Background:Residents are required to participate in practice-based learning and improvement. Most commonly, a resident-initiated patient follow-up log is used to meet the requirement. We sought to provide residents with follow-up information in an efficient, value-added manner via a patient follow-up report (PFUR). Methods:The PFUR is an automated monthly report sent to individual residents via email. It was generated from the electronic medical record and included five categories of cases: patients who were discharged and returned for admission within 72 h, diagnosis-based criteria, patients who expired during the hospital stay, patients who were admitted to or upgraded to the intensive care unit (ICU) within 24 h of admission, and patients independently flagged by the care team for follow-up. The PFURs were analyzed for 6 months after implementation for number and categorization of cases included as well as via survey of the residents. Results:In 6 months, 1078 patients, generating 1155 follow-ups, were included on the PFUR. ICU upgrades were the most represented category (41%), followed by diagnosis-based criteria (30%). Patients who were discharged and admitted within 72 h were least commonly represented on the PFUR (2%). Seventy-eight percent of residents felt that patient follow-ups were valuable to their education and 82% felt that the PFUR impacted the clinical care they provided. The PFUR was preferred by 90% of resident respondents and had an average value rating of 4.38 out of 5. Conclusions:Overall numbers of patient follow-ups significantly increased after implementation of the PFUR. Certain categories were more represented overall and within each class, which has implications for future educational initiatives. After a pilot period, the novel PFUR appears to be more efficient, accessible, and highly valued than the log used previously. Programs looking to maximize the educational benefits of patient follow-ups may consider a similar initiative.

Purpose: Medical school admissions committees are tasked with choosing tomorrow’s physicians. As studies are published on the importance of enrolling culturally aware and diverse medical student bodies, admissions committees have made concerted efforts to achieve these goals. 1,2 The necessity of these efforts is further highlighted by the racial and social unrest following George Floyd’s murder and the COVID-19 pandemic, which continue to underscore health inequities among minority communities in our country. 3 The interview day presents a unique opportunity to assess the values of an applicant and to highlight a medical school’s mission. 4,5 Adding local community members to the interview day both deepens the university’s dedication to the surrounding community and allows applicants to demonstrate cultural sensitivity. To date, few medical schools have incorporated community members into the interview day. 2 Furthermore, no studies have demonstrated the effect of adding these members on the interview day and incoming class. By incorporating the community interview, we sought to integrate community interaction and evaluation into every interview day. Our aims were to: Demonstrate to applicants that we value the community’s influence on medical student selection. Build connections with the local community. Ensure that members of the local community have the opportunity to assess applicants. Attract medical students who prioritize working with minority communities. Increase student body diversity. Approach: Community interviewers were selected from an existing community collaboration with our school. Interviewers were selected because they live or work in the surrounding neighborhood and were active members of the community. Majority interviewers identified as Black. Community interviewers evaluated each applicant on interpersonal communication and their potential ability to work effectively with communities that suffer disparities. Additionally, community interviewers assessed their own comfort level in seeing the students as their future physicians. Community interviewers were compensated for their time and expertise. To assess the initiative’s effectiveness, we surveyed the community interviewers and applicants after their interview. Survey data was analyzed after one-third of the interviews were conducted. Applicants were able to comment specifically on the community interview portion of their day. Outcomes: Two hundred interviewed applicants responded to the survey; 90% of survey respondents “strongly agree” or “somewhat agree” that the community member interview added value to their day; 89% “strongly agree” or “somewhat agree” that it gave the applicant a better sense of our values as a medical school; 80% of survey respondents said they were “more likely to attend our medical school because of the community interview.” Among the 92 free-text responses, 78% of comments about the community interview were positive, 13%, negative, and 9%, neutral. Discussion: Our survey results show that reception of this initiative has been overwhelmingly positive, with the majority of applicants believing the community interview added value to their overall interview day. Also, community members have expressed a greater connection with our medical school as a result of their involvement. If similar projects are to be implemented at other institutions, a strong community–university relationship should be established first. Self-selection of applicants who prioritize working with historically underserved and discriminated populations may be seen. As we continue to assess this project, we hope to longitudinally track its results and assess its effect on class demographics, peer-to-peer interaction, and university–community relationships. Significance: This innovative initiative has implications on the accepted medical school class and our relationship with the local community. By presenting how our institution incorporated community member involvement into our interview day, we hope to help other institutions do the same. Furthermore, we believe that incorporating programs like these will deepen our connection with the local community and make urban institutions, like ours, better partners with surrounding marginalized communities. Acknowledgments: The authors wish to thank their community member interviewers, the Student Diversity Council at the Temple School of Medicine, and Dr. Maryellen E. Gusic, MD, for their participation, help, and guidance on this project.

Objectives:Emergency medicine (EM) residents are currently evaluated via The Milestones, which have been shown to be imperfect and subjective. There is also a need for residents to achieve competency in patient safety and quality improvement processes, which can be accomplished through provision of peer comparison metrics. This pilot study aimed to evaluate the implementation of an objective peer comparison system for metrics that quantified aspects of quality and safety, efficiency and throughput, and utilization.Methods:This pilot study took place at an academic, tertiary care center with a 3-year residency and 14 residents per postgraduate year (PGY) class. Metrics were compared within each PGY class using Wilcoxon signed-rank and rank-order analyses.Results:Significant changes were seen in the majority of the metrics for all PGY classes. PGY3s accounted for the significant change in EKG and X-ray reads, while PGY1s and PGY2s accounted for the significant change in disposition to final note share. Physician evaluation to disposition decision was the only metric that did not reach significance in any class.Conclusions:These preliminary data suggest that providing objective metrics is possible. Peer comparison metrics could provide an effective objective addition to the milestone evaluation system currently in use.

The Accreditation Council for Graduate Medical Education requires residents to participate in scholarship and requires residency programs to provide an environment within which residents can acquire skills related to scholarly activities. However, consensus on the definition of scholarship and structure of program environments does not yet exist. We designed and implemented a content expert program (CEP) in 2015, in which each resident worked with a faculty advisor to develop a longitudinal scholarly activity linked to a core area of practice and, in doing so, became the department's “content expert.” We hypothesized that the CEP would significantly increase the number of scholarly outputs per resident.

