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Volume 15, Issue 6, 2014
Societal Impact on Emergency Care
Compassion Fatigue is Similar in Emergency Medicine Residents Compared to other Medical and Surgical Specialties
Introduction: Compassion fatigue (CF) is the emotional and physical burden felt by those helping others in distress, leading to a reduced capacity and interest in being empathetic towards future suffering. Emergency care providers are at an increased risk of CF secondary to their first responder roles and exposure to traumatic events. We aimed to investigate the current state of compassion fatigue among emergency medicine (EM) resident physicians, including an assessment of contributing factors.
Methods: We distributed a validated electronic questionnaire consisting of the Professional Quality of Life Scale with subscales for the three components of CF (compassion satisfaction, burnout and secondary traumatic stress), with each category scored independently. We collected data pertaining to day- versus night-shift distribution, hourly workload and child dependents. We included residents in EM, neurology, orthopedics, family medicine, pediatrics, obstetrics, and general surgery.
Results: We surveyed 255 residents, with a response rate of 75%. Of the 188 resident respondents, 18% worked a majority of their clinical shifts overnight, and 32% had child dependents. Burnout scores for residents who worked greater than 80 hours per week, or primarily worked overnight shifts, were higher than residents who worked less than 80 hours (mean score 25.0 vs 21.5; p=0.013), or did not work overnight (mean score 23.5 vs 21.3; p=0.022). EM residents had similar scores in all three components of CF when compared to other specialties. Secondary traumatic stress scores for residents who worked greater than 80 hours were higher than residents who worked less than 80 hours (mean score 22.2 vs 19.5; p=0.048), and those with child dependents had higher secondary traumatic stress than those without children (mean score 21.0 vs 19.1; p=0.012).
Conclusion: CF scores in EM residents are similar to residents in other surgical and medical specialties. Residents working primarily night shifts and those working more than 80 hours per week appear to be at high risk of developing compassion fatigue. Residents with children are more likely to experience secondary traumatic stress. [West J Emerg Med. 2014;15(6):–0]
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BE-SAFE: Bedside Sonography for Assessment of the Fetus in Emergencies: Educational Intervention for Late-pregnancy Obstetric Ultrasound
Introduction: Late obstetric emergencies are time critical presentations in the emergency department. Evaluation to ensure the safety of mother and child includes rapid assessment of fetal viability, fetal heart rate (FHR), fetal lie, and estimated gestational age (EGA). Point-of-care (POC) obstetric ultrasound (OBUS) offers the advantage of being able to provide all these measurements. We studied the impact of POC OBUS training on emergency physician (EP) confidence, knowledge, and OBUS skill performance on a live model.
Methods: This is a prospective observational study evaluating an educational intervention we designed, called the BE-SAFE curriculum (BEdside Sonography for the Assessment of the Fetus in Emergencies). Subjects were a convenience sample of EP attendings (N=17) and residents (N=14). Prior to the educational intervention, participants completed a self-assessment survey on their confidence regarding OBUS, and took a pre-test to assess their baseline knowledge of OBUS. They then completed a 3-hour training session consisting of didactic and hands-on education in OBUS. After training, each subject’s time and accuracy of performance of FHR, EGA, and fetal lie was recorded. Post-intervention knowledge tests and confidence surveys were administered. Results were compared with non-parametric t-tests.
Results: Pre- and post-test knowledge assessment scores for previously untrained EPs improved from 65.7% [SD=20.8] to 90% [SD=8.2] (p<0.0007). Self-confidence on a scale of 1-6 improved significantly for identification of FHR, fetal lie, and EGA. After training, the average times for completion of OBUS critical skills were as follows: cardiac activity (9s), FHR (68.6s), fetal lie (28.1s), and EGA (158.1 sec). EGA estimates averaged 28w0d (25w0d-30w6d) for the model’s true gestational age of 27w0d.
Conclusion: After a focused POC OBUS training intervention, the BE-SAFE educational intervention, EPs can accurately and rapidly use ultrasound to determine FHR, fetal lie, and estimate gestational age in mid-late pregnancy. [West J Emerg Med. 2014;15(6):–0]
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Performance Accuracy of Hand-on-needle versus Hand-on-syringe Technique for Ultrasound-guided Regional Anesthesia Simulation for Emergency Medicine Residents
Objectives: Ultrasound-guided nerve blocks (UGNBs) are increasingly used in emergency care. The hand-on-syringe (HS) needle technique is ideally suited to the Emergency Department setting because it allows a single operator to perform the block without assistance. The HS technique is assumed to provide less exact needle control than the alternative two operator hand-on-needle (HN) technique; however this assumption has never been directly tested. The primary objective of this study was to compare accuracy of needle targeting under ultrasound guidance by Emergency Medicine (EM) residents using HN and HS techniques on a standardized gelatinous simulation model.
