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Open Access Publications from the University of California

Volume 13, Issue 4, 2012


Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement

Introduction: Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement.

Methods: This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigatorusing first the low-frequency (5–1 MHz) followed by the high-frequency (10–5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation ofTT placement.

Results: Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10–5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode.

Conclusion: Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10–5 MHz) linear transducer. [West J Emerg Med. 2012;13(4):305–311.]


Evaluation of Breast Disorders with Ultrasound

[West J Emerg Med. 2012;13(4):312–000.]

  • 1 supplemental video

Tuberculous Pleural Effusion

Pleural effusions are a common finding in emergency departments, with cytologic analysis traditionally required for definitive diagnosis. This article describes a classic sonographic appearance of tuberculous pleural effusion. [West J Emerg Med. 2012;13(4):313–314.]

  • 1 supplemental video

Ultrasound-Guided Hip Arthrocentesis in a Child with Hip Pain and Fever

Children presenting to the emergency department with hip pain and fever are at risk for significant morbidity due to septic arthritis. Distinguishing between septic arthritis and other causes of hip pain may be challenging. Sonographic visualization of the hip with real-time ultrasound-guided arthrocentesis may allow faster differentiation between etiologies, hastening definitive therapy and improving analgesia. This report describes the use of hip sonography in a case of Lyme arthritis. The authors review the medical literature in support of bedside hip sonography and discuss how to perform ultrasound-guided hip arthrocentesis. Clinical findings in septic and Lyme arthritis are also described. [West J Emerg Med. 2012;13(4):316–319.]

  • 1 supplemental file

Ultrasound Guidance for Central Venous Access by Emergency Physicians in Colorado

Introduction: To survey emergency physicians (EP) regarding the frequency of use of ultrasound guidance for placement of central venous catheters (UGCVC) and to assess their perceptions regarding the technique and barriers to its implementation.

Methods: A 25-question Web-based survey was e-mailed to all members of the Colorado chapter of the American College of Emergency Physicians with a listed e-mail address. A total of 3 reminderswere sent to nonresponders.

Results: Responses were received from 116 out of 330 invitations. Ninety-seven percent (n¼112) of respondents indicated they have an ultrasound machine available in their emergency department, and 78% indicated they use UGCVC. Seventy-seven percent (n ¼ 90) agreed with the statement, ‘‘Ultrasound guidance is the preferred method for central venous catheter placement in the emergencydepartment.’’ However, 23% of respondents stated they have received no specific training in UGCVC. Twenty-six percent (n ¼28) of respondents stated they felt ‘‘uncomfortable’’ or ‘‘very uncomfortable’’with UGCVC, and 47% cite lack of training in UGCVC as a barrier to performing the technique.

Conclusion: Although the majority of surveyed EPs feel UGCVC is a valuable technique and do perform it, a significant percentage reported receiving no training in the procedure and also reported being uncomfortable performing it. Nearly half of those surveyed cited lack of training as a barrier to more widespread implementation of UGCVC. This suggests that there continues to be a need for education and training of EPs in UGCVC. [West J Emerg Med. 2012;13(4):320–325.]


Focused Cardiac Ultrasound for the Detection of a Ventricular Aneurysm

Left ventricular aneurysm (LVA) is a rare and dangerous disease process, for which rapid diagnosis can expedite further evaluation and treatment. Here we present the first case of LVA detected by focused cardiac ultrasound in a case of a patient with electrocardiographic findings consistent with a ST elevation myocardial infarction. [West J Emerg Med. 2012;13(4):326-328.]

  • 1 supplemental video

Injury Prevention and Population Health

Descriptions of Motor Vehicle Collisions by Participants in Emergency Department–Based Studies: Are They Accurate?

Introduction: We examined the accuracy of research participant characterizations of motor vehicle collisions (MVC).

