Reduction in Radiation Exposure through a Stress Test Algorithm in an Emergency Department Observation Unit

Volume 17, Issue 2, March 2016.
Margarita E. Pena, MD, et al.

Introduction: Clinicians are urged to decrease radiation exposure from unnecessary medical
procedures. Many emergency department (ED) patients placed in an observation unit (EDOU) do not
require chest pain evaluation with a nuclear stress test (NucST). We sought to implement a simple
ST algorithm that favors non-nuclear stress test (Non-NucST) options to evaluate the effect of the
algorithm on the proportion of patients exposed to radiation by comparing use of NucST versus NonNucST
pre- and post-algorithm.
Methods: An ST algorithm was introduced favoring Non-NucST and limiting NucST to a subset of
EDOU patients in October 2008. We analyzed aggregate data before (Jan-Sept 2008, period 1) and
after (Jan-Sept 2009 and Jan-Sept 2010, periods 2 and 3 respectively) algorithm introduction. A
random sample of 240 EDOU patients from each period was used to compare 30-day major adverse
cardiac events (MACE). We calculated confidence intervals for proportions or the difference between
two proportions.
Results: A total of 5,047 STs were performed from Jan-Sept 2008-2010. NucST in the EDOU
decreased after algorithm introduction from period 1 to 2 (40.7%, 95% CI [38.3-43.1] vs. 22.1%, 95%
CI [20.1-24.1]), and remained at 22.1%, 95% CI [20.3-24.0] in period 3. There was no difference in
30-day MACE rates before and after algorithm use (0.1% for period 1 and 3, 0% for period 2).
Conclusion: Use of a simple ST algorithm that favors non-NucST options decreases the proportion
of EDOU chest pain patients exposed to radiation exposure from ST almost 50% by limiting NucST
to a subset of patients, without a change in 30-day MACE.

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Acute Stroke: Current Evidence-based Recommendations for Prehospital Care

Volume 17, Issue 2, March 2016.
Nancy K. Glober, MD, et al.

Introduction: In the United States, emergency medical services (EMS) protocols vary widely across
jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation
and treatment of a patient with a suspected stroke and to compare these recommendations against
the current protocols used by the 33 EMS agencies in the state of California.
Methods: We performed a literature review of the current evidence in the prehospital treatment of
a patient with a suspected stroke and augmented this review with guidelines from various national
and international societies to create our evidence-based recommendations. We then compared
the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations.
The specific protocol components that we analyzed were the use of a stroke scale, blood glucose
evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and
cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization.
Results: Protocols across EMS agencies in California varied widely. Most used some sort of stroke
scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the
evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring
was recommended in 58% and 33% recommended an ECG. More than half required the direct
transport to a primary stroke center and 88% recommended hospital notification.
Conclusion: Protocols for a patient with a suspected stroke vary widely across the state of
California. The evidence-based recommendations that we present for the prehospital diagnosis and
treatment of this condition may be useful for EMS medical directors tasked with creating and revising
these protocols.

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Factors Associated with First-Pass Success in Pediatric Intubation in the Emergency Department

Volume 17, Issue 2, March 2016.
Tadahiro Goto, MD, et al.

Introduction: The objective of this study was to investigate the factors associated with first-pass
success in pediatric intubation in the emergency department (ED).
Methods: We analyzed the data from two multicenter prospective studies of ED intubation in 17
EDs between April 2010 and September 2014. The studies prospectively measured patient’s age,
sex, principal indication for intubation, methods (e.g., rapid sequence intubation [RSI]), devices, and
intubator’s level of training and specialty. To evaluate independent predictors of first-pass success,
we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we
repeated the analysis in children <10 years.
Results: A total of 293 children aged ≤18 years who underwent ED intubation were eligible for the
analysis. The overall first-pass success rate was 60% (95%CI [54%-66%]). In the multivariable
model, age ≥10 years (adjusted odds ratio [aOR], 2.45; 95% CI [1.23-4.87]), use of RSI (aOR, 2.17;
95% CI [1.31-3.57]), and intubation attempt by an emergency physician (aOR, 3.21; 95% CI [1.78-
5.83]) were significantly associated with a higher chance of first-pass success. Likewise, in the
sensitivity analysis, the use of RSI (aOR, 3.05; 95% CI [1.63-5.70]), and intubation attempt by an
emergency physician (aOR, 4.08; 95% CI [1.92-8.63]) were significantly associated with a higher
chance of first-pass success.
Conclusion: Based on two large multicenter prospective studies of ED airway management, we
found that older age, use of RSI, and intubation by emergency physicians were the independent
predictors of a higher chance of first-pass success in children. Our findings should facilitate
investigations to develop optimal airway management strategies in critically-ill children in the ED.

