Learner Perceptions of Electronic End-of-shift Evaluations on An Emergency Medicine Clerkship.

OBJECTIVES: As students on an emergency medicine (EM) rotation work with different faculty on a daily basis, EM clerkships often incorporate an end-of-shift evaluation to capture sufficient student performance data. Electronic shift evaluations have been shown to increase faculty completion compliance. This study aimed to examine learner perceptions of their individualized feedback during an EM clerkship following the adoption of an electronic evaluation tool. METHODS: This retrospective study examined end-of-rotation surveys that students complete at the conclusion of their EM rotation. Survey respondents used a standard Likert scale (1-5). This study examined responses to the question: "The feedback I received on this rotation was adequate." The study period included the 3 academic years prior to and subsequent to the adoption of an electronic evaluation system (replacing paper end-of-shift evaluations). The primary outcome was the mean Likert score and the secondary outcome was the percentage of students who rated their feedback a "5" or "strongly agree." RESULTS: A total of 491 students responded (83.9% response rate) to the survey during the paper evaluation period, while 427 responded (80.7% response rate) in the electronic period. The mean response improved from 4.02 (paper evaluations) to 4.22 (electronic evaluations; mean difference = 0.20, p < 0.05). The percentage of students who responded with a 5 improved (31% with paper evaluations vs. 41% with electronic evaluations, p < 0.05). CONCLUSIONS: The adoption of an electronic end-of-shift evaluation system was associated with improved learner perception of their feedback as compared to paper evaluations. Electronic evaluations are a useful tool to gather just-in-time data on learner performance.

Acute Liver Injury After Long-Term Herbal "Liver Cleansing" and "Sleep Aid" Supplement Use.

BACKGROUND: Acute liver injury is reported in association with toxins, pharmaceuticals, and viral infections. Increasingly prevalent are cases of herbal- and dietary supplement-related hepatotoxicity. Early recognition of this potentially life-threatening complication by emergency care providers leads to more appropriate management and disposition. CASE REPORT: A 53-year-old woman presented to the emergency department with a 3-day history of jaundice and increased abdominal girth after a month-long use of a combination herbal "liver-cleansing" compound and a nightly herbal "sleep aid." The "Liver Detoxifier and Regenerator" listed multiple constituents, including concentrated scute root and turmeric root; "Restful Sleep" listed multiple constituents, including valerian. Emergency department evaluation revealed marked hyperbilirubinemia with liver enzyme elevations indicative of cholestatic jaundice. Imaging studies, including ultrasound and abdominal magnetic resonance imaging, revealed hepatomegaly and steatosis without biliary dilatation; a biopsy specimen was obtained, and the results were consistent with drug-induced liver injury. The patient's liver function abnormalities gradually improved with discontinuation of the products as well as a tapered course of corticosteroid therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A significant proportion of the U.S. adult population uses herbal and dietary supplements. Most patients do not discuss nonprescription medication use with their providers and many physicians will not specifically ask about herbal supplements. It is important for emergency physicians to be aware of the potential for herbal supplements to contribute to acute liver injury and be able to investigate the active agents reported in these formulations. The diagnostic criteria for cholestatic jaundice and drug-induced liver injury are discussed.

Pharmacologically-induced Recreational Priapism: Case Report and Review.

INTRODUCTION: Priapism, a time-sensitive urologic emergency, is associated with hematologic disorders, malignancies, trauma, pharmaceuticals, and recreational drugs. CASE REPORT: A 51-year-old male presented with 36 hours of priapism after recreational use of nonprescribed pharmaceuticals including an oral phosphodiesterase inhibitor and intracorporally injected erectile medications, together with unspecified quantities of cocaine and alcohol. Venous blood gas confirmed ischemic priapism. Detumescence was achieved with intracavernosal phenylephrine injection, aspiration, and irrigation. CONCLUSION: This case highlights the risk that recreational use of vasoactive medications by patients who seek to prolong sexual activity may lead to delayed presentation for ischemic priapism.

Hypertensive Urgency: An Undesirable Complication of a "Male Performance" Herbal Product.

BACKGROUND: Hypertensive urgency is a clinical scenario that may be associated with herbal supplement use and that requires special consideration with regard to emergency department management. CASE REPORT: A 49-year-old man presented to the emergency department with palpitations and severely elevated blood pressure without evidence of end organ dysfunction. Hypertension failed to be controlled with multiple doses of oral clonidine and intravenous labetalol. The patient later admitted to using an herbal supplement containing yohimbine, a selective ⍺2-adrenoreceptor antagonist specifically linked to cases of refractory hypertension. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Between 17-35% of the U.S. adult population may use herbal supplements on a sporadic or regular basis; pharmacologically active agents in herbal supplements may affect both a patient's presentation and response to treatment. Most patients do not mention over-the-counter and herbal products in their medication profile unless specifically asked, and therefore it is important for emergency physicians to be aware of the pharmacologic effects of herbal supplements in the evaluation and treatment of refractory severe hypertension.

Acute Hepatitis B with Pancreatitis and Cholecystitis Leading to Acute Liver Failure and Death.

Acute liver failure is defined as severe acute liver injury, concurrent with encephalopathy and loss of hepatic synthetic function, in a patient without known pre-existing liver disease. Evaluation of acute liver failure in the emergency department should focus on identification of treatable causes. Acute liver failure from acute hepatitis B infection is a rare but potentially lethal occurrence. Multi-organ dysfunction from acute liver failure may be exacerbated by metabolic and inflammatory reactions associated with acute pancreatitis, which accompanies approximately 5% of cases of acute viral hepatitis. Transplant-free survival rate with liver failure from acute hepatitis B is unfortunately less than 20%.

Acute chest pain after bench press exercise in a healthy young adult.

