Teaching Rapid Assessment Skills in Triage for the Emergency Medicine Clerkship

BACKGROUND

Rapidly assessing an undifferentiated patient and developing a gestalt for "sick vs. not sick" is a core component of emergency medicine (EM). Developing this skill requires clinical experience and pattern recognition, which can be difficult to attain during a typical EM clerkship.

OBJECTIVE

We developed a novel approach to teaching medical students rapid assessment skills in the emergency department (ED) by implementing a teaching shift in triage.

METHODS

Fourth-year medical students in our EM clerkship in fall 2019 were scheduled one shift in triage with a dedicated teaching attending. The students evaluated patients under direct supervision, discussed their immediate differential diagnosis, and proposed an initial workup. The attending gave real-time feedback using a standardized direct observation tool. Students completed an electronic pre and post survey (5-point Likert scale) to assess their comfort level in the following areas: performing a rapid triage assessment, determining "sick vs. not sick", performing a focused physical examination, developing a targeted differential diagnosis, and ordering an initial diagnostic workup.

RESULTS

Twenty-one students participated in the triage shifts. There was a significant improvement in self-assessed comfort with performing a rapid triage assessment, mean pre 2.76 and post 4.43 (p < 0.0001). There were also significant improvements in the four other survey areas (p < 0.004 or less).

CONCLUSIONS

A teaching shift in triage can increase medical students' self-assessed rapid assessment skills for patients in the ED. Benefits to the teaching attending included the opportunity to perform direct observation, give real-time feedback, and identify real-time teaching moments.

Foreign Bodies of the Ear, Nose and Throat

Foreign bodies to the ear, nose, and throat often can be managed in the emergency department, particularly if the patient offers a history consistent with foreign body and is calm and compliant with the examination and removal attempts. Tips for success include analgesia, adequate visualization, immobilization of the patient's head, dexterity and experience level of the provider, and minimizing attempts at removal. It is critical to recognize the risks involved with certain retained objects (button batteries or sharp objects) and when to call a consultant to help facilitate safe, successful removal of objects to the ear, nose, and throat.

Implementing a third-year emergency medicine medical student curriculum

BACKGROUND

Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations.

OBJECTIVE

A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation.

DISCUSSION

Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for each content area.

CONCLUSIONS

This consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution.

Clinical outcomes of ED patients with bandemia

BACKGROUND

Although an elevated white blood cell count is a widely utilized measure for evidence of infection and an important criterion for evaluation of systemic inflammatory response syndrome, its component band count occupies a more contested position within clinical emergency medicine. Recent studies indicate that bandemia is highly predictive of a serious infection, suggesting that clinicians who do not appreciate the value of band counts may delay diagnosis or overlook severe infections.

OBJECTIVES

Whereas previous studies focused on determining the quantitative value of the band count (ie, determining sensitivity, threshold for bandemia, etc.), this study directs attention to patient-centered outcomes, hypothesizing that the degree of bandemia predisposes patients to subsequent negative clinical outcomes associated with underappreciated severe infections.

METHODS

This retrospective study of electronic medical records includes patients who initially presented to the emergency department (ED) with bandemia and were subsequently discharged from the ED. These patients were screened for repeat ED visits within 7 days and death within 30 days.

RESULTS

In patients with severe bandemia who were discharged from the ED, there was a 20.9% revisit rate at 7 days and a 4.9% mortality rate at 30 days, placing severely bandemic patients at 5 times significantly greater mortality compared to nonbandemic patients (P = .032).

CONCLUSION

Our review of patient outcomes suggests that the degree of bandemia, especially in the setting of concurrent tachycardia or fever, is associated with greater likelihood of negative clinical outcomes.

Medical student perceptions on the instruction of the emergency medicine oral case presentation

BACKGROUND

The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction.

OBJECTIVES

We aimed to document medical student perceptions and expectations of the instruction of the EM OCP.

METHODS

We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions.

RESULTS

One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship evaluation (77%), and felt that additional teaching was required beyond their current medical school instruction (78%). A minority report being specifically taught the EM OCP (37%), that their instruction was consistent (29%), or that expectations of the EM OCP were clear (21%). Respondents felt that brief instruction during their orientation (65%) and reading with a portable summary card (45%) would improve their EM OCP skills, whereas other modalities would be less helpful.

CONCLUSION

This study identifies a need for additional specific and consistent teaching of the EM OCP to medical students and their preference on how to receive this instruction.

Developing a third-year emergency medicine medical student curriculum: a syllabus of content

Emergency medicine (EM) educators have published several curricular guides designed for medical student rotations and experiences. These guides primarily provided brief overviews of opportunities to incorporate EM into all 4 years of the medical student curriculum, with one specific to the fourth year. However, there are no published guidelines specific to third-year medical students rotating in EM. Given the differences between third-year and fourth-year students in terms of clinical experience, knowledge, and skills, the Clerkship Directors in Emergency Medicine (CDEM) established the Third-year EM Medical Student Curriculum Work Group to create a third-year curriculum. The work group began this process by developing consensus-based recommendations for the content of a third-year medical student EM rotation, which are presented in this syllabus.