older than men (57 vs. 53 years; p�0.04), more likely to have hypertension (64 vs.45%; p�0.001), diabetes (34 vs. 15%; p � 0.001), and a greater body mass index(33 vs. 29 kg/m2; p�0.01). Total cholesterol (194 vs. 178 mg/dl; p�0.01) and HDLcholesterol (44 vs. 38 mg/dl; p � 0.001) were significantly higher in women, whilethere were no differences in LDL cholesterol (105 vs. 107 mg/dl; p�0.8). Womenwere less likely to be smokers (29 vs. 53%; p � 0.001). Women were more likely todescribe their pain as pressure like in the center of the chest with radiation to neckand jaw, while men were more likely to describe their pain to be either pressure likeor sharp in the center or left chest with radiation to the arm. Women were morelikely to have onset of chest pain at rest (70 vs. 58%; p�0.04). An equal number ofwomen and men had acute coronary syndrome by cardiac enzymes (25.2 vs. 29.4%;p�0.52). Both women and men underwent similar numbers of electrocardiograms,echocardiograms, and heart catheterizations. However, 91% of men had angiographicevidence of CAD as compared to 41% in women (p � 0.001).

Conclusion: We found significant gender differences in the clinical presentation,co-morbid conditions, and angiographic evidence of CAD in patients presenting tothe emergency department with non-traumatic chest pain. However, in contrast toour previous study, no significant gender differences in the evaluation andmanagement of these patients were identified. Emergency physicians have led the wayin closing the gender gap in the evaluation and treatment of chest pain in women.

37 Utility of Acute Cardiac Ischemia Time-InsensitivePredictive Instrument in the Chest Pain ObservationUnit

Manini AF, McAfee AT, Noble VE, Bohan JS/Harvard Affiliated EmergencyMedicine Residency, Boston, MA; Brigham and Women’s Hospital, Boston, MA;Massachusetts General Hospital, Boston, MA

Study Objectives: To evaluate if the Acute Cardiac Ischemia Time-InsensitivePredictive Instrument (ACI-TIPI) is associated with outcomes for emergencydepartment (ED) patients in the chest pain observation unit (CPU).

Methods: This prospective cohort study evaluated ED patients at a universityhospital with a 55,000 visit ED and 10-bed CPU. ED patients with suspectedmyocardial ischemia who were considered by the attending to be at low risk andtriaged to the CPU after initially negative cardiac enzymes were eligible. Adversecardiac outcomes included any of the following within 30 days: cardiac death,myocardial infarction (troponin I � 0.09 milligrams/deciliter), unstable angina,coronary revascularization, or positive cardiac diagnostic testing (results determinedby an attending cardiologist as part of each patient’s routine work-up). Diagnostictesting included: exercise treadmill, stress echocardiography, stress thallium perfusion,positron emission tomography, and coronary angiography. Risk of outcome, oddsratios (OR), and exact confidence intervals (CI) were calculated.

Results: Of 214 patients with ACI-TIPI recorded in the CPU, 33 (15%) werelost to follow-up, leaving 181 patients (mean ACI-TIPI 17.5, 54.7% female) forevaluation. Incidence of 30-day adverse cardiac events was 11.6% (CI 7.3-17.2) forall patients, 6.2% (CI 2-13.8) for ACITIPI 10 or less, and 16% (CI 9.4-24.7) forACITIPI � 10. ACI-TIPI � 10 was significantly associated with adverse cardiacevents when compared to ACI-TIPI 10 or less (OR 2.9, p 0.047, CI 1.01-8.28).

Conclusion: ACI-TIPI is highly correlated with 30-day outcomes for ED patientstriaged to the CPU. Use of a dichotomous cutoff of 10% identifies patients atsignificantly higher cardiac risk, and may be useful for ED triage algorithms.

