Does the Concept of the “Flipped Classroom” Extend to the Emergency Medicine Clinical Clerkship?

Introduction Linking educational objectives and clinical learning during clerkships can be difficult. Clinical shifts during emergency medicine (EM) clerkships provide a wide variety of experiences, some of which may not be relevant to recommended educational objectives. Students can be directed to standardize their clinical experiences, and this improves performance on examinations. We hypothesized that applying a “flipped classroom” model to the clinical clerkship would improve performance on multiple-choice testing when compared to standard learning. Methods Students at two institutions were randomized to complete two of four selected EM clerkship topics in a “flipped fashion,” and two others in a standard fashion. For flipped topics, students were directed to complete chief complaint-based asynchronous modules prior to a shift, during which they were directed to focus on the chief complaint. For the other two topics, modules were to be performed at the students’ discretion, and shifts would not have a theme. At the end of the four-week clerkship, a 40-question multiple-choice examination was administered with 10 questions per topic. We compared performance on flipped topics with those performed in standard fashion. Students were surveyed on perceived effectiveness, ability to follow the protocol, and willingness of preceptors to allow a chief-complaint focus. Results Sixty-nine students participated; examination scores for 56 were available for analysis. For the primary outcome, no difference was seen between the flipped method and standard (p=0.494.) A mixed model approach showed no effect of flipped status, protocol adherence, or site of rotation on the primary outcome of exam scores. Students rated the concept of the flipped clerkship highly (3.48/5). Almost one third (31.1%) of students stated that they were unable to adhere to the protocol. Conclusion Preparation for a clinical shift with pre-assigned, web-based learning modules followed by an attempt at chief-complaint-focused learning during a shift did not result in improvements in performance on a multiple-choice assessment of knowledge; however, one third of participants did not adhere strictly to the protocol. Future investigations should ensure performance of pre-assigned learning as well as clinical experiences, and consider alternate measures of knowledge.

CT scan to search for alternate causes of pain General surgery consultation in the ED 4. A 55yo male presents to the ED with a three-day history of abdominal pain. The pain is described as migratory and sporadic in waves. He has nausea and has vomited several times over the last few hours. Additionally, he has not had a bowel movement or passed gas for the past three days. On physical exam, his abdomen is distended and diffusely tender to palpation. Bowel sounds are present and are hyperechoic with the pain. Vital signs are T: 101F, BP110/80, P110, R24. Labs show WBC 14, and ABG shows pH 7.25, pO2 80, pCO2 26, HCO3 16.
What is the next best step in management?
Analgesics, antiemetics, and bowel rest Air contrast enema Emergent colonoscopy NG tube, IVFs, and antibiotics 5. A 78yo female presents to the ED with sudden onset, acute, generalized abdominal pain w/vomiting. PMH is significant for chronic HTN, CVA, and DM. She takes no medications. Vital signs are: T101F, BP190/110, P120 and irregular, R24. She is in significant discomfort. On physical exam, there is diffuse tenderness to palpation in the abdomen. No bowel sounds are heard. Guaiac test is positive. Troponin is normal. Labs show WBC 18. What is the most likely etiology of her symptoms?

