Putting Theory to Practice: Applying Cognitive Load Theory to Resident Medical Education.

OBJECTIVE: We built 2 versions of an asynchronous pediatric orthopedic educational intervention for emergency medicine residents and sought to compare the two. We hypothesized that the version incorporating more instructional scaffolding in the form of a cognitive aid (CA) would optimize germane cognitive load for our target novice learners and result in higher test scores. METHODS: Learners were block randomized to either a "CA" or "non-CA" arm, each containing a random set of 18 modules. The CA arm incorporated an orthopedic fracture classification chart embedded within the diagnostic questions to guide the learner in forming a diagnosis. The non-CA arm was designed with more active learning as the classification chart was provided only after each diagnostic answer submission. For both arms, the final 6 modules completed per learner were scored. Learners also completed a perceived cognitive load assessment tool measured on a 10-point Likert scale. RESULTS: Learners in the non-CA arm had a mean total score on the testing modules of 33% correct compared with a mean total score of 44% correct for learners in the CA arm (mean difference, 11; 95% confidence interval, 4%-19%, P = 0.005). There was a trend for the CA arm to have lower perceived overall cognitive load scores; however, this did not reach statistical significance. CONCLUSIONS: Emergency medicine residents performed better after completing the CA version of our educational intervention. Applying cognitive load theory to an educational intervention may increase its success among target learners.

An itchy rash and muscle weakness.

Dermatomyositis is a rare disease affecting primarily skin and muscles and is associated with malignancies, especially in at-risk patients. Clinical presentations vary widely but proximal muscle weakness and typical skin findings should prompt consideration of the diagnosis. Immunosuppressive therapy is required, as is continued screening for malignant disease during follow-up.

Mediastinitis Secondary to Peripherally Inserted Central Catheter Migration and Perforation after Minor Trauma: A Case Report.

INTRODUCTION: The use of peripherally inserted central catheters (PICC) has been integral to the advancement of medical care in both in-patient and out-patient arenas. However, our knowledge of PICC line complications remains incomplete, particularly in regard to venous perforation and extraluminal migration. Utilization of displaced catheters harbors lethal complications and is an infrequently reported phenomenon, with traumatic etiologies only referenced as possible mechanisms; however, to date no formal cases have been reported. CASE REPORT: We report a case of a fall associated with extraluminal PICC migration and perforation causing mediastinitis and severe sepsis after total parenteral nutrition (TPN) infusion in a 54-year-old woman. Our patient required a right-sided PICC for long-term home TPN due to severe malnutrition following gastric bypass surgery. During a routine home care visit our patient was found tachypneic, hypoxic, and short of breath. Computed topography imaging in the emergency department (ED) identified the injury, likely related to the recent fall. The patient experienced a complicated hospital course after removal of the PICC. Although rare, PICC line migrations and perforations cause serious complications that should be considered by emergency physicians evaluating patients with chronic indwelling vascular access. CONCLUSION: Given the efficacy and widespread use of PICC lines, we present this case as a rarely reported but life-threatening complication that requires particular attention. Emergency physicians should be aware of such PICC line complications when encountering patients with chronic indwelling vascular access.

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records.

OBJECTIVE: The aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders. METHODS: We identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA. RESULTS: Of 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of "4" (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients. CONCLUSIONS: Do-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.

TRIAD III: nationwide assessment of living wills and do not resuscitate orders.

BACKGROUND: Concern exists that living wills are misinterpreted and may result in compromised patient safety. OBJECTIVE: To determine whether adding code status to a living will improves understanding and treatment decisions. METHODS: An Internet survey was conducted of General Surgery, and Family, Internal, and Emergency Medicine residencies between May and December 2009. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention. Questions were formatted as dichotomous responses. Correct response rate was based on legal statute. Significance of changes in response due to the addition of either clinical context (past medical history/signs/symptoms) or code status was assessed by contingency table analysis. RESULTS: Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded. At baseline, 22% denoted "full code" as the code status for a typical living will, and 36% equated "full care" with a code status DNR. Adding clinical context improved correct responses by 21%. Specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12-17% by adding code status ("Full Code," "Hospice Care") or worsened 22% ("DNR"). CONCLUSION: Misunderstanding of advance directives is a nationwide problem. Addition of code status may help to resolve the problem. Further research is required to ensure safety, understanding, and appropriate care to patients.