there was a disrupted circadian rhythm (after two consecutive 12-hour night shiftsfollowing a period of no night shifts for at least two weeks), and the other, at a timewhen there was no disruption (after a 12-hour day shift, at the end of a two-week dayblock). To control for the effect of learning between the two surveys, approximatelyhalf of the residents began the study after a day shift, the other half, after a night shift.

Results: Of 33 subjects, 14 (42%) completed the day session first. We foundstatistically significant differences (p � 0.1) in cognition following a night shift inseveral attributes. [Of note, a p-value of 0.1 is considered significant in the field ofexperimental economics and in other disciplines pertaining to human behavior andcognitive reasoning.] Subjects were more risk-averse, less trusting, less generous/fair,and they employed less extensive reasoning and analytic sophistication. No significantdifferences were found in impulsivity or impatience.

Conclusions: Emergency medicine residents are more risk-adverse, less trusting,less generous, and generally less cognitively capable after the second of twoconsecutive night shifts.

100 High Fidelity Simulator Vs. Low Fidelity Manikin: ASimulator Did Not Improve Scores on a MultipleChoice Exam

Morgan MW, Hegarty CB/Regions Hospital, St Paul, MN

Study Objectives: In response to a focus on patient safety and health care qualitythose involved in medical education have had to look for alternatives to the livepatient model. We attempted to look for improvement in multiple choice test scoreswhen using a high fidelity simulator in place of a low fidelity manikin forresuscitation workshops.

Methods: A multiple choice test was constructed to evaluate knowledge ofresuscitation in medical and trauma settings. These tests were felt to be externally validafter review by 3 faculty closely involved with medical student education after somemodifications were made. The test was administered to a test group of 8 students. Thetests were evaluated for internal validity using the Kuder-Richardson formula. Themedical resuscitation test achieved a score of 0.48, while the trauma resuscitation testachieved a score of 0.70. The tests were graded and these results were used to generate apower analysis. The power analysis suggested that 16 students would need to take the testto detect a difference of 12% (essentially 3 questions) at a power level of 80%. For 6months following this trauma and medical resuscitation workshops were conducted withhalf performed as previously done with a low fidelity plastic manikin and oral stimuli forthe participants, half were performed at the simulation center using a human patientsimulator (METI, USA). Scenarios were the same for the manikin and simulator.Associated props such as EKGs and x-rays were the same in both groups. There was oneinstructor that was presents for all of the workshops. The simulator and manikin werealternated in successive months such that they had equal chance of being the first orsecond workshop to eliminate the potential advantage of being the method of the secondworkshop in a month (with the same students). Students took the test before and after theworkshops. In all 32 students tested in each group (original format and simulator). Resultsfrom before and after the workshops were compared. The mean change from before andafter was compared between the 2 groups. A students T test was used for this comparison.

Results: There was no significant difference in the improvement from before toafter testing between the 2 groups.The mean increases in test scores were 1.605 forthe high fidelity simulator and 1.611 for the low fidelity manikin format. Neither thetwo sample t-test (p�.98) nor the Wilcoxin rank sum test (p�0.83) achievedsignificance at the .05 level.

Conclusion: No difference was found in the improvement of multiple choice testscores after a resuscitation workshop for students using a simulator over a manikin.

101 Substance Use in Emergency Medicine TrainingPrograms

McBeth BD, Ankel FK, Ling LJ, McNamara RM, Flottemesch TJ, Asplin BR,Mason E/Regions Hospital, St. Paul, MN; Hennepin County Medical Center,Minneapolis, MN; Temple University Hospital, Philadelphia, PA

Substance abuse among resident physicians may present a significant risk to boththe resident using those substances as well as the patients they treat. A previous surveyof emergency medicine (EM) residents in 1992 indicated past year use of cocaine,oral opiates and marijuana to be 1.0%, 1.5% and 8.8%, respectively.

Study Objectives: Our aim was to explore the prevalence, patterns and trends ofsubstance use among emergency medicine residents. Given increasing nationalprevalence, we hypothesized increased past year use rates for cocaine, oral opiates andmarijuana among emergency medicine residents.

Methods: In February 2006, following the American Board of Emergency Medicine

in-training exam, a voluntary, anonymous survey of all active EM residents wasdistributed. If programs were unable or unwilling to distribute the surveys following theexam, they were encouraged to do so at a later time. Data regarding 15 substances, CAGEscreening (“Cut down”, “Annoyed”, “Guilty” and “Eye-opener” questions), andperceptions of personal patterns of substance use were collected.

