Volume 15 Issue 6 Archives - The Western Journal of Emergency Medicine

Societal Impact on Emergency Care

Special Delivery

Volume 15, Issue 6, September 2014
Lori Ludeman, MD

Two months into my intern year I experienced something that I thought only happened on television. It was 3 a.m. on a relatively uneventful night shift. Being one of the newest residents working that evening I expected to get the less desirable cases, and this one felt no different. A new patient showed up on the grease board: a 22-year-old female with a chief complaint of constipation.

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Compassion Fatigue is Similar in Emergency Medicine Residents Compared to other Medical and Surgical Specialties

Volume 15, Issue 6, September 2014
M. Fernanda Bellolio, MD, MS et al.

Compassion fatigue (CF) is the emotional and physical burden felt by those helping others in distress, leading to a reduced capacity and interest in being empathetic towards future suffering. Emergency care providers are at an increased risk of CF secondary to their first responder roles and exposure to traumatic events. We aimed to investigate the current state of compassion fatigue among emergency medicine (EM) resident physicians, including an assessment of contributing factors.

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BE-SAFE: Bedside Sonography for Assessment of the Fetus in Emergencies: Educational Intervention for Late-pregnancy Obstetric Ultrasound

Volume 15, Issue 6, September 2014
Sachita Shah, MD et al.

Late obstetric emergencies are time critical presentations in the emergency department. Evaluation to ensure the safety of mother and child includes rapid assessment of fetal viability, fetal heart rate (FHR), fetal lie, and estimated gestational age (EGA). Point-of-care (POC) obstetric ultrasound (OBUS) offers the advantage of being able to provide all these measurements. We studied the impact of POC OBUS training on emergency physician (EP) confidence, knowledge, and OBUS skill performance on a live model.

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Performance Accuracy of Hand-on-needle versus Hand-on-syringe Technique for Ultrasound-guided Regional Anesthesia Simulation for Emergency Medicine Residents

Volume 15, Issue 6, September 2014
Brian Johnson, MD, MPH et al.

Ultrasound-guided nerve blocks (UGNB) are increasingly used in emergency care. The hand-on-syringe (HS) needle technique is ideally suited to the emergency department setting because it allows a single operator to perform the block without assistance.

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Consensus Development of a Pediatric Emergency Medicine Clerkship Curriculum

Volume 15, Issue 6, September 2014
Kim L. Askew, MD et al.

As emergency medicine (EM) has become a more prominent feature in the clinical years of medical school training, national EM clerkship curricula have been published to address the need to standardize students’ experiences in the field. However, current national student curricula in EM do not include core pediatric emergency medicine (PEM) concepts.

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Appendicitis During Pregnancy with a Normal MRI

Volume 15, Issue 6, September 2014
Matthew M. Thompson, DO et al.

Abdominal pain frequently represents a diagnostic challenge in the acute setting. In pregnant patients, the gravid abdomen and concern for ionizing radiation exposure further limit evaluation. If undiagnosed, appendicitis may cause disastrous consequences for the mother and fetus. We present the case of a pregnant female who was admitted for right lower quadrant abdominal pain. Advanced imaging of the abdomen and pelvis was interpreted to be either indeterminate or normal and a diagnosis of acute appendicitis was made on purely clinical grounds. This patient’s management and a literature review of diagnostic techniques for acute appendicitis during pregnancy are discussed.

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Pyocystis and Prostate Abscess in a Hemodialysis Patient in the Emergency Department

Volume 15, Issue 6, September 2014
Phillip Stafford, MD et al.

The urinary tract is an often forgotten and under-appreciated source of infection in anuric hemodialysis patients. Bladder abscess, also called pyocystis, is a severe complication of low urinary flow that can be difficult to detect, leading to delays in treatment and increased morbidity. The emergency physician should maintain a high suspicion for pyocystis, which can be quickly diagnosed by bedside ultrasound. We report a case of a hemodialysis patient with an initially minor presentation who developed sepsis secondary to pyocystis and prostate abscess.

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Blunt Trauma Patient with Esophageal Perforation

Volume 15, Issue 6, September 2014
Nese C. Oray, MD et al.