EMF-1 Repolarization Alternans as a NovelMechanism of Calcium-MediatedArrhythmogenesis in Heart Failure

Wilson LD, Jeyaraj D, Hoeker GS, Said TH, Laurita KR, Rosenbaum DS/MetroHealth Medical Center, Cleveland, OH

Study Objectives: The vast majority of sudden cardiac deaths (SCD) occur inpatients with ventricular contractile dysfunction (i.e. heart failure). However, themechanisms linking mechanical to electrophysiological dysfunction in the heart areunclear. Impaired calcium (Ca) cycling is the most striking abnormality of failingmyocytes and is most directly responsible for contractile dysfunction; yet it remainsunclear how this influences susceptibility to arrhythmias. Repolarization alternans(R-ALT, beat-to-beat alternation of cardiac cellular action potential duration),manifest clinically as T wave alternans, is closely associated with susceptibility toSCD. Because susceptibility to R-ALT is mechanistically related to impaired calciumcycling in normal hearts, we hypothesize that: 1) Heart failure (HF) enhancessusceptibility to R-ALT, creating a substrate for reentrant arrhythmogenesis and 2)

Increased susceptibility to R-ALT is mechanistically related to HF-inducedimpairment of calcium cycling.

Methods and Results: Optical action potentials were recorded with high temporal(0.5ms), voltage (0.5mv) and spatial resolution (1mm) in canine wedge preparationsfrom normal hearts and hearts in which HF was produced by chronic rapid pacing(each N�12). HF lowered the pacing heart rate (HR) threshold for the developmentof R-ALT from 242 � 25 bpm to 181�18 bpm (p � .001). Spatially discordantalternans (different regions of cells alternating in opposite phase), which ismechanistically linked to the development of ventricular fibrillation (VF), wasobserved in all HF hearts, but only 50% of normal hearts (p � .01). Moreover, HFlowered the pacing HR threshold for the development of discordant alternans from327 � 41 bpm to 257�31 bpm (p � .001). Increased susceptibility to discordantalternans was associated with pacing-induced VF in � 90% of HF hearts, but lessthan 10% of normal hearts (p � .001). To investigate cellular mechanisms of R-ALTin HF, dual optical mapping of action potentials and intracellular Ca was performedin a subset of preparations. HF lowered the HR threshold for Ca-ALT (beat to beatalternations of cellular Ca cycling) from 239�27 to 169�15 bpm (p � .001).Importantly, not only were the HR thresholds for Ca-ALT and R-ALT nearlyidentical in HF, but 1) Ca-ALT and R-ALT always developed simultaneously in thesame cells and 2) The magnitude of Ca-ALT and R-ALT were closely coupled(correlation coefficient .87) at all pacing HRs tested, suggesting that increasedsusceptibility to R-ALT in HF is mechanistically related to increased susceptibility toCa ALT and HF-induced impairment of Ca cycling.

Conclusions: HF increases susceptibility to arrhythmogenic repolarizationalternans. In HF, development of repolarization alternans is closely coupled todevelopment of calcium alternans, suggesting that HF-induced impairment ofcalcium cycling may be a mechanism responsible for the enhanced susceptibility torepolarization alternans and arrhythmogenesis in HF.

38 The Attitude and Perception of Emergency DepartmentPatients Regarding Medical Students

Wald DA, Ander DS, Richardson B, Manthey D, Kruus L, Fisher J/TempleUniversity School of Medicine, Philadelphia, PA; Emory University School ofMedicine, Atlanta, GA; Mount Sinai Medical Center, New York, NY; Wake ForrestUniversity Health Science Center, Winston-Salem, NC; Beth Israel DeaconessMedical Center, Boston, MA

Study Objectives: In the past decade, a number of studies have been published inthe family practice, internal medicine, obstetrical, and general surgical literature onpatient’s perceptions of medical students (MS). However, there have been few studiespublished on the attitude and perceptions of emergency department (ED) patientsregarding the participation of medical students in their health care. This study soughtto identify and report the attitude and perception of ED patients regarding their pastand present experiences with MS, and the professional attributes and behaviors of MSwho have participated in their health care.

Methods: In the fall - winter of 2005, a survey instrument was developed andpiloted by the authors. The survey instrument was modified from questionnairespreviously administered to patients in different health care settings. This survey wastailored towards the emergency medicine patient population. Trained undergraduatestudents assisted with implementation of this self administered survey during peakhours (10a - 10p) at one university affiliated tertiary care ED. All stable patients, 18years of age or older were eligible for participation.

