Liudvikas Jagminas

EVALUATION OF A TEACHING LABORATORY USING A CADAVER MODEL FOR TUBE THORACOSTOMY

A prior study evaluated the efficacy of a dog laboratory to teach residents chest tube thoracostomy. This study evaluated a similarly structured program using human cadavers. A prospective repeat measure study of chest tube thoracostomy placement training was performed in a university laboratory setting using human cadavers. Ten Emergency Medicine residents were given a written pretest, followed by training. Resident attempts were then timed. The following day, a repeat test was administered. Three weeks later, a third written post-test was conducted. The written test scores improved for every participant. Mean times for procedure completion improved from 86 sec to 34 sec during the first session, and remained stable over 4 attempts from 30 sec to 32 sec during the second session. This approach to teaching clinical procedures should be considered for Emergency Medicine residency programs and for continuing education courses that emphasize procedural skills.

Fatal spontaneous rupture of a gravid uterus: Case report and literature review of uterine rupture

Spontaneous uterine rupture is a life-threatening obstetrical emergency encountered infrequently in the emergency department. The diagnosis of spontaneous uterine rupture is often missed or delayed, leading to maternal and fetal mortality. Emergency physicians must consider this diagnosis when presented with a pregnant patient in shock with abdominal pain. We present the case of a 38-year-old gravid female who presented to the emergency department in cardiac arrest 24 hours after an initial complaint of abdominal pain. We review the uterine rupture literature with specific focus on risk factors, signs and symptoms, diagnosis, treatment, and outcome.

Boerhaave's syndrome presenting with abdominal pain and right hydropneumothorax

This case of Boerhaaves Syndrome had several unusual features including a delayed presentation and right-sided esophageal perforation. The patients initial episode of hematemesis may have been caused by a small mucosal laceration in the area of the Barretts lesion that later ruptured. On the other hand, if initially there was an esophageal rupture, it did not violate the parietal pleura or mediastinum. The overlying pleura remained intact until digested by gastric contents, thereby causing a right-sided hydropneumo thorax and a marked increase in symptoms, which promoted the patient to come to the ED. Because the patient initially appeared stable and had a history of emesis 4 days before presentation, and because an initial chest X-ray interpretation overlooked the right-sided apical pneumothorax, Boerhaaves Syndrome was not considered initially. Aspiration pneumonia, pancreatitis, alcoholic gastritis, or active peptide ulcer disease were in our initial differential. It was only after the repeat chest X-ray, which more obviously showed the pneumothorax, and insertion of the chest tube that the correct diagnosis was made. Had the pneumothorax not been overlooked initially, the diagnosis may have been made earlier. It is apparent from this case and a review of the literature that Boerhaaves Syndrome is an uncommon clinical entity and has varying modes of presentation, making the diagnosis a difficult clinical challenge. Boerhaaves Syndrome should be considered in all ill-appearing patients presenting with the combination of gastrointestinal and respiratory complaints. The single most important test may be the upright chest X-ray. However, if it is normal, and there is a high index of suspicion, esophagograms and or chest CT may be required to demonstrate the lesion. Because survival is directly related to the time to diagnosis and treatment, a high clinical suspicion can decrease the substantial morbidity and mortality associated with Boerhaaves Syndrome.

Emergency Medical Services in the Reconstruction Phase following a Major Earthquake: A Case Study of the 1988 Armenia Earthquake

STUDY OBJECTIVE To use the clinical activities of an ambulance service as a tool to assess the residual and unmet medical needs of a city in the aftermath of a major earthquake and to apply that assessment to the development of a training curriculum for the prehospital personnel. METHODS The researchers conducted structured interviews with health care workers at all levels of the emergency health care delivery system in Gyumrii, Armenia, and carried out a retrospective frequency analysis of 29,010 ambulance runs for an 11-month period from February through December 1992. Runs first were assigned into the broad categories of: 1) Adult Medical; 2) Pediatric Medical; or 3) Trauma, and then, according to diagnosis. The runs then were classified further as: 1) Primary Care; 2) Basic Life Support (BLS); or 3) Advanced Life Support (ALS). RESULTS Adult Medical calls represented 24,684 (85%), Pediatric Medical calls 459 (1.6%), and Trauma calls 3,867 (13%). Only 12% of all ambulance calls resulted in transport to a medical facility, although this percentage was higher in children. Thirty percent of Adult Medical patients were diagnosed by the emergency medical providers as having exclusively a psychiatric problem. CONCLUSION In the late aftermath of a devastating earthquake, the ambulance service in Gyumrii, Armenia has been delivering a substantial proportion of non-emergency, primary care services. They have adopted this unconventional role to compensate for the deficit in health care facilities and personnel created by the disaster. The training program that the investigators developed reflected the actual work activities of the prehospital personnel demonstrated in their assessment.

Reduction of opioid prescribing through the sharing of individual physician opioid prescribing practices

Background: Drug overdoses are the most common cause of accidental death in the United States, with the majority being attributed to opioids. High per capita opioid prescribing is correlated with higher rates of opioid abuse and death. We aimed to determine the impact of sharing individual prescribing data on the rates of opioid prescriptions written for patients discharged from the emergency department (ED). Methods: This was a pre‐post intervention at a single community ED. We compared opioid prescriptions written on patient discharge before and after an intervention consisting of sharing individual and comparison prescribing data. Clinicians at or over one standard deviation above the mean were notified via standard template electronic communication. Results: For each period, we reported the median number of monthly prescriptions written by each clinician, accounting for the total number of patient discharges. The pre‐intervention median was 12.5 prescriptions per 100 patient discharges (IQR 10–19) compared to 9 (IQR 6–11) in the post‐intervention period (p < 0.001). This represents a 28% reduction in the overall rate of opioid prescriptions written per patient discharged. Using interrupted time series analysis for monthly rates, this was associated with a reduction in opioid prescriptions, showing a decrease of almost 9 prescriptions for every 100 discharges over the 6 months of the study (p = 0.032). Conclusion: Our study demonstrates the sharing of individual opioid prescribing data was associated with a reduction in opioid prescribing at a single institution.