Assessing for Gender Disparities in the Selection of Chief Residents of Emergency Medicine Residency Programs.

Introduction: Although the number of women physicians has been increasing, there may be gender disparities in the assessment of female emergency medicine residents. This study sought to determine if female emergency medicine residents are less likely to become chief residents than males. Methods: In July 2017, an anonymous survey was distributed to the program coordinators of all accredited emergency medicine residency programs in the United States. The survey requested the number of males and females in each graduating class from 2015 to 2017. The percentage of female residents who were chief residents was calculated and compared to that for males. Secondly, an analysis was performed to see if the region of the country or method of chief resident selection was associated with the chances of females becoming chief residents. Results: Program coordinators from 57 residency programs responded to our survey (34% response rate). Of the 683 females in the three graduating classes, 182 (26.6%) were selected as chiefs. This percentage was very similar for males: 26.7% (311/1164). No differences in the female chief resident percentages were seen based upon the region of the country. Females were more likely to be chief residents in programs that selected chief residents by resident vote. No other factor relating to how chief residents are selected was found to have a statistically significant association with the percentage of female chief residents. Conclusions: We found no evidence of a gender disparity with regards to the selection of chief residents for emergency medicine programs.

Intravenous fluid bolus rates and pediatric diabetic ketoacidosis resolution.

BACKGROUND: Recent data have challenged the notion that rapid intravenous fluid administration results in adverse neurologic outcomes in children with diabetic ketoacidosis (DKA). While many physicians still administer a cautious 10 cc/kg bolus of intravenous fluids for pediatric DKA patients, there may be benefits to using a larger bolus. METHODS: This was a retrospective chart review of all pediatric patients with DKA presenting to a single emergency department (ED) between 2013 and 2015. Patients who received a bolus of 10 cc/kg or less in the ED were compared to patients who received >10 cc/kg of fluids. The primary outcome was the difference in hospital length-of-stay between the two groups. Secondarily, we compared groups with regards to the time to bicarbonate normalization. RESULTS: In sum, 170 pediatric DKA ED visits were analyzed. Patients who received a 10 cc/kg bolus or less of fluids in the ED had a mean hospital length-of-stay > that was 0.38 days longer (95% CI: 0.006 to 0.75 days) than those who received >10 cc/kg. On multivariable regression analysis, the difference between groups was diminished and no longer statistically significant. The time to bicarbonate normalization was 0.12 days longer (95% CI -0.029 to 0.27) in the 10 cc/kg or less group than the >10 cc/kg group. CONCLUSIONS: After adjustment for confounders, no statistically significant differences in outcomes were seen in pediatric DKA patients who received a 10 cc/kg bolus or less compared to those who received a larger initial bolus.

Professionalism Milestones Assessments Used by Emergency Medicine Residency Programs: A Cross-sectional Survey.

INTRODUCTION: Professionalism is a vital component of quality patient care. While competency in professionalism is Accreditation Council for Graduate Medical Education (ACGME)-mandated, the methods used to evaluate professionalism are not standardized, calling into question the validity of reported measurements. We aimed to determine the type and frequency of methods used by United States (US) -based emergency medicine (EM) residencies to assess accountability (Acc) and professional values (PV), as well as how often graduating residents achieve competency in these areas. METHODS: We created a cross-sectional survey exploring assessment and perceived competency in Acc and PV, and then modified the survey for content and clarity through feedback from emergency physicians not involved in the study. The final survey was sent to the clinical competency committee (CCC) chair or program director (PD) of the 185 US-based ACGME-accredited EM residencies. We summarized results using descriptive statistics and Fisher's exact testing. RESULTS: A total of 121 programs (65.4%) completed the survey. The most frequently used methods of assessment were faculty shift evaluation (89.7%), CCC opinion (86.8%), and faculty summative evaluation (76.4%). Overall, 37% and 42% of residency programs stated that nearly all (greater than 95%) of their graduating residents achieve mastery of Acc and PV non-technical skills, respectively. Only 11.2% of respondents felt their programs were very effective at determining mastery of non-technical skills. CONCLUSION: EM residency programs relied heavily on faculty shift evaluations and summative opinions to determine resident competency in professionalism, with feedback from peers, administrators, and other staff less frequently incorporated. Few residency programs felt their current methods of evaluating professionalism were very effective.

Seizure as a presentation of pulmonary embolism.

BACKGROUND: Seizure is estimated to be the presenting symptom of pulmonary embolism (PE) < 1% of the time. A review of the available literature on the subject indicates that many of the reported cases are postmortem findings, and invariably, are examples of delayed diagnosis and treatment. OBJECTIVES: To heighten physician awareness of the possibility of a PE in patients initially presenting with seizures, and to bring to light some key aspects of the history and physical examination that may assist in the final diagnosis. CASE REPORT: A 76-year-old man presented to the Emergency Department (ED) after suffering from two tonic-clonic seizures at home. He had a history of one isolated seizure 4 years prior, for which he was not prescribed any medication after full evaluation, including a negative electroencephalogram. In the ED, he was noted to have a resting tachycardia and a room air oxygen saturation of 92%. This prompted further evaluation in the ED. Electrocardiography and D-dimer were ordered, and both were found to be abnormal. Computed tomography scan was positive for multiple large pulmonary emboli. The patient was given an appropriate dose of enoxaparin and admitted to the internal medicine service. CONCLUSION: Despite an atypical presentation, the authors were able to diagnose the patient due to a high level of suspicion for the disease. Our goal is to make physicians more attuned to the possibility of a PE as a final diagnosis in patients who present with new-onset seizures.

Hemorrhagic gastritis with dabigatran in a patient with renal insufficiency.

BACKGROUND: Dabigatran etexilate is the first oral direct thrombin inhibitor approved in the United States. Unlike warfarin, dabigatran has no known antidote. Providers should be aware of patients that may be at risk for dabigatran coagulopathies and recognize potential treatment options. OBJECTIVE: To report a case of hemorrhagic gastritis in a patient with chronic renal insufficiency recently initiated on dabigatran etexilate. CASE SUMMARY: An 85-year-old white man with a known history of hypertension and stage III chronic kidney disease presented to the Emergency Department complaining of dark stools, shortness of breath, and abdominal pain. The patient recently started dabigatran 150mg twice daily for new-onset atrial fibrillation. An upper gastrointestinal endoscopy identified non-specific gastritis with hemorrhage. It was determined to be probable using the Naranjo Probability Scale that gastrointestinal hemorrhaging was a result of dabigatran therapy. Fresh frozen plasma was used to reverse the dabigatran-induced coagulopathy. CONCLUSION: This case highlights the challenges that providers may face when dealing with life-threatening bleeding in patients receiving dabigatran.