Prehospital Buprenorphine Treatment for Opioid Use Disorder by Paramedics: First Year Results of the EMS Buprenorphine Use Pilot.

BACKGROUND: Prehospital initiation of buprenorphine treatment for Opioid Use Disorder (OUD) by paramedics is an emerging potential intervention to reach patients at greatest risk for opioid-related death. Emergency medical services (EMS) patients who are at high risk for overdose deaths may never engage in treatment as they frequently refuse transport to the hospital after naloxone reversal. The potentially important role of EMS as the initiator for medication for opioid use disorder (MOUD) in the most high-risk patients has not been well described. SETTING: This project relies on four interventions: a public access naloxone distribution program, an electronic trigger and data sharing program, an "Overdose Receiving Center," and a paramedic-initiated buprenorphine treatment. For the final intervention, paramedics followed a protocol-based pilot that had an EMS physician consultation prior to administration. RESULTS: There were 36 patients enrolled in the trial study in the first year who received buprenorphine. Of those patients receiving buprenorphine, only one patient signed out against medical advice on scene. All other patients were transported to an emergency department and their clinical outcome and 7 and 30 day follow ups were determined by the substance use navigator (SUN). Thirty-six of 36 patients had follow up data obtained in the short term and none experienced any precipitated withdrawal or other adverse outcomes. Patients had a 50% (18/36) rate of treatment retention at 7 days and 36% (14/36) were in treatment at 30 days. CONCLUSION: In this small pilot project, paramedic-initiated buprenorphine in the setting of data sharing and linkage with treatment appears to be a safe intervention with a high rate of ongoing outpatient treatment for risk of fatal opioid overdoses.

Prehospital Initiation of Buprenorphine Treatment for Opioid Use Disorder by Paramedics.

Prehospital initiation of buprenorphine treatment for Opioid Use Disorder (OUD) by paramedics is an emerging potential intervention. Many patients who may be at high risk for overdose deaths may never engage in treatment because they frequently refuse transport. Recent data have demonstrated a significant increase in both short and long term mortality following an opioid overdose. We describe 3 preliminary cases with a novel intervention of initiating Buprenorphine in the prehospital setting for symptoms of opioid withdrawal, regardless of etiology. In addition, we describe tracking of long term engagement in additional services as part of an integrated approach to combatting the opioid epidemic through EMS focused interventions.

Overdose Receiving Centers - An Idea Whose Time Has Come?

Drug overdose deaths have been the leading cause of accidental death in the United States with two thirds involving opioids. Strong evidence supports the efficacy of medications for addiction treatment such as buprenorphine and harm reduction strategies such as naloxone distribution. While emergency medical service (EMS) systems have defined specialty centers for the treatment of many significant life threatening disease (trauma, stroke, myocardial infarction) implementation of opioid use disorder systems of care that integrate EMS are uncommon. As fentanyl drives the third wave of the opioid epidemic, EMS systems are uniquely positioned to direct patients to hospitals that can provide the best care for patients with Opiate Use Disorder (OUD.) Emergency Departments which have established systems for early intervention and treatment for patients with opioid use disorders have shown higher engagement in treatment programs. This, in turn, leads to lower mortality. EMS systems which designate specialty centers for overdose patients may show a public health mortality benefit.

Innovation in Residency Selection: The AAMC Standardized Video Interview.

PURPOSE: Innovative tools are needed to shift residency selection toward a more holistic process that balances academic achievement with other competencies important for success in residency. The authors evaluated the feasibility of the AAMC Standardized Video Interview (SVI) and evidence of the validity of SVI total scores. METHOD: The SVI, developed by the Association of American Medical Colleges, consists of six questions designed to assess applicants' interpersonal and communication skills and knowledge of professionalism. Study 1 was conducted in 2016 for research purposes. Study 2 was an operational pilot administration in 2017; SVI data were available for use in residency selection by emergency medicine programs for the 2018 application cycle. Descriptive statistics, correlations, and standardized mean differences were used to examine data. RESULTS: Study 1 included 855 applicants; Study 2 included 3,532 applicants. SVI total scores were relatively normally distributed. There were small correlations between SVI total scores and United States Medical Licensing Examination Step exam scores, Alpha Omega Alpha Honor Medical Society membership, and Gold Humanism Honor Society membership. There were no-to-small group differences in SVI total scores by gender and race/ethnicity, and small-to-medium differences by applicant type. CONCLUSIONS: Findings provide initial evidence of the validity of SVI total scores and suggest that these scores provide different information than academic metrics. Use of the SVI, as part of a holistic screening process, may help program directors widen the pool of applicants invited to in-person interviews and may signal that programs value interpersonal and communication skills and professionalism.

