Volume 12 Issue 2 Archives - The Western Journal of Emergency Medicine

Self-Knotting of a Nasogastric Tube

A 78-year-old male with multiple previous abdominal operations presented to the emergency department (ED) with abdominal pain and vomiting. Computed tomography (CT) revealed a small bowel obstruction.

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Superior Mesenteric Vein Thrombosis Mimicking Acute Appendicitis

Abdominal pain is one of the most common presenting complaints to the emergency department. Mesenteric venous thrombosis represents an important cause to consider in patients with acute abdominal pain. The diagnosis is often delayed, and cases traditionally have been identified either at laparotomy or at autopsy. In this case, we describe a 21-year-old female with acute onset of right lower quadrant pain attributable to a hyperhomocysteinemia related non-occlusive superior mesenteric vein thrombosis. This case highlights how the use of computed tomography in select cases can lead to earlier recognition of this condition and increasingly allow for non-surgical treatment.

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Extra-adrenal Pheochromocytoma in an Adolescent

A 17-year-old male with symptoms of headache and diaphoresis presented to the emergency department. He had eight months of noted hypertension attributed to medications. On arrival his blood pressure was 229/117mmHg, and he was ill-appearing. His blood pressure was managed aggressively, and he was diagnosed with extra-adrenal pheochromocytoma by computed tomography. He eventually underwent resection of the mass. Children with severe, symptomatic hypertension should be evaluated for pheochromocytoma. Although rare, it is curable. Failure to diagnose carries a high risk of morbidity and mortality.

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Those Who Can, Do and They Teach Too: Faculty Clinical Productivity and Teaching

Academic emergency physicians (EPs) often feel that the demands of clinical productivity, income generation, and patient satisfaction conflict with educational objectives. The objective of this study was to explore whether the quality of faculty bedside teaching of residents correlated with high clinical productivity, measured by relative value units (RVUs). We also explored the strategies of high-performing faculty for optimal RVU generation and teaching performance.

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Test Characteristics of Urine Dipstick for Identifying Renal Insufficiency in Patients with Diabetes

To evaluate the test characteristics of the urine dipstick as a screening tool for elevated serum creatinine in patients with uncontrolled diabetes mellitus in the emergency department (ED).

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Comparison of Pressures Applied by Digital Tourniquets in the Emergency Department

Digital tourniquets used in the emergency department have been scrutinized due to complications associated with their use, including neurovascular injury secondary to excessive tourniquet pressure and digital ischemia caused by a forgotten tourniquet. To minimize these risks, a conspicuous tourniquet that applies the least amount of pressure necessary to maintain hemostasis is recommended.

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Artifact Simulating Fracture on Cervical Spine Computed Tomography

We present the case of a 31-year-old trauma patient with computed tomography concerning significant C3–C4 subluxation. The abnormality is due to an artifact with which emergency physicians should be aware.

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Vertebrobasilar Artery Occlusion

The presentation of vertebrobasilar artery occlusion varies with the cause of occlusion and location of ischemia. This often results in delay in diagnosis. Areas of the brain supplied by the posterior circulation are difficult to visualize and usually require angiography or magnetic resonance imaging. Intravenous thrombolysis and local-intra arterial thrombolysis are the most common treatment approaches used. Recanalization of the occluded vessel significantly improves morbidity and mortality. Here we present a review of the literature and a case of a patient with altered mental status caused by vertebrobasilar artery occlusion.

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The Impact of Cardiac Contractility on Cerebral Blood Flow in Ischemia

In cerebral regions affected by ischemia, intrinsic vascular autoregulation is often lost. Blood flow delivery depends upon cardiac function and may be influenced by neuro-endocrine mediated myocardial suppression. Our objective is to evaluate the relation between ejection fraction (EF) and transcranial doppler (TCD) peak systolic velocities (PSV) in patients with cerebral ischemic events.

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Myocardial Ischemia with Penetrating Thoracic Trauma

Penetrating trauma is a rare cause of myocardial infarction. Our report describes a 47-year-old female who presented with a gunshot wound from a shotgun and had an ST-elevation myocardial infarction. The patient received emergent coronary angiography, which demonstrated no evidence of coronary atherosclerotic disease but did show occlusion of a marginal vessel secondary to a pellet. The patient was managed medically for the myocardial infarction without cardiac sequelae. Patients with penetrating trauma to the chest should be evaluated for myocardial ischemia. Electrocardiography, echocardiography and cardiac angiography play vital roles in evaluating these patients and helping to guide management.

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Takotsubo Syndrome in African American vs. Non-African American Women

Takotsubo syndrome (TTS) is a reversible cause of heart failure rarely described in African-American patients. This study aimed to compare and contrast the clinical characteristics of TTS in African-American (AA) and non-African-American (NAA) patients.

