Current Issue: Volume 22 Issue 2

Response to: “Management of Chloroquine and Hydroxychloroquine Poisoning: Do Not Miss the Time of Tracheal Intubation and Mechanical Ventilation”

Lebin, JA.

We thank Drs. Megarbane and Schicchi for their thoughtful comments on our manuscript and efforts to highlight pertinent in vitro and in vivo literature. As stated in our manuscript, we agree that aggressive supportive care is the mainstay of treatment for acute chloroquine and hydroxychloroquine toxicity, including management of the airway with appropriate ventilation, if necessary.

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Management of Chloroquine and Hydroxychloroquine Poisoning: Do Not Miss the Time of Tracheal Intubation and Mechanical Ventilation

Megarbane, B.

We would like to comment on Lebin and LeSaint’s overview of chloroquine/hydroxychloroquine (CQ/HoCQ) toxicity and management.1 The authors focused on the indications and administration modalities of hypertonic sodium bicarbonate, diazepam, and epinephrine. Surprisingly, they did not consider the role and indications of tracheal intubation and mechanical ventilation, while representing the mainstay of treatment.

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Telephonic Medical Toxicology Service in a Low-Resource Setting: Setup, Challenges, and Opportunities

Hitti, E.

Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting.

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Performance of Prognostication Scores for Mortality in Injured Patients in Rwanda

Tang, OY.

While trauma prognostication and triage scores have been designed for use in lower-resourced healthcare settings specifically, the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood. This study evaluated the Kampala Trauma Score (KTS), Revised Trauma Score (RTS), and Triage Early Warning Score (TEWS) for accuracy in predicting mortality among injured patients seeking emergency department (ED) care at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda.

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Central Venous Catheter Adverse Events Are not Associated with Crowding Indicators

Theodoro, DL.

Crowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU).

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Patient Communication

“I wanted to participate in my own care”: Evaluation of a Patient Navigation Program

Samuels, EA.

Patient navigation programs can help people overcome barriers to outpatient care. Patient experiences with these programs are not well understood. The goal of this study was to understand patient experiences and satisfaction with an emergency department (ED)-initiated patient navigation (ED-PN) intervention for US Medicaid-enrolled frequent ED users.

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Critical Care

Response to: “POCUS to Confirm Intubation in a Trauma Setting”

Gottlieb, M.

We thank the authors for their insights and for sharing this case. The authors describe a patient who was intubated with the endotracheal tube (ETT) located at the tip of the carina, thereby allowing for bilateral lung sliding, while placing the ETT at risk of converting to a mainstem intubation.

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Critical Care

POCUS to Confirm Intubation in a Trauma Setting

Scheier, E.

In the recent edition of the Western Journal of Emergency Medicine, Gottlieb and colleagues discuss point of care ultrasound (POCUS) confirmation of intubation.1 Up to 25% of intubations using the classic formula of endotracheal tube (ETT) depth equal to three times the ETT diameter are inappropriately positioned,2 and 35–60% of mainstem intubations are missed by auscultation.1 Therefore, chest radiograph (CXR) has traditionally been used for confirmation of appropriate ETT placement.

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Critical Care

Respone to: “Limitations of Retrospective Chart Reviews to Determine Rare Events, and the Unknown Relative Risk of Droperidol”

Cole, JB.

We thank the authors for their interest in our article, and for highlighting some important limitations of our work. 1 We are grateful for the opportunity to address these concerns further.

Regarding the authors’ first concern, indeed we already acknowledge in our limitations section that many of our patients did not receive continuous cardiac monitoring, and asymptomatic events could have been missed. While the clinical importance of asymptomatic self-terminating dysrhythmias is debatable, this question has fortunately been addressed by the DORM II investigators, who prospectively studied patients receiving droperidol for acute behavioral disturbance in multiple Australian emergency departments (ED). All patients in that study were initially treated in a critical care bed and attached to a cardiac monitor. When available, continuous ECG recordings were later analyzed, no patients had dysrhythmias, and while QT prolongation was observed the investigators found it was frequently due to causes other than droperidol. 2 We believe the incidence of such transient asymptomatic dysrhythmias in our study is likely miniscule.

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Critical Care

Comment on “The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department”

DiSalvo, PC.

We read with interest the recent article discussing QT prolongation and torsade des pointes (TdP) and droperidol.1 The paucity of readily available antipsychotics and antiemetics that are not associated with QT prolongation makes selection of an appropriate pharmaceutical challenging in ideal situations and decidedly complex when confronted with an agitated, delirious, or intoxicated patient.

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Critical Care

Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation

Ives Tallman, CM.

Emergency department (ED) patients are frequently ventilated with excessively large tidal volumes for predicted body weight based on height, which has been linked to poorer patient outcomes. We hypothesized that supplying tape measures to respiratory therapists (RT) would improve measurement of actual patient height and adherence to a lung-protective ventilation strategy in an ED-intensive care unit (ICU) environment.

