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Discourse in Emergency Medicine and Population Health

Sedation-assisted Orthopedic Reduction in Emergency Medicine: The Safety and Success of a One Physician/One Nurse Model

We applaud Vinson and Hoehn for eloquently demonstrating that the performance of sedation assisted procedures in the emergency department (ED) does not necessarily require a 2 physician team. From a Canadian perspective, where single physician coverage in smaller EDs is common, this has important implications in terms of efficiency of patient care, reduction in the need for patient transfer and decreasing the time to definitive treatment for ED patients.

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Injury Prevention

Compliance with an Ordinance Requiring the Use of Personal Flotation Devices by Children in Public Waterways

Intro: For children ages 1–14, 21.6% of drowning cases involve swimming, wading, or playing in natural bodies of water, such as rivers and lakes. Personal flotation devices (PFDs) are believed to be an effective prevention measure. We measure compliance with city and county ordinances, publicized but not actively enforced, requiring that PFDs be worn by children accessing public bodies of water in Sacramento County, California.
Conclusion: The combination of a statutory requirement and a cost-elimination strategy was associated with moderate rates of PFD use that were highest among young children.

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Endemic Infections

Emergency Physicians’ Adherence to Center for Disease Control and Prevention Guidance During the 2009 Influenza A H1N1 Pandemic

Intro: Little is known regarding compliance with management guidelines for epidemic influenza in adult emergency department (ED) settings during the 2009 novel influenza A (H1N1) epidemic, especially in relation to the Centers for Disease Control and Prevention (CDC) guidance.
Conclusion: During the recent H1N1 pandemic, most admitted patients received ED diagnostic testing corresponding to the current recommended guidance. Antibiotic treatment for ED patients admitted with suspected influenza is not uncommon…

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Provider Workforce

Board-Certified Emergency Physicians Comprise a Minority of the Emergency Department Workforce in Iowa

Introduction: The objective of our study is to better understand the current staffing practices of Iowa emergency departments (EDs).
Conclusion: Many EDs in Iowa remain staffed by family medicine-trained physicians and are being increasingly staffed by APPs. Without the contribution of family physicians, large areas of the state would be unable to provide adequate emergency care. Board-certified emergency physicians remain concentrated in urban areas of the state, where patient volumes and acuity support their hiring.

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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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Diagnostic Acumen

A 37-year-old Woman with Altered Mental Status and Urinary Frequency

We present a case report of a patient who initially presented with altered mental status and significant urinary frequency. Over the course of her emergency department stay, she then developed tachycardia out of proportion to a new fever along with a respiratory alkalosis. Although each objective finding has a broad differential diagnosis, thyroid storm was the only unifying diagnosis when all findings were present.

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Diagnostic Acumen

Shock Index and Early Recognition of Sepsis in the Emergency Department: Pilot Study

Intro: Our objective was to compare the ability of SI, individual vital signs, and the systemic inflammatory response syndrome (SIRS) criteria to predict the primary outcome of hyperlactatemia (serum lactate ≥ 4.0 mmol/L) as a surrogate for disease severity, and the secondary outcome of 28-day mortality.
Conclusion: In this cohort, SI ≥ 0.7 performed as well as SIRS in NPV and was the most sensitive screening test for hyperlactatemia and 28-day mortality. SI ≥ 1.0 was the most specific predictor of both outcomes.

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Diagnostic Acumen

Primary Meningococcal Arthritis Leading to Neisseria Meningitidies Purpura Fulminans

Primary meningococcal arthritis (PMA) is a rare infectious disease that occurs in as little as 1% of meningococcal infections. PMA is arthritis without meningitis, fever, rash, and hemodynamic instability. It is usually preceded by an upper respiratory infection in 50–55% of presentations, and patients may appear nontoxic, afebrile, and polyarthralgic. Despite definition they may have a rash.

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Diagnostic Acumen

Hickam’s Dictum

A 15-year-old female presented to the emergency department (ED) with a 1-week history of fevers, vomiting, back pain and dysuria. Her primary care physician started her on cefdinir for a urinary tract infection. On initial evaluation she was febrile, tachycardic, and had an exam notable for tenderness of both the left costovertebral angle and suprapubic region.

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Diagnostic Acumen

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.

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Diagnostic Acumen

Jael’s Syndrome: Facial Impalement

Penetrating injuries to the face or neck can cause difficult airway issues. There is a relative dearth of literature to define the best approach to these patients. Impalement injuries are uncommon, and survivable injuries are most commonly confined to the abdomen or thorax. We report the case of a patient with an obviously difficult airway due to a facial impalement (Jael’s Syndrome) injured at a local construction site.

