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Background: Vital signs are an essential component of the emergency department (ED) assessment. Vital sign abnormalities are associated with adverse events in the ED setting and may indicate a risk of poor outcomes after ED discharge., Clinical Question: What is the risk of adverse events among adult patients with abnormal vital signs at the time of ED discharge?, Evidence Review: Studies retrieved included 6 retrospective studies with adult patients discharged from the ED. These studies evaluated adverse outcomes in adult patients discharged from the ED with abnormal vital signs. Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians., Conclusion: Based on the available evidence, the specific vital sign abnormality and the number of total abnormalities influence the risk of adverse outcomes after discharge. Vital sign abnormalities at the time of discharge also increase the risk of ED revisit. The most common abnormal vital sign at the time of discharge is tachycardia., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The emergency medicine (EM) milestones are objective behaviors that are categorized into thematic domains called "subcompetencies" (eg, emergency stabilization). The scale for rating milestones is predicated on the assumption that a rating (level) of 1.0 corresponds to an incoming EM-1 resident and a rating of 4.0 is the "target rating" (albeit not an expectation) for a graduating resident. Our aim in this study was to determine the frequency with which graduating residents received the target milestone ratings., Methods: This retrospective, cross-sectional study was a secondary analysis of a dataset used in a prior study but was not reported previously. We analyzed milestone subcompetency ratings from April 25-June 24, 2022 for categorical EM residents in their final year of training. Ratings were dichotomized as meeting the expected level at the time of program completion (ratings of ≥3.5) and not meeting the expected level at the time of program completion (ratings of ≤3.0). We calculated the number of residents who did not achieve target ratings for each of the subcompetencies., Results: In Spring 2022, of the 2,637 residents in the spring of their last year of training, 1,613 (61.2%) achieved a rating of ≥3.5 on every subcompetency and 1,024 (38.8%) failed to achieve that rating on at least one subcompetency. There were 250 residents (9.5%) who failed to achieve half of their expected subcompetency ratings and 105 (4.0%) who failed to achieve the expected rating (ie, rating was ≤3.0) on every subcompetency., Conclusion: When using an EM milestone rating threshold of 3.5, only 61.2% of physicians achieved the target ratings for program graduation; 4.0% of physicians failed to achieve target ratings for any milestone subcompetency; and 9.5% of physicians failed to achieve the target ratings for graduating residents in half of the subcompetencies., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. Drs. Gorgas, Ankel, and Carter are members of the American Board of Emergency Medicine (ABEM), Board of Directors. Drs. Joldersma, Barton, and Reisdorff are employees of ABEM. ABEM receives no revenue from Emergency Medicine Milestones reporting. There are no other conflicts of interest or sources of funding to declare.

Background: Prior research has provided retrospective validity evidence for an abbreviated Copenhagen Burnout Inventory (CBI) to measure burnout among emergency medicine (EM) residents. We sought to provide additional validity and reliability evidence for the two-factor, six-item abbreviated CBI., Methods: This cross-sectional study used data from the abbreviated CBI that was administered following the 2022 American Board of Emergency Medicine In-training Examination. Confirmatory factor analysis (CFA) was performed and the prevalence of burnout among EM residents was determined., Results: Of the 8918 eligible residents, 7465 (83.7%) completed the abbreviated CBI. CFA confirmed the previously developed model of two factors using six items answered with a 1- to 5-point Likert scale. The internal factor was derived from personal and work-related burnout and the external factor was related to caring for patients. The reliability was determined using Cronbach's alpha (0.87). The overall prevalence of burnout was 49.4%; the lowest prevalence was at the EM1 level (43.1%) and the highest was at the EM2 level (53.8%)., Conclusions: CFA of the abbreviated CBI demonstrated good reliability and model fit. The two-factor, six-item survey instrument identified an increase in the prevalence of burnout among EM residents that coincided with working in the COVID-19 environment. The abbreviated CBI has sufficient reliability and validity evidence to encourage its broader use., (© 2024 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Objectives: The American Board of Emergency Medicine (ABEM) Emergency Medical Services Medicine (EMS) subspecialty was approved by the American Board of Medical Specialties on September 23, 2010. Subspecialty certification in EMS was contingent on two key elements-completing Accreditation Council for Graduate Medical Education (ACGME)-accredited EMS training and passing the subspecialty certification examination developed by ABEM. The first EMS certification examination was offered in October 2013. Meaningful certification requires rigorous assessment. In this instance, the EMS certification examination sought to embrace the tenets of validity, reliability, and fairness. For the purposes of this report, the sources of validity evidence were anchored on the EMS core content, the examination development process, and the association between fellowship training and passing the certification examination., Methods: We chose to use validity evidence that included: 1) content validity (based on the EMS core content); 2) response processes (test items required intended cognitive processes); 3) internal structure supported by the internal relationships among items; 4) relations to other variables, specifically the association between examination performance and ACGME-accredited fellowship training; and 5) the consequences of testing., Results: There is strong content validity evidence for the EMS examination based on the core content and its detailed development process. The core content and supporting job-task analysis was also used to define the examination blueprint. Internal structure support was evidenced by Cronbach's coefficient alpha, which ranged from 0.82 to 0.92. Physicians who completed ACGME-accredited EMS fellowship training were more likely to pass the EMS certification examination (chi square, p  < 0.0001; Cramér's, V  = 0.24). Finally, there were two sources of consequential validity evidence-use of test results to determine certification and use of the resulting certificate., Conclusions: There is substantial and varied validity evidence to support the use of the EMS certifying examination in making summative decisions to award certification in EMS. Of note, there was a statistically significant association between ACGME-accredited fellowship training and passing the examination.

Objectives: The COVID-19 pandemic was disruptive for trainees and may have affected career decisions for some learners. This study examined the impact of the pandemic on emergency medicine (EM) resident perceptions of their mental health, perceptions of personal safety, and career choice regret., Methods: This was a cross-sectional survey study administered following the 2021 American Board of Emergency Medicine In-Training Examination (ITE). Survey measures included suicidal ideation (SI), COVID concerns in terms of infection prevention and control (IPC) training, COVID risk to self and/or COVID risk to family, and COVID-related career regret. COVID concerns were compared by gender and race/ethnicity using Pearson's chi-square tests. Multivariable logistic regression models were used to test the association between SI and COVID concerns, resident characteristics, and program characteristics., Results: A total of 6980 out of 8491 EM residents (82.2%) from 244 programs completed the survey. Only 1.1% of participants reported insufficient training in COVID IPC practices. Participants were concerned about COVID risk to themselves (40.3%) and to their families (63.3%) due to their job roles. These concerns were more common among women or nonbinary (vs. men); all other races/ethnicities (vs. non-Hispanic Whites); senior residents (vs. PGY-1, PGY-2 residents); and residents who were married or in relationships (vs. single or divorced). A total of 6.1% of participants reported that COVID made them reconsider choosing EM as their career. Career regret in this cohort was higher than that in the proportion (3.2%) expressing career regret in the 2020 ITE ( p  < 0.001). Career regret was more common among women or nonbinary (vs. men); all other races/ethnicities (vs. non-Hispanic Whites); and senior residents (vs. PGY-1, PGY-2 residents). The overall SI rate was 2.6%, which did not differ from that of the 2020 sample of EM residents (2.5%, p  = 0.88)., Conclusions: Many EM residents reported concerns about COVID risks to themselves and their families. Although the rate of SI remained unchanged, more EM residents reported career regret during the COVID pandemic., Competing Interests: Drs. Barton and Reisdorff are employees of the American Board of Emergency Medicine. The other authors declare no conflicts of interest., (© 2024 Society for Academic Emergency Medicine.)

