Scott Joing

Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab

OBJECTIVES The objective was to compare time to completion, failure rate, and subjective difficulty of a new cricothyrotomy technique to the standard technique. The new bougie-assisted cricothyrotomy technique (BACT) is similar to the rapid four-step technique (RFST), but a bougie and endotracheal tube are inserted rather than a Shiley tracheostomy tube. METHODS This was a randomized controlled trail conducted on domestic sheep. During a 3-month period inexperienced residents or students were randomized to perform cricothyrotomy on anesthetized sheep using either the standard technique or the BACT. Operators were trained with an educational video before the procedure. Time to successful cricothyrotomy was recorded. The resident or student was then asked to rate the difficulty of the procedure on a five-point scale from 1 (very easy) to 5 (very difficult). RESULTS Twenty-one residents and students were included in the study: 11 in the standard group and 10 in the BACT group. Compared to the standard technique, the BACT was significantly faster with a median time of 67 seconds (interquartile range [IQR] = 55-82) versus 149 seconds (IQR = 111-201) for the standard technique (p = 0.002). The BACT was also rated easier to perform (median = 2, IQR = 1-3) than the standard technique (median = 3, IQR = 2-4; p = 0.04). The failure rate was 1/10 for the BACT compared to 3/11 for the standard method (p = NS). CONCLUSIONS This study demonstrates that the BACT is faster than the standard technique and has a similar failure rate when performed by inexperienced providers on anesthetized sheep.

The Millennial Generation and “The Lecture”

This lecture can be viewed in its entirety online by visiting http://vimeo.com/24148123.

Seventy-two-hour antibiotic retrieval from the ED: a randomized controlled trial of discharge instructional modality

BACKGROUND Limited health literacy is a risk factor for poor outcomes in numerous health care settings. Little is known about the impact of instructional modality and health literacy on adherence to emergency department (ED) discharge instructions. PURPOSE To examine the impact of instructional modality on 72-hour antibiotic retrieval among ED patients prescribed outpatient antibiotics for infections. METHODS English-speaking ED patients diagnosed as having acute infections and prescribed outpatient antibiotics were randomized to standard discharge instructions, standard instructions plus text-messaged instructions, or standard instructions plus voicemailed instructions targeting ED prescriptions. Health literacy was determined by validated instrument. Seventy-two-hour antibiotic retrieval, 30-day report of prescription completion, and discharge instructional modality preference were assessed. RESULTS Nearly one-quarter of the 2521 participants demonstrated low health literacy. Low health literacy predicted decreased 72-hour antibiotic retrieval (χ(2) = 9.56, P=.008). No significant association with antibiotic retrieval was noted across the 3 treatment groups (χ(2) = 5.112, P=.078). However, patients randomized to the text message group retrieved antibiotic prescriptions within 72 hours more frequently than did those randomized to the voicemail treatment group (χ(2) = 4.345, P=.037), and patients with low health literacy randomized to voicemailed instructions retrieved their antibiotic prescriptions less frequently than did those randomized to standard of care instructions (χ(2) = 5.526, P=.019). Reported instructional modality preferences were inconsistent with the primary findings of the study. CONCLUSIONS Discharge instructional modality impacts antibiotic retrieval in patients with low health literacy. Preference for discharge instructional modality varies by degree of health literacy, but does not predict which modality will optimize 72-hour antibiotic retrieval.

Retrograde Intubation for Ace Inhibitor–Induced Angioedema

R.C. is a 49-year-old man who presented to triage with complaints of lip and tongue swelling. He noted symptoms upon awakening with progression over the next 2 hours. Medical history is significant for hypertension. His medications are lisinopril and hydrochlorothiazide. On examination, the patient was afebrile, mildly tachypneic, and sitting upright on the cart. He was speaking in short sentences with a hoarse voice and complaining of dysphagia. The head, eyes, and ear ⁄ nose ⁄ throat exam revealed significant edema of his lips and his posterior oropharynx. His lungs were clear and there was no stridor. An IV was established and he was given 0.3 mg of epinephrine subcutaneously and 125 mg of Solu-Medrol intravenously. Fiber-optic–assisted nasotracheal intubation and subsequent RSI and direct laryngoscopy were unsuccessful. Because the patient maintained oxygen saturations greater than 99% with bag-valve mask ventilation, the decision was made to perform a retrograde intubation (Figure 1). The retrograde intubation was successfully completed with one attempt (available as supporting information in the online version of this paper). Oxygen saturations remained above 90% for the entire case.