The AAMC Standardized Video Interview: Reactions and Use by Residency Programs During the 2018 Application Cycle.

PURPOSE: To evaluate how emergency medicine residency programs perceived and used Association of American Medical Colleges (AAMC) Standardized Video Interview (SVI) total scores and videos during the Electronic Residency Application Service 2018 cycle. METHOD: Study 1 (November 2017) used a program director survey to evaluate user reactions to the SVI following the first year of operational use. Study 2 (January 2018) analyzed program usage of SVI video responses using data collected through the AAMC Program Director's Workstation. RESULTS: Results from the survey (125/175 programs; 71% response rate) and video usage analysis suggested programs viewed videos out of curiosity and to understand the range of SVI total scores. Programs were more likely to view videos for attendees of U.S. MD-granting medical schools and applicants with higher United States Medical Licensing Examination Step 1 scores, but there were no differences by gender or race/ethnicity. More than half of programs that did not use SVI total scores in their selection processes were unsure of how to incorporate them (36/58; 62%) and wanted additional research on utility (33/58; 57%). More than half of programs indicated being at least somewhat likely to use SVI total scores (55/97; 57%) and videos (52/99; 53%) in the future. CONCLUSIONS: Program reactions on the utility and ease of use of SVI total scores were mixed. Survey results indicate programs used the SVI cautiously in their selection processes, consistent with AAMC recommendations. Future user surveys will help the AAMC gauge improvements in user acceptance and familiarity with the SVI.

Traumatic Injuries of the Ear, Nose and Throat.

This article reviews the presentation, diagnosis, and management of common traumatic injuries of the ear, nose, and throat, including laryngeal trauma, auricular and septal hematomas, and tympanic membrane rupture.

Identifying the Emergency Medicine Personality: A Multisite Exploratory Pilot Study.

OBJECTIVES: This study aimed to understand the personality characteristics of emergency medicine (EM) residents and assess consistency and variations among residency programs. METHODS: In this cross-sectional study, a convenience sample of residents (N = 140) at five EM residency programs in the United States completed three personality assessments: the Hogan Personality Inventory (HPI)-describing usual tendencies; the Hogan Development Survey (HDS)-describing tendencies under stress or fatigue; and the Motives, Values, and Preferences Inventory (MVPI)-describing motivators. Differences between EM residents and a normative population of U.S. physicians were examined with one-sample t-tests. Differences between EM residents by program were analyzed using one-way analysis of variance tests. RESULTS: One-hundred forty (100%), 124 (88.6%), and 121 (86.4%) residents completed the HPI, HDS, and MVPI, respectively. For the HPI, residents scored lower than the norms on the adjustment, ambition, learning approach, inquisitive, and prudence scales. For the HDS, residents scored higher than the norms on the cautious, excitable, reserved, and leisurely scales, but lower on bold, diligent, and imaginative scales. For the MVPI, residents scored higher than the physician population norms on altruistic, hedonistic, and aesthetics scales, although lower on the security and tradition scales. Residents at the five programs were similar on 22 of 28 scales, differing on one of 11 scales of the HPI (interpersonal sensitivity), two of 11 scales of the HDS (leisurely, bold), and three of 10 scales of the MVPI (aesthetics, commerce, and recognition). CONCLUSIONS: Our findings suggest that the personality characteristics of EM residents differ considerably from the norm for physicians, which may have implications for medical students' choice of specialty. Additionally, results indicated that EM residents at different programs are comparable in many areas, but moderate variation in personality characteristics exists. These results may help to inform future research incorporating personality assessment into the resident selection process and the training environment.

Transition of Care Practices from Emergency Department to Inpatient: Survey Data and Development of Algorithm.

