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Open Access Publications from the University of California

Volume 17, Issue 5, 2016

Volume 17 Issue 5

Endemic Infections

Mumps Virus: Modification of the Identify-Isolate-Inform Tool for Frontline Healthcare Providers

Mumps is a highly contagious viral infection that became rare in most industrialized countriesfollowing the introduction of measles-mumps-rubella (MMR) vaccine in 1967. The disease, however,has been re-emerging with several outbreaks over the past decade. Many clinicians have neverseen a case of mumps. To assist frontline healthcare providers with detecting potential casesand initiating critical actions, investigators modified the “Identify-Isolate-Inform” tool for mumpsinfection. The tool is applicable to regions with rare incidences or local outbreaks, especially seenin college students, as well as globally in areas where vaccination is less common. Mumps beginswith a prodrome of low-grade fever, myalgias and malaise/anorexia, followed by development ofnonsuppurative parotitis, which is the pathognomonic finding associated with acute mumps infection.Orchitis and meningitis are the two most common serious complications, with hearing loss andinfertility occurring rarely. Providers should consider mumps in patients with exposure to a knowncase or international travel to endemic regions who present with consistent signs and symptoms.If mumps is suspected, healthcare providers must immediately implement standard and dropletprecautions and notify the local health department and hospital infection control personnel. [West JEmerg Med. 2016;17(5)490-496.]

Population Health Research Design

Discriminating Between Legitimate and Predatory Open Access Journals: Report from the International Federation for Emergency Medicine Research Committee

Introduction: Open access (OA) medical publishing is growing rapidly. While subscription-based publishing does not charge the author, OA does. This opens the door for “predatory” publishers who take authors’ money but provide no substantial peer review or indexing to truly disseminate research findings. Discriminating between predatory and legitimate OA publishers is difficult.

Methods: We searched a number of library indexing databases that were available to us through the University of California, Irvine Libraries for journals in the field of emergency medicine (EM). Using criteria from Jeffrey Beall, University of Colorado librarian and an expert on predatory publishing, and the Research Committee of the International Federation for EM, we categorized EM journals as legitimate or likely predatory.

Results: We identified 150 journal titles related to EM from all sources, 55 of which met our criteria for OA (37%, the rest subscription based). Of these 55, 25 (45%) were likely to be predatory. We present lists of clearly legitimate OA journals, and, conversely, likely predatory ones. We present criteria a researcher can use to discriminate between the two. We present the indexing profiles of legitimate EM OA journals, to inform the researcher about degree of dissemination of research findings by journal.

Conclusion: OA journals are proliferating rapidly. About half in EM are legitimate. The rest take substantial money from unsuspecting, usually junior, researchers and provide no value for true dissemination of findings. Researchers should be educated and aware of scam journals. [West J Emerg Med. 2016;17(5)497- 507.]



Blog and Podcast Watch: Pediatric Emergency Medicine

Introduction: By critically appraising open access, educational blogs and podcasts in emergency medicine (EM) using an objective scoring instrument, this installment of the ALiEM (Academic Life in Emergency Medicine) Blog and Podcast Watch series curated and scored relevant posts in the specific areas of pediatric EM.


Methods: The Approved Instructional Resources – Professional (AIR-Pro) series is a continuously building curriculum covering a new subject area every two months. For each area, six EM chief residents identify 3-5 advanced clinical questions. Using to search blogs and podcasts, relevant posts are scored by eight reviewers from the AIR-Pro Board, which is comprised of EM faculty and chief residents at various institutions. The scoring instrument contains five measurement outcomes based on 7-point Likert scales: recency, accuracy, educational utility, evidence based, and references. The AIR-Pro label is awarded to posts with a score of ≥26 (out of 35) points. An “Honorable Mention” label is awarded if Board members collectively felt that the posts were valuable and the scores were > 20.


Results: We included a total of 41 blog posts and podcasts. Key educational pearls from the 10 high quality AIR-Pro posts and four Honorable Mentions are summarized.


Conclusion: The WestJEM ALiEM Blog and Podcast Watch series is based on the AIR and AIR-Pro series, which attempts to identify high quality educational content on open-access blogs and podcasts. Until more objective quality indicators are developed for learners and educators, this series provides an expert-based, crowdsourced approach towards critically appraising educational social media content for EM clinicians. [West J Emerg Med. 2016;17(5)513-518.]


Academic Primer Series: Five Key Papers Fostering Educational Scholarship in Junior Academic Faculty

Introduction: Scholarship is an essential part of academic success. Junior faculty members are often unfamiliar with the grounding literature that defines educational scholarship. In this article, the authors aim to summarize five key papers outlining scholarship in the setting of academic contributions for emerging clinician educators.

