Diabetic Ketoacidosis.

This article reviews the most current literature on diabetic ketoacidosis, including how to make the diagnosis and management. It discusses euglycemic diabetic ketoacidosis and the risk factors for this rare but dangerous disease process. Pertinent pearls and pitfalls encountered by the emergency physician when managing these patients are included. Because these patients often stay in the emergency department for prolonged periods, recommendations on transitioning to subcutaneous insulin are included, along with dosing recommendations. Finally, the article reviews how to disposition patients with diabetic ketoacidosis and examines important factors that lead to a successful discharge home.

Emergency Considerations of Infective Endocarditis.

Although still a rare bacterial infection of the endocardium of the heart, the incidence of infective endocarditis continues to increase with the increased use of intracardiac devices, indwelling lines, and surgical procedures being done on patients. The diagnosis of infective endocarditis remains challenging and requires a high level of suspicion to initiate the appropriate investigation and treatment. Serious complications can still occur despite optimal care, so it is helpful that these patients be managed by a team that includes infectious disease, cardiology, and cardiac surgeons.

Chest imaging of hypersensitivity pneumonitis induced by heroin abuse.

Long-term abuse of nasally inhaled substances such as heroin can result in life-threatening hypersensitivity pneumonitis and respiratory distress. In the setting of hypoxia, a chest CTA is often necessary to see the extent of the lung involvement and to rule out pulmonary emboli.

A Financial Plot to Reduce the Burden of Medical School Tuition Fees.

Tuition fees for medical school are continuously and riotously increasing. This upsurge is amassing debts on the backs of students. In the class of 2018, 75% finished medical school with an outstanding balance of $196,520, on average-a $5826 increase from 2017. Tuition fees differ in terms of the ownership of the medical school (public vs. private) and according to the medical student residence status (in-state or out-of-state). It is critical that students arrange a long-term budget that shows them where they stand: in surplus or in deficit. Students may classify expenditures into two groups: "fixed" and "variable," where they can manipulate the variable expenses to fit into their budget. To pay for their tuition, medical students have four possibilities: cash, scholarships and grants, service-obligation scholarships, and loans. Loans are the most common alternatives, and so there are Traditional Repayment Plans and Income-Driven Repayment Plans. This article serves to provide medical students with attainable alternatives for funding their education and for repaying their debts.

Emergency Medicine Interest Groups.

Emergency Medicine Interest Groups (EMIGs) serve as a bountiful resource for students interested in pursuing a career in Emergency Medicine (EM). In this article we elaborate on how medical students can get involved as members in an EMIG, discuss opportunities for leadership through these groups, detail how to make the most out of the EMIG (including a listing of important lectures, workshops/labs and opportunities for growth and advancement), provide a framework for how to institute a new EMIG when one does not exist, and discuss considerations for international EMIG groups.

Research and Scholarly Projects.

The idea of doing a research or scholarly project can be very daunting, however, the satisfaction of seeing a project to its completion is very rewarding. In this article, we provide medical students with guidance on whether they should take on a research or scholarly project during medical school, and how to get started, publish, and then present their project. We also highlight how such a project can benefit an applicant applying for residency training.

Medical Student Leadership in Emergency Medicine.

Emergency medicine is a profession that requires good leadership skills. Emergency physicians must be able to instill confidence in both the staff and patients, inspire the best in others, have the enthusiasm to take on a surplus of responsibilities, and maintain calmness during unexpected circumstances. Accordingly, residency program directors look carefully for leadership qualities and potential among their applicants. Although some people do have a predisposition to lead, leadership can be both learned and taught. In this article, we provide medical students with the tools that will help them acquire those qualities and thus make them more desirable by program directors.

The Medical School Years.

Medical school can be very challenging, especially when students are considering applying to competitive specialties, like emergency medicine. Once medical students know that emergency medicine is the field they want to specialize in, a multitude of other questions arise, including how many EM rotations should they do? How can they shine during their EM rotations? When should they schedule their rotations, electives, and sub-internships? How can they get the strongest letters of recommendation? What are residency program directors looking for? Therefore, we are going to present in the Medical Student Forum section of the Journal of Emergency Medicine a series of six articles covering this and more.

Designing the Third- and Fourth-Years Clerkship Schedule.

Deciding on a specialty may be one of the most daunting parts of medical school. Accordingly, it is important for medical students to make informed decisions regarding their choice of specialty. To do so, they should start planning early by contemplating possible career choices during the first 2 years of medical school, followed by properly designing their third- and fourth-year schedules. This article provides guidance and advice to medical students on how to schedule their clinical clerkships in order to optimize their ability to decide on a field of medicine to study and, ideally, to prepare them for a career in emergency medicine.