INTRODUCTION: We aimed to assess the current scope of handoff education and practice among resident physicians in academic centers and to propose a standardized handoff algorithm for the transition of care from the emergency department (ED) to an inpatient setting. METHODS: This was a cross-sectional survey targeted at the program directors, associate or assistant program directors, and faculty members of emergency medicine (EM) residency programs in the United States (U.S.). The web-based survey was distributed to potential subjects through a listserv. A panel of experts used a modified Delphi approach to develop a standardized algorithm for ED to inpatient handoff. RESULTS: 121 of 172 programs responded to the survey for an overall response rate of 70.3%. Our survey showed that most EM programs in the U.S. have some form of handoff training, and the majority of them occur either during orientation or in the clinical setting. The handoff structure from ED to inpatient is not well standardized, and in those places with a formalized handoff system, over 70% of residents do not uniformly follow it. Approximately half of responding programs felt that their current handoff system was safe and effective. About half of the programs did not formally assess the handoff proficiency of trainees. Handoffs most commonly take place over the phone, though respondents disagree about the ideal place for a handoff to occur, with nearly equivalent responses between programs favoring the bedside over the phone or face-to-face on a computer. Approximately two-thirds of responding programs reported that their residents were competent in performing ED to inpatient handoffs. Based on this survey and on the review of the literature, we developed a five-step algorithm for the transition of care from the ED to the inpatient setting. CONCLUSION: Our results identified the current trends of education and practice in transitions of care, from the ED to the inpatient setting in U.S. academic medical centers. An algorithm, which guides this process, is proposed to address the current gap in the standardized approach to ED to inpatient handoffs that were identified in the survey's assessment of needs.

D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study.

INTRODUCTION: Prehospital first responders historically have used an IV bolus of 50 mL of 50% dextrose solution (D50) for the treatment of hypoglycemia in the field. A local Emergency Medical Services (EMS) system recently approved a hypoglycemia treatment protocol of IV 10% dextrose solution (D10) due to occasional shortages and higher cost of D50. We use the experience of this EMS system to report the feasibility, safety, and efficacy of this approach. METHODS: Over the course of 104 weeks, paramedics treated 1,323 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 1,157 (87.5%) patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 871 (75%) of these 1,157. We captured the 871 patients' capillary glucose response to initial infusion of 100 mL of D10 and fit a linear regression line between elapsed time and difference between initial and repeat glucose values. We also explored the need for repeat glucose infusions as well as feasibility, and safety. RESULTS: The study cohort included 469 men and 402 women with a median age of 66. The median initial field blood glucose was 37 mg/dL, while the subsequent blood glucose had a median of 91 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100mL D10 infusion. Of 871 patients, 200 (23.0%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia and seven (0.8%) patients required a third dose. There were no reported deaths or other adverse events related to D10 administration for hypoglycemia. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation. CONCLUSIONS: The results of one local EMS system over a 104-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative to D50. D50 may also have theoretical risks including extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. Additionally, our data suggest that there may be little or no short-term decrease in blood glucose results after D10 administration.

What Predicts Performance? A Multicenter Study Examining the Association Between Resident Performance, Rank List Position, and United States Medical Licensing Examination Step 1 Scores.

BACKGROUND: Each application cycle, emergency medicine (EM) residency programs attempt to predict which applicants will be most successful in residency and rank them accordingly on their program's Rank Order List (ROL). OBJECTIVE: Determine if ROL position, participation in a medical student rotation at their respective program, or United States Medical Licensing Examination (USMLE) Step 1 rank within a class is predictive of residency performance. METHODS: All full-time EM faculty at Los Angeles County + University of Southern California (LAC + USC), Harbor-UCLA (Harbor), Alameda Health System-Highland (Highland), and the University of California-Irvine (UCI) ranked each resident in the classes of 2013 and 2014 at time of graduation. From these anonymous surveys, a graduation ROL was created, and using Spearman's rho, was compared with the program's adjusted ROL, USMLE Step 1 rank, and whether the resident participated in a medical student rotation. RESULTS: A total of 93 residents were evaluated. Graduation ROL position did not correlate with adjusted ROL position (Rho = 0.14, p = 0.19) or USMLE Step 1 rank (Rho = 0.15, p = 0.14). Interestingly, among the subgroup of residents who rotated as medical students, adjusted ROL position demonstrated significant correlation with final ranking on graduation ROL (Rho = 0.31, p = 0.03). CONCLUSIONS: USMLE Step 1 score rank and adjusted ROL position did not predict resident performance at time of graduation. However, adjusted ROL position was predictive of future residency success in the subgroup of residents who had completed a sub-internship at their respective programs. These findings should guide the future selection of EM residents.

