Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: The Emergency Medicine Education and Research by Global Experts (EMERGE) network was formed to generate and translate evidence to improve global emergency care. We share the challenges faced and lessons learned in establishing a global research network.

Methods: We describe the challenges encountered when EMERGE proposed the development of a global Emergency Department (ED) visit registry. The proposed registry was to be a 6-month, retrospective, deidentified, parsimonious dataset of routinely collected variables, such as patient demographics, diagnosis, and disposition.

Results: Obtaining reliable, accurate, and pertinent data from participating EDs is challenging in a global context. Barriers experienced ranged from variable data taxonomies, need for language translation, varying processes for data cleaning and transfer of deidentified data, navigating numerous data protection regulations and substantial variation in each participating institution’s research infrastructure including training in research related activities. We have overcome many of these challenges through creating detailed data sharing agreements with bilateral regulatory oversight, developing relationships with and training site health informaticians to ensure secure transfer of deidentified data, and formalizing a transfer process ensuring data privacy.

Conclusions: We believe that networks like EMERGE are integral to provide the necessary platforms for education, training and research collaborations. We identified substantial challenges in data sharing and variation in local sites’ research infrastructure, and propose approaches which may overcome the data quality and access issues that we encountered.

Objectives: Although factors related to a return visit to the emergency department (ED) have been reported, only few studies have examined “high-risk” ED revisits with serious adverse outcomes. This study aimed to describe the incidence and trend of high-risk ED revisits in United States EDs and to investigate factors associated with these revisits.

Methods: Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010–2018. Adult ED revisits within 72 hours of a previous discharge were identified using a mark on the Patient Record Form. High-risk revisits were defined as revisits with serious adverse outcomes, including intensive care unit admissions, emergency surgery, cardiac catheterization, or cardiopulmonary resuscitation (CPR) during the return visit. Analyses used descriptive statistics and multivariable logistic regression accounting for NHAMCS's complex survey design.

Results: Over the 9-year study period, there were an estimated 37,700,000 revisits, and the proportion of revisits in the entire ED population decreased slightly from 5.1% in 2010 to 4.5% in 2018 (P for trend = 0.02). By contrast, there were an estimated 827,000 high-risk ED revisits, and the proportion of high-risk revisits in the entire ED population remained stable at approximately 0.1%. The mean age of these high-risk revisit patients was 57 years, and 43% were men. Approximately 6% of the patients were intubated, and 13% received CPR. Most of them were hospitalized, and 2% died in the ED. Multivariable analysis showed older age (65+ years), Hispanic ethnicity, daytime visits, and arrival by ambulance during the revisit were independent predictors of high-risk revisits.

Introduction

The decision to discharge a patient from the hospital with confirmed or suspected COVID-19 is fraught with challenges. Patients who are discharged home must be both medically stable and able to safely isolate to prevent disease spread. Socioeconomically disadvantaged patient populations in particular may lack resources to safely quarantine and are at high risk for COVID-19 morbidity.

Methods

We developed a telehealth follow-up program for emergency department (ED) patients who received testing for COVID-19 from April 24 to June 29, 2020 and were discharged home. Patients who were discharged with a pending COVID-19 test received follow up calls on Days 1, 4 and 8. The objective of our program was to screen and provide referrals for health-related social needs (HRSNs); conduct clinical screening for worsening symptoms; and deliver risk-reduction strategies for vulnerable individuals. Retrospective chart review was conducted on all patients in this cohort to collect demographic information, testing results, and outcomes of clinical symptom and HRSN screening. Our primary outcome measurement was the need for clinical reassessment and referral for an unmet HRSN.

Results

From April 24th to June 29th, 2020, we made calls to 1,468 patients tested for COVID-19 and discharged home. On Day 4, we reached 67.0% of the 1,468 patients called. Of these, 15.9% were referred to a PA out of concern for clinical worsening and 12.4% were referred to an ED Patient Navigator for HRSNs. On Day 8, we reached 81.8% of the 122 patients called. Of these, 19.7% were referred to a PA for clinical reassessment and 14.0% of patients were referred to an ED Patient Navigator for HRSNs. Our intervention reached 1,069 patients, of which 12.6% required referral for HRSNs and 1.3% (n=14) were referred to the ED or Respiratory Illness Clinic due to concern for worsening clinical symptoms.

