Using computerized data to identify adverse drug events in outpatients.

OBJECTIVE: To evaluate the use of a computer program to identify adverse drug events (ADEs) in the ambulatory setting and to evaluate the relative contribution of four computer search methods for identifying ADEs, including diagnosis codes, allergy rules, computer event monitoring rules, and text searching. DESIGN: Retrospective analysis of one year of data from an electronic medical record, including records for 23,064 patients with a primary care physician, of whom 15,665 actually came for care. MEASUREMENT: Presence of an ADE; sensitivity and specificity of computer searches for ADE. RESULTS: The computer program identified 25,056 incidents, which were associated with an estimated 864 (95 percent confidence interval [CI], 750-978) ADES. Thus, the ADE rate was 5.5 (CI, 5.2-5.9) per 100 patients coming for care. Furthermore, in 79 (CI, 68-89) ADEs, the patient required hospitalization, resulting in an estimated rate of 3.4 (CI, 2.7-4.3) admissions per 1,000 patients. The sensitivity of the search methods for identifying ADEs was estimated to be 58 (CI, 18-98) percent, and the estimated specificity was 88 (CI, 87-88) percent. The positive predictive value was 7.5 (CI, 6.5-8.5) percent, and the negative predictive value was 99.2 (CI, 95.5-99.98) percent. Compared with age and gender-matched controls with no positive screen, patients with ADEs had twice as many outpatient visits and were taking nearly three times as many drugs. Antihypertensives, ACE-inhibitors, antibiotics, and diuretics were associated with 56 (CI, 47-65) percent of ADES. Among ADEs, 23 (CI, 16-32) percent were life-threatening or serious, and 38 (CI, 29-47) percent were judged preventable. CONCLUSION: Computerized search programs can detect ADEs, and free-text searches were especially useful. Adverse drug events were frequent, and admissions were not rare, although most hospitals today do not identify them. Thus, such detection programs demonstrate "value-added" for the electronic record and may be useful for directing and assessing the impact of quality improvement efforts.

A computerized method for identifying incidents associated with adverse drug events in outpatients.

INTRODUCTION: In inpatients, computer monitors have been used to improve the detection of adverse drug events (ADEs). However, similar programs have not been available in outpatients. OBJECTIVE: To describe an approach for detecting incidents suggesting that an ADE may have occurred in outpatients by adapting methods from inpatient computer monitoring and developing terminology searches of electronic medical records. METHODS: One year of information from the outpatient electronic medical record (EMR) at one hospital and its clinics was reviewed. Altogether, 23064 patients and 88514 visits were identified. Patient demographics, medical problem lists, ICD-9 claims, patient allergies, medication history and all clinic visit notes were extracted and merged. We then searched for incidents suggesting that an ADE might be present using four methods: ICD-9 claims, new allergies, computer rules linking laboratory data to known medication exposures, and a medical terminology lexicon (M2D2). In this report, we describe how these search methods were developed to allow for ADE identification. CONCLUSION: The ability to carry out such quality-related work is an example of the benefits of the outpatient EMR that may not be apparent to those institutions considering adopting it.

High altitude retinal hemorrhages in a Colorado skier.

High altitude retinal hemorrhages are commonly seen at altitudes above 4270 m. While these hemorrhages are generally asymptomatic, macular involvement may result in permanent visual acuity deficit. We present the case of a 29-year-old male recreational skier who traveled to a ski resort at 2930 m, ascended to 3470 m, and developed acute mountain sickness, high altitude pulmonary edema, and bilateral retinal hemorrhages. A funduscopic examination to determine if macular retinal hemorrhage is present may be performed by clinicians in the final assessment of patients following altitude illness.

Seeking care for nonurgent medical conditions in the emergency department: through the eyes of the patient.

