Post-traumatic left anterior descending artery dissection.

BACKGROUND: Patients who experience trauma, particularly thoracic trauma, may be at risk for missed cardiac injury. CASE REPORT: We present a case of a 36-year-old male presenting to the Emergency Department (ED) as a trauma after a high-speed motor vehicle crash. After computed tomography (CT) scans revealed a right hemopneumothorax and multiple orthopedic injuries, the patient was admitted to the trauma neuroscience intensive care unit (TNICU), where telemetry revealed ST elevations. An electrocardiogram (EKG) was performed and he was noted to have an acute anterolateral STEMI. The patient was intubated and underwent a cardiac catheterization that revealed a dissection of his left anterior descending (LAD) coronary artery and a stent was successfully placed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In cases of trauma patients who can't report the symptoms they are experiencing, or have distracting injury, there is the potential for a missed diagnosis of either significant cardiac injury and/or myocardial infarction (MI). Emergency physicians should be aware that an EKG is recommended in the ED evaluation of a trauma patient, especially those with thoracic trauma.

Brief Motivational Interviewing for Substance Use by Medical Students Is Effective in the Emergency Department.

BACKGROUND: Efficacy of medical student substance use interventions in the emergency department (ED) setting remains unstudied. OBJECTIVE: In this pilot study, we set out to determine whether medical students could perform a brief motivational interview for substance use in the ED. METHODS: At two hospitals, medical students utilized motivational interviewing skills taught by their medical school curriculum and administered a substance use intervention to ED patients who met the study definition of unhealthy substance use. RESULTS: In 6 weeks, medical students gave a brief intervention to 102 subjects. The mean age of the subjects was 46.9 (standard deviation 15.6) years. The majority, 86 (86.3%) identified as white. Fifty-four (52.9%) identified as male. Eighty of 102 (78.4%) participants completed a phone follow-up assessment. Of the 69 smokers, 11 (15.9%) reported attempting to quit or quitting completely. Of the 33 with high-risk alcohol use, 11 (33.3%) were abstaining completely from alcohol use and an additional 12 (36.4%) reported a decrease in alcohol daily consumption (measured in drinks per day). Warm hand-off success for street drugs or at-risk alcohol use was 13.6% for those who received an intervention. CONCLUSIONS: It is feasible for medical students to perform a substance use intervention in the ED setting. Medical student contributions as a part of the team response to this public health crisis provide an opportunity for further discussion and research.

Standardized Direct Observation Assessment Tool: Using a Training Video.

BACKGROUND: We developed a DVD training tool to educate physicians evaluating emergency residents on accurate Standardized Direct Observation Assessment Tool (SDOT) application. OBJECTIVE: Our goal was to assess whether this training video improved attendings' and senior residents' SDOT use. METHODS: Participants voluntarily completed SDOT evaluations based on a scripted "test" video. A DVD with "positive" and "negative" scenarios of proper SDOT use was viewed. It included education on appropriate recording of 26 behaviors. The test scenario was viewed again and follow-up SDOTs submitted. Performances by attendings and residents on the pre- and post-test SDOTs were compared. RESULTS: Twenty-six attendings and 26 senior residents participated. Prior SDOT experience was noted for 8 attendings and 11 residents. For 20 anchors, participants recorded observed behaviors with statistically significant difference on one each of the pretest (no. 20; p = 0.034) and post-test (no. 14; p = 0.041) SDOTs. On global competency assessments, pretest medical knowledge (p = 0.016) differed significantly between groups. The training intervention changed one anchor (no. 5; p = 0.035) and one global assessment (systems-based practice; p = 0.031) more negatively for residents. Recording SDOTs with exact agreement occurred 48.73% for attendings pretest and 54.41% post-test; resident scores were 45.86% and 49.55%, respectively. DVD exposure slightly raised attending scores (p = 0.289) and significantly lowered resident scores (p = 0.046). CONCLUSIONS: Exposure to an independently developed SDOT training video tended to raise attending scores, though without significance, while at the same time lowered senior resident scores statistically significantly. Emergency attendings' and senior residents' SDOT scoring rarely differed with significance; about half of anchor behaviors were recorded with exact agreement. This suggests senior residents, with appropriate education, may participate in SDOT assessment.