Methods: The authors conducted a consensus-building process to generate a list of key papers that describe the importance and significance of academic scholarship, informed by social media sources. We then used a three-round voting methodology, akin to a Delphi study, to determine the papers with the most impact.

Results: A summary of the five most important papers on the topic domain of academic scholarship, as determined by this mixed group of junior faculty members and faculty developers, is presented in this paper. We subsequently wrote a summary of these five papers and their relevance to junior faculty members and faculty developers, as well.

Conclusion: Five papers on educational scholarship, deemed essential by the authors’ consensus process, are presented in this paper. These papers may help provide the foundational background to help junior faculty members gain a grasp of the academic scholarly environment. This list may also inform senior faculty and faculty developers on the needs of junior faculty members in the nascent stages of their careers. [West JEmerg Med. 2016;17(5)519-526.]


Technology in Emergency Medicine

Mobile COWs (Computer on Wheels): Hamburger or VEAL?

The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 galvanized the universal adoption of electronic health record (EHR) systems to improve the quality, delivery, and coordination of patient care.1 Initial results demonstrated improvement in population health outcomes and increased transparency.2-3 Through the HITECH Act’s Meaningful Use (MU) incentives, EHR adoption also promised shorter hospital stays, reduced costs and improved access to healthcare data.4 These promises, however, never materialized; studies have demonstrated that EHR adoption causes decreased rates of patients seen per hour, highly variable documentation times, and increased order entry times.5

The unintended consequences of the HITECH Act are exacerbated in the emergency department (ED). While the few studies examining practical limitations of ED EHR use are limited to single-site studies with variable, non-validated outcomes, they suggest that MU obstructs ED best customs and practices and is potentially dangerous. 6-7 For instance, real-time computerized charting is difficult because it requires a bedside computer and Internet access, but installing the required hardware is limited by cost and regulations governing the use and renovation of hospital facilities.8 MU requirements also stipulate a transition to computerized physician order entry (CPOE); however, prior studies have demonstrated that CPOE increases order entry times, exacerbating the well-documented issue of ED crowding and boarding.1,5,9 In emergent situations, CPOE forces physicians to leave the deteriorating patient’s bedside to access a computer before treatment can be rendered.


Optic Nerve Sheath Diameter Measurement During Diabetic Ketoacidosis: A Pilot Study

Introduction: Optic nerve sheath diameter (ONSD) measurement accurately detects elevated intracranial pressure and may facilitate early recognition of diabetic ketoacidosis-related cerebral edema (DKA-CE). Our objective was to assess how ONSD measurement varies during T1D-related illness, in order to determine the potential of this tool for discrimination of subclinical DKA-CE.

Methods: We prospectively enrolled patients aged 7–18 years into three study arms: 1) well-controlled type 1 diabetes; 2) type 1 diabetes with hyperglycemia; 3) DKA. Exclusion criteria included >10 mL/kg of intravenous fluid or insulin prior to transfer, or conditions predisposing to increased intracranial or intraocular pressure. ONSD measurements were obtained within 4h of arrival. One-way ANOVA and multivariable linear regression were used to assess ONSD between groups and association with known DKA-CE risk factors, respectively. Reliability measures were assessed and target enrollment was 36 patients per arm based on sample size calculations.

Results: We enrolled 108 patients. No patients had clinically overt DKA-CE. The between group difference in mean ONSD (mm ± SD) among patients with well-controlled type 1 diabetes (5.2 ± 0.85), T1D with hyperglycemia (5.0 ± 0.91), and DKA (5.2 ± 0.92) was not significant (p=0.79). Mean ONSD was not independently associated with presenting laboratory parameters, known DKA-CE risk factors, or time to ultrasound. There was good agreement between sonographers (88.9% agreement; intraclass correlation coefficient 0.71).

Conclusion: ONSD measurements did not vary significantly based on T1D-related illness severity, and thus, may not sufficiently discriminate subclinical DKA-CE.

  • 1 supplemental file

Critical Care

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey

Introduction: Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI.

Methods: A cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients.


Results: In total, 1,758 physicians were surveyed (response rate 50.2%, 882/1758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, 1.44-3.36, p < 0.001).


Conclusion: Pre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation. [West J Emerg Med. 2016;17(5)542-548.]


  • 1 supplemental PDF

Leadership and Teamwork in Trauma and Resuscitation

Introduction: Leadership skills are described by the American College of Surgeons’ ATLS course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders.

Methods: We searched the PubMed database using the keywords “leadership” and then either “trauma” or “resuscitation” as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders.

Results: We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance.

Conclusion: Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership’s effect on patient-level outcome. [West J Emerg Med. 2016;17(5)549-556.]


Emergency Department Operations

Does Pneumatic Tube System Transport Contribute to Hemolysis in ED Blood Samples?


Introduction: Our goal was to determine if the hemolysis among blood samples obtained in an emergency department and then sent to the laboratory in a pneumatic tube system was different from those in samples that were hand-carried.

Methods: The hemolysis index is measured on all samples submitted for potassium analysis. We queried our hospital laboratory database system (SunQuest®) for potassium results for specimens obtained between January 2014 and July 2014. From facility maintenance records, we identified periods of system downtime, during which specimens were hand-carried to the laboratory.

Results: During the study period, 15,851 blood specimens were transported via our pneumatic tube system and 92 samples were hand delivered. The proportions of hemolyzed specimens in the two groups were not significantly different (13.6% vs. 13.1% [p=0.9]). Results were consistent when the criterion was limited to gross (3.3% vs 3.3% [p=0.99]) or mild (10.3% vs 9.8% [p=0.88]) hemolysis. The hemolysis rate showed minimal variation during the study period (12.6%–14.6%).

Conclusion: We found no statistical difference in the percentages of hemolyzed specimens transported by a pneumatic tube system or hand delivered to the laboratory. Certain features of pneumatic tube systems might contribute to hemolysis (e.g., speed, distance, packing material). Since each system is unique in design, we encourage medical facilities to consider whether their method of transport might contribute to hemolysis in samples obtained in the emergency department. [West J Emerg Med. 2016;17(5)557-560.]


Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality

Introduction: Attending physician judgment is the traditional standard of care for emergency department (ED) admission decisions. The extent to which variability in admission decisions affect cost and quality is not well understood. We sought to determine the impact of variability in admission decisions on cost and quality.

Methods: We performed a retrospective observational study of patients presenting to a university-affiliated, urban ED from October 1, 2007, through September 30, 2008. The main outcome measures were admission rate, fiscal indicators (Medicaid-denied payment days), and quality indicators (15- and 30-day ED returns; delayed hospital admissions). We asked each attending to estimate his/her inpatient admission rate and correlated his personal assessment with actual admission rates.

Results: Admission rates, even after adjusting for known confounders, were highly variable (15.2%-32.0%) and correlated with Medicaid denied-payment day rates (p=0.038). There was no correlation with quality outcome measures (30-day ED return or delayed hospital admission). There was no significant correlation between actual and self-described admission rate; the range of mis-estimation was 0% to 117%.

Conclusion: Emergency medicine attending admission rates at this institution are highly variable, unexplained by known confounding variables, and unrelated to quality of care, as measured by 30-day ED return or delayed hospital admission. Admission optimization represents an important untapped potential for cost reduction through avoidable hospitalizations, with no apparent adverse effects on quality. [West JEmerg Med. 2016;17(5)561-566.]



Workplace Violence and Harassment Against Emergency Medicine Residents

Introduction: Several studies have shown that workplace violence in the emergency department (ED) iscommon. Residents may be among the most vulnerable staff, as they have the least experience with thesevolatile encounters. The goal for this study was to quantify and describe acts of violence against emergencymedicine (EM) residents by patients and visitors and to identify perceived barriers to safety.

Methods: This cross-sectional survey study queried EM residents at multiple New York City hospitals. Theprimary outcome was the incidence of violence experienced by residents while working in the ED. Thesecondary outcomes were the subtypes of violence experienced by residents, as well as the perceivedbarriers to safety while at work.

Results: A majority of residents (66%, 78/119) reported experiencing at least one act of physical violenceduring an ED shift. Nearly all residents (97%, 115/119) experienced verbal harassment, 78% (93/119) hadexperienced verbal threats, and 52% (62/119) reported sexual harassment. Almost a quarter of residentsfelt safe “Occasionally,” “Seldom” or “Never” while at work. Patient-based factors most commonly cited ascontributory to violence included substance use and psychiatric disease.

Conclusion: Self-reported violence against EM residents appears to be a significant problem. Incidenceof violence and patient risk factors are similar to what has been found previously for other ED staff.Understanding the prevalence of workplace violence as well as the related systems, environmental, andpatient-based factors is essential for future prevention efforts. [West J Emerg Med. 2016;17(5)567-573.]

  • 1 supplemental file

Derivation of Two Critical Appraisal Scores for Trainees to Evaluate Online Educational Resources: A METRIQ Study

Introduction: Online education resources (OERs) like blogs and podcasts frequently augment or replace traditional medical education resources such as textbooks and lectures. Trainees’ ability to evaluate these resources is poor, and no quality assessment aids have been developed to assist them. This study derived a quality evaluation instrument for this purpose.

Methods: We used a three-phase methodology. In Phase 1, a previously derived list of 151 OER quality indicators was reduced to 13 items using data from published consensus-building studies (of medical educators, expert podcasters, and expert bloggers) and further evaluation by our team. In Phase 2, these 13 items were converted to seven-point Likert scales used by trainee raters (n=40) to evaluate 39 OERs. The reliability and usability of these 13 rating items was determined using responses from trainee raters, and top items were used to create two OER quality evaluation instruments. In Phase 3, these instruments were compared to an external certification process (the ALiEM AIR certification) and the gestalt evaluation of 39 blog posts by 20 faculty educators.

Results: Two quality-evaluation instruments were derived with fair inter-rater reliability: the METRIQ-8 Score (Inter class correlation coefficient [ICC]=0.30, p<0.001) and the METRIQ-5 Score (ICC=0.22, p<0.001). Both scores, when calculated using the derivation data, correlated with educator gestalt (Pearson’s r=0.35, p=0.03 and r=0.41, p<0.01, respectively) and were related to increased odds of receiving an ALiEM AIR certification (Odds Ratio=1.28, p=0.03; OR=1.5, p=0.004, respectively).

Conclusion: Two novel scoring instruments with adequate psychometric properties were derived to assist trainees in evaluating OER quality and correlated favourably with gestalt ratings of online educational resources by faculty educators. Further testing is needed to ensure these instruments are accurate when applied by trainees. [West J Emerg Med. 2016;17(5)574-584.]


  • 1 supplemental file

Health Outcomes

Treatment of Nausea and Vomiting in Pregnancy: Factors Associated with ED Revisits

Introduction: Nausea and vomiting in pregnancy (NVP) is a condition that commonly affects women in thefirst trimester of pregnancy. Despite frequently leading to emergency department (ED) visits, little evidenceexists to characterize the nature of ED visits or to guide its treatment in the ED. Our objectives were toevaluate the treatment of NVP in the ED and to identify factors that predict return visits to the ED for NVP.

Methods: We conducted a retrospective database analysis using the electronic medical record from asingle, large academic hospital. Demographic and treatment variables were collected using a chart reviewof 113 ED patient visits with a billing diagnosis of “nausea and vomiting in pregnancy” or “hyperemesisgravidarum.” Logistic regression analysis was used with a primary outcome of return visit to the ED for thesame diagnoses.

Results: There was wide treatment variability of nausea and vomiting in pregnancy patients in the ED.Of the 113 patient visits, 38 (33.6%) had a return ED visit for NVP. High gravidity (OR 1.31, 95% CI [1.06-1.61]), high parity (OR 1.50 95% CI [1.12-2.00]), and early gestational age (OR 0.74 95% CI [0.60-0.90])were associated with an increase in return ED visits in univariate logistic regression models, while onlyearly gestational age (OR 0.74 95% CI [0.59-0.91]) was associated with increased return ED visits in amultiple regression model. Admission to the hospital was found to decrease the likelihood of return ED visits(p=0.002).

Conclusion: NVP can be difficult to manage and has a high ED return visit rate. Optimizing care with aggressive,standardized treatment in the ED and upon discharge, particularly if factors predictive of return EDvisits are present, may improve quality of care and reduce ED utilization for this condition. [West J EmergMed. 2016;17(5)585-590.]


  • 2 supplemental PDFs

Association of Age, Systolic Blood Pressure, and Heart Rate with Adult Morbidity and Mortality after Urgent Care Visits

Introduction: Little data exists to help urgent care (UC) clinicians predict morbidity and mortality risk. Age, systolic blood pressure (SBP), and heart rate (HR) are easily obtainable and have been used in other settings to predict short-term risk of deterioration. We hypothesized that there is a relationship between advancing age, SBP, HR, and short-term health outcomes in the UC setting.

Methods: We collected retrospective data from 28 UC clinics and 22 hospitals between years 2008-2013. Adult patients (≥18 years) were included if they had a unique UC visit and HR or SBP data. Three endpoints following UC visit were assessed: emergency department (ED) visit within three days, hospitalization within three days, and death within seven days. We analyzed associations between age, SBP, HR and endpoints using local regression with a binomial likelihood. Five age groups were chosen from previously published national surveys. Vital sign (VS) distributions were determined for each age group, and the central tendency was compared against previously published norms (90-120mmHg for SBP and 60-100bpm for HR.)

Results: A total of 1,705,730 encounters (714,427 unique patients) met the inclusion criteria; 51,446 encounters (2.99%) had ED visit within three days; 12,397 (0.72%) experienced hospitalization within three days; 302 (0.02%) died within seven days of UC visit. Heart rate and SBP combined with advanced age predicted the probability of ED visit (p<0.0001) and hospitalization (p<0.0001) following UC visit. Significant associations between advancing age and death (p<0.0001), and VS and death (p<0.0001) were observed. Odds ratios of risk were highest for elderly patients with lower SBP or higher HR. Distributions and central tendency of SBP were higher than published normal ranges for all age groups.

Conclusion: Among adults seeking care in the UC, associations between HR and SBP and likelihood of ED visits and hospitalization were more pronounced with advancing age. Death following UC visit had a more limited association with advancing age or the VS evaluated. Rapidly increasing risk below SBP of 100-110 mmHg in older patients suggests that accepted normal ranges for SBP may need to be redefined for patients treated in the UC clinic. [West J Emerg Med. 2016;17(5)591-599.]


Behavioral Health

The Peregrinating Psychiatric Patient in the Emergency Department

Many emergency department (ED) psychiatric patients present after traveling. Although such travel, orperegrination, has long been associated with factitious disorder, other diagnoses are more commonamong travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers’intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of localresources complicate treatment. These patients can consume disproportionate time and resources fromemergency providers. We review the literature on the emergency psychiatric treatment of peregrinatingpatients and use case examples to illustrate common presentations and treatment strategies. Difficultiesin studying this population and suggestions for future research are discussed. [West J Emerg Med.2016;17(5)600-606.]

Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions

Introduction: Patients with mental health conditions frequently use emergency medical services.  Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.

Methods: We conducted a secondary analysis of administrative data on all adult ED visits in 2012 in an urban safety-net hospital. Patient demographics, mental health status, homelessness, insurance coverage, level of acuity, and ED disposition per ED visit were analyzed using multilevel modeling to control for multiple visits nested within patients. We performed multivariate logistic regressions to evaluate if homelessness moderated the likelihood of mental health patients’ 30-day ED revisits and hospital readmissions.

Results: Study included 139,414 adult ED visits from 92,307 unique patients (43.5±15.1 years, 51.3% male, 68.2% Hispanic/Latino). Nearly 8% of patients presented with mental health conditions, while 4.6% were homeless at any time during the study period. Among patients with mental health conditions, being homeless contributed to an additional 28.0% increase in likelihood (4.28 to 5.48 odds) of 30-day ED revisits and 38.2% increase in likelihood (2.04 to 2.82 odds) of hospital readmission, compared to non-homeless, non-mental health (NHNM) patients as the base category. Adjusted predicted probabilities showed that homeless patients presenting with mental health conditions have a 31.1% chance of returning to the ED within 30-day post discharge and a 3.7% chance of hospital readmission, compared to non-homeless patients presenting with mental health conditions (25.2%, 2.6%) and NHNM (7.7%, 1.5%).

Conclusion: Homeless patients presenting with mental health conditions were more likely to return to the ED within 30 days and to be readmitted to the hospital. Interventions providing housing might improve their overall care management and have the potential to reduce ED revisits and hospital readmissions. [West JEmerg Med. 2016;17(5)607-612.]


ED Patients with Prolonged Complaints and Repeat ED Visits Have an Increased Risk of Depression

Introduction: The objective of this study was to explore associations between presenting chief complaints of prolonged symptomatology, patient usage of the emergency department (ED), and underlying depression so that emergency physicians may better target patients for depression screening.

Methods: A convenience sample of ED patients were administered the Beck Depression Inventory-II (BDI-II) to assess for depression. We correlated completed BDI-II surveys to patient information including demographics, pertinent history of present illness information, and past medical history.

Results: Out of 425 participants screened, we identified complaints of two weeks or longer in 92 patients (22%). Of these patients, mild to severe depression was recognized in over half of the population (47), yet only nine patients reported a prior depression diagnosis. These 92 patients also visited the ED three times as frequently as those patients with more acute complaints (p<0.001). Finally, our study showed that patients with mild to severe depression had three times as many ED visits compared to patients with minimal or no depression (p<0.001).

Conclusion: Patients with complaints of symptomatology two weeks or longer are more likely to have underlying depression when presenting to the ED. Patients with three or more ED visits within the past year also have a greater incidence of underlying depression. We found a strong correlation between complaints with symptomatology of two weeks or longer and multiple ED visits, in which underlying depression may have contributed to these patients’ ED visits. [West J Emerg Med. 2016;17(5)613-616.]


Diagnostic Acumen

Adolescent with Foot Pain

A previously healthy 14-year-old female presented to the emergency department because of a left foot injury. She reported “twisting” her foot while walking. She complained of left foot pain, but was able to ambulate with a limp. Physical exam was significant for soft tissue edema and isolated tenderness to the dorsum of the left foot in the region of the cuboid.  She had full range of motion at the ankle joint without pain or tenderness and was neurovascularly intact. Radiographs were obtained and revealed cuboid subluxation (Figure).


Hemorrhagic Encephalopathy From Acute Baking Soda Ingestion

Baking soda is a readily available household product composed of sodium bicarbonate. It can be used asa home remedy to treat dyspepsia. If used in excessive amounts, baking soda has the potential to causea variety of serious metabolic abnormalities. We believe this is the first reported case of hemorrhagicencephalopathy induced by baking soda ingestion. Healthcare providers should be aware of the dangers ofbaking soda misuse and the associated adverse effects. [West J Emerg Med. 2016;17(5)619-622.]

Two Cases of Anti-NMDA Receptor Encephalitis

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a form of autoimmune encephalitis with prominent neuropsychiatric features. Patients present with acute psychosis, memory impairment, dyskinesias, seizures, and/or speech disorders. The clinical course is often complicated by respiratory failure, requiring intubation. Approximately half of patients are found to have an associated ovarian tumor, which expresses NMDAR (Tuzun). Recognition of anti-NMDAR encephalitis by emergency physicians is essential in order to initiate early treatment and avoid psychiatric misdiagnosis. The disease is highly treatable with tumor removal and immunosuppression, and most patients demonstrate a full recovery. In this case series, we report two cases of anti-NMDAR encephalitis in adult women in the United States and provide a review of the literature.

A Rare but Important Clinical Presentation of Induced Methemoglobinemia

Phenazopyridine is considered one of the classic causes of drug-induced methemoglobinemia. It is often taught as such and seen in board review courses. Nevertheless, the epidemiology is unknown, presentation quite rare, and less than five cases have been reported in PubMed in over 35 years.1-4 We present a case with a different set of patient characteristics than seen in the few recent case reports, and an approach to treatment that validates further uniqueness, justifying reporting the case in the literature. In particular, the patient was a young otherwise-healthy adult, with the initial diagnosis and decision to treat based on clinical grounds versus laboratory values.


A Curious Case of Right Upper Quadrant Abdominal Pain

An otherwise healthy 36-year-old man presented with sudden-onset right upper quadrant abdominal pain and vomiting. A bedside ultrasound, performed to evaluate hepatobiliary pathology, revealed a normal gallbladder but free intraperitoneal fluid. After an expedited CT and emergent explorative laparotomy, the patient was diagnosed with a small bowel obstruction with ischemia secondary to midgut volvulus. Though midgut volvulus is rare in adults, delays in definitive diagnosis and management can result in bowel necrosis. Importantly, an emergency physician must be able to recognize bedside ultrasound findings associated with acutely dangerous intrabdominal pathology. [West J Emerg Med. 2016;17(5)630-633.]

Prehospital Care

A Comparison of Chest Compression Quality Delivered During On-Scene and Ground Transport Cardiopulmonary Resuscitation

Introduction: American Heart Association (AHA) guidelines recommend cardiopulmonary resuscitation (CPR) chest compressions 1.5 to 2 inches (3.75-5 cm) deep at 100 to 120 per minute. Recent studies demonstrated that manual CPR by emergency medical services (EMS) personnel is substandard. We hypothesized that transport CPR quality is significantly worse than on-scene CPR quality.

Methods: We analyzed adult patients receiving on-scene and transport chest compressions from nine EMS sites across two Midwestern states from May 2008 to July 2010. Two periods were analyzed: before and after visual feedback. CPR data were collected and exported with the Zoll M series monitor and a sternally placed accelerometer measuring chest compression rate and depth. We compared compression data with 2010 AHA guidelines and Zoll RescueNet Code Review software. CPR depth and rate were “above (deep),” “in,” or “below (shallow)” the target range according to AHA guidelines. We paired on-scene and transport data for each patient; paired proportions were compared with the nonparametric Wilcoxon signed rank test.

Results: In the pre-feedback period, we analyzed 105 of 140 paired cases (75.0%); in the post-feedback period, 35 of 140 paired cases (25.0%) were analyzed. The proportion of correct depths during on-scene compressions (median, 41.9%; interquartile range [IQR], 16.1-73.1) was higher compared to the paired transport proportion (median, 8.7%; IQR 2.7-48.9). Proportions of on-scene median correct rates and transport median correct depths did not improve in the post-feedback period.

Conclusion: Transport chest compressions are significantly worse than on-scene compressions. Implementation of visual real-time feedback did not affect performance. [West J Emerg Med. 2016;17(5)634-639.]

Determinants of Success and Failure in Prehospital Endotracheal Intubationa

Introduction: This study aimed to identify factors associated with successful endotracheal intubation (ETI) by a multisite emergency medical services (EMS) agency.

Methods: We collected data from the electronic prehospital record for all ETI attempts made from January through May 2010 by paramedics and other EMS crew members at a single multistate agency. If documentation was incomplete, the study team contacted the paramedic. Paramedics use the current National Association of EMS Physicians definition of an ETI attempt (laryngoscope blade entering the mouth). We analyzed patient and EMS factors affecting ETI.

Results: During 12,527 emergent ambulance responses, 200 intubation attempts were made in 150 patients. Intubation was successful in 113 (75%). A crew with paramedics was more than three times as likely to achieve successful intubation as a paramedic/emergency medical technician-Basic crew (odds ratio [OR], 3.30; P=.03). A small tube (£7.0 inches) was associated with a more than 4-fold increased likelihood of successful ETI compared with a large tube (³7.5 inches) (OR, 4.25; P=.01). After adjustment for these features, compared with little or no view of the glottis, a partial or entire view of the glottis was associated with a nearly 13-fold (OR, 12.98; P=.001) and a nearly 40-fold (OR, 39.78; P<.001) increased likelihood of successful intubation, respectively.

Conclusion: Successful ETI was more likely to be accomplished when a paramedic was partnered with another paramedic, when some or all of the glottis was visible and when a smaller endotracheal tube was used. [West J Emerg Med. 2016;17(5)640-647.]

Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria

Introduction: We aimed to pilot test the delivery of sepsis education to emergency medical services (EMS) providers and the feasibility of equipping them with temporal artery thermometers (TATs) and handheld lactate meters to aid in the prehospital recognition of sepsis.


Methods: This study used a convenience sample of prehospital patients meeting established criteria for sepsis. Paramedics received education on systemic inflammatory response syndrome (SIRS) criteria, were trained in the use of TATs and hand-held lactate meters, and enrolled patients who had a recent history of infection, met ≥ 2 SIRS criteria, and were being transported to a participating hospital. Blood lactate was measured by paramedics in the prehospital setting and again in the emergency department (ED) via usual care. Paramedics entered data using an online database accessible at the point of care.


Results: Prehospital lactate values obtained by paramedics ranged from 0.8 to 9.8 mmol/L, and an elevated lactate (i.e. ≥ 4.0) was documented in 13 of 112 enrolled patients (12%). The unadjusted correlation of prehospital and ED lactate values was 0.57 (p< 0.001). The median interval between paramedic assessment of blood lactate and the electronic posting of the ED-measured lactate value in the hospital record was 111 minutes. Overall, 91 patients (81%) were hospitalized after ED evaluation, 27 (24%) were ultimately diagnosed with sepsis, and 3 (3%) died during hospitalization. Subjects with elevated prehospital lactate were somewhat more likely to have been admitted to the intensive care unit (23% vs 15%) and to have been diagnosed with sepsis (38% vs 22%) than those with normal lactate levels, but these differences were not statistically significant.


Conclusion: In this pilot, EMS use of a combination of objective SIRS criteria, subjective assessment of infection, and blood lactate measurements did not achieve a level of diagnostic accuracy for sepsis that would warrant hospital prenotification and committed resources at a receiving hospital based on EMS assessment alone. Nevertheless, this work provides an early model for increasing EMS awareness and the implementation of novel devices that may enhance the prehospital assessment for sepsis. Additional translational research studies with larger numbers of patients and more robust methods are needed. [West J Emerg Med. 2016;17(5)648-655.]


Geospatial Analysis of Pediatric EMS Run Density and Endotracheal Intubation

Introduction: The association between geographic factors, including transport distance, and pediatricemergency medical services (EMS) run clustering on out-of-hospital pediatric endotracheal intubation isunclear. The objective of this study was to determine if endotracheal intubation procedures are more likely tooccur at greater distances from the hospital and near clusters of pediatric calls.

Methods: This was a retrospective observational study including all EMS runs for patients less than 18years of age from 2008 to 2014 in a geographically large and diverse Oregon county that includes denselypopulated urban areas near Portland and remote rural areas. We geocoded scene addresses using theautomated address locator created in the cloud-based mapping platform ArcGIS, supplemented with manualaddress geocoding for remaining cases. We then use the Getis-Ord Gi spatial statistic feature in ArcGIS tomap statistically significant spatial clusters (hot spots) of pediatric EMS runs throughout the county. We thensuperimposed all intubation procedures performed during the study period on maps of pediatric EMS-runhot spots, pediatric population density, fire stations, and hospitals. We also performed multivariable logisticregression to determine if distance traveled to the hospital was associated with intubation after controlling forseveral confounding variables.

Results: We identified a total of 7,797 pediatric EMS runs during the study period and 38 endotrachealintubations. In univariate analysis we found that patients who were intubated were similar to those who werenot in gender and whether or not they were transported to a children’s hospital. Intubated patients tendedto be transported shorter distances and were older than non-intubated patients. Increased distance fromthe hospital was associated with reduced odds of intubation after controlling for age, sex, scene location,and trauma system entry status in a multivariate logistic regression. The locations of intubations weresuperimposed on hot spots of all pediatric EMS runs. This map demonstrates that most of the intubationsoccurred within areas where pediatric EMS calls were highly clustered. By mapping the intubationprocedures and pediatric population density, we found that intubation procedures were not clustered in asimilar distribution to the pediatric population in the county.

Conclusion: In this geographically diverse county the location of intubation procedures was similar to theclustering of pediatric EMS calls, and increased distance from the hospital was associated with reducedodds of intubation after controlling for several potential confounding variables. [West J Emerg Med.2016;17(5)656-661.]


The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval

Introduction: A lack of coordination between emergency medical services (EMS), emergency departments (ED) and systemwide management has contributed to extended ambulance at-hospital times at local EDs. In an effort to improve communication within the local EMS system, the Baltimore City Fire Department (BCFD) placed a medical duty officer (MDO) in the fire communications bureau. It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the EMS at-hospital time.

Methods: The MDO was implemented on November 11, 2013. A senior EMS paramedic was assigned to the position and was placed in the fire communication bureau from 9 a.m. to 9 p.m., seven days a week. We defined the pre-intervention period as August 2013 - October 2013 and the post-intervention period as December 2013 - February 2014. We also compared the post-intervention period to the “seasonal match control” one year earlier to adjust for seasonal variation in EMS volume. The MDO was tasked with the prospective management of city EMS resources through intensive monitoring of unit availability and hospital ED traffic. The MDO could suggest alternative transport destinations in the event of ED crowding. We collected and analyzed data from BCFD computer-aided dispatch (CAD) system for the following: ambulance response times, ambulance at-hospital interval, hospital diversion and alert status, and “suppression wait time” (defined as the total time suppression units remained on scene until ambulance arrival). The data analysis used a pre/post intervention design to examine the MDO impact on the BCFD EMS system.

Results: There were a total of 15,567 EMS calls during the pre-intervention period, 13,921 in the post-intervention period and 14,699 in the seasonal match control period one year earlier. The average at-hospital time decreased by 1.35 minutes from pre- to post-intervention periods and 4.53 minutes from the pre- to seasonal match control, representing a statistically significant decrease in this interval. There was also a statistically significant decrease in hospital alert time (approximately 1,700 hour decrease pre- to post-intervention periods) and suppression wait time (less than one minute decrease from pre- to post- and pre- to seasonal match control periods). The decrease in ambulance response time was not statistically significant.

Conclusion: Proactive deployment of a designated MDO was associated with a small, contemporaneous reduction in at-hospital time within an urban EMS jurisdiction. This project emphasized the importance of better communication between EMS systems and area hospitals as well as uniform reporting of variables for future iterations of this and similar projects. [West J Emerg Med. 2016;17(5)662-668.]




West J Emerg Med. 2016 May;17(3):264-70.Anticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016.

Christos S, Naples R.

Erratum in West J Emerg Med. 2016 September;17(5):450. Dosage error in published figure; MEDLINE/PubMed Figure 3 is corrected and provided.

PMCID: PMC4899056 [PubMed - indexed for MEDLINE]