Sarah R. Williams MD, MHPE, PCC, BCC

All Publications

• Pitfalls in the Use of Ocular Ultrasound for Evaluation of Acute Vision Loss. journal of emergency medicine Schott, M. L., Pierog, J. E., Williams, S. R. 2013; 44 (6): 1136-1139

  Abstract

  Retinal detachment is a true medical emergency. It is a time-critical, vision-threatening disease often first evaluated in the Emergency Department (ED). Diagnosis can be extremely challenging and confused with other ocular pathology. Several entities can mimic retinal detachment, including posterior vitreous detachment and vitreous hemorrhage. Ocular ultrasound can assist the emergency physician in evaluating intraocular pathology, and it is especially useful in situations where fundoscopic examination is technically difficult or impossible. Accurate and rapid diagnosis of retinal detachment can lead to urgent consultation and increase the likelihood of timely vision-sparing treatment.This case demonstrates both the utility of ocular ultrasound in the accurate and timely diagnosis of retinal detachment and potential pitfalls in the evaluation of intraocular pathology in the ED.A 38-year-old woman presented with acute onset of bilateral visual loss that was concerning for retinal detachment. Rapid evaluation of the intraocular space was performed using bedside ocular ultrasound. Bedside ocular ultrasound correctly diagnosed retinal detachment in the right eye. Posterior vitreous detachment in the left eye was incorrectly diagnosed as retinal detachment.This case illustrates the importance of bedside ocular ultrasound and highlights some of the pitfalls that can occur when evaluating for retinal detachment. Following is a discussion regarding methods to distinguish retinal detachment from vitreous hemorrhage and posterior vitreous detachment.

  View details for DOI 10.1016/j.jemermed.2012.11.079

  View details for PubMedID 23522956

• FOCUSED CARDIAC ULTRASOUND TRAINING: HOW MUCH IS ENOUGH? JOURNAL OF EMERGENCY MEDICINE Chisholm, C. B., Dodge, W. R., Balise, R. R., Williams, S. R., Gharahbaghian, L., Beraud, A. 2013; 44 (4): 818-822

  Abstract

  Focused transthoracic echocardiography (F-TTE) is an important tool to assess hemodynamically unstable patients in the Emergency Department. Although its scope has been defined by the American College of Emergency Physicians, more research is needed to define an optimal F-TTE training program, including assessment of proficiency.The goal of this study was to determine the effectiveness of current standards in post-residency training to reach proficiency in F-TTE.Fourteen staff Emergency Physicians were enrolled in a standardized teaching curriculum specifically designed to meet the 2008 American College of Emergency Physicians' guidelines for general ultrasound training applied to echocardiography. This training program consisted of 6 h of didactics and 6 h of scanning training, followed by independent scanning over a 5-month period. Acquisition of echocardiographic knowledge was assessed by an online pre- and post-test. At the conclusion of the study, a hands-on skills test assessed the trainees' ability to perform and interpret F-TTE.Ninety percent of trainees passed the written post-test. Two views, the parasternal long and short axis, were easily obtainable, regardless of the level of training or the number of ultrasounds completed. Other views were more difficult to master, but strong trends toward increased competency were evident after 10 h of mixed didactic and scanning training and > 45 ultrasounds.A short, 12-h didactic training in F-TTE provided proficiency in image interpretation and in obtaining adequate images from the parasternal window. More extensive training is needed to master the apical and subcostal windows in a timely manner.

  View details for DOI 10.1016/j.jemermed.2012.07.092

  View details for PubMedID 23351569

• Developing and Assessing Initiatives Designed to Improve Clinical Teaching Performance ACADEMIC EMERGENCY MEDICINE Khandelwal, S., Bernard, A. W., Wald, D. A., Manthey, D. E., Fisher, J., Ankel, F., Williams, S. R., Szyld, D., Riddle, J., Ericsson, K. A. 2012; 19 (12): 1350-1353

  Abstract

  To improve the teaching performance of emergency physicians, it is necessary to understand the attributes of expert teachers and the optimal methods to deliver faculty development. A working group of medical educators was formed to review the literature, summarize what is known on the topic, and provide recommendations for future research. This occurred as a track of the 2012 Academic Emergency Medicine (AEM) consensus conference "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success." The group concluded that the current state of research on these topics is limited. Improvement in understanding will come through research focusing on Kirkpatrick's higher levels of evaluation (behavior and results).

  View details for DOI 10.1111/acem.12029

  View details for Web of Science ID 000312740100007

• USE OF CADAVER MODELS IN POINT-OF-CARE EMERGENCY ULTRASOUND EDUCATION FOR DIAGNOSTIC APPLICATIONS JOURNAL OF EMERGENCY MEDICINE Zaia, B. E., Briese, B., Williams, S. R., Gharahbaghian, L. 2012; 43 (4): 683-691

  Abstract

  As the use of bedside emergency ultrasound (US) increases, so does the need for effective US education.To determine 1) what pathology can be reliably simulated and identified by US in human cadavers, and 2) feasibility of using cadavers to improve the comfort of emergency medicine (EM) residents with specific US applications.This descriptive, cross-sectional survey study assessed utility of cadaver simulation to train EM residents in diagnostic US. First, the following pathologies were simulated in a cadaver: orbital foreign body (FB), retrobulbar (RB) hematoma, bone fracture, joint effusion, and pleural effusion. Second, we assessed residents' change in comfort level with US after using this cadaver model. Residents were surveyed regarding their comfort level with various US applications. After brief didactic sessions on the study's US applications, participants attempted to identify the simulated pathology using US. A post-lab survey assessed for change in comfort level after the training.Orbital FB, RB hematoma, bone fracture, joint effusion, and pleural effusion were readily modeled in a cadaver in ways typical of a live patient. Twenty-two residents completed the pre- and post-lab surveys. After training with cadavers, residents' comfort improved significantly for orbital FB and RB hematoma (mean increase 1.6, p<0.001), bone fracture (mean increase 2.12, p<0.001), and joint effusion (1.6, p<0.001); 100% of residents reported that they found US education using cadavers helpful.Cadavers can simulate orbital FB, RB hematoma, bone fracture, joint effusion, and pleural effusion, and in our center improved the comfort of residents in identifying all but pleural effusion.

