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Open Access Publications from the University of California

Volume 17, Issue 6, 2016

Endemic Infections

Dengue, Zika and Chikungunya: Emerging Arboviruses in the New World

The arboviruses that cause dengue, chikungunya, and zika illnesses have rapidly expanded across the globe in recent years, with large-scale outbreaks occurring in Western Hemisphere territories in close proximity to the United States (US). In March 2016, the Centers for Disease Control and Protection (CDC) expanded its vector surveillance maps for A. aegypti and A. albopictus, the mosquito vectors for these arboviruses. They have now been shown to inhabit a larger portion of the United States, including the heavily populated northeast corridor. Emergency physicians need to further familiarize themselves with these diseases, which have classically been considered only in returning travelers but may soon be encountered in the US even in the absence of travel. In this paper, we discuss the presentation and treatment of dengue, zika, and chikungunya, as well as special challenges presented to the emergency physician in evaluating a patient with a suspected arbovirus infection.


Characterization of Chemical Suicides in the United States and its Adverse Impact on Responders and Bystanders

ABSTRACT Introduction: A suicide trend that involves mixing household chemicals to produce hydrogen sulfide or hydrogen cyanide, commonly referred to as a detergent, hydrogen sulfide, or chemical suicide is a continuing problem in the United States (US). Because there is not one database responsible for tracking chemical suicides, the actual number of incidents in the US is unknown. To prevent morbidity and mortality associated with chemical suicides, it is important to characterize the incidents that have occurred in the United States. Methods: Data from 2011-2013 from state health departments participating in the Agency for Toxic Substances and Disease Registry’s National Toxic Substance Incidents Program (NTSIP) were analyzed. NTSIP is a web-based chemical incident surveillance system that tracks the public health consequences (e.g., morbidity, mortality) from acute chemical releases. Reporting sources for NTSIP incidents typically include first responders, hospitals, state environmental agencies, and media outlets. To find chemical suicide incidents in NTSIP’s database, open text fields were queried in the comment, synopsis, and contributing factors variables for potential incidents. Results: Five of the nine states participating in NTSIP reported a total of 22 chemical suicide incidents or attempted suicides during 2011-2013. These states reported a total of 43 victims: 15 suicide victims who died, 7 people who attempted suicide but survived, 8 responders, and 4 employees working at a coroner’s office; the remainder were members of the general public. None of the injured responders reported receiving HazMat technician level training, and none had documented appropriate personal protective equipment (PPE). Conclusion: Chemical suicides produce lethal gases that can pose a threat to responders and bystanders. Describing the characteristics of these incidents can help raise awareness among responders and the public about the dangers of chemical suicides. Along with increased awareness education is also needed on how to protect themselves.

Emergency Department Administration

Are Usual and Customary Charges Reasonable?

An editorial about the use of usual and customary charges for out-of-network benefit determinations.

Injury Prevention and Population Health

A Call for Better Opioid Prescribing Training and Education

With national attention on the current opioid epidemic, a growing focus has been placed on provider prescribing practices. Medical students and residents experience significant variation in the quality of education they receive on substance use detection and intervention in the Emergency Department. To achieve a better standard of education, clinical educators will need to (A) develop a clearer understanding of the impact of provider prescribing patterns on the opioid epidemic, (B) promote uptake of evidence-based opioid prescribing guidelines in their emergency departments, and (C) introduce and integrate opioid management and addiction medicine training formally into their medical school curricula.

Healthcare Utilization

Utility of Chest Radiography in Emergency Department Patients Presenting with Syncope

Background: Syncope has myriad etiologies, ranging from benign to immediately life threatening. This frequently leads to over testing. Chest x-rays are among these commonly performed tests despite their uncertain diagnostic yield.

Objectives: To quantify the distribution of normal and abnormal chest x-rays in patients presenting with a chief complaint of syncope, stratified by those who did or did not have an adverse event at thirty days.

Methods: Prospective cohort of consecutive patients presenting to an urban tertiary care academic medical center with a chief complaint of syncope from 2003-2006.  The frequency and findings for each CXR were reviewed, as well as ED and hospital discharge diagnoses as well as thirty-day outcome.

Results: There were 575 total subjects, 39.7% were male, and the mean age was 57.2 (SD 24.6).  Of the 575 total subjects, 403 (70.1%) had chest x-rays performed, and 116 (20.2%) had an adverse event after their syncope.  Of the 116 people who had an adverse event, 15 (12.9%) had a positive CXR, 81 (69.8%) had a normal CXR, and 20 (17.2%) did not have a CXR as part of the initial evaluation.  Among the 459 people who did not have an adverse event 3 (0.7%) had a positive CXR, 304 (66.2%) had a normal CXR, and 152 (33.1%) did not have a CXR performed.

