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Open Access Publications from the University of California

CPC-EM Full-Text Issue

Medical Legal Case Report

Establishing a Novel Group-based Litigation Peer Support Program to Promote Wellness for Physicians Involved in Medical Malpractice Lawsuits

Introduction: Being named as a defendant in a malpractice lawsuit is known to be a particularly high-stress and vulnerable time for a physician. Medical malpractice stress syndrome (MMSS) is a consequence of being named as a physician defendant in a malpractice lawsuit. Symptoms include depression, anxiety, and insomnia, which may lead to burnout, loss of confidence in clinical decision-making, substance abuse, strain on personal and professional relationships, and suicidal ideation. Although the legal process requires strict confidentiality regarding the specific details of the legal case, discussing the emotional impact of the case is not prohibited. Given that physicians often do not choose formalized therapy with a licensed professional, there is a recognized need to provide physicians with options to support their wellness during a lawsuit.

Methods: The peer support model is a promising option to address the negative impacts to wellness that physician defendants face during medical malpractice lawsuits. We developed and implemented a peer support program to provide a safe, protected space for discussion of the personal impact of a lawsuit and to normalize this experience among peer physicians.

Results: Physicians were receptive to joining a peer support group to discuss the personal impacts of being named in a medical malpractice lawsuit. Participants in this novel group-based program found it helpful and would unanimously recommend it to others who are being sued.

Conclusion: To our knowledge, this pilot study is the first to implement and assess a facilitated, group-based peer support model for emergency physicians who are named as defendants in malpractice lawsuits. While group discussions demonstrated that symptoms of acute distress and MMSS were prevalent among physicians who were being sued, in this study physicians were receptive to and felt better after peer support sessions. Despite increasing burnout in the specialty of emergency medicine (EM) during the study time frame, burnout did not worsen in participants. Extrapolating from this pilot program, we hypothesize that formal peer support offered by EM groups can be an effective option to normalize the experience of being sued, promote wellness, and benefit physicians who endure the often long and stressful process of a medical malpractice lawsuit.

Case Series

Mpox in the Emergency Department: A Case Series

Introduction: We sought to describe the demographic characteristics, clinical features, and outcomes of a cohort of patients who presented to our emergency departments with mpox (formerly known as monkeypox) infection between May 1–August 1, 2022.

Case Series: We identified 145 patients tested for mpox, of whom 79 were positive. All positive cases were among cisgender men, and the majority (92%) were among men who have sex with men. A large number of patients (39%) were human immunodeficiency virus (HIV) positive. There was wide variation in emergency department (ED) length of stay (range 2–16 hours, median 4 hours) and test turnaround time (range 1–11 days, median 4 days). Most patients (95%) were discharged, although a substantial proportion (22%) had a return visit within 30 days, and 28% ultimately received tecrovirimat.

Conclusion: Patients who presented to our ED with mpox had similar demographic characteristics and clinical features as those described in other clinical settings during the 2022 outbreak. While there were operational challenges to the evaluation and management of these patients, demonstrated by variable lengths of stay and frequent return visits, most were able to be discharged.

  • 1 supplemental ZIP

Spontaneous Coronary Artery Dissection: A Case Series Reviewing Typical Presentations of an Atypical Pathology

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction. Patients suffering SCAD are often young women without typical risk factors for atherosclerotic heart disease. Clinicians should maintain a high index of suspicion for SCAD.

Case series: We report three cases of patients with SCAD from a single physician in a six-month period. Each case is unique and highlights the varied presentations and epidemiological risk factors associated with this condition.

Discussion: We believe these cases are unique in that they provide insights into the variable presentations and conditions frequently associated with SCAD and will help clinicians maintain a high index of suspicion for this difficult to diagnose and rare cause of type 2 myocardial infarction. We discuss differences in interventional techniques and medical management.

