Meloy Patrick, Rutz Daniel R, Bhambri Amit
Emory University School of Medicine, Department of Emergency Medicine, Atlanta, GA.
University of Wisconsin-Madison School of Medicine and Public Health, Department of Emergency Medicine, Madison, WI.
J Educ Teach Emerg Med. 2023 Jan 31;8(1):O1-O23. doi: 10.21980/J80S8J. eCollection 2023 Jan.
Emergency medicine residents and medical students on emergency medicine rotations.
Acute chest syndrome is a life-threatening, potentially catastrophic complication of sickle cell disease.1,2 It occurs in approximately 50% of patients with sickle cell disease, with up to 13% all-cause mortality.1 Most common in children aged 2-4, up to 80% of patients with a prior diagnosis of acute chest syndrome will have recurrence of this syndrome.4 Diagnostic criteria include a new infiltrate on pulmonary imaging combined with any of the following: fever > 38.5°C (101.3°F), cough, wheezing, hypoxemia (PaO2 < 60 mm Hg), tachypnea, or chest pain.4,5 The pathophysiology of acute chest syndrome involves vaso-occlusion in pulmonary vessels resulting in hypoxia, release of inflammatory mediators, acidosis, and infarction of lung tissue. The most common precipitants are infections (viral or bacterial), rib infarction, and fat emboli.1,2,4 Patients commonly present with fever, dyspnea, cough, chills, chest pain, or hemoptysis. Diagnosis is made through physical exam, blood work, and chest imaging.1,2 Chest radiograph is considered the gold standard for imaging modality.3 Management of acute chest syndrome includes hydration with IV crystalloid solutions, antibiotics, judicious analgesia, oxygen, and, in severe cases, transfusion.6 Emergency medicine practitioners should keep acute chest syndrome as a cannot miss, high consequence differential diagnosis for all patients with sickle cell disease presenting to the Emergency Department.
At the end of this oral board session, examinees will: 1) demonstrate the ability to obtain a complete medical history; 2) demonstrate the ability to perform a detailed physical examination in a patient with respiratory distress; 3) identify a patient with respiratory distress and hypoxia and manage appropriately (administer oxygen, place patient on monitor); 4) investigate the broad differential diagnoses which include acute chest syndrome, pneumonia, acute coronary syndrome, acute congestive heart failure, acute aortic dissection and acute pulmonary embolism; 5) list the appropriate laboratory and imaging studies to differentiate acute chest syndrome from other diagnoses (complete blood count, comprehensive metabolic panel, brain natriuretic peptide (BNP), lactic acid, procalcitonin, EKG, troponin level, d-dimer, chest radiograph); 6) identify a patient with acute chest syndrome and manage appropriately (administer intravenous pain medications, administer antibiotics after obtaining blood cultures, emergent consultation with hematology) and 7) provide appropriate disposition to the intensive care unit after consultation with hematology.
This case is used as a method to assess learners' ability to rapidly assess a patient in respiratory distress. The learner needs to address a limited differential diagnosis list while simultaneously stabilizing and treating the patient. The "patient" becomes an active participant in the case, with repeated requests for pain medication, and appropriate analgesic administration is required as a critical action. For faculty, this case is used to assist with periodic assessment of resident performance while in the emergency department (ED).We use oral board testing as one additional tool to assess residents' critical thinking, while still applying the pressure that is needed to pass the oral certification examination. Large groups of residents can be assessed in short periods of time without needing to "wait" for this particular patient presentation to be seen in the ED.In this case, learners were assessed using a free online evaluation tool, Google forms. Multiple questions were written for each critical action, and the Google form served as the online evaluation and repository of this information. The critical actions of the case were then tied to Emergency Medicine Milestones, and the results were compiled for use during resident clinical competency evaluations. Residents were provided with immediate feedback of their performance and were also given their electronic evaluations when requested.
To assess the strengths and weaknesses of the case, learners and instructors were given the opportunity to provide electronic feedback after the case was completed. Subsequent modifications were made based on the feedback provided. Additionally, learners answered written multiple-choice questions after the case to assess for retention of the material.
Senior and junior residents alike enjoyed the process of an oral board simulation as an alternative to a more formal lecture. Seniors also stated that they felt more confident with their ability to pass the oral certification examination after having gone through oral board testing while in residency. Overall, the case was rated relatively highly, with residents scoring the case as 4.3 ± 0.186, 95% confidence interval (1-5 Likert scale, 5 being excellent, n=53) after their assessment was completed.
Students and residents who participated in the oral board exam formatting found this to be preferable to a traditional lecture and enjoyed the learning environment. Faculty also found this type of participation to be more engaging and were pleased with the ability to perform high-stress assessments with low stakes. The content contained in the case is relevant to all emergency medicine trainees, and this formatting forces the learner to be an active participant in the learning session. The case is a good model for the high-stakes testing of the oral certification exam and is an effective way to test a resident's ability to rapidly assess and manage a life-threatening condition in the ED.
