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Open Access Publications from the University of California

Volume 16, Issue 2, 2015

Endemic Infections

Identify-Isolate-Inform: A Tool for Initial Detection and Management of Measles Patients in the Emergency Department

Measles (rubeola) is a highly contagious airborne disease that was declared eliminated in the the year 2000. Only sporadic U.S. cases and minor outbreaks occurred until the larger outbreakbeginning in 2014 that has become a public health emergency. The “Identify-Isolate-Inform” toolwill assist emergency physicians to be better prepared to detect and manage measles patientspresenting to the emergency department. Measles typically presents with a prodrome of high fever,and cough/coryza/conjunctivitis, sometimes accompanied by the pathognomonic Koplik spots.Two to four days later, an erythematous maculopapular rash begins on the face and spreads downthe body. Suspect patients must be immediately isolated with airborne precautions while awaitinglaboratory confirmation of disease. Emergency physicians must rapidly inform the local public healthdepartment and hospital infection control personnel of suspected measles cases. [West J EmergMed. 2015;16(2):212–219.]

Behavioral Health

Kiosk versus In-person Screening for Alcohol and Drug Use in the Emergency Department: Patient Preferences and Disclosure

Introduction: Annually eight million emergency department (ED) visits are attributable to alcoholuse. Screening ED patients for at-risk alcohol and substance use is an integral component ofscreening, brief intervention, and referral to treatment programs, shown to be effective at reducingsubstance use. The objective is to evaluate ED patients’ acceptance of and willingness to disclosealcohol/substance use via a computer kiosk versus an in-person interview.

Methods: This was a cross-sectional, survey-based study. Eligible participants included thosewho presented to walk-in triage, were English-speaking, ≥18 years, were clinically stable andable to consent. Patients had the opportunity to access the kiosk in the ED waiting room, andwere approached for an in-person survey by a research assistant (9am-5pm weekdays). Bothsurveys used validated assessment tools to assess drug and alcohol use. Disclosure statistics andpreferences were calculated using chi-square tests and McNemar’s test.

Results: A total of 1,207 patients were screened: 229 in person only, 824 by kiosk, and 154 byboth in person and kiosk. Single-modality participants were more likely to disclose hazardousdrinking (p=0.003) and high-risk drug use (OR=22.3 [12.3-42.2]; p<0.0001) via kiosk. Participantswho had participated in screening via both modalities were more likely to reveal high-risk drug useon the kiosk (p=0.003). When asked about screening preferences, 73.6% reported a preference foran in-person survey, which patients rated higher on privacy and comfort.

Conclusion: ED patients were significantly more likely to disclose at-risk alcohol and substance use toa computer kiosk than an interviewer. Paradoxically patients stated a preference for in-person screening,despite reduced disclosure to a human screener. [West J Emerg Med. 2015;16(2):220–228.]

  • 1 supplemental PDF

Healthcare Utilization

Patients Who Use Multiple EDs: Quantifying the Degree of Overlap between ED Populations

Introduction: The degree to which individual patients use multiple emergency departments (EDs)is not well-characterized. We determined the degree of overlap in ED population between threegeographically proximate hospitals.

Methods: This retrospective cohort study reviewed administrative hospital records from 2003 to2007 for patients registered to receive ED services at an urban academic, urban community, andsuburban community ED located within 10 miles of one another. We determined the proportion whosought care at multiple EDs and secondarily characterized patterns of repeat encounters.

Results: There were 795,176 encounters involving 282,903 patients. There were 89,776 (31%)patients with multiple encounters to a single ED and 39,920 (14%) patients who sought care frommultiple EDs. The 39,920 patients who sought care from multiple EDs generated 185,629 (23%)of all encounters. Patients with repeat encounters involving multiple EDs were more likely to befrequent or highly frequent users (30%) than patients with multiple encounters to a single ED (14%).