Methods: We conducted an emergency department-based prospective study of adults presenting for care after experiencing an MVC. Study participants completed a structured clinical interview that assessed the number of lanes of the road where the collision took place, vehicle type, road condition, speed limit, seat belt use, airbag deployment, vehicle damage, time of collision, and use of ambulance transportation. Study participant data were then compared with information recorded by Michigan State Police at the scene of the MVC. Agreement between research participant reports and police-reported data were assessed by using percentage agreement and j coefficients for categorical variables and correlation coefficients for continuous variables.

Results: There were 97 study participants for whom emergency department interviews and Michigan State Police Report information were available. Percentage agreement was 51% for number of lanes,76% for car drivability, 88% for road condition, 91% for vehicle type, 92% for seat belt use, 94% for airbag deployment, 96% for speed limit, 97% for transportation by ambulance, and 99% for vehicle seat position. j values were 0.32 for seat belt use, 0.34 for number of lanes, 0.73 for vehicle type, 0.76 for speed limit, 0.77 for road condition, 0.87 for airbag deployment, 0.90 for vehicle seat position, and 0.94for transport by ambulance. Correlation coefficients were 0.95 for the time of the collision, and 0.58 for extent of damage to the vehicle. Most discrepancies between patients and police about extent of vehicle damage occurred for cases in which the patient reported moderate or severe damage but the police reported only slight damage.

Conclusion: For most MVC characteristics, information reported by research participants was consistent with police-reported data. Agreement was moderate or high for characteristics of greatestrelevance to injury biomechanics. These results suggest that research participant report is an acceptable source of collision information. [West J Emerg Med. 2012;13(4):329–334.]

International Medicine

A Survey Study of Institutional Review Board Thought Processes in the United States and South Korea

Introduction: In the last several decades, South Korea has rapidly adopted Western customs and practices. Yet, cultural differences between South Korea and the United States exist. The purpose ofthis study was to identify and characterize potential cultural differences in the Korean and US institutional review board (IRB) approach to certain topics.

Methods: A qualitative analysis of a 9-item survey, describing 4 research study case scenarios, sent to IRB members from the United States and South Korea. The case scenarios involved the followingissues: (1) the need for consent for retrospective chart review when research subjects receive their care after the study is conceived; (2) child assent; (3) individual versus population benefit; and (4) exception from informed consent in emergency resuscitation research. The free-text responses were analyzed and abstracted for recurrent themes.

Results: Twenty-three of the 45 survey recipients completed the survey, for an overall response rate of 51%. The themes that emerged were as follows: (1) the importance of parental authority among Korean participants versus the importance of child autonomy and child assent among US participants; (2) the recognition of the rights of a proxy or surrogate who can represent an individual’s values by all participants; and (3) the importance of the community, expressed by the Korean respondents, versus individualism, expressed by US respondents.

Conclusion: Whereas US participants appear to emphasize the importance of the individual and the autonomy of a child, the Korean respondents stressed the importance of parental authority andbenefiting the community, above and beyond that of the individual person. However, there was substantial overlap in the themes expressed by respondents from both countries. [West J Emerg Med.2012;13(4):335–341.]


Emergency Department Administration

Emergency Physicians Research Common Problems in Proportion to their Frequency

Introduction: Emergency medicine (EM) organizations such as the Society for Academic Emergency Medicine and the Institute of Medicine have called for more clinical research as a way of addressing thescarcity of research in EM. Previous investigations have examined funding and productivity in EM research, but whether EM researchers preferentially concentrate on certain patient-related topics is notknown. We hypothesized that at least part of the scarcity of EM research is from the tendency of EM researchers, like researchers in other fields, to focus on rarer conditions with higher morbidity or mortality instead of on more common conditions with less acuity. This study compared the frequency of specific medical conditions presenting to emergency departments nationwide with the frequency of emergency physician research on those same conditions.