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Moving Beyond Screening: How Emergency Departments Can Help Extinguish the HIV/AIDS Epidemic

Volume 17, Issue 2, March 2016.
Michael Menchine, MD, MPH, et al.

While great strides have been made in diagnostic and treatment strategies, human immunodeficiency
virus (HIV) remains a major public health epidemic. The Centers for Disease Control and Prevention
(CDC) Morbidity and Mortality Weekly Report article, “Vital Signs: HIV Diagnosis, Care, and Treatment
Among Persons Living with HIV – United States, 2011,” highlights current areas of concern regarding
HIV diagnosis and care. The CDC estimates that 1.2 million people in the U.S. are living with HIV.
Of them, 86% have received a diagnosis (14% remain undiagnosed and unaware), but only 40%
are engaged in care and a mere 30% are virally suppressed. Emergency departments (EDs) can
play a major role in combatting the HIV epidemic through regular screening and facilitating linkage
to chronic HIV care. Universal opt-out screening as recommended by the CDC in 2006 has been
shown to be effective but expensive, and has not been widely implemented in EDs nationwide. Costeffective
models and a renewed commitment from ED providers are needed to enhance ED-based HIV
containment strategies.

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Growing Trend of Alternative Tobacco Use Among the Nation’s Youth: A New Generation of Addicts

Volume 17, Issue 2, March 2016.
John R. Marshall, MD, et al.

The Centers for Disease Control and Prevention (CDC) has published significant data and trends
related to the rising epidemic of usage of alternate forms of tobacco among the nation’s youth.
For the first time ever, the use of the electronic cigarette (e-cigarrette) has surpassed traditional
cigarette usage in adolescents. E-cigarettes are battery-operated products designed to deliver
aerosolized nicotine and other flavors to the consumer. Most look like conventional cigarettes
but some resemble everyday items such as pens, USB drives, and memory sticks. In the
following article, we present findings from the CDC’s Morbidity and Mortality Weekly Report with
commentary on the state of this growing epidemic and barriers to effective screening methods.

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Impact of a Dedicated Emergency Medicine Teaching Resident Rotation at a Large Urban Academic Center

Volume 17, Issue 2, March 2016.
James Ahn, MD, et al.

Introduction: In the face of declining bedside teaching and increasing emergency department
(ED) crowding, balancing education and patient care is a challenge. Dedicated shifts by teaching
residents (TRs) in the ED represent an educational intervention to mitigate these difficulties. We
aimed to measure the perceived learning and departmental impact created by having TR.
Methods: TRs were present in the ED from 12pm-10pm daily, and their primary roles were to
provide the following: assist in teaching procedures, give brief “chalk talks,” instruct junior trainees
on interesting cases, and answer clinical questions in an evidence-based manner. This observational
study included a survey of fourth-year medical students (MSs), residents and faculty at an academic
ED. Surveys measured the perceived effect of the TR on teaching, patient flow, ease of procedures,
and clinical care.
Results: Survey response rates for medical students, residents, and faculty are 56%, 77%, and
75%, respectively. MSs perceived improved procedure performance with TR presence and the
majority agreed that the TR was a valuable educational experience. Residents perceived increased
patient flow, procedure performance, and MS learning with TR presence. The majority agreed that
the TR improved patient care. Faculty agreed that the TR increased resident and MS learning, as
well as improved patient care and procedure performance.
Conclusion: The presence of a TR increased MS and resident learning, improved patient care and
procedure performance as perceived by MSs, residents and faculty. A dedicated TR program can
provide a valuable resource in achieving a balance of clinical education and high quality healthcare.

