Paucis Verbis card: The low risk ACS patient

Emergency physicians evaluate millions of patients who present with chest pain annually. How do you really know who are at no-risk and low-risk for acute coronary syndrome (ACS)?

There is unfortunately no perfect or simple answer.

It's all about risk stratification and knowing the insensitive nature of the history, physical, EKG, and diagnostic tests.

Here is another installment of the Paucis Verbis (In a Few Words) e-card series on the topic of Low Risk ACS Chest Pain from EM Clinics of North America.

Feel free to download this card and print on a 4'' x 6'' index card...

[MS Word] [PDF]

See other Paucis Verbis cards.

Other medical blogs of note

I've been totally content having my blog site be the little engine that could. It has a small but loyal readership. Recently, however, I've gotten a spike in the number of hits. Wondering why, I found out that I've been nominated and am a finalist as the best new Best New Medical Weblog for 2009 on the MedGadget site.

My first thought was:
Wait, what?!

My second thought was:
How cool. Lots of new blogs I didn't even know about. Check them out!

Best Medical WeblogThe Blog that Ate Manhattan
Clinical Cases and Images
Clinical Correlations
Dr Shock MD PhD
Gary Schwitzer's HealthNewsReview Blog
mobihealthnews
Musings of a Distractible Mind

Best New Medical Weblog (established in 2009)
Academic Life in Emergency Medicine
Celebrity Diagnosis
MassDevice
mobihealthnews
SCOPE
StorytellERdoc

Best Clinical Sciences Weblog
Allergy Notes
Clinical Cases and Images
Clinical Correlations
Life in the Fast Lane
Renal Fellow Network

Go to the MedGadget website to view the others nominated and to vote!

Trick of the trade: Irrigating scalp lacerations

Thanks to my new-found Emergency Medicine friend in Turkey, Dr. John Fowler has some useful tips about scalp lacerations.

Often patients with scalp lacerations have clotted blood in their hair. While we can irrigate the wound itself (and unavoidably soaking the patient in cold irrigation fluid), a lot of blood remains stuck in their hair. It would be nice if we could completely wash out the blood. This would further allows us to detect occult scalp lacerations.

Photo courtesy of Dr. John Fowler

Trick of the Trade #1:
Position head in sink with pullout faucet head.

Based on the hairdresser sink idea, have the patient either sit in a chair or lay in a gurney with his/her head beyond the edge. If seated, the patient should extend his/her neck into the sink. Wash out all the blood in the hair and then irrigate the scalp laceration in the sink.

If in a gurney, the patient can be placed in a little Trendelenburg position with the head resting in the sink, to ensure that the fluids run into the sink (instead of down the patient's back).

Wash out the blood using the pullout faucet head. If this unavailable, consider using saline bottles with multiple holes on the top, created by 18 gauge needles, to bulk irrigate. See prior irrigation trick.

Trick of the Trade #2:
Make a "sink" using a plastic basin.

Since I am oftentimes irrigating patients still in cervical spine immobilization, I can't extend their neck into a sink. So I bring the "sink" to them. I cut out a partial opening in a plastic basin and place the patient's head in the basin. This basin collects the irrigation fluid. If the fluid overflows, use a Yankauer to suction the fluid away. Irrigate using the saline bottle technique explained above.

Work in progress: Scoring 2009 educational research publications

As mentioned in earlier post, I am part of a fun and amazingly accomplished team of medical educators in Emergency Medicine. We are publishing an annual series reviewing the top educational research publications for the year, based on methodology, innovation, and relevance to EM. See the PubMed abstract of our publication reviewing 2008 articles.

Here is the list of 31 articles from 2009, which have made the cut for review by our 6-person team.

