David E. Manthey

The Impact of Psychiatric Patient Boarding in Emergency Departments

Objectives. Studies have demonstrated the adverse effects of emergency department (ED) boarding. This study examines the impact of resource utilization, throughput, and financial impact for psychiatric patients awaiting inpatient placement. Methods. The authors retrospectively studied all psychiatric and non-psychiatric adult admissions in an Academic Medical Center ED (>68,000 adult visits) from January 2007-2008. The main outcomes were ED length of stay (LOS) and associated reimbursement. Results. 1,438 patients were consulted to psychiatry with 505 (35.1%) requiring inpatient psychiatric care management. The mean psychiatric patient age was 42.5 years (SD 13.1 years), with 2.7 times more women than men. ED LOS was significantly longer for psychiatric admissions (1089 min, CI (1039–1140) versus 340 min, CI (304–375); P < 0.001) when compared to non-psychiatric admissions. The financial impact of psychiatric boarding accounted for a direct loss of (

Emergency medicine clerkship curriculum: an update and revision.

1,198) compared to non-psychiatric admissions. Factoring the loss of bed turnover for waiting patients and opportunity cost due to loss of those patients, psychiatric patient boarding cost the department

Tension Hydrothorax Due to Ventriculopleural Shunting

2,264 per patient. Conclusions. Psychiatric patients awaiting inpatient placement remain in the ED 3.2 times longer than non-psychiatric patients, preventing 2.2 bed turnovers (additional patients) per psychiatric patient, and decreasing financial revenue.

The Centers for Medicare and Medicaid Services (CMS) Community-Acquired Pneumonia Core Measures Lead to Unnecessary Antibiotic Administration by Emergency Physicians

In 2006, the latest version of a national curriculum for the fourth-year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth-year EM clerkship educational syllabi has been developed.

Painless acute aortic dissection presenting as left lower extremity numbness

Tension hydrothorax is rare, with few cases reported in the literature dating back to the late 1960s. We report a case of tension hydrothorax in a patient with a ventriculopleural shunt who improved dramatically after thoracentesis. The discussion includes a brief review of ventriculopleural shunts and pleural physiology.

Videos in clinical medicine. Emergency pericardiocentesis.

OBJECTIVES The objectives were to assess emergency physician (EP) understanding of the Centers for Medicare and Medicaid Services (CMS) core measures for community-acquired pneumonia (CAP) guidelines and to determine their self-reported effect on antibiotic prescribing patterns. METHODS A convenience sample of EPs from five medical centers in North Carolina was anonymously surveyed via a Web-based instrument. Participants indicated their level of understanding of the CMS CAP guidelines and the effects on their prescribing patterns for antibiotics. RESULTS A total of 121 EPs completed the study instrument (81%). All respondents were aware of the CMS CAP guidelines. Of these, 95% (95% confidence interval [CI] = 92% to 98%) correctly understood the time-based guidelines for antibiotic administration, although 24% (95% CI = 17% to 31%) incorrectly identified the onset of this time period. Nearly all physicians (96%; 95% CI = 93% to 99%) reported institutional commitment to meet these core measures, and 84% (95% CI = 78% to 90%) stated that they had a department-based CAP protocol. More than half of the respondents (55%; 95% CI = 47% to 70%) reported prescribing antibiotics to patients they did not believe had pneumonia in an effort to comply with the CMS guidelines, and 42% (95% CI = 34% to 50%) of these stated that they did so more than three times per month. Only 40% (95% CI = 32% to 48%) of respondents indicated a belief that the guidelines improve patient care. Of those, this was believed to occur by increasing pneumonia awareness (60%; 95% CI = 52% to 68%) and improving hospital processes when pneumonia is suspected (86%; 95% CI = 80% to 92%). CONCLUSIONS Emergency physicians demonstrate awareness of the current CMS CAP guidelines. Most physicians surveyed reported the presence of institutional protocols to increase compliance. More than half of EPs reported that they feel the guidelines led to unnecessary antibiotic usage for patients who are not suspected to have pneumonia. Only 40% of EPs believe that CAP awareness and expedient care resulting from these guidelines has improved overall pneumonia-related patient care. Outcome-based data for non-intensive care unit CAP patients are lacking, and EPs report that they prescribe antibiotics when they may not be necessary to comply with existing guidelines.

