Medical student perceptions on the instruction of the emergency medicine oral case presentation.

BACKGROUND: The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction. OBJECTIVES: We aimed to document medical student perceptions and expectations of the instruction of the EM OCP. METHODS: We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions. RESULTS: One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship evaluation (77%), and felt that additional teaching was required beyond their current medical school instruction (78%). A minority report being specifically taught the EM OCP (37%), that their instruction was consistent (29%), or that expectations of the EM OCP were clear (21%). Respondents felt that brief instruction during their orientation (65%) and reading with a portable summary card (45%) would improve their EM OCP skills, whereas other modalities would be less helpful. CONCLUSION: This study identifies a need for additional specific and consistent teaching of the EM OCP to medical students and their preference on how to receive this instruction.

Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates.

Background: More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency. Methods: This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email. Results: A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001). Conclusions/discussion: This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.

Pertussis in an elderly Asian-American man: a case report.

Cough is a frequent presenting complaint in the Emergency Department. The differential diagnosis for cough is variable depending on patient age and symptom duration. We report the case of an elderly gentleman with a history of asthma who presented with cough, with the ultimate diagnosis of Bordetella pertussis infection. The management of the patient in the Emergency Department placed hospital staff at risk for infection from a virulent pathogen. Details regarding typical and atypical presentations of pertussis and the establishment of transmission-based precautions are discussed.

A Nationwide Survey of Program Directors on Resident Attrition in Emergency Medicine.

INTRODUCTION: Despite the burdens that resident attrition places upon programs and fellow trainees, emergency medicine (EM) as a specialty has only begun to explore the issue. Our primary objectives were to quantify attrition in EM residency programs and elucidate the reasons behind it. Our secondary objectives were to describe demographic characteristics of residents undergoing attrition, personal factors associated with attrition, and methods of resident replacement. METHODS: We conducted a national survey study of all EM program directors (PDs) during the 2018-2019 academic year. PDs were asked to identify all residents who had left their program prior to completion of training within the last four academic years (2015-2016 to 2018-2019), provide relevant demographic information, select perceived reasons for attrition, and report any resident replacements. Frequencies, percentages, proportions, and 95% confidence intervals were obtained for program- and resident-specific demographics. We performed Fisher's exact tests to compare reasons for attrition between age groups. RESULTS: Of 217 PDs successfully contacted, 118 completed the questionnaire (response rate of 54%). A third of programs (39 of 118) reported at least one resident attrition. A total of 52 residents underwent attrition. Attrition was most likely to occur prior to completion of two years of training. Gender and underrepresented minority status were not associated with attrition. Older residents were more likely to leave due to academic challenges. The most common reported reason for attrition was to switch specialties. Resident replacement was found in 42% of cases. CONCLUSION: One-third of programs were affected by resident attrition. Gender and underrepresented minority status were not associated with attrition.

Rate of Programs Affected by Resident Attrition and Program Factors Associated With Attrition in Emergency Medicine.

BACKGROUND: Resident attrition negatively affects residents and programs. The incidence of attrition in emergency medicine (EM) and program-specific factors associated with attrition remain unclear. OBJECTIVE: We quantified the percentage of EM residencies affected by attrition between 2007 and 2016 and identified program-specific factors associated with attrition. METHODS: We performed a retrospective analysis of data derived from the American Medical Association National Graduate Medical Education Census. We defined attrition as any postgraduate who left their residency training program prior to completion. We calculated the percentage of residency programs that experienced attrition and the overall incidence of attrition. We used Fisher's exact tests, Wilcoxon rank sum tests, and t tests, as well as multivariable logistic regression, to identify program-specific factors associated with attrition. RESULTS: Between 2007 and 2016, 139 EM residency programs (82%) experienced attrition of at least 1 resident. An average of 23% of EM training programs experienced attrition annually. The incidence of EM resident attrition averaged 0.85% per year. Program-specific factors associated with attrition include 4-year residencies (P = .031), programs with medium class size (P = .0003), more female residents (P = .002), and more female faculty (P = .003). After analysis, only medium class size (compared to small) was associated with attrition (odds ratio = 4.96, 95% confidence interval 1.65-14.91). CONCLUSIONS: Between 2007 and 2016, while the incidence of resident attrition in EM was low (< 1%), the majority of programs experienced resident attrition. Medium class size (7 to 12 residents) was the only program-specific factor associated with increased attrition.

Chemical, thermal, and biological ocular exposures.

Chemical or radiant energy injuries to the eyes are considered ocular burns. The majority of these injuries are occupation-related. Chemical burns are by far more common and represent a true emergency. Thermal and UV injuries are associated with severe pain, but often result in less long-term sequelae than chemical injuries do. The term "biologic exposure" refers to an exposure to human blood or other body fluid. This article describes patterns of these injuries and exposures, with particular emphasis on emergent management and including acute diagnostic and treatment considerations.

Academic Primer Series: Eight Key Papers about Education Theory.

INTRODUCTION: Many teachers adopt instructional methods based on assumptions of best practices without attention to or knowledge of supporting education theory. Familiarity with a variety of theories informs education that is efficient, strategic, and evidence-based. As part of the Academic Life in Emergency Medicine Faculty Incubator Program, a list of key education theories for junior faculty was developed. METHODS: A list of key papers on theories relevant to medical education was generated using an expert panel, a virtual community of practice synthetic discussion, and a social media call for resources. A three-round, Delphi-informed voting methodology including novice and expert educators produced a rank order of the top papers. RESULTS: These educators identified 34 unique papers. Eleven papers described the general use of education theory, while 23 papers focused on a specific theory. The top three papers on general education theories and top five papers on specific education theory were selected and summarized. The relevance of each paper for junior faculty and faculty developers is also presented. CONCLUSION: This paper presents a reading list of key papers for junior faculty in medical education roles. Three papers about general education theories and five papers about specific educational theories are identified and annotated. These papers may help provide foundational knowledge in education theory to inform junior faculty teaching practice.