• Adler, M. D., J. A. Vozenilek, et al. (2009). "Development and evaluation of a simulation-based pediatric emergency medicine curriculum." Academic Medicine 84(7): 935-41.
• Augestad, K. M., R. O. Lindsetmo, et al. (2009). "Overcoming distance: video-conferencing as a clinical and educational tool among surgeons.[see comment]." World Journal of Surgery 33(7): 1356-65.
• Barsuk, J. H., E. R. Cohen, et al. (2009). "Use of simulation-based education to reduce catheter-related bloodstream infections.[see comment]." Archives of Internal Medicine 169(15): 1420-3.
• Bernstein, S. L., E. D. Boudreaux, et al. (2009). "Efficacy of a brief intervention to improve emergency physicians' smoking cessation counseling skills, knowledge, and attitudes." Substance Abuse 30(2): 158-81.
• Blaivas, M., S. Adhikari, et al. (2009). "An unseen danger: frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance.[see comment]." Critical Care Medicine 37(8): 2345-9; quiz 2359.
• Carter, K. A., B. C. Dawson, et al. (2009). "RVU ready? Preparing emergency medicine resident physicians in documentation for an incentive-based work environment." Academic Emergency Medicine 16(5): 423-8.
• Cicero, M. X., E. Blake, et al. (2009). "Impact of an educational intervention on residents' knowledge of pediatric disaster medicine." Pediatric Emergency Care 25(7): 447-51.
• Donoghue AJ, Durbin DR, Nadel FM, Stryjewski GR, Kost SI, Nadkarni VM. Effect of high-fidelity simulation on Pediatric Advanced Life Support training in pediatric house staff: a randomized trial. Pediatr Emerg Care. 2009 Mar;25(3):139-44.
• Fernandez, R., S. Compton, et al. (2009). "The presence of a family witness impacts physician performance during simulated medical codes." Critical Care Medicine 37(6): 1956-60.
• Gerbase, M. W., M. Germond, et al. (2009). "When the evaluated becomes evaluator: what can we learn from students' experiences during clerkships?" Academic Medicine 84(7): 877-85.
• Girzadas, D. V., Jr., M. S. Antonis, et al. (2009). "Hybrid simulation combining a high fidelity scenario with a pelvic ultrasound task trainer enhances the training and evaluation of endovaginal ultrasound skills." Academic Emergency Medicine 16(5): 429-35.
• Goldman, E., M. Plack, et al. (1108). "Learning in a Chaotic Environment." Journal of Workplace Learning 21(7): 555-574.
• Hoffman, L., K. Bott, et al. (2009). "Influence of assigned reading on senior medical student clinical performance." The Western Journal of Emergency Medicine 10(1): 23-9.
• Hsieh, Y. H., J. J. Jung, et al. (2009). "Emergency Medicine Resident Attitudes and Perceptions of HIV Testing Before and After a Focused Training Program and Testing Implementation." Academic Emergency Medicine 16(11): 1165-1173.
• Jason Thurman, R., E. Katz, et al. (2009). "Emergency medicine residency applicant perceptions of unethical recruiting practices and illegal questioning in the match." Academic Emergency Medicine 16(6): 550-7.
• Jeanmonod, R., C. Brook, et al. (2009). "Resident productivity as a function of emergency department volume, shift time of day, and cumulative time in the emergency department." American Journal of Emergency Medicine 27(3): 313-9.
• Kimmel, S., S. L. Smith, et al. (2009). "Tobacco Screening Multicomponent Quality Improvement Network Program: Beyond Education." Academic Emergency Medicine 16(11): 1186-1192.
• Kruger, A., B. Gillmann, et al. (2009). "Teaching non-technical skills for critical incidents: Crisis resource management training for medical students]." Anaesthesist 58(6): 582-8.
• Larsen, D. P., A. C. Butler, et al. (2009). "Repeated testing improves long-term retention relative to repeated study: a randomised controlled trial." Medical Education 43(12): 1174-81.
• Laskey, S., R. K. Cydulka, et al. (2009). "Applicant considerations associated with selection of an emergency medicine residency program." Academic Emergency Medicine 16(4): 355-59.
• Ledrick, D., S. Fisher, et al. (2009). "An assessment of emergency medicine residents' ability to perform in a multitasking environment." Academic Medicine 84(9): 1289-94.
• McIntosh, M. S., J. Konzelmann, et al. (2009). "Stabilization and treatment of dental avulsions and fractures by emergency physicians using just-in-time training." Annals of Emergency Medicine 54(4): 585-92.
• Narang, A. T., P. F. Oldeg, et al. (2009). "Comparison of intubation success of video laryngoscopy versus direct laryngoscopy in the difficult airway using high-fidelity simulation." Simulation in Healthcare: The Journal of The Society for Medical Simulation 4(3): 160-5.
• Nguyen HB, Daniel-Underwood L, Van Ginkel C, Wong M, Lee D, Lucas AS, Palaganas J, Banta D, Denmark TK, Clem K. An educational course including medical simulation for early goal-directed therapy and the severe sepsis resuscitation bundle: an evaluation for medical student training. Resuscitation. 2009 Jun;80(6):674-9.
• Penciner, R. and R. Penciner (2009). "Emergency medicine preclerkship observerships: evaluation of a structured experience." CJEM Canadian Journal of Emergency Medical Care 11(3): 235-9.
• Southern, W. N., J. H. Arnsten, et al. (2009). "The effect of erroneous computer interpretation of ECGs on resident decision making." Medical Decision Making 29(3): 372-6.
• Ten Eyck, R. P., M. Tews, et al. (2009). "Improved medical student satisfaction and test performance with a simulation-based emergency medicine curriculum: a randomized controlled trial." Annals of Emergency Medicine 54(5): 684-91.
• Williams, J. B., M. A. McDonough, et al. (2009). "Intermethod reliability of real-time versus delayed videotaped evaluation of a high-fidelity medical simulation septic shock scenario." Academic Emergency Medicine 16(9): 887-93.
• Woo, M. Y., J. Frank, et al. (2009). "Effectiveness of a novel training program for emergency medicine residents in ultrasound-guided insertion of central venous catheters." Canadian Journal of Emergency Medicine 11(4): 343-348.
• Wright, M. C., B. G. Phillips-Bute, et al. (2009). "Assessing teamwork in medical education and practice: relating behavioural teamwork ratings and clinical performance." Medical Teacher 31(1): 30-8.
• Zabar, S., T. Ark, et al. (2009). "Can unannounced standardized patients assess professionalism and communication skills in the emergency department?" Academic Emergency Medicine 16(9): 915-8.

