Anton Grunfeld

Improving the Emergency Department detection rate of domestic violence using direct questioning

The purpose of this study was to compare the domestic violence (DV) rate identified with simple direct questioning to a historical cohort of patients receiving routine emergency department (ED) care. One thousand ED charts of female patients were retrospectively reviewed. Each patient in the prospective cohort was asked five DV specific questions. The historical cohort revealed a DV prevalence rate of 0.4%. The prospective study group of 302 patients identified 11 (3.6%) patients who admitted to acute DV on direct questioning. Ten of these patients accepted help. Twenty (6.6%) were identified as probable DV and 12 (4%) admitted to past violence. The total number of victims of DV, past, present, and probable was 43 (14.2%). This increase in detection from 0.4% (4/1000) to 14.2% (43/302) is significant at p < 0.001. Only 1.3% of patients refused to participate in the DV specific questions. The conclusion of the study indicated that the use of simple, direct questioning significantly improves the detection rate of DV in the ED.

Using tomography to diagnose occult ankle fractures.

STUDY OBJECTIVES To determine the incidence of occult ankle fractures and to determine whether an ankle effusion identified radiographically correlated with the presence of an occult fracture. METHODS Attending physicians in the emergency department of a university hospital prospectively identified patients with acute ankle injuries that produced ecchymosis or edema over two or more major ligaments of the ankle. Plain radiographs of these patients demonstrated ankle effusions without fractures. A consecutive sample of patients with acute ankle injuries was selected. Thirty-six of 1,151 patients were eligible to enter the study; 2 of these patients subsequently were excluded from the data analysis. All eligible patients underwent plain ankle tomography at 3-mm intervals in the coronal and sagittal planes. The types and frequencies of occult ankle fractures identified on plain film tomography were noted. The distention of the ankle joint capsule of enrolled patients was measured to determine if the degree of effusion correlated with the presence of an occult fracture. RESULTS The minimum incidence of occult fractures in the general population with ankle injuries was 1%. Twelve of 34 patients (35%) with acute, severe injuries had occult fractures. Depending on the size, an effusion was correlated with the presence of an occult fracture in 35% to 85% of the study population. CONCLUSION Plain film tomography should be used when evaluating ankle injuries if both edema or ecchymosis over two or more stabilizing ligaments and radiographic evidence of an effusion are present simultaneously.

An Internet primer for emergency physicians: Part I

The growth of the popularity of the Internet is nothing short of phenomenal. Increasingly, valuable medical information is becoming available on line for physicians and health consumers alike. Physicians can clearly benefit personally and professionally by obtaining access to the Internet. The purpose of this article is to introduce the Internet to physicians who have limited experience with this new medium. It discusses the concept of the Internet, the necessary computer components and modem for on line connection, and the various types of Internet Service Providers. A glossary is also provided to explain some of the most common terminology used in the Internet culture.

Assessing for Domestic Violence Exposure in Primary Care Settings The Transition from Classroom to Clinical Practice

To evaluate the ability of medical students to apply domestic violence training in an early clinical experience, a cross-sectional survey was undertaken among 2nd-year medical students from the University of British Columbia during their rural family practice practicum. Participants recorded whether they assessed adult patients for exposure to domestic violence during routine office visits. Domestic violence was discussed in 11% of the 341 recorded patient encounters. All discussions involved female patients. Domestic violence was discussed in 27% of the one-on-one encounters with patients versus 3.6% of the encounters in which a preceptor was present. Barriers that prevented medical students from undertaking assessment and counseling included lack of mentoring and role modeling and a perceived lack of privacy and time available. Application of classroom knowledge in this challenging domain requires preceptorship by appropriately trained supervisors in the clinical setting.

THE INTERNET: WHAT'S ALL THE FUSS ABOUT?

Few developments in the Twentieth Century have had as much real or potential impact on global communication as has the development of the Internet. One can reflect upon the invention of the telegraph, telephone, wireless radio and television, and the great communication advances of modern society, but all of these combined will likely pale in comparison with the ultimate potential of the Internet. The Internet contains an avalanche of medical information. Physicians can use a Web browser such as Netscape ( 1) to visit such exciting places as the Virtual Hospital and participate in its distance learning program for physicians (2). The latest abstracts submitted to the Society of Academic Emergency Medicine are available on-line for all to read (3). Search engines such as Lycos (4) and Yahoo (5) allow users to sift through millions of Web pages to locate the desired pieces of information. And information is there in abundance. Every conceivable aspect of every conceivable topic is represented in some manner on the Internet. New additions are added hourly in this information explosion of nuclear proportion. Sophisticated databases that were formerly accessible only through complex mainframe computing systems are now easily accessible from a personal computer with a modem line to a local Internet connector. In this issue of the Journal, we inaugurate a new section dedicated to the Internet and committed to providing stimulating and educational information of practical use to emergency physicians. The lead-off article, which appears this month, deals with the fundamental definitions of the Internet, hardware required to establish an Internet connection, and an overview of the attributes and resources of the Internet. A companion article shall appear in a subsequent issue, exploring search engines and other connectivity software, all with a clear focus on the emergency physician as user. In future issues, w’e will explore the databases and Internet sites that are of relevance to the clinical, teaching, and research aspects of the practice of emergency medicine. When appropriate, comparisons and analysis will be undertaken to provide the reader with a critical appraisal of the hardware, software, and informational components of the Internet. We invite reader comments, suggestions, and articles. The section editors, Dr. Grunfeld and Dr. Ho, can be reached viae-mail at: grunfeld@unixg.ubc.ca and kho@unixg.ubc.ca. We

Photodocumentation as an emergency department documentation tool in soft tissue infection: a randomized trial

OBJECTIVES Current documentation methods for patients with skin and soft tissue infections receiving outpatient parenteral anti-infective therapy (OPAT) include written descriptions and drawings of the infection that may inadequately communicate clinical status. We undertook a study to determine whether photodocumentation (PD) improves the duration of outpatient treatment of skin and soft tissue infections. METHODS A single-blinded, prospective, randomized trial was conducted in the emergency departments of a community hospital and an academic tertiary centre. Participants included consecutive patients age ≥ 14 years presenting with noninvasive skin and soft tissue infections requiring OPAT. Patients in the intervention arm were treated with standard of care plus PD at each emergency physician assessment. Control subjects received care provided at the discretion of the treating physician and non-photographic documentation. The primary outcome was duration of therapy measured in half-days. The required sample size to detect a difference of one half-day was 253 patients per group (α  =  0.05). Secondary outcomes included (1) completion and therapeutic failure rates, (2) patient satisfaction, and (3) physician and nurse satisfaction. RESULTS Enrolment was slower and follow-up rates lower than anticipated, and the trial was terminated when funds were exhausted. A total of 468 subjects with similar age and gender characteristics were enrolled, with 244 receiving the intervention and 224 in the control arm. The mean OPAT duration was similar in the two groups (3.6 days v. 3.5 days, p  =  0.73). No differences in the rate for completion and therapeutic failure were observed (71% v. 68% and < 1% for both, respectively). Survey response rates varied significantly: patients, 65%; nurses, 17%; and physicians, 87%. Physicians endorsed more comfort with their assessment and OPAT judgment with PD (65% and 64%, respectively). Physicians cited too much time lost with technological challenges, which would affect implementation in a busy ED. CONCLUSIONS PD as an intervention is acceptable to patients and has reasonable endorsement by the majority of physicians. This trial had significant limitations that threatened the integrity of the study, so the results are inconclusive.