Joshua Jauregui

The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study

BackgroundPrior research suggests that the ratio of the ultrasound-measured diameter of the inferior vena cava to the aorta correlates with the level of dehydration in children. This study was designed to externally validate this and to access the accuracy of the ultrasound measured inspiratory IVC collapse and physician gestalt to predict significant dehydration in children in the emergency department.MethodsWe prospectively enrolled a non-consecutive cohort of children ≤18 years old. Patient weight, ultrasound measurements of the IVC and Ao, and physician gestalt were recorded. The percent weight change from presentation to discharge was used to calculate the degree of dehydration. A weight change of ≥5% was considered clinically significant dehydration. Receiver operating characteristic (ROC) curves were constructed for each of the ultrasound measurements and physician gestalt. Sensitivity (SN) and specificity (SP) were calculated based on previously established cutoff points of the IVC/Ao ratio (0.8), the IVC collapsibility index of 50%, and a new cut off point of IVC collapsibility index of 80% or greater. Intra-class correlation coefficients were calculated to assess the degree of inter-rater reliability between ultrasound observers.ResultsOf 113 patients, 10.6% had significant dehydration. The IVC/Ao ratio had an area under the ROC curve (AUC) of 0.72 (95% CI 0.53 to 0.91) and, with a cutoff of 0.8, produced a SN of 67% and a SP of 71% for the diagnosis of significant dehydration. The IVC collapsibility index of 50% had an AUC of 0.58 (95% CI 0.44 to 0.72) and, with a cutoff of 80% collapsibility, produced a SN of 83% and a SP of 42%. The intra-class correlation coefficient was 0.83 for the IVC/Ao ratio and 0.70 for the IVC collapsibility. Physician gestalt had an AUC of 0.61 (95% CI 0.44 to 0.78) and, with a cutoff point of 5, produced a SN of 42% and a SP of 65%.ConclusionsThe ultrasound-measured IVC/Ao ratio is a modest predictor of significant dehydration in children. The inspiratory IVC collapse and physician gestalt were poor predictors of the actual level of dehydration in this study.

External validation and comparison of three pediatric clinical dehydration scales

Objective To prospectively validate three popular clinical dehydration scales and overall physician gestalt in children with vomiting or diarrhea relative to the criterion standard of percent weight change with rehydration. Methods We prospectively enrolled a non-consecutive cohort of children ≤ 18 years of age with an acute episode of diarrhea or vomiting. Patient weight, clinical scale variables and physician clinical impression, or gestalt, were recorded before and after fluid resuscitation in the emergency department and upon hospital discharge. The percent weight change from presentation to discharge was used to calculate the degree of dehydration, with a weight change of ≥ 5% considered significant dehydration. Receiver operating characteristics (ROC) curves were constructed for each of the three clinical scales and physician gestalt. Sensitivity and specificity were calculated based on the best cut-points of the ROC curve. Results We approached 209 patients, and of those, 148 were enrolled and 113 patients had complete data for analysis. Of these, 10.6% had significant dehydration based on our criterion standard. The Clinical Dehydration Scale (CDS) and Gorelick scales both had an area under the ROC curve (AUC) statistically different from the reference line with AUCs of 0.72 (95% CI 0.60, 0.84) and 0.71 (95% CI 0.57, 0.85) respectively. The World Health Organization (WHO) scale and physician gestalt had AUCs of 0.61 (95% CI 0.45, 0.77) and 0.61 (0.44, 0.78) respectively, which were not statistically significant. Conclusion The Gorelick scale and Clinical Dehydration Scale were fair predictors of dehydration in children with diarrhea or vomiting. The World Health Organization scale and physician gestalt were not helpful predictors of dehydration in our cohort.

Who Are the Most Influential Emergency Physicians on Twitter

Introduction Twitter has recently gained popularity in emergency medicine (EM). Opinion leaders on Twitter have significant influence on the conversation and content, yet little is known about these opinion leaders. We aimed to describe a methodology to identify the most influential emergency physicians (EP) on Twitter and present a current list. Methods We analyzed 2,234 English-language EPs on Twitter from a previously published list of Twitter accounts generated by a snowball sampling technique. Using NodeXL software, we performed a network analysis of these EPs and ranked them on three measures of influence: in-degree centrality, eigenvector centrality, and betweenness centrality. We analyzed the top 100 users in each of these three measures of influence and compiled a list of users found in the top 100 in all three measures. Results Of the 300 total users identified by one of the measures of influence, there were 142 unique users. Of the 142 unique users, 61 users were in the top 100 on all three measures of influence. We identify these 61 users as the most influential EM Twitter users. Conclusion We both describe a method for identifying the most influential users and provide a list of the 61 most influential EPs on Twitter as of January 1, 2016. This application of network science to the EM Twitter community can guide future research to better understand the networked global community of EM.