Objectives: The American Board of Emergency Medicine (ABEM) requires a written examination (the Qualifying Examination) followed by the Oral Certifying Examination (OCE) to obtain ABEM certification. Maintaining ABEM certification is associated with fewer state medical board (SMB) disciplinary actions. We sought to determine the association between poor initial performance on the OCE and subsequent severe SMB disciplinary action., Methods: We included physicians who completed US categorical emergency medicine residencies in 2016 and earlier. We classified OCE performance as good (passed on first attempt) and poor (never passed or required > 1 attempt to pass). We obtained data on physician SMB disciplinary actions from the National Practitioner Data Bank that were limited to actions that denied licensure or altered the status of a medical license (eg, suspension). We determined the association between poor OCE performance and subsequent severe SMB disciplinary action., Results: Of 34,871, 93.5% passed the OCE on the first attempt, 6.1% required multiple attempts, and 0.3% never passed. Of the physicians (93.5%) with good OCE performance, 1.0% received a severe SMB action. Among physicians with poor OCE performance, 2.3% received a severe action; and of those who never passed, 1.7% received a severe action (Table 1). Poor OCE performance was associated with an increased odds of severe SMB disciplinary action (OR 2.21, 95% CI: 1.57-3.12)., Conclusion: Physicians with poor OCE performance exhibited higher odds of experiencing a subsequent severe SMB disciplinary action. The OCE may have utility as a predictor of future professionalism or clinical performance., Competing Interests: Drs. Johnston, Kraus, and Reisdorff are employees of the ABEM. Dr. Keim is a member of the ABEM Board of Directors. ABEM receives revenue for administering the OCE., (© 2024 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Objective: This study compares performance data from physicians completing 3-year versus 4-year emergency medicine residency training programs. Currently, there are 2 training formats and little is known about objective performance differences., Methods: This was a retrospective cross-sectional analysis of emergency residents and physicians. Multiple analyses were conducted comparing physicians' performances, including Accreditation Council of Graduate Medical Education Milestones and American Board of Emergency Medicine In-training Examination (ITE), Qualifying Examination (QE), Oral Certification Examination (OCE), and program extensions from 3-year and 4-year residency programs. Some confounding variables were not or could not be considered, such as rationale for medical students to choose one format over another, as well as application and final match rates., Results: Milestone scores are higher for emergency medicine 3 residents in 1-3 programs (3.51) versus emergency medicine 3 residents in 1-4 programs (3.07; P  < 0.001, d  = 1.47) and highest for emergency medicine 4 residents (3.67). There was no significant difference in program extension rates (emergency medicine 1-3, 8.1%; emergency medicine 1-4, 9.6%; P  = 0.05, ω  = 0.02). ITE scores were higher for emergency medicine 1, 2, and 3 residents from 1-3 programs and emergency medicine 4 residents from 1-4 programs scored highest. Mean QE score was slightly higher for emergency 1-3 physicians (83.55 vs 83.00; P  < 0.01, d  = 0.10). QE pass rate was higher for emergency 1-3 physicians (93.1% vs 90.8%; P  < 0.001, ω  = 0.08). Mean OCE score was slightly higher for emergency 1-4 physicians (5.67 vs 5.65; P  = 0.03 , d  = -0.07) but did not reach a priori statistical significance (α < 0.01). OCE pass rate was also slightly higher for emergency 1-4 physicians (96.9% vs 95.5%; P  = 0.06, ω  = -0.07) but also non-significant., Conclusions: These results suggest that although performance measures demonstrate small differences between physicians from emergency medicine 1-3 and 1-4 programs, these differences are limited in their ability to make causal claims about performance on the basis of program format alone., Competing Interests: Drs. Carter, Gorgas, and Gausche‐Hill are on the Board of Directors of the American Board of Emergency Medicine (ABEM); Dr. Beeson is a former director for ABEM; Dr. Santen is an oral examiner volunteer for ABEM and consultant for the American Medical Association; and Drs. Joldersma, Barton, and Reisdorff are employees of ABEM., (© 2023 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Study Objective: The influence of workplace mistreatment on the well-being and career satisfaction of emergency medicine residents is unknown. This study examined the relationships between burnout, career choice regret, and workplace mistreatment in a national sample of emergency medicine residents., Methods: This was a secondary analysis of a survey study on the prevalence of workplace mistreatment among emergency residents. Residents who reported emotional exhaustion or depersonalization at least once per week were considered to have burnout. Residents who reported dissatisfaction with their decision to become an emergency physician were considered to have career choice regret. Respondents also reported the type (discrimination, abuse, sexual harassment) and frequency of mistreatment over the academic year. Multivariable logistic regression, adjusting for program characteristics, was used to examine resident characteristics associated with burnout and career choice regret, with the frequency of mistreatment as a covariate., Results: Of the 8,162 eligible residents, 7,680 (94.1 %) participated. About a third of respondents reported burnout (2,188 of 6,902, 31.7%), whereas a minority (224 of 6,923, 3.2%) reported career choice regret. Of the 7,087 responses on mistreatment frequency, 2,117 (29.9%) reported "a few times per year," and 1,296 (18.3%) reported "a few times per month or more." Compared with residents who never experienced mistreatment, residents who reported increasing frequencies of mistreatment were associated with having burnout-from mistreatment a few times per year (OR [odds ratio],1.6; 99% CI [confidence interval], 1.3 to 1.9) to a few times per month or more (OR, 3.3; 99% CI, 2.7 to 4.1). Compared with residents without burnout, residents who reported burnout were associated with having career choice regret (OR, 11.3; 99% CI, 7.0 to 18.1). After adjusting for burnout, there were no significant relationships between the frequency of mistreatment and career choice regret., Conclusions: Workplace mistreatment is associated with burnout, but not career choice regret, among emergency medicine residents. Efforts to address workplace mistreatment may improve emergency medicine residents' professional well-being., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: Income fairness is important, but there are limited data that describe income equity among emergency physicians. Understanding the magnitude of and factors associated with income differences may be helpful in eliminating disparities. This study analyzed the associations of demographic factors, training, practice setting, and board certification with emergency physician income., Methods: We distributed a survey to professional members of the American College of Emergency Physicians. The survey included questions on annual income, educational background, practice characteristics, gender, age, race, ethnicity, international medical graduate status, type of medical degree (MD vs DO), completion of a subspecialty fellowship, job characteristics, and board certification. Respondents also reported annual income. We used linear regression to determine the respondent characteristics associated with reported annual income., Results: From 45,961 members we received 3407 responses (7.4%); 2350 contained complete data for regression analysis. The mean reported annual income was $315,306 (95% confidence interval [CI], $310,649 to $319,964). The mean age of the respondents was 47.4 years, 37.4% were women, 3.2% were races underrepresented in medicine (Black, American Indian, or Alaskan Native), and 4.8% were Hispanic or Latino. On linear regression, female gender was associated with lower reported annual income; difference -$43,565, 95% CI, -$52,217 to -$34,913. Physician age, degree (MD vs DO), underrepresented racial minority status, and underrepresented ethnic minority status were not associated with annual income. Fellowship training was associated with lower income; Accreditation Council for Graduate Medical Education (ACGME) program difference -$30,048; 95% CI, -$48,183 to -$11,912, non-ACGME-program difference -$27,640, 95% CI, -$40,970 to -$14,257. Working at a for-profit institution was associated with higher income; difference $12,290, 95% CI, $3693 to $20,888. Board certification was associated with higher income; difference, $43,267, 95% CI, $30,767 to $55,767., Conclusions: This study identified income disparities associated with gender, practice setting, fellowship completion, and American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certification., Competing Interests: Earl J. Reisdorff is employed by the American Board of Emergency Medicine. Catherine A. Marco is a former member of the Board of Directors of the American Board of Emergency Medicine., (© 2023 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: The American Board of Emergency Medicine (ABEM) in-person Oral Certification Examination (OCE) was halted abruptly in 2020 due to the COVID-19 pandemic. The OCE was reconfigured to be administered in a virtual environment starting in December 2020., Objectives: The purpose of this investigation was to determine whether there was sufficient validity and reliability evidence to support the continued use of the ABEM virtual Oral Examination (VOE) for certification decisions., Methods: This retrospective, descriptive study used multiple data sources to provide validity evidence and reliability data. Validity evidence focused on test content, response processes, internal structure (e.g., internal consistency and item response theory), and the consequences of testing. A multifaceted Rasch reliability coefficient was used to measure reliability. Study data were from two 2019 in-person OCEs and the first four VOE administrations., Results: There were 2279 physicians who took the 2019 in-person OCE examination and 2153 physicians who took the VOE during the study period. Among the OCE group, 92.0% agreed or strongly agreed that the cases on the examination were cases that an emergency physician should be expected to see; 91.1% of the VOE group agreed or strongly agreed. A similar pattern of responses given to a question about whether the cases on the examination were cases that they had seen. Additional evidence of validity was obtained by the use of the EM Model, the process for case development, the use of think-aloud protocols, and similar test performance patterns (e.g., pass rates). For reliability, the Rasch reliability coefficients for the OCE and the VOE during the study period were all >0.90., Conclusions: There was substantial validity evidence and reliability to support ongoing use of the ABEM VOE to make confident and defensible certification decisions., Competing Interests: CRC is a former director of the American Board of Emergency Medicine. DGG, and DLG are directors of the American Board of Emergency Medicine Board of Directors. EJR, KBJ, and KCR are employed by the American Board of Emergency Medicine., (© 2023 The Authors. AEM Education and Training published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Objective: The Copenhagen Burnout Inventory (CBI) is an open-access, valid, and reliable instrument measuring burnout that includes 19 items distributed across the following 3 domains (factors): personal burnout, work burnout, and patient burnout. The primary objective of this study was to determine the validity and reliability of an abbreviated CBI to assess burnout in emergency medicine residents., Methods: This cross-sectional study used data from the CBI that followed the 2021 American Board of Emergency Medicine In-training Examination. Exploratory factor analysis (EFA) was followed by confirmatory factor analysis (CFA)., Results: Of the 8491 eligible residents, 7225 (85.1%) completed the survey; the EFA cohort included 3613 residents and the CFA cohort included 3612 residents. EFA showed 2 eigenvalues ≥1, an internal factor and an external factor. There were 6 CBI items that contributed to the 2 factors. The first factor was related to personal burnout and work-related burnout and the second factor was related to working with patients. There were 4 CBI items that contributed to the internal factor and 2 CBI items that contributed to the external factor. Using the abbreviated CBI, the incidence of a resident having 1 or both types of burnout was 34.1%., Conclusions: This study provides validity evidence and reliability support for the use of a 6-item, 2-factor abbreviated CBI. A shorter, reliable, valid, and publicly accessible burnout inventory provides numerous advantages for burnout research in emergency medicine., Competing Interests: Melissa A. Barton, Mary M. Johnston, and Earl J. Reisdorff are employed by the American Board of Emergency Medicine. Lewis S. Nelson is a former member of the Board of Directors of the American Board of Emergency Medicine., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: Health care inequity is corrected more readily when safe, high-quality care is provided by physicians who reflect the gender, race, and ethnicity of patient communities. It is important to train and evaluate racially diverse physicians involved in residency training., Objective: This study sought to determine any test-taking differences for black Emergency Medicine (EM) residents and whether any such differences would narrow as residency progressed., Methods: This was an observational, cross-sectional study that reviewed performance (scaled scores) on the American Board of Emergency Medicine (ABEM) In-Training Examination (ITE) for 2018, 2019, and 2020. The study included EM residents in 3-year programs who took the ITE. A linear regression model was used for the variables of race, which included black physicians and white physicians (reference group), and level of training (EM resident year 1 [EM1] as the reference group)., Results: There were 9591 residents included; 539 were black and 9052 were white. Mean scaled scores were higher as a function of training level. Regression showed a scaled score intercept of 73.51. The ITE score increased for all groups as a function of training level (EM2 β = +5.45, p < 0.0001; EM3 β = +8.09, p < 0.0001). The regression coefficient for black residents was -5.87 (p < 0.0001). There was relative improvement by training level compared with improvement in the reference group, but this difference was not materially or statistically significant., Conclusion: In this study of the ABEM ITE, a test-taking performance gap identified early in residency for black physicians persisted into late residency., (Copyright © 2022. Published by Elsevier Inc.)