Correlation Between United States Medical Licensing Examination and Comprehensive Osteopathic Medical Licensing Examination Scores for Applicants to a Dually Approved Emergency Medicine Residency.

BACKGROUND: It is important for emergency medicine (EM) residency programs to be able to correlate the United States (US) Medical Licensing Examination (USMLE) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) scores of applicants. OBJECTIVE: We sought to determine the correlation between USMLE and COMLEX scores for EM residency applicants. METHODS: Retrospectively, from 2006 through 2013, USMLE and COMLEX examination scores for applicants to our 4-year, 56-member, dually approved EM residency were analyzed. Using the COMLEX score as the outcome variable and USMLE score as the predictor, multiple linear regression models, stratified by test step, were created. RESULTS: There were 556 students representing 25 discrete medical schools included. Pair 1 consisted of applicants submitting COMLEX Level-1 and USMLE Step-1 scores (n = 486). Pair 2 were those with COMLEX Level-2 and USMLE Step-2 scores (n = 356). For Pair 1, mean, standard deviation, and median scores on the COMLEX were 551, 69, and 548, respectively; for the USMLE, scores were 216, 16, and 217, respectively. Results for Pair 2 on COMLEX were 566, 80, and 562, respectively; USMLE results were 228, 18, and 229, respectively. A strong correlation was observed for Pair 1 (r = 0.78; p < 0.001). A 1-point increase in USMLE Step-1 is associated with a 3.55-point increase in the COMLEX Level-1 score (ß = 3.55; 95% confidence interval [CI] 3.30-3.80; p < 0.001). A similar strong correlation was observed for Pair 2 (r = 0.72; p < 0.001), where a 1-point increase in USMLE Step-2 is associated with a 3.29-point increase in the COMLEX Level-2 score (ß = 3.29; 95% CI 2.96-3.62; p < 0.001). CONCLUSIONS: A strong positive correlation between Steps 1 and 2 of the USMLE and COMLEX was found.

Comparison of airway intubation devices when using a biohazard suit: a feasibility study.

OBJECTIVES: We set out to compare emergency medicine residents' intubating times and success rates for direct laryngoscopy (DL), GlideScope-assisted intubation (GS), and the Supraglottic Airway Laryngopharyngeal Tube (SALT) airway with and without biohazard gear. METHODS: Each resident passed through 2 sets of 3 testing stations (DL, GS, SALT) in succession, intubating Laerdal mannequin heads with the 3 modalities after randomization to start with or without biohazard gear. RESULTS: Thirty-seven residents participated, and 27 were male (73%); 14 (37.8%) had prior experience intubating in biohazard suits. There was a statistically significant difference in those who had prior intubation experience between DL (37, 100%), GS (32, 86.5%), and SALT (12, 32.4%) (P < .001) and in median time to intubation (48 seconds, no suit; 57 seconds, with suits) (P = .03). There was no statistically significant difference between the overall times to intubate for the 3 devices. First-pass success was highest for DL (91.2%, no suit; 83.7%, suit) followed by GS (89%, no suit; 78.3%, suit) and SALT (51%, no suit; 67.6%, suit). CONCLUSION: A minority of participants had prior experience intubating in biohazard suits. Use of biohazard suits extends time to successful intubation. There was no difference in time to intubation for the 3 devices, but first-pass success was highest for DL (with or without biohazard gear).

Traumatic dislocation of the first carpometacarpal joint.

We present a case report and review of the literature of traumatic dislocation of the carpometacarpal joint of the left thumb without associated fracture. The injury was sustained while skiing, and after emergency department diagnosis, the dislocation was reduced and the joint stabilized with a splint. The patient was discharged with close follow-up with a hand surgeon for definitive surgical fixation. Carpometacarpal joint dislocations of the thumb are exceedingly rare injuries and require appropriate diagnosis and treatment to minimize the morbidity and loss of function that can occur with these injuries.

Severe Hypokalemia Causing Ventricular Tachycardia: A Case Report.

