Loss of international medical experiences: knowledge, attitudes and skills at risk

Background Despite the great influence International Medical Experiences (IMs) can have on young physicians and their impact on patients and communities, they are not offered in all training programs and are at risk of being reduced in some due to stringent guidelines for funding of graduate medical education. Discussion IMs provide unique experiences in clinical, epidemiologic, cultural, and political arenas. From an educational perspective, they broaden a physician's differential diagnostic skills and introduce clinical entities rarely seen in the U.S. Time spent in developing countries emphasizes the importance of community health and increases cultural and linguistic competence. Experience working with the underserved during an IM has been shown to increase interest in volunteerism, humanitarian efforts, and work with underserved populations both in the US and abroad. IMs also afford physicians the opportunity to learn about the delivery of health care abroad and are associated with an increase in primary care specialty choice. Summary It is time for the leaders in graduate medical education to prioritize international health opportunities. Leaders in academic medicine can press for changes in reimbursement patterns at the national level or special funds for international electives. Hospitals can set up separate accounts to help finance resident salaries and benefits while abroad. Individual departments must be flexible with resident schedules to allow elective time. Medical students and housestaff can organize and lobby larger organizations such as the American Medical Association (AMA), the American Association of Medical Colleges (AAMC), and specialty groups to make IMs universally accessible.</p

Utility Of An Emergency Department Clinical Protocol For Early Identification of Coronavirus Infection

Introduction: We assessed the utility of an emergency department (ED) protocol using clinical parameters to rapidly distinguish likelihood of novel coronavirus 2019 (COVID-19) infection; the applicability aimed to stratify infectious-risk pre-polymerase chain reaction (PCR) test results and accurately guide early patient cohorting decisions.Methods: We performed this prospective study over a two-month period during the initial surge of the 2020 COVID-19 pandemic in a busy urban ED of patients presenting with respiratory symptoms who were admitted for in-patient care. Per protocol, each patient received assessment consisting of five clinical parameters: presence of fever; hypoxia; cough; shortness of breath/dyspnea; and performance of a chest radiograph to assess for bilateral pulmonary infiltrates. All patients received nasopharyngeal COVID-19 PCR testing.Results: Of 283 patients studied, 221 (78%) were PCR+ and 62 (22%) PCR-. Chest radiograph revealed bilateral pulmonary infiltrates in 85%, which was significantly more common in PCR+ (94%) vs PCR- (52%) patients (P &lt; 0.0001). The rate of manifesting all five positive clinical parameters was significantly greater in PCR+ (63%) vs PCR- (6.5%) patients (P &lt; 0.0001). For PCR+ outcome, the presence of all five positive clinical parameters had a specificity of 94%, positive predictive value of 98%, and positive likelihood ratio of 10.Conclusions: Using an ED protocol to rapidly assess five clinical parameters accurately distinguishes likelihood of COVID-19 infection prior to PCR test results, and can be used to augment early patient cohorting decisions

Correlation of venous lactate and time of death in emergency department patients with noncritical lactate levels and mortality from trauma

Background: Serum venous lactate (LAC) levels help guide emergency department (ED) resuscitation of patients with major trauma. Critical LAC level (CLAC, ≥4.0 mmol/L) is associated with increased disease severity and higher mortality in injured patients. The characteristics of injured patients with non-CLAC (NCLAC) (<4.0 mmol/L) and death have not been previously described. Objectives: (1) To describe the characteristics of patients with venous NCLAC and death from trauma. (2) To assess the correlation of venous NCLAC with time of death. Methods: A retrospective cohort study at an urban teaching hospital between 9/2011 and 8/2014. Inclusion: All trauma patients (all ages) who presented to the ED with any injury and met all criteria: (1) Venous LAC drawn at the time of arrival that resulted in an NCLAC level; (2) were admitted to the hospital; (3) died during their hospitalization. Exclusion: CLAC. Outcome: Correlation of NCLAC and time of death. Data were extracted from an electronic medical record by trained data abstractors using a standardized protocol. Cross-checks were performed on 10% of data entries and inter-observer agreement was calculated. Data were explored using descriptive statistics and Kaplan–Meier curves were created to define survival estimates. Data are presented as percentages with 95% confidence interval (CI) for proportions and medians with quartiles for continuous variables. Kaplan–Meier curves with differences in time to events based on LAC are used to analyze the data. Results: A total of 60 patients met the inclusion criteria. The median age was 52 years (quartiles: 30, 75) and 73% were male (age range 2–92). The median LAC in the overall cohort was 1.9 mmol/L (quartiles: 1.5, 2.1). Sixteen patients (27%) died during the first 24 h with 5 (31%) due to intracranial hemorrhage. The median survival time was 5.6 days (134.4 h) (95% CI: 2.3–12.6). Conclusions: In trauma patients with NCLAC who died during the index hospitalization, the median survival time was 5.6 days, approximately one-third of patients died within the first 24 h. These findings indicate that relying on a triage NCLAC level alone may result in underestimating injury severity and subsequent morbidity and mortality