Hilarie Cranmer

Predictors of delay in presentation to the ED in patients with suspected acute coronary syndromes

Delays in seeking medical attention for patients with acute coronary syndromes (ACS) preclude early application of life-saving treatment and diminish efficacy. Previous studies suggest 3-hour delays between onset of symptoms and ED arrival in patients with typical presentations of acute myocardial infarction (AMI). A prospective observational study was conducted in an urban ED measuring lag time (LT) among adults presenting within 48 hours of onset of symptoms suggestive of ACS. Univariate and multiple regression analyses were performed on 5 predictors: age, sex, symptoms at presentation, and 2 different outcomes (AMI and ACS). Three hundred seventy-four patients were enrolled. Mean age was 63 years with 38% 70 years or older. Seventy-three percent of all patients with suspected ACS presented with chest pain, 27% with atypical symptoms. Overall mean LT was 8.7 hours (standard deviation 11). In subgroup analysis, patients aged >/=70 years were more likely to have LTs >12 hours (29% vs. 19% P =.043) and patients without chest pain had longer mean LTs (11.6 vs. 7.6 hours, P =.01). Delay in ED presentation is group specific. Advanced age and patients with atypical symptoms are predictive of longer LTs. Contrary to previously published data, patients with symptoms suspicious for ACS can delay an average of 9 hours, which might alter current thinking in the prevention and care of these patients.

Assessment of knowledge retention and the value of proctored ultrasound exams after the introduction of an emergency ultrasound curriculum

BackgroundOptimal training required for proficiency in bedside ultrasound is unknown. In addition, the value of proctored training is often assumed but has never been quantified.MethodsTo compare different training regimens for both attending physicians and first year residents (interns), a prospective study was undertaken to assess knowledge retention six months after an introductory ultrasound course. Eighteen emergency physicians and twelve emergency medicine interns were assessed before and 6 months after an introductory ultrasound course using a standardized, image-based ultrasound test. In addition, the twelve emergency medicine interns were randomized to a group which received additional proctored ultrasound hands-on instruction from qualified faculty or to a control group with no hands-on instruction to determine if proctored exam training impacts ultrasound knowledge. Paired and unpaired estimates of the median shift in test scores between groups were made with the Hodges-Lehmann extension of the Wilcoxon-Mann-Whitney test.ResultsSix months after the introductory course, test scores (out of a 24 point test) were a median of 2.0 (95% CI 1.0 to 3.0) points higher for residents in the control group, 5.0 (95% CI 3.0 to 6.0) points higher for residents in the proctored group, and 2.5 (95% CI 1.0 to 4.0) points higher for the faculty group. Residents randomized to undergo proctored ultrasound examinations exhibited a higher score improvement than their cohorts who were not with a median difference of 3.0 (95% CI 1.0 to 5.0) points.ConclusionWe conclude that significant improvement in knowledge persists six months after a standard introductory ultrasound course, and incorporating proctored ultrasound training into an emergency ultrasound curriculum may yield even higher knowledge retention.

Strengthening the Detection of and Early Response to Public Health Emergencies: Lessons from the West African Ebola Epidemic

Mark Siedner and colleagues reflect on the early response to the Ebola epidemic and lessons that can be learned for future epidemics.

Typhoon Haiyan and the Professionalization of Disaster Response

When international medical response teams landed in the Philippines after Typhoon Haiyan, they had to act as professional humanitarian responders. Medical responders to disasters can help best when they are well prepared and function as part of a coordinated effort.

Acute Right Lower Quadrant Pain in a Patient With Leukemia

Typhlitis or neutropenic enterocolitis is a life-threatening, necrotizing process of the cecum whose incidence is increasing. It is usually encountered in patients with leukemia who have recently undergone chemotherapy. Neutropenic enterocolitis presents as fever, abdominal pain, and diarrhea in neutropenic patients. As the incidence of neutropenic enterocolitis increases, emergency physicians must be aware of this rapidly progressive and potentially fatal disease.

Academic Institutions' Critical Guidelines for Health Care Workers Who Deploy to West Africa for the Ebola Response and Future Crises.

The unprecedented Ebola Virus Disease (EVD) outbreak in West Africa, with its first cases documented in March 2014, has claimed the lives of thousands of people, and it has devastated the health care infrastructure and workforce in affected countries. Throughout this outbreak, there has been a critical lack of health care workers (HCW), including physicians, nurses, and other essential non-clinical staff, who have been needed, in most of the affected countries, to support the medical response to EVD, to attend to the health care needs of the population overall, and to be trained effectively in infection protection and control. This lack of sufficient and qualified HCW is due in large part to three factors: 1) limited HCW staff prior to the outbreak, 2) disproportionate illness and death among HCWs caused by EVD directly, and 3) valid concerns about personal safety among international HCWs who are considering responding to the affected areas. These guidelines are meant to inform institutions who deploy professional HCWs.

Development of an Evaluation Framework Suitable for Assessing Humanitarian Workforce Competencies During Crisis Simulation Exercises

The need to provide a professionalization process for the humanitarian workforce is well established. Current competency-based curricula provided by existing academically affiliated training centers in North America, the United Kingdom, and the European Union provide a route toward certification. Simulation exercises followed by timely evaluation is one way to mimic the field deployment process, test knowledge of core competences, and ensure that a competent workforce can manage the inevitable emergencies and crises they will face. Through a 2011 field-based exercise that simulated a humanitarian crisis, delivered under the auspices of the World Health Organization (WHO), a competency-based framework and evaluation tool is demonstrated as a model for future training and evaluation of humanitarian providers.

The Zika Virus outbreak in Brazil: knowledge gaps and challenges for risk reduction

We analyzed uncertainties and complexities of the Zika virus outbreak in Brazil, and we discuss risk reduction for future emergencies. We present the public health situation in Brazil and concurrent determinants of the epidemic and the knowledge gaps that persist despite building evidence from research, making public health decisions difficult. Brazil has adopted active measures, but producing desired outcomes may be uncertain because of partial or unavailable information. Reducing population group vulnerabilities and acting on environmental issues are medium- to long-term measures. Simultaneously dealing with information gaps, uncontrolled disease spread, and vulnerabilities is a new risk scenario and must be approached decisively to face emerging biothreats.

Sign Me Up: Rules of the Road for Humanitarian Volunteers During the Ebola Outbreak

The current Ebola outbreak is the worst global public health emergency of our generation, and our global health care community must and will rise to serve those affected. Aid organizations participating in the Ebola response must carefully plan to carry out their responsibility to ensure the health, safety, and security of their responders. At the same time, individual health care workers and their employers must evaluate the ability of an aid organization to protect its workers in the complex environment of this unheralded Ebola outbreak. We present a minimum set of operational standards developed by a consortium of Boston-based hospitals that a professional organization should have in place to ensure the health, safety, and security of its staff in response to the Ebola virus disease outbreak.

Uterine rupture with peritonitis in a nongravid uterus eight weeks after cesarean section

AbstractThe CT findings of uterine rupture are critical to recognize so that early surgical intervention can improve survival and potentially avoid hysterectomy. We report a case of uterine rupture in a nongravid uterus.