We are "grading" each article based on:

• Introduction
• Design of study methodology
• Strength of study design
• Data collection process
• Data analysis
• Discussion section
• Limitations section
• Innovation of project
• Relevance of project to EM
• Clarity of writing

The articles with the top scores and inter-rater agreement will be discussed in our 2009 review. Email me if you'd like to score the articles along with us for fun. I'll send you the article pdf's and our score sheet!

Article review: EKG interpretation by the computer

What is your reading of this EKG?

Having a computer interpretation printed on EKGs is always a nice backup when reading EKGs. In my experience, the reading is a useful adjunct but it sometimes "overcalls" ST elevation MIs. It is great, though, in picking up subtle pacemaker spikes and calculating QTc intervals.

In this publication, the authors ask - Do erroneous computer interpretations of EKGs affect resident decision making?

In this study, 105 emergency medicine and internal medicine residents were presented with a paper case of a patient with chest pain. Each resident randomly picked up 1 of 2 EKGs (shown above). One EKG had no computer interpretation. The other had an ERRONEOUS computer interpretation, which read:

ST ELEVATION CONSIDER INFERIOR INJURY OR ACUTE INFARCT
** ** ** ** * ACUTE MI * ** ** ** **

Each resident was asked categorize the EKG reading into one of the 3 groups:

• Diagnostic of ischemia or infarct
• Nondiagnostic (correct answer)
  
• Normal

The resident was also asked to provide their recommendation:

• Urgent revascularization
• Maximal medical treatment for ischemia
• Minimal medical treatment for ischemia (correct answer)
  

Results

(Click to enlarge image.)

The distribution of EKG readings (diagnostic vs nondiagnostic vs normal) between the 2 resident groups were equivalent.

Residents who received EKGs with an erroneous computer interpretation were more likely to recommend urgent revascularization than those who had no computer interpretation (30% vs 10%, p=0.01).

More specifically, in the subgroup of residents who read the EKG as "diagnostic of ischemia/infarct" (n=48), the residents who had erroneously computer-interpreted EKGs were more likely to recommend urgent revascularization than the other group of residents (54% vs 25%, p=0.048).

Bottom Line
Having an erroneous computer interpretation of the EKG did not influence the residents' READING of the EKG. It did, however, influence their MANAGEMENT recommendations. In this case where the computer interpretation read "acute MI", residents were more swayed towards a more aggressive plan.