Bench press exercise, which involves repetitive lifting of weights to full arm extension while lying supine on a narrow bench, has been associated with complications ranging in acuity from simple pectoral muscle strain, to aortic and coronary artery dissection. A 39-year-old man, physically fit and previously asymptomatic, presented with acute chest pain following bench press exercise. Diagnostic evaluation led to the discovery of critical multivessel coronary occlusive disease, and subsequently, highly elevated levels of lipoprotein (a). Judicious use of ancillary testing may identify the presence of "high-risk" conditions in a seemingly "low-risk" patient. Emergency department evaluation of the young adult with acute chest pain must take into consideration an extended spectrum of potential etiologies, so as to best guide appropriate management.

Unilateral mydriasis due to hemorrhoidal ointment.

BACKGROUND: The finding of a unilaterally dilatated pupil in a patient who is otherwise alert and unimpaired can pose an interesting diagnostic problem. Algorithms have outlined the approach to evaluating anisocoria, but do not stress the importance of toxic exposures. CASE REPORT: A patient with a history of depression and chronic headaches was referred to the emergency department from an ophthalmologist's clinic with the findings of asymmetrically dilatated pupils and blurred vision. Detailed history revealed that for several weeks before the onset of symptoms, the patient applied to her eyelids hemorrhoidal ointment that contained an active ingredient known to produce mydriasis. CONCLUSION: In the absence of neurologic deficits, clinical history should search for a toxic or pharmacologic etiology of abnormal mydriasis. A detailed physical examination and bedside diagnostic maneuvers can help distinguish benign causes of an abnormally dilatated pupil from more serious causes relating to central nervous system lesions, potentially sparing the patient from unnecessary neuroimaging.

Acute hip pain and inability to ambulate: a rare presentation for perirectal abscess.

A patient with acute hip pain out of proportion to physical findings and inability to weight bear despite negative plain films warrants further in-depth evaluation. Correctly diagnosing the cause of hip pain, a common emergency department (ED) complaint, may be a challenge in the geriatric population (Perron A, Miller M, Brady W. Orthopedic pitfalls in the ED: radiographically occult hip fracture. Am J Emerg Med 2002; 20: 234-7; Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med 2009; 37: 144-52; Kiu A, Khan S. Radiology of acute hip and femoral injuries. Br J Hosp Med (London) 2010; 71: M22-M24; Zacher J, Gursche A. Regional musculoskeletal conditions: hip pain. Best Pract Res Clin Rheumatol 2003; 17: 71-85). A perirectal abscess as a cause of acute hip pain and inability to ambulate, with gluteus muscle inflammation but no evidence for bone or joint infection, has not been described, to the authors' knowledge. An 82-year-old woman with a history of diabetes, previously ambulatory, presented to the ED after being found on her apartment floor by a visiting health aide, complaining of acute pain in her left hip. Pain was exacerbated by palpation and range of motion testing, and she was unable to bear weight. There was no report of fever, rectal or abdominal pain, bleeding, or painful defecation. Plain films were negative for fracture or lytic lesion. Computerized tomography (CT) of the hip and pelvis was then obtained, which was negative for boney abnormality but revealed a 5-cm ischiorectal abscess with inflammation of the adjacent gluteus muscle. This case illustrates the potentially subtle nature of a deep perirectal abscess in an elderly patient. The CT imaging, useful for investigating the possibility of occult femoral neck fracture, was fortuitous in leading to the diagnosis. One must consider the possibility of visceral processes causing referred pain, when evaluating the patient with an acutely painful hip (Perron A, Miller M, Brady W. Orthopedic pitfalls in the ED: radiographically occult hip fracture. Am J Emerg Med 2002; 20: 234-7; Zacher J, Gursche A. Regional musculoskeletal conditions: hip pain. Best Pract Res Clin Rheumatol 2003; 17: 71-85).

Malaria in pregnancy: update on emergency management.

BACKGROUND: Pregnancy complicates the diagnosis, treatment, and clinical course of malaria. This clinical problem may be encountered in emergency department patients due to international travel. CASE REPORT: A primigravida woman at 20 weeks gestation presented to the Emergency Department with episodic fever, chills, headache, and nausea after travel to India and Asia. She had not taken malaria prophylaxis. After hospitalization, she developed acute respiratory distress syndrome and required intensive care management. Although she ultimately recovered from severe infection with Plasmodium vivax, she was not able to sustain her pregnancy and suffered a miscarriage. CONCLUSION: This case illustrates the serious nature of malaria in the pregnant patient. For this high-risk group, there is an increased incidence of severe anemia, as well as acute respiratory distress syndrome and pulmonary edema. A guideline is presented for the initial choice of anti-malarial drug treatment for the pregnant patient.

Are one or two dangerous? Camphor exposure in toddlers.

Serious pediatric toxicity resulting from exposure to small amounts of camphor-containing products has long been a problem. Twenty years ago the United States Food and Drug Administration took several actions in an attempt to ameliorate this risk. Despite these changes, camphor remains commonly available in many nonprescription vaporized or topical "cold" medications, topical musculoskeletal anesthetic "rubs" and "cold sore" preparations, though its efficacy is largely unproven. Data from the American Association of Poison Control Centers demonstrate that camphor continues to be a common source of pediatric exposures. A review of the literature reveals persistent reports of toxicity resulting from exposure to relatively small amounts. In the pediatric population, exposure to as little as 500 mg is cited as a cause of mortality. More commonly, 750 to 1000 mg are associated with the development of seizures and death. Currently available products with 10% camphor contain 500 mg in 5 mL. It is concluded that small doses are dangerous. In children less than 6 years of age, exposure to 500 mg or more requires rapid triage to the closest health care facility.