James E. Colletti

The Management of Children with Gastroenteritis and Dehydration in the Emergency Department

BACKGROUND Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain. OBJECTIVE To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis. DISCUSSION The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported. CONCLUSIONS In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.

The "Good" Dean's Letter

Purpose To determine whether a correlation exists between the term “good” on the summative, comparative assessment of a students Medical Student Performance Evaluation (MSPE) and his or her actual performance in medical school. Method The authors reviewed the MSPEs submitted to three residency programs to determine the presence of the term “good” in either the summary paragraph or the appendices. Next, they noted, for institutions using “good,” the percentile rankings of those students who received “good” as a descriptor. To examine the consistency among institutions regarding the percentile ranking denoted by “good,” they dichotomized the data into students below and above the bottom 25th percentile. They analyzed the data using a nonparametric test because of their nonnormal distribution. Results The authors collected MSPEs from 122 of the 125 Liaison Committee on Medical Education–accredited medical schools that were graduating students in 2008. Of these 122 institutions, 34 (28%) used the term “good.” All 34 institutions used the term to characterize students in the bottom 50% of the graduating class. The authors found a significant difference in the percentile ranking of students described as “good” between institutions using it to describe the bottom 25% and institutions using the term to describe those in the 25th to 50th percentiles (median ranking of 12.5% versus 30%, P < .0001). Conclusions Overall, the term “good” in the MSPE describes students in the bottom 50% of the class; therefore, the term “good,” as used to describe performance in medical school, consistently indicates below-average performance.

DEVELOPING A STANDARDIZED FACULTY EVALUATION IN AN EMERGENCY MEDICINE RESIDENCY

BACKGROUND Quality educators are a core component of successful residency training. A structured, consistent, validated evaluation of clinical educators is important to improve teaching aptitude, further faculty development, and improve patient care. STUDY OBJECTIVES The authors sought to identify specific domains of instructional quality and to develop a composite instrument for assessing instructional quality. METHODS The study setting is a 3-year residency program. Residents rated the quality of faculty member instruction using an 18-item survey twice over a 2-year period (2004-2005). Each survey item used a 9-point scale. Factor analysis employing a Varimax rotation identified domains of instructional performance. Cronbachs alpha was used to assess the internal consistency of the identified domains. RESULTS There were 29 faculty members evaluated. Using 2004 data, five domains of instructional quality were identified that explained 92.5% of the variation in survey responses (χ(2) = 2.33, P = 0.11). These were: Competency and Professionalism (30% of variation), Commitment to Knowledge and Instruction (23%), Inclusion and Interaction (17%), Patient Focus (13%), and Openness to Ideas (9%). Competency and Professionalism included appropriate care, effective patient communication, use of new techniques, and ethical principles. Commitment to Knowledge and Instruction included research, mentoring, feedback, and availability. Inclusion and Interaction included procedural participation and bedside teaching. Patient Focus included compassion, effective care, and sensitivity to diverse populations. Openness to Ideas included enthusiasm and receptivity of new ideas. These five domains were consistent in the 2005 data (Cronbachs alpha 0.68-0.75). CONCLUSIONS A five-domain instrument consistently accounted for variations in faculty teaching performance as rated by resident physicians. This instrument may be useful for standardized assessment of instructional quality.

Phlegmasia cerulea dolens in a patient with an inferior vena cava filter.

A 54-year-old man presented to an outside facility for evaluation of sudden-onset back pain radiating to his flanks. His past medical history included a remote multisystem trauma complicated by atrial fibrillation, lower extremity fasciotomy, and subsequent placement of an inferior vena cava (IVC) filter for pulmonary embolism prophylaxis during the convalescence from his acute injuries. On presentation, his initial systolic blood pressure was 60 mm Hg; immediate fluid resuscitation and pain management were undertaken and the patient was transferred via helicopter to our facility before imaging studies were performed or laboratory data obtained. On arrival, the patient was complaining of 10/10 back pain radiating to his flanks, as well as pain in his bilateral lower extremities. Physical examination revealed a patient in mild distress, with a pulse of 70 beats/min and a blood pressure of 123/80 mm Hg. He was awake, alert, and oriented, and his cardiopulmonary examination was unremarkable. The patient was able to move all of his extremities, but his lower extremities were cyanotic and

Teaching and clinical efficiency: competing demands.

