Chao-Wen Chen

Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study

BackgroundTo evaluate the effectiveness of a multifaceted intervention in improving emergency department (ED) patient privacy and satisfaction in the crowded ED setting.MethodsA pre- and post-intervention study was conducted. A multifaceted intervention was implemented in a university-affiliated hospital ED. The intervention developed strategies to improve ED patient privacy and satisfaction, including redesigning the ED environment, process management, access control, and staff education and training, and encouraging ethics consultation. The effectiveness of the intervention was evaluated using patient surveys. Eligibility data were collected after the intervention and compared to data collected before the intervention. Differences in patient satisfaction and patient perception of privacy were adjusted for predefined covariates using multivariable ordinal logistic regression.ResultsStructured questionnaires were collected with 313 ED patients before the intervention and 341 ED patients after the intervention. There were no important covariate differences, except for treatment area, between the two groups. Significant improvements were observed in patient perception of “personal information overheard by others”, being “seen by irrelevant persons”, having “unintentionally heard inappropriate conversations from healthcare providers”, and experiencing “providers’ respect for my privacy”. There was significant improvement in patient overall perception of privacy and satisfaction. There were statistically significant correlations between the intervention and patient overall perception of privacy and satisfaction on multivariable analysis.ConclusionsSignificant improvements were achieved with an intervention. Patients perceived significantly more privacy and satisfaction in ED care after the intervention. We believe that these improvements were the result of major philosophical, administrative, and operational changes aimed at respecting both patient privacy and satisfaction.

Combination of white blood cell count with liver enzymes in the diagnosis of blunt liver laceration

BACKGROUNDnIt is sometimes difficult to decide whether to perform abdominal computed tomographic (CT) scans for possible liver laceration in patients who have sustained less severe or minor blunt abdominal trauma. This study was conducted to find out whether the basic laboratory workup could provide information of possible liver laceration in blunt abdominal trauma patients and act as an indication for CT scans.nnnMETHODSnIn this retrospective case-control study, we included 289 patients who had sustained blunt abdominal injury for which they received abdominal CT scans in our emergency department. Of the 289 patients, the study group (n = 42) included patients who had been found to have liver lacerations after obtaining the CT; the controls (n = 42) were those not found to have such injuries by the same method with matching of age and sex.nnnRESULTSnIn patients with blunt abdominal injuries, there is a strong difference in liver laceration between elevation of white blood cell (WBC) counts (P = .001), aspartate aminotransferase (AST) (P < .001), and alanine aminotransferase (ALT) (P < .001). A logistic regression model demonstrated that WBC count and AST were independently associated with liver laceration. With elevations of serum AST greater than 100 IU/L, ALT greater than 80 IU/L, and WBC count greater than 10u2005000/mm(3), we found a sensitivity and specificity of 90.0% and 92.3%, respectively, in the 42 liver laceration victims.nnnCONCLUSIONnIn patients with blunt abdominal trauma, elevated WBC counts together with elevated AST and ALT are strongly associated with liver laceration and warrant further imaging studies and management.

Traumatic hyoid bone fracture in patient wearing a helmet: a case report

Fractures of hyoid bone are rare and most of the injuries cause by strangulation. Hyoid bone fractures are usually the result of direct trauma to the neck through manual strangulation or hanging, blunt trauma or from projectiles. But hyoid bone fracture caused by helmet strap has not been reported before. We present a young man wearing a helmet had an isolated hyoid bone fractures after a motorcycle-to-motorcycle accident. So, we should be more aware that helmet wearing riders are prone to have this kind of injury.

Neck collar used in treatment of victims of urban motorcycle accidents: over- or underprotection?

BACKGROUNDnCervical collar brace protection of the cervical spine at the scene of the incident is the first priority for emergency medical technicians treating patients who have sustained trauma. However, there is still controversy between over- or underprotection. The objective of this study was to survey the cervical spine injury of lightweight motorcycle accident victims and further evaluate the neck collar protection policy.nnnMATERIALS AND METHODSnWe retrospectively reviewed patients who sustained lightweight motorcycle injuries, assumed to have been at a low velocity, with incidence of cervical spine damage, from a single medical centers trauma registration from 2008 to 2009. Patients were divided into 2 groups: those who were immobilized by cervical collar brace and those who were not.nnnRESULTSnOf the 8633 motorcycle crash victims, 63 patients had cervical spine injury. The average of the injury severity score in these patients was 14.31 ± 8.25. There was no significant correlation of cervical spine injury between the patients who had had the neck collar applied and those who had not (χ(2), P = .896). The length of stay in intensive care unit was longer in the patients who had the neck collar applied, but the total hospital length of stay was not statistically different to the patients who did not have the neck collar applied.nnnCONCLUSIONnThe incidence of cervical spinal injuries in the urban area lightweight motorcyclists is very low. Prehospital protocol for application of a cervical collar brace to people who have sustained a lightweight motorcycle accident in the urban area should be revised to avoid unnecessary restraint and possible complications.

Protrusion of a migrated fish bone in the neck

Uningested fish bone swallowing is common, but protrusion of the unswallowed fish bone from the neck is very rare. We report a 3-cm fish bone, which was not diagnosed during the patient first visit at emergency room, resulting in a protrusion out of the patients neck skin 21 days later after ingurgitation of the bone. The migrated fish bone was safety pulled out directly after obtaining computed tomography of the neck to make sure no soft tissue or major artery involved. Migration of ingested fish bone is an uncommon complication, which has the potential risk to cause morbidity and mortality. Therefore, if findings of physical examination, x-rays, or laryngoscope are negative, it is important to recheck the patient if sore throat persists. Obtaining a neck computed tomography or performing gastroendoscopy to rule out the possible mis-swallowing of fish bone should be warranted. To the authors knowledge, such a case has not been previously reported in medical literature.

