Ryan Walsh

Risk Acceptance and Desire for Shared Decision Making in Pediatric Computed Tomography Scans: A Survey of 350.

Objective The dual goals of this study were to assess the level of radiation risk parents are comfortable with and also whether they expect a shared decision making conversation. Methods A convenience sample of adult patients in the emergency department was surveyed. Participants were educated regarding the associated radiation risk with computed tomography (CT) scans. They were then surveyed about their willingness to accept the risk of radiation exposure to their children given varying degrees of pretest probability of a clinically significant finding. Additionally, participants were surveyed regarding whether a physician should provide shared decision making. Results A total of 350 surveys were collected. For low, moderate, and high pretest probability of a positive finding on CT, the proportion of participants who would want a CT for their child was 37% (95% confidence interval [95% CI], 32–43%), 70% (95% CI, 65–75%), and 89% (95% CI, 85–92%), respectively. If the likelihood of a positive CT scan was very low (<5%), 24% (95% CI, 20–29%) were willing to have the study performed on their child. Participants would not want a CT for their child regardless of the probability of finding significant pathology in 9% of those surveyed (28/315). Participants wanted a physician to counsel them before ordering a potentially dangerous test in 93% of the surveys. In a test with an estimated 1:1000 risk of cancer, 91% of participants felt that a doctor should always discuss the risk before ordering the study. Conclusions Parents are less willing to accept the risk of radiation from CT scan on their child as the likelihood of positive findings decrease. Parents overwhelmingly want an informed discussion before getting a potentially dangerous test.

Assessment of the Acute Psychiatric Patient in the Emergency Department: Legal Cases and Caveats

Abstract : Assessment of the acute psychiatric emergency is challenging and fraught with error. This paper, using legal cases, will discuss the assessment of new onset psychiatric illness, exacerbation of chronic psychiatric disease, and the suicidal patient. We will share diagnostic caveats, medical clearance, and suicide assessment tools. The authors, who have significant medical legal experience, selectively chose illustrative legal cases to discuss caveats of assessment of acute psychiatric emergencies. We selected representative cases after reviewing legal journals and publications. Cases involving restraint and sedation were excluded as they were covered in a prior manuscript. Psychosis is a relatively common syndrome affecting 3% to 5% of the population at some point in life. Encountering undiagnosed psychiatric conditions, such as psychosis or bipolar disorder, is commonplace for the emergency physician (EP). The following case illustrates the challenge and importance of the assessment of new onset psychiatric disorders.

Comparison of Preloaded Bougie versus Standard Bougie Technique for Endotracheal Intubation in a Cadaveric Model

Introduction We compared intubating with a preloaded bougie (PB) against standard bougie technique in terms of success rates, time to successful intubation and provider preference on a cadaveric airway model. Methods In this prospective, crossover study, healthcare providers intubated a cadaver using the PB technique and the standard bougie technique. Participants were randomly assigned to start with either technique. Following standardized training and practice, procedural success and time for each technique was recorded for each participant. Subsequently, participants were asked to rate their perceived ease of intubation on a visual analogue scale of 1 to 10 (1=difficult and 10=easy) and to select which technique they preferred. Results 47 participants with variable experience intubating were enrolled at an emergency medicine intern airway course. The success rate of all groups for both techniques was equal (95.7%). The range of times to completion for the standard bougie technique was 16.0–70.2 seconds, with a mean time of 29.7 seconds. The range of times to completion for the PB technique was 15.7–110.9 seconds, with a mean time of 29.4 seconds. There was a non-significant difference of 0.3 seconds (95% confidence interval −2.8 to 3.4 seconds) between the two techniques. Participants rated the relative ease of intubation as 7.3/10 for the standard technique and 7.6/10 for the preloaded technique (p=0.53, 95% confidence interval of the difference −0.97 to 0.50). Thirty of 47 participants subjectively preferred the PB technique (p=0.039). Conclusion There was no significant difference in success or time to intubation between standard bougie and PB techniques. The majority of participants in this study preferred the PB technique. Until a clear and clinically significant difference is found between these techniques, emergency airway operators should feel confident in using the technique with which they are most comfortable.

Comparison of intubation performance by emergency medicine residents using gum elastic bougie versus standard stylet in simulated easy and difficult intubation scenarios.

We sought to evaluate the success rate and time to endotracheal intubation by emergency medicine residents with stylet reinforced endotracheal tube (ETT‐S) versus intubation with a gum elastic bougie (GEB) in simulated easy and difficult airways on a cadaveric model.

Unique mechanism of chance fracture in a young adult male

Since the first description of the Chance fracture in 1948, there have been few case reports of unique mechanisms causing this classical flexion-extension injury to the spine in motor vehicle accidents, sports injury, and falls. To our knowledge, this injury has not been reported from a fall with the mechanistic forces acting laterally on the spine and with spinal support in place. We present a 21-year-old male who slid down a flight of stairs onto his side wearing a heavy mountaineering style backpack, subsequently sustaining a Chance fracture of his first lumbar vertebrae.

