Emergency Medicine Interest Groups.

Emergency Medicine Interest Groups (EMIGs) serve as a bountiful resource for students interested in pursuing a career in Emergency Medicine (EM). In this article we elaborate on how medical students can get involved as members in an EMIG, discuss opportunities for leadership through these groups, detail how to make the most out of the EMIG (including a listing of important lectures, workshops/labs and opportunities for growth and advancement), provide a framework for how to institute a new EMIG when one does not exist, and discuss considerations for international EMIG groups.

Clerkships in Emergency Medicine.

Planning for clerkships in emergency medicine (EM) can be stressful, prolonged, and challenging. Therefore, medical students should start planning for them early. In this article, we offer guidance regarding several issues pertinent to the EM clerkship, such as the best time to schedule one (or more) during medical school, the most appropriate institution or program to schedule it, the process of selecting and applying for the clerkship, and the number of EM clerkships to consider. We will explain why an EM clerkship should be scheduled between June and October and the reason that 2 EM clerkships at different sites are sufficient for the majority of students. Additionally, we emphasize that clerkships in emergency departments associated with EM residency programs or with reputations for outstanding student teaching tend to be most beneficial. Above all, students interested in EM should attempt to leave a great impression after completing their clerkships by providing stellar patient care, demonstrating enthusiasm at all times, and maintaining professionalism. In turn, they will gain knowledge and clinical experiences that should prove valuable in their future.

Vision, Aphasia, Neglect Assessment for Large Vessel Occlusion Stroke.

BACKGROUND AND PURPOSE: Vision, Aphasia, Neglect (VAN) is a large vessel occlusion (LVO) screening tool that was initially tested in a small study where emergency department (ED) nurses were trained to perform VAN assessment on stroke code patients. We aimed to validate the VAN assessment in a larger inpatient dataset. METHODS: We utilized a large dataset and used National Institute of Health Stroke Scale (NIHSS) performed by physicians to extrapolate VAN. VAN was compared to NIHSS greater than or equal to 6 and established prehospital LVO screening tools including Rapid Arterial Occlusion Evaluation scale (RACE), Field Assessment Stroke Triage for Emergency Destination (FAST-ED), and Cincinnati Pre-hospital Stroke Scale (CPSS). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under receiver operating characteristics curve was calculated to estimate the predictive value of LVO. RESULTS: VAN was comparable in sensitivity (79% versus 80%) and NPV (88% versus 87%) to NIHSS greater than or equal to 6. It was superior in specificity (69% versus 57%), PPV (53% versus 46%) and accuracy to NIHSS greater than or equal to 6 (72% versus 64%) with significant receiver operating curve (.74 versus .69, P = .02). VAN also had comparable area under the curve when compared to RACE, FAST-ED, and CPSS however slightly lower accuracy (69%-73%) compared to RACE (76%), FAST-ED (77%), and CPSS (75%). VAN had the highest NPV among all screening assessments (88%). CONCLUSIONS: VAN is a simple screening tool that can identify LVOs with adequate accuracy in hospital setting. Future studies need to be conducted in prehospital setting to validate its utility to detect LVOs in the field.

Vision, Aphasia, Neglect Assessment to Predict Neurosurgical Intervention in Patients with Nontraumatic Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: The Vision, Aphasia, and Neglect (VAN) screening tool is a simple bedside test developed to identify patients with large vessel occlusion stroke. In the setting of intracerebral hemorrhage (ICH), there are very few bedside predictors of need for neurosurgical interventions other than age and Glasgow Coma Scale (GCS). We aimed to assess the utility of the VAN screening tool in predicting the need for neurosurgical intervention in patients with ICH. METHODS: We accessed sensitivity, specificity, positive predictive value, negative predictive value (NPV), and area under receiver operating characteristics curve of VAN for identifying ICH patients who require neurosurgical intervention. RESULTS: Among 228 ICH patients, 176 were VAN positive and 52 were VAN negative. On unadjusted analyses, VAN positive patients had a significantly higher ICH volume, GCS score, and National Institutes of Health Stroke Scale score (P < .001 for all). As compared to VAN negative patients, significantly higher proportion of VAN positive ICH patients (15.4% versus 32.4%) underwent a neurosurgical procedure such as external ventricular drain (EVD) and/or hematoma evacuation with craniotomy or craniectomy. The VAN screening tool had high sensitivity and NPV (100%) in predicting the need for craniectomy or hematoma evacuation, but had lower sensitivity (87.7%) for any neurosurgical procedure, as 15.4% of VAN negative patients received EVD. CONCLUSIONS: Our study suggests that VAN screening tool can identify high-risk ICH patients who are more likely to undergo craniotomy or craniectomy but is less sensitive to rule out need for EVD.

