Spontaneous globe rupture in a patient with extensive ocular surgical history.

Globe rupture is visually dramatic in appearance for emergency clinicians and is a sight-threatening injury for the patient. It requires prompt ophthalmologic surgical intervention for optimal outcomes. Cases are typically the result of ocular trauma; however, this case highlights a rare instance of spontaneous globe rupture in a patient with an extensive ocular surgical history.

Assessment of Emergency Medicine Resident Performance in a Pediatric In Situ Simulation Using Multi-Source Feedback.

Introduction Multi-source feedback (MSF) is an evaluation method mandated by the Accreditation Council for Graduate Medical Education (ACGME). The Queen's Simulation Assessment Tool (QSAT) has been validated as being able to distinguish between resident performances in a simulation setting. The QSAT has also been demonstrated to have excellent MSF agreement when used in an adult simulation performed in a simulation lab. Using the QSAT, this study sought to determine the degree of agreement of MSF in a single pediatric (Peds) simulation case conducted in situ in a Peds emergency department (ED). Methods This Institutional Review Board-approved study was conducted in a four-year emergency medicine residency. A Peds resuscitation case was developed with specific behavioral anchors on the QSAT, which uses a 1-5 scale in each of five categories: Primary Assessment, Diagnostic Actions, Therapeutic Actions, Communication, and Overall Assessment. Data was gathered from six participants for each simulation. The lead resident self-evaluated and received MSF from a junior peer resident, a fixed Peds ED nurse, a random ED nurse, and two faculty (one fixed, the other from a dyad). The agreement was calculated with intraclass correlation coefficients (ICC). Results The simulation was performed on 35 separate days over two academic years. A total of 106 MSF participants were enrolled. Enrollees included three faculty members, 35 team leaders, 34 peers, 33 ED registered nurses (RN), and one Peds RN; 50% of the enrollees were female (n=53). Mean QSAT scores ranged from 20.7 to 23.4. A fair agreement was demonstrated via ICC; there was no statistically significant difference between sources of MSF. Removing self-evaluation led to the highest ICC. ICC for any single or grouped non-faculty source of MSF was poor. Conclusion Using the QSAT, the findings from this single-site cohort suggest that faculty must be included in MSF. Self-evaluation appears to be of limited value in MSF with the QSAT. The degree of MSF agreement as gathered by the QSAT was lower in this cohort than previously reported for adult simulation cases performed in the simulation lab. This may be due to either the pediatric nature of the case, the location of the simulation, or both.

Assessment of Emergency Medicine Resident Performance in an Adult Simulation Using a Multisource Feedback Approach.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) specifically notes multisource feedback (MSF) as a recommended means of resident assessment in the emergency medicine (EM) Milestones. High-fidelity simulation is an environment wherein residents can receive MSF from various types of healthcare professionals. Previously, the Queen's Simulation Assessment Tool (QSAT) has been validated for faculty to assess residents in five categories: assessment; diagnostic actions; therapeutic actions; interpersonal communication, and overall assessment. We sought to determine whether the QSAT could be used to provide MSF using a standardized simulation case. METHODS: Prospectively after institutional review board approval, residents from a dual ACGME/osteopathic-approved postgraduate years (PGY) 1-4 EM residency were consented for participation. We developed a standardized resuscitation after overdose case with specific 1-5 Likert anchors used by the QSAT. A PGY 2-4 resident participated in the role of team leader, who completed a QSAT as self-assessment. The team consisted of a PGY-1 peer, an emergency medical services (EMS) provider, and a nurse. Two core faculty were present to administer the simulation case and assess. Demographics were gathered from all participants completing QSATs. We analyzed QSATs by each category and on cumulative score. Hypothesis testing was performed using intraclass correlation coefficients (ICC), with 95% confidence intervals. Interpretation of ICC results was based on previously published definitions. RESULTS: We enrolled 34 team leader residents along with 34 nurses. A single PGY-1, a single EMS provider and two faculty were also enrolled. Faculty provided higher cumulative QSAT scores than the other sources of MSF. QSAT scores did not increase with team leader PGY level. ICC for inter-rater reliability for all sources of MSF was 0.754 (0.572-0.867). Removing the self-evaluation scores increased inter-rater reliability to 0.838 (0.733-0.910). There was lesser agreement between faculty and nurse evaluations than from the EMS or peer evaluation. CONCLUSION: In this single-site cohort using an internally developed simulation case, the QSAT provided MSF with excellent reliability. Self-assessment decreases the reliability of the MSF, and our data suggest self-assessment should not be a component of MSF. Use of the QSAT for MSF may be considered as a source of data for clinical competency committees.

Alternative Markers of Performance in Simulation: Where We Are and Where We Need To Go.