Study Objective: The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians., Methods: To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios., Results: The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030., Conclusion: The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative., (Copyright © 2021 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: Burnout afflicts emergency physicians (EPs) to a significant degree. The impact of burnout spans from decreased clinical efficiency to increased medical errors to heightened risk of physician suicide. This large-scale study captures responses from emergency medicine (EM) residents regarding two burnout items and examines the correlation between in-training examination (ITE) scores and burnout risk as well as that between residency year and burnout risk., Methods: This was a prospective, mixed-methods, cross-sectional cohort study. All residents in U.S. categorical EM residents who took the 2019 ITE were included. At the end of the ITE, residents were invited to complete a voluntary survey that included two items from the Maslach Burnout Inventory (MBI) that have been found to be strongly indicative of burnout: one about self-perception of being burned out and one about feelings of callousness. Responses were on a 7-level Likert scale (1-7), ranging from very low frequency (1) to very high frequency (7). Measurements included the number of residents in each year-level of training (EM1-EM4), the MBI item ratings, and the ABEM ITE score. Performance, as measured by the scaled, equated score, was compared to the MBI item responses. A corrected Spearman's correlation coefficient (ρ) was used to compare continuous data (score) against a discrete ordinal variable (MBI Likert response)., Results: There were 2,501 EM1 residents, 2,389 EM2 residents, 2,206 EM3 residents, and 616 EM4 residents in the study group. There were 7,206 (93.4%) physicians who completed the first MBI question about burnout; 7,172 (93%) completed the second MBI question about callousness. There was no statistically significant association between the burnout item response and ITE performance (ρ = -0.03; p = 0.015). There was a positive, statistically significant association between the callousness item response and higher ITE performance (ρ = 0.07; p < 0.001). There was a statistically significant association between the response to the burnout item and training level (ρ = 0.07; p <0.001). There was also a statistically significant association between the response to the callousness item and training level (ρ = 0.15; p < 0.001). The overall prevalence of burnout risk in various training levels were EM1, 28.2%; EM2, 39%; EM3, 41.1%; and EM4, 43.3%., Conclusions: Our study found no significant correlation between ITE score and burnout risk. There was a weakly positive correlation between ITE scores and callousness. Based on our study results, ITE scores may not be useful in prognosticating burnout risk for EM residents and, interestingly, higher ITE scores correlated to stronger feelings of callousness. Our study indicates that EM residents at higher levels of training reported stronger self-perceptions of burnout and callousness. Further investigation into why residents at higher levels of training may experience greater burnout risk is warranted., (© 2020 The Authors. AEM Education and Training published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Background: In certain medical specialties, board certification is associated with a lower risk of state medical board disciplinary actions., Objective: The association between maintaining American Board of Emergency Medicine (ABEM) certification and state medical disciplinary actions had not been studied. This study was undertaken to determine if maintaining ABEM certification was associated with a lower risk of disciplinary action., Methods: This investigation was a historical cohort study using Cox regression. Physicians who did not have a lapse in ABEM certification were compared with physicians who had a lapse to determine the risk of disciplinary action. Lapsing was determined at the expiration of the initial certificate. This study included all physicians who obtained initial ABEM certification from 1980-2005. Additional covariates of interest included the number of attempts on the ABEM Qualifying Examination (1 vs. >1), the geographic region of the physician's residence, and the country of medical school., Results: There were 23,002 physicians in the study cohort. Of these, 3370 (14.7%) let their certification lapse after initial certification. There were 701 (3.0%) physicians with disciplinary events. Lapsed physicians had higher rates of disciplinary actions than physicians who did not lapse (6.4% vs. 2.5%). ABEM-certified physicians who did not lapse were significantly less likely to be disciplined as physicians who let their certificate lapse (hazard ratio 0.50 [95% confidence interval 0.42-0.59])., Conclusions: The absolute incidence of physicians with a disciplinary action in this study cohort was low (3.0%). Maintaining ABEM certification was associated with a lower risk of state medical board disciplinary actions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Graduates of emergency medicine residency programs can seek certification from the American Board of Emergency Medicine (ABEM), yet the costs and perceived value by residents is not clear., Objective: This report sought to better define the value of board certification by asking physicians taking the ABEM Oral Certification Examination (OCE) to describe its costs (eg, time, money) and perceived benefits., Methods: A descriptive, cross-sectional, voluntary, anonymous survey was administered to physicians taking the 2018 spring and fall ABEM OCEs. Response frequencies were used to report response rates., Results: There were 2016 physicians who participated in the 2018 OCEs, of whom 1565 (78%) completed a survey. With respect to preparation, 38% (599 of 1565 responses) spent more than 30 hours preparing for the examination. Regarding the expense of preparing for the examination, 21% (328) spent nothing, 50% (776) spent less than $1,000, and 2% (38) spent more than $3,000. Most physicians (80%, 1254) reported a learning benefit to preparing for and taking the OCE. There were 49% (765) of respondents who reported that preparing for the examination reinforced their knowledge of emergency medicine; 20% (311) reported no learning benefit. Most physicians (92%, 1442) reported that ABEM certification provided a career benefit, the most common of which was more career opportunities (69%, 1076)., Conclusions: Initial certification requires a considerable investment of time and money. Physicians seeking initial ABEM certification found both learning and professional benefits, with the most frequently reported being reinforcement of medical knowledge and more career opportunities., Competing Interests: Conflict of interest: Dr Reisdorff is employed by the American Board of Emergency Medicine (ABEM). Drs Baren, Beeson, Chudnofsky, Goyal, Kowalenko, and Mallory are members of the ABEM board of directors, which offers ABEM certification. Dr Heller is a former member., (Accreditation Council for Graduate Medical Education 2019.)

