Edward Ullman

Benefit of Transferring ST-Segment–Elevation Myocardial Infarction Patients for Percutaneous Coronary Intervention Compared With Administration of Onsite Fibrinolytic Declines as Delays Increase

Background— Although randomized trials suggest that transfer for primary percutaneous coronary intervention (X-PCI) in ST-segment–elevation myocardial infarction is superior to onsite fibrinolytic therapy (O-FT), the generalizability of these findings to routine clinical practice is unclear because door-to-balloon (XDB) times are rapid in randomized trials but are frequently prolonged in practice. We hypothesized that delays resulting from transfer would reduce the survival advantage of X-PCI compared with O-FT. Methods and Results— ST-segment–elevation myocardial infarction patients enrolled in the National Registry of Myocardial Infarction (NRMI) within 12 hours of pain onset were identified. Propensity matching of patients treated with X-PCI and O-FT was performed, and the effect of PCI-related delay on in-hospital mortality was assessed. PCI-related delay was calculated by subtracting the XDB from the door-to-needle time in each matched pair. Conditional logistic regression adjusted for patient and hospital variables identified the XDB door-to-needle time at which no mortality advantage for X-PCI over O-FT was present. Eighty-one percent of X-PCI patients were matched (n=9506) to O-FT patients (n=9506). In the matched cohort, X-PCI was performed with delays >90 minutes in 68%. Multivariable analysis found no mortality advantage for X-PCI over O-FT when XDB door-to-needle time exceeded ≈120 minutes. Conclusion— PCI-related delays are extensive among patients transferred for X-PCI and are associated with poorer outcomes. No differential excess in mortality was seen with X-PCI compared with O-FT even with long PCI-related delays, but as XDB door-to-needle time times increase, the mortality advantage for X-PCI over O-FT declines.

Morbidity of DSM-IV Axis I disorders in patients with noncardiac chest pain: Psychiatric morbidity linked with increased pain and health care utilization.

The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) revealed a psychiatrically heterogeneous sample of whom 44% had a current Axis I psychiatric disorder. A total of 41% were diagnosed with a current anxiety disorder, and 13% were diagnosed with a mood disorder. Overall, 75% of patients had an Axis I clinical or subclinical disorder. Lifetime diagnoses of anxiety (55%) and mood disorders (44%) were also prevalent, including major depressive disorder (41%), social phobia (25%), and panic disorder (22%). Patients with an Axis I disorder reported more frequent and more painful chest pain compared with those without an Axis I disorder. Presence of an Axis I disorder was associated with increased life interference and health care utilization. Findings reveal that varied DSM-IV Axis I psychiatric disorders are prevalent among patients with NCCP, and this psychiatric morbidity is associated with a less favorable NCCP presentation. Implications for early identification of psychiatric disorders are discussed.

Acute complications associated with shoulder dislocation at an academic Emergency Department.

Shoulder dislocation is the most frequent dislocation treated in the Emergency Department (ED). Orthopedic literature cites up to a 55% incidence of fracture, vascular or neurologic injury associated with this injury, but these studies suffer from referral bias. No large ED series has been reported. This retrospective chart review was conducted in an academic ED for patients with shoulder dislocation presenting July 1, 1995-June 30, 2000. There were 263 charts identified; 73 were miscoded and 5 were lost, leaving 190 for analysis. Mean age was 34.3 years. Fifty-five patients had at least one fracture (29%), 48 of which (76%) were of the Hill-Sachs type. Despite presence of a fracture, all shoulders underwent successful ED reduction. Sensory nerve deficits were found in 24 (12.6%), which persisted after reduction in 25% of these patients. No vascular injuries were identified. The finding of fracture in 33% of patients with shoulder dislocation is in the range of rates reported in the orthopedic literature (15-55%). The finding that, despite the presence of a fracture, all underwent successful closed reduction is important, as one-third of these patients will have this condition. Neurologic deficits in 12% is significantly lower than the 21-65% reported in the orthopedic literature. Although complications associated with shoulder dislocation were relatively common, they did not significantly affect ED management.

Pulmonary trauma: Emergency department evaluation and management

Pulmonary trauma is a significant cause of morbidity and mortality in the United States. It is imperative for the emergency physician to identify promptly patients who require immediate therapy. In patients who have limited injuries, literature shows that often conservative management provides improved outcome. As the exposure to automobiles and firearms continues to increase in the setting of improved prehospital management, the emergency physician will encounter an increasing amount of pulmonary trauma. This rise in respiratory injuries will require a more aggressive approach of patients with minimal morbidity and mortality. A systematic approach to respiratory injuries is crucial to improving patient outcomes.

Complete heart block complicating the head impulse test.