Conclusion: While only 14% of patients received care from more than one ED, they wereresponsible for a quarter of ED encounters. Patients who use multiple EDs are more oftenfrequent or highly frequent users than are repeat ED visitors to the same ED. Overlap between ED populations is sufficient to warrant consideration by multiple domains of research, practice, andpolicy. [West J Emerg Med. 2015;16(2):229–233.]

Ethical and Legal Issues

Do Emergency Physicians and Medical Students Find It Unethical to ‘Look up’ Their Patients on Facebook or Google?

Introduction: The use of search engines and online social media (OSM) websites by healthcareproviders is increasing and may even be used to search for patient information. This raises severalethical issues. The objective of this study is to evaluate the prevalence of OSM and web-searchingfor patient information and to explore attitudes towards the ethical appropriateness of these practicesby physicians and trainees in the emergency department (ED).

Methods: We conducted an online survey study of Canadian emergency physicians and traineeslisted under then Canadian Association of Emergency Physicians (CAEP) and senior medicalstudents at the University of Toronto.

Results: We received 530 responses (response rate 49.1%): 34.9% medical students, 15.5%residents, 49.6% staff physicians. Most had an active Facebook account (74%). Sixty-fourparticipants (13.5%) had used Google to research a patient and 10 (2.1%) had searched for patientson Facebook. There were no differences in these results based on level of training, and 25% ofphysicians considered using Facebook to learn about a patient “very unethical.” The most frequentethical concerns were with violation of patient confidentiality, dignity, and consent. The practice wasusually not disclosed to patients (14%), but often disclosed to senior colleagues (83%).

Conclusion: This is the first study examining the prevalence of and attitudes towards onlinesearching for obtaining patient information in the ED. This practice occurs among staff physiciansand trainees despite ethical concerns. Future work should explore the utility and desirability ofsearching for patient information online. [West J Emerg Med. 2015;16(2):234–239.]

Technology in Emergency Care

The Social Media Index: Measuring the Impact of Emergency Medicine and Critical Care Websites

Introduction: The number of educational resources created for emergency medicine and criticalcare (EMCC) that incorporate social media has increased dramatically. With no way to assess theirimpact or quality, it is challenging for educators to receive scholarly credit and for learners to identifyrespected resources. The Social Media index (SMi) was developed to help address this.

Methods: We used data from social media platforms (Google PageRanks, Alexa Ranks, FacebookLikes, Twitter Followers, and Google+ Followers) for EMCC blogs and podcasts to derive threenormalized (ordinal, logarithmic, and raw) formulas. The most statistically robust formula wasassessed for 1) temporal stability using repeated measures and website age, and 2) correlationwith impact by applying it to EMCC journals and measuring the correlation with known journalimpact metrics.

Results: The logarithmic version of the SMi containing four metrics was the most statistically robust.It correlated significantly with website age (Spearman r=0.372; p<0.001) and repeated measuresthrough seven months (r=0.929; p<0.001). When applied to EMCC journals, it correlated significantlywith all impact metrics except number of articles published. The strongest correlations were seenwith the Immediacy Index (r=0.609; p<0.001) and Article Influence Score (r=0.608; p<0.001).

Conclusion: The SMi’s temporal stability and correlation with journal impact factors suggests thatit may be a stable indicator of impact for medical education websites. Further study is needed todetermine whether impact correlates with quality and how learners and educators can best utilizethis tool. [West J Emerg Med. 2015;16(2):242–249.]

DOI: 10.5811/westjem.2015.1.24860

Non-thrombotic Abnormalities on Lower Extremity Venous Duplex Ultrasound Examinations

Introduction: Emergency physician-performed compression ultrasonography focuses primarily onthe evaluation of the proximal veins of the lower extremity in patients with suspected deep venousthrombosis (DVT). A detailed sonographic evaluation of lower extremity is not performed. Theobjective of this study was to determine the prevalence of non-thrombotic findings on comprehensivelower extremity venous duplex ultrasound (US) examinations performed on emergency department(ED) patients.