Case Reports

Costoclavicular Brachial Plexus Block Facilitates Painless Upper Extremity Reduction: A Case Report

Introduction: The costoclavicular brachial plexus block (CCBPB) has emerged as a more effective approach to regional anesthesia of the upper extremity. The costoclavicular space is the anterior portion of the superior thoracic aperture, located between the clavicle and first rib. The brachial plexus cords traverse this space clustered together in a superficial location lateral to the axillary artery and share a consistent topographical relationship to one another. By targeting the brachial plexus at this specific anatomical location, the CCBPB offers a powerful, single-shot, sensorimotor block of the upper extremity below the shoulder. We present a novel application of the CCBPB to facilitate emergency department (ED) analgesia and closed reduction of an upper extremity fracture.

Case Report: A 25-year-old male presented to the ED with a traumatic Colles fracture sustained during a high-speed motor vehicle collision. Despite multimodal analgesia, the patient reported intractable severe pain with intolerance of radial manipulation. An ultrasound-guided CCBPB was performed to augment pain control and avoid procedural sedation, resulting in dense, surgical anesthesia of the upper extremity, and painless fracture reduction.

Conclusion: Regional anesthesia is an effective component of multimodal pain management and another tool in the emergency physician’s analgesic armamentarium. In acute orthopedic traumas necessitating emergent reduction, regional blocks serve as rescue pain control and can obviate the need for procedural sedation. In terms of targeted upper extremity analgesia, the CCBPB offers effective, single-shot, sensorimotor blockade below the shoulder, mitigating use of opioids and their deleterious side effects, while simultaneously avoiding incomplete blockade or phrenic nerve palsy associated with other approaches to brachial plexus blockade.

  • 1 supplemental video

A Case Report of Anesthesia-Induced Diffuse Alveolar Hemorrhage Presenting to the Emergency Department

Introduction: The inhaled anesthetic sevoflurane is an uncommon etiology of diffuse alveolar hemorrhage (DAH). As DAH typically presents in the inpatient, postoperative setting, it has been infrequently reported in the anesthesiology literature and, to our knowledge, has not been reported in the emergency medicine literature to date.

Case Report: We describe the presentation of a young, healthy male in respiratory distress to a busy urban emergency department (ED) after an outpatient surgical procedure. We highlight the etiology of post-anesthesia DAH and the acute management of this rare diagnosis in the ED.

Conclusion: With outpatient surgical centers becoming an increasingly popular option for lower risk procedures, emergency physicians would benefit from understanding this presentation and its pathophysiology.

Cerebellar Infarction from a Vertebral Artery Dissection after Blunt Chest Injury: A Case Report

Introduction: Traumatic vertebral artery dissections resulting in stroke are relatively rare occurrences, especially in the absence of classic physical examination findings.

Case Report: We present the case of a 30-year-old male with chest pain following a car axle falling onto his chest while trying to change a tire. He was discharged from the emergency department after having a negative workup for thoracic injury. Six hours later, the patient returned with headache and was found to have a cerebellar stroke secondary to vertebral artery dissection. After hospitalization, the patient was discharged home without any neurological deficits.

Conclusion: As they are usually asymptomatic, up to 80% of patients with blunt cerebrovascular injury will have delayed or missed diagnoses. Given the increased awareness of vascular injuries and their high morbidity, physicians should maintain a high index of suspicion for this diagnosis.

Not All Sacral Wounds Are Sacral Decubitus Ulcers: A Case Report

Introduction: Sacral wounds are commonly seen in the emergency department and typically get diagnosed as a pressure ulcer of varying stage. However, other disease processes and infections can affect the sacrum.

Case Report: Presented here is the case of an evolving sacral wound in a 70-year-old, immunocompromised woman that was eventually found to be localized herpes zoster and later became disseminated.

Conclusion: This case demonstrates the need for a broad differential diagnosis for sacral wounds that include atypical presentations for herpes zoster or herpes simplex virus. We discuss the guidelines for treatment and the classification of localized vs disseminated herpes zoster.

A Case Report of Pneumoretroperitoneum from Blunt Trauma in a Patient with Chronic Obstructive Pulmonary Disease

Introduction: Pneumomediastinum is a rare complication of blunt traumatic injury and is thought to be due to the Macklin effect, a pathophysiologic process comprised of three steps: alveolar rupture secondary to blunt injury; air dissecting along bronchovascular sheaths; and spread of pulmonary interstitial edema into the mediastinal space. Pneumomediastinum is rarely associated with pneumoretroperitoneum.

