A novel approach to incorporating evidence-based medicine into an emergency medicine clerkship.

OBJECTIVES: Despite the growing emphasis of evidence-based medicine (EBM) in the medical school curriculum, and the recognition of EBM's role in the practice of emergency medicine (EM), there are no current guidelines on how to teach EBM to fourth-year medical students during their EM rotations. The goal was to create a unique EM clerkship curriculum that teaches students to incorporate EBM into their clinical decision-making and complies with the core curriculum recommendations of the Clerkship Directors in Emergency Medicine (CDEM). PROJECT DESCRIPTION: Prior to a scheduled, case-based small group discussion, students are provided with a clinically relevant question to investigate. Case discussions are led by EM faculty with each case highlighting a core EM topic developed by CDEM. During the case discussion, the assigned clinical question is addressed and a plan of care is presented based on the tenets of EBM. Faculty members function as moderators for these discussions and provide individual feedback regarding search strategies, appraisal of the literature findings, and applicability to the patient population. This multifaceted approach to EBM through the incorporation of individual student literature searches, clinical vignettes, small group discussion with consensus building, and faculty moderation with timely feedback is an innovative educational technique. Future educational research must explore the efficacy of this curriculum and whether or not the model produces greater long-term understanding of EBM by students and if similar curricula can be executed at other institutions. CONCLUSIONS: The authors have developed a novel fourth-year EM clerkship curriculum that integrates EBM through the use of a highly interactive, faculty-led, small group-learning environment that encourages students to develop the necessary skills to integrate EBM into their clinical practice.

X-ray-negative posterior sternoclavicular dislocation after minor trauma.

Posterior sternoclavicular dislocation is a rare injury that must be recognized by the emergency physician because failure to rapidly reduce can lead to serious vascular complications. A high index of suspicion must be maintained in the appropriate setting because these injuries are difficult to detect on physical examination as well as on plain radiography. We present a case of a 19-year-old man with an isolated posterior sternoclavicular dislocation, in the setting of minor blunt trauma. The correct diagnosis required multiple imaging modalities over 2 emergency department visits and was ultimately successfully managed with intraoperative reduction.

Spontaneous splenic hemorrhage after initiation of dabigatran (Pradaxa) for atrial fibrillation.

Dabigatran etexilate (Pradaxa; Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT) is an oral anticoagulant that produces a reliable, dose-dependent anticoagulant effect without the need for routine laboratory monitoring. Dabigatran is a direct thrombin inhibitor, acting like other members in its class (bivalirudin, argatroban) to impede the clotting process through selective and reversible binding with both free and clot-bound thrombin. Dabigatran anticoagulates rapidly: plasma levels peak 2 hours after absorption, with a half-life that ranges between 12 and 17 hours. Dabigatran was approved by the Food and Drug Administration in October 2010 after it compared favorably with warfarin in a large clinical trial studying its efficacy in stroke prevention in atrial fibrillation. Currently, there is no laboratory test on the market by which a physician can quantify the anticoagulation effect of dabigatran, nor is there any antidote to reverse a life-threatening bleed should it occur. We present a case of a patient with splenic hemorrhagic soon after initiation of dabigatran.