Assessment of Head CT Interpretation Abilities of Fourth-Year Medical Students

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Assessment of Head CT Interpretation Abilities of Fourth-Year Medical Students
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  objectives of this descriptive study were to determine how often emergency medicine(EM) residents perform CALEs in patients with MICCs, why they perform theseexams, and who taught them this practice.Methods: In June 2004 we surveyed all EM residents at an urban 4-year EMresidency. Using a 10-point numerical visual analog scale (0=never, 5=about half thetime, 10=always), residents were asked to indicate often they generally performCALEs on their ED patients with MICCs. Those selecting scores of 5 or greater wereasked to identify their motivating factors for performing routine CALEs and thesources that most influenced this practice.Results: 100% (38) of the EM residents were evaluated; 76% (29) performCALEs in half or more of patients with MICCs. On 10-point visual analog scales (0=no influence, 10=maximum influence), the primary reasons they performCALEs on these patients were the need for this screening care in the underservedED patient population (mean 6.3 G 3.2), the belief that such exams are thestandard of care within EM (mean 6.0 G 3.3), and the establishment of physician-patient rapport (mean 6.0 G 3.2). Less influential reasons includedmalpractice prevention (mean 5.1 G 3.1), patient expectations (mean 4.3 G 3.0),and diagnostic certainty (mean 3.9 G 2.5). Residents identified medical schoolinstructors (25; 86%) and ED attending physicians (22; 76%) as the principalteachers of this practice.Conclusions: Most EM residents perform routine CALEs on patients withMICCs. They learn this practice in medical school and from ED attendings; they perform these exams to provide screening care to underserved populations, toestablish patient rapport, and to abide by their understanding of EM’s standardof care. 96  Competency Evaluation in a Cohort of EmergencyMedicine Residents Using Strategic ManagementSimulation McCabe JB,  Satish U, Streufert S, SUNY Upstate Medical University, Syracuse,NY; Pennsylvania State University, Hershey, PA Study Objectives: Successful resident training must include both the acquisitionof required knowledge and the ability to use knowledge appropriately. Evaluation of competence must focus on ‘‘content’’ based skills, and also on effective decisionmaking abilities. The SMS (Strategic Management Simulations) is a content-freeinternationally validated tool used to assess and train professionals. We hypothesizedthat we could use SMS to assess resident decision-making abilities and that simulationresults would compare favorably to faculty evaluations of these residents.Methods: Twenty-two Emergency Medicine residents participated in the SMSsimulations. The internationally validated simulation technology measures 25parameters of decision making (i.e. levels of activity, speed emergent functioning,initiative, planning, and strategy). Residents dealt with a complex task environmentthat provided multiple challenges over a period of approximately two hours. Sixteenfaculty members of the department rank ordered the residents.Results: SMS simulation performance data were calculated by the associatedcomputer system. Faculty rank order data were correlated with simulation measures.Independent simulation measures that are relevant to effective functioning inemergency settings correlated highly (above r=.80; p \ .005) with the faculty ratings.Conclusion: SMS simulation measures generated excellent predictions of globalfaculty ratings. The high correlations were specifically obtained for the demands madeby the occupational specialty of the participating residents. Using the SMS simulationto assess residents in Emergency Medicine is valuable since simulation basedinformation about resident decision-making competency is obtained in a short two-hour period. In contract, faculty impressions of resident functioning may take monthsand/or years to develop and stabilize. The information obtained on specificcomponents of decision-making makes training focused on time effective. 97  Experiential Learning in Emergency Medicine Finnell JT,  Seupaul RA, Indiana University, Indianapolis, IN Objective: The ACGME establishes standards for graduate medical educationand continually assesses educational programs under its jurisdiction. Whileexperiential learning is a critical component of GME training, there are no methodsto evaluate the individual clinical experiences of residents and how these experiencesrelate to their specialties’ program requirements. In real-time, Electronic MedicalRecord (EMR) systems may provide a method to aggregate and describe residentexperiences in an automated fashion. This information could provide a greaterunderstanding of missed training opportunities in both individual resident andfacility level experiences. Given the breadth of the emergency medicine, wehypothesize that the clinical experiences of EM residents would represent only a smallportion of the program requirements as outlined by the ACGME in the ‘‘Model of Clinical Practice of Emergency Medicine’’.Methods:  Design  : Retrospective observational.  