ACH YEAR, PHYSICIANS IN CANAdian and US emergency departments (EDs) treat more than 8 million patients with head injury, representing approximately 6.7% of the 120 million total ED visits. 1 Although some of these patients have sustained moderate or severe head injury leading to death or serious morbidity, the vast majority of patients are classified as having minimal or minor head injury. 2,3 Patients with minimal head injury have not experienced loss of consciousness or other neurological alteration. Minor head injury or concussion is defined by a history of loss of consciousness, amnesia, or disorientation See also pp 1519 and 1551 and Patient Page.

For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography.

OBJECTIVES Training and practice in medicine are inherently stressful. Research into the effects of acute stressors has revealed significant variability in individual responses to stressors, with performance impairments occurring in those who demonstrate elevated subjective and physiological responses. Cognitive appraisals (subjective assessment of situational demands and available resources) of a stressor have been proposed as a predictor variable in stress responses. However, the relationship between cognitive appraisal and stress responses has not been tested empirically in complex realistic situations. The purpose of this study was to determine the extent to which cognitive appraisal affects a medical trainee's subjective and physiological stress responses to high-acuity simulated clinical situations. METHODS Thirteen emergency medicine and general surgery residents participated in high (HS) and low (LS) stress trauma resuscitation simulations. Subjective (cognitive appraisal and State-Trait Anxiety Inventory [STAI]) and physiological (salivary cortisol) measures were collected at baseline and in response to participation in each scenario. RESULTS Post-scenario STAI scores, cognitive appraisal and cortisol levels were higher in the HS scenario compared with the LS scenario. For the participants who appraised the scenarios as 'threats' (in which the demands outweighed the resources), the ratio of perceived demands to resources was positively correlated with cortisol levels (r = 0.59, p < 0.05) and STAI responses (r = 0.64, p < 0.05). By contrast, for the participants who appraised the scenarios as 'challenges' (in which resources were sufficient to meet the demands), the perceived ratio of demands to resources was not correlated with either the STAI scores or cortisol levels. CONCLUSIONS Subjective appraisals of a situation appear to play an important role in stress responses, which have previously been shown to impair performance. As such, training for high-acuity events should include interventions targeting stress management skills.

Objectives: Web-based learning has several potential advantages over lectures, such as anytime-anywhere access, rich multimedia, and nonlinear navigation. While known to be an effective method for learning facts, few studies have examined the effectiveness of Web-based formats for learning procedural skills. The authors sought to determine whether a Web-based tutorial is at least as effective as a didactic lecture for learning ultrasound-guided vascular access (UGVA).Methods: Participating staff emergency physicians (EPs) and junior emergency medicine (EM) residents with no UGVA experience completed a precourse test and were randomized to either a Web-based or a didactic group. The Web-based group was instructed to use an online tutorial and the didactic group attended a lecture. Participants then practiced on simulators and live models without any further instruction. Following a rest period, participants completed a four-station objective structured clinical examination (OSCE), a written examination, and a postcourse questionnaire. Examination results were compared using a noninferiority data analysis with a 10% margin of difference.Results: Twenty-one residents and EPs participated in the study. There were no significant differences in mean OSCE scores (absolute difference = )2.8%; 95% confidence interval [CI] = )9.3% to 3.8%) or written test scores (absolute difference = )1.4%; 95% CI = )7.8% to 5.0%) between the Web group and the didactic group. Both groups demonstrated similar improvements in written test scores (26.1% vs. 25.8%; p = 0.95). Ninety-one percent (10 ⁄ 11) of the Web group and 80% (8 ⁄ 10) of the didactic group participants found the teaching format to be effective (p = 0.59).Conclusions: Our Web-based tutorial was at least as effective as a traditional didactic lecture for teaching the knowledge and skills essential for UGVA. Participants expressed high satisfaction with this teaching technology. Web-based teaching may be a useful alternative to didactic teaching for learning procedural skills.ACADEMIC EMERGENCY MEDICINE 2008; 15:949-954 ª