Conclusion

In this patient population, the demand for interventions to address social needs was as high as the need for clinical reassessment. Similar ED-based programs should be considered to help support patients’ interdependent social and health needs, beyond those related to COVID-19.

Introduction

Critically ill patients are frequently transferred from other hospitals to the Emergency department (ED) of tertiary hospitals. Due to the unforeseen transfer, the ED length of stay (LOS) of the patient is likely to be prolonged along with other adverse effects. The present study aimed to confirm whether the establishment of an organized unit called the Emergency Transfer Coordination Center (ETCC) to systematically coordinate emergency transfers is effective in reducing the ED LOS of transferred critically ill patients.

Methods

The present study is a retrospective observational study focusing on patients who were transferred from other hospitals and admitted to the intensive care unit (ICU) of the ED in a tertiary hospital located in northwestern Seoul, the capital city of South Korea from January 2019 to December 2020. The exposure variable of the study was ETCC approval before transfer and ED LOS was the primary outcome. Propensity score matching was used for comparison between the group with ETCC approval and the control group.

Results

Participants comprised 1097 patients admitted to the ICU after being transferred from other hospitals, of which, 306 patients (27.9%) were transferred with ETCC approval. The median ED LOS in the ETCC approved group was significantly reduced to 277 minutes compared to 385 minutes in the group without ETCC approval. ETCC had a greater effect on reducing evaluation time than boarding time, which was the same for populations with different clinical features.

Conclusion

ETCC can be effective in systematically reducing critical patients’ ED LOS who are transferred from other hospitals to tertiary hospitals suffering from severe crowding.

Introduction: Frostbite leads to progressive ischemia eventually causing tissue necrosis if not quickly reversed. Patients with frostbite tend to present to the emergency department (ED) for assessment and treatment. Acute management includes rewarming, pain management, and (when indicated) thrombolytic therapy. Thrombolytic therapy in severe frostbite injury may decrease rates of amputation and improve patient outcomes. Fluorescence microangiography (FMA) has been used to distinguish between perfused and non-perfused tissue. The purpose of this study was to evaluate the potential role of FMA in the acute care of patients with frostbite, specifically its role as a tool to identify perfusion deficit following severe frostbite injury, and to explore its role in time to tissue plasminogen activator (tPA).

Methods: This retrospective analysis included all patients from December 2020–March 2021 who received FMA in a single ED as part of their initial frostbite evaluation. In total, 42 patients presented to the ED with concern for frostbite and were evaluated using FMA.

Results: Mean time from arrival in the ED to FMA was 46.3 minutes. Of the 42 patients, 14 had clinically significant perfusion deficits noted on FMA and received tPA. Mean time to tPA (measured from ED arrival to administration of tPA) for these patients was 117.4 minutes. This is significantly faster than average historical times at our institution of 240-300 minutes.

Conclusion: Bedside FMA provides objective information regarding perfusion deficits and allows for faster decision-making and improved times to tPA. Fluorescence microangiography shows promise for quick and efficient evaluation of perfusion deficits in frostbite-injured patients. This could lead to faster tPA administration and potentially greater rates of tissue salvage after severe frostbite injury.

Introduction: Acute appendicitis is the most common non-obstetrical surgical emergency in pregnancy. Ultrasound is the imaging tool of choice, but its use is complicated due to anatomical changes during pregnancy and depends on the clinician’s expertise. In this study, our aim was to investigate the diagnostic accuracy of point-of-care ultrasound (POCUS) in suspected appendicitis in pregnant women.

Methods: We conducted a retrospective analysis of all pregnant women undergoing POCUS for suspected appendicitis between June 2010–June 2020 in a tertiary emergency department. The primary outcome was to establish sensitivity, specificity, and likelihood ratios of POCUS in diagnosing acute appendicitis, overall and for each trimester. We used histology of the appendix as the reference standard in case of surgery. If appendectomy was not performed, the clinical course until childbirth was used to rule out appendicitis. If the patients underwent magnetic resonance imaging (MRI), we compared readings to POCUS.