Sickle cell anemia, vaso-occlusive pain crisis, acute chest syndrome, hypoxia, pneumonia, sepsis.
急诊医学住院医师以及参加急诊医学轮转的医学生。
急性胸部综合征是镰状细胞病一种危及生命、可能引发灾难性后果的并发症。它在约50%的镰状细胞病患者中出现，全因死亡率高达13%。最常见于2至4岁儿童，既往诊断为急性胸部综合征的患者中，高达80%会复发该综合征。诊断标准包括肺部影像学出现新的浸润影，并伴有以下任何一项：发热>38.5°C（101.3°F）、咳嗽、喘息、低氧血症（动脉血氧分压<60 mmHg）、呼吸急促或胸痛。急性胸部综合征的病理生理学涉及肺血管的血管闭塞，导致缺氧、炎症介质释放、酸中毒以及肺组织梗死。最常见的诱因是感染（病毒或细菌）、肋骨梗死和脂肪栓子。患者通常表现为发热、呼吸困难、咳嗽、寒战、胸痛或咯血。通过体格检查、血液检查和胸部影像学进行诊断。胸部X线片被认为是影像学检查的金标准。急性胸部综合征的治疗包括静脉输注晶体溶液进行补液、使用抗生素、谨慎镇痛、吸氧，严重时进行输血。急诊医学从业者应将急性胸部综合征作为所有到急诊科就诊的镰状细胞病患者不可漏诊的、后果严重的鉴别诊断疾病。
在本次口试环节结束时，考生应能够：1）展示获取完整病史的能力；2）展示对呼吸窘迫患者进行详细体格检查的能力；3）识别呼吸窘迫和低氧血症患者并进行适当处理（给予氧气、将患者置于监测之下）；4）探究广泛的鉴别诊断，包括急性胸部综合征、肺炎、急性冠状动脉综合征、急性充血性心力衰竭、急性主动脉夹层和急性肺栓塞；5）列出用于区分急性胸部综合征与其他诊断的适当实验室和影像学检查（全血细胞计数、综合代谢指标、脑钠肽（BNP）、乳酸、降钙素原、心电图、肌钙蛋白水平、D - 二聚体、胸部X线片）；6）识别急性胸部综合征患者并进行适当处理（给予静脉止痛药物、在获取血培养后给予抗生素、紧急会诊血液科）；7）在与血液科会诊后将患者妥善安置到重症监护病房。
本病例用作评估学习者对呼吸窘迫患者进行快速评估能力的一种方法。学习者需要在稳定和治疗患者的同时处理有限的鉴别诊断清单。“患者”成为病例中的积极参与者，会反复要求使用止痛药物，而适当给予止痛药物是一项关键操作。对于教员而言，本病例用于协助对住院医师在急诊科期间的表现进行定期评估。我们使用口试作为评估住院医师批判性思维的另一工具，同时施加通过口试认证考试所需的压力。无需“等待”在急诊科看到特定患者表现，就能在短时间内对大量住院医师进行评估。在本病例中，使用免费在线评估工具谷歌表单对学习者进行评估。针对每个关键操作编写了多个问题，谷歌表单作为该信息的在线评估和存储库。然后将病例的关键操作与急诊医学里程碑相关联，汇总结果用于住院医师临床能力评估。为住院医师提供其表现的即时反馈，并在他们要求时给予电子评估。
为评估该病例的优缺点，在病例完成后让学习者和教员有机会提供电子反馈。根据提供的反馈进行后续修改。此外，学习者在病例结束后回答书面多项选择题以评估对内容的掌握情况。
高级和初级住院医师都喜欢口试模拟过程，而不是更正式的讲座。高级住院医师还表示，在住院期间经历口试测试后，他们对通过口试认证考试的能力更有信心。总体而言，该病例评分相对较高，住院医师在完成评估后将该病例评分为4.3 ± 0.186，95%置信区间（1 - 5李克特量表，5分为优秀，n = 53）。
参加口试形式考试的学生和住院医师发现这比传统讲座更可取，并喜欢这种学习环境。教员也发现这种参与方式更有吸引力，并对能够在低风险情况下进行高压力评估感到满意。病例中包含的内容与所有急诊医学实习生相关，这种形式迫使学习者成为学习环节的积极参与者。该病例是口试认证考试高风险测试的良好模型，是测试住院医师在急诊科快速评估和处理危及生命状况能力的有效方式。
镰状细胞贫血、血管闭塞性疼痛危象、急性胸部综合征、低氧血症、肺炎、脓毒症
