John Patterson

Comparison of Transthecal Digital Block and Traditional Digital Block for Anesthesia of the Finger

STUDY OBJECTIVE To compare the newly described transthecal (TT) and traditional (TD) methods of digital block anesthesia with regard to length of time to achieve anesthesia and pain during infiltration. DESIGN Prospective, randomized, controlled, blinded study. PARTICIPANTS Healthy adult paid volunteers. INTERVENTIONS Each subject received a TT block on one hand and a TD block on the opposite hand. All blocks were performed by the same investigator and were rated by an evaluator who was blinded to the technique that was used. Time to loss of pin-prick sensation was measured, and the pain of the procedure was recorded by the subject on a 10-cm visual-analog scale. RESULTS A total of 162 blocks (81 TT and 81 TD) were performed in 31 different subjects. All blocks were successful. Mean time to anesthesia for TT block was 188 seconds compared with 152 seconds for the TD block (P < .01). Mean analog pain score was slightly higher for TT block than for TD block (1.7 versus 1.4, P = .02). CONCLUSION TT block is clinically equal to the TD method in terms of time to anesthesia and visual-analog pain score.

Impact of emergency medicine resident training in ultrasonography on ultrasound utilization

Training programs in bedside ultrasound for emergency physicians often encounter considerable resistance, partly because of concern that the number of radiology-interpreted studies ordered from the ED may decrease. This study attempted to determine the effect of instituting an ED training program in ultrasound on the ordering of formal studies from a department of radiology. This retrospective, computer-assisted review compared all abdominal sonograms ordered from the ED of a busy community hospital in the 3 years before introduction of an ultrasound training program (1992 through 1994) with those ordered in the 2 years after the programs inception (1995, 1996). The number of formal studies significantly increased after institution of the training program, both in terms of absolute numbers (annual mean 181 v 95, P < .001) and as a percentage of all outpatient sonograms ordered at the institution (9.8% v 5.1%, P < .001). Introduction of a teaching program in emergency ultrasound appears to increase utilization of formal ultrasound services, at least during the training period.

Short- and Long-term Effects of Emergency Medicine Sonography on Formal Sonography Use A Decade of Experience

Objectives. It has been reported that use of formal sonographic studies by departments of radiology initially increases after inception of an emergency medicine (EM) sonography training program, but there are no data on whether this trend continues as the training program matures. The purpose of this study was to evaluate the effect of an ongoing EM sonography program on formal sonography use after more than a decade of experience. Methods. This retrospective, computer‐assisted review compared emergency department (ED) abdominal sonographic studies ordered in the 3 years before inception of an EM sonography program (1992–1994) with those ordered in the 8 years after its inception (1995–2002). To determine the relative change, all abdominal sonograms ordered by ED physicians were compared with equivalent outpatient formal sonograms by all other physicians in the hospital. The study site is a community teaching hospital with a current ED census of 50,000. Results. In the initial 4 years (1995–1998), the number of formal studies increased significantly in both absolute numbers (annual mean, 95 versus 162; P < .002) and as a percentage of all outpatient sonograms ordered at the institution (5.1% versus 8.5%; P < .0001). However, in the following 4 years (1999–2002), the absolute number of formal studies remained constant but decreased when adjusted for an increased ED census. Emergency department–ordered formal studies also decreased as a percentage of all sonograms ordered (5.1% versus 4.1%; P = .002). Conclusions. Emergency department use of formal sonography services increases with the introduction of ED sonography but decreases markedly as the program matures.

Effect of CBC results on ED management of women with lower abdominal pain

Recent studies have suggested that the results of complete blood counts (CBCs) are neither sensitive nor specific in diagnosing abdominal pain, but no study has attempted to determine whether CBC results actually influence the management of ED patients. This study attempted to determine whether CBC results in women with lower abdominal pain affect ED disposition or diagnosis. One hundred women between the ages of 15 and 45 with lower abdominal pain presenting to a community hospital ED with an annual census of 45,000 were enrolled in this prospective study. Before review of the CBC results but after review of all other studies, the ED physician recorded a presumptive diagnosis and indicated whether consultation and/or admission were warranted. After the results of the CBC were reviewed, these factors were reassessed. Patient management or ED diagnosis was affected in two cases (2%; 95% confidence interval 0% to 7%), one resulting in appropriate discharge and one resulting in unnecessary admission. It was concluded that in young women with abdominal pain CBC results rarely affect clinical decision-making.

A new method for rapid fluid bolus infusion into a peripheral vein

OBJECTIVE To compare the flow rates achieved by a new short-tubed infusion device with those obtained with a conventional apparatus, using gravity, manual pressure, and pneumatic inflation as the driving forces. METHODS Ten paramedic volunteers were recruited for this prospective, randomized, controlled laboratory study. For the short-tubing setup, a new device, the port, was used to adapt standard 18-cm extension tubing directly to an i.v. bag [short tubing/port (STP) setup]. For the conventional (CON) setup, 280-cm tubing was used. Both study setups were tested on each of the volunteers with flow from a standard 250-mL bag of normal saline subjected to three types of driving force: 1) gravity alone, 2) pressure supplied by two hands squeezing the i.v. bag, and 3) a pneumatic pressure bag continuously inflated to 300 mm Hg. The mean flow rates for each driving force were compared between the two setups. RESULTS Using gravity flow, no significant difference was noted between the STP setup and the CON setup (0.40 vs 0.45 mL/sec, respectively, p > 0.4). However, when flow was augmented by pressure supplied by two hands squeezing the bag, mean flow was greater for the STP setup than for the CON setup (4.5 vs 2.7 mL/sec, respectively, p < 0.001). When flow was augmented by a pneumatic bag at 300 mm Hg, mean flow was again greater for the STP setup (5.6 mL/sec) than for the CON setup (3.3 mL/sec, p < 0.001). CONCLUSION Flow of crystalloid under pressure into a peripheral vein is markedly increased with the new STP setup as compared with the CON setup. Incorporation of this new setup in prehospital care would allow EMS personnel to infuse fluid more rapidly and conveniently during transport.

Eye patch treatment for the pain of corneal abrasion

The traditional use of patching and topical antibiotics in the treatment of corneal abrasion has recently been challenged, particularly after foreign body removal. In a prospective, controlled, randomized study of 33 patients treated in the emergency department for eye pain and corneal abrasion, we attempted to determine whether eye patching affected the pain of simple corneal abrasions. After fluorescein examination with magnification (x 5), a visual analog pain score was recorded and the patient was randomized to either the patched or nonpatched group. A standard analgesic was supplied, and all patients had follow-up at 24 hours, when repeat pain scores and analgesic use were recorded. The groups were compared by using the Wilcoxons rank sum test, Students t test, and analysis of covariance as required. There was no significant difference in the mean changes in pain scores between the patched and nonpatched groups. Analgesic use was also similar. We conclude that routine eye patching does not favorably affect the pain associated with the treatment of simple corneal abrasion.