A slow-onset, long-duration indanamine monoamine reuptake inhibitor as a potential maintenance pharmacotherapy for psychostimulant abuse: effects in laboratory rat models relating to addiction.

Slow-onset, long-lasting dopamine reuptake blockers with reduced abuse potential have been suggested as maintenance therapies for cocaine addiction. We have synthesized a series of 3-(3',4'-dichlorophenyl)-1-indanamine monoamine reuptake inhibitors as candidates for such maintenance pharmacotherapy. The initial lead compound, the N,N-dimethyl analogue 30,640 was then subjected to testing in addiction-relevant animal models. Compound 30,640 (2 mg/kg i.p.) produced a pronounced slow-onset, long-lasting increase (300-400%) in extracellular nucleus accumbens dopamine levels, as measured by in vivo brain microdialysis in awake laboratory rats. Slow-onset, long-lasting decreases (40-80%) in the dopamine metabolites 3,4-dihydroxyphenylacetic acid and homovanillic acid, and the serotonin metabolite 5-hydroxyindoleacetic acid were also seen. Compound 30,640 (3 or 5 mg/kg i.p.) also produced a significant (approximately 30%) slow-onset, long-lasting enhancement of electrical brain-stimulation reward, which was additive with that of cocaine (5 mg/kg i.p.). When given to cocaine-administering rats, 30,640 (2.5, 3, 5, or 10 mg/kg i.p.) significantly inhibited (30-60%) intravenous cocaine self-administration, with a pronounced long-lasting profile. In sum, 30,640 showed cocaine-like effects, but with a marked slow-onset, long-lasting profile. We conclude that the prodrug strategy employed in the design of 30,640 achieved its goal. We suggest that such compounds may be useful as maintenance pharmacotherapies for psychostimulant addiction.

Electrical and chemical stimulation of the basolateral complex of the amygdala reinstates cocaine-seeking behavior in the rat.

RATIONALE: The basolateral complex of the amygdala (BLC) is part of a neural circuit that is activated in humans during cocaine craving elicited by exposure to drug-related environmental cues. In animals, the BLC is necessary for cocaine-seeking behavior elicited by cocaine-associated cues. It has not been determined whether BLC activation is sufficient to reinstate cocaine seeking. OBJECTIVES: To determine whether electrical or excitatory amino-acid stimulation of the BLC is sufficient to induce reinstatement of cocaine seeking in rats. METHODS: Rats were catheterized and trained to lever-press for intravenous cocaine infusions on a fixed ratio (FR)-1 schedule of reinforcement. Once baseline cocaine-taking criteria were met, lever-pressing behavior was extinguished by substitution of saline for cocaine. After meeting criteria for extinction, animals were subjected to brief electrical (20 Hz, 400 microA or 2 Hz, 400 microA; 200 pulses per stimulation) or N-methyl- d-aspartate (NMDA; 250 ng/0.5 microl) BLC stimulation and lever pressing behavior was monitored. RESULTS. Electrical BLC stimulation with 20-Hz produced reinstatement of lever pressing previously associated with cocaine self-administration, while 2-Hz stimulation did not. Electrical stimulation of cerebellar and medial forebrain bundle loci did not reinstate cocaine seeking. Hence, the reinstatement was frequency dependent and anatomically selective. NMDA microinjections into the BLC also reinstated cocaine-seeking behavior. CONCLUSIONS: BLC stimulation is sufficient to reinstate cocaine-seeking behavior in the rat. These results are congruent with the hypothesis that the basolateral complex of the amygdala is part of a neural system mediating drug-seeking behavior.

Comparison of intubation success of video laryngoscopy versus direct laryngoscopy in the difficult airway using high-fidelity simulation.

INTRODUCTION: A number of devices, including video laryngoscopy, are used to aid in managing difficult airways. The goal of this study was to compare timing and success of video laryngoscopy to standard laryngoscopic intubation using a simulation mannequin in normal and difficult airway scenarios. METHODS: Residents and attending physicians of a PGY 2-4 emergency medicine residency program participated. A single, high-fidelity simulation mannequin was used. Each participant received an in-service on the video laryngoscope (GlideScope). Three airway settings were used: standard, decreased neck mobility, and tongue edema. Participants intubated with a Macintosh blade and video laryngoscope in each scenario, and graded the best view achieved using the Cormack-Lehane classification. Outcome measures included time to view the vocal cords, time to intubation, grading of view, and intubation success or failure. Institutional Review Board approval was obtained. RESULTS: Fifty-two participants were enrolled. Participants successfully intubated the mannequin faster using the Macintosh blade in both the normal and neck immobility settings (9.4 seconds faster, 95% CI 3.2-15.7, P = 0.004, 16.1 seconds faster, 95% CI 3.6-28.7, P = 0.01). In the tongue edema setting, however, video laryngoscopy provided a better grade view of the cords, a higher success rate of viewing the cords at time of intubation (50% vs. 12%), and a higher rate of successful intubations (83% vs. 23%). The GlideScope also significantly reduced the time needed to view the cords (89 seconds reduction, 95% CI 54.4-123.7, P < 0.0001) and intubate (131.3 seconds reduction, 95% CI 99.1-163.6, P< 0.0001) for the tongue edema setting. CONCLUSIONS: In the most difficult airway case, tongue edema, the video laryngoscope provided an enhanced view of the cords using less time, increased intubation success, and decreased the time to intubation.