Volume 17 Issue 1 Archives - The Western Journal of Emergency Medicine

The San Bernardino, California, Terror Attack: Two Emergency Departments’ Response

Volume 17, Issue 1, January 2016.
Carol Lee, MD, et al.

On December 2, 2015, a terror attack in the city of San Bernardino, California killed 14 Americans
and injured 22 in the deadliest attack on U.S. soil since September 11, 2001. Although emergency
personnel and law enforcement officials frequently deal with multi-casualty incidents (MCIs), what
occurred that day required an unprecedented response. Most of the severely injured victims were
transported to either Loma Linda University Medical Center (LLUMC) or Arrowhead Regional
Medical Center (ARMC). These two hospitals operate two designated trauma centers in the region
and played crucial roles during the massive response that followed this attack. In an effort to shed a
light on our response to others, we provide an account of how these two teaching hospitals prepared
for and coordinated the medical care of these victims.
In general, both centers were able to quickly mobilize large number of staff and resources. Prior
disaster drills proved to be invaluable. Both centers witnessed excellent teamwork and coordination
involving first responders, law enforcement, administration, and medical personnel from multiple
specialty services. Those of us working that day felt safe and protected. Although we did identify
areas we could have improved upon, including patchy communication and crowd-control, they were
minor in nature and did not affect patient care.
MCIs pose major challenges to emergency departments and trauma centers across the country.
Responding to such incidents requires an ever-evolving approach as no two incidents will present
exactly alike. It is our hope that this article will foster discussion and lead to improvements in
management of future MCIs.

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Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidality

Volume 17, Issue 1, January 2016.
Carol W. Runyan, MPH, PhD, et al.

Introduction: A youth’s emergency department (ED) visit for suicidal behaviors or ideation
provides an opportunity to counsel families about securing medications and firearms (i.e., lethal
means counseling).
Methods: In this quality improvement project drawing on the Counseling on Access to Lethal Means
(CALM) model, we trained 16 psychiatric emergency clinicians to provide lethal means counseling
with parents of patients under age 18 receiving care for suicidality and discharged home from a
large children’s hospital. Through chart reviews and follow-up interviews of parents who received
the counseling, we examined what parents recalled, their reactions to the counseling session, and
actions taken after discharge.
Results: Between March and July 2014, staff counseled 209 of the 236 (89%) parents of eligible
patients. We conducted follow-up interviews with 114 parents, or 55% of those receiving the
intervention; 48% of those eligible. Parents had favorable impressions of the counseling and
good recall of the main messages. Among the parents contacted at follow up, 76% reported all
medications in the home were locked as compared to fewer than 10% at the time of the visit. All who
had indicated there were guns in the home at the time of the visit reported at follow up that all were
currently locked, compared to 67% reporting this at the time of the visit.
Conclusion: Though a small project in just one hospital, our findings demonstrate the feasibility
of adding a counseling protocol to the discharge process within a pediatric psychiatric emergency
service. Our positive findings suggest that further study, including a randomized control trial in more
facilities, is warranted.

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Ethical and Legal Issues

Emergency Physicians as Good Samaritans: Survey of Frequency, Locations, Supplies and Medications

Volume 17, Issue 1, January 2015.
Taylor W. Burkholder, MD, MPH, et al.

Introduction: Little is known about the frequency and locations in which emergency physicians
(EPs) are bystanders to an accident or emergency; equally uncertain is which contents of an
“emergency kit” may be useful during such events. The aim of this study was to describe the
frequency and locations of Good Samaritan acts by EPs and also determine which emergency kit
supplies and medications were most commonly used by Good Samaritans.
Methods: We conducted an electronic survey among a convenience sample of EPs in Colorado.
Results: Respondents reported a median frequency of 2.0 Good Samaritan acts per five years of
practice, with the most common locations being sports and entertainment events (25%), road traffic
accidents (21%), and wilderness settings (19%). Of those who had acted as Good Samaritans, 86%
reported that at least one supply would have been useful during the most recent event, and 66%
reported at least one medication would have been useful. The most useful supplies were gloves
(54%), dressings (34%), and a stethoscope (20%), while the most useful medications were oxygen
(19%), intravenous fluids (17%), and epinephrine (14%).
Conclusion: The majority of EPs can expect to provide Good Samaritan care during their careers
and would be better prepared by carrying a kit with common supplies and medications where they
are most likely to use them.