Methods: We performed a retrospective six-year review of an academic ED’s records of adultpatients who underwent a comprehensive lower extremity duplex venous US examination for theevaluation of DVT. The entire US report was thoroughly reviewed for non-thrombotic findings.

Results: We detected non-thrombotic findings in 263 (11%, 95% CI [9.5-11.9%]) patients. Amongthe non-thrombotic findings, venous valvular incompetence (81, 30%) was the most frequent,followed by cyst/mass (41, 15%), lymphadenopathy (33, 12%), phlebitis (12, 4.5%), hematoma (8,3%), cellulitis (1, 0.3%) and other (6, 2.2%).

Conclusion: In our study, we detected a variety of non-thrombotic abnormalities on comprehensive lowerextremity venous duplex US examinations performed on ED patients. Some of these abnormalities couldbe clinically significant and potentially be detected with point-of-care lower extremity US examinationsif the symptomatic region is evaluated. In addition to assessment of the proximal veins for DVT, werecommend sonographic evaluation of the symptomatic area in the lower extremity when performingpoint-of-care ultrasound examinations to identify non-thrombotic abnormalities that may requireimmediate intervention or close follow up. [West J Emerg Med. 2015;16(2):250–254.]

Can Emergency Physicians Perform Common Carotid Doppler Flow Measurements to Assess Volume Responsiveness?

Introduction: Common carotid flow measurements may be clinically useful to determine volumeresponsiveness. The objective of this study was to assess the ability of emergency physicians (EP)to obtain sonographic images and measurements of the common carotid artery velocity time integral(VTi) for potential use in assessing volume responsiveness in the clinical setting.

Methods: In this prospective observational study, we showed a five-minute instructional videodemonstrating a technique to obtain common carotid ultrasound images and measure the commoncarotid VTi to emergency medicine (EM) residents. Participants were then asked to image thecommon carotid artery and obtain VTi measurements. Expert sonographers observed participantsimaging in real time and recorded their performance on nine performance measures. An expertsonographer graded image quality. Participants were timed and answered questions regarding easeof examination and their confidence in obtaining the images.

Results: A total of 30 EM residents participated in this study and each performed the examinationtwice. Average time required to complete one examination was 2.9 minutes (95% CI [2.4-3.4 min]). Participants successfully completed all performance measures greater than 75% of the time, with theexception of obtaining measurements during systole, which was completed in 65% of examinations.Median resident overall confidence in accurately performing carotid VTi measurements was 3 (on ascale of 1 [not confident] to 5 [confident]).

Conclusion: EM residents at our institution learned the technique for obtaining common carotidartery Doppler flow measurements after viewing a brief instructional video. When assessed atperforming this examination, they completed several performance measures with greater than 75%success. No differences were found between novice and experienced groups. [West J Emerg Med.2015;16(2):255–259.]

  • 2 supplemental videos

Bedside Ultrasound Identification of Infectious Flexor Tenosynovitis in the Emergency Department

Infectious flexor tenosynovitis (FTS) is a serious infection of the hand and wrist that can lead tonecrosis and amputation without prompt diagnosis and surgical debridement. Despite the growinguse of point-of-care ultrasound (POCUS) by emergency physicians there is only one reported caseof the use of POCUS for the diagnosis of infectious FTS in the emergency department setting.We present a case of a 58 year-old man where POCUS identified tissue necrosis and fluid alongthe flexor tendon sheath of the hand. Subsequent surgical pathology confirmed the diagnosis ofinfectious FTS. [West J Emerg Med. 2015;16(2):260–262.]

  • 2 supplemental videos

Change in Intraocular Pressure During Point-of-Care Ultrasound

Introduction: Point-of-care ocular ultrasound (US) is a valuable tool for the evaluation of traumaticocular injuries. Conventionally, any maneuver that may increase intraocular pressure (IOP) isrelatively contraindicated in the setting of globe rupture. Some authors have cautioned against theuse of US in these scenarios because of a theoretical concern that an US examination may causeor exacerbate the extrusion of intraocular contents. This study set out to investigate whether ocularUS affects IOP. The secondary objective was to validate the intraocular pressure measurementsobtained with the Diaton® as compared with standard applanation techniques (the Tono-Pen®).