Residency Applicant Preferences of Online Systems for Scheduling Interviews.

BACKGROUND: Residency applicants often have difficulty coordinating interviews with multiple programs. An online scheduling system might improve this process. OBJECTIVE: The authors sought to determine applicant mean time to schedule interviews and satisfaction using online scheduling compared with manual scheduling. METHODS: An electronic survey was sent to US graduates applying to any of 6 emergency medicine programs in the 2014-2015 application cycle. Of the participant programs, 3 used an online system and 3 did not. Applicants were asked to report estimated time to schedule with the online system compared to their average time using other methods, and to rate their satisfaction with the scheduling process. RESULTS: Of 1720 applicants to at least 1 of the 6 programs, 856 completed the survey (49.8%). Respondents reported spending less time scheduling interviews using the online system compared to other systems (median of 5 minutes [IQR 3-10] versus 60 minutes [IQR 15-240], respectively, P < .0001). In addition, applicants preferred using the online system (93.6% versus 1.4%, P < .0001.) Applicants were also more satisfied with the ease of scheduling their interviews using the online system (91.5% versus 11.0%, P < .0001) and felt that the online system aided them in coordinating travel arrangements (74.7% versus 41.5%, P < .01.). CONCLUSIONS: An online interview scheduling system is associated with time savings for applicants as well as higher satisfaction among applicants, both in ease of scheduling and in coordinating travel arrangements. The results likely are generalizable to other medical and surgical specialties.

How Prevalent Are Potentially Illegal Questions During Residency Interviews? A Follow-up Study of Applicants to All Specialties in the National Resident Matching Program.

PURPOSE: To describe the prevalence and effects on applicants of being asked potentially illegal questions during the residency interview process by surveying all residency applicants to all specialties. METHOD: The authors surveyed all applicants from U.S. medical schools to residency programs in all specialties in 2012-2013. The survey included questions about the prevalence of potentially illegal questions, applicants' level of comfort with such questions, and whether such questions affected how applicants ranked programs. Descriptive statistics, tests of proportions, t tests, and logistic regression modeling were used to analyze the data. RESULTS: Of 21,457 eligible applicants, 10,976 (51.1%) responded to the survey. Overall, 65.9% (7,219/10,967) reported receiving at least one potentially illegal question. More female respondents reported being asked questions about gender (513/5,357 [9.6%] vs. 148/5,098 [2.9%]), marital status (2,895/5,283 [54.8%] vs. 2,592/4,990 [51.9%]), or plans for having children (889/5,241 [17.0%] vs. 521/4,931 [10.6%]) than male respondents (P < .001). Those in surgical specialties were more likely to have received a potentially illegal question than those in nonsurgical specialties (1,908/2,330 [81.9%] vs. 5,311/8,281 [64.1%]). Questions regarding their commitment to the program were reported by 15.5% (1,608/10,378) of respondents. Such potentially illegal questions negatively affected how respondents ranked programs. CONCLUSIONS: Two-thirds of applicants reported being asked potentially illegal questions. More women than men reported receiving questions about marital status or family planning. Potentially illegal questions negatively influence how applicants perceive and rank programs. A formal interview code of conduct or interviewer training could help to address these issues.

Handoff Practices in Emergency Medicine: Are We Making Progress?

