Importance of the Emergency Medicine Application Components: The Medical Student Perception.

BACKGROUND: The National Resident Matching Program (NRMP) application has several elements. With limited time and resources, students must prioritize the key application elements on which to focus. It is unclear if medical students applying to emergency medicine (EM) prioritize the same items as program directors. OBJECTIVE: We sought to determine medical student perception of the importance of each factor of the NRMP application to an EM residency. METHODS: This was a cross-sectional study approved by the Institutional Review Board at an academic tertiary care Level I trauma center. A pilot-tested and validated survey tool was given to all medical students rotating in EM during an 18-month period. The students ranked each application item on a 5-point scale (1 = not important and 5 = very important) with verbal anchors. RESULTS: Of 136 medical students, 85.3% responded. Excluded were 31% who were not planning to apply to EM, leaving 80 responses for analysis. Items ranked higher were EM rotation grade, interview, clinical rotation grades, and letters of recommendation. Less emphasis was placed on Alpha Omega Alpha (AOA) honor society status, publication in medical literature, and personal statement. Items most agreed upon and believed to be most important by the students were EM rotation grade, interviews, and clinical rotation grades. CONCLUSIONS: This is similar to previously reported rankings by program directors. Although medical students agreed on the importance of most aspects of the NRMP application, areas of discordance included emphasis on extracurricular activities and AOA. This can have implications for medical student mentoring and advising.

Renal failure in a patient with postpolio syndrome and a normal creatinine level.

Patients with renal failure who are taking trimethoprim have an increased risk of developing hyperkalemia, which can cause muscle weakness. In patients with postpolio syndrome, a normal creatinine level could be abnormally high, renal failure is possible because of lack of creatinine production, and the muscle weakness from resultant hyperkalemia could be more severe because of their underlying condition. This abnormally high creatinine level has been termed from this point relative renal failure. The objective of the study was to review a case in which relative renal failure and hyperkalemia caused muscle weakness that manifested as shortness of breath and confusion with electrocardiographic changes. A dehydrated patient with relative renal failure and postpolio syndrome had taken trimethoprim-sulfamethoxazole that caused symptomatic hyperkalemia. The patient presented with muscle weakness, shortness of breath, and confusion, with her postpolio syndrome compounding the situation and likely making the muscle weakness more severe. A patient on trimethoprim with renal failure is at an increased risk of developing hyperkalemia. Patients with postpolio syndrome could have severe muscle weakness from the hyperkalemia and could have renal failure even with a normal creatinine level. This case report will remind treating physicians to evaluate such patients for hyperkalemia if they present with muscle weakness, especially if the patient has renal failure and is on trimethoprim.

Female authorship in emergency medicine parallels women practicing academic emergency medicine.

BACKGROUND: Studies have shown that women in emergency medicine (EM) lag behind their male counterparts in academic productivity. OBJECTIVES: We compared the proportion of female attending physicians from EM academic programs to the proportion of female first or second authors of original scientific manuscripts and case reports from four major EM journals in a single year. METHODS: We used a retrospective cross-sectional design. Original scientific manuscripts and case reports from four major EM journals published in 2005: Academic Emergency Medicine, Annals of Emergency Medicine, American Journal of Emergency Medicine, and Journal of Emergency Medicine were reviewed to determine genders of first and second authors. The proportion of female first or second authorship was then compared to the proportion of female EM attending physicians from 134 academic EM programs in the United States. Data were analyzed using Pearson's chi-squared and Clopper-Pearson binomial confidence intervals as appropriate. A p-value of ≤ 0.05 was considered significant. RESULTS: The percentage of female faculty; 940/3571 (26.32%, 95% confidence interval [CI] 24.9-27.8%) vs. the percentage of female first or second authorship 289/1123 (25.73%, 95% CI 23.3-28.4%) was not statistically significant (p = 0.562). There was no difference in the proportion of male and female authors with multiple manuscripts (p = 0.889). CONCLUSIONS: As measured by first and second authorship, there was no discrepancy between the proportion of female EM faculty and the proportion of female authorship in EM literature from 2005.

Emergency medicine resident performed bedside ultrasonography of the gallbladder in non-fasted healthy volunteers.

