Carotid and vertebral arterial dissections in the emergency department

Although carotid and vertebral (cervical) arterial dissections are not common presentations to the emergency department, timely and appropriate diagnostic strategies will allow early initiation of effective treatment therapies. Cervical arterial dissection occurs when the intimal wall of an artery is damaged as a result of trauma or defect. As blood fills the layers of the arterial wall, thrombi form, which can lead to stroke, pseudoaneurysm, vessel occlusion, and stroke. Intracranial dissections may result in subarachnoid hemorrhage. Because cervical arterial dissections may present with common signs and symptoms such as headache, neck pain, neurological deficits, and stroke, it is essential that dissection be considered early and ruled out quickly. Computed tomographic angiography, magnetic resonance angiography, and digital subtraction angiography may be used for diagnosis. Anticoagulation or antiplatelet therapy is the mainstay of treatment for spontaneous or traumatic dissections and will reduce the risk of stroke. Endovascular therapy or surgery may be indicated. Recurrence or rebleeding is a significant risk and must be managed.

Optimizing resident training: results and recommendations of the 2009 Council of Residency Directors consensus conference

This paper reports the results of a consensus conference of the Council of Emergency Medicine Residency Directors (CORD) to discuss the experiential training component of residency education in the emergency department (ED) and to make recommendations on structuring clinical training. Self-selected emergency medicine (EM) educators discussed experiential training focusing on three topic areas: 1) methods to optimize training in the clinical setting, 2) identification of goals and objectives by training year, and 3) determination of measurable behaviors demonstrating achievement of goals and objectives by residents. Topic areas were organized into the following questions: 1) what is the optimal number and evolution of ED shifts for EM residents during their residency training, 2) what clinical skills are expected of a resident at each level of training, and 3) what objective measures should be used to provide evidence of resident competency? Participants attended a lecture on the goals of the conference, the questions to be answered, and the role and implementation of deliberate practice into experiential training. Attendees were divided into three groups, each discussing one question. Each group had two discussion leaders. All discussions were digitally recorded for accuracy. After discussion all groups reconvened and reported summaries of discussions and recommendations to ensure group agreement. There were 59 participants representing 42 training programs. Educators agree that essential features of designing the ED clinical experience include the need to: 1) structure and tailor the clinical experience to optimize learning, 2) establish expectations for clinical performance based on year of training, and 3) provide feedback that is explicit to year-specific performance expectations.

Scholarly tracks in emergency medicine

Over the past decade, some residency programs in emergency medicine (EM) have implemented scholarly tracks into their curricula. The goal of the scholarly track is to identify a niche in which each trainee focuses his or her scholarly work during residency. The object of this paper is to discuss the current use, structure, and success of resident scholarly tracks. A working group of residency program leaders who had implemented scholarly tracks into their residency programs collated their approaches, implementation, and early outcomes through a survey disseminated through the Council of Emergency Medicine Residency Directors (CORD) list-serve. At the 2009 CORD Academic Assembly, a session was held and attended by approximately 80 CORD members where the results were disseminated and discussed. The group examined the literature, discussed the successes and challenges faced during implementation and maintenance of the tracks, and developed a list of recommendations for successful incorporation of the scholarly track structure into a residency program. Our information comes from the experience at eight training programs (five 3-year and three 4-year programs), ranging from 8 to 14 residents per year. Two programs have been working with academic tracks for 8 years. Recommendations included creating clear goals and objectives for each track, matching track topics with faculty expertise, protecting time for both faculty and residents, and providing adequate mentorship for the residents. In summary, scholarly tracks encourage the trainee to develop an academic or clinical niche within EM during residency training. The benefits include increased overall resident satisfaction, increased success at obtaining faculty and fellowship positions after residency, and increased production of scholarly work. We believe that this model will also encourage increased numbers of trainees to choose careers in academic medicine.

Resident training in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency Medicine Residency Directors Conference

Over the past 25 years, research performed by emergency physicians (EPs) demonstrates that bedside ultrasound (US) can improve the care of emergency department (ED) patients. At the request of the Council of Emergency Medicine Residency Directors (CORD), leaders in the field of emergency medicine (EM) US met to delineate in consensus fashion the model "US curriculum" for EM residency training programs. The goal of this article is to provide a framework for providing US education to EM residents. These guidelines should serve as a foundation for the growth of resident education in EM US. The intent of these guidelines is to provide minimum education standards for all EM residency programs to refer to when establishing an EUS training program. The document focuses on US curriculum, US education, and competency assessment. The use of US in the management of critically ill patients will improve patient care and thus should be viewed as a required skill set for all future graduating EM residents. The authors consider EUS skills critical to the development of an emergency physician, and a minimum skill set should be mandatory for all graduating EM residents. The US education provided to EM residents should be structured to allow residents to incorporate US into daily clinical practice. Image acquisition and interpretation alone are insufficient. The ability to integrate findings with patient care and apply them in a busy clinical environment should be stressed.

Substance use measures among women in early pregnancy

OBJECTIVE

Our purpose was to compare self-reported and biochemical measures for tobacco, marijuana, and cocaine exposures among women early in pregnancy.

STUDY DESIGN

Women who were in the early stages of pregnancy and were examined in an inner-city emergency department were enrolled. Tobacco, marijuana, and cocaine use was measured by self-report and urinalysis. Cocaine use was also assessed by hair analysis.

RESULTS

Data were available for 789 women. Among those reporting past use of tobacco, marijuana, and cocaine, 25.2%, 23.9%, and 22.7%, respectively, had positive results of urinary assays; among those reporting current use, 77.2%, 86.6%, and 75.9% had positive findings, whereas among those reporting never use 5.6%, 5. 7%, and 3.6% of results were positive. Hair analysis, in comparison with urine testing, for cocaine identified 4 times as many exposures among women who reported never using cocaine.

CONCLUSIONS

Urinary assays were equally likely to be positive among women reporting never use and those reporting past use of tobacco, marijuana, or cocaine. Thus women with a positive biologic assay result were as likely to deny use of tobacco as they were to deny marijuana, or cocaine.

Poisonings: food, fish, shellfish

Not every traveler who gets sick away from home has an infection; some are poisoned. This article describes common and dangerous illnesses caused by food-borne toxins. It explores the toxic illnesses acquired from fish or seafood, including scombroid, ciguatera, pufferfish toxicity, and a variety of shellfish poisonings. It also provides a brief overview of plant toxicity. Although gastroenteritis is a common feature of many food poisonings, this article emphasizes those processes associated with neurologic manifestations, as they tend to be more dangerous to patients and less well understood by physicians. It also stresses strategies to prevent food poisoning.