AEM Early Access

AEM Early Access 19: Threat Perceptions in the Emergency Department

Welcome to the nineteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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Development and Validation of a Measure to Assess Patients’ Threat Perceptions in the Emergency Department. Talea Cornelius, Ph.D., M.S.W., Sachin Agarwal, M.D., M.P.H., Othanya Garcia, B.A., William Chaplin, Ph.D., Donald Edmondson, Ph.D., M.P.H., Bernard P. Chang, M.D.

listen now: interview with first author dr Talea cornelius, phd, MSW

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Talea Cornelius, PhD MSW

Center for Behavioral Cardiovascular Health

Columbia University Medical Center



Threat perceptions in the Emergency Department (ED) (e.g., patients’ subjective feelings of helplessness or lack of control) during evaluation for an acute coronary syndrome (ACS) are associated with the development of posttraumatic stress disorder (PTSD), and PTSD has been associated with medication nonadherence, cardiac event recurrence, and mortality. This study reports the development and validation of a 7‐item measure of ED Threat Perceptions in English‐ and Spanish‐speaking patients evaluated for ACS.


Participants were drawn from an observational cohort study of 1,000 patients evaluated for ACS between 2013‐2016 in a large, New York City hospital. Participants reported on threat perceptions in the ED and during inpatient stay (using 12 items previously identified as predictive of PTSD) and reported on cardiac‐induced PTSD one month post‐discharge. Exploratory and confirmatory factor analyses were used to establish the factor structure and test measurement invariance. Validity and reliability were examined, as was the association of ED Threat Perceptions with cardiac‐induced PTSD.


Factor analyses identified a 7‐item measure of ED Threat Perceptions (e.g., “I feel helpless,” “I am worried that I am going to die”) for both English‐ and Spanish‐speaking patients. ED Threat Perceptions demonstrated convergent validity, correlating with ED stress and ED crowdedness (rs = .29, .14), good internal consistency (α = .82), and stability (r = .61). Threat Perceptions were associated with cardiac‐induced acute stress at inpatient and PTSD symptoms at one month (rs = .43, .39).


This brief tool assessing ED Threat Perceptions has clinical utility for providers to identify patients at risk for developing cardiac‐induced PTSD and is critical to inform research on whether threat may be modified in‐ED to reduce PTSD incidence.

AEM Education and Training 07: Virtual Reality as an Interview Technique for EM Applicants

Welcome to the seventh episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to AEM E&T Articles or Articles in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

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DISCUSSING (click on title to access):

Virtual Reality as an Interview Technique in Evaluation of Emergency Medicine Applicants. Scott B. Crawford, MD, Stormy M. Monks, PhD, MPH, and Radosveta N. Wells, MD


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Scott Crawford, MD

Department of Emergency Medicine

Department of Emergency Medicine, Texas Tech University Health Science Center El Paso


Need for Innovation
Current interviewing strategies and the standardized letter of evaluation may not provide enough insight into preferred resident characteristics. Emergency medicine (EM) residency programs are challenged with identifying trainees who can problem solve, communicate, and work well with fellow health professionals.

Structured interviews have previously been used and can help predict success but candidates have reported a negative impression with their use.

Objective of Innovation
This structured virtual reality (VR) interviewing method was designed so that interviewers can observe the communication abilities, subtle personality traits, and teamwork skills of applicants interviewed at an EM residency program.

Development Process
A consumer VR headset became available and in combination with an interactive team game was incorporated into a standardized team‐based interview session. This session was designed to allow observation of candidates’ communication, problem solving, and teamwork skills.

Implementation Phase
Surveys were collected to examine the satisfaction of EM residency applicants who participated in this novel standardized interviewing method using a VR headset. After the submission of rank lists, but prior to Match Day, those who interviewed were e‐mailed a voluntary, anonymous, and confidential survey asking about their interview experience, specifically about the VR portion. The survey was sent to 102 applicants with 63 responses for a 62% response rate at the completion of the 2015 to 2016 interview season.

Overall study findings suggested that participants had a highly favorable impression of the VR portion of the interview. Specifically, participants reported that this interview technique was appropriate and worthwhile. Additionally, participants attested that the Oculus portion of the interview gave insight to their work ethic, personality, and communication skills and how they work with others.

Reflective Discussion
The novel interviewing method used in this study allowed interviewers to gain insight beyond that of the paperwork and brief face‐to‐face interaction. Study findings suggest that interviewees accepted the use of this novel interview method. It has been incorporated into our interview process for three consecutive years.


AEM Early Access 18: The YEARS Criteria in Evaluating PE

Welcome to the eighteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Christopher Kabrhel MD,MPH  Astrid Van Hylckama Vlieg PhD  Alona Muzikanski MS Adam Singer MD  Gregory J. Fermann MD  Samuel Francis MD  Alex Lim kakeng MD Ann Marie Chang MD  Nicholas Giordano MA  Blair Parry BA.


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Christopher Kabrhel MD, MPH

Associate Professor, Harvard Medical School

Director, Center for Vascular Emergencies

Department of Emergency Medicine

Massachusetts General Hospital


It may be possible to safely rule out pulmonary embolism (PE) in patients with low pre‐test probability (PTP) using a higher than standard D‐dimer threshold. The YEARS criteria, which includes three questions from the Wells PE Score to identify low PTP patients and a variable D‐dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14% in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States.

Prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria: “Does the patient have clinical signs or symptoms of DVT?”, “Does the patient have hemoptysis?”, “Are alternative diagnoses less likely than PE?” with YEARS (+) being any “yes” response. A negative D‐dimer was <1000 mg/dL for YEARS (‐) patients, and <500 mg/dL for YEARS (+) patients. We calculated test characteristics and used Fisher's exact test to compare proportions of patients who would have been referred for imaging and patients who would have had PE “missed.”.

Of 1789 patients, 84 (4%) had PE, 1134 (63%) were female, 1038 (58%) were White and mean age was 48 years. Using the standard D‐dimer threshold, 940 (53%) would not have had imaging, with 2 (0.2%, 95% CI: 0.02%, 0.60% “missed” PE. Using YEARS adjustment, 1204 (67%, 95% CI: 65%, 69%) would not have been referred for imaging, with 6 (0.5%, 95% CI: 0.18%, 1.1%) “missed” PE, and using “alternative diagnoses less likely than PE” adjustment, 1237 (69%, 95% CI: 67%, 71%) would not have had imaging with 6 (0.49%, 95% CI: 0.18%, 1.05%) “missed” PE. Sensitivity was 97.6% (95% CI: 91.7%‐99.7%) for the standard threshold, and 92.9% (95% CI: 85%‐97%) for both adjusted thresholds. NPV was nearly 100% for all approaches.

D‐dimer adjustment based on pre‐test probability may result in a reduced need for imaging to evaluate possible PE, with some additional “missed” PE but no decrease in NPV.