Commentary Archives - The Western Journal of Emergency Medicine

Endemic Infections

Preparedness, Adaptation, and Innovation: Approach to the COVID-19 Pandemic at a Decentralized, Quaternary Care Department of Emergency Medicine

Yaffee, AQ.

The COVID-19 pandemic has required healthcare systems to be creative and adaptable in response to an unprecedented crisis. Below we describe how we prepared for and adapted to this pandemic at our decentralized, quaternary-care department of emergency medicine, with specific recommendations from our experience. We discuss our longstanding history of institutional preparedness, as well as adaptations in triage, staffing, workflow, and communications. We also discuss innovation through working with industry on solutions in personal protective equipment, as well as telemedicine and methods for improving morale. These preparedness and response solutions and recommendations may be useful moving forward as we transition between response and recovery in this pandemic as well as future pandemics.

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Endemic Infections

Telemedicine to Decrease Personal Protective Equipment Use and Protect Healthcare Workers

Ribeira, R.

Infectious disease outbreaks, such as coronavirus disease 2019 (COVID-19), place tremendous strain on availability of personal protective equipment (PPE) and frontline healthcare providers. Readily available PPE can substantially reduce the rate of infection in healthcare workers and the spread of the illness.1,2 The lack of adequate PPE places providers at increased risk of infection, increases healthcare worker stress, and decreases staffing as providers fall ill. We know that inadequate PPE and risk of becoming infected are primary concerns of healthcare providers during pandemics, serving as key drivers in their willingness to work.3,4 Therefore, it is imperative that efforts are undertaken to minimize the threat facing them and their families.5 Here, we describe an emergency department (ED) effort to safely limit PPE use and decrease the risk of illness to providers by implementing telemedicine to care for patients already within our department walls.

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Endemic Infections

CEdRIC: Strategy for Patient Education During COVID-19 Triage

Pétré, B.

The current coronavirus disease 2019 (COVID-19) pandemic is forcing healthcare systems around the word to organise care differently than before. Prompt detection and effective triage and isolation of potentially infected and infectious patients are essential to preventing unnecessary community exposure. Since there are as yet no medications to treat or vaccines to prevent COVID-19, prevention focuses on self-management strategies, creating patient education challenges for physicians doing triage and testing. This article describes a five-step process for effectively educating, at discharge, patients who are suspected of being infectious and instructed to self-isolate at home. We are proposing the CEdRIC strategy as a practical, straightforward protocol that meets patient education and health psychology science requirements. The main goal of the CEdRIC process is to give patients self-management strategies aimed at preventing complications and disease transmission. The COVID-19 pandemic is challenging clinicians to rapidly teach their patients self-management strategies while managing the inherent pressures of this emergency situation. The CEdRIC strategy is designed to deliver key information to patients and standardize the discharge process. CEdRIC is currently being tested at triage centres in Belgium. Formal assessment of its implementation is still needed.

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Point-of-Care Ultrasound for Intubation Confirmation of COVID-19 Patients

Gottlieb, M.

The novel coronavirus disease of 2019 (COVID-19) is associated with significant morbidity and mortality, as well as large numbers of patients requiring endotracheal intubation. While much of the literature has focused on the intubation technique, there is scant discussion of intubation confirmation. Herein, we discuss the limitations of traditional confirmatory approaches, summarize the literature supporting a role for point-of-care ultrasound in this application, and propose an algorithm for intubation confirmation among COVID-19 patients.

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United States Congressional COVID-19 Legislation: Recent Laws and Future Topics

Dowling, MK.

Nothing is normal now, least of all the United States Congress. As the novel coronavirus (COVID-19) pandemic devastates Americans’ health and livelihoods, Congress has passed sweeping legislation to address the nation’s parallel medical and economic crises. These legislative interventions have important implications for emergency physicians—as frontline workers, family members, and advocates. This article summarizes the new laws’ most relevant provisions for emergency physicians.

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Endemic Infections

Drive-through Medicine for COVID-19 and Future Pandemics

Ngo, J.

The outbreak of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has reached pandemic levels and continues to spread across much of the world.1 Hospitals and public health authorities are struggling to appropriately manage potentially infectious individuals to limit transmission to others, care for ill patients with proven or suspected COVID-19, and restart society after the pandemic. Crucial features of a successful response to a pandemic virus are early detection and isolation of potentially infectious individuals.2

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Transitioning Traditions in the Time of COVID

Romeo, ME.