Results: A total of 61 women were included in the study, of whom 34 (55.7%) underwent appendectomy and in 30 (49.2%) an acute appendicitis was histopathologically confirmed. Sensitivity of POCUS was 66.7% (confidence interval [CI] 95% 47.1-82.7), specificity 96.8% (CI 95% 83.3-99.9), and positive likelihood ratio 20.7. Performance of POCUS was comparable in all trimesters, with highest sensitivity in the first trimester (72.7%). The MRI reading showed a sensitivity of 84.6% and a specificity of 100%. In the four negative appendectomies a MRI was not performed.

Conclusion: Point-of-care ultrasound showed a high specificity and positive likelihood ratio in diagnosing acute appendicitis in pregnant women in all trimesters with suspected appendicitis. In negative (or inconclusive) cases further imaging as MRI could be helpful to avoid negative appendectomy.

Introduction: Urolithiasis causes severe acute pain and is commonly treated with opioid analgesics in the emergency department (ED). We examined opioid analgesic use after episodes of acute pain. 

Methods: Using data from a longitudinal trial of ED patients with urolithiasis, we constructed multivariable models to estimate the adjusted probability of opioid analgesic use 3, 7, 30, and 90 days after ED discharge. We used multiple imputation to account for missing data and weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. We used weighted multivariable regression to compare longitudinal opioid analgesic use for those prescribed vs not prescribed an opioid analgesic at discharge, stratified by reported pain at ED discharge. 

Results: Among 892 adult ED patients with urolithiasis, 79% were prescribed an opioid analgesic at ED discharge. Regardless of reporting pain at ED discharge, those who were prescribed an opioid analgesic were significantly more likely to report using it one, three, and seven days after the visit in weighted multivariable analysis. Among those who were not prescribed an opioid analgesic, an estimated 21% (not reporting pain at ED discharge) and 30% (reporting pain at discharge) reported opioid analgesic use at day three. Among those prescribed an opioid analgesic, 49% (no pain at discharge) and 52% (with pain at discharge) reported using an opioid analgesic at day three. 

Conclusion: Urolithiasis patients who received an opioid analgesic at ED discharge were more likely to continue using an opioid analgesic than those who did not receive a prescription at the initial visit, despite the time-limited nature of urolithiasis.

Introduction: While females make up more than half of medical school matriculants, they only comprise about one third of emergency medicine (EM) residents. We examined EM residency cohorts with entering years of 2014–2017 to estimate the ratio of males to females among residents and program leadership to determine what correlation existed, if any, between program leadership and residency gender distributions. 

Methods: We identified 171 accredited EM residency programs in the United States with resident cohorts entering between 2014-2017 with publicly available data that were included in the study. The number of male and female residents and program directors were counted. We then confirmed the counts by contacting the programs directly to confirm accuracy of the data collected from program websites. 

Results: Within the included 171 programs, the overall male to female EM resident ratio was 1.78:1. Individual program ratios ranged from 0.85-8.0. Only eight programs (5.6%) had a female-predominant ratio. Among program directors, the overall male to female ratio was 2.17:1. TThe gender of the program director did not have a statistically significant correlation with the male to female ratio among its residents (P = .93). 

Conclusion: Within 171 residency programs across the US with entering cohorts between 2014-2017, the average male to female ratio among residents is nearly 2:1. No significant correlation exists between the gender distribution among a program’s leadership and its residents.

Introduction: Few studies have investigated the management of COVID-19 cases from the operational perspective of the emergency department (ED), We sought to compare the management and outcome of COVID-19 positive and negative patients who presented to French EDs.

Methods: We conducted a prospective, multicenter, observational study in four EDs. Included in the study were adult patients (≥18 years) between March 6–May 10, 2020, were hospitalized, and whose presenting symptoms were evocative of COVID-19. We compared the clinical features, management, and prognosis of patients according to their confirmed COVID-19 status.

Results: Of the 2,686 patients included in this study, 760 (28.3%) were COVID-19 positive. Among them, 364 (48.0%) had hypertension, 228 (30.0%) had chronic cardiac disease, 186 (24.5%) had diabetes, 126 (16.6%) were obese, and 114 (15.0%) had chronic respiratory disease. The proportion of patients admitted to intensive care units (ICU) was higher among COVID-19 positive patients (185/760, 24.3%) compared to COVID-19 negative patients (206/1,926, 10.7%; P <0.001), and they required mechanical ventilation (89, 11.9% vs 37, 1.9%; P <0.001) and high-flow nasal cannula oxygen therapy (135, 18.1% vs 41, 2.2%; P < 0.001) more frequently. The in-hospital mortality was significantly higher among COVID-19 positive patients (139, 18.3% vs 149, 7.7%; P <0.001).

