Current Issue: Volume 17 Issue 4 Archives - The Western Journal of Emergency Medicine

Treatment Protocol Assessment

Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm

Volume 17, Issue 4, July 2016
Levi Kitchen, MD et al.

Unilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a common emergency department (ED) presentation. Proximal DVT (thrombus in the popliteal or femoral veins) can usually be diagnosed and treated at the initial ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep venous thrombosis (IC-DVT) often remains a consideration. The current standard for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography (WLUS), a test that is unavailable in many hospitals outside normal business hours. When WLUS is not available from the ED, recommendations for managing suspected IC-DVT vary. The objectives of the study is to use current evidence and recommendations to (1) propose a diagnostic algorithm for IC-DVT when definitive testing (WLUS) is unavailable; and (2) summarize the controversy surrounding IC-DVT treatment.

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Endemic Infections

Perception of the Risks of Ebola, Enterovirus-E68 and Influenza Among Emergency Department Patients

Volume 17, Issue 4, July 2016
Lauren K. Whiteside, MD, MS et al.

Emerging infectious diseases often create concern and fear among the public. Ebola virus disease (EVD) and enterovirus (EV-68) are uncommon viral illnesses compared to influenza. The objective of this study was to determine risk for these viral diseases and then determine how public perception of influenza severity and risk of infection relate to more publicized but less common emerging infectious diseases such as EVD and EV-68 among a sample of adults seeking care at an emergency department (ED) in the United States.

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Contrast CT Scans in the Emergency Department Do Not Increase Risk of Adverse Renal Outcomes

Volume 17, Issue 4, July 2016
Michael Heller, MD et al.

It has long been accepted that intravenous contrast used in both computed tomography (CT) and plain imaging carries a risk of nephropathy and renal failure, particularly in subpopulations thought to be at highest risk.1-3 Although early studies used high osmolality contrast media that is not typical of emergency department (ED) use today, the issue of contrast-induced nephropathy (CIN) is still an area of active interest with many studies appearing each year from many different specialties, on its pathogenesis, incidence, prevention and treatment.4-7 The plethora of data has usually focused on the incidence of CIN, usually defined as a small (such as 25% or an absolute increase of 0.5mg/dL) increase in creatinine after receiving intravenous (IV) contrast for either a particular indication (such as cardiac catheterization) or in a particular patient group (diabetics); the meaning of a creatinine rise in this setting is not at all clear, however.8-10 Many regimens have been proposed to ameliorate this creatinine rise, but there is a scarcity of data on what actual adverse clinical events occur and whether these can truly be ascribed to the IV contrast itself rather than the events that might well occur in a (usually) hospitalized population that required imaging. A few authors have even expressed doubt as to whether modern iodinated contrast (which is iso-osmolal) is a nephrotoxin.11-13

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Trends in Hospital Admission and Surgical Procedures Following ED visits for Diverticulitis

Volume 17, Issue 4, July 2016
Margaret B. Greenwood-Ericksen, MD, MPH et al.

Diverticulitis is a common diagnosis in the emergency department (ED). Outpatient management of diverticulitis is safe in selected patients, yet the rates of admission and surgical procedures following ED visits for diverticulitis are unknown, as are the predictive patient characteristics. Our goal is to describe trends in admission and surgical procedures following ED visits for diverticulitis, and to determine which patient characteristics predict admission.

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Prehospital Care

Accuracy of Perceived Estimated Travel Time by EMS to a Trauma Center in San Bernardino County, California

Volume 17, Issue 4, July 2016
Michael M. Neeki, DO, MS, et al.

Mobilization of trauma resources has the potential to cause ripple effects throughout hospital operations. One major factor affecting efficient utilization of trauma resources is a discrepancy between the prehospital estimated time of arrival (ETA) as communicated by emergency medical services (EMS) personnel and their actual time of arrival (TOA). The current study aimed to assess the accuracy of the perceived prehospital estimated arrival time by EMS personnel in comparison to their actual arrival time at a Level II trauma center in San Bernardino County, California.

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Prehospital Care

Impact of Prehospital Care on Outcomes in Sepsis: A Systematic Review

Volume 17, Issue 4, July 2016
Michael Smyth, MSc, et al.

Sepsis is a common and potentially life-threatening response to an infection. There are an estimated 150,000 cases of severe sepsis resulting in more than 44,000 deaths each year in the United Kingdom (UK). It has been reported that over 70% of sepsis cases stem from the community with one study suggesting two-thirds of severe sepsis cases are initially seen in the emergency department (ED).2 Approximately half of all ED sepsis patients will arrive via emergency medical services (EMS). Sepsis patients transported to the ED by EMS are likely to be sicker than those arriving by other means, with up to 80% of severe sepsis patients admitted to intensive care from the ED having been transported by EMS.