Case Report: We present a case of a patient who suffered a cardiac arrest after a fall during a chronic obstructive pulmonary disease exacerbation, leading to pneumoretroperitoneum.

Conclusion: This case highlights the complications that can arise from blunt trauma and how underlying lung pathology can worsen these complications.

Common Iliac Artery Mycotic Pseudoaneurysm Associated with a Prevertebral Infection: A Case Report

Introduction: Mycotic pseudoaneurysms are rare but severe sequelae of an arterial wall infection. If undiagnosed and untreated they can lead to significant morbidity and mortality through complications such as arterial rupture or dissection.
Case report: This report details the case of a 64-year-old-male who developed a left common iliac artery mycotic pseudoaneurysm from Proteus mirabilis, which was associated with a prevertebral abscess. The patient presented with isolated, left lower extremity edema and intermittent fevers. The case is unique in both the pathogen (P mirabilis) and in its association with presumed direct arterial wall infection from an adjacent prevertebral abscess.
Conclusion: The obscure presentation highlights the need for a high clinical suspicion of such a diagnosis when a patient presents with a certain constellation of symptoms and the right predisposing risk factors in their history.

Spontaneous Aortic Rupture: A Case Report

Introduction: Acute aortic syndrome (AAS) includes the disease processes of aortic dissection, penetrating atherosclerotic ulcer, and intramural hematoma. This case demonstrates an atypical presentation of the disease and offers approaches to potentially prevent missed diagnoses.

Case Report: An 87-year-old female with hypertension and Alzheimer’s dementia presented to the emergency department with stable vital signs and a chief complaint of throat pain. Initial work-up was significant for ischemia on electrocardiogram and elevated troponin. Computed tomography of the soft tissue neck revealed evidence of a ruptured aorta.

Conclusion: Aortic rupture is a fatal complication of AAS. In an elderly patient with a history of hypertension, ischemic changes on electrocardiogram, and nonspecific pain, AAS should be on the emergency physician’s differential even in the setting of a benign or limited history and exam.

Intentional Overdose on Liquid Clonazolam Reversed with Flumazenil: A Case Report

Introduction: Clonazolam is a designer benzodiazepine that can be purchased illicitly on the internet. The use of designer benzodiazepines is increasing in both the United States and abroad, and patients may present to the emergency department (ED) after intentional or non-intentional overdose.

Case report: This case report describes a patient who presented to a community ED after an intentional overdose on liquid clonazolam and was successfully treated with flumazenil.

Conclusion: Since the pharmacologic action of clonazolam is similar to benzodiazepines, the sedative-hypnotic effect can be reversed with flumazenil, a benzodiazepine antagonist.

Traumatic Anterior Tibial Artery Pseudoaneurysm: A Case Report

Introduction: Traumatic pseudoaneurysms of the limbs are rare, with few cases described in vascular literature. Treatment is variable and dependent upon presentation and impact on local anatomy affected. Rapid assessment can be performed with ultrasound and assist in treatment decisions. We describe a case of traumatic anterior tibial artery pseudoaneurysm, which was rapidly identified with point-of-care ultrasound leading to definitive surgical management.

Case Report: A 37-year-old female presented to the emergency department for evaluation of right lower extremity pain and swelling following an exercise session with weighted squats and thigh abductor machines. She was found to have an anterior tibial artery pseudoaneurysm on point-of-care ultrasound, later confirmed with formal ultrasound as well as angiography, and was admitted for surgical management.

Conclusion: Traumatic pseudoaneurysms can rapidly be differentiated from other mass lesions and contributors to compartment syndrome using point-of-care ultrasound.

An Uncommon Diagnosis of Necrotizing Mastoiditis Presenting as Bell’s Palsy: A Case Report

Introduction: The benign nature of Bell’s palsy has led to a lack of a standardized work-up, and dangerous underlying mimics are at risk of being missed.