INTRODUCTION: The policy goal of shifting nonurgent visits from the emergency department to nonemergency health care settings is commonly devised, planned, and implemented without considering patients' perspectives. The purpose of this study was to gain an understanding of the context in which patients choose to seek health care in an emergency department. Human science provided the framework for this exploratory descriptive research study. METHODS: This study was conducted at an urban, university emergency department in Denver, Colo. Uninsured adult patients triaged as nonurgent who were being discharged home were eligible to participate. Eligible patients from 15 randomly selected shifts were asked to participate. Following their ED visit, open-ended interviews began with the question, "Can you tell me the story, or the chain of events, that led to your coming to the emergency department today?" Each interview was audiotaped. Transcripts were analyzed to identify common themes. Patients also rated their severity of illness from 1 (not severe) to 5 (life-threatening), and they rated their satisfaction with the health care they received from 1 (not satisfied) to 5 (extremely satisfied). RESULTS: The 30 study participants ranged in age from 17 to 60 years; 22 participants (73%) were women. Most patients (73%) rated their severity of illness as 3 or less and their satisfaction with the health care they received as 4 or more (83%). Five themes for seeking care were identified: (1) toughing it out, (2) symptoms overwhelming self-care measures, (3) calling a friend, (4) nowhere else to go, and (5) convenience. Despite the fact that the patients had nonurgent medical problems, their stories revealed that distress in their lives had influenced their need for emergency care. CONCLUSIONS: Access was prominent in the minds of uninsured patients seeking ED care for nonurgent medical diagnoses. Typically, patients did not perceive themselves as having an urgent problem, had been unsuccessful in gaining access to alternative non-ED health care settings, and found the emergency department to be a convenient and quality source of health care. The patients' stories relayed a context for ED visits that goes beyond medical diagnoses. This perspective has important implications for quality care delivery and for including patients in planning ways to access emergency health care.

Unique curriculum for emergency medicine residents as medical directors for rural out-of-hospital agencies.

BACKGROUND: Many rural communities have difficulty maintaining a medical director for their emergency medical services (EMS). Local physicians may be overwhelmed, be hesitant to take on additional responsibilities, and feel unskilled in providing the necessary leadership. Without a medical director, rural EMS agencies are frequently forced to shut down, thus depriving the community of local out-of-hospital care. OBJECTIVES: To meet the needs of rural EMS agencies for medical direction, to provide a unique opportunity for emergency medicine (EM) residents to acquire EMS medical direction skills, and to fulfill the obligation of EM residencies to provide both didactic and experiential training in EMS. PROGRAM DESCRIPTION: This article describes a curriculum, now being used in Colorado, for placing EM residents as EMS medical directors for rural out-of-hospital agencies that have lost their medical directors. Residents visit these rural communities 6-12 times a year, provide continuing education through interactive lectures, develop or revise EMS protocols and policies, perform quality assurance reviews, troubleshoot problems, and assist in EMS planning for the community. Residents are supervised by the Colorado state EMS medical director. CONCLUSIONS: This unique program enables local EMS agencies to continue their service while providing clear educational benefit for the EM residents. This paper demonstrates how this program has been working successfully in the state of Colorado by placing residents in four distinct rural and mountainous communities.

Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1,561 patients.

BACKGROUND: Thoracic aortic injury (TAI) is a devastating condition in which prompt recognition can obviate morbidity and mortality. It is a long-held belief that TAI is more likely when there is a "major mechanism of injury." The purposes of this prospective study were to determine mechanism characteristics that are predictive of TAI and to evaluate chest computed tomography (CT) as a screening tool for TAI. METHODS: Over a 5 1/2 year period, blunt chest trauma patients at two Level I trauma centers were evaluated for potential TAI. Patients were assigned mechanism and radiograph scores from 1 (low suspicion for TAI) to 5 (very high suspicion for TAI). Immediate aortography was obtained when suspicion for TAI was very high. The remaining patients were evaluated with contrast-enhanced chest CT. Confirmatory aortography was obtained on all positive chest CT scans and on all patients with mechanism scores of 4 or 5 even if the CT was negative. Mechanism and radiographic data were correlated with the results of aortic imaging. RESULTS: Of the 1,561 patients evaluated for TAI, 30 aortic injuries were found. The assessment of mechanism was imperfect with a reliance on often incomplete and subjective data. The subjective mechanism score proved to be the most useful predictor of TAI. Radiographic scores were useful but insensitive for intimal injuries. Computed tomography was found to have 100% and 100% NPV for TAI. CONCLUSION: Considering the inherent difficulties in identifying patients at risk for TAI and the effectiveness of chest CT as a screening tool for aortic injury, we recommend liberal use of chest CT in blunt chest trauma. Guidelines for determining the need for aortic imaging are outlined.

Can chest CT be used to exclude aortic injury?

