J Emerg Med
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We report on a process for assessing the communication skills of emergency medicine residents that includes 1) a faculty development initiative; 2) videotaping of actual resident-patient encounters in the emergency department; and 3) creation of an observation instrument for evaluating communication behaviors. We tested this observation instrument for inter-rater reliability, finding moderate-to-high agreement for only 11 of 32 items. ⋯ There was poor or no agreement for behaviors related to establishing rapport, gathering information, and contracting or informing. Challenges of assessing interpersonal skills of emergency medicine residents are discussed.
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Case Reports
Epidural pneumatosis associated with spontaneous pneumomediastinum: case report and review of the literature.
Epidural pneumatosis rarely has been reported in association with spontaneous pneumomediastinum. We report a case of an asymptomatic 24-year-old male who presented after forceful vomiting with both findings. The patient recovered uneventfully without residual signs or symptoms. We discuss spontaneous pneumomediastinum as well as epidural pneumatosis and review reported cases in the literature.
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Although intravenous (i.v.) administration of antiepileptic drugs is the preferred route of therapy in status epilepticus, intramuscular (i.m.) delivery may provide a valuable alternative when there are obstacles to venous access. Compared to other treatment options such as rectal drug administration, which is as challenging as the i.v. route in a convulsing patient, the i.m. route is easier and less invasive. The two most commonly used first-line anticonvulsants, diazepam and lorazepam, may be administered i.m., but are absorbed from the i.m. site more slowly than midazolam. ⋯ Because of its water solubility, midazolam is rapidly absorbed from the injection site and has excellent local tolerability. The pharmacodynamic effects of midazolam can be seen within seconds of its administration, and seizure arrest is usually attained within 5 to 10 min. Case reports and a recent randomized trial that demonstrate the successful use of i.m. midazolam in the termination of epileptic seizures are reviewed.
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Pediatric resuscitation is challenging for the emergency physician because the diverse range in the age and size of the patients encountered complicates the appropriate selection of medications, equipment, and supplies. The following enhancements in the pediatric resuscitation room were made to facilitate effective management of critically ill neonates and children: 1) expanding the concept of the Broselow tape as the central color theme of organization of all medication doses and equipment; 2) use of a large, simplified, color-coded wall chart to define patient parameters; 3) color-coded equipment; 4) adjustable "break-away" resuscitation stretcher; and 5) equipment suspended from the ceiling: a) radiant warmer; b) suction, oxygen, and electricity; c) cardiac monitor and fluid controller; d) X-ray unit. These changes give the resuscitation team greater accessibility to both the patient and the needed resuscitation supplies.
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A prospective study of Emergency Medicine (EM) residents was conducted over two consecutive 1-month periods at a rural tertiary-care teaching hospital with a residency in EM to evaluate the effect of a 4-h pain management education program on the assessment and management of acute pain in the emergency department (ED). All patients presenting to the ED with an acute, painful condition were eligible to participate in the survey. Patients were excluded if they had taken any pain medication within 4 h of presenting to the ED, or had any condition requiring immediate resuscitation, suspected cardiac pain, or pain from a potential surgical abdomen. ⋯ Only 65% of the patients studied before the EP had significant reduction in their pain scores after 30 min in the ED; after institution of the EP, 92% had a significant reduction in their pain scores at 30 min. Similarly, a significant improvement was seen in the patients' global evaluation of treatment after the educational program was instituted. It appears that the use of a 4-h educational program on pain assessment and management directed toward EM residents in their training can improve their skills at recognizing and treating painful conditions.