Hypokalemia and hyperosmolar hyperglycemic syndrome (HHS) are two reversible but potentially fatal disorders that are important to identify and treat urgently. A 43-year-old patient presented to the ED with altered mental status and slurred speech, difficulty communicating, left-sided facial droop, and stool incontinence according to emergency medical services. This was preceded by 1.5 weeks of nausea, vomiting, polydipsia, and weight loss. On presentation, the patient was found tachycardic and tachypneic, with uncertain neurological deficits on physical exam, hyperglycemia, and electrocardiogram (EKG) abnormalities. Lab data were consistent with hyperosmolar hyperglycemic nonketotic coma. This case provides two important clinical scenarios in which cardiac EKG abnormalities and focal neurological deficits are the product of hyperosmolality and electrolyte abnormalities. Hypokalemia with EKG abnormalities consistent with a potential ischemic disease can progress into wide complex tachycardia and ventricular fibrillation. Hyperosmolar hyperglycemia may manifest with focal neurological deficits and without the classical presentation of a coma. Careful consideration of EKG and lab values in the context of clinical presentation may provide clues to resolvable etiologies. We report a case of a patient who presented to the ED with hypokalemia and HHS, both reversible but potentially fatal disorders that are important to identify and urgently treat.

Differential diagnosis generators: an evaluation of currently available computer programs.

BACKGROUND: Differential diagnosis (DDX) generators are computer programs that generate a DDX based on various clinical data. OBJECTIVE: We identified evaluation criteria through consensus, applied these criteria to describe the features of DDX generators, and tested performance using cases from the New England Journal of Medicine (NEJM©) and the Medical Knowledge Self Assessment Program (MKSAP©). METHODS: We first identified evaluation criteria by consensus. Then we performed Google® and Pubmed searches to identify DDX generators. To be included, DDX generators had to do the following: generate a list of potential diagnoses rather than text or article references; rank or indicate critical diagnoses that need to be considered or eliminated; accept at least two signs, symptoms or disease characteristics; provide the ability to compare the clinical presentations of diagnoses; and provide diagnoses in general medicine. The evaluation criteria were then applied to the included DDX generators. Lastly, the performance of the DDX generators was tested with findings from 20 test cases. Each case performance was scored one through five, with a score of five indicating presence of the exact diagnosis. Mean scores and confidence intervals were calculated. KEY RESULTS: Twenty three programs were initially identified and four met the inclusion criteria. These four programs were evaluated using the consensus criteria, which included the following: input method; mobile access; filtering and refinement; lab values, medications, and geography as diagnostic factors; evidence based medicine (EBM) content; references; and drug information content source. The mean scores (95% Confidence Interval) from performance testing on a five-point scale were Isabel© 3.45 (2.53, 4.37), DxPlain® 3.45 (2.63-4.27), Diagnosis Pro® 2.65 (1.75-3.55) and PEPID™ 1.70 (0.71-2.69). The number of exact matches paralleled the mean score finding. CONCLUSIONS: Consensus criteria for DDX generator evaluation were developed. Application of these criteria as well as performance testing supports the use of DxPlain® and Isabel© over the other currently available DDX generators.

Cardiopulmonary resuscitation prescription program: a pilot randomized comparator trial.

BACKGROUND: The American Heart Association wants to increase the number of citizens who know how to perform cardiopulmonary resuscitation (CPR). It is unknown whether giving patients a prescription (Rx) to learn CPR is effective. We sought to determine if patients with, or at risk for, heart disease and their families were more likely to follow prescriptive advice to buy a CPR Anytime™ kit (American Heart Association, Dallas, TX) or to take a CPR class. METHODS: This was a prospective randomized pilot study of a convenience sample of 162 patients who presented to one of three recruiting sites: a suburban community emergency department (ED), an office-based primary care (IM), or cardiology (CD) setting. After consent was obtained, CPR-naïve participants aged>44 years were randomized to one of two study arms. One group received a Rx for a CPR Anytime™ self-learning kit, consisting of a CPR mannequin and a 22-minute DVD. The comparator group was prescribed a CPR class. RESULTS: At the IM office, 7/29 (24%), at the CD office 3/25 (12%), and at the ED 2/23 (9%) patients purchased the CPR kit. Across both investigational arms, 4 were lost to follow-up, yielding approximately 15% (12/77) who followed Rx advice to purchase the CPR kit and 0% (0/79) who took a CPR class. Cumulatively, a participant was significantly more likely to purchase a kit than to take a class (p=0.0004). CONCLUSION: Patients can be motivated to purchase CPR Anytime™ kits but not to take a CPR class from prescribed advice.