OBJECTIVES: Transitions of care present a risk for communication error and may adversely affect patient care. This study addresses the scope of current handoff practices amongst U.S. emergency medicine (EM) residents. In addition, it evaluates current educational and evaluation practices related to handoffs. Given the ever-increasing emphasis on transitions of care in medicine, we sought to determine if interval changes in resident transition of care education, assessment, and proficiency have occurred. METHODS: This was a cross-sectional survey study guided by the Kern model for medical curriculum development. The Council of Residency Directors Listserv provided access to 175 programs. The survey focused on elucidating current practices of handoffs from emergency physicians (EPs) to EPs, including handoff location and duration, use of any assistive tools, and handoff documentation in the emergency department (ED) patient's medical record. Multiple-choice questions were the primary vehicle for the response process. A four-point Likert-type scale was used in questions regarding perceived satisfaction and competency. Respondents were not required to answer all questions. Responses were compared to results from a similar 2011 study for interval changes. RESULTS: A total of 127 of 175 programs responded to the survey, making the overall response rate 72.6%. Over half of respondents (72 of 125, 57.6%) indicated that their ED uses a standardized handoff protocol, which is a significant increase from 43.2% in 2011 (p = 0.018). Of the programs that do have a standardized system, a majority (72 of 113, 63.7%) of resident physicians use it regularly. Significant increases were noted in the number of programs offering formal training during orientation (73.2% from 59.2%; p = 0.015), decreases in the number of programs offering no training (2.4% from 10.2%; p = 0.013), and no assessment of proficiency (51.5% from 69.8%; p = 0.006). No significant interval changes were noted in handoffs being documented in the patient's medical record (57.4%), the percentage of computer/electronic signouts, or the level of dissatisfaction with handoff tools (54.1%). Less than two-thirds of respondents (80 of 126, 63.5%) indicated that their residents were "competent" or "extremely competent" in delivering and receiving handoffs. CONCLUSIONS: An insufficient level of handoff training is currently mandated or available for EM residents, and their handoff skills appear to be developed mostly informally throughout residency training with varying results. Programs that have created a standardized protocol are not ensuring that the protocol is actually being employed in the clinical arena. Handoff proficiency most often goes unevaluated, although it is improved from 2011.

Prehospital Administration of Epinephrine in Pediatric Anaphylaxis.

Anaphylaxis in the pediatric population is both serious and potentially lethal. The incidence of allergic and anaphylactic reactions has been increasing and the need for life saving intervention with epinephrine must remain an important part of Emergency Medical Services (EMS) provider training. Our aim was to characterize dosing and timing of epinephrine, diphenhydramine, and albuterol in the pediatric patient with anaphylaxis. In this retrospective chart review, we studied prehospital medication administration in pediatric patients ages 1 month up to 14 years old classified as having a severe allergic reaction or anaphylaxis. We compared rates of epinephrine, diphenhydramine, and albuterol given to patients with allergic conditions including anaphylaxis. In addition, we calculated the rate of epinephrine administration in cases of anaphylaxis and determined what percentage of time the epinephrine was given by EMS or prior to their arrival. Of the pediatric patient contacts, 205 were treated for allergic complaints. Of those with allergic complaints, 98 of 205 (48%; 95% CI 41%, 55%) had symptoms consistent with anaphylaxis and indications for epinephrine. Of these 98, 53 (54%, 95% CI 44%, 64%) were given epinephrine by EMS or prior to EMS arrival. Among the patients in anaphylaxis not given epinephrine prior to EMS arrival, 6 (12%; 95% CI 3%, 21%) received epinephrine from EMS, 10 (20%; 95% CI 9%, 30%) received diphenhydramine only, 9 (18%, 95% CI 7%-28%) received only albuterol and 17 (33%, 95% CI 20%-46%) received both albuterol and diphenhydramine. 9 patients in anaphylaxis received no treatment prior to arriving to the emergency department (18%, 95% CI 7%-28%). In pediatric patients who met criteria for anaphylaxis and the use of epinephrine, only 54% received epinephrine and the overwhelming majority received it prior to EMS arrival. EMS personnel may not be treating anaphylaxis appropriately with epinephrine.

Asking for a commitment: violations during the 2007 match and the effect on applicant rank lists.