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Emergency Department Access

Access to In-Network Emergency Physicians and Emergency Departments Within Federally Qualified Health Plans in 2015

Volume 17, Issue 1, January 2016.
Stephen C. Dorner, MSc, et al.

Introduction: Under regulations established by the Affordable Care Act, insurance plans must meet
minimum standards in order to be sold through the federal Marketplace. These standards to become
a qualified health plan (QHP) include maintaining a provider network sufficient to assure access to
services. However, the complexity of emergency physician (EP) employment practices – in which
the EPs frequently serve as independent contractors of emergency departments, independently
establish insurance contracts, etc… – and regulations governing insurance repayment may hinder
the application of network adequacy standards to emergency medicine. As such, we hypothesized
the existence of QHPs without in-network access to EPs. The objective is to identify whether
there are QHPs without in-network access to EPs using information available through the federal
Marketplace and publicly available provider directories.
Results: In a national sample of Marketplace plans, we found that one in five provider networks
lacks identifiable in-network EPs. QHPs lacking EPs spanned nearly half (44%) of the 34 states
using the federal Marketplace.
Conclusion: Our data suggest that the present regulatory framework governing network adequacy
is not generalizable to emergency care, representing a missed opportunity to protect patient access
to in-network physicians. These findings and the current regulations governing insurance payment to
EPs dis-incentivize the creation of adequate physician networks, incentivize the practice of balance
billing, and shift the cost burden to patients.

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Emergency Department Access

Association of Insurance Status with Severity and Management in ED Patients with Asthma Exacerbation

Volume 17, Issue 1, January 2016.
Kohei Hasegawa, MD, MPH, et al.

frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine
the relationship of insurance status – a proxy for socioeconomic status – with asthma severity and
management in adults. The objective is to investigate chronic and acute asthma management disparities
by insurance status among adults requiring emergency department (ED) treatment in the United States.
Methods: We conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients,
aged 18-54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture,
practice charts, certification) before reviewing randomly selected charts. We categorized patients
into three groups based on their primary health insurance: private, public, and no insurance.
Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period)
and management prior to the index ED visit, acute asthma management in the ED, and prescription
at ED discharge.
Results: The analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had
private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with
private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits
during the preceding year (35%, 49%, and 45%, respectively; p<0.001). Despite the higher chronic
severity, those with no insurance were less likely to have guideline-recommended chronic asthma care
– i.e., lower use of inhaled corticosteroids (ICS [41%, 41%, and 29%; p<0.001]) and asthma specialist
care (9%, 10%, and 4%; p<0.001). By contrast, there were no significant differences in acute asthma
management in the ED – e.g., use of systemic corticosteroids (75%, 79%, and 78%; p=0.08) or initiation
of ICS at ED discharge (12%, 12%, and 14%; p=0.57) – by insurance status.
Conclusion: In this multicenter observational study of ED patients with acute asthma, we found
significant discrepancies in chronic asthma severity and management by insurance status. By
contrast, there were no differences in acute asthma management among the insurance groups.

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Healthcare Utilization

Randomized Controlled Trial of Electronic Care Plan Alerts and Resource Utilization by High Frequency Emergency Department Users with Opioid Use Disorder

Volume 17, Issue 1, January 2016.
Niels Rathlev, MD, et al.

