Mark Silverberg

Increasing ventilator surge capacity in disasters: ventilation of four adult-human-sized sheep on a single ventilator with a modified circuit.

OBJECTIVE Recent manmade and natural disasters have focused attention on the need to provide care to large groups of patients. Clinicians, ethicists, and public health officials have been particularly concerned about mechanical ventilator surge capacity and have suggested stock-piling ventilators, rationing, and providing manual ventilation. These possible solutions are complex and variously limited by legal, monetary, physical, and human capital restraints. We conducted a study to determine if a single mechanical ventilator can adequately ventilate four adult-human-sized sheep for 12h. METHODS We utilized a four-limbed ventilator circuit connected in parallel. Four 70-kg sheep were intubated, sedated, administered neuromuscular blockade and placed on a single ventilator for 12h. The initial ventilator settings were: synchronized intermittent mandatory ventilation with 100% oxygen at 16 breaths/min and tidal volume of 6 ml/kg combined sheep weight. Arterial blood gas, heart rate, and mean arterial pressure measurements were obtained from all four sheep at time zero and at pre-determined times over the course of 12h. RESULTS The ventilator and modified circuit successfully oxygenated and ventilated the four sheep for 12h. All sheep remained hemodynamically stable. CONCLUSION It is possible to ventilate four adult-human-sized sheep on a single ventilator for at least 12h. This technique has the potential to improve disaster preparedness by expanding local ventilator surge capacity until emergency supplies can be delivered from central stockpiles. Further research should be conducted on ventilating individuals with different lung compliances and on potential microbial cross-contamination.

Axillary breast tissue mistaken for suppurative hidradenitis: an avoidable error☆

The differential diagnosis for a solitary axillary mass is extensive. Based on the initial history and physical examination of the patient presented in this case report, the diagnosis of suppurative hidradenitis was incorrectly reached. This subjected her to a surgical procedure that was not indicated for the actual diagnosis of ectopic axillary breast tissue. This article reviews the workup for a solitary axillary mass and discusses multiple aspects of ectopic breast tissue.

What Does Remediation and Probation Status Mean? A Survey of Emergency Medicine Residency Program Directors

OBJECTIVES Emergency medicine (EM) residency program directors (PDs) nationwide place residents on remediation and probation. However, the Accreditation Council for Graduate Medical Education and the EM PDs have not defined these terms, and individual institutions must set guidelines defining a change in resident status from good standing to remediation or probation. The primary objective of this study was to determine if EM PDs follow a common process to guide actions when residents are placed on remediation and probation. METHODS An anonymous electronic survey was distributed to EM PDs via e-mail using SurveyMonkey to determine the current practice followed after residents are placed on remediation or probation. The survey queried four designations: informal remediation, formal remediation, informal probation, and formal probation. These designations were compared for deficits in the domains of medical knowledge (MK) and non-MK remediation. The survey asked what process for designation exists and what actions are triggered, specifically if documentation is placed in a residents file, if the graduate medical education (GME) office is notified, if faculty are informed, or if resident privileges are limited. Descriptive data are reported. RESULTS Eighty-one of 160 PDs responded. An official policy on remediation and/or probation was reported by 41 (50.6%) programs. The status of informal remediation is used by 73 (90.1%), 80 (98.8%) have formal remediation, 40 (49.4%) have informal probation, and 79 (97.5%) have formal probation. There was great variation among PDs in the management and definition of remediation and probation. Between 81 and 86% of programs place an official letter into the residents file regarding formal remediation and probation. However, only about 50% notify the GME office when a resident is placed on formal remediation. There were no statistical differences between MK and non-MK remediation practices. CONCLUSIONS There is significant variation among EM programs regarding the process of remediation and probation. The definition of these terms and the actions triggered are variable across programs. Based on these findings, suggestions toward a standardized approach for remediation and probation in GME programs are provided.

What is the prevalence and success of remediation of emergency medicine residents

Introduction The primary objective of this study was to determine the prevalence of remediation, competency domains for remediation, the length, and success rates of remediation in emergency medicine (EM). Methods We developed the survey in Surveymonkey™ with attention to content and response process validity. EM program directors responded how many residents had been placed on remediation in the last three years. Details regarding the remediation were collected including indication, length and success. We reported descriptive data and estimated a multinomial logistic regression model. Results We obtained 126/158 responses (79.7%). Ninety percent of programs had at least one resident on remediation in the last three years. The prevalence of remediation was 4.4%. Indications for remediation ranged from difficulties with one core competency to all six competencies (mean 1.9). The most common were medical knowledge (MK) (63.1% of residents), patient care (46.6%) and professionalism (31.5%). Mean length of remediation was eight months (range 1–36 months). Successful remediation was 59.9% of remediated residents; 31.3% reported ongoing remediation. In 8.7%, remediation was deemed “unsuccessful.” Training year at time of identification for remediation (post-graduate year [PGY] 1), longer time spent in remediation, and concerns with practice-based learning (PBLI) and professionalism were found to have statistically significant association with unsuccessful remediation. Conclusion Remediation in EM residencies is common, with the most common areas being MK and patient care. The majority of residents are successfully remediated. PGY level, length of time spent in remediation, and the remediation of the competencies of PBLI and professionalism were associated with unsuccessful remediation.