Case Report: An 84-year-old female with a history of vertigo presented to the emergency department with a left-sided facial droop consistent with Bell’s palsy. After further work-up, the patient was diagnosed with bilateral necrotizing mastoiditis.

Conclusion: Unilateral facial weakness involving the forehead and palpebral fissures is often diagnosed as idiopathic Bell’s palsy. Various pathologies can present with unilateral facial weakness, and the differential needs to remain broad.

Diagnosis of Endophthalmitis and Orbital Abscess by Ultrasound: A Case Report

Introduction: The diagnosis of ocular pathology by point-of-care ultrasound (POCUS) has been well established for entities such as retinal detachment, vitreous hemorrhage, posterior vitreous detachment, and lens dislocation.1 However, the use of ultrasound to detect other conditions such as orbital abscess and endophthalmitis in the emergency setting is rarely reported.

Case Report: We present a case in which POCUS was used to confirm the suspected diagnosis of endophthalmitis and orbital abscess. This case report will review the ultrasonographic findings of orbital abscess and endophthalmitis, as well as briefly discuss the literature for the use of ultrasound for these applications.

Conclusion: Point-of-care ultrasound can be used to rapidly diagnose infectious pathology of the eye and orbit, which could potentially decrease time to diagnosis and time to consultation of these vision-threatening pathologies.

  • 1 supplemental video

Images in Emergency Medicine

Pyolaryngocele Presenting with Acute-onset Stridor

Case presentation: This case describes the classic imaging findings of pyolaryngocele and highlights the importance of prompt imaging for diagnosis of clinically occult airway lesions. The case also highlights how pyolaryngoceles can become large and present with acute-onset clinical symptoms, including stridor and dyspnea.

Discussion: Pyolaryngoceles represent an uncommon but life-threatening complication of laryngoceles. Laryngoceles are frequently seen as an incidental, abnormal, air-filled dilation of the laryngeal saccule related to various local pathologies of the larynx. They are often asymptomatic. Occasionally they can become secondarily infected, in which case they are called pyolaryngocele, and they can cause rapid-onset, life-threatening airway compromise.

Bullous Pemphigoid Causing Successive Emergency Department Visits

Case Presentation: In this case presentation, an 84-year-old male with Fitzpatrick type IV skin tone experienced blistering due to bullous pemphigoid (BP), first on the distal upper left extremity and then on the distal lower extremities, chest, and back. These symptoms resulted in three visits to the emergency department within a month, as well as an episode of hospitalization. Despite treatment, the blistering did not resolve until future outpatient care with dermatology.

Discussion: Bullous pemphigoid is a rare autoimmune disease where autoantibodies target hemidesmosomal proteins causing basement membrane destruction and tense subepithelial bullae with pruritus. While uncommon, the incidence of BP is increasing. Bullous pemphigoid tends to affect older adults, appearing as a rash prior to bullae formation on the abdomen, extremities, groin, axillae, or mucosa. Bullous pemphigoid may also be drug-related with atypical symptoms. Diagnosis of BP should be based on immunopathology, and initial treatment of BP is through corticosteroid or doxycycline.

A Woman with Abdominal Pain After Lap-belt Trauma

Case presentation: A 24-year-old female presented to the emergency department with diffuse abdominal pain after involvement as a restrained driver in a motor vehicle collision (MVC). Computed tomography of the abdomen revealed a traumatic abdominal wall hernia due to rectus wall rupture with complete bowel herniation.

Discussion: A traumatic abdominal wall hernia is a rare complication of blunt abdominal trauma that is typically associated with injury from a motorcycle handlebar but is more commonly seen after a MVC. It is important to consider this diagnosis when evaluating patients with abdominal pain after blunt abdominal trauma from either of these mechanisms.

Letters to the Editor

Clarifications on: Pectoralis Blocks Nomenclature and Clinical Applications of Regional Anesthesia Techniques for Breast and Thorax

This is in response to the recently published case series applying pectoralis blocks (Pecs blocks) for infective breast conditions by  Brewer et al. I wish to provide a few clarifications regarding the Pecs blocks and other blocks such as Pecs Zero block, Serratus anterior plane block, Erector spinae block that can be adopted in an emergency department setting.