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Warfarin Overdose in a Breast-feeding Woman

We describe a case of a breastfeeding woman with an accidental warfarin overdose resulting in a markedly elevated prothrombin time. The breast-fed infant was evaluated and tested for ill effects. We discuss the use of warfarin while breast-feeding.

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Molar Pregnancy with False Negative β-hCG Urine in the Emergency Department

This case describes an atypical presentation of molar pregnancy in an emergency department patient with abdominal pain and vaginal bleeding. The patient demonstrated clinical features of hydatidiform mole, including acute discharge of a large, grape-like vesicular mass, despite multiple negative urine pregnancy tests. These false-negative qualitative human chorionic gonadotropin assays were likely caused by the “high-dose hook effect” and may have delayed proper care of the patient, who displayed pulmonary choriocarcinoma at the time of diagnosis.

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Does Pelvic Exam in the Emergency Department Add Useful Information?

Physicians are taught that the pelvic exam is a key part of the evaluation of a woman presenting with abdominal pain or vaginal bleeding. However, the exam is time consuming and invasive, and its use in the emergency department (ED) has not been prospectively evaluated. We evaluated how often the findings of the pelvic exam changed management in a cohort of consecutive female patients presenting with acute abdominal pain or vaginal bleeding.

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Ed Administration

Predicting Patient Patterns in Veterans Administration Emergency Departments

Veteran’s Affairs (VA) hospitals represent a unique patient population within the healthcare system; for example, they have few female and pediatric patients, typically do not see many trauma cases and often do not accept ambulance runs. As such, veteran-specific studies are required to understand the particular needs and stumbling blocks of VA emergency department (ED) care. The purpose of this paper is to analyze the demographics of patients served at VA EDs and compare them to the national ED population at large. Our analysis reveals that the VA population exhibits a similar set of common chief complaints to the national ED population (and in similar proportions) and yet differs from the general population in many ways. For example, the VA treats an older, predominantly male population, and encounters a much lower incidence of trauma. Perhaps most significantly, the incidence of psychiatric disease at the VA is more than double that of the general population (10% vs. 4%) and accounts for a significant proportion of admissions (23%). Furthermore, the overall admission percentage at the VA hospital is nearly three times that of the ED population at large (36% versus 13%). This paper provides valuable insight into the make-up of a veteran’s population and can guide staffing and resource allocation accordingly.

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Ed Administration

Impact of an Expeditor on Emergency Department Patient Throughput

Our hypothesis was that an individual whose primary role was to assist with patient throughput would decrease emergency department (ED) length of stay (LOS), elopements and ambulance diversion. The objective of this study was to measure how the use of an expeditor affected these throughput metrics.

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Ed Administration

Financial Impact of Emergency Department Crowding

The economic benefits of reducing emergency department (ED) crowding are potentially substantial as they may decrease hospital length of stay. Hospital administrators and public officials may therefore be motivated to implement crowding protocols. We sought to identify a potential cost of ED crowding by evaluating the contribution of excess ED length of stay (LOS) to overall hospital length of stay.

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Ed Administration

Applying Lean: Implementation of a Rapid Triage and Treatment System

Emergency department (ED) crowding creates issues with patient satisfaction, long wait times and leaving the ED without being seen by a doctor (LWBS). Our objective was to evaluate how applying Lean principles to develop a Rapid Triage and Treatment (RTT) system affected ED metrics in our community hospital.

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Rural-Urban Disparities in Emergency Department Intimate Partner Violence Resources

Little is known about availability of resources for managing intimate partner violence (IPV) at rural hospitals. We assessed differences in availability of resources for IPV screening and management between rural and urban emergency departments (EDs) in Oregon.

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Online Health Information Impacts Patients’ Decisions to Seek Emergency Department Care

To investigate the impact of online health information (OHI) and patients’ decisions to seek emergency department (ED) care.

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Transphyseal Fracture of the Distal Humerus in a Neonate

An 18-hour-old neonate was found to have absent movement of the left arm and a mildly edematous elbow following precipitous delivery with observed traction applied to the left arm.

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Test Characteristics of Urinalysis to Predict Urologic Injury in Children

To use receiver operator characteristic curve methodology to determine the test characteristics of microscopic hematuria for identifying urologic injuries in children who underwent computed tomography (CT) of the abdomen and pelvis as part of a trauma evaluation.

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Management of Pediatric Skin Abscesses in Pediatric, General Academic and Community Emergency Departments

To compare the evaluation and management of pediatric cutaneous abscess patients at three different emergency department (ED) settings.

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

Child abuse experts use diagnostic findings of subdural hematoma and retinal hemorrhages as near-pathognomonic findings to diagnose shaken baby syndrome. This article reviews the origin of this link and casts serious doubt on the specificity of the pathophysiologic connection.

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