Introduction: There is a paucity of literature supporting the use of electronic alerts for patients
with high frequency emergency department (ED) use. We sought to measure changes in opioid
prescribing and administration practices, total charges and other resource utilization using electronic
alerts to notify providers of an opioid-use care plan for high frequency ED patients.
Methods: This was a randomized, non-blinded, two-group parallel design study of patients who
had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical
electronic health records participated. Patients were randomized into “Care Plan” versus “Usual Care
groups”. Between the years before and after randomization, we compared as primary outcomes
the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and
administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED
visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging
[MRI]) studies, and 5) inpatient admissions.
Results: A total of 40 patients were enrolled. For ED and inpatients in the “Usual Care” group, the
proportion of morphine mg equivalents received in the post-period compared with the pre-period was
15.7%, while in the “Care Plan” group the proportion received in the post-period compared with the
pre-period was 4.5% (ratio=0.29, 95% CI [0.07-1.12]; p=0.07). For discharged patients in the “Usual
Care” group, the proportion of morphine mg equivalents prescribed in the post-period compared with
the pre-period was 25.7% while in the “Care Plan” group, the proportion prescribed in the post-period
compared to the pre-period was 2.9%. The “Care Plan” group showed an 89% greater proportional
change over the periods compared with the “Usual Care” group (ratio=0.11, 95% CI [0.01-0.092];
p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT
or MRI or inpatient admissions.
Conclusion: Electronic care plans were associated with an incremental decrease in opioids (in
morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED
use.

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Healthcare Utilization

Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation

Volume 17, Issue 1, January 2016.
Michael Gottlieb, MD, et al.

Introduction: Most emergency physicians routinely obtain shoulder radiographs before and after
shoulder dislocations. However, currently there is limited literature demonstrating how frequently
new fractures are identified on post-reduction radiographs. The primary objective of this study
was to determine the frequency of new, clinically significant fractures identified on post-reduction
radiographs with a secondary outcome assessing total new fractures identified.
Methods: We conducted a retrospective chart review using appropriate International Classification
of Diseases, 9th Revision (ICD-9) codes to identify all potential shoulder dislocations that were
reduced in a single, urban, academic emergency department (ED) over a five-year period. We
excluded cases that required operative reduction, had associated proximal humeral head or shaft
fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted
separately by two study investigators with disagreements settled by consensus among three
investigators. Images from indeterminate cases were reviewed by a radiology attending physician
with musculoskeletal expertise. The primary outcome was the percentage of new, clinically
significant fractures defined as those altering acute ED management. Secondary outcomes included
percentage of new fractures of any type.
Results: We identified 185 total patients meeting our study criteria. There were no new,
clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI
[3.3%-10.7%]) total new fractures identified, all of which were without clinical significance for
acute ED management.
Conclusion: Post-reduction radiographs do not appear to identify any new, clinically significant
fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED
setting for shoulder dislocations.

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Healthcare Utilization

Identifying Frequent Users of an Urban Emergency Medical Service Using Descriptive Statistics and Regression Analyses

Volume 17, Issue 1, January 2015.
Chenelle Norman, MPH, et al.

This retrospective cohort study provides a descriptive analysis of a population that frequently uses
an urban emergency medical service (EMS) and identifies factors that contribute to use among all
frequent users. For purposes of this study we divided frequent users into the following groups: lowfrequent
users (4 EMS transports in 2012), medium-frequent users (5 to 6 EMS transports in 2012),
high-frequent users (7 to 10 EMS transports in 2012) and super-frequent users (11 or more EMS
transports in 2012). Overall, we identified 539 individuals as frequent users.
For all groups of EMS frequent users (i.e. low, medium, high and super) one or more hospital
admissions, receiving a referral for follow-up care upon discharge, and having no insurance were
found to be statistically significant with frequent EMS use (P<0.05). Within the diagnostic categories,
41.61% of super-frequent users had a diagnosis of “primarily substance abuse/misuse” and among
low-frequent users a majority, 53.33%, were identified as having a “reoccurring (medical) diagnosis.”
Lastly, relative risk ratios for the highest group of users, super-frequent users, were 3.34 (95% CI
[1.90-5.87]) for obtaining at least one referral for follow-up care, 13.67 (95% CI [5.60-33.34]) for
having four or more hospital admissions and 5.95 (95% CI [1.80-19.63]) for having a diagnoses of
primarily substance abuse/misuse.
Findings from this study demonstrate that among low- and medium-frequent users a majority of
patients are using EMS for reoccurring medical conditions. This could potentially be avoided with
better care management. In addition, this study adds to the current literature that illustrates a strong
correlation between substance abuse/misuse and high/super-frequent EMS use. For the subgroup
analysis among individuals 65 years of age and older, we did not find any of the independent
variables included in our model to be statistically significant with frequent EMS use.

