Hypertensive Emergency Team-Based Learning.

Audience: The target audiences for this team-based learning (TBL) activity are resident physicians and medical students. Introduction: According to the Centers for Disease Control and Prevention (CDC), nearly half of the adults in the United States have hypertension,1 which is a leading cause of cardiovascular disease and premature death.2 In extreme cases, patients may present in hypertensive emergencies, defined as an acute, marked elevation of systolic blood pressure >180mmHg or diastolic blood pressure >120mmHg with evidence of organ dysfunction.3,4 Patients presenting to the emergency department (ED) with symptoms of hypertensive emergencies must be promptly diagnosed and treated to prevent further morbidity and mortality. This TBL utilizes four clinical cases to educate resident physicians and medical students not only on the recognition of hypertensive emergencies, but also on the workup, management, and disposition of patients who present to the ED with hypertension. Educational Objectives: By the end of this TBL session, learners should be able to: 1) define features of asymptomatic hypertension versus hypertensive emergency, 2) discuss which patients with elevated blood pressure may require further diagnostic workup and intervention, 3) identify a differential diagnosis for patients presenting with elevated blood pressures, 4) recognize the features of different types of end-organ damage, 5) review an algorithm for the pharmacologic management of hypertensive emergencies, 6) indicate dosing and routes of various anti-hypertensive medications, 7) choose the appropriate treatment for a patient who is hypertensive and presenting with flash pulmonary edema, 8) identify an aortic dissection on computed tomography (CT), 9) choose the appropriate treatment for a patient who is hypertensive and presenting with an aortic dissection, 10) identify intracranial hemorrhage on CT, 11) choose the appropriate treatment for a patient who is hypertensive and presenting with an intracranial hemorrhage, and 12) describe the intervention for warfarin reversal. Educational Methods: This is a classic TBL that includes an individual readiness assessment test (iRAT), a multiple-choice group readiness assessment test (gRAT), and a group application exercise (GAE). Research Methods: Learners and instructors were given the opportunity to provide verbal feedback after completion of the TBL. Learners included senior medical students and first-, second-, and third-year emergency-medicine residents. Learners were specifically asked if they felt the cases were educational, relevant, and useful to their training. Results: Six resident physicians and three medical students volunteered their verbal feedback, and agreed when they were specifically asked if the cases were educational, relevant, and useful to their training. The same learners also agreed when asked if they felt the TBL was a more enjoyable activity than a direct lecture to refresh their knowledge and skills. One instructor observed that interns and medical students were generally able to reach a correct diagnosis; however, they seemed to struggle more with describing appropriate pharmacologic interventions when compared to more senior learners. Discussion: Hypertension is a common complaint and incidental finding in patients presenting to the ED. Given its non-specific value, it can be a difficult topic for the novice healthcare provider to master. The differential diagnosis for a patient presenting with hypertension is vast, ranging from benign to emergent, and can sometimes necessitate minimal to substantial workups. Thus, this TBL is a useful, relevant, and effective exercise for residents-in-training to review and understand the management of hypertension. Topics: Hypertension, hypertensive emergency, asymptomatic hypertension, flash pulmonary edema, aortic dissection, intracranial hemorrhage, warfarin reversal, team-based learning.

Calcium Channel Blocker Overdose.

