Paul Jhun

Nonconvulsive Status Epilepticus in Hepatic Encephalopathy

We discuss a case of a 64-year-old male with a history of liver failure presenting with altered mental status, initially diagnosed with hepatic encephalopathy but ultimately diagnosed with nonconvulsive status epilepticus (NCSE) by electroencephalogram (EEG). NCSE is a difficult diagnosis to make, given no clear consensus on diagnostic criteria. Especially in the intensive care unit setting of persistent altered mental status with no clear etiology, NCSE must be considered in the differential diagnosis, as the consequences of delayed diagnosis and treatment can be substantial. EEG can be useful in the evaluation of patients with hepatic encephalopathy who have persistently altered levels of consciousness despite optimal medical management.

Trust Me, This Is the Worst “Acne” of Your Life!

ANNALS CASE A 55-year-old woman presented to the emergency department (ED) with a 2-week history of a pruritic rash and progressive weakness. The eruption, first affecting the abdomen, appeared 9 days after initiation of vancomycin and cefepime (Figure 1). The patient had a temperature of 38.4 C (101.1 F) and a pulse rate of 160 beats/min. Physical examination revealed diffuse, edematous, erythematous plaques with overlying pustules and isolated bullae (Figure 2). The oral mucosa was not involved. Laboratory investigation identified an elevated lactate level of 6.4 mmol/L and leukocytosis of 28.9 10^9/L. To paraphrase Indiana Jones.rashes, why did it have to be rashes? When you take a look at these images, the rash is pretty impressive, and the patient sounds sick. A decision to admit this patient is probably the easy part. Butwhat’s your working diagnosis and what should you do next? Is this purpura fulminans in evolution or some autoimmune reaction? Do you give empiric antibiotics? Do you give empiric corticosteroids? Read on.

Penetrating Neck Injury: What’s In and What’s Out?

Editor’s note: Annals has partnered with Hippo Education and EM:RAP, enabling our readers without subscriptions to Hippo EM Board Review or EM:RAP to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and Hippo Education, EM:RAP or its authors.

A Clinical Decision Rule for Thoracolumbar Spine Imaging in Blunt Trauma

Editor’s Note: Annals has partnered with Hippo Education and EM:RAP, enabling our readers without subscriptions to Hippo EM Board Review or EM:RAP to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and Hippo Education, EM:RAP, or its authors.

Chest Pain Bounce-Back: Posterior Sternoclavicular Dislocation

Editor’s note: Annals has partnered with Hippo Education and EM:RAP, enabling our readers without subscriptions to Hippo EM Board Review or EM:RAP to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and Hippo Education, EM:RAP or its authors.

Pyoderma Gangrenosum: An Inside Job.

Editor’s note: Annals has partnered with EM:RAP, enabling our readers without subscriptions to the EM:RAP service to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine. There are no financial relationships or other consideration between Annals and EM:RAP or its authors.

Why Does Your Dandruff Smell Like Urine

ANNALS CASE A 26-year-old man with hypertension and end-stage renal disease (ESRD) presents to the emergency department (ED) with worsening shortness of breath developing during the past 2 weeks. He is visibly dyspneic and has difficulty speaking. He is alert but is slow to respond to questions. He reports that he stopped attending dialysis approximately 3 weeks ago because of fear that the dialysis staff was “stealing” his blood. On physical examination, white flaky material is noted on the patient’s scalp (Figure). The blood urea nitrogen (BUN) level is 249 mg/dL.

Brave new world of emergency medicine education.

To say that the past 25 years has seen unprecedented change in medicine, education and information technologies is to be redundant, stale and absolutely right! In 1989, the modern Internet did not exist. There was no Amazon®, Wikipedia or online textbooks. Most people used corded phones to make calls for goodness’ sake! If an emergency physician needed to look up the best therapy for asthma exacerbations, he or she headed to the book rack in the back of the emergency room and flipped through the index of some giant tome to find information that was often several years outdated. The present paper is being written on Google® Docs, shared internationally among four authors separated by over 5000 miles and group-edited in real time. Google® did not exist in 1989. Most people had never heard of a laptop let alone the idea of having most of the world’s information accessible immediately on a slick beautiful device in their pocket. The change has been so fast, so radical and so complete, that it is almost impossible for us to fathom it, let alone try and describe it to people who have not lived it. It has changed EVERYTHING and EVERYONE, and emergency medicine is no exception! We will attempt to explain how far information technology in emergency medicine education has come, where we are now and perhaps where we might go soon.

