internal and external support.
Igiene e sanita pubblicaAnnamaria Servadio, Matteo Tamburlani, Maria Campitelli, Paola Barletta, Edoardo Martella, Alessia Alessi, Cinzia Barletta, Enrico Mirante
BACKGROUND: In Emergency Medicine units, physiotherapy must address motor and respiratory needs in complex patients, often with limited professional resources that are not exclusively dedicated to the unit. Describing service volume, coverage and response capacity is relevant to physiotherapy planning and resource governance. OBJECTIVE: To describe the volume, coverage, timeliness and response capacity of physiotherapy activity delivered by a single professional resource assigned to the Emergency Medicine unit, while secondarily characterising patients, interventions, pathways and outcomes and, in a selected subsample, pre-post changes in functional and symptom-related outcomes. METHODS: Retrospective observational study based on the clinical registry of the Emergency Medicine unit at Sant'Eugenio Hospital in Rome. A total of 335 physiotherapy episodes were analysed: 197 in 2025 and 138 in the first half of 2026, corresponding respectively to 684 and 377 hospital admissions. The service was provided by a single physiotherapist, present six hours per day from Monday to Saturday, not exclusively dedicated to the unit, with no Sunday or public-holiday coverage. All requests for functional assessment and physiotherapy management submitted by the unit physicians were assessed. In a selected subsample of 162 episodes, T0-T1 changes in the Barthel Index, Trunk Control Test, NRS and Borg scale were also explored, together with associations with timeliness and treatment days. RESULTS: The proportion of hospital admissions receiving physiotherapy assessment increased from 28.8% in 2025 to 36.6% in the first half of 2026 (difference 7.8 percentage points; p=0.009). Mean monthly physiotherapy episodes increased from 16.4 to 23.0, while physiotherapy episodes per bed/month increased from 1.09 to 1.28. Response capacity to received requests was 100% in both periods. The population had a median age of 77 years; 58.5% of episodes fell within respiratory clinical macro-areas. Barthel and Trunk scores were associated with final discharge destination, while no overall associations emerged between type of physiotherapy intervention and outcome. In the subsample with serial assessments, all outcomes showed a significant T0-T1 change (p<0.001); assessment within ≤24 hours was not associated with greater improvement, whereas treatment days were positively correlated with improvement in Barthel (ρ=0.882), Trunk (ρ=0.443), NRS (ρ=0.673) and Borg (ρ=0.382), all p<0.001. CONCLUSIONS: A single shared physiotherapy resource, responding to demand from the clinical unit, ensured that all medical requests were addressed and achieved increasing service penetration despite the absence of Sunday and public-holiday coverage. The findings support the organisational value of a structured physiotherapy presence in Emergency Medicine. In the subsample with serial measures, functional and symptom-related improvement was also observed, with a dose-response relationship between treatment days and magnitude of change. These clinical analyses remain exploratory and do not allow causal inference.