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Emergency Department Operations

Emergency Department Length of Stay for Maori and European Patients in New Zealand

Volume 17, Issue 4, July 2016
David Prisk, DO et al.

Emergency department length of stay (ED LOS) is currently used in Australasia as a quality measure. In our ED, Maori, the indigenous people of New Zealand, have a shorter ED LOS than European patients. This is despite Maori having poorer health outcomes overall. This study sought to determine drivers of LOS in our provincial New Zealand ED, particularly looking at ethnicity as a determining factor.

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Emergency Department Operations

Comparison of Result Times Between Urine and Whole Blood Point-of-care Pregnancy Testing

Volume 17, Issue 4, July 2016
Michael Gottlieb, MD, et al.

Point-of-care (POC) pregnancy testing is commonly performed in the emergency department (ED). One prior study demonstrated equivalent accuracy between urine and whole blood for one common brand of POC pregnancy testing. Our study sought to determine the difference in result times when comparing whole blood versus urine for the same brand of POC pregnancy testing.

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Body Mass Index is a Poor Predictor of Bedside Appendix Ultrasound Success or Accuracy

Volume 17, Issue 4, July 2016
Samuel Lam, MD, et al.

In recent years studies have been published on the use of beside ultrasound (BUS) to diagnose appendicitis in the emergency department (ED). Its popularity is likely due to the improving ultrasound skills of emergency physicians, as well as the obvious BUS advantages of no ionizing radiation emission, and ease of performance and interpretation at the bedside. Use of ultrasound in suspected appendicitis is also supported by American College of Radiology recommendations, especially in the pediatric population.

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Check the Head: Emergency Ultrasound Diagnosis of Fetal Anencephaly

Volume 17, Issue 4, July 2016
John Hall, MD, et al.

Early pregnancy complaints in emergency medicine are common. Emergency physicians (EP) increasingly employ ultrasound (US) in the evaluation of these complaints. As a result, it is likely that rare and important diagnoses will be encountered. We report a case of fetal anencephaly diagnosed by bedside emergency US in a patient presenting with first-trimester vaginal bleeding.

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Diagnosis of Pyomyositis in a Pediatric Patient with Point-of-Care Ultrasound

Volume 17, Issue 4, July 2016
Siamak Moayedi, MD, et al.

A three-year-old girl presented to the emergency department (ED) for five days of pain and decreased mobility of the left shoulder. She had been evaluated in the ED five days prior for shoulder pain after a minor slip and fall with negative clavicle radiographs, and was discharged home with supportive care. Since the initial visit, her shoulder pain increased and she would not use her arm. Physical examination demonstrated subtle swelling of the left anterior shoulder without erythema, warmth, or fluctuance. Her exam yielded mild tenderness to palpation and markedly decreased range of motion secondary to pain. Point-of-care shoulder ultrasound revealed an enlarged deltoid muscle with a heterogeneous fluid collection within the muscle, but no joint effusion (Video).

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Tachyarrhythmia in Wolff-Parkinson-White Syndrome

Volume 17, Issue 4, July 2016
Kelly Kesler, MD, et al.

A 29-year-old female with no significant past medical history presented with palpitations, nausea, diaphoresis and lightheadedness. Symptoms began 15 minutes prior to arrival. She reported several similar episodes previously that self-resolved within seconds, but had no previous medical evaluations for these symptoms. Initial vital signs were significant for blood pressure of 93/61, irregular heart rate between 180 and 200, respiratory rate of 18, and oxygen saturation of 99% on room air. Physical examination was otherwise unremarkable. The electrocardiogram (ECG) is shown in Figure 1. This was interpreted as atrial fibrillation with rapid ventricular rate, and the patient was treated with rate control with no effect. The patient later spontaneously converted to normal sinus rhythm and repeat ECG was notable for delta waves concerning for Wolff-Parkinson-White Syndrome (WPW) as seen in Figure 2. She was admitted to cardiology for cardiac ablation.

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A Woman with Vaginal Bleeding and an Intrauterine Device

Volume 17, Issue 4, June 2016
Zachary Dezman, MD, MS, et al.

A sexually active 35-year old woman presented to the emergency department with intermittent vaginal spotting and pelvic cramping over the preceding four weeks. She had an intrauterine device (IUD) placed three months prior and has never been pregnant. The threads of the IUD and a small amount of blood coming from the cervix were seen on pelvic exam. Laboratory testing revealed a β-human chorionic gonadotropin level of 70,000 mIU/mL. Pelvic ultrasound imaging showed the IUD and a viable intrauterine pregnancy.