Methods: We enrolled a convenience sample of healthy adult volunteers. We obtained thebaseline IOP for each patient by using a transpalpebral tonometer. Ocular US was then performedon each subject using a high-frequency linear array transducer, and a second IOP was obtainedduring the US examination. A third IOP measurement was obtained following the completionof the US examination. To validate transpalpebral measurement, a subset of subjects alsounderwent traditional transcorneal applanation tonometry prior to the US examination as a baselinemeasurement. In a subset of 10 patients, we obtained baseline pre-ultrasound IOP measurementswith the Diaton® and Tono-Pen®, and then compared them.

Results: The study included 40 subjects. IOP values during ocular US examination were slightlygreater than baseline (average +1.8mmHg, p=0.01). Post-US examination IOP values were notsignificantly different than baseline (average -0.15mmHg, p=0.42). In a subset of 10 subjects, IOPvalues were not significantly different between transpalpebral and transcorneal tonometry (average+0.03mmHg, p=0.07).

Conclusion: In healthy volunteer subjects, point-of-care ocular US causes a small and transientincrease in IOP. We also showed no difference between the Diaton® and Tono-Pen® methodsof IOP measurement. Overall, the resulting change in IOP with US transducer placement isconsiderably less than the mean diurnal variation in healthy subjects, or pressure generated byphysical examination, and is therefore unlikely to be clinically significant. However, it is important totake caution when performing ocular ultrasound, since it is unclear what the change in IOP would bein patients with ocular trauma. [West J Emerg Med. 2015;16(2):263–268.]

  • 1 supplemental file

Health Outcomes

Young Patients with Suspected Uncomplicated Renal Colic are Unlikely to Have Dangerous Alternative Diagnoses or Need Emergent Intervention

Introduction: In the United States there is debate regarding the appropriate first test for new-onsetrenal colic, with non-contrast helical computed tomography (CT) receiving the highest ratings fromboth Agency for Healthcare Research and Quality and the American Urological Association. This isbased not only on its accuracy for the diagnosis of renal colic, but also its ability to diagnose othersurgical emergencies, which have been thought to occur in 10-15% of patients with suspected renalcolic, based on previous studies. In younger patients, it may be reasonable to attempt to avoidimmediate CT if concern for dangerous alternative diagnosis is low, based on the risks of radiationfrom CTs, and particularly in light of evidence that patients with renal colic have a very high likelihoodof having multiple CTs in their lifetimes. The objective is to determine the proportion of patients witha dangerous alternative diagnosis in adult patients age 50 and under presenting with uncomplicated(non-infected) suspected renal colic, and also to determine what proportion of these patientsundergo emergent urologic intervention.

Methods: Retrospective chart review of 12 months of patients age 18-50 presenting with “flankpain,” excluding patients with end stage renal disease, urinary tract infection, pregnancy and trauma.Dangerous alternative diagnosis was determined by CT.

Results: Two hundred and ninety-one patients met inclusion criteria. One hundred and fifteenpatients had renal protocol CTs, and zero alternative emergent or urgent diagnoses were identified(one-sided 95% CI [0-2.7%]). Of the 291 encounters, there were 7 urologic procedures performedupon first admission (2.4%, 95% CI [1.0-4.9%]). The prevalence of kidney stone by final diagnosiswas 58.8%.

Conclusion: This small sample suggests that in younger patients with uncomplicated renal colic, thebenefit of immediate CT for suspected renal colic should be questioned. Further studies are neededto determine which patients benefit from immediate CT for suspected renal colic, and which patientscould undergo alternate imaging such as ultrasound. [West J Emerg Med. 2015;16(2):269–275.]

Characteristics of Patients That Do Not Initially Respond to Intravenous Antihypertensives in the Emergency Department: Subanalysis of the CLUE Trial

Introduction: Hypertensive emergency has a high mortality risk and the treatment goal is to quicklylower blood pressure with intravenous (IV) medications. Characteristics that are associated withnon-response to IV antihypertensives have not been identified. The objective is to identify patientcharacteristics associated with resistance to IV antihypertensives.

