Asking for a commitment: violations during the 2007 match and the effect on applicant rank lists.

INTRODUCTION: Applicants to residency face a number of difficult questions during the interview process, one of which is when a program asks for a commitment to rank the program highly. The regulations governing the National Resident Matching Program (NRMP) match explicitly forbid any residency programs asking for a commitment. METHODS: We conducted a cross-sectional survey of applicants from U.S. medical schools to five specialties during the 2006-2007 interview season using the Electronic Residency Application Service of the Association of American Medical Colleges. Applicants were asked to recall being asked to provide any sort of commitment (verbal or otherwise) to rank a program highly. Surveys were sent after rank lists were submitted, but before match day. We analyzed data using descriptive statistics and logistic regression. RESULTS: There were 7,028 unique responses out of 11,983 surveys sent for a response rate of 58.6%. Of those who identified their specialty (emergency medicine, internal medicine, obstetrics and gynecology [OBGYN], general surgery and orthopedics), there were 6,303 unique responders. Overall 19.6% (1380/7028) of all respondents were asked to commit to a program. Orthopedics had the highest overall prevalence at 28.9% (372/474), followed by OBGYN (23.7%; 180/759), general surgery (21.7%; 190/876), internal medicine (18.3%; 601/3278), and finally, emergency medicine (15.4%; 141/916). Of those responding, 38.4% stated such questions made them less likely to rank the program. CONCLUSION: Applicants to residencies are being asked questions expressly forbidden by the NRMP. Among the five specialties surveyed, orthopedics and OBGYN had the highest incidence of this violation. Asking for a commitment makes applicants less likely to rank a program highly.

An unusual cause of congestive heart failure in a young woman.

BACKGROUND: Congestive heart failure (CHF) is a common Emergency Department (ED) disorder that accounts for >5 million ED visits annually. Although quite rare, patent ductus arteriosus (PDA) is a serious cause of CHF that if left untreated can lead to life-threatening sequelae, such as hypertensive pulmonary vascular disease, endarteritis, and aneurysms of the ductus. OBJECTIVE: To discuss a case of PDA leading to CHF that illustrates one of the common complications of untreated PDA. CASE REPORT: A 35-year-old woman presented to the ED with a 2-month history of shortness of breath, dyspnea on exertion, decreased exercise tolerance, and orthopnea. The physical examination revealed a 4/6 continuous machine-like murmur. In the presence of new CHF and an atypical murmur, a transthoracic echocardiogram was performed that confirmed the diagnosis of PDA. She underwent an uncomplicated percutaneous closure of the ductus with significant improvement in her symptoms. CONCLUSIONS: Persistent PDA in adulthood is a rare but important cause of CHF with significant morbidity and mortality if not appropriately diagnosed and treated.

How prevalent are potentially illegal questions during residency interviews?

PURPOSE: To study the prevalence of potentially illegal questions in residency interviews and to identify the impact of such questions on applicants' decisions to rank programs. METHOD: Using an Electronic Residency Application Service-supported survey, the authors surveyed all applicants from U.S. medical schools to residency programs in five specialties (internal medicine, general surgery, orthopedic surgery, obstetrics-gynecology [OB/GYN], and emergency medicine) in 2006-2007. The survey included questions about the frequency with which respondents were asked about gender, age, marital status, couples matching, current children, intent to have children, ethnicity, religion, or sexual orientation, and the effect that such questions had on their decision to rank programs. RESULTS: Of 11,983 eligible applicants, 7,028 (58.6%) completed a survey. Of respondents, 4,557 (64.8%) reported that they were asked at least one potentially illegal question. Questions related to marital status (3,816; 54.3%) and whether the applicant currently had children (1,923; 27.4%) were most common. Regardless of specialty, women were more likely than men to receive questions about their gender, marital status, and family planning (P < .001). Among those respondents who indicated their specialty, those in OB/GYN (162/756; 21.4%) and general surgery (214/876; 24.4%) reported the highest prevalence of potentially illegal questions about gender. Being asked a potentially illegal question negatively affected how respondents ranked that program. CONCLUSIONS: Many residency applicants were asked potentially illegal questions. Developing a formal interview code of conduct targeting both applicants and programs may be necessary to address the potential flaws in the resident selection process.

Can We Exclude the Diagnosis of Non-ST Segment Myocardial Infarction on the Basis of a Single Troponin I and a Symptom Duration ≥8 Hours?

