A Case Report of a Man with Burning Arm and Leg Weakness.

A 44-year-old male presented with sudden onset of severe left arm burning dysesthesia and bilateral leg numbness and weakness for several hours. He denied any recent illnesses or trauma and was previously healthy. His exam showed decreased strength to his left upper extremity, decreased light touch sensation to bilateral lower extremities, and urinary retention. Computed tomography (CT) and magnetic resonance imaging (MRI) of the cervical spine were performed, which demonstrated acute cervical myelopathy due to congenital cervical stenosis, a less common finding. Congenital cervical stenosis is the narrowing of the cervical spinal canal that is not due to structural, infectious, vascular, or malignant causes. This is an important diagnosis to consider in patients who present with neurologic symptoms without risk factors for common myelopathy causes (eg, degenerative changes). Early diagnosis and treatment are essential to prevent long term neurologic deficits. Topics: Neurosurgery, cervical myelopathy, acute neurologic deficits.

Are You Applying to More Than One Specialty?

Although the majority of U.S. medical students predominantly apply to only one specialty, some apply to more than one. When it comes to emergency medicine (EM), applicants may apply to additional specialties due to several reasons: being international medical graduates as well as their inability to make a decision regarding the choice of specialty, fear from the growing competitiveness of EM, or the desire to stay in a specific geographic area. Accordingly, in this article we aim to guide medical students through the process of applying to more than one specialty, including using the Electronic Residency Application Service application, writing a personal statement, getting letters of recommendation, and an Early Match. Moreover, we elaborate on the effect of applying to more than one specialty on a student's application to a residency in EM.

Flipping the Classroom in Medical Student Education: Does Priming Work?

INTRODUCTION: The emergency medicine (EM) clerkship curriculum at Los Angeles County + University of Southern California Medical Center includes monthly lectures on pediatric fever and shortness of breath (SOB). This educational innovation evaluated if learning could be enhanced by "priming" the students with educational online videos prior to an in-class session. Factors that impacted completion rates were also evaluated (planned specialty and time given for video viewing). METHODS: Twenty-minute videos were to be viewed prior to the didactic session. Students were assigned to either the fever or SOB group and received links to those respective videos. All participating students took a pre-test prior to viewing the online lectures. For analysis, test scores were placed into concordant groups (test results on fever questions in the group assigned the fever video and test results on SOB questions in the group assigned the SOB video) and discordant groups (crossover between video assigned and topic tested). Each subject contributed one set of concordant results and one set of discordant results. Descriptive statistics were performed with the Mann-Whitney U test. Lecture links were distributed to students two weeks prior to the in-class session for seven months and three days prior to the in-class session for eight months (in which both groups included both EM-bound and non-EM bound students). RESULTS: In the fifteen-month study period, 64% of students rotating through the EM elective prepared for the in class session by watching the videos. During ten months where exclusively EM-bound students were rotating (n=144), 71.5% of students viewed the lectures. In four months where students were not EM-bound (n=54), 55.6% of students viewed the lectures (p=0.033). Participation was 60.2% when lecture links were given three days in advance and 68.7% when links were given two weeks in advance (p=0.197). In the analysis of concordant scores, the pre-test averaged 56.7% correct, the immediate post-test averaged 78.1% correct, and the delayed post-test was 67.2%. In the discordant groups, the pretest averaged 51.9%, the immediate posttest was 67.1% and the delayed by 68.8%. In the concordant groups, the immediate post-test scores improved by 21.4%, compared with 15.2% in the discordant groups (p = 0.655). In the delayed post-test the concordant scores improved by 10.5% and discordant scores by 16.9 percent (p=0.609). Sixty-two percent of students surveyed preferred the format of online videos with in-class case discussion to a traditional lecture format. CONCLUSION: Immediate post-tests and delayed post-tests improved but priming was not demonstrated to be a statistically superior educational method in this study. Medical student completion of the preparatory materials for the EM rotation session increased when the students were EM-bound. Participation rates were not significantly different when given at two weeks versus three days.

Does the Flipped Classroom Improve Learning in Graduate Medical Education?