Conclusion: Emergency departments were on the frontline during the COVID-19 pandemic and had to manage potential COVID-19 patients. Understanding what happened in the ED during this first outbreak is crucial to underline the importance of flexible organizations that can quickly adapt the bed capacities to the incoming flow of COVID-19 positive patients.

Introduction: The purpose of this study was to assess the added clinical value of oblique knee radiographs four-view (4V) compared to orthogonal anteroposterior (AP) and lateral radiographs in a two-view (2V) series.

Methods: We obtained 200 adult, 4V knee radiographs in 200 patients in the ED and randomly divided them into two groups with 100 series in each group. Ten reviewers — three musculoskeletal radiologists and seven orthopedic surgeons — performed radiograph analyses. These reviewers were randomly divided evenly into group one and group two. Reviewers were blinded to patient data and first reviewed 2V radiographs (AP/lateral) only, and then reviewed 4V radiographs, including AP/lateral, and two additional oblique views for the same patients at least four weeks later. Acute pathology identification and the need for further imaging was assessed for all reviewers, and clinical decision-making (operative vs nonoperative treatment, need for admission, need for additional imaging) was assessed only by the seven orthopaedic surgeon reviewers. 

Results: Mean sensitivity for pathology identification was 79% with 2V and 81% with 4V (P =0.25). Intra-observer kappa value was 0.81 (range 0.54-1.00). Additional oblique radiographs led orthopaedic reviewers to change their treatment recommendations in 62/329 patients (18.84%) (P <0.001). Eight of 329 radiographic series were identified as “critical misses.” (2.43%) (P =0.004), when pathology was reported as normal or reviewers recommended nonoperative treatment on 2V radiographs but changed their recommendation to operative management after the addition of oblique radiographs. The number needed to treat (NNT) for any treatment change and for “critical misses” was 83 and 643, respectively.  

Conclusion: Although the addition of oblique radiographs may improve a clinician’s ability to identify subtle pathologic findings not identified on 2V, it rarely leads to significant changes in treatment recommendations. Given the high NNT, limiting the usage of these oblique radiographs in the general patient population may reduce costs without significantly affecting patient care.

Introduction: Regional anesthesia (RA) has become a prominent component of multimodal pain management in emergency medicine (EM), and its use has increased rapidly in recent decades. Nevertheless, there is a paucity of data on how RA practice has evolved in the specialty. In this study we sought to investigate how RA has been implemented in EM by analyzing trends of published articles and to describe the characteristics of the published research.

Methods: We retrieved RA-related publications from the SciVerse Scopus database from inception to January 13, 2022, focusing on studies associated with the use of RA in EM. The primary outcome was an analysis of trend based on the number of annual publications. Other outcomes included reports of technique diversity by year, trends in the use of individual techniques, and characteristics of published articles. We used linear regression analysis to analyze trends.

Results: In total, 133 eligible publications were included. We found that overall 23 techniques have been described and results published in the EM literature. Articles related to RA increased from one article in 1982 to 18 in 2021, and the rate of publication has increased more rapidly since 2016. Reports of lower extremity blocks (60.90%) were published most frequently in ranked-first aggregated citations. The use of thoracic nerve blocks, such as the erector spinae plane block, has increased exponentially in the past three years. The United States (41.35%) has published the most RA-related articles. Regional anesthesia administered by emergency physicians (52.63%) comprised the leading field in published articles related to RA. Most publications discussed single-shot (88.72%) and ultrasound-guided methods (55.64%).

Conclusion: This study highlights that the number of published articles related to regional anesthesia in EM has increased. Although RA research has primarily focused on lower extremity blocks, clinical researchers continue to broaden the field of study to encompass a wide spectrum of techniques and indications.

Introduction: People experiencing homelessness have high rates of social needs when presenting for emergency department (ED) services, but less is known about patients with housing instability who do not meet the established definitions of homelessness.

Methods: We surveyed patients in an urban, safety-net ED from June–August 2018. Patients completed two social needs screening tools and responded to additional questions on housing. Housing status was determined using validated questions about housing stability.