Background. The use of a single troponin measurement to exclude the diagnosis of non-ST segment myocardial infarction (NSTEMI) in patients that present with ischemic symptom duration ≥8 hours is sometimes used in the Emergency Department. Study Objective. To describe the characteristics of patients with initial nondiagnostic troponin values who develop a positive troponin while in the Emergency Department and to evaluate whether NSTEMI can be excluded using symptom duration ≥8 hours and initial troponin I. Methods. Retrospective chart review of patients evaluated for NSTEMI in the Emergency Department. Results. 4,510 patients had at least two troponin I values obtained during the two-year study period. 115 (2.5%) of these patients had an initially nondiagnostic (<0.6 ng/mL) and subsequent positive (≥0.6 ng/mL) troponin I result. Twenty-five (22%) of the 115 had duration of symptoms ≥8 hours. Of these 25 patients, 18 had an intermediate first troponin value (i.e., >0.06 ng/mL, but <0.6 ng/mL). Only two of the remaining seven patients had a final primary diagnosis of NSTEMI. Conclusion. The use of a negative initial troponin I together with a symptom onset of ≥8 hours defines a population with a very low incidence of a hospital diagnosis of NSTEMI.

Effect of head rotation on vascular anatomy of the neck: an ultrasound study.

Carotid artery injury is a serious complication of landmark-guided internal jugular catheterization. Studies have determined that the internal jugular vein (IJV) frequently overlaps the carotid artery (CA), which has been postulated to increase the rate of arterial injury. The purpose of this study was to define the anatomic relationship of the IJV and CA by describing CA overlap by the more superficial IJV. We also seek to determine the effect of head rotation on the amount of overlap, which may have implications for IJV catheter placement. We prospectively studied the vascular anatomy of the neck in 156 Emergency Department patients. The primary intervention was head rotation to the left, as if the patient was positioned for right IJV catheterization. The patient's head was positioned at 0, 45 and 90 degrees of rotation. Ultrasound images were obtained in a transverse orientation. The percentage overlap of the CA by the IJV was measured. We also measured the distance between the jugular vein and the carotid artery. In neutral position, there was a mean overlap of 29% at the apex of the sternocleidomastoid. As the head was turned, the percent overlap increased. At 90 degrees, there was a mean overlap of 72%. Differences were determined to be significant by analysis of variance (ANOVA) with a p < 0.001. Furthermore, we found a distance of 10 mm between IJV and CA when the head is in neutral position. As the head was turned, the jugular-carotid distance decreased to 1 mm in the far lateral head position. These differences were also found to be significant by ANOVA with a p < 0.001. We concluded that the IJV overlaps the CA in the neutral position to a significant degree. This overlap increases until the head is fully turned, where most of the CA is overlapped by the IJV. This may help explain the mechanism of CA puncture. We propose two modifications to standard IJV line technique: minimize the patients' head rotation; and use ultrasound guidance for IJV catheterization.

Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography.

OBJECTIVES: Emergency department (ED) bedside echocardiography may offer useful information on cardiac function and volume status. The authors evaluated the accuracy of emergency physician (EP) performance of echocardiography in the assessment of left ventricular ejection fraction (LVEF) and central venous pressure (CVP). METHODS: The authors conducted a cross-sectional observational study at an urban teaching ED, involving a convenience sample of patients presenting to the ED between September 2000 and February 2001. Level III-credentialed EP sonographers who had undergone a three-hour training session in limited echocardiography, focusing on LVEF and CVP measurement, performed echocardiograms. Vital signs and indication for echocardiography were documented on a study data sheet. LVEF was rated as poor (<30%), moderate (30%-55%), or normal (>55%) and an absolute percentage. Central venous pressure categories included low (<5 cm), moderate (5-10 cm), and high (>10 cm). Formal echocardiograms were obtained within a four-hour window on all patients and interpreted by a staff cardiologist. Correlation analysis was performed using the kappa correlation coefficient for LVEF and CVP categories and a Pearson correlation coefficient for LVEF measurement. RESULTS: A total of 115 patients were assessed for LVEF, and 94 patients had complete information for CVP. Indications for echocardiography included chest pain (45.1%), congestive heart failure (38.1%), dyspnea (5.7%), and endocarditis (10.6%). Results showed a LVEF correlation of r(2) = 0.712 with 86.1% overall agreement. Subgroup analysis revealed the highest agreement (92.3%) between EP and formal echocardiograms within the normal LVEF category, followed by 70.4% agreement in the poor LVEF category and 47.8% in the moderate LVEF category. Central venous pressure measurements resulted in 70.2% overall raw agreement between EP and formal echocardiograms. Subgroup analysis revealed the highest agreement (83.3%) within the high CVP category followed by 66.6% in the moderate and 20% in the low categories. CONCLUSIONS: Experienced EP sonographers with a small amount of focused additional training in limited bedside echocardiography can assess LVEF accurately in the ED.

