Emergency medicine rural rotations: a program director's guide.

The Institute of Medicine's 2006 report titled "Hospital-Based Emergency Care: At the Breaking Point" called national attention to the lack of specialty-trained emergency care practitioners, particularly in rural America. One suggested strategy for narrowing the gap between the prevalence of residency-trained, board-certified emergency physicians practicing in rural and urban emergency departments is the development of rural clinical experiences for emergency medicine residents during the course of their training. This article addresses promotion of a rural emergency medicine rotation to hospital leadership and resident recruits, examines funding sources, discusses medical liability and disability insurance options, provides suggestions for meeting faculty and planned educational activity residency review committee requirements, and offers guidance about site selection to direct emergency medicine academic leaders considering or planning a new rural emergency medicine rotation.

Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

There has been tremendous progress in reducing disability and death from ACS. But many patients still die before reaching the hospital because patients and family members fail to recognize the signs of ACS and fail to activate the EMS system. Once the patient with ACS contacts the healthcare system, providers must focus on support of cardiorespiratory function, rapid transport, and early classification of the patient based on ECG characteristics. Patients with STEMI require prompt reperfusion; the shorter the interval from symptom onset to reperfusion, the greater the benefit. In the STEMI population, mechanical reperfusion with percutaenous coronary intervention improves survival and decreases major cardiovascular events compared to fibrinolysis. Patients with UA/NSTEMI (non-STEMI ACS) or nonspecific or normal ECGs require risk stratification and appropriate monitoring and therapy. Healthcare providers can improve survival rates and myocardial function of patients with ACS by providing skilled, efficient, and coordinated out-of-hospital and in-hospital care.

El gran reto del dolor torácico en los servicios de urgencias / The significant challenge of chest pain in the emergency department

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Critical care aspects in the management of patients with acute coronary syndromes.

The spectrum of acute coronary syndromes (ACS) includes several clinical complexes that frequently cause critical instability in affected patients. This article focuses on several critical care aspects of these unstable ACS patients. The management of cardiogenic shock can be particularly challenging because the mechanical defects are varied in cause, severity, and specific treatment. Complications of fibrinolytic therapy are potentially deadly and arrhythmias are relatively common in the ACS patients. Discussions on the management of these problems should help the emergency physician more effectively to treat critically ill patients with ACS.

The effect of performance incentives on resident documentation in an emergency medicine residency program.

We sought to improve resident chart documentation in an academic emergency department using an incentive. A stipend for educational expenses was offered to residents for documenting charts above specific threshold Evaluation & Management (E&M) levels. Comparisons were made with historical levels. Twenty-two residents participated over 4 months (70% received the stipend). Documentation levels increased significantly from 2.86 and 3.04 during historical controls to 3.31 during the study period (p < 0.05). Fifty-six percent of charts were documented at 99284 or 99285 during the study period compared to 39% and 23% in the control periods (p < 0.05). Three months after the plan (with no incentives), documentation continued to improve, with 59% documented at 99284 or 99285. Mean collection per patient was $48.05 for the study period and $42.36 and $35.86 for the historical periods (p < 0.05). Implementation of a resident incentive program to enhance chart documentation may considerably improve documentation and resident education in proper chart documentation.

Acute reperfusion therapy in acute myocardial infarction.

The ECG classification of acute myocardial infarctions has had a profound influence on the treatment of patients with AMI. Deciding whether a patient has ST-segment elevations or a new left bundle branch block or neither of these findings on ECG launches the treating physician down two different treatment pathways: patients with ST-elevation MI need to be assessed for immediate re-perfusion therapy, whereas patients with non-ST-elevation MI are best treated with aggressive medical management without acute reperfusion.

The interrater variation of ED abdominal examination findings in patients with acute abdominal pain.

OBJECTIVE: The physical examination of the abdomen is crucial to emergency department (ED) management of patients with abdominal pain. We sought to determine the interrater variation between attending and resident physicians in detecting abdominal exam findings. METHODS: Research enrollers surveyed attending and resident physicians on abdominal exam findings in the ED in patients with abdominal pain. Strength of agreement was calculated using the kappa statistic. RESULTS: A convenience sample of 122 surveys was completed. Calculated kappa results are in parentheses. There was almost perfect agreement on the presence of masses and substantial agreement on the need for imaging studies. There was moderate agreement on guarding, distension, tenderness, and need for laboratory tests and surgical consultation. For 88 (72%) patients with tenderness, substantial agreement was calculated for epigastric tenderness, moderate agreement on right upper quadrant, supraumbilical, suprapubic, left lower quadrant, right lower quadrant tenderness, and fair agreement on left upper quadrant tenderness. Sixty-one (50%) patients received pain medicine in the ED. Among those, there was fair agreement on a presence of a surgical abdomen. Upper level resident physicians noted a higher level of agreement with the attending physician for tenderness than junior resident physicians. CONCLUSIONS: There was moderate agreement between resident and attending physicians for most of the findings in patients with abdominal pain. Recognition that selected findings are more variable than others should encourage careful confirmation of resident physicians' assessments in teaching settings.

Reciprocal ST segment depression: impact on the electrocardiographic diagnosis of ST segment elevation acute myocardial infarction.

Acute myocardial infarction (AMI) is one of many causes of electrocardiographic ST segment elevation (STE) in ED chest pain (CP) patients; at times, the electrocardiographic diagnosis may be difficult. Coexistent ST segment depression has been reported to assist in the differentiation of non-infarction causes of STE from AMI-related ST segment elevation. The objective was to determine the effect of AMI diagnosis on the presence of STD among ED CP patients with electrocardiographic STE. Adult CP patients with electrocardiographic STE in at least 2 anatomically distributed leads were reviewed for the presence or absence of ST segment depression in at least 1 lead and separated into 2 groups, both with and without ST segment depression. A comparison of the 2 groups was performed in 2 approaches: all STE patients and then only with STE patients who lacked confounding electrocardiographic pattern (bundle branch block [BBB], left ventricular hypertrophy [LVH], or right ventricular paced rhythm [VPR]). All patients in the study underwent prolonged observation in the ED (at least 8 hours) with 3 serial troponin T determinations and 3 electrocardiograms (ECG). AMI was diagnosed by abnormal serum troponin T values (>0.1 mg/dL); electrocardiographic STE diagnoses of non-AMI causes were determined by medical record review. There were 171 CP patients with STE were entered in the study with 112 (65.5%) individuals show ST segment depression. When considering all study patients, ST segment depression was present at statistically equal rates in AMI and non-AMI situations (P = NS). The sensitivity, specificity, positive predictive value, and negative predictive value for the electrocardiographic diagnosis of AMI were 63%, 34%, 30%, and 67%, respectively. Patients with confounding patterns (LVH 46, BBB 19, and VPR 6) were removed from the analysis group, leaving 100 patients for analysis; 38 of these patients had ST segment depression. When considering this group of study patients, ST segment depression was present significantly more often in AMI patients (P <.0001). The sensitivity, specificity, positive predictive value, and negative predictive value for the electrocardiographic diagnosis of AMI were 69%, 93%, 93%, and 71%, respectively. Clinical diagnoses were as follows: 56 AMI, 50 USAP, and 65 noncoronary syndrome. When all CP patients with electrocardiographic STE are considered, the presence of ST segment depression is not helpful in distinguishing AMI from non-AMI. If one considers only patterns which lack electrocardiographic ST segment depression caused by altered intraventricular conduction, the presence of ST segment depression strongly suggests the diagnosis of AMI. In these cases, reciprocal ST segment depression is of considerable value in establishing the electrocardiographic diagnosis of STE AMI.