Results: Of the 1,263 eligible patients, 758 (60.0%) completed the survey. Among respondents, 40% identified as Latinx, 39% Black, 15% White, 5% Asian, and 8% other race/ethnicities. The median age was 42 years (interquartile range [IQR]: 29-57). and 54% were male. Of the 758 patients who completed the survey, 281 (37.1%) were housed, 213 (28.1%) were unstably housed, and 264 (34.8%) were homeless. A disproportionate number of patients experiencing homelessness were male (63.3%) and Black (54.2%), P <0.001, and a disproportionate number of unstably housed patients were Latinx (56.8%) or were primarily Spanish speaking (49.3%), P <0.001. Social needs increased across the spectrum of housing from housed to unstably housed and homeless, even when controlling for demographic characteristics.

Conclusion: Over one in three ED patients experience homelessness, and nearly one in three are unstably housed. Notable disparities exist by housing status, and there is a clear increase of social needs across the housing spectrum. Emergency departments should consider integrating social screening tools for patients with unstable housing.

Introduction: Acquiring parental consent is critical to pediatric clinical research, especially in interventional trials. In this study we investigated demographic, clinical, and environmental factors associated with likelihood of parental permission for enrollment in a study of therapies for diabetic ketoacidosis (DKA) in children.

Methods: We analyzed data from patients and parents who were approached for enrollment in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) trial at one major participating center. We determined the influence of various factors on patient enrollment, including gender, age, distance from home to hospital, insurance status, known vs new onset of diabetes, glycemic control (hemoglobin A1c), DKA severity, gender of the enroller, experience of the enroller, and time of enrollment. Patients whose parents consented to participate were compared to those who declined participation using bivariable and multivariable analyses controlling for the enroller.

Results: A total of 250 patient/parent dyads were approached; 177 (71%) agreed to participate, and 73 (29%) declined. Parents of patients with previous episodes of DKA agreed to enroll more frequently than those with a first DKA episode (94.3% for patients with 1-2 previous DKA episodes, 92.3% for > 2 previous episodes, vs 64.9% for new onset diabetes and 63.2% previously diagnosed but no previous DKA). Participation was also more likely with more experienced enrollers (odds ratio [95% confidence interval] of participation for an enroller with more than two years’ experience vs less than two years: 2.46 [1.53, 3.97]). After adjusting for demographic and clinical factors, significant associations between participation and both DKA history and enroller experience remained. Patient age, gender, distance of home from hospital, glycemic control, insurance status, and measures of DKA severity were not associated with likelihood of participation.

Conclusion: Familiarity with the disease process (previously diagnosed diabetes and previous experience with DKA) and experience of the enroller favorably influenced the likelihood of parental permission for enrollment in a study of DKA in children.

Introduction

The purpose of this study was to quantify the effects of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency departments (PEDs) across the United States (US), specifically its impact on trainee clinical education as well as patient volume, admission rates, and staffing models.

Methods

We conducted a cross-sectional study of US PEDs, targeting PED clinical leaders via a web-based REDCap questionnaire.  The survey was sent via 3 national pediatric emergency medicine distribution lists, with several follow-up reminders.

Results

There were 46 questionnaires included, completed by PED directors from 25 states.  Forty-two sites provided PED volume and admission data for early pandemic (March-July 2020), and a pre-pandemic comparison period (March-July 2019).   Mean PED volume decreased > 32% for each studied month, with a maximum mean reduction of 63.6% (April 2020).  Mean percentage of pediatric admissions over baseline also peaked in April 2020 at 38.5% and remained 16.4% above baseline by July 2020.

During the study period, 33 (71.1%) sites had decreased provider staffing at some point.  Only 3 sites (6.7%) reported decreased faculty protected time.  All PEDs reported staffing changes, including decreased mid-level use, increased on-call staff, movement of staff between PED and other units, and added tele-visit shifts.  Twenty-six sites (56.5%) raised their patient age cutoff; median was 25 years (IQR 25-28).

Of 44 sites hosting medical trainees, 37 (84,1%) reported a decrease in trainee number or elimination altogether.  Thirty (68.2%) sites had restrictions on patient care provision by trainees:  28 (63.6%) affected medical students, 12 (27.3%) affected residents and 2 (4.5%) impacted fellows.  Fifteen sites (34.1 %) had restrictions on procedures performed by medical students (29.5%), residents (20.5%), or fellows (4.5%).

