INTRODUCTION:Unplanned out-of-hospital births are uncommon and associated with serious complications. Most emergency medical services (EMS) personnel receive little or no instruction on emergent vaginal delivery. Our in-person (IP) lecture and simulation training on emergent vaginal delivery for EMS personnel previously demonstrated improvement in knowledge and confidence. With COVID-19 we adapted the same curriculum into a virtual training session (VTS). In-person simulation increases confidence and knowledge, but less is known about virtual simulation training. The purpose of this study was to assess EMS personnel’s knowledge and confidence after IP versus VTS in emergent vaginal delivery.METHODS:The IP and VTS participants received the same lecture on emergent delivery either in-person or virtually. The IP group received in-person simulation training using a birth simulator. The VTS group received simulation training via virtual demonstration on the same model. Participants completed pretraining and posttraining surveys to assess knowledge and confidence. Responses were analyzed and compared using Student’s t test.RESULTS:Ninety-eight participants (59 IP, 39 VTS) participated with 100% survey completion. Pretraining knowledge scores were similar (IP 45% versus VTS 37%, P=.22). Although both groups showed improvement, the IP group had significantly higher posttraining knowledge scores (IP 99% versus VTS 75%, P<.01). More IP participants reported confidence in performing emergent delivery after training (IP 100% versus VTS 51%, P<.01).CONCLUSION:Live in-person instruction and simulation training of emergent vaginal delivery among EMS personnel results in higher knowledge scores and confidence when compared to virtual instruction and simulation training. Further evaluation is needed to determine generalizability to other learner groups.

Introduction: Insulinomas are the most common cause of hypoglycemia related to endogenous hyperinsulinism. It occurs in 1-4 people per million in the general population. Symptoms include diaphoresis, palpitations, tremors and even confusion or behavioral/personality changes.1 The small size of insulinomas presents a challenge in diagnosis via standard imaging techniques.2 Case Description/Methods: A 47-year-old healthcare worker with a history of goiter presented with 6 months of memory problems and associated lightheadedness, tremors, and blurry vision. She endorsed a 15-pound weight gain in the past month. She also recalled lapses in memory such as forgetting where she parked her car at the grocery store and more dangerously occurring during work when she was not able to remember if she administered medications to patients appropriately. Historical episodes of hypoglycemia had been ongoing for the past 2 years. Baseline labs included a mildy elevated c-peptide, normal IGF-2, TSH, and cortisol, and negative insulin antibody and sulfonyurea screen. Physical examination was normal. MRI showed no pancreatic abnormalities and she was subsequently admitted to our hospital for 72hour inpatient fast. The fast ended at 22 hours due symptomatic hypoglycemia that resolved after administration of glucagon. Labs revealed blood glucose of 42, insulin 9 mU/L, beta-hydroxybutyrate 0.4 mg/dL, C-peptide 1.4 ng/L , proinsulin 40.5 pmol/L which were all diagnostic for insulinoma. CT abdomen showed no enhancing pancreatic masses or metastatic lesions. Thus, the patient underwent endoscopic ultrasound (EUS) fine-needle aspiration which identified an 8x5 mm lesion in the tail of the pancreas. Pathology showed a well-differentiated neuroendocrine tumor, and the patient underwent radiofrequency ablation (RFA). Four months later, the patient was no longer symptomatic and no biochemical evidence of hyperinsulinemia remained on laboratory evaluation. Discussion: Insulinomas remain a diagnostic challenge, due to their rare presentation, nonspecific symptoms and small size. Although most insulinomas are benign with survival rate of 95% they require surgical intervention or radiofrequency ablation to improve survival. Diagnosis of a suspected insulinoma can be made via labs during a supervised, prolonged fast and accurate localization of smaller tumors may require minimally invasive procedures, like EUS. 2

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