Methods: This prospective, randomized study evaluated task performance. Needle targeting accuracy using the HN and HS techniques was compared. Each participant performed a set of structured needling maneuvers (both simple and difficult) on a standardized partial-task simulator. Time to task completion, needle visualization during advancement, and accuracy of needle tip at targeting were evaluated. Resident technique preference was assessed using a post-task survey.
Results: 60 tasks performed by 10 EM residents were evaluated. There was no significant difference in time to complete the simple model (HN vs. HS, 18 seconds vs. 18 seconds, p=0.93), time to complete the difficult model (HN vs. HS, 56 seconds vs. 50 seconds, p=0.63), needle visualization, or needle tip targeting accuracy. Most residents (60%) preferred the HS technique.Conclusion: For EM residents learning UGNBs, the HN technique was not associated with superior needle control. Our results suggest that the single operator HS technique provides equivalent needle control when compared to the two-operator HN technique.
Introduction: As emergency medicine (EM) has become a more prominent feature in the clinical years of medical school training, national EM clerkship curricula have been published to address the need to standardize students’ experiences in the field. However, current national student curricula in EM do not include core pediatric emergency medicine (PEM) concepts.
Methods: A workgroup was formed by the Clerkship Directors in Emergency Medicine and the Pediatric Interest Group of the Society of Academic Emergency Medicine to develop a consensus on the content to be covered in EM and PEM student courses.
Results: The consensus is presented with the goal of outlining principles of pediatric emergency care and prioritizing students’ exposure to the most common and life-threatening illnesses and injuries.
Conclusion: This consensus curriculum can serve as a guide to directors of PEM and EM courses to optimize PEM knowledge and skills education. [West J Emerg Med. 2014;15(6):–0]
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Abdominal pain frequently represents a diagnostic challenge in the acute setting. In pregnant patients, the gravid abdomen and concern for ionizing radiation exposure further limit evaluation. If undiagnosed, appendicitis may cause disastrous consequences for the mother and fetus. We present the case of a pregnant female who was admitted for right lower quadrant abdominal pain. Advanced imaging of the abdomen and pelvis was interpreted to be either indeterminate or normal and a diagnosis of acute appendicitis was made on purely clinical grounds. This patient’s management and a literature review of diagnostic techniques for acute appendicitis during pregnancy are discussed. [West J Emerg Med. 2014;15(6):-0]
The urinary tract is an often forgotten and under-appreciated source of infection in anuric hemodialysis patients. Bladder abscess, also called pyocystis, is a severe complication of low urinary flow that can be difficult to detect, leading to delays in treatment and increased morbidity. The emergency physician should maintain a high suspicion for pyocystis, which can be quickly diagnosed by bedside ultrasound. We report a case of a hemodialysis patient with an initially minor presentation who developed sepsis secondary to pyocystis and prostate abscess. [West J Emerg Med. 2014;15(6):-0]
Traumatic perforation of the esophagus due to blunt trauma is a rare thoracic emergency. The most common causes of esophageal perforation are iatrogenic, and the upper cervical esophageal region is the most often injured. Diagnosis is frequently determined late, and mortality is therefore high. This case report presents a young woman who was admitted to the emergency department (ED) with esophageal perforation after having fallen from a high elevation. Esophageal perforation was diagnosed via thoracoabdominal tomography with ingestion of oral contrast. The present report discusses alternative techniques for diagnosing esophageal perforation in a multitrauma patient. [West J Emerg Med. 2014;15(6):-0]
Haff disease, rhabdomyolysis after ingesting certain types of fish, was first reported in 1924 in Europe. There have been a limited number of cases reported in the United States. We present the case of a patient who presents with symptoms of rhabdomyolysis after eating cooked buffalo fish purchased at a suburban grocery market. [West J Emerg Med. 2014;15(6):-0]
Emergency Department Access
Introduction: When a psychiatric patient in the emergency department requires inpatient admission, but no bed is available, they may become a “boarder.” The psychiatric emergency service (PES) has been suggested as one means to reduce psychiatric boarding, but the frequency and characteristics of adult PES boarders have not been described.
Methods: We electronically extracted electronic medical records for adult patients presenting to the PES in an urban county safety-net hospital over 12 months. Correlative analyses included Student’s t-tests and multivariate regression.
Results: 521 of 5363 patient encounters (9.7%) resulted in boarding. Compared to non-boarding encounters, boarding patient encounters were associated with diagnoses of a primary psychotic, anxiety, or personality disorder, or a bipolar manic/mixed episode. Boarders were also more likely to be referred by family, friends or providers than self-referred; arrive in restraints; experience restraint/seclusion in the PES; or be referred for involuntary hospitalization. Boarders were more likely to present to the PES on the weekend. Substance use was common, but only tobacco use was more likely associated with boarding status in multivariate analysis.
Conclusion: Boarding is common in the PES, and boarders have substantial psychiatric morbidity requiring treatment during extended PES stays. We question the appropriateness of PES boarding for seriously ill psychiatric patients. [West J Emerg Med. 2014;15(6):-0]
Introduction: Research has described emergency department (ED) use patterns in detail. However, evidence is lacking on how, at the time a decision is made, patients decide if healthcare is required or where to seek care.
Methods: Using community-based participatory research methods, we conducted a mixed-methods descriptive pilot study. Due to the exploratory, hypothesis-generating nature of this research, we did not perform power calculations, and financial constraints only allowed for 20 participants. Hypothetical vignettes for the 10 most common low acuity primary care complaints (cough, sore throat, back pain, etc.) were texted to patients twice daily over six weeks, none designed to influence the patient’s decision to seek care. We conducted focus groups to gain contextual information about participant decision-making. Descriptive statistics summarized responses to texts for each scenario. Qualitative analysis of open-ended text message responses and focus group discussions identified themes associated with decision-making for acute care needs.
Results: We received text survey responses from 18/20 recruited participants who responded to 72% (1092/1512) of the texted vignettes. In 48% of the vignettes, participants reported they would do nothing, for 34% of the vignettes participants reported they would seek care with a primary care provider, and 18% of responses reported they would seek ED care. Participants were not more likely to visit an ED during “off-hours.” Our qualitative findings showed: 1) patients don’t understand when care is needed; 2) patients don’t understand where they should seek care.
Conclusion: Participants were unclear when or where to seek care for common acute health problems, suggesting a need for patient education. Similar research is necessary in different populations and regarding the role of urgent care in acute care delivery. [West J Emerg Med. 2014;15(6):-0]
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Emergency Department Operations
Introduction: There is scant literature regarding the optimal resident physician staffing model of academic emergency departments (ED) that maximizes learning opportunities. A department of emergency medicine at a large inner-city academic hospital initiated a team-based staffing model. Its pre-interventional staffing model consisted of residents and attending physicians being separately assigned patients, resulting in residents working with two different faculty providers in the same shift. This study aimed to determine if the post-interventional team-based system, in which residents were paired with a single attending on each shift, would result in improved residents’ learning and clinical experiences as manifested by resident evaluations and the number of patients seen.
Methods: This retrospective before-and-after study at an academic ED with an annual volume of 52,000 patients examined the mean differences in five-point Likert-scale evaluations completed by residents assessing their ED rotation experiences in both the original and team-based staffing models. The residents were queried on their perceptions of feeling part of the team, decision-making autonomy, clinical experience, amount of supervision, quality of teaching, and overall rotational experience. We also analyzed the number of patients seen per hour by residents. Paired sample t-tests were performed. Residents who were in the program in the year preceding and proceeding the intervention were eligible for inclusion.
Results: 34 of 38 eligible residents were included (4 excluded for lack of evaluations in either the pre- or post-intervention period). There was a statistically significant improvement in resident perception of the quality and amount of teaching, 4.03 to 4.27 (mean difference=0.24, p=0.03). There were non-statistically significant trends toward improved mean scores for all other queries. Residents also saw more patients following the initiation of the team-based model, 1.24 to 1.56 patients per hour (mean difference=0.32, p=0.0005).
Conclusion: Adopting a team-based physician staffing model is associated with improved resident perceptions of quality and amount of teaching. Residents also experience a greater number of patient evaluations in a team-based model. [West J Emerg Med. 2014;15(6):-0]
Introduction: Because lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem. Our goal was to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize ED patients. The PPMs are clinically experienced registered nurses trained in the institution-specific criteria for correct unit and bed placement.
