Philip Shayne

Thyrotoxic Periodic Paralysis Terminated With Intravenous Propranolol

Thyrotoxic periodic paralysis (TPP) is an uncommon syndrome that can be fatal. We report the case of a patient with acute, severe muscle weakness and hypokalemia who was diagnosed in the emergency department to have thyrotoxicosis with acute TPP. The hypokalemia was treated aggressively with potassium without effect. After administration of i.v. propranolol, the patient had complete resolution of symptoms, with mild rebound hyperkalemia. The literature on the use of propranolol in TPP is reviewed, and the known pathophysiology of TPP is discussed.

Gaps in procedural experience and competency in medical school graduates.

OBJECTIVES The goal of undergraduate medical education is to prepare medical students for residency training. Active learning approaches remain important elements of the curriculum. Active learning of technical procedures in medical schools is particularly important, because residency training time is increasingly at a premium because of changes in the Accreditation Council for Graduate Medical Education duty hour rules. Better preparation in medical school could result in higher levels of confidence in conducting procedures earlier in graduate medical education training. The hypothesis of this study was that more procedural training opportunities in medical school are associated with higher first-year resident self-reported competency with common medical procedures at the beginning of residency training. METHODS A survey was developed to assess self-reported experience and competency with common medical procedures. The survey was administered to incoming first-year residents at three U.S. training sites. Data regarding experience, competency, and methods of medical school procedure training were collected. Overall satisfaction and confidence with procedural education were also assessed. RESULTS There were 256 respondents to the procedures survey. Forty-four percent self-reported that they were marginally or not adequately prepared to perform common procedures. Incoming first-year residents reported the most procedural experience with suturing, Foley catheter placement, venipuncture, and vaginal delivery. The least experience was reported with thoracentesis, central venous access, and splinting. Most first-year residents had not provided basic life support, and more than one-third had not performed cardiopulmonary resuscitation (CPR). Participation in a targeted procedures course during medical school and increasing the number of procedures performed as a medical student were significantly associated with self-assessed competency at the beginning of residency training. CONCLUSIONS Recent medical school graduates report lack of self-confidence in their ability to perform common procedures upon entering residency training. Implementation of a medical school procedure course to increase exposure to procedures may address this challenge.

Emergency medicine milestones.

Michael S. Beeson, MD, MBA, is Residency Program Director in the Department of Emergency Medicine, Akron General Medical Center; Wallace A. Carter, MD, is Residency Program Director in the Department of Emergency Medicine, New York Presbyterian Hospital; Theodore A. Christopher, MD, is Professor and Chairman of the Department of Emergency Medicine, Thomas Jefferson University and Hospitals; Jonathan W. Heidt, MD, is Clinical Instructor in the Division of Emergency Medicine, Washington University School of Medicine in St Louis; James H. Jones, MD, is Professor of Clinical Emergency Medicine in the Department of Emergency Medicine, Indiana University School of Medicine; Lynne E. Meyer, PhD, MPH, is Executive Director of the Review Committee for Emergency Medicine, Accreditation Council for Graduate Medical Education; Susan B. Promes, MD, is Professor and Vice Chair for Education in the Department of Emergency Medicine, University of California, San Francisco; Kevin G. Rodgers, MD, is Professor in the Department of Emergency Medicine, Indiana University School of Medicine; Philip H. Shayne, MD, is Professor and is Program Director and Vice Chair for Education in the Department of Emergency Medicine, Emory University School of Medicine; Mary Jo Wagner, MD, is Residency Program Director and Chief in the Department of Emergency Medicine, Central Michigan University College of Medicine; and Susan R. Swing, PhD, is Vice President of Outcome Assessment at the Accreditation Council for Graduate Medical Education.

Fatal posterior sternoclavicular joint dislocation due to occult trauma.

Posterior sternoclavicular joint dislocations (PSCJDs) are extremely rare, emergent injuries. We present an unprecedented case of a 16-year-old boy without any initial history or signs of trauma who died of a brachiocephalic vein laceration secondary to an occult PSCJD. The pathophysiology, treatment, and diagnosis of PSCJD are discussed.

Critical appraisal of emergency medicine educational research: the best publications of 2009.