Introduction Teaching ability and efficiency of clinical operations are important aspects of physician performance. In order to promote excellence in education and clinical efficiency, it would be important to determine physician qualities that contribute to both. We sought to evaluate the relationship between teaching performance and patient throughput times. Methods The setting is an urban, academic emergency department with an annual census of 65,000 patient visits. Previous analysis of an 18-question emergency medicine faculty survey at this institution identified 5 prevailing domains of faculty instructional performance. The 5 statistically significant domains identified were: Competency and Professionalism, Commitment to Knowledge and Instruction, Inclusion and Interaction, Patient Focus, and Openness and Enthusiasm. We fit a multivariate, random effects model using each of the 5 instructional domains for emergency medicine faculty as independent predictors and throughput time (in minutes) as the continuous outcome. Faculty that were absent for any portion of the research period were excluded as were patient encounters without direct resident involvement. Results Two of the 5 instructional domains were found to significantly correlate with a change in patient treatment times within both datasets. The greater a physicians Commitment to Knowledge and Instruction, the longer their throughput time, with each interval increase on the domain scale associated with a 7.38-minute increase in throughput time (90% confidence interval [CI]: 1.89 to 12.88 minutes). Conversely, increased Openness and Enthusiasm was associated with a 4.45-minute decrease in throughput (90% CI: −8.83 to −0.07 minutes). Conclusion Some aspects of teaching aptitude are associated with increased throughput times (Openness and Enthusiasm), while others are associated with decreased throughput times (Commitment to Knowledge and Instruction). Our findings suggest that a tradeoff may exist between operational and instructional performance.

Myth: Cool mist is an effective therapy in the management of croup.

Croup is the most common infectious cause of acute airway obstruction in children between 1 and 6 years of age, accounting for 90% of cases of stridor. The majority of cases of croup are caused by parainfluenza and occur during the late fall and winter. Mist has been a mainstay for croup since the 19th century and, even today, many emergency departments (EDs) routinely begin cool mist therapy for patients with croup. Further therapy of croup typically includes nebulized racemic epinephrine and corticosteroids.

PEDIATRIC EMERGENCY MEDICINE FELLOWSHIPS: FACULTY AND RESIDENT TRAINING PROFILES

The objective of this study was to evaluate the faculty and graduate training profiles of Pediatric Emergency Medicine (PEM) fellowship training programs. An electronic 10-point questionnaire was sent to 57 PEM fellowship directors, with a 70% response rate. Analysis of the individual certification of faculty members in PEM training programs demonstrated that the largest represented training types were general pediatricians and pediatricians with PEM sub-certification (29% and 62% representation, respectively). The remaining faculty types consistently showed < 5% overall involvement. Reported estimates on faculty delivery of clinical training, didactic training, and procedural skills demonstrated that pediatricians sub-board certified in PEM consistently administered the highest percentage of these skill sets (74%, 68%, and 68%, respectively). Emergency Medicine-trained physicians showed a relative increase of involvement in fellowship programs administered by Emergency Medicine departments and in those programs located within adult hospitals. Yet, this involvement still remained substantially lower than that of the pediatric-type faculty. Program directors of fellowships within pediatric hospitals and those administered by Pediatric programs demonstrated a preference for general pediatricians with sub-board certification in PEM to improve their faculty pools. Program directors of fellowship programs located in adult hospitals and those administered by departments of EM demonstrated no preference in training type. Lastly, program directors report that 95% of past graduates received their primary board certification through Pediatrics and only 5% received their primary board certification through Emergency Medicine. There are currently many more pediatric-trained physicians among PEM fellowship faculty and graduates. This survey has demonstrated that there has been a decline in EM-trained physicians involved in PEM fellowships since 2000.

