Carrie Tibbles

Diagnosis of acute neurological emergencies in pregnant and post-partum women

Acute neurological symptoms in pregnant and post-partum women could be caused by exacerbation of a pre-existing neurological condition, the initial presentation of a non-pregnancy-related problem, or a new acute-onset neurological problem that is either unique to or occurs with increased frequency during or just after pregnancy. Pregnant and postpartum patients with headache and neurological symptoms are often diagnosed with pre-eclampsia; however, a range of other causes must also be considered, such as cerebral venous sinus thrombosis and reversible cerebral vasoconstriction syndrome. Precise diagnosis is essential to guide subsequent management. Our ability to differentiate between the specific causes of acute neurological symptoms in pregnant and post-partum patients is likely to improve as we learn more about the pathogenesis of these disorders.

Validity and reliability of the MTI Photoscreener

Objectives. The prevalence and necessity for early detection sion problems illustrate the need for improved methods of vision screening in preschool children. This study assessed the validity and reliability of a new device, the MTI Photoscreener in a cross-sectional field study. Methods. An appropriate sample size (>140) was calculated and recruited for the study. All children (N = 161) in a migrant workers summer education program were screened with the MTI Photoscreener. Simultaneously and in a masked design, disease status was determined by the odified Clinic Technique, a well established method for diagnosing the conditions which the MTI screener was designed to detect. Results. Validity measures revealed a sensitivity of 54%, specificity of 87%, Ø coefficient of 0.40, and positive predictive value of 52%. Repeatability was assessed by the k coefficient, by a test for effect modification by examiner, and by comparison of sensitivity and specificity across 12 masked examiners. The k coefficient was 0.38. A test for effect modification suggested that differences existed among the examiners. Variability of sensitivity was high, but variability of specificity was low. Conclusions. Methods for vision screening in preschool children are limited. The MTI Photoscreener is an easy and efficient method, but the validity and reliability is a concern. Comparison of our results with other studies suggests future potential for this instrument provided protocols are refined and further field studies reveal efficacy.

IMPLEMENTATION OF AN EMERGENCY DEPARTMENT SIGN-OUT CHECKLIST IMPROVES TRANSFER OF INFORMATION AT SHIFT CHANGE

BACKGROUND Transitions of care are ubiquitous in the emergency department (ED) and inevitably introduce the opportunity for errors. Few emergency medicine residency programs provide formal training or a standard process for patient handoffs. Checklists have been shown to be effective quality-improvement measures in inpatient settings and may be a feasible method to improve ED handoffs. OBJECTIVE To determine if the use of a sign-out checklist improves the accuracy and efficiency of resident sign-out in the ED. METHODS A prospective pre-/postinterventional study of residents rotating in the ED at a tertiary academic medical center. Trained research assistants observed resident sign-out during shift change over a 2-week period and completed a data collection tool to indicate whether or not key components of sign-out occurred and time to sign out each patient. An electronic sign-out checklist was implemented using a multi-faceted educational effort. A 2-week postintervention observation phase was conducted. Proportions, means, and nonparametric comparison tests were calculated using STATA. RESULTS One hundred fifteen sign-outs were observed prior to checklist implementation and 114 were observed after. Significant improvements were seen in four sign-out components: reporting of history of present illness increased from 81% to 99%, ED course increased from 75% to 86%, likely diagnosis increased from 60% to 77%, and team awareness of plan increased from 21% to 41%. Use of the repeat-back technique decreased from 13% to 5% after checklist implementation and time to sign-out showed no significant change. CONCLUSION Implementation of a checklist improved the transfer of information without increasing time to sign-out.