INTRODUCTION: Applicants to residency face a number of difficult questions during the interview process, one of which is when a program asks for a commitment to rank the program highly. The regulations governing the National Resident Matching Program (NRMP) match explicitly forbid any residency programs asking for a commitment. METHODS: We conducted a cross-sectional survey of applicants from U.S. medical schools to five specialties during the 2006-2007 interview season using the Electronic Residency Application Service of the Association of American Medical Colleges. Applicants were asked to recall being asked to provide any sort of commitment (verbal or otherwise) to rank a program highly. Surveys were sent after rank lists were submitted, but before match day. We analyzed data using descriptive statistics and logistic regression. RESULTS: There were 7,028 unique responses out of 11,983 surveys sent for a response rate of 58.6%. Of those who identified their specialty (emergency medicine, internal medicine, obstetrics and gynecology [OBGYN], general surgery and orthopedics), there were 6,303 unique responders. Overall 19.6% (1380/7028) of all respondents were asked to commit to a program. Orthopedics had the highest overall prevalence at 28.9% (372/474), followed by OBGYN (23.7%; 180/759), general surgery (21.7%; 190/876), internal medicine (18.3%; 601/3278), and finally, emergency medicine (15.4%; 141/916). Of those responding, 38.4% stated such questions made them less likely to rank the program. CONCLUSION: Applicants to residencies are being asked questions expressly forbidden by the NRMP. Among the five specialties surveyed, orthopedics and OBGYN had the highest incidence of this violation. Asking for a commitment makes applicants less likely to rank a program highly.

Residency applicants prefer online system for scheduling interviews.

INTRODUCTION: Residency coordinators may be overwhelmed when scheduling residency interviews. Applicants often have to coordinate interviews with multiple programs at once, and relying on verbal or email confirmation may delay the process. Our objective was to determine applicant mean time to schedule and satisfaction using online scheduling. METHODS: This pilot study is a retrospective analysis performed on a sample of applicants offered interviews at an urban county emergency medicine residency. Applicants were asked their estimated time to schedule with the online system compared to their average time using other methods. In addition, they were asked on a five-point anchored scale to rate their satisfaction. RESULTS: Of 171 applicants, 121 completed the survey (70.8%). Applicants were scheduling an average of 13.3 interviews. Applicants reported scheduling interviews using the online system in mean of 46.2 minutes (median 10, range 1-1800) from the interview offer as compared with a mean of 320.2 minutes (median 60, range 3-2880) for other programs not using this system. This difference was statistically significant. In addition, applicants were more likely to rate their satisfaction using the online system as "satisfied" (83.5% vs 16.5%). Applicants were also more likely to state that they preferred scheduling their interviews using the online system rather than the way other programs scheduled interviews (74.2% vs 4.1%) and that the online system aided them coordinating travel arrangements (52.1% vs 4.1%). CONCLUSION: An online interview scheduling system is associated with higher satisfaction among applicants both in coordinating travel arrangements and in overall satisfaction.

Change to an informal interview dress code improves residency applicant perceptions.

INTRODUCTION: Residency interview apparel has traditionally been the dark business suit. We changed the interview dress code from a traditionally established unwritten 'formal' attire to an explicitly described 'informal' attire. We sought to assess if the change in dress code attire changed applicants' perceptions of the residency program or decreased costs. METHODS: The authors conducted an anonymous survey of applicants applying to one emergency medicine residency program during two application cycles ending in 2012 and 2013. Applicants were asked if the change in dress code affected their perception of the program, comfort level, overall costs and how it affected their rank lists. RESULTS: We sent the survey to 308 interviewed applicants over two years. Of those, 236 applicants completed the survey for a combined response rate of 76.6% (236/308). Among respondents, 85.1% (200 of 235) stated they appreciated the change; 66.7% (154 of 231) stated the change caused them to worry more about what to wear. Males were more uncomfortable than females due to the lack of uniformity on the interview day (18.5% of males [25/135] vs. 7.4% of females [7/95], collapsed results p-value 0.008). A total of 27.7% (64/231) agreed that the costs were less overall. The change caused 50 of 230 (21.7%) applicants to rank the program higher on their rank list and only one applicant to rank the program lower. CONCLUSION: A change to a more informal dress code resulted in more comfort and fewer costs for applicants to a single residency program. The change also resulted in some applicants placing the program higher on their rank order list.

Sevoflurane administration initiated out of the ED for life-threatening status asthmaticus.

