Background A significant number of chest pain patients had previous cardiac imaging tests (CIT) performed before being presented to the Emergency Department (ED). The HEART (history, electrocardiogram, age, risk factors, and troponin) score has been used to risk-stratify chest pain patients in the ED, but not particularly for patients with CIT performed. We aim to modify the current HEART score with the addition of most recent CIT findings (referred to as HEART2 score), to predict a 30-day major adverse cardiac event (MACE) among ED chest pain patients, compare the performance accuracy of using HEART versus HEART2 score for 30-day MACE outcome predictions, and further determine the value of HEART2 in a subset group of ED chest pain patients (i.e., ones with previous CIT). Methods This is a single-center observational study. We included chest pain patients with HEART scores calculated during their index ED visits. A modified HEART2 score was developed with the addition of CIT findings as one of the HEART2 components. Patients were divided into three groups, including low (≤ 3), moderate (4–6), and high-risk HEART/HEART2 scores (≥ 7). MACE occurrence of a patient with different risks of HEART and HEART2 scores and overall performance accuracy of HEART versus HEART2 score predicting MACE outcomes were compared. Results We included a total of 9419 chest pain patients at ED, among which one out of five patients (1874/9419) had previous CIT performed. Fewer (38.2%) of such patients had low-risk HEART scores in comparison to 55.5% of low-risk HEART2 scores (p < 0.001). The MACE outcomes were similar in low-risk HEART patients compared with low-risk HEART2 patients (2.2% versus 3.1%, p = 0.3021). The overall performance accuracy of using the HEART2 score to stratify chest pain patients with previous CIT was better than using the HEART score’s (AUC 0.74 versus 0.71, p = 0.0082). Conclusions Using the HEART2 score might be suitable to stratify low-to-moderate risk chest pain patients at ED with a similar 30-days MACE occurrence compared to the HEART score. More importantly, with the use of similar low-risk criteria (HEART2 ≤ 3), over 45% more chest pain patients with previous CIT performed could be discharged directly from ED.

Introduction: High-fidelity medical simulation is widely used in emergency medicine training because it mirrors the fast-paced environment of the emergency department (ED). However, simulation is not common in emergency medicine training programs in lower-resourced countries as cost, availability of resources, and faculty experience are potential limitations. We initiated a simulation curriculum in a low-resource environment. Methods: We created a simulation lab for medical officers and students on their emergency medicine rotation at a teaching hospital in Patan, Nepal, with 48,000 ED patient visits per year. We set up a simulation lab consisting of a room with one manikin, an intubation trainer, and a projector displaying a simulation cardiac monitor. In this environment, we ran a total of eight cases over 4 simulation days. Debriefing was done at the end of each case. At the end of the curriculum, an electronic survey was delivered to the medical officers to seek improvement for future cases. Results: All eight cases were well received, and learners appreciated the safe learning space and teamwork. Of note, the first simulation case that was run (the airway lab) was more difficult for learners due to lack of experience. Survey feedback included improving the debriefing content and adding further procedural skills training. Discussion: Simulation is a valuable experience for learners in any environment. Although resources may be limited abroad, a sustainable simulation lab can be constructed and potentially play a supportive role in developing an emergency medicine curriculum.

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A 37 yo man presented to the ED with sudden onset of left sided chest pain and dyspnea after lifting a box. On physical examination the patient was hypotensive (86/55), tachycardiac (HR 125), hypoxic (88%), diaphoretic, with diminished left sided breath sounds. A portable chest x-ray revealed a large left tension pneumothorax with rightward tracheal deviation and mediastinal shift. (Image 1) The patient was placed on oxygen and an emergent needle decompression thoracostomy was performed. A 14-gauge needle was placed into the lateral 4th intercostal space at the mid-axillary line with immediate return of air and improvement in vital signs and symptoms. The needle was then used as a guide for placement of a percutaneous chest tube via the Seldinger technique. (Total procedure time was < 4 min.) A chest x-ray showed re-expansion of the left lung with the chest tube. (Image 2) The patient was admitted to the pulmonary service in stable condition.