Fungal Rhino-orbital Cerebritis in a Patient with Steroid-induced Ketoacidosis.

Fungal rhino-orbital cerebritis is a devastating opportunistic invasive disease. Survival requires urgent diagnosis. Thus, all patients at risk who present with rhinosinusitis-type symptoms and have co-morbid conditions that decrease their immunocompetence should trigger the clinician's consideration of this disease. Treatment includes antifungals and emergent surgical debridement.

Purinergic regulation of vascular tone in the retrotrapezoid nucleus is specialized to support the drive to breathe.

Cerebral blood flow is highly sensitive to changes in CO2/H+ where an increase in CO2/H+ causes vasodilation and increased blood flow. Tissue CO2/H+ also functions as the main stimulus for breathing by activating chemosensitive neurons that control respiratory output. Considering that CO2/H+-induced vasodilation would accelerate removal of CO2/H+ and potentially counteract the drive to breathe, we hypothesize that chemosensitive brain regions have adapted a means of preventing vascular CO2/H+-reactivity. Here, we show in rat that purinergic signaling, possibly through P2Y2/4 receptors, in the retrotrapezoid nucleus (RTN) maintains arteriole tone during high CO2/H+ and disruption of this mechanism decreases the CO2ventilatory response. Our discovery that CO2/H+-dependent regulation of vascular tone in the RTN is the opposite to the rest of the cerebral vascular tree is novel and fundamentally important for understanding how regulation of vascular tone is tailored to support neural function and behavior, in this case the drive to breathe.

Developing and Implementing a Multisource Feedback Tool to Assess Competencies of Emergency Medicine Residents in the United States.

OBJECTIVES: Multisource feedback (MSF) has potential value in learner assessment, but has not been broadly implemented nor studied in emergency medicine (EM). This study aimed to adapt existing MSF instruments for emergency department implementation, measure feasibility, and collect initial validity evidence to support score interpretation for learner assessment. METHODS: Residents from eight U.S. EM residency programs completed a self-assessment and were assessed by eight physicians, eight nonphysician colleagues, and 25 patients using unique instruments. Instruments included a five-point rating scale to assess interpersonal and communication skills, professionalism, systems-based practice, practice-based learning and improvement, and patient care. MSF feasibility was measured by percentage of residents who collected the target number of instruments. To develop internal structure validity evidence, Cronbach's alpha was calculated as a measure of internal consistency. RESULTS: A total of 125 residents collected a mean of 7.0 physician assessments (n = 752), 6.7 nonphysician assessments (n = 775), and 17.8 patient assessments (n = 2,100) with respective response rates of 67.2, 75.2, and 77.5%. Cronbach's alpha values for physicians, nonphysicians, patients, and self were 0.97, 0.97, 0.96, and 0.96, respectively. CONCLUSIONS: This study demonstrated that MSF implementation is feasible, although challenging. The tool and its scale demonstrated excellent internal consistency. EM educators may find the adaptation process and tools applicable to their learners.

Assessing professionalism: summary of the working group on assessment of observable learner performance.

Professionalism is one of the six Accreditation Council on Graduate Medical Education (ACGME) core competencies on which emergency medicine (EM) residents are assessed. However, very few assessment tools exist that have been rigorously evaluated in this population. One goal of the 2012 Academic Emergency Medicine consensus conference on education research in EM was to develop a research agenda for testing and developing tools to assess professionalism in EM residents. A literature review was performed to identify existing assessment tools. Recommendations on future research directions were presented at the consensus conference, and an agenda was developed.

View from the door: Making pediatric transport decisions based on first impressions.