Methods: This study is a structured retrospective review and comparison of 2 databases during an 11-year span. Principal diagnoses made by emergency physicians as reported by the National HospitalAmbulatory Medical Care Survey were compared to all first-author publications by emergency physicians as reported in PubMed between 1996 and 2006. Statistics included correlations and linear regression with the number of emergency department (ED) visits per diagnosis as the independent variable and the number of articles published as the dependent variable.

Results: During the study period, there was significant concordance between the frequency of presenting conditions in the emergency department and the frequency of research being performed onthose conditions, with a high correlation of 0.85 (P,0.01). More common ED diagnoses such as injury/poisoning, symptoms/ill-defined conditions, and diseases of the respiratory system accounted for 60.9% of ED principal diagnoses and 50.2% of the total research published in PubMed.

Conclusion: Unlike researchers in other fields, emergency physicians investigate clinical problems in almost the exact proportion as those conditions are encountered in the emergency department. The scarcity of EM research does not have to do with a skewed focus toward less common patient problems.

How Accurately Can Emergency Department Providers Estimate Patient Satisfaction?

Introduction: Patient satisfaction is an important measure of emergency department (ED) quality of care. Little is known about providers’ ability to estimate patient satisfaction. We aimed to measure providers’ ability to assess patient satisfaction and hypothesized that providers could accurately estimate overall patient satisfaction.

Methods: We surveyed ED patients regarding satisfaction with their care. Treating providers completed analogous surveys, estimating patients’ responses. Sexual assault victims and non-English-speaking or severely ill patients were excluded. Satisfaction responses were categorized as ‘‘satisfied’’ or ‘‘not satisfied.’’ Patient satisfaction scores were considered the ‘‘gold standard,’’ and providers’ perceptions of the patient satisfaction were considered tests. Measures of diagnosticaccuracy, such as positive predictive value (PPV) and sensitivity, were used to assess how accurately the provider could estimate his or her patient’s satisfaction.

Results: Here, 242/457 eligible patients (53%) completed the survey; 227 providers (94%) completed a corresponding survey. Subject-reported overall satisfaction was 96.6%, compared with a provider estimated rate of 94.4%. The sensitivity and PPV of the provider’s estimate of the patient’s satisfaction were 95.2 (95% confidence interval [CI] 91.4, 97.7) and 97.5 (95% CI 94.4, 99.2), respectively, for overall patient satisfaction. The PPV was similar for clarity of communication. The PPV was 78.9 for perceived length of ED stay (99% CI 70.8, 85.6) and 82.6 for quality of pain control (95% CI 68.6, 92.2). Accuracy of attending and resident estimates of patient satisfaction did not differ significantly. The agreement between patient-reported and provider-estimated patient satisfaction was not associated with age, gender, patient disposition, or ED divert status.

Conclusion: Providers are able to assess overall patient satisfaction and clarity of communication with a high accuracy. Physician estimates of pain control and perceived length of stay have a moderate accuracy. [West J Emerg Med. 2012;13(4):351–357.]


Successful Introduction of an Emergency Department Electronic Heal th Record

Our emergency department had always relied on a paper-based infrastructure. Our goal was to convert to a paperless, efficient, easily accessible, technologically advanced system to support optimal care. We outline our sequential successful transformation, and describe the resistance, costs, incentives and benefits of the change. Critical factors contributing to the significant change included physician leadership, training and the rate of the endorsed change. We outline various tactics, tools, challenges and unintended benefits and problems. [West J Emerg Med. 2012;13(4):358-361.]

Clinical Practice

Therapy Dogs in the Emergency Department

Introduction: This study examined acceptance by staff and patients of a therapy dog (TD) in the emergency department (ED).

Methods: Immediately after TD visits to a University Hospital ED, all available ED staff, patients, and their visitors were invited to complete a survey.

Results: Of 125 ‘‘patient’’ and 105 staff responses, most were favorable. Ninety-three percent of patients and 95% of staff agreed that TDs should visit EDs; 87.8% of patients and 92% of staff approved of TDs for both adult and pediatric patients. Fewer than 5% of either patients or staff were afraid of the TDs. Fewer than 10% of patients and staff thought the TDs posed a sanitary risk or interfered with staff work.

