Michael C. Wadman

Problem gambling in the partner of the emergency department patient as a risk factor for intimate partner violence

It has been suggested that the increase in gambling activity nationally has resulted in an increase in intimate partner violence (IPV). There are apparently no studies that have assessed problem gambling as a risk factor for IPV. To determine if problem gambling in the partner is a risk factor for IPV, a cross-sectional study was conducted at a university-based Emergency Department (ED). All women aged 19 to 65 years who presented to the ED for treatment and were not decisionally incapacitated or acutely ill were eligible. Data were collected by a research assistant during 4 or 8-h blocks covering each day of the week over a 10-week period during the months of June through August 1999. There were 300 consecutive women approached, and 286 (95%) agreed to participate. Of the women who agreed to participate, 237 (83%) reported having an intimate partner in the last year, and 61 (25.7%) of these women were categorized as experiencing IPV. The odds ratio (OR) of experiencing IPV was the main outcome measure, estimated using standard logistic regression, given the presence of various personal and partner characteristics, including problem gambling in the partner. The results revealed that the relative odds were elevated for women whose partners were problem gamblers (adjusted OR: 10.5; 95% CI: 1.3-82) or problem drinkers (adjusted OR: 6.1; 95% CI: 2.5-14). The presence of both problem gambling and problem drinking in the partner was associated with an even higher OR (adjusted OR: 50; 95% CI: 9-280). Our study shows that problem gambling in the partner is associated with IPV. The causes of IPV are not fully known, but the association of problem gambling in the partner with IPV could lead to new intervention strategies and Emergency Medicine research in the future.

Domestic violence homicides: ED use before victimization.

The purpose of this study was to document prior emergency department (ED) use and injuries presented by victims of domestic violence (DV) homicides. We identified all female DV homicide cases investigated by Kansas City, Missouri, Police Department (KCPD) officials over 5 years. Medical Records from 12 hospitals were searched to determine how many homicide victims were in the ED within the 2 years preceding their homicide. The records were reviewed and classified according to the Flitcraft Criteria. KCPD documented 139 female homicides victims, with 34 (24.5%) of these ruled DV-related. Of these 34 victims, 15 (44%) presented to an ED within 2 years of homicide. The 15 subjects made 48 total visits, which included 20 (42%) injury-related visits. Fourteen (93%) of the victims seen in the ED presented with injuries on at least 1 encounter. Eight patients had head injuries (53.3%), 2 had perineal lacerations (13.3%), 2 had rapes (13.3%), and 1 had a suicide attempt (6.7%). The medical records of 8 (53.3%) of the 15 victims yielded at least suggestive evidence of battering. There was documented domestic violence in 2 cases and intervention in none. Because nearly half of all women who were victims of a DV-related homicide had been in the ED within 2 years before their deaths, the ED could play an important role in prevention. Approximately one half had documentation at least suggestive of battering. These results suggest the potential for universal screening, and documented safety assessments.

The pyramid of injury: Using ecodes to accurately describe the burden of injury

STUDY OBJECTIVE Although much is known about injury-related deaths from the use of external cause of injury codes (ecodes) on death certificates, the contribution of nonfatal injury is unknown, with most information based on estimates from national surveys. Some states mandate ecoding of charts for hospitalized patients, but few require ecode assignment for emergency department (ED) records. Missouri and Nebraska mandated ecoding of ED records in 1993 and 1994, respectively, allowing for a more complete description of injuries in those states. We describe fatal and nonfatal injury frequencies in Missouri and Nebraska by using ecodes, with graphic representation in the form of injury pyramids. METHODS Ecode frequencies for 1996 to 1998 for all injury causes in Missouri and Nebraska were reported directly from their respective health departments. The ecode frequencies were grouped according to the Centers for Disease Control and Preventions ecode matrix for presenting injury and mortality data. RESULTS During the study period, 13,052 deaths, 131,210 hospitalizations, and 1,914,140 ED visits occurred as the result of injury. The most frequent lethal injuries were unintentional motor vehicle crashes (32.3% of total deaths), self-inflicted gunshot wound (13.2%), unintentional falls (11.3%), gunshot wound from an assault (7.7%), and unintentional poisoning (4.3%). The leading causes of injury-related hospitalization were unintentional falls (47.8% of total hospitalizations), unintentional motor vehicle crashes (15.5%), self-inflicted poisoning (6.5%), and overexertion or strenuous movements (2.4%). Of 1.9 million ED injury visits, unintentional falls accounted for 24.3%, unintentionally being struck by an object or person for 14.6%, unintentional motor vehicle crashes for 11.4%, unintentionally being cut or pierced for 10.7%, and overexertion or strenuous movements for 8.5%. CONCLUSION Ecoding in Missouri and Nebraska provides a comprehensive data retrieval system that allows for a graphic depiction of the burden of injury derived from real patient encounters within specific geographic regions.