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Can Simulation Measure Differences in Task-Switching Ability Between Junior and Senior Emergency Medicine Residents?

Volume 17, Issue 2, March 2016.
Dustin Smith, MD, et al.

Introduction: Work interruptions during patient care have been correlated with error. Task-switching
is identified by the Accreditation Council for Graduate Medical Education (ACGME) as a core
competency for emergency medicine (EM). Simulation has been suggested as a means of assessing
EM core competencies. We assumed that senior EM residents had better task-switching abilities
than junior EM residents. We hypothesized that this difference could be measured by observing the
execution of patient care tasks in the simulation environment when a patient with a ST-elevation
myocardial infarction (STEMI) interrupted the ongoing management of a septic shock case.
Methods: This was a multi-site, prospective, observational, cohort study. The study population
consisted of a convenience sample of EM residents in their first three years of training. Each subject
performed a standardized simulated encounter by evaluating and treating a patient in septic shock.
At a predetermined point in every sepsis case, the subject was given a STEMI electrocardiogram
(ECG) for a separate chest pain patient in triage and required to verbalize an interpretation and
action. We scored learner performance using a dichotomous checklist of critical actions covering
sepsis care, ECG interpretation and triaging of the STEMI patient.
Results: Ninety-one subjects participated (30 postgraduate year [PGY]1s, 32 PGY2s, and 29
PGY3s). Of those, 87 properly managed the patient with septic shock (90.0% PGY1s, 100%
PGY2, 96.6% PGY 3s; p=0.22). Of the 87 who successfully managed the septic shock, 80 correctly
identified STEMI on the simulated STEMI patient (86.7% PGY1s, 96.9% PGY2s, 93.1% PGY3s;
p=0.35). Of the 80 who successfully managed the septic shock patient and correctly identified the
STEMI, 79 provided appropriate interventions for the STEMI patient (73.3% PGY1s, 93.8% PGY2s,
93.8% PGY3s; p=0.07).
Conclusion: When management of a septic shock patient was interrupted with a STEMI ECG in a
simulated environment we were unable to measure a significant difference in the ability of EM residents
to successfully task-switch when compared across PGY levels of training. This study may help refine
the use of simulation to assess EM resident competencies.

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Impact of Mental Health and Substance Use Disorders on Emergency Department Visit Outcomes for HIV Patients

Volume 17, Issue 2, March 2016.
Brian Y. Choi, MD, MPH, et al.

Introduction: A disproportionate number of individuals with human immunodeficiency virus (HIV)
have mental health and substance-use disorders (MHSUDs), and MHSUDs are significantly
associated with their emergency department (ED) visits. With an increasing share of older adults
among HIV patients, this study investigated the associations of MHSUDs with ED outcomes of HIV
patients in four age groups: 21-34, 35-49, 50-64, and 65+ years.
Methods: We used the 2012 Nationwide Emergency Department Sample (NEDS) dataset (unweighted
n=23,244,819 ED events by patients aged 21+, including 115,656 visits by patients with
HIV). Multinomial and binary logistic regression analyses, with “treat-and-release” as the base
outcome, were used to examine associations between ED outcomes and MHSUDs among visits that
included a HIV diagnosis in each age group.
Results: Mood and “other” mental disorders had small effects on ED-to-hospital admissions, as
opposed to treat-and-release, in age groups younger than 65+ years, while suicide attempts had
medium effects (RRR=3.56, CI [2.69-4.70]; RRR=4.44, CI [3.72-5.30]; and RRR=5.64, CI [4.38-
7.26] in the 21-34, 35-49, and 50-64 age groups, respectively). Cognitive disorders had mediumto-large
effects on hospital admissions in all age groups and large effects on death in the 35-49
(RRR=7.29, CI [3.90-13.62]) and 50-64 (RRR=5.38, CI [3.39-8.55]) age groups. Alcohol use
disorders (AUDs) had small effects on hospital admission in all age groups (RRR=2.35, 95% CI
[1.92-2.87]; RRR=2.15, 95% CI [1.95-2.37]; RRR=1.92, 95% CI [1.73-2.12]; and OR=1.93, 95%
CI [1.20-3.10] in the 21-34, 35-49, 50-64, and 65+ age groups, respectively). Drug use disorders
(DUDs) had small-to-medium effects on hospital admission (RRR=4.40, 95% CI [3.87-5.0];
RRR=4.07, 95% CI [3.77-4.40]; RRR=4.17, 95% CI [3.83-4.55]; and OR=2.53, 95% CI [2.70-
3.78] in the 21-34, 35-49, 50-64, and 65+ age groups, respectively). AUDs and DUDs were also
significantly related to the risk of death, and DUDs had a small effect on the risk of discharge
against medical advice in the 35-49 and 50-64 age groups.
Conclusion: The high prevalence of MHSUDs and their significant roles in ED visit outcomes in
patients with HIV provide support for integrated care for these patients outside the ED to reduce
their ED visits and costly hospital admissions and institutional care that follows, especially for the
increasing numbers of older adults with HIV.