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Critical Care

Transfer of Patients with Spontaneous Intracranial Hemorrhage who Need External Ventricular Drain: Does Admission Location Matter?

Tran, QC.

Patients with spontaneous intracranial hemorrhage (sICH) are associated with high mortality and require early neurosurgical interventions. At our academic referral center, the neurocritical care unit (NCCU) receives patients directly from referring facilities. However, when no NCCU bed is immediately available, patients are initially admitted to the critical care resuscitation unit (CCRU). We hypothesized that the CCRU expedites transfer of sICH patients and facilitates timely external ventricular drain (EVD) placement comparable to the NCCU.

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Critical Care

Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock

Musikatavorn, K.

The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy.

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Critical Care

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

Pacheco, GS.

The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED).

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Emergency Medicine Journal Editorial Boards: Analysis of Gender, H-Index, Publications, Academic Rank, and Leadership Roles

Hutchinson, D.

Our goal in this study was to determine female representation on editorial boards of high-ranking emergency medicine (EM) journals. In addition, we examined factors associated with gender disparity, including board members’ academic rank, departmental leadership position, h-index, total publications, total citations, and total publishing years.

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Provider Workforce

The Psychological Impact of COVID-19 on Hospital Staff

Hassamal, S.

The coronavirus 2019 (COVID-19) pandemic has created a mental health crisis among hospital staff who have been mentally and physically exhausted by uncertainty and unexpected stressors. However, the mental health challenges and complexities faced by hospital staff in the United States has not been fully elucidated. To address this gap, we conducted this study to examine the prevalence and correlates of depression and anxiety among hospital staff in light of the COVID-19 pandemic.

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Nobody Wants to Be Narcan’d: A Pilot Qualitative Analysis of Drug Users’ Perspectives on Naloxone

Lai, JT.

Bystander naloxone distribution is an important component of public health initiatives to decrease opioid-related deaths. While there is evidence supporting naloxone distribution programs, the effects of increasing naloxone availability on the behavior of people who use drugs have not been adequately delineated. In this study we sought to 1) evaluate whether individuals’ drug use patterns have changed due to naloxone availability; and 2) explore individuals’ knowledge of, access to, experiences with, and perceptions of naloxone.

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Suicide Among the Emergency Medical Systems Occupation in the United States

Vigil, NH.

Suicide claimed 47,173 lives in 2017 and is the second leading cause of death for individuals 15–34 years old. In 2017, rates of suicide in the United States (US) were double the rates of homicide. Despite significant research funding toward suicide prevention, rates of suicide have increased 38% from 2009 to 2017. Recent data suggests that emergency medical services (EMS) workers are at a higher risk of suicidal ideation and suicide attempts compared to the general public. The objective of this study was to determine the proportionate mortality ratio (PMR) of suicide among firefighters and emergency medical technicians (EMT) compared to the general US working population.

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Examining the Timeliness of ST-elevation Myocardial Infarction Transfers

Ward, MJ.

Despite large-scale quality improvement initiatives, substantial proportions of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention centers do not receive percutaneous coronary intervention within the recommended 120 minutes. We sought to examine the contributory role of emergency medical services (EMS) activation relative to percutaneous coronary intervention center activation in the timeliness of care for patients transferred with STEMI.

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Effect of Implementation of HEART Chest Pain Protocol on Emergency Department Disposition, Testing and Cost

Bylund, WE.

Symptoms concerning for acute coronary syndromes (ACS) such as chest pain and dyspnea are some of the most common reasons for presenting to an emergency department (ED). The HEART score (history, electrocardiogram, age, risk factors and troponin) was developed and has been externally validated in an emergency setting to determine which patients with chest pain are at increased risk for poor outcomes. Our hospital adopted a HEART score-based protocol in late 2015 to facilitate the management and disposition of these patients. In this study we aimed to analyze the effects of the adoption of this protocol. Prior studies have included only patients with chest pain. We included both patients with chest pain and patients with only atypical symptoms.

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Types and Timing of Teaching During Clinical Shifts in an Academic Emergency Department

Baugh, JJ.

Academic emergency physicians must find ways to teach residents, medical students, and advanced practice providers amidst the myriad demands on their time during clinical shifts. In this study, we sought to characterize in detail what types of teaching occurred, how often they occurred, and how attending teaching styles differed at one academic emergency department (ED).

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Emergency Medicine Intern Education for Best Practices in Opioid Prescribing

Lowy, R.

Opioid exposure has been identified as a contributing factor to the opioid epidemic. Reducing patient exposure, by altering heavy opioid prescribing patterns but appropriately addressing patient pain, may represent one approach to combat this public health issue. Our goal was to create and implement an opioid education program for emergency medicine (EM) interns as a means of establishing foundational best practices for safer and more thoughtful prescribing.

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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

3800 W Chapman Ave Ste 3200
Orange, CA 92868, USA
Phone: 1-714-456-6389


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

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.