Dominique Vanpee

How to construct and implement script concordance tests: insights from a systematic review

Medical Education 2012: 46: 552–563

Rectus Sheath Hematoma

We describe 3 patients with rectus sheath hematoma presenting to the emergency department. Prompt consideration of this uncommon cause of abdominal pain may prevent more expensive and invasive diagnostic tests and, in some cases, unnecessary hospitalization and laparotomy.We describe 3 patients with rectus sheath hematoma presenting to the emergency department. Prompt consideration of this uncommon cause of abdominal pain may prevent more expensive and invasive diagnostic tests and, in some cases, unnecessary hospitalization and laparotomy.

What is so difficult about managing clinical reasoning difficulties

Medical Education 2012: 46 : 216–227

Elderly heart failure patients with drug-induced serious hyperkalemia.

We report four cases of hyperkalemia induced by the association of spironolactone with ACE inhibitor in geriatric patients. Over a period of one year, four elderly patients treated for congestive heart failure with this association were admitted to the Geriatric Ward with serious hyperkalemia. These occurrences represented one third of all-cause severe hyperkalemia cases admitted during this one-year period. A common observation in our cases was that the dose of spironolactone employed far exceeded the recommended dosages. These cases illustrate that spironolactone dosage must be kept low in the setting of chronic congestive heart failure treatment, as well as the need for close monitoring of frail elderly patients who are given this combination.

Ingestion of antacid tablets (Rennie) and acute confusion.

The authors describe a case of milk-alkali syndrome in a man who consumed antacid tablets (Rennie) for chronic epigastric pain. Simultaneous occurrence of hypercalcemia, metabolic alkalosis, and renal insufficiency, in conjunction with the appropriate history of ingestion of calcium carbonate-containing antacids, was suggestive of the syndrome. The syndrome became uncommon with the advent of modern ulcer therapy, but currently is increasing in frequency with the calcium supplementation drugs taken to prevent osteoporosis. This syndrome may produce life-threatening hypercalcemia.

Use of portfolios as a learning and assessment tool in a surgical practical session of urology during undergraduate medical training

We chose to introduce a portfolio as a learning and assessment tool in a practical training session of urological surgery for undergraduate medical students. Our primary objectives were to develop the students’ self reflexive ability in front of complex medical cases and to teach them how to identify their learning needs in a short period of time, on a specific topic. Students completed, during their training session, a portfolio on a urological topic under the constant supervision of a tutor. The students were evaluated on their portfolios presentation with a 20-point grade grid known in advance. Even in a surgical training session, a portfolio can be a useful learning and assessment tool. It clearly encourages self-reflection and pre-professional practice.

Non-invasive positive pressure ventilation for exacerbation of chronic obstructive pulmonary patients in the emergency department.

Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) commonly present to the emergency department for treatment. Some of them, despite appropriate therapy become more dyspnoeic with increasing acute respiratory failure. The requirement for intubation and mechanical ventilation is for these patients often associated with a prolonged and complicated intensive care unit stay and has been associated with morbidity and mortality rates in excess. Non-invasive ventilation (NIV) emerged recently as a means of reducing those complications. NIV can be a safe and effective means of augmenting ventilation and decreasing inspiratory work in many patients with acute exacerbation of COPD. NIV is generally started in the intensive care unit. Except for a few negative studies, the overall compending studies seem to be in favour of the utilization of NIV in cases of exacerbation of COPD patients. There are few published data on the question whether NIV could or should be started earlier and initiated in the emergency department. It seems that NIV treatment could be an effective addition to standard treatment especially for acute exacerbation of COPD. A more extensive and routine use of non-invasive ventilation in the emergency department requires further study.

Evaluation of flow limitation in elderly patients unable to perform a forced expiratory maneuver

Background and aims: The assessment of pulmonary function in elderly persons is not often easy in the clinical practice because of poor patient collaboration. A new technique, negative expiratory pressure (NEP), should provide a simple, rapid and non-invasive method for detecting flow limitation without collaboration of the patients. Our aim was to investigate whether it is possible to detect an expiratory flow limitation during resting breathing with NEP in elderly patients unable to perform a forced expiratory maneuver. Methods: In 15 elderly inpatients (4 males and 11 females, mean age 83±4.7 SD years) unable to realize the classical forced expiratory maneuver because of poor coordination or cognitive disturbance, we applied the NEP technique during spontaneous breathing. Results: NEP application during resting breathing was easily and rapidly performed in all cases without side effects. During NEP (−5 cmH2O and NEP −10cm H2O), 6 and 5/15 patients were flow limited; mean flow limitation was 60±9% and 70±15% respectively. These results were reproducible with repeated NEP tests. Conclusions: Application of negative pressure at the mouth during tidal expiration provides a simple method for detecting expiratory flow limitation during spontaneous breathing in elderly patients with poor collaboration.

Cases in electrocardiography

Early identification and treatment, including administration of intravenous thrombolytics, coronary angioplasty, and adjunctive therapies, has been shown to benefit patients who present with acute myocardial infarction. However, only a small percentage of these patients receive such therapies because of late presentation, associated risks, and controversies surrounding certain myocardial infarct subsets. The logistics involved in carrying out these treatments have resulted in unnecessary prehospital and in-hospital delays. These issues make essential the availability of a streamlined protocol that should be updated at regular intervals to ensure that these time-dependent therapies are more routinely and rapidly utilized. This article discusses these topics in conceptual format and provides a ready-to-use protocol.

Assessing clinical reasoning using a script concordance test with electrocardiogram in an emergency medicine clerkship rotation

Objectives Script concordance tests (SCTs) can be used to assess clinical reasoning, especially in situations of uncertainty, by comparing the responses of examinees with those of emergency physicians. The examinees answers are scored based on the level of agreement with responses provided by a panel of experts. Emergency physicians are frequently uncertain in the interpretation of ECGs. Thus, the aim of this study was to validate an SCT combined with an ECG. Methods An SCT-ECG was developed. The test was administered to medical students, residents and emergency physicians. Scoring was based on data from a panel of 12 emergency physicians. The statistical analyses assessed the internal reliability of the SCT (Cronbachs α) and its ability to discriminate between the different groups (ANOVA followed by Tukeys post hoc test). Results The SCT-ECG was administered to 21 medical students, 19 residents and 12 emergency physicians. The internal reliability was satisfactory (Cronbachs α=0.80). Statistically significant differences were found between the groups (F0.271=21.07; p<0.0001). Moreover, significant differences (post hoc test) were detected between students and residents (p<0.001), students and experts (p<0.001), and residents and experts (p=0.017). Conclusions This SCT-ECG is a valid tool to assess clinical reasoning in a context of uncertainty due to its high internal reliability and its ability to discriminate between different levels of expertise.