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Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting

Volume 17, Issue 2, March 2016.
Scott L. Zeller, MD, et al.

Introduction: Patient agitation represents a significant challenge in the emergency department
(ED), a setting in which medical staff are working under pressure dealing with a diverse range of
medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff,
and others at risk, makes it imperative to address agitated behavior rapidly and efficiently. Time
constraints and limited access to specialist psychiatric support have in the past led to the strategy
of “restrain and sedate,” which was believed to represent the optimal approach; however, it is
increasingly recognized that more patient-centered approaches result in improved outcomes. The
objective of this review is to raise awareness of best practices for the management of agitation in the
ED and to consider the role of new pharmacologic interventions in this setting.
Discussion: The Best practices in Evaluation and Treatment of Agitation (BETA) guidelines
address the complete management of agitation, including triage, diagnosis, interpersonal
calming skills, and medicine choices. Since their publication in 2012, there have been further
developments in pharmacologic approaches for dealing with agitation, including both new agents
and new modes of delivery, which increase the options available for both patients and physicians.
Newer modes of delivery that could be useful in rapidly managing agitation include inhaled, buccal/
sublingual and intranasal formulations. To date, the only formulation administered via a nonintramuscular
route with a specific indication for agitation associated with bipolar or schizophrenia
is inhaled loxapine. Non-invasive formulations, although requiring cooperation from patients, have
the potential to improve overall patient experience, thereby improving future cooperation between
patients and healthcare providers.
Conclusion: Management of agitation in the ED should encompass a patient-centered approach,
incorporating non-pharmacologic approaches if feasible. Where pharmacologic intervention is
necessary, a cooperative approach using non-invasive medications should be employed where

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Care of Psychiatric Patients: The Challenge to Emergency Physicians

Volume 17, Issue 2, March 2016.
Leslie Zun, MD, MBA, et al.

Psychiatric patients frequently present to the emergency
department (ED) for care when they are in crisis. Recent
studies demonstrate about 10% of all ED patients present with
psychiatric illness. However, this is not an adequate estimate
of the number of patients because many of these patients do
not have a psychiatric diagnosis. Two recent studies have
demonstrated that 45% of adults and 40% of pediatric patients
who present to the ED with non-psychiatric complaints have
undiagnosed mental illness. These studies did not determine
whether these psychiatric illnesses affected the patients’
presentation. The purpose of this article is to discuss disparity
and challenges in caring for these patients.

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Diagnostic Acumen

Electronic Vapor Cigarette Battery Explosion Causing Shotgun-like Superficial Wounds and Contusion

Volume 17, Issue 2, March 2016.
Siri Shastry, MD, et al.

Electronic vapor cigarettes (E-cigarettes) were created
in 2003 as an alternative to traditional tobacco cigarettes.
E-cigarettes have been available in the United States since
2006. The typical E-cigarette consists of a cartridge that
contains liquid, an atomizer that heats the liquid (i.e. acts
as a vaporizer), as well as a battery. The liquid contained
within the cartridge contains nicotine, propylene glycol and/
or glycerol as well as flavorings.The consumer uses an
E-cigarette through either pushing a button or inhalation,
which triggers heating and therefore aerosolizes the liquid
within the cartridge, emulating cigarette “smoke.” The newest
E-cigarettes are larger than nicotine cigarettes and employ
stronger, rechargeable batteries as a power source.

