David Della-Giustina

Emergency Medicine Residents Consistently Rate Themselves Higher than Attending Assessments on ACGME Milestones

Introduction In 2012 the Accreditation Council for Graduate Medical Education (ACGME) introduced the Next Accreditation System (NAS), which implemented milestones to assess the competency of residents and fellows. While attending evaluation and feedback is crucial for resident development, perhaps equally important is a resident’s self-assessment. If a resident does not accurately self-assess, clinical and professional progress may be compromised. The objective of our study was to compare emergency medicine (EM) resident milestone evaluation by EM faculty with the same resident’s self-assessment. Methods This is an observational, cross-sectional study that was performed at an academic, four-year EM residency program. Twenty-five randomly chosen residents completed milestone self-assessment using eight ACGME sub-competencies deemed by residency leadership as representative of core EM principles. These residents were also evaluated by 20 faculty members. The milestone levels were evaluated on a nine-point scale. We calculated the average difference between resident self-ratings and faculty ratings, and used sample t-tests to determine statistical significance of the difference in scores. Results Eighteen residents evaluated themselves. Each resident was assessed by an average of 16 attendings (min=10, max=20). Residents gave themselves statistically significant higher milestone ratings than attendings did for each sub-competency examined (p<0.0001). Conclusion Residents over-estimated their abilities in every sub-competency assessed. This underscores the importance of feedback and assessment transparency. More attention needs to be paid to methods by which residency leadership can make residents’ self-perception of their clinical ability more congruent with that of their teachers and evaluators. The major limitation of our study is small sample size of both residents and attendings.

Evaluation of a new nonnvasive device in determining hemoglobin levels in emergency department patients.

Introduction: The Masimo Radical-7 Pulse CO-Oximeter is a medical device recently approved by the US Food and Drug Administration that performs noninvasive oximetry and estimated venous or arterial hemoglobin measurements. A portable, noninvasive device that rapidly measures hemoglobin concentration could be useful in both austere and modern hospital settings. The objective of this study is to determine the degree of variation between the devices estimated hemoglobin measurement and the actual venous hemoglobin concentration in undifferentiated emergency department (ED) patients. Methods: We conducted a prospective, observational, cross-sectional study of adult patients presenting to the ED. The subjects consisted of a convenience sample of adult ED patients who required a complete blood count as part of their care in the ED. A simultaneous probe hemoglobin was obtained and recorded. Results: Bias between probe and laboratory hemoglobin measurements was –0.5 (95% confidence interval, – 0.8 to –0.1) but this was not statistically significant from 0 (t0.05,124 = 0.20, P > 0.5). The limits of agreement were –4.7 and 3.8, beyond the clinically relevant standard of equivalency of ± 1 g/dL. Conclusion: These data suggest that noninvasive hemoglobin determination is not sufficiently accurate for emergency department use.

Propofol and Etomidate are Safe for Deep Sedation in the Emergency Department

This study describes deep sedations performed for painful procedures completed in the emergency department at an academic tertiary care hospital during an 18-month period. One hundred consecutive cases were retrospectively reviewed to describe indications, complications, procedural lengths, medication dosing, and safety of these sedations. Propofol and etomidate were the preferred agents. We found that there were relatively few complications (10%), with only 2 of these (2%) being major complications. All complications were brief and did not adversely affect patient outcomes. This data further demonstrate the safety profile of deep sedation medications in the hands of emergency physicians trained in sedation and advanced airway techniques.

Impact of Decontamination Therapy on Ultrasound Visualization of Ingested Pills

Introduction Acute toxic ingestion is a common cause of morbidity and mortality. Emergency physicians (EP) caring for overdose (OD) patients are often required to make critical decisions with incomplete information. Point of care ultrasound (POCUS) may have a role in assisting EPs manage OD patients. We evaluated the impact of different liquid adjuncts used for gastric decontamination on examiners’ ability to identify the presence of tablets using POCUS, and assessed examiners’ ability to quantify the numbers of tablets in a simulated massive OD. Methods This prospective, blinded, pilot study was performed at an academic emergency department. Study participants were volunteer resident and staff EPs trained in POCUS. Five nontransparent, sealed bags were prepared with the following contents: 1 liter (L) of water, 1 L of water with 50 regular aspirin (ASA) tablets, 1 L of water with 50 enteric-coated aspirin tablets (ECA), 1 L of polyethylene glycol (PEG) with 50 ECA, and 1 L of activated charcoal (AC) with 50 ECA. After performing POCUS on each of the bags using a 10-5 MHz linear array transducer, participants completed a standardized questionnaire composed of the following questions: (1) Were pills present? YES/NO; (2) If tablets were identified, estimate the number (1–10, 11–25, >25). We used a single test on proportions using the binomial distribution to determine if the number of EPs who identified tablets differed from 50% chance. For those tablets identified in the different solutions, another test on proportions was used to determine whether the type of solution made a difference. Since 3 options were available, we used a probability of 33.3%. Results Thirty-seven EPs completed the study. All (37/37) EP’s correctly identified the absence of tablets in the bag containing only water, and the presence of ECA in the bags containing water and PEG. For Part 2 of the study, most participants - 25/37 (67.5%) using water, 23/37 (62.1%) using PEG, and all 37 (100%) using AC - underestimated the number of ECA pills in solution by at least 50%. Conclusion There may be a potential role for POCUS in the evaluation of patients suspected of acute, massive ingested OD. EPs accurately identified the presence of ECA in water and PEG, but underestimated the number of tablets in all tested solutions.