This article on alternative markers of performance in simulation is the product of a session held during the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." There is a dearth of research on the use of performance markers other than checklists, holistic ratings, and behaviorally anchored rating scales in the simulation environment. Through literature review, group discussion, and consultation with experts prior to the conference, the working group defined five topics for discussion: 1) establishing a working definition for alternative markers of performance, 2) defining goals for using alternative performance markers, 3) implications for measurement when using alternative markers, identifying practical concerns related to the use of alternative performance markers, and 5) identifying potential for alternative markers of performance to validate simulation scenarios. Five research propositions also emerged and are summarized.

Baclofen Toxicity Causing Acute, Reversible Dyskinesia.

The following unique case demonstrates an episode of acute dyskinesia secondary to oral baclofen toxicity. We discuss an 80-year-old man with a history of Stage III chronic kidney disease, coronary artery disease, diabetes and stroke who presented to the Emergency Department with new onset of behavioral changes and irregular jerking movements. The patient had been recently prescribed baclofen 10mg twice daily for a back strain he suffered; he subsequently was admitted to the hospital, and his symptoms resolved within 48 hours of admission and discontinuance of baclofen.

Diagnosis and management of depression in children and young people: summary of updated NICE guidance.

This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

Sex differences in cardiac arrest survivors who receive therapeutic hypothermia.

OBJECTIVE: Sex differences have not been well defined for patients undergoing therapeutic hypothermia (TH). We aimed to determine sex differences in mortality and Cerebral Performance Category (CPC) scores at discharge among those receiving TH. METHODS: This retrospective cohort study used data abstracted from an "ICE alert" database, an institutional protocol expediting mild TH for postarrest patients. Quality assurance variables (such as age, time to TH, CPC scores, and mortality) were reviewed and compared by sex. χ2 Test and Wilcoxon rank sum test were used. Stepwise logistic regression was used to assess the association between mortality and sex, while controlling for patient characteristics and clinical presentation of cardiac arrest. RESULTS: Three hundred thirty subjects were analyzed, 198 males and 132 females. Subjects' mean age (SD) was 61.7 years (15.0); there was no significant sex difference in age. There were no statistically significant sex differences in history of coronary artery disease, congestive heart failure, arrhythmia, hypertension, chronic obstructive pulmonary disease, renal disease, type 1 and/or type 2 diabetes mellitus, or those previously healthy. Obesity (body mass index>35 kg/m2) was more likely in females (37, 28.0%) than males (35, 17.7%); P=.03. Females (64, 49.6%) were more likely than males (71, 36.8%) to have shock; P=.02. There was no difference in arrest to initiating hypothermia, but there was a significant difference in time to target temperature (in median minutes, interquartile range): male (440, 270) vs female (310, 270), P=.003. There was no statistical difference in CPC at discharge. Crude mortality was not different between sexes: male, 67.7%; female, 70.5%; P=.594. However, after controlling for differences in age, obesity, shock, and other variables, females were less likely to die (odds ratio, 0.46; 95% confidence interval, 0.23-0.92; P=.03) than males. CONCLUSION: There is no statistically significant difference in CPC or crude mortality outcomes between sexes. After adjusting for confounders, females were 54% less likely to die than males.

Pharmacological blockade of the dive response: effects on heart rate and diving behaviour in the harbour seal (Phoca vitulina).

While diving, harbour seals (Phoca vitulina) manage their oxygen stores through cardiovascular adjustments, including bradycardia, a concurrent reduction in cardiac output, and peripheral vasoconstriction. At the surface, post-dive tachycardia facilitates rapid reloading of oxygen stores. Although harbour seals can tolerate >20 min of submergence, the majority of their natural dives are only 2-6 min and are usually followed by surface intervals that are <1 min, so they spend approximately 80% of their time submerged. Given that harbour seals meet their ecological needs through repetitive short aerobic dives, we were interested in the functional role, if any, of the dive response during these short dives. During voluntary diving in an 11 m deep tank, the cardiovascular responses to submergence of five harbour seals were manipulated using specific pharmacological antagonists, and the effects on diving behaviour were observed. Effects of pharmacological blockade on heart rate were also examined to assess the autonomic control of heart rate during voluntary diving. Heart rate was recorded using subcutaneous electrodes and data loggers, while diving behaviour was monitored using a video camera. The muscarinic blocker methoctramine blocked diving bradycardia, the alpha-adrenergic blocker prazosin blocked diving vasoconstriction, and the beta-adrenergic blocker metoprolol blocked post-dive tachycardia. Heart-rate analysis indicated that diving bradycardia is primarily modulated by the vagus, while post-dive tachycardia results from parasympathetic withdrawal as well as increased sympathetic stimulation of the heart. None of the pharmacological blockers had any effect on average dive or surface interval duration. Seals maintained a high percentage of time spent diving in all treatments. Thus, harbour seals do not appear to need the dive response during short dives in order to maintain an efficient dive strategy.