Traumatic perforation of the esophagus due to blunt trauma is a rare thoracic emergency. The most common causes of esophageal perforation are iatrogenic, and the upper cervical esophageal region is the most often injured. Diagnosis is frequently determined late, and mortality is therefore high. This case report presents a young woman who was admitted to the emergency department (ED) with esophageal perforation after having fallen from a high elevation. Esophageal perforation was diagnosed via thoracoabdominal tomography with ingestion of oral contrast. The present report discusses alternative techniques for diagnosing esophageal perforation in a multitrauma patient.

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Quincke’s Disease: Isolated Uvulitis

Volume 15, Issue 6, September 2014
Joseph R. Shiber, MD et al.

A 27 year-old previously healthy man complained of sudden onset of gagging and foreign-body sensation that awoke him.

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Haff Disease: Rhabdomyolysis After Eating Buffalo Fish

Volume 15, Issue 6, September 2014
Linda L. Herman, MD et al.

Haff disease, rhabdomyolysis after ingesting certain types of fish, was first reported in 1924 in Europe. There have been a limited number of cases reported in the United States. We present the case of a patient who presents with symptoms of rhabdomyolysis after eating cooked buffalo fish purchased at a suburban grocery market.

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Complex Thoracic Aortic Dissection

Volume 15, Issue 6, September 2014
Mihir Patel, MD et al.

A 50-year-old man presented with sudden onset abdominal pain and non-productive cough. Past medical history was significant for hypertension, treated with hydrochlorothiazide, azilsartan and a beta-blocker. Cardiovascular exam was notable for soft diastolic murmur in right second intercostal space and an abdominal bruit in umbilical region.

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Emergency Department Access

Who’s Boarding in the Psychiatric Emergency Service?

Volume 15, Issue 6, September 2014
Scott A. Simpson, MD, MPH et al.

When a psychiatric patient in the emergency department requires inpatient admission, but no bed is available, they may become a “boarder.” The psychiatric emergency service (PES) has been suggested as one means to reduce psychiatric boarding, but the frequency and characteristics of adult PES boarders have not been described.

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Emergency Department Access

Exploring Real-time Patient Decision-making for Acute Care: A Pilot Study

Volume 15, Issue 6, September 2014
Adam L. Sharp, MD, MS et al.

Research has described emergency department (ED) use patterns in detail. However, evidence is lacking on how, at the time a decision is made, patients decide if healthcare is required or where to seek care.

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Emergency Department Operations

Implementation of a Team-based Physician Staffing Model at an Academic Emergency Department

Volume 15, Issue 6, September 2014
Jose V. Nable, MD et al.

There is scant literature regarding the optimal resident physician staffing model of academic emergency departments (ED) that maximizes learning opportunities. A department of emergency medicine at a large inner-city academic hospital initiated a team-based staffing model.

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Emergency Department Operations

Reducing Patient Placement Errors in Emergency Department Admissions: Right Patient, Right Bed

Volume 15, Issue 6, September 2014
Niels K. Rathlev, MD et al.

Because lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem. Our goal was to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize ED patients. The PPMs are clinically experienced registered nurses trained in the institution-specific criteria for correct unit and bed placement.

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Injury Outcomes

Motor Vehicle Crash-Associated Eye Injuries Presenting to U.S. Emergency Departments

Volume 15, Issue 6, September 2014
Grayson W. Armstrong, BA et al.

Motor vehicle crashes (MVCs) are a leading cause of injury in the United States (U.S.). Detailed knowledge of MVC eye injuries presenting to U.S. emergency departments (ED) will aid clinicians in diagnosis and management. The objective of the study was to describe the incidence, risk factors, and characteristics of non-fatal motor vehicle crash-associated eye injuries presenting to U.S. EDs from 2001 to 2008.

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Self-Cannibalism: The Man Who Eats Himself

Volume 15, Issue 6, September 2014
Atakan Yilmaz, MD et al.