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Don’t Forget What You Can’t See: A Case of Ocular Syphilis

Volume 17, Issue 4, June 2016
Monica Lee, MD, et al.

This case describes an emergency department (ED) presentation of ocular syphilis in a human immunodeficiency virus (HIV) infected patient. This is an unusual presentation of syphilis and one that emergency physicians should be aware of. The prevalence of syphilis has reached epidemic proportions since 2001 with occurrences primarily among men who have sex with men (MSM). This is a case of a 24-year-old male who presented to our ED with bilateral painless vision loss. The patient’s history and ED workup were notable for MSM, positive rapid plasmin reagin (RPR) and HIV tests and fundus exam consistent with ocular syphilis, specifically uveitis. Ocular manifestations of syphilis can present at any stage of syphilis. The 2010 Centers for Disease Control and Prevention guidelines now recommend that ocular syphilis be treated as neurosyphilis regardless of the lumbar puncture results. There is a paucity of emergency medicine literature on ocular syphilis. For emergency physicians it is important to be aware of iritis, uveitis, or chorioretinitis as ocular manifestations of neurosyphilis especially in this high-risk population and to obtain RPR and HIV tests in the ED to facilitate early diagnosis, and treatment and to prevent irreversible vision loss.

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Patient Communication

Giving Your Cell Phone Number to Patients

Volume 17, Issue 4, July 2016
C. Ferrell Varner, MD

Below is a letter concerning contact with patients. I have found this practice useful. It decreases anxiety on the part of the patient and the doctor. I write to recommend it to emergency physicians everywhere.

I give my cell phone number to patients all the time. By that I mean 2–3 times a shift. I have been doing it for years, almost since I first got a cell phone. I have given it out hundreds of times. I recommend that we encourage our emergency medicine (EM) residents to do so also. It is an easy option, and it can help avoid all sorts of problems. Discretion is in order, but there are not a lot of exceptions. There are some types of patients that I do not give it to.

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Increasing Completion Rate of an M4 Emergency Medicine Student End-of-Shift Evaluation Using a Mobile Electronic Platform and Real-Time Completion

Volume 17, Issue 4, July 2016
Matthew C. Tews, DO, MS et al.

Medical students on an emergency medicine rotation are traditionally evaluated at the end of each shift with paper-based forms, and data are often missing due to forms not being turned in or completed. Because students’ grades depend on these evaluations, change was needed to increase form rate of return. We analyzed a new electronic evaluation form and modified completion process to determine if it would increase the completion rate without altering how faculty scored student performance.

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Reaching Out of the Box: Effective Emergency Care Requires Looking Outside the Emergency Department

Volume 17, Issue 4, July 2016
Dr. Daniel Dworkis, MD, PhD, et al.

Patients do not start to exist when they arrive at the door of our emergency departments (ED), nor do they stop existing when they leave. Instead, before they fall ill or become injured they live and exist somewhere and when they are discharged from our care they will likely return to that same somewhere. As emergency providers (EPs), our attention must be focused on the patients in front of us, but fundamentally the details of this “somewhere” directly affect our ability to provide safe and effective emergency care. Specifically, both patient-specific factors like homelessness, immigration status, living situation, or insurance coverage, and structural factors arising from broader community and societal forces like food deserts, community violence, and poor housing quality can strongly impact both emergency presentations and our ability to safely and effectively discharge patients. Here, we argue that our duty as EPs extends beyond the four walls of our EDs into life in our communities, and that understanding and addressing the unique strengths and needs of the communities we serve is a crucial component of our ability to provide effective emergency care.

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Addressing Social Determinants of Health from the Emergency Department through Social Emergency Medicine

Volume 17, Issue 4, July 2016
Erik S. Anderson, MD, et al.

Dialogue and policy surrounding healthcare reform have drawn increasing interest to the social factors, accountable for nearly one-third of annual deaths in the United States, that affect the health of populations. The Affordable Care Act (ACA) includes provisions for health systems to address social determinants of health, but how this is to be accomplished remains uncertain. If we are to make progress as a health system in addressing social determinants of health, we must open a dialogue and practice that reaches patients at the front lines of the medical system and population health – including in the emergency department (ED). The fact that emergency physicians care for patients who are complicated both medically and socially is no surprise, but the idea that we have an important role to play in the social determinants of health of our patients is, while controversial, gaining increasing attention among emergency physicians across the country. This interest comes largely from necessity, as we face a daunting task of providing care to the large volume of vulnerable patients who seek refuge in our EDs.

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