Methods: This was a subanalysis of patients enrolled in the previously described comparativeeffectiveness trial of IV nicardipine vs. labetalol use in the emergency department (CLUE) study, arandomized trial of nicardipine vs. labetalol. Non-responders were defined as those patients whodid not achieve target systolic blood pressure (SBP), as set by the treating physician, within thirtyminutes of IV antihypertensive medication, +/- 20mmHg. Stepwise logistic regression was used toidentify covariates associated with the measurement outcomes.

Results: CLUE enrolled 226 patients, 52.7% female, 76.4% black, mean age of 52.6±14.6 years,of whom 110 were treated with nicardipine and 116 with labetalol. The median (IQR) initial systolicblood pressure was 211mmHg (198, 226), 210 (200, 230), and 211mmHg (198,226), for the total,non-responder, and responder cohorts, respectively (p-value=0.65, 95% CI [-5.8-11.3]). Twentyninewere non-responders, 9 in the nicardipine and 20 in the labetalol group. In univariate analysis,several symptoms suggestive of end organ damage were associated with non-response. Aftermultiple variable logistic regression (AUC = 0.72), treatment with labetalol (OR 2.7, 95% CI [1.1-6.7]), history of stroke (OR 5.4, 95% CI [1.6-18.5]), and being male (OR 3.3, 95% CI [1.4-8.1]) wereassociated with failure to achieve target blood pressure.

Conclusion: Male gender and history of previous stroke are associated with difficult to controlblood pressure. [West J Emerg Med. 2015;16(2):276–283.]

Long-term Neurological Outcomes in Adults with Traumatic Intracranial Hemorrhage Admitted to ICU versus Floor

Introduction: The objective of this study was to compare long-term neurological outcomes in low-risk patients with traumatic intracranial hemorrhage (tICH) admitted to the ICU (intensive care unit) versus patients admitted to the floor.

Methods: This retrospective study was conducted at a Level 1 trauma center from October 1, 2008, to February 1, 2013. We defined low-risk patients as age less than 65 years, isolated head injury, normal admission mental status, and no shift or swelling on initial head CT (computed tomography). Clinical data were abstracted from a trauma registry and linked to a brain injury database. We compared the Extended Glasgow Outcome Scale (GOS-E) score at six months between patients admitted to the ICU and patients admitted to the floor. We did a risk-adjusted analysis of the influence of floor admission on a normal GOS-E.

Results: We identified 151 patients; 45 (30%) were admitted to the floor and 106 (70%) to the ICU. Twenty-three (51%; 95% CI [36-66%]) patients admitted to the floor and 55 (52%; 95% CI [42-62%]) patients admitted to the ICU had a normal GOS-E. On adjusted analysis; the odds ratio for floor admission was 0.77 (95% CI [0.36-1.64]) for a normal GOS-E at six months.

Conclusion: Long-term neurological outcomes in low-risk patients with tICH were not markedly different between patients admitted to the ICU and those admitted to the floor. However, we were unable to demonstrate non-inferiority on adjusted analysis. Future work aimed at a larger, prospective cohort may better evaluate the relative impacts of admission type on outcomes. [West J Emerg Med. 2015;16(2):284–290.]

  • 2 supplemental files

Diagnostic Acumen

Headache in Pregnancy: An Approach to Emergency Department Evaluation and Management

Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges. There are important unique considerations regarding the differential diagnosis, imaging options, and medical management. Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy. Preeclampsia, a serious condition unique to pregnancy, must also be considered. A high index of suspicion for carbon monoxide toxicity should be maintained. Primary headaches should be a diagnosis of exclusion. When advanced imaging is indicated, magnetic resonance imaging (MRI) should be used, if available, to reduce radiation exposure. Contrast agents should be avoided unless absolutely necessary. Medical therapy should be selected with careful consideration of adverse fetal effects. Herein, we present a review of the literature and discuss an approach to the evaluation and management of headache in pregnancy [West J Emerg Med. 2015;16(2):291–301.]