Distribution of Emergency Departments According to Annual Visit Volume and Urban–Rural Status: Implications for Access and Staffing

OBJECTIVES ongoing efforts to improve access to emergency care and emergency department (ED) staffing would benefit from a better understanding of the distribution of EDs in the United States by size and location. This article describes the distribution of U.S. ED visit volumes according to ED urban versus rural status. METHODS the authors used the 2007 National Emergency Department Inventories (NEDI)-USA database to identify all nonfederal U.S. hospitals with EDs and their annual ED visit volumes. One of twelve 2003 Urban Influence Codes was applied to each ED location based on its county. These categories were collapsed into urban counties and three types of rural counties: adjacent to urban, large nonadjacent, and small nonadjacent. The number of emergency physicians (EPs) needed to staff the higher-volume rural EDs was estimated. RESULTS of the 4,874 U.S. EDs in 2007, 58% were in urban counties and 42% in rural counties. Among the 2,038 rural EDs, 56% were adjacent to urban, 15% were large nonadjacent, and 29% were small nonadjacent. Of the 1,503 lower-volume (< 10,000 visit) EDs, 21% were in urban counties. Of the 3,371 higher-volume (≥ 10,000 visit) EDs, 25% were in rural counties. Of the 857 higher-volume rural EDs, 66% were adjacent to urban, 22% were large nonadjacent, and 12% were small nonadjacent. The authors estimate that approximately 5,600 EPs are needed to staff these higher-volume rural EDs. CONCLUSIONS there are many lower-volume EDs in urban areas and higher-volume EDs in rural areas. Most higher-volume rural EDs are in rural areas adjacent to urban counties. These data challenge popular assumptions regarding ED visit volumes, locations, and staffing needs.

Ergonomics of novices and experts during simulated endotracheal intubation

Endotracheal Intubation (ETI) is an airway procedure commonly used to secure the airway for a variety of medical conditions. Proficiency in ETI procedures requires significant clinical experience and insufficient data currently exists describing the physical ergonomics of successful direct laryngoscopy. The research objectives of this study were to examine how ETI time, error and practitioner biomechanics varied among clinical experience levels and hospital bed heights. The participant population included novice and expert personnel, differentiated by their exposure to ETI procedures. Participants used a standard laryngoscope and blade to perform ETI trials on an airway manikin trainer at predesigned hospital bed heights. Participants were evaluated based on ETI time and accuracy, as well as wrist postures and muscle utilization. Hospital bed height did not affect task completion time, error rates or muscle utilization. Expert participants exhibited less ulnar deviation and forearm supination during task trials, as well as a higher utilization of the bicep brachii and anterior deltoid muscles. Expert grasped instrumentation differently, requiring less wrist manipulation required to achieve ideal instrument positions. By encouraging ergonomic best-practices in hand and arm postures during ETI training, the opportunity exists to improve patient safety and reduce the learning curve associated with ETI procedures.

Assessment of a Chief Complaint-Based Curriculum for Resident Education in Geriatric Emergency Medicine

Introduction We hypothesized that a geriatric chief complaint–based didactic curriculum would improve resident documentation of elderly patient care in the emergency department (ED). Methods A geriatric chief complaint curriculum addressing the 3 most common chief complaints—abdominal pain, weakness, and falls—was developed and presented. A pre- and postcurriculum implementation chart review assessed resident documentation of the 5 components of geriatric ED care: 1) differential diagnosis/patient evaluation considering atypical presentations, 2) determination of baseline function, 3) chronic care facility/caregiver communication, 4) cognitive assessment, and 5) assessment of polypharmacy. A single reviewer assessed 5 pre- and 5 postimplementation charts for each of 18 residents included in the study. We calculated 95% confidence and determined that statistical significance was determined by a 2-tailed z test for 2 proportions, with statistical significance at 0.003 by Bonferroni correction. Results For falls, resident documentation improved significantly for 1 of 5 measures. For abdominal pain, 2 of 5 components improved. For weakness, 3 of 5 components improved. Conclusion A geriatric chief complaint–based curriculum improved emergency medicine resident documentation for the care of elderly patients in the ED compared with a non–age-specific chief complaint–based curriculum.

