Third-year Emergency Medicine Research Articles

Correlation between CUS and DUS for DVT diagnosis in lower extremities in the emergency department

Background: Deep venous thrombosis (DVT) is one of the most serious thrombotic events and one of the most common cardiovascular causes associated with death due to pulmonary embolism in the emergency department. Objectives: This study aimed to determine the correlation between two-point compression ultrasonography (CUStwo-point) and doppler ultrasound (DUS) in the diagnosis of DVT of the lower extremities. Methods: This descriptive–analytical cross-sectional study was conducted on all patients with suspected DVT referred to two emergency departments over 6 months. Initially, all patients underwent CUStwo-point using a linear probe on the common femoral and popliteal veins, which was performed by an emergency medicine specialist. Then DUS was performed on all patients by radiologists who were unaware of the results of CUStwo-point. The results obtained from the two procedures were recorded in a data collection form by a third-year emergency medicine assistant. The data was analyzed by SPSS 23 software. Results: Overall, 129 patients were enrolled, the mean age of whom was 56.18 ± 16.33.68 years. There were 68 males (52.7%) and 61 females (47.3%) among the participants. The positivity or negativity of the data retrieved from CUStwo-point and DUS was assessed by the McNemar test, and a P-value of 1 indicated the homogeneity of both tests. Compared to DUS (as the gold standard), the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CUStwo-point method were obtained as 97.56%, 95.74%, 97.56%, 95.74%, and 96.9%, respectively. The accuracy of 96.9% of CUStwo-point along with Cohen’s kappa of 0.93 indicated a high agreement between the two ultrasound methods. Conclusion: CUS seems to be a non-invasive, safe, and accessible method in the emergency department that can provide an appropriate alternative to DUS for the diagnosis of DVT in the lower extremities.

Determining the Diagnostic Value of Ultrasound and CT Scan in Diagnosing Kidney Damage in Patients with Blunt Abdominal and Pelvic Trauma

Background and Objective: Abdominal trauma is one of the most common causes of death in trauma patients, occurring in 20% of cases. Kidney damage is the most common complication of non-penetrating abdominal trauma. In patients with abdominal trauma, it is important to diagnose and treat possible abdominal injuries. The presence of hematuria and clinical examinations often have little sensitivity and specificity to diagnose the intra-abdominal injury. Although Computed Tomography (CT) scan is the standard diagnostic method for abdominal trauma, it has its own drawbacks, including radiation. On the contrary, ultrasound is a cheaper, more repetitive, and non-invasive procedure. The present study aimed to determine the diagnostic value of Focused Assessment with Sonography for Trauma (FAST) scan and ultrasound by a radiologist in comparison with abdomen and pelvis CT scan with intravenous (IV) contrast in determining the severity of kidney damage in patients with microscopic hematuria due to non-penetrating abdominal and pelvic trauma. Materials and Methods: This forward-looking study was conducted on patients with blunt abdominal trauma with hematuria in Hamadan Besat Educational and Medical Center in 2018 and 2019. The sampling was performed by census method based on inclusion and exclusion criteria. Patient demographic information, as well as accident information that led to abdominal trauma, were recorded in a checklist. All participants were trained by a third-year emergency medicine assistant and then by a third- or fourth-year radiology assistant via FAST ultrasound to diagnose free abdominal fluid. In the next step, all participants were examined after IV contrast injection using a CT scan device. Finally, the data were analyzed in SPSS software (version 22) using appropriate statistical methods. Results: In this study, 60 eligible patients, including 47 males (78.4%) and 13 females (21.6%), with a mean age of 36.75±17.81 years, were examined. The percentage of agreement between the FAST ultrasound findings performed in the emergency and radiology departments was 93.3%. The agreement between the two methods was significant, with a coefficient of 0.837 (P<0.001). Sensitivity (75 and 80), specificity (100 and 92.5), positive (100 and 84.2) and negative (88.8 and 90.2) predictive values, as well as the accuracy (91.6 and 88.3) of FAST ultrasound, in both emergency and radiology groups were acceptable in comparison with CT scan. Conclusion: As evidenced by the obtained results, it can be concluded that ultrasound is a reliable tool for examining patients with abdominal trauma with suspected kidney damage.