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Diagnostic Acumen

Salicylate Toxicity from Genital Exposure to a Methylsalicylate-Containing Rubefacient

Volume 17, Issue 2, March 2016.
Trevonne M. Thompson, MD, et al.

Methylsalicylate-containing rubefacients have been reported to cause salicylate poisoning after
ingestion, topical application to abnormal skin, and inappropriate topical application to normal
skin. Many over-the-counter products contain methylsalicylate. Topical salicylates rarely produce
systemic toxicity when used appropriately; however, methylsaliclyate can be absorbed through intact
skin. Scrotal skin can have up to 40-fold greater absorption compared to other dermal regions. We
report a unique case of salicylate poisoning resulting from the use of a methylsalicylate-containing
rubefacient to facilitate masturbation in a male teenager. Saliclyate toxicity has not previously been
reported from the genital exposure to methylsaliclyate.

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Diagnostic Acumen

Traumatic Arthrotomy with Pneumarthrosis on Plain Radiograph of the Knee

Volume 17, Issue 2, March 2016.
Timothy D. Roberts, MBChB

An eight-year-old boy presented to the emergency
department (ED) with a 2cm-long laceration over the
prepatellar region of his left knee after falling over and
cutting his knee on broken glass. Physical examination
demonstrated the laceration breached the dermis but
otherwise there was no obvious defect in the deep fascial

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Diagnostic Acumen

Young Woman with a Fever and Chest Pain

Volume 17, Issue 2, March 2016.
Kristin H. Dwyer, MD, MPH, et al.

A 26-year-old female presented to the emergency
department with three days of subjective fevers, dry cough
and pleuritic chest discomfort. On exam, her vital signs
were significant for a heart rate of 106/minute and oxygen
saturation of 95% on room air. Her lung exam revealed
decreased breath sounds at the right base. A bedside lung
ultrasound and a chest radiograph were performed.

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Diagnostic Acumen

Bullosis Diabeticorum

Volume 17, Issue 2, March 2016.
Meina J. Michael, BS, et al.

A 63-year-old female with insulin-dependent type II
diabetes mellitus and end-stage renal disease presented to the
emergency department with spontaneous blistering to the tips
of her left index and middle fingers. The blisters had gradually
become tense and mildly painful over the preceding 10 days.
She denied burn injury, trauma, fever, or new medications.
On physical exam, the patient was noted to have a tense,
nontender bullae on the pad of the left middle finger, and a
collapsed, hemorrhagic bullae on the left index finger. There
were no signs of inflammation or infection. A radiograph of
the left hand, complete blood count, and basic metabolic panel
were unremarkable. The diagnosis of bullosis diabeticorum
was made, and supported by a consulting endocrinologist.

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Diagnostic Acumen

Turbid Peritoneal Fluid

Volume 17, Issue 2, March 2016.
Samuel L. Burleson, MD, et al.

A 58-year-old female with a past medical history of
hepatitis C virus-induced cirrhosis presented to the emergency
department with three days of increasing abdominal pain,
chills, and nausea and vomiting. Abdominal physical
examination revealed gross ascites with fluid wave. Diagnostic
paracentesis resulted in the aspiration of approximately 60mL
of white turbid peritoneal fluid (Figure).

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There’s an App for That? Highlighting the Difficulty in Finding Clinically Relevant Smartphone Applications

Volume 17, Issue 2, March 2016.
Warren Wiechmann, MD, MBA, et al.