Conclusion

This study highlights the marked impact of the COVID-19 pandemic on US PEDs, noting decreased patient volumes, increased admission rates, and alterations in staffing models.  During the early pandemic, educational restrictions for trainees in the PED setting disproportionately affected medical students over residents, with fellow experience largely preserved.  Our findings quantify the magnitude of these impacts on trainee pediatric clinical exposure during this period.

Introduction: The Emergency Department (ED) acts as a safety net for our healthcare system. While studies have shown increased prevalence of social risks and needs among ED patients, there are many outstanding questions about the validity and use of social risks and needs screening tools in the ED setting.

Methods: In this paper, we present research gaps and priorities pertaining to social risks and needs screening tools used in the ED, identified through a consensus approach informed by literature review and external expert feedback as part of the 2021 SAEM Consensus Conference -- From Bedside to Policy: Advancing Social Emergency Medicine and Population Health.

Results: Four overarching research gaps were identified: (1) Defining the purpose and ethical implications of ED-based screening; (2) Identifying domains of social risks and needs; (3) Developing and validating screening tools; and (4) Defining the patient population and type of screening performed. Furthermore, the following research questions were determined to be of highest priority: (1) What screening tools should be used to identify social risks and needs? (2) Should individual EDs use a national standard screening tools or customized screening tools? (3) What are the most prevalent social risks and needs in the ED? and (4) Which social risks and needs are most amenable to intervention in the ED setting?

Conclusion: Answering these research questions will facilitate the use of evidence-based social risks and needs screening tools that address knowledge gaps and improve the health of our communities by better understanding the underlying determinants contributing to their presentation and health outcomes.

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Case Presentation

An 85-year-old male presented to the emergency department after a motor vehicle collision and developed progressive neurological deficits.  CT imaging demonstrated epidural thickening from C2-C7, and MRI was notable for a cervicothoracic epidural hematoma.  The patient underwent emergent decompression with a favorable outcome.

Discussion

Cases of traumatic spinal epidural hematomas are rarely seen in the emergency department.  These are part of a small subset of operative neurological emergencies that benefit from urgent operative intervention.

Case presentation. A 16-year-old female presented to the emergency department with a four-day history of right lower quadrant abdominal pain for several hours. The patient was afebrile and physical examination was notable for isolated tenderness in the right lower quadrant. Ultrasound and computed tomography demonstrated an adnexal cystic structure. Pelvic magnetic resonance imaging was ordered to better characterize the pathology. Discussion. Isolated fallopian tube torsion is an uncommon entity requiring prompt surgical intervention. Recognition and appropriate management are essential.

Case Presentation

A 26-year-old man was impaled by a nail after a nail gun accident. He was fully conscious with weakness and loss of sensation in the extremities. Cervical computed tomography showed a 9-cm long nail penetrating the spinal cord. The nail was removed 6 hours after the incident. The neurological deficits gradually improved, and at the 3-month follow-up, the patient had completely recovered from muscle weakness.

Discussion

The present case showed a favorable neurological course, which was be attributable to the fact that the cervical spinal cord injury did not involve the corticospinal tracts and anterior horn.

ABSTRACT

A 31-year old female with a history of laparoscopic assisted vaginal hysterectomy presented by ambulance to the emergency department with acute onset of abdominal pain and a vaginal protrusion which occurred while straining to pass a bowel movement.  Physical examination was notable for a flat but slightly tender abdomen, normal bowel sounds, scant vaginal bleeding, and a 15cm long, blood-tinged mass protruding from the vagina.  A brief and unsuccessful attempt at reduction was made by the emergency physician.  Obstetrics and Gynecology was consulted, and the patient was taken to the operating

DIAGNOSIS

Omental prolapse through vaginal cuff dehiscence.  Following vaginal hysterectomy, the vaginal cuff is closed surgically¹.  Occasionally, this site can dehisce, allowing abdominal contents to enter the vagina or protrude through the vaginal canal. Vaginal cuff dehiscence is estimated to have a rate of 0.39%. It is more commonly seen after total laparoscopic hysterectomy (1.35%) compared with laparoscopic-assisted vaginal hysterectomy, (0.28%)².