Morphological Regeneration and Functional Recovery of Neuromuscular Junctions after Tourniquet-Induced Injuries in Mouse Hindlimb

Tourniquet application and its subsequent release cause serious injuries to the skeletal muscle, nerve, and neuromuscular junction (NMJ) due to mechanical compression and ischemia-reperfusion (IR). Monitoring structural and functional repair of the NMJ, nerve, and skeletal muscle after tourniquet-induced injuries is beneficial in exploring potential cellular and molecular mechanisms responsible for tourniquet-induced injuries, and for establishing effective therapeutic interventions. Here, we observed long-term morphological and functional changes of the NMJ in a murine model of tourniquet-induced hindlimb injuries. Unilateral hindlimbs of C57/BL6 mice were subjected to 3 h of tourniquet by placing an orthodontic rubber band, followed by varied periods of tourniquet release (1 day, 3 days, 1 week, 2 weeks, 4 weeks, and 6 weeks). NMJ morphology in the gastrocnemius muscle was imaged, and the endplate potential (EPP) was recorded to evaluate NMJ function. In NMJs, nicotinic acetylcholine receptor (nAChR) clusters normally displayed an intact, pretzel-like shape, and all nAChR clusters were innervated (100%) by motor nerve terminals. During 3 h of tourniquet application and varied periods of tourniquet release, NMJs in the gastrocnemius muscle were characterized by morphological and functional changes. At 1 day and 3 days of tourniquet release, nAChR clusters retained normal, pretzel-like shapes, whereas motor nerve terminals were completely destroyed and no EPPs recorded. From 1 to 6 weeks of tourniquet release, motor nerve terminals gradually regenerated, even reaching that seen in sham mice, whereas nAChR clusters were gradually fragmented with prolongation of tourniquet release. Additionally, the amplitude of EPPs gradually increased with prolongation of tourniquet release. However, even at 6 weeks after tourniquet release, the amplitude of EPPs did not restore to the level seen in sham mice (13.9 ± 1.1 mV, p < 0.05 vs. sham mice, 29.8 ± 1.0 mV). The data suggest that tourniquet application and subsequent release impair the structure and function of NMJs. Morphological change in motor nerve terminals is faster than in nAChR clusters in NMJs. Slow restoration of fragmented nAChR clusters possibly dampens neuromuscular transmission during the long phase following tourniquet release.

Assessment of a Human Cadaver Model for Training Emergency Medicine Residents in the Ultrasound Diagnosis of Pneumothorax

Objectives. To assess a human cadaver model for training emergency medicine residents in the ultrasound diagnosis of pneumothorax. Methods. Single-blinded observational study using a human cadaveric model at an academic medical center. Three lightly embalmed cadavers were used to create three “normal lungs” and three lungs modeling a “pneumothorax.” The residents were blinded to the side and number of pneumothoraces, as well as to each others findings. Each resident performed an ultrasound examination on all six lung models during ventilation of cadavers. They were evaluated on their ability to identify the presence or absence of the sliding-lung sign and seashore sign. Results. A total of 84 ultrasound examinations (42-“normal lung,” 42-“pneumothorax”) were performed. A sliding-lung sign was accurately identified in 39 scans, and the seashore sign was accurately identified in 34 scans. The sensitivity and specificity for the sliding-lung sign were 93% (95% CI, 85–100%) and 90% (95% CI, 81–99%), respectively. The sensitivity and specificity for the seashore sign were 80% (95% CI, 68–92%) and 83% (95% CI, 72–94%), respectively. Conclusions. Lightly embalmed human cadavers may provide an excellent model for mimicking the sonographic appearance of pneumothorax.

Using the Battlefield Telemedicine System (BTS) to train deployed medical personnel in complicated medical tasks - a proof of concept.

This work describes the use of Adobe Connect software along with algorithm software to provide the necessary audio visual communication platform for telementoring a complex medical procedure to novice providers located at a distant site.

A comparison of an integrated suction blade versus a traditional videolaryngoscope blade in the endotracheal intubation of a hemorrhagic cadaver model - a pilot study.

In this pilot study, we evaluated two types of videolaryngoscope blades (integrated suction vs. traditional) with the Storz CMAC videolaryngoscope in the intubation of a lightly embalmed hemorrhagic cadaver model. No significant differences were found between the devices in the success rates for the intubations. The study subjects indicated a preference for the integrated suction blade in hemorrhagic airway intubation.