Creation and implementation of a national emergency medicine fourth-year student examination.

BACKGROUND: A National Board of Medical Examiners examination does not exist for Emergency Medicine (EM) students. To fill this void, the Clerkship Directors in Emergency Medicine tasked a committee with development of an examination for 4th-year (M4) EM students, based on a published syllabus, and consisting of questions written according to published question-writing guidelines. STUDY OBJECTIVES: Describe examination development and statistics at 9 months. METHODS: The committee reviewed an existing EM student question database at www.saemtests.org for statistical performance, compliance with item-writing guidelines, and topic inclusion within the published EM M4 syllabus. For syllabus topics without existing questions, committee members wrote new items. LXR 6.0 software (Applied Measurement Professionals, Inc., Georgetown, SC) was used for examination administration. Data gathered included numbers of examinations completed, mean scores with SD, and point biserial correlation (rpb). RESULTS: Of the 553 questions assessed, 157 questions met the stated criteria, and 37 were included in the examination. Thirteen new questions were written by committee members to cover all curriculum topics. The National EM M4 Examination was released online August 1, 2011. Nine months later, the examination had been completed 1642 times by students from 27 clerkships. Mean score was 79.69% (SD 3.89). Individual question difficulties ranged from 26% to 99%. Question rpbs ranged from 0.067 to 0.353, mean 0.213 (SD 0.066). CONCLUSIONS: A national group of EM educators developed an examination to assess a published clerkship syllabus. The examination contains questions written according to published item-writing guidelines, and exhibits content validity, appropriate difficulty levels, and adequate question discriminatory ability.

Interpreting red blood cells in lumbar puncture: distinguishing true subarachnoid hemorrhage from traumatic tap.

OBJECTIVES: The study purpose was to determine the optimal use of lumbar puncture (LP) red blood cell (RBC) counts to identify subarachnoid hemorrhage (SAH) when some blood remains in the final tube. METHODS: A case series was performed at a tertiary emergency department (ED). Records of 4,496 consecutive adult patients billed for LPs between 2001 and 2009 were reviewed. Inclusion criteria were headache (HA), final tube RBCs ≥ 5, and neurovascular imaging within 2 weeks of the visit. Demographics, relevant history and physical examination components, LP results, and neuroimaging findings were recorded for 280 patients. True-positive (TP) and true-negative (TN) SAH were strictly defined. Primary outcomes were the areas under the receiver operating characteristic curves (AUC) for final tube RBC count, differential RBC count between the final and initial tubes, and absolute differential RBC count between the final and initial tubes divided by the mean RBC count of the two tubes (also called the percent change in RBC count). RESULTS: There were 26 TP and 196 TN results; 58 patients were neither. The TP group consisted of 19 patients with visible or possible SAH on imaging (17 on noncontrast head computed tomography [CT; 12 definite and five possible] and two on magnetic resonance imaging), six with xanthochromia and a vascular lesion (aneurysm or arteriovenous malformation [AVM] > 2 mm), and one with xanthochromia and polymerase chain reaction (PCR)-positive meningitis. As a test for SAH, final tube RBC AUC was 0.85 (95% confidence interval [CI] = 0.80 to 0.91). Interval likelihood ratios (LRs) for final tube RBC count were LR 0 (95% CI = 0 to 0.3) for RBCs < 100, LR 1.6 (95% CI = 1.1 to 2.3) for 100 < RBCs < 10,000, and LR 6.3 (95% CI = 4.8 to 23.4) for RBCs > 10,000. Differential RBC count was not associated with SAH, with AUC 0.45 (95% CI = 0.31 to 0.60). However, the percent change in RBC count between the final and initial tubes had an AUC 0.84 (95% CI = 0.78 to 0.90), and the optimal test threshold for SAH was 0.63, with positive LR 3.6 (95% CI = 2.7 to 4.7) and negative LR 0.10 (95% CI = 0.03 to 0.4) for percent change <63% and >63%, respectively. This test added additional independent information to the final tube RBC count based on improved logistic regression model fit and discriminatory ability as measured by the LR test and c statistic, respectively. CONCLUSIONS: Final LP tube RBC count and the percent change in RBC count, but not the simple differential count between the final and initial tubes, were associated with SAH. In this sample, there were no patients with SAH who had RBCs < 100 in the final tube, and RBCs > 10,000 increased the odds of SAH by a factor of 6.

Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.

OBJECTIVES: The objective was to compare the effectiveness of intravenous (IV) procainamide and amiodarone for the termination of spontaneous stable sustained ventricular tachycardia (VT). METHODS: A historical cohort study of consecutive adult patients with stable sustained VT treated with IV amiodarone or procainamide was performed at four urban hospitals. Patients were identified for enrollment by admissions for VT and treatment with the study agents in the emergency department (ED) from 1993 to 2008. The primary measured outcome was VT termination within 20 minutes of onset of study medicine infusion. A secondary effectiveness outcome was the ultimate need for electrical therapy to terminate the VT episode. Major adverse effects were tabulated, and blood pressure responses to medication infusions were compared. RESULTS: There were 97 infusions of amiodarone or procainamide in 90 patients with VT, but the primary outcome was unknown after 14 infusions due to administration of another antidysrhythmic during the 20-minute observation period. The rates of VT termination were 25% (13/53) and 30% (9/30) for amiodarone and procainamide, respectively. The adjusted odds of termination with procainamide compared to amiodarone was 1.2 (95% confidence interval [CI]=0.4 to 3.9). Ultimately, 35/66 amiodarone patients (53%, 95% CI=40 to 65%) and 13/31 procainamide patients (42%, 95% CI=25 to 61%) required electrical therapy for VT termination. Hypotension led to cessation of medicine infusion or immediate direct current cardioversion (DCCV) in 4/66 (6%, 95% CI=2 to 15%) and 6/31 (19%, 95% CI=7 to 37%) patients who received amiodarone and procainamide, respectively. CONCLUSIONS: Procainamide was not more effective than amiodarone for the termination of sustained VT, but the ability to detect a significant difference was limited by the study design and potential confounding. As used in practice, both agents were relatively ineffective and associated with clinically important proportions of patients with decreased blood pressure.

Anatomy of a clerkship test.

Written examinations are frequently used to assess medical student performance. Within emergency medicine (EM), a National Board of Medical Examiners (NBME) subject examination for EM clerkships does not exist. As a result, clerkship directors frequently generate examinations within their institution. This article reviews the literature behind the use of standardized examinations in evaluating medical student performance, describes methods for generating well-written test questions, reviews the statistical concepts of reliability and validity that are necessary to evaluate an examination, and proposes future directions for testing EM students.

A four-year perspective of Society for Academic Emergency Medicine tests: an online testing tool for medical students.

Nationwide survey findings that most U.S. emergency medicine clerkship directors were interested in participating in a methodologically rigorous student testing program prompted the development of the Society for Academic Emergency Medicine (SAEM) Medical Student Online Testing Service (SAEM Tests). This article describes the development of SAEM Tests and details usage and progress since the on-line release in June 2005. Specifically, we review the construction of SAEM Tests and present validity and difficulty statistics obtained at the first analysis of test performance 6 months after its release and again 12 months later after revisions aimed at enhancing test performance. We then review the current status of SAEM Tests and summarize future goals and directions.

Opioid analgesia and assessment of the sonographic Murphy sign.

Administration of intravenous opioid analgesia to patients with undifferentiated abdominal pain remains a controversial topic in many emergency departments. To determine whether opioid analgesia impacts assessment of the sonographic Murphy sign (SM) in evaluating acute gallbladder disease (GBD), a retrospective chart review was undertaken. The chart review encompassed 119 patients, 21% of whom, having received opioid analgesia before ultrasound, constituted the opioid group. Between the opioid and control (i.e., no opioid analgesia) groups, there were no significant differences in SM sensitivity (48.2%; CI 28.7-68.1% vs. 68.8%; CI 41.3-89%, respectively) or specificity (92.5%; CI 83.4-97.5% vs. 88.9%; CI 51.8-99.7%, respectively) for GBD. There was no association between opioid analgesia and false-positive SM (OR 0.74, CI 0.08-6.65), or false-negative SM (OR 1.42, CI 0.46-4.43). We conclude that the test characteristics of SM are unaffected by opioid analgesia.