Jaguar Attack on a Child: Case Report and Literature Review

Jaguar attacks on humans rarely occur in the wild. When they do, they are often fatal. We describe a jaguar attack on a three-year-old girl near her home deep in a remote area of the Guyanese jungle. The patient had a complex but, relatively, rapid transport to a medical treatment facility for her life-threatening injuries. The child, who suffered typical jaguar-inflicted injury patterns and survived, is highlighted. We review jaguar anatomy, environmental status, hunting and killing behaviors, and discuss optimal medical management, given the resource-limited treatment environment of this international emergency medicine case. [West J Emerg Med. 2015;16(2):303–309.]

Spontaneous Pneumomediastinum on Bedside Ultrasound: Case Report and Review of the Literature

Spontaneous pneumomediastinum is a rare disease process with no clear etiology, although it is thought to be related to changes in intrathoracic pressure causing chest pain and dyspnea. We present a case of a 17-year-old male with acute chest pain evaluated initially by bedside ultrasound, which showed normal lung sliding but poor visualization of the parasternal and apical cardiac views due to significant air artifact, representing air in the thoracic cavity. The diagnosis was later verified by chest radiograph. We present a case report on ultrasound-diagnosed pneumomediastinum, and we review the diagnostic modalities to date. [West J Emerg Med. 2015;16(2):321–324.]

  • 1 supplemental video

Disaster Response Team FAST Skills Training with a PortableUltrasound Simulator Compared to Traditional Training: Pilot Study

Introduction: Pre-hospital focused assessment with sonography in trauma (FAST) has been effectively used to improve patient care in multiple mass casualty events throughout the world. Although requisite FAST knowledge may now be learned remotely by disaster response team members, traditional live instructor and model hands-on FAST skills training remains logistically challenging. The objective of this pilot study was to compare the effectiveness of a novel portable ultrasound (US) simulator with traditional FAST skills training for a deployed mixed provider disaster response team.

Methods: We randomized participants into one of three training groups stratified by provider role: Group A. Traditional Skills Training, Group B. US Simulator Skills Training, and Group C. Traditional Skills Training Plus US Simulator Skills Training. After skills training, we measured participants’ FAST image acquisition and interpretation skills using a standardized direct observation tool (SDOT) with healthy models and review of FAST patient images. Pre- and post-course US and FAST knowledge were also assessed using a previously validated multiple-choice evaluation. We used the ANOVA procedure to determine the statistical significance of differences between the means of each group’s skills scores. Paired sample t-tests were used to determine the statistical significance of pre- and post-course mean knowledge scores within groups.

Results: We enrolled 36 participants, 12 randomized to each training group. Randomization resulted in similar distribution of participants between training groups with respect to provider role, age, sex, and prior US training. For the FAST SDOT image acquisition and interpretation mean skills scores, there was no statistically significant difference between training groups. For US and FAST mean knowledge scores, there was a statistically significant improvement between pre- and post-course scores within each group, but again there was not a statistically significant difference between training groups.

Conclusion: This pilot study of a deployed mixed-provider disaster response team suggests that a novel portable US simulator may provide equivalent skills training in comparison to traditional live instructor and model training. Further studies with a larger sample size and other measures of short- and long-term clinical performance are warranted. [West J Emerg Med. 2015;16(2):325–330.]


Asking for a Commitment: Violations during the 2007 Match and the Effect on Applicant Rank Lists

Introduction: Applicants to residency face a number of difficult questions during the interview process, one of which is when a program asks for a commitment to rank the program highly. The regulations governing the National Resident Matching Program (NRMP) match explicitly forbid any residency programs asking for a commitment.