Do incoming residents vary in measures of emotional status even prior to residency training?

Objectives: To determine whether Empathy, Emotional Intelligence, and Burnout scores differ by specialty in incoming residents. Methods: This is a single-site, prospective, cross-sectional study. Three validated survey instruments, the Jefferson Scale of Physician Empathy, Maslach Burnout Inventory, and Emotional and Social Competency Inventory, were written into a survey platform as a single 125-question Qualtrics survey. Over three academic years, 2015-2017, 229 incoming residents across all specialties were emailed the survey link during orientation. Residents were grouped by incoming specialty with anonymity assured. A total of 229 responses were included, with 121 (52.8%) identifying as female. Statistical analysis was performed using the Analysis of Variance or Kruskal-Wallis test, Chi-Square or Fisher's Exact test, and Independent Samples t-test or Mann Whitney U test. A Bonferroni correction was applied for pairwise comparisons. Results: Family Medicine had a higher median Jefferson Scale of Physician Empathy score (127) compared to Emergency Medicine (115), (U=767.7, p=0.0330). Maslach Burnout Inventory depersonalization and personal accomplishment subcategory scores showed a significant difference between specialties when omnibus tests were performed, but pairwise comparisons with emergency medicine residents showed no differences. Differences were found in the Maslach Burnout Inventory categories of Depersonalization (χ2(8, N=229) =15.93, p=0.0434) and Personal Accomplishment level (χ2(8, N=229) =20.80, p=0.0077) between specialties. Conclusions: Differences in measures of well-being exist across specialties, even prior to the start of residency training. The implication for educators of residency training is that some incoming residents, regardless of specialty, already exhibit troublesome features of burnout, and resources to effectively deal with these residents should be developed and utilized.

Developing Emotional Intelligence Through a Longitudinal Leadership Curriculum in UME: Combating the Decline in Medical Student Empathy.

We report on a novel curriculum (Scholarly Excellence, Leadership Experiences, Collaborative Training [SELECT]) in an allopathic medical school designed to prepare students to be physician leaders while remaining empathetic by combating burnout. SELECT students were surveyed annually. The survey contained the Jefferson Scale of Empathy (JSE) and Maslach Burnout Inventory (MBI). In this cohort, empathy did not decrease, as measured by the JSE, and SELECT students' MBI Depersonalization burnout scores decreased after year 3. In summary, in this allopathic US medical school utilizing a novel curriculum, there was no significant decline in empathy after the third year of medical school. The SELECT program appears to mitigate the decline in empathy and increased Depersonalization burnout levels often seen at the end of the third year of medical school.

Appropriate Evaluation of Psychiatric Patients Highlighted by Creutzfeldt-Jakob Disease: A Case Report.

INTRODUCTION: Determination of medical stability for patients presenting with psychiatric complaints is common for emergency clinicians. A thorough history and physical examination is important. CASE REPORT: A 53-year-old male presented to the emergency department (ED) with depression, suicidal ideation, and decline in activities of daily living over six months. While his initial neurologic examination was non-focal, subsequent re-evaluations demonstrated significant changes, and he was ultimately diagnosed with Creutzfeldt-Jakob disease. CONCLUSION: This case demonstrates how a detailed history of the present illness could have led to a more accurate and timely medical disposition from the ED.

Sex-specific Outcomes in a Substance Use Intervention Program.