Neonatal Umbilical Mass

A 41-day-old girl presented to the emergency department with a new dark red mass protruding from the umbilicus noted 3.5 hours prior to presentation. The patient’s mother reported the umbilical stump fell off at 4 days of life, but the patient continued to have intermittent clear green drainage from a small mass at the base of the umbilicus. The patient was born full-term with an otherwise unremarkable medical history. Physical exam revealed a small, moist, erythematous mass protruding from the umbilicus (Figure). The mass was removed with minimal bleeding and no pain while attempting silk ligation. The specimen was sent for pathology, which returned 3 days later with the diagnosis of umbilical granuloma. Figure. View from above (A) and from the side (B) with umbilicus retracted to demonstrate pedunculated stump of the umbilical granuloma. An umbilical granuloma is a common benign abnormality in neonates that form from excess granulation tissue remaining at the base of the umbilicus after cord separation. It forms during the first few weeks of life and should not be present at birth. They typically are associated with persistent drainage involving the umbilicus after cord separation.1 It is a soft, round, moist, usually pink, friable, pedunculated mass, typically 3–10 mm in diameter. Umbilical polyps, urachal tract, and omphalomesenteric duct remnants must be considered.1,2 Multiple techniques are available to treat umbilical granulomas. Application of topical antibiotics, elimination of friction, air drying with alcohol wipes, and application of common table salt are conservative measures that may allow for epithelialization.3–5 Cauterization with silver nitrate is the most common treatment and generally requires multiple applications.1,6 Ligature, electrocautery, and cryosurgery are other treatment options. Further evaluation for other pathology is warranted if the lesion fails to resolve with silver nitrate and/or ligation.1,5,7

Comparison of Intubation Using Personal Protective Equipment and Standard Uniform in Simulated Cadaveric Models

Introduction The use of personal protection equipment (PPE) for patient care can have an impact on the delivery of effective patient care. The purpose of this study is to examine the effects of basic PPE on intubation times and corresponding success rates in cadaver models. Methods A prospective crossover design using a single cohort of emergency medicine residents was used for this study. The primary objective is to compare time with intubation in standard uniform (e.g., scrubs without PPE) and using PPE. The secondary objectives are measuring success rates of intubation and the perceived difficulty of intubation when using PPE. Results The mean time to intubation in the standard uniform group was 18.85 s, whereas the mean time to intubation in the PPE group was 19.29. The overall success rate in the standard uniform group was 83% compared with the PPE group, which was 72%. The perceived difficulty was higher in the PPE group (3.38) when compared with the standard uniform. Conclusion Although the mean intubation times between the groups were not significantly different, the overall success rate was significantly higher in the standard uniform group when compared with PPE group. The perceived difficulty rating was also noted to be significantly higher in the PPE group when compared with the standard uniform group.

52 Procedures in 52 Weeks: An innovative curriculum for emergency medicine residents

The specialty of Emergency Medicine (EM) requires that providers are as competent in rare procedures as they are in common ones. This creates a challenge for EM educators, who are charged with graduating competent physicians who have the mental and technical expertise to perform such a breadth of procedures. To facilitate this instruction, we have created a weekly procedure curriculum that utilizes videos coupled with hands on instruction to teach 52 EM procedures. We have found this curriculum to be very effective and easy to implement into our residency training schedule.

Pacing-induced Cardiomyopathy

We present a case of pacing-induced cardiomyopathy. The patient presented with clinical symptoms of dyspnea, leg swelling, and orthopnea several months after a dual-chambered pacemaker was placed for third-degree heart block. The echocardiogram demonstrated a depressed ejection fraction. Coronary angiography was performed, which showed widely patent vessels. Single- and dual-chambered pacemakers create ventricular dyssynchrony, which in turn can cause structural, molecular changes leading to cardiomyopathy. With early intervention of biventricular pacemaker replacement, these changes can be reversible; thus, a timely diagnosis and awareness is warranted.

Safely Managing Acute Osteoarthritis in the Emergency Department: An Evidence-Based Review

BACKGROUND Joint pain caused by acute osteoarthritis (OA) is a common finding in the emergency department. Patients with OA often have debilitating pain that limits their function and ability to complete their activities of daily living. In addition, OA has been associated with a high percentage of arthritis-related hospital admissions and an increased risk of all-cause mortality. Safely managing OA symptoms in these patients can present many challenges to the emergency provider. OBJECTIVES We review the risks and benefits of available treatment options for acute OA-related pain in the emergency department. In addition, evidence-based recommendations will be made for safely managing pain and disability associated with OA in patients with comorbidities, including cardiovascular disease, renal insufficiency, and risk factors for gastrointestinal bleeding. DISCUSSION Commonly used treatments for OA include acetaminophen, oral nonsteroidal anti-inflammatory drugs, and opioids, each with varying degrees of efficacy and risk depending on the patients underlying comorbidities. Effective alternative therapies, such as topical preparations, intra-articular corticosteroid injections, bracing, and rehabilitation are likely underused in this setting. CONCLUSIONS Emergency providers should be aware of the risks and benefits of all treatment options available for acute OA pain, including oral medications, topical preparations, corticosteroid injections, bracing, and physical therapy.