Emergency Medicine has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of six organizations: the American Board of Emergency Medicine (ABEM), the administrative organization for the project, the American College of Emergency Physicians (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents' Association (EMRA), the Residency Review Committee for Emergency Medicine (RRC-EM), and the Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empiric data gathered from actual emergency department visits and several expert panels (1Hockberger R.S. LaDuca A. Orr N.A. et al.Creating the model of a clinical practice: the case of emergency medicine.Acad Emerg Med. 2003; 10: 161-168Crossref PubMed Scopus (0) Google Scholar). The resulting product was first published in 2001, and has successfully served as the common source document for all emergency medicine organizations (2Core Content Task Force II. The Model of the Clinical Practice of Emergency Medicine.Ann Emerg Med. 2001; 37: 745-770Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar,3Core Content Task Force II. The Model of the Clinical Practice of Emergency Medicine.Acad Emerg Med. 2001; 8: 660-681Crossref PubMed Scopus (38) Google Scholar). One of its strengths is incorporating the reality that emergency medicine is a specialty driven by symptoms not diagnoses, requiring simultaneous therapeutic and diagnostic interventions. The task force that developed the EM Model recommended that a new task force, composed of representatives from all six organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of emergency medicine; to consider alterations to the EM Model suggested by the collaborating organizations; and to recommend changes to the six sponsoring organizations. The initial 2-year review occurred in 2003, with representatives from each of the six organizations suggesting changes and reporting how their respective organizations had used the document. The initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005 (4Hockberger R.S. Binder L.S. Chisholm C.D. et al.The Model of the Clinical Practice of Emergency Medicine: a 2-year update.Ann Emerg Med. 2005; 45: 659-674Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,5Hockberger R.S. Binder L.S. Chisholm C.D. et al.The Model of the Clinical Practice of Emergency Medicine: a 2-year update.Acad Emerg Med. 2005; 12: 543-558Crossref Google Scholar). Subsequently, a task force met every 2 years to review the EM Model and recommend changes (6Thomas H.A. Binder L.S. Chapman D.M. et al.The 2003 Model of the Clinical Practice of Emergency Medicine: the 2005 update.Ann Emerg Med. 2006; 48: e1-e17Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 7Thomas H.A. Binder L.S. Chapman D.M. et al.The 2003 Model of the Clinical Practice of Emergency Medicine: the 2005 update.Acad Emerg Med. 2006; 13: 1070-1073Crossref PubMed Scopus (22) Google Scholar, 8Thomas H.A. Beeson M.S. Binder L.S. et al.The 2005 Model of the Clinical Practice of Emergency Medicine: the 2007 update.Acad Emerg Med. 2008; 15: 776-779Crossref PubMed Scopus (28) Google Scholar, 9Thomas H.A. Beeson M.S. Binder L.S. et al.The 2005 Model of the Clinical Practice of Emergency Medicine: the 2007 update.Ann Emerg Med. 2008; 52: e1-e17Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 10Perina D.G. Beeson M.S. Char D.M. et al.The 2007 Model of the Clinical Practice of Emergency Medicine: the 2009 update.Acad Emerg Med. 2011; 18: e8-e26Crossref PubMed Scopus (18) Google Scholar, 11Perina D.G. Beeson M.S. Char D.M. et al.The 2007 Model of the Clinical Practice of Emergency Medicine: the 2009 update.Ann Emerg Med. 2011; 57: e1-e15Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 12Perina D.G. Brunett C.P. Caro D.A. et al.The 2011 Model of the Clinical Practice of Emergency Medicine.Acad Emerg Med. 2012; 19: e19-e40Crossref PubMed Scopus (37) Google Scholar, 13Counselman F.L. Borenstein M.A. Chisholm C.D. et al.The 2013 Model of the Clinical Practice of Emergency Medicine.Acad Emerg Med. 2014; 21: 574-598Crossref PubMed Scopus (41) Google Scholar). In 2013, a seventh organization, the American Academy of Emergency Medicine (AAEM), was added as a collaborating organization. In 2014, the collaborating organizations made the decision to review the EM Model on a 3-year review cycle, beginning in 2016. The 2016 update was published in Journal of Emergency Medicine in 2017 (14Counselman F.L. Babu K. Edens M.A. et al.The 2016 Model of the Clinical Practice of Emergency Medicine.J Emerg Med. 2017; 52: 846-849Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar). In 2019, the AAAEM Resident and Student Association was added as an eighth collaborating organization. This article provides a brief review of the original EM Model, along with the changes to the EM Model as recommended by the 2019 EM Model Review Task Force. Significant changes occurred with the 2019 review, including the addition of oncologic emergencies in the newly renamed “Category 8, Hematologic and Oncologic Disorders.” A summary of all 2019 changes and an update on current uses of the EM Model by the seven collaborating EM organizations are also included in this article. The EM Model is a three-dimensional description of EM clinical practice. The three dimensions are patient acuity; physician tasks; and a listing of medical knowledge, patient care, and procedural skills. All of these dimensions are interrelated and used concurrently by a physician when providing patient care. The emergency physician's initial approach is determined by the acuity of the patient's presentation. While assessing the patient, the physician completes a series of tasks in collecting information. Through this process, the physician is able to select the possible etiologies of the patient's problem from the listing of medical knowledge, patient care, and procedural skills. Through simultaneous application of all three components, the physician is able to determine the most probable diagnosis and implement a treatment plan for the patient. The three dimensions, as revised in 2019, are included in Table 1, Table 2, Table 3, Table 4.Table 1Matrix of Physician Tasks by Patient AcuityPhysician TasksPatient AcuityCriticalEmergentLower AcuityPrehospital careEmergency stabilizationPerformance of focused history and physical examinationModifying factorsProfessional issuesLegal issuesDiagnostic studiesDiagnosisTherapeutic interventionsPharmacotherapyObservation and reassessmentConsultationTransitions of carePrevention and educationDocumentationTask switching/Multiple patient careTeam managementMass casualty/Disaster managementPatient-centered communication skillsPrognosis Open table in a new tab Table 2Patient Acuity DefinitionsCriticalEmergentLower AcuityPatient presents with symptoms of a life-threatening illness or injury with a high probability of mortality if immediate intervention is not begun to prevent further airway, respiratory, hemodynamic, and/or neurologic instability.Patient presents with symptoms of an illness or injury that may progress in severity or result in complications with a high probability for morbidity if treatment is not begun quickly.Patient presents with symptoms of an illness or injury that have a low probability of progression to more serious disease or development of complications. Open table in a new tab Table 3Physician Task DefinitionsPhysician TaskDefinitionPrehospital careParticipate actively in prehospital care; provide direct patient care or on-line or off-line medical direction or interact with prehospital medical providers; assimilate information from prehospital care into the assessment and management of the patient.Emergency stabilizationConduct primary assessment and take appropriate steps to stabilize and treat patients.Performance of focused history and physical examinationEffectively interpret and evaluate the patient's symptoms and history; identify pertinent risk factors in the patient's history; provide a focused evaluation; interpret the patient's appearance, vital signs and condition; recognize pertinent physical findings; perform techniques required for conducting the examination.Modifying factorsRecognize age, gender, ethnicity, barriers to communication, socioeconomic status, underlying disease, gender identity, sexual orientation, and other factors that may affect patient management.Professional issuesUnderstand and apply principles of professionalism and ethics pertinent to patient management.Legal issuesUnderstand and apply legal concepts pertinent to the practice of emergency medicine.Diagnostic studiesSelect and perform the most appropriate diagnostic studies and interpret the results, e.g., electrocardiogram, emergency ultrasound, and radiographic and laboratory tests.DiagnosisDevelop a differential diagnosis and establish the most likely diagnosis in light of the history, physical, interventions, and test results.Therapeutic interventionsPerform procedures and nonpharmacologic therapies, and counsel.PharmacotherapySelect, prescribe, and be aware of adverse effects of appropriate pharmaceutical agents based on relevant considerations such as intended effect, financial considerations, possible adverse effects, patient preferences, institutional policies, and clinical guidelines; monitor and intervene in the event of adverse effects in the emergency department.Observation and reassessmentEvaluate and re-evaluate the effectiveness of a patient's treatment or therapy, including addressing complications and potential errors; monitor, observe, manage, and maintain the stability of one or more patients who are at different stages in their workups.ConsultationCollaborate with physicians and other professionals to help guide optimal management