Feedback in Medical Education: An Evidence-based Guide to Best Practices from the Council of Residency Directors in Emergency Medicine.

Within medical education, feedback is an invaluable tool to facilitate learning and growth throughout a physician's training and beyond. Despite the importance of feedback, variations in practice indicate the need for evidence-based guidelines to inform best practices. Additionally, time constraints, variable acuity, and workflow in the emergency department (ED) pose unique challenges to providing effective feedback. This paper outlines expert guidelines for feedback in the ED setting from members of the Council of Residency Directors in Emergency Medicine Best Practices Subcommittee, based on the best evidence available through a critical review of the literature. We provide guidance on the use of feedback in medical education, with a focus on instructor strategies for giving feedback and learner strategies for receiving feedback, and we offer suggestions for fostering a culture of feedback.

Intravenous Lidocaine for Acute Pain: A Systematic Review.

This systematic review evaluates the safety and efficacy of intravenous (IV) lidocaine for the treatment of acute pain in adult patients. The PubMed database was searched for randomized controlled trials, retrospective cohort studies, case series, and case reports evaluating the use of IV lidocaine for the treatment of acute pain in adult patients, published between January 1970 and January 2018. The primary outcome was pain reduction via the Visual Analog Scale, Verbal Rating Scale, or Numeric Rating Scale among patients treated with IV lidocaine and placebo or active controls. Safety outcomes included both nonserious and serious adverse events. A total of 347 titles and abstracts were screened, and after full-text review, 13 studies met the inclusion criteria involving 512 patients. The four active controls studied were IV morphine, IV ketorolac, IV dihydroergotamine (DHE), and IV chlorpromazine (CPZ). The dosing of IV lidocaine varied among studies between a weight-based dose of a 1- to 2-mg/kg bolus, a fixed-bolus dose of 50-100 mg, and a 1-mg/kg/hour continuous infusion. Monitoring of serum lidocaine concentrations was not done routinely. Intravenous lidocaine had superior efficacy to morphine for renal colic and critical limb ischemia, superior efficacy to DHE for acute migraine, and equivalent efficacy to ketorolac for acute radicular lower back pain. However, lidocaine was less effective than CPZ for the treatment of acute migraine. The most common adverse event reported among all studies were neurologic effects such as altered mental status and slurred speech. Due to the inconsistency in dosing, length of administration, and lack of serum monitoring, the absolute safety of IV lidocaine for acute pain is unknown. Larger, prospective studies are needed before the routine use of IV lidocaine can be recommended for all types of acute pain.

Medical Student Perception of Resident Versus Attending Contributions to Education on Co-Supervised Shifts During the Emergency Medicine Clerkship.

OBJECTIVE: The objective was to assess medical student perception of resident and attending contributions to nine Accreditation Council for Graduate Medical Education educational objectives during their emergency medicine (EM) clerkship. METHODS: This was a prospective survey study of fourth-year medical students during their EM clerkship in a single academic emergency department. Students anonymously completed end-of-shift surveys if supervised by both resident and attending physicians. Students estimated the relative educational contribution from resident and attending on a 100-point visual analog scale (-50 to 50) with -50 = 100% resident contribution, +50 = 100% attending contribution, and 0 = equal contributions by resident and attendings. Nine educational objectives were surveyed: evidence-based medicine (EBM), clinical knowledge, chart documentation, bedside teaching, patient throughput, interpersonal communication, oral patient presentations, efficiency, and procedural instruction. RESULTS: We collected 274 surveys from 65 students. Of the nine objectives, students perceived that residents contributed more than attendings in eight of nine (results reported as mean values with 95% confidence intervals): clinical knowledge -4.5 (-7.3 to -1.7), chart documentation -8.0 (-12.0 to -4.0), bedside teaching -8.6 (-12.0 to -5.2), throughput -13.0 (-16.4 to -9.6), oral presentations -14.2 (-17.3 to -11), efficiency -14.4 (-17.6 to -11.3), procedural instruction -20.2 (-24.0 to -16.5), and interpersonal communication -13.5 (-17.7 to -9.4). The sole outlier favoring attendings was EBM: 5.5 (1.9 to 9.1). CONCLUSIONS: Medical students perceive resident physicians to contribute more than attendings for most of their EM educational objectives, with faculty providing the greatest contribution to their EBM training.

When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications.

The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain. The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine.