Josh Greenstein

Impact of Hurricane Sandy on the Staten Island University Hospital Emergency Department

UNLABELLED Introduction On October 29, 2012, Hurricane Sandy touched down in New York City (NYC; New York USA) causing massive destruction, paralyzing the city, and destroying lives. Research has shown that considerable damage and loss of life can be averted in at-risk areas from advanced preparation in communication procedures, evacuation planning, and resource allocation. However, research is limited in describing how natural disasters of this magnitude affect emergency departments (EDs). Hypothesis/Problem The aim of this study was to identify and describe trends in patient volume and demographics, and types of conditions treated, as a result of Hurricane Sandy at Staten Island University Hospital North (SIUH-N; Staten Island, New York USA) site ED. METHODS A retrospective chart review of patients presenting to SIUH-N in the days surrounding the storm, October 26, 2012 through November 2, 2012, was completed. Data were compared to the same week of the year prior, October 28, 2011 through November 4, 2011. Daily census, patient age, gender, admission rates, mode of arrival, and diagnoses in the days surrounding the storm were observed. RESULTS A significant decline in patient volume was found in all age ranges on the day of landfall (Day 0) with a census of 114; -55% compared to 2011. The daily volume exhibited a precipitous drop on the days preceding the storm followed by a return to usual volumes shortly after. A notably larger percentage of patients were seen for medication refills in 2012; 5.8% versus 0.4% (P<.05). Lacerations and cold exposure also were increased substantially in 2012 at 7.6% versus 2.8% (P<.05) and 3.8% versus 0.0% (P<.05) of patient visits, respectively. A large decline in admissions was observed in the days prior to the storm, with a nadir on Day +1 at five percent (-22%). Review of admitted patients revealed atypical admissions for home care service such as need for supplemental oxygen or ventilator. In addition, a drop in Emergency Medical Services (EMS) utilization was seen on Days 0 and +1. The SIUH-N typically sees 18% of patients arriving via EMS. On Day +1, only two percent of patients arrived by ambulance. CONCLUSION The daily ED census saw a significant decline in the days preceding the storm. In addition, the type of conditions treated varied from baseline, and a considerable drop in hospital admissions was seen. Data such as these presented here can help make predictions for future scenarios. Greenstein J , Chacko J , Ardolic B , Berwald N . Impact of Hurricane Sandy on the Staten Island University Hospital emergency department. Prehosp Disaster Med. 2016;31(3):335-339.

Effect of an emergency department opioid prescription policy on prescribing patterns

Background: Staten Island University Hospital is located in NYC, where the opioid epidemic has resulted in significant mortalities from unintentional overdoses. In 2013 as a response to the rising threat to our community, our Emergency Department (ED) administration adopted a clinical practice policy focused on decreasing the prescription of controlled substances. The effects of this policy on our provider prescription patterns are presented here. Methods: A retrospective chart review of patients prescribed opioids from the ED before and after policy implementation was performed. Dates chosen for analysis was November 1, 2012 through January 31, 2013 and November 1, 2013 through January 31, 2014; these time periods were used to serve as a seasonally comparative group pre and post clinical practice policy implementation. Opioids written for the treatment of cough, and for children under eighteen were excluded from analysis. Patient age, sex, diagnoses, and prescription formulation, strength, and pill number was recorded for each patient receiving an opioid prescription. Results: There was a drop in the total prescriptions from 1756 to 1128 without a change in the average number of pills (12.78 vs 12.44) or average total dose prescribed (69.39 vs 68.98) mg of morphine equivalent per prescription. Additionally, there were sizable reductions in opioid prescriptions written for arthralgias/myalgias, dental pain, soft tissue injuries, and headaches. Conclusion: The opioid clinical policy had a clear effect in decreasing the number of patients prescribed opioids. Such policies may be the key to reducing the epidemic and saving lives from unintentional opioid overdoses.

