Dan Mayer

Analyzing clinical case distributions to improve an emergency medicine clerkship

Recommendations for a core curriculum for undergraduate emergency medicine education have been published. It is expected that a combination of bedside teaching and didactic sessions will cover all aspects of the curriculum, but this has not been demonstrated. This study describes a method of using the distribution of clinical cases to shape the mix of clinical and didactic learning in an emergency medicine clerkship. All senior students at the Albany Medical College participate in a four-week emergency medicine rotation. A brief log describing each clinical encounter is maintained by the students. Data from one year were sorted into 32 categories adapted from American College of Emergency Physicians guidelines and were tabulated. A criterion of 80% of students encountering at least one case in each category was chosen to ensure a reasonable level of exposure to a particular case or topic. One hundred twenty-three students were exposed to an average of 63.7 +/- 27.5 (SD) patients. Seven categories met the criterion, and the remaining 25 categories failed the criterion. Results indicate that exposure to certain categories of patients with appropriate monitoring can be reasonably ensured in our clinical setting. The didactic portion of the curriculum can be adjusted so that categories not meeting the clinical criterion will be emphasized, whereas those meeting the criterion will be de-emphasized. A method has been described that identifies gaps in the clinical exposure of students and permits appropriate identification of didactic sessions to create a clerkship more consistent with recommended guidelines.

Bilateral vocal cord hematomas associated with shoulder harness use

A case of bilateral vocal cord hematomas caused by a shoulder harness injury is presented. The patient was restrained by a three-point belt system and was involved in a front-end collision. She presented with mild facial and chest injuries and a contusion of the neck. One hour after injury she began to complain of hoarseness without airway compromise. Fiberoptic laryngoscopy showed bilateral true vocal cord hematomas. The patient had an uneventful hospital course and a full recovery. The importance of the mechanism of injury and associated injuries is discussed.

Delayed presentation of an epidural hematoma

Abstract The formation of delayed intracranial hematomas should be considered in a head-injured patient who experiences clinical deterioration, especially after surgical evacuation of an initial hematoma or placement of an ICP monitor. Development of increased ICP or neurological deterioration following the administration of mannitol should also raise suspicion of new lesions. Immediate follow-up CT should be performed for declining neurological status. Repeat CT is recommended within 24 hours of admission or within 24 hours after craniotomy, even if the patients neurological status has not deteriorated. New mass effects are often seen in patients who deteriorate neurologically after head injury.

The injured ankle and foot

In this pair of articles, Gavin Falk and Tom Fahey (doi:10.1136/bmj.b2899) set out what to consider when using a clinical prediction rule, and Dan Mayer (doi:10.1136/bmj.b2901) shows how one such rule, the Ottawa ankle rules, is applied

Isolated talus fractures: Description of a new clinical sign

Isolated talus fractures are very uncommon and are usually associated with severe trauma. Five cases of isolated talus fracture associated with relatively minor trauma are reported. These five patients had one clinical sign in common, pain out of proportion to the severity of their injury. The treatment of talus fractures is reviewed.

Shigella-induced encephalopathy in an adult

A 71-year-old woman presented with altered level of consciousness following episodes of diarrhea and abdominal pain. Shigella sonnei was later cultured from her stool. Although neurological complications, primarily seizures, have been reported sequelae in children afflicted shigellosis, there are only rare cases of encephalopathy in affected adults. A brief discussion of the neurological complications of Shigella infection and the yet undetermined role of Shiga toxin in producing neurotoxicity are presented.

Clarification: Editorial Oversight of Results Reported in Annals

To the Editor: The letter to the editor by Carson and the reply by Green and Schriger raise some important questions about the nature of noninferiority studies and the meaning of these results in the article by Rehrer et al. In my opinion both sides are correct. Noninferiority studies have recently enjoyed resurgence by examining previously validated and investigational therapies. The key to interpreting these studies lies in two domains, defining the noninferiority margin and interpreting the statistical outcomes. The principle of a noninferiority study is that we are “very sure” that the experimental therapy is not worse than the standard control therapy. The noninferiority margin is the maximal difference in outcomes that we would consider not to be clinically significant. This is determined according to previous studies of the control intervention. This tends to be selected in a more or less subjective manner. A more clinically relevant interpretation of this margin is the number needed to treat to fail the outcome. In the study by Rehrer et al, the noninferiority margin selected was 8%, the same as a number needed to treat to fail the outcome of 13. For every 13 patients treated with oral dexamethasone, one additional patient will fail therapy and return to the ED within 14 days with an exacerbation of asthma. The next issue is that of statistical significance. In a noninferiority study, the a priori hypothesis is that the experimental treatment is not worse than the control and is therefore either better or the same. This allows use of a one-tailed statistical test in calculating the P value and the 95% confidence intervals (CIs) of the difference between groups found in the study. Using a 1-tailed test means that finding superiority would not be statistically significant because this result could have occurred by chance alone when in fact the two are equivalent. If we used the standard 2-tailed test, the P value is .51, whereas it is .29 with the 1-tailed test. Interpreting this CI to calculate number needed to treat to fail the outcome is a bit more complex. If the CI is completely within the noninferiority range, we accept the results to be “statistically significant.” In the case of the study by Rehrer et al, the difference between groups was 2.3% and the 95% CI was –4.1% to 8.6%, which was not