Clerkships in Emergency Medicine.

Planning for clerkships in emergency medicine (EM) can be stressful, prolonged, and challenging. Therefore, medical students should start planning for them early. In this article, we offer guidance regarding several issues pertinent to the EM clerkship, such as the best time to schedule one (or more) during medical school, the most appropriate institution or program to schedule it, the process of selecting and applying for the clerkship, and the number of EM clerkships to consider. We will explain why an EM clerkship should be scheduled between June and October and the reason that 2 EM clerkships at different sites are sufficient for the majority of students. Additionally, we emphasize that clerkships in emergency departments associated with EM residency programs or with reputations for outstanding student teaching tend to be most beneficial. Above all, students interested in EM should attempt to leave a great impression after completing their clerkships by providing stellar patient care, demonstrating enthusiasm at all times, and maintaining professionalism. In turn, they will gain knowledge and clinical experiences that should prove valuable in their future.

Risk Management and Avoiding Legal Pitfalls in the Emergency Treatment of High-Risk Orthopedic Injuries.

Many orthopedic injuries can have hidden risks that result in increased liability for the emergency medicine practitioner. It is imperative that emergency medicine practitioners consider the diagnoses of compartment syndrome, high-pressure injury, spinal epidural abscess, and tendon lacerations in the right patient. Consideration of the diagnosis and prompt referrals can help to minimize the complications these patients often develop.

The Standardized Video Interview: How Does It Affect the Likelihood to Invite for a Residency Interview?

BACKGROUND: The Association of American Medical Colleges instituted a standardized video interview (SVI) for all applicants to emergency medicine (EM). It is unclear how the SVI affects a faculty reviewer's decision on likelihood to invite an applicant (LTI) for an interview. OBJECTIVES: The objective was to determine whether the SVI affects the LTI. METHODS: Nine Accreditation Council of Graduate Medication Education (ACGME)-accredited EM residency programs participated in this prospective, observational study. LTI was defined on a 5-point Likert scale as follows: 1 = definitely not invite, 2 = likely not invite, 3 = might invite, 4 = probably invite, 5 = definitely invite. LTI was recorded at three instances during each review: 1) after typical screening (blinded to the SVI), 2) after unblinding to the SVI score, and 3) after viewing the SVI video. RESULTS: Seventeen reviewers at nine ACGME-accredited residency programs participated. We reviewed 2,219 applications representing 1,424 unique applicants. After unblinding the SVI score, LTI did not change in 2,065 (93.1%), increased in 85 (3.8%) and decreased in 69 (3.1%; p = 0.22). In subgroup analyses, the effect of the SVI on LTI was unchanged by United States Medical Licensing Examination score. However, when examining subgroups of SVI scores, the percentage of applicants in whom the SVI score changed the LTI was significantly different in those that scored in the lower and upper subgroups (p < 0.0001). The SVI video was viewed in 816 (36.8%) applications. Watching the video did not change the LTI in 631 (77.3%); LTI increased in 106 (13.0%) and decreased in 79 (9.7%) applications (p = 0.04). CONCLUSIONS: The SVI score changed the LTI in 7% of applications. In this group, the score was equally likely to increase or decrease the LTI. Lower SVI scores were more likely to decrease the LTI than higher scores were to increase the LTI. Watching the SVI video was more likely to increase the LTI than to decrease it.

The AAMC Standardized Video Interview and the Electronic Standardized Letter of Evaluation in Emergency Medicine: A Comparison of Performance Characteristics.

PURPOSE: To compare the performance characteristics of the electronic Standardized Letter of Evaluation (eSLOE), a widely used structured assessment of emergency medicine (EM) residency applicants, and the Association of American Medical Colleges (AAMC) Standardized Video Interview (SVI), a new tool designed by the AAMC to assess interpersonal and communication skills and professionalism knowledge. METHOD: The authors matched EM residency applicants with valid SVI total scores and completed eSLOEs in the 2018 Match application cycle. They examined correlations and group differences for both tools, United States Medical Licensing Examination (USMLE) Step exam scores, and honor society memberships. RESULTS: The matched sample included 2,884 applicants. SVI score and eSLOE global assessment ratings demonstrated small positive correlations approaching r = 0.20. eSLOE ratings had higher correlations with measures of academic ability (USMLE scores, academic honor society membership) than did SVI scores. Group differences were minimal for the SVI, with scores slightly favoring women (d = -0.21) and US-MD applicants (d = 0.23-0.42). Group differences in eSLOE ratings were small, favoring women over men (approaching d = -0.20) and white applicants over black applicants (approaching d = 0.40). CONCLUSIONS: Small positive correlations between SVI score and eSLOE global assessment ratings, alongside varying correlations with academic ability indicators, suggest these are complementary tools. Findings suggest the eSLOE is subject to similar sources and degrees of bias as other common assessments; these group differences were not observed with the SVI. Further examination of both tools is necessary to understand their ability to predict clinical performance.

