Publications

Point-of-care ultrasound (POCUS) has emerged as a powerful tool for bedside diagnosis and management, offering real-time clinical insights and cost savings. Its integration into rural family medicine could reduce reliance on advanced imaging, improve patient satisfaction, and support physician versatility across primary, emergency, and procedural care. Despite these advantages, POCUS adoption remains limited, largely due to ambiguous and inconsistent reimbursement policies. Rural Health Clinic all-inclusive payment models, state Medicaid variability, and Local Coverage Determination gaps undermine financial sustainability. Cost analyses demonstrate meaningful system-level savings, yet physician revenue remains constrained, particularly in Medicare-heavy rural populations. Policy solutions include adjusting rural payment models, establishing national Local Coverage Determinations (LCDs), introducing visit modifiers, and leveraging tele-ultrasound and hybrid training approaches. Complementary pathways, such as limited out-of-pocket patient payments, may provide short-term support but risk inequities. Aligning reimbursement policy with demonstrated clinical and economic benefits is critical to scaling POCUS in rural family medicine and strengthening equitable access to care.

OBJECTIVE: The objective of this study was to evaluate the impact of operator training level, specifically comparing Emergency Medicine (EM) attending physicians and residents, on the analgesic efficacy of ultrasound-guided nerve blocks (UGNBs) performed in the emergency department (ED).

METHODS: This is a secondary analysis of the National Ultrasound-Guided Nerve (NURVE) Block Registry, involving 11 U.S. EDs from January 1, 2022, to December 31, 2023. Adult patients undergoing UGNBs for acute pain or procedural analgesia were included, totaling 1595 procedures after exclusion of incomplete post-procedural pain scores. The primary outcome was percent pain reduction, with >50% defined as clinically meaningful and > 75% as substantial analgesia. Subgroup analyses were performed by operator experience and block type.

RESULTS: Attendings achieved clinically meaningful pain reduction in 80.7% of cases versus 63.4% for residents, and substantial reduction in 68.1% vs 47.7% respectively (p < 0.001). This difference persisted at the highest experience level (>20 prior blocks: 82.3% vs 71.0%, p = 0.0007) and was observed across block types, reaching significance for erector spinae plane blocks (79.6% vs 63.6%, p = 0.01). Complications were rare (0.13%), with both events in resident-performed blocks.

CONCLUSION: UGNBs performed by attendings were associated with greater analgesic success compared with those by residents, yet both groups achieved high rates of clinically meaningful pain reduction with very low complication rates. These results underscore the role of experience in UGNB efficacy while supporting the safety and effectiveness of supervised resident performance in the ED.

BACKGROUND: This study aimed to demonstrate the feasibility of using computer vision (CV) to unobtrusively extract body motion metrics from videos of emergency medicine (EM) clinicians, and gather validity evidence of these metrics to differentiate POCUS skills between novice and experts, as well as to capture skills gained over time.

METHODS: Prospective cohort study including novice and expert EM clinicians performing echocardiogram (ECHO) and focused assessment with sonography for trauma (FAST) exams on a live simulated patient. Expert observers provided objective structured clinical examination (OSCE) scores (numerical ratings on a scale from 1 to 100), and sonographers' hands and head motion metrics (path length, speed, acceleration, jerk, and smoothness) were extracted via CV using 2-dimensional videos. Data points were captured at baseline, and for novices at baseline and after 12-15 months of residency training.

RESULTS: CV achieved high detection rates (99.52% ECHO, 98.70% FAST). At baseline, experts demonstrated superior OSCE scores (ECHO: 98.6 ± 2.1 vs 63.4 ± 17.0; FAST: 99.2 ± 1.5 vs 68.9 ± 17.7, p < 0.001) and faster task completion (101.8 ± 44.7 vs 240.3 ± 84.1 s, p < 0.001). Experts exhibited smoother hand movements (left hand smoothness: -129.3 ± 47.6 vs -241.3 ± 64.6, p < 0.001) and reduced total path lengths. After 12-15 months of training, novices showed significant improvements in OSCE scores (ECHO: 85.3 ± 10.3; FAST: 84.8 ± 6.5) and task efficiency (134.0 ± 35.6 s), with improvements in motion smoothness and reduced path lengths (p < 0.001). Motion metrics strongly correlated with OSCE scores (r = 0.455-0.783) and task completion time (r = 0.491-0.951).