Setting:   Large urban academic EDwith an annual census of 106,000.  Subjects:   EM residents who rotated in the ED from January 1, 2004 through June 30, 2004. The IRB approved the study. The UMLS is a repository of biomedical vocabularies and integrates these concepts, as well as therelations among these concepts. We assigned a unique identifier from the UMLS toeach EM Model term. Similarly, we assigned an identifier to the primary dischargediagnosis seen by the EM residents in the ED. Using structured query language, wemapped each discharge diagnosis to the EM Model through the identifier.Results:Duringthesixmonthstudyperiod,we studied50residentswhogenerated11,991 discharge diagnoses. Of these diagnoses, 1,471 were unique terms and 76%(1,129) mapped to a CUI. There were 1,025 Model of Clinical Practice terms and96% (982) mapped to a CUI. Overall, based upon a single release diagnosis, EMresidents were exposed to 47% of the Model of Clinical Practice in the ED setting.Conclusions: Residency programs are the richest learning environment mostphysicians will ever experience. We describe an automated process, using existing Electronic Medical Record (EMR) information, to aggregate and compare theresident clinical exposures to the Model of Clinical Practice of Emergency Medicine.Emergency medicine residents had substantial exposure to many of the elements of their program requirements. Program directors could use this information to tailorthe educational requirements to the individual resident, the residency class, or theentire program - adding missed clinical experiences, or enhancing learning modelscovered less frequently. 98  Assessment of Head CT Interpretation Abilitiesof Fourth-Year Medical Students Broder J,  Hobgood C, Harrigan M, Felix A, University of North Carolinaat Chapel Hill, Chapel Hill, NC Study Objectives: Interpretation of head CT is essential for the practiceof emergency medicine. Particularly important is the ability to identify intracranial hemorrhage, acute infarction, mass effect, and signs of increasedintracranial pressure. The ability to recognize hemorrhage or infarction isespecially critical in the treatment of patients with suspected ischemic stroke,as the presence of these findings contraindicates the administration of systemicthrombolytic therapy. Prior studies of the abilities of emergency medicine residents tointerpret head CT have shown deficiencies, both in the ability to detect hemorrhageand especially in the ability to detect infarction. We sought to determine the ability of fourth-year medical students to identify a variety of head CT scan abnormalities andto determine the presence of contraindications to thrombolytic therapy. We alsomeasured the effect of a teaching intervention on these endpoints.Methods: The study population was a convenience sample of fourth yearmedical students participating in a mandatory stroke education component of a ‘‘capstone course’’ at a single US medical school. No exclusion criteria wereapplied. A pretest was administered, composed of questions relating to 9 CTscans selected by consensus of the authors to represent a range of normal andpathologic findings which might be encountered in emergency departmentpatients with stroke-like neurological symptoms. A single representative imagefrom each CT was displayed for each question. CTs demonstrated the following findings: normal, hemorrhage (subarachnoid, subdural, epidural, intraparenchymal),infarct, hydrocephalus, midline meningioma, mass with vasogenic edema.Questions were multiple choice and required the subjects to identify the type of abnormality (if any), the location of the lesion, and the presence or absence of contraindications to thrombolytic therapy. A one hour live teaching module withpowerpoint head CT images and a discussion of thrombolytic therapy followed. A posttest was administered immediately following the teaching module. Theposttest was identical in format to the pretest with the identical types of pathology but with a new set of CT images, matched for difficulty by consensus of theauthors. IRB approval was obtained prior to study enrollment.Results: 133 subjects were enrolled. The mean pre-test score was 55.92%, with a range from 25.93-77.78%. (Std deviation 10.14). The mean post-test score