In 1979 Drs. Lewis Goldfrank and Neal Lewin astutely perceived that the Bellevue Hospital emergency ward, the safety net of New York City, provided an exceptional learning environment for patient care. Every patient, in some capacity, was deemed an invaluable educational opportunity, and through this ideology the tradition of “Morning Report” was born. It would become a staple of the residency, and the department community as a whole, for the next 40 years.

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Using Tenecteplase for Acute Ischemic Stroke: What Is the Hold Up?

Zitek, MD, et al.

This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.

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Societal Impact on Emergency Care

How a Bill Becomes a Law, or How a Truly Terrible Bill Becomes Less Awful

Moulin, MD, et al.

The fundamental challenge is that our policymakers and legislators do not share our understanding or experiences. Their contact with emergency medicine (EM) is as a patient and family member, or through news stories of sympathetic patients.

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Evidence-Informed Practice: Diagnostic Questions in Urinary Tract Infections in the Elderly

Pescatore, DO, et al.

We performed a historical and clinical review of the growing body of literature suggesting measurable differences in the systemic immune response manifest among patients with asymptomatic pyuria and UTI, including increases in the pro-inflammatory cytokine interleukin-6 and the acute phase reactant procalcitonin.

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Trials and Tribulations in Implementation of the Emergency Medicine Milestones from the Frontlines

Sheng, MD, et al.

As part of medical education’s shift toward competency-based education (CBE), the Accreditation Council for Graduate Medical Education (ACGME) announced the Milestones Project in 2008 to create an outcomes-based model of competency development. The goal was to characterize specific accomplishments or behaviors demonstrated by physician trainees as they progressed toward independent practice.

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Stewarding Recovery from the Opioid Crisis Through Health System Initiatives

Perrone, MD, et al.

We describe a group of adoptable efforts that have been utilized successfully at our institutions and may be adapted and optimized to the needs and resources of other hospitals and health care systems.

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Gun Violence: A Biopsychosocial Disease

Hargarten, MD, et al.

The medical community must answer recent calls to engage in gun violence prevention, and employing this model of gun violence as a biopsychosocial disease provides a framework for engagement.

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Predatory Publisher Attempts to Compromise WestJEM’s Integrity

Langdorf, MD, et al.

The advance of Open Access publishing has given rise to a parallel and nefarious process called predatory publishing. Predatory publishing is defined as publishing that “upholds few if any of the best practices, yet demands payment for publishing, even from those most unable to pay.

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Population Health Research Design

Getting Found: Indexing and the Independent Open Access Journal

Getting Found: Indexing and the Independent Open Access Journal
Katie Fourtney, JD, MLIS, et al.

Running an independent journal takes much effort, even if only focusing on managing the process of moving articles through the process of submission, review, and publication. Yet publishing an article is not the only goal. Even a great article has little impact unless it can easily be discovered for people to read and cite. Without visibility, even a journal with a terrific editorial board will not get the high quality submissions its editors seek.

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Trauma Triage and Trauma System Performance

Volume 17, Issue 3, May 2016
Gary Johnson, MD

Trauma systems seek to provide complex medical care at the correct time and the correct place. During the past four decades numerous articles have been published that validate trauma systems from many points of view. Achievements of trauma systems include improvement in mortality and morbidity, efficiencies of care, and economic outcomes. Prehospital policy execution is intrinsic to trauma system performance. Trauma system criteria are relatively standardized. However, flexibility in emergency medical service (EMS) decision-making is commonly allowed. These decisions have major impacts on resource allocation, trauma center utilization, and patient outcome.

In this edition, Holst, et al1 reviewed adult emergency department (ED) trauma deaths as reported in the 2010 National Emergency Department Sample. They recorded the association of these deaths to trauma or non-trauma center designation, as well as geographic and patient demographics including rural vs urban site, gender, and patient income data. They found that one half of all trauma ED deaths nationally and one third of ED urban trauma patients died in non-trauma centers. Both elderly trauma deaths and deaths due to falls more frequently occurred in non-trauma centers. Like most studies describing trauma system performance, this is a retrospective review taken from a large database. Therefore, causation of outcome cannot be directly attributed to undertriage. However, the magnitude of the non-trauma center death rate merits further investigation.