CONCLUSIONS: CV successfully extracted objective motion metrics that differentiated POCUS skill levels between novices and experts and captured skill development over time. This approach offers a scalable, unobtrusive method for objective POCUS assessment, while supporting competency-based medical education frameworks.

Ultrasound-guided nerve blocks (USGNBs) are increasingly used in the emergency department (ED) as a safe and effective part of multimodal pain management. Their use has been shown to reduce reliance on opioids and procedural sedation, improve pain scores, and enhance functional outcomes for patients. Additionally, USGNBs in the ED have a complication rate of 0.4%, markedly lower than procedural sedation (4-11%), and they significantly reduce opioid requirements, which is critical considering the current opioid epidemic and the risks of persistent opioid use and overdose. Despite these benefits, relevant concerns about medicolegal liability, informed consent, evolving standards of care, may still influence the adoption of USGNBs in clinical practice. To address these issues, this review examines the legal risks associated with USGNBs by drawing on current clinical literature, closed claims data, and case law. We highlight common adverse events such as peripheral nerve injury and local anesthetic systemic toxicity and assess their legal implications. Potential legal risk including liability related to alternatives like opioid use and procedural sedation, are discussed. While the risk of litigation remains low when best practices are followed, failing to offer a USGNB when clearly indicated may increasingly be viewed as a liability if preventable complications occur. This article aims to provide a practical, interdisciplinary framework, including legal risk assessment, training, credentialing, and risk mitigation, to help clinicians, educators, and hospital administrators safely and confidently integrate USGNBs into ED practice.

When given a sample of 100 emergency department discharge instructions, Claude Sonnet, a large language model, produced accurate Spanish translations as evaluated by Spanish-speaking physicians and medical interpreters.

Non-evidence based factors influence post-surgical opioid prescribing practices. Delivering automated near real-time opioid prescribing feedback may encourage providers to prescribe opioid quantities which are more aligned with patient consumption and institutional guidelines. COVID-19 presented unprecedented challenges to healthcare delivery. We observed a substantial deviation in guideline-concordant opioids prescribing during the initial outbreak. However, our institution's pre-existing opioid prescribing feedback system and decision aid may have helped limit the duration and magnitude of the observed deviations by informing prescribers of atypically large opioid prescriptions and encouraging use of institutional data. Combined with provider education, a non-directive decision aid, in the form of near, real-time email feedback, may be an effective mechanism to advance evidence-based opioid prescribing, as it retains flexibility and provider autonomy while encouraging data-driven decision making.

BACKGROUND: Emergency physician-performed ultrasound-guided nerve blocks are becoming more commonplace as an integral component of multimodal analgesia. Ultrasound-guided nerve blocks (UGNBs) can be used to safely and effectively treat pain from commonly encountered pathologies or to facilitate procedures.

OBJECTIVES: There is, currently, variability in the use of nerve blocks in emergency departments (ED) based on training, comfort, and resources; however, it is likely that this method of analgesia will continue to expand into ED practice. In this piece, we review the evidence for several high-utility nerve blocks that have been successfully used in the ED.

DISCUSSION: In this article, we specifically review the superficial cervical plexus block, interscalene brachial plexus nerve block, serratus anterior plane block, erector spinae plane block, pericapsular nerve block, and transgluteal sciatic nerve block.

CONCLUSION: UGNBs are increasingly being incorporated into ED patient care and becoming a critical tool as a part of an opioid reduction strategy. The group of UGNBs listed in this article represent a list of commonly performed blocks and should be considered when offering optimal multimodal analgesia to the acutely injured patient.