Comparing Resident Procedures in Rural Versus Urban Emergency Departments.

Background: Rural rotations can be a valuable experience for emergency medicine (EM) residents. To date, there has not been a retrospective cohort study comparing procedures performed at urban versus rural emergency departments (EDs).Objectives: The purpose of this study was to compare procedures performed by EM residents in urban versus rural EDs, with the hypothesis that there will be no significant difference in the procedures performed.Methods: A retrospective cohort study was conducted comparing procedures performed by second- and third-year EM residents based on medical chart review. The procedures were counted at three locations in West Virginia, including a small rural ED, a large rural ED, and a tertiary care ED. Procedure notes were collected from September 2018 to September 2019. The final analysis included nine months, as three months did not have residents at all locations. Eight procedures were standardized based on the number of procedures performed per 100 hours worked by residents. A comparison of total procedures and complex versus simple procedures was performed. A Kruskal-Wallis H test was performed to compare resident hours for procedures between each of the three locations. To compare each of the hospitals to one another separately, Mann-Whitney U tests were performed.Results: The total resident hours worked included 1,800 at the small rural ED, 13,725.5 at the tertiary care ED, and 5,319 at the large rural ED. A p-value of 0.0311 for the Kruskal-Wallis H Test indicated a difference between at least two of the ED sites. A statistically significant difference exists (p-value = 0.0135) between the urban ED (95% CI: 0.15-0.62) and the large rural ED (95% CI: 0.54-1.53). There was no significant difference in complex versus simple procedures among the three locations (p-value = 0.4159).Conclusions: When compared with the tertiary care ED, residents performed more total procedures at the large rural ED and similar total procedure numbers at the small rural ED when standardized for hours worked. There was no significant difference when comparing complex and simple procedures among the three locations.

Getting to the heart of the issue: senior emergency resident electrocardiogram interpretation and its impact on quality assurance events.

ObjectiveElectrocardiogram (ECG) interpretation skills are of critical importance for diagnostic accuracy and patient safety. In our emergency department (ED), senior third-year emergency medicine residents (EM3s) are the initial interpreters of all ED ECGs. While this is an integral part of emergency medicine education, the accuracy of ECG interpretation is unknown. We aimed to review the adverse quality assurance (QA) events associated with ECG interpretation by EM3s.MethodsWe conducted a retrospective study of all ED ECGs performed between October 2015 and October 2018, which were read primarily by EM3s, at an urban tertiary care medical center treating 56,000 patients per year. All cases referred to the ED QA committee during this time were reviewed. Cases involving a perceived error were referred to a 20-member committee of ED leadership staff, attendings, residents, and nurses for further consensus review. Ninety-five percent confidence intervals (CIs) were calculated.ResultsEM3s read 92,928 ECGs during the study period. Of the 3,983 total ED QA cases reviewed, errors were identified in 268 (6.7%; 95% CI, 6.0%–7.6%). Four of the 268 errors involved ECG misinterpretation or failure to act on an ECG abnormality by a resident (1.5%; 95% CI, 0.0%–2.9%).ConclusionA small percentage of the cases referred to the QA committee were a result of EM3 misinterpretation of ECGs. The majority of emergency medicine residencies do not include the senior resident as a primary interpreter of ECGs. These findings support the use of EM3s as initial ED ECG interpreters to increase their clinical exposure.

Mastering Electrocardiogram Interpretation Skills Through a Perceptual and Adaptive Learning Module.

