Review

Critical Care

Anticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016

Volume 17, Issue 3, May 2016
Steve Christos, DO, MS et al.

Anticoagulation is the mainstay of medical treatment, prevention and reduction of recurrent venous thromboembolism, stroke prevention in patients with non-valvular atrial fibrillation, and it reduces the incidence of recurrent ischemic events and death in patients with acute coronary syndrome. Options for anticoagulation have been steadily increasing. Physicians need to be aware of the clinical profile of anticoagulation agents, reversal agents and treatment strategies in the face of major bleeding.

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Education

Survey of Individual and Institutional Risk Associated with the Use of Social Media

Volume 17, Issue 3, May 2016
Manish Garg, MD, et al.

Introduction: Residents and faculty in emergency medicine (EM) residency programs might
be unaware of the professional and legal risks associated with the use of social media (SM).
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The objective of this study was to identify and characterize the types and reported incidence of
unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal
and institutional risks.
Methods: This multi-site study used an 18-question survey tool that was distributed electronically
to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine
Residency Directors (CORD), and the residents of 14 EM programs during the study period May
to June 2013.
Results: We received 1,314 responses: 772 from residents and 542 from faculty. Both
groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use
by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents
reported posting of one of the following by a resident peer or nursing colleague: identifiable
patient information (26%); or a radiograph, clinical picture or other image (52%). Residents
reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%),
and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by
NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph,
clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted
images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or
inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued
reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were
more likely to post photos of their resident peers or nursing colleagues in an intoxicated state
than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and
identifiable patient information (p=0.0004) than were residents.
Conclusion: EM residents and faculty members cause and encounter HRTPE frequently while
using SM; these events present significant risks to the individuals responsible and their associated
institution. Awareness of these risks should prompt responsible SM use and consideration of
CORD’s Social Media Task Force recommendations.

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Outlaw Motorcycle Gangs: Aspects of the One-Percenter Culture for Emergency Department Personnel to Consider

Volume 15, Issue 4, July 2014
Anand N. Bosmia, BA et al.

Outlaw motorcycle gangs (OMGs) are an iconic element of the criminal landscape in the United States, the country of their origin. Members of OMGs may present to the emergency department (ED) as a result of motor vehicle accidents or interpersonal violence. When one member of an OMG is injured, other members and associates are likely to arrive in the ED to support the injured member.

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Ethical and Legal Issues

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

Volume 15, Issue 3, May 2014
Benjamin Good, MD et al.

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.

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Injury Outcomes

Tackling the Global Challenge: Humanitarian Catastrophes

Volume 15, Issue 2, March 2014
Kenneth V. Iserson, MD, MBA et al.

“Humanitarian catastrophes,” conflicts and calamities generating both widespread human suffering and destructive events, require a wide range of emergency resources. This paper answers a number of questions that humanitarian catastrophes generate: Why and how do the most-developed countries—those with the resources, capabilities, and willingness to help—intervene in specific types of disasters? What ethical and legal guidelines shape our interventions? How well do we achieve our goals? It then suggests a number of changes to improve humanitarian responses, including better NGO-government cooperation, increased research on the best disaster response methods, clarification of the criteria and roles for humanitarian (military) interventions, and development of post-2015 Millennium Development Goals with more accurate progress measures.

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Emergency Department Access Healthcare Utilization

New Drugs and Devices from 2011 – 2012 That Might Change Your Practice

To be honest, I thought this would be a lost cause. Even after skipping a New Drugs and Devices essay in 2012, I figured that I would have to search long and hard to find 10 new things that emergency practitioners needed to know about. Although there were no true blockbuster medications for emergency physicians, I nonetheless found 10 medicines that we probably should know, along with a new device that may change the way we work up patients with palpitations, and a clever new delivery system for subcutaneous epinephrine.

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Ethical and Legal Issues

Integrated Model of Palliative Care in the Emergency Department

An integrated model of palliative care in the emergency department (ED) of an inner city academic teaching center utilized existing hospital resources to reduce hospital length of stay (LOS) and reduce overall cost. Benefits related to resuscitation rates, intensity of care, and patient satisfaction are attributed to the ED-based palliative team’s ability to provide real time consults, and utilize InterQual criteria to admit to a less costly level of care or transfer directly to home or hospice.

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Ethical and Legal Issues

Medical-legal Issues in the Agitated Patient: Cases and Caveats

Volume 14, Issue 5, September 2013
Jessica Thomas, MD, et al.

More than any other area of emergency medicine, legal issues are paramount when caring for an agitated patient. It is imperative to have a clear understanding of these issues to avoid exposure to liability. These medico-legal issues can arise at the onset, during, and at discharge of care and create several duties. At the initiation of care, the doctor has a duty to evaluate for competence and the patient’s ability to consent. Once care has begun, patients may require restraint if they become combative or violent.

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Emergency Department Operations

Measuring Power in an Emergency Department to Improve Processes and Decrease the Length of Stay to their Optimum Value

Volume 14, Issue 5, September 2013
Bert A. Silich, MD, MS

Many emergency departments (EDs) compare themselves to national productivity benchmarks, such as the average patients/hour or relative value units (RVUs)/hour. Making these comparisons does not provide a tool to determine which processes need improvement, most urgently, within the ED to improve efficiency. Furthermore, there has been no clear means to determine how to set reasonable goals based on the capabilities of the particular ED under study.