  View details for DOI 10.1016/j.jemermed.2012.01.057

  View details for PubMedID 22504086

• D-Dimer Is Not Elevated in Asymptomatic High Altitude Climbers after Descent to 5340 m: The Mount Everest Deep Venous Thrombosis Study (Ev-DVT) HIGH ALTITUDE MEDICINE & BIOLOGY Zafren, K., Feldman, J., Becker, R. J., Williams, S. R., Weiss, E. A., Deloughery, T. 2011; 12 (3): 223-227

  Abstract

  We performed this study to determine the prevalence of elevated D-dimer, a marker for deep venous thrombosis (DVT), in asymptomatic high altitude climbers. On-site personnel enrolled a convenience sample of climbers at Mt. Everest Base Camp (Nepal), elevation 5340 m (17,500 ft), during a single spring climbing season. Subjects were enrolled after descent to base camp from higher elevation. The subjects completed a questionnaire to evaluate their risk factors for DVT. We then performed a D-dimer test in asymptomatic individuals. If the D-dimer test was negative, DVT was considered ruled out. Ultrasound was available to perform lower-extremity compression ultrasounds to evaluate for DVT in case the D-dimer was positive. We enrolled 76 high altitude climbers. None had a positive D-dimer test. The absence of positive D-dimer tests suggests a low prevalence of DVT in asymptomatic high altitude climbers.

  View details for DOI 10.1089/ham.2010.1101

  View details for PubMedID 21962065

• Acetazolamide fails to decrease pulmonary artery pressure at high altitude in partially acclimatized humans HIGH ALTITUDE MEDICINE & BIOLOGY Basnyat, B., Hargrove, J., Holck, P. S., Srivastav, S., Alekh, K., Ghimire, L. V., Pandey, K., Griffiths, A., Shankar, R., Kaul, K., Paudyal, A., Stasiuk, D., Basnyat, R., Davis, C., Southard, A., Robinson, C., Shandley, T., Johnson, D. W., Zafren, K., Williams, S., Weiss, E. A., Farrar, J. J., Swenson, E. R. 2008; 9 (3): 209-216

  Abstract

  In this randomized, double-blind placebo controlled trial our objectives were to determine if acetazolamide is capable of preventing high altitude pulmonary edema (HAPE) in trekkers traveling between 4250 m (Pheriche)\4350 m (Dingboche) and 5000 m (Lobuje) in Nepal; to determine if acetazolamide decreases pulmonary artery systolic pressures (PASP) at high altitude; and to determine if there is an association with PASP and signs and symptoms of HAPE. Participants received either acetazolamide 250 mg PO BID or placebo at Pheriche\Dingboche and were reassessed in Lobuje. The Lake Louise Consensus Criteria were used for the diagnosis of HAPE, and cardiac ultrasonography was used to measure the velocity of tricuspid regurgitation and estimate PASP. Complete measurements were performed on 339 of the 364 subjects (164 in the placebo group, 175 in the acetazolamide group). No cases of HAPE were observed in either study group nor were differences in the signs and symptoms of HAPE found between the two groups. Mean PASP values did not differ significantly between the acetazolamide and placebo groups (31.3 and 32.6 mmHg, respectively). An increasing number of signs and symptoms of HAPE was associated with elevated PASP (p < 0.01). The efficacy of acetazolamide against acute mountain sickness, however, was significant with a 21.9% incidence in the placebo group compared to 10.2 % in the acetazolamide group (p < 0.01). Given the lack of cases of HAPE in either group, we can draw no conclusions about the efficacy of acetazolamide in preventing HAPE, but the absence of effect on PASP suggests that any effect may be minor possibly owing to partial acclimatization during the trek up to 4200 m.

  View details for DOI 10.1089/ham.2007.1073

  View details for Web of Science ID 000259759600004

  View details for PubMedID 18800957

• Airway Ultrasound: Confirming Endotracheal Intubation with Color Doppler Ultrasound Academic Emergency Medicine Williams SR, Gharahbaghian L, Wu T, Goodwin T, Harter K, Angelotti T, Jeffrey RB, Auerbach P 2008; May (abstract)
• Ultrasonographic diagnosis of retinal detachment in the emergency department Ann Emerg Med. Lewin MR, Williams SR, Ahuja Y 2005; 45 (1): 97-8
• Confirmation of endotracheal intubation using color-Doppler ultrasound. 2nd World Congress in Emergency and Critical Care Ultrasound, Abstract Book, 2006. Abstract 4 Williams SR, Wu T, Jeffrey B, Angelotti T, Auerbach PS
• Tips for developing a coaching program in medical education. Medical education online Miller-Kuhlmann, R., Sasnal, M., Gold, C. A., Nassar, A. K., Korndorffer, J. R., Van Schaik, S., Marmor, A., Williams, S., Blankenburg, R., Rassbach, C. E. 2024; 29 (1): 2289262

  Abstract

  This article provides structure to developing, implementing, and evaluating a successful coaching program that effectively meets the needs of learners. We highlight the benefits of coaching in medical education and recognize that many educators desiring to build coaching programs seek resources to guide this process. We align 12 tips with Kern's Six Steps for Curriculum Development and integrate theoretical frameworks from the literature to inform the process. Our tips include defining the reasons a coaching program is needed, learning from existing programs and prior literature, conducting a needs assessment of key stakeholders, identifying and obtaining resources, developing program goals, objectives, and approach, identifying coaching tools, recruiting and training coaches, orienting learners, and evaluating program outcomes for continuous program improvement. These tips can serve as a framework for initial program development as well as iterative program improvement.