β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review.

This is a systematic review of the literature to compare the efficacy of calcium channel blockers to &bgr;-blockers for acute rate control of atrial fibrillation with rapid ventricular response in the emergency department setting. PubMed, EMBASE, and the Cochrane Registry were searched. Relative risk (95% confidence interval) was calculated between drugs and methodological quality of included studies was evaluated. Of the 1003 studies yielded by our initial search, two met inclusion criteria and provided sufficient data. These were randomized double-blinded studies (n=92) comparing intravenous diltiazem with intravenous metoprolol. The combined relative risk of acute rate control by diltiazem versus metoprolol was 1.8 (95% confidence interval 1.2–2.6). On the basis of the paucity of available evidence, diltiazem may be more effective than metoprolol in achieving rapid rate control, but high-quality randomized studies are needed.

The effect of pregnancy on the response to blood loss in a rat model.

STUDY OBJECTIVES A commonly held belief is that the blunted hemodynamic response to hemorrhage observed in pregnant women is secondary to expanded blood volume. In addition to increased blood volume, pregnancy is also a vasodilated state. Vasodilatation may have deleterious effects on the response to hemorrhage by inhibiting central blood shunting after blood loss. How these conflicting variables of increased blood volume and vasodilatation integrate into a whole body model of maternal hemorrhagic shock has yet to be studied in a controlled experiment. We tested the null hypothesis that there would be no difference in the hemodynamic and metabolic responses to hemorrhage between pregnant (PRG) and non-pregnant (NPRG) rats. METHODS Twenty-four adult female Sprague-Dawley rats (12 PRG and 12 NPRG) were anesthetized with Althesin via the intraperitoneal route. Femoral arteries were cannulated by cut-down. Twelve (six PRG and six NPRG) rats underwent controlled catheter hemorrhage of 25% of their total blood volume. Twelve rats (six PRG and six NPRG) served as non-hemorrhage controls. Mean arterial pressure (MAP) and base excess (BE) were measured pre-hemorrhage and then every 15 min post-hemorrhage for the next 90 min. Data were reported as mean+/-standard error of the mean (S.E.M.) over the 90-min post-hemorrhage observation period. Group comparisons were analyzed by ANOVA with repeated values post-hoc by Bonferroni. Statistical significance was defined by an alpha=0.05. RESULTS PRG and NPRG rats were evenly matched for MAP (P=0.788) and BE (P=0.146) pre-hemorrhage. Post-hemorrhage there were no mortalities in either group. Post-hemorrhage both the PRG and NPRG groups experienced significant (P=0.011) drops in systolic and diastolic blood pressures as compared to their non-hemorrhage controls. Post-hemorrhage there was no significant (P=0.43) difference in MAP between the PRG (89+/-2 mmHg) and NPRG (80+/-2 mmHg) rats. BE also dropped significantly within both PRG (P=0.004) and NPRG (P=0.001) groups post-hemorrhage. No significant (P=0.672) difference was noted in BE between PRG and NPRG groups post-hemorrhage -6.1+/-0.3 mEq/l and -6.9+/-0.4 mEq/l, respectively. CONCLUSION After a controlled hemorrhage of 25% of total blood volume we found no significant differences in MAP and BE between pregnant and non-pregnant rats. Pregnancy does not affect the response to hemorrhage.

Defining uniform processes for remediation, probation, and termination in residency training

It is important that residency programs identify trainees who progress appropriately, as well as identify residents who fail to achieve educational milestones as expected so they may be remediated. The process of remediation varies greatly across training programs, due in part to the lack of standardized definitions for good standing, remediation, probation, and termination. The purpose of this educational advancement is to propose a clear remediation framework including definitions, management processes, documentation expectations and appropriate notifications. Informal remediation is initiated when a resident’s performance is deficient in one or more of the outcomes-based milestones established by the Accreditation Council for Graduate Medical Education, but not significant enough to trigger formal remediation. Formal remediation occurs when deficiencies are significant enough to warrant formal documentation because informal remediation failed or because issues are substantial. The process includes documentation in the resident’s file and notification of the graduate medical education office; however, the documentation is not disclosed if the resident successfully remediates. Probation is initiated when a resident is unsuccessful in meeting the terms of formal remediation or if initial problems are significant enough to warrant immediate probation. The process is similar to formal remediation but also includes documentation extending to the final verification of training and employment letters. Termination involves other stakeholders and occurs when a resident is unsuccessful in meeting the terms of probation or if initial problems are significant enough to warrant immediate termination.

