Trick of the Trade: Don’t have a mirror in the ED?

mirrorSeveral times in the ED, I have needed a mirror for patient care.

Example 1

A moderately intoxicated patient presents with a facial or scalp laceration. S/he adamantly refuses to have it repaired in the ED, because of the disbelief of that there is indeed a laceration. You want to show the patient, using a mirror, but you don’t have one. (more…)

2016-11-11T19:01:52-07:00

Article review: How do you assess the quality of educational research articles?

Imagine this. You are about to conduct an innovative educational project and want to get a research publication out of it. What are considered strong methodological qualities of an educational research study? What can you do to improve your chances for publication?

The authors in this study developed and use an instrument to help measure the methodological quality of quantitative studies in medical education. This instrument, the Medical Education Research Study Quality Instrument (MERSQI), was used to show that scores were predictive of manuscript acceptance into the 2008 Journal of General Internal Medicine (JGIM) special issue on medical education.

What is the MERSQI instrument?
The 10-item MERSQI instrument can be divided into 6 domains, each with a maximum score of 3 points. Numbers within parenthesis denote the number of different items assessed in that domain. The maximum score is 18.

  • Study design
  • Sampling (2)
  • Type of data
  • Validity of evaluation instrument (3)
  • Data analysis (2)
  • Outcomes

The specific scoring criteria are seen in this table below, from an earlier publication on the MERSQI instrument (Reed DA et al, Association between funding and quality of published medical education research. JAMA. 2007;298(9):1002-1009). This earlier publication showed that a high MERSQI score correlated with successful funding of the study.

MERSQI scoring criteria (3 points per domain)
Click to enlarge table image.


So what garners a perfect MERSQI score of 18?

  • A randomized controlled trial conducted at over 2 institutions
  • A response rate of >75%
  • Data assessment was done using an objective measure (not self-assessment by study participant)
  • When using an evaluation instrument, internal structure validity, content validity, and criterion validity are reported.
  • The data is analyzed appropriately and goes beyond just descriptive analysis.
  • The outcome measure goes beyond simple survey measures and focuses on instead patient/health care outcomes.

Getting a perfect score of 18 is extremely difficult, as evidenced in this article. In the 100 submitted manuscripts to JGIM, the mean MERSQI score was 9.6 (range 5-15.5). Most manuscripts were single-group cross-sectional studies (54%), conducted at a single institution (78%). Few (36%) reported validity evidence for their evaluation instruments.

The mean total MERSQI score of accepted manuscripts was significantly higher than rejected manuscripts (p=0.003).

  • Mean score for ACCEPTED manuscript = 10.7
  • Mean score for REJECTED manuscript = 9.0

I have found the MERSQI scoring instrument extremely helpful in helping me design my educational research studies. Methodologic rigor is almost always the Achilles heel of rejected educational research submissions.

Reference

Reed DA, Beckman TJ, Wright SM, et al. Predictive validity evidence for medical education research study quality instrument scores: quality of submissions to JGIM’s Medical Education Special Issue. J Gen Intern Med. 2008 Jul;23(7):903-7.

2016-10-26T17:05:40-07:00

Trick of the Trade: Easy ocular application of fluoroscein

Fluorescein-1Gently instilling a fluorescein drop into a patient’s eye requires that the patient keep his/her eye still. What do you do for a patient who can’t quite stay still enough, such as an infant? This is an innovative trick of the trade, written by Dr. Sam Ko (Loma Linda EM resident) and Kimberly Chan (Loma Linda medical student).

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2016-11-11T19:01:53-07:00

Trick of the Trade: Super-sensitive to eyedrops

CornealUlcer-largeWe commonly encounter ocular complaints in the Emergency Department. Eye pain can result from chemical exposure, a foreign body, or infection. The first step involves instilling a few drops of topical anesthetics, such as proparacaine, to provide some pain relief. Occasionally, however, you encounter a patient who just can’t keep his/her eye open because of the fear of eyedrops.

(more…)

2016-11-11T19:01:54-07:00

Article review: Bedside teaching in the ED

Bedside teaching is a unique educational skill, which academic faculty are often assumed to just know how to do. In the ED, it is especially difficult to do this well, because of crowding and unexpected time-sensitive clinical issues, which create distractions and general chaos. Experientially, unpredictable clinical issues negatively impact bedside teaching. Thus, faculty should be flexible and knowledgeable of basic bedside teaching tenets.

(more…)

2016-10-26T17:05:40-07:00

Tricks of the Trade: Low tech solutions to esophageal foreign bodies

DoxycyclinePatients can present to Emergency Departments with esophageal foreign bodies. Recently, a patient presented with a doxycycline pill stuck in her esophagus at the mid-chest level. She was taking it for pneumonia. Despite drinking deluges of water for the past 12 hours, the pill remains stuck. You know that doxycycline (pills shown on right)  is one of several medications (along with iron or potassium supplements, quinidine, aspirin, bisphosphonates) known for causing erosive pill esophagitis.

She presents to your ED.

What do you do?

With so many direct visualization tools in the ED now available to emergency physicians such as Glidescopes and nasopharyngoscopes, you might be tempted to take a look. However, you can first take a low-tech approach to propel the pill into the stomach. Each of these options has its unique risks and complications, and the risks/benefits should be weighed appropriately.

  • Glucagon IV – relaxes lower esophageal sphincter (LES)
  • Nitroglycerin SL – relaxes LES – beware of acute hypotension
  • Nifedifine SL – relaxes LES – beware of acute hypotension
  • Carbonated beverage PO- gas forming agent to increase intraesophageal pressure

Instead of pharmacologically moving the pill into the stomach, you can also consider mechanically pushing the pill down using an orogastric tube or blindly pulling it out through the mouth using a foley catheter.

ensureTrick of the Trade: What did we do?

Before we entertained the pharmacologic options, we gave the patient a can of Ensure, because it has a higher viscosity than water. Fifteen minutes later, the pill was pushed into the stomach and the patient’s foreign-body symptoms resolved. A simple $1.50 solution.

Teaching point

Tell all your patients receiving doxycycline to drink plenty of fluids when taking the medication.

Caveat

These low-tech solutions are only appropriate for pill foreign bodies and impacted food boluses in the esophagus, which are at low risk for esophageal perforation. These are NOT applicable to special situations such as button batteries, sharp objects, fish/chicken bones, and coins.

 

2016-11-11T19:01:54-07:00

Article review: Handoffs in the Emergency Department

One shared experience amongst all emergency physicians is the “handoff” or “signout” of patients at the end of your shift to the oncoming physician. A recent article in Annals of Emergency Medicine explores and explains how this process can often lead to delays and errors in patient management. Just envision ED handoffs as a high-stakes game of Telephone, which you played as a child.

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2016-10-26T17:05:40-07:00