  View details for DOI 10.1080/10872981.2023.2289262

  View details for PubMedID 38051864

• Assessing Team Performance: A Mixed-Methods Analysis Using Interprofessional in situ Simulation. The western journal of emergency medicine Rider, A. C., Williams, S. R., Jones, V., Rebagliati, D., Schertzer, K., Gisondi, M. A., Sebok-Syer, S. S. 2024; 25 (4): 557-564

  Abstract

  Optimizing the performance of emergency department (ED) teams impacts patient care, but the utility of current, team-based performance assessment tools to comprehensively measure this impact is underexplored. In this study we aimed to 1) evaluate ED team performance using current team-based assessment tools during an interprofessional in situ simulation and 2) identify characteristics of effective ED teams.This mixed-methods study employed case study methodology based on a constructivist paradigm. Sixty-three eligible nurses, technicians, pharmacists, and postgraduate year 2-4 emergency medicine residents at a tertiary academic ED participated in a 10-minute in situ simulation of a critically ill patient. Participants self-rated performance using the Team Performance Observation Tool (TPOT) 2.0 and completed a brief demographic form. Two raters independently reviewed simulation videos and rated performance using the TPOT 2.0, Team Emergency Assessment Measure (TEAM), and Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS). Following simulations, we conducted semi-structured interviews and focus groups with in situ participants. Transcripts were analyzed using thematic analysis.Eighteen team-based simulations took place between January-April 2021. Raters' scores were on the upper end of the tools for the TPOT 2.0 (R1 4.90, SD 0.17; R2 4.53, SD 0.27, IRR [inter-rater reliability] 0.47), TEAM (R1 3.89, SD 0.19; R2 3.58, SD 0.39, IRR 0.73), and Ottawa GRS (R1 6.6, SD 0.56; R2 6.2, SD 0.54, IRR 0.68). We identified six themes from our interview data: team member entrustment; interdependent energy; leadership tone; optimal communication; strategic staffing; and simulation empowering team performance.Current team performance assessment tools insufficiently discriminate among high performing teams in the ED. Emergency department-specific assessments that capture features of entrustability, interdependent energy, and leadership tone may offer a more comprehensive way to assess an individual's contribution to a team's performance.

  View details for DOI 10.5811/westjem.18012

  View details for PubMedID 39028241

• Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs. BMC medical education Williams, S. R., Sebok-Syer, S. S., Caretta-Weyer, H., Katznelson, L., Dohn, A. M., Park, Y. S., Gisondi, M. A., Tekian, A. 2023; 23 (1): 434

  Abstract

  Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions.Using a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees' experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses.687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame.Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.

  View details for DOI 10.1186/s12909-023-04355-5

  View details for PubMedID 37312085

• The OSSE: Development and validation of an "Objective Structured Supervision Evaluation". AEM education and training Pokrajac, N., Roszczynialski, K. N., Rider, A., Poffenberger, C. M., Williams, S., Eakin, M. K., Sapp, R. W., Jenkins, E., Gisondi, M. A., Schertzer, K. 2022; 6 (4): e10784

  Abstract

  Trainee supervision and teaching are distinct skills that both require faculty physician competence to ensure patient safety. No standard approach exists to teach physician supervisory competence, resulting in variable trainee oversight and safety threats. The Objective Structured Teaching Evaluation (OSTE) does not adequately incorporate the specific skills required for effective supervision. To address this continuing medical education gap, the authors aimed to develop and identify validity evidence for an "Objective Structured Supervision Evaluation" (OSSE) for attending physicians, conceptually modeled on the historic OSTE.An expert panel used an iterative process to create an OSSE instrument, which was a checklist of key supervision items to be evaluated during a simulated endotracheal intubation scenario. Three trained "standardized residents" scored faculty participants' performance using the instrument. Validity testing modeled a contemporary approach using Kane's framework. Participants underwent simulation-based mastery learning (SBML) with deliberate practice until meeting a minimum passing standard (MPS).The final instrument contained 19 items, including three global rating measures. Testing domains included supervision climate, participant control of patient care, trainee evaluation, instructional skills, case-specific measures, and overall supervisor rating. Reliability of the assessment tool was excellent (ICC range 0.84-0.89). The assessment tool had good internal consistency (Cronbach's α = 0.813). Out of 24 faculty participants, 17 (70.8%) met the MPS on initial assessment. All met the MPS after SBML and average score increased by 19.5% (95% CI of the difference 10.3%-28.8%, p = 0.002).

  View details for DOI 10.1002/aet2.10784

  View details for PubMedID 35903423

  View details for PubMedCentralID PMC9305721

• The OSSE: Development and validation of an "Objective Structured Supervision Evaluation" AEM EDUCATION AND TRAINING Pokrajac, N., Roszczynialski, K. N., Rider, A., Poffenberger, C., Williams, S., Eakin, M., Sapp, R. W., Jenkins, E., Gisondi, M. A., Schertzer, K. 2022; 6 (4)

  View details for DOI 10.1002/aet2.10784

  View details for Web of Science ID 000828655600001

• A Brief Coaching Pilot Enhances Professional Identity Formation and Clinical Skills Acquisition During Emergency Medicine Clerkships Shortened by COVID-19. The western journal of emergency medicine Dixon, W., Gallegos, M., Williams, S. 1800; 23 (1): 30-32

  Abstract

  INTRODUCTION: The Covid-19 pandemic limited educational and career development opportunities for medical students, requiring innovative programs to accelerate professional identity formation and clinical skills acquisition.METHODS: We developed a brief coaching intervention that took place over the advanced (sub-internship) emergency medicine rotation at our institution. We trained coaches using a newly developed workshop, who met with students for an average of 4.5 hours over 3 weeks.IMPACT/EFFECTIVENESS: We showed that this coaching program was both feasible and impactful for faculty coaches and medical students.