Diagnosis and Treatment of Pulmonary Embolism Using Bedside Limited Ultrasound

A 64-year-old male with a history of coronary artery disease presented to the emergency department with acute onset of shortness of breath and chest pain. The patient stated that his symptoms felt similar to an episode two weeks earlier when he was treated for congestive heart failure. An electrocardiogram was negative for acute myocardial infarction. A bedside echocardiogram performed to evaluate cardiac function revealed an enlarged right ventricle (Figure 1, video), raising the suspicion for pulmonary embolism. The emergency physician immediately performed a bedside lower extremity ultrasound and diagnosed a right deep vein thrombosis (Figure 2, video). Anticoagulation therapy with intravenous heparin was initiated immediately after the bedside ultrasounds were completed. Chest X-ray showed Westermark’s sign (a relative lack of pulmonary lung markings) on the right (Figure 3). The diagnosis of pulmonary embolism was later confirmed by a computed tomography angiogram (Figure 4). This case demonstrates how bedside ultrasound can be used to assist in the diagnosis of patients with undifferentiated shortness of breath or chest pain.

Remote emergency release of blood products using a custom iPad application: IPAD APPLICATION FOR REMOTE EMERGENCY RELEASE

Hennepin County Medical Center (HCMC) is a Level I trauma hospital with approximately 160 massive transfusions annually, most initiated in the emergency department (ED). Although emergency release red blood cell (RBC) units are always available from the blood bank, it may take 15 to 20 minutes to reach the ED by runner. While there are commercial solutions (e.g., Hemosafe, Haemonetics) to remotely issue blood products, their cost can be prohibitive. We developed a novel software and hardware system to control and monitor the emergency release of RBCs in the HCMC ED (see figure, schematic workflow shown). The system utilizes the access control features on an Omnicell, Inc. medication dispensing cabinet to release the lock on a blood refrigerator door. To obtain emergency release blood, trained ED staff unlock the refrigerator using the Omnicell by entering their identification (ID) and a patient ID and selecting blood products, like they would for dispensing medication. If no patient ID is available (e.g., before patient arrival), release can occur to an unidentified

Discharge instruction delivery/modality and antibiotic retrieval: the author replies

We are grateful to Dr Ayubi for his constructive comments regarding the statistical analyses used in the referenced study. Dr Ayubi correctly points out that no statistically significant association was found between discharge instructionalmodality and 72-hour antibiotic retrieval. However, this comment specifically references our predetermined primary outcome, which compared all groups (Table 3 of the original study). Additional paired analyses did, as noted, reveal a statistically significant difference in 72-hour antibiotic retrieval between those patients randomized to receive discharge instructions via text message and those randomized to voicemail. Dr Ayubi correctly highlights this distinction; no contradiction exists in these findings. Dr Ayubi inquires further regarding the use of Pearson χ analysis, rather than regression analysis reporting a relative measure of the strength of association. Our primary goal in undertaking this investigation was to characterize the rates of 72-hour antibiotic retrieval among patients randomized to written, spoken, and texted instructional modalities at discharge from emergency department visits. It is our assertion that relative measures are—particularly in this novel investigation within a line of research that remains nascent—of considerably less utility than the simple finding that an association exists. It was thus not our intention to suggest the strength of association of our findings; this adds little to our understanding of an issue whose complexity is incompletely captured in a single-center study subject to the limitations referencedwithin. Rather, our findings that voicemail appears inferior to both text-messaged and standard-of-care instructional modalities, and that patient-reported preferences for discharge instructional modality are discordantwith thesefindings, serve as a call to investigators working to optimize the care of limited health literacy patients. Among patients discharged from the emergency department with outcomes that are predicated, at least in part, on their capacity to understand and act on instructions beyond the limits of the patient-provider interaction, additional researchwill be helpful in articulating the strength of the associations described in this investigation.

Producing a Successful PeRLs Video

Academic Emergency Medicine publishes selected peer-reviewed videos that present state-of-the-art research, practice, and evidence in the field of emergency medicine. These videos are referred to as peer-reviewed lectures (PeRLs). This commentary reviews considerations for creating, filming, and producing high-quality PeRLs videos.

Biliary ultrasound instructional video.

Right upper quadrant pain and midepigastric pain are common emergency department complaints. This instructional video (available as supporting information in the online version of this paper) provides a basic review of biliary disease processes and explores the application of bedside ultrasound. Instruction is provided on performing bedside biliary ultrasound, including evaluation of the gallbladder for cholelithiasis (Figure 1) and cholecystitis, as well as evaluation of the common bile duct for signs of choledocholithiasis.