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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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Crossing Borders

Volume 17, Issue 1, January 2016.
Erik D. Barton, MD, MS, MBA

As emergency physicians, we are privileged to be
in a field that crosses more boundaries than any other
medical specialty. It is a calling. Our skills are portable
and transferable across cultural and geographic disparities.
For these reasons, many of us are drawn to sharing our
knowledge and training across the globe – towards treating
patients in underserved and austere environments abroad. The
rapid growth of international and global health educational
initiatives across our U.S. residency training programs is a
direct result of those undeniable forces. Additionally, inclusion
of such rotations becomes a powerful resident recruitment
tool as more and more of our trainees are looking for these
opportunities during their formative years.

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Healthcare Utilization

Achieving the Triple Aim Through Informed Consent for Computed Tomography

Volume 16, Issue 7, December 2015.
Dylan Carney, MD, et al.

At the end of a particularly busy shift, you meet Mary,
a 24 year-old female with no past medical history, who
presents with six hours of crampy, intermittent, periumbilical
abdominal pain but no associated fever, nausea, vomiting,
diarrhea or anorexia. Her vital signs are normal and her
abdominal and gynecological exams are notable only for mild,
diffuse abdominal tenderness without rebound or guarding.
Her lab results and urinalysis are unremarkable, and her pain
improves somewhat with intravenous pain medications. You
explain to the patient that you have a low suspicion for an
intraabdominal emergency, but cannot be certain without
a computed tomography (CT) scan. “I’ll do whatever you
recommend,” she replies. The patient ultimately gets a CT,
which is normal, and she is discharged 30 minutes later with a
diagnosis of nonspecific abdominal pain.

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Societal Impact on Emergency Care

Opioid Considerations for Emergency Practice

Volume 16, Issue 7, December 2015.
Thomas Terndrup, MD

On a backdrop of increasingly distressing opioid misuse
in our communities, and safety concerns expressed by The
Joint Commission and others, emergency physicians are
further increasing their utilization of these important agents
in our patients. Are we selecting the best opioid for our
patients? Are we providing the relief they need? And are we
doing this safely? We all hope these questions can effectively
be answered yes, now and into our futures.

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Societal Impact on Emergency Care

Transformative Leadership: Emergency Physicians Lead AOA and AMA

Volume 16, Issue 5, December 2015.
Kory S. London, MD, et al.

Introduction: Feedback on patient satisfaction (PS) as a means to monitor and improve
performance in patient communication is lacking in residency training. A physician’s promotion,
compensation and job satisfaction may be impacted by his individual PS scores, once he is in
practice. Many communication and satisfaction surveys exist but none focus on the emergency
department setting for educational purposes. The goal of this project was to create an emergency
medicine-based educational PS survey with strong evidence for content validity.
Methods: We used the Delphi Method (DM) to obtain expert opinion via an iterative process of
surveying. Questions were mined from four PS surveys as well as from group suggestion. The DM
analysis determined the structure, content and appropriate use of the tool. The group used four-point
Likert-type scales and Lynn’s criteria for content validity to determine relevant questions from the
stated goals.
Results: Twelve recruited experts participated in a series of seven surveys to achieve consensus. A
10-question, single-page survey with an additional page of qualitative questions and demographic
questions was selected. Thirty one questions were judged to be relevant from an original 48-question list.
Of these, the final 10 questions were chosen. Response rates for individual survey items was 99.5%.
Conclusion: The DM produced a consensus survey with content validity evidence. Future work will
be needed to obtain evidence for response process, internal structure and construct validity.

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Optimizing Neurologically Intact Survival from Sudden Cardiac Arrest: A Call to Action

Volume 15, Issue 7, November 2015
Jeffrey M. Goodloe, MD et al.

The U.S. national out-of-hospital and in-hospital cardiac arrest survival rates, although improving recently, have remained suboptimal despite the collective efforts of individuals, communities, and professional societies.

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Wordsmithing in Medical Toxicology: A Primer on Portmanteaus

Volume 15, Issue 4, July 2014
Timothy J. Meehan, MD, MPH

The history of language is littered with neologisms. When different cultures met, some words were subsumed – “hamburgesa,” the Spanish word for hamburger is an example. Sometimes spelling is changed in order to denote a cultural difference. There are a number of words that end in ‘er’ in American English, but finish with a ‘re’ in the British usage. Finally, some words are simply combined, deriving their meaning from their individual components, but in their artistry and simplicity are able to exceed the sum of their parts. Words such as these, a particular form of neologism called a portmanteau, can denote an entire idea in a single instant and provide the wordsmith with a particular type of joy.

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