Jason D. Heiner

The Ultrasound Identification of Simulated Long Bone Fractures by Prehospital Providers

OBJECTIVEnIn austere environments, patient management decisions are often limited by obtainable resources. Portable ultrasound may allow for the detection of fractures when imaging modalities such as radiography are unavailable. We used a simulation training model in a pilot study to examine the ability of emergency medical technicians (EMTs) to detect the presence or absence of a variety of simulated fracture patterns with portable ultrasound.nnnMETHODSnThe fracture simulation model is composed of a mechanically fractured bare turkey leg bone housed in a shallow container within a completely opaque gelatin solution. Five different fracture patterns were created. Twenty EMTs sonographically evaluated these models with a portable ultrasound device to determine the presence or absence of a fracture.nnnRESULTSnEMTs correctly identified the presence or absence of a fracture in the no fracture, transverse fracture, and oblique fracture models 95% of the time. They always correctly identified the presence of a fractured model when assessing the comminuted and segmental fracture models. Across all fracture patterns, a final detection sensitivity of 97.5% (95% confidence interval [CI]: 94.1%-100.0%) and a specificity of 95.0% (95% CI: 85.4%-100.0%) were observed.nnnCONCLUSIONSnUsing portable ultrasound, EMTs correctly detected the presence or absence of simulated long bone fractures with a high degree of sensitivity and specificity. Future studies may evaluate the ability of other groups to use ultrasound to assist in the diagnosis of fractures and examine the clinical impact of this skill in environments where conventional imaging modalities are limited or unavailable.

A Child with Benign Acute Childhood Myositis After Influenza

BACKGROUNDnBenign acute childhood myositis (BACM) is a rare transient muscle syndrome classically occurring in children after a viral upper respiratory infection (URI). BACM causes difficulty walking due to severe bilateral calf pain. The incidence of this well-described phenomenon is uncertain but infrequent, and it is typically appreciated during times of large influenza outbreaks and epidemics. The URI symptoms that precede BACM are consistent with an uncomplicated viral influenza infection and include fever, malaise, cough, sore throat, headache, and rhinitis.nnnOBJECTIVESnLittle is written in the Emergency Medicine literature regarding this clinical entity. In this report, a brief review of BACM from the current literature is provided, as well as tools to aid in differentiating it from more severe but similar disorders such as rhabdomyolysis and Guillain-Barré syndrome.nnnCASE REPORTnWe present a case of BACM in a 7-year-old boy who presented to the emergency department after a resolving URI with the acute onset of calf pain causing alarming difficulty in his ability to walk. His presentation was typical for BACM and his condition improved with supportive treatment.nnnCONCLUSIONSnAlthough quite alarming and potentially puzzling to the physician who is not familiar with BACM, this syndrome is self limited and spontaneously resolves with no specific intervention. Recognition of this rare but distinct clinical entity by the emergency physician can spare a patient from potentially unneeded invasive testing and hospital admission.

A Simulation Model for the Ultrasound Diagnosis of Long-bone Fractures

Introduction: Ultrasound is emerging as a promising tool for the diagnosis of skeletal fractures, particularly in environments where conventional radiography may be absent or limited. This article presents a high-fidelity, practical simulation model for the ultrasound diagnosis of long-bone fractures and also examines the ability of physicians to diagnose the presence or absence of different fracture patterns using this model. Methods: The bony component of the model is a bare turkey leg bone that is mechanically fractured and housed in a shallow plastic container within a gelatin-based solution. Twenty physicians sonographically evaluated five models with different fracture patterns for the presence or absence of a fracture and were then queried regarding their opinion of this model as a teaching tool. Results: Physicians were able to correctly identify the presence or absence of a fractured model with 100% sensitivity and 100% specificity across all fracture patterns and expressed agreement that this would be a useful teaching model. Conclusions: This high-fidelity, practical model is simple to construct, and the creation of a variety of fracture patterns is possible. Physicians found this to be a potentially useful teaching tool and correctly identified the presence or absence of different simulated fractures. Further studies may validate this simulation model as a teaching tool in the sonographic assessment of long bones for the presence of fractures and examine the potential clinical impact of this trainer.

Cervical epidural hematoma after chiropractic spinal manipulation

Spinal epidural hematoma is a rare but potentially devastating complication of spinal manipulation therapy. This is a case report of a healthy pregnant female who presented to the emergency department with a cervical epidural hematoma resulting from chiropractic spinal manipulation therapy that responded to conservative treatment rather than the more common route of surgical management.

The ability of emergency nurses to detect simulated long bone fractures with portable ultrasound

Fractures are a common emergency department (ED) diagnosis. Ultrasound is a useful tool to evaluate for the presence of long bone fractures and can be performed by minimally trained individuals. We examined the ability of ED nurses to sonographically detect long bone fractures using a recently described training model. The fracture model consisted of a turkey long bone within a firm gelatin matrix. Emergency nurses examined five fracture models with a portable ultrasound machine to determine the presence or absence of a fracture. Overall accuracy was compared via chi-square analysis to the ability of physicians to complete the same assessment. Thirty nurses sonographically assessed the models. An overall sensitivity of 98% (95% confidence interval: 92-99%) and specificity of 93% (95% confidence interval: 76-99%) was observed for the detection of a fractured model. No difference in fracture detection accuracy (p>0.05) was revealed compared to an evaluation by 30 ED physicians. While the clinical impact of this ability remains uncertain, future utilization of nursing ability to detect fractures by ultrasound may improve patient care in ways such as more efficient triaging of radiographs and the mobilization of resources for fracture reduction.

A new simulation model for skin abscess identification and management.

Introduction: Cutaneous abscesses are common, and emergency physicians in training must develop competency with abscess identification and management through incision and drainage. Although simulation models can enable proficiency in such skills, current abscess models described in the literature suffer from limitations. The author presents a novel abscess management training simulator evaluated by physicians. Methods: An artificial abscess wall tunneled near the surface of a chicken breast is injected with mock purulent material to create the simulator. Twenty physicians familiar with abscess identification and management assessed the model. The educational value of the model and its sonographic fidelity were evaluated via closed-ended questions and open-ended feedback. Results: All 20 physician evaluators agreed that an abscess simulator model would be a useful teaching tool and that this particular abscess model would be a useful teaching tool. The evaluators found the model to realistically simulate a real abscess, but cited the lack of purulent loculations as a potential limitation. When responding to the statement “the ultrasound image of the simulated abscess appears realistic,” all physicians either “strongly agreed” or “agreed” with the statement (n = 20). Discussion: This new simulation model may be an effective tool to teach skin abscess management. Physicians who evaluated the simulated abscess found that it replicates the classic palpable fluctuance and ultrasound findings of an actual abscess, and it can be surgically incised and drained in a similar fashion. Although physicians agreed that this model would be useful, future studies may validate this task trainer as an effective teaching tool.

10% Povidone-Iodine May Be a Practical Field Water Disinfectant

OBJECTIVEnA paucity of data exists regarding the use of iodophores such as povidone-iodine (PVI) to disinfect water. We sought to determine a practical minimal disinfecting concentration of 10% PVI over different contact times and temperatures when added to water inoculated with E. coli.nnnMETHODSn1:100, 1:1,000, and 1:10,000 dilutions of 10% PVI were created. Escherichia coli was exposed to these dilutions for 5, 15, and 30 minutes at 10, 20, and 30°C. Bactericidal activity was neutralized with 0.5% sodium thiosulfate. Mean viable colony forming units (CFUs) was determined after triplicate plating on Luria-bertani agar and 24 hours of incubation at 37°C. Effective bactericidal activity was defined as a 5-log reduction.nnnRESULTSnOf the 200,000 E. coli plated, no CFUs were observed after exposure to the 1:100 dilution. After 5 minutes of contact time with the 1:1,000 dilution, at 10°C CFUs were too numerous to count (TNTC), at 20°C the mean CFU count was 92 (standard error ±11), and at 30°C the mean CFU count was 25 (standard error ±8). No CFUs were observed after 15 minutes of exposure to the 1:1,000 dilution across experimental temperatures. The 1:10,000 dilution always yielded CFU growth that was TNTC.nnnCONCLUSIONSnThe lowest disinfecting concentration of 10% PVI was the 1:1,000 dilution at 15 minutes of contact time. This supports the use of PVI for water disinfection against E. coli, the organism most commonly responsible for travelers diarrhea. Further studies may assess its effectiveness against more virulent water borne pathogens.

