J Emerg Med
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Clerkship directors routinely evaluate medical students using multiple modalities, including faculty assessment of clinical performance and written examinations. Both forms of evaluation often play a prominent role in final clerkship grade. The degree to which these modalities correlate in an emergency medicine (EM) clerkship is unclear. ⋯ Faculty evaluations of medical students across multiple domains of competency correlate poorly with written examination performance during an EM clerkship. Educators need to consider the limitations of examination score in assessing students' ability to provide quality patient clinical care.
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Case Reports
Right Coronary Dissection and Left Anterior Descending Thrombus: Dual Dilemma in a Young Cardiac Arrest Survivor.
ST-elevation myocardial infarction (STEMI) leading to cardiac arrest is an exceptionally rare occurrence in young adults. Those affected tend to abuse sympathomimetic drugs, have strong family histories, or have a significant burden of cardiac risk factors. Another uncommon cause of STEMI is coronary artery dissection, which overwhelmingly affects middle- and older-aged women with few cardiac risk factors. ⋯ A 22-year-old athlete with no medical history was admitted to our institution post-cardiac arrest with an anterior STEMI and concomitant right coronary dissection. To our knowledge, this represents the first documented case of these simultaneous pathologies in a young cardiac arrest survivor. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Myocardial infarction is rare in young adults, and a diverse range of etiologies must be considered promptly to prevent delays in time-sensitive therapies, such as antiplatelet agents and revascularization. The emergency physician is most often the first point of contact in patients with acute coronary syndromes, and the failure to recognize it in young adults threatens them with premature death and potentially life-long disability.
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Total anomalous pulmonary venous return (TAPVR) is an uncommon congenital heart defect. Obstructed forms are more severe, and typically present earlier in life, usually in the immediate newborn period, with symptoms of severe cyanosis and respiratory failure. ⋯ A 13-day-old boy presented to the emergency department (ED) with respiratory extremis. He appeared cyanotic and limp, and was found to have significant hypoxia with oxygen saturation of 40%. He had no improvement of oxygenation with bag-valve-mask ventilation despite a fraction of inspired oxygen near 100%. This gave clear indication that the hypoxia was caused by a shunt and not by hypoventilation, a ventilation/perfusion mismatch, or a barrier to diffusion. Next, the patient was intubated emergently. Broad spectrum antibiotics and fluid resuscitation with normal saline were initiated. A chest radiograph showed evidence of pulmonary edema vs. diffuse interstitial disease. Cardiology was consulted and evaluated the child with an echocardiogram, which revealed TAPVR with infradiaphragmatic obstructed veins. Once stabilized, he was transferred for definitive surgical repair. This is, to our knowledge, the first reported case of TAPVR with infradiaphragmatic obstruction presenting to the ED with hemodynamic and respiratory compromise beyond the first week of life. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite improvements in antenatal and newborn screening, congenital heart disease often remains an elusive diagnosis. Some patients with these critical lesions are discharged home before the manifestation of their disease becomes apparent. Once symptomatic, these patients often present to the ED in extremis. We conclude that it is important to recognize this presentation to ensure proper evaluation and early diagnosis. If misdiagnosed, many of the usual therapies for other diseases could be detrimental.