Tweet Now, See You In the ED Later? Examining the Association Between Alcohol-related Tweets and Emergency Care Visits

BACKGROUND Alcohol use is a major and unpredictable driver of emergency department (ED) visits. Regional Twitter activity correlates ecologically with behavioral outcomes. No such correlation has been established in real time. OBJECTIVES The objective was to examine the correlation between real-time, alcohol-related tweets and alcohol-related ED visits. METHODS We developed and piloted a set of 11 keywords that identified tweets related to alcohol use. In-state tweets were identified using self-declared profile information or geographic coordinates. Using Datasift, a third-party vendor, a random sample of 1% of eligible tweets containing the keywords and originating in state were downloaded (including tweet date/time) over 3 discrete weeks in 3 different months. In the same time frame, we examined visits to an urban, high-volume, Level I trauma center that receives > 25% of the emergency care volume in the state. Alcohol-related ED visits were defined as visits with a chief complaint of alcohol use, positive blood alcohol, or alcohol-related ICD-9 code. Spearmans correlation coefficient was used to examine the hourly correlation between alcohol-related tweets, alcohol-related ED visits, and all ED visits. RESULTS A total of 7,820 tweets (representing 782,000 in-state alcohol-related tweets during the 3 weeks) were identified. Concurrently, 404 ED visits met criteria for being alcohol-related versus 2939 non-alcohol-related ED visits. There was a statistically significant relationship between hourly alcohol-related tweet volume and number of alcohol-related ED visits (rs = 0.31, p < 0.00001), but not between hourly alcohol-related tweet volume and number of non-alcohol-related ED visits (rs = -0.07, p = 0.11). CONCLUSION In a single state, a statistically significant relationship was observed between the hourly number of alcohol-related tweets and the hourly number of alcohol-related ED visits. Real-time Twitter monitoring may help predict alcohol-related surges in ED visits. Future studies should include larger numbers of EDs and natural language processing.

Effect of a Novel Engagement Strategy Using Twitter on Test Performance.

Introduction Medical educators in recent years have been using social media for more penetrance to technologically-savvy learners. The utility of using Twitter for curriculum content delivery has not been studied. We sought to determine if participation in a social media-based educational supplement would improve student performance on a test of clinical images at the end of the semester. Methods 116 second-year medical students were enrolled in a lecture-based clinical medicine course, in which images of common clinical exam findings were presented. An additional, optional assessment was performed on Twitter. Each week, a clinical presentation and physical exam image (not covered in course lectures) were distributed via Twitter, and students were invited to guess the exam finding or diagnosis. After the completion of the course, students were asked to participate in a slideshow “quiz” with 24 clinical images, half from lecture and half from Twitter. Results We conducted a one-way analysis of variance to determine the effect Twitter participation had on total, Twitter-only, and lecture-only scores. Twitter participation data was collected from the end-of-course survey and was defined as submitting answers to the Twitter-only questions “all or most of the time”, “about half of the time”, and “little or none of the time.” We found a significant difference in overall scores (p<0.001) and in Twitter-only scores (p<0.001). There was not enough evidence to conclude a significant difference in lecture-only scores (p=0.124). Students who submitted answers to Twitter “all or most of the time” or “about half the time” had significantly higher overall scores and Twitter-only scores (p<0.001 and p<0.001, respectively) than those students who only submitted answers “little or none of the time.” Conclusion While students retained less information from Twitter than from traditional classroom lecture, some retention was noted. Future research on social media in medical education would benefit from clear control and experimental groups in settings where quantitative use of social media could be measured. Ultimately, it is unlikely for social media to replace lecture in medical curriculum; however, there is a reasonable role for social media as an adjunct to traditional medical education.

Workplace violence in the emergency department in India and the United States

Background: Internationally, emergency medicine (EM) physicians are vulnerable to both physical and verbal violence. Few studies have examined or compared perceptions and the impacts of workplace violence in India and the United States (US). Objectives: To assess the perceived incidence of workplace violence and its implications on sleep, missed days of work, fear in the workplace, and overall job satisfaction. Materials and Methods: This was an anonymous, prospective, cross-sectional electronic survey of EM residents and physicians. A cohort of physicians in the US was matched to a cohort of physicians in India. Results: Overall, 286 physicians were eligible to participate, 177 responded (98 people from the US and 79 from Indian, for a 62% total response rate). In the US 100% of respondents witnessed verbal violence, whereas only 23% of verbal abuse cases were reported. In India, 89% of respondents witnessed verbal abuse, 46% of cases were reported. Respondents in the US both witnessed and experienced significantly more verbal and physical abuse (P < 0.001). Despite the differences in perceived rates of violence, there were no significant differences between country cohorts regarding the consequences of these incidents. This includes self-reported sleep, missed days of work, and fear of going to the workplace. US respondents were less satisfied with their jobs due to workplace violence as compared to their Indian colleagues (P = 0.041). Conclusion: ED workplace violence is common internationally, underreported, and results in poor job satisfaction, workplace fear, and loss of sleep. The following core competencies are addressed in this article: Patient care, Professionalism, Systems-based practice.