Warren Wiechmann

Prospective Analysis of Single Operator Sonographic Optic Nerve Sheath Diameter Measurement for Diagnosis of Elevated Intracranial Pressure

Introduction The accurate diagnosis of elevated intracranial pressure (eICP) in the emergent setting is a critical determination that presents significant challenges. Several studies show correlation of sonographic optic nerve sheath diameter (ONSD) to eICP, while others show high inter-observer variability or marginal performance with less experienced sonographers. The objective of our study is to assess the ability of bedside ultrasound measurement of ONSD to identify the presence of eICP when performed by a single experienced sonographer. We hypothesize that ONSD measurement is sensitive and specific for detecting eICP and can be correlated with values obtained by external ventricular device (EVD). Methods This was a prospective blinded observational study conducted in a neurocritical care unit of a level 1 trauma center. ONSD measurement was performed on a convenience sample of 27 adult patients who required placement of an invasive intracranial monitor as part of their clinical care. One certified sonographer/physician performed all ultrasounds within 24 hours of placement of EVD. The sonographer was blinded to the ICP recorded by invasive monitor at the time of the scan. A mean ONSD value of ≥5.2 mm was taken as positive. Results The sonographer performed 27 ocular ultrasounds on individual patients. Six (22%) of these patients had eICP (EVD measurement of >20 mmHg). Spearman rank correlation coefficient of ONSD and ICP was 0.408 (p=0.03), demonstrating a moderate positive correlation. A ROC curve was created to determine the optimal cut off value to distinguish an eICP greater than 20 mmHg. The area under the receiver operator characteristic curve was 0.8712 (95% confidence interval [CI]=0.67 to 0.96). ONSD ≥5.2 mm was a good predictor of eICP (>20 mmHg) with a sensitivity of 83.3% (95% CI=35.9% to 99.6%) and specificity of 100% (95% CI=84.6% to 100%). Conclusion While the study suggests ONSD measurements performed by a single skilled operator may be both sensitive and specific for detecting eICP, confirmation in a much larger sample is needed. Ocular ultrasound may provide additional non-invasive means of assessing eICP.

There's an App for That? Highlighting the Difficulty in Finding Clinically Relevant Smartphone Applications.

Introduction The use of personal mobile devices in the medical field has grown quickly, and a large proportion of physicians use their mobile devices as an immediate resource for clinical decision-making, prescription information and other medical information. The iTunes App Store (Apple, Inc.) contains approximately 20,000 apps in its “Medical” category, providing a robust repository of resources for clinicians; however, this represents only 2% of the entire App Store. The App Store does not have strict criteria for identifying content specific to practicing physicians, making the identification of clinically relevant content difficult. The objective of this study is to quantify the characteristics of existing medical applications in the iTunes App Store that could be used by emergency physicians, residents, or medical students. Methods We found applications related to emergency medicine (EM) by searching the iTunes App Store for 21 terms representing core content areas of EM, such as “emergency medicine,” “critical care,” “orthopedics,” and “procedures.” Two physicians independently reviewed descriptions of these applications in the App Store and categorized each as the following: Clinically Relevant, Book/Published Source, Non-English, Study Tools, or Not Relevant. A third physician reviewer resolved disagreements about categorization. Descriptive statistics were calculated. Results We found a total of 7,699 apps from the 21 search terms, of which 17.8% were clinical, 9.6% were based on a book or published source, 1.6% were non-English, 0.7% were clinically relevant patient education resources, and 4.8% were study tools. Most significantly, 64.9% were considered not relevant to medical professionals. Clinically relevant apps make up approximately 6.9% of the App Store’s “Medical” Category and 0.1% of the overall App Store. Conclusion Clinically relevant apps represent only a small percentage (6.9%) of the total App volume within the Medical section of the App Store. Without a structured search-and-evaluation strategy, it may be difficult for the casual user to identify this potentially useful content. Given the increasing adoption of devices in healthcare, national EM associations should consider curating these resources for their members.

Trends in diabetes-related visits to US EDs from 1997 to 2007.