Although accurate interpretation of the standard 12-lead electrocardiogram (ECG) is fundamental to diagnosing heart disease, several prior studies report low accuracy rates among medical students, residents, and practicing physicians. The objective of this study was to determine if an online ECG Perceptual and Adaptive Learning Module (ECG PALM) is an efficient instrument to teach ECG interpretation. The ECG PALM consists of 415 unique ECG tracings with associated pretest, posttest, and delayed tests, each using 30 additional ECGs to gauge the effectiveness and durability of training. Between 2013 and 2015, a total of 113 third-year and 156 fourth-year medical students and 34 first-year, 41second-year, and 37 third-year emergency medicine residents completed the PALM and associated tests. We measured two mastery criteria: accuracy, the percentage of correct interpretations, and fluency, the percentage of images interpreted accurately within 15seconds. The ECG PALM produced statistically significant improvements (0.0001<p<0.0045) in student and resident performance for both accuracy (effect size=0.9 to 3.2) and fluency (effect size=2.5 to 3.1) following training ranging from 46±24minutes (R3s) to 88±32minutes (third-year medical students). Medical students and residents performed significantly better on a test the year following training (delayed test) than those without prior ECG PALM training (pretest). The fluency of R3 residents in classifying the 15 diagnostic categories was less than 60% for nine of the 15 diagnoses and greater than 80% for only one. Following PALM training, fluency was higher than 80% for seven of the 15 categories and less than 60% for only two categories. Accuracy in recognizing ST-elevation myocardial infarctions (STEMIs) was high both before and after PALM training for R3s, but fluency was only 64% for anterior STEMIs on the pretest, increasing to 93% following PALM training. These observations suggest that the ECG PALM is an effective and durable supplemental tool for developing mastery in interpreting common ECG abnormalities.

Targeted Simulation-based Leadership Training for Trauma Team Leaders.

IntroductionEffective team leadership is linked to better teamwork, which in turn is believed to improve patient care. Simulation-based training provides a mechanism to develop effective leadership behaviors. Traditionally, healthcare curricula have included leadership as a small component of broader teamwork training, with very few examples of leadership-focused curricula. The objective of this work is to describe a novel simulation-based team leadership curriculum that easily adapts to individual learners.MethodsWe created a simulation-based team leadership training for trauma team leaders in graduate medical education. Participants included second- and third-year emergency medicine and surgery residents. Training consisted of a single, four-hour session and included facilitated discussion of trauma leadership skills, a brief didactic session integrating leadership behaviors into Advanced Trauma Life Support®, and a series of simulations and debriefing sessions. The simulations contained adaptable components that facilitated individualized learning while delivering set curricular content. A survey evaluation was administered 7–24 months following the training to assess self-reported implementation of trained material.ResultsA total of 36 residents participated in the training and 23 (64%) responded to the survey. The majority of respondents (n = 22, 96%) felt the training was a valuable component of their residency education and all respondents reported ongoing use of at least one behavior learned during the training. The most commonly cited skills for ongoing use included the pre-arrival brief (n = 21, 91%) and prioritization (n = 21, 91%).ConclusionWe delivered a leadership-focused, simulation-based training that 1) adapted to learners’ individual needs, and 2) was perceived to impact practice up to 24 months post-training. More work is needed to understand the impact of this training on learner knowledge and behavior, as well as patient outcomes.

The Value of Red Cell Distribution Width (RDW) and Trauma-Associated Severe Hemorrhage (TASH) in Predicting Hospital Mortality in Multiple Trauma Patients.

Objective: To investigate the role of red cell distribution width (RDW) in comparison with Trauma-Associated Severe Hemorrhage (TASH) system in predicting the mortality of multiple trauma patients, referred to the hospital emergency department.Methods:This follow-up study was conducted on multiple trauma patients (age ≥ 18 years) with Injury Severity Scores (ISS) of ≥ 16, who were referred to the emergency department from March 1, 2017, to December 1, 2017. First, all patients were evaluated based on the Advanced Trauma Life Support (ATLS) guidelines, and then, their blood samples were sent for RDW measurements at baseline and 24 hours after admission. The ISS, Revised Trauma Score (RTS), and TASH were measured in the follow-ups and recorded by third-year emergency medicine residents. Hospital mortality was considered as the outcome of the study.Results:In this study, 200 out of 535 multiple trauma patients were recruited. The frequency of hospital mortality was 19 (9.5%). In the univariate analysis, there was no significant relationship between hospital mortality and RDW at baseline, RDW on the first day, and ΔRDW (RDW at baseline - RDW on the first day), unlike ISS, RTS, TASH (p=0.97, P= 0.28, and p=0.24, respectively). On the other hand, in the multivariate analysis, ISS, RTS, and TASH showed a significant relationship with hospital mortality. The greatest area under the ROC curve (AUC) was attributed to TASH and RTS systems (0.94 and 0.93, respectively). Conclusion:TASH scoring system, which was mainly designed to predict the need for massive transfusion, may be of prognostic value for hospital mortality in multiple trauma patients, similar to ISS and RTS scoring systems.