A Novel Approach to Medical Student Peer-assisted Learning Through Case-based Simulations

Introduction Peer-assisted learning (PAL) is the development of new knowledge and skills through active learning support from peers. Benefits of PAL include introduction of teaching skills for students, creation of a safe learning environment, and efficient use of faculty time. We present a novel approach to PAL in an emergency medicine (EM) clerkship curriculum using an inexpensive, tablet-based app for students to cooperatively present and perform low-fidelity, case-based simulations that promotes accountability for student learning, fosters teaching skills, and economizes faculty presence. Methods We developed five clinical cases in the style of EM oral boards. Fourth-year medical students were each assigned a unique case one week in advance. Students also received an instructional document and a video example detailing how to lead a case. During the 90-minute session, students were placed in small groups of 3–5 students and rotated between facilitating their assigned cases and participating as a team for the cases presented by their fellow students. Cases were supplemented with a half-mannequin that can be intubated, airway supplies, and a tablet-based app (SimMon,

Mixed propranolol and tizanidine overdose treated with intravenous lipid emulsion

22.99) to remotely display and update vital signs. One faculty member rotated among groups to provide additional assistance and clarification. Three EM faculty members iteratively developed a survey, based on the literature and pilot tested it with fourth-year medical students, to evaluate the course. Results 135 medical students completed the course and course evaluation survey. Learner satisfaction was high with an overall score of 4.6 on a 5-point Likert scale. In written comments, students reported that small groups with minimal faculty involvement provided a safe learning environment and a unique opportunity to lead a group of peers. They felt that PAL was more effective than traditional simulations for learning. Faculty reported that students remained engaged and required minimal oversight. Conclusion Unlike other simulations, our combination of brief, student-assisted cases using low-fidelity simulation provides a cost-, resource- and time-effective way to implement a medical student clerkship educational experience.

Emergency Medicine Resident Perceptions of Medical Professionalism

abstract We describe a case of mixed propranolol and tizanidine overdose and response to treatment with intravenous lipid emulsion (ILE) in conjunction with glucagon therapy. A 35-year-old male was unresponsive after intentional overdose of propanolol and tizanidine. He was bradycardic, hypertensive, and obtunded on the first medical contact. He received glucagon with moderate improvement in heart rate, followed by a bolus of ILE. Minutes after receiving ILE he became alert and responsive, and had further improvement in heart rate. This case suggests that ILE may reverse the effects of propanolol and tizanidine toxicity in overdose.

How to Teach in the Emergency Department

Introduction Medical professionalism is a core competency for emergency medicine (EM) trainees; but defining professionalism remains challenging, leading to difficulties creating objectives and performing assessment. Because professionalism is dynamic, culture-specific, and often taught by modeling, an exploration of trainees’ perceptions can highlight their educational baseline and elucidate the importance they place on general conventional professionalism domains. To this end, our objective was to assess the relative value EM residents place on traditional components of professionalism. Methods We performed a cross-sectional, multi-institutional survey of incoming and graduating EM residents at four programs. The survey was developed using the American Board of Internal Medicine’s “Project Professionalism” and the Accreditation Council of Graduate Medical Education definition of professionalism competency. We identified 27 attributes within seven domains: clinical excellence, humanism, accountability, altruism, duty and service, honor and integrity, and respect for others. Residents were asked to rate each attribute on a 10-point scale. We analyzed data to assess variance across attributes as well as differences between residents at different training levels or different institutions. Results Of the 114 residents eligible, 100 (88%) completed the survey. The relative value assigned to different professional attributes varied considerably, with those in the altruism domain valued significantly lower and those in the “respect for others” and “honor and integrity” valued significantly higher (p<0.001). Significant differences were found between interns and seniors for five attributes primarily in the “duty and service” domain (p<0.05). Among different residencies, significant differences were found with attributes within the “altruism” and “duty and service” domains (p<0.05). Conclusion Residents perceive differences in the relative importance of traditionally defined professional attributes and this may be useful to educators. Explanations for these differences are hypothesized, as are the potential implications for professionalism education. Because teaching professional behavior is taught most effectively via behavior modeling, faculty awareness of resident values and faculty development to address potential gaps may improve professionalism education.

Appropriateness of Facebook Friending Between Residents and Attending Physicians

Teach effectively in the Emergency Department (ED) by leveraging the challenges of the ED environment to create spaces and opportunities for learning. Use a framework to start your teaching—this helps learners approach patients in a systematic way to create learning opportunities on every case. Employ a strategy of “planned spontaneity” that allows for interruption. Effective teachers use the unpredictable, undifferentiated patient to help learners become more comfortable with uncertainty and the management of the sick, undifferentiated patient. Finally, take advantage of the communication skills required to practice emergency medicine well, and use them to teach important interpersonal and communication skills.