Results: All ED patients that were approached, provided verbal consent andcompleted the survey (n�216). 50% of participants were female, 87% were AfricanAmerican, and 17% were white. 54% of participants reported that a MS hadpreviously helped take care of them. 79% of the prior MS encounters took place in ahospital setting (48% ED, 31% inpatient). 91% of these patients rated their overallprior experience with a MS as good, very good, or excellent. 79% of participantsreported that they would be comfortable discussing personal health information witha MS, and 74% would feel comfortable being examined by a MS. When asked aboutthe “best” way for a MS to learn how to take care of a patient presenting to the ED,84% reported that a MS should care for real ED patients under the supervision of adoctor. 84% of patients reported that because they were presenting to a teachinghospital, they would expect that a MS would be involved in their care. Of patientswho were presently cared for by a MS, 78% reported that the MS treated them in away that was compassionate and caring, and 85% reported that the MS treated themin a way that was respectful of their privacy. Additionally, of the patients cared for bya MS, 87% reported that their present experience was positive, and 72% reportedthat they benefited from having a MS involved in their care. However, only 36% of

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patients reported that the MS introduced themselves as either a “medical student” ora “student doctor” and 9% of patients reported that the MS used confusing medicalterms or language.

Conclusion: Overall, the preliminary results suggest that the majority of patientshaving past or present experiences with MS in the ED have positive encounters.Many patients seem to feel comfortable interacting with MS, and most patientspresenting to a teaching hospital would expect a MS to be involved with their care.The data also suggests that some students may need to be reminded about properstudent-patient introductions and avoiding the use of confusing medical terms orlanguage. Further research in this area is necessary to better understand therelationship between ED patients and MS.

39 Effectiveness of a Multi-Format Approach to TeachingEmergency Medicine Residents Early Goal-DirectedTherapy

Baez AA, Hou P, Shapiro N, Filbin M, Binstadt E, Pozner C, Barker T, Nelson S,Pallin DJ/Brigham and Women’s Hospital/Harvard Medical School, Boston, MA;Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA;Massachusetts General Hospital/Harvard Medical School, Boston, MA; Brighamand Women’s Hospital/Children’s Hospital Boston/ Harvard Medical School,Boston, MA

Emergency physicians are required to have a “Mastery” level for critical care skills.Recent studies have demonstrated that early goal-directed therapy (EGDT) reducedmortality when initiated in the ED. We developed a multi-format curriculum onEGDT, combining high-fidelity simulation, mock oral boards, didactics, and hands-on tutorials.

Study Objectives: To assess the immediate and long term effectiveness of a Multi-Format Approach to Teaching Emergency Medicine residents EGDT.

Methods: We used a matched before-and-after design to study the curriculum,given to EM residents in an urban, tertiary academic medical center. The educationalintervention was a 3 hour course comprising simultaneous (a) didactic sessions; (b)Socratic presentations by attendings and respiratory therapists; and (c) three 25minute-long simulation stations (of these, 2 were high-fidelity multimedia humanpatient simulations; in the 3rd station, junior residents practiced central venouscatheterization on manikins and senior residents participated in EGDT-themed mockoral boards). Critiques were provided in a non-threatening debriefing environment.We used 8-item questionnaires to assess knowledge and opinions (comfort with andacceptance of EGDT) immediately before and after the intervention, and at onemonth. We used paired Student t-tests to compare pre- and post-test scores(% questions correct), with p-values �� 0.05 considered significant.

Results: 26 residents participated in the teaching session. A total of 20 residentscompleted the immediate posttest, and 19 completed the 1-month follow-up. Themean score improved by 26.3 percentage points (p � 0.001, 95% CI 15.9 to 36.6)from 61.2% pre to 87.5% post. The improvement persisted to one month, with amean score of 86.8% (mean difference from pre-test 31.3 p�� 0.001, 95% CI 19.5to 43.2). The improvement was seen in both knowledge (p � 0.001) and opinion(p�0.001) subsets of the questionnaire. Participants rated the course 4.6 on a 5-pointscale (4 � “effective,” 5 “very effective”) immediately afterwards. At 1 month,participants gave an average rating of 4.4. At one month, 64.3% of participants saidthey had taken care of septic patients after the course; these rated the course at 3.8(“effective”) in improving their diagnostic and therapeutic skills.

Conclusions: This state-of-the art, multiformat EGDT course significantlyimproved the cognitive skills and knowledge of resident physicians, and theimprovement persisted at one-month follow-up.

40 The Addition of a Dedicated Medical Student TeachingAttending Improves Both Emergency DepartmentFaculty and Resident Satisfaction

Kilgannon JH, Cassidy-Smith TN, Nyce AL, Chansky ME, Baumann BM/UMDNJ-RWJMS at Camden, Camden, NJ

Background: As overcrowding in emergency departments continues to rise, so toodo the demands on emergency physicians. Academic attending physicians may findthemselves additionally compromised with this trend toward overcrowding as they tryto instruct both residents and medical students while maintaining a high level ofpatient care.