PURPOSE: We performed an emergency department (ED)-based substance use screening, motivational interview-based intervention, and treatment referral program with the goal of determining sex-specific outcomes. Specifically, in this quality improvement project, we aimed to determine whether there was a difference among sexes in the type of substances used; the frequency of positive screening results for substance use disorder; agreeing to an intervention; the type of follow-up evaluation, participation, and referral; and attempts to change substance use after intervention. METHODS: We prospectively studied a convenience sample of patients at 3 hospitals in Northeastern Pennsylvania from May 2017 through February 2018. Inclusion criteria for participation in this study were age ≥18 years; ability to answer survey questions; willingness and ability (not being too ill) to participate in intervention(s); and when screened, admitting to use of alcohol, tobacco, potentially addictive prescription drugs, or street drugs. Practitioners in the ED screened patients. For those with unhealthy substance use, a brief motivational interview was performed. Participants were each given referrals and information in accordance with the particular substance used and their assessed readiness to change. Individuals who completed the intervention were contacted by telephone for follow-up. Self-reported outcomes and the frequency of successful warm hand-off referrals were assessed. FINDINGS: Of the 2209 individuals screened, 976 (44.2%) were male. Overall, 547 patients screened positive for at least 1 of the unhealthy substances for a prevalence of 24.8% (95% confidence interval, 22.9%-26.6%). In this population, a greater proportion of men screened positive than women (30.5% vs 20.2%, P = 0.01). Although the finding was not statistically significant, men (106 [35.6%]) were more likely than women (81 [32.5%]) to agree to an ED intervention. At telephone follow-up, men were more likely to report participating in a treatment or support program than women (32.9% vs 18.2%, P = 0.035). Frequencies of warm hand-off referrals were 11 of 106 (10.4%) for men and 2 of 81 (2.5%) for women. IMPLICATIONS: Our small study found that unhealthy substance use rates were greater overall in men than women. Overall participation differences between men and women who agreed to take part in substance intervention and accepted a referral for follow-up treatment were not statistically significant. At telephone follow-up, more men reported participating in a treatment program than women. Direct referral (warm hand-off) rates to treatment programs were small in both sexes but greater in men than women.

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric.

PURPOSE: The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing. METHODS: After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician's assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents' teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents' teaching, while residents self-assessed their performance. The participants' demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants' mean scores. FINDINGS: Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P < 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents' evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students' evaluations of the residents' teaching skills by residents' gender did not reveal gender differences. IMPLICATIONS: MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents' teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula.

MRI diagnosis of herpes simplex encephalitis in an elderly man with nonspecific symptoms.

A 78-year-old male presented to the Emergency Department complaining of a 1-week onset of increasing fatigue and anorexia. The patient was previously well but had a history of depression, chronic diarrhea, and hypertension. His examination was remarkable for mild fever (100.1°F). He had no acute neurologic deficits. The patient felt better after intravenous fluids and was discharged to follow-up with the primary care provider. With no resolution of symptoms and new memory loss, the patient's primary care doctor ordered an MRI which revealed abnormal signal/patchy enhancement of the left temporal lobe indicative (pathognomonic) of herpes simplex encephalitis. This case emphasizes the importance of early consideration of herpes simplex encephalitis in the differential of patient's with these symptoms.

Factors associated with burnout during emergency medicine residency.

OBJECTIVES: While the prevalence of burnout in practicing emergency physicians has been studied, little is known of the prevalence and risk factors in emergency medicine (EM) residents. The aim of this study was to assess the prevalence of burnout among EM residents and the individual-level factors associated with burnout. METHODS: Eight EM residency programs were surveyed using the Maslach Burnout Inventory (MBI). Demographic data and data on job satisfaction and tolerance of uncertainty in clinical decision-making were collected using validated instruments. RESULTS: Of 289 eligible residents, 218 completed the MBI (response rate = 75%). A total of 142 residents (65%) met the criteria for burnout. Complete data sets of the other instruments were obtained from 193 (response rate = 67%), and this group comprised our study population. Subjects having a significant other or spouse had a higher prevalence of burnout compared to single residents (60% vs. 40%, p = 0.002). Poor global job satisfaction (p < 0.0001), lack of administrative autonomy (p = 0.021), and lack of clinical autonomy (p = 0.031) correlated with burnout, as did intolerance of uncertainty (p = 0.015). CONCLUSIONS: Burnout is highly prevalent in EM residents. Interventions should be targeted at 1) improving resident autonomy in the emergency department where possible, 2) supervision and instruction on medical decision-making that may affect or teach individuals to cope with risk tolerance, and 3) social supports to reduce work-home conflicts during training.