Introduction: The use of personal mobile devices in the medical field has grown quickly, and a large
proportion of physicians use their mobile devices as an immediate resource for clinical decisionmaking,
prescription information and other medical information. The iTunes App Store (Apple,
Inc.) contains approximately 20,000 apps in its “Medical” category, providing a robust repository
of resources for clinicians; however, this represents only 2% of the entire App Store. The App
Store does not have strict criteria for identifying content specific to practicing physicians, making
the identification of clinically relevant content difficult. The objective of this study is to quantify
the characteristics of existing medical applications in the iTunes App Store that could be used by
emergency physicians, residents, or medical students.
Methods: We found applications related to emergency medicine (EM) by searching the iTunes App
Store for 21 terms representing core content areas of EM, such as “emergency medicine,” “critical
care,” “orthopedics,” and “procedures.” Two physicians independently reviewed descriptions of
these applications in the App Store and categorized each as the following: Clinically Relevant, Book/
Published Source, Non-English, Study Tools, or Not Relevant. A third physician reviewer resolved
disagreements about categorization. Descriptive statistics were calculated.
Results: We found a total of 7,699 apps from the 21 search terms, of which 17.8% were clinical,
9.6% were based on a book or published source, 1.6% were non-English, 0.7% were clinically
relevant patient education resources, and 4.8% were study tools. Most significantly, 64.9% were
considered not relevant to medical professionals. Clinically relevant apps make up approximately
6.9% of the App Store’s “Medical” Category and 0.1% of the overall App Store.
Conclusion: Clinically relevant apps represent only a small percentage (6.9%) of the total App
volume within the Medical section of the App Store. Without a structured search-and-evaluation
strategy, it may be difficult for the casual user to identify this potentially useful content. Given the
increasing adoption of devices in healthcare, national EM associations should consider curating
these resources for their members.

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Point-of-Care Ultrasound to Evaluate a Teenager with Presyncope

Volume 17, Issue 2, March 2016.
Michael T. Long, MD

A 16-year-old male presented with three months of
palpitations at rest, fatigue, and episodic pre-syncope; his
paternal grandfather died following presumed premature
myocardial infarction at age 30. He was seen and discharged
one week previously at an outside emergency department
(ED). He followed up with his pediatrician and was promptly
referred to our pediatric ED for evaluation given his risk factors.
Pertinent vitals on arrival were pulse 110, blood pressure
129/66, and oxygen saturation 97% on room air. His exam
was remarkable for a left upper sternal border 2/6 holosystolic
murmur with radiation to apex. In addition, the patient had a
chest radiograph (Figure), a nonspecific but abnormal EKG, and
a point-of-care ultrasound (POCUS) of the heart performed.

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Retrospective Review of Ocular Point-of-Care Ultrasound for Detection of Retinal Detachment

Volume 17, Issue 2, March 2016.
Bradley Jacobsen, BS, et al.

Introduction: Retinal detachment is an ocular emergency that commonly presents to the
emergency department (ED). Ophthalmologists are able to accurately make this diagnosis with a
dilated fundoscopic exam, scleral depression or ophthalmic ultrasound when a view to the retina is
obstructed. Emergency physicians (EPs) are not trained to examine the peripheral retina, and thus
ophthalmic ultrasound can be used to aid in diagnosis. We assessed the accuracy of ocular point-ofcare
ultrasound (POCUS) in diagnosing retinal detachment.
Methods: We retrospectively reviewed charts of ED patients with suspected retinal detachment
who underwent ocular POCUS between July 2012 and May 2015. Charts were reviewed for
patients presenting to the ED with ocular complaints and clinical concern for retinal detachment.
We compared ocular POCUS performed by EPs against the criterion reference of the consulting
ophthalmologist’s diagnosis.
Results: We enrolled a total of 109 patients. Of the 34 patients diagnosed with retinal detachment
by the ophthalmologists, 31 were correctly identified as having retinal detachment by the EP using
ocular POCUS. Of the 75 patients who did not have retinal detachment, 72 were ruled out by ocular
POCUS by the EP. This resulted in a POCUS sensitivity of 91% (95% CI [76-98]) and specificity of
96% (95% CI [89-99]).
Conclusion: This retrospective study suggests that ocular POCUS performed by EPs can aid in the
diagnosis of retinal detachment in ED.

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Mistakes and Pitfalls Associated with Two-Point Compression Ultrasound for Deep Vein Thrombosis

Volume 17, Issue 2, March 2016.
Tony Zitek, MD, et al.

