Preclinical medical student observations associated with later professionalism concerns.

PURPOSE: Professionalism is a core physician competency and identifying students at risk for poor professional development early in their careers may allow for mentoring. This study identified indicators in the preclinical years associated with later professionalism concerns. METHODS: A retrospective analysis of observable indicators in the preclinical and clinical years was conducted using two classes of students (n = 226). Relationships between five potential indicators of poor professionalism in the preclinical years and observations related to professional concerns in the clinical years were analyzed. RESULTS: Fifty-three medical students were identified with at least one preclinical indicator and one professionalism concern during the clinical years. Two observable preclinical indicators were significantly correlated with unprofessional conduct during the clinical years: Three or more absences from attendance-required sessions (odds ratio 4.47; p=.006) and negative peer assessment (odds ratio 3.35; p=.049). CONCLUSIONS: We identified two significant observable preclinical indicators associated with later professionalism concerns: excessive absences and negative peer assessments. Early recognition of students at risk for future professionalism struggles would provide an opportunity for proactive professional development prior to the clinical years, when students' permanent records may be affected. Peer assessment, coupled with attention to frequent absences, may be a method to provide early recognition.

Recurrent spontaneous globe subluxation: a case report and review of manual reduction techniques.

BACKGROUND: Spontaneous globe subluxation is an uncommon problem that develops acutely and can present with significant patient distress from ocular pain and vision loss. OBJECTIVES: To present an unusual case of recurrent spontaneous globe subluxation and describe several methods emergency physicians can use to reduce a subluxation. CASE REPORT: We describe a patient with recurrent spontaneous globe subluxation who presented to the Emergency Department with acute ocular pain and vision loss. The subluxation was emergently reduced, resolving the pain and restoring normal vision. Various manual reduction techniques are discussed. CONCLUSION: There are a number of manual reduction techniques used for treating spontaneous globe subluxation.

Educator's blueprint: A guide for clinician-educators to achieve promotion in emergency medicine.

Promotion and tenure (P&T) can be a complex process, which many junior faculty in academic emergency medicine may struggle navigating. This paper presents perspectives and key considerations to guide faculty through the promotions process. We explore tips through three key phases: plotting the course for a successful academic career, collecting data to support academic advancement, and packaging materials into a compelling application portfolio. This resource can inform faculty and faculty developers when planning for P&T.

Faculty physicians and new physicians disagree about which procedures are essential to learn in medical school.

BACKGROUND: Clinical procedures taught in the undergraduate medical curriculum are important for subsequent residency training and clinical practice. Published reports suggest that medical schools may not be adequately teaching procedures. This study identifies procedures considered essential by residents completing internship and by medical school faculty, and determines agreement on their importance for medical student education. METHODS: Two hundred and thirty-five physicians (184 new physicians who recently completed internship and 51 medical school teaching faculty) categorized 31 clinical procedures based on the importance for internship. New physicians who had completed internship reported the level of training received in medical school for each procedure. RESULTS: Survey responses were 76% (faculty) and 70% (new physicians who had completed internship). The faculty majority identified 14 procedures as 'Must Know.' New physicians disagreed on 8 of these and categorized an additional 5 as essential. There was 32% concordance for the 19 procedures identified by either group. New physicians reported 'Limited Hands-On Training' for all 19 procedures but 'Comprehensive Hands-On Training' for only two. CONCLUSIONS: New physicians who have completed internship and medical school faculty do not agree on procedures essential for internship. A core educational list of 19 procedures was identified using the responses from these two groups.

Large group high-fidelity simulation enhances medical student learning.

