Chad S. Kessler

Underreporting of blood and body fluid exposures among health care students and trainees in the acute care setting: a 2007 survey.

BACKGROUND It has been estimated that more than 8 million health care workers (HCWs) in the United States may be exposed to blood and body fluids via sharp and mucocutaneous exposures. METHODS An anonymous questionnaire was distributed among 505 HCWs. The target sample population included all the medical students; nursing professionals; dental professionals; and residents in internal medicine, emergency medicine, surgery, and obstetrics and gynecology at the University of Illinois Medical Center, Chicago, Illinois, a metropolitan tertiary care and referral center for Northern Illinois and Northwest Indiana. The sample was limited by the number of HCWs who were available to take the survey. The number and the characteristics of occupational exposures and reporting practices were recorded and compiled. Subsequently, a review of the English literature was performed using PubMed to analyze reasons for underreporting. Secondary and tertiary articles were located based on findings from the initial searches. RESULTS One hundred three of 455 (22.6%) HCWs reported a sharps exposure during their career, including their student years; thirty-four (33.0%) of these were not reported. One hundred five of 455 (23.1%) HCWs reported a mucocutaneous exposure during their career; 87 (82.9%) of these were not reported. The most common year of exposure was the intern year. The most common reason for not reporting was the belief that the exposure was not significant, followed by the combination of believing the exposure was not significant and being too busy. CONCLUSION Underreporting of blood and body fluid exposures is common because of a belief that most exposures are not significant. More education of HCWs is needed to change this perspective.

Ultrasound training for medical students and internal medicine residents—A needs assessment

While sonography has been a mainstay of certain medical specialties, such as obstetrics and gynecology, internal medicine has been slower to integrate this technology into practice. No standardized training in sonography exists for either medical students or internal medicine residents, and little is known about the current competency and utilization of ultrasound among these groups. The goal of this article is to examine the present state of ultrasound education among internal medicine residents and medical students at a major university hospital.

The use of sodium polystyrene sulfonate in the inpatient management of hyperkalemia

BACKGROUND Limited data exist on the precise dose of sodium polystyrene sulfonate (SPS) needed for specific potassium concentrations in the management of mild to moderate hyperkalemia in an inpatient hospital setting. METHODS A retrospective cohort study involving a review of electronic medical records of inpatients receiving SPS for the treatment of hyperkalemia was conducted at the Jesse Brown Veteran Affairs Medical Center, between January 1, 2006 and December 31, 2006. Hyperkalemia was defined as a serum potassium concentration >5.1 mmol/L. The primary endpoint was the mean change in potassium concentration associated with specific SPS dosage administration. RESULTS A total of 122 patients were selected for inclusion in the analysis. The mean potassium concentrations before SPS administration were 5.40 ± 0.18 mmol/L, 5.51 ± 0.30, 5.83 ± 0.46, and 5.92 ± 0.30 in the 15, 30, 45, and 60 gm groups, respectively. The mean potassium concentration decreased by 0.82 ± 0.48 mmol/L in the 15 gm group, 0.95 ± 0.47 in the 30 gm group, 1.11 ± 0.58 in the 45 gm group, and 1.40 ± 0.42 in the 60 gm group. After a single dose of SPS, the mean potassium concentration was within normal range in 115 patients (94%). CONCLUSIONS A possible direct dose response relationship between SPS and the reduction in serum potassium concentration was found and should be evaluated prospectively.

Consultation in the Emergency Department: A Qualitative Analysis and Review

BACKGROUND No studies have evaluated the consultation process or attempted to define a standardized approach that could improve communication and patient outcomes. OBJECTIVE To perform a qualitative analysis of emergency medicine (EM) consultation to reveal its complexity and elucidate strategies and frameworks for physician-to-physician communication. METHODS Data were collected in three phases: informal interviews conducted in an emergency department (ED), 10-question surveys given to a subset of EM and specialty physicians, and semi-structured 1-h group interviews using open-ended questions to further explore issues and trends elicited from the survey responses. In addition, we conducted an extensive literature search focused on health care and business consultation and communication. RESULTS Seventy-six percent (29 of 38) of emergency and specialty physicians completed the 10-question survey in its entirety. Three themes were identified from the survey responses: organizational skills, interpersonal and communication skills, and medical knowledge. Of 95 total comments, 41 (43%) focused on organizational skills, 26 (27%) on interpersonal and communication skills, and 28 (30%) on medical knowledge. There were 29 comments regarding poor consultations: 15 issues with organization, 6 with interpersonal and communication skills, and 8 with medical knowledge. The literature search revealed several models and types of consultation, but no standard algorithm currently exists. CONCLUSIONS We recommend focusing on organizational skills, interpersonal and communication skills, and medical knowledge when teaching ED consultation and present a conceptual framework of the Five Cs Consultation Model: contact, communication, core question, collaboration, and closing the loop.

Thrombotic Thrombocytopenic Purpura: A Hematological Emergency

BACKGROUND Thrombotic thrombocytopenic purpura is a hematological emergency and diagnostic challenge. The critical determinant of outcome is timely diagnosis and treatment. OBJECTIVES Describe the pathophysiology, presentation, diagnosis, and treatment of thrombotic thrombocytopenic purpura. DISCUSSION Thrombotic thrombocytopenic purpura has a varied presentation and a tendency to mimic several disorders. However, it may be at least provisionally diagnosed in the patient with thrombocytopenia and microangiopathic hemolytic anemia without alternate cause. The mainstay of treatment is immediate plasma exchange to be repeated until platelet count is stabilized. Adjuvant therapies include corticosteroids, rituximab, and cyclosporine. CONCLUSION It is essential for the emergency physician to be aware of thrombotic thrombocytopenic purpuras range of presentations, diagnostic criteria, and treatment.

