Volume 14 Issue 6 Archives - The Western Journal of Emergency Medicine

Injury Outcomes

Does Young Age Merit Increased Emergency Department Trauma Team Response?

Volume 14, Issue 6, 2014
James F. Holmes, MD, MPH, et al.

To determine if increased trauma team response results in alterations in resource use in a population of children <6 years, especially in those least injured.

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Injury Outcomes

Emergency Department Visits by Older Adults for Motor Vehicle Collisions

Volume 14, Issue 6, November 2013
Jody A. Vogel, MD, et al.

To describe the epidemiology and characteristics of emergency department (ED) visits by older adults for motor vehicle collisions (MVC) in the United States (U.S.).

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Injury Outcomes Injury Prevention

Emergency Departments and Older Adult Motor Vehicle Collisions

In 2009 the Centers for Disease Control and Prevention reported that there were 33 million licensed drivers 65 years and older in the U.S. This represents a 23 percent increase from 1999, a number that is predicted to double by 2030. Although motor vehicle collisions related to emergency department visits for older adults are lower per capita than for younger adults, the older-adults MVCs require more resources, such as additional diagnostic imaging and increased odds of admission.

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Emergency Department Operations

The Impact of Working with Medical Students on Resident Productivity in the Emergency Department

Volume 14, Issue 6, November 2013
Travis Cobb, MD, et al.

Academic emergency departments (ED) strive to balance educational needs of residents and medical students with service requirements that optimize patient care. No study to date has evaluated whether resident precepting of medical students affects residents’ clinical productivity. Understanding the interplay of these variables may allow for ED staffing that maximizes productivity. We sought to determine whether the precepting of medical students impacts resident productivity.

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Emergency Department Operations

Predictive Value of Capnography for Suspected Diabetic Ketoacidosis in the Emergency Department

Volume 14, Issue 6, November 2013
Hassan Soleimanpour, MD, et al.

Metabolic acidosis confirmed by arterial blood gas (ABG) analysis is one of the diagnostic criteria for diabetic ketoacidosis (DKA). Given the direct relationship between end-tidal carbon dioxide (ETCO2), arterial carbon dioxide (PaCO2), and metabolic acidosis, measuring ETCO2 may serve as a surrogate for ABG in the assessment of possible DKA. The current study focuses on the predictive value of capnography in diagnosing DKA in patients referring to the emergency department (ED) with increased blood sugar levels and probable diagnosis of DKA.

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Emergency Department Operations

Does High Body Mass Index Obviate the Need for Oral Contrast in Emergency Department Patients?

Volume 14, Issue 6, November 2013
Matthew L. Harrison, DO, et al.

Do higher BMI values sufficiently enhance the ability of a radiologist to read a computed tomography (CT) of the abdomen and pelvis, so that the need for oral contrast to be given is precluded?

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Provider Workforce

Mid-level Providers Working in a Low-acuity Area are More Productive than in a High-acuity Area

Mid-level providers (MLP) are extensively used in staffing emergency departments (ED). We sought to compare the productivity of MLPs staffing a low-acuity and high-acuity area of a community ED.

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Emergency Department Access

National Study of Non-urgent Emergency Department Visits and Associated Resource Utilization

Reducing non-urgent emergency department (ED) visits has been targeted as a method to produce cost savings. To better describe these visits, we sought to compare resource utilization of ED visits characterized as non-urgent at triage to immediate, emergent, or urgent (IEU) visits.

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Emergency Department Access

Time to Focus on Improving Emergency Department Value Rather Than Discouraging Emergency Department Visits

Recently policymakers, payers, and the media have focused attention on avoiding ‘inappropriate’ or ‘unnecessary’ emergency department visits.1 Some states and payers have tried to institute co-pays or deny coverage for visits deemed to be non urgent with the goal of decreasing unnecessary emergency department (ED) visits.2,3 The discussion is predicated upon the ‘common knowledge’ that by diverting unnecessary ED visits, substantial healthcare spending will be avoided. This ‘common knowledge’ is wrong.

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Provider Workforce

Implementation of a Successful Incentive-Based Ultrasound Credentialing Program for Emergency Physicians

With the rapid expansion of emergency ultrasound, resident education in ultrasound has become more clearly developed and broadly integrated. However, there still exists a lack of guidance in the training of physicians already in practice to become competent in this valuable skill. We sought to employ a step-wise, goal-directed, incentive-based credentialing program to educate emergency physicians in the use of emergency ultrasound. Successful completion of this program was the primary outcome.

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Emergency Department Access Healthcare Utilization

New Drugs and Devices from 2011 – 2012 That Might Change Your Practice

To be honest, I thought this would be a lost cause. Even after skipping a New Drugs and Devices essay in 2012, I figured that I would have to search long and hard to find 10 new things that emergency practitioners needed to know about. Although there were no true blockbuster medications for emergency physicians, I nonetheless found 10 medicines that we probably should know, along with a new device that may change the way we work up patients with palpitations, and a clever new delivery system for subcutaneous epinephrine.