Results: 133 of 134 EM residencies distributed the surveys (participation rate99%). Response rate was 55% of the EM residents who took the in-training exam(2361/4281). 66.3% reported daily caffeine use (29.7% reported feelingimpaired/dependent on caffeine). 5.0% reported daily alcohol use (up from 3.3%in 1992)(p � 0.001). Using CAGE screening questions, 7.9% were classified assuspicious/at risk for alcoholism (1 affirmative answer) and 6.1% as meetingcriteria for diagnosis for alcoholism (2 or more affirmative answers) duringresidency. This compares to 7.6% suspicious/at risk (p�0.45) and 4.9%diagnostic (p�0.27) in 1992. Increasing positive CAGE screening questionscorrelated with increasing frequency of alcohol consumption and resident self-perception of alcohol dependence (both p � 0.0001). Although the number ofresidents reporting past marijuana use has declined (52.3% in 1992 to 45.1%today)(p � 0.001), there is a trend toward increased past year use (8.8% to11.7%)(p�0.31), and past month use (2.5% to 4.0%)(p�0.1). Significantlyfewer residents had ever used cocaine: 23.0% in 1992, vs. 7.6% in this study(p � 0.001), though past year use rates of cocaine (1.0% in 1992 vs 1.1% today)were not different (p�0.49). Significantly fewer residents had ever used oralopiates: 5.0% in 1992 vs. 3.9% today (p�0.003), though past year use rates werenot different (1.5% in 1992 vs. 1.4% today)(p�0.49). Other drug use (LSD,PCP, heroin, amphetamines) remained uncommon.

Conclusion: Despite increasing national prevalence, cocaine and oral opiate usedoes not appear to be increasing among EM residents. Although fewer residents havetried marijuana, there may be a greater number using in the last month and year.Daily alcohol use does appear to be increasing among emergency medicine residents.Educators should be aware of these trends, and this may allow them to targetresources for impaired and at-risk residents.

102 Modafinil and Zolpidem Use Among EmergencyMedicine Residents

McBeth BD, McNamara RM, Ankel FK, Ling LJ, Flottemesch TJ, Asplin BR,Mason E/Regions Hospital, St. Paul, MN; Temple University Hospital,Philadelphia, PA; Hennepin County Medical Center, Minneapolis, MN

Emergency physicians may be at increased risk for development of Shift Work SleepDisorder and other sleep problems due to the constant variation of shift patterns in mostschedules. Residents, with typically longer shifts and more total clinical hours, may beespecially susceptible to circadian disruption and resulting sleep impairment, and may usemedications to alter their sleep-wake patterns.

Study Objectives: Our aim was to examine the use of modafinil and zolpidem byemergency medicine (EM) residents to alter sleep/wake patterns.

Methods: In February 2006, following the American Board of EmergencyMedicine in-training exam, a voluntary, written survey of all active EM residentswas distributed. A one page directed questionaire was used to qualitatively assessfrequency, timing, and perception of use patterns for residents who have usedmodafinil and zolpidem. Side effects were also recorded.

Results: 133 of 134 EM residencies distributed the surveys (participation rate99%). Response rate was 55% of the EM residents who took the in-training exam(2361/4281). 2.4% of EM residents reported past modafinil use, with 67.9% ofthose having used it initiating use during residency. Of those residents usingmodafinil, 13.5% report that they have used a second dose at least once after anight shift to remain awake, and 23.8% report using it for sleepiness notassociated with night shifts. 62.9% felt that their clinical performance was “muchbetter” or “slightly better” following modafinil use, and there was an associationbetween better perceived clinical performance and frequency of use (p�0.023).Most commonly reported side effects included insomnia, agitation/restlessness,palpitations and nausea/anorexia. Past zolpidem use was reported by 21.8% ofEM residents (15.3% in the past year, 9.4% in the past month). 62.5% of thoseresidents having used zolpidem reported initiating use during residency. Mostresidents who report using zolpidem indicate that they use it to help transitionback to days after a series of night shifts (79.0%). 30.2% felt that their clinicalperformance was “much better” or “slightly better” following zolpidem use, and10.0% felt that it was “much worse” or “slightly worse”. There was a trendtoward better perceived clinical performance and increased frequency of use(p�0.088). Most commonly reported side effects included drowsiness, dizziness,

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headache, hallucinations, depression/mood lability and amnesia. There was noassociation between pattern of scheduling (circadian, blocked, random) andfrequency of modafinil (p�0.64) or zolpidem use (p�0.97).

Conclusion: Zolpidem use is common among EM residents, with most usersinitiating use during residency. Modafinil use is relatively uncommon, thoughmost using have also initiated use during residency. Side effects are commonlyreported, and the long-term safety of these agents remains unclear.

103 The Learning Curve of Emergency MedicineResidents Learning to Perform Limited BiliarySonography

Jang T, Rueggeri W, Dyne P/Olive View-UCLA Medical Center, Sylmar, CA

Study Objectives: To prospectively assess the early learning curve of emergencymedicine residents training in limited biliary sonography (LBS).

Methods: This was a prospective study at an urban, academic ED with a PGY2-4EM residency from August 1999 to August 2005. Patients with suspectedcholelithiasis and/or cholecystitis underwent resident-performed LBS followed byabdominal US (AUS) by the department of radiology. Results of LBS were comparedto AUS by the department of radiology using a pre-designed, standardized data sheet.

