Current Issue: Volume 24 Issue 3

Physician Productivity and Supervision

Author Affiliation Kraftin E. Schreyer, MD, MBA Lewis Katz School of Medicine at Temple University, Department of Emergency Medicine, Philadelphia, Pennsylvania Diane Kuhn, MD, PhD Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana Vicki Norton, MD Florida Atlantic University, Department of Emergency Medicine, Boca Raton, Florida Patient acuity Documentation Emergency department operations […]

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Efficacy of Low-dose Ketamine for Control of Acute Pain in the Emergency Setting: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Mengyao Ying, MD

Ketamine can be particularly helpful in situations where the clinician is not able to administer opioids and require an alternate analgesic, such as for patients who are already on high-dose opioids, have a history of addiction, or for opioid-naïve children and adults. In this review, our goal was to obtain a comprehensive estimate of the efficacy and safety of low-dose ketamine (dose less than 0.5 milligrams per kilogram or equivalent) compared to opiates for the control of acute pain in the emergency setting.

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Evaluation of an Emergency Department-based Palliative Care Extender Program on Hospital and Patient Outcomes

Kalpana Narayan Shankar, MD, MSc, MSHP

Boston Medical Center (BMC), a safety-net hospital, treated a substantial portion of the Boston cohort that was sick with COVID-19. Unfortunately, these patients experienced high rates of morbidity and mortality given the significant health disparities that many of BMC’s patients face. Boston Medical Center launched a palliative care extender program to help address the needs of critically ill ED patients under crisis conditions. In this program evaluation our goal was to assess outcomes between those who received palliative care in the emergency department (ED) vs those who received palliative care as an inpatient or were admitted to an intensive care unit (ICU).

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Emergency Department Preparedness to Care for Sexual Assault Survivors: A Nationwide Study

Kristen Chalmers, BA

Emergency departments (ED) provide trauma-informed care to sexual assault (SA) survivors and connect them with comprehensive services. Through surveying SA survivor advocates, we aimed to 1) document updated trends in the quality of care and resources offered to SA survivors and 2) identify potential disparities according to geographic regions in the US, urban vs rural clinic locations, and the availability of sexual assault nurse examiners (SANE).

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Optimal Image Gain Intensity of Point-of-care Ultrasound when Screening for Ocular Abnormalities in the Emergency Department

Melissa Chang, BS

Point-of-care ultrasound (POCUS) plays a pivotal role in evaluating ocular complaints in the emergency department (ED). The rapid and non-invasive nature of ocular POCUS makes it a safe and informative imaging modality. Previous studies have investigated using ocular POCUS to diagnose posterior vitreous detachment (PVD), vitreous hemorrhage (VH), and retinal detachment (RD); however, there are few studies that assess image optimization techniques and how they impact the overall accuracy of ocular POCUS.

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End-tidal Carbon Dioxide + Return of Spontaneous Circulation After Cardiac Arrest (RACA) Score to Predict Outcomes After Out-of-hospital Cardiac Arrest

Cheng-Yi Wu, MD

The return of spontaneous circulation after cardiac arrest (RACA) score is a well-validated model for estimating the probability of return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA) by incorporating several variables, including gender, age, arrest aetiology, witness status, arrest location, initial cardiac rhythms, bystander cardiopulmonary resuscitation (CPR), and emergency medical services (EMS) arrival time. The RACA score was initially designed for comparisons between different EMS systems by standardising ROSC rates. End-tidal carbon dioxide (EtCO2) is a quality indicator of CPR. We aimed to improve the performance of the RACA score by adding minimum EtCO2 measured during CPR to develop the EtCO2 + RACA score for OHCA patients transported to an emergency department (ED).

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Effectiveness of Hospital-directed Wellness Interventions in COVID-19: A Cross-sectional Survey

Adrian Cotarelo, MD, MHS

Hospitals have implemented various wellness interventions to offset the negative effects of coronavirus disease 2019 (COVID-19) on emergency physician morale and burnout. There is limited high quality evidence regarding effectiveness of hospital-directed wellness interventions, leaving hospitals without guidance on best practices. We sought to determine intervention effectiveness and frequency of use in the spring/summer 2020. The goal was to facilitate evidence-based guidance for hospital wellness program planning.

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Effects of Non-physician Practitioners on Emergency Medicine Physician Resident Education

Andrew W. Phillips, MD, MEd

The effects of non-physician practitioners (NPP) such as physician assistants and nurse practitioners on the education of emergency medicine (EM) residents have not previously been specifically evaluated. Emergency medicine societies have made policy statements regarding NPP presence in EM residencies without the benefit of empiric studies.