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Prehospital Care

In-flight Medical Emergencies

Author Affiliation Amit Chandra, MD, MSc  University of Botswana School of Medicine, Botswana Shauna Conry, MD  CEP America, United States Introduction Discussion Abstract Introduction: Research and data regarding in-flight medical emergencies during commercial air travel are lacking. Although volunteer medical professionals are often called upon to assist, there are no guidelines or best practices to […]

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Prehospital Care

Reducing Ambulance Diversion at Hospital and Regional Levels: Systemic Review of Insights from Simulation Models

Author Affiliation M. Kit Delgado, MD, MS  Stanford University, Division of Emergency Medicine, Stanford, California Lesley J. Meng, HBA, BMSc  Columbia University, Mailman School of Public Health, New York City, New York Mary P. Mercer, MD, MPH  University of California San Francisco, San Francisco General Hospital, San Francisco, California Jesse M. Pines, MD, MBA, MSCE […]

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Patient Communication

Death Notification in the Emergency Department: Survivors and Physicians

When patients die in the emergency department (ED), emergency physicians (EP) must disclose the bad news to family members. The death is often unexpected and the act of notification can be difficult. Many EPs have not been trained in the skill of communicating death to family members. This article reviews the available literature regarding ED death notification training and proposes future directions for educational interventions to improve physician communication in ED death disclosure.

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Guidelines for Field Triage of Injured Patients: In conjunction with the Morbidity and Mortality Weekly Report published by the Center for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to the national public health burden associated with trauma and injury. In the United States (U.S.), injury is the leading cause of death for persons aged 1–44 years. In 2008, approximately 30 million injuries resulted in an emergency department (ED) evaluation; 5.4 million (18%) of these patients were transported by Emergency Medical Services (EMS). EMS providers determine the severity of injury and begin initial management at the scene.

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Holiday Plants with Toxic Misconceptions

Several plants are used for their decorative effect during winter holidays. This review explores the toxic reputation and proposed management for exposures to several of those, namely poinsettia (Euphorbia pulcherrima), English holly (Ilex aquifolium), American holly (Ilex opaca), bittersweet (Solanum dulcamara), Jerusalem cherry (Solanum pseudocapsicum), American mistletoe (Phoradendron serotinum), and European mistletoe (Viscum album).

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Bladder Bulge: Unifying Old and New Sonographic Bladder Wall Abnormalities in Ureterolithiasis

Approximately 1% of all emergency department (ED) visits are for treatment of urinary tract stone disease (renal colic, kidney stones, urolithiasis). Renal colic is a common condition affecting approximately 7–13% of the population during their lifetime and those who are afflicted are likely to have recurrent attacks throughout their lives. Through the following case series, we present sonographic bladder wall findings in patients with renal colic.

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Current Trends in the Management of Difficult Urinary Catheterizations

Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands or other potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failed catheterization and concomitant complications increase. Repeated and unsuccessful attempts at urinary catheterization induce stress and pain for the patient, injury to…

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Radiation Dose From Medical Imaging: A Primer for Emergency Physicians

Medical imaging now accounts for most of the US population’s exposure to ionizing radiation. A substantial proportion of this medical imaging is ordered in the emergency setting. We aim to provide a general overview of radiation dose from medical imaging with a focus on computed tomography, as well as a literature review of recent efforts to decrease unnecessary radiation exposure to patients in the emergency department setting.

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Emergency Department Management of Delirium in the Elderly

An increasing number of elderly patients are presenting to the emergency department. Numerous studies have observed that emergency physicians often fail to identify and diagnose delirium in the elderly. These studies also suggest that even when emergency physicians recognized delirium, they still may not have fully appreciated the import of the diagnosis. Delirium is not a normal manifestation of aging and, often, is the only sign of a serious underlying medical condition. This article will review the significance, definition, and principal features of delirium so that emergency physicians may better appreciate, recognize, evaluate, and manage delirium in the elderly.

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Challenging the Pathophysiologic Connection between Subdural Hematoma, Retinal Hemorrhage, and Shaken Baby Syndrome

Author Affiliation Christopher S Greeley, MD University of Texas Health Science Center at Houston The Western Journal of Emergency Medicine has received a detailed critique by Dr Christopher Greeley of the article, “Challenging the Pathophysiologic Connection between Subdural Hematoma, Retinal Hemorrhage, and Shaken Baby Syndrome” by Dr Steven Gabaeff, published in May 2011, Volume XII, Issue 2. […]

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Bath Salts: The Ivory Wave of Trouble

Bath salts pose an increasing public health risk in the United States, with reports of toxicity and mortality increasing along with calls to poison centers throughout the United States. Packages labeled with innocuous monikers such as White Ice, Ivory Wave, Ocean Snow, Lunar Wave, and Vanilla Sky intentionally belie the dangerous substances within, which are by no means intended to replace legitimate bath products.

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Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup

In this article, the authors discuss several aspects of seclusion and restraint, including review of the Centers for Medicare and Medicaid Services guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff, and a review of quality improvement and risk management strategies that have been effective in decreasing their use in various treatment settings.

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The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup

In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic drugs, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multiple or idiopathic causes.

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Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup

Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state.

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Psychiatric Evaluation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychiatric Evaluation Workgroup

It is difficult to fully assess an agitated patient, and the complete psychiatric evaluation usually cannot be completed until the patient is calm enough to participate in a psychiatric interview. Nonetheless, emergency clinicians must perform an initial mental status screening to begin this process as soon as the agitated patient presents to an emergency setting.

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Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup

Author Affiliation Kimberly Nordstrom, MD, JD Denver Health Medical Center, University of Colorado Denver, Department of Psychiatry, Denver, Colorado Leslie S Zun, MD Mount Sinai Hospital, Chicago Medical School, Department of Emergency Medicine, Chicago, Illinois Michael P Wilson, MD, PhD UC San Diego Health System, Department of Emergency Medicine, San Diego, California Victor Stiebel MD […]

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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389
Email: editor@westjem.org

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.