Methods: We conducted two pilot studies that included all patients who were admitted to the adult hospital medicine service: 1) 10/24 to 11/22/2010 (30 days); and 2) 5/24 to 7/4/2011 (42 days). Each pilot study consisted of a baseline control period and a subsequent study period of equal duration. In each pilot we measured: 1) the number of “lateral transfers” or assignment errors in patient placement, 2) median length of stay (LOS) for “all” and “admitted” patients and 3) inpatient occupancy. In pilot 2, we added as a measure code 44s, i.e. status change from inpatient to observation after patients are admitted, and also equipped all emergency physicians with portable phones in order to improve the efficiency of the process.
Results: In pilot 1, the number of “lateral transfers” (incorrect patient placement assignments) during the control period was 79 of the 854 admissions (9.3%) versus 27 of 807 admissions (3.3%) during the study period (P<0.001). We found no statistically significant differences in inpatient occupancy or ED LOS for “all” or for “admitted” patients. In pilot 2, the number of “lateral transfers” was 120 of 1,253 (9.6%) admissions in the control period and 42 of 1,229 (3.4%) admissions in the study period (P<0.001). We found a 49-minute (352 vs. 401 minutes) decrease in median LOS for “admitted” ED patients during the study period compared with the control period (P=0.04). The code 44 rates, median LOS for “all” patients and inpatient occupancy did not change.
Conclusion: Inclusion of the PPM in a three-way handoff conversation between emergency physicians and hospitalist providers significantly decreased the number of “lateral transfers.” Moreover, adding status determination and portable phones for emergency physicians improved the efficiency of the process and was associated with a 49 (12%) minute decrease in LOS for admitted patients. [West J Emerg Med. 2014;15(6):-0]
Introduction: Motor vehicle crashes (MVCs) are a leading cause of injury in the United States (U.S.). Detailed knowledge of MVC eye injuries presenting to U.S. emergency departments (ED) will aid clinicians in diagnosis and management. The objective of the study was to describe the incidence, risk factors, and characteristics of non-fatal motor vehicle crash-associated eye injuries presenting to U.S. EDs from 2001 to 2008.
Methods: Retrospective cross-sectional study using the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) from 2001 to 2008 to assess the risk of presenting to an ED with a MVC-associated eye injury in relation to specific occupant characteristics, including age, gender, race/ethnicity, disposition, and occupant (driver/passenger) status.
Results: From 2001 to 2008, an estimated 75,028 MVC-associated eye injuries presented to U.S. EDs. The annual rate of ED-treated eye injuries resulting from MVCs declined during this study period. Males accounted for 59.6% of eye injuries (95% confidence interval [CI] 56.2%-63.0%). Rates of eye injury were highest among 15-19 year olds (5.8/10,000 people; CI 4.3-6.0/10,000) and among African Americans (4.5/10,000 people; CI 2.0-7.1/10,000). Drivers of motor vehicles accounted for 62.2% (CI 58.3%-66.1%) of ED-treated MVC eye injuries when occupant status was known. Contusion/Abrasion was the most common diagnosis (61.5%; CI 56.5%-66.4%). Among licensed U.S. drivers, 16-24 year olds had the highest risk (3.7/10,000 licensed drivers; CI 2.6-4.8/10,000).
Conclusion: This study reports a decline in the annual incidence of ED-treated MVC-associated eye injuries. The risk of MVC eye injury is greatest among males, 15 to 19 year olds and African Americans. [West J Emerg Med. 2014;15(6):-0]
Self-mutilation is a general term for a variety of forms of intentional self-harm without the wish to die. Although there have been many reports of self-mutilation injuries in the literature, none have reported self-cannibalism after self-mutilation. In this article we present a patient with self-cannibalism following self-mutilation.
A 34-year-old male patient was brought to the emergency department from the prison with a laceration on the right leg. Physical examination revealed a well-demarcated rectangular soft tissue defect on his right thigh. The prison authorities stated that the prisoner had cut his thigh with a knife and had eaten the flesh. [West J Emerg Med. 2014;15(6):-0]
Ultrasound-guided nerve blocks are quickly becoming integrated into emergency medicine practice for pain control and as an alternative to procedural sedation. Common, but potentially catastophic errors have not been reported outside of the anesthesiology literature. Evaluation of the brachial plexus with color Doppler should be standard for clinicians performing a supraclavicular brachial plexus block to determine ideal block location and prevention of inadvertant intravascular injection. [West J Emerg Med. 2014;15(6):-0]
A 41-year-old woman presented to the emergency department with a chief complaint of hematuria three days status post extracorporeal shockwave lithotripsy. The patient described a three-day history of worsening left-sided abdominal pain immediately following the procedure. She denied any fever, chills, changes in bowel habits, hematochezia, increased urinary frequency, urinary urgency, or dysuria.