Objective: The ABEM ConCert Examination is a summative examination that ABEM-certified physicians are required to pass once in every 10-year cycle to maintain certification. This study was undertaken to identify practice settings of emergency physicians, and to determine if there was a difference in performance on the 2017 ConCert between physicians of differing practice types and settings., Methods: This was a mixed methods cross sectional-study, using a post-examination survey and test performance data. All physicians taking the 2017 ConCert Examination who completed three survey questions pertaining to practice type, practice locations, and teaching were included. These three questions address different aspects of academia: self-identification, an academic setting, and whether the physician teaches., Results: Among 2796 test administrations of the 2017 ConCert Examination, 2693 (96.3%) completed the three survey questions about practice environment. The majority (N = 2054; 76.3%) self-identified as primarily being a community physician, 528 (19.6%) as academic, and 111 (4.1%) as other. The average ConCert Examination score for community physicians was 83.5 (95% CI, 83.3-83.8); the academic group was 84.8 (95% CI, 84.3-85.3); and the other group was 82.3 (95% CI, 81.1-83.6). After controlling for initial ability as measured by the Qualifying Examination score, there was no significant difference in performance between academic and community physicians (p = .10)., Conclusions: Academic emergency physicians and community emergency physicians scored similarly on the ConCert. Working at a community teaching hospital was associated with higher examination performance. Teaching medical learners, especially non-emergency medicine residents, was also associated with better examination performance., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: In 2013, milestone ratings became a reporting requirement for emergency medicine (EM) residency programs. Programs rate each resident in the fall and spring on 23 milestone subcompetencies., Objective: This study examined the incidence of straight line scoring (SLS) for EM Milestone ratings, defined as a resident being assessed the same score across the milestone subcompetencies., Methods: This descriptive analysis measured the frequencies of SLS for all Accreditation Council for Graduate Medical Education (ACGME)-accredited EM programs during the 2015-2016 academic year. Outcomes were the frequency of SLS in the fall and spring milestone assessments, changes in the number of SLS reports, and reporting trends. Chi-square analysis compared nominal variables., Results: There were 6257 residents in the fall and 6588 in the spring. Milestone scores were reported for 6173 EM residents in the fall (99% of 6257) and spring (94% of 6588). In the fall, 93% (5753 residents) did not receive SLS ratings and 420 (7%) did, with no significant difference compared with the spring (5776 [94%] versus 397 [6%]). Subgroup analysis showed higher SLS results for residents' first ratings (183 of 2136 versus 237 of 4220, P < .0001) and for their final ratings (200 of 2019 versus 197 of 4354, P < .0001). Twenty percent of programs submitted 10% or more SLS ratings, and a small percentage submitted more than 50% of ratings as SLS., Conclusions: Most programs did not submit SLS ratings. Because of the statistical improbability of SLS, any SLS ratings reduce the validity assertions of the milestone assessments., Competing Interests: Conflict of interest: Drs Beeson, Counselman, and Muelleman are directors for the American Board of Emergency Medicine. Drs Hamstra, Yamazaki, and Holmboe are employed by the Accreditation Council for Graduate Medical Education. Dr Shayne is the Chair of the Residency Review Committee for Emergency Medicine. Drs Barton and Reisdorff are employed by the American Board of Emergency Medicine. None of the investigators received financial compensation for the reported activity.

