Hypokalemia causing rhabdomyolysis in a patient with short bowel syndrome.

BACKGROUND: Rhabdomyolysis, usually in the setting of trauma or drug use, is frequently seen in the emergency setting, and often leads to hyperkalemia at presentation. Hypokalemia, however, is a potentially underrecognized cause of rhabdomyolysis. CASE REPORT: We present a case of rhabdomyolysis likely due to hypokalemia in the setting of short bowel syndrome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although less common, hypokalemia can be a significant cause of rhabdomyolysis via its effects on muscle. This scenario should be considered in the differential diagnosis of patients at risk for hypokalemia who present with weakness. Rapid recognition of this relationship and rapid correction of hypokalemia may prove very important in preventing the deleterious effects of rhabdomyolysis.

Predictors of a Top Performer During Emergency Medicine Residency.

BACKGROUND: Emergency Medicine (EM) residency program directors and faculty spend significant time and effort creating a residency rank list. To date, however, there have been few studies to assist program directors in determining which pre-residency variables best predict performance during EM residency. OBJECTIVE: To evaluate which pre-residency variables best correlated with an applicant's performance during residency. METHODS: This was a retrospective multicenter sample of all residents in the three most recent graduating classes from nine participating EM residency programs. The outcome measure of top residency performance was defined as placement in the top third of a resident's graduating class based on performance on the final semi-annual evaluation. RESULTS: A total of 277 residents from nine institutions were evaluated. Eight of the predictors analyzed had a significant correlation with the outcome of resident performance. Applicants' grade during home and away EM rotations, designation as Alpha Omega Alpha (AOA), U.S. Medical Licensing Examination (USMLE) Step 1 score, interview scores, "global rating" and "competitiveness" on nonprogram leadership standardized letter of recommendation (SLOR), and having five or more publications or presentations showed a significant association with residency performance. CONCLUSION: We identified several predictors of top performers in EM residency: an honors grade for an EM rotation, USMLE Step 1 score, AOA designation, interview score, high SLOR rankings from nonprogram leadership, and completion of five or more presentations and publications. EM program directors may consider utilizing these variables during the match process to choose applicants who have the highest chance of top performance during residency.

Assessing clinical reasoning skills following a virtual patient dizziness curriculum.

OBJECTIVES: Dizziness is a common medical symptom that is frequently misdiagnosed. While virtual patient (VP) education has been shown to improve diagnostic accuracy for dizziness as assessed by VPs, trainee performance has not been assessed on human subjects. The study aimed to assess whether internal medicine (IM) interns after training on a VP-based dizziness curriculum using a deliberate practice framework would demonstrate improved clinical reasoning when assessed in an objective structured clinical examination (OSCE). METHODS: All available interns volunteered and were randomized 2:1 to intervention (VP education) vs. control (standard clinical teaching) groups. This quasi-experimental study was conducted at one academic medical center from January to May 2021. Both groups completed pre-posttest VP case assessments (scored as correct diagnosis across six VP cases) and participated in an OSCE done 6 weeks later. The OSCEs were recorded and assessed using a rubric that was systematically developed and validated. RESULTS: Out of 21 available interns, 20 participated. Between intervention (n=13) and control (n=7), mean pretest VP diagnostic accuracy scores did not differ; the posttest VP scores improved for the intervention group (3.5 [SD 1.3] vs. 1.6 [SD 0.8], p=0.007). On the OSCE, the means scores were higher in the intervention (n=11) compared to control group (n=4) for physical exam (8.4 [SD 4.6] vs. 3.9 [SD 4.0], p=0.003) and total rubric score (43.4 [SD 12.2] vs. 32.6 [SD 11.3], p=0.04). CONCLUSIONS: The VP-based dizziness curriculum resulted in improved diagnostic accuracy among IM interns with enhanced physical exam skills retained at 6 weeks post-intervention.

Prevalence of Horizontal Canal Variant in 3,975 Patients With Benign Paroxysmal Positional Vertigo: A Cross-sectional Study.