Implementing a Third-Year Emergency Medicine Medical Student Curriculum

BackgroundEmergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. ObjectiveA recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. DiscussionIncluded are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for each content area. ConclusionsThis consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution.

A novel use of Twitter to provide feedback and evaluations

Inconsistencies in work schedules and faculty supervision are barriers to monthly emergency medicine (EM) resident doctor evaluations. Direct and contemporaneous feedback may be effective in providing specific details that determine a resident's evaluation. To determine whether Twitter, an easy to use application that is available on the Internet via smartphones and desktops, can provide direct and contemporaneous feedback that is easily accessible, and easy to store and refer back to. First- to third-year EM residents were administered a survey to assess their thoughts on the current monthly evaluation system. Subsequently, residents obtained a Twitter account and were instructed to follow a single general faculty Twitter account for ease of data collection. Following completion of an 8-week study period, a second survey was administered to assess resident thoughts on contemporaneous feedback and evaluations versus the traditional form. Of the 24 EM residents, 13 were available for study. A total of 220 'tweets' were provided by seven faculty members, with a mean of 11 tweets (range 8-17) per resident. The 13 residents received a total of eight formal evaluations from 19 faculty members. The second survey demonstrated that this method provided more detailed evaluations and increased the volume of feedback. Contemporaneous feedback and evaluation provides a greater volume of feedback that is more detailed than end-of-course evaluations. Twitter is an effective and easy means to provide this feedback. Limitations included the length of study time and the inability to have all of the EM residents involved in the study.

Evaluation of a Computer-Based Educational Intervention to Improve Medical Teamwork and Performance During Simulated Patient Resuscitations

To determine the impact of a low-resource-demand, easily disseminated computer-based teamwork process training intervention on teamwork behaviors and patient care performance in code teams. A randomized comparison trial of computer-based teamwork training versus placebo training was conducted from August 2010 through March 2011. This study was conducted at the simulation suite within the Kado Family Clinical Skills Center, Wayne State University School of Medicine. Participants (n = 231) were fourth-year medical students and first-, second-, and third-year emergency medicine residents at Wayne State University. Each participant was assigned to a team of four to six members (nteams = 45). Teams were randomly assigned to receive either a 25-minute computer-based training module targeting appropriate resuscitation teamwork behaviors or a placebo training module. Teamwork behaviors and patient care behaviors were video recorded during high-fidelity simulated patient resuscitations and coded by trained raters blinded to condition assignment and study hypotheses. Teamwork behavior items (e.g., "chest radiograph findings communicated to team" and "team member assists with intubation preparation") were standardized before combining to create overall teamwork scores. Similarly, patient care items ("chest radiograph correctly interpreted"; "time to start of compressions") were standardized before combining to create overall patient care scores. Subject matter expert reviews and pilot testing of scenario content, teamwork items, and patient care items provided evidence of content validity. When controlling for team members' medically relevant experience, teams in the training condition demonstrated better teamwork (F [1, 42] = 4.81, p < 0.05; ηp = 10%) and patient care (F [1, 42] = 4.66, p < 0.05; ηp = 10%) than did teams in the placebo condition. Computer-based team training positively impacts teamwork and patient care during simulated patient resuscitations. This low-resource team training intervention may help to address the dissemination and sustainability issues associated with larger, more costly team training programs.

Procedure Simulation Cart

Recent strides have been made to incorporate simulation into procedural training to ensure that first attempts at procedures are on tissue simulators or mannequins. However, simulation sessions are typically in controlled, stress-free periods, independent of clinical care. Our goal was to try to incorporate the use of procedure task-trainers into resident and medical student education during real-time clinical care. Third-year emergency medicine residents during their 4-week teaching rotation will utilize the simulation cart to assist in teaching procedural skills to fourth-year medical students and junior residents.