PURPOSE: To determine whether chest computed tomography (CT) can be used to exclude aortic injury. MATERIALS AND METHODS: Patients in whom there was very high suspicion of traumatic aortic injury were examined with aortography only. Other patients were examined with contrast material-enhanced CT. Follow-up aortography was performed in all patients with moderate to high suspicion of traumatic aortic injury and in all patients with CT scans that were positive for traumatic aortic injury. CT scans were regarded as positive when they showed mediastinal hematoma or direct findings of aortic injury. During a 4 1/2-year period, 1,009 patients (263 female, 746 male; age range, 3-90 years) were evaluated for possible traumatic aortic injury. RESULTS: Of the 207 patients who underwent aortography directly without CT, 10 had traumatic aortic injury. Of the 802 patients who were examined with CT, 382 underwent follow-up aortography. In this group, there were 10 true-positive and no false-negative CT scans. CT had 100% sensitivity and a 100% negative predictive value for the detection of traumatic aortic injury.

The diagnosis of acute mountain sickness in preverbal children.

OBJECTIVE: To establish diagnostic criteria for acute mountain sickness (AMS) in preverbal children. DESIGN: Nonrandomized control trial. SETTING: Ambulatory. PARTICIPANTS: Children aged 3 through 36 months and adults from the Denver, Colo, area (altitude, 1610 m). MAIN OUTCOME MEASURES: The Lake Louise Scoring System was modified, using a fussiness score as the headache equivalent and a pediatric symptom score to assess appetite, vomiting, playfulness, and ability to sleep. Acute mountain sickness was assessed by combining the fussiness and pediatric symptom scores to produce what we termed the Children's Lake Louise AMS Score (CLLS). INTERVENTIONS: Parents recorded the fussiness score at 11 AM, 1, 3, and 5 PM, and the pediatric symptom score at 3:00 PM each day. Each subject traveled twice, with 1 day considered a control. Days 1 and 2 were measurements at home; day 3 reflected travel without altitude change to 1615 m; and 1 week later, day 4 involved travel to 3488 m. On days 3 and 4 the accompanying adults completed the Lake Louise Scoring System. RESULTS: Twenty-three subjects (14 boys; mean+/-SD age, 20.7+/-9.0 months) participated. The mean CLLS demonstrated no differences on days 1, 2, or 3. On day 4, 5 subjects (21.7%) had AMS, established as a CLLS of 7 or higher, and these scores normalized 2 hours after descent. Forty-five adults participated and 9 (20%) had AMS. CONCLUSIONS: We define AMS in preverbal children as a CLLS of 7 or higher with a fussiness score of 4 or higher and a pediatric symptom score of 3 or higher, in the setting of recent altitude gain. The incidence of AMS in preverbal children (21.7%) was similar to that in adults (20%).

High-altitude medicine.

This article discusses prevention, recognition, and treatment of altitude illnesses, especially acute mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema. Physicians advising travelers and trekkers who will be visiting high-altitude areas will find an organized approach to giving pretravel advice. Physicians practicing in or visiting high-altitude areas will find guidelines for diagnosis and treatment. This article also addresses the issue of patients with underlying diseases who wish to travel to high-altitude destinations.

Open thoracotomy procedural competency: validity study of teaching and assessment modalities.

STUDY OBJECTIVES: To determine (1) reliability and validity estimates of three modalities used to assess open thoracotomy procedural competency and (2) the effect of computer practice on procedural performance as measured by the three assessment modalities. METHODS: An experimental, sequential assessment design with volunteer examinees completing all three assessment modalities (paper, computer, pig model) was implemented at the animal support facilities of a university medical school with an affiliated emergency medicine residency program. Level of physician training (student, resident, faculty) and type of computer practice (thoracotomy, cricothyrotomy) were independent variables. Procedural competency scores were determined for each modality; scores were defined in terms of performance time and performance accuracy for three thoracotomy procedures (opening the chest, pericardiotomy, and aortic cross-clamping). RESULTS: Thoracotomy performance on the pig reliably discriminated among examinees known to differ in level of training. However, computer simulation performance did not significantly differ among examinees with different levels of training. Computer simulation practice significantly improved later performance on the computer assessment (P < .05) but not on the pig assessment. The greatest predictor of procedural competency (time and accuracy) on the pig assessment was the ability to sequentially order procedural steps. CONCLUSION: This study establishes the pig model as superior to the paper and computer models as the criterion standard for open thoracotomy assessment. Psychometric properties support the pig model as the most reliable and valid model yet described for assessing thoracotomy procedural competency. Computer simulation practice using visual images (complex anatomy) and the sequential ordering of procedural steps through paper modeling show promise for teaching and assessment of prerequisite skills required to develop psychomotor procedural competency.