of patients.Transitions of careArrange for patient admission, discharge (including follow-up plan), observation, or transfer and transitions of care as appropriate, and communicate these arrangements effectively with patients, family, and involved health care team members.Prevention and educationApply epidemiologic information to patients at risk; conduct patient education; select appropriate disease and injury prevention, and harm reduction techniques.DocumentationCommunicate patient care information in a concise and appropriate manner that facilitates quality care. This includes documentation and medical decision-making variables related to billing, coding, and reimbursement for patient care.Task switching/Multiple patient carePrioritize and implement the evaluation and management of multiple patients in the emergency department, including handling interruptions and task-switching, in order to provide optimal patient care.Team managementCoordinate, educate, or supervise members of the patient management team and utilize appropriate hospital resources.Mass casualty/Disaster managementUnderstand and apply the principles of disaster and mass casualty management including preparedness, triage, mitigation, response, and recovery.Patient-centered communication skillsEstablish rapport with and demonstrate empathy toward patients and their families; listen effectively to patients and their families. Identify situations that require individualized communication, such as goals of care, end of life care, and palliative options.PrognosisForecast the likely outcome of a medical disease or traumatic condition. Open table in a new tab Table 4Medical Knowledge, Patient Care, and Procedural Skills1.0 SIGNS, SYMPTOMS, AND PRESENTATIONSCriticalEmergentLower Acuity1.1 Abnormal Vital Signs 1.1.1 HypothermiaXXX 1.1.2 FeverXXX 1.1.3 BradycardiaXXX 1.1.4 TachycardiaXX 1.1.5 Bradypnea/ApneaXX 1.1.6 TachypneaXX 1.1.7 HypoxiaXX 1.1.8 HypotensionXX 1.1.9 HypertensionXXX1.2 Pain 1.2.1 Pain (unspecified)XXX 1.2.2 Headache (See 12.3)XXX 1.2.3 Eye painXX 1.2.4 Chest painXXX 1.2.5 Abdominal painXXX 1.2.6 Pelvic and genital painXXX 1.2.7 Back painXXX 1.2.8 Chronic painX 1.2.9 Extremity painXXX 1.2.10 Neck painXXX1.3 General 1.3.1 Altered mental statusXXX 1.3.2 Anuria/OliguriaX 1.3.3 AscitesXX 1.3.4 AtaxiaXX 1.3.5 Auditory disturbancesX 1.3.6 BleedingXXX 1.3.7 Congestion/RhinorrheaX 1.3.8 Constipation/ObstipationXX 1.3.9 CoughXX 1.3.10 Crying/FussinessXX 1.3.11 CyanosisX 1.3.12 DehydrationXX 1.3.13 DiarrheaXX 1.3.14 DysmenorrheaX 1.3.15 DysphagiaXX 1.3.16 DysuriaX 1.3.17 EdemaXX 1.3.18 Failure to thriveXX 1.3.19 Fatigue/MalaiseXX 1.3.20 Feeding problemsX 1.3.21 HematemesisXX 1.3.22 HematuriaXX 1.3.23 HemoptysisXX 1.3.24 HiccupX 1.3.25 JaundiceX 1.3.26 Joint swellingXX 1.3.27 LethargyXXX 1.3.28 Lightheadedness/DizzinessXX 1.3.29 LimpXX 1.3.30 LymphadenopathyX 1.3.31 Mechanical and indwelling devices, complicationsXXX 1.3.32 Nausea/VomitingXX 1.3.33 Occupational exposureXX 1.3.34 PalpitationsXXX 1.3.35 ParalysisXX 1.3.36 Paresthesia/DysesthesiaXX 1.3.37 PoisoningXXX 1.3.38 PruritusXX 1.3.39 RashXXX 1.3.40 Rectal bleedingXXX 1.3.41 ShockX 1.3.42 Shortness of breathXX 1.3.43 Sore throatXX 1.3.44 StridorXX 1.3.45 Syncope/Near syncopeXXX 1.3.46 TinnitusX 1.3.47 TremorXX 1.3.48 Urinary incontinenceX 1.3.49 Urinary retentionX 1.3.50 Vaginal bleedingXXX 1.3.51 Vaginal dischargeX 1.3.52 Visual disturbancesXX 1.3.53 WeaknessXX 1.3.54 WheezingXX 1.3.55 ToxidromesXXX 1.3.56 Sudden unexpected infant death (SUID)X 1.3.57 Suicidal ideationXXX 1.3.58 Brief resolved unexplained events (BRUE)XXX 1.3.59 Intoxication syndromesXXX 1.3.60 Postsurgical complicationsXXX2.0 ABDOMINAL AND GASTROINTESTINAL DISORDERSCriticalEmergentLower Acuity2.1 Abdominal Wall 2.1.1 HerniasXX 2.1.2 HematomaX2.2 Esophagus 2.2.1 Infectious disorders2.2.1.1 Candida (See 4.4.2.1, 7.4.6)XX2.2.1.2 Viral esophagitisXX 2.2.2 Inflammatory disorders2.2.2.1 EsophagitisXX2.2.2.2 Gastroesophageal reflux (GERD)X2.2.2.3 Toxic effects of caustic agents (See 17.1.16.1)2.2.2.3.1 AcidXX2.2.2.3.2 AlkaliXX 2.2.3 Motor abnormalities 2.2.4 Structural disorders2.2.4.1 Boerhaave's syndromeXX2.2.4.2 DiverticulaXX2.2.4.3 Foreign bodyX2.2.4.4 HerniasXX2.2.4.5 Mallory-Weiss syndromeXX2.2.4.6 Stricture and stenosisXX2.2.4.7 Tracheoesophageal fistulaXX2.2.4.8 VaricesXX 2.2.5 TumorsXX2.3 Liver 2.3.1 Noninfectious hepatitis/CirrhosisXX2.3.1.1 AlcoholicXX2.3.1.2 Biliary obstructiveX2.3.1.3 Drug-inducedXX2.3.1.4 Nonalcoholic steatohepatitis (NASH)X 2.3.2 Hepatorenal failureXX 2.3.3 Infectious disordersXX2.3.3.1 AbscessX2.3.3.2 HepatitisX2.3.3.3 PerihepatitisX 2.3.4 TumorsXX 2.3.5 Hepatic encephalopathyXX2.4 Gallbladder and Biliary Tract 2.4.1 CholangitisXX 2.4.2 CholecystitisXX 2.4.3 Cholelithiasis/CholedocholithiasisXX 2.4.4 TumorsXX2.5 Pancreas 2.5.1 PancreatitisXX 2.5.2 TumorsXX 2.5.3 PseudocystX2.6 Peritoneum 2.6.1 Spontaneous bacterial peritonitisXX 2.6.2 Abdominal compartment syndromeXX2.7 Stomach 2.7.1 Infectious disordersX 2.7.2 Inflammatory disorders2.7.2.1 GastritisXX 2.7.3 Peptic ulcer diseaseXX2.7.3.1 HemorrhageXX2.7.3.2 PerforationXX 2.7.4 Structural disorders2.7.4.1 Congenital hypertrophic pyloric stenosisX2.7.4.2 Foreign bodyXX 2.7.5 TumorsXX 2.7.6 GastroparesisXX 2.7.7 Cyclic vomiting syndrome (See 17.1.24.1.1)XX2.8 Small Bowel 2.8.1 Infectious disordersXX 2.8.2 Inflammatory disorders2.8.1.1 Regional enteritis/Crohn's diseaseXX2.8.1.2 Gluten enteropathy/Celiac diseaseX 2.8.3 Motor abnormalities2.8.3.1 ObstructionXX2.8.3.2 Paralytic ileusX 2.8.4 Structural disorders2.8.4.1 Aortoenteric fistulaX2.8.4.2 Congenital anomaliesXX2.8.4.3 Intestinal malabsorptionXX2.8.4.4 Meckel's diverticulumXX 2.8.5 TumorsXX 2.8.6 Vascular insufficiencyXX2.9 Large Bowel 2.9.1 Infectious disorders2.9.1.1 Antibiotic-associatedX2.9.1.2 BacterialXX2.9.1.3 ParasiticXX2.9.1.4 ViralXX 2.9.2 Inflammatory disorders2.9.2.1 AppendicitisX2.9.2.2 Necrotizing enterocolitis (NEC)XX2.9.2.3 Radiation colitisX2.9.2.4 Ulcerative colitisXX2.9.2.5 Neutropenic enterocolitis/TyphlitisXX 2.9.3 Motor abnormalities2.9.3.1 Hirschsprung's diseaseXX2.9.3.2 Irritable bowelX2.9.3.3 ObstructionXX 2.9.4 Structural disorders2.9.4.1 Congenital anomaliesXX2.9.4.2 DiverticulaXX2.9.4.3 IntussusceptionXX2.9.4.4 VolvulusXX 2.9.5 TumorsXX2.10 Rectum and Anus 2.10.1 Infectious disorders2.10.1.1 Perianal/Anal abscessXX2.10.1.2 Perirectal abscessX2.10.1.3 Pilonidal cyst and abscessXX 2.10.2 Inflammatory disorders2.10.2.1 ProctitisX 2.10.3 Structural disorders2.10.3.1 Anal fissureX2.10.3.2 Anal fistulaXX2.10.3.3 Congenital anomaliesX2.10.3.4 Foreign bodyXX2.10.3.5 HemorrhoidsX2.10.3.6 Rectal prolapseX 2.10.4 TumorsXX2.11 Spleen 2.11.1 AsplenismXX 2.11.2 SplenomegalyX 2.11.3 Vascular insufficiency/InfarctionXXX2.12 Specific Post-surgical Populations 2.12.1 Bariatric surgeryXXX 2.12.2 OstomyXX3.0 CARDIOVASCULAR DISORDERSCriticalEmergentLower Acuity3.1 Cardiopulmonary ArrestX3.2 Congenital Abnormalities of the Cardiovascular SystemXXX 3.2.1 Tetralogy of Fallot spellsXX 3.2.2 Patent ductus arteriosus-dependent congenital heart anomaliesXX3.3 Disorders of Circulation 3.3.1 Arterial3.3.1.1 AneurysmXXX3.3.1.2 DissectionX3.3.1.2.1 AorticXXX3.3.1.2.2 Non-aorticXXX3.3.1.3 ThromboembolismXX 3.3.2 Venous3.3.2.1 Thromboembolism (See 16.6.2)XX3.4 Disturbances of Cardiac Rhythm 3.4.1 Cardiac dysrhythmiasXXX3.4.1.1 VentricularXX3.4.1.2 SupraventricularXXX3.4.1.3 Pulseless electrical activityX 3.4.2 Conduction disordersXXX3.5 Diseases of the Myocardium, Acquired 3.5.1 Cardiac failureXX3.5.1.1 Cor pulmonaleXX3.5.1.2 High outputXX3.5.1.3 Low outputXX 3.5.2 CardiomyopathyXXX3.5.2.1 HypertrophicXXX3.5.2.2 DilatedXXX 3.5.3 Congestive heart failureXX 3.5.4 Coronary syndromesXX 3.5.5 Ischemic heart diseaseXX 3.5.6 Myocardial infarctionXX 3.5.7 MyocarditisXXX 3.5.8 Ventricular aneurysmXXX3.6 Diseases of the Pericardium 3.6.1 Pericardial tamponade (See 18.1.2.6)XX 3.6.2 PericarditisXX3.7 HypertensionXXX 3.7.1 Asymptomatic hypertensionX 3.7.2 Hypertensive emergencyXX3.8 TumorsXX3.9 Valvular DisordersXXX 3.9.1 EndocarditisXX3.10 Cardiovascular Devices 3.10.1 Pacemaker/Automatic implantable cardioverter-defibrillator (AICD)XXX 3.10.2 Left ventricular assist device (LVAD)XXX4.0 CUTANEOUS DISORDERSCriticalEmergentLower Acuity4.1 Cancers of the Skin 4.1.1 Basal cellX 4.1.2 Kaposi's sarcomaX 4.1.3 MelanomaX 4.1.4 Squamous cellX4.2 Ulcerative Lesions 4.2.1 DecubitusXX 4.2.2 Venous stasisX 4.2.3 Diabetic foot ulcersXX4.3 Dermatitis 4.3.1 Atopic/EczemaX 4.3.2 ContactX 4.3.3 PsoriasisX 4.3.4 SeborrheaX4.4 Infections 4.4.1 Bacterial4.4.1.1 AbscessXX4.4.1.2 CellulitisXX4.4.1.3 ErysipelasX4.4.1.4 ImpetigoX4.4.1.5 Necrotizing infectionXX 4.4.2 Fungal4.4.2.1 Candida (See 2.2.1.1, 7.4.6)X4.4.2.2 DermatophytesX 4.4.3 EctoparasitesX 4.4.4 Viral4.4.4.1 Aphthous ulcersX4.4.4.2 Childhood exanthems (See 10.6.8, 10.6.9)X4.4.4.3 Herpetic infections (See 10.6.4, 10.6.5, 13.1.3.1)XX4.4.4.4 Human papillomavirus (HPV) (See 13.1.3.2)X4.4.4.5 Molluscum contagiosumX4.5 Maculopapular Lesions 4.5.1 Erythema multiformeXX 4.5.2 Pityriasis roseaX 4.5.3 UrticariaXX 4.5.4 Drug eruptionsXX4.6 Papular/Nodular Lesions 4.6.1 Hemangioma/LymphangiomaX 4.6.2 LipomaX 4.6.3 Sebaceous cystX 4.6.4 Erythema nodosumX4.7 Vesicular/Bullous Lesions 4.7.1 PemphigusX 4.7.2 Staphylococcal scalded skin syndromeXX 4.7.3 Stevens-Johnson syndromeXX 4.7.4 Toxic epidermal necrolysisXX 4.7.5 Bullous pemphigoidXX4.8 Purpuric RashXXX 4.8.1 Henoch-Schӧnlein purpura (HSP)X5.0 ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERSCriticalEmergentLower Acuity5.1 Acid–base Disturbances 5.1.1 Metabolic or respiratory5.1.1.1 AcidosisXX5.1.1.2 AlkalosisXXX 5.1.2 Mixed acid–base balance disorderXX5.2 Adrenal Disease 5.2.1 Corticoadrenal