Risk factors include trauma from sexual intercourse, repetitive Valsalva maneuvers, smoking, malnutrition, anemia, diabetes, immunosuppression, and corticosteroid use².  Cases typically present as vaginal spotting or post-coital bleeding, and occasionally pelvic pressure or protrusion².  Most cases occur within weeks to months after the procedure, but some can present years later. Patients are at risk for infection due to exposure of peritoneal contents to vaginal and skin flora.  Management includes administration of broad-spectrum antibiotics.  Partial dehiscence can be managed with rest, but large dehiscence is usually managed surgically.

This case highlights the importance of the pelvic exam in patients with vaginal bleeding and abdominal pain, and care should be taken to not mistake protruding omental tissue for prolapsed vaginal mucosa.

REFERENCES

1.     Binz NM, et al. Complications of Gynecologic Procedures. Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

2.     Clarke-Pearson D, & Geller E. Complications of Hysterectomy. Obstetrics & Gynecology, 121 (3), 654-673; 2013.

Wealthy nations must step up support for Africa and vulnerable countries in addressing past, present and future impacts of climate change

Introduction: Racial disparities in pain management have been reported among emergency department (ED) patients. In this study we evaluated the association between patients’ self-identified race/ethnicity and the administration of opioid analgesia among ED patients with abdominal pain, the most common chief complaint for ED presentations in the United States.

Methods: This was a retrospective cohort study of adult (age ≥18 years) patients who presented to the ED of a single center with abdominal pain from January 1, 2019–December 31, 2020. We collected demographic and clinical information, including patients’ race and ethnicity, from the electronic health record. The primary outcome was the ED administration of any opioid analgesic (binary). Secondary outcomes included the administration of non-opioid analgesia (binary) and administration of any analgesia (binary). We used logistic regression models to estimate odds ratios (OR) of the association between a patient’s race/ethnicity and analgesia administration. Covariates included age, sex, initial pain score, Emergency Severity Index, and ED visits in the prior 30 days. Subgroup analyses were performed in non-pregnant patients, those who underwent any imaging study, were admitted to the hospital, and who underwent surgery within 24 hours of ED arrival.

Results: We studied 7,367 patients: 45% (3,314) were non-Hispanic (NH) White; 28% (2,092) were Hispanic/Latinx; 19% (1,384) were NH Black, and 8% (577) were Asian. Overall, 44% (3,207) of patients received opioid analgesia. In multivariable regression models, non-White patients were less likely to receive opioid analgesia compared with White patients (OR 0.73, 95% CI 0.65-0.83 for Hispanic/Latinx patients; OR 0.62, 95% CI 0.54-0.72 for Black patients; and OR 0.64, 95% CI 0.52-0.78 for Asian patients). Black patients were also less likely to receive non-opioid analgesia, and Black and Hispanic/Latinx patients were less likely than White patients to receive any analgesia. The associations were similar across subgroups; however, the association was attenuated among patients who underwent surgery within 24 hours of ED arrival. 

Conclusion: Hispanic/Latinx, Black, and Asian patients were significantly less likely to receive opioid analgesia than White patients when presenting to the ED with abdominal pain. Black patients were also less likely than White patients to receive non-opioid analgesia.

Once articles have been accepted for publication but have not yet been assigned to an issue, we place them here.

ABSTRACT

INTRODUCTION

Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that secrete catecholamines. Symptoms of these tumors are related directly to catecholamine excess but can be intermittent and easily misattributed to other more common pathologies.  Identification in the Emergency Department is inherently difficult.  In the COVID-19 pandemic physicians have had to account for both the disease itself as well as associated increased prevalence of cardiac, pulmonary, and vascular complications. Such shifting of disease prevalence arguably makes rarer diseases, like pheochromocytoma, less likely to be recognized.

CASE REPORT

We report a case of pheochromocytoma discovered in the emergency department in a patient who presented with fatigue, tachycardia, and diaphoresis. The differential included pulmonary embolism, cardiomyopathy, congestive heart failure and infectious causes.  A broad workup was begun including serology, electrocardiogram, Computed Tomography Angiogram (CTA), and COVID-19 testing. This patient was evaluated in the winter of 2020, the local height of the COVID-19 pandemic, and was found to be positive.  A tiny retroperitoneal tumor was reported on CTA as “incidental” in the setting of multifocal pneumonia from COVID-19 infection. But further history taking discovered many years of intermittent symptoms and suggested that the tumor may be more contributory to the patient’s presentation. Subsequent MRI and surgical pathology confirmed the pheochromocytoma.