Objectives: The American Board of Emergency Medicine (ABEM) has introduced a new testing format for the oral certification examination (OCE): the enhanced oral or "eOral" format. The purpose of this study was to perform initial validity analyses of the eOral format. The two hypotheses were: 1) the case content in the eOral format was sufficiently similar to clinical practice and 2) the eOral case materials were sufficiently similar to clinical practice. The eOral and traditional formats were compared for these characteristics., Methods: This was a prospective survey study. The survey was administered as a voluntary postexamination activity at the end of the 2015 spring (April 25-27) and fall (October 10-13) ABEM OCEs. The survey is a routine part of the ABEM oral examination experience. For 2015, two additional questions were added to gauge the similarity of the eOral format to clinical practice. Validity was defined by content and substantive elements within Messick's model of construct validity as well as portions of Kane's validity model., Results: Of the 1,746 physicians who took the oral examination, 1,380 physicians (79.0%) completed all or part of the study survey questions. The majority of respondents agreed the patient presentations in the cases were similar (strongly agreed or agreed) to cases seen in clinical practice, in both the traditional cases (95.1%) and the eOral cases (90.1%). Likewise, the majority of respondents answered that the case materials (e.g., laboratory, radiographs) were similar (strongly agreed or agreed) to what they encounter in clinical practice, both in the traditional format (85.8%) and in the eOral cases (93.7%)., Conclusions: Most emergency physicians reported that the types of cases tested in the traditional and eOral formats were similar to cases encountered in clinical practice. In addition, most physicians found the case materials to be similar to what is seen in clinical practice. This study provides early validity evidence for the eOral format., (© 2016 by the Society for Academic Emergency Medicine.)

Background: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted requirements that limited the number of hours residents could spend on duty, and in 2011, it revised these requirements., Objective: This study explored whether the implementation of the 2003 and 2011 duty hour limits was associated with a change in emergency medicine residents' performance on the American Board of Emergency Medicine (ABEM) Qualifying Examination (QE)., Methods: Beginning with the 1999 QE and ending with the 2014 QE, candidates for whom all training occurred without duty hour requirements (Group A), candidates under the first set of duty hour requirements (Group C), and candidates under the second set of duty hour requirements (Group E) were compared. Comparisons included mean scores and pass rates., Results: In Group A, 5690 candidates completed the examination, with a mean score of 82.8 and a 90.2% pass rate. In Group C, 8333 candidates had a mean score of 82.4 and a 90.5% pass rate. In Group E, there were 1269 candidates, with a mean score of 82.5 and an 89.4% pass rate. There was a small but statistically significant decrease in the mean scores (0.04, P  < .001) after implementation of the first duty hour requirements, but this difference did not occur after implementation of the 2011 standards. There was no difference among pass rates for any of the study groups (χ 2  = 1.68, P  = .43)., Conclusions: We did not identify an association between the 2003 and 2011 ACGME duty hour requirements and performance of test takers on the ABEM QE., Competing Interests: The authors declare they have no competing interests.

Objective: As part of the American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) program, ABEM-certified physicians are required to pass the Continuous Certification (ConCert) examination at least every 10 years. With the 2015 ConCert examination, ABEM sought to better understand emergency physicians' perceptions of the benefits of preparing for and taking the examination and the career benefits of staying ABEM-certified., Methods: This was a prospective survey study. A voluntary postexamination survey was administered at the end of the 2015 ABEM ConCert examination (September 21-26, 2015). Physicians were asked about the benefits of preparing for the examination and maintaining ABEM certification. Examination performance was compared to perceptions of learning and career benefits., Results: Of the 2,601 on-time test takers, 2,511 respondents participated (96.5% participation rate). The majority of participants (92.0%) identified a benefit to preparing for the ConCert examination, which included reinforced medical knowledge (73.9%), increased knowledge (66.8%), and making them a better clinician (39.4%). The majority of respondents (90.8%) identified a career benefit of maintaining ABEM certification, which included more employment options (73.8%), more positively viewed by other physicians (56.8%), and better financial outcomes (29.8%). There was a statistically significant association between the perception of knowledge reinforcement and examination performance (p < 0.001). There was also a statistically significant association between the perception that staying certified created more career opportunities and examination performance (p < 0.001)., Conclusions: Most emergency physicians identified benefits of preparing for and taking the ABEM ConCert examination, which included reinforcing or adding medical knowledge and making them better clinicians. Most physicians also found career benefits to remaining ABEM-certified, which included greater employment choices, higher financial compensation, and higher esteem from other physicians. The belief that preparing for and taking the examination reinforced medical knowledge was associated with better examination performance., (© 2016 by the Society for Academic Emergency Medicine.)