insufficiencyXX 5.2.2 Cushing's syndromeXX5.3 Fluid and Electrolyte Disturbances 5.3.1 Calcium metabolismXXX 5.3.2 Hypervolemia/HypovolemiaXXX 5.3.3 Potassium metabolismXXX 5.3.4 Sodium metabolismXXX 5.3.5 Magnesium metabolismXX 5.3.6 Phosphorus metabolismXX5.4 Glucose Metabolism 5.4.1 Diabetes mellitusXXX5.4.1.1 Complications in glucose metabolism5.4.1.1.1 HyperglycemiaXX5.4.1.1.2 Diabetic ketoacidosis (DKA)XXX5.4.1.1.3 Hyperosmolar hyperglycemic stateXX5.4.1.1.4 HypoglycemiaXX5.5 Nutritional Disorders 5.5.1 Vitamin deficienciesX 5.5.2 Wernicke-Korsakoff syndromeX 5.5.3 MalabsorptionXX 5.5.4 MalnutritionXX5.6 Parathyroid DiseaseXX5.7 Pituitary DisordersXX 5.7.1 PanhypopituitarismX5.8 Thyroid Disorders 5.8.1 HyperthyroidismXXX 5.8.2 HypothyroidismXXX 5.8.3 ThyroiditisXX 5.8.4 Thyroid stormXX5.9 Tumors of Endocrine Glands 5.9.1 AdrenalXX5.9.1.1 PheochromocytomaXX 5.9.2 PituitaryXX 5.9.3 ThyroidXX6.0 ENVIRONMENTAL DISORDERSCriticalEmergentLower Acuity6.1 Bites and Envenomation (See 18.1.3.2) 6.1.1 ArthropodsXX6.1.1.1 InsectsX6.1.1.2 ArachnidsXX 6.1.2 MammalsXX 6.1.3 Marine organisms (See 17.1.20)XXX 6.1.4 ReptilesXXX6.2 Dysbarism 6.2.1 Air embolismXX 6.2.2 BarotraumaXXX 6.2.3 Decompression syndromeXX6.3 Electrical Injury (See 18.1.3.3.1)XXX 6.3.1 LightningXX6.4 High-altitude Illness 6.4.1 Acute mountain sicknessXX 6.4.2 High-altitude cerebral edemaXX 6.4.3 High-altitude pulmonary edemaXX6.5 Submersion IncidentsXXX6.6 Temperature-related Illness 6.6.1 HeatXXX 6.6.2 ColdXXX6.6.2.1 FrostbiteXX6.6.2.2 HypothermiaXX6.7 Radiation EmergenciesXXX7.0 HEAD, EAR, EYE, NOSE, THROAT DISORDERSCriticalEmergentLower Acuity7.1 Ear 7.1.1 Foreign bodyXX7.1.1.1 Impacted cerumenX 7.1.2 LabyrinthitisX 7.1.3 MastoiditisX 7.1.4 Ménière's diseaseX 7.1.5 Otitis externaX7.1.5.1 InfectiveX7.1.5.1.1 MalignantX 7.1.6 Otitis mediaXX 7.1.7 Perforated tympanic membrane (See 18.1.11.2)X 7.1.8 PerichondritisXX7.2 Eye 7.2.1 External eye7.2.1.1 Burn confined to eye (See 18.1.10.2)X7.2.1.2 ConjunctivitisX7.2.1.3 Corneal abrasions (See 18.1.10.1)XX7.2.1.4 Disorders of lacrimal systemXX7.2.1.5 Foreign bodyXX7.2.1.6 Disorders of the eyelidsX7.2.1.7 KeratitisXX 7.2.2 Anterior pole7.2.2.1 GlaucomaXX7.2.2.2 Hyphema (See 18.1.10.5)XX7.2.2.3 Iritis (See 18.1.10.8)XX7.2.2.4 HypopyonX 7.2.3 Posterior pole7.2.3.1 Choroiditis/ChorioretinitisX7.2.3.2 Optic neuritisX7.2.3.3 PapilledemaXX7.2.3.4 Retinal detachments and defects (See 18.1.10.7)X7.2.3.5 Retinal vascular occlusionX 7.2.4 Orbit7.2.4.1 Cellulitis7.2.4.1.1 PreseptalX7.2.4.1.2 Septal/OrbitalX7.2.4.2 EndophthalmitisX7.3 Nose 7.3.1 EpistaxisXXX 7.3.2 Foreign bodyXX 7.3.3 RhinitisX 7.3.4 SinusitisX7.4 Oropharynx/Throat 7.4.1 DentalgiaX 7.4.2 Diseases of the oral soft tissue7.4.2.1 Ludwig's anginaXX7.4.2.2 StomatitisX7.4.2.3 Gingival and periodontal disordersXX7.4.2.4 Odontogenic infections/AbscessesXX 7.4.3 Diseases of the salivary glands7.4.3.1 SialolithiasisXX7.4.3.2 Suppurative parotitisX 7.4.4 Foreign bodyXX 7.4.5 Larynx/Trachea7.4.5.1 Epiglottitis (See 16.1.1.2)XX7.4.5.2 LaryngitisX7.4.5.3 TracheitisXX7.4.5.4 Tracheostomy complicationsXXX 7.4.6 Oral candidiasis (See 2.2.1.1, 4.4.2.1)X 7.4.7 Peritonsillar abscessX 7.4.8 Pharyngitis/TonsillitisX 7.4.9 Retropharyngeal abscessXX 7.4.10 Temporomandibular joint disordersX7.5 TumorsXXX8.0 HEMATOLOGIC AND ONCOLOGIC DISORDERSCriticalEmergentLower Acuity8.1 Blood Transfusion 8.1.1 ComplicationsXX8.2 Hemostatic Disorders 8.2.1 Coagulation defectsXXX8.2.1.1 AcquiredXXX8.2.1.2 HemophiliasXXX8.2.1.3 Anticoagulation agentsXXX 8.2.2 Disseminated intravascular coagulationX 8.2.3 Platelet disordersXXX8.2.3.1 ThrombocytopeniaXX8.2.3.2 Idiopathic thrombocytopenic purpuraXXX8.2.3.3 Thrombotic thrombocytopenic purpuraXX8.3 LymphomasXX8.4 PancytopeniaXX8.5 Red Blood Cell Disorders 8.5.1 Anemias8.5.1.1 AplasticXX8.5.1.2 HemoglobinopathiesXX8.5.1.2.1 Sickle cell anemiaXXX8.5.1.2.2 ThalassemiaXX8.5.1.3 HemolyticX8.5.1.4 Hypochromic8.5.1.4.1 Iron deficiencyXX8.5.1.5 MegaloblasticXX 8.5.2 PolycythemiaXX 8.5.3 Methemoglobinemia (See 17.1.21)XX8.6 White Blood Cell Disorders 8.6.1 LeukemiaXX 8.6.2 Multiple myelomaXX 8.6.3 LeukopeniaXX8.7 Oncologic EmergenciesXXX 8.7.1 Febrile neutropeniaXXX 8.7.2 Hypercalcemia of malignancyXXX 8.7.3 Hyperviscosity syndromeXXX 8.7.4 Malignant pericardial effusionXXX 8.7.5 Spinal cord compression (See 12.10)XX 8.7.6 Superior vena cava syndromeXX 8.7.7 Tumor hemorrhageXXX 8.7.8 Tumor lysis syndromeXX9.0 IMMUNE SYSTEM DISORDERSCriticalEmergentLower Acuity9.1 Collagen Vascular Disease 9.1.1 Raynaud's diseaseX 9.1.2 Reactive arthritis (See 11.3.1.6)XX 9.1.3 Rheumatoid arthritis (See 11.3.1.3)XX 9.1.4 SclerodermaXX 9.1.5 Systemic lupus erythematosusXX 9.1.6 VasculitisXX9.2 Hypersensitivity 9.2.1 Allergic reactionXX 9.2.2 AnaphylaxisX 9.2.3 AngioedemaXX 9.2.4 Drug allergiesXXX9.3 Transplant-related ProblemsXXX 9.3.1 ImmunosuppressionXX 9.3.2 RejectionXX9.4 Immune Complex DisordersX 9.4.1 Mucocutaneous lymph node syndrome (Kawasaki syndrome)XX 9.4.2 Rheumatic feverXX 9.4.3 SarcoidosisXX 9.4.4 Post-streptococcal glomerulonephritis (See 15.3.1)X9.5 Medication-induced ImmunosuppressionXX 9.5.1 Chemotherapeutic agentsXX 9.5.2 SteroidsXX 9.5.3 Targeted immune modulatorsXX10.0 SYSTEMIC INFECTIOUS DISORDERSCriticalEmergentLower Acuity10.1 Bacterial 10.1.1 Bacterial food poisoningXX10.1.1.1 BotulismXX 10.1.2 ChlamydiaXX 10.1.3 GonococcusXX 10.1.4 MeningococcusXX 10.1.5 Mycobacterium10.1.5.1 Atypical mycobacteriaXX10.1.5.2 TuberculosisXX 10.1.6 Other bacterial diseasesXX10.1.6.1 Gas gangrene (See 11.6.3)XX 10.1.7 Sepsis/BacteremiaXX10.1.7.1 ShockX10.1.7.2 Toxic shock syndromeXX 10.1.8 Spirochetes10.1.8.1 SyphilisXX 10.1.9 TetanusXX10.2 Biological Warfare AgentsXX10.3 Fungal InfectionsXX10.4 Protozoan/Parasites 10.4.1 MalariaX 10.4.2 ToxoplasmosisXX10.5 Tick-borne 10.5.1 Anaplasmosis (Ehrlichiosis)X 10.5.2 Lyme diseaseX 10.5.3 Rocky Mountain spotted feverX 10.5.4 BabesiosisX10.6 ViralXX 10.6.1 Infectious mononucleosisXX 10.6.2 Influenza/ParainfluenzaXX 10.6.3 ArbovirusXXX 10.6.4 Herpes simplex (See 4.4.4.3, 13.1.3.1)XX 10.6.5 Herpes zoster/Varicella (See 4.4.4.3)XX 10.6.6 HIV/AIDSXXX 10.6.7 RabiesX 10.6.8 Roseola (See 4.4.4.2)X 10.6.9 Rubella (See 4.4.4.2)X 10.6.10 MeaslesXXX 10.6.11 Mumps (Paramyxovirus)XX10.7 Emerging Infections/PandemicsXXX10.8 Drug ResistanceXXX11.0 MUSCULOSKELETAL DISORDERS (NONTRAUMATIC)CriticalEmergentLower Acuity11.1 Bony Abnormalities 11.1.1 Aseptic/Avascular necrosisXX 11.1.2 OsteomyelitisX 11.1.3 TumorsXX 11.1.4 Atypical fracturesXX11.1.4.1 OsteoporoticXX11.1.4.2 Tumor-relatedXX11.1.4.3 Congenital disordersXX11.2 Disorders of the Spine 11.2.1 Disc disordersXX 11.2.2 Inflammatory/Infectious spondylopathiesXX 11.2.3 Radiculopathy (See 12.7.3)XX 11.2.4 Spinal stenosisXX 11.2.5 Cervical painXXX 11.2.6 Thoracic painXXX 11.2.7 Lumbosacral painXXX11.2.7.1 Cauda equina syndrome (See 18.1.15.1)XX11.2.7.2 SacroiliitisX11.2.7.3 SciaticaXX 11.2.8 DiscitisXX11.3 Joint Abnormalities 11.3.1 Arthritis11.3.1.1 SepticX11.3.1.2 Crystal arthropathiesXX11.3.1.3 Rheumatoid (See 9.1.3)X11.3.1.4 JuvenileX11.3.1.5 OsteoarthrosisX11.3.1.6 Reactive arthritis (See 9.1.2)XX 11.3.2 Developmental dysplasia of the hipXX 11.3.3 Slipped capital femoral epiphysisX 11.3.4 SynovitisXX11.4 Muscle Abnormalities 11.4.1 MyositisX 11.4.2 RhabdomyolysisXX11.5 Overuse Syndromes 11.5.1 BursitisX 11.5.2 Muscle strainsX 11.5.3 Peripheral nerve syndromeX11.5.3.1 Carpal tunnel syndromeX 11.5.4 TendinopathyX 11.5.5 Stress reaction fractureXX11.6 Soft Tissue Infections 11.6.1 FasciitisXXX 11.6.2 FelonX 11.6.3 Gangrene (See 10.1.6.1)XX 11.6.4 ParonychiaXX 11.6.5 TenosynovitisXX12.0 NERVOUS SYSTEM DISORDERSCriticalEmergentLower Acuity12.1 Cranial Nerve DisordersX 12.1.1 Idiopathic facial nerve paralysis (Bell's palsy)X 12.1.2 Trigeminal neuralgiaX12.2 Demyelinating DisordersXX 12.2.1 Multiple sclerosisXX12.3 Headache (See 1.2.2)XXX 12.3.1 TensionX 12.3.2 VascularXX 12.3.3 ClusterXX12.4 HydrocephalusXX 12.4.1 Normal pressureXX 12.4.2 Shunt complicationsX12.5 Infections/Inflammatory Disorders 12.5.1 EncephalitisXX 12.5.2 Intracranial and intraspinal abscessXX 12.5.3 Meningitis12.5.3.1 BacterialXX12.5.3.2 ViralXXX12.5.3.3 FungalXXX 12.5.4 MyelitisX12.5.4.1 Acute flaccid myelitisX 12.5.5 NeuritisX12.6 Movement DisordersXX 12.6.1 Dystonic reactionXX 12.6.2 Chorea/ChoreiformX 12.6.3 Tardive dyskinesiaX12.7 Neuromuscular Disorders 12.7.1 Guillain-Barré syndromeXX 12.7.2 Myasthenia gravisXXX 12.7.3 Peripheral neuropathy (See 11.2.3)X12.8 Other Conditions of the Brain 12.8.1 Dementia (See 14.5.2)X 12.8.2 Parkinson's diseaseX 12.8.3 Idiopathic intracranial hypertensionXX 12.8.4 Cerebral venous sinus thrombosisXXX 12.8.5 Posterior reversible encephalopathy syndrome (PRES)XX 12.8.6 Transient global amnesiaX12.9 Seizure Disorders 12.9.1 EpileptiformXXX12.9.1.1 NeonatalXX12.9.1.2 FebrileXXX12.9.1.3 Status epilepticusX12.9.1.4 NonconvulsiveacXX12.9.1.5 Drug-inducedXX 12.9.2 NonepileptiformX12.10 Spinal Cord Compression (See 8.7.5)XX12.11 Stroke 12.11.1 Hemorrhagic12.11.1.1 IntracerebralXX12.11.1.2 SubarachnoidXX 12.11.2 Ischemic12.11.2.1 EmbolicXX12.11.2.2 ThromboticXX12.12 Transient Cerebral IschemiaXX12.13 TumorsXXX12.14 DeliriumXXX 12.14.1 Excited delirium syndromeXX13.0 OBSTETRICS AND GYNECOLOGYCriticalEmergentLower Acuity13.1 Female Genital Tract 13.1.1 Cervix13.1.1.1 Cervicitis and endocervicitisXX13.1.1.2 TumorsX 13.1.2 Infectious disorders13.1.2.1 Pelvic inflammatory diseaseX13.1.2.1.1 Fitz-Hugh-Curtis syndromeX13.1.2.1.2 Tuboovarian abscessX13.1.2.2 UrethritisX13.1.2.3 Gangrene of perineumXX 13.1.3 Lesions13.1.3.1 Herpes simplex (See 4.4.4.3, 10.6.4)X13.1.3.2 Human papillomavirus (HPV) (See 4.4.4.4)X 13.1.4 Ovary13.1.4.1 CystX13.1.4.2 TorsionX13.1.4.3 Tumor