Thus, beware the EKG computer interpretation.

In the end, the patient with the EKG above had a normal cardiac catheterization. She had pericarditis.

Reference
Southern WN, Arnsten JH. The Effect of Erroneous Computer Interpretation of ECGs on Resident Decision Making. Med Decis Making. 2009;29:372–6.

Paucis verbis card: The Red Eye

Here is another installment of the Paucis Verbis (In a Few Words) e-card series on the topic of The Red Eye from EM Clinics of North America.

Here are some images:

Epidemic keratoconjunctivitis
(note subtle white precipitates over pupil)

Bacterial conjunctivitis
(note injection along inferior fornix)

Episcleritis


Scleritis
(note bluish hue of deep scleral vessels)

Acute angle closure glaucoma
(note corneal edema)


Feel free to download this card and print on a 4'' x 6'' index card...
[MS Word] [PDF]

See other Paucis Verbis cards.

Hot off the press: International EM opportunity in Bali

Anyone have the block of Mar 5-Apr 4, 2010 available to volunteer their time teaching in Bali? If you are a 3rd resident or above, or a practicing emergency physician, you are eligible. Preference is given to residents though.

Read more about it from the website link, or read more below in a summary page, sent by Nicole Durden from the Center for International Medicine's Program Manager.

Trick of the Trade: Modified hair apposition technique

Hair apposition technique (HAT)

I got a nice email from Dr. John Fowler from Turkey who recently published a modified version of the Hair Apposition Technique (HAT) trick in the American Journal of Emergency Medicine in 2009.

Read more about the traditional HAT trick.

The HAT trick allows for scalp laceration closure by using scalp hair and tissue adhesive glue. Contraindications to this technique for wound closure include hair strands less than 3 cm, because it is difficult to manually manipulate short hair.

Trick of the trade: Modified HAT trick

The modified version of the HAT trick (modHAT) uses Kelly clamps to allow for instrument-manipulation of the hair bundles. This is different from the traditional technique, where the provider twists hair strands manually. The Kelly clamps allow the provider to twist hair strands as short as 1 cm.

In a study with 67 patients, there were very few complications. One patient developed local alopecia in the area of the laceration. This likely was caused by excess tissue adhesive spilling into the wound itself.

Another noted complication was the tissue adhesive glue not peeling off of the hair after 2 weeks. In 7 of the 67 patients, they cut off the "hair-glue knot". This likely was because more than 1 drop of glue was applied to each twisted hair bundle. By applying only 1 drop per bundle, the patient can more easily tweeze the glue off with a comb. Bottom line: More is NOT always better.

Reference
Karaduman S, et al. Modified hair apposition technique as the primary closure method for scalp lacerations. Amer J Emerg Med (2009) 27, 1050–5.

Work in progress: Business card in progress

I had no idea that image and graphic design are so important in organizations. In my own little EM world, fonts, colors, and layout design are completely foreign concepts.

I am a member of the Board for a young non-profit group KidsCareEverywhere and am trying to develop polished business cards and letterheads for our group. Fortunately, my graphics design friend Sue is saving the day. She has volunteered to do some amazing pro bono work for us. Her work is in a whole different league from what we could even imagine.

Check out this business card layout. I'm too embarrassed to even post my ideas.

Article review: Feedback in the Emergency Department

Feedback is important in teaching and learning.

I am constantly surprised by medical student and resident comments that they rarely receive feedback. In contrast, seemingly on every shift, I hear faculty giving little nuggets of feedback - during the oral presentation, during the resuscitation, after a difficult interaction, etc. There must be some disconnect.

This multi-institutional, survey-based, observational study at 17 EM residency programs asked attending physicians and residents about feedback in the ED. The primary outcome measure was overall satisfaction with feedback.

Results
The response rate was 71% for attendings (373/525) and 60% for residents (356/596). Side note: Survey studies are generally inconclusive if response rates are <70%.

There was a statistically significant difference between the feedback satisfaction scores (on scale of 1-10 with 10 being highest satisfaction).

• Attending physicians: 5.97
• Resident physicians: 5.29

Furthermore, when evaluating the quality of different aspects of feedback delivery, there were statistically significant differences in the satisfaction ratings between the attendings and residents. Overall, attendings felt more satisfied with feedback delivery on various topics than residents were.