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Point-of-Care Multi-Organ Ultrasound Improves Diagnostic Accuracy in Adults Presenting to the Emergency Department with Acute Dyspnea

Volume 17, Issue 1, January 2015.
Daniel Mantuani, MD, et al.

Introduction: Determining the etiology of acute dyspnea in emregency department (ED) patients is
often difficult. Point-of-care ultrasound (POCUS) holds promise for improving immediate diagnostic
accuracy (after history and physical), thus improving use of focused therapies. We evaluate the impact
of a three-part POCUS exam, or “triple scan” (TS) – composed of abbreviated echocardiography,
lung ultrasound and inferior vena cava (IVC) collapsibility assessment – on the treating physician’s
immediate diagnostic impression.
Methods: A convenience sample of adults presenting to our urban academic ED with acute dyspnea
(Emergency Severity Index 1, 2) were prospectively enrolled when investigator sonographers
were available. The method for performing components of the TS has been previously described
in detail. Treating physicians rated the most likely diagnosis after history and physical but before
other studies (except electrocardiogram) returned. An investigator then performed TS and disclosed
the results, after which most likely diagnosis was reassessed. Final diagnosis (criterion standard)
was based on medical record review by expert emergency medicine faculty blinded to TS result.
We compared accuracy of pre-TS and post-TS impression (primary outcome) with McNemar’s
test. Test characteristics for treating physician impression were also calculated by dichotomizing
acute decompensated heart failure (ADHF), chronic obstructive pulmonary disease (COPD) and
pneumonia as present or absent.
Results: 57 patients were enrolled with the leading final diagnoses being ADHF (26%), COPD/
asthma (30%), and pneumonia (28%). Overall accuracy of the treating physician’s impression
increased from 53% before TS to 77% after TS (p=0.003). The post-TS impression was 100%
sensitive and 84% specific for ADHF.
Conclusion: In this small study, POCUS evaluation of the heart, lungs and IVC improved the
treating physician’s immediate overall diagnostic accuracy for ADHF, COPD/asthma and pneumonia
and was particularly useful to immediately exclude ADHF as the cause of acute dyspnea.

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Strain Echocardiography in Acute Cardiovascular Diseases

Volume 17, Issue 1, January 2016.
Mark Favot, MD, et al.

Echocardiography has become a critical tool in the evaluation of patients presenting to
the emergency department (ED) with acute cardiovascular diseases and undifferentiated
cardiopulmonary symptoms. New technological advances allow clinicians to accurately measure left
ventricular (LV) strain, a superior marker of LV systolic function compared to traditional measures
such as ejection fraction, but most emergency physicians (EPs) are unfamiliar with this method of
echocardiographic assessment.
This article discusses the application of LV longitudinal strain in the ED and reviews how it has been
used in various disease states including acute heart failure, acute coronary syndromes (ACS) and
pulmonary embolism.
It is important for EPs to understand the utility of technological and software advances in ultrasound
and how new methods can build on traditional two-dimensional and Doppler techniques of
standard echocardiography. The next step in competency development for EP-performed focused
echocardiography is to adopt novel approaches such as strain using speckle-tracking software in
the management of patients with acute cardiovascular disease. With the advent of speckle tracking,
strain image acquisition and interpretation has become semi-automated making it something
that could be routinely added to the sonographic evaluation of patients presenting to the ED with
cardiovascular disease. Once strain imaging is adopted by skilled EPs, focused echocardiography
can be expanded and more direct, phenotype-driven care may be achievable for ED patients with a
variety of conditions including heart failure, ACS and shock.

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Ultrasound Evaluation of Upper Extremity Deformity

Volume 17, Issue 1, January 2016.
Adam Janicki, MD, et al.

A 64-year-old woman presented to the emergency department
after falling when she tripped on a rock while doing yard work.
Physical examination revealed an open deformity of the left
forearm (Figure 1). Radial pulse was palpable, sensation was
intact, and she had normal range of motion of the fingers. While
awaiting radiographs, bedside ultrasound was performed (Video).
Ultrasound revealed intact radius and ulna and a large linear
foreign body. The wooden foreign body was removed at the
bedside (Figure 2) and patient was admitted for observation and
intravenous antibiotics.

