Point-of-care ultrasound modalities in terms of diagnosing acute decompensated heart failure in emergency department; a diagnostic accuracy study.

This study aimed to compare the diagnostic accuracy of heart, lung and inferior vena cava (IVC) ultrasonography modalities, alone and combined, for possible added accuracy in diagnosing acute decompensated heart failure (ADHF), in a group of patients with the final diagnosis of ADHF based on plasma level of B-type natriuretic peptide (BNP) as the standard. The present study is a diagnostic accuracy study, which was carried out in the emergency department of Imam Khomeini hospital, affiliated to Tehran University of Medical Sciences, in 2014-2015. All patients over 18 years old, who were referred to emergency department with complaint of acute dyspnea were regarded as eligible and no exclusion criteria were considered. All ultrasounds were performed by a trained emergency medicine resident and then saved and classified for each patient, separately, and reviewed by the attending emergency medicine physician. In this study, patients with BNP levels higher than 500 pg/ml were considered positive for dyspnea caused by heart failure. A total of 120 patients with an average age of 60.83 ± 16.528 years were studied, 64 (53%) of which were male. In total, 47.5% of patients had a BNP level over 500 pg/ml. Among patients with positive ultrasound, 94.7% were true positive and among those with a negative ultrasound, 61.4% were true negative. Based on the findings, B-line ≥ 10 has the highest specificity and left ventricular ejection fraction (LVEF) < 45% has the highest sensitivity. The combination of LVEF and IVC collapsibility index (IVC-CI), LVEF and BLC, IVC-CI and BLC, and IVC-CI and BBPC had a higher specificity rate and combination of LVEF and BBPC and BLC and BBPC had the highest sensitivity. Sensitivity, specificity, positive predictive value and negative predictive value of all three ultrasounds combined were 31.6%, 98.4%, 94.7% and 61.4%, respectively. In this study, the diagnostic accuracy of double and triple ultrasonography of heart, lung and IVC in the diagnosis of ADHF was very high, among which triple ultrasonography was more preferable.

Comparison of exogenous melatonin versus placebo on sleep efficiency in emergency medicine residents working night shifts: A randomized trial.

BACKGROUND: Sleep deprivation resulting from night shifts, is a major cause of burnout among physicians. Exogenous melatonin may improve sleep quality in night-shift workers. The study aims to compare the effectiveness of melatonin versus placebo on sleep efficiency in emergency medicine (EM) residents. METHODS: A randomized, double-blind, replicated crossover trial was performed on EM residents. This study consisted of 4 phases within a month with intervention periods of 2 nights and washouts of 6 days. In our study, EM residents had nine-hour shifts on 6 consecutive days, 2 mornings, 2 evenings and 2 nights and then 2 days off. At the end of shifts' cycle, 24 EM residents were given 3 mg melatonin or placebo (12 in each arm of the study) for 2 consecutive nights after the second night shift with crossover to the other arm after a six-day off drug. This crossover intervention was repeated for two more another time. Finally, we created 48 cases and comparisons in each arm. Different items related to sleep quality were assessed and compared both within the same group and between the two groups. RESULTS: In the melatonin group, daytime sleepiness (calculated by Karolinska Sleep Scale) had a significant reduction after taking the second dose of drug (P=0.003) but the same result was not observed when comparing the 2 groups. Mood status (calculated by Profile of Mood States) showed no remarkable difference between the 2 groups. CONCLUSION: Melatonin might have a limited benefit on sleep quality in EM residents working night shifts.

Pain management of acute limb trauma patients with intravenous lidocaine in emergency department.

INTRODUCTION: This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management. METHODS: This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant. RESULTS: Fifty patients with the mean age of 31.28±8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9±1.4 and morphine: 8.0±1.4 (p=0.57) and after 1 hour were, lidocaine: 2.28±1.2 and morphine: 3.2±1.7. Although the pain score decreased significantly in both group (p=0.027), there were not any clinically and statistically significant difference between the two groups (p=0.77). Patients' satisfaction with pain management in both groups were almost similar (p=0.49). CONCLUSION: The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.

Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study.

INTRODUCTION: Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients' flow in the ED is termed triage. OBJECTIVE: This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%. METHOD: This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients' charts, an expert panel evaluated the validity of the triage level. RESULTS: During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel's evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen's weighted kappa being 0.966 (CI 0.985-0.946, p < 0.001) and 0.813 (CI 0.856-0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen's weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001). CONCLUSION: The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses.

Pain Management Using Acupuncture Method in Migraine Headache Patients; A Single Blinded Randomized Clinical Trial.

BACKGROUND: There were numerous studies using acupuncture for pain relief and in most, the effect of this technique on preventing migraine attacks has been investigated. In those several studies that surveyed the effect of acupuncture on treatment of migraine headaches, the conclusion was not completely persuaded and they suggested further researches on this topic. OBJECTIVES: The purpose of this study is to examine the effect of acupuncture on controlling acute migraine attacks. METHODS: This study was a single blinded randomized clinical trial that was conducted on patients with a diagnosis of acute migraine attacks. At the time of reference, the patient's pain intensity was measured and recorded in a written checklist. Acupuncture was done in the intervention group with thin metallic needles, which enter certain points in the ear's skin; including shen men, autonomic, thalamus, frontal, and temple. In the placebo group, similar needles were used, however, they were inserted into unusual points. Thereafter, in 30 minutes, one, two, and four hours after the treatment, the pain intensity was also asked and compared with the reference time's score. RESULTS: A total of 60 patients with the mean age of 31.4 ± 7.6 years were enrolled and 83.3% of them were women. There was no significant difference between two groups in terms of the baseline characteristics of participants including age, sex and pain duration before admission (P > 0.05). According to the results, there was a significant difference between the two groups on the checkpoints of 15, 30, 45, and 60 minutes after acupuncture (P < 0.05); however, the pain scores were not statistically different between the two groups on two, three, and four hours after intervention (P > 0.05). CONCLUSIONS: Based on the findings of our study, although the pain score was lower in the intervention group than the control group during first hour after the acupuncture, there was no significant change in pain score thereafter. Comparison of the two groups showed no differences between acupuncture and placebo acupuncture on decreasing the mean pain score.

Comparison of exogenous melatonin versus placebo on sleep efficiency in emergency medicine residents working night shifts: A randomized trial / 世界急诊医学杂志（英文）

BACKGROUND: Sleep deprivation resulting from night shifts, is a major cause of burnout among physicians. Exogenous melatonin may improve sleep quality in night-shift workers. The study aims to compare the effectiveness of melatonin versus placebo on sleep efficiency in emergency medicine (EM) residents. METHODS: A randomized, double-blind, replicated crossover trial was performed on EM residents. This study consisted of 4 phases within a month with intervention periods of 2 nights and washouts of 6 days. In our study, EM residents had nine-hour shifts on 6 consecutive days, 2 mornings, 2 evenings and 2 nights and then 2 days off. At the end of shifts' cycle, 24 EM residents were given 3 mg melatonin or placebo (12 in each arm of the study) for 2 consecutive nights after the second night shift with crossover to the other arm after a six-day off drug. This crossover intervention was repeated for two more another time. Finally, we created 48 cases and comparisons in each arm. Different items related to sleep quality were assessed and compared both within the same group and between the two groups. RESULTS: In the melatonin group, daytime sleepiness (calculated by Karolinska Sleep Scale) had a significant reduction after taking the second dose of drug (P=0.003) but the same result was not observed when comparing the 2 groups. Mood status (calculated by Profile of Mood States) showed no remarkable difference between the 2 groups. CONCLUSION: Melatonin might have a limited benefit on sleep quality in EM residents working night shifts.

Implementation a Medical Simulation Curriculum in Emergency Medicine Residency Program.