BACKGROUND: The flipped classroom model for didactic education has recently gained popularity in medical education; however, there is a paucity of performance data showing its effectiveness for knowledge gain in graduate medical education. OBJECTIVE: We assessed whether a flipped classroom module improves knowledge gain compared with a standard lecture. METHODS: We conducted a randomized crossover study in 3 emergency medicine residency programs. Participants were randomized to receive a 50-minute lecture from an expert educator on one subject and a flipped classroom module on the other. The flipped classroom included a 20-minute at-home video and 30 minutes of in-class case discussion. The 2 subjects addressed were headache and acute low back pain. A pretest, immediate posttest, and 90-day retention test were given for each subject. RESULTS: Of 82 eligible residents, 73 completed both modules. For the low back pain module, mean test scores were not significantly different between the lecture and flipped classroom formats. For the headache module, there were significant differences in performance for a given test date between the flipped classroom and the lecture format. However, differences between groups were less than 1 of 10 examination items, making it difficult to assign educational importance to the differences. CONCLUSIONS: In this crossover study comparing a single flipped classroom module with a standard lecture, we found mixed statistical results for performance measured by multiple-choice questions. As the differences were small, the flipped classroom and lecture were essentially equivalent.

Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis.

OBJECTIVES: Early aggressive intravenous hydration is recommended for acute pancreatitis treatment although randomized trials have not documented benefit. We performed a randomized trial of aggressive vs. standard hydration in the initial management of mild acute pancreatitis. METHODS: Sixty patients with acute pancreatitis without systemic inflammatory response syndrome (SIRS) or organ failure were randomized within 4 h of diagnosis to aggressive (20 ml/kg bolus followed by 3 ml/kg/h) vs. standard (10 ml/kg bolus followed by 1.5 mg/kg/h) hydration with Lactated Ringer's solution. Patients were assessed at 12-h intervals. At each interval, in both groups, if hematocrit, blood urea nitrogen (BUN), or creatinine was increased, a bolus of 20 ml/kg followed by 3 ml/kg/h was given; if labs were decreased and epigastric pain was decreased (measured on 0-10 visual analog scale), hydration was then given at 1.5 ml/kg/h and clear liquid diet was started. The primary endpoint, clinical improvement within 36 h, was defined as the combination of decreased hematocrit, BUN, and creatinine; improved pain; and tolerance of oral diet. RESULTS: The mean age of the patients was 45 years and only 14 (23%) had comorbidities. A higher proportion of patients treated with aggressive vs. standard hydration showed clinical improvement at 36 h: 70 vs. 42% (P=0.03). The rate of clinical improvement was greater with aggressive vs. standard hydration by Cox regression analysis: adjusted hazard ratio=2.32, 95% confidence interval 1.21-4.45. Persistent SIRS occurred less commonly with aggressive hydration (7.4 vs. 21.1%; adjusted odds ratio (OR)=0.12, 0.02-0.94) as did hemoconcentration (11.1 vs. 36.4%, adjusted OR=0.08, 0.01-0.49). No patients developed signs of volume overload. CONCLUSIONS: Early aggressive intravenous hydration with Lactated Ringer's solution hastens clinical improvement in patients with mild acute pancreatitis.

The Flipped Classroom in Emergency Medicine Using Online Videos with Interpolated Questions.

BACKGROUND: Utilizing the flipped classroom is an opportunity for a more engaged classroom session. This educational approach is theorized to improve learner engagement and retention and allows for more complex learning during class. No studies to date have been conducted in the postgraduate medical education setting investigating the effects of interactive, interpolated questions in preclassroom online video material. OBJECTIVES: We created a flipped classroom for core pediatric emergency medicine (PEM) topics using recorded online video lectures for preclassroom material and interactive simulations for the in-classroom session. METHODS: Lectures were filmed and edited to include integrated questions on an online platform called Zaption. One-half of the residents viewed the lectures uninterrupted (Group A) and the remainder (Group B) viewed with integrated questions (2-6 per 5-15-min segment). Residents were expected to view the lectures prior to in-class time (total viewing time of approximately 2½ h). The 2½-h in-class session included four simulation and three procedure stations, with six PEM faculty available for higher-level management discussion throughout the stations. Total educational time of home preparation and in-class time was approximately 5 h. RESULTS: Residents performed better on the posttest as compared to the pretest, and their satisfaction was high with this educational innovation. In 2014, performance on the posttest between the two groups was similar. However, in 2015, the group with integrated questions performed better on the posttest. CONCLUSION: An online format combined with face-to-face interaction is an effective educational model for teaching core PEM topics.