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Pediatric Application of Cuffed Endotracheal Tube

Jung Heon Kim, MD

A young child’s larynx was formerly believed to be narrowest at the cricoid level, circular in section, and funnel shaped. This supported the routine use of uncuffed endotracheal tubes (ETTs) in young children despite the benefits of cuffed ETTs, such as lower risk for air leakage and aspiration. In the late 1990s, evidence supporting the pediatric use of cuffed tubes emerged largely from anesthesiology studies, while some technical flaws of the tubes remained a concern. Since the 2000s, imaging-based studies have clarified laryngeal anatomy, revealing that it is narrowest at the glottis, elliptical in section, and cylindrical in shape. The update was contemporaneous with technical advances in the design, size, and material of cuffed tubes. The American Heart Association currently recommends the pediatric use of cuffed tubes. In this review, we present the rationale for using cuffed ETTs in young children based on our updated knowledge of pediatric anatomy and technical advances.

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Socioeconomic Risk Factors for Pediatric Out-of-hospital Cardiac Arrest: A Statewide Analysis

Calvin Lukas Kienbacher, MD, PhD

Economic hardship is a major threat to children’s health, implying that pediatric out-of-hospital cardiac arrest (pOHCA) might be promoted by lower incomes and child poverty. To target resources, it is helpful to identify geographical hotspots. Rhode Island is the smallest state by area in the United States of America. It has one million inhabitants and is comparable to many larger cities worldwide. We aimed to investigate the possible associations of pOHCA with economic factors and the coronavirus 2019 (COVID-19) pandemic. Our goal was to identify high-risk areas and evaluate whether the COVID-19 pandemic had an influence on delays in prehospital care.

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Blood Vessel Occlusion by the Layperson Audiovisual Assist Tourniquet (LAVA TQ) Compared to the Combat Application Tourniquet: Randomized Controlled Trial

Craig Goolsby, MD, MEd, MHCDS

While windlass-rod style tourniquets stop bleeding in limbs when used by skilled responders, they are less successful in the hands of the untrained or not recently trained public. To improve usability, an academic-industry partnership developed the Layperson Audiovisual Assist Tourniquet (LAVA TQ). The LAVA TQ is novel in design and technology and addresses known challenges in public tourniquet application. A previously published multisite, randomized controlled trial of 147 participants showed that the LAVA TQ is much easier for the lay public to use compared to the Combat Application Tourniquet (CAT). This study evaluates the LAVA TQ’s ability to occlude blood flow in humans compared to the CAT.

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Nonfatal Injuries Sustained in Mass Shootings in the US, 2012–2019: Injury Diagnosis Matrix, Incident Context, and Public Health Considerations

Matthew P. Czaja, MPH

The epidemic of gun violence in the United States (US) is exacerbated by frequent mass shootings. In 2021, there were 698 mass shootings in the US, resulting in 705 deaths and 2,830 injuries. This is a companion paper to a publication in JAMA Network Open, in which the nonfatal outcomes of victims of mass shootings have been only partially described.

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Characterizing Social Insecurity in a Rural North Carolina Emergency Department

Elizabeth Gignac, DO

Social insecurity, a form of deprivation of social amenities, if present among patients presenting in a rural emergency department (ED) can be a source of medical burden and poor health outcomes. Although knowledge and understanding of the insecurity profile of such patients is necessary for targeted care that improves their health outcomes, the concept has not been comprehensively quantified. In this study we explored, characterized, and quantified the social insecurity profile of ED patients at a rural teaching hospital in southeastern North Carolina with a large Native American population.

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Emergency Department Length of Stay Is Associated with Delirium in Older Adults

Natalie M Elder, MD

Incident delirium in older patients is associated with prolonged hospitalization and mortality. A recent study suggested an association between emergency department (ED) length of stay (LOS), time in ED hallways, and incident delirium. In this study we further evaluated the emerging association between incident delirium with ED LOS, time in ED hallways, and number of non-clinical patient moves in the ED.

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Effect of a Home Health and Safety Intervention on Emergency Department Use in the Frail Elderly: A Prospective Observational Study

Sandy Bogucki, MD, PhD

Geriatric patients are often frail and may lose independence through a variety of mechanisms including cognitive decline, reduced mobility, and falls. Our goal was to measure the effect of a multidisciplinary home health program that assessed frailty and safety and then coordinated ongoing delivery of community resources on short-term, all-cause emergency department (ED) utilization across three study arms that attempted to stratify frailty by fall risk.

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Ratio of Oxygen Saturation to Inspired Oxygen, ROX Index, Modified ROX Index to Predict High Flow Cannula Success in COVID-19 Patients: Multicenter Validation Study

Onlak Ruangsomboon, MD

High-flow nasal cannula (HFNC) is a respiratory support measure for coronavirus 2019 (COVID-19) patients that has been increasingly used in the emergency department (ED). Although the respiratory rate oxygenation (ROX) index can predict HFNC success, its utility in emergency COVID-19 patients has not been well-established. Also, no studies have compared it to its simpler component, the oxygen saturation to fraction of inspired oxygen (SpO2/FiO2 [SF]) ratio, or its modified version incorporating heart rate. Therefore, we aimed to compare the utility of the SF ratio, the ROX index (SF ratio/respiratory rate), and the modified ROX index (ROX index/heart rate) in predicting HFNC success in emergency COVID-19 patients.