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Diagnostic Acumen

Acute Abdominal Pain in an End Stage Renal Disease Patient

An 81-year-old female with history of end stage renal disease on hemodialysis presented with worsening of abdominal pain of 2 days’ duration. The pain started as a dull ache over the lower abdomen 2 months earlier, diffuse but especially prominent over the lower quadrant, and was unrelieved by analgesic medications.

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Diagnostic Acumen

Cardiac Tamponade

A 49-year-old man was brought to the emergency department by ambulance after he sustained a stab wound to the chest. He was alert but diaphoretic, with an initial systolic blood pressure of 90 by palpation and a heart rate of 110. A 1 cm laceration was noted at the left lower sternal border. Lung sounds were clear bilaterally, and heart sounds were muted.

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Diagnostic Acumen

Levamisole-adulterated Cocaine Induced Vasculitis with Skin Ulcerations

A 40-year-old man with Hepatitis C and a history of cocaine abuse presented with multiple stages of painful rashes on his extremities and ears. On examination, the patient had several areas of purpuric macules and retiform purpura to his legs and ears, as well as large ulcerations with erythematous borders on bilateral lower extremities

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Injury Outcomes

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.

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Injury Outcomes

Riding the Escalator: How Dangerous is it Really?

Intro: About 10,000 escalator-related injuries per year result in emergency department treatment in the United States. Since the 1990s, a steady increase has been reported, but few statistics on escalator-related injuries have been published worldwide.
Conclusion: Escalator accidents can result in severe trauma. Significant gender differences in escalator accidents have been observed. Alcohol intoxication and age are significant risk factors in escalator-related accidents and might be possible targets for preventive measures.

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Education

Bedside Teaching on Time to Disposition Improves Length of Stay for Critically-ill Emergency Departments Patients

Introduction: We tested the effect of a brief disposition process intervention on residents’ time to disposition and emergency department (ED) length of stay (LOS) in high acuity ED patients.
Conclusion: Prompting residents to enter administrative disposition orders in high acuity patients is associated with significant reduction in both time to disposition and ED LOS.

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Education

Multimedia Education Increases Elder Knowledge of Emergency Department Care

Introduction: The purpose of this study was to evaluate a multi-media education intervention as a method for informing independently living elders about ED care. The program delivered messages categorically as, the number of tests, providers, decisions and disposition decision making.
Conclusion: A short video with graphic side-bar information is an effective educational strategy to improve elder understanding of expectations during a hypothetical ED encounter following calling 911.

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Ultrasound Diagnosis of a Left Atrial Myxoma in the Emergency Department

A 61-year-old male with a 1-year history of bilateral lower extremity swelling and a chronic cough was referred to the emergency department (ED) for an abnormal echocardiogram. The patient also reported experiencing intermittent episodes of chest pressure. He stated that he was referred from his doctor after he received a cardiac echocardiography examination that showed possible mitral valve vegetations. On review of systems, he also admitted to intermittent chest palpitations.

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Bedside Ultrasound in a Case of Blunt Scrotal Trauma

This case study describes a patient who suffered blunt force trauma to the scrotum. Use of bedside emergency ultrasound facilitated early diagnosis of a ruptured testicle and allowed for prompt urological consultation and timely surgical repair. The utility of bedside emergency ultrasound in the evaluation of testicular trauma, as well as the outcome of our case, is discussed here.

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Ultrasound Detection of a Renal Mass in a Patient with Flank Pain and Hematuria

Flank pain with hematuria is a common chief complaint in the emergency department (ED). Patients are often diagnosed with renal calculi or pyelonephritis and discharged with analgesics or antibiotics and follow-up. This case study describes a patient who presented to the ED with a 1 week history of flank pain and hematuria and was subsequently found to have a large renal mass on bedside ultrasound.

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Ultrasound Detection of a Molar Pregnancy in the Emergency Department

A 32 year-old female presented to the emergency department (ED) with complaints of mild vaginal spotting accompanied by uterine cramping. She was referred to the ED for an “abnormal pregnancy.” She was a G1P0 and her last menstrual period was 7 weeks 5 days prior. Physical examination demonstrated a well appearing female with normal vital signs.

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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: westjem@gmail.com

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WestJEM
ISSN: 1936-900X
e-ISSN: 1936-9018

CPC-EM
ISSN: 2474-252X

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.