BACKGROUND: Previous work shows feasibility for large group high-fidelity simulation with correlation to basic science in the preclinical curriculum. AIMS: This project studies whether large group simulation leads to enhanced basic science learning. METHODS: This was an educational performance study before and after high-fidelity simulation for first-year medical students. Basic neuroscience concepts were reinforced with simulation, and pretesting and posttesting were analysed along with summative exam results. The number correct was compared on a contingency table using the Mantel-Haenszel chi-squared test and same student correlation was accounted for with a 'Generalized Estimating Equations' model. RESULTS: The study included 112 students; three were excluded for missing data. Students showed statistically significant improvement on two of the four questions, and a nonsignificant improvement or equivalent performance on two questions. Students were significantly more likely to get all four responses correct on the posttest than on the pretest. Summative testing 11 days later had >80% correct responses for three factual recall questions and 58% correct responses for a single knowledge application question. CONCLUSIONS: Simulation is an effective teaching method for preclinical basic science education. Students demonstrated significant improvements after participating in a live interactive simulation scenario.

A case of intrauterine molar pregnancy with coexistent ectopic pregnancy.

We describe a woman who presented to the Emergency Department (ED) with vaginal bleeding and abdominal pain. She was initially diagnosed by the emergency physician with a molar pregnancy by transvaginal ultrasound, which was confirmed and treated by the consulting obstetrical service with a dilatation and curettage the following day. The patient was discharged home later that same day and subsequently returned to the ED after several hours complaining of an acute worsening of her abdominal pain with associated fatigue and lightheadedness. Transabdominal ultrasound performed by the emergency physician demonstrated intra-abdominal free fluid, and the obstetrical service was immediately contacted. Subsequent operative management identified a separate ruptured ectopic pregnancy in the fallopian tube that was confirmed by pathologic analysis after laparoscopic removal.

Emergency department management of meningitis and encephalitis.

Bacterial meningitis and viral encephalitis are infectious disease emergencies that can cause significant patient morbidity and mortality. Clinicians use epidemiologic, historical, and physical examination findings to identify patients at risk for these infections, and central nervous system (CNS) imaging and lumbar puncture (LP) may be needed to further evaluate for these diagnoses. The diagnosis of bacterial meningitis can be challenging, as patients often lack some of the characteristic findings of this disease with presentations that overlap with more common disorders seen in the emergency department. This article addresses considerations in clinical evaluation, need for CNS imaging before LP, interpretation of cerebrospinal fluid results, standards for and effects of timely antibiotic administration, and recommendations for specific antimicrobial therapy and corticosteroids.

Drug Insight: steroids in CNS infectious diseases--new indications for an old therapy.

Infectious diseases of the CNS lead to overwhelming inflammatory processes within the brain and spinal cord that contribute substantially to patient morbidity and mortality. Pharmacological strategies to modulate inflammation have been investigated, although the resulting guidelines have sometimes been contradictory. Steroids have been proposed as adjunctive treatments for bacterial meningitis, tuberculous meningitis and herpes simplex virus encephalitis. Well-designed randomized controlled trials have established dexamethasone as an adjunctive therapy for adult patients receiving antibiotics for bacterial meningitis, and physicians prescribing the initial antibiotics need to be aware of current guidelines. Morbidity and mortality in patients with tuberculous meningitis exceeds 50%. Steroid treatments reduce mortality through an as yet unknown mechanism, although their effects on morbidity are less clear. Herpes simplex virus encephalitis is also associated with considerable morbidity and mortality. Despite a lack of randomized trials, there is some evidence that steroids used alongside antiviral therapy might be beneficial in this condition. As we discuss in this Review, systemic steroid treatment is an important aspect of treatment regimens for CNS infectious diseases, and the recent literature provides guidelines for the use of steroids in combination with appropriate antimicrobial therapy.

A skin abscess model for teaching incision and drainage procedures.

BACKGROUND: Skin and soft tissue infections are increasingly prevalent clinical problems, and it is important for health care practitioners to be well trained in how to treat skin abscesses. A realistic model of abscess incision and drainage will allow trainees to learn and practice this basic physician procedure. METHODS: We developed a realistic model of skin abscess formation to demonstrate the technique of incision and drainage for educational purposes. The creation of this model is described in detail in this report. RESULTS: This model has been successfully used to develop and disseminate a multimedia video production for teaching this medical procedure. Clinical faculty and resident physicians find this model to be a realistic method for demonstrating abscess incision and drainage. CONCLUSION: This manuscript provides a detailed description of our model of abscess incision and drainage for medical education. Clinical educators can incorporate this model into skills labs or demonstrations for teaching this basic procedure.