  View details for DOI 10.5811/westjem.2021.12.53917

  View details for PubMedID 35060857

• Mastery learning improves simulated central venous catheter insertion by emergency medicine teaching faculty Academic Emergency Medicine Education & Training Pokrajac, N., Schertzer, K., Rosczcnyialski, K. N., Rider, A., Williams, S. R., Poffenberger, C. M., Gisondi, M. A. 2021

  View details for DOI 10.1002/aet2.10703

• The Utility of Color Doppler to Confirm Endotracheal Tube Placement: A Pilot Study. The western journal of emergency medicine Gildea, T. H., Anderson, K. L., Niknam, K. R., Gharahbaghian, L., Williams, S. R., Angelotti, T., Auerbach, P. S., Lobo, V. 2020; 21 (4): 871–76

  Abstract

  INTRODUCTION: Grayscale ultrasound (US) imaging has been used as an adjunct for confirming endotracheal tube (ETT) placement in recent years. The addition of color Doppler imaging (CDI) has been proposed to improve identification but has not been well studied. The aim of this study was to assess whether CDI improves correct localization of ETT placement.METHODS: A convenience sample of emergency and critical care physicians at various levels of training and experience participated in an online assessment. Participants viewed US video clips of patients, which included either tracheal or esophageal intubations captured in grayscale or with CDI; there were five videos of each for a total of 20 videos. Participants were asked to watch each clip and then assess the location of the ETT.RESULTS: Thirty-eight subjects participated in the online assessment. Levels of training included medical students (13%), emergency medicine (EM) residents (50%), EM attendings (32%), and critical care attendings (5%). The odds ratio of properly assessing tracheal placement using color relative to a grayscale imaging technique was 1.5 (p = 0.21). Regarding the correct assessment of esophageal placement, CDI had 1.4 times the odds of being correctly assessed relative to grayscale (p = 0.26). The relationship between training level and correct assessments was not significant for either tracheal or esophageal placements.CONCLUSION: In this pilot study we found no significant improvement in correct identification of ETT placement using color Doppler compared to grayscale ultrasound; however, there was a trend toward improvement that might be better elucidated in a larger study.

  View details for DOI 10.5811/westjem.2020.5.45588

  View details for PubMedID 32726258

• Comparison of the Standardized Video Interview and Interview Assessments of Professionalism and Interpersonal Communication Skills in Emergency Medicine. AEM education and training Hopson, L. R., Dorfsman, M. L., Branzetti, J., Gisondi, M. A., Hart, D., Jordan, J., Cranford, J. A., Williams, S. R., Regan, L. 2019; 3 (3): 259–68

  Abstract

  Objectives: The Association of American Medical Colleges Standardized Video Interview (SVI) was recently added as a component of emergency medicine (EM) residency applications to provide additional information about interpersonal communication skills (ICS) and knowledge of professionalism (PROF) behaviors. Our objective was to ascertain the correlation between the SVI and residency interviewer assessments of PROF and ICS. Secondary objectives included examination of 1) inter- and intrainstitutional assessments of ICS and PROF, 2) correlation of SVI scores with rank order list (ROL) positions, and 3) the potential influence of gender on interview day assessments.Methods: We conducted an observational study using prospectively collected data from seven EM residency programs during 2017 and 2018 using a standardized instrument. Correlations between interview day PROF/ICS scores and the SVI were tested. A one-way analysis of variance was used to analyze the association of SVI and ROL position. Gender differences were assessed with independent-groups t-tests.Results: A total of 1,264 interview-day encounters from 773 unique applicants resulted in 4,854 interviews conducted by 151 interviewers. Both PROF and ICS demonstrated a small positive correlation with the SVI score (r=0.16 and r=0.17, respectively). ROL position was associated with SVI score (p<0.001), with mean SVI scores for top-, middle-, and bottom-third applicants being 20.9, 20.5, and 19.8, respectively. No group differences with gender were identified on assessments of PROF or ICS.Conclusions: Interview assessments of PROF and ICS have a small, positive correlation with SVI scores. These residency selection tools may be measuring related, but not redundant, applicant characteristics. We did not identify gender differences in interview assessments.

  View details for DOI 10.1002/aet2.10346

  View details for PubMedID 31360819

• The Birth of a Return to work Policy for New Resident Parents in Emergency Medicine ACADEMIC EMERGENCY MEDICINE Gordon, A., Sebok-Syer, S. S., Dohn, A. M., Smith-Coggins, R., Wang, N., Williams, S. R., Gisondi, M. A. 2019; 26 (3): 317–26

  View details for DOI 10.1111/acem.13684

  View details for Web of Science ID 000461220000006

• The Birth of a Return to Work Policy for New Resident Parents in Emergency Medicine. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Gordon, A. J., Sebok-Syer, S., Dohn, A. M., Smith-Coggins, R., Wang, N. E., Williams, S. R., Gisondi, M. A. 2019

  Abstract

  OBJECTIVE: With the rising number of female physicians, there will be more children than ever born in residency and the current system is inadequate to handle this increase in new resident parents. Residency is stressful and rigorous in isolation, let alone when pregnant or with a new child. Policies that ease these stressful transitions are generally either insufficient or do not exist. Therefore, we created a comprehensive Return to Work Policy for resident parents and piloted its implementation. Our policy aims to: 1) establish a clear, shared understanding of the regulatory and training requirements as they pertain to parental leave, 2) facilitate a smooth transition for new parents returning back to work, and 3) summarize the local and institutional resources available for both males and females during residency training.METHOD: In Fall 2017, a task force was convened to draft a Return to Work Policy for New Resident Parents. The task force included 9 key stakeholders (i.e., residents, faculty, and administration) at our institution and was made up of 3 Graduate Medical Education (GME) Program Directors, a Vice Chair of Education, a Designated Institutional Official (DIO), a Chief Resident, and 3 members of our academic department's Faculty Affairs Committee. The task force was selected because of individual expertise in gender equity issues, mentorship of resident parents, GME, and departmental administration.RESULTS: After development, the policy was piloted from November 2017 to June 2018. Our pilot implementation period included 7 new resident parents. All of these residents received schedules that met the return to work scheduling terms of our Return to Work Policy including no overnight shifts, no sick call, no more than 3 shifts in a row. Of equal importance, throughout our pilot, the emergency department schedules at all of our clinical sites remained fully staffed and our sick call pool was unaffected.CONCLUSION: Our Return to Work Policy for New Resident Parents provides a comprehensive guide to training requirements and family leave policies, an overview of available resources, and a scheduling framework that makes for a smooth transition back to clinical duties. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30636353