Status asthmaticus is both a common and dangerous cause of acute dyspnea in the emergency department (ED) setting. Although most cases respond favorably to standard treatment, there are rare cases in which therapy beyond traditional treatment is needed. One of these treatment modalities includes inhalational anesthesia. We present a case in which inhaled sevoflurane was initiated out of the ED for a life-threatening asthma exacerbation refractory to conventional treatment. To our knowledge, this is only the second case to report the use of inhaled anesthetics initiated out of the ED for status asthmaticus and is the first report of its kind to thoroughly detail the respiratory response noted while inhalation anesthesia was being implemented. A brief review of other case reports involving the use of sevoflurane for asthma is included. This case, as well as the others reviewed, illustrates the significant beneficial effect inhaled anesthetics can have on asthma, making this a treatment modality that must be recognized and appreciated by all emergency medicine providers.

A multicenter study of the family educational rights and privacy act and the standardized letter of recommendation: impact on emergency medicine residency applicant and faculty behaviors.

BACKGROUND: Residency applicants have the right to see letters of recommendation written on their behalf. It is not known whether applicants are affected by waiving this right. OBJECTIVES: Our multicenter study assessed how frequently residency applicants waived their FERPA rights to view their letters of recommendation, and whether this affected the ratings they were given by faculty. METHODS: We reviewed all ERAS-submitted letters of recommendation to 14 ACGME-accredited programs in 2006-2007. We collected ERAS ID, program name, FERPA declaration, standardized letter of recommendation (SLOR) use, and SLOR Global Assessment ranking. The percentage of applicants who waived their FERPA rights was determined. Chi-square tests of independence assessed whether applicants' decision to waive their FERPA rights was associated with their SLOR Global Assessment. RESULTS: We examined 1776 applications containing 6424 letters of recommendations. Of 2736 letters that specified a Global Assessment, 2550 (93%) applicants waived their FERPA rights, while 186 did not. Of the applicants who chose not to waive their rights, 45.6% received a ranking of Outstanding, 35.5% Excellent, 18.3% Very Good, and 1.6% Good. Of applicants who waived their FERPA rights, 35.1% received a ranking of Outstanding, 49.6% Excellent, 13.7% Very Good, and 1.6% Good. Applicants who did not waive their FERPA rights were more likely to receive an Outstanding Assessment (P  =  .003). CONCLUSIONS: The majority (93%) of residency applicants waived their FERPA rights. Those who did not waive their rights had a statistically higher chance of receiving an Outstanding Assessment than those who did.

The July Effect: is emergency department length of stay greater at the beginning of the hospital academic year?

INTRODUCTION: There has been concern of increased emergency department (ED) length of stay (LOS) during the months when new residents are orienting to their roles. This so-called "July Effect" has long been thought to increase LOS, and potentially contribute to hospital overcrowding and increased waiting time for patients. The objective of this study is to determine if the average ED LOS at the beginning of the hospital academic year differs for teaching hospitals with residents in the ED, when compared to other months of the year, and as compared to non-teaching hospitals without residents. METHODS: We performed a retrospective analysis of a nationally representative sample of 283,621 ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), from 2001 to 2008. We stratified the sample by proportion of visits seen by a resident, and compared July to the rest of the year, July to June, and July and August to the remainder of the year. We compared LOS for teaching hospitals to non-teaching hospitals. We used bivariate statistics, and multivariable regression modeling to adjust for covariates. RESULTS: Our findings show that at teaching hospitals with residents, there is no significant difference in mean LOS for the month of July (275 minutes) versus the rest of the year (259 min), July and August versus the rest of the year, or July versus June. Non-teaching hospital control samples yielded similar results with no significant difference in LOS for the same time periods. There was a significant difference found in mean LOS at teaching hospitals (260 minutes) as compared to non-teaching hospitals (185 minutes) throughout the year (p<0.0001). CONCLUSION: Teaching hospitals with residents in the ED have slower throughput of patients, no matter what time of year. Thus, the "July Effect" does not appear to a factor in ED LOS. This has implications as overcrowding and patient boarding become more of a concern in our increasingly busy EDs. These results question the need for additional staffing early in the academic year. Teaching hospitals may already institute more robust staffing during this time, preventing any significant increase in LOS. Multiple factors contribute to long stays in the ED. While patients seen by residents stay longer in the ED, there is little variability throughout the academic year.