INTRODUCTION: The primary goal of the Pediatric Assessment Triangle (PAT) is to objectify the "view from the door." Although the PAT is widely taught to prehospital providers and health-care professionals, the tool has not yet been validated. Before one can study the validity of the PAT, one needs to fully describe the practicality and functionality of the tool by exploring whether it's being used, and if so, how it's being used. The primary objective of this study was to determine if experienced providers can use the information gathered from the "view from the door" to make transport decisions on pediatric patients, and if that information fits in with the PAT. METHODS: This is a study using ethnographic analysis strategies for development of themes. A convenience group of 12 EMTs was recruited to observe two videos of pediatric patients and make a transport decision based on their observations. RESULTS: The mean time to transport decision was 12.25 seconds with a standard deviation of 8.8 seconds. Medics chose to "load and go" in 71% of the cases, and there was no correlation between CUPS status and transport decision as measured by chi square analysis. The information used most frequently to make transport decisions by medics in this study included: a simultaneous airway/breathing assessment, a level of consciousness assessment, a circulatory status assessment, a treatment plan and an anticipation of negative outcomes. CONCLUSIONS: The data from this study support that there are several features of the "view from the door" that experienced prehospital providers are using to make transport decisions on pediatric patients, and they fit in with the PAT. The data also support that the tool is a time-efficient method of triaging patients.

Pneumomediastinum from nasal insufflation of cocaine.

Chest pain is a common presenting symptom of cocaine users to the emergency department that requires a thorough work up. Pneumomediastinum is an uncommon complication of cocaine abuse that occurs more commonly when cocaine is smoked, but can also occur when cocaine is nasally insufflated. Our case report presents a patient with pneumomediastinum secondary to cocaine insufflation and reviews the necessary diagnostic tests that must be performed to rule out secondary pneumomediastinum, a severe life-threatening condition. Our case is unique, as it is one of a few reported cases of pneumomediastinum occurring after the use of intranasal cocaine.

Teaching and assessing procedural skills using simulation: metrics and methodology.

Simulation allows educators to develop learner-focused training and outcomes-based assessments. However, the effectiveness and validity of simulation-based training in emergency medicine (EM) requires further investigation. Teaching and testing technical skills require methods and assessment instruments that are somewhat different than those used for cognitive or team skills. Drawing from work published by other medical disciplines as well as educational, behavioral, and human factors research, the authors developed six research themes: measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time. The article reviews relevant and established educational research methodologies and identifies gaps in our knowledge of how physicians learn procedures. The authors present questions requiring further research that, once answered, will advance understanding of simulation-based procedural training and assessment in EM.

Medical screening in the emergency department for psychiatric admissions: a procedural analysis.

Patients who are admitted to psychiatric inpatient wards often undergo a medical screening examination in the emergency department to rule out serious or underlying medical conditions that may be better treated elsewhere. Unfortunately, prior research has been conflicting on the relative merits of various screening procedures, making it difficult to implement guidelines. A systematic review of the literature was undertaken to research the current state of knowledge in medical screening procedures. Electronic searches were conducted in PubMed, MEDLINE, and the Cochrane Library for publication years 1966-2003. No restrictions were placed on language or on quality of publications. Twelve studies were found that reported specific yields of various screening procedures. Results indicate that medical history, physical examination, review of systems, and tests for orientation have relatively high yields for detecting active medical problems in patients presenting with psychiatric complaints. Routine laboratory investigations generally have a low yield for clinically significant findings. However, these should be added selectively for four groups at higher risk of serious medical conditions, i.e., the elderly, substance users, patients with no prior psychiatric history, and patients with preexisting medical disorders and/or concurrent medical complaints.

Contemporary trends in pediatric sedation and analgesia.

The ability to provide safe, effective procedural sedation and analgesia is a necessary skill for physicians caring for the acutely ill or injured pediatric patient. They physician should be familiar with the agent(s) chosen, including dosage, duration, adverse effects, and contraindications. The choice of agent and regimen should be individualized for the patient and situation. Successful outcomes depend on performing careful pre- and post-sedation evaluations, following appropriate monitoring and equipment guidelines, and having the knowledge and skills to manage any adverse cardiorespiratory event.