• The Council of Emergency Medicine Residency Directors Speaker Evaluation Form for Medical Conference Planners. AEM education and training Phillips, A. W., Diller, D., Williams, S., Park, Y. S., Fisher, J., Biese, K., Ufberg, J. 2017; 1 (4): 340–45

  Abstract

  Objectives: No summative speaker evaluation form with validity and reliability evidence currently exists in the English medical education literature specifically to help conference planners make future decisions on speakers. We seek to perform a proof-of-concept evaluation of a concise, effective evaluation form to be filled out by audience members to aid conference planners.Methods: We created the Council of Emergency Medicine Residency Directors (CORD-EM) form, a novel, three-question speaker evaluation form for the CORD-EM national conference and evaluated it for proof of concept. The CORD-EM form was analyzed with three evaluators and randomized to select only two evaluators' ratings to make results more generalizable to a generic audience evaluating the speaker.Results: Forty-six total evaluations ranged from 6 to 9 (mean ± standard deviation = 8.1 ± 1.2). The form demonstrated excellent internal consistency (Cronbach's alpha = 0.923) with good inter-rater reliability (intraclass correlation = 0.617) in the conference context.Conclusions: The CORD-EM speaker evaluation form is, to our knowledge, the first evaluation form with early reliability and validity evidence specifically designed to help conference planners. Our results suggest that a short speaker evaluation form can be an effective instrument in the toolbox for conference planners.

  View details for PubMedID 30051053

• The Council of Emergency Medicine Residency Directors Speaker Evaluation Form for Medical Conference Planners AEM EDUCATION AND TRAINING Phillips, A. W., Diller, D., Williams, S., Park, Y., Fisher, J., Biese, K., Ufberg, J. 2017; 1 (4): 340-345

  View details for DOI 10.1002/aet2.10051

  View details for Web of Science ID 000770013100011

• Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam. The western journal of emergency medicine Lobo, V., Hunter-Behrend, M., Cullnan, E., Higbee, R., Phillips, C., Williams, S., Perera, P., Gharahbaghian, L. 2017; 18 (2): 270-280

  Abstract

  The focused assessment with sonography in trauma (FAST) exam is a critical diagnostic test for intraperitoneal free fluid (FF). Current teaching is that fluid accumulates first in Morison's pouch. The goal of this study was to evaluate the "sub-quadrants" of traditional FAST views to determine the most sensitive areas for FF accumulation.We analyzed a retrospective cohort of all adult trauma patients who had a recorded FAST exam by emergency physicians at a Level I trauma center from January 2012 - June 2013. Ultrasound fellowship-trained faculty with three emergency medicine residents reviewed all FAST exams. We excluded studies if they were incomplete, of poor image quality, or with incorrect medical record information. Positive studies were assessed for FF localization, comparing the traditional abdominal views and on a sub-quadrant basis: right upper quadrant (RUQ)1 - hepato-diaphragmatic; RUQ2 - Morison's pouch; RUQ3 - caudal liver edge and superior paracolic gutter; left upper quadrant (LUQ)1 - splenic-diaphragmatic; LUQ2 - spleno-renal; LUQ3 - around inferior pole of kidney; suprapubic area (SP)1 - bilateral to bladder; SP2 - posterior to bladder; SP3 - posterior to uterus (females). FAST results were confirmed by chart review of computed tomography results or operative findings.Of the included 1,008 scans, 48 (4.8%) were positive. The RUQ was the most positive view with 32/48 (66.7%) positive. In the RUQ sub-quadrant analysis, the most positive view was the RUQ3 with 30/32 (93.8%) positive.The RUQ is most sensitive for FF assessment, with the superior paracolic gutter area around the caudal liver edge (RUQ3) being the most positive sub-quadrant within the RUQ.

  View details for DOI 10.5811/westjem.2016.11.30435

  View details for PubMedID 28210364

• Reply. Journal of ultrasound in medicine Kanaan, N. C., Lipman, G. S., Constance, B. B., Holck, P. S., Preuss, J. F., Williams, S. R. 2016; 35 (2): 456-457

  View details for DOI 10.7863/ultra.15.10050

  View details for PubMedID 26795047

• Handoff Practices in Emergency Medicine: Are We Making Progress? ACADEMIC EMERGENCY MEDICINE Hern, H. G., Gallahue, F. E., Burns, B. D., Druck, J., Jones, J., Kessler, C., Knapp, B., Williams, S. 2016; 23 (2): 197-201

  Abstract

  Transitions of care present a risk for communication error and may adversely affect patient care. This study addresses the scope of current handoff practices amongst U.S. emergency medicine (EM) residents. In addition, it evaluates current educational and evaluation practices related to handoffs. Given the ever-increasing emphasis on transitions of care in medicine, we sought to determine if interval changes in resident transition of care education, assessment, and proficiency have occurred.This was a cross-sectional survey study guided by the Kern model for medical curriculum development. The Council of Residency Directors Listserv provided access to 175 programs. The survey focused on elucidating current practices of handoffs from emergency physicians (EPs) to EPs, including handoff location and duration, use of any assistive tools, and handoff documentation in the emergency department (ED) patient's medical record. Multiple-choice questions were the primary vehicle for the response process. A four-point Likert-type scale was used in questions regarding perceived satisfaction and competency. Respondents were not required to answer all questions. Responses were compared to results from a similar 2011 study for interval changes.A total of 127 of 175 programs responded to the survey, making the overall response rate 72.6%. Over half of respondents (72 of 125, 57.6%) indicated that their ED uses a standardized handoff protocol, which is a significant increase from 43.2% in 2011 (p = 0.018). Of the programs that do have a standardized system, a majority (72 of 113, 63.7%) of resident physicians use it regularly. Significant increases were noted in the number of programs offering formal training during orientation (73.2% from 59.2%; p = 0.015), decreases in the number of programs offering no training (2.4% from 10.2%; p = 0.013), and no assessment of proficiency (51.5% from 69.8%; p = 0.006). No significant interval changes were noted in handoffs being documented in the patient's medical record (57.4%), the percentage of computer/electronic signouts, or the level of dissatisfaction with handoff tools (54.1%). Less than two-thirds of respondents (80 of 126, 63.5%) indicated that their residents were "competent" or "extremely competent" in delivering and receiving handoffs.An insufficient level of handoff training is currently mandated or available for EM residents, and their handoff skills appear to be developed mostly informally throughout residency training with varying results. Programs that have created a standardized protocol are not ensuring that the protocol is actually being employed in the clinical arena. Handoff proficiency most often goes unevaluated, although it is improved from 2011.

  View details for DOI 10.1111/acem.12867

  View details for PubMedID 26765246

• Reply. Journal of ultrasound in medicine Kanaan, N. C., Lipman, G. S., Constance, B. B., Holck, P. S., Preuss, J. F., Williams, S. R. 2016; 35 (2): 458-459

  View details for DOI 10.7863/ultra.15.11073

  View details for PubMedID 26795049

• Optic Nerve Sheath Diameter Increase on Ascent to High Altitude Correlation With Acute Mountain Sickness JOURNAL OF ULTRASOUND IN MEDICINE Kanaan, N. C., Lipman, G. S., Constance, B. B., Hoick, P. S., Preuss, J. F., Williams, S. R. 2015; 34 (9): 1677-1682

  Abstract

  Elevated optic nerve sheath diameter on sonography is known to correlate with increased intracranial pressure and is observed in acute mountain sickness. This study aimed to determine whether optic nerve sheath diameter changes on ascent to high altitude are associated with acute mountain sickness incidence.Eighty-six healthy adults enrolled at 1240 m (4100 ft), drove to 3545 m (11,700 ft) and then hiked to and slept at 3810 m (12,500 ft). Lake Louise Questionnaire scores and optic nerve sheath diameter measurements were taken before, the evening of, and the morning after ascent.The incidence of acute mountain sickness was 55.8%, with a mean Lake Louise Questionnaire score ± SD of 3.81 ± 2.5. The mean maximum optic nerve sheath diameter increased on ascent from 5.58 ± 0.79 to 6.13 ± 0.73 mm, a difference of 0.91 ± 0.55 mm (P = .09). Optic nerve sheath diameter increased at high altitude regardless of acute mountain sickness diagnosis; however, compared to baseline values, we observed a significant increase in diameter only in those with a diagnosis of acute mountain sickness (0.57 ± 0.77 versus 0.21 ± 0.76 mm; P = .04). This change from baseline, or Δ optic nerve sheath diameter, was associated with twice the odds of developing acute mountain sickness (95% confidence interval, 1.08-3.93).The mean optic nerve sheath diameter increased on ascent to high altitude compared to baseline values, but not to a statistically significant degree. The magnitude of the observed Δ optic nerve sheath diameter was positively associated with acute mountain sickness diagnosis. No such significant association was found between acute mountain sickness and diameter elevation above standard cutoff values, limiting the utility of sonography as a diagnostic tool.

  View details for DOI 10.7863/ultra.15.14.10060

  View details for Web of Science ID 000360777600021

• Optic Nerve Sheath Diameter Increase on Ascent to High Altitude: Correlation With Acute Mountain Sickness. Journal of ultrasound in medicine Kanaan, N. C., Lipman, G. S., Constance, B. B., Holck, P. S., Preuss, J. F., Williams, S. R. 2015; 34 (9): 1677-1682

  Abstract

  Elevated optic nerve sheath diameter on sonography is known to correlate with increased intracranial pressure and is observed in acute mountain sickness. This study aimed to determine whether optic nerve sheath diameter changes on ascent to high altitude are associated with acute mountain sickness incidence.Eighty-six healthy adults enrolled at 1240 m (4100 ft), drove to 3545 m (11,700 ft) and then hiked to and slept at 3810 m (12,500 ft). Lake Louise Questionnaire scores and optic nerve sheath diameter measurements were taken before, the evening of, and the morning after ascent.The incidence of acute mountain sickness was 55.8%, with a mean Lake Louise Questionnaire score ± SD of 3.81 ± 2.5. The mean maximum optic nerve sheath diameter increased on ascent from 5.58 ± 0.79 to 6.13 ± 0.73 mm, a difference of 0.91 ± 0.55 mm (P = .09). Optic nerve sheath diameter increased at high altitude regardless of acute mountain sickness diagnosis; however, compared to baseline values, we observed a significant increase in diameter only in those with a diagnosis of acute mountain sickness (0.57 ± 0.77 versus 0.21 ± 0.76 mm; P = .04). This change from baseline, or Δ optic nerve sheath diameter, was associated with twice the odds of developing acute mountain sickness (95% confidence interval, 1.08-3.93).The mean optic nerve sheath diameter increased on ascent to high altitude compared to baseline values, but not to a statistically significant degree. The magnitude of the observed Δ optic nerve sheath diameter was positively associated with acute mountain sickness diagnosis. No such significant association was found between acute mountain sickness and diameter elevation above standard cutoff values, limiting the utility of sonography as a diagnostic tool.