Program Visits and Residency Interviews.

Interviews and program visits play a major role in the National Resident Matching Program application process. They are a great opportunity for programs to assess applicants and vice versa. Irrespective of all other elements in the application profile, these can make it or break it for an applicant. In this article, we assist applicants in planning their residency interviews and program visits. We elaborate on the keys to success, including planning of the interviews in a proper and timely fashion, searching programs individually, conducting mock interviews, following interview and program visit etiquette, and carefully scheduling and making travel arrangements. We also guide applicants through what to expect and is expected of them during their interview and visit.

Selecting a Medical School Advisor.

Having an advisor offers medical students many advantages, including increased likelihood of matching into their top choices. Interestingly, students who choose emergency medicine (EM) as a specialty are more likely to seek advising. However, finding and optimally utilizing an EM faculty advisor is often challenging for the medical student. In this article, we tackle the different ways to seek advising, including the 'virtual advisor program' implemented by the Society for Academic Emergency Medicine, the 'e-Advisor Program' instigated by the Clerkship Director in EM Group, the 'member exclusive mentorship program' of the Emergency Medicine Residency Association, as well as peer-based mentoring. More so, we discuss the consensus recommendations developed by the Student Advising Task Force to guide both students planning to apply to EM and their advisors to ensure high-caliber advising.

Management of mild traumatic brain injury in the emergency department.

With over 1.7 million people in the United States seeking medical attention for head injury each year, emergency clinicians are challenged daily to screen quickly for the small subset of patients who harbor a potentially lethal intracranial lesion while minimizing excessive cost, unnecessary diagnostic testing, radiation exposure, and admissions. Whether working at a small, rural hospital or a large inner-city public hospital, emergency clinicians play a critical role in the diagnosis and management of mild traumatic brain injury. This review assesses the burgeoning research in the field and reviews current clinical guidelines and decision rules on mild traumatic brain injury, addressing the concept of serial examinations to identify clinically significant intracranial injury, the approach to pediatric and elderly patients, and the management of patients who are on anticoagulants or antiplatelet agents or have bleeding disorders. The evidence on sports-related concussion and postconcussive syndrome is reviewed, and tools for assessments and discharge are included.

Male victims of partner violence: prevalence and accuracy of screening tools.

The objective of this study was to determine the accuracy of two brief surveys for detection of male victims of intimate partner violence (IPV) in the Emergency Department (ED). This study was conducted prospectively in an urban, teaching hospital over 6 weeks; all men triaged to the acute care portion of the ED were eligible for enrollment. Exclusion criteria included age less than 18 years, refusal, altered mental status, or condition requiring lifesaving intervention. Data included demographics, Revised Conflict Tactics Scale (CTS2) score, and scores on two brief surveys of IPV: the HITS ("Hurt/Insult/Threaten/Scream") scale and the Partner Violence Screen (PVS). The CTS2 uses previously validated population scores for female to male psychological aggression and physical assault. Neither the HITS nor the PVS has been validated for use in the ED for detecting male victims of IPV. There were 116 men approached for enrollment; nearly half completed all surveys. Mean age was 41.8 years, and the sample was 73% African-American and 20% white. Thirty-nine percent had positive scores on the psychological aggression portion of the CTS2, whereas 20% had positive scores on the physical assault subscale. Comparing the HITS and PVS to both the psychological and physical portions of the CTS2 resulted in sensitivities of 30-45% and specificities of 83-88%. False negative rates on the two brief surveys ranged from 14-33%, and negative predictive values and positive likelihood ratios were low. Neither the HITS nor the PVS accurately screens male victims of IPV in the ED. Further research is needed to develop a valid, brief screening test to identify male victims of IPV in an acute setting. (c) 2006 Elsevier Inc.