BACKGROUND: Gallbladder ultrasonography is a commonly performed test in the emergency department. It is unknown whether a non-fasting state alters the visualization of the gallbladder by emergency medicine (EM) residents. OBJECTIVES: We conducted this study to determine whether EM residents are able to visualize the gallbladder in volunteers who have recently consumed a fatty meal. METHODS: This study used a prospective, single-blinded, randomized controlled design. Initial scans were performed on fasting volunteers. A fatty meal was then consumed. Thirty minutes after eating, a different resident, who was unaware of whether the volunteer had eaten or fasted, performed a second scan. To control for operator bias, 10% of subjects remained fasting between scans. Student's paired-samples t-test, Pearson's chi-squared, and McNemar test were determined as appropriate. RESULTS: A total of 92 scans from 46 volunteers were analyzed. EM residents were able to visualize the gallbladder in all 40 pre-prandial scans (100%) and all 40 post-prandial scans (100%). Gallbladder area as measured in the longitudinal axis decreased 20% from a mean baseline of 11.58 +/- 4.86 cm(2) (95% confidence interval [CI] 11.17-12.98) to 9.2 +/- 5.04 cm(2) (95% CI 7.74-10.66, p = 0.0009) after food intake. Total time to scan for the fasting volunteers (110.2 s, 95% CI 84.34-136) did not change significantly from non-fasting volunteers (129.7 s, 95% CI 110.29-149.01, p = 0.153). CONCLUSIONS: EM residents are able to visualize the gallbladder in non-fasted healthy volunteers.

Emergency ultrasound usage among recent emergency medicine residency graduates of a convenience sample of 14 residencies.

BACKGROUND: Emergency Medicine (EM) residency graduates are trained to perform Emergency Medicine bedside ultrasound (EMBU). However, the degree to which they use this skill in their practice after graduation is unknown. OBJECTIVES: We sought to test the amount and type of usage of EMBU among recent residency graduates, and how usage and barriers vary among various types of EM practice settings. METHODS: Graduates from 14 EM residency programs in 2003-2005 were surveyed on their current practice setting and use of EMBU. RESULTS: There were 252 (73%) graduates who completed the survey. Of the 73% of respondents reporting access to EMBU, 98% had used it within the past 3 months. Access to EMBU was higher in academic (97%) vs. community teaching (79%) vs. community non-teaching settings (62%) (p < 0.001), and in Emergency Departments (EDs) where yearly census exceeded 60,000 visits (87% vs. 65%, p < 0.001). Physicians in academic settings reported "high use" of EMBU more frequently than those in community settings for most modalities. FAST (focused assessment by sonography in trauma) was the most common high-use application and the most useful in practice. The greatest impediment to EMBU use was "not enough time" (61%). CONCLUSIONS: Ultrasound usage among recent EM residency graduates is significantly higher in teaching than in community settings and in high-volume EDs. Its use is more widespread than in previous reports in all types of practice. There is a wide range of utilization of ultrasound in the various applications in emergency practice, with the evaluation of trauma being the most common.

Heterotopic gestation: another possibility for the emergency bedside ultrasonographer to consider.

Emergency bedside ultrasonography has become an important tool in differentiating an intrauterine from an ectopic pregnancy. As the odds of a heterotopic pregnancy were thought to be minute, some ultrasonographers and Emergency Physicians certified in bedside ultrasonography have taught that an intrauterine gestation with fetal heart tones clinches the diagnosis of intrauterine pregnancy. However, with the current rise in heterotopic gestations, this standard of care should be re-evaluated. If emergency bedside ultrasonography reveals an intrauterine gestation in the presence of either a moderate amount of free fluid in the pelvis or a co-existent ovarian cyst, one must consider and search for a heterotopic pregnancy.

Factors Affecting Candidate Placement on an Emergency Medicine Residency Program's Rank Order List.

INTRODUCTION: Several factors influence the final placement of a medical student candidate on an emergency medicine (EM) residency program's rank order list, including EM grade, standardized letter of recommendation, medical school class rank, and US Medical License Examination (USMLE) scores. We sought to determine the correlation of these parameters with a candidate's final rank on a residency program's rank order list. METHODS: We used a retrospective cohort design to examine 129 candidate packets from an EM residency program. Class ranks were assessed according to the instructions provided by the students' medical schools. EM grades were scored from 1 (honors) to 5 (fail). Global assessments noted on the standardized letter of recommendation (SLOR) were scored from 1 (outstanding) to 4 (good). USMLE scores were reported as the candidate's 3-digit scores. Spearman's rank correlation coefficient was used to analyze data. RESULTS: Electronic Residency Application Service packets for 127/129 (98.4%) candidates were examined. The following parameters correlated positively with a candidate's final placement on the rank order list: EM grade, ρ = 0.379, P < 0.001; global assessment, ρ = 0.332, P < 0.001; and class rank, ρ = 0.234, P = 0.035. We found a negative correlation between final placement on the rank order list with both USMLE step 1 scores, ρ = -0.253, P=0.006; and USMLE step 2 scores, ρ = -0.348, P = 0.004. CONCLUSION: Higher scores on EM rotations, medical school class ranks, and SLOR global assessments correlated with higher placements on a rank order list, whereas candidates with higher USMLE scores had lower placements on a rank order list. However, none of the parameters examined correlated strongly with ultimate position of a candidate on the rank list, which underscores that other factors may influence a candidate's final ranking.