Flavia Nobay

Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized trial of ultrasound in trauma

OBJECTIVE There is a paucity of evidence demonstrating that emergency department (ED) ultrasound changes clinical practice in trauma patients. We hypothesized that the presence of ultrasound would affect clinical decision making as evidenced through abdominal computed tomographic (CT) scan use in blunt multiple trauma patients. METHODS This study used a prospective randomized format in an urban county ED with Level II trauma center status (ED census, 72,000 patients per year). Participants were patients with multiple blunt injuries meeting trauma center triage criteria. Patients were randomized to receive either abdominal ultrasound or no ultrasound (control) during initial ED resuscitation. The primary outcome variable was use of abdominal CT scan in patients with and without ultrasound. RESULTS Two hundred eight patients were enrolled. The mean age was 40 +/- 18 years, and 62% were men. Mechanism of injury was motor vehicle crash, 56%; automobile versus pedestrian, 18%; motorcycle crash, 16%; falls, 10%; and other, 10%. One hundred four ultrasound and 104 control patients were analyzed. There were no apparent differences between ultrasound and control groups in demographics, injury type, or Injury Severity Score. Fifty-four of 104 (52%) of the control group received abdominal CT scans versus 37 of 104 (36%) abdominal CT scans for the ultrasound group; mean difference in proportions was 15.9 (p < 0.01; 95% confidence interval, 2.6-29.1). CONCLUSION In this trial, the routine use of abdominal ultrasound in the evaluation of patients with multiple blunt injuries resulted in significantly fewer abdominal CT scans being obtained. A larger trial is needed to more clearly define the clinical and financial impact of ultrasound in the management of blunt abdominal trauma.

The Outcomes of Emergency Pharmacist Participation During Acute Myocardial Infarction

BACKGROUND Current guidelines recommend door-to-balloon times of 90 min or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction (STEMI). OBJECTIVES To determine if a clinical pharmacist for the ED (EPh) is associated with decreased door/diagnosis-to-cardiac catheterization laboratory (CCL) time and decreased door-to-balloon time. METHODS A retrospective observational cohort study of ED patients with STEMI requiring urgent cardiac catheterization was conducted. Blinded data collection included timing of ED and CCL arrival, diagnostic electrocardiogram (ECG), and balloon angioplasty. For cases diagnosed after ED arrival, diagnosis time was substituted for door time. Diagnosis was the time ST elevations were evident on serial ECG. EPh present and not-present groups were compared. During the study period there were two EPhs and presence was determined by their scheduled time in the ED. Univariate and multivariate analyses was used to detect differences. RESULTS Multivariate analysis of 120 patients, controlled for CCL staff presence and arrival by pre-hospital services, determined that EPh presence is associated with a mean 13.1-min (95% confidence interval [CI] 6.5-21.9) and 11.5-min (95% CI 3.9-21.5) decrease in door/diagnosis-to-CCL and door-to-balloon times, respectively. Patients were more likely to achieve a door/diagnosis-to-CCL time≤ 30 min (odds ratio [OR] 3.1, 95% CI 1.3-7.8) and≤ 45 min (OR 2.9, 95% CI-1.0, 8.5) and a door-to-balloon time≤ 90 min (OR 1.9, 95% CI 0.7-5.5) more likely when the EPh was present. CONCLUSIONS EPh presence during STEMI presentation to the ED is independently associated with a decrease in door/diagnosis-to-CCL and door-to-balloon times.

Emergency Department Ultrasound Credentialing: A Sample Policy and Procedure

Emergency physician use of bedside ultrasound has increased dramatically over the last two decades. However, many emergency departments find it difficult to gain formal hospital credentialing for bedside sonography. We present the Emergency Department (ED) Ultrasound Credentialing Policy from the University of California, San Francisco. Although the American College of Emergency Physicians has published formal guidelines on this subject, they are not written in such a way that they are readily transcribed into a document suitable for review by credentialing committees and executive medical boards. Our policy details the background of emergency bedside ultrasound, the goals of its use, the scope of emergency physician sonography, credentialing criteria, and an example of a quality assurance program. We have not changed the components of the previously published guidelines. Rather, this document has withstood the rigor of our own credentialing process and is presented as an example in the hopes that it may help other EDs who seek credentialing in their institutions. This document is intended as a guideline for credentialing committees and will require alteration to meet the needs of each different hospital; however, the overall framework should allow for a less time-consuming process.

Pitfalls in First-Trimester Bleeding

The focus of this article is first-trimester bleeding. Vaginal bleeding during the first 3 months of pregnancy is a common event. It is important that the emergency physicians recognize patients with vaginal bleeding who may have an adverse outcome if misdiagnosed or not treated appropriately in the emergency department. Causes of first-trimester vaginal bleeding include implantation bleeding, spontaneous abortions, ectopic pregnancy, and lesions involving the female reproductive system and perineal area infections.