Perceptions of the 2011 ACGME duty hour requirements among residents in all core programs at a large academic medical center

BackgroundThe Accreditation Council for Graduate Medical Education (ACGME) implemented revisions to resident duty hour requirements (DHRs) in 2011 to improve patient safety and resident well-being. Perceptions of DHRs have been reported to vary by training stage and specialty among internal medicine and general surgery residents. The authors explored perceptions of DHRs among all residents at a large academic medical center.MethodsThe authors administered an anonymous cross-sectional survey about DHRs to residents enrolled in all ACGME-accredited core residency programs at their institution. Residents were categorized as medical and pediatric, surgery, or other.ResultsIn total, 736 residents representing 24 core specialty residency programs were surveyed. The authors received responses from 495 residents (67%). A majority reported satisfaction (78%) with DHRs and believed DHRs positively affect their training (73%). Residents in surgical specialties and in advanced stages of training were significantly less likely to view DHRs favorably. Most respondents believed fatigue contributes to errors (89%) and DHRs reduce both fatigue (80%) and performance of clinical duties while fatigued (74%). A minority of respondents (37%) believed that DHRs decrease medical errors. This finding may reflect beliefs that handovers contribute more to errors than fatigue (41%). Negative perceived effects included diminished patient familiarity and continuity of care (62%) and diminished clinical educational experiences for residents (41%).ConclusionsA majority of residents reported satisfaction with the 2011 DHRs, although satisfaction was significantly less among residents in surgical specialties and those in advanced stages of training.

Gender Distribution Among American Board of Medical Specialties Boards of Directors

Since 1995, women have comprised more than 40% of all medical school graduates. However, representation at leadership levels in medicine remains considerably lower. Gender representation among the American Board of Medical Specialties (ABMS) boards of directors (BODs) has not previously been evaluated. Our objective was to determine the relative representation of women on ABMS BODs and compare it with the in-training and in-practice gender composition of the respective specialties. The composition of the ABMS BODs was obtained from websites in March 2016 for all Member Boards. Association of American Medical Colleges and American Medical Association data were utilized to identify current and future trends in gender composition. Although represented by a common board, neurology and psychiatry were evaluated separately because of their very different practices and gender demographic characteristics. A total of 25 specialties were evaluated. Of the 25 specialties analyzed, 12 BODs have proportional gender representation compared with their constituency. Seven specialties have a larger proportion of women serving on their boards compared with physicians in practice, and 6 specialties have a greater proportion of men populating their BODs. Based on the most recent trainee data (2013), women have increasing workforce representation in almost all specialties. Although women in both training and practice are approaching equal representation, there is variability in gender ratios across specialties. Directorship within ABMS BODs has a more equitable gender distribution than other areas of leadership in medicine. Further investigation is needed to determine the reasons behind this difference and to identify opportunities to engage women in leadership in medicine.

Progression of Emergency Medicine Resident Patient Experience Scores by Level of Training

Background: Patient satisfaction surveys are vital to measuring a patient’s experience of care. How scores of patients managed by emergency medicine (EM) residents change as residents progress through training is not known. Objectives: To evaluate whether EM residents’ patient satisfaction scores improve as residency training progresses, similar to clinical skill improvement. Methods: A retrospective cross-sectional study evaluated the correlation of patient satisfaction scores with EM resident year of training from 2015 through 2017. We evaluated for a change in score over time for the 4 “physician questions” and the “overall” score. Results: We evaluated 1684 Press Ganey surveys linked to 40 EM resident physicians during the study period. The mean top box scores for the 4 physician questions (concern for comfort [P = .72], courtesy [P = .55], informative about treatment [P = .46], and listening [P = .91]) and overall assessment of emergency department care (P = .51) were not significantly improved over the course of resident. Conclusion: We did not observe a difference in EM residents’ patient experience scores as their level of training progressed. Comprehensive patient experience training for residents might be needed.