OBJECTIVES The objective was to critically appraise and highlight medical education research published in 2012 that was methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine (EM). METHODS A search of the English language literature in 2012 querying Education Resources Information Center (ERIC), PsychInfo, PubMed, and Scopus identified EM studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. This year, publications limited to a single-site survey design that measured satisfaction or self-assessment on unvalidated instruments were not formally reviewed. Six reviewers then independently ranked all remaining publications using one of two scoring systems depending on whether the study methodology was primarily qualitative or quantitative. Each scoring system had nine criteria, including four related to methodology, that were chosen a priori, to standardize evaluation by reviewers. The quantitative study scoring system was used previously to appraise medical education published annually in 2008 through 2011, while a separate, new qualitative study scoring system was derived and implemented consisting of parallel metrics. RESULTS Forty-eight medical education research papers met the a priori criteria for inclusion, and 33 (30 quantitative and three qualitative studies) were reviewed. Seven quantitative and two qualitative studies met the criteria for inclusion as exemplary and are summarized in this article. CONCLUSIONS This critical appraisal series aims to promote superior education research by reviewing and highlighting nine of the 48 major education research studies with relevance to EM published in 2012. Current trends and common methodologic pitfalls in the 2012 papers are noted.

The Effect of Emergency Department Crowding on Education: Blessing or Curse?

Emergency department (ED) crowding is a national crisis that contributes to medical error and system inefficiencies. There is a natural concern that crowding may also adversely affect undergraduate and graduate emergency medicine (EM) education. ED crowding stems from a myriad of factors, and individually these factors can present both challenges and opportunities for education. Review of the medical literature demonstrates a small body of evidence that education can flourish in difficult clinical environments where faculty have a high clinical load and to date does not support a direct deleterious effect of crowding on education. To provide a theoretical framework for discussing the impact of crowding on education, the authors present a conceptual model of the effect of ED crowding on education and review possible positive and negative effects on each of the six recognized Accreditation Council for Graduate Medical Education (ACGME) core competencies.

Highlights in Emergency Medicine Medical Education Research: 2008

OBJECTIVES The purpose of this article is to highlight medical education research studies published in 2008 that were methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine. METHODS Through a PubMed search of the English language literature in 2008, 30 medical education research studies were independently identified as hypothesis-testing investigations and measurements of educational interventions. Six reviewers independently rated and scored all articles based on eight anchors, four of which related to methodologic criteria. Articles were ranked according to their total rating score. A ranking agreement among the reviewers of 83% was established a priori as a minimum for highlighting articles in this review. RESULTS Five medical education research studies met the a priori criteria for inclusion and are reviewed and summarized here. Four of these employed experimental or quasi-experimental methodology. Although technology was not a component of the structured literature search employed to identify the candidate articles for this review, 14 of the articles identified, including four of the five highlighted articles, employed or studied technology as a focus of the educational research. Overall, 36% of the reviewed studies were supported by funding; three of the highlighted articles were funded studies. CONCLUSIONS This review highlights quality medical education research studies published in 2008, with outcomes of relevance to teaching and education in emergency medicine. It focuses on research methodology, notes current trends in the use of technology for learning in emergency medicine, and suggests future avenues for continued rigorous study in education.

Conference attendance does not correlate with emergency medicine residency in-training examination scores.

OBJECTIVES The residency review committee for emergency medicine (EM) requires residents to have greater than 70% attendance of educational conferences during residency training, but it is unknown whether attendance improves clinical competence or scores on the American Board of Emergency Medicine (ABEM) in-training examination (ITE). This study examined the relationship between conference attendance and ITE scores. The hypothesis was that greater attendance would correlate to a higher examination score. METHODS This was a multi-center retrospective cohort study using conference attendance data and examination results from residents in four large county EM residency training programs. Longitudinal multi-level models, adjusting for training site, U.S. Medical Licensing Examination (USMLE) Step 1 score, and sex were used to explore the relationship between conference attendance and in-training examination scores according to year of training. Each year of training was studied, as well as the overall effect of mean attendance as it related to examination score. RESULTS Four training sites reported data on 405 residents during 2002 to 2008; 386 residents had sufficient data to analyze. In the multi-level longitudinal models, attendance at conference was not a significant predictor of in-training percentile score (coefficient = 0.005, 95% confidence interval [CI] = -0.053 to 0.063, p = 0.87). Score on the USMLE Step 1 examination was a strong predictor of ITE score (coefficient = 0.186, 95% CI = 0.155 to 0.217; p < 0.001), as was female sex (coefficient = 2.117, 95% CI = 0.987 to 3.25; p < 0.001). CONCLUSIONS Greater conference attendance does not correlate with performance on an individuals ITE scores. Conference attendance may represent an important part of EM residency training but perhaps not of ITE performance.

A Case-Control Study of Risk Factors That Predict Femoral Arterial Injury in Penetrating Thigh Trauma ☆ ☆☆ ★

STUDY HYPOTHESIS Femoral artery injuries can be predicted by the mechanism of injury, wound location and tract, and physical findings following penetrating thigh trauma. DESIGN Retrospective case-control study. PARTICIPANTS All 808 consecutive patients undergoing femoral arteriography for penetrating thigh trauma from September 1986 through December 1990 were eligible for inclusion in the study. All 50 patients in the eligible population with proven femoral artery injuries diagnosed by angiogram were the study subjects. Fifty patients with penetrating thigh trauma who had angiograms negative for injury and were systematically chosen from the eligible population served as controls. INTERVENTIONS Data included mechanism of injury; location of wound entrance, tract, exit, and retained missile; physical findings (including ankle-brachial index); and the presence of femur fractures. Physical findings were divided into hard findings (pulse abnormality, expanding hematoma, or pulsatile bleeding) or soft findings (neurologic deficit, hypotension without another source, or bruit/thrill). RESULTS Of the 808 eligible patients, 50 (6.2%) had a femoral arterial injury on angiography, 20 (40%) of which were clinically occult injuries. A medial thigh tract made an arterial injury 58 times more likely (odds ratio [OR], 57.5; P < .001) and was present in 100% of cases and 64% of controls. An anteromedial thigh tract made an arterial injury 12 times more likely (OR, 11.5; P < .001) and was present in 92% of cases and 50% of controls. A wound with hard physical findings was 118 times more likely to have an arterial injury (OR, 118; P < .00001) and was found in 54% of cases and none of the controls. The presence of any physical finding made an arterial injury 36 times more likely (OR, 36; P < .00001) and was found in 60% of cases and 4% of controls. The presence of a femur fracture or a gunshot mechanism was not predictive of injury. CONCLUSION Only patients with medial thigh wounds need to undergo angiography for the detection of femoral artery injuries. This approach would have reduced the angiography rate by 36% in this series. Had angiography been performed only on patients with any physical findings, a 70% reduction in the rate of angiography would have been achieved, although five occult arterial injuries per year would have been missed. Angiography should not be performed solely because of a gunshot mechanism or the presence of a femur fracture.

Reporter-Interpreter-Manager-Educator (RIME) Descriptive Ratings as an Evaluation Tool in an Emergency Medicine Clerkship

BACKGROUND Emergency Medicine (EM) clerkships traditionally assess students using numerical ratings of clinical performance. The descriptive ratings of the Reporter, Interpreter, Manager, and Educator (RIME) method have been shown to be valuable in other specialties. OBJECTIVES We hypothesized that the RIME descriptive ratings would correlate with clinical performance and examination scores in an EM clerkship, indicating that the RIME ratings are a valid measure of performance. METHODS This was a prospective cohort study of an evaluation instrument for 4(th)-year medical students completing an EM rotation. This study received exempt Institutional Review Board status. EM faculty and residents completed shift evaluation forms including both numerical and RIME ratings. Students completed a final examination. Mean scores for RIME and clinical evaluations were calculated. Linear regression models were used to determine whether RIME ratings predicted clinical evaluation scores or final examination scores. RESULTS Four hundred thirty-nine students who completed the EM clerkship were enrolled in the study. After excluding items with missing data, there were 2086 evaluation forms (based on 289 students) available for analysis. There was a clear positive relationship between RIME category and clinical evaluation score (r(2)=0.40, p<0.01). RIME ratings correlated most strongly with patient management skills and least strongly with humanistic qualities. A very weak correlation was seen with RIME and final examination. CONCLUSION We found a positive association between RIME and clinical evaluation scores, suggesting that RIME is a valid clinical evaluation instrument. RIME descriptive ratings can be incorporated into EM evaluation instruments and provides useful data related to patient management skills.