IntroductionTo obtain a residency match, medical students entering emergency medicine (EM) must complete away rotations, submit a number of lengthy applications, and travel to multiple programs to interview. The expenses incurred acquiring this residency position are burdensome, but there is little specialty-specific data estimating it. We sought to quantify the actual cost spent by medical students applying to EM residency programs by surveying students as they attended a residency interview.MethodsResearchers created a 16-item survey, which asked about the time and monetary costs associated with the entire EM residency application process. Applicants chosen to interview for an EM residency position at our institution were invited to complete the survey during their interview day.ResultsIn total, 66 out of a possible 81 residency applicants (an 81% response rate) completed our survey. The “average applicant” who interviewed at our residency program for the 2015–16 cycle completed 1.6 away, or “audition,” rotations, each costing an average of $1,065 to complete. This “average applicant” applied to 42.8 programs, and then attended 13.7 interviews. The cost of interviewing at our program averaged $342 and in total, an average of $8,312 would be spent in the pursuit of an EM residency.ConclusionDue to multiple factors, the costs of securing an EM residency spot can be expensive. By understanding the components that are driving this trend, we hope that the academic EM community can explore avenues to help curtail these costs.

Objectives A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs). Methods We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning March 2012.A Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision (ICD-9) codes. Bivariate (χ2) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being an FEDU. Results The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being an FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and ICD-9 codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290–319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissueB disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women. Conclusions Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.

This report reviews a case of dermatomyositis presenting with weakness and extensive calcification in an adult. While dermatomyositis is not uncommon in adults, it is uncommon for calcifications to be present. Children develop calcifications more frequently than adults. When present in adults, small calcifications on areas of frequent trauma such as elbows and fingers are more common. However, this patient presented with large calcified deposits in his abdomen and extremities. His treatment and course are described.

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Introduction Antimicrobial stewardship programs (ASPs) continuously strive to optimize antibiotic use, while minimizing antibiotic‐associated adverse events. Among potential targets for antibiotic use reduction, fluoroquinolones (FQs) are an attractive drug class for ASPs due to their wide spectrum of activity, known adverse event profile, and availability of less toxic therapeutic options. The use of peer comparison on antibiotic use by ASPs has been described but is limited primarily to the outpatient setting. Objectives To assess the impact of peer comparison using prescriber‐specific reports on FQ use and hospital‐acquired Clostridioides difficile rates across a 16‐facility community hospital system. Methods In January 2017, we began providing quarterly facility‐specific peer comparison reports to high‐volume antibiotic prescribers in three different medical specialties across our health‐system: Internal Medicine/Hospitalists/Family Medicine, Intensivists/Pulmonologists, and infectious diseases (ID). We completed a quasi‐experimental study designed to assess aggregated hospital data, evaluating FQ days of therapy/1000 patient days (DOT/1000 PD) in the intervention period (January‐December 2017), and compared with the baseline period (January‐December 2016). Additional outcomes that were evaluated include total antibiotic consumption (DOT/1000 PD), total percentage of antibiotics attributable to FQs, and cases of hospital‐acquired C. difficile/10000 PD (HA‐CD). Results Compared with the baseline period, FQ use decreased by 29% (baseline—83.9 DOT/1000 PD; intervention—58.5 DOT/1000 PD; P < 0.001). The overall percentage of antibiotics that were attributable to FQs also decreased in the intervention period (baseline—15.4%; intervention—11.3%; P < 0.001). During the intervention period, there were no significant increases in other key antibiotic classes, including antipseudomonal beta‐lactams and third‐generation cephalosporins. The rate of HA‐CD decreased by 20% in the intervention period compared with baseline. Conclusion In a large community hospital system, the use of peer comparison reports based on prescriber specialty reduced FQ use, and may potentially reduce adverse events associated with FQ use.

Objective.-As the highest peak on the planet, Mount Everest provides a truly austere environment in which to practice medicine. We examined records of all visits to the Everest Base Camp Medical Clinic (Everest ER) to characterize the medical problems that occur in these patients. Methods.-A retrospective analysis of medical records from the first 10 years of operation (2003-2012) was performed. Descriptive data collected included patient demographics, diagnoses, treatments, prescriptions, medications dispensed, and evacuation type, if any. Results.-In all, 2941 patients were seen for a total of 3569 diagnoses. The number of patient visits each year at the Everest ER increased at a greater rate than the total numbers of climbers attempting Mount Everest over this period. The most commonly treated patients were Nepalese, accounting for 51% of all nationalities. The most common medical diagnoses were from pulmonary causes such as high altitude cough and upper respiratory infections, comprising more than 38% of all medical diagnoses. The most common traumatic diagnoses were from dermatologic causes such as frostbite and lacerations, comprising 56% of all traumatic diagnoses. Pulmonary and dermatologic diagnoses were also the most frequent reasons for evacuation from Everest Base Camp, most commonly for high altitude pulmonary edema and frostbite, respectively. Conclusions.-Medical professionals treating patients at extreme altitude should have a broad scope of practice and should be well prepared to deal with serious traumas from falls, cold exposure injuries, and altitude illness.

Introduction: Although emergency medicine (EM) residency program directors (PD) have multiple sources to evaluate each applicant, some programs await the release of the medical student performance evaluation (MSPE) to extend interview offers. While prior studies have demonstrated that MSPE content is variable and selectively positive, no prior work has evaluated the impact of the MSPE on the likelihood to invite (LTI) applicants for a residency interview. This study aimed to evaluate how information in the MSPE impacted LTI, with the hypothesis that changes in LTI would be relatively rare based on MSPE review alone. Methods: We conducted a prospective, observational study analyzing applications to three EM residency programs during the 2019-2020 match cycle. Reviewers assessed applications and rated the LTI on a five-point Likert scale where LTI was defined as follows: 1 = definitely no; 2 = probably no; 3 = unsure; 4 = probably yes; and 5 = definitely yes. The LTI was recorded before and after MSPE review. A change in LTI was considered meaningful when it changed the overall trajectory of the applicant’s likelihood to receive an invitation to interview. Results: We reviewed a total of 877 applications with the LTI changing ≥1 point on the Likert scale 160 (18.2%) times. The LTI was meaningfully impacted in a minority of applications – 48 total (5.5 %, p< 0.01) – with only 1 (0.11%) application changing from 1 or 2 (definitely/probably no) to 4 or 5 (probably/definitely yes) and 34 (3.8%) changing from 3 (unsure) to 4 or 5 (probably/definitely yes). Thirteen (1.5%) applications changed from 4 or 5 (probably/definitely yes) to 3 (unsure or probably/definitely no). Conclusion: Review of the MSPE resulted in a meaningful change in LTI in only 5.5% of applications. Given the time required for program leadership to review all parts of the variably formatted MSPEs, this finding supports a more efficient application review, where the PD’s focus is on succinct and objective aspects of the application, such as the Standardized Letter of Evaluation.

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