PRACTICING EMERGENCY PHYSICIANS REPORT PERFORMING WELL ON MOST EMERGENCY MEDICINE MILESTONES

BACKGROUND The Accreditation Council for Graduate Medical Educations Next Accreditation System endorsed specialty-specific milestones as the foundation of an outcomes-based resident evaluation process. These milestones represent five competency levels (entry level to expert), and graduating residents will be expected to meet Level 4 on all 23 milestones. Limited validation data on these milestones exist. It is unclear if higher levels represent true competencies of practicing emergency medicine (EM) attendings. OBJECTIVE Our aim was to examine how practicing EM attendings in academic and community settings self-evaluate on the new EM milestones. METHODS An electronic self-evaluation survey outlining 9 of the 23 EM milestones was sent to a sample of practicing EM attendings in academic and community settings. Attendings were asked to identify which level was appropriate for them. RESULTS Seventy-nine attendings were surveyed, with an 89% response rate. Sixty-one percent were academic. Twenty-three percent (95% confidence interval [CI] 20%-27%) of all responses were Levels 1, 2, or 3; 38% (95% CI 34%-42%) were Level 4; and 39% (95% CI 35%-43%) were Level 5. Seventy-seven percent of attendings found themselves to be Level 4 or 5 in eight of nine milestones. Only 47% found themselves to be Level 4 or 5 in ultrasound skills (p = 0.0001). CONCLUSIONS Although a majority of EM attendings reported meeting Level 4 milestones, many felt they did not meet Level 4 criteria. Attendings report less perceived competence in ultrasound skills than other milestones. It is unclear if self-assessments reflect the true competency of practicing attendings. The study design can be useful to define the accuracy, precision, and validity of milestones for any medical field.

The Taxonomy of Emergency Department Consultations—Results of an Expert Consensus Panel

INTRODUCTION AND NECESSITY FOR TAXONOMY OF CONSULTATIONS The basis of all consultations is communication between clinicians. Consultation is a “service type provided by a physician whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician or other appropriate source.” Patient safety is a major concern in physician-to-physician communication, with evidence showing that transitions of care, specifically during consultations, are high-risk periods. Effective interpersonal communication is fundamental to safe patient care. It lies at the core of the continuum of care from clinician to clinician, shift to shift, between departments and between hospitals. In the emergency department (ED), there is a high frequency of consultations on a wide spectrum of disease processes and medical conditions facing emergency physicians. Additionally, with the increasing scrutiny of resource use and transfers of care, including consultants in crowded EDs, improving safety during consultations grows increasingly important. Consultations may have a place early in what often becomes a transfer of responsibility for patients, yet they are distinct from handoffs or transfers of care. Like transfers in care, there is no current agreement on the definition of a “standard” consultation between an emergency physician and the wide variety of specialists with whom they regularly consult (M. Cohen, B. Hilligoss, unpublished data, 2010). Consultations vary in type and content within and across EDs. They range from questions to requests for procedural assistance, can occur in person or by telephone, and are performed by various types of providers. According to the National Hospital Ambulatory Medical Care Survey, there were 117 million ED visits in 2007. A recent review found that 20% to 40% of patients admitted from the ED received at least 1 specialist consultation during their ED course. In addition, a recent study showed a 94% increase in the probability that an ED’s patient visit would result in a consultation or referral to a specialist between 1999 and 2009. (

Consensus of the Millennium Conference on Teaching High Value Care

Abstract Issue: Healthcare costs have spiraled out of control, yet students and residents may lack the knowledge and skills to provide high value care, which emphasizes the best possible care while reducing unnecessary costs. Evidence: Mainly national campaigns are aimed at physicians to reconsider their test ordering behaviors, identify overused diagnostics, and disseminate innovative practices. These efforts will fall short if principles of high value care are not incorporated across the spectrum of training for the next generation of physicians. Implications: Consensus findings of an invitational conference of 7 medical school teams consisting of academic leaders included strategies for institutions to meaningfully incorporate high value care into their medical school, residency, and faculty development curricula.

Public Health Education for Emergency Medicine Residents

Emergency medicine (EM) has an important role in public health, but the ideal approach for teaching public health to EM residents is unclear. As part of the national Regional Public Health-Medicine Education Centers-Graduate Medical Education initiative from the CDC and the American Association of Medical Colleges, three EM programs received funding to create public health curricula for EM residents. Curricula approaches varied by residency. One program used a modular, integrative approach to combine public health and EM clinical topics during usual residency didactics, one partnered with local public health organizations to provide real-world experiences for residents, and one drew on existing national as well as departmental resources to seamlessly integrate more public health-oriented educational activities within the existing residency curriculum. The modular and integrative approaches appeared to have a positive impact on resident attitudes toward public health, and a majority of EM residents at that program believed public health training is important. Reliance on pre-existing community partnerships facilitated development of public health rotations for residents. External funding for these efforts was critical to their success, given the time and financial restraints on residency programs. The optimal approach for public health education for EM residents has not been defined.

Near drowning and adult respiratory distress syndrome.

