Preparing medical students for residency in emergency medicine involves education in many areas of knowledge and skill, including instruction in advanced emergency procedures. We outline the logistics involved in running a training course in advanced emergency procedures for 4 th year medical students and report student perceptions of course impact. The course is a cadaver based training lab which utilizes several teaching modalities including a web based syllabus and online streaming video, didactic lecture, hands on practice with models and ultrasound, and hands on practice with unembalmed (fresh) cadavers. The course focuses on 7 emergent procedural skills, including deep venous access via the subclavian, internal jugular and femoral veins, tube thoracostomy, saphenous vein cutdown, intraosseous line placement and emergency cricothyrotomy. It is taught by attending emergency physicians and anatomy department faculty.After completion of the course, 33 students reported their self-assessment on a five-point Likert scale. Data was evaluated using a paired T -test (two-tailed). Students reported a mean increase in their understanding of the indications for the procedures from 3.3 ±1.1 before to 4.8 ±0.4 after the course, p = 0.004, 95% CI 0.7 -2.0. Students reported a mean increase in their understanding of how to perform the procedures from 2.1 ±0.9 before to 4.6 ±0.6 after the course, p = 0.003, 95% CI 1.9 -3.0. Students reported a mean increase in their comfort level performing the procedures from 1.6 ±0.8 before to 4.2 ±0.7 after the course, p < 0.001, 95% CI 2.0 -2.9. Our experience supports the value of an advanced emergency procedural training course using an unembalmed cadaver-based lab and incorporating several teaching modalities. By outlining the logistics involved in running the course, including curriculum, equipment and cost, we hope to facilitate use of this teaching modality in other medical schools and to generate interest in future research regarding the utility of this approach to procedural training.

Preparing medical students for residency in emergency medicine involves education in many areas of knowledge and skill, including instruction in advanced emergency procedures. We outline the logistics involved in running a training course in advanced emergency procedures for 4 th year medical students and report student perceptions of course impact. The course is a cadaver based training lab which utilizes several teaching modalities including a web based syllabus and online streaming video, didactic lecture, hands on practice with models and ultrasound, and hands on practice with unembalmed (fresh) cadavers. The course focuses on 7 emergent procedural skills, including deep venous access via the subclavian, internal jugular and femoral veins, tube thoracostomy, saphenous vein cutdown, intraosseous line placement and emergency cricothyrotomy. It is taught by attending emergency physicians and anatomy department faculty.After completion of the course, 33 students reported their self-assessment on a five-point Likert scale. Data was evaluated using a paired T -test (two-tailed). Students reported a mean increase in their understanding of the indications for the procedures from 3.3 ±1.1 before to 4.8 ±0.4 after the course, p = 0.004, 95% CI 0.7 -2.0. Students reported a mean increase in their understanding of how to perform the procedures from 2.1 ±0.9 before to 4.6 ±0.6 after the course, p = 0.003, 95% CI 1.9 -3.0. Students reported a mean increase in their comfort level performing the procedures from 1.6 ±0.8 before to 4.2 ±0.7 after the course, p < 0.001, 95% CI 2.0 -2.9. Our experience supports the value of an advanced emergency procedural training course using an unembalmed cadaver-based lab and incorporating several teaching modalities. By outlining the logistics involved in running the course, including curriculum, equipment and cost, we hope to facilitate use of this teaching modality in other medical schools and to generate interest in future research regarding the utility of this approach to procedural training.

St. John's wort is a common plant that has been used medicinally for over 20 centuries. This herb is currently used by millions of people, primarily as natural antidepressant; yet, its efficacy is still under constant debate. St. John's wort contains a large aromatic molecule, hypericin, twisted by steric interactions into the shape of a propeller. For use as antidepressant, St. John's wort is standardized to the content of hypericin, but this molecule was recently found not to be the active ingredient. A totally different bicyclic molecule with complex substitution pattern, hyperforin, was then studied as the causative agent. Both molecules are strongly active in biological systems. Hypericin has shown antiviral activity and is a potent natural photosensitizer that has been used in photodynamic therapy against cancer and against HIV in stored blood. Hyperforin was found to activate a particular receptor in the liver that induces the production of an enzyme used for the metabolism of medications. This effect causes more rapid breakdown of many prescription medications and can interfere with their effectiveness. This finding should prompt a reevaluation of regular use of St. John's wort.

Introduction. Prehospital treatment of patients with acute decompensated heart failure (ADHF) has been shown to decrease mortality and morbidity. Vital sign changes have been proposed as clinical endpoints in the evaluation of prehospital treatment for this condition. Objective. To examine the effect of prehospital treatments on vital signs among patients with ADHF. Methods. Records of an urban emergency medical services system from September 1, 2002, through September 1, 2003, were queried for patients who had a paramedic impression of shortness of breath or respiratory distress and had received nitroglycerin and/or furosemide. Demographics, initial and repeat vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation), and medications and doses were collected. Results. Three hundred nineteen patients were included; the average age was 77 (±12) years and 47% were male. Treatments administered to these patients included nitroglycerin, 296 (93%); furosemide, 194 (61%); albuterol, 189 (59%); aspirin, 57 (18%); morphine, 20 (6%); and prehospital intubation, 15 (5%). Patients were initially hypertensive [mean ± standard deviation of systolic blood pressure (SBP) was 167 ±37 mm Hg], tachycardic (heart rate 106 ± 24 beats/min), tachypneic (respiratory rate 33 ± 7 breaths/min), and hypoxic (pulse oximetry 88% ± 9.5%). After treatment, mean changes included decreases (95% confidence interval)

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