Pediatric Case of Accidental Oral Overdose of Methotrexate

Acute aortic dissection may have variable presentations, making the diagnosis clinically challenging. Acute neurologic syndromes secondary to dissection of the aorta are uncommon. However, including aortic dissection in the differential diagnosis is imperative. This report describes the first reported case of an acute thoracic aortic dissection presenting with the chief complaint of unilateral lower extremity numbness. Peripheral ischemic neuropathy as the result of vascular occlusion is uncommon. The pathophysiology and clinical manifestations of ischemic neuropathies in the setting of acute aortic dissection are discussed.

Stages of competency for medical procedures

INDICATIONS Pericardiocentesis is indicated as an emergency procedure in patients with cardiac tamponade. Accumulation of fluid in the pericardial sac can increase the pressure around the heart. The intrapericardial pressure then increases until it equals the right ventricular diastolic pressure and then the left ventricular diastolic pressure, which leads to impaired cardiac filling and decreased cardiac output.1 The drop in cardiac output resulting from this increased pressure can be severe enough to cause pulseless electrical activity. Because of the distensibility of the pericardial sac, large amounts of f luid can accumulate gradually without hemodynamic effects. However, rapid accumulation of a small amount of fluid may overwhelm the distensibility of the pericardium with a rapid increase in intrapericardial pressure, leading to hemodynamic compromise.2 The classic presentation of patients with pericardial tamponade includes Beck’s triad of jugular venous distention from elevated systemic venous pressure, distant heart sounds, and hypotension.3 Most patients will have at least one of these signs; all three rarely appear simultaneously, and then only briefly before cardiac arrest. Jugular venous distention can be difficult to assess in obese or hypovolemic patients. Distant heart sounds may signify a pericardial effusion but can also occur in response to obesity or chronic obstructive pulmonary disease. A pericardial friction rub may or may not be present, regardless of the size of the effusion,1 but is often present with an inflammatory effusion.2 Tachypnea is a common clinical finding in patients with cardiac tamponade,1 and dyspnea is the most frequently reported symptom on presentation,4 with a sensitivity of about 87 to 88% for cardiac tamponade.1,5 Other signs of cardiac tamponade include a pulsus paradoxus (a drop in systolic pressure greater than 10 mm Hg during normal inspiration), an electrocardiogram with a low-voltage QRS or electrical alternans, and Kussmaul’s sign, in which there is increased jugular venous distention on inspiration. In most cases, acute pericardial fluid collection is not detected on chest radiography unless more than 200 ml of fluid has accumulated. Enlarged cardiac silhouettes are more likely to be seen in cases of postsurgical or chronic pericardial fluid collections. In such patients, the detection of cardiomegaly on chest radiography has a sensitivity of about 89% for cardiac tamponade.1 The rate of pericardial fluid accumulation has a sizable effect on the rate of clinical decompensation. The pericardial sac normally contains 15 to 30 ml of serous fluid.1 A patient with a rapidly accumulating pericardial effusion may present with severe respiratory distress, agitation, tachycardia, and hypotension, followed by quick progression to obtundation, bradycardia, and pulseless electrical activity.

Developing a Third‐year Emergency Medicine Medical Student Curriculum: A Syllabus of Content

Methotrexate is a chemotherapy antimetabolite, folic acid antagonist, that inhibits the enzyme dihydrofolate reductase resulting in decreased levels of tetrahydrofolate in the cells. This in turn blocks synthesis of thymidylate, a nucleotide necessary for DNA synthesis. It is readily absorbed from the gastrointestinal tract. Toxicity from overdose can affect multiple organ systems including bone marrow, liver, intestinal tract, kidneys, lungs, skin, and blood vessels, resulting in death in severe cases. Methotrexate is widely used to treat neoplastic disease, dermatologic disorders (psoriasis), and rheumatologic disorders (severe rheumatoid arthritis). As its indications for use increase, more accidental overdoses can be expected. We present the treatment and clinical course of one such case, that of a 2-year-old who accidentally took her grandmothers arthritis pills. Her initial serum level was 10 times greater than that needed to cause toxicity. She was treated with gastric lavage, activated charcoal, leucovorin rescue, and ICU admission. Her clinical course was unremarkable, and the only evidence of toxicity was a mild elevation in a liver-associated enzyme that resolved without any clinical sequela. Leucovorin at a dose equal to or greater than the possible ingestion should be given as soon as possible in methotrexate overdoses.

Faculty physicians and new physicians disagree about which procedures are essential to learn in medical school.

Background:  Basic medical procedures have historically been taught at the bedside, without a formal curriculum. The supervision of basic procedures is often provided by the next most senior member of the health care team, who themselves may have very little experience. This approach does not allow for preparatory reading or deliberate practise of the procedure, and trainees often track the number of completed procedures as the only evidence of competency, without documented assessments of quality.