Emergency diagnosis and treatment of adult meningitis.

Despite the existence of antibiotic therapies against acute bacterial meningitis, patients with the disease continue to suffer significant morbidity and mortality in both high and low-income countries. Dilemmas exist for emergency medicine and primary-care providers who need to accurately diagnose patients with bacterial meningitis and then rapidly administer antibiotics and adjunctive therapies for this life-threatening disease. Physical examination may not perform well enough to accurately identify patients with meningitis, and traditionally described lumbar puncture results for viral and bacterial disease cannot always predict bacterial meningitis. Results from recent studies have implications for current treatment guidelines for adults with suspected bacterial meningitis, and it is important that physicians who prescribe the initial doses of antibiotics in an emergency setting are aware of guidelines for antibiotics and adjunctive steroids. We present an overview and discussion of key diagnostic and therapeutic decisions in the emergency evaluation and treatment of adults with suspected bacterial meningitis.

Using high-fidelity emergency simulation with large groups of preclinical medical students in a basic science course.

BACKGROUND: High-fidelity patient simulation is often used to teach clinical patient management and decision-making with small groups. This pilot project determined feasibility for large-group educational presentations using simulation for preclinical basic science courses. METHODS: We developed an emergency patient simulation encounter illustrating basic neuroscience concepts. Physician actors interacted with a high-fidelity simulated patient mannequin in a lecture hall. First and second year medical students were active participants in the 90 minute live event in large groups. Digital video was recorded and written feedback was obtained from participants. RESULTS: The simulation was presented four times to a total of 202 students. Video review demonstrated extensive interaction within the large groups. Case management discussions included basic science topics, autonomic pathways, and neuropharmacology. Student feedback revealed 98% rated the correlation to basic science concepts as very good or outstanding, and 99% rated the same for overall presentation. CONCLUSIONS: Live large-group simulation presentations are feasible in a non-traditional location, correlate with basic science in the preclinical medical curriculum, and are well-received by students.

Pediatric Needle Cricothyrotomy: A Case for Simulation in Prehospital Medicine.

INTRODUCTION: A patient that cannot be oxygenated or ventilated requires immediate and effective assessment, treatment, and transportation. Pediatric needle cricothyrotomy is used infrequently, therefore providers have a tendency to lose proficiency. Simulation training and evaluation are valuable tools to improve provider experience and skill. METHODS: A case was designed involving a 3-year-old male with a peanut allergy that presents with rash, swelling, and severe respiratory distress. The patient's respiratory distress and swelling worsens despite treatment with epinephrine and other allergic reaction medications. The patient then becomes unresponsive and impossible to oxygenate or ventilate. The primary objective of this case is airway management with needle cricothyrotomy in the pediatric population. A secondary objective is appropriate postprocedure management including appropriate ventilation rates and emergency medical transportation methods. RESULTS: This case was initially presented to 45 paramedics. Provider comfort with managing airway emergencies in young children improved from 47% to 89%. Confidence in performing pediatric needle cricothyrotomy improved from 16% to 87%. All providers felt the exercise was valuable and 98% felt the simulation provided appropriate realism. DISCUSSION: This scenario provides an outstanding opportunity for paramedic evaluation and training in pediatric needle cricothyrotomy and significantly improved the comfort level of providers' management of a failed pediatric airway. As we reflected on the use of this module, it was apparent that this was a very beneficial opportunity to spend one-on-one time between participants and their medical director. The training staff also benefited from the repeated emphasis of good assessment and treatment of a complex patient scenario.

Evaluating educational interventions in emergency medicine.