• Quality of positive feedback (50% attendings, 36% residents)
• " of constructive feedback (29% attendings, 22% residents)
• " of feedback re: procedural skills (48% attendings, 34% residents)
• " of documentation (36% attendings, 28% residents)
• " of ED flow management (29% attendings, 21% residents)
• " of evidence-based decision making (28% attendings, 18% residents)
  

What is more interesting to me is the discrepancy between what the attendings and residents perceived in frequency of feedback. Specifically, 42% of attendings stated that feedback delivery was being done on every shift. Contrast this to only 7% of residents who felt the same. Why the disconnect? Is it purely misperception?

In re-reading this article, I wonder how this question was phrased though. Was it indeed perception or fact?

Let's say there are usually 5 residents per attending shift, and the attending gives feedback every shift to at least 1 person. When surveyed, the attending would answer - "Yes, I give daily feedback". In contrast, because there are multiple learners, residents may not have received daily feedback. By law of averages, residents would have received feedback every 5 shifts.

The data showing that 42% of attendings and 7% of residents were involved in feedback delivery every shift may actually be true (rather than pure perception). This illustrates the trickiness of designing and writing surveys.

Bottom Line
We should be working to improve positive and constructive feedback delivery in the Emergency Department, despite the various obstacles.

Reference
Yarris L, et al. Attending and resident satisfaction with feedback in the emergency department. Acad Emerg Med. 2009; 16:S76–S8.

Also see previous post on Failing at Feedback in Medical Education.

Paucis Verbis card: Supratherapeutic INR

What do you do in these cases?

• A man on coumadin for atrial fibrillation arrives because he has increased bruising on his skin. He is otherwise asymptomatic. He was told to come to the ED because of a lab result showing INR = 6.
• A woman on coumadin for atrial fibrillation arrives because of melena and hematemesis. She looks extremely sheet-white pale. Her vital signs are surprising normal. Stat labs show a hematocrit of 15 and an INR value that the lab is "unable to calculate" because it is so high.
  

Every couple of years, the American College of Chest Physicians (ACCP) publishes evidence-based clinical guidelines for Antithrombotic and Thrombolytic Therapy. The 8th edition, published in 2008, includes a supplemental section on "Pharmacology and Management of the Vitamin K Antagonists".

Also, an oldie but goodie table that I often refer to is a 1998 JAMA article providing causes (with odds ratios) for overanticoagulation.

Answers to cases:

• INR=6 with minimal symptoms: Hold coumadin +/- give vitamin K 1 mg po.
• INR uncalculatable with GI bleed: Hold coumadin, FFP, pRBC transfusion, +/- factor concentrates, +/- vitamin K 10 mg IV slow push. (We actually elected not to give IV vitamin K because of the risk of life-threatening anaphylaxis and the fact that the patient was relatively stable.)
  

In this installment of the Paucis Verbis (In a Few Words) e-card series, the topic is Supratherapeutic INR.

Feel free to download this card and print on a 4'' x 6'' index card...
[MS Word] [PDF]

See other Paucis Verbis cards.

-

SAEM Innovations in EM Education abstracts due Jan 20

The abstract submission deadline for the upcoming SAEM annual meeting has come and passed. However, the Innovations in EM Education (IEME) abstract deadline is January 20. So, if you have an innovative educational project, consider submitting an abstract. Instructions can be found at the SAEM Meeting website.

Here were the abstracts accepted in 2009:

• A Novel Approach to Teaching Periocardiocentesis
• Receiving: The Use of Web 2.0 to Create a Dynamic Learning Forum to Enrich Resident Education
• A Model for Ultrasound-Assisted lumbar Puncture
• "Sim Wars": A New Edge to Academic Residency Competitions
• Use of Simulation Technology in Forensic Medical Education
• The Thanksgiving Turkey Tap: A New and Simple Model for Teaching Ultrasound-Guided Thoracentesis
• Geriatric Emergency Medicine Educational Module: Abdominal pain in the Older Adult
• The Emergency Informatics Transition Course: A Flexible, On-Line Course in Health Informatics for Emergency Medicine Clinicians and Trainees
• The ER of the Future: an Interdisciplinary Graduate Course in Healthcare Design
• Teamwork Training for Interdisciplinary Applications
• Skin Abscess Model for Incision and Drainage
• Model for Ultrasound Assisted Lumbar Puncture Training
• Geriatric Emergency Medicine With Integrated Simulation Curriculum
• An Inexpensive, Easily Constructed, Reusable Task Trainer for Simulating Ultrasound-Guided Pericardiocentesis
• Multimedia Emergency Bedside Ultrasound Quality Assurance Feedback
• The E.R. Game
• Effect of an Integrated of Public Health Curriculum in an Emergency Medicine Residency
• Basic Emergency Medicine Skills Workshop as the Introduction to the Medical School Clinical Skills Curriculum
• Use of Embalming Machine to Create Central Venous Access Model in Human Cadavers
• Competency Testing Using a Novel Eye Tracking Device

Today, I submitted an abstract about this very blog (read below), entitled "Faculty Blogging: A novel approach to teaching in the Web 2.0 era". It's grown beyond a fun little experiment that was originally built as an outlet to formalize my thoughts about academia. Now it's received over 13,000 visits. Cross my fingers that I get accepted.

A blog, a contraction of "web log", is an online journal with periodic updates by the author(s). In the digital age of Web 2.0, blogs have become extremely popular. Rarely are there blogs on medical education and academia.

In July 2009, a new blog was created called “Academic Life in Emergency Medicine”, authored by a single faculty member in academic emergency medicine (EM). The website is http://AcademicLifeInEM.blogspot.com.

The purpose of this blog is to provide readers with an informal and accessible insight into academia, from the perspective of a faculty member with a niche in education, educational innovations, and educational technologies. The target audience is broad and includes medical students, EM residents, and practicing emergency physicians in the United States and internationally.

The blog currently follows a Monday through Friday schedule of postings. The schedule is as follows: review of a medical education article (Mon), works in progress and faculty hero spotlights (Tue), sneak peek from my "Tricks of the Trade" ACEP News column (Wed), what's on my mind? (Thu), and Paucis Verbis "peripheral brain" project (Fri).

Website Activity: During the period of July 1, 2009 to January 13, 2010, the author posted 163 entries. Based on Google Analytics tracking, the website has recorded 13,218 visits with 20,358 different pages viewed. These visits came from 2,035 cities and 6 continents. There are 5,728 inbound links from other websites to this blog.

Conclusion: A faculty blog website is a novel, dynamic, and interactive approach to teaching EM using Web 2.0 technology.

Trick of the Trade: Pediatric Distractors

Remember back in the day when we made simple toys for pediatric patients to focus on during the physical exam? Remember the inflated medical glove +/- a face drawn on it?

I just encountered a FREE iPhone application (Eye Handbook), which has a lot of useful features. I currently only use the Pediatric Fixation animations. They can be found under the "Testing" section. Kids (and often adults too!) become mesmerized and distracted by the cartoon animations... although I find the dancing hippo a little disturbing.

Despite walking into a room with a crying child, I often can come in and get a really accurate and quiet exam when the child views the animations. It's like a magical light switch. Crying. iPhone turns on. No crying. I feel like a child-whisperer.

This is especially useful in performing the lung and abdominal exam. This helped us determine that this boy with abdominal pain and vomiting actually had a non-tender abdomen.

Equally amazing, without any instruction, the child swiped his finger over the iPhone screen to turn the page. This allowed him to view the other animations. Kids are amazing these days.

Work in progress: Pediatric ultrasound videos

A few years ago, I helped a colleague of mine Dr. Ron Dieckmann build his major international, clinical-decision support software for Pediatric EM. This software is called PEMSoft. I helped build the Procedures section, which contains text, graphics, and often movies of the procedures.

PEMSoft, which is currently in CD-ROM format, is actively being converted to an online format. This allows for us (KidsCareEverywhere - a non-profit organization) to more-easily deliver this resource to underserved countries.

I am currently working with Dr. Jason Fischer (Highland EM Ultrasound Fellow), an over-achiever friend of mine who has also finished a 2-year Pediatric EM Fellowship at Children's Hospital of Oakland. We are developing an entire Pediatric Ultrasound section for PEMSoft. Pediatric bedside ultrasonography in the ED is an emerging field of EM. In the right setting, it is a great imaging modality, especially given the recent literature about CT irradiation risks.