Applying simulation in medical education is becoming more and more popular. The use of simulation in medical training has led to effective learning and safer care for patients. Nowadays educators have confronted with the challenge of respecting patient safety or bedside teaching. There is widespread evidence, supported by robust research, systematic reviews and meta-analysis, on how much effective simulation is. Simulation supports the acquisition of procedural, technical and non-technical skills through repetitive practice with feedbacks. Our plan was to induct simulation in emergency medicine residency program in order to ameliorate our defects in clinical bedside training. Our residents believed that simulation could be effective in their real medical practice. They mentioned that facilitators' expertise and good medical knowledge, was the strongest point of the program and lack of proper facilities was the weakest.

Abdominal and pelvic CT scan interpretation of emergency medicine physicians compared with radiologists' report and its impact on patients' outcome.

PURPOSE: In this study, the impact of contrast-enhanced abdominopelvic CT scan interpretations by emergency medicine team on patients' morbidity and mortality was evaluated and their interpretations were compared to radiologists' reports. METHODS: During a 3-month period, all patients who had undergone a contrast-enhanced abdominopelvic CT scan at the emergency department enrolled in this study. All CT scans were interpreted blindly by the emergency medicine (ED) attending physicians and the patients were treated accordingly. Radiologists reported all the CT scans within 12 h. Radiologists' reports were put into the agreement or disagreement group retrospectively. A panel of experts further evaluated the disagreement groups' medical charts and placed them in clinically significant or insignificant group based on the follow-up for 28 days. RESULTS: In this study, 170 CT scans were interpreted. The agreement rate was 68.2%. In the clinically significant disagreement group, eight patients did not receive the required treatment and three patients were over treated. Although the overall mortality rate was 5, none could have been prevented by a prompt radiologist's report. The disagreement group had longer hospital stay (p = 0.006) and transfer to other wards (p = 0.035). The inter-rater reliability between emergency medicine attending physicians and attending radiologists was substantial (kappa = 0.77) and statistically significant (p < 0.0001). CONCLUSION: Our findings support the cautious use of ED physicians' CT scan interpretations for patients' management. Ideally, the ED physicians should utilize a real-time radiologist interpretation in critical patients. This collaboration will result in better patient management.

Long-Term Outcome of Bariatric Surgery in Morbidly Obese Adolescents: a Systematic Review and Meta-Analysis of 950 Patients with a Minimum of 3 years Follow-Up.

BACKGROUND: Obesity in pediatric and adolescent population has reached a universal pandemic. This study aimed to summarize the literature on the longest available outcome of bariatric surgery in morbidly obese adolescents. METHODS: A systematic review was conducted to pool available data on the longest available (>3 years) weight loss and comorbidity resolution outcome in adolescent bariatric surgery. RESULTS: A total of 14 studies reporting the result of bariatric surgery after 3 years in 950 morbidly obese adolescents were included. Preoperative age and BMI ranged from 12 to 19 years and from 26 to 91 kg/m2, respectively. Females were the predominant gender (72.8%). Laparoscopic roux-en-Y gastric bypass (n = 453) and adjustable gastric banding (n = 265) were the most common bariatric procedure performed. The number of patients at the latest follow-up was 677 (range from 2 to 23 years). On average, patients lost 13.3 kg/m2 of their BMI. Among comorbidities, only diabetes mellitus resolved or improved dramatically. Of 108 readmissions, 91 led to reoperation. There was a weight regain < 5 kg/m2 between 5 and 6 years of follow-up. Removal, exchange, or conversion of the previous band constituted the majority of the revisional procedures. Three deaths were reported. No long-term data was obtainable on nutritional deficiency or growth status of adolescents who underwent a bariatric procedure. CONCLUSION: Although bariatric surgery is a safe and effective procedure in the treatment of adolescent morbid obesity, long-term data is scarce regarding its nutritional and developmental complication in this growing population of patients.

Vapocoolant Spray Effectiveness on Arterial Puncture Pain: A Randomized Controlled Clinical Trial.