Closed internal degloving injury with conservative treatment.

In the emergency department, we frequently manage patients with multiple contusions and bruise over the trunk without severe injuries. Emergency department discharge is a common option for these patients, and we may neglect the existence of closed internal degloving injury, which is a soft tissue injury with pelvic trauma, combining the subcutaneous tissue torn away from the underlying fascia followed by a cavity being filled with hematoma and liquefied fat created in the next few days (Harefuah 2006;145:111-3:66, J Trauma 1997;42:1046). We report the unusual occurrence of this entity in an 18-year-old man. He encountered a scooter accident and experienced a few days of hospitalization because of thoracispinal (T10 and T11) process fracture. He was discharged, but a fluctuating mass developed at the lumbar area 10 days later. The comprehensive survey excluded the cerebrospinal fluid leakage associated with spinal fracture, and internal degloving injury was diagnosed. Percutaneous drainage with compressive bondage was aggressively used. Even though the treatment course was time consuming, the lesion eventually disappeared 10 months after his first visit.

Traumatic Tricuspid Insufficiency with Chordae Tendinae Rupture: A Case Report and Literature Review

With the increase in the number of automobile accidents, traumatic tricuspid insufficiency, a rare complication of non‐penetrating blunt chest injury, has become an important problem. This kind of injury has been found more frequently during the last decade, partly because of better diagnostic procedures and a better understanding of the pathology. Here, we report a 22‐year‐old male patient who suffered chest trauma from an automobile accident. Echocardiography demonstrated tricuspid chordae tendinae rupture with remarkable tricuspid regurgitation. We discuss this case in comparison with the previous literature. This case reminds us that physicians in the emergency department should be aware of this potential complication following non‐penetrating chest trauma.

Management of motorcycle accident-related blunt hepatic injury-a different strategy.

BACKGROUNDnIn motorcycle accidents, especially in an urban area with lightweight motorcycles, the belly of the motorcyclist is not protected, and this makes this type of trauma a cause of blunt hepatic injuries. This study investigated the effect and safety of using nonoperative management and selective early angioembolization to treat patients with blunt liver injuries as a result of motorcycle accident.nnnMETHODSnThis was a retrospective study of the hepatic injuries sustained by motorcyclists involved in traffic accidents. We collected patient demographic information, the severity of total injuries, grade of liver injury, associated concomitant injuries, management scheme, and outcome of patients from 2006 to 2007. These patients were treated nonoperatively with selective early angioembolization and close monitoring in our intensive care unit (ICU).nnnRESULTSnWe reviewed the cases of 266 patients sustaining blunt abdominal injuries. Thirty-four patients (12.78%) had hepatic injuries. All survived with no obvious morbidity, and no further invasive procedures were performed after admission to ICU. There was no significant association between grade of injury and ICU length of stay (P = .073), but there was a significant association between grade and in-patient length of stay on our regular ward (P = .001).nnnCONCLUSIONnMost patients with hepatic injury caused by motorcycle accidents can be treated safely by nonoperative management. Early selective angioembolization improved the success of nonoperative management of blunt liver injury without other surgical intervention. Routine follow-up with computed axial tomography scans and endoscopic retrograde cholangiopancreatography may not be necessary because complications associated with hepatic injuries were rare.

Eosinophilic Cellulitis After Honeybee Sting

Stings by honeybees are not uncommon and most cases cause pain but no significant medical problems. Some patients, however, have lethal complications such as acute anaphylactic shock. Cellulitis caused by honeybee sting is very rare and can be a late complication in some patients. We report a 45-year-old female patient who was stung by a honeybee, and whose right forearm showed progressive swelling with bullous formation after the sting. She was sent to our emergency department with the diagnosis of right hand cellulitis. After treatment with antibiotics for 5 days, the lesions showed no response. Then, systemic steroid was used and the lesion gradually resolved. Diagnosis of Wells syndrome was made according to clinical appearance, course and characteristic histopathological findings.

Effects of the Emergency Trauma Training Course on the Confidence of Final-Year Medical Students Dealing with Trauma Patients

Trauma is an important issue that has been neglected in the training of medical students. This study evaluated the effects of the Emergency Trauma Training Course (ETTC), after completion of standard medical training, on seventh‐year medical students. The ETTC was designed in Taiwan by the Taiwan Society of Emergency Medicine to train physicians and registered nurses who care for trauma patients in the emergency department (ED). We implemented the course for our medical students internship. One hundred and fifty‐one participants were divided into three groups: Group A included 36 medical students before they entered their internship in hospital; Group B included 41 medical students who had received 6 months of internship training in hospital; and Group C included 74 ED nurses. Group C was used to test Cronbachs alpha coefficient of the questionnaire. After the training course, the participants had a final examination and filled out a questionnaire about the training course and their levels of self‐confidence. There were no differences in scores between the medical students in Groups A and B (p = 0.064). Using repeated measures analysis of variance, we found that confidence before training was low, with no difference between Groups A and B. Confidence improved after training, but there was still no significant difference between the groups (p = 0.875). However, there were significant differences between confidence levels before and after the training course (p < 0.001). Therefore, although inhospital training for 6 months failed to increase confidence, the confidence of final year medical students after completion of their training was improved by the ETTC. This indicates that the ETTC could increase the confidence of participants. This is the first evaluation of the implementation of the ETTC for final‐year medical students in Taiwan. Based on our results, we highly recommend that this training course be taught to final‐year medical students before they practice in hospital.