Audience: Emergency medicine residents and medical students on emergency medicine rotation. Background: Calcium channel blocker (CCB) overdoses can be severe with potentially serious adverse outcomes. CCBs work by blocking the calcium channels on smooth and cardiac muscle tissue. At low dose ranges, dihydropyridine CCBs (such as nifedipine, amlodipine, and nicardipine) block the L-type calcium receptors in the peripheral vasculature, whereas non-dihydropyridine CCBs (such as: verapamil and diltiazem) affect the L-type calcium receptors in the myocardium.1 Because of this distinction, dihydropyridine CCB toxicity manifests as arterial vasodilation and non-dihydropyridine CCB toxicity is associated with cardiac manifestations such as bradycardia and negative inotropy.2 It is important to note that in high concentrations (such as in overdoses), CCBs lose specificity for their specific receptors and can show all the manifestations of toxicity such as bradycardia, peripheral vasodilation, and hypotension. Patients can develop both vasoplegic shock from peripheral vasodilation and cardiogenic shock. This is a high acuity low occurrence case with infrequently used but specific treatments, and thus this case provides educational value. Educational Objectives: At the end of this oral board session, examinees will: (1) demonstrate ability to evaluate a patient with undifferentiated shock with bradycardia and discuss the differential diagnosis, (2) recognize the signs and symptoms of calcium channel blocker overdose, (3) demonstrate ability to manage treatment of a patient with calcium channel overdose. Educational Methods: This oral board case followed the standard American Board of Emergency Medicine-style case in a tertiary care hospital with access to all specialists and resources needed. This case was tested using 12 resident volunteers ranging from PGY 1-2 in an ACGME (Accreditation Council for Graduate Medical Education) accredited emergency medicine residency program. Research Methods: Immediate feedback was solicited both from the learners and from the evaluators following the debriefing session. Residents were asked to evaluate the educational value of the case using a 1-5 Likert scale (5 being excellent). Evaluators were asked to score the residents using the ACGME core competencies with a scale of 1-8, 1-4 being unacceptable and 5-8 being acceptable. Results: Seven PGY1 residents and five PGY2 residents, thus twelve residents in total, completed the case. The average score was 5.10/8. Three residents missed zero critical actions. The most common critical action missed was consulting cardiology or cardiothoracic surgery for circulatory support options. Many residents failed to recognize that the patient did not have a perfusing blood pressure at the beginning of the case and did not start CPR. Although most residents recognized the patient's hemodynamic collapse was from a calcium channel blocker overdose, most did not know the treatment for this beyond atropine and intravenous fluids.The learners rated the educational value of the case as 4.9/5. Seven residents reported that the case definitely increased their medical knowledge; five residents reported that it somewhat increased their medical knowledge. All residents rated the case as helpful in preparing to manage this medical condition. Discussion: The educational content from this case was effective. This is a high acuity low occurrence case that has unique treatments that are not commonly used. This makes this case excellent for practice and discussion. We learned during implementation that this case has a high degree of difficulty compared to other cases, and junior learners will need more prompting. It is also important for the proctor to keep the case moving because there is a lot to cover in the allotted amount of time. Topics: Calcium channel blocker overdose, toxicology.

Does Applicant Gender Have an Effect on Standardized Letters of Evaluation Obtained During Medical Student Emergency Medicine Rotations?

BACKGROUND: The standardized letter of evaluation (SLOE) in emergency medicine (EM) is one of the most important items in a student's application to EM residency and replaces narrative letters of recommendation. The SLOE ranks students into quantile categories in comparison to their peers for overall performance during an EM clerkship and for their expected rank list position. Gender differences exist in several assessment methods in undergraduate and graduate medical education. No authors have recently studied whether there are differences in the global assessment of men and women on the SLOE. OBJECTIVES: The objective of this study was to determine if there is an effect of student gender on the outcome of a SLOE. METHODS: This was a retrospective observational study examining SLOEs from applications to a large urban, academic EM residency program from 2015 to 2016. Composite scores (CSs), comparative rank scores (CRSs), and rank list position scores (RLPSs) on the SLOE were compared for female and male applicants using Mann-Whitney U-test. RESULTS: From a total 1,408 applications, 1,038 applicants met inclusion criteria (74%). We analyzed 2,092 SLOEs from these applications. Female applicants were found to have slightly lower and thus better CRSs, RLPSs, and CSs than men. The mean CRS for women was 2.27 and 2.45 for men (p < 0.001); RLPS for women was 2.32 and 2.52 for men (p < 0.001) and CS was 4.59 for women and 4.97 for men (p < 0.001). CONCLUSIONS: Female applicants have somewhat better performance on the EM SLOE than their male counterparts.

A Retrospective Cohort Study of the Effect of Home Institution on Emergency Medicine Standardized Letters of Evaluation.