Objectives: To maintain certification by the American Board of Emergency Medicine (ABEM), physicians are required to pass the Continuous Certification (ConCert) examination at least every 10 years. On the 2014 ConCert postexamination survey, ABEM sought to understand the manner in which ABEM diplomates prepared for the test and to identify associations between test preparation approaches and performance on the ConCert examination., Methods: This was a cross-sectional survey study. The survey was administered at the end of the 2014 ConCert examination. Analyses included chi-square and linear regression to determine the association of preparation methods with performance., Results: Of the 2,431 on-time test-takers, 2,338 (96.2%) were included. The most commonly used study approach was the review of written materials designed for test preparation (1,585; 67.8%), followed by an online training course (1,006; 43.0%). There were 758 (32.4%) physicians who took a single onsite board review course, while 41 (1.8%) took two or more onsite courses. Most physicians (1,611; 68.9%) spent over 35 hours preparing for the ConCert examination. The study method that was most associated with favorable test scores was the review of written materials designed for test preparation (p < 0.001). Attending an onsite preparation course was associated with poorer performance (p < 0.001). There was a significant association between no additional preparation and failing the examination (chi-square with Yates correction; p = 0.001)., Conclusions: A substantial majority (97.8%) of physicians taking the 2014 ABEM ConCert examination prepared for it. The majority of physicians used written materials specifically designed for test preparation. Reviewing written materials designed for test preparation was associated with the highest performance., (© 2016 by the Society for Academic Emergency Medicine.)

Objectives: The Accreditation Council for Graduate Medical Education (ACGME) Milestones describe behavioral markers for the progressive acquisition of competencies during residency. As a key component of the Next Accreditation System, all residents are evaluated for the acquisition of specialty-specific Milestones. The objective was to determine the validity and reliability of the emergency medicine (EM) Milestones., Methods: The ACGME and the American Board of Emergency Medicine performed this single-event observational study. The data included the initial EM Milestones performance ratings of all categorical EM residents submitted to the ACGME from October 31, 2013, to January 6, 2014. Mean performance ratings were determined for all 23 subcompetencies for every year of residency training. The internal consistency (reliability) of the Milestones was determined using a standardized Cronbach's alpha coefficient. Exploratory factor analysis was conducted to determine how the subcompetencies were interrelated., Results: EM Milestone performance ratings were obtained on 100% of EM residents (n = 5,805) from 162 residency programs. The mean performance ratings of the aggregate and individual subcompetency scores showed discrimination between residency years, and the factor structure further supported the validity of the EM Milestones. The reliability was α = 0.96 within each year of training., Conclusions: The EM Milestones demonstrated validity and reliability as an assessment instrument for competency acquisition. EM residents can be assured that this evaluation process has demonstrated validity and reliability; faculty can be confident that the Milestones are psychometrically sound; and stakeholders can know that the Milestones are a nationally standardized, objective measure of specialty-specific competency acquisition., (© 2015 by the Society for Academic Emergency Medicine.)

Objectives: The American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) program requires every ABEM-certified physician to attest to participating in a quality improvement (QI) activity every 5 years. Understanding the type and frequency of these QI activities could inform the emergency medicine community about the variety of QI activities in which emergency physicians (EPs) are involved. These QI activities could provide ideas for the development of additional quality measures., Methods: This was a retrospective descriptive study of self-reported QI activity attestations from the ABEM MOC program during 2013. Attestations were provided by ABEM-certified EPs using the ABEM MOC website. The type, number, and cumulative frequency of activities are reported., Results: ABEM received 9,380 attestations for QI activities in 91 different categories. The three most commonly reported activities were acute myocardial infarction-percutaneous coronary intervention within 90 minutes of arrival (includes door-to-balloon time), door-to-doctor times, and throughput time measures. These three activities comprised 36.4% of attestations. More than half (54.4%) of the attestations were captured by the five most frequently attested activities, 67.1% by the top seven categories, and 89.9% by the top 21 categories. Of these 21 categories, 10 involved clinical protocols, nine were time-centered measures, and two were patient-centered activities., Conclusions: This report demonstrates that diverse QI activities occur in emergency departments (EDs) across the United States. The majority of reported projects are nested in a few categories, following recognized areas of emphasis in emergency care, particularly in areas using time-sensitive metrics., (© 2015 by the Society for Academic Emergency Medicine.)

Objectives: The initial step in certification by the American Board of Emergency Medicine (ABEM) requires passing a multiple-choice-question qualifying examination. The qualifying examination is typically taken in the first year after residency training. This study was undertaken to determine if a delay in taking the qualifying examination is associated with poorer performance. The authors also examined the relationship between in-training examination scores and qualifying examination scores., Methods: This was a pooled time-series cross-section study. Primary measurements were initial qualifying examination scores, the timing of the qualifying examination, and in-training examination scores. The three groups, based on qualifying examination timing, were immediate, 1-year delay, and ≥2-year delay. In-training examination scores were analyzed to determine the relationship between intrinsic ability, examination timing, and qualifying examination scores. For analysis, a generic pooled ordinary least-squares dummy variable model with robust standard errors was used. A pre hoc level of significance was determined to be α < 0.01., Results: There were 16,353 qualifying examination test administrations between 2000 and 2012. In-training examination scores were positively correlated with qualifying examination scores (p < 0.001). The group pass rates were 98.9% immediate, 95.6% 1-year delay, and 86.6% ≥2-year delay. After controlling for in-training examination scores, delay taking the qualifying examination of 1 year was associated with a decrease in score of -0.6 (p = 0.003). A delay in taking the qualifying examination ≥2 years was associated with a decrease in score of -2.5 points (p < 0.001)., Conclusions: After accounting for innate ability using in-training examination scores, delay taking the qualifying examination was associated with poorer performance. This effect was more pronounced if the delay was ≥2 years., (© 2014 by the Society for Academic Emergency Medicine.)

Objectives: The American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) program is a four-step process that includes the Continuous Certification (ConCert) examination. The ConCert examination is a validated, summative examination that assesses medical knowledge and clinical reasoning. ABEM began administering the ConCert examination in 1989. The ConCert examination must be passed at least every 10 years to maintain certification. This study was undertaken to determine longitudinal physician performance on the ConCert examination., Methods: In this longitudinal review, ConCert examination performance was compared among residency-trained emergency physicians (EPs) over multiple examination cycles. Longitudinal analysis was performed using a growth curve model for unbalanced data to determine the growth trajectories of EP performance over time to see if medical knowledge changed. Using initial certification qualifying examination scores, the longitudinal analysis corrected for intrinsic variances in physician ability., Results: There were 15,085 first-time testing episodes from 1989 to 2012 involving three examination cycles. The mean adjusted examination scores for all physicians taking the ConCert examination for a first cycle was 85.9 (95% confidence interval [CI] = 85.8 to 85.9), the second cycle mean score was 86.2 (95% CI = 86.0 to 86.3), and the third cycle was 85.4 (95% CI = 85.0 to 85.8). Using the first examination cycle as a reference score, the growth curve model analysis resulted in a coefficient of +0.3 for the second cycle (p < 0.001) and -0.5 for the third cycle (p = 0.02). Initial qualifying (written) examination scores were significant predictors for ConCert examination scores., Conclusions: Over time, EP performance on the ConCert examination was maintained. These results suggest that EPs maintain medical knowledge over the course of their careers as measured by a validated, summative medical knowledge assessment., (© 2014 by the Society for Academic Emergency Medicine.)