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Emergency Medicine Resident Rotations Abroad: Current Status and Next Steps

Volume 17, Issue 1, January 2016.
Stephen C. Morris, MD, MPH, et al.

Introduction: International rotations for residents are increasingly popular, but there is a dearth of
evidence to demonstrate that these rotations are safe and that residents have appropriate training
and support to conduct them.
Methods: A survey was sent to all U.S. emergency medicine (EM) residencies with publicly
available e-mail addresses. The survey documents and examines the training and support that
emergency medicine residents are offered for international rotations and the frequency of adverse
safety events.
Results: 72.5% of program director responded that their residents are participating in rotations
abroad. However, only 15.4% of programs reported offering training specific to working abroad. The
results point to an increased need for specific training and insurance coverage.
Conclusion: Oversight of international rotations should be improved to guarantee safety and
education benefit.

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Emergency Department of a Rural Hospital in Ecuador

Volume 17, Issue 1, January 2016.
Tara Johnson, MD, MPH, et al.

Introduction: There is a paucity of data studying patients and complaints presenting to emergency
departments (EDs) in low- and middle-income countries. The town of Pedro Vicente Maldonado
(PVM) is located in the northwestern highlands of Ecuador. Hospital PVM (HPVM) is a rural teaching
hospital providing family medicine residency training. These physicians provide around-the-clock
acute medical care in HPVM’s ED. This study provides a first look at a functioning ED in rural Latin
America by reviewing one year of ED visits to HPVM.
Methods: All ED visits between April 14, 2013, and April 13, 2014, were included and analyzed,
totaling 1,239 patient visits. Data were collected from their electronic medical record and exported
into a de-identified Excel® database where it was sorted and categorized. Variables included age,
gender, mode of arrival, insurance type, month and day of the week of the service, chief complaint,
laboratory and imaging requests, and disposition. We performed descriptive statistics, and where
possible, comparisons using Student’s T or chi-square, as appropriate.
Results: Of the 1239 total ED visits, 48% were males and 52% females; 93% of the visits were
ambulatory, and 7% came by ambulance. Sixty-three percent of the patients had social security
insurance. The top three chief complaints were abdominal pain (25.5%), fever (15.1%) and trauma
(10.8%). Healthcare providers requested labs on 71.3% of patients and imaging on 43.2%. The
most frequently requested imaging studies were chest radiograph (14.9%), upper extremity
radiograph (9.4%), and electrocardiogram (9.0%). There was no seasonal or day-of-week
variability to number of ED patients. The chief complaint of human or animal bite made it more
likely the patient would be admitted, and the chief complaint of traumatic injury made it more likely
the patient would be transferred.
Conclusion: Analysis of patients presenting to a rural ED in Ecuador contributes to the global study
of acute care in the developing world and also provides a self-analysis identifying disease patterns
of the area, training topics for residents, areas for introducing protocols, and information to help
planning for rural EDs in low- and middle-income countries.

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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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Medication Overdoses at a Public Emergency Department in Santiago, Chile

Volume 17, Issue 1, January 2016.
Pablo Aguilera, MD, et al.

Introduction: While a nationwide poison control registry exists in Chile, reporting to the center is
sporadic and happens at the discretion of the treating physician or by patients’ self-report. Moreover,
individual hospitals do not monitor accidental or intentional poisoning in a systematic manner. The
goal of this study was to identify all cases of intentional medication overdose (MO) that occurred
over two years at a large public hospital in Santiago, Chile, and examine its epidemiologic profile.
Methods: This study is a retrospective, explicit chart review conducted at Hospital Sótero del Rio
from July 2008 until June 2010. We included all cases of identified intentional MO. Alcohol and
recreational drugs were included only when they were ingested with other medications.
Results: We identified 1,557 cases of intentional MO and analyzed a total of 1,197 cases,
corresponding to 0.51% of all emergency department (ED) presentations between July 2008 and
June 2010. The median patient age was 25 years. The majority was female (67.6%). Two peaks
were identified, corresponding to the spring of each year sampled. The rate of hospital admission
was 22.2%. Benzodiazepines, selective serotonin reuptake inhibitors, and tricyclic antidepressants
(TCA) were the causative agents most commonly found, comprising 1,044 (87.2%) of all analyzed
cases. Acetaminophen was involved in 81 (6.8%) cases. More than one active substance was
involved in 35% of cases. In 7.3% there was ethanol co-ingestion and in 1.0% co-ingestion of some
other recreational drug (primarily cocaine). Of 1,557 cases, six (0.39%) patients died. TCA were
involved in two of these deaths.
Conclusion: Similar to other developed and developing nations, intentional MO accounts for a
significant number of ED presentations in Chile. Chile is unique in the region, however, in that
its spectrum of intentional overdoses includes an excess burden of tricyclic antidepressant and
benzodiazepine overdoses, a relatively low rate of alcohol and recreational drug co-ingestion, and a
relatively low rate of acetaminophen ingestion.