Adverse Events Much More Likely with Repeated Intubation Attempts

The incidence of adverse events tripled when a second attempt was needed. To determine the association between adverse events and number of endotracheal intubation attempts, researchers reviewed standardized data collected from 1828 orotracheal intubations performed at an academic emergency department during 4 years. Almost all of the intubations (98%) were by performed by trainees, mostly second- and third-year emergency medicine residents. Adverse events were defined as accidental extubation, aspiration, cardiac arrest, cuff leak, dental trauma, dysrhythmia, esophageal intubation, hypotension (decrease in systolic blood pressure <90 mm Hg), laryngospasm, mainstem intubation, oxygen desaturation (decrease in oxygen saturation 10%), and pneumothorax. Intubation was successful on the first attempt in 73% cases and in two or more attempts in the remainder. The incidence of adverse events increased with the number of attempts: 14%, 47%, 64%, and 71% with one, two, three, and four or more attempts, respectively. The most common adverse events in patients requiring multiple attempts were oxygen desaturation (38%), esophageal intubation (16%), aspiration (6%), and mainstem intubation (4%).

The Impact of Working with Medical Students on Resident Productivity in the Emergency Department

Introduction:Academic emergency departments (ED) strive to balance educational needs of residents and medical students with service requirements that optimize patient care. No study to date has evaluated whether resident precepting of medical students affects residents’ clinical productivity. Understanding the interplay of these variables may allow for ED staffing that maximizes productivity. We sought to determine whether the precepting of medical students impacts resident productivity.Methods:This study was performed at a tertiary care ED with a 70,000 annual patient census. We performed a computer-based (Verinet Systems, Alachua, Fl) retrospective review of patient encounters initiated by second- and third-year emergency medicine residents (PGY2 and PGY3) assigned to medical student precepting shifts and compared these shifts with those of the same residents when not working with students. Data collection over 12 months included shift length from the monthly schedule and number of patients and relative value units (RVUs) from the Verinet System. Patients seen per hour (pt/hr) and relative value unit per hour (RVUs/hr) were calculated. We compared parameters using two-tailed t-tests. The hospital’s institutional review board approved this study.Results:Daily census was 202 on days without medical student rotators and 200 on days with student rotators (p=0.29). While precepting students, PGY3s saw 1.40 pt/hr versus 1.39 pt/hr without students (p=0.88) and PGY2s saw 1.28 pt/hr with students compared to 1.28 pt/hr without students (p=0.94). PGY3s generated 3.97 RVU/hr with students and 4.03 RVU/hr while working independently (p=0.68) and PGY2s generated 3.82 RVU/hr working with students versus 3.74 RVU/hr without (p=0.44). There were no productivity differences between resident precepting shifts and regular shifts.Conclusion:In this study, resident productivity was not affected by precepting medical students.

Secondary confirmation of endotracheal tube position by diaphragm motion in right subcostal ultrasound view

Aims:To assess the sensitivity and specificity of right subcostal ultrasound view to confirm correct endotracheal tube intubation (ETT).Materials and Methods:In this prospective study, apneic or paralyzed patients who had an indication of intubation were selected. Intubation and ventilation with bag were performed by the skilled third-year emergency medicine residents. The residents, following a brief training course of ultrasonography, interpreted the diaphragm motion, and identified either esophageal or tracheal intubation. The confirmation of ETT placement was done by the sonographer. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for tracheal versus esophageal intubation.Results:A total of 57 patients aged 59 ± 5 who underwent ETT insertion were studied. Thirty-four of them were male (60%). Ultrasound correctly identified 11 out of 12 esophageal intubations for a sensitivity of 92% (95% CI = 62-100), but misidentified one esophageal intubation as tracheal. Sonographers correctly identified 43 out of 45 (96%) tracheal intubations for a specificity of 96% (95% CI = 85-99), but misdiagnosed two tracheal intubations as esophageal.Conclusions:This study suggests that diaphragm motion in right subcostal ultrasound view is an effective adjunct to diagnose ETT place in patients undergoing intubation in emergency department.