Coping with the death of a patient in the emergency department.

p r d y p p o r [Ann Emerg Med. 2011;58:295-298.] Facing the death of a patient can have a profound emotional influence on the physician. The act of communicating this loss to surviving family and friends is difficult under the best of circumstances and may be even more challenging in a busy emergency department with a sudden, unpredicted death. However, the medical literature for any specialty rarely discusses the lasting effect of a patient’s death on the physician. There is a paucity of relevant discussion in both the general emergency medicine literature and emergency medicine resident training program curricula. In fact, the existing emergency medicine literature is limited to educational topics such as death notification, organ donation, and postdeath procedures. In this Residents’ Perspective, we discuss what may be learned from other specialties about the effects of patient death on the physician and potentially useful coping tools and resources that are available. We pay particular attention to how emergency medicine residents can best prepare for, learn from, and grow through this often challenging experience.

Blurry Vision and Abnormal Sweating

A 29-year-old woman presented to the emergency department, complaining of slightly blurry vision. She also observed that after exercise, her face seemed to sweat unevenly. A white perspiration detection powder was applied to her face, which changes color from white to deep purple in the presence of moisture by an iodinated starch reaction. The staining pattern shown was revealed after she was placed in a hot room for several minutes (Figure). Figure. After application of perspiration detection powder and placement in a hot room. Used with permission of Jason D. Heiner, MD, Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA.

Pediatric Urinary Retention and Constipation: Vaginal Agenesis with Hematometrocolpos

An 11-year-old healthy female presented to the emergency department with three days of worsening suprapubic pain, urinary retention, and constipation. She was afebrile with normal vital signs. Her physical examination was notable for suprapubic distention and bulging pink vaginal tissue at the introitus. Bedside ultrasound suggested a distended bladder. Placement of a Foley catheter returned 550mL of urine with improvement of the patient’s discomfort, but repeat ultrasound visualized a persistent hypoechoic mass adjacent to the newly decompressed bladder (Figure). The obstructive cause of her abdominal pain and urinary retention was revealed by magnetic resonance imaging (MRI) of the pelvis, which confirmed distal vaginal agenesis with uterine distention from hematometrocolpos (Figure). A Foley catheter was temporarily left in place, and after pediatric and gynecological consultation and operative intervention, she was later free of obstructive symptoms after surgical correction of her vaginal agenesis and hematometrocolpos. n n n nFigure n nLong axis transabdominal sonographic view (left) of the patient’s abdomen revealing intrauterine low-level echogenic material (asterisk) communicating with the vaginal vault and a Foley catheter within a decompressed bladder (arrow). Sagittal ... n n n nMullerian duct abnormalities, such as imperforate hymen, transverse vaginal septum, and vaginal agenesis, may be associated with abdominal pain or other symptoms of pelvic outlet obstruction, hematocolpos, and amenorrhea in the early adolescent years.1–4 While the prevalence of congenital uterine anomalies is estimated at 6.7%, Mullerian agenesis with lack of vaginal or uterine development is thought to only occur in one out of every 4,000–10,000 females.1,2 These errors in development are strongly associated with a number of other congenital anomalies including urinary tract abnormalities such as renal agenesis in an estimated 18–40% of patients, particularly when a hymen is absent.3–5 Visualization of vaginal-appearing tissue on physical examination instead of bulging bluish tissue more indicative of an imperforate hymen may suggest vaginal agenesis, but both ultrasound and MRI are recommended to adequately characterize pelvic and neighboring anatomy.6