OBJECTIVE The aims of the study were to describe temporal trends in the number, proportion, and per capita use of diabetes-related emergency department (ED) visits and to examine any racial/ethnic disparity in ED use for diabetes-related reasons. METHODS We analyzed the ED portion of the National Hospital Ambulatory Medical Care Survey from 1997 through 2007. Diabetes-related ED visits were identified by International Classification of Diseases, Ninth Revision codes. Descriptive statistics were developed. Weighted linear and logistic regression models were used to determine significance of temporal trends, and multivariate logistic regression was used to examine racial/ethnic disparities. RESULTS A total of 20.2 million (1.69%; 95% confidence interval [CI], 1.59%-1.78%) ED visits were diabetes-related during the study period. We observed significant increases in the number and proportion of diabetes-related ED visits. Overall, there was a 5.6% relative annual increase in the proportion of ED visits that were diabetes-related during the study period. However, the per capita ED use among the population with diabetes did not change over time (P>.05 for trend). On multivariate analysis, black race (odds ratio, 1.8; 95% CI, 1.7-2.0), Hispanic ethnicity (odds ratio, 1.6; 95% CI, 1.4-1.8), and advancing age were associated with significantly higher odds of having a diabetes-related visit. CONCLUSIONS Despite a marked increase in number and proportion of diabetes-related ED visits during the study period, the per capita use of ED services for diabetes-related visits among the diabetic population remained stable.

Medical student use of the iPad in the clerkship curriculum

There is little precedence for the implementation of a medical school iPad programme in a clinical setting. This study analysed students’ use of iPad apps and perceptions of the iPad as a clinical tool in a clinical third‐year medical school curriculum.

The Med AppJam: A Model for an Interprofessional Student-Centered mHealth App Competition

The Med AppJam is a 2-week long competition where students from the University of California, Irvine School of Medicine are partnered with students from the University of California, Irvine School of Information and Computer Sciences in interprofessional teams to develop mobile health applications for use by clinicians and patients. The success of the Med AppJam comes from the unique opportunity for students to mutually contribute their content expertise to improve the clinical landscape while expanding their technology literacy and savvy. Since 2012, about 285 computer science students and over 90 medical students have collaborated to design and develop 53 iOS mHealth apps during the event. The Med AppJam model has been replicated in an Autism AppJam, a competition focused on the needs of a specific population, and with high school students in a mini Pre-Med AppJam using a paper prototyping approach. It is proposed that other medical schools consider implementation of a local Med AppJam as a viable model for engaging students in technology for healthcare.

Ten Tips for Engaging the Millennial Learner and Moving an Emergency Medicine Residency Curriculum into the 21st Century

Introduction Millennial learners are changing the face of residency education because they place emphasis on technology with new styles and means of learning. While research on the most effective way to teach the millennial learner is lacking, programs should consider incorporating educational theories and multimedia design principles to update the curriculum for these new learners. The purpose of the study is to discuss strategies for updating an emergency medicine (EM) residency program’s curriculum to accommodate the modern learner. Discussion These 10 tips provide detailed examples and approaches to incorporate technology and learning theories into an EM curriculum to potentially enhance learning and engagement by residents. Conclusion While it is unclear whether technologies actually promote or enhance learning, millennials use these technologies. Identifying best practice, grounded by theory and active learning principles, may help learners receive quality, high-yield education. Future studies will need to evaluate the efficacy of these techniques to fully delineate best practices.

Skatepark-related injuries in a southern California skatepark and their associated short-term disability and healthcare utilization.

Objective:To assess the types of injuries, the extent of short-term disability, and the degree of healthcare utilization in skatepark-injured patients. Design:The study design was a prospective case series with 1-year follow-up. Setting:Level I trauma center and emergency department located in Orange, California. Participants:Subjects age 7 years or older who sustained an injury at a local skatepark and were treated in our emergency department were included in the study. Ninety-five subjects were enrolled with a total of 97 injury encounters. Main Outcome Measurements:Types of injuries, extent of short-term disability, degree of healthcare utilization. Results:Emergency department diagnoses included 57 fractures, 6 dislocations, 15 strains/sprains/contusions, 7 lacerations, 2 dental fractures, 9 head injuries, and 1 intra-abdominal injury. Nine of the emergency department encounters terminated in admission to the hospital. The peak sum of time lost from school, work, parental time lost from work, and specialist visits were found to occur at 1 month postinjury. Similarly, the number of postinjury follow-up medical visits peaked at the 1-month interval. Subject disability was largely categorized as moderate initially, with a subsequent reduction to no disability by the 9th postinjury month. Conclusion:Skatepark-related injuries can yield substantial time lost from school and work, considerable short-term disability, and an increase in healthcare resource utilization.