CONCLUSION

This case presentation highlights the importance of careful history taking, keeping a broad differential, and examining incidental findings in the context of the patient’s presentation.

Pancreatitis after Esophagogastroduodenoscopy (EGD) is not a common occurrence, particularly in the setting of a normal serum lipase. The lack of commonality may delay diagnosis and treatment in some patients presenting to the emergency department with abdominal pain after an otherwise uncomplicated procedure. This case report serves to bring awareness to this potential procedural complication and the possibility of pancreatitis with a normal serum lipase.

Takotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease. We describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point of care ultrasound (POCUS) associated with traumatic hand amputation.  The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition ten days later. Emergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.

Introduction: Iron deficiency anemia is commonly seen in the emergency department, and the cause can be complex and variable.  Chronic lice infestation as the etiology of severe iron deficiency anemia has not been well studied and is mostly limited to case reports.

Case Report: We present a case of a female without known medical history who presented to the emergency department for generalized weakness and was found to have severe anemia in the setting of chronic lice infestation.  This patient’s hypotension was initially unresponsive to fluid resuscitation which allowed for consideration of other etiologies of this patient’s presentation and an unusual case of severe anemia.

Conclusion: Severe and chronic pediculosis can cause chronic blood loss and be an unusual and rare cause of iron deficiency anemia.  In the setting of anemia and hypotension unresponsive to fluid resuscitation, consideration should be given to early PRBC transfusion and subsequent investigation of causes of severe anemia.

Introduction

This case reviews a patient who presented to the emergency department (ED) with homonymous hemianopsia, a rare manifestation of partial status epilepticus of the occipital lobe.  Her initial brain computerized axial tomographic (CT) perfusion scan and magnetic resonance imaging (MRI) revealed novel findings associated with this diagnosis.

Case Report

A 70-year-old female presented to our ED with left visual field hemianopsia, dyskinesia, dysmetria and facial droop. Her initial diagnosis was left posterior fossa circulation cerebrovascular accident.  However, her neuroimaging indicated hypervascularity of the left occipital lobe without evidence of infarct or structural lesion. A cerebral angiogram excluded arterio-venous malformation.  Subsequently, an electroencephalogram showed left occipital lobe status epilepticus.

Conclusion

Hemianopsia is a rare presentation of partial status epilepticus mimicking stroke.  Hypervascularity seen on advanced neuroimaging may have suggested this diagnosis on initial ED evaluation.

ABSTRACT

Introduction: Emergency department (ED) staff are at a high risk for compassion fatigue (CF) due to a work environment that combines high patient acuity, violence, and other workplace stressors. This multi-faceted syndrome has wide-ranging impacts which, if left untreated, can lead to adverse mental health conditions including depression, anxiety, and substance use disorders. However, the majority of studies examining CF look solely at clinicians; as a result, there is no information on the impact of CF across other roles that are involved in supporting patient care. We conducted this study to establish the prevalence of CF across both clinical and non-clinical roles in the adult ED setting.

Methods: For this single institution cross-sectional study, all full- and part-time ED staff members who worked at least 50% of their shifts in the ED or within the adult trauma service line were eligible to participate. Using the Professional Quality of Life (ProQOL-5) scale, which measures CF via compassion satisfaction (CS), burnout (BO), and secondary traumatic stress (STS), we assessed for group differences between roles using non-parametric one-way ANOVA.

Results: A total of 152 participants (response rate = 38.0%) completed the survey. This included attending physicians (n = 15, 9.7%), resident/fellow physicians (n = 23, 15.1%), staff nurses (n = 54, 35.5%), emergency technicians (n = 21, 13.8%), supportive clinical staff (n = 28, 18.4%), and supportive ancillary staff (n = 11, 7.2%). Across all roles, the majority of respondents had average levels of BO (median = 25.0, IQR 20.0 – 29.0) and STS (median = 23.0, IQR 18.0 – 27.0) coupled with high levels of CS (median = 38.0, IQR 33.0 – 43.0). There was a difference in CS by role (p = .01), with nurses reporting lower CS than attending physicians. STS also differed by role (p = .01), with attending physicians reporting lower STS than both emergency technicians and nurses. Group differences were not seen in BO.