The Development of Best Practice Recommendations to Support the Hiring, Recruitment, and Advancement of Women Physicians in Emergency Medicine

BACKGROUND Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support womens professional development in both community and academic EM settings. METHODS We formed a working group from the leadership of two EM womens organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. RESULTS An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. CONCLUSIONS Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

A Novel Internet Based Geriatric Education Program for Emergency Medical Services Providers

Despite caring for large numbers of older adults, prehospital emergency medical services (EMS) providers receive minimal geriatrics‐specific training while obtaining their certification. Studies have shown that they desire further training to improve their comfort level and knowledge in caring for older adults, but continuing education programs to address these needs must account for each EMS providers specific needs, consider each providers learning styles, and provide an engaging, interactive experience. A novel, Internet‐based, video podcast–based geriatric continuing education program was developed and implemented for EMS providers, and their perceived value of the program was evaluated. They found this resource to be highly valuable and were strongly supportive of the modality and the specific training provided. Some reported technical challenges and the inability to engage in a discussion to clarify topics as barriers. It was felt that both of these barriers could be addressed through programmatic and technological revisions. This study demonstrates the proof of concept of video podcast training to address deficiencies in EMS education regarding the care of older adults, although further work is needed to demonstrate the educational effect of video podcasts on the knowledge and skills of trainees.

Iodide mumps: a case report of complicated radioactive iodine causing sialadenitis

Radiation sialadenitis is an uncommon adverse reaction to radioactive iodide therapy. Sialadenitis due to radiation exposure has a dose-related damage that can follow an acute or chronic inflammatory nature. We present a case of a patient who developed radiation sialadenitis after radioactive iodide therapy for papillary thyroid cancer resulting in severe parotid swelling and swelling, which resulted in an emergency department visit and had complete resolution with conservative management.

Sick and unsheltered: Homelessness as a major risk factor for emergency care utilization

Objective Homelessness is a critical public health issue and socioeconomic epidemic associated with a disproportionate burden of disease and significant decrease in life expectancy. We compared emergency care utilization between individuals with documented homelessness to those enrolled in Medicaid without documented homelessness. Methods We conducted a retrospective cohort study consisting of electronic medical record review of demographics, chief complaints, and health care utilization metrics of adults with homelessness compared to a group enrolled in Medicaid without identified homelessness. The chart review spanned two years of emergency visits at a single urban, academic, tertiary care medical center. Descriptive statistics, bivariate and multivariate analyses were utilized. Results Over the study period, 986 patients experiencing homelessness accounted for 7532 ED visits, with a mean of 7.6 (SD 19.9) and max of 316 visits. The control group of 3482 Medicaid patients had 5477 ED visits, with a mean of 1.6 visits (SD 2.1) and max of 49 visits. When controlling for age, sex, race, ethnicity, and ESI, those living with homelessness were 7.65 times more likely to return to the ED within 30 days of their previous visit, 9.97 times more likely to return within 6 months, 10.63 times more likely to return within one year, and 11 times more likely to return within 2 years. Conclusions Compared to non‐homeless Medicaid patients, patients with documented homelessness were over seven times more likely to return to the ED within 30 days and over eleven times more likely to return to the ED in two years.

Bronchoscopic Findings Associated with Inhaled Chlorine Toxicity.

A 42-year-old male presented to the emergency department (ED) with respiratory distress shortly after accidentally inhaling granular chlorine powder while treating his pool. He reported a history of hypertension, was not a smoker, and had no history of reactive airway disease. After exposure to the powdered chlorine, the patient immediately noticed symptoms of shortness of breath, cough, chest tightness, eye pain, tearing, and blurred vision. Per Emergency Medical Services (EMS), he was placed on 100% oxygen via a nonrebreather for respiratory distress, despite initial O2 saturation of 97% and over the course of transport his O2 saturation dropped to 88%. EMS noted significant diaphoresis and flushing. Upon arrival, his vital signs included an oxygen saturation of 99% on room air. Physical examination revealed mild expiratory wheezes and bilaterally injected sclerae. The patient’s presenting chest x-ray study (Figure 1) was relatively unremarkable. Despite his benign appearance on initial presentation and treatment with bronchodilators, he rapidly deteriorated and developed increasing shortness of breath, cough, and bilateral crackles on examination. He was admitted to the intensive care unit, where he was eventually intubated > 60 h after his exposure for worsening respiratory distress. A post-intubation chest x-ray study revealed significant pulmonary edema, acute respiratory distress