Introduction: Two-point compression ultrasound is purportedly a simple and accurate means to
diagnose proximal lower extremity deep vein thrombosis (DVT), but the pitfalls of this technique
have not been fully elucidated. The objective of this study is to determine the accuracy of emergency
medicine resident-performed two-point compression ultrasound, and to determine what technical
errors are commonly made by novice ultrasonographers using this technique.
Methods: This was a prospective diagnostic test assessment of a convenience sample of adult
emergency department (ED) patients suspected of having a lower extremity DVT. After brief training
on the technique, residents performed two-point compression ultrasounds on enrolled patients.
Subsequently a radiology department ultrasound was performed and used as the gold standard.
Residents were instructed to save videos of their ultrasounds for technical analysis.
Results: Overall, 288 two-point compression ultrasound studies were performed. There were 28
cases that were deemed to be positive for DVT by radiology ultrasound. Among these 28, 16 were
identified by the residents with two-point compression. Among the 260 cases deemed to be negative
for DVT by radiology ultrasound, 10 were thought to be positive by the residents using two-point
compression. This led to a sensitivity of 57.1% (95% CI [38.8-75.5]) and a specificity of 96.1% (95%
CI [93.8-98.5]) for resident-performed two-point compression ultrasound. This corresponds to a
positive predictive value of 61.5% (95% CI [42.8-80.2]) and a negative predictive value of 95.4%
(95% CI [92.9-98.0]). The positive likelihood ratio is 14.9 (95% CI [7.5-29.5]) and the negative
likelihood ratio is 0.45 (95% CI [0.29-0.68]). Video analysis revealed that in four cases the resident
did not identify a DVT because the thrombus was isolated to the superior femoral vein (SFV), which
is not evaluated by two-point compression. Moreover, the video analysis revealed that the most
common mistake made by the residents was inadequate visualization of the popliteal vein.
Conclusion: Two-point compression ultrasound does not identify isolated SFV thrombi, which
reduces its sensitivity. Moreover, this technique may be more difficult than previously reported, in
part because novice ultrasonographers have difficulty properly assessing the popliteal vein.

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Computerized Diagnostic Assistant for the Automatic Detection of Pneumothorax on Ultrasound: A Pilot Study

Volume 17, Issue 2, March 2016.
Shane M. Summers, MD, RDMS, et al.

Introduction: Bedside thoracic ultrasound (US) can rapidly diagnose pneumothorax (PTX) with
improved accuracy over the physical examination and without the need for chest radiography (CXR);
however, US is highly operator dependent. A computerized diagnostic assistant was developed
by the United States Army Institute of Surgical Research to detect PTX on standard thoracic US
images. This computer algorithm is designed to automatically detect sonographic signs of PTX
by systematically analyzing B-mode US video clips for pleural sliding and M-mode still images for
the seashore sign. This was a pilot study to estimate the diagnostic accuracy of the PTX detection
computer algorithm when compared to an expert panel of US trained physicians.
Methods: This was a retrospective study using archived thoracic US obtained on adult patients
presenting to the emergency department (ED) between 5/23/2011 and 8/6/2014. Emergency
medicine residents, fellows, attending physicians, physician assistants, and medical students
performed the US examinations and stored the images in the picture archive and communications
system (PACS). The PACS was queried for all ED bedside US examinations with reported positive
PTX during the study period along with a random sample of negatives. The computer algorithm then
interpreted the images, and we compared the results to an independent, blinded expert panel of
three physicians, each with experience reviewing over 10,000 US examinations.
Results: Query of the PACS system revealed 146 bedside thoracic US examinations for analysis.
Thirteen examinations were indeterminate and were excluded. There were 79 true negatives, 33
true positives, 9 false negatives, and 12 false positives. The test characteristics of the algorithm
when compared to the expert panel were sensitivity 79% (95 % CI [63-89]) and specificity 87%
(95% CI [77-93]). For the 20 images scored as highest quality by the expert panel, the algorithm
demonstrated 100% sensitivity (95% CI [56-100]) and 92% specificity (95% CI [62-100]).
Conclusion: This novel computer algorithm has potential to aid clinicians with the identification of
the sonographic signs of PTX in the absence of expert physician sonographers. Further refinement
and training of the algorithm is still needed, along with prospective validation, before it can be utilized
in clinical practice.

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Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back

Volume 17, Issue 2, March 2016.
Talayeh Rezayat, DO, MPH, et al.