Evidence‐based Medicine

Summary:  Evidence‐based medicine (EBM) has become a watchword for “the new” medical practice in the new century. Whether it represents a paradigm shift or simply a codification of the scientific method in medicine will be debated for years to come. Regardless of the place of EBM in medicine, this “movement” has served an important role in moving physician practice into the realm of becoming more scientific (albeit empirical) and transparent. There are still many problems to be addressed in the global application of the best evidence for medical practice. These include low‐quality studies, delays in implementation of clear‐cut improvements, outright fraud and deceit, and wariness on the part of physicians to change their practice. By working to understand the underpinnings of EBM (basic statistical concepts and critical thinking) we can advance the practice of medicine along the moral high road of science.

Letter to the Editor: A Commentary on Maya J. Goldenberg's “The Doctor–Patient Relationship in the Age of Evidence-Based Health Care (and Not the ‘Post-Managed Care Era’)”

Maya J. Goldenberg’s letter to the editor in response to the article by Alexander and Lantos on “The Doctor–Patient Relationship in the Age of Managed Care” completely misses the point (Goldenberg 2006). Evidence-based health care is not to blame for the decline of the quality of the doctor-patient relationship. The rise of evidence-based health care occurred at the same time that the doctor-patient relationship has been eroded. Attributing a cause and effect relationship is, at best, a misguided attempt to negate the epidemiological approach to disease. At worst, it is a rejection of critical thinking and the scientific method in modern medical care. Unfortunately, this approach can lead people (patients) to accept other types of healing that may sound good on paper, but accomplish nothing for the patient except perhaps to relieve their wallet of some weight and maybe make them feel a little better and satisfied, without improving their health outcomes. I would pose this question to Ms. Goldenberg: “If a well done randomized clinical trial showed a clear benefit of therapy A over B would you want your physician to give you therapy B because she thought it would be better for you?” The essence of the doctor–patient relationship is clear and accurate communication between the doctor and patient. Physicians have a duty to provide clear and accurate evidence so that a patient can determine how that medical decision fits in with their values. This cannot be done unless the physician has obtained and critically evaluated the available evidence. If the members of the health care team allow the “bracketing of the individual patient in favor of a highly rationalized population based and fragmented approach to health care” (Goldenberg 2006, W32), we have only ourselves to blame for loosing the confidence of the public in our provision of health care. Applying the best evidence to the health care of an individual patient does not mean abandoning the humanity of the patient and “holistic” way we treat that person (managing their symptoms within the context of the person, their community and society) and providing “caring” health care. Barr (2006) comments that the profession’s failure to live up to their trust is major cause for the reason we are in this dilemma now and that the profession has “neglected . . . pursuit of scientific truth” (p. 33) in favor of guaranteed incomes. He states that physicians should be pleased that patients are “armed with print outs of reports of recent research” and share science and uncertainty with patients. Aultman (2006) is concerned that physicians believe that managed care leads to unethical practices and the inability to deliver the highest quality care, which is only defined through the presence of adequate evidence. Tauber (2006) describes the “crisis in trust” that developed since the 1960s as a symptom of the glue of society becoming undone. We can get back some trust by maintaining the moral high ground relating to the science of medicine, in the form of evidence-based practice and always working for the patient’s best interest. When managed care explicitly and overtly supercedes the patient’s best interest, the physician’s ethical duty is to stand up for her patient. A physician going against the best evidence clearly violates the ethical trust of their patients. It is precisely this doctor–patient relationship that needs to be expanded upon and developed in the context of evidence-based practice while allowing the patient to become a full partner in sharing the decision making process. We are not mindless or mechanical, but thinking human beings who believe in applying the scientific method to maximize the benefits of modern medicine. Sir William Osler said this best when he said “medicine is the science of uncertainty and the art of probability”. That is the definition of evidence-based health care.