OBJECTIVES:Fractures comprise 3% of all emergency department (ED) visits. Although emergency physicians are often responsible for managing most of the initial care of these patients, many report a lack of proficiency and comfort with these skills. The primary objective was to assess how prepared recent emergency medicine (EM) residency graduates felt managing closed fractures upon completion of residency. Secondary objectives included whether residency training or independent practice contributed most to the current level of comfort with these procedures and which fractures were most commonly reduced without orthopedic consultation.METHODS:An anonymous online survey was sent to graduates from seven EM residency programs over a 3-month period to evaluate closed fracture reduction training, practice, and comfort level. Each site primary investigator invited graduates from 2010 to 2014 to participate and followed a set schedule of reminders.RESULTS:The response rate was 287/384 (74.7%) and included 3-year (198/287, 69%) and 4-year (89/287, 31%) programs. Practice in community, academic, and hybrid ED settings was reported by 150/287 (52.3%), 64/287 (22.3%), and 73/287 (25.4%), respectively. It was indicated by 137/287 (47.7%) that they reduce closed fractures without a bedside orthopedic consultation greater than 75% of the time. The majority of graduates felt not at all prepared (35/287, 12.2%) or somewhat prepared (126/287, 43.9%) upon residency graduation. Postresidency independent practice contributed most to the current level of comfort for 156/287 (54.4%). The most common fractures requiring reduction were wrist/distal radius and/or ulna, next finger/hand, and finally, ankle/distal tibia and/or fibula.CONCLUSIONS:Although most recent graduates feel at least "somewhat" prepared to manage closed fractures in the ED, most felt that independent practice was a greater contributor to their current level of comfort than residency training. Recent graduates indicate that fracture reduction without orthopedic consultation is common in today's clinical practice. This survey identifies common fractures requiring reduction which EM residencies may wish to consider prioritizing in their emergency orthopedic curricula to better prepare their residents for independent clinical practice.