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark
approach has become less used in comparison to ultrasound (US) guided internal jugular
catheterization due to a higher rate of mechanical complications. A growing body of evidence
indicates that SCV catheterization with real-time US guidance can be accomplished safely and
efficiently. While several cannulation approaches with real-time US guidance have been described,
available literature suggests that the infraclavicular, longitudinal “in-plane” technique may be
preferred. This approach allows for direct visualization of needle advancement, which reduces risk
of complications and improves successful placement. Infraclavicular SCV cannulation requires
simultaneous use of US during needle advancement, but for an inexperienced operator, it is more
easily learned compared to the traditional landmark approach. In this article, we review the evidence
supporting the use of US guidance for SCV catheterization and discuss technical aspects of the
procedure itself.

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Critical Care

Effects of Intraosseous Tibial vs. Intravenous Vasopressin in a Hypovolemic Cardiac Arrest Model

Volume 17, Issue 2, March 2016.
Justin Fulkerson, MSN, et al.

Introduction: This study compared the effects of vasopressin via tibial intraosseous (IO) and
intravenous (IV) routes on maximum plasma concentration (Cmax), the time to maximum
concentration (Tmax), return of spontaneous circulation (ROSC), and time to ROSC in a
hypovolemic cardiac arrest model.
Methods: This study was a randomized prospective, between-subjects experimental design. A
computer program randomly assigned 28 Yorkshire swine to one of four groups: IV (n=7), IO tibia
(n=7), cardiopulmonary resuscitation (CPR) + defibrillation (n=7), and a control group that received
just CPR (n=7). Ventricular fibrillation was induced, and subjects remained in arrest for two minutes.
CPR was initiated and 40 units of vasopressin were administered via IO or IV routes. Blood samples
were collected at 0.5, 1, 1.5, 2, 2.5, 3, and 4 minutes. CPR and defibrillation were initiated for
20 minutes or until ROSC was achieved. We measured vasopressin concentrations using highperformance
liquid chromatography.
Results: There was no significant difference between the IO and IV groups relative to achieving
ROSC (p=1.0) but a significant difference between the IV compared to the CPR+ defibrillation
group (p=0.031) and IV compared to the CPR-only group (p=0.001). There was a significant
difference between the IO group compared to the CPR+ defibrillation group (p=0.031) and IO
compared to the CPR-only group (p=0.001). There was no significant difference between the CPR
+ defibrillation group and the CPR group (p=0.127). There was no significant difference in Cmax
between the IO and IV groups (p=0.079). The mean ± standard deviation of Cmax of the IO group
was 58,709±25,463pg/mL compared to the IV group, which was 106,198±62,135pg/mL. There was
no significant difference in mean Tmax between the groups (p=0.084). There were no significant
differences in odds of ROSC between the tibial IO and IV groups.
Conclusion: Prompt access to the vascular system using the IO route can circumvent the
interruption in treatment observed with attempting conventional IV access. The IO route is an
effective modality for the treatment of hypovolemic cardiac arrest and may be considered first line for
rapid vascular access.

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Emergency Department Operations

Physician Quality Reporting System Program Updates and the Impact on Emergency Medicine Practice

Volume 17, Issue 2, March 2016.
Jennifer L. Wiler, MD, MBA, et al.

In 2007, the Centers for Medicaid and Medicare Services (CMS) created a novel payment program to
create incentives for physician’s to focus on quality of care measures and report quality performance
for the first time. Initially termed “The Physician Voluntary Reporting Program,” various Congressional
actions, including the Tax Relief and Health Care Act of 2006 (TRHCA) and Medicare Improvements
for Patients and Providers Act of 2008 (MIPPA) further strengthened and ensconced this program,
eventually leading to the quality program termed today as the Physician Quality Reporting System
(PQRS). As a result of passage of the Affordable Care Act of 2010, the PQRS program has expanded
to include both the “traditional PQRS” reporting program and the newer “Value Modifier” program
(VM). For the first time, these programs were designed to include pay-for-performance incentives for
all physicians providing care to Medicare beneficiaries and to measure the cost of care. The recent
passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act
in March of 2015 includes changes to these payment programs that will have an even more profound
impact on emergency care providers. We describe the implications of these important federal policy
changes for emergency physicians.

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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

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.