Conversion disorder presenting as hemiplegia and hemianesthesia with loss of neurologic reflexes: a case report.

Conversion disorders can present with a variety of sensorimotor signs and symptoms. We present the case of a young woman who presented with sudden onset hemiplegia and hemianesthesia including unilateral loss of deep tendon reflexes, Babinski reflex, and loss of rectal tone with bladder incontinence. The loss of rectal tone, loss of deep tendon reflexes, and a flaccid Babinski reflex are unusual signs in conversion disorders. A thorough medical workup including x-rays, CT scans, and magnetic resonance imaging revealed no organic causes for the neurologic deficits. Before the onset of symptoms, the patient was emotionally upset during an argument, which may have provided the psychologic stressor necessary for a conversion disorder. The young woman gradually regained full neurologic function over the next 14 hours. Conversion disorders should be considered when the neurologic findings do not correspond to known anatomic or physiologic pathways, although a thorough medical investigation must be performed to search for organic causes.

Louisiana motorcycle fatalities linked to statewide helmet law repeal.

BACKGROUND: On August 15, 1999, Louisiana's mandatory motorcycle helmet law was repealed. Our primary objective was to determine if the repeal resulted in an increase in motorcyclist morbidity and mortality. METHODS: We retrospectively evaluated the frequency of helmet use and morbidity and mortality before and after the repeal of the law. Fatality statistics for Louisiana were obtained through the National Highway Safety Traffic Association between 1994 and 2002. Injury statistics were totaled for motorcyclists admitted to Medical Center of Louisiana New Orleans during the same period of time. RESULTS: Statewide, helmet use decreased 21.2% (p < 0.001, chi-square) after repeal of the helmet law, while locally, helmet use decreased 34.7% (p < 0.001). Fatalities significantly increased after the repeal, both statewide (3.0%-3.9%, p < 0.05) and locally (3.8%-5.8%, p < 0.0001). CONCLUSION: Motorcycle helmet use decreased significantly and motorcyclist fatality rates increased significantly after repeal of the Louisiana mandatory helmet law.

Prediction of intracranial injury in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms.

STUDY OBJECTIVE: Indications for computed tomography (CT) in children with minor head injury remain controversial. The objective of this preliminary study is to determine whether a clinical decision rule developed for adults could be used in children aged 5 years and older. METHODS: A prospective questionnaire was completed on all patients who were aged 5 to 17 years with major mechanisms of injury resulting in minor head injury (defined as normal Glasgow Coma Scale or modified coma scale in infants, plus normal brief neurologic examination) and loss of consciousness. The questionnaire documented 6 clinical variables: headache, emesis, intoxication, seizure, short-term memory deficits, and physical evidence of trauma above the clavicles. CT was obtained for all patients, findings were compared with the results of the questionnaires, and the sensitivity and specificity of the decision rule were determined. RESULTS: Throughout a 30-month period, 175 patients were enrolled, with a mean age of 12.8 years. Fourteen (8%) patients had intracranial injury or depressed skull fracture on CT. The presence of any of the 6 criteria was significantly associated with an abnormal CT scan result (P<.05) and was 100% (95% confidence interval 73% to 100%) sensitive for identifying patients with intracranial injury. CONCLUSION: In this preliminary study, CT use in pediatric patients with minor head injury could have been safely reduced by 23% by using a clinical decision rule previously validated in adults.