Douglas Rappaport

Background: Gender disparities have been reported in Emergency Medicine (EM) residency milestone attainment, with some studies showing male residents achieving higher competency-based ratings than female residents despite similar clinical exposure. Prior research suggests subjective faculty evaluation and implicit bias may contribute to these differences. The influence of resident self-assignment of patients on milestone attainment remains unclear, and the potential contribution of differential patient exposure through self-selection has not been directly investigated. Objectives: To determine whether gender differences exist in the types of patients or acuity levels that EM residents self-assign to determine if this could potentially explain the differences seen in EM milestone achievement across genders. Methods: Design and Setting: Retrospective chart review of EM resident patient selection at the Mayo Clinic Arizona Emergency Department from September 2018 through December 2022. Patients: The study was conducted at a single academic emergency department with resident and attending physician staffing. The study was determined to be IRB exempt. Data Collection: Epic electronic medical record data included resident and attending gender, patient demographics, chief complaint, Emergency Severity Index (ESI) triage level, vital signs, method of arrival, and procedures performed. Statistical Analysis: Continuous variables were compared using Student’s t-test or Wilcoxon rank-sum test; categorical variables were compared using chi-square test. Significance was set at p < 0.05. Analyses were performed using SAS version 9.4. Results: A total of 14,279 cases were analyzed. No significant differences were observed between female and male residents in patient chief complaint, age, race, gender, means of arrival, attending gender (p = 0.10872), or total procedures performed (p = 0.23102). Female residents saw patients with higher initial respiratory rates (p = 0.04313) and trended non-significantly toward higher-acuity ESI levels 1–2 (p = 0.07214). Conclusion: When residents self-assign patients in the emergency department, no meaningful gender differences exist in patient selection, procedural exposure, or gender attending assignment. These findings suggest that observed gender disparities in milestone attainment are unlikely driven by clinical exposure or patient selection, supporting that other factors may contribute to these differences.

Introduction: Central retinal artery occlusion (CRAO) is a neurological and ophthalmologic emergency that presents as sudden, painless, monocular vision loss. Central retinal artery occlusioncan be classified as arteritic or non-arteritic. Most cases of non-arteritic CRAO are due to embolism, commonly from atherosclerosis of the ipsilateral carotid artery. More proximal sources of embolism are uncommon but can occur. Prompt recognition of CRAO is critical for vision preservation therapy and initiation of ischemic stroke diagnosis protocols. Case Report: We present the case of a 66-year-old female who presented to the emergency department eight hours after sudden, painless, monocular vision loss. Her past medical history included type II diabetes, hypertension, and hyperlipidemia. She had previously undergone bilateral lens replacement for cataracts three years prior and had a history of intermittent floaters, which had been worsening over the previous six months. She denied any associated pain, headache, speech difficulty, focal weakness, and ocular trauma. Point-of-care ultrasound (POCUS) of the affected eye revealed the presence of a retrobulbar spot sign, which is associated with CRAO with a non-arteritic embolic etiology. Conclusion: Point-of-care ultrasound is an efficient diagnostic tool for the assessment of acute, painless, monocular vision loss. The presence of a retrobulbar spot sign indicates central retinal artery occlusion, providing both diagnostic and prognostic information. Although not a definitive diagnostic tool, POCUS can expedite treatment for patients with central retinal artery occlusion, a diagnosis with a time-sensitive treatment window.

Purpose: This study assessed the association between holding an additional graduate degree beyond a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) and residency match outcomes. Specifically, the authors examined graduate degree attainment trends among residency applicants and evaluated whether graduate degree holders experience lower match rates than non-holders. Methods: A retrospective, observational analysis was conducted using publicly available data from the National Resident Matching Program's Charting Outcomes in the Match reports (2016-2024). The 10 specialties with the highest applicant volumes were analyzed, encompassing 80 136 matched and 6820 unmatched U.S. MD and DO senior applicants. Trends in graduate degree attainment were evaluated using linear regression models. Match rates were stratified by graduate degree status and compared using two-proportion z-tests based on aggregated matched and unmatched counts for each specialty and overall. Results: From 2016 to 2024, the proportion of graduate degree holders entering the match increased significantly for MD (15.77% to 18.29%, P = .0008) and DO (19.93% to 23.31%, P = .0151) applicants. Across all 10 specialties, graduate degree holders matched at lower rates than non-holders. Among MD applicants, graduate degree holders matched at 92.57% compared with 94.12% for non-graduates (P < .0001), with specialty-specific differences ranging from 0.22% in Psychiatry to 4.61% in Anesthesiology; five specialties demonstrated statistically significant disparities. Among DO applicants, graduate degree holders matched at 84.54% compared with 88.64% for non-graduates (P < .0001), with specialty-specific differences ranging from 1.44% in Family Medicine to 10.48% in Obstetrics and Gynecology; five specialties also reached statistical significance. Conclusions: The proportion of graduate degree holders in the residency match is increasing, and these applicants experience lower match rates than non-holders. These findings challenge the assumption that additional graduate education provides a competitive advantage and underscore the need for further research into the applicant-level factors contributing to these disparities.

Introduction: Sternoclavicular joint injuries are rare and potentially life-threatening injuries due to their proximity to vital mediastinal structures. In adolescents, skeletal immaturity can add complexity to the injury due to potential involvement of the physis. A physeal fracture with displacement can appear as a dislocation on imaging, also known as pseudo-dislocation. Additionally, this anatomic area is difficult to visualize with plain radiographs, which can result in misdiagnosis and delayed treatment. Case Report: We present a case of a 15-year-old male athlete who presented to the emergency department with severe right clavicular pain four hours after sustaining a football injury. Plain radiographs obtained at an outside facility as well as repeat plain radiographs at our facility showed no evidence of fracture or dislocation. The patient’s degree of pain and physical exam findings prompted further imaging with computed tomography (CT), ultimately revealing a physeal fracture of the medial right clavicle with posterior and superior displacement. Conclusion: Sternoclavicular joint injuries in skeletally immature patients are complex and require immediate diagnosis and intervention. Plain radiographs are often unreliable in recognizing these injuries and, in our case, the physeal fracture with displacement was not radiographically apparent on two separate occasions. Advanced imaging with CT revealed the diagnosis, highlighting the importance of a detailed physical exam and for physicians to maintain a high index of clinicalsuspicion when evaluating adolescents with high-impact trauma, even in the setting of negative plain radiographs.

Proximal avulsion of the rectus femoris tendon is an uncommon injury in athletes and is rarely associated with direct trauma and extensive hematoma. We describe a 25‐year‐old competitive taekwondo athlete who developed acute hip flexor weakness and thigh swelling after a direct anterior thigh kick. Bedside musculoskeletal ultrasound demonstrated disruption of rectus femoris architecture with intramuscular hematoma, and magnetic resonance imaging confirmed complete avulsion of both proximal heads of the rectus femoris with tendon retraction and a large associated hematoma. The patient had sustained a recent prior quadriceps injury with hematoma. Recurrent hematoma development warranted hematologic testing, which revealed an isolated Factor VIII deficiency. Given his high functional demands, he underwent open surgical repair. This case highlights the importance of early imaging and consideration of operative management in high‐level athletes presenting with trauma‐related rectus femoris avulsion. It also highlights the importance of hematologic workups in athletes presenting with unexplained recurrent hematomas to effectively risk‐stratify surgery and return to sport.