Atrial thrombus with embolism
Compression of the SMA Mesenteric artery thrombus formation Mesenteric vein thrombosis 6. A 55yo male presents to the ED with acute abdominal pain. The pain is "up near my ribs." He vomited once, and almost immediately after a dull, aching pain spread through his entire stomach. He has had stomach pain for several months. PMH is significant for DM and HTN. He is a chronic heavy smoker and drinker. VS: 100F, BP160/90, P100, R24. On physical exam, the abdomen is diffusely tender to palpation w/o rigidity or guarding. Upright CXR is shown.
What is the most appropriate next step? Antibiotics, IVFs, and bowel rest CT scan of the abdomen without contrast General surgery consultation NG tube gastric decompression 7. A 21yo female presents to the ED with a history of right lower abdominal pain for the past several days. The pain varies between mild and intense from hour to hour. Exam shows a patient with right sided lower abdominal tenderness without rebound or guarding. Vital signs are: 98F, BP120/80, P80, R20.
What is the most appropriate initial diagnostic test?
Beta HCG CT scan of the abdomen Ultrasound of the right abdomen Urinalysis 8. An 80yo female presents to the ED 30 minutes after the sudden onset of severe upper stomach pain and diaphoresis. The pain radiates to the back and both scapulae. She also complains of nausea and vomiting x 2 times. PMH is signficiant for PUD, gallstones, and stable angina. VS: 98F, BP120/70, P90, R20. Physical exam shows mild tenderness to palpation in the epigastrium with a negative Murphy's sign. Troponin levels are pending.
What is the most appropriate initial study to perform?
Abdominal plain films Blood glucose CT scan of the abdomen electrocardiogam LFTs and lipase 9. A 23yo G0 female presents to the ED with lower abdominal pain, nausea and vomiting for several days. She is sexually active and uses birth control. LMP is 13 days ago. Vital signs: 103F, BP 110/70, P110, R24. Exam shows diffuse tenderness to palpation over the lower abdomen and pelvis. A pelvic exam is performed showing greenish, purulent discharge from the cervix. The uterus and adnexa are exquisitely tender to palpation and motion without any masses noted. Cultures have been sent to the lab.
What is the most appropriate management?
Discharge pending cultures Intramuscular ceftriazone and antiemetics Intravenous cefoxitin and doxycycline Oral ceftriaxone and doxycycline Outpatient treatment with metronidazole and ampicillin 10. A 24 yo G1P1 female with no prior medical history presents with 1 hour of sudden, severe right lower quadrant abdominal pain. She is sexually active and is due to start her period this week. She takes no medicines. Vitals show HR 113, BP 123/87, RR 23, T 98.6, SpO2 99% on room air. On exam she is in severe pain, curled up on the bed. Abdomen is tender in the lower right and suprapubic with no rebound or guarding. A pregnancy test is done, and she is not pregnant. What is the most appropriate diagnostic study?
Acute abdominal series CT scan of the abdomen and pelvis Complete blood count with differential Transvaginal ultrasonography Ultrasound of the right upper quadrant AMS 11. A 20yo female presents to the ED from college with confusion and disorientation. According to friends, the patient has been ill with vomiting and abdominal pain for 24 hours. Prior to onset of the vomiting, she had been very thirsty and losing weight for weeks. Her vital signs are 100/56, P120, T98.4, R28. Pulse oximetry is 94% on room air. On exam, she is barely arousable but is able to move everything on neurological testing.
What is the most appropriate initial test?
CT scan of the head Blood glucose Electrocardiogram Serum sodium level Urine pregnancy 12. A 40yo female postal worker presents to the ED after co-workers found her confused and disoriented in her vehicle. According to them, the patient had spent the morning delivering letters. She had just returned to the job after knee surgery. The patient takes methimazole. VS BP130/90, P120, T105F, R22, SpO2 98% RA. On physical exam, her skin is warm and dry, pupils are constricted but symmetric and reactive, and neuro exam is normal except for inability to converse or follow commands.
What is the most appropriate initial treatment for her condition? While you're taking care of her, her daughter and granddaughter come to the room after being discharged for headaches and vomiting as well.
What is the most appropriate treatment for the suspected condition?
Albuterol by nebulizer Intravenous normal saline Oxygen by non-rebreather Metoclopramide and fluids 14. A 45 year old alcoholic presents to the ED intoxicated after being found lying on the ground outside a convenience store. He is given IV fluids, a meal, and allowed to sober up. On recheck several hours later, he is still confused and slurring his speech. Vital signs are: HR 98, BP 106/53, RR 19, SpO2 95% on room air. His exam is normal except for an ataxic gait.
What is the most appropriate management course?
CT scan of the head Electrocardiogram Lorazepam and IVFs Thiamine and glucose 15. A 24yo army recruit presents to the ED after collapsing at basic training. Fellow recruits claim he lost consciousness on the field, and in the ED he appears confused. No recent illnesses prior to this incident. He does take Claritin for allergies. Vital signs are: BP 90/60, HR 120, R22, T105. He is restless, pupils are reactive and symmetric to light, lung exam reveals mild expiratory wheezing, and his skin appears dry and hot. Neurologic exam is otherwise normal. U/A shows large blood on dipstick but no RBCs on microscopic analysis.
What is the most appropriate initial treatment? Acetaminophen Cool mist and fans Dantrolene Empiric antibiotics Lorazepam 16. A 65yo male presents to the ED with sudden-onset R-sided weakness and aphasia. All symptoms began suddenly 1 hour ago. PMH is significant for DM, chronic back pain, arthritis, atrial fibrillation, and eczema. The patient is on glipizide, aspirin, cyclobenzaprine, metoprolol and topical hydrocortisone. Vital signs are: BP 220/105, P113 and irregular, R20, T99F. Exam shows moderate aphasia, R sided facial droop and hand grip weakness.
What is the most appropriate initial management? A 27-year-old man previously healthy man taking no medications is brought to the emergency department by an ambulance after he was in a one-car motor vehicle collision. Paramedics report that the patient was the unrestrained driver of a car that struck a telephone pole head-on. The patient is immobilized with a cervical collar and on a board. He is conscious and says he has chest pain. Pulse rate is 140/min, respirations are 40/min, and systolic blood pressure is 80 mmHg. On physical examination, the neck veins are distended, the trachea is displaced to the right, and the left side of the chest is hyper-resonant to percussion. Heart sounds are distant. On the basis of these findings, this patient has most likely sustained which of the following traumatic injuries? a.

31.
A 55 yo woman comes with severe bleeding from her mouth and nose. She reports increased cough, shortness of breath, and abdominal pain for 2 days. Yesterday her stool was black and she woke with "blood all over my pillow." She is pale with shallow, labored respirations. She coughs up blood, but is otherwise hard to arouse. You assist her breathing with bag-valve-mask ventilation at a rate of 30. Her heart rate is 140, BP is 82/51, and oxygen saturation is 88%. IV access is established and a NS bolus is being given. Which of the following should be done FIRST? a. Place a nasogastric tube to check for blood in the stomach b. Order a blood transfusion c. Endotracheal intubation d. Arrange for endoscopy e. Arrange for pulmonary arty embolization 32.
A 35-year-old man with cystic fibrosis comes complaining of sudden onset of chest pain referred to the shoulder. His pain is worse with deep breaths. He denies trauma, drug use, or palpitations. The likely treatment for this patient will include: a.

39.
A 70-year-old man presents with shortness of breath, fever and productive cough for 3 days. He is a chronic smoker on home O2. CXR shows right lower lobe consolidation. In the ED, his condition worsens and he requires intubation and ventilation with subclavian IV access. Immediately after that management, he deteriorates rapidly. Exam reveals absent right side breath sounds. What is the next best step in management? a. CXR b. ABG c. IV fluids and pressors d. Needle thoracostomy e. Cricothyroidotomy 40. A 66-year-old woman comes with worsening shortness of breath. She reports increasing breathlessness when laying flat, swelling of her feet and ankles, and extreme shortness of breath when trying to climb stairs. She has not been able to drink much because of mild nausea. Temperature is 98.8, Respirations 42, HR 120, and oxygen saturation 93% on oxygen face mask. The best first step in management is: a. Sublingual nitroglycerine b. Aggressive lasix infusion c. Intubation d. EKG for presumed myocardial infarction e. Tube thoracostomy for pneumothorax