Flipping the Classroom in Medical Student Education: Does Priming Work?

Introduction The emergency medicine (EM) clerkship curriculum at Los Angeles County + University of Southern California Medical Center includes monthly lectures on pediatric fever and shortness of breath (SOB). This educational innovation evaluated if learning could be enhanced by “priming” the students with educational online videos prior to an in-class session. Factors that impacted completion rates were also evaluated (planned specialty and time given for video viewing). Methods Twenty-minute videos were to be viewed prior to the didactic session. Students were assigned to either the fever or SOB group and received links to those respective videos. All participating students took a pre-test prior to viewing the online lectures. For analysis, test scores were placed into concordant groups (test results on fever questions in the group assigned the fever video and test results on SOB questions in the group assigned the SOB video) and discordant groups (crossover between video assigned and topic tested). Each subject contributed one set of concordant results and one set of discordant results. Descriptive statistics were performed with the Mann-Whitney U test. Lecture links were distributed to students two weeks prior to the in-class session for seven months and three days prior to the in-class session for eight months (in which both groups included both EM-bound and non-EM bound students). Results In the fifteen-month study period, 64% of students rotating through the EM elective prepared for the in class session by watching the videos. During ten months where exclusively EM-bound students were rotating (n=144), 71.5% of students viewed the lectures. In four months where students were not EM-bound (n=54), 55.6% of students viewed the lectures (p=0.033). Participation was 60.2% when lecture links were given three days in advance and 68.7% when links were given two weeks in advance (p=0.197). In the analysis of concordant scores, the pre-test averaged 56.7% correct, the immediate post-test averaged 78.1% correct, and the delayed post-test was 67.2%. In the discordant groups, the pretest averaged 51.9%, the immediate posttest was 67.1% and the delayed by 68.8%. In the concordant groups, the immediate post-test scores improved by 21.4%, compared with 15.2% in the discordant groups (p = 0.655). In the delayed post-test the concordant scores improved by 10.5% and discordant scores by 16.9 percent (p=0.609). Sixty-two percent of students surveyed preferred the format of online videos with in-class case discussion to a traditional lecture format. Conclusion Immediate post-tests and delayed post-tests improved but priming was not demonstrated to be a statistically superior educational method in this study. Medical student completion of the preparatory materials for the EM rotation session increased when the students were EM-bound. Participation rates were not significantly different when given at two weeks versus three days.

Does the Flipped Classroom Improve Learning in Graduate Medical Education

BACKGROUND The flipped classroom model for didactic education has recently gained popularity in medical education; however, there is a paucity of performance data showing its effectiveness for knowledge gain in graduate medical education. OBJECTIVE We assessed whether a flipped classroom module improves knowledge gain compared with a standard lecture. METHODS We conducted a randomized crossover study in 3 emergency medicine residency programs. Participants were randomized to receive a 50-minute lecture from an expert educator on one subject and a flipped classroom module on the other. The flipped classroom included a 20-minute at-home video and 30 minutes of in-class case discussion. The 2 subjects addressed were headache and acute low back pain. A pretest, immediate posttest, and 90-day retention test were given for each subject. RESULTS Of 82 eligible residents, 73 completed both modules. For the low back pain module, mean test scores were not significantly different between the lecture and flipped classroom formats. For the headache module, there were significant differences in performance for a given test date between the flipped classroom and the lecture format. However, differences between groups were less than 1 of 10 examination items, making it difficult to assign educational importance to the differences. CONCLUSIONS In this crossover study comparing a single flipped classroom module with a standard lecture, we found mixed statistical results for performance measured by multiple-choice questions. As the differences were small, the flipped classroom and lecture were essentially equivalent.