Conclusions:  Among patient who had an adverse event after their syncope, the majority of patients had a normal CXR.  More data is needed to validate this conclusion.

Health Outcomes

Variation of Blunt Traumatic Injury with Age in Older Adults: Statewide Analysis 2011-14

Introduction Traumatic injury is a leading cause of death and disability in adults ≥ 65 years old, but there are few epidemiological studies addressing this issue. The aim of this epidemiological study was to assess how characteristics of blunt traumatic injuries in adults ≥ 65 vary by age.

Methods Using data from the a single-state trauma registry, this retrospective cohort study examined injured patients ≥ 65 admitted to all level I and level II trauma centers in Pennsylvania between 2011 and 2014 (n=38,562). Patients were stratified by age into three subgroups (age 65-74; 75-84; ≥85).  Demographics, injury, and system-level variables were compared across groups using the Kruskal-Wallis test for continuous variables and the Cochran–Armitage test for categorical variables.

Results Female sex (48.6% vs. 58.7% vs. 67.7%), white race (89.1% vs. 92.6% vs. 94.6%), and non-Hispanic ethnicity (97.5% vs. 98.6% vs. 99.4%) increased significantly with age across age groups.  As age increased, the proportion of falls (69.9% vs. 82.1% vs. 90.3%), in-hospital mortality (4.6% vs. 6.2% vs. 6.8%), and proportion of patients arriving to the hospital via ambulance also increased (73.6% vs. 75.8% vs. 81.1%), while mean injury severity (10.3 vs. 10.1 vs. 9.6)  and the proportion of level one trauma alerts (10.6% vs. 8.2% vs. 6.7%) decreased. No trend was seen between age and patient transfer status.  The five most common diagnoses were vertebral fracture, rib fracture, head contusion, open head wound, and intracranial hemorrhage.Conclusions This study highlights several new areas for further exploration such as the decrease in trauma alert level with age, the increase in mortality with age, and the decrease in demographic diversity with age among older adults receiving care at a trauma center. This descriptive study provides a framework for future research on the relationship between age and blunt traumatic injury in older adults.

Somnabulism: Emergency Department Admissions Due to Sleepwalking-Related Trauma


Somnambulism is a state of dissociated consciousness, in which the affected person is partially asleep and partially awake. There is a pervasive public opinion that sleepwalkers are protected from hurting themselves. There have been few scientific reports of trauma associated with somnambulism and there are no published investigations on the epidemiology or trauma patterns associated with somnambulism.


All emergency department admissions to Inselspital, Bern, Switzerland, from January 1, 2000 until August 11, 2015 were included when the patient had suffered a trauma associated with somnambulism. Demographic data (age, gender, nationality) and medical data (mechanism of injury, final diagnosis, hospital admission, mortality and medication on admission) were included.


Of a total of 650,000 screened emergency department admissions, 11 were associated with trauma and sleepwalking. Two patients (18.2%) had a history of known NREM parasomnias. The leading cause of admission was falls. Four patients required hospital admission for orthopaedic injuries needing further diagnostic testing and treatment (36.4%). These included two patients with multiple injuries (18.2%). None of the admitted patients died.


Although sleepwalking is benign in the majority of cases and most of the few injured patients did not require hospitalisation, major injuries are possible. When patients present with falls of unknown origin, the possibility should be evaluated that they were caused by somnambulism.

Prehospital Care

Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Helicopter EMS Transport

Study Objectives

Endotracheal intubation is a common intervention in critical care patients undergoing Helicopter Emergency Medical Services (HEMS) transportation.  Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service.  Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring.  Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow.  Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure.  This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS.


We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or Emergency Medical Services (EMS) agency.  Flight crews measured the ETT cuff pressures using a commercially available device.  Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure.  Crews logged the results on a research form and the data were analyzed using Microsoft Excel and an online statistical analysis tool.


We analyzed data for 55 patients.  There was a mean age of 57 years (range 18-90).  The mean ETT cuff pressure was 70 (95% CI, 61-80) cmH2O.  The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p<0.0001).  Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum.  The most frequently recorded pressure was >120 cmH2O, the maximum pressure on the analog gauge.


