Immersive learning environments that use virtual simulation (VS) technology are increasingly relevant as medical learners train in an environment of restricted clinical training hours and a heightened focus on patient safety. We conducted a consensus process with a breakout group of the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." This group examined the current uses of VS in training and assessment, including limitations and challenges in implementing VS into medical education curricula. We discuss the role of virtual environments in formative and summative assessment. Finally, we offer recommended areas of focus for future research examining VS technology for assessment, including high-stakes assessment in medical education. Specifically, we discuss needs for determination of areas of focus for VS training and assessment, development and exploration of virtual platforms, automated feedback within such platforms, and evaluation of effectiveness and validity of VS education.

Background Clinical decision rules have been developed and validated for the evaluation of patients presenting with suspected pulmonary embolism (PE) to the emergency department (ED). Objectives To assess the percentage of computed tomographic pulmonary angiography (CT-PA) which could have been avoided by use of the Wells score coupled with D-dimer testing (Wells/D-dimer) or Pulmonary Embolism Rule-Out Criteria (PERC) in ED patients with suspected PE. Methods The authors conducted a prospective cohort study of adult ED patients undergoing CT-PA for suspected PE. Wells score and PERC were calculated. A research blood sample was obtained for D-dimer testing for subjects who did not undergo testing as part of their ED evaluation. The primary outcome was PE by CT-PA or 90-day follow-up. Secondary outcomes were ED length of stay (LOS) and CT-PA time as defined by time from order to initial radiologist interpretation. Results Of 152 suspected PE subjects available for analysis (mean age 46.3±15.6 years, 74% female, 59% black or African American, 11.8% diagnosed with PE), 14 (9.2%) met PERC, none of whom were diagnosed with PE. A low-risk Wells score (≤4) was assigned to 110 (72%) subjects, of whom only 38 (35%) underwent clinical D-dimer testing (elevated in 33/38). Of the 72 subjects with low-risk Wells scores who did not have D-dimers performed in the ED, archived research samples were negative in 16 (22%). All 21 subjects with low-risk Wells scores and negative D-dimers were PE-negative. CT-PA time (median 160 minutes) accounted for more than half of total ED LOS (median 295 minutes). Conclusions In total, 9.2% and 13.8% of CT-PA could have been avoided by use of PERC and Wells/D-dimer, respectively.

The factors that contribute to pulmonary embolism (PE), a potentially fatal complication of deep vein thrombosis (DVT), remain poorly understood. Whereas fibrin clot structure and functional properties have been implicated in the pathology of venous thromboembolism and the risk for cardiovascular complications, their significance in PE remains uncertain. Therefore, we systematically compared and quantified clot formation and lysis time, plasminogen levels, viscoelastic properties, activated factor XIII cross-linking, and fibrin clot structure in isolated DVT and PE subjects. Clots made from plasma of PE subjects showed faster clot lysis times with no differences in lag time, rate of clot formation, or maximum absorbance of turbidity compared with DVT. Differences in lysis times were not due to alterations in plasminogen levels. Compared with DVT, clots derived from PE subjects showed accelerated establishment of viscoelastic properties, documented by a decrease in lag time and an increase in the rate of viscoelastic property formation. The rate and extent of fibrin cross-linking by activated factor XIII were similar between clots from DVT and PE subjects. Electron microscopy revealed that plasma fibrin clots from PE subjects exhibited lower fiber density compared with those from DVT subjects. These data suggest that clot structure and functional properties differ between DVT and PE subjects and provide insights into mechanisms that may regulate embolization.

IntroductionIn today’s team-oriented healthcare environment, high-quality patient care requires physicians to possess not only medical knowledge and technical skills but also crisis resource management (CRM) skills. In emergency medicine (EM), the high acuity and dynamic environment makes CRM skills of physicians particularly critical to healthcare team success. The Accreditation Council of Graduate Medicine Education Core Competencies that guide residency program curriculums include CRM skills; however, EM residency programs are not given specific instructions as to how to teach these skills to their trainees. This article describes a simulation-based CRM course designed specifically for novice EM residents.MethodsThe CRM course includes an introductory didactic presentation followed by a series of simulation scenarios and structured debriefs. The course is designed to use observational learning within simulation education to decrease the time and resources required for implementation. To assess the effectiveness in improving team CRM skills, two independent raters use a validated CRM global rating scale to measure the CRM skills displayed by teams of EM interns in a pretest and posttest during the course.ResultsThe CRM course improved leadership, problem solving, communication, situational awareness, teamwork, resource utilization and overall CRM skills displayed by teams of EM interns. While the improvement from pretest to posttest did not reach statistical significance for this pilot study, the large effect sizes suggest that statistical significance may be achieved with a larger sample size.ConclusionThis course can feasibly be incorporated into existing EM residency curriculums to provide EM trainees with basic CRM skills required of successful emergency physicians. We believe integrating CRM training early into existing EM education encourages continued deliberate practice, discussion, and improvement of essential CRM skills.

Snapping scapula syndrome is a rare condition characterized by crepitus of the scapula on motion of the ipsilateral upper extremity. It may be quite painful and disabling. The majority of cases are due to bursal and muscular disorders. Snapping scapula syndrome secondary to an underlying osteochondroma is an even more infrequent phenomenon. The case presented highlights the unusual post pubertal growth of an osteochondroma of the scapula that progressed to develop a snapping scapular syndrome. Review of the literature revealed less than fifty reported cases of this phenomenon secondary to an underlying osteochondroma.