Background: The Lifelong Learning and Self-assessment (LLSA) component of the American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) program is a self-assessment exercise for physicians. Beginning in 2011, an optional continuing medical education (CME) activity was added., Objectives: As a part of a CME activity option for the LLSA, a survey was used to determine the relevancy of the LLSA readings and the degree to which medical knowledge garnered by the LLSA activity would modify clinical care., Methods: Survey results from the 2011 LLSA CME activity were reviewed. This survey was composed of seven items, including questions about the relevancy of the readings and the impact on the physician's clinical practice. The questions used a 5-point Likert scale and data underwent descriptive analyses., Results: There were 2841 physicians who took the LLSA test during the study period, of whom 1354 (47.7%) opted to participate in the 2011 LLSA CME activity. All participants completed surveys. The LLSA readings were reported to be relevant to the overall clinical practice of Emergency Medicine (69.6% strongly relevant, 28.1% some relevance, and 2.3% little or no relevance), and provided information that would likely help them change their clinical practices (high likelihood 38.8%, some likelihood 53.0%, little or no change 8.2%)., Conclusions: The LLSA component of the ABEM MOC program is relevant to the clinical practice of Emergency Medicine. Through this program, physicians gain new knowledge about the practice of Emergency Medicine, some of which is reported to change physicians' clinical practices., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties sought to define milestones for skill and knowledge acquisition during residency training. Milestones are significant objective observable events. The milestones are listed within a structure that is derived from the ACGME general competencies. Major groups of milestones are called "subcompetencies." The original 24 subcompetencies containing 255 milestones for emergency medicine (EM) were developed through a multiorganizational group representing most EM stakeholder groups. To assure that the milestones reflected EM resident progress throughout training, the EM Milestones Working Group (EM MWG) sought to validate the individual milestones., Methods: A computer-based survey was sent to all EM residency programs. The survey period began on April 30, 2012, and concluded on May 15, 2012. Respondents were asked to assign each milestone to a specific level of skill or knowledge acquisition. These levels ranged from a beginning resident to an accomplished clinician. There were two different forms that divided the milestones into two groups of 12 subcompetencies each. Surveys were randomly assigned to programs., Results: There were five respondents (the program director and four key faculty) requested from each of the 159 residences. There were responses from 96 programs (60.4%). Of the 795 survey recipients, 28 were excluded due to prior exposure to the EM milestones. Of the remaining 767 potential respondents, 281 completed the survey (36.6%) within a 16-day period. Based on the survey results, the working group adjusted the milestones in the following ways: one entire subcompetency (teaching) was eliminated, six new milestones were created, 34 milestones were eliminated, 26 milestones were reassigned to a lower level score, and 20 were reassigned to a higher level. Nineteen milestones were edited to provide greater clarity. The final result was 227 discrete milestones among 23 subcompetencies., Conclusions: The EM milestones were validated through a milestone assignment process using a computer-based survey completed by program directors and key faculty. Milestones were revised in accordance with the results to better align assignment within each performance level., (© 2013 by the Society for Academic Emergency Medicine.)

Objectives: This was a point-prevalence study designed to quantify the magnitude of emergency department (ED) overcrowding and inpatient boarding. Every ED in Michigan was surveyed at a single point in time on a Monday evening. Given the high patient volumes on Monday evenings, the effect on inpatient boarding the next morning was also reviewed., Methods: All 134 EDs within the state of Michigan were contacted and surveyed on Monday evening, March 16, 2009, over a single hour and again the following morning. Questions included data on annual census, bed number, number of admitted patients within the ED, ambulance diversion, and ED length of stay., Results: Data were obtained from 109 of the 134 (81%) hospitals on Monday evening and 99 (74%) on Tuesday morning. There was no difference in annual visits or ED size between participating and nonparticipating EDs. Forty-seven percent of EDs were boarding inpatients on Monday evening, compared with 30% on Tuesday morning. The mean estimated boarding times were 3.7 hours (Monday evening) and 7.2 hours (Tuesday morning). Twenty-four percent of respondents met the definition of overcrowded during sampling times. There was a significant relationship between inpatient boarding and ED overcrowding (p < 0.001). Only three EDs were actively diverting ambulances., Conclusions: In this study on a single Monday evening, 47% of EDs in Michigan were actively boarding inpatients, while 24% were operating beyond capacity. On the following morning (Tuesday), EDs had fewer boarded inpatients than on Monday evening. However, these boarded inpatients remained in the ED for a significantly longer duration., (© 2011 by the Society for Academic Emergency Medicine.)

The rapid neuroimaging of a patient that has suffered a stroke is a critical preamble to the emergent initiation of thrombolytic therapy. Emergency physicians must be familiar with normal brain structures as they appear on CT, as well as common stroke patterns. The more facile emergency physicians are at interpreting the head CT, the better they can communicate with consulting specialists and deliver prompt care to patients that present with neurologic emergencies.

The Accreditation Council for Graduate Medical Education (ACGME) has promoted six areas that should be addressed during graduate medical training, or "general competencies" (GCs). According to the ACGME, these GCs should be reflected in the educational processes of all residency programs. In promulgating these competencies, however, the ACGME has not provided examples of core content, methods of implementation, or methods of evaluation. The authors propose a practical method for modifying an existing evaluation format, providing a template other programs could use in assessing residents' acquisition of the knowledge, skills, and attitudes reflected in the GCs.

Background: QT dispersion has been proposed as a noninvasive measurement of the degree of inhomogeneity in myocardial repolarization. Increased QT dispersion has been reported after myocardial infarction. We hypothesized that increased QT dispersion may be a useful adjunct for risk stratification in patients being evaluated in a chest pain center., Methods and Results: Patients were admitted to the chest pain center for evaluation of chest pain. Exclusion criteria included (1) systolic blood pressure <90 mm Hg, (2) ischemia or infarction on the initial electrocardiograph (ECG), (3) elevated creatine kinase or MB fraction, and (4) chest pain associated with cocaine use. Serial creatine kinase and MB levels and ECGs were obtained at 0, 6, and 9 hours. Patients were monitored for (1) creatine kinase and MB rise, (2) ECG changes for infarction, (3) ST-segment changes, and (4) rest angina. A negative evaluation at the chest pain center led to an exercise stress test. Patients with a positive exercise stress test were admitted for further evaluation and patients with a negative exercise stress test result were discharged home. Patients were divided into 3 groups. Group 1 consisted of patients who were found to have an acute myocardial infarction (AMI), group 2 consisted of patients with prior history of coronary artery disease but no evidence of AMI, and group 3 consisted of patients without prior coronary artery disease or AMI. QT dispersion was measured on the initial ECG in all patients. A total of 586 patients were evaluated. Group 1 consisted of 13 patients with mean QT dispersion of 44.6+/-18.5 ms, group 2 consisted of 267 patients with a mean QT dispersion of 10.0+/-13.8 ms, and group 3 consisted of 303 patients with a mean QT dispersion of 10.5+/-10.0 ms. Analysis of variance showed a significantly higher QT dispersion in patients who had AMI compared with other patients with chest pain (P< .001)., Conclusions: QT dispersion can be a useful diagnostic adjunct for detection of AMI in patients with chest pain with a normal ECG and normal cardiac enzymes.

