Authors: Ashley Pilgrim
Categories: Oral Boards
Source: Journal of Education & Teaching in Emergency Medicine
Doi: 10.21980/J8CW67
Authors: Ashley Pilgrim
Emergency medicine residents and medical students on emergency medicine rotation.
Acute pulmonary edema is a common and potentially fatal presentation in the emergency department. More than 1 million patients are admitted annually with a diagnosis of pulmonary edema secondary to cardiac causes.1 Pulmonary edema is broadly split into two main cardiogenic and noncardiogenic. Cardiogenic pulmonary edema is characterized by acute dyspnea caused by the accumulation of fluid within the lung’s interstitial and/or alveolar spaces, which is the result of acutely elevated cardiac filling pressures.2 Noncardiogenic pulmonary edema is characterized by fluid accumulation within the alveolar space in the absence of elevated pulmonary capillary wedge pressure.2 These patients often present critically ill, and rapid identification and aggressive management is paramount in caring for patients with pulmonary edema. Dyspnea is the most common presentation with a sensitivity of 89% but a low specificity of 51%.3 Workup of pulmonary edema often includes laboratory testing, electrocardiogram (EKG), chest x-ray (CXR), and often bedside ultrasound (US) and echocardiography.4 Pulmonary edema management depends on the etiology but is often focused on preload and afterload reduction. Diuretics, nitrates, and optimizing ventilatory support through non-invasive and invasive strategies are the mainstay of treatment.
At the end of this practice oral boards case, the learner
Practice oral boards
Immediate Feedback was solicited from the learners and observers participating in the case both by verbal discussion and completion of a rating for the case following the debriefing. The efficacy of the educational content was assessed by comparing scoring measures across residents based on the training year. Scoring measures of the American College of Graduate Medical Education (ACGME) core competencies were performed using a scale from 1 – 8, 1–4 being unacceptable performance and 5 – 8 being acceptable. Efficacy was assumed based on full completion of the case by the residents who acted as practice oral board candidates, and a debriefing session followed to discuss the key components of the case.
This case was presented to twelve Emergency Medicine Residents, seven PGY 1 and five PGY 2 at a relatively new residency program. The overall average score for the residents was 5.62. The PGY 1 Residents’ average on the case was 5.56, and the average for the PGY 2 Residents was slightly better at 5.70. The slight improvement noted by the PGY 2 Residents is likely attributable to more clinical experience; however, both classes did not have any prior exposure to the oral board format until this simulated experience. Six residents completed all critical actions in the case. Of those who missed a critical action, failing to diagnose NSTEMI and consulting cardiology were the most common. All learners found educational value in the case with an overall rating of 4.83 (1–5 Likert scale, 5 being excellent).
Acute pulmonary edema and NSTEMI are common diagnoses that will be frequently encountered for most emergency physicians. This case highlights the need for early identification and aggressive management of the patient presenting with respiratory distress. The differential for respiratory distress is large, but most learners were able to quickly identify pulmonary edema based on the exam findings of jugular vein distention (JVD), rales, and lower extremity edema. Most learners quickly escalated to a non-rebreather mask and ultimately to BPAP (bilevel positive airway pressure) without requesting to intubate the patient. There was notable variation in the approach to administering nitrates, but most ordered an intravenous (IV) nitroglycerin (NTG) drip and requested pharmacy assistance in dosing. Diuretics were ordered by all the learners, but some were hesitant to start early because they felt the effect would be delayed. Some of the residents did not identify ischemic changes on the EKG at first glance but did request to review a second time when the troponin result was positive. All residents gave aspirin after noting the positive troponin, but not all were able to make a clear diagnosis of NSTEMI or consult cardiology. Although the case was relatively straightforward, residents enjoyed early diagnosis and aggressive management of the patient with impending respiratory failure. Many residents are asking for an ultrasound early in the workup of this patient presenting in respiratory distress. Although not a critical action in this case, it highlights the emphasis placed on ultrasonography in the current emergency medicine curriculum.
Pulmonary Edema, Cardiovascular emergencies, NSTEMI.
The presented case requires the residents to care for the patient presenting in acute respiratory distress. The residents must be able to quickly manage impending respiratory failure and treat it aggressively to avoid the patient deteriorating. They must be able to perform a full history and physical exam to arrive at the diagnosis of pulmonary edema and NSTEMI amongst a very wide differential diagnosis for respiratory distress. The oral board format worked best for this case so learners could troubleshoot the escalation of oxygenation and ventilation techniques, manage multiple medications, and navigate multiple conversations between the patient, family, and cardiology and ICU consultants.
This case is best implemented using the oral board simulation as structured by the American Board of Emergency Medicine (ABEM). Learners were shown an instructional video from ABEM prior to starting the cases to familiarize them with the format and structure of the real oral boards. This case was presented to seven PGY 1 and five PGY 2 Emergency Medicine Residents. Following the case, direct feedback was given to the learner with specific focus and education on the critical actions of the case. Learners were graded on a scale of 1–8 based on the ACGME core competencies as well as their ability to complete the six critical actions in this case. Results were recorded on a grading sheet by each examiner and submitted with data input into a Microsoft Excel spreadsheet. The learners had an overall score of 5.62 (1–4 unacceptable performance, 5–8 acceptable) with six of the twelve learners meeting all critical actions. The PGY 1 Residents average on the case was 5.56 and the average for the PGY 2 Residents was slightly better at 5.70. Following the case, learners were given a survey rating the educational value of the case using the Likert scale (1–5, 5 being excellent). The case was found to hold educational value to all the learners with a score of 4.83. There were no major modifications needed in this case, and the learners overall felt the case to be relatively straightforward. There was some additional prompting needed to call cardiology to discuss the NSTEMI, and some learners required prompting to further discuss the history of chest pain once they became focused on treating the pulmonary edema. Most learners requested to start a nitroglycerin drip, but many were not sure of an appropriate starting dose and requested to have the pharmacy dose the medication. Overall, we feel this is a frequently encountered scenario in the emergency department and learners will benefit from keeping a broad differential with a focus on aggressive management of the patient in respiratory distress.