Arterial blood gas (ABG) sampling is a painful procedure with no perfect technique for quelling the discomfort. An ideal local anesthesia should be rapid, easy to learn, inexpensive, and noninvasive. This study was aimed to compare pain levels from ABG sampling performed with vapocoolant spray in comparison to placebo. We hypothesized that pretreatment with the vapocoolant would reduce the pain of arterial puncture by at least 1 point on a 10 point verbal numeric scale. We have evaluated the effectiveness of a vapocoolant spray in achieving satisfactory pain control in patients undergoing ABG sampling in this randomized placebo controlled trial. Eighty patients were randomized to 2 groups: group A, who received vapocoolant spray, and group B, who received water spray as placebo (Control group). Puncture and spray application pain was assessed with numerical rating scale (0, the absence of pain; 10, greatest imaginable pain) and number of attempts was recorded. The pain score during ABG sampling was not lower in group A compared with group B significantly (4.78±1.761 vs. 4.90±1.837; P:0.945). This study showed that while the spray exerts more application pain, the number of attempts required for ABG sampling was not significantly lower in group A compared with group B (1.38±0.54 vs. 1.53±0.68; P=0.372). Vapocoolant spray was not effective in ABG pain reduction, had milder application pain compared to placebo (P<0.05), but did not reduce sampling attempts. At present, this spray cannot be recommended for arterial puncture anesthesia, and further study on different timing is necessary.

Preferred view and transducer in lumbar ultrasound in overweight and obese patients.

BACKGROUND: Ultrasound can be used to facilitate lumbar puncture, especially in obese patients. METHODS: In this study, midline and paramedian approaches with curved and linear transducers were compared in patients with Body Mass Index (BMI) above 25 kg/m2 for the identification of spinal landmarks. In each view, six major landmarks, including spinous process, ligamentum flavum, laminae, epidural space, subarachnoid space and posterior longitudinal ligament, were detected by emergency medicine residents and were then reviewed by radiologists. RESULTS: Sixty patients with a mean BMI of 29.18 enrolled in the study. This study showed that a curved transducer detected major landmarks more accurately compared to a linear transducer. There was also a poor kappa correlation between these transducers in the midline and paramedian approaches. CONCLUSION: This study showed that ultrasound can detect lumbar landmarks in overweight and obese patients, with the paramedian approach and a curved transducer being superior to the midline approach and a linear transducer in detecting these landmarks.

Artificial Intelligence-Based Triage for Patients with Acute Abdominal Pain in Emergency Department; a Diagnostic Accuracy Study.

INTRODUCTION: Artificial intelligence (AI) is the development of computer systems which are capable of doing human intelligence tasks such as decision making and problem solving. AI-based tools have been used for predicting various factors in medicine including risk stratification, diagnosis and choice of treatment. AI can also be of considerable help in emergency departments, especially patients' triage. OBJECTIVE: This study was undertaken to evaluate the application of AI in patients presenting with acute abdominal pain to estimate emergency severity index version 4 (ESI-4) score without the estimate of the required resources. METHODS: A mixed-model approach was used for predicting the ESI-4 score. Seventy percent of the patient cases were used for training the models and the remaining 30% for testing the accuracy of the models. During the training phase, patients were randomly selected and were given to systems for analysis. The output, which was the level of triage, was compared with the gold standard (emergency medicine physician). During the test phase of the study, another group of randomly selected patients were evaluated by the systems and the results were then compared with the gold standard. RESULTS: Totally, 215 patients who were triaged by the emergency medicine specialist were enrolled in the study. Triage Levels 1 and 5 were omitted due to low number of cases. In triage Level 2, all systems showed fair level of prediction with Neural Network being the highest. In Level 3, all systems again showed fair level of prediction. However, in triage Level 4, decision tree was the only system with fair prediction. CONCLUSION: The application of AI in triage of patients with acute abdominal pain resulted in a model with acceptable level of accuracy. The model works with optimized number of input variables for quick assessment.

Bariatric surgery in morbidly obese patients with inflammatory bowel disease: A systematic review.