Dr.Micheal Buggia:Today’s case is that of a 19-year-old man presenting to the Emergency Department (ED) as a trauma activation. The patient was water tubing behind a boat, and as the boat stopped suddenly, he ran into it head first. The patient was wearing a life preserver vest. Witnesses reported that the patient had loss of consciousness and was pulled into the boat shortly after the accident. It took approximately 2 min for the patient to return to his baseline level of consciousness. On arrival to the ED, the patient was awake and his only complaint was mild headache. He denied any shortness of breath, chest pain, abdominal pain, or extremity injury. Dr. Alden Landry: Did the patient have any significant past medical history? Dr. Buggia: No, this was an otherwise healthy 19-year-old man. Dr. Carrie Tibbles:What did you find on your primary survey of this patient? Dr. Louisa Canham: On presentation, his initial vital signs were: temperature 36.8 C (98.2 F), heart rate 87 beats/min, blood pressure 130/70 mm Hg, respiratory rate 24 breaths/min, and oxygen saturation 94% on room air. On primary survey, the patient’s airway was intact, he had equal and clear breath sounds bilaterally, and palpable radial pulses.His score on theGlasgowComaScalewas 15. Dr. Tibbles: What findings were discovered on secondary survey? Dr. Canham: On secondary survey, the only significant finding was a 4-cm laceration to the chin. The patient had a nonfocal neurologic examination and did

Cough and hemoptysis in athletes of an ice hockey team.

Dr. Eugene Yim: Today’s case is that of a 22-year-old ice hockey player who developed respiratory complaints after an away game at a competing school. This athlete presented to the Emergency Department (ED) approximately 10 h after a hockey game. In the preceding weeks before the game, the patient had been sick with an upper respiratory illness, for which he completed a course of antibiotics for a presumed bronchitis. His symptoms had largely resolved by the time of the game, and he was able to perform without any physical limitations. While in the locker room after the game, he noticed a strange odor and a brown-colored gas being emitted from an ice resurfacing machine adjacent to the locker room entrance. Although he had an ongoing cough for the couple weeks before the game, his cough was exacerbated while in the locker room after the game. His symptoms were only mild at the time, and he had an unremarkable return home. He felt well the rest of the evening and was able to fall asleep without difficulty. The following morning, the patient woke up with a worsening cough that produced blood-tinged sputum and saliva. He also developed shortness of breath and chest pain with his cough. After his presentation to the ED, many of his teammates also presented with similar symptoms. Dr. Carrie Tibbles: Can you describe the initial appearance of the patient in the ED? Dr. Ashleigh Hegedus: Upon initial examination in the ED, the patient was resting comfortably and was in no acute distress. He denied dizziness, headache, nausea, and vomiting. His physical examination was essentially

The “Hidden Costs” of Graduate Medical Education in the United States

The cost of graduate medical education in the United States is subsidized by the federal government through direct and indirect Medicare payments. These payments are intended to cover the portion of resident salaries, teaching expenses, and indirect hospital costs associated with the academic mission attributable to the care of Medicare beneficiaries, using a complex allocation formula. However, there are other program expenses associated with medical education that are not reimbursed by Medicare and still significantly affect the competitiveness and quality of the educational programs. Although most educators recognize the amount of extra work and money required to run high-quality training programs, there are few analyses demonstrating the actual amount and effect of these extra expenditures on graduate medical education.1-4 Programs often spend significant amounts on recruitment efforts, including interviews, travel reimbursements, and orientation days. They purchase resource education materials for residents, such as books, simulation training, digital resources, association and membership dues, and in-service examinations to support their education. For scientific meetings and events, they often pay for travel and lodging expenses, program application fees and food; graduation ceremonies, awards, and certificates add to the expenses of running a program. Other items purchased for trainee support include laboratory coats, office supplies, computer hardware and software, parking, meal cards, and pagers. As fiscal pressures intensify for academic medical centers and associated faculty practice plans, it is essential to identify the magnitude and distribution of these “hidden costs” of residency training. As part of a strategic review of education and budgets, the 8 core Accreditation Council for Graduate Medical Education (ACGME) residency programs (comprising 461 trainees) at an academic medical center reported all nonsalary costs of training residents. The programs were asked to identify the costs by category of expenditure (using the 4 categories noted above) and the source of the funding: hospital cost center, physician practice plan, or special funds (eg, philanthropy, grants). The total annual hidden costs for resident education at that institution were