We are writing teaching modules for:

• Pneumothorax
• Hemothorax
• Pericardial effusion
• Abdominal free fluid in RUQ , LUQ and pelvis
• Bladder sizing (for catheterization)
• FB in soft tissue
• Abscess
• Vascular access

If you would like to contribute a non-copyrighted video for any of these modules, please email me. I'd love to include and would credit you, if we use it. Your video could be helping emergency physicians and pediatricians around the world, ranging from big-city U.S. hospitals to rural villages in Vietnam.

If you would like FREE access to PEMSoft Online, Ron has temporarily opened it up for free during this beta-test phase. It is still in a relatively basic form, but you can get the gist of the software. For Mac users, you need to have the plug-in Flip4Mac to view the videos.

Website:

www.pemsoft.com

Article review: Conference attendance ≠ better test scores

Not all learners should be expected
to have the same learning style.

This is exemplified in a recent multicenter study, which addresses whether attendance at weekly residency conferences correlates with a better in-service training examination (ITE) score. The ITE score was used as an outcome measure, because it correlates with the resident's likelihood for passing the official ABEM Board Exams. Both tests draw from questions in the Model of the Clinical Practice of Emergency Medicine.

Methodology
In this multicenter (4-site), retrospective cohort study, data from 405 residents were collected. Regression analysis was done for the entire data set, and also breaking down the data by PGY-training year. This latter step was done in case training level showed a different correlation between conference attendance and ITE score.

Results
There was no correlation between conference attendance rate and the ITE score, whether you look at the entire data set or whether you looked in a year-by-year analysis. The study, however, did find 2 significant predictors of ITE score:

• USMLE step 1 score (Median of all residents = 220; IQR = 209-234)
  
• Female sex (sorry, guys)
  

Comments

• This was a retrospective study. A better study would be to do this prospectively.
• Each residency program has a different conference curriculum. This may have confounded the data.
• Data was not collected on the residents' self-study or other educational practices.
• Because the RRC-EM standards require at least 70% conference attendance, the data only looks at residents with ≥70% attendance. What would the ITE scores have been for residents who had, for instance, 0% attendance rates? Now THAT would be interesting.
  

My opinion
I personally believe that residency conferences has only a minimal-to-modest impact on how residents perform on their ITE exam and even how they perform clinically. Conference time does serve a good function though. It allows residents and faculty to socialize and provides residents with a little escape from the day-to-day clinical duties. This could just as well be accomplished by weekly or monthly "wellness sessions" where all residents are excused from clinical services.

Based on results from this study, perhaps we should re-look at the RRC-EM requirement for 70% minimum attendance at the 5 hours/week conference curriculum. For me, I'd like to see more time and resources spent towards providing a variety of learning tools for the residents. This would accommodate the residents' various learning styles and afford residency programs more flexibility in custom-tailoring education for each individual.

My blog review of a CORD consensus article which discusses alternatives and improvements for the current EM residency conference requirement.


Reference
Hern HG, et al. Conference attendance does not correlate with emergency medicine residency in-training examination scores. Acad Emerg Med. 209; 16:S63-S66.

Paucis Verbis card: TIA prognosis

CT showing left parietal ischemic CVA

Here is another installment of the Paucis Verbis (In a Few Words) e-card series on the topic of Transient Ischemic Attacks (TIA) from EM Clinics of North America. I use this card a lot specifically for the ABCD2 risk-stratification score.

Feel free to download this card and print on a 4'' x 6'' index card...
[MS Word] [PDF]

Other Paucis Verbis cards:
Shock
CNS Infections

Reference
Ross M, Nahab F. Management of transient ischemia attacks in the twenty-first century. Emerg Med Clin North Am. 2009 Feb; 27(1):51-69, viii.

Article review: The EM residency conference requirement

I'm reviewing another medical education article in this week's blog. It is also from the inaugural educational supplement in Academic Emergency Medicine. I'll be running a discussion session at the 2010 CORD Academic Assembly on "Maintaining Educational Excellence in the Era of ED Crowding". I hope to also publish a consensus statement, similar to those found in this journal issue.