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Healthcare Utilization

Effectiveness of a Drill-assisted Intraosseous Catheter versus Manual Intraosseous Catheter by Resident Physicians in a Swine Model

Our objective was to compare the effectiveness, speed, and complication rate of the traditional manually placed intraosseous (IO) catheter to a mechanical drill-assisted IO catheter by emergency medicine (EM) resident physicians in a training environment.

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Ethical and Legal Issues

Integrated Model of Palliative Care in the Emergency Department

An integrated model of palliative care in the emergency department (ED) of an inner city academic teaching center utilized existing hospital resources to reduce hospital length of stay (LOS) and reduce overall cost. Benefits related to resuscitation rates, intensity of care, and patient satisfaction are attributed to the ED-based palliative team’s ability to provide real time consults, and utilize InterQual criteria to admit to a less costly level of care or transfer directly to home or hospice.

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Visualization of Cardiac Thrombus by Bedside Ultrasound

A 85-year-old man with sudden onset of dyspnea and chest pain with an history of immobilization due to right tibia plateau fracture after traffic accident 2 months ago was admitted to our emergency department.

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Uncommon Etiology of Chest Pain: Pulmonary Sequestration

Chest pain is a common presenting symptom in the emergency department. After ruling out emergent causes, emergency physicians need to identify and manage less commonly encountered conditions. Pulmonary sequestration (PS) is a rare congenital condition involving pulmonary parenchyma. In PS, a portion of non-functional lung tissue receives systemic blood supply from an anomalous artery. While most individuals with PS present in early life with symptoms of difficulty feeding, cyanosis, and dyspnea, some present later with recurrent pneumonia, hemoptysis, or productive cough. In this report, we present a case of PS in an adult with acute onset pleuritic chest pain.

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Total Collapse of the Heart

An approximately 30 year-old Ugandan male was found unresponsive on an American base in Iraq. The patient was altered and combative with no signs of trauma. A chest x-ray was performed showing an enlarged cardiac silhouette and pulmonary edema. The patient required intubation during which a large amount of edema fluid was produced.

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Ultrasound Diagnosis of Bilateral Tubo-ovarian Abscesses in the Emergency Department

A previously healthy 30-year-old woman (gravida 1 para 1) presented to the emergency department (ED) with 5 days of lower abdominal pain, fever, and nausea. On examination, she had a temperature of 37.6° Celsius, pulse 116 beats/ minute, blood pressure 123/65 mmHg, respiratory rate 18 breaths/minute, and oxygen saturation 98% on room air. On bimanual examination, the patient exhibited bilateral adnexal tenderness, but no cervical motion tenderness. Relevant laboratory studies included negative urine beta-hCG, white blood cell count 17.4×103/μL and lactate 2.4 mmol/L.

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Evolution of a Round Pneumonia

A previously healthy 14-year-old male presented to the emergency department (ED) complaining of 2 days of subacute onset, right-anterior pleuritic chest pain. He reported an associated dry cough, but denied fever, sputum, hemoptysis, shortness of breath, orthopnea, leg swelling, weight loss or night sweats. The patient had no known sick contacts, and had no identifiable cardiac or thromboembolic risk factors.

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A Painful, Blistering Rash

A 67-year-old man presented with painful oral and skin lesions developing over the last 2 months. The lesions initially formed in his mouth and lips, and slowly spread to his torso, groin, and extremities (Figure 1). The lesions began as blisters that broke easily and were exquisitely painful to light touch.

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Sedative Dosing of Propofol for Treatment of Migraine Headache in the Emergency Department: A Case Series

Migraine headaches requiring an emergency department visit due to failed outpatient rescue therapy present a significant challenge in terms of length of stay (LOS) and financial costs. Propofol therapy may be effective at pain reduction and reduce that length of stay given its pharmacokinetic properties as a short acting intravenous sedative anesthetic and pharmacodynamics on GABA mediated chloride flux.

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Needle Decompression in Appalachia Do Obese Patients Need Longer Needles?

Needle decompression of a tension pneumothorax can be a lifesaving procedure. It requires an adequate needle length to reach the chest wall to rapidly remove air. With adult obesity exceeding one third of the United States population in 2010, we sought to evaluate the proper catheter length that may result in a successful needle decompression procedure. Advance Trauma Life Support (ATLS) currently recommends a 51 millimeter (mm) needle, while the needles stocked in our emergency department are 46 mm. Given the obesity rates of our patient population, we hypothesize these needles would not have a tolerable success rate of 90%.

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Olivier Syndrome: Traumatic Asphyxia

A 51 year-old woman was found confused while crawling across a field. She had marked facial cyanosis and edema with cutaneous petechiae, subconjuctival hemorrhages, and echymosis across her anterior neck (image 1).

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Provider Workforce

A Survey of Graduating Emergency Medicine Residents’ Experience with Cricothyrotomy

The Emergency Medicine (EM) Residency Review Committee stipulates that residents perform 3 cricothyrotomies in training but does not distinguish between those done on patients or via other training methods. This study was designed to determine how many cricothyrotomies residents have performed on living patients, the breadth and prevalence of alternative methods of instruction, and residents’ degree of comfort with performing the procedure unassisted.

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