BACKGROUND: The standardized letter of evaluation (SLOE) was developed to make letters of recommendation in emergency medicine (EM) more objective and discerning. Typically, students obtain one SLOE from a home EM rotation and at least one more SLOE from an away clerkship. It is unclear if students perform better on their home or away EM rotations. OBJECTIVE: The purpose of this study was to determine if students perform better on the group SLOE at their home institution compared to an away institution. METHODS: The authors performed a retrospective application review of all allopathic applicants to an urban, academic EM residency program. The authors calculated a composite score (CS) for each group SLOE, using the global assessment scores for comparative rank and rank list position. A lower CS indicates better performance. The authors compared mean CS for students' first home rotations with first away rotations. For students in the study who had a third (second away or second home site) SLOE available, the authors compared mean CS on the students' first SLOEs with mean CS on the students' third SLOEs. RESULTS: A total of 624 records were included in the primary analysis. There was a small, but significant difference between mean CS for students' home rotations when compared to away rotations (4.67 vs. 4.85, p = 0.024). Students performed better on their home rotations. Students who had three SLOEs available performed worse on their third rotation (first = 4.40, second = 4.63, third = 4.77, p = 0.012 for first vs. third). For all available SLOEs, more than 50% of students fell into the top 10% or top one-third categories. CONCLUSION: Students perform slightly better on their home EM rotations. Students' mean SLOE CS is slightly worse for a third rotation when compared to a first rotation.

Submassive Central Saddle and Extensive Bilateral Pulmonary Embolism Presenting as Syncope Treated with Catheter-directed Therapy.

Massive and submassive pulmonary emboli (PE) are rare but potentially life-threatening medical conditions that necessitate immediate recognition and appropriate treatment. We report a 52-year-old man who was found to have a submassive central saddle and extensive bilateral PEs after experiencing a syncopal event and who had evidence of right heart strain and pulmonary hypertension. He was subsequently treated with catheter-assisted thrombectomy and pulmonary artery tissue plasminogen activator administration. This case report presents an outcome in a patient who received an innovative therapy that has not been well established in this subset of patients.

Use of Physician-in-Triage Model in the Management of Abdominal Pain in an Emergency Department Observation Unit.

INTRODUCTION: Given the nationwide increase in emergency department (ED) visits it is of paramount importance for hospitals to find efficient ways to manage patient flow. The purpose of this study was to determine whether there is a significant difference in success rates, length of stay (LOS), and other demographic factors in two cohorts of patients admitted directly to an ED observation unit (EDOU) under an abdominal pain protocol by a physician in triage (bypassing the main ED) versus those admitted via the traditional pathway (evaluated and treated in the main ED prior to EDOU admission). METHODS: This was a retrospective cohort study of patients admitted to a protocol-driven EDOU with a diagnosis of abdominal pain in a single university hospital center ED. We obtained compiled data for all patients admitted to the EDOU with a diagnosis of abdominal pain that met EDOU protocol admission criteria. We divided data for each cohort into age, gender, payer status, and LOS. The data were then analyzed to assess any significant differences between the cohorts. RESULTS: A total of 327 patients were eligible for this study (85 triage group, 242 main ED group). The total success rate was 90.8% (n=297) and failure rate was 9.2% (n=30). We observed no significant differences in success rates between those dispositioned to the EDOU by triage physicians (90.6%) and those via the traditional route (90.5 % p) = 0.98. However, we found a significant difference between the two groups regarding total LOS with significantly shorter main ED times and EDOU times among patients sent to the EDOU by the physician-in-triage group (p< .001). CONCLUSION: There were no significant differences in EDOU disposition outcomes in patients admitted to an EDOU by a physician-in-triage or via the traditional route. However, there were statistically significant shorter LOSs in patients admitted to the EDOU by triage physicians. The data from this study support the implementation of a physician-in-triage model in combination with the EDOU in improving efficiency in the treatment of abdominal pain. This knowledge may spur action to cut healthcare costs and improve patient flow and timely decision-making in hospitals with EDOUs.