BACKGROUNDS: With increased prevalence of obesity, the number of inflammatory bowel disease (IBD) patients suffering from morbid obesity has raised. It is not clear yet if bariatric surgery is a safe and effective option in this population. OBJECTIVES: Our systematic review aims to summarize the available literature on the safety and efficacy of bariatric surgery in morbidly obese patients with IBD. SETTING: University hospital, Iran. METHODS: A PubMed/MEDLINE search was performed to identify studies reporting the outcome of morbidly obese IBD patients. Postoperative outcome of IBD patients after bariatric surgery were pooled for early and late complications, change of IBD status, and medication alteration. RESULTS: A total of 7 studies reported post-bariatric surgery outcomes of 43 morbidly obese IBD patients (31 females, 11 males) with an age ranging from 30 to 64 years and a body mass index from 35.7 to 71 kg/m2. Of these, 25 suffered Crohn's disease (CD) (58.2%) and 18 were ulcerative colitis (UC) patients (41.8%). The small bowel was the most common involved gastrointestinal segment in 27.3% of patients. CD patients more commonly underwent sleeve gastrectomy (72%), while UC patients similarly underwent sleeve gastrectomy and Roux-en-Y gastric bypass (44.4%). After a follow-up of 8 to 77 months, IBD patients lost up to 71.4%±5.9% of excess weight and 14.3 kg/m2±5.7 kg/m2 of body mass index. There were 9 early (21.4%) and 10 late (23.8%) postoperative complications related to the bariatric procedure. IBD remitted in 20 patients (47.6%), improved in 2 patients (4.8%), but exacerbated in 7 patients (16.7%). CONCLUSIONS: Although available data on morbidly obese patients with IBD is scarce, bariatric surgery seems to be a safe and effective option for these patients with no added morbidity or mortality. Further studies are necessary to confirm this data.

Distance Learning Can Be as Effective as Traditional Learning for Medical Students in the Initial Assessment of Trauma Patients.

Distance learning is expanding and replacing the traditional academic medical settings. Managing trauma patients seems to be a prerequisite skill for medical students. This study has been done to evaluate the efficiency of distance learning on performing the initial assessment and management in trauma patients, compared with the traditional learning among senior medical students. One hundred and twenty senior medical students enrolled in this single-blind quasi-experimental study and were equally divided into the experimental (distance learning) and control group (traditional learning). All participants did a written MCQ before the study. The control group attended a workshop with a 50-minute lecture on initial management of trauma patients and a case simulation scenario followed by a hands-on session. On the other hand, the experimental group was given a DVD with a similar 50-minute lecture and a case simulation scenario, and they also attended a hands-on session to practice the skills. Both groups were evaluated by a trauma station in an objective structured clinical examination (OSCE) after a month. The performance in the experimental group was statistically better (P=0.001) in OSCE. Distance learning seems to be an appropriate adjunct to traditional learning.

Contextualization and validation of the interprofessional collaborator assessment rubric (ICAR) through simulation: Pilot investigation.

BACKGROUND: Simulation can be used for educating, evaluating and assessing psychometric properties of an instrument. The aim of this study was to contextualize and assess the validity and reliability of the Interprofessional Collaborative Assessment tool (ICAR) in an Iranian context using simulation. METHODS: In this descriptive study, contextualization of the ICAR was assessed through several steps. Firstly, validity assessment was approved through expert panels and Delphi rounds. Secondly, reliability assessment was done by arranging a simulation video and assessing reproducibility, test-retest (ICC), internal consistency (Cronbach's Alpha) and inter-rater reliability (Kappa).The participants included 26 experts, 27 students and 6 staff of the Standardized Simulation Office of Teheran University of Medical Sciences. RESULTS: Contextualization and validity of the ICAR were approved in an Iranian context. The reliability of the tool was computed to be 0.71 according to Cronbach´s Alpha. The test-retest was calculated to be 0.76. CONCLUSION: The Iranian ICAR can be a useful tool for evaluating interprofessional collaborative competencies. The development of the instrument through a simulation scenario has been a positive prospect for researchers.