Self-mutilation is a general term for a variety of forms of intentional self-harm without the wish to die. Although there have been many reports of self-mutilation injuries in the literature, none have reported self-cannibalism after self-mutilation. In this article we present a patient with self-cannibalism following self-mutilation.
A 34-year-old male patient was brought to the emergency department from the prison with a laceration on the right leg. Physical examination revealed a well-demarcated rectangular soft tissue defect on his right thigh. The prison authorities stated that the prisoner had cut his thigh with a knife and had eaten the flesh.

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Color Doppler Ultrasound-guided Supraclavicular Brachial Plexus Block to Prevent Vascular Injection

Volume 15, Issue 6, September 2014
Christopher Hahn, MD et al.

Ultrasound-guided nerve blocks are quickly becoming integrated into emergency medicine practice for pain control and as an alternative to procedural sedation. Common, but potentially catastophic errors have not been reported outside of the anesthesiology literature. Evaluation of the brachial plexus with color Doppler should be standard for clinicians performing a supraclavicular brachial plexus block to determine ideal block location and prevention of inadvertant intravascular injection.

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Renal Rupture Following Extracorporeal Shockwave Lithotripsy

Volume 15, Issue 6, September 2014
Sam S. Torbati, MD et al.

A 41-year-old woman presented to the emergency department with a chief complaint of hematuria three days status post extracorporeal shockwave lithotripsy. The patient described a three-day history of worsening left-sided abdominal pain immediately following the procedure. She denied any fever, chills, changes in bowel habits, hematochezia, increased urinary frequency, urinary urgency, or dysuria.

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Impact of Post-Intubation Interventions on Mortality in Patients Boarding in the Emergency Department

Volume 15, Issue 6, September 2014
Rahul Bhat, MD et al.

Emergency physicians frequently perform endotracheal intubation and mechanical ventilation. The impact of instituting early post-intubation interventions on patients boarding in the emergency department (ED) is not well studied. We sought to determine the impact of post-intubation interventions (arterial blood gas sampling, obtaining a chest x-ray (CXR), gastric decompression, early sedation, appropriate initial tidal volume, and quantitative capnography) on outcomes of mortality, ventilator-associated pneumonia (VAP), ventilator days, and intensive care unit (ICU) length-of-stay (LOS).

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Mirror Image Artifact Mimicking Heterotopic Pregnancy on Transvaginal Ultrasound: Case Series

Volume 15, Issue 6, September 2014
Radhika Malhotra, MD et al.

Vaginal bleeding in early pregnancy is a common emergency department complaint. Point-of-care ultrasound is a useful tool to evaluate for intrauterine ectopic pregnancy. Emergency physicians performing these studies need to be cognizant of artifacts produced by ultrasound technology, as they can lead to misdiagnosis. We present two cases where mirror-image artifacts initially led to a concern for heterotopic pregnancies but were excluded on further imaging.

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Ultrasound Detection of Superior Vena Cava Thrombus

Volume 15, Issue 6, September 2014
Aaron Birch, MD et al.

Superior vena cava (SVC) syndrome is most commonly the insidious result of decreased vascular flow through the SVC due to malignancy, spontaneous thrombus, infections, and iatrogenic etiologies.
Clinical suspicion usually leads to computed tomography to confirm the diagnosis. However, when a patient in respiratory distress requires emergent airway management, travel outside the emergency department is not ideal. With the growing implementation of point-of-care ultrasound (POCUS), clinicians may make critical diagnoses rapidly and safely. We present a case of SVC syndrome due to extensive thrombosis of the deep venous system cephalad to the SVC diagnosed by POCUS.

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From the Heart: Interatrial Septal Aneurysm Identified on Bedside Ultrasound

Volume 15, Issue 6, September 2014
Michael Butterfield, MD, MS, MPH et al.

A 61 year-old man presented to the Emergency Department for one day of nonspecific chest pain. Bedside echocardiogram performed by the emergency physician revealed normal systolic cardiac function but also showed a large ( > 10mm) bicornuate interatrial septal aneurysm (IASA) projecting into the right atrium (Figure 1, Video 1). There was no evidence of intraatrial thrombus. A formal echocardiogram performed later that day confirmed the diagnosis and also detected a patent foramen ovale (PFO) with a left-to-right shunt that reversed with Valsalva maneuver.

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