Casey Z. MacVane

Treating opioid addiction with buprenorphine-naloxone in community-based primary care settings.

PURPOSE Office-based treatment of opioid addiction with a combination of buprenorphine and naloxone was approved in 2002. Efficacy of this treatment in nonresearch clinical settings has not been studied. We examined the efficacy and practicality of buprenorphine-naloxone treatment in primary care settings. METHODS We studied a cohort of 99 consecutive patients enrolled in buprenor-phine-naloxone treatment for opioid dependence at 2 urban primary care practices: a hospital-based primary care clinic, and a primary care practice in a free-standing neighborhood health center. The primary outcome measure was sobriety at 6 months as judged by the treating physician based on periodic urine drug tests, as well as frequent physical examinations and questioning of the patients about substance use. RESULTS Fifty-four percent of patients were sober at 6 months. There was no significant correlation between sobriety and site of care, drug of choice, neighborhood poverty level, or dose of buprenorphine-naloxone. Sobriety was correlated with private insurance status, older age, length of treatment, and attending self-help meetings. CONCLUSIONS Opioid-addicted patients can be safely and effectively treated in nonresearch primary care settings with limited on-site resources. Our findings suggest that greater numbers of patients should have access to buprenorphine-naloxone treatment in nonspecialized settings.

Implementation of transvaginal ultrasound in an emergency department residency program: an analysis of resident interpretation.

BACKGROUND Emergency physicians are increasingly performing transvaginal ultrasound (TVUS) to rule out ectopic pregnancy. However, little is known about appropriate educational pathways to train emergency medicine residents in TVUS. STUDY OBJECTIVES To evaluate the ability of Emergency Medicine (EM) residents who underwent a training program in TVUS to detect the presence or absence of an intrauterine pregnancy (IUP) in patients of < 13 weeks gestation with vaginal bleeding or abdominal pain, as compared to the final interpretation of each study as determined by the Emergency Department (ED) Director of Ultrasound. METHODS This was a prospective, observational study in a single residency program. Training included a lecture, competency examination, and 10 supervised TVUSs. The EM residents then performed TVUSs with the goal of determining the presence or absence of an IUP without input from an attending physician. Correlation with the ED Director of Ultrasound was assessed for the cohort, and stratified by year of training. RESULTS There were 22 residents who performed 75 TVUSs over 17 months. Correlation with the ED Director of Ultrasound was 93.3%. Differences in correlation with the ED Director of Ultrasound were noted when compared by year of training: post-graduate year (PGY)-3 (93.3%), PGY-2 (92.1%), and PGY-1 (100%); p < 0.001. CONCLUSION Residents were able to perform TVUSs to determine the presence or absence of an IUP in patients in whom the diagnosis of ectopic pregnancy was being considered with a high degree of correlation with the ED Director of Ultrasound after a brief training program. Correlation with the ED director of ultrasound was influenced by year of training.

Unintentional ingestion of ziprasidone in a 22-month-old.

Unintentional ingestions are a common presentation to the emergency department in the pediatric population. However, very few ingestions of an atypical antipsychotic, such as ziprasidone, have been described in the emergency medicine literature. While the prevalence of these newer antipsychotics increases in the general population, emergency physicians can expect to see more patients with accidental or intentional overdoses. Many emergency physicians may be unfamiliar with the presentation, initial workup, and expected clinical course of such an overdose. We describe a case of an unintentional ingestion of ziprasidone tablets in a 22-month-old girl who presented to the emergency department with somnolence, drooling, and poor tone.

Intern as Patient: A Patient Experience Simulation to Cultivate Empathy in Emergency Medicine Residents

Introduction Prior work links empathy and positive physician-patient relationships to improved healthcare outcomes. The objective of this study was to analyze a patient experience simulation for emergency medicine (EM) interns as a way to teach empathy and conscientious patient care. Methods We conducted a qualitative descriptive study on an in situ, patient experience simulation held during EM residency orientation. Half the interns were patients brought into the emergency department (ED) by ambulance and half were family members. Interns then took part in focus groups that discussed the experience. Data collected during these focus groups were coded by two investigators using a grounded theory approach and constant comparative methodology. Results We identified 10 major themes and 28 subthemes in the resulting qualitative data. Themes were in three broad categories: the experience as a patient or family member in the ED; application to current clinical practice; and evaluation of the exercise itself. Interns experienced firsthand the physical discomfort, emotional stress and confusion patients and families endure during the ED care process. They reflected on lessons learned, including the importance of good communication skills, frequent updates on care and timing, and being responsive to the needs and concerns of patients and families. All interns felt this was a valuable orientation experience. Conclusion Conducting a patient experience simulation may be a practical and effective way to develop empathy in EM resident physicians. Additional research evaluating the effect of participation in the simulation over a longer time period and assessing the effects on residents’ actual clinical care is warranted.

Congratulations, You’re Pregnant! Now About Your Shifts . . . : The State of Maternity Leave Attitudes and Culture in EM

Introduction Increasing attention has been focused on parental leave, but little is known about early leave and parental experiences for male and female attending physicians. Our goal was to describe and quantify the parental leave experiences of a nationally representative sample of emergency physicians (EP). Methods We conducted a web-based survey, distributed via emergency medicine professional organizations, discussion boards, and listservs, to address study objectives. Results We analyzed data from 464 respondents; 56% were women. Most experienced childbirth while employed as an EP. Fifty-three percent of women and 60% of men reported working in a setting with a formal maternity leave policy; however, 36% of women and 18% of men reported dissatisfaction with these policies. Most reported that other group members cover maternity-related shift vacancies; a minority reported that pregnant partners work extra shifts prior to leave. Leave duration and compensation varied widely, ranging from no compensated leave (18%) to 12 or more weeks at 100% salary (7%). Supportive attitudes were reported during pregnancy (53%) and, to a lesser degree (43%), during leave. Policy improvement suggestions included the development of clear, formal policies; improving leave duration and compensation; adding paternity and adoption leave; providing support for physicians working extra to cover colleagues’ leave; and addressing breastfeeding issues. Conclusion In this national sample of EPs, maternity leave policies varied widely. The duration and compensation during leave also had significant variation. Participants suggested formalizing policies, increasing leave duration and compensation, adding paternity leave, and changing the coverage for vacancies to relieve burden on physician colleagues.