Study Objectives: To determine whether dedicated teaching attending shifts for

medical student education would improve both faculty and resident satisfaction withtheir clinical emergency department experience.

Methods: This was a prospective, cross-sectional survey of emergency departmentattendings and residents. The setting was an urban, academic center with an annualcensus of 47,000 patients. A dedicated teaching attending was added to the clinicalschedule for two 6 hour shifts each week. The teaching attending’s sole responsibilitywas to supervise and mentor all on-duty medical students, thereby allowing the otherED faculty to focus on patient care and resident preceptorship. Participants wereasked to rate the impact of the dedicated medical student teaching attending on thefollowing items using a 5 point Likert-type scale (1 � poor, 3 � adequate, 5 �excellent): Quality of bedside teaching, attending availability to precept apresentation, attending supervision, timeliness of patient disposition, and overallquality of patient care during both teaching attending and non-teaching attendingshifts. Mean scores are presented and student’s t tests were used for comparisons. Thisstudy was deemed exempt by our Institutional Review Board.

Results: Thirteen attendings (93%) and 20 (95%) residents participated.Attendings reported improvements in all medical student items. The greatestincreases were noted in ability to listen to medical student presentations, 2.2 (noteaching attending) to 4.8 (teaching attending) (p � 0.003) improvements in theinitiation of laboratory testing, 1.8 to 4.5 (p � 0.001), the timeliness of patientdisposition, 2.1 to 4.3 (p � 0.001), and medical student supervision, 2.2 to 4.3, (p �0.001). During the same intervention period, the attendings’ perception of residentteaching also demonstrated improvements in mean scores. Quality of bedsideteaching increased from 3.1 to 4 (p � 0.001), availability to hear a residentpresentation rose 3.4 to 4.2 (p�0.001), and resident supervision improved 3.4 to 4.1(p�0.02). When the residents were surveyed, they noted an improvement in thetimeliness of patient dispositions with the teaching attending, 3.5 to 3.8 (p�0.01) aswell as bedside teaching 3.3 to 3.6 (p�0.03) There were trends toward improvementin resident preceptorship and quality of patient care, but these were not significant.

Conclusions: The addition of dedicated medical student teaching attending shiftsimproved faculty satisfaction with medical student education in all items. Thepresence of this teaching attending also had a positive influence on faculty perceptionof residents’ clinical experience with improved attending supervision and bedsideteaching. Resident satisfaction was affected to a lesser extent.

41 The Evolution of Computer-Based Learning Styles inMedical Education

McKeown NJ, Tews M, Hughes MJ/Michigan State University, East Lansing, MI

Study Objectives: For years, printed text was the dominant way of storing anddisseminating medical information. Now, computer databases and the Internet arethe fastest and easiest way to store and access large amounts of information. Currentmedical students have grown up in an environment of computer-aided education. Wesought to evaluate the students’ preferences and reading performance whencomparing computer use to traditional reading sources.

Methods: This was a prospective study using 87 1st and 2nd year medicalstudents at Michigan State University College of Osteopathic Medicine. Studentswere randomized into three groups based on how a medical journal article was to beread: 1) paper print out; 2) reading off a computer monitor or 3) using a handheldPDA. Following this, they were asked to answer 10 questions about the article. Testswere scored and the time it took to read the article was recorded. One-way ANOVAwas used for statistics.

Results: Most (98.9%) students owned a computer and used their computer from1 to 5 hours each day (85.0%). 66.7% indicated they used it for medical reference.However, 73 (84.9%) still preferred to study for a test from a textbook. The averagetime it took for students to read the article was 12.3 minutes (95%C.I. 11.6-13.0)and the average score on the test was 83.0% (95% C.I. 80.4-85.6). There was nostatistically significant difference between the type of media used and the time it tookto read the article (p � 0.373), or the percentage correct on the test (p � 0.139) Inthe post-test survey, most students (85.1%) who read the article on computer orPDA, still preferred to read from a printed format.

Conclusions: Contrary to our hypothesis, medical students preferred to use paperto read their article instead of computer-based media. Their time to read the article,or their tests scores did not differ between the three groups. In the age of computer-based information, these medical students commonly use a computer in every-daylife, but still rely on paper-based information as the primary source of their readingand studying.

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