Standardized Video Interviews Do Not Correlate to United States Medical Licensing Examination Step 1 and Step 2 Scores.

INTRODUCTION: In 2017, the Standardized Video Interview (SVI) was required for applicants to emergency medicine (EM). The SVI contains six questions highlighting professionalism and interpersonal communication skills. The responses were scored (6-30). As it is a new metric, no information is available on correlation between SVI scores and other application data. This study was to determine if a correlation exists between applicants' United States Medical Licensing Examination (USMLE) and SVI scores. We hypothesized that numeric USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores would not correlate with the SVI score, but that performance on the Step 2 Clinical Skills (CS) portion may correlate with the SVI since both test communication skills. METHODS: Nine EM residency sites participated in the study with data exported from an Electronic Residency Application Service (ERAS®) report. All applicants with both SVI and USMLE scores were included. We studied the correlation between SVI scores and USMLE scores. Predetermined subgroup analysis was performed based on applicants' USMLE Step 1 and Step 2 CK scores as follows: (≥ 200, 201-220, 221-240, 241-260, >260). We used linear regression, the Kruskal-Wallis test and Mann-Whitney U test for statistical analyses. RESULTS: 1,325 applicants had both Step 1 and SVI scores available, with no correlation between the overall scores (p=0.58) and no correlation between the scores across all Step 1 score ranges, (p=0.29). Both Step 2 CK and SVI scores were available for 1,275 applicants, with no correlation between the overall scores (p=0.56) and no correlation across all ranges, (p=0.10). The USMLE Step 2 CS and SVI scores were available for 1,000 applicants. Four applicants failed the CS test without any correlation to the SVI score (p=0.08). CONCLUSION: We found no correlation between the scores on any portion of the USMLE and the SVI; therefore, the SVI provides new information to application screeners.

Diltiazem versus metoprolol for rate control in atrial fibrillation with rapid ventricular response in the emergency department.

PURPOSE: The impact of patient-specific factors on the choice of ß-blocker versus calcium channel blocker therapy for rate control in emergency department (ED) patients treated for atrial fibrillation (AF) was investigated. METHODS: A retrospective cohort study was conducted to evaluate the influence of demographics, prior medication use, hemodynamic and clinical characteristics, and other variables on selection of first-line therapy for AF among patients admitted to the ED of an academic medical center over a 22-month period (October 2012-July 2014) who received i.v. treatment with either the ß-blocker metoprolol (n = 45) or the calcium channel blocker diltiazem (n = 55) for rate control. RESULTS: Significant predictors of the selection of metoprolol versus diltiazem included a past history of AF (odds ratio [OR], 8.3; 95% confidence interval [CI], 1.396-72.713; p = 0.032) or diabetes mellitus (OR, 7.2; 95% CI, 1.208-58.490; p = 0.042) and being prescribed a ß-blocker prior to presentation (OR, 27.8; 95% CI, 4.704-272.894; p = 0.001); a history of calcium channel blocker use prior to ED presentation was a negative predictor of ß-blocker use for initial rate control (OR, 0.1; 95% CI, 0.005-0.265; p = 0.002). No differences in the effectiveness or safety of diltiazem and metoprolol were identified. Indicators of hemodynamic and clinical response to ED management were not predictive of discharge medication selection. CONCLUSION: The drug class used for rate control prior to ED admission was the most significant predictor of medication selection for rate control in the ED setting.

Survey of Individual and Institutional Risk Associated with the Use of Social Media.

INTRODUCTION: Residents and faculty in emergency medicine (EM) residency programs might be unaware of the professional and legal risks associated with the use of social media (SM). The objective of this study was to identify and characterize the types and reported incidence of unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal and institutional risks. METHODS: This multi-site study used an 18-question survey tool that was distributed electronically to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine Residency Directors (CORD), and the residents of 14 EM programs during the study period May to June 2013. RESULTS: We received 1,314 responses: 772 from residents and 542 from faculty. Both groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents reported posting of one of the following by a resident peer or nursing colleague: identifiable patient information (26%); or a radiograph, clinical picture or other image (52%). Residents reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%), and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph, clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were more likely to post photos of their resident peers or nursing colleagues in an intoxicated state than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and identifiable patient information (p=0.0004) than were residents. CONCLUSION: EM residents and faculty members cause and encounter HRTPE frequently while using SM; these events present significant risks to the individuals responsible and their associated institution. Awareness of these risks should prompt responsible SM use and consideration of CORD's Social Media Task Force recommendations.