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Disparities Exist in the Application of Low Tidal-volume Ventilation in the Emergency Department

Michael Self, MD

Low tidal-volume ventilation (LTVV), defined as a maximum tidal volume of 8 milliliters per kilogram (mL/kg) of ideal body weight, is a key component of lung protective ventilation. Although emergency department (ED) initiation of LTVV has been associated with improved outcomes, disparities in LTVV application exist. In this study our aim was to evaluate whether rates of LTVV are associated with demographic and physical characteristics in the ED.

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Feasibility of a Multifaceted Social Emergency Medicine Curriculum for Emergency Medicine Residents

Erin F. Shufflebarger, MD

Emergency physicians are in a unique position to impact both individual and population health needs. Despite this, emergency medicine (EM) residency training lacks formalized education n the social determinants of health (SDoH) and integration of patient social risk and need, which are core components of social EM (SEM). The need for such a SEM-based residency curriculum has been previously recognized; however, there is a gap in the literature related to demonstration and feasibility. In this study we sought to address this need by implementing and evaluating a replicable, multifaceted introductory SEM curriculum for EM residents. This curriculum is designed to increase general awareness related to SEM and to increase ability to identify and intervene upon SDoH in clinical practice.

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Feedback in Medical Education: An Evidence-based Guide to Best Practices from the Council of Residency Directors in Emergency Medicine

Sreeja Natesan, MD

Within medical education, feedback is an invaluable tool to facilitate learning and growth throughout a physician’s training and beyond. Despite the importance of feedback, variations in practice indicate the need for evidence-based guidelines to inform best practices. Additionally, time constraints, variable acuity, and workflow in the emergency department (ED) pose unique challenges to providing effective feedback. This paper outlines expert guidelines for feedback in the ED setting from members of the Council of Residency Directors in Emergency Medicine Best Practices Subcommittee, based on the best evidence available through a critical review of the literature. We provide guidance on the use of feedback in medical education, with a focus on instructor strategies for giving feedback and learner strategies for receiving feedback, and we offer suggestions for fostering a culture of feedback.

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Political Priorities, Voting, and Political Action Committee Engagement of Emergency Medicine Trainees: A National Survey

Rachel E. Solnick, MD, MSc

Medicine is increasingly influenced by politics, but physicians have historically had lower voter turnout than the general public. Turnout is even lower for younger voters. Little is known about the political interests, voting activity, or political action committee (PAC) involvement of emergency physicians in training. We evaluated EM trainees’ political priorities, use of and barriers to voting, and engagement with an emergency medicine (EM) PAC.

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A Case of Human Trafficking in Appalachia and What Emergency Physicians Can Learn from It

Kelli L. Jarrell, MD, MPH

Human trafficking is an ongoing, global human rights crisis and one of the largest illicit industries worldwide. Although there are thousands of victims identified each year within the United States, the true extent of this problem remains unknown due to the paucity of data. Many victims seek care in the emergency department (ED) while being trafficked but are often not identified by clinicians due to lack of knowledge or misconceptions about trafficking. We present a case of an ED patient being trafficked in Appalachia as an educational stimulus and discuss several unique aspects of trafficking in rural communities, including lack of awareness, prevalence of familial trafficking, high rates of poverty and substance use, cultural differences, and a complex highway network system. The lack of data, appropriate resources, and training for healthcare professionals also poses distinct issues. We propose an approach to identify and treat victims of human trafficking in the ED, with a focus on rural EDs. This approach includes improving data collection and availability on local patterns of trafficking, improving clinician training in identification, and care of victims using trauma-informed techniques. While this case illustrates unique features of human trafficking in the Appalachian region, many of these themes are common to rural areas across the US. Our recommendations emphasize strategies to adapt evidence-based protocols, largely designed in and for urban EDs, to rural settings where clinicians may be less familiar with human trafficking.

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Winter Walk

Corey S. Hazekamp, MD, MS

Winter Walk is a photo essay meant to be an inspirational commentary on emergency medicine’s role in meeting the needs of our most vulnerable patients. Oftentimes, the social determinants of health, now well reviewed in the modern medical school curriculum, become intangible concepts that get lost amongst the busy environment of the emergency department. The photos within this commentary are striking and will move readers in various ways. The authors hope that these powerful images generate a mix of emotion that ultimately motivates emergency physicians to embrace the emerging role in addressing the social needs of our patients both inside and outside the emergency department.

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Agitation Management in the Emergency Department with Physical Restraints: Where Do These Patients End Up?

Erin L. Simon, DO

Agitation is frequently encountered in the emergency department (ED) and can range from psychomotor restlessness to overt aggression and violent behavior. Among all ED patients, 2.6% present with agitation or become agitated during their ED visit. We aimed to determine ED disposition for patients requiring agitation management with physical restraints.

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Association Between the Affordable Care Act and Emergency Department Visits for Psychiatric Disease

Afsaneh Asgharian, PhD

Emergency department (ED) utilization for psychiatric disease is increasing, and a lack of health insurance has been identified as a potential cause of preventable or avoidable ED use. Through the Affordable Care Act (ACA), more uninsured individuals gained health insurance; however, the effects of increased health insurance coverage on ED utilization for psychiatric disease have not been examined.

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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.