Spuriously elevated potassium levels due to hemolysis are common in the Emergency Department (ED). Given that true hyperkalemia can be a serious and potentially life-threatening condition, potassium levels are often repeated in order to rule out true hyperkalemia.

BACKGROUND:Maternal resuscitation in the emergency department requires planning and special consideration of the physiologic changes of pregnancy. Perimortem cesarean delivery (PMCD) is a rare but potentially life-saving procedure for both mother and fetus. Emergency physicians should be aware of the procedure's indications and steps because it needs to be performed rapidly for the best possible outcomes.OBJECTIVE:We sought to review the approach to the critically ill pregnant patient in light of new expert guidelines, including indications for PMCD and procedural techniques.DISCUSSION:The prevalence of maternal cardiac arrest and survival outcomes of PMCD in the emergency department setting are difficult to estimate. Advanced cardiovascular life support protocols should be followed in maternal arrest with special considerations made based on the physiologic changes of pregnancy. The latest recommendations for maternal resuscitation are reviewed, including advance planning, rapid determination of gestational age, emergent delivery, and postprocedure considerations for PMCD.CONCLUSIONS:Maternal resuscitation requires knowledge of physiologic changes and evidence-based recommendations. PMCD outcomes are best for both mother and fetus when the procedure is performed rapidly and efficiently in the appropriate setting. Emergency physicians should be familiar with this unique clinical scenario so they are adequately prepared to intervene in order to improve maternal and fetal morbidity and mortality.