Patients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum.  These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow.  Hospital and EMS providers should use ETT cuff manometry to ensure that they inflate ETT cuffs to safe pressures.

Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to Urban Emergency Departments

Background. Emergency medical services (EMS) agencies transport a significant majority of patients with low acuity and non-emergent conditions to local emergency departments (ED), affecting the entire emergency care system’s capacity and performance. Opportunities exist for alternative models that integrate technology, telehealth, and more appropriately aligned patient navigation. While a limited number of programs have evolved recently, no empirical evidence exists for their efficacy. This research describes the development and comparative effectiveness of one large urban program. Methods. “Blinded for Peer Review” EMS initiated the Emergency Telehealth and Navigation (ETHAN) program in 2014. ETHAN combines telehealth, social services, and alternative transportation to navigate primary care related patients away from the ED where possible. Using a case-control study design with multiple outcome variables, we describe the program and compare differences in effectiveness measures relative to the control group. Results. During the first 12 months, 5,570 patients received the intervention. We found a 76% decrease in ambulance transports to the ED with the intervention (18% vs. 74%, P<.001). EMS productivity (median time from EMS notification to unit back in service) was 44 minutes faster for the ETHAN group (39 vs. 83 minutes, median). There were no statistically significant differences in mortality or patient satisfaction. Conclusions. We found that mobile technology-driven delivery models are effective at reducing unnecessary ED ambulance transports and increasing EMS unit productivity. This provides support for broader EMS mobile integrated health programs in other regions.


Blog and Podcast Watch: Neurologic Emergencies

Introduction: The Academic Life in Emergency Medicine (ALiEM) Blog and Podcast Watch presents high quality open access educational blogs and podcasts in emergency medicine (EM) based on the ongoing ALiEM Approved Instructional Resources (AIR) and AIR-Professional series. Both series critically appraise resources using an objective scoring rubric. This installment of the Blog and Podcast Watch highlights the topic of neurologic emergencies from the AIR series.


Methods: The AIR series is a continuously building curriculum which follows the Council of Emergency Medicine Residency Director’s (CORD) annual testing schedule. For each module, relevant content is collected from the top 50 Social Media Index sites published within the previous 12 months, and scored by 8 board members using 5 equally weighted measurement outcomes: Best Evidence in Emergency Medicine (BEEM) score, accuracy, educational utility, evidence based, and references. Resources scoring ≥30 out of 35 available points receive an AIR label. Resources scoring 27-29 receive an Honorable Mention label, if the executive board agrees that the post is accurate and educationally valuable.


Results: A total of 125 blog posts and podcasts were evaluated. Key educational pearls from the 14 AIR posts are summarized, and the 20 Honorable Mentions are listed.

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. This series provides an expert-based, post-publication curation of educational social media content for EM clinicians with this installment focusing on neurologic emergencies.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience


Introduction: Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. We report our efforts of integrating POCUS into the medical curriculum through a multi-disciplinary effort. Our objective is to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students.


This was a pilot study to introduce ultrasonography into the “blinded for peer review” curriculum to first and second year medical students.  Didactic and hands-on sessions were introduced to first year students during gross anatomy and to second year students in the physical exam course.  Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam were measured by a post-assessment survey.

RESULTS: All 1st year anatomy students (n=176) participated in small group hands-on US sessions. In the 2nd year physical diagnosis course, 38 students participated in 4 sessions.  All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the 4 year medical school curriculum.

CONCLUSIONS AND RELEVANCE: POCUS can effectively be integrated into the existing medical school curriculum by utilizing didactic and small group hands-on sessions.  Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality.  Future goals include expanding on this work to incorporate US education into all 4 years of medical school.

Patient Safety

Use of Physician Concerns and Patient Complaints as Quality Assurance Markers in Emergency Medicine


Background: The value of systematic evaluation of both patient and physician identified QA issues in emergency medicine remains poorly characterized as a marker for Emergency Department (ED) quality assurance.

Objective: The objective of this study was to determine whether systematic screening and evaluation of patient and physician concerns is useful for identifying physician errors resulting in either an adverse event or a near miss event.

Methods: Retrospective, observational cohort study of consecutive patients presenting to an urban, tertiary care academic medical center ED with an annual volume of 57,000 patients between January 2008 and December 2014. Our hospital has an electronic system that easily allows physicians to register a concern or self-identify a potential QA issue for subsequent review. In our system, both patient and physician concerns are then assigned for review by physician evaluators not involved with the patients’ care. Patient complaints were initially prescreened by an experienced evaluator and those not pertaining to possible physician error, such as complaints related to billing, creature comfort, communication, nursing related complaints and waiting times were eliminated unless the reviewer identified a possible physician error. If in addition to these other factors, a potential QA issue was present, the case was referred to the QA committee Reviewers are prompted to use a structured 8-point Likert scale to assess for the presence of error and adverse events. If a reviewer assessed that the case involved a possible error or adverse event that resulted in the need for intervention, additional treatment, or caused patient harm, it was referred to a 20-member quality assurance (QA) committee of ED physicians and nurses who made a final determination as to whether or not an error or adverse event occurred.

Results: We identified 570 concerns within a data-base of 383,419 ED presentations, of which 33 were patient-generated and 537 were physician-generated. In the subset of cases where there was a complaint by either patient or physician, physician errors that led to a preventable adverse event were detected in 2.9% of cases (95%CI 1.52% to 4.28%). Further analysis revealed that 9.1% (95%CI 2-24%) of patient complaints correlated to preventable errors leading to an adverse event. In contrast, 2.6% (2-4%) of QA concerns made by a physician alone were found to be preventable physician errors leading to an adverse event. Near miss events (errors without adverse outcome) were more accurately reported by physicians, with physician error found in 12.1% of reported cases (95%CI 10-15%) and in 9.1% of those reported by patients (95%CI 2-24%). Adverse events in general that were not deemed to be due to preventable physician error were found in 12.1% of patient complaints (95%CI 3-28%) and in 5.8% of physician QA concerns (95%CI 4-8%).

Conclusion: Screening and systemized evaluation of emergency department patient and physician complaints may be an underutilized and efficient quality assurance tool. Patient complaints may more accurately identify physician errors that result in preventable adverse events, while physician QA concerns may be more likely to uncover a near miss that did not lead to an adverse event.

Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs



Academic Emergency Department (ED) handoffs are high-risk transfer of care events. Emergency medicine residents are inadequately trained to handle these vital transitions.

We aimed to explore what modifications the I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver) handoff system requires to be effectively modified for use in ED inter-shift handoffs.


This mixed-method needs assessment conducted at an academic ED explored the suitability of the I-PASS system for ED handoffs. We conducted a literature review, focus groups, and then a survey. We sought to identify the distinctive elements of ED handoffs and discern how these could be incorporated into the I-PASS system.


Focus group participants agreed the Patient summary should be adapted to include anticipated disposition of patient. Participants generally endorsed the order and content of the other elements of the I-PASS tool. The survey yielded several wording changes to reflect contextual differences. Themes from all qualitative sources converged to suggest changes for brevity and clarity (Figure 1). Most participants agreed that the I-PASS tool would be well suited to the emergency department setting.


With modifications for context, brevity, and clarity, the I-PASS system may be well suited for application to the ED setting. This study provides qualitative data in support of utilizing the I-PASS tool and concrete suggestions for how to modify the I-PASS tool for the ED. Implementation and outcome research is needed to investigate if the I-PASS tool is feasible and improves patient outcomes in the ED environment.

Critical Care

First Report of Survival in Refractory Ventricular Fibrillation After Dual-Axis Defibrillation and Esmolol Administration

Ventricular fibrillation (VF) is a potentially fatal dysrhythmia associated with acute myocardial infarction. The longer a patient waits for definitive care, the greater their chance of mortality.  There is a subset of patients, however, who suffered a VF arrest, received appropriate care, and despite standard medications (epinephrine and amiodarone) and multiple defibrillations (3+ attempts at 200 J of biphasic current), remained in refractory VF (RVF), also known as electrical storm.  The mortality for these patients is as high as 97%. We present the case of a patient who, because of a novel approach, survived RVF to discharge and outpatient follow-up.

Application of Circumferential Compression Device (Binder) in Pelvic Injuries: Room for Improvement



The use of a noninvasive pelvic circumferential compression device (PCCD) to achieve  pelvic stabilization by both decreasing pelvic volume and limiting inter-fragmentary motion, has become commonplace and is a well-established component of ATLS protocol in the treatment of pelvic ring injuries. The Purpose of this study was to evaluate 1) how consistently a PCCD was placed on patients who arrived at our Hospital with  unstable pelvic ring injuries 2) if they were placed in a timely manner and  3) if hemodynamic instability influenced their use .



An IRB approved retrospective study was preformed on 112 consecutive unstable pelvic ring injuries,  managed over a 2 year period at our Level 1 Trauma center. Our Hospital Electronic Medical Record  was used to review  EMT, Physician , Nurse’s , Operative notes  and  radiographic images in order to obtain information on the injury and PCCD application. The injuries were classified by an Orthopaedic Trauma Surgeon and a senior  Orthopaedic Resident. Proper application of a pelvic binder using a sheet is demonstrated.



Only 47% of unstable pelvic fractures received PCCD placement, despite being the standard of care according to ATLS.  Lateral Compression mechanism pelvic injuries received PCCDs in 33% of cases, while AP Compression and Vertical sheer injuries  had applications in 63% of cases.  Most of these PCCD devices were applied after imaging (72%) Hemodynamic instability did not influence PCCD application.



PCCD placement was missed in many (37%) of APC and VS mechanism injuries, where their application can be critical to providing stability.  Furthermore, in order to provide rapid stability, Pelvic circumferential compression devices should be applied after secondary examination, rather than after waiting for imaging results.  Better education on, exam of the pelvis during the secondary survey, timing and technique of PCCD placement at our institution is required in order to improve treatment of pelvic ring injuries.

Autoinjectors Preferred for Intramuscular Epinephrine in Anaphylaxis and Allergic Reactions

Introduction: Epinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) health care providers regarding 2 methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery.

Methods: This observational study adhered to survey reporting guidelines. It was performed through a Web-based survey completed by health care providers at an academic ED. The participants consisted of all ED providers, including staff physicians, resident physicians, pharmacists, advanced practice providers, and nurses. The primary outcomes were assessment of provider perceptions and identification of the preferred IM epinephrine administration method by ED health care providers.

Results: Of 217 ED health care providers invited to participate, 172 (79%) completed the survey. Overall, 82% of respondents preferred the autoinjector method of epinephrine administration. Providers rated the autoinjector method more favorably with regard to time required for training, ease of use, convenience, satisfaction with weight-based dosing, risk of dosing errors, and speed of administration (P<.001 for all comparisons). However, manual injection use was rated more favorably with regard to risk of provider self-injury and patient cost (P<.001 for both comparisons). Three participants (2%) reported a finger stick injury from an epinephrine autoinjector.

Conclusion: ED health care providers preferred the autoinjector method of IM epinephrine administration for the management of anaphylaxis or allergic reactions. Epinephrine autoinjector use may reduce barriers to epinephrine administration for the management of anaphylaxis in the ED.

  • 1 supplemental PDF

Behavioral Health

Hours and Miles: Patient and Health System Implications of Transfer for Psychiatric Bed Capacity

Introduction: An increasing number of behavioral health (BH) patients are presenting to the emergency department (ED) while BH resources continue to decline. This situation may lead to more external transfers to find care.

Methods: This is a retrospective cohort study of consecutive patients presenting to a tertiary care academic ED from February 1, 2013, through January 31, 2014. Patients were identified through electronic health record documentation of psychiatric consultation during ED evaluation. Electronic health records were reviewed for demographic characteristics, diagnoses, payer source, ED length of stay, ED disposition, arrival method, and distance traveled to an external facility for inpatient admission. Univariable and multivariable associations with transfer to an external facility in comparison with patients admitted internally were evaluated with logistic regression models and summarized with odds ratios (ORs).

Results: We identified 2,585 BH visits, of which 1,083 (41.9%) resulted in discharge. A total of 1,502 patient visits required inpatient psychiatric admission, and of these cases, 177 patients (11.8%; 95% CI, 10.2%-13.5%) required transfer to an external facility. The median ED length of stay for transferred patients was 13.9 hours (interquartile range [IQR], 9.3-20.2 hours; range, 3.0-243.0 hours). The median distance for transport was 83 miles (IQR, 42-111 miles; range, 42-237 miles). In multivariable analysis, patients with suicidal or homicidal ideation had increased risk of transfer (odds ratio [OR] [95% CI], 1.93 [1.22-3.06]; P=.005). Children younger than 18 years (OR [95% CI], 2.34 [1.60-3.40]; P<.001) and adults older than 65 years (OR [95% CI], 3.46 [1.93-6.19]; P<.001) were more likely to require transfer and travel farther to access care.

Conclusions: Patients requiring external transfer for inpatient psychiatric care were found to have prolonged ED lengths of stay. Patients with suicidal and homicidal ideation as well as children and adults older than 65 years are more likely to require transfer.

Impact of Prior Therapeutic Opioid Use by Emergency Department Providers