Methods: We conducted a cross-sectional survey of applicants from U.S. medical schools to five specialties during the 2006-2007 interview season using the Electronic Residency Application Service of the Association of American Medical Colleges. Applicants were asked to recall being asked to provide any sort of commitment (verbal or otherwise) to rank a program highly. Surveys were sent after rank lists were submitted, but before match day. We analyzed data using descriptive statistics and logistic regression. 

Results: There were 7,028 unique responses out of 11,983 surveys sent for a response rate of 58.6%. Of those who identified their specialty (emergency medicine, internal medicine, obstetrics and gynecology [OBGYN], general surgery and orthopedics), there were 6,303 unique responders. Overall 19.6% (1380/7028) of all respondents were asked to commit to a program. Orthopedics had the highest overall prevalence at 28.9% (372/474), followed by OBGYN (23.7%; 180/759), general surgery (21.7%; 190/876), internal medicine (18.3%; 601/3278), and finally, emergency medicine (15.4%; 141/916). Of those responding, 38.4% stated such questions made them less likely to rank the program.

Conclusion: Applicants to residencies are being asked questions expressly forbidden by the NRMP. Among the five specialties surveyed, orthopedics and OBGYN had the highest incidence of this violation. Asking for a commitment makes applicants less likely to rank a program highly. [West J Emerg Med. 2015;16(2):331-335.]

Virtual Alternative to the Oral Examination for Emergency Medicine Residents

Introduction: The oral examination is a traditional method for assessing the developing physician’s medical knowledge, clinical reasoning and interpersonal skills. The typical oral examination is a face-to-face encounter in which examiners quiz examinees on how they would confront a patient case. The advantage of the oral exam is that the examiner can adapt questions to the examinee’s response. The disadvantage is the potential for examiner bias and intimidation. Computer-based virtual simulation technology has been widely used in the gaming industry. We wondered whether virtual simulation could serve as a practical format for delivery of an oral examination. For this project, we compared the attitudes and performance of emergency medicine (EM) residents who took our traditional oral exam to those who took the exam using virtual simulation.

Methods: EM residents (n=35) were randomized to a traditional oral examination format (n=17) or a simulated virtual examination format (n=18) conducted within an immersive learning environment, Second Life (SL). Proctors scored residents using the American Board of Emergency Medicine oral examination assessment instruments, which included execution of critical actions and ratings on  eight competency categories (1-8 scale). Study participants were also surveyed about their oral examination experience.

Results: We observed no differences between virtual and traditional groups on critical action scores or scores on eight competency categories. However, we noted moderate effect sizes favoring the Second Life group on the clinical competence score. Examinees from both groups thought that their assessment was realistic, fair, objective, and efficient. Examinees from the virtual group reported a preference for the virtual format and felt that the format was less intimidating.

Conclusion: The virtual simulated oral examination was shown to be a feasible alternative to the traditional oral examination format for assessing EM residents. Virtual environments for oral examinations should continue to be explored, particularly since they offer an inexpensive, more comfortable, yet equally rigorous alternative. [West J Emerg Med. 2015;16(2):–0.]

  • 1 supplemental video

Structured Communication: Teaching Delivery of Difficult News with Simulated Resuscitations in an Emergency Medicine Clerkship

Introduction: The objective is to describe the implementation and outcomes of a structured communication module used to supplement case-based simulated resuscitation training in an emergency medicine (EM) clerkship.

Methods: We supplemented two case-based simulated resuscitation scenarios (cardiac arrest and blunt trauma) with role-play in order to teach medical students how to deliver news of death and poor prognosis to family of the critically ill or injured simulated patient. Quantitative outcomes were assessed with pre and post-clerkship surveys. Secondarily, students completed a written self-reflection (things that went well and why; things that did not go well and why) to further explore learner experiences with communication around resuscitation. Qualitative analysis identified themes from written self-reflections.

