Earl J. Reisdorff

Stress fracture of the first rib from serratus anterior tension: An unusual mechanism of injury

Fracture of the first rib usually results from high-impact, direct trauma. Stress fractures are less common and are associated with minimal morbidity. The case of a patient with a stress fracture resulting from the use of an exercise machine is reported. Previous reports have attributed stress and fatigue fractures of the first rib to the forces exerted by the scalene muscles. A new pathophysiologic mechanism involving the serratus anterior muscle is introduced and is supported by T2 relaxation times from magnetic resonance imaging. Stress and fatigue fractures of the first rib have minimal complications. An aggressive diagnostic evaluation of first rib fractures occurring by this mechanism is not warranted.

The Emergency Medicine Milestones: A Validation Study

OBJECTIVESnThe Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties sought to define milestones for skill and knowledge acquisition during residency training. Milestones are significant objective observable events. The milestones are listed within a structure that is derived from the ACGME general competencies. Major groups of milestones are called subcompetencies. The original 24 subcompetencies containing 255 milestones for emergency medicine (EM) were developed through a multiorganizational group representing most EM stakeholder groups. To assure that the milestones reflected EM resident progress throughout training, the EM Milestones Working Group (EM MWG) sought to validate the individual milestones.nnnMETHODSnA computer-based survey was sent to all EM residency programs. The survey period began on April 30, 2012, and concluded on May 15, 2012. Respondents were asked to assign each milestone to a specific level of skill or knowledge acquisition. These levels ranged from a beginning resident to an accomplished clinician. There were two different forms that divided the milestones into two groups of 12 subcompetencies each. Surveys were randomly assigned to programs.nnnRESULTSnThere were five respondents (the program director and four key faculty) requested from each of the 159 residences. There were responses from 96 programs (60.4%). Of the 795 survey recipients, 28 were excluded due to prior exposure to the EM milestones. Of the remaining 767 potential respondents, 281 completed the survey (36.6%) within a 16-day period. Based on the survey results, the working group adjusted the milestones in the following ways: one entire subcompetency (teaching) was eliminated, six new milestones were created, 34 milestones were eliminated, 26 milestones were reassigned to a lower level score, and 20 were reassigned to a higher level. Nineteen milestones were edited to provide greater clarity. The final result was 227 discrete milestones among 23 subcompetencies.nnnCONCLUSIONSnThe EM milestones were validated through a milestone assignment process using a computer-based survey completed by program directors and key faculty. Milestones were revised in accordance with the results to better align assignment within each performance level.

Assessing the new general competencies for resident education: a model from an emergency medicine program.

The Accreditation Council for Graduate Medical Education (ACGME) has promoted six areas that should be addressed during graduate medical training, or “general competencies” (GCs). According to the ACGME, these GCs should be reflected in the educational processes of all residency programs. In promulgating these competencies, however, the ACGME has not provided examples of core content, methods of implementation, or methods of evaluation. The authors propose a practical method for modifying an existing evaluation format, providing a template other programs could use in assessing residents acquisition of the knowledge, skills, and attitudes reflected in the GCs.

Initial Validity Analysis of the Emergency Medicine Milestones.

OBJECTIVESnThe Accreditation Council for Graduate Medical Education (ACGME) Milestones describe behavioral markers for the progressive acquisition of competencies during residency. As a key component of the Next Accreditation System, all residents are evaluated for the acquisition of specialty-specific Milestones. The objective was to determine the validity and reliability of the emergency medicine (EM) Milestones.nnnMETHODSnThe ACGME and the American Board of Emergency Medicine performed this single-event observational study. The data included the initial EM Milestones performance ratings of all categorical EM residents submitted to the ACGME from October 31, 2013, to January 6, 2014. Mean performance ratings were determined for all 23 subcompetencies for every year of residency training. The internal consistency (reliability) of the Milestones was determined using a standardized Cronbachs alpha coefficient. Exploratory factor analysis was conducted to determine how the subcompetencies were interrelated.nnnRESULTSnEM Milestone performance ratings were obtained on 100% of EM residents (n = 5,805) from 162 residency programs. The mean performance ratings of the aggregate and individual subcompetency scores showed discrimination between residency years, and the factor structure further supported the validity of the EM Milestones. The reliability was α = 0.96 within each year of training.nnnCONCLUSIONSnThe EM Milestones demonstrated validity and reliability as an assessment instrument for competency acquisition. EM residents can be assured that this evaluation process has demonstrated validity and reliability; faculty can be confident that the Milestones are psychometrically sound; and stakeholders can know that the Milestones are a nationally standardized, objective measure of specialty-specific competency acquisition.

Prehospital interventions in children

OBJECTIVESnFrequently performing procedures assists in skill maintenance. This study was conducted to characterize frequency and types of basic and advanced prehospital interventions performed on children.nnnMETHODSnA retrospective study was conducted over a three-month period from emergency medical services (EMS) units working in central Michigan. Data were collected for age, sex, at-scene time, total run time, basic procedures (e.g., spinal immobilization), and advanced procedures (e.g., venous access).nnnRESULTSnA total of 535 EMS runs were reviewed. Runs were excluded for transport refusal (105) and site-to-site transfer (6). Of the remaining 424 children, 287 received an intervention (group 1) and 137 did not (group 2). Group 1 (9.5 +/- 5.6 years) was older (p < 0.001) than group 2 (6.0 +/- 5.8 years). There was no gender predominance between group 1 and group 2 (p = 0.06). In group 1 there were 104 patients who received multiple procedures. Basic procedures (n = 382) included spinal immobilization (149), oxygen administration (123), splinting (27), wound care (24), use of military anti-shock trousers (4), and cardiopulmonary resuscitation (1). Advanced procedures (n = 112) included venous access (65), medications of all routes (26), and cardiacoximetry monitoring (21). No child had an intraosseous line started and no child was successfully intubated. Only 82 of the 424 children (19.3%) had an advanced procedure. Group 1 at-scene times (16.1 +/- 8.1 min) were longer (p < 0.001) than those of group 2 (11.1 +/- 6.6 min). Total run times for group 1 (35.7 +/- 15.5 min) were longer (p < 0.001) than those for group 2 (26.7 +/- 11.3 min).nnnCONCLUSIONSnAdvanced EMS procedures were performed on only 19.3% of children. Opportunities to perform critical interventions (e.g., intubation) were rarely present. Children receiving procedures were older and had longer scene and run times.