BACKGROUND Symptoms of acute vestibular syndrome include dizziness, nausea, vomiting, and postural instability. The cause may be a peripheral or central lesion. Distinguishing between these two causes is critical because the treatments differ completely. One bedside test to help make this distinction clinically is the head impulse test (HIT), sometimes called the head thrust test. OBJECTIVE To describe a case of complete heart block associated with performance of the HIT. DESIGN Case report. SETTING Academic medical center. PATIENT A 52-year-old woman presented to the emergency department with sudden onset of dizziness. INTERVENTION The HIT. MAIN OUTCOME MEASURE Use of the HIT to help distinguish between a peripheral or central lesion in a patient with dizziness. RESULTS Complete heart block occurred immediately after performance of the HIT. CONCLUSIONS Physicians may perform this test in an office, emergency department, or inpatient setting and should be aware that occasionally patients may have a severe vagal reaction including complete heart block.

Physician Variability in Management of Emergency Department Patients with Chest Pain

Introduction Chest pain is a common emergency department (ED) presentation accounting for 8–10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level. Methods We conducted a single-institution retrospective observational study of ED patients with a diagnosis of chest pain as determined by diagnostic code from our hospital administrative database. We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram (ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into two groups: “admission” (this included observation and inpatients) and “discharged.” We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values. Results Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89–172). Average admission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’ characteristics, years elapsed since finishing medical school demonstrated a trend towards association with a higher admission probability. Conclusion There is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role.

Evaluating the utility of ST elevation in lead II > lead III in differentiating pericardial disease from STEMI

Background Accurate diagnosis of ST elevation myocardial infarction (STEMI) is complicated by the presence of mimickers such as pericarditis, one of the most common reasons for (negative) emergency cardiac catheterization. Beyond common electrocardiogram (ECG) criteria for pericarditis, a rule of ST segment elevation in lead II greater than lead III (II > III), has been described in literatures and lectures to suggest pericardial disease (PD) and not STEMI. The objective of this study is to define the operating characteristics for the ability of the II > III rule to discriminate PD from STEMI.

Re: “Emergency Medicine Faculty Are Poor at Predicting Burnout in Individual Trainees: An Exploratory Study”

Burnout is a serious and growing condition in emergency medicine, and as the article suggests, it is significantly underrecognized. While the article is laudable in many respects, the authors do not spend much time discussing the ethical and professional implications of discovering serious negative mental states in residents as part of their study. How was this sensitive information handled after it was discovered? Were the residents informed if they tested positive or informed that their mentor thought they were burned out? Was the residency leadership or was their mentor informed of their status? Given this incredible sensitive information and its potential implications we think that it is important for them to comment on the consent process and the guidance they received from the human subject review board to make the article stronger in its own right and for setting precedent for future investigations. Matthew L. Wong, MD, MPH and Edward Ullman, MD Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (MLWong@bidmc.harvard.edu)

Derivation and Validation of a Record Linkage Algorithm between EMS and the Emergency Department

Background Linking EMS electronic patient care reports (ePCRs) to ED records can provide clinicians access to vital information that can alter management. It can also create rich databases for research and quality improvement. Unfortunately, previous attempts at ePCR - ED record linkage have had limited success. Objective To derive and validate an automated record linkage algorithm between EMS ePCR’s and ED records using supervised machine learning. Methods All consecutive ePCR’s from a single EMS provider between June 2013 and June 2015 were included. A primary reviewer matched ePCR’s to a list of ED patients to create a gold standard. Age, gender, last name, first name, social security number (SSN), and date of birth (DOB) were extracted. Data was randomly split into 80%/20% training and test data sets. We derived missing indicators, identical indicators, edit distances, and percent differences. A multivariate logistic regression model was trained using 5k fold cross-validation, using label k-fold, L2 regularization, and class re-weighting. Results A total of 14,032 ePCRs were included in the study. Inter-rater reliability between the primary and secondary reviewer had a Kappa of 0.9. The algorithm had a sensitivity of 99.4%, a PPV of 99.9% and AUC of 0.99 in both the training and test sets. DOB match had the highest odd ratio of 16.9, followed by last name match (10.6). SSN match had an odds ratio of 3.8. Conclusions We were able to successfully derive and validate a probabilistic record linkage algorithm from a single EMS ePCR provider to our hospital EMR.

Interview day environment may influence applicant selection of emergency medicine residency programs

Introduction The structure of the interview day affects applicant interactions with faculty and residents, which can influence the applicant’s rank list decision. We aimed to determine if there was a difference in matched residents between those interviewing on a day on which didactics were held and had increased resident and faculty presence (didactic day) versus an interview day with less availability for applicant interactions with residents and faculty (non-didactic day). Methods This was a retrospective study reviewing interview dates of matched residents from 2009–2015. Results Forty-two (61.8%) matched residents interviewed on a didactic day with increased faculty and resident presence versus 26 (38.2%) on a non-didactic interview day with less availability for applicant interactions (p = 0.04). Conclusion There is an association between interviewing on a didactic day with increased faculty and resident presence and matching in our program.