This article presents the proceedings of the 2012 Academic Emergency Medicine consensus conference breakout group charged with identifying areas necessary for future research regarding effectiveness of educational interventions for teaching emergency medicine (EM) knowledge, skills, and attitudes outside of the clinical setting. The objective was to summarize both medical and nonmedical education literature and report the consensus formation methods and results. The authors present final statements to guide future research aimed at evaluating the best methods for understanding and developing successful EM curricula using all types of educational interventions.

The Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia core measures lead to unnecessary antibiotic administration by emergency physicians.

OBJECTIVES: The objectives were to assess emergency physician (EP) understanding of the Centers for Medicare and Medicaid Services (CMS) core measures for community-acquired pneumonia (CAP) guidelines and to determine their self-reported effect on antibiotic prescribing patterns. METHODS: A convenience sample of EPs from five medical centers in North Carolina was anonymously surveyed via a Web-based instrument. Participants indicated their level of understanding of the CMS CAP guidelines and the effects on their prescribing patterns for antibiotics. RESULTS: A total of 121 EPs completed the study instrument (81%). All respondents were aware of the CMS CAP guidelines. Of these, 95% (95% confidence interval [CI] = 92% to 98%) correctly understood the time-based guidelines for antibiotic administration, although 24% (95% CI = 17% to 31%) incorrectly identified the onset of this time period. Nearly all physicians (96%; 95% CI = 93% to 99%) reported institutional commitment to meet these core measures, and 84% (95% CI = 78% to 90%) stated that they had a department-based CAP protocol. More than half of the respondents (55%; 95% CI = 47% to 70%) reported prescribing antibiotics to patients they did not believe had pneumonia in an effort to comply with the CMS guidelines, and 42% (95% CI = 34% to 50%) of these stated that they did so more than three times per month. Only 40% (95% CI = 32% to 48%) of respondents indicated a belief that the guidelines improve patient care. Of those, this was believed to occur by increasing pneumonia awareness (60%; 95% CI = 52% to 68%) and improving hospital processes when pneumonia is suspected (86%; 95% CI = 80% to 92%). CONCLUSIONS: Emergency physicians demonstrate awareness of the current CMS CAP guidelines. Most physicians surveyed reported the presence of institutional protocols to increase compliance. More than half of EPs reported that they feel the guidelines led to unnecessary antibiotic usage for patients who are not suspected to have pneumonia. Only 40% of EPs believe that CAP awareness and expedient care resulting from these guidelines has improved overall pneumonia-related patient care. Outcome-based data for non-intensive care unit CAP patients are lacking, and EPs report that they prescribe antibiotics when they may not be necessary to comply with existing guidelines.

CNS injury, glial scars, and inflammation: Inhibitory extracellular matrices and regeneration failure.

Spinal cord and brain injuries lead to complex cellular and molecular interactions within the central nervous system in an attempt to repair the initial tissue damage. Many studies have illustrated the importance of the glial cell response to injury, and the influences of inflammation and wound healing processes on the overall morbidity and permanent disability that result. The abortive attempts of neuronal regeneration after spinal cord injury are influenced by inflammatory cell activation, reactive astrogliosis and the production of both growth promoting and inhibitory extracellular molecules. Despite the historical perspective that the glial scar was a mechanical barrier to regeneration, inhibitory molecules in the forming scar and methods to overcome them have suggested molecular modification strategies to allow neuronal growth and functional regeneration. Unlike myelin associated inhibitory molecules, which remain at largely static levels before and after central nervous system trauma, inhibitory extracellular matrix molecules are dramatically upregulated during the inflammatory stages after injury providing a window of opportunity for the delivery of candidate therapeutic interventions. While high dose methylprednisolone steroid therapy alone has not proved to be the solution to this difficult clinical problem, other strategies for modulating inflammation and changing the make up of inhibitory molecules in the extracellular matrix are providing robust evidence that rehabilitation after spinal cord and brain injury has the potential to significantly change the outcome for what was once thought to be permanent disability.