242 The Provision of Diagnosis at Emergency Department Discharge: A Pilot Study

Study Objectives: Understanding the cause of patients' symptoms usually involves identification of a pathological diagnosis, without which effective treatment often cannot be initiated. Anecdotal reports suggest that emergency department (ED) providers do not prioritize giving pathological diagnoses to patients at time of discharge, and often reiterate the patient's symptom as the discharge “diagnosis.” No study has examined the proportion of patients who receive a pathological diagnosis at ED discharge that explains the likely cause of their symptoms. Our pilot study sought to identify the proportion of patients at a large teaching hospital who receive a symptomatic versus pathological diagnosis at ED discharge.Methods: We performed a chart review of all adult patients who were discharged from an urban ED with an emergency medicine residency and an annual visit volume of 88,000. All charts of patients presenting with the 3 most common ED chief complaints (chest pain, abdominal pain, and headache) were reviewed by a 4th-year medical student and a third-year emergency medicine resident. Charts were coded as either symptomatic or pathological diagnosis based on the discharge diagnosis provided by the attending physician. Those with both symptomatic and pathological discharge diagnosis (eg “chest pain” and “muscular chest pain”) were coded as pathological diagnosis. Those that received different coding by the 2 reviewers were subject to an analysis by a third adjudicator, an emergency medicine attending.Results: 797 charts met the inclusion criteria. Five charts (0.6%) were coded differently by the 2 reviewers; a discussion with the third reviewer resulted in consensus in all cases. The table below shows the number and percentage of symptomatic versus pathological discharge diagnosis for patients presenting with one of these 3 chief complaints:Tabled 1Conclusion: According to our pilot study at a large teaching hospital, it appears that most patients are discharged from the ED without a pathological diagnosis that explains the likely cause of their symptoms. Future studies will investigate whether this finding is consistent across institutions, and whether provision of a pathological diagnosis affects ED clinical outcomes, including patient satisfaction. Study Objectives: Understanding the cause of patients' symptoms usually involves identification of a pathological diagnosis, without which effective treatment often cannot be initiated. Anecdotal reports suggest that emergency department (ED) providers do not prioritize giving pathological diagnoses to patients at time of discharge, and often reiterate the patient's symptom as the discharge “diagnosis.” No study has examined the proportion of patients who receive a pathological diagnosis at ED discharge that explains the likely cause of their symptoms. Our pilot study sought to identify the proportion of patients at a large teaching hospital who receive a symptomatic versus pathological diagnosis at ED discharge. Methods: We performed a chart review of all adult patients who were discharged from an urban ED with an emergency medicine residency and an annual visit volume of 88,000. All charts of patients presenting with the 3 most common ED chief complaints (chest pain, abdominal pain, and headache) were reviewed by a 4th-year medical student and a third-year emergency medicine resident. Charts were coded as either symptomatic or pathological diagnosis based on the discharge diagnosis provided by the attending physician. Those with both symptomatic and pathological discharge diagnosis (eg “chest pain” and “muscular chest pain”) were coded as pathological diagnosis. Those that received different coding by the 2 reviewers were subject to an analysis by a third adjudicator, an emergency medicine attending. Results: 797 charts met the inclusion criteria. Five charts (0.6%) were coded differently by the 2 reviewers; a discussion with the third reviewer resulted in consensus in all cases. The table below shows the number and percentage of symptomatic versus pathological discharge diagnosis for patients presenting with one of these 3 chief complaints: Conclusion: According to our pilot study at a large teaching hospital, it appears that most patients are discharged from the ED without a pathological diagnosis that explains the likely cause of their symptoms. Future studies will investigate whether this finding is consistent across institutions, and whether provision of a pathological diagnosis affects ED clinical outcomes, including patient satisfaction.

Developing a Third‐year Emergency Medicine Medical Student Curriculum: A Syllabus of Content

Emergency medicine (EM) educators have published several curricular guides designed for medical student rotations and experiences. These guides primarily provided brief overviews of opportunities to incorporate EM into all 4 years of the medical student curriculum, with one specific to the fourth year. However, there are no published guidelines specific to third-year medical students rotating in EM. Given the differences between third-year and fourth-year students in terms of clinical experience, knowledge, and skills, the Clerkship Directors in Emergency Medicine (CDEM) established the Third-year EM Medical Student Curriculum Work Group to create a third-year curriculum. The work group began this process by developing consensus-based recommendations for the content of a third-year medical student EM rotation, which are presented in this syllabus.