  View details for DOI 10.7863/ultra.15.14.10060

  View details for PubMedID 26269295

• Development and Evaluation of Standardized Narrative Cases Depicting the General Surgery Professionalism Milestones. Academic medicine Rawlings, A., Knox, A. D., Park, Y. S., Reddy, S., Williams, S. R., Issa, N., Jameel, A., Tekian, A. 2015; 90 (8): 1109-1115

  Abstract

  Residency programs now are required to use educational milestones, which has led to the need for new methods of assessment. The literature suggests that narrative cases are a promising tool to track residents' progress. This study demonstrates the process for developing and evaluating narrative cases representing the five levels of the professionalism milestones.In 2013, the authors identified 28 behaviors in the Accreditation Council for Graduate Medical Education general surgery professionalism milestones. They modified previously published narrative cases to fit these behaviors. To evaluate the quality of these cases, the authors developed a 28-item, five-point scale instrument, which 29 interdisciplinary faculty completed. The authors compared the faculty ratings by narrative case and specialty with the authors' initial rankings of the cases by milestone level. They used t tests and analysis of variance to compare mean scores across specialties.The authors developed 10 narrative cases, 2 for each of the 5 milestone levels. Each case contained at least 20 of the 28 behaviors identified in the milestones. Mean faculty ratings matched the milestone levels. Reliability was good (G coefficient = 0.86, phi coefficient = 0.85), indicating consistency in raters' ability to determine the proper milestone level for each case.The authors demonstrate a process for using specialty-specific milestones to develop narrative cases that map to a spectrum of professionalism behaviors. This process can be applied to other competencies and specialties to facilitate faculty awareness of resident performance descriptors and provide a frame of reference for milestones assessment.

  View details for DOI 10.1097/ACM.0000000000000739

  View details for PubMedID 25922918

• Prehospital Evaluation of Effusion, Pneumothorax, and Standstill (PEEPS): Point-of-care Ultrasound in Emergency Medical Services. The western journal of emergency medicine Bhat, S. R., Johnson, D. A., Pierog, J. E., Zaia, B. E., Williams, S. R., Gharahbaghian, L. 2015; 16 (4): 503-509

  Abstract

  In the United States, there are limited studies regarding use of prehospital ultrasound (US) by emergency medical service (EMS) providers. Field diagnosis of life-threatening conditions using US could be of great utility. This study assesses the ability of EMS providers and students to accurately interpret heart and lung US images.We tested certified emergency medical technicians (EMT-B) and paramedics (EMT-P) as well as EMT-B and EMT-P students enrolled in prehospital training programs within two California counties. Participants completed a pre-test of sonographic imaging of normal findings and three pathologic findings: pericardial effusion, pneumothorax, and cardiac standstill. A focused one-hour lecture on emergency US imaging followed. Post-tests were given to all EMS providers immediately following the lecture and to a subgroup one week later.We enrolled 57 prehospital providers (19 EMT-B students, 16 EMT-P students, 18 certified EMT-B, and 4 certified EMT-P). The mean pre-test score was 65.2%±12.7% with mean immediate post-test score of 91.1%±7.9% (95% CI [22%-30%], p<0.001). Scores significantly improved for all three pathologic findings. Nineteen subjects took the one-week post-test. Their mean score remained significantly higher: pre-test 65.8%±10.7%; immediate post-test 90.5%±7.0% (95% CI [19%-31%], p<0.001), one-week post-test 93.1%±8.3% (95% CI [21%-34%], p<0.001).Using a small sample of EMS providers and students, this study shows the potential feasibility for educating prehospital providers to accurately identify images of pericardial effusion, pneumothorax, and cardiac standstill after a focused lecture.

  View details for DOI 10.5811/westjem.2015.5.25414

  View details for PubMedID 26265961

• Change in Intraocular Pressure During Point-of-Care Ultrasound WESTERN JOURNAL OF EMERGENCY MEDICINE Berg, C., Doniger, S. J., Zaia, B., Williams, S. R. 2015; 16 (2): 263–68

  Abstract

  Point-of-care ocular ultrasound (US) is a valuable tool for the evaluation of traumatic ocular injuries. Conventionally, any maneuver that may increase intraocular pressure (IOP) is relatively contraindicated in the setting of globe rupture. Some authors have cautioned against the use of US in these scenarios because of a theoretical concern that an US examination may cause or exacerbate the extrusion of intraocular contents. This study set out to investigate whether ocular US affects IOP. The secondary objective was to validate the intraocular pressure measurements obtained with the Diaton® as compared with standard applanation techniques (the Tono-Pen®).We enrolled a convenience sample of healthy adult volunteers. We obtained the baseline IOP for each patient by using a transpalpebral tonometer. Ocular US was then performed on each subject using a high-frequency linear array transducer, and a second IOP was obtained during the US examination. A third IOP measurement was obtained following the completion of the US examination. To validate transpalpebral measurement, a subset of subjects also underwent traditional transcorneal applanation tonometry prior to the US examination as a baseline measurement. In a subset of 10 patients, we obtained baseline pre-ultrasound IOP measurements with the Diaton® and Tono-Pen®, and then compared them.The study included 40 subjects. IOP values during ocular US examination were slightly greater than baseline (average +1.8mmHg, p=0.01). Post-US examination IOP values were not significantly different than baseline (average -0.15mmHg, p=0.42). In a subset of 10 subjects, IOP values were not significantly different between transpalpebral and transcorneal tonometry (average +0.03mmHg, p=0.07).In healthy volunteer subjects, point-of-care ocular US causes a small and transient increase in IOP. We also showed no difference between the Diaton® and Tono-Pen® methods of IOP measurement. Overall, the resulting change in IOP with US transducer placement is considerably less than the mean diurnal variation in healthy subjects, or pressure generated by physical examination, and is therefore unlikely to be clinically significant. However, it is important to take caution when performing ocular ultrasound, since it is unclear what the change in IOP would be in patients with ocular trauma.

  View details for PubMedID 25834668

• Cardiac Echocardiography CRITICAL CARE CLINICS Perera, P., Lobo, V., Williams, S. R., Gharahbaghian, L. 2014; 30 (1): 47-?