Background and Objectives: Current understanding based on older studies is that pc-BPPV is far more common than hc-BPPV. Such studies are limited by small sample sizes, and often the supine roll test for hc-BPPV is not performed. To better estimate the prevalence of hc-BPPV, we studied a large cross-section of patients with VOG-diagnosed BPPV. Methods: Using a cross-sectional study of patients with BPPV, we investigated patients referred to NeuroEquilibrium specialty clinics throughout India between January 1, 2021, and December 31, 2021. All patients were evaluated with video oculography (VOG) during positional tests, and all diagnoses were confirmed by a neurotologist and neurologist. Results: Of 3,975 patients with VOG-confirmed and specialist-diagnosed BPPV (median age, 51 years; 56.6% women), pc-BPPV accounted for 1,901 (47.8%), hc-BPPV was seen in 1,842 (46.3%), and anterior canal BPPV was found in 28 (0.7%) patients. Discussion: This study found that hc-BPPV is far more common than previously reported. It is important to perform the supine roll test in addition to the Dix-Hallpike in all patients suspected with BPPV. Better training to diagnose patients with BPPV and to accurately recognize the nystagmus pattern of hc-BPPV should be a priority.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department.

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

Diagnostic accuracy of lung ultrasound for SARS-CoV-2: a retrospective cohort study.

BACKGROUND: As medical infrastructures are strained by SARS-CoV-2, rapid and accurate screening tools are essential. In portions of the world, reverse transcription polymerase chain reaction (RT-PCR) testing remains slow and in limited supply, and computed tomography is expensive, inefficient, and involves exposure to ionizing radiation. Multiple studies evaluating the efficiency of lung point-of-care ultrasound (POCUS) have been published recently, but include relatively small cohorts and often focus on characteristics associated with severe illness rather than screening efficacy. This study utilizes a retrospective cohort to evaluate the test characteristics (sensitivity, specificity, likelihood ratios, predictive values) of lung POCUS in the diagnosis of SARS-CoV-2, and to determine lung score cutoffs that maximize performance for use as a screening tool. RESULTS: Lung POCUS examinations had sensitivity 86%, specificity 71.6%, NPV 81.7%, and PPV 77.7%. The Lung Ultrasound Score had an area under the curve of 0.84 (95% CI 0.78, 0.90). When including only complete examinations visualizing 12 lung fields, lung POCUS had sensitivity 90.9% and specificity 75.6%, with NPV 87.2% and PPV 82.0% and an area under the curve of 0.89 (95% CI 0.83, 0.96). Lung POCUS was less accurate in patients with a history of interstitial lung disease, severe emphysema, and heart failure. CONCLUSIONS: When applied in the appropriate patient population, lung POCUS is an inexpensive and reliable tool for rapid screening and diagnosis of SARS-CoV-2 in symptomatic patients with influenza-like illness. Adoption of lung POCUS screening for SARS-CoV-2 may identify patients who do not require additional testing and reduce the need for RT-PCR testing in resource-limited environments and during surge periods.

Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study.

OBJECTIVES: Diagnostic errors are pervasive in medicine and most often caused by clinical reasoning failures. Clinical presentations characterized by nonspecific symptoms with broad differential diagnoses (e.g., dizziness) are especially prone to such errors. METHODS: We hypothesized that novice clinicians could achieve proficiency diagnosing dizziness by training with virtual patients (VPs). This was a prospective, quasi-experimental, pretest-posttest study (2019) at a single academic medical center. Internal medicine interns (intervention group) were compared to second/third year residents (control group). A case library of VPs with dizziness was developed from a clinical trial (AVERT-NCT02483429). The approach (VIPER - Virtual Interactive Practice to build Expertise using Real cases) consisted of brief lectures combined with 9 h of supervised deliberate practice. Residents were provided dizziness-related reading and teaching modules. Both groups completed pretests and posttests. RESULTS: For interns (n=22) vs. residents (n=18), pretest median diagnostic accuracy did not differ (33% [IQR 18-46] vs. 31% [IQR 13-50], p=0.61) between groups, while posttest accuracy did (50% [IQR 42-67] vs. 20% [IQR 17-33], p=0.001). Pretest median appropriate imaging did not differ (33% [IQR 17-38] vs. 31% [IQR 13-38], p=0.89) between groups, while posttest appropriateness did (65% [IQR 52-74] vs. 25% [IQR 17-36], p<0.001). CONCLUSIONS: Just 9 h of deliberate practice increased diagnostic skills (both accuracy and testing appropriateness) of medicine interns evaluating real-world dizziness 'in silico' more than ∼1.7 years of residency training. Applying condensed educational experiences such as VIPER across a broad range of common presentations could significantly enhance diagnostic education and translate to improved patient care.

A physicochemical model of crystalloid infusion on acid-base status.