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Critical Care

Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access

Volume 17, Issue 1, January 2016.
Adam J. Ash, DO, et al.

This is a case report describing the ultrasound-guided placement of a peripheral intravenous
catheter into the internal jugular vein of a patient with difficult vascular access. Although this
technique has been described in the past, this case is novel in that the Seldinger technique was
used to place the catheter. This allows for safer placement of a longer catheter (2.25”) without the
need for venous dilation, which is potentially hazardous.

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Shot in the Heart

Volume 17, Issue 1, January 2016.
Abdullah Bakhsh, MD, et al.

A 25-year-old male was brought in by ambulance to
the emergency department (ED) after sustaining a gunshot
wound to his chin and left shoulder. Upon arrival to the
ED, his airway was intact without evidence of blood in the
oropharynx. He was found to have slightly diminished breath
sounds on the left side, with respirations at 34 breaths per
minute, a blood pressure of 72/50mmHg, and a heart rate of
76 beats per minute with cool extremities and poor peripheral
pulses. His focused abdominal sonography in trauma exam
showed a foreign body within the right ventricle without a
pericardial effusion (Figure 1 and Video). An upright portable
chest radiograph performed immediately thereafter showed
blunting of the left costophrenic angle with a bullet fragment
overlying the cardiac shadow (Figure 2).

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A Rare Cause of Headache

Volume 17, Issue 1, January 2016.
Rohat Ak, MD, et al.

A 45-year-old man presented with headache for two days.
He described the quality of headache as throbbing, and it was
unilateral. There was no history of fever, vomiting, blurred
vision, ear discharge or trauma, no relevant past medical or
drug history and no family history of note. On examination,
he was afebrile with pulse 76/min, regular, blood pressure of
130/80mmHg. His pupils and speech appeared normal. There
were no papilledema, sensory deficit, focal neurological deficit
or signs of meningeal irritation. Hyperdensity of right transverse
sinus (Figure 1) and superior sagittal sinus was identified on
unenhanced computed tomography (CT). Magnetic resonance
venography (MRV) demonstrated lack of flow in right transverse
sinus (Figure 2) and superior sagittal sinus.

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Tension Hydrothorax from Disseminated Endometriosis

Volume 17, Issue 1, January 2016.
AnnaKate Deal, MD, et al.

We present the case of a 34-year-old woman presenting to
the emergency department (ED) with dyspnea, cough, and fever.
She was found to have a tension hydrothorax and was treated
with ultrasound-guided thoracentesis in the ED. Subsequent
inpatient evaluation showed the patient had disseminated
endometriosis. Tension hydrothorax has not been previously
described in the literature as a complication of this disease.

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Frozen Funding on Firearm Research: “Doing Nothing Is No Longer an Acceptable Solution”

Volume 17, Issue 1, January 2016.
Marian E. Betz, MD, MPH, et al.

December 2015 saw another Congressional budget
standoff and threatened government shutdown. This omnibus
bill was particularly important for public health, because – for
the first time in years – it contained language that would have
reversed a 19-year-old prohibition on Centers for Disease
Control and Prevention (CDC) funding for research on firearm
injury. Unfortunately, 2016’s final Omnibus Appropriations
bill did not reverse this prohibition. And so another year
begins with the United States – and the world – debating
how to solve the problem of firearm violence in this country,
without the benefit of objective public health research.

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