Objectives to direct the training of emergency medicine residents on off-service rotations: pulmonary.

This article outlines the objectives for a resident rotation in pulmonary diseases. It is part of a continuing series on the goals and objectives to direct Emergency Medicine resident training on off-service rotations. Pulmonary disease accounts for a high percentage of presenting complaints and potentially life-threatening disease in the emergency department. Because of the frequency of respiratory disease in Emergency Medicine, many Emergency Medicine residencies offer individual off-service rotations in Pulmonary Medicine. The objectives of this article are viewed as a one-month component of an Internal Medicine Rotation in the first year of training. These objectives are designed to help focus the resident's reading and study during a pulmonary off-service rotation.

Objectives to direct the training of emergency medicine residents on off-service rotations: ophthalmology.

This is the ninth article in a continuing series for emergency medicine education. Ophthalmology is the topic. Since ophthalmologic problems are common in the emergency department and have obvious importance in clinical care, the time spent on an ophthalmology rotation can be very valuable in emergency medicine training. This experience is often limited to a 2-week rotation. Therefore, clear goals and objectives take on a greater significance for the resident-in-training.

Objectives to direct the training of emergency medicine residents on off-service rotations: critical care medicine, Part 2.

This article is the second of two parts outlining the objectives for resident rotations in intensive care units. It is part of a larger continuing series on the goals and objectives to direct the training of emergency medicine residents on off-service rotations. The critical care unit allows the resident an opportunity to provide continuing care for critically ill patients, many of whom enter the health care system through the emergency department. Critical care medicine is a natural continuum of emergency medicine, and provides the resident with the ability to follow the natural progression of seriously ill patients, as well as build confidence and experience in caring for the critically ill and injured. These objectives are designed to help focus the resident's reading and study during the rotation.

Objectives to direct the training of emergency medicine residents on off-service rotations: critical care medicine, Part 1.

This article is the first of two parts outlining the objectives for a resident rotating in the intensive care unit (ICU). It is part of a larger continuing series on the goals and objectives to direct the training of emergency medicine residents on off-service rotations. The critical care unit is a valuable rotation that allows the resident to see and care for critically ill patients, many of whom present initially to the emergency department. Critical care is a logical continuum for the sick and injured patient as he moves from the prehospital and emergency department (ED) settings to the ICU. These objectives are designed to focus the resident's reading and study during a critical care rotation.

Objectives to direct the training of emergency medicine residents on off-service rotations: hand surgery.

This is the fifth article in a continuing series on objectives to direct the training of emergency medicine residents. The emergency physician frequently must deal with hand injuries. Often these may appear innocuous; recognition of these injuries requires certain technical skills and a working knowledge of these entities. Specific objectives presented provide guidance for the didactic content as well as skill mastery for the resident experience.

Objectives to direct the training of emergency medicine residents on off-service rotations: dermatology.

This is the fifth in a continuing series of objectives to direct resident training in emergency medicine. Approximately 50% of resident experience and training in emergency medicine takes place outside of the direct control and influence of full-time emergency medicine faculty. To gain some direction and control over these off-service rotations, objectives and references are offered here. Objectives for a dermatology rotation as well as contents and references are presented.

Objectives to direct the training of emergency medicine residents in off-service rotations: plastic surgery.

This is the fourth article in a continuing series on objectives for emergency medicine training; plastic surgery objectives will be presented. Plastic surgery topics overlap many in emergency medicine. Specific behaviorally based objectives for mastery of skills in plastic surgery are outlined. Specific references are provided for additional information and reinforcement in skill mastery. The basic concepts of plastic surgery are probably best learned by observation and supervised performance. Specific objectives provide guidance and direction for the didactic as well as the supervised experiences in skill mastery. These objectives provide a structure for systematically learning and mastering the content presented on a plastic surgical rotation or experience in emergency medicine training.

Objectives to direct the training of emergency medicine residents on off-service rotations: orthopedics.

In this third article in a continuing series on objectives for emergency medicine training, orthopedic objectives are presented. Orthopedic complaints are common in emergency medicine. Direction in mastering evaluative, cognitive, and procedural skills are provided utilizing behaviorally based objectives and references. These objectives provide a structure for systematically learning the content of orthopedics through enlightened patient care, questioning of attending physicians and supervisors, and directed reading.

Objectives to direct the training of emergency medicine residents in off-service rotations: dental emergencies.

Patients presenting for emergency care with complaints of dental origin are common. Rarely are dental topics systematically addressed during training rotations. In this second article in a continuing series on objectives for emergency medicine resident training, dental emergency objectives will be presented. Instructions for use of the references and objectives are provided. Cognitive and evaluative objectives are organized for mastery. A list of resources including references and audio visual materials are outlined. The objectives and reference materials presented provide a structure for the systematic study of dental emergencies in emergency medicine resident training.