The objective of this study is to develop a physicochemical model of the projected change in standard base excess (SBE) consequent to the infused volume of crystalloid solutions in common use. A clinical simulation of modeled acid-base and fluid compartment parameters was conducted in a 70-kg test participant at standard physiologic state: pH =7.40, partial pressure of carbon dioxide (PCO2) = 40 mm Hg, Henderson-Hasselbalch actual bicarbonate ([HCO3]HH) = 24.5 mEq/L, strong ion difference (SID) = 38.9 mEq/L, albumin = 4.40 g/dL, inorganic phosphate = 1.16 mmol/L, citrate total = 0.135 mmol/L, and SBE =0.1 mEq/L. Simulations of multiple, sequential crystalloid infusions up to 10 L were conducted of normal saline (SID = 0), lactated Ringer's (SID = 28), plasmalyte 148 (SID = 50), one-half normal saline þ 75 mEq/L sodium bicarbonate (NaHCO3; SID = 75), 0.15 mol/L NaHCO3 (SID = 150), and a hypothetical crystalloid solution whose SID = 24.5 mEq/L, respectively. Simulations were based on theoretical completion of steady-state equilibrium and PCO2 was fixed at 40 mm Hg to assess nonrespiratory acid-base effects. A crystalloid SID equivalent to standard state actual bicarbonate (24.5 mEq/L) results in a neutral metabolic acid-base status for infusions up to 10 L. The 5 study solutions exhibited curvilinear relationships between SBE and crystalloid infusion volume in liters. Solutions whose SID was greater than 24.5 mEq/L demonstrated a progressive metabolic alkalosis and less, a progressive metabolic acidosis. In a human model system, the effects of crystalloid infusion on SBE are a function of the crystalloid and plasma SID, volume infused, and nonvolatile plasma weak acid changes. A projection of the impact of a unit volume of various isotonic crystalloid solutions on SBE is presented. The model's validation, applications, and limitations are examined.

Peripheral Vertigo.

This article summarizes the systematic assessment of the dizzy patient who presents with peripheral vertigo. It demonstrates the steps and tests necessary using the Triage-Timing-Trigger-Test (Triage + TiTraTe) method to accurately diagnose the underlying most probable cause while ruling out life-threatening causes. Using video support and just-in-time infographics, it demonstrates the Dix-Hallpike, Semont, Epley, and HINTS maneuvers.

The Flipped Classroom: A Critical Appraisal.

INTRODUCTION: The objective of this study was to review and critically appraise the medical education literature pertaining to a flipped-classroom (FC) education model, and to highlight influential papers that inform our current understanding of the role of the FC in medical education. METHODS: A search of the English-language literature querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 296 papers related to the FC using either quantitative, qualitative, or review methods. Two reviewers independently screened each category of publications using previously established exclusion criteria. Eight reviewers then independently scored the remaining 54 publications using either a qualitative, quantitative, or review-paper scoring system. Each scoring system consisted of nine criteria and used parallel metrics that have been previously used in critical appraisals of education research. RESULTS: A total of 54 papers (33 quantitative, four qualitative, and 17 review) on FC met a priori criteria for inclusion and were critically appraised and reviewed. The top 10 highest scoring articles (five quantitative studies, two qualitative studies, and three review papers) are summarized in this article. CONCLUSION: This installment of the Council of Emergency Medicine Residency Directors (CORD) Academy Critical Appraisal series highlights 10 papers that describe the current state of literature on the flipped classroom, including an analysis of the benefits and drawbacks of an FC approach, practical implications for emergency medicine educators, and next steps for future research.

Optimizing Mastery Learning Environments: A New Approach to Deliberate Practice for Simulation-based Learning.

BACKGROUND: Deliberate practice (DP) is a method of mastery learning widely used in healthcare education. Investigations into improved mastery learning environments are important as we move to competency-based educational models. The objective of this pilot project is to create and test the feasibility of a simulation-based learning methodology based on close adherence to the tenants of DP for the acquisition of mastery knowledge. METHODS: We created a new methodology for simulation-based mastery learning modules after review of the tenants of DP. A module was constructed to highlight important aspects of supraventricular tachycardia (SVT) management in accordance with current American Heart Association practice guidelines and underwent expert review. Ten emergency medicine interns completed the module as part of the pilot. The number of case attempts, critical actions completed, and time to cardioversion of unstable patients were recorded. Resident confidence was reported before and several months after the module via survey instrument. RESULTS: Six cases of patients presenting with SVT were created and critical actions were defined. Cases were ordered in increasing difficulty to form a module in which learners were placed immediately into more complex contexts to practice the skill of SVT management with feedback provided between each case attempt. Residents averaged 2.5 attempts to complete case one. All completed case six on first attempt. All residents completed the six cases within the 2-hour module. Time to cardioversion decreased significantly on repetitive practice. Increased resident confidence in several areas of SVT management was maintained several months postintervention. CONCLUSION: The best methods for the use of DP to encourage mastery learning have not been well defined. Participation in our pilot case increased novice trainee performance and confidence in the management of SVT. Several challenges inherent in testing mastery knowledge acquisition were encountered and will inform future study of this new educational strategy.

Do End-of-Rotation and End-of-Shift Assessments Inform Clinical Competency Committees' (CCC) Decisions?

INTRODUCTION: Clinical Competency Committees (CCC) require reliable, objective data to inform decisions regarding assignment of milestone proficiency levels, which must be reported to the Accreditation Council for Graduate Medical Education. After the development of two new assessment methods, the end-of-shift (EOS) assessment and the end-of-rotation (EOR) assessment, we sought to evaluate their performance. We report data on the concordance between these assessments, as well as how each informs the final proficiency level determined in biannual CCC meetings. We hypothesized that there would be a high concordance level between the two assessment methods, including concordance of both the EOS and EOR with the final proficiency level designation by the CCC. METHODS: The residency program is an urban academic four-year emergency medicine residency with 48 residents. After their shifts in the emergency department (ED), residents handed out EOS assessment forms asking about individual milestones from 15 subcompetencies to supervising physicians, as well as triggered electronic EOR-doctor (EORd) assessments to supervising doctors and EOR-nurse (EORn) to nurses they had worked with after each two-week ED block. EORd assessments contained the full proficiency level scale from 16 subcompetencies, while EORn assessments contained four subcompetencies. Data reports were generated after each six-month assessment period and data was aggregated. We calculated Spearman's rank order correlations for correlations between assessment types and between assessments and final CCC proficiency levels. RESULTS: Over 24 months, 5,234 assessments were completed. The strongest correlations with CCC proficiency levels were the EORd for the immediate six-month assessment period prior (rs 0.71-0.84), and the CCC proficiency levels from the previous six-months (rs 0.83-0.92). EOS assessments had weaker correlations (rs 0.49 to 0.62), as did EORn (rs 0.4 to 0.73). CONCLUSION: End-of-rotation assessments completed by supervising doctors are most highly correlated with final CCC proficiency level designations, while end-of-shift assessments and end-of-rotation assessments by nurses did not correlate strongly with final CCC proficiency levels, both with overestimation of levels noted. Every level of proficiency the CCC assigned appears to be highly correlated with the designated level in the immediate six-month period, perhaps implying CCC members are biased by previous level assignments.

Using the Electronic Medical Record to Reduce Unnecessary Ordering of Coagulation Studies for Patients with Chest Pain.

INTRODUCTION: Our goal was to reduce ordering of coagulation studies in the emergency department (ED) that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR). METHODS: We used a pre and post quasi-experimental study design to evaluate the impact of an EMR-based intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured via detailed review of randomly sampled encounters during two-month periods before and after intervention. We classified existing orders as clinically indicated or non-value added. Order frequencies were calculated as percentages, and we assessed differences between groups by chi-square analysis. RESULTS: Pre-intervention, 73.8% (76/103) of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76) were non-value added. Post-intervention, 38.5% (40/104) of patients with chest pain had coagulation studies ordered, of which 60% (24/40) were non-value added. There was an absolute reduction of 35.3% (95% confidence interval [CI]: 22.7%, 48.0%) in the total ordering of coagulation studies and 26.4% (95% CI: 13.8%, 39.0%) in non-value added order placement. CONCLUSION: Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies.

Feedback in Medical Education: A Critical Appraisal.