Demographics and Fellowship Training of Residency Leadership in EM: A Descriptive Analysis

Introduction Emergency medicine (EM) fellowships are becoming increasingly numerous, and there is a growing trend among EM residents to pursue postgraduate fellowship training. Scant data have been published on the prevalence of postgraduate training among emergency physicians. We aimed to describe the prevalence and regional variation of fellowships among EM residency leadership. Methods We conducted an online anonymous survey that was sent to the Council of EM Residency Directors (CORD) membership in October 2014. The survey was a brief questionnaire, which inquired about fellowship, secondary board certification, gender, and length in a leadership position of each member of its residency leadership. We separated the responses to the survey into four different geographic regions. The geographic regions were defined by the same classification used by the National Resident Matching Program (NRMP). We defined residency leadership as program director (PD), associate PD and assistant PD. Residencies that did not complete the survey were then individually contacted to encourage completion. The survey was initially piloted for ease of use and understanding of the questions with a select few EM PDs. Results We obtained responses from 145 of the 164 Accrediting Council for Graduate Medical Education-accredited EM residencies (88%). The fellowship prevalence among PDs, associate PDs, and assistant PDs was 21.4%, 20.3%, and 24.9% respectively. The most common fellowship completed was a fellowship in toxicology. Secondary board certification among PDs, associate PDs, and assistant PDs was 9.7%, 4.8%, and 2.9% respectively. Eighty-two percent of PDs have at least five years in residency leadership. Seventy-six percent of PDs were male, and there was a near-even split of gender among associate PDs and assistant PDs. The Western region had the highest percentage of fellowship and or secondary board certification among all levels of residency leadership. Conclusion There is a low prevalence of fellowship training and secondary board certification among EM residency leadership, with the most common being toxicology. Assistant PDs, the majority of whom had less than five years residency leadership experience, had the highest percentage of fellowship training. There may be a regional variation in the percentage of residency leadership completing postgraduate training.

Child with Testicular Pain

CASE PRESENTATION An 11-year-old boy presented to the emergency department (ED) with sudden onset severe atraumatic right testicular pain, associated with nausea and vomiting. On examination, the patient exhibited a slight horizontal lie of the right testicle as well as an absent cremasteric reflex on the right. Urology was emergently consulted. Though vascular flow was noted bilaterally on spectral Doppler (Images 2), the patient underwent surgical detorsion due to Staten Island University Hospital, Northwell Health, Department of Emergency Medicine, Staten Island, New York Staten Island University Hospital, Northwell Health, Department of Radiology, Staten Island, New York *

Newborn with a depression to her skull

A 9 week-old female, born via normal spontaneous vaginal delivery at 40 weeks, presented to the emergency department for a depression to her left skull, first noticed 3 three weeks prior. Ping Pong Fractures should be recognized and appropriately treated by an emergency physician.

A low fidelity eye model for lateral canthotomy training

We introduce a low-fidelity, low-cost, reusable training model for the lateral canthotomy procedure. We believe that this trainer has the potential to improve clinicians’ knowledge and skill of the procedure, especially when cost or access to higher-fidelity trainers is prohibitive.

Pericardial Effusion With Oreo Cookie Sign

A 60-year-old woman undergoing treatment for lymphoma presented to the emergency department with progressive dyspnea over a 3-month period. The patient was mildly tachycardic and tachypneic, but her vital signs and the physical examination were otherwise unremarkable. A chest radiograph was obtained (Figure 1), and the diagnosis of pericardial effusion with the ‘‘Oreo cookie’’ sign was confirmed by ultrasound in the emergency department.

Blunt traumatic axillary artery truncation, in the absence of associated fracture

BACKGROUND Axillary artery injuries can be associated with both proximal humeral fractures (Naouli et al., 2016; Ng et al., 2016) [1,2] as well as shoulder dislocations (Leclerc et al., 2017; Karnes et al., 2016) [3,4]. We report a rare case of an isolated axillary artery truncation following blunt trauma without any associated fracture or dislocation. CASE REPORT A 58-year-old male presented to the emergency department for evaluation after falling on his outstretched right arm. The patient was found to have an absent right radial pulse with decreased sensation to the right arm. Point of care ultrasound showed findings suspicious for traumatic axillary artery injury, and X-rays did not demonstrate any fracture. Computed tomography with angiography confirmed axillary artery truncation with active extravasation. The patient underwent successful vascular repair with an axillary artery bypass. Although extremity injuries are common in emergency departments, emergency physicians need to recognize the risk for vascular injuries, even without associated fracture or dislocation.