Third‐year Medical Student Rotations in Emergency Medicine: A Survey of Current Practices

Exposure to emergency medicine (EM) is a crucial aspect of medical student education, yet one that is historically absent from third-year medical student training. There are limited data describing the existing third-year rotations. The goal of this study is to identify the content and structure of current EM rotations specific to third-year students. An institutional review board-approved survey of clerkship characteristics was designed by consensus opinion of clerkship directors (CDs). The survey was distributed to 32 CDs at institutions with known EM clerkships involving third-year students. Twenty-three (72%) CDs responded to the survey. Sixty-five percent have rotations designed specifically for third-year students, of which 33% are required clerkships. Twenty-seven percent of rotations have prerequisite rotations; 37% of rotations include shifts in the pediatric ED. Clinical time averages four 8-hour shifts per week for 4 weeks; all rotations include weekly didactic time specific to third-year students. A wide variety of textbooks are used; some programs employ simulation labs. Two-thirds of the rotations have a required write-up or presentation; 53% include a final exam. Student evaluations are written and verbal. Most rotations receive more support from the EM departments than from the medical schools for physical space, administrative needs, and faculty time. Among those surveyed, students from institutions requiring a third-year EM rotation have a higher rate of application to EM residencies. There is variability in the content and structure of existing third-year EM rotations, as well as in financial and administrative needs and support. These data can help to inform CDs and departments that are starting or modifying EM third-year rotations, as well as contribute to the development of curricula for such rotations.

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The Enucleated Eye

Feasibility and reliability of a multisource feedback tool for emergency medicine residents.

While the Accreditation Council for Graduate Medical Education recommends multisource feedback (MSF) of resident performance, there is no uniformly accepted MSF tool for emergency medicine (EM) trainees, and the process of obtaining MSF in EM residencies is untested. To determine the feasibility of an MSF program and evaluate the intraclass and interclass correlation of a previously reported resident professionalism evaluation, the Humanism Scale (HS). To assess 10 third-year EM residents, we distributed an anonymous 9-item modified HS (EM-HS) to emergency department nursing staff, faculty physicians, and patients. The evaluators rated resident performance on a 1 to 9 scale (needs improvement to outstanding). Residents were asked to complete a self-evaluation of performance, using the same scale. Generalizability coefficients (Eρ(2)) were used to assess the reliability within evaluator classes. The mean score for each of the 9 questions provided by each evaluator class was calculated for each resident. Correlation coefficients were used to evaluate correlation between rater classes for each question on the EM-HS. Eρ(2) and correlation values greater than 0.70 were deemed acceptable. EM-HSs were obtained from 44 nurses and 12 faculty physicians. The residents had an average of 13 evaluations by emergency department patients. Reliability within faculty and nurses was acceptable, with Eρ(2) of 0.79 and 0.83, respectively. Interclass reliability was good between faculty and nurses. An MSF program for EM residents is feasible. Intraclass reliability was acceptable for faculty and nurses. However, reliable feedback from patients requires a larger number of patient evaluations.

The Impact of Emergency Department Overcrowding on Resident Education

Background Few studies have evaluated the effect of Emergency Department (ED) overcrowding on resident education. Objectives To determine the impact of ED overcrowding on Emergency Medicine (EM) resident education. Materials and Methods A prospective cross-sectional study was performed from March to May 2009. Second- and third-year EM residents, blinded to the research objective, completed a questionnaire at the end of each shift. Residents were asked to evaluate the educational quality of each shift using a 10-point Likert scale. Number of patients seen and procedures completed were recorded. Responses were divided into ED overcrowding (group O) and non-ED overcrowding (group N) groups. ED overcrowding was defined as >2 h of ambulance diversion per shift. Questionnaire responses were compared using Mann–Whitney U tests. Number of patients and procedures were compared using unpaired T-tests. Results During the study period, 125 questionnaires were completed; 54 in group O and 71 in group N. For group O, the median educational value score was 8 (interquartile range [IQR] 7–10), compared to 8 (IQR 8–10) for group N ( p = 0.24). Mean number of patients seen in group O was 12.3 (95% confidence interval [CI] 11.4–13.2), compared to 13.9 (95% CI 12.7–15) in group N ( p = 0.034). In group O, mean number of procedures was 0.9 (95% CI 0.6–1.2), compared to 1.3 (95% CI 1–1.6) in group N ( p = 0.047). Conclusions During overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.