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Study Objectives: To determine the effectiveness of an Evidence-Based Medicine Objective Structured Clinical Examination (EBM OSCE) with standardized patients for end of third year medical students at our institution.Methods: This was a single-center prospective cross-sectional study. As part of the eight-station OSCE examination, the investigators developed and implemented a new 25-minute EBM OSCE station with the goal of evaluating students' ability to search for a relevant article, appraise the article, define and discuss the concept of relative risk and number needed to treat with regards to the administration of dexamethasone for rebound migraines. The OSCE case involved a highly educated patient with a history of recurrent debilitating migraines who has brought eight specific questions regarding the use of steroids for migraine headaches. Students were provided computer stations equipped to record a log of the searches performed.Results: One hundred four third-year medical students participated in this study. The average number of search tools used by the students was 4 (SD¼ 2). A total of 896 searches were performed by 104 students. The two most commonly used Web sites were uptodate.com and google.com. Sixty-nine percent (95% CI, 60% to 78%) of students were able to find a meta-analysis regarding the use of dexamethasone for the prevention of rebound migraines. Fifty-two percent of students were able to explain that patients who took dexamethasone had a moderate RR (0.68 -0.78) of having a recurrent migraine, and 71% of students were able to explain to the standardized patient that the NNT for dexamethasone was nine.Conclusion: Standardized patients were successfully used to evaluate medical student EBM skills during an OSCE.

Study Objectives: Involuntary emergency psychiatric holds are placed on individuals suspected of having mental illness who are deemed to be dangerous to themselves or others. The purpose is to legally detain them for an emergency psychiatric evaluation. Although the situation arises frequently in all communities, the process that follows placement of such a hold varies immensely across the country; even neighboring counties having very different protocols. In many cases, these patients are then taken to a health care facility, usually an emergency department (ED). Though an estimated 5.3 million ED visits or 4% of all visits result in a primary diagnosis related to mental health or substance abuse and 30% of these patients arrive by ambulance. However, it is unknown if this is due to patient choice or if it is due to local protocols. For example, though law enforcement professionals are often responsible for placing holds, Alameda County in California has established a protocol that uses Emergency Medical Services (EMS) to triage and transport patients once they are placed on involuntary holds. Though many patients need to be medically evaluated prior to psychiatric evaluation, field triage allows EMS to directly transport a significant portion of patients to a stand-alone psychiatric ED. The purpose of this investigation was to describe and understand the resulting burden on EMS.Methods: Data was obtained on all ambulance transports dispatched by Alameda County EMS over a two-year period from April 2014 to April 2016. The county's collects electronic data on every transport, and encodes multiple variables including if the patient was on an involuntary psychiatric hold. We identified all patients, including pediatric patients, on an involuntary psychiatric hold using this variable.Results: Between April 2014 and April 2016, Alameda County EMS transported 246,422 patients, and 12% (n¼29,557) of all patient transport encounters were for involuntary psychiatric holds. Transports for patients on involuntary holds accounted for 14% (n¼44,331/315,925 hours) of all cumulative EMS transport time. The median age of patients on psychiatric holds was 36 (IQR:25-50), as compared to age 56 (IQR: 37-72) for those transported for other reasons (p<0.001). 37% of involuntary hold patients did not have insurance, as compared to 22% of patients transported for other reasons (p<0.001). 41% (n¼12,170/29,557) of patients on an involuntary hold were transported directly to a stand-alone psychiatric facility for evaluation, while the remaining 59% (n¼17,387) were taken to an emergency department. Of the patients taken to an ED, 42% (n¼7,281/17,387) had a clear indication for ED transport per the EMS protocol; 1923 patients were under 12 years or over 65 years of age, 2,840 patients had a pulse>120 bpm, 4,153 had a GCS<15, and 1,044 were given intramuscular midazolam in the field for sedation.Conclusions: 12% of all EMS transports in Alameda County were for patients on involuntary psychiatric holds, and 59% of all such patients were tran...