was69.06%, with a range from 44.44-92.59% (Std deviation 9.38). Students correctly identified the presence of infarction in 81.2% on the pre-test and 97.0% on thepost-test. Students recognized other findings with the following accuracy on thepre- and post-tests: normal (73.7%, 77.4%), epidural hematoma (78.9%, 92.5%),subdural hematoma (30.1%, 12.0%), subarachnoid hemorrhage (18.8%, 36.8%),intraparenchymal hemorrhage (32.3%, 69.9%), meningioma (39.1%, 69.2%), masswith edema (1.5%, 0.75%). When hemorrhage of any type was present, studentsfailed to recognize a contraindication to thrombolytic therapy in 25.2% of cases on Research Forum   Abstracts Volume  46, no. 3 :  September  2005  Annals  of    Emergency Medicine  S29  the pre-test and 19.9% on the post-test. When visible infarction was present on CT,89.5% and 35.3% of students (pre-test, post-test) stated that no contraindications tothrombolytic therapy were present. When the CT scan was normal, 34.6% and27.1% erroneously stated that contraindications to thrombolytic therapy were present(pre- and post-tests).Conclusion: Although fourth-year medical students made improvements indiagnostic accuracy for many types of hemorrhage and infarction throughparticipation in an educational intervention, significant errors persist in both CTinterpretation and the application of indications and contraindications tothrombolytic therapy. We are developing instructional modules specifically targetedat correcting these errors. 99  Knowledge of Invasive Procedures and ProceduralCompetency After Participation in Training Labs Shah C,  Stu¨rmann KM, Ripper J, Hsu CK, The Brooklyn Hospital Center, Brooklyn,NY; Beth Israel Medical Center, New York, NY; Newark Beth Israel Medical Center,Newark, NJ Study Objectives: To evaluate knowledge of invasive procedures and to evaluateprocedural competency after participation in multiple procedure labs.Methods: Residents attended multiple didactic sessions and labs that includedusing a live animal model to train more than 15 procedures (Intraosseous lineplacement, venous cut-down, EKG-guided pericardiocentesis, sonographic evaluationof pericardial effusion, thoracostomy, thoracotomy, pericardiotomy, open cardiacmassage, cardiorrhaphy, blunt dissection and cross-clamping of the aorta, diagnosticperitoneal lavage, retrograde intubation, cricothyrotomy, lateral canthotomy). During the residency, residents took a multiple choice exam to evaluate procedural‘‘ knowledge  ’’. Senior residents were critiqued by masked observers during individuallabs for procedural ‘‘ competency  ’’ using a standard critical points score sheet.Results: Scores were stratified by the number of labs attended ‘‘ Knowledge  ’’ N=63..0 lab: mean group score: 35% correct. Three or less labs: 51.6%. Four or more57.5%. ‘‘ Competency  ’’: N=10. Three or less labs mean group score: 41.6 %. Four ormore 65.3%.Conclusion: Residents who attended a lab four or more times have an improved‘‘knowledge’’ and improved procedural ‘‘competency’’ over those who took a procedure lab three or fewer times. 100  Acceptance of an Internet-Based Resident TestingTool Beeson MS,  Jwayyed S, Summa Health System, Akron, OH Study Objectives: The use of Internet-based educational curricula (IBEC) is anefficient mechanism to deliver educational resources to learners. In 2002 CORDdeveloped an online resident curricular testing tool consisting of 1900 questionsorganized into 36 practice and 30 scored tests. The questions are categorized by content. Residents receive feedback of answer choice only with practice tests. Resultsof scored tests are emailed to only program directors.Objective: To determine if an Internet-based testing system developed by theCouncil of Emergency Medicine Residency Directors (CORD) (CORD-IBTS) isuseful to emergency medicine resident educators. This study was considered exempt by our IRB.Methods: A retrospective cross-sectional analysis examined the use CORD-IBTS. A brief survey was sent to program directors in 2004, consisting of Likert-typequestions.  Subjects  : Emergency medicine residency programs that subscribe to theCORD-IBTS. The CORD-IBTS consists of 1900 questions organized into 36practice and 30 scored tests. The questions are categorized by content area as definedby the Model of the Clinical Practice of Emergency Medicine. Residents receivefeedback of answer choice with practice tests, but no feedback from scored tests.Results of practice tests are emailed to residents and results of scored tests emailedto program directors.Results: Data on the utilization of the CORD-IBTS from 2002-2004 wasreviewed (see Table): 70 of 111 (63%) programs that subscribe to theCORD-IBTS responded to the survey. 56/70 (80%) reported they found theCORD-IBTS useful or very useful (mean 4.1, CI 3.9-4.2) and 27/70 (39%) asked formore on-line tests. 