OBJECTIVE: The objective was to review and critically appraise the medical education literature pertaining to feedback and highlight influential papers that inform our current understanding of the role of feedback in medical education. METHODS: A search of the English language literature in querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 327 feedback-related papers using either quantitative (hypothesis-testing or observational investigations of educational interventions), qualitative methods (exploring important phenomena in emergency medicine [EM] education), or review methods.Two reviewers independently screened each category of publications using previously established exclusion criteria. Six reviewers then independently scored the remaining 54 publications using a qualitative, quantitative, or review paper scoring system. Each scoring system consisted of nine criteria and used parallel scoring metrics that have been previously used in critical appraisals of education research. RESULTS: Fifty-four feedback papers (25 quantitative studies, 24 qualitative studies, five review papers) met the a priori criteria for inclusion and were reviewed. Eight quantitative studies, nine qualitative studies, and three review papers were ranked highly by the reviewers and are summarized in this article. CONCLUSIONS: This inaugural Council of Emergency Medicine Residency Directors Academy critical appraisal highlights 20 feedback in medical education papers that describe the current state of the feedback literature. A summary of current factors that influence feedback effectiveness is discussed, along with practical implications for EM educators and the next steps for research.

An Assessment Tool for the Placement of Ultrasound-Guided Peripheral Intravenous Access.

Background Ultrasound-guided peripheral intravenous line (USGPIV) placement is becoming an important tool in current clinical practice. Many residency programs utilize unstructured clinical observation to evaluate residents in this and other procedural skills. Simulation-based assessment permits educators to make objective, standardized observations, and may be ideal for assessment of important procedural competencies. Objective We created a simulation-based assessment tool for the skill of USGPIV placement. Methods A checklist tool was developed by a review of relevant literature and an expert review in accordance with established guidelines. Emergency medicine residents were recruited and surveyed on previous experience with USGPIV placement. Blinded, independent reviewers then utilized the checklist to assess residents as they made up to 3 attempts at USGPIV placement on a simulated pediatric arm. Results Of the 26 residents enrolled in our study, 26 participated (100%). A best attempt checklist score greater than or equal to 9 out of 10 correlated with expert performance (P < .001). Agreement between independent raters on first-attempt USGPIV placement score was determined by weighted kappa statistics to be 0.93 (95% CI 086-1.00). Conclusions The checklist assessment tool has acceptable interrater reliability and ability to distinguish performance at differing levels of competence. We propose this tool as a valuable component in the assessment of USGPIV access, and we hope this article serves as a roadmap for other educators to create similar assessment tools.

Determinants of infant sleep position in an urban population.

The incidence of SIDS has decreased by 40% since the Back to Sleep campaign was initiated. However, the rate of SIDS in the District of Columbia continues to be approximately double the national rate. The purpose of this study was to determine the prevalence and determinants of prone sleeping among infants in the District of Columbia and to ascertain what information is being provided to parents by health care professionals by a cross-sectional survey of parents of infants 0-6 months of age presenting for well child care at Children's Health Center, Children's National Medical Center, in Washington, DC. We recruited a consecutive sample of 126 parent-infant pairs, of which 92.9% were African-American. The average infant was 73 days old, was 3,003 grams at birth, and was full term. When asked how the infants were placed for sleep the night before the interview, 34.1 % of parents had placed the infant supine, 50.8% side, and 15.1% prone. Nearly half (48%) of infants slept in an adult bed with the mother. More than one third of the infants had been placed prone for sleep at least once since hospital discharge. Most common reasons for sleeping supine included SIDS risk reduction or health care professional advice. Side sleepers did so primarily because of concern about vomiting, health care provider advice, or SIDS. Infants were placed prone primarily because the infant slept better. When asked about information received from a health care provider, 70.6% of parents stated that they had received information about sleep position and 64.3% about the hazards of passive smoking. Eight parents observed nursery personnel placing their infants prone. Only 16.7% of the total study population had received a Back to Sleep brochure, read it, and recalled that it recommended back sleeping. Infants were more likely to sleep prone if there was a grandparent in the home (OR 2.9, p<0.05) or if they were the firstborn (OR 2.17, p<0.05). Infants were more likely to sleep supine if parents had heard a back recommendation from a health care professional (OR 5.7, p<0.001). Infants were least likely to sleep supine if the parents had heard a side or a side/back recommendation (OR 0.26, p=0.001). Infant sleep position was not ter, reading the Back to Sleep brochure. In conclusion, more than one third (35.7%) of infants in this predominantly African-American population have been placed prone for sleep at least once; 15% slept prone the night before the interview. Almost one third of parents received no information about sleep position, but parents receiving a verbal supine recommendation were most likely to place their infant supine. Receiving written information did not affect sleep position. Improved educational efforts for parents of African-American newborns should continue to focus on encouraging supine positioning, smoke cessation, and other safe sleep practices.