Cerebral and coronary air embolism: an intradepartmental suicide attempt.

Uncooperative but alert on arrival, a 21-year-old suicidal man was found suddenly unconscious with agonal respirations 2 h into his Emergency Department evaluation. Initially admitted for ingesting multiple pills and self-inflicting a deep wrist laceration, the patient now had a Glasgow Coma Scale score of 3, a dense left-sided hemiplegia, and an electrocardiogram suggestive of acute myocardial infarction. This constellation of physical findings, together with an echocardiogram revealing bi-ventricular gas artifact, led to a diagnosis of coronary and cerebral air emboli. The patient was urgently resuscitated and then underwent hyperbaric oxygen therapy. Subsequent examination confirmed a full recovery. This article details this unprecedented case, as well as clinically relevant aspects of air embolism.

Goal-directed abdominal ultrasonography: impact on real-time decision making in the emergency department.

The impact of "goal-directed" abdominal ultrasound (US) on real-time decision making in the emergency department (ED) was studied, with specific emphasis on the certainty of diagnosis, treatment, and disposition plans. A prospective, interventional study enrolled 212 patients at a county teaching hospital ED, who underwent bedside US by experienced ED sonographers. A study questionnaire was completed documenting the US indication, working diagnosis, treatment, and disposition plan. The physicians assigned pre-test and post-test levels of certainty for the diagnosis, treatment plan, and disposition on an integral scale from 1 to 10. Scores for diagnosis were further categorized into low (1-3), moderate (4-7) and high certainty of disease. Absolute mean changes in level of certainty for diagnosis, treatment, and disposition were 3.2 (95% CI 3.1-3.3), 2.0 (95% CI 1.9-2.1), and 1.9 (95% CI 1.8-2.0), respectively. The direction of change after US for certainty of diagnosis was evenly split, with 47% increasing and 47% decreasing. The majority of patients categorized as either high or low certainty of disease had US results concordant with the physician's initial assessment. However, 16% moved from either high to low or from low to high certainty categories after US. Patients with moderate certainty moved evenly to either the low or high post-test category in 97% of cases. Treatment and disposition decisions were less impacted by US, with the majority of cases increasing in certainty irrespective of the US results. Bedside ultrasonography in the ED has an important impact on real-time decision-making, particularly in terms of the certainty of diagnosis.

Ultrasound in emergency and ambulatory medicine

Our primary reason for writing this book is to help physicians interested in ultrasonography get started. While the scope and importance of ultrasonography has grown tremendously over the past several decades, the strategy for introducing ultrasonography into nontraditional settings of emergency medicine and primary care deserves special attention. The photographs, artist’s drawings, and graphics are selected to illustrate basic concepts as well as to provide a framework for more advanced use of the technology. Our aim is to make ultrasonography as accessible and clinically relevant as possible. The term “goal-directed ultrasound” means using the images as an integral part of the diagnostic and therapeutic process. Finally, this book is designed to get nonradiologists excited about the possibilities ultrasound can offer. We started out looking for the obvious right upper quadrant and pelvic pathologic conditions. Then we added the aorta and blood in the abdomen as a result of trauma and then blood around the heart. Later we began to visualize the internal jugular vein before placing our central venous lines and we looked at the heart during medical codes to definitively document pulseless electrical activity (PEA). More recently, we began looking at the kidneys to identify hydronephrosis, leg veins to assess for deep venous thrombosis, the space above the diaphragm to look for pleural effusion, and the soft tissues to identify foreign bodies or abscess formation. All these subjects and more are discussed in this book. Just before this text went to print we discovered another use for ultrasonography that has never been discussed in the literature. We had a morbidly obese patient from whom we were unable to obtain spinal fluid even with by visualizing the echos caused by her spine. The applications are exciting and can have a significant impact on the quality of patient care