  Abstract

  Focused cardiac echocardiography has become a critical diagnostic tool for the emergency physician and critical care physician caring for patients in shock and following trauma to the chest, and those presenting with chest pain and shortness of breath,. Cardiac echocardiography allows for immediate diagnosis of pericardial effusions and cardiac tamponade, evaluation of cardiac contractility and volume status, and detection of right ventricular strain possibly seen with a significant pulmonary embolus. This article addresses how to perform cardiac echocardiography using the standard windows, how to interpret a focused goal-directed examination, and how to apply this information clinically at the bedside.

  View details for DOI 10.1016/j.ccc.2013.08.003

  View details for PubMedID 24295841

• Thoracic Ultrasonography CRITICAL CARE CLINICS Lobo, V., Weingrow, D., Perera, P., Williams, S. R., Gharahbaghian, L. 2014; 30 (1): 93-?

  Abstract

  Thoracic ultrasonography (US) has proved to be a valuable tool in the evaluation of the patient with shortness of breath, chest pain, hypoxia, or after chest trauma. Its sensitivity and specificity for detecting disease is higher than that of a chest radiograph, and it can expedite the diagnosis for many emergent conditions. This article describes the technique of each thoracic US application, illustrating both normal and abnormal findings, as well as discussing the literature. Bedside thoracic US has defined imaging benefits in a wide range of thoracic disease, and US guidance has been shown to facilitate thoracic and airway procedures.

  View details for DOI 10.1016/j.ccc.2013.08.002

  View details for PubMedID 24295842

• The FAST and E-FAST in 2013: Trauma Ultrasonography Overview, Practical Techniques, Controversies, and New Frontiers CRITICAL CARE CLINICS Williams, S. R., Perera, P., Gharahbaghian, L. 2014; 30 (1): 119-?

  Abstract

  This article reviews important literature on the FAST and E-FAST examinations in adults. It also reviews key pitfalls, limitations, and controversies. A practical "how-to" guide is presented. Lastly, new frontiers are explored.

  View details for DOI 10.1016/j.ccc.2013.08.005

  View details for PubMedID 24295843

• Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement. The western journal of emergency medicine Jenkins, J. A., Gharahbaghian, L., Doniger, S. J., Bradley, S., Crandall, S., Spain, D. A., Williams, S. R. 2012; 13 (4): 305-311

  Abstract

  Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement.This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigator using first the low-frequency (5-1 MHz) followed by the high-frequency (10-5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation of TT placement.Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10-5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode.Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10-5 MHz) linear transducer.

  View details for DOI 10.5811/westjem.2011.10.6680

  View details for PubMedID 22942927

  View details for PubMedCentralID PMC3421967

• Drug storage and stability (revised), Paul S. Auerbach, editor Wilderness Medicine, Management of Wilderness and Environmental Emergencies, 5th edition Williams SR, Nix D, Patel K 2007
• Ultrasonographic diagnosis of retinal detachment in the emergency department ANNALS OF EMERGENCY MEDICINE Lewin, M. K., Williams, S. R. 2005; 45 (1): 97-98

  View details for DOI 10.1016/j.annemergmed.2004.07.456

  View details for Web of Science ID 000226250100029

  View details for PubMedID 15635323

• Regional vs systemic antivenom administration in the treatment of snake venom poisoning in a rabbit model: A pilot study Research Forum of the American-College-of-Emergency-Physicians Norris, R. L., Dery, R., Johnson, C., Williams, S., Rose, K., Young, L., McDougal, L. R., Bouley, D., Oehlert, J., Thompson, R. C. ALLIANCE COMMUNICATIONS GROUP DIVISION ALLEN PRESS. 2003: 231–35

  Abstract

  To develop a model that compares 2 different routes of antivenom administration (standard intravenous [IV] administration vs regional administration below a tourniquet) to assess their ability to limit muscle necrosis in a rabbit model of rattlesnake venom poisoning.New Zealand white rabbits were randomly assigned to 4 groups. All animals underwent general anesthesia and were then injected intramuscularly (IM) with a sublethal dose of western diamond-back rattlesnake (Crotalus atrox) venom in the right thigh and a similar volume of normal saline (NS) control in the left thigh. Thirty minutes later, standard treatment group animals (n = 4) received 1 vial of reconstituted Antivenin (Crotalidae) Polyvalent (ACP) and 10 mL of NS through an ear vein. Experimental treatment group animals (n = 4) had their lower extremities exsanguinated and isolated by arterial tourniquets. One vial of ACP was then given through a distal IV in the envenomed extremity, and 10 mL of NS was given through an IV in the sham extremity. Tourniquets were removed 30 minutes later. Positive control group animals (n = 2) similarly had their lower extremities exsanguinated and isolated by tourniquets. They then received 10 mL of NS through distal IVs in each lower extremity. Tourniquets were again removed after 30 minutes. Negative control group animals (n = 2) received 2 doses of NS only (10 mL each) through an ear vein. Serum creatinine phosphokinase (CPK) levels were drawn at baseline and 48 hours following venom injection. At 48 hours, the animals were injected with technetium pyrophosphate. Two hours later, they were euthanized, and the lower extremities were scanned to determine levels of radionucleotide uptake in envenomed muscles compared to contralateral sham-injected muscles. The anterior thigh muscle groups were then removed, fixed, stained, sectioned, and analyzed in a blinded fashion by a veterinary pathologist for muscle necrosis grading.There was no evidence of statistically significant differences in changes in serum CPK levels (from baseline to 48 hours), technetium pyrophosphate uptake ratios (right leg/left leg), or muscle necrosis indices in any 2-group analysis.Results of this pilot study do not suggest any beneficial effect of ACP, in the dose and routes used, in limiting local muscle necrosis following IM rattlesnake venom poisoning in the rabbit model.

  View details for PubMedID 14719857

• Please see full list of publications on attached CV (1992-present). (Under photo above) Williams SR 1992