The Treatment of Cutaneous Abscesses: Comparison of Emergency Medicine Providers' Practice Patterns

Introduction Cutaneous abscesses are commonly treated in the emergency department (ED). Although incision and drainage (I&D) remains the standard treatment, there is little high-quality evidence to support additional interventions such as pain control, type of incision, and use of irrigation, wound cultures, and packing. Although guidelines exist to support clinician management of abscesses, they do not clearly specify these additional interventions. This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting. Methods: Four hundred and seventy-four surveys were distributed to 15 EDs across the United States. Participants were queried about their level of training and practice environment as well as specific questions regarding their management of cutaneous abscesses in the ED. Results: In total, 350 providers responded to the survey (74%). One hundred eighty-nine respondents (54%) were attending physicians, 135 (39%) were residents, and 26 (7%) were midlevel providers. Most providers (76%) used narcotics for pain management, 71% used local anesthetic over the roof of the abscess, and 60% used local anesthetic in a field block for pain control. More than 48% of responders routinely used irrigation after (I&D). Eighty-five percent of responders used a linear incision to drain the abscess and 91% used packing in the wound cavity. Thirty-two percent routinely sent wound cultures and 17% of providers routinely prescribed antibiotics. Most providers (73%) only prescribed antibiotics if certain historical factors or physical findings were present on examination. Antibiotic treatment, if used, favored a combination of 2 or more drugs to cover both Streptococcus and methicillin-resistant Staphylococcus aureus (47%). Follow-up visits were most frequently recommended at 48 hours unless wound was concerning and required closer evaluation. Conclusion: Variability exists in the treatment strategies for abscess care. Most providers used narcotic analgesics in addition to local anesthetic, linear incisions, and packing. Most providers did not irrigate, order wound cultures, or routinely prescribe oral antibiotics unless specific risk factors or physical signs were present. Limited evidence is available at this time to guide these treatment strategies.

The Emergency Department Approach to Syncope: Evidence-based Guidelines and Prediction Rules

Syncope is a sudden, transient loss of consciousness associated with inability to maintain postural tone followed by spontaneous recovery and return to baseline neurologic status. Global cerebral hypoperfusion is the final pathway common to all presentations of syncope, but this symptom presentation has a broad differential diagnosis. It is important to identify patients whose syncope is a symptom of a potentially life-threatening condition. This article reviews the current status of syncope from the emergency department perspective, focusing on the current evidence behind the various clinical decision rules derived during the past decade.

I'm clear, you're clear, we're all clear: improving consultation communication skills in undergraduate medical education.

Requesting and providing consultations are daily occurrences in most teaching hospitals. With increased attention on transitions of care in light of the recent scrutiny of duty hours, consultations and other interphysician interactions, such as handoffs, are becoming increasingly important. As modern medicine increases in complexity, the skill of communicating with medical colleagues throughout the continuum of care becomes more challenging. Like many of the other skills acquired by medical students, consultation communication is often learned by casual observation and through trial and error. Without formal training, however, miscommunications will continue to occur, nearly ensuring that medical errors happen. Interphysician communication skills, therefore, need to be emphasized in undergraduate and graduate medical education instead of being left to happenstance or hit-or-miss practice. In this article, the authors review two models for understanding and teaching the consultation process--5Cs and PIQUED--both of which were developed for specific subsets of learners. They then combine the two to create a consultation model that may be more widely applied.

The Current State of Core Competency Assessment in Emergency Medicine and a Future Research Agenda: Recommendations of the Working Group on Assessment of Observable Learner Performance

In 2012, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Next Accreditation System (NAS) for residency program accreditation. With implementation of the NAS, residents are assessed according to a series of new emergency medicine (EM)-specific performance milestones, and the frequency of assessment reporting is increased. These changes are driving the development of new assessment tools for the NAS that can be feasibly implemented by EM residency programs and that produce valid and reliable assessment data. This article summarizes the recommendations of the writing group on assessment of observable learner performance at the 2012 Academic Emergency Medicine consensus conference on education research in EM that took place on May 9, 2012, in Chicago, Illinois. The authors define an agenda for future assessment tool research and development that was arrived at by consensus during the conference.

Assessing Patient Care: Summary of the Breakout Group on Assessment of Observable Learner Performance

There is an established expectation that physicians in training demonstrate competence in all aspects of clinical care prior to entering professional practice. Multiple methods have been used to assess competence in patient care, including direct observation, simulation-based assessments, objective structured clinical examinations (OSCEs), global faculty evaluations, 360-degree evaluations, portfolios, self-reflection, clinical performance metrics, and procedure logs. A thorough assessment of competence in patient care requires a mixture of methods, taking into account each methods costs, benefits, and current level of evidence. At the 2012 Academic Emergency Medicine (AEM) consensus conference on educational research, one breakout group reviewed and discussed the evidence supporting various methods of assessing patient care and defined a research agenda for the continued development of specific assessment methods based on current best practices. In this article, the authors review each methods supporting reliability and validity evidence and make specific recommendations for future educational research.