Physical exam revealed tenderness to palpation in the left upper quadrant, left flank and periumbilical region with mild guarding. Laboratory studies revealed an anemic patient with downward trending hematocrit (red blood cell count of 3.41 106/µL, hemoglobin of 10.6 g/dL, and a hematocrit of 31.3% down from 43% a week and a half prior). Urinalysis revealed red and cloudy urine with 3+ leukocytes.
A chest radiograph was unremarkable. A computed tomography of the chest, abdomen, and pelvis showed a laceration to the lateral aspect of the mid left kidney with a hematoma measuring 3.2 cm in thickness (Figure). The patient was subsequently admitted to the hospital for monitoring and discharged on day nine. [West J Emerg Med. 2014;15(6):-0]
Impact of Post-Intubation Interventions on Mortality in Patients Boarding in the Emergency Department
Introduction: Emergency physicians frequently perform endotracheal intubation and mechanical ventilation. The impact of instituting early post-intubation interventions on patients boarding in the emergency department (ED) is not well studied. We sought to determine the impact of post-intubation interventions (arterial blood gas sampling, obtaining a chest x-ray (CXR), gastric decompression, early sedation, appropriate initial tidal volume, and quantitative capnography) on outcomes of mortality, ventilator-associated pneumonia (VAP), ventilator days, and intensive care unit (ICU) length-of-stay (LOS).
Methods: This was an observational, retrospective study of patients intubated in the ED at a large tertiary-care teaching hospital and included patients in the ED for greater than two hours post-intubation. We excluded them if they had incomplete data, were designated “do not resuscitate,” were managed primarily by the trauma team, or had surgery within six hours after intubation.
Results: Of 169 patients meeting criteria, 15 died and 10 developed VAP. The mortality odds ratio (OR) in patients receiving CXR was 0.10 (95% CI 0.01 to 0.98), and 0.11 (95% CI 0.03 to 0.46) in patients receiving early sedation. The mortality OR for patients with 3 or fewer interventions was 4.25 (95% CI 1.15 to 15.75) when compared to patients with 5 or more interventions. There was no significant relationship between VAP rate, ventilator days, or ICU LOS and any of the intervention groups.
Conclusion: The performance of a CXR and early sedation as well as performing five or more vs. three or fewer post-intubation interventions in boarding adult ED patients was associated with decreased mortality. [West J Emerg Med. 2014;15(6):-0]
Technology in Emergency Medicine
Vaginal bleeding in early pregnancy is a common emergency department complaint. Point-of-care ultrasound is a useful tool to evaluate for intrauterine ectopic pregnancy. Emergency physicians performing these studies need to be cognizant of artifacts produced by ultrasound technology, as they can lead to misdiagnosis. We present two cases where mirror-image artifacts initially led to a concern for heterotopic pregnancies but were excluded on further imaging. [West J Emerg Med. 2014;15(6):-0]
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Superior vena cava (SVC) syndrome is most commonly the insidious result of decreased vascular flow through the SVC due to malignancy, spontaneous thrombus, infections, and iatrogenic etiologies. Clinical suspicion usually leads to computed tomography to confirm the diagnosis. However, when a patient in respiratory distress requires emergent airway management, travel outside the emergency department is not ideal. With the growing implementation of point-of-care ultrasound (POCUS), clinicians may make critical diagnoses rapidly and safely. We present a case of SVC syndrome due to extensive thrombosis of the deep venous system cephalad to the SVC diagnosed by POCUS. [West J Emerg Med. 2014;15(6):-0]
- 1 supplemental video
A 61 year-old man presented to the Emergency Department for one day of nonspecific chest pain. Bedside echocardiogram performed by the emergency physician revealed normal systolic cardiac function but also showed a large ( > 10mm) bicornuate interatrial septal aneurysm (IASA) projecting into the right atrium (Figure 1, Video 1). There was no evidence of intraatrial thrombus. A formal echocardiogram performed later that day confirmed the diagnosis and also detected a patent foramen ovale (PFO) with a left-to-right shunt that reversed with Valsalva maneuver. [West J Emerg Med. 2014;15(6):–0]
- 1 supplemental video