Internal medicine residents across all post-graduate year (PGY) levels at our institution lacked confidence to independently perform core internal medicine procedures. Utilizing simulation-based medical education as an adjunct to clinical training is well accepted by internal medicine trainees, and resulted in significantly improved procedural confidence. This intervention was well received by trainees and could feasibly be replicated at other active-duty military internal medicine residency programs to assist with readiness. Research is currently in progress to correlate in-situ competency and evaluate clinical outcomes of this improved confidence.

Sulfhemoglobin is formed by the irreversible bonding of sulfur atoms to the heme molecule. Oxygen is then unable to bind the heme molecule, rendering the hemoglobin molecule unable to carry oxygen. The most common etiology of sulfhemoglobinemia is the use/misuse of sulfur-containing medications such as AZO. Unlike methemoglobin, sulfhemoglobin, due to its irreversible binding, has no antidote, and the treatment is ultimately supportive. We present a case of a 53-year-old female who presented to the emergency room endorsing dysuria and was noted to have abnormally low oxygen saturation (SpO2) despite having high arterial oxygen pressure (PaO2) on blood gas. History was significant for dysuria developed while traveling and the use of over-the-counter AZO four times daily for the past 10 days. She was diagnosed with a presumed dyshemoglobinemia and, upon return of send-out labs, was confirmed to have sulfhemoglobinemia attributed to phenazopyridine. This case highlights the importance of the recognition of potential dyshemoglobinemias and consideration of sulfhemoglobinemia as a potential causative etiology, especially in patients taking sulfur-containing medications.