The sudden loss of consciousness in a child is concerning to both patients and their parents. Although most cases of syncope in children are benign, an adequate evaluation is required to exclude life-threatening disorders. Patient history and physical examination may be sufficient to define the cause of syncope in a large percentage of pediatric cases. The events and setting preceding the syncopal episode provide clues in defining the nature of the event.

Objectives: Frequently performing procedures assists in skill maintenance. This study was conducted to characterize frequency and types of basic and advanced prehospital interventions performed on children., Methods: A retrospective study was conducted over a three-month period from emergency medical services (EMS) units working in central Michigan. Data were collected for age, sex, at-scene time, total run time, basic procedures (e.g., spinal immobilization), and advanced procedures (e.g., venous access)., Results: A total of 535 EMS runs were reviewed. Runs were excluded for transport refusal (105) and site-to-site transfer (6). Of the remaining 424 children, 287 received an intervention (group 1) and 137 did not (group 2). Group 1 (9.5 +/- 5.6 years) was older (p < 0.001) than group 2 (6.0 +/- 5.8 years). There was no gender predominance between group 1 and group 2 (p = 0.06). In group 1 there were 104 patients who received multiple procedures. Basic procedures (n = 382) included spinal immobilization (149), oxygen administration (123), splinting (27), wound care (24), use of military anti-shock trousers (4), and cardiopulmonary resuscitation (1). Advanced procedures (n = 112) included venous access (65), medications of all routes (26), and cardiacoximetry monitoring (21). No child had an intraosseous line started and no child was successfully intubated. Only 82 of the 424 children (19.3%) had an advanced procedure. Group 1 at-scene times (16.1 +/- 8.1 min) were longer (p < 0.001) than those of group 2 (11.1 +/- 6.6 min). Total run times for group 1 (35.7 +/- 15.5 min) were longer (p < 0.001) than those for group 2 (26.7 +/- 11.3 min)., Conclusions: Advanced EMS procedures were performed on only 19.3% of children. Opportunities to perform critical interventions (e.g., intubation) were rarely present. Children receiving procedures were older and had longer scene and run times.

The sudden unexpected death of an athlete is a disturbing and tragic event. Sudden cardiac death in the young athlete is caused primarily by cardiomyopathies and nonatherosclerotic coronary artery abnormalities; in the mature athlete, the most prevalent cause of sudden cardiac death is atherosclerotic coronary disease. The job of the emergency physician is to resuscitate those who succumb to ventricular dysrhythmias during exercise and to screen patients for potential risk of sudden cardiac death when they present with warning symptoms such as syncope.

There are an estimated 4,300 cases of postoperative hemorrhage after tonsillectomy in the United States each year. Most patients seek care in the Emergency Department for this potentially fatal condition. This study was performed to characterize the clinical presentation of patients seeking Emergency Department (ED) care for posttonsillectomy and postadenoidectomy hemorrhage (PTAH). In addition, the investigators attempted to describe the ED treatment for PTAH. A retrospective review of ED and inpatient medical records was executed for patients presenting to the ED with PTAH from June 1, 1983 to May 31, 1993. All patients presenting to the ED who received a final ED diagnosis of PTAH were included in the study. The setting included two community-based teaching hospitals that share a single emergency medicine residency. The combined ED census averaged 72,000 annual visits over the study period. The ED population included both children and adults. Neither hospital had an otolaryngology residency, nor was there 24 hour in-hospital otolaryngology staffing. Factors that were reviewed included patient age, gender, final disposition, presenting vital signs, time from the initial surgery to the time of bleeding, ED treatment, and the interaction with the on-call otolaryngologist. Subpopulations were defined primarily by age (child versus adult) and disposition (home versus hospital). chi 2 Analysis was used for most comparisons. When chi 2 analysis showed an association, the phi (phi) coefficient was calculated to determine the strength of the association. When appropriate, means were compared using the Student's two-tailed t test.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients who present to the Emergency Department with a behavioral or cognitive disorder should be treated in an organized fashion. The most important element of their care is determining the etiology of their abnormality, whether organic or functional. The history and physical examination, along with laboratory and ancillary testing, should be directed toward this objective. The mental status examination plays a critical role in establishing the diagnosis. It must be focused and brief. By focusing on seven major areas (affect, attention, language, orientation, memory, visual-spatial ability, and conceptualization), a quick and thorough examination of the patient's mental status can be performed.

Fracture of the first rib usually results from high-impact, direct trauma. Stress fractures are less common and are associated with minimal morbidity. The case of a patient with a stress fracture resulting from the use of an exercise machine is reported. Previous reports have attributed stress and fatigue fractures of the first rib to the forces exerted by the scalene muscles. A new pathophysiologic mechanism involving the serratus anterior muscle is introduced and is supported by T2 relaxation times from magnetic resonance imaging. Stress and fatigue fractures of the first rib have minimal complications. An aggressive diagnostic evaluation of first rib fractures occurring by this mechanism is not warranted.

A case of profound digital vasoconstriction caused by the accidental injection of epinephrine from a commercial bee sting kit is reported. One hour later the patient had a cold, painful, blanched finger. A digital block using a 2-mg dose of phentolamine mixed with 2% lidocaine was performed. Thirty minutes after treatment, the finger was pink and warm. The patient reported a marked decrease in pain. Reexamination 12 hours later showed only mild tenderness at the fingertip. No tissue necrosis occurred. One month after injection, there were no apparent sequelae. Although the use of alpha-adrenergic blocking agents by regional infiltration to treat accidental infusion or extravasation of epinephrine has been suggested, no reports of this technique are found in the emergency medicine literature. The mechanism of digital vasoconstriction and the action of phentolamine are discussed.

Status epilepticus is a neurologic emergency with an 8% to 12% mortality. Rapid ablation of seizure activity is imperative. Although intravenous administration of diazepam is the preferred immediate treatment, vascular access is often difficult to achieve. Rectal administration of diazepam is easily accomplished during status epilepticus. Five cases in which diazepam administered in the rectal lumen stopped seizure activity are reported. Rectal diazepam appears to be safe and efficacious. It should be considered as an alternate to intravenous therapy when immediate vascular access is delayed. Rectal diazepam may have great benefit in the prehospital setting.