Results: A total of 120 medical students completed the pre and post-clerkship surveys. Majority of respondents reported that they had witnessed or role-played the delivery of difficult news, but only few had real-life experience of delivering news of death (20/120, 17%) and poor prognosis (34/120, 29%). This communication module led to statistically significant increased scores for comfort, confidence, and knowledge with communicating difficult news of death and poor prognosis. Pre-post scores increased for those agreeing with statements (somewhat/very much) for delivery of news of poor prognosis: comfort 69% to 81%, confidence 66% to 81% and knowledge 76% to 90% as well as for statements regarding delivery of news of death: comfort 52% to 68%, confidence 57% to 76% and knowledge 76% to 90%. Respondents report that patient resuscitations (simulated and/or real) generated a variety of strong emotional responses such as anxiety, stress, grief and feelings of loss and failure.

Conclusion: A structured communication module supplements simulated resuscitation training in an EM clerkship and leads to a self-reported increase in knowledge, comfort, and competence in communicating difficult news of death and poor prognosis to family. Educators may need to seek ways to address the strong emotions generated in learners with real and simulated patient resuscitations. [West J Emerg Med. 2015;16(2):344–352.]


  • 2 supplemental files

Residency Applicants Prefer Online System for Scheduling Interviews

Introduction: Residency coordinators may be overwhelmed when scheduling residency interviews.Applicants often have to coordinate interviews with multiple programs at once, and relying on verbalor email confirmation may delay the process. Our objective was to determine applicant mean time toschedule and satisfaction using online scheduling.

Methods: This pilot study is a retrospective analysis performed on a sample of applicants offeredinterviews at an urban county emergency medicine residency. Applicants were asked their estimatedtime to schedule with the online system compared to their average time using other methods. Inaddition, they were asked on a five-point anchored scale to rate their satisfaction.

Results: Of 171 applicants, 121 completed the survey (70.8%). Applicants were scheduling anaverage of 13.3 interviews. Applicants reported scheduling interviews using the online systemin mean of 46.2 minutes (median 10, range 1-1800) from the interview offer as compared with amean of 320.2 minutes (median 60, range 3-2880) for other programs not using this system. Thisdifference was statistically significant. In addition, applicants were more likely to rate their satisfactionusing the online system as “satisfied” (83.5% vs 16.5%). Applicants were also more likely to statethat they preferred scheduling their interviews using the online system rather than the way otherprograms scheduled interviews (74.2% vs 4.1%) and that the online system aided them coordinatingtravel arrangements (52.1% vs 4.1%).

Conclusion: An online interview scheduling system is associated with higher satisfaction amongapplicants both in coordinating travel arrangements and in overall satisfaction. [West J Emerg Med.2015;16(2):352-354.]

Emergency Medicine Residency Boot Camp Curriculum: A Pilot Study

Introduction: Establishing a boot camp curriculum is pertinent for emergency medicine (EM) residents in order to develop proficiency in a large scope of procedures and leadership skills.  In this article, we describe our program’s EM boot camp curriculum as well as measure the confidence levels of resident physicians through a pre- and post-boot camp survey.

Methods: We designed a one-month boot camp curriculum with the intention of improving the confidence, procedural performance, leadership, communication and resource management of EM interns. Our curriculum consisted of 12 hours of initial training and culminated in a two-day boot camp. The initial day consisted of clinical skill training and the second day included code drill scenarios followed by interprofessional debriefing.  

Results: Twelve EM interns entered residency with an overall confidence score of 3.2 (1-5 scale) across all surveyed skills. Interns reported the highest pre-survey confidence scores in suturing (4.3) and genitourinary exams (3.9). The lowest pre-survey confidence score was in thoracostomy (2.4). Following the capstone experience, overall confidence scores increased to 4.0. Confidence increased the most in defibrillation and thoracostomy. Additionally, all interns reported post-survey confidence scores of at least 3.0 in all skills, representing an internal anchor of “moderately confident/need guidance at times to perform procedure.”

Conclusion: At the completion of the boot camp curriculum, EM interns had improvement in self-reported confidence across all surveyed skills and procedures. The described EM boot camp curriculum was effective, feasible and provided a foundation to our trainees during their first month of residency. [West J Emerg Med. 2015;16(2):356–361.]