Emergency Physician Risk Estimates and Admission Decisions for Chest Pain: A Web-Based Scenario Study

Study objective: We conducted this study to better understand how emergency physicians estimate risk and make admission decisions for patients with low‐risk chest pain. Methods: We created a Web‐based survey consisting of 5 chest pain scenarios that included history, physical examination, ECG findings, and basic laboratory studies, including a negative initial troponin‐level result. We administered the scenarios in random order to emergency medicine residents and faculty at 11 US emergency medicine residency programs. We randomized respondents to receive questions about 1 of 2 endpoints, acute coronary syndrome or serious complication (death, dysrhythmia, or congestive heart failure within 30 days). For each scenario, the respondent provided a quantitative estimate of the probability of the endpoint, a qualitative estimate of the risk of the endpoint (very low, low, moderate, high, or very high), and an admission decision. Respondents also provided demographic information and completed a 3‐item Fear of Malpractice scale. Results: Two hundred eight (65%) of 320 eligible physicians completed the survey, 73% of whom were residents. Ninety‐five percent of respondents were wholly consistent (no admitted patient was assigned a lower probability than a discharged patient). For individual scenarios, probability estimates covered at least 4 orders of magnitude; admission rates for scenarios varied from 16% to 99%. The majority of respondents (>72%) had admission thresholds at or below a 1% probability of acute coronary syndrome. Respondents did not fully differentiate the probability of acute coronary syndrome and serious outcome; for each scenario, estimates for the two were quite similar despite a serious outcome being far less likely. Raters used the terms “very low risk” and “low risk” only when their probability estimates were less than 1%. Conclusion: The majority of respondents considered any probability greater than 1% for acute coronary syndrome or serious outcome to be at least moderate risk and warranting admission. Physicians used qualitative terms in ways fundamentally different from how they are used in ordinary conversation, which may lead to miscommunication during shared decisionmaking processes. These data suggest that probability or utility models are inadequate to describe physician decisionmaking for patients with chest pain.

Who to Interview? Low Adherence by U.S. Medical Schools to Medical Student Performance Evaluation Format Makes Resident Selection Difficult.

Introduction The Medical Student Performance Evaluation (MSPE) appendices provide a program director with comparative performance for a student’s academic and professional attributes, but they are frequently absent or incomplete. Methods We reviewed MSPEs from applicants to our emergency medicine residency program from 134 of 136 (99%) U.S. allopathic medical schools, over two application cycles (2012–13, 2014–15). We determined the degree of compliance with each of the five recommended MSPE appendices. Results Only three (2%) medical schools were compliant with all five appendices. The medical school information page (MSIP, appendix E) was present most commonly (85%), followed by comparative clerkship performance (appendix B, 82%), overall performance (appendix D, 59%), preclinical performance (appendix A, 57%), and professional attributes (appendix C, 18%). Few schools (7%) provided student-specific, comparative professionalism assessments. Conclusion Medical schools inconsistently provide graphic, comparative data for their students in the MSPE. Although program directors (PD) value evidence of an applicant’s professionalism when selecting residents, medical schools rarely provide such useful, comparative professionalism data in their MSPEs. As PDs seek to evaluate applicants based on academic performance and professionalism, rather than standardized testing alone, medical schools must make MSPEs more consistent, objective, and comparative.

Intubating Ebola Patients: Technical Limitations of Extensive Personal Protective Equipment

As hospitals across the nation were preparing for the possibility of Ebola or Middle Eastern respiratory syndrome (MERS-CoV) cases, healthcare workers underwent intricate training in the use of personal protective equipment (PPE). An Ebola or MERS-CoV patient requiring intubation places a healthcare worker at risk for exposure to bodily secretions. The procedure must be performed only after appropriate PPE is donned.1 Intubating while wearing PPE is yet another challenge identified in caring for these patients. Manual dexterity and free movement decreases when wearing PPE, and may increase length of time to successful intubation. We elicited the opinion of subjects performing direct laryngoscopy versus video-assisted laryngoscopy on manikins while wearing PPE. Additionally, we recorded multiple intubation attempts by these clinicians using Google Glass. Two PPE-donned clinicians both agreed that intubation was not technically different between direct versus video-assisted techniques. However, the subjects felt that direct laryngoscopy was noticeably more labor intensive than the video-assisted technique. Subjects also felt more temperature-related discomfort during direct laryngoscopy. For one subject, contamination was more common during direct laryngoscopy, when the PPE hood contacted the patient’s face or endotracheal tube. From this simulation experience, we recommend video laryngoscopy as a preferred method of intubating a patient while donning PPE. Video Ebola intubation video.