Lorraine G. Thibodeau

Vaginal evisceration 1

Intestinal evisceration through the vagina is exceptionally rare. We report the cases of two patients presenting with this unusual clinical condition. Predisposing factors and management of vaginal evisceration are discussed.

Emergency medicine clerkship curriculum: an update and revision.

In 2006, the latest version of a national curriculum for the fourth-year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth-year EM clerkship educational syllabi has been developed.

Incidence of aspiration after urgent intubation

This study sought to determine the incidence of aspiration after urgent endotracheal intubation (ET) performed in the emergency department (ED), and to offer a descriptive evaluation of these intubations. In a retrospective review of 133 charts, 87 patients met inclusion criteria. Aspiration occurred in 3 (3.5%) patients (95% confidence interval, 0%, 7.4%). One had witnessed aspiration, and 2 had positive sputum cultures. None of the 87 patients had a positive chest radiograph or unexplained hypoxemia up to 48 hours after ET. Rapid-sequence induction and oral ET was performed in 79 (91%) patients, whereas 4 spontaneously breathing patients were nasally intubated. Seventy percent of patients underwent ET by PGY I or II residents, 29% by PGY III or IV residents, and 1% by ED attending physicians. Seventy-seven patients were intubated on the first attempt, and airway blood or vomitus during ET was noted in 11 patients. This study offers significant descriptive information regarding urgent ET performed in the ED, and shows that aspiration after urgent ET occurs infrequently in ED patients.

Evaluating educational interventions in emergency medicine.

This article presents the proceedings of the 2012 Academic Emergency Medicine consensus conference breakout group charged with identifying areas necessary for future research regarding effectiveness of educational interventions for teaching emergency medicine (EM) knowledge, skills, and attitudes outside of the clinical setting. The objective was to summarize both medical and nonmedical education literature and report the consensus formation methods and results. The authors present final statements to guide future research aimed at evaluating the best methods for understanding and developing successful EM curricula using all types of educational interventions.

An Evaluation of Resident Work Profiles, Attending–Resident Teaching Interactions, and the Effect of Variations in Emergency Department Volume on Each

OBJECTIVES This study examines the effect of variations in emergency department (ED) volume on physician work efficiency (new patients per hour) and work profile (patient-related activities, including both direct and indirect patient care) and whether these differ between first- (Postgraduate Year [PGY]1) and third- (PGY3) year residents. The authors also determine if changes in volume are associated with changes in teaching interactions between attending and resident physicians. METHODS This was a prospective observational study of resident and attending physicians in the ED. Research assistants (RAs) followed ED residents during clinical shifts and recorded a multitude of data including the amount of time spent in specific activities, the number of new patients seen, and the frequency of attending physician teaching interactions. RESULTS Third-year residents see more new patients per hour (1.79 vs. 1.16, p < 0.001) than do their first-year counterparts. In addition, third-year residents spend almost 50% less time with each patient (10.7 minutes vs. 19.4 minutes, p < 0.001), and first-year residents spend three times as much time per shift discussing patients with attending physicians (59.4 minutes vs. 27.3 minutes, p = 0.002). More of the PGY1/attending interactions resulted in educational exchanges (54.9% vs. 34.6%, p = 0.003). PGY1 residents also spend more time on dictations per patient (9.6 minutes vs. 5.4 minutes, p = 0.01) and more time on paperwork per patient (18.5 minutes vs. 6.5 minutes, p = 0.007). As ED volume tripled, PGY1 residents were able to increase their patient load to a greater extent than were PGY3 residents by decreasing the length of each patient encounter as volume increased. Overall, ED volume had no effect on the number of teaching interactions, although the length of exchange decreased as volume increased. CONCLUSIONS Third-year residents see and carry more patients than do their first-year counterparts. They do so primarily by decreasing the amount of time spent with patients and attendings and working more efficiently overall. However, they are not as capable of altering their work profiles in the face of increased volume as their first-year counterparts. While the length of teaching interactions is decreased as volume increases, the number of those interactions resulting in teaching remains constant regardless of volume.

Nonconvulsive status epilepticus

A 49-year-old man presented with dizziness and altered behavior associated with a nonconvulsive seizure. He had a long history of well-controlled tonic-clonic seizures and daily episodes of 10-second staring spells. Despite normal neurological and laboratory examinations, an emergent electroencephalogram showed changes consistent with nonconvulsive generalized status epilepticus.

Emergency medicine clerkship directors: current workforce.

Introduction The emergency medicine clerkship director serves an important role in the education of medical students. The authors sought to update the demographic and academic profile of the emergency medicine clerkship director. Methods We developed and implemented a comprehensive questionnaire, and used it to survey all emergency medicine clerkship directors at United States allopathic medical schools accredited by the Liaison Committee on Medical Education. We analyzed and interpreted data using descriptive statistics. Results One hundred seven of 133 (80.4%) emergency medicine clerkship directors completed the survey. Clerkship Director’s mean age was 39.7 years (SD-7.2), they were more commonly male 68.2%, of Caucasian racial backgrounds and at the instructor or assistant professor (71.3%) level. The mean number of years of experience as clerkship director was 5.5 (SD-4.5). The mean amount of protected time for clerkship administration reported by respondents was 7.3 hours weekly (SD-5.1), with the majority (53.8%) reporting 6 or more hours of protected time per week. However, 32.7% of emergency medicine clerkship directors reported not having any protected time for clerkship administration. Most clerkship directors (91.6%) held additional teaching responsibilities beyond their clerkship and many were involved in educational research (49.5%). The majority (79.8%), reported being somewhat or very satisfied with their job as clerkship director. Conclusion Most clerkship directors were junior faculty at the instructor or assistant professor rank and were involved with a variety of educational endeavors beyond the clerkship.