Author(s): Phillips, A; Diller, D; Williams, S; Soo Park, Y; Fisher, J; Biese, K; Ufberg, J

Most peer-reviewed journals follow a similar process for assessing whether a manuscript is suitable for publication. This chapter is a general guide to this process, but it is critical to review the 'Information for Authors' page or website where each journal spells out its unique process and requirements. Most journals have a screening process, and nothing will delay your article being sent out for review more surely than not following the journal's directions.

Background Precipitous obstetric deliveries can occur outside of the labor and delivery suite, often in the emergency department (ED). Shoulder dystocia is an obstetric emergency with significant risk of adverse outcome. Objective To review multiple techniques for managing a shoulder dystocia in the ED. Discussion We review various techniques and approaches for achieving delivery in the setting of shoulder dystocia. These include common maneuvers, controversial interventions, and interventions of last resort. Conclusions Emergency physicians should be familiar with multiple techniques for managing a shoulder dystocia to reduce the chances of fetal and maternal morbidity and mortality.

Background Orbital compartment syndrome is a sight-threatening emergency. Vision may be preserved when timely intervention is performed. Objective To present a case of orbital compartment syndrome caused by traumatic retrobulbar hemorrhage and the procedure of lateral canthotomy and cantholysis, reviewed with photographic illustration. Discussion Lateral canthotomy and cantholysis are readily performed at the bedside with simple instruments. The procedure may prevent irreversible blindness in cases of acute orbital compartment syndrome. Conclusions Emergency physicians should be familiar with lateral canthotomy and cantholysis in the management of orbital compartment syndrome to minimize the chance of irreversible visual loss.