Article topic:
Alternatives to the EM residency conference requirement

The article reviewed here discusses the required 5 hours of weekly conference time for all EM residency programs. Is there evidence that this is the best way to teach our residents? Are there alternatives?

The current EM Residency Review Committee program requirements are:

• Offer residents an average of at least 5 hours ⁄ week of planned educational experiences developed by the EM training program
• Ensure that residents are relieved of their clinical duties to attend these planned experiences. The program should ensure that residents attend on average 70% of the offerings.
  

When they were first developed, the requirements advantageously protected the educational mission of the EM residency, especially in the setting of residents feeling the pull of clinical duties from various services. Appropriately "education" should hold equal or more weight than pure "service".

Having this weekly "protected time", however, comes with disadvantages. There are major scheduling and duty hour challenges. Additionally, the requirement places significant emphasis on quantity rather than quality of education. Who came up with the number that 5 hours/week of conference would ensure an adequately trained emergency physician?

Personally, I think the required 5 hours/week of conference time is an antiquated way of ensuring educational excellence. If you could design something better from scratch, how would you design the curriculum? The published consensus recommendations closely mirror what I believe.

The bottom-line message that I completely agree with is that the measure of success of an educational curriculum should be resident learning outcomes rather than quantity of conference hours attended.

Other consensus recommendations:

• There should be different conference requirements for 3 vs 4 year programs. If 3 years of 5 hrs/week of didactics is sufficient education for clinical competency, why do 4 year programs have extra hours of didactics? Perhaps 4-year programs should have fewer hours/week of conference, so that the total number of hours is similar to 3-year programs.
  

• 70% attendance requirement. Each program should be allowed flexibility to determine what is considered the minimum standard of education. There are unique local program and individual resident needs to consider. While more difficult to measure, learning outcomes should be more the focus rather than conference attendance.
  

• Synchronous versus asynchronous learning. Programs should be allowed to take advantage of both synchronous and asynchronous teaching modalities.
  

What I hope is that the ACGME listens to the recommendations from this consensus statement. EM residencies need more flexibility in order to build the best-fit curricular model for their particular program.

In the end, medical education will need to evolve to match the following:

• Program and institutional demands
• Effective learning strategies for the current and upcoming generation
• 21st century resources

Reference
Sadosty AT, Goyal DG, Hern HG, et al. Alternatives to the Conference Status Quo: Summary Recommendations from the 2008 CORD Academic Assembly Conference Alternatives Workgroup. Acad Emerg Med. 2009; 16:S25–S31.

Trick of the Trade: Finger nailbed laceration repair

Over the years, I have been frustrated by how inelegant finger nailbed closure is. Nailbed lacerations are often sustained by a major crush injury, resulting in a stellate and irregular laceration pattern. This typically also requires the crushed fingernail to be removed. Cosmesis is never ideal because pieces of the nailbed are often missing, as seen in the photo above.

Occasionally, nailbed lacerations are caused by a cutting rather than a crush mechanism. In these cases, I use a different technique. I leave the fingernail on. In fact, I use the fingernail to help reapproximate the nailbed edges.

Trick of the Trade: Nailbed repair
This technique requires that the fingernail has a simple linear laceration through it. The fingernail has to be relatively still adherent to the nailbed. The case below is a patient who sustained a fingertip laceration with an industrial skill saw.

• Carefully perform a distal neurovascular exam.

• Perform a digital nerve block of the finger.

• Copiously irrigate the laceration because this is almost always an open fracture.

• Carefully create 2 holes (blue arrows) in the fingernail on either side of the laceration using electrocautery. Be careful not to injure the nailbed.

• Suture the fingernail back together by placing a non-absorbable, simple interrupted suture through the two fingernail holes. There is no need to puncture through the nailbed. Reapproximating the fingernail should also pull the nailbed edges together.

• Remove the sutures after 7-10 days.

Here is a follow-up photo of the same patient who returned 72 hours later for a wound check. Although the photo is a little fuzzy, you can see that the wound was healing well.


Advantages of this technique:

• Less traumatic repair of the nailbed
• Preservation of the eponychial fold because the native fingernail remains in place. A new fingernail can grow out normally.