High-altitude pulmonary edema at a ski resort.

Medical records of 150 patients with high-altitude pulmonary edema seen over a 39-month period in a Colorado Rocky Mountain ski area at 2,928 m (9,600 ft) (mean age 34.4 years; 84% male) were reviewed. The mean time to the onset of symptoms was 3 +/- 1.3 days after arrival. Common symptoms were dyspnea, cough, headache, chest congestion, nausea, fever, and weakness. Orthopnea, hemoptysis, and vomiting were rare, occurring in 7%, 6%, and 16%, respectively. Symptoms of cerebral edema occurred in 14%. A temperature exceeding 100 degrees F occurred in 20%, and 17% had a systolic blood pressure of 150 mm of mercury or higher. Blood pressures were higher in patients older than 50 years (142 mm of mercury). Rales were present in 85%, and a pulmonary infiltrate was present in 88%; both were most commonly bilateral or on the right side. The amount of infiltrate was mild. Men appeared to be more susceptible than women to high-altitude pulmonary edema. Pulse oximetry in 45 patients showed a mean oxygen saturation of 74% (38% to 93%). Treatment methods depended on severity and included a return to quarters for portable nasal oxygen, an overnight stay in the clinic for continuing oxygen, or a descent to Denver for recovery or admission to a hospital. All patients received oxygen for 2 to 4 hours in the clinic. There were no deaths or complications.

Sea-level physical activity and acute mountain sickness at moderate altitude.

The effect of previous physical conditioning on young well-conditioned mountaineers in relationship to acquiring acute mountain sickness is controversial. Data show both increased and decreased effects on the incidence of altitude illness. How general tourists at moderate altitudes are affected is unknown. To determine the influence of sea-level habitual physical activity on the incidence of mountain sickness, we surveyed 205 participants in a scientific conference at 3,000 m (9,840 ft). A 36-item questionnaire was distributed to the subjects 48 hours after arrival at altitude. Their sea-level physical activity (SLPA) was measured by a published and validated instrument that included questions about patterns of work, sporting, and leisure-time activities. Acute mountain sickness was defined as the presence of 3 or more of the following symptoms: headache, dyspnea, anorexia, fatigue, insomnia, dizziness, or vomiting. Most of the respondents were male (62%) from sea level (89%) with a mean age of 36 +/- 8.7 (standard deviation) years (range, 22 to 65). Nearly all (94%) were nonsmokers, and 28% had acute mountain sickness. The mean SLPA score was 8.0 +/- 1.3 (range, 5.1 to 12.0). No statistically significant difference in mean SLPA scores was found between those with and without acute mountain sickness (8.1 versus 7.8), nor in the individual indices (work, 2.5 versus 2.4; sport, 2.9 versus 2.7; leisure, 2.8 versus 2.7). We conclude that habitual physical activity performed at sea level does not play a role in the development of altitude illness at moderate altitude in a general tourist group.

How well do older persons tolerate moderate altitude?

We studied the physiologic and clinical responses to moderate altitude in 97 older men and women (aged 59 to 83 years) over 5 days in Vail, Colorado, at an elevation of 2,500 m (8,200 ft). The incidence of acute mountain sickness was 16%, which is slightly lower than that reported for younger persons. The occurrence of symptoms of acute mountain sickness did not parallel arterial oxygen saturation or spirometric or blood pressure measurements. Chronic diseases were present in percentages typical for ambulatory elderly persons: 19 (20%) had coronary artery disease, 33 (34%) had hypertension, and 9 (9%) had lung disease. Despite this, no adverse signs or symptoms occurred in our subjects during their stay at this altitude. Our findings suggest that persons with preexisting, generally asymptomatic, cardiovascular or pulmonary disease can safely visit moderate altitudes.

Emergency thoracotomy: comparison of medical student, resident, and faculty performances on written, computer, and animal-model assessments.