Rectal diazepam in pediatric status epilepticus.

Status epilepticus is a neurologic emergency with an 8% to 12% mortality. Rapid ablation of seizure activity is imperative. Although intravenous administration of diazepam is the preferred immediate treatment, vascular access is often difficult to achieve. Rectal administration of diazepam is easily accomplished during status epilepticus. Five cases in which diazepam administered in the rectal lumen stopped seizure activity are reported. Rectal diazepam appears to be safe and efficacious. It should be considered as an alternate to intravenous therapy when immediate vascular access is delayed. Rectal diazepam may have great benefit in the prehospital setting.

Syncope in children

The sudden loss of consciousness in a child is concerning to both patients and their parents. Although most cases of syncope in children are benign, an adequate evaluation is required to exclude life-threatening disorders. Patient history and physical examination may be sufficient to define the cause of syncope in a large percentage of pediatric cases. The events and setting preceding the syncopal episode provide clues in defining the nature of the event.

QT dispersion may be a useful adjunct for detection of myocardial infarction in the chest pain center

BACKGROUNDnQT dispersion has been proposed as a noninvasive measurement of the degree of inhomogeneity in myocardial repolarization. Increased QT dispersion has been reported after myocardial infarction. We hypothesized that increased QT dispersion may be a useful adjunct for risk stratification in patients being evaluated in a chest pain center.nnnMETHODS AND RESULTSnPatients were admitted to the chest pain center for evaluation of chest pain. Exclusion criteria included (1) systolic blood pressure <90 mm Hg, (2) ischemia or infarction on the initial electrocardiograph (ECG), (3) elevated creatine kinase or MB fraction, and (4) chest pain associated with cocaine use. Serial creatine kinase and MB levels and ECGs were obtained at 0, 6, and 9 hours. Patients were monitored for (1) creatine kinase and MB rise, (2) ECG changes for infarction, (3) ST-segment changes, and (4) rest angina. A negative evaluation at the chest pain center led to an exercise stress test. Patients with a positive exercise stress test were admitted for further evaluation and patients with a negative exercise stress test result were discharged home. Patients were divided into 3 groups. Group 1 consisted of patients who were found to have an acute myocardial infarction (AMI), group 2 consisted of patients with prior history of coronary artery disease but no evidence of AMI, and group 3 consisted of patients without prior coronary artery disease or AMI. QT dispersion was measured on the initial ECG in all patients. A total of 586 patients were evaluated. Group 1 consisted of 13 patients with mean QT dispersion of 44.6+/-18.5 ms, group 2 consisted of 267 patients with a mean QT dispersion of 10.0+/-13.8 ms, and group 3 consisted of 303 patients with a mean QT dispersion of 10.5+/-10.0 ms. Analysis of variance showed a significantly higher QT dispersion in patients who had AMI compared with other patients with chest pain (P< .001).nnnCONCLUSIONSnQT dispersion can be a useful diagnostic adjunct for detection of AMI in patients with chest pain with a normal ECG and normal cardiac enzymes.

Emergency care for posttonsillectomy and postadenoidectomy hemorrhage

There are an estimated 4,300 cases of postoperative hemorrhage after tonsillectomy in the United States each year. Most patients seek care in the Emergency Department for this potentially fatal condition. This study was performed to characterize the clinical presentation of patients seeking Emergency Department (ED) care for posttonsillectomy and postadenoidectomy hemorrhage (PTAH). In addition, the investigators attempted to describe the ED treatment for PTAH. A retrospective review of ED and inpatient medical records was executed for patients presenting to the ED with PTAH from June 1, 1983 to May 31, 1993. All patients presenting to the ED who received a final ED diagnosis of PTAH were included in the study. The setting included two community-based teaching hospitals that share a single emergency medicine residency. The combined ED census averaged 72,000 annual visits over the study period. The ED population included both children and adults. Neither hospital had an otolaryngology residency, nor was there 24 hour in-hospital otolaryngology staffing. Factors that were reviewed included patient age, gender, final disposition, presenting vital signs, time from the initial surgery to the time of bleeding, ED treatment, and the interaction with the on-call otolaryngologist. Subpopulations were defined primarily by age (child versus adult) and disposition (home versus hospital). chi 2 Analysis was used for most comparisons. When chi 2 analysis showed an association, the phi (phi) coefficient was calculated to determine the strength of the association. When appropriate, means were compared using the Students two-tailed t test.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute digitalis poisoning: The role of intravenous magnesium sulfate

Acute digitalis poisoning is a complex emergency with a reported mortality rate of 3% to 25%. In severe overdose, the sodium, potassium-adenosine triphosphatase system is severely inhibited, leading to cardiac dysrhythmias and an elevation of the serum potassium. Magnesium, a cofactor regulating this ion transport system, can successfully treat acute digitalis-induced rhythm disturbances and restore the transmembrane potassium gradient. This paper discusses the cellular mechanism involved in digitalis toxicity and reviews the literature concerning the use of magnesium in acute cardiac glycoside poisoning.