Results: 1,520 patients underwent LBS exam by 113 residents. Sensitivity andspecificity of LBS for various pathologic biliary findings were:

Operators performing their 1st- 40th exams could not reliably detect biliarydilation, GBWT, sludge, or PCFF. Operators performing their 1st-25th exams couldnot reliably detect gall stones.

Conclusion: There is an appreciable learning curve among residents learning toperform LBS that persists up to 40 exams. More training in LBS may be required forcompetency than current guidelines suggest.

104 Description and Assessment of a New Model forCricothyrotomy

Long MA, Robey III WC, Corcoran KJ, Brewer KL/Brody School of Medicine atEast Carolina University, Greenville, NC

Study Objective: Most physicians have little opportunity to perform or practicesurgical cricothyrotomy. We describe and assess a combined prosthetic-animal modelfor cricothyrotomy.

Methods: Using inexpensive corrugated plastic tubing, a rubber chair-leg tip, andduct tape, we constructed a prosthetic airway to simulate laryngeal cartilage,cricothyroid membrane, and trachea. This prosthesis was then surgically implantedunder abdominal skin and subcutaneous tissues of an adult, anesthetized pigconcurrently being utilized for an emergency invasive procedures course. Emergencymedicine and trauma faculty (N�20) volunteered to identify anatomical landmarks,perform a surgical cricothyrotomy on the combined model, and complete aquestionnaire. The questionnaire employed a 5-point Likert scale (Strongly Disagree-1to Strongly Agree-5) to compare the model’s surface anatomy and physiology(bleeding, tissue response) to that of an adult human. The model was also assessed foreducational effectiveness. Comparisons were made to mannequin, cadaver, and liveanimal airway models. Evaluator’s years of clinical experience, specialty training, andnumbers of cricothyrotomies performed were documented.

Results: The physician evaluators had 12.5�6.3 mean years of clinical emergencymedicine experience. All but two evaluators had performed multiple cricothyrotomies

on actual patients. Physicians surveyed found the combined model to be realistic forsimulating cricothyrotomy, with an overall mean rating of 4.4�0.50 (4.0 median).The model’s surface anatomy closely approximated that of an adult human, with amean score of 4.5�0.51 (4.5 median). The mean physiology score was 3.2�1.10(3.5 median). In terms of educational effectiveness, this model received a mean ratingof 4.45�0.60 (4.5 median). All evaluators ranked the prosthetic-animal model assuperior or at least equal to other cricothyrotomy simulation models.

Conclusions: The prosthetic-animal model appears to be an effective educationaltool. The combined model design offers more realistic anatomy and tissue responseswhen compared to alternative models and allows physicians to practice multiple (6-8)cricothyrotomies using only one anesthetized animal. This model has the potential toincrease procedural competency and ultimately promote greater patient safety.

105 Emergency DepartmentHyperutilization

Shiber JR, Longley MB, Brewer KL/East Carolina University, Greenville, NC

Study Objectives: Emergency Department (ED) overcrowding is a significantissue across the U.S. Recent studies attempting to identify frequent utilizers of the EDhave set the threshold very low (2-3 visits/year). We have coined a novel term,Hyperutilizer (HU) to define that population that averages 1or more visits/monthover the study period of three years. Our purpose was to describe this population, andcompare this group to the general ED population to determine if there areidentifiable risk factors associated with hyperutiliaztion.

Methods: A retrospective cohort study conducted in a university tertiary level 1trauma center with 65,000 visits/year. A review of the ED database between 1/1/01and 12/31/04 identified all patients with � 35 visits. This HU cohort (N�49) wascompared to a second randomly selected group of non-HU patients (N�50) on thefollowing measures: age, gender, insurance status, association with a PMD, dwellinglocation, chief complaint, co-morbidities, and disposition (admission versus dischargehome).

Results: The HU group was significantly older (mean 49.45 years) than the non-HU group (37.32 years) with a P � .0001. Using a frequency distribution analysis,there were no differences between the groups in gender, insurance status, associationwith a PMD, dwelling location, and ED disposition. There were more than twice asmany HU than non-HU sent to psychiatric units, but this trend was not statisticallysignificant. The HU group had significantly more chief complaints in themusculoskeletal, neurological, pulmonary, psychiatric, and substance abuse categories,while the non-HU group had significantly more in the cardiovascular (CV),genitourinary (GU), HEENT, and traumatic categories. A univariant logisticalregression found that previous CV, GU, or psychiatric disease were predictors of HU.

Conclusion: The HU group is older, and is more likely to have a history of CV,GU, and psychiatric disease, but is similar to the non-HU group in other measuredparameters. The HU cohort has equal access to health care, does not appear to bemore ill based on disposition, but has more associated psychiatric disease than thenon-HU cohort.

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