The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department.

Clinical assessment and classification of shock is extremely difficult to conduct on critically ill patients especially upon arrival at the emergency department. Resuscitative point-of-care ultrasound could be used for rapid initial diagnosis and better management. In this study, the results of using the RUSH (Rapid Ultrasound in Shock) exam to determine the type of shock in the emergency department are compared to the final diagnosis of patients. This was a single-center prospective study in which all patients with an unknown type of shock and no prior treatment were included. Parallel to the standard resuscitative management and diagnosis of the emergency team, the RUSH exam was performed blindly on the patient by an emergency medicine staff who was not part of the patient's caregiving team. The results of the RUSH exam were then compared to the final diagnosis of the patients and the 48-h outcome. Twenty-five patients were enrolled in this study. The overall kappa correlation of the RUSH exam compared with the final diagnosis was 0.84 which is an almost perfect agreement. The overall sensitivity of the RUSH exam was 88 % and the specificity was 96 %. Although the mortality rate was 64 %, there was not a significant relationship between mortality and the protocol used for diagnosis. The RUSH exam could be used in emergency wards to detect types of shock.

Comparing the brain CT scan interpretation of emergency medicine team with radiologists' report and its impact on patients' outcome.

Requesting non-enhanced brain CT scans for trauma and non-trauma patients in ER is very common. In this study, the impact of incorrect brain CT scan interpretations by emergency medicine team on patients' primary and secondary outcome was evaluated in the setting where neuroradiologist reports are not always available. During a 3-month period, 450 patients were enrolled and followed for 28 days. All CT scans were interpreted by the emergency medicine team, and the patients were managed accordingly. Neuroradiologists' reports were considered as gold standard, and the patients were then grouped into the agreement or disagreement group. A panel of experts further evaluated the disagreement group and placed them in clinically significant and insignificant. The agreement rate between emergency medicine team and neuroradiologists was 86.4 %. The inter-rater reliability between emergency team and neuroradiologists was substantial (kappa = 0.68) and statistically significant (p < 0.0001). Only five patients did not receive the necessary management, and among them, only one patient died, and 12 patients received unnecessary management including repeated CT scan, brain MRI, and lumbar puncture. Forty-one patients were managed clinically appropriate in spite of misinterpretation. A 28-day follow-up showed a mortality rate of 0.2 %; however, expert panel believed the death of this patient was not related to the CT scan misinterpretation. We conclude that although the disagreement rate in this study was 13.6 %, primary and secondary outcomes were not clinically jeopardized according to the expert panel idea and 28-day follow-up results.

Evaluating the quality of the educational environment for medical interns in an emergency department using the DREEM inventory.

Moving toward establishing more student center educational environment to meet the ever-changing learning expectations in a challenging climate like emergency department for under graduates is an intimidating task. In our newly founded academic emergency department, every step toward scoring as a dynamic and modern educational environment for both undergraduates and postgraduates would be a great success. The last 18 months of undergraduate medical education in Iran is considered as an internship. Interns have two months mandatory emergency department rotation during that period. This study has design to evaluate the medical students' conception about the educational environment using the Dundee Ready Education Environment Measure (DREEM) questionnaire. 156 undergraduate interns during their two months emergency medicine rotation from October 2009 to March 2010 enrolled into a cross sectional observational study to anonymously fill up the DREEM questionnaire  on the last week of the course. The overall mean score of DREEM questionnaire was 134.79 out of 200 for the emergency department.  The mean scores are 135.37 in female (n=87) group and 131.56 in male (n=69) group.  There was not any significant difference between two genders (P>0.05). A score of 134.79 is compatible with the modern universities. Scores of 100 or less indicate serious problems and scores above 170 is compatible with ultimate student centered and modern educational environment. Such an achievement in the start of the new installed Emergency Medicine program is admirable, hence great effort must be put to pinpoint problems and fix them. DREEM questionnaire helped us moving toward a more student center environment in the emergency department.