OBJECTIVE: In clinical practice, thoracotomy and other critical emergency procedures are rarely required. Consequently, medical students and residents have difficulty acquiring procedural competency in these critical procedures. The authors developed objective written, computer, and animal-model assessments of thoracotomy procedural competency to permit comparison of the reliability and validity of these three procedural assessment modalities. METHODS: Thoracotomy procedural competency was evaluated for 18 persons at three levels of training (medical student, resident, faculty), using written, computer, and animal-model assessments. A prospective, sequential assessment design was used, with the examinees serving as their own controls. Procedural competency was defined in terms of performance time (animal time scale) and performance accuracy (written accuracy, computer accuracy, and animal accuracy scales) for three thoracotomy procedures (opening the chest, pericardiotomy, and aortic cross-clamping). Level of training was the independent variable, and procedural competency scores were the outcome measures. Confounding variables included previous thoracotomy and computer experience. RESULTS: Computer and animal-model assessments produced reliable results (Chronbach's alpha > 0.50). The animal time scale and computer accuracy scale best reflected the expected skill differences among levels of physician training, providing support for construct validity. In contrast, written and animal accuracy scale scores did not significantly differ by level of physician training. Moreover, previous thoracotomy experience (i.e., number of procedures previously performed) was not a significant predictor of procedural competency. CONCLUSIONS: This study demonstrates that critical emergency medicine procedures can be evaluated reliably and validly using computer simulation and animal-model assessments. Neither previous thoracotomy experience nor knowledge of procedure content adequately predicts thoracotomy competency.

Acute mountain sickness in a general tourist population at moderate altitudes.

OBJECTIVE: To determine the incidence of acute mountain sickness in a general population of visitors to moderate elevations, the characteristics associated with it, and its effect on physical activity. DESIGN: A cross-sectional study. SETTING: Resort communities located at 6300 to 9700 feet elevation in the Rocky Mountains of Colorado. PARTICIPANTS: Convenience sample of 3158 adult travelers, 16 to 87 years old (mean age [+/- SD], 43.8 +/- 11.8 years). RESULTS: Twenty-five percent of the travelers to moderate elevations developed acute mountain sickness, which occurred in 65% of travelers within the first 12 hours of arrival. Fifty-six percent of those with symptoms reduced their physical activity. The odds favoring acute mountain sickness were 3.5 times as large for visitors whose permanent residence was below 3000 feet elevation as for those whose residence was above 3000 feet; 2.8 times as large for visitors with previous symptoms of acute mountain sickness; and twice as large in travelers younger than 60 years. Women, obese persons, those in poor or average physical condition, and those with underlying lung disease also had a higher occurrence of acute mountain sickness (P < 0.05). CONCLUSIONS: Acute mountain sickness occurs in 25% of visitors to moderate altitudes and affects activity in most symptomatic visitors. Persons who are younger, less physically fit, live at sea level, have a history of acute mountain sickness, or have underlying lung problems more often develop these symptoms.

Acute mountain sickness in children at 2835 meters.

OBJECTIVE: Acute mountain sickness has been described in adults but little is known concerning its occurrence in children. Our objective was to determine the incidence of acute mountain sickness in children. METHODS: A survey questionnaire was completed by 558 children (aged 9 to 14 years) after they ascended from 1600 to 2835 m and from 405 similarly aged children after travel at sea level. RESULTS: Three or more of the following symptoms in the high-altitude setting were considered as the case definition of acute mountain sickness: headache, loss of appetite, vomiting, fatigue, insomnia, shortness of breath, and dizziness. One hundred fifty-six (28%) of the children at 2835 m developed acute mountain sickness. Three or more symptoms developed in a smaller, but nonetheless considerable, number (86 [21%]) of children at sea level. Headache, shortness of breath, and dizziness were reported more frequently at high altitude than at low altitude, whereas the other symptoms occurred with equal frequency at the two locations. CONCLUSIONS: More than one fourth of the children visiting high altitude developed acute mountain sickness. A high proportion (21%) of children at sea level developed similar symptoms, suggesting that an appreciable portion of the symptoms present were due to factors other than altitude, such as travel, anxiety, or disruption of daily routine.

Reemergence of self-induced abortions.

Two cases of adolescent females attempting self-induced abortions are presented. Many ramifications and complications of illegal abortions are discussed as they affect the patient and society. In addition, we discuss the future of medical education as well as the economic aspects of health care in relationship to illegal abortions.

