Journal Club in Residency Education: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors.

Journal clubs are an important tool for critically appraising articles and keeping up-to-date with the current literature. This paper provides a critical review of the literature on the design and structure of journal clubs in residency education with a focus on preparation, topic selection, implementation, and integration of technology. Recommendations for preparation include developing clearly defined goals and objectives that are agreed upon by all journal club participants; mentorship from experienced faculty members to ensure appropriate article selection, maintenance of structure, and applicability to objectives; distribution of articles to participants 1-2 weeks prior to the scheduled session with reminders to read the articles at predetermined intervals; and the use of a structured critical appraisal tool for evaluating the articles. Recommendations for topic selection include selecting a primary objective of either critical appraisal or informing clinical practice and ensuring that the articles align with the objective; involving learners in the topic- and article-selection process; and having the article selection driven by a specific clinical question. Recommendations for implementation include hosting sessions in the evening and away from the hospital environment; providing food to participants; hosting meetings on a monthly basis at regularly scheduled intervals; mandating journal club attendance; and using theories of adult learning. Recommendations for integration of technology include using previously established, effective strategies and determining the feasibility of creating an online journal club versus joining an established journal club. It is the authors' intention that after reading this paper readers will have new strategies and techniques for implementing and running a journal club at their home institutions.

Utilization of a gum elastic bougie to facilitate single lung intubation.

INTRODUCTION: Patients with severe pulmonary hemorrhage due to unilateral trauma or a bleeding cancer often present to the emergency department in acute respiratory distress. Although it is generally recommended to perform single lung intubation, most emergency department providers do not have access to or are not familiar with double-lumen endotracheal tubes, and blind insertion of an endotracheal tube to maximum depth does not ensure that the proper (nonhemorrhagic) lung is ventilated. Therefore, single lung intubation may be significantly delayed in these patients. The purpose of this study was to assess the accuracy of using a gum elastic bougie ("bougie") to facilitate single lung intubation. METHODS: We conducted a prospective, randomized, blinded pilot study assessing the accuracy of bougie-guided single lung intubation in a fresh human cadaveric model. Two investigators each inserted a bougie under video laryngoscope guidance. After passing the vocal cords, the intubator would be randomized to turn the bougie 90° clockwise (for right mainstem intubation) or 90° counterclockwise (for left mainstem intubation). The bougie was then advanced until resistance was met, and the endotracheal tube was subsequently advanced over the bougie. After intubation, a board-certified pulmonologist investigator who was blinded to the initial lung selection used a fiberoptic bronchoscope to confirm placement by assessing endotracheal tube location with respect to the carina. The primary outcome was the accuracy of correct lung placement. RESULTS: Two providers performed a total of 45 placements. There were 22 right mainstem and 23 left mainstem intubations. The overall accuracy was 100% (95% confidence interval, 90.2%-100%) for both right and left mainstem intubations. DISCUSSION: In our cadaveric model of mainstem intubation, bougie-guided single lung intubation was highly accurate for both left and right mainstem intubations. Future studies should assess the accuracy of this technique among different providers and bodies, as well as live patients.

Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation.

INTRODUCTION: Most emergency physicians routinely obtain shoulder radiographs before and after shoulder dislocations. However, currently there is limited literature demonstrating how frequently new fractures are identified on post-reduction radiographs. The primary objective of this study was to determine the frequency of new, clinically significant fractures identified on post-reduction radiographs with a secondary outcome assessing total new fractures identified. METHODS: We conducted a retrospective chart review using appropriate International Classification of Diseases, 9(th) Revision (ICD-9) codes to identify all potential shoulder dislocations that were reduced in a single, urban, academic emergency department (ED) over a five-year period. We excluded cases that required operative reduction, had associated proximal humeral head or shaft fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted separately by two study investigators with disagreements settled by consensus among three investigators. Images from indeterminate cases were reviewed by a radiology attending physician with musculoskeletal expertise. The primary outcome was the percentage of new, clinically significant fractures defined as those altering acute ED management. Secondary outcomes included percentage of new fractures of any type. RESULTS: We identified 185 total patients meeting our study criteria. There were no new, clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI [3.3%-10.7%]) total new fractures identified, all of which were without clinical significance for acute ED management. CONCLUSION: Post-reduction radiographs do not appear to identify any new, clinically significant fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED setting for shoulder dislocations.

The FLUSH study--flush the line and ultrasound the heart: ultrasonographic confirmation of central femoral venous line placement.