The longer one practices emergency medicine, the more it becomes clear that many common practices are driven by dogma, untested conventional wisdom, and opinions of both actual and self-proclaimed experts. Working with residents and students on a day-to-day basis is often the only thing that slows down busy clinicians long enough to consider the lack of evidence supporting many common practices. Seemingly innocuous questions such as “Do I need to wear sterile gloves to repair this simple laceration?” or “Do I really need to pack this abscess?” are enough to send a seasoned attending physician running to the literature after almost every shift. Dogma is easy—it gets us through the day without feeling silly about how little we truly know to be fact. It fills many of the voids in our collective knowledge and persists in our clinical practices until someone challenges it with real-world clinical evidence. It is very likely that much of the conventional wisdom taught in medical school and residency, and reiterated in lectures and textbooks, is actually valid. However, it has been shown several times over the past few decades that at least some of the core beliefs that pervade the daily practice of medicine are eventually proven wrong. Some notable examples include the discovery that peptic ulcer disease was not caused simply by an overproduction of gastric acid, and the discovery of the positive effects of beta-blockers in congestive heart failure. Often, ill-informed conventional wisdom persists because investigators are unable to persuade local institutional review boards that a putative “standard of care” merits reconsideration. Equipoise is a guiding principal of ethical clinical trials. As traditionally interpreted, equipoise exists when there is no expert consensus that one treatment alternative is superior to another. Clinical trials can move forward only when experts agree that proposed treatment options appear equally efficacious and none pose an increased risk of harm to the patient. This principle is intended to protect human subjects from being assigned to treatments that are reasonably likely to be less effective or more harmful than current standards of care. The concept of clinical equipoise has been challenged in the medical literature.1 The standard-of-care treatment option may itself be based on poor evidence. It is often unclear when an individual or committee is qualified to render the “expert” opinion regarding the efficacy of treatment options. It is very possible that one investigator may be able to persuade his institutional review board that treatment standards merit reconsideration, while another investigator would find his local board unmoved by the same argument. Clearly, the definition of standard of care is subject to divergent interpretation, and many clinical practices go unchallenged because of the hurdle presented by need to demonstrate therapeutic equipoise, however well intended. Emergency physicians have been taught that topical anesthetic use is associated with poor healing and recurrent trauma in the management of corneal abrasions.2 These fears are grounded in laboratory-based studies and case reports that described the prolonged, unsupervised use (or abuse) of topical anesthetics. However, studies published in the 1990s have demonstrated the safety and efficacy of topical anesthetics in postphotorefractive keratectomy patients.3, 4 We suspect that many an emergency physician would take home a bottle of topical anesthetic if he or she personally sustained a corneal abrasion and would use it without too much hesitation. Yet we deny our patients this same courtesy, discharging them instead with prescriptions for oral pain medications, which have their own possible adverse consequences.5 In this issue of Academic Emergency Medicine, Dr. Waldman and colleagues6 report the results of a study examining the safety and efficacy of topical tetracaine in the treatment of corneal abrasions. This is the largest ED-based study to date on this topic. We applaud the authors for challenging common wisdom through this double-blind, randomized trial. We also applaud their institutional review board for finding the clinical equipoise to allow this trial to proceed despite the frequently stated opinion that the use of topical anesthetics deviates from the standard of care. The study demonstrated no complications specifically attributable to topical anesthetic use among the 59 patients in the tetracaine group, yielding a 95% confidence interval (CI) of a topical anesthetic–induced complication between zero and 6.1%. Additionally, there was no significant difference in healing between the groups as measured by persistent fluorescein uptake at the 48-hour recheck. At least one follow-up encounter was completed on each study patient. While median visual analog scale (VAS) pain scores were lower in the tetracaine group at all study time points after presentation, the mixed-model analysis did not demonstrate a clinically significant difference in pain scores between the two groups. However, patients rated the study drug to be significantly more effective on a global rating scale (7.7 vs. 3.8 on the numeric 0 to 10 rating scale, p < 0.0005). The reason for the dichotomous findings related to pain control efficacy is not entirely clear, and the authors proffer several possible explanations. Whether or not to start using tetracaine routinely in the treatment of simple corneal abrasions remains up to the reader. While this study found no complications, the width of the 95% CI may cause some to consider waiting for further study. Additionally, the seemingly conflicting results of the mixed-model VAS score analysis and the analysis of the global effectiveness ratings may lead some to question the efficacy of topical anesthetics. What is clear is that these authors have, at the very least, opened the door to the use of a promising, inexpensive medication once considered off-limits to our patients after ED discharge. Future trials will likely answer any remaining questions regarding safety and efficacy, but the investigators hoping to conduct those trials can thank the authors of this manuscript for paving the road to institutional review board approval.

Background: Pneumothorax has traditionally been treated in the Emergency Department by tube thoracostomy. However, this is an invasive procedure with high risk of complication and prolonged hospitalization. Discussion: In select settings, there are alternative forms of management of pneumothorax that carry lower risks and may reduce hospital stay. This article reviews the settings in which less invasive treatment, including observation alone, may be indicated. This article also reviews the techniques for simple aspiration and small-bore catheter insertion (by either Seldinger or catheter-over-wire technique) with Heimlich valve, as well as the indications, contraindications, and potential risks and benefits of each. Conclusions: The practices of observation, simple aspiration, and small-bore catheter insertion with Heimlich valve for selected patients may decrease complications, time, and costs by avoiding invasive procedures and hospital admissions. (c) 2013 Elsevier Inc.

Appendicitis, diverticulitis, and colitis are common gastrointestinal conditions presenting to the emergency department (ED). Although it is a common condition, the diagnosis of appendicitis remains challenging, and the approach to this disease continues to evolve. The diagnostic approach to diverticulitis is more straightforward, and treatment and the decision whether to hospitalize varies with disease severity. Colitis may be caused by inflammatory bowel disease, ischemia, or infection. This article details an ED-based approach to each of these disease entities.

Background: Ethics education is an essential component of graduate medical education in emergency medicine. A sound understanding of principles of bioethics and a rational approach to ethical decision-making are imperative. Objective: This article addresses ethics curriculum content, educational approaches, educational resources, and resident feedback and evaluation. Discussion: Ethics curriculum content should include elements suggested by the Liaison Committee on Medical Education, Accreditation Council for Graduate Medical Education, and the Model of the Clinical Practice of Emergency Medicine. Essential ethics content includes ethical principles, the physician-patient relationship, patient autonomy, clinical issues, end-of-life decisions, justice, education in emergency medicine, research ethics, and professionalism. Conclusion: The appropriate curriculum in ethics education in emergency medicine should include some of the content and educational approaches outlined in this article, although the optimal methods for meeting these educational goals may vary by institution. (C) 2011 Elsevier Inc.

BACKGROUND: Recent data suggest that during mechanical ventilation the lateral-horizontal patient position (in which the endotracheal tube is horizontal) decreases the risk of ventilator-associated pneumonia, compared to the recommended semi-recumbent position (in which the endotracheal tube slopes downward into the trachea). We tested the feasibility of the lateral-horizontal patient position, measured the incidence of aspiration of gastric contents, and watched for any adverse effects related to the lateral-horizontal position. METHODS: Ten adult intensive care unit patients were ventilated for 64 hours in the standard semi-recumbent position, and ten for 12 24 hours in the lateral-horizontal position. Tracheal secretions were collected every 8 hours and every 4 hours, respectively, and tested for pepsin, which is a marker of gastric contents. We also recorded clinical, physiologic, and outcome variables. RESULTS: The patients remained stable during ventilation in the lateral-horizontal position, and no adverse events occurred. Pepsin was detected in the trachea of 7 semi-recumbent patients and in five of the lateral-horizontal patients (P = .32). The number of ventilator-free days was 8 days (range 0-21 days) in the semi-recumbent patients, versus 24 days (range 12-25 days) in the lateral-horizontal patients (P = .04). CONCLUSIONS: Implementing the lateral-horizontal position for 12-24 hours in adult intubated intensive care unit patients is feasible, and our patients had no adverse events. The incidence of aspiration of gastric contents in the lateral-horizontal position seems to be similar to that in the semi-recumbent position.

Medicine Review: Preparing for the Boards, by Richard Harrigan, Matthew Tripp, and Jacob Ufberg, uniquely combines a comprehensive, bulleted review of all required subjects with a thorough practice exam of board-style questions, giving you all the tools you need to be prepared and confident during the American Board of Emergency Medicine's qualifying exam and beyond! You can also access the online Q&A review at expertconsult.com.