Introduction There is a paucity of quantitative research regarding the effect of coronavirus 2019 (COVID-19) on Emergency Department (ED) visits in the United States, and specifically mental health–related ED visits. The small existing body of research describes an overall decline in ED visits worldwide; however, there are anecdotal reports that psychiatric complaints to the ED have increased during the pandemic. The primary objective of this study was to describe the volume of mental health ED visits at a single ED during the COVID-19 pandemic compared to previous years. Materials and Methods This was a single-center, retrospective chart review of adult patients evaluated in the ED at an academic military medical facility from March to December of 2017-2020 for mental health. The electronic medical record was queried for mental health International Classification of Diseases, 10th Revision diagnosis codes. Demographic data including age, gender, disposition, diagnosis, and beneficiary status were collected, and Pearson Chi-Square was used to assess for statistical significance between years. Results There was a total of 1,486 mental health ED visits from March to December 2020, compared to an average of 1,668 visits from March to December 2017-2019. Statistically significant (P < 0.05) differences, between 2020 and the prior 3 years combined, were identified in the categories of age, disposition, beneficiary status, and diagnosis. In 2020, there was a lower proportion of visits for patients aged ≥60 (1.2%) than in 2017-2019 (2.5%). Active-duty patients comprised a higher proportion of mental health visits in 2020 (82.4%) versus 2017-2019 (77%). Proportionately fewer patients were admitted in 2020 (25.2%) versus 2017-2019 (29.2%). Adjustment disorders made up 19.0% of visits in 2020 versus 23.2% in 2017-2019, and suicidal ideation and intentional self-inflicted injury comprised 43.3% in 2020 compared with 40.4% in 2017-2019. Conclusion There was a significant decline in ED visits for patients over the age of 60 but a significant increase in visits for active-duty patients. Fewer patients were admitted compared to previous years. There was a significant increase in patients diagnosed with suicidal ideation and intentional self-inflicted injury in 2020 compared to previous years. Alarmingly, this study shows increased rates of self-harm and suicidal ideation. Further study is needed to determine why these effects were seen and if there is a higher risk for suicide attempt or completion in these populations. These results indicate that military leadership and the military health system is failing to adequately support and protect service members and their families during these uniquely stressful times. High-level attention to this issue by military leadership is required; the readiness and safety of the nation’s fighting force is at stake.

Background Over the past decade, the use of technology‐enhanced simulation in emergency medicine (EM) education has grown, yet we still lack a clear understanding of its effectiveness. This systematic review aims to identify and synthesize studies evaluating the comparative effectiveness of technology‐enhanced simulation in EM. Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, Web of Science, and Scopus to identify EM simulation research that compares technology‐enhanced simulation with other instructional modalities. Two reviewers screened articles for inclusion and abstracted information on learners, clinical topics, instructional design features, outcomes, cost, and study quality. Standardized mean difference (SMD) effect sizes were pooled using random effects. Results We identified 60 studies, enrolling at least 5279 learners. Of these, 23 compared technology‐enhanced simulation with another instructional modality (e.g., living humans, lecture, small group), and 37 compared two forms of technology‐enhanced simulation. Compared to lecture or small groups, we found simulation to have nonsignificant differences for time skills (SMD 0.33, 95% confidence interval [CI] −0.23 to 0.89, n = 3), but a large, significant effect for non–time skills (SMD 0.82, 95% CI 0.18 to 1.46, n = 8). Comparison of alternative types of technology‐enhanced simulation found favorable associations with skills acquisition, of moderate magnitude, for computer‐assisted guidance (compared to no computer‐assisted guidance), for time skills (SMD 0.50, 95% CI −1.66 to 2.65, n = 2) and non–time skills (SMD 0.57, 95% CI 0.33 to 0.80, n = 6), and for more task repetitions (time skills SMD 1.01, 95% CI 0.16 to 1.86, n = 2) and active participation (compared to observation) for time skills (SMD 0.85, 95% CI 0.25 to 1.45, n = 2) and non–time skills (SMD 0.33 95% CI 0.08 to 0.58, n = 3). Conclusions Technology‐enhanced simulation is effective for EM learners for skills acquisition. Features such as computer‐assisted guidance, repetition, and active learning are associated with greater effectiveness.

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BackgroundKetamine is a dissociative anaesthetic currently used in a variety of healthcare applications. Effects are dose dependent and cause escalating levels of euphoria, analgesia, dissociation and amnesia. Ketamine can be given via intravenous, intramuscular, nasal, oral and aerosolised routes. A 2012 memorandum and the 2014 Tactical Combat Casualty Care (TCCC) guidelines included ketamine as part of the ‘Triple Option’ for analgesia. This study investigated the effect of ketamine adoption by the US military TCCC guidelines on opioid use between 2010 and 2019.MethodsThis was a retrospective review of deidentified Department of Defense Trauma Registry data. The study was approved by the Institutional Review Board of Naval Medical Center San Diego (NMCSD) and facilitated by a data sharing agreement between NMCSD and the Defense Health Agency. Patient encounters from all US military operations from January 2010 to December 2019 were queried. All administrations of any pain medications via any route were included.Results5965 patients with a total of 8607 pain medication administrations were included. Between 2010 and 2019, the yearly percentage of ketamine administrations rose from 14.2% to 52.6% (p<0.001). The percentage of opioid administrations decreased from 85.8% to 47.4% (p<0.001). Among the 4104 patients who received a single dose of pain medication, the mean Injury Severity Score for those who received ketamine was higher than for those who received an opioid (mean=13.1 vs 9.8, p<0.001).ConclusionMilitary opioid use declined as ketamine use increased over 10 years of combat. Ketamine is generally used first for more severely injured patients and has increasingly been employed by the US military as the primary analgesic for combat casualties.