Conclusion: Both patients and staff approve of TDs in an ED. The benefits of animal-assisted therapy should be further explored in the ED setting. [West J Emerg Med. 2012;13(4):363–365.]


The Ottawa Knee Rule: Examining Use in an Academic Emergency Department

Introduction: The Ottawa Knee Rule is a validated clinical decision rule for determining whether knee radiographs should be obtained in the setting of acute knee trauma. The objectives of this study were to assess physician knowledge of, barriers to implementation of, and compliance with the Ottawa Knee Rule in academic emergency departments (EDs), and evaluate whether patient characteristics predict guideline noncompliance.

Methods: A 10 question online survey was distributed to all attending ED physicians working at three affiliated academic EDs to assess knowledge, attitudes and self-reported practice behaviors relatedto the Ottawa Knee Rule. We also performed a retrospective ED record review of patients 13 years of age and older who presented with acute knee trauma to the 3 study EDs during the 2009 calendar year, and we analyzed ED records for 19 variables.

Results: ED physicians (n = 47) correctly answered 73.2% of questions assessing knowledge of the Ottawa Knee Rule. The most commonly cited barriers to implementation were “patient expectations” and system issues, such as “orthopedics referral requirement.” We retrospectively reviewed 838 records, with 260 eligible for study inclusion. The rate of Ottawa Knee Rule compliance was retrospectively determined to be 63.1%. We observed a statistically significant correlation betweenOttawa Knee Rule compliance and patient age, but not gender, insurance status, or provider type, among others.

Conclusion: Compliance with the Ottawa Knee Rule among academic ED healthcare providers is poor, which was predicted by patient age and not other physician or patient variables. Improving compliance will require comprehensive educational and systemic interventions. [West J Emerg Med. 2012;13(4):366-373.]

  • 1 supplemental PDF

Baclofen Withdrawal Presenting as Irritability in a Developmentally Delayed Child

Irritability in children has a broad differential diagnosis, ranging from benign processes to lifethreatening emergencies. In children with comorbid conditions and developmental delay, the diagnostic process becomes more challenging. This case report describes a developmentally delayed 14-year-old boy who presented with pain and crying caused by a malfunction of a surgically implanted baclofen pump. We describe recommendations concerning the diagnostic evaluation, medical management, and surgical repair. [West J Emerg Med. 2012;13(4):373-375.]



Emergency Physician Estimation of Blood Loss

Introduction: Emergency physicians (EP) frequently estimate blood loss, which can have implications for clinical care. The objectives of this study were to examine EP accuracy in estimating blood loss on different surfaces and compare attending physician and resident performance.

Methods: A sample of 56 emergency department (ED) physicians (30 attending physicians and 26 residents) were asked to estimate the amount of moulage blood present in 4 scenarios: 500 mL spilled onto an ED cot; 25 mL spilled onto a 10-pack of 434-inch gauze; 100 mL on a T-shirt; and 150 mL in a commode filled with water. Standard estimate error (the absolute value of (estimated volume actual volume)/actual volume3100) was calculated for each estimate.

Results: The mean standard error for all estimates was 116% with a range of 0% to 1233%. Only 8% of estimates were within 20% of the true value. Estimates were most accurate for the sheet scenario andworst for the commode scenario. Residents and attending physicians did not perform significantly differently (P . 0.05).

Conclusion: Emergency department physicians do not estimate blood loss well in a variety of scenarios. Such estimates could potentially be misleading if used in clinical decision making. Clinical experience does not appear to improve estimation ability in this limited study. [West J Emerg Med. 2012;13(4):376–379.]



Allergic Dermatitis due to Topical Antibiotics

In this report we present a case of allergic dermatitis from chronic use of antibiotic ointment mistakenly diagnosed as a localized finger infection. [West J Emerg Med. 2012;13(4):380–382.]