PIP: Two case studies are presented which show the damaging effects of self-induced abortion. Both cases involved adolescents who were recently treated in the Emergency Medical Department of the University of Colorado Hospital. Case I involved a 16-year-old indigent girl who arrived with vaginal bleeding and abdominal pain. The self-induced abortion had been attempted with a coat hanger inserted into the cervical os some time in the 3 days before admission to the hospital. The reason for the attempt was lack of money for a therapeutic abortion. The patient presented with a blood pressure of 110/70 tore, pulse of 80 beats/min, respiration of 20 breaths/min, and temperature of 37.5 degrees Centigrade. Pelvic examination revealed muco-purulent drainage with marked cervical and bilateral adnexal tenderness. Laboratory white cell count was 6400 mm, hematocrit was 40.7, and a beta subunit human chorionic gonadotropin pregnancy test was negative. The patient may indeed not have been pregnant. Treatment involved administration of 250 mg ceftriaxone intramuscularly and oral doxycycline for pelvic inflammatory disease. The recovery was uneventful. Case II involved a 17-year-old female who had run into walls, hit herself in the abdomen, and bathed in vinegar and water. Her vital signs were good, physical examination revealed a well-nourished, well-developed gravid female in no acute distress. She was referred to Planned Parenthood, psychiatric counseling, and told to return if pains developed. She had the therapeutic abortion which she thought she could not afford. Of the 6 million pregnancies in the US, 56.5% are unintended. Figures on attempted self-induced abortion are unknown. These 2 cases of low income adolescents draw attention to issues that have not been addressed in medical literature in 15 years. A brief summary is provided on abortion availability and the history of self-induced abortion methods. Discussion is also directed to morbidity and mortality trends, the psychologic impact on the mother, the fiscal impact of illegal abortions and their complications, and future prospects in the US. Concern is raised that restrictive legislation on abortions will lead to increases in unwanted pregnancies and illegal abortions with their inevitable complications. These issues place emergency medicine and physicians in the center of the policy debate.

The role of the pneumatic antishock garment in penetrating cardiac wounds.

UNLABELLED: OBJECTIVE--To determine the impact of the pneumatic antishock garment on survival in patients with cardiac wounds. DESIGN--A retrospective review of a 6.5-year experience in a population of patients with gunshot or stab wounds to the heart (N = 70). SETTING--The city and county of Denver, Colo, where all patients were transported by paramedic ambulances to Denver General Hospital, an urban, level 1 trauma center. PATIENTS--All patients were analyzed, including those transported to the emergency department with no vital signs at the trauma scene. Only patients with definite penetrating cardiac injuries were included. METHODS--Paramedic trip sheets and emergency department, operating room, in-hospital, and autopsy records were reviewed. Demographic, clinical outcome, and treatment data were collected. A multiple logistic regression model was developed to determine which characteristics and treatment variables were independently predictive of patient outcome. The ability of each independent variable to predict outcome was determined by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS--Seventy patients (31 gunshot and 39 stab wounds) had a revised trauma score of 2.8 +/- 4.0 (mean +/- SD; range, 0-12; median, 0). Thirty-two (46%) had cardiac tamponade. Overall, 21 (30%) of the patients survived. In the logistic model, the presence of cardiac tamponade (OR, 9.1; 95% CI, 1.5 to 56.1) and a higher revised trauma score were associated with higher survival. Inflation of the pneumatic antishock garment was associated with sevenfold lower survival (adjusted OR, 0.14; 95% CI, 0.02 to 0.86); the effect was negative across all trauma score groups. CONCLUSION: --Survival in patients with penetrating cardiac wounds is highly associated with anatomic and physiologic factors, while application of the pneumatic antishock garment appears to be detrimental.

A model preclinical, clinical, and graduate educational curriculum in emergency medicine for medical students and rotating residents.

The Society for Academic Emergency Medicine model curriculum for medical students and rotating residents was developed over a two-year period. The document was created as a complementary work to the undergraduate Core Content to provide appropriate emphasis, structure, and suggestions on the teaching of emergency medicine core curriculum topics at all levels. Consensus on the curriculum contents was reached from a national sample of emergency medicine educators. An educational matrix format was used to enhance flexibility based on the educational level of the learner and the instructional strengths of the teacher, and allowing for incorporation of a problem-based learning format. An outline of document contents and representative samples from each section are included; the entire document is available from SAEM.