Kriti Bhatia

Incorporating simulation into a residency curriculum.

The integration of simulation into a medical postgraduate curriculum requires informed implementation in ways that take advantage of simulations unique ability to facilitate guided application of new knowledge. It requires review of all objectives of the training program to ensure that each of these is mapped to the best possible learning method. To take maximum advantage of the training enhancements made possible by medical simulation, it must be integrated into the learning environment, not simply added on. This requires extensive reorganization of the resident didactic schedule. Simulation planning is supported by clear learning objectives that define the goals of the session, promote learner investment in active participation and allow for structured feedback for individual growth. Teaching to specific objectives using simulation requires an increased time commitment from teaching faculty and careful logistical planning to facilitate flow of learners through a series of simulations in ways that maximize learning. When applied appropriately, simulation offers a unique opportunity for learners to acquire and apply new knowledge under direct supervision in ways that complement the rest of the educational curriculum. In addition, simulation can improve the learning environment and morale of residents, provide additional methods of resident evaluation, and facilitate the introduction of new technologies and procedures into the clinical environment.

Implementation of small-group reflection rounds at an emergency medicine residency program.

Few residency curricular interventions have focused on improving well-being and promoting humanism. We describe the implementation of a novel curriculum based on small-group reflection rounds--the Emergency Medicine Reflection Rounds (EMRR)--at a 4-year US emergency medicine (EM) residency. During the inaugural year (2010-2011), nine residents volunteered to take part in 1-hour monthly sessions with faculty facilitators. Residents were provided with a confidential environment to discuss difficult ethical and interpersonal encounters from their clinical experiences. Ongoing feedback from participants was solicited, culminating with a four-question survey in which all respondents remarked that the EMRR contributed to improving their own well-being and agreed that it provided an important forum for residents to discuss difficult issues in a safe environment. In this article, we describe our innovation as an example of a wellness initiative that has promoted reflective practice and fostered cooperative learning around the communication, professional, and ethical challenges inherent in EM practice. Our EMRR model may be useful to other EM residences looking to supplement their wellness curriculum.

A novel mentorship programme for residents integrating academic development, clinical teaching and graduate medical education assessment.

IntroductionMentorship fosters career development and growth. During residency training, mentorship should support clinical development along with intellectual and academic interests. Reported resident mentoring programmes do not typically include clinical components. We designed a programme that combines academic development with clinical feedback and assessment in a four-year emergency medicine residency programme.MethodsIncoming interns were assigned an advisor. At the conclusion of the intern year, residents actively participated in selecting a mentor for the duration of residency. The programme consisted of quarterly meetings, direct clinical observation and specific competency assessment, assistance with lecture preparation, real-time feedback on presentations, simulation coaching sessions, and discussions related to career development. Faculty participation was recognized as a valuable component of the annual review process. Residents were surveyed about the overall programme and individual components.ResultsOver 88 % of the respondents said that the programme was valuable and should be continued. Senior residents most valued the quarterly meetings and presentation help and feedback. Junior residents strongly valued the clinical observation and simulation sessions.ConclusionsA comprehensive mentorship programme integrating clinical, professional and academic development provides residents individualized feedback and coaching and is valued by trainees. Individualized assessment of clinical competencies can be conducted through such a programme.

Diffuse Abdominal Pain and Fever in an Elderly Man

Dr. Margaret Greenwood-Ericksen: Today’s case is that of a 67-year-old man who presented to the Emergency Department (ED) with a 1-day history of fever and abdominal pain. The pain was described as gradual in onset, progressively worsening, and diffuse. Associated symptoms included fatigue, nausea, and anorexia. He denied vomiting, diarrhea, bloody stools, or urinary complaints. The patient had several chronic medical conditions, including atrial fibrillation, for which he took warfarin and an indolent leukemia for which he was prescribed methotrexate and prednisone. One month prior, he developed septic arthritis, which led to methicillinsensitive Staphylococcus aureus bacteremia, requiring hospital admission and a prolonged course of antibiotics. Hewas discharged to a rehabilitation facility 1 week prior to ED presentation on a 6-week course of cefazolin. A review of his rehabilitation facility flowcharts indicated a temperature of 38.9 C several hours prior to ED presentation. On arrival to the ED, vital signs were as follows: temperature 38.9 C, heart rate 98 beats/min, blood pressure 96/68 mm Hg, respiratory rate 20 breaths/min, and oxygen saturation 97% on room air. He appeared pale and thin, and he was interactive and able to convey his recent

Rash and Shock

Dr. Lulu Wang: Today’s case is that of a 76-year-old gentleman who presented to the emergency department (ED) with left groin rash. The patient first noticed symptoms 5 days before presentation, when a small painless nodule appeared in his left inguinal fold, which he presumed to be a lymph node. Over the following week, the skin surrounding the nodule became erythematous and tender, expanding to cover a large area of his left groin. The rash was not bothersome and did not impede the patient’s range of motion. He had not suffered any known trauma, or chemical or allergen exposure to the region. He denied any accompanying fever or chills and did not notice any spontaneous drainage. He was seen by his primary care physician earlier on the day of ED presentation. In clinic, his blood pressure was 70/40 mm Hg and he was diaphoretic. A 12-lead electrocardiogram showed new-onset atrial fibrillation with occasional premature ventricular contractions. He was referred to the ED for further evaluation. Dr. Eric Nadel: Can you describe his physical examination upon presentation to the ED? Dr. Wang: His vital signs were: temperature 36.6 C, blood pressure 78/42 mmHg, heart rate 97 beats/min, respiratory rate 20 breaths/min, and oxygen saturation 95% on room air. On examination, he was obese, alert, wellappearing, in no acute distress, and speaking in full sentences. The respiratory examination was notable for normal respiratory effort, with lungs clear to auscultation bilaterally. The heart was tachycardic with an irregularly

Fever and Back Pain in a Preschool Teacher

Dr. Kimberly Stanford: Today’s case is that of a 29-year-old woman with no significant past medical history who was transferred to the Emergency Department (ED) after presenting to an outside hospital with fever and back pain. The patient reported that shewas well until 4 days prior when she developed fever up to 39.2 C, rigors, and midline thoracic pain. She denied neck stiffness, vomiting, diarrhea, rash, or cough. She denied recent travel outside of the Boston area, sick contacts, intravenous drug abuse, spinal injections, high-risk sexual exposures, or insect bites. She worked as a teacher in a preschool. She had no past medical history, took no medications, and had no known allergies to medications. She drank one or two alcoholic drinks on weekends and did not smoke or use illicit drugs. On the day of symptom onset, she presented to an outside hospital ED, where her vital signs were within normal limits. Her evaluation included a complete blood count, which showed a white blood cell count of 4.34 K/uL and platelets of 167 K/uL, as well as a basic metabolic panel and computed tomography (CT) scan of her abdomen and pelvis, both of which were normal. She was discharged home with supportive care. Since discharge, she continued to spike high fevers and feel unwell, prompting a second presentation at the same facility. At the time of the second visit, 3 days later, her laboratory work was notable for new leukopenia (white blood

Jaundice, Anemia, and Hypoxemia

*Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, †Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, ‡Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, §Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, and kDepartment of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Emily S. Miller, MD, Department of Emergency Medicine, Harvard Medical School, Boston, MA 02118

A Young Man with Acute Chest Pain

*Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts Reprint Address: Emily Senecal Miller, MD, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Zero Emerson Place Suite 3B, Boston, MA 02118