44 (62.9%) would like the online tests to be linked to a curriculardocument.Conclusion: The CORD-IBTS is increasingly used by emergency medicineresidencies and residents. The majority of residencies enrolled reported theCORD-IBTS to be useful or very useful. 101  Retrospective Review of Relationship BetweenSpectator Illness and Temperature at Division IFootball Games Winslow JE III,  Wake Forest University Health Sciences, Winston-Salem, NC Study Objectives: This study sought to determine the relationship between thetemperatures at college football games and the number of patients seen by medicalproviders onsite.Methods:  Design:   This is a retrospective review of medical records from 19Division I football games from the years 2001 to 2003. A model was constructedusing linear regression by estimating the maximum likelihood estimation of the vectorbeta. A Poisson distribution was specified for the distribution of the outcome variablewhich was the number of patients seen divided by the total number attending thegame.  Subjects:   Any person regardless of age who presented to the on site medicalproviders for treatment was counted as a patient seen. Weather data was collectedfrom the National Weather Service.Results: The average number of spectators at each event was 27,029 (95% CI23,802-30,256). The average temperature at each game was 17.7 degrees Celsius (95%CI 14.2-21.2). For each 1 degree increase in temperature Celsius the probability of a patient presenting for treatment increases by 3% (95% CI of 1%- 5%). The following formula can be used to estimate the number of patients seen during a given game.Predicted # of Patients = (e 8  4084 +   0316 * Temperature C ) * number of spectators.Conclusion: These results show that temperature is an important factor to takeinto account when determining the medical resources required to care for thespectators at outdoor football games and the predicted temperature can help predictthe number of patients which will be seen at football games. 102  Prehospital Use of Hydroxocobalamin in ChildrenExposed to Fire Smoke Haouach H,  Fortin JL, Chaybany B, Essouri S, Berton L, Catineau J, Galinski M,Lapostolle F, SAMU 93, Bobigny, France Study Objectives: Hydroxocobalamin is a cyanide antidote that appears to haverapid antidotal activity and a favorable risk: benefit ratio when used in the prehospitaland hospital settings to treat victims of cyanide poisoning, including that caused by smoke inhalation. Because it appears to lack the toxicity of other cyanide antidotes,hydroxocobalamin may be particularly useful for vulnerable populations such aspediatric patients. This study was conducted to describe the effects of hydroxocobalamin as prehospital treatment for suspected cyanide poisoning causedby smoke inhalation in children.Methods: In this multicenter, retrospective investigation, outcomes afterprehospital use of hydroxocobalamin for smoke inhalation-associated cyanidepoisoning in children % 18 years treated in 4 mobile intensive care units (SAMUs) and2 pediatric intensive care units (ICUs) in France were assessed.Results: Data were available for 41 children. Two thirds (68%) were male. Median(25th percentile-75th percentile) age was 5 (4-8) years. Thirty-nine percent (39%)of children presented with cutaneous burns covering a median body surface of 13%(6-30). Laboratory assessments at admission (n=24) showed pH=7.22 (7.09-7.33),sodium bicarbonates=17 mmol/L (12-23), and lactates=4.0 mmol/L (2.5-11.4).Hydroxocobalamin was administered to 18children in cardiac arrest,of whom 11 diedat the scene, 6 died at the ICU, and 1 survived. Overall mortality in children who wereinitially in cardiac arrest was 94% (17/18). Hydroxocobalamin was administered to 23children not in cardiac arrest, 17 of whom were intubated at the scene. There was a lossof consciousness in 16 cases. All were hospitalized. Overall mortality among thosewithout cardiac arrest was 4% (1/23). Initial prehospital mortality was 27% (11/41);hospital mortality was 23% (7/30); and total mortality was 44% (18/41).Conclusion: Mortality in children with suspected smoke inhalation-associatedcyanide poisoning was high. After treatment with hydroxocobalamin, survival ratewas low (6%) in smoke-exposed children in cardiac arrest but, in contrast, survivalrate was high (96%) in smoke-exposed children not in cardiac arrest but. Thesefindings suggested the importance of prompt initiation of antidotal therapy inchildren presenting with conscious impairment. suspected of having smokeinhalation-associated cyanide poisoning. Research Forum   AbstractsS30  Annals  of    Emergency Medicine Volume  46, no. 3 :  September  2005
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