Objectives to direct the training of emergency medicine residents on off-service rotations.

Up to 50% of the 36 months of resident training in emergency medicine may be on off-service rotations. The experience on these rotations can lack educational content and opportunity pertinent to emergency medicine. The resident rarely has readily available and structured guidance to optimize training in terms of the anticipated needs of the specialty. In response to this problem, the authors have written curricula containing subject content listings, objectives, and supplied references for 16 off-service rotations. A plan for implementing the materials and an example from the obstetrics-gynecology rotation is given. After 12 months' experience, the authors have subjective responses from residents and off-service program directors that support the value of this information. Positive reports include: Residents having a better understanding of faculty expectations, improved "consistency of experience," residents appreciating the added attention, improved performance, and expanded reading efforts. One expressed concern is "too much to read." The project continues to evolve.

Pharyngeal tracheal lumen airway training: failure to discriminate between esophageal and endotracheal modes and failure to confirm ventilation.

The pharyngeal tracheal lumen (PTL) airway is a new airway control device for emergency medical technicians (EMTs) and paramedics and functions as either an esophageal obturator or an endotracheal tube. We developed a ten-step PTL airway training protocol that included proper airway insertion, patient ventilation, and confirmation of tube placement by auscultation. We then prospectively evaluated the effectiveness of training by testing the ability of 32 EMTs and paramedics to discriminate between esophageal and endotracheal mode placement. Training consisted of a group demonstration followed by supervised individual practice on a Laerdal Adult Intubation Model. All 70 insertion attempts resulted in esophageal obturator mode placement. As a result, trainees did not have an opportunity to practice discrimination between esophageal and endotracheal placement. Six weeks after initial training, 19 of the entry group were randomly and blindly assigned to ventilate each of two Laerdal models that had been previously intubated with the PTL, one in esophageal mode and the other in endotracheal mode. In the esophageal mode, 15 of 19 trainees (79%) correctly selected the esophageal port to ventilate, but four (21%) could not decide and abandoned the airway. In the tracheal mode, 16 of 19 trainees (84%) correctly selected the tracheal port to ventilate, one (5%) was unable to decide, and two (10.5%) selected the wrong tube and attempted ventilation with the esophageal port even though the tracheal balloon was completely occluding the airway. Ventilation was confirmed with auscultation in only 50% of the attempts (19 of 38). Our study indicates that the training protocol was inadequate to teach critical decision-making in the use of the PTL airway.(ABSTRACT TRUNCATED AT 250 WORDS)

Ruptured thoracic aneurysm presenting as dyspnea and hypotension.

A 65-year-old woman with a two-day history of progressive back pain presented with acute dyspnea, tachypnea, hypotension, and tachycardia. The patient was being treated for chronic obstructive lung disease and long-standing hypertension. She evidenced unilateral diminished breath sounds and wheezing. A portable chest radiograph in the emergency department revealed a large left pleural effusion. A hemothorax was confirmed by thoracentesis, and a 7-cm descending thoracic aortic aneurysm was demonstrated by angiography. The patient underwent successful surgical resection and Dacron graft repair of the aneurysm. This case emphasizes the need for maintaining a high index of suspicion for atypical presentations of ruptured thoracic aneurysms and for using diagnostic thoracentesis in pleural effusions of unknown etiology.

Changes in somatosensory evoked potentials in dogs following cardiac arrest and resuscitation.

The effect of cardiac arrest induced global cerebral ischemia on the peripheral, spinal cord, and cortical somatosensory evoked potentials (SSEP) was studied in 7 mongrel dogs. Following the recording of control responses in each animal, ventricular fibrillation was induced and the dogs were allowed to fibrillate for a random time varying between 30 s and 15 min. The animals were then resuscitated using a standardized resuscitation protocol, and evoked potentials were recorded at intervals up to 1 h post resuscitation. A grading scale was devised to categorize the evoked potentials according to degree of abnormality. We found that peripheral SSEPs were well preserved up to 22 min ischemia time. Spinal cord potentials became abnormal with ischemia times greater than 9.5 min. Cortical traces were essentially normal with less than 4 min ischemia time, variable with 4-9.5 min and markedly abnormal with greater than 9.5 min ischemia. Somatosensory evoked potentials may be a useful adjunct in the monitoring of cerebral function following cardiac arrest.

Needle emboli to lung following intravenous drug abuse.

Presented is the case of a 36-year-old man using central venous sites for injection of street drugs. X-ray study revealed numerous retained subcutaneous needles as well as a needle that had embolized to the lung periphery. This represents, to the best of our knowledge, a previously unreported complication of central venous injection of street drugs.