STUDY OBJECTIVE: Inadvertent arterial placement of a femoral venous catheter may result in serious morbidity, including limb necrosis. The Flush the Line and Ultrasound the Heart (FLUSH) test is visualization of the heart by a subxiphoid ultrasonic view while the central catheter is flushed with agitated saline solution. We wish to determine whether the FLUSH test can verify proper femoral venous line placement. METHODS: We prospectively studied a convenience sample of children undergoing cardiac catheterization, for whom both femoral venous and arterial access were part of their standard care. The cardiologist flushed manually agitated saline solution through each catheter in randomized sequence while the blinded physician sonographer recorded the presence or absence of right atrial opacification. We calculated the sensitivity and specificity of the FLUSH test relative to our reference standard, the cardiologist's fluoroscopic visualization of catheter wire placement. RESULTS: Of the 51 subjects enrolled, the FLUSH test was 100% sensitive (95% confidence interval 95% to 100%) and 90.3% specific (95% confidence interval 81% to 96%) in confirming femoral catheter placement. In no case was an arterial flush misidentified as a femoral flush. The interrater reliability of the test was strong: κ 0.82 for all images and 0.9 for those of good quality. CONCLUSION: The FLUSH test is simple and reliable, and appears to accurately confirm femoral venous line placement.

An unusual case of epistaxis-juvenile nasopharyngeal angiofibroma.

BACKGROUND: Epistaxis is a common complaint seen in the younger population. Its etiology is typically from the anterior nares, although we present a case of epistaxis from an uncommon source-juvenile nasopharyngeal angiofibroma. Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular, benign, yet locally invasive tumor that occurs in preadolescent males. OBJECTIVES: To illustrate a case of epistaxis from an uncommon source. CASE REPORT: A 21-year-old man with a past medical history of allergic rhinitis presented to the Emergency Department (ED) after 6 months of intermittent yet worsening epistaxis. He described the bleeding as sudden onset that resolved after 30 min of direct compression of the external nares. He denied any history of digital manipulation, trauma, or bleeding disorders. Upon arrival in the ED, he had brisk bleeding from the right naris that was initially controlled with phenylephrine nasal spray. A small round friable mass was visualized in the right posterior nasal cavity. Further hemostasis of the epistaxis was achieved using a nasal tampon moistened with phenylephrine, and a computed tomography scan of the sinus revealed a soft tissue mass almost completely occupying the sphenoid sinus and extending into the nasopharynx and posterior ethmoids. There was also expansion and bony erosion of the right pterygopalatine fossa. A final diagnosis of JNA was made and the patient was given follow-up with an otorhinolaryngologist, who ultimately surgically resected the mass. CONCLUSIONS: JNA is a highly vascular, benign, yet locally invasive tumor that occurs in preadolescent males. This case illustrates the importance of appreciating the more uncommon cases of epistaxis, especially when conventional methods of treatment have initially failed.

CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison.

BACKGROUND: An estimated 10,000 Americans suffer cervical spine injuries each year. More than 800,000 cervical spine radiographs (CSR) are ordered annually. The human and healthcare costs associated with these injuries are enormous especially when diagnosis is delayed. Controversy exists in the literature concerning the diagnostic accuracy of CSR, with reported sensitivity ranging from 32% to 89%. We sought to compare prospectively the sensitivity of cervical CT (CCT) to CSR in the initial diagnosis of blunt cervical spine injury for patients meeting one or more of the NEXUS criteria. METHODS: The study prospectively compared the diagnostic accuracy of CSR to CCT in consecutive patients evaluated for blunt trauma during 23 months at an urban, public teaching hospital and Level I Trauma Center. Inclusion criteria were adult patient, evaluated for blunt cervical spine injury, meeting one or more of the NEXUS criteria. All patients received both three-view CSR and CCT as part of a standard diagnostic protocol. Each CSR and CCT study was interpreted independently by a different radiology attending who was blinded to the results of the other study. Clinically significant injuries were defined as those requiring one or more of the following interventions: operative procedure, halo application, and/or rigid cervical collar. RESULTS: Of 1,583 consecutive patients evaluated for blunt cervical spine trauma, 78 (4.9%) patients received only CCT or CSR and were excluded from the study. Of the remaining 1,505 patients, 78 (4.9%) had evidence of a radiographic injury by CSR or CCT. Of these 78 patients with radiographic injury, 50 (3.3%) patients had clinically significant injuries. CCT detected all patients with clinically significant injuries (100% sensitive), whereas CSR detected only 18 (36% sensitive). Of the 50 patients, 15 were at high risk, 19 at moderate risk, and 16 at low risk for cervical spine injury according to previously published risk stratification. CSR detected clinically significant injury in 7 high risk (46% sensitive), 7 moderate risk (37% sensitive), and 4 low risk patients (25% sensitive). CONCLUSION: Our results demonstrate the superiority of CCT compared with CSR for the detection of clinically significant cervical spine injury. The improved ability to exclude injury rapidly provides further evidence that CCT should replace CSR for the initial evaluation of blunt cervical spine injury in patients at any risk for injury.