Heart Rate Variability and Acute Stress Among Novice Airway Managers.

BACKGROUND: The nature of medical emergencies places emergency physicians at risk for high levels of acute psychological stress (APS). Stress-modifying techniques like visualization, breath control, and mental practice may help mitigate APS, but objective markers of stress are difficult to measure in the clinical setting. We explored the relationship between heart rate variability (HRV), a real-time measure of autonomic arousal, and self-reported APS among emergency medicine (EM) residents learning to intubate on actual patients. METHODS: This was a prospective study of postgraduate year 1 (PGY-1) EM residents at a single academic medical center during their 1-month anesthesia rotation. We obtained repeated measures of HRV immediately before and during the first intubation attempt each day. Participants completed the modified Spielberger State-Trait Anxiety Inventory (STAI-6) before intubation attempts and scored intubation difficulty using the Intubation Difficulty Scale. We analyzed HRV using root mean square of successive differences and analyzed data using clustered data methods and Pearson correlation coefficients. RESULTS: We enrolled eight PGY-1 residents and recorded 64 intubations. Mean HRV in the 2 minutes before intubation (17.88 ± 9.22) and during intubation (21.17 ± 13.46) was significantly lower than resting baseline (32.09 ± 15.23; adjusted mean difference [95% CI] = -13.90 [-20.35 to -7.45], p < 0.001; and -10.77 [-17.65 to -3.88], p = 0.02). Preintubation anxiety was negatively correlated with HRV (r = -0.39 [-0.58 to -0.16], p = 0.001). Intubation difficulty was not significantly correlated with HRV (r = -0.12 [-0.36 to 0.13], p = 0.35). CONCLUSIONS: HRV shows promise as a real-time index of autonomic arousal and may serve as an outcome measure in the evaluation of stress-modifying interventions.

How do novices learn physical examination skills? A systematic review of the literature.

BACKGROUND: Physical Examination (PE) skills are vital for patient care, and many medical students receive their first introduction to them in their pre-clinical years. A substantial amount of curriculum time is devoted to teaching these skills in most schools. Little is known about the best way to introduce PE skills to novice learners. OBJECTIVE: Our objective was to conduct a systematic review of how medical students are first taught PE skills and the evidence supporting these strategies. DESIGN: We searched ERIC, SCOPUS, MEDLINE, PubMed and EMBASE for descriptions of complete PE curricula for novice learners. Inclusion criteria were: (1) English language; (2) subjects were enrolled in medical school and were in the preclinical portion of their training; (3) description of a method to teach physical examination skills for the first time; (4) description of the study population; (5) Description of a complete PE curriculum. We used the Medical Education Research Study Quality Instrument (MERSQI) score to evaluate the quality of evidence provided. RESULTS: Our search returned 5,418 articles; 32 articles met our inclusion criteria. Two main types of curricula were reported: comprehensive 'head-to-toe' PE curricula (18%) and organ system-based curricula (41%). No studies compared these directly, and only two evaluated trainees' clinical performance. The rest of the articles described interventions used across curricula (41%). Median MERSQI score was 10.1 Interquartile range 8.1-12.4. We found evidence for the use of non-faculty teaching associates, technology-enhanced PE education, and the addition of clinical exposure to formal PE teaching. CONCLUSIONS: The current literature on teaching PE is focused on describing innovations to head-to-toe and organ system-based curricula rather than their relative effectiveness, and is further limited by its reliance on short-term outcomes. The optimal strategy for novice PE instruction remains unknown.

A Comparison of Urolithiasis in the Presence and Absence of Microscopic Hematuria in the Emergency Department.

INTRODUCTION: Urolithiasis is a common medical condition that accounts for a large number of emergency department (ED) visits each year and contributes significantly to annual healthcare costs. Urinalysis is an important screening test for patients presenting with symptoms suspicious for urolithiasis. At present there is a paucity of medical literature examining the characteristics of ureteral stones in patients who have microscopic hematuria on urinalysis versus those who do not. The purpose of this study was to examine mean ureteral stone size and its relationship to the incidence of clinically significant hydronephrosis in patients with and without microscopic hematuria. METHODS: This is a retrospective chart review of patient visits to a single, tertiary academic medical center ED between July 1, 2008, and August 1, 2013, of patients who underwent non-contrast computed tomography of the abdomen and pelvis and urinalysis. For patient visits meeting inclusion criteria, we compared mean stone size and the rate of moderate-to-severe hydronephrosis found on imaging in patients with and without microscopic hematuria on urinalysis. RESULTS: Out of a total of 2,370 patient visits 393 (16.6%) met inclusion criteria. Of those, 321 (82%) had microscopic hematuria present on urinalysis. Patient visits without microscopic hematuria had a higher rate of moderate-to-severe hydronephrosis (42%), when compared to patients with microscopic hematuria present (25%, p=.005). Mean ureteral stone size among patient visits without microscopic hematuria was 5.7 mm; it was 4.7 mm for those patients with microscopic hematuria (p=.09). For ureteral stones 5 mm or larger, the incidence of moderate-to-severe hydronephrosis was 49%, whereas for ureteral calculi less than 5 mm in size, the incidence of moderate-to-severe hydronephrosis was 14% (p < 0.0001). CONCLUSION: Patients visiting the ED with single-stone ureterolithiasis without microscopic hematuria on urinalysis could be at increased risk of having moderate-to-severe hydronephrosis compared to similar patients presenting with microscopic hematuria on urinalysis. Although the presence of hematuria on urinalysis is a moderately sensitive screening test for urolithiasis, these results suggest patients without hematuria tend to have more clinically significant ureteral calculi, making their detection more important. Clinicians should maintain a high index of suspicion for urolithiasis, even in the absence of hematuria, since ureteral stones in these patients were found to be associated with a higher incidence of obstructive uropathy.

Implementation of a 4-Year Point-of-Care Ultrasound Curriculum in a Liaison Committee on Medical Education-Accredited US Medical School.

OBJECTIVES: The established benefits of point-of-care ultrasound have given rise to multiple new and innovative curriculums to incorporate ultrasound teaching into medical education. This study sought to measure the educational success of a comprehensive and integrated 4-year point-of-care ultrasound curriculum. METHODS: We integrated a curriculum consisting of traditional didactics combined with asynchronous learning modules and hands-on practice on live models with skilled sonographers into all 4 years of education at a Liaison Committee on Medical Education-accredited US Medical School. Each graduating student was administered an exit examination with 48 questions that corresponded to ultrasound milestones. RESULTS: Ninety-five percent (n = 84) of fourth-year medical students completed the exit examination. The mean score was 79.5% (SD, 10.2%), with mean scores on the ultrasound physics and anatomy subsections being 77.1% (SD, 11.0%) and 85.9% (SD, 21.0%), respectively. CONCLUSIONS: A comprehensive 4-year point-of-care ultrasound curriculum integrated into medical school may successfully equip graduating medical students with a fundamental understanding of ultrasound physics, anatomy, and disease recognition.