Walter L. Green

Man With a Rash

A 48-year-old man with a history of hypertension and medication noncompliance presented to the emergency department, complaining of a generalized pruritic rash for 2 weeks that began at both ankles and spread to his knees, back, and arms. He observed polydipsia but denied other medical problem or rashes, allergens, travel, infectious agents, medications, fever, or dysuria. On physical examination, he had a symmetric erythematous papular rash with firm centers that were creamy white but not pustular. No scaling or crust was present and there was sparing of the face, palms, and soles. The greatest concentration of lesions was on the extensor surfaces of the knees (Figures 1 and 2). A point-of-care glucose level was greater than 500 mg/dL. A laboratory test provided the diagnosis. Figure 1. The patient’s right knee. Figure 2. A close-up image of the patient’s left knee.

Direct Observation Assessment of Milestones: Problems with Reliability

Introduction Emergency medicine (EM) milestones are used to assess residents’ progress. While some milestone validity evidence exists, there is a lack of standardized tools available to reliably assess residents. Inherent to this is a concern that we may not be truly measuring what we intend to assess. The purpose of this study was to design a direct observation milestone assessment instrument supported by validity and reliability evidence. In addition, such a tool would further lend validity evidence to the EM milestones by demonstrating their accurate measurement. Methods This was a multi-center, prospective, observational validity study conducted at eight institutions. The Critical Care Direct Observation Tool (CDOT) was created to assess EM residents during resuscitations. This tool was designed using a modified Delphi method focused on content, response process, and internal structure validity. Paying special attention to content validity, the CDOT was developed by an expert panel, maintaining the use of the EM milestone wording. We built response process and internal consistency by piloting and revising the instrument. Raters were faculty who routinely assess residents on the milestones. A brief training video on utilization of the instrument was completed by all. Raters used the CDOT to assess simulated videos of three residents at different stages of training in a critical care scenario. We measured reliability using Fleiss’ kappa and interclass correlations. Results Two versions of the CDOT were used: one used the milestone levels as global rating scales with anchors, and the second reflected a current trend of a checklist response system. Although the raters who used the CDOT routinely rate residents in their practice, they did not score the residents’ performances in the videos comparably, which led to poor reliability. The Fleiss’ kappa of each of the items measured on both versions of the CDOT was near zero. Conclusion The validity and reliability of the current EM milestone assessment tools have yet to be determined. This study is a rigorous attempt to collect validity evidence in the development of a direct observation assessment instrument. However, despite strict attention to validity evidence, inter-rater reliability was low. The potential sources of reducible variance include rater- and instrument-based error. Based on this study, there may be concerns for the reliability of other EM milestone assessment tools that are currently in use.

Perineal Rash and Perianal Pain.

A 21-year-old homeless woman presented for a generalized rash. The city police received a call from a recreational center because this patient was crying about a body-wide rash that was painful and they brought her to the Emergency Department (ED). After being placed in a room for evaluation, she admitted to not only a generalized rash but also a perineal and perianal rash (Figures 1 and 2). She described the rash as pruritic in nature and had noticed it just 4 days prior. She confirmed dyspareunia and perianal pain but denied any fevers, chills, vaginal bleeding, or discharge. She was sexually active and admitted to multiple sexual partners with unprotected vaginal and anal intercourse. She denied intravenous drug use or any travel outside of the continental United States. She denied any past medical problems or medication use. Surgical history included a cesarean section and hysterectomy. Her vital signs were normal, with a blood pressure of 131/81 mm Hg, heart rate of 84 beats/min, temperature of 35.8 C (96.4 F), and pulse oximetry of 95% on room air. Her physical examination was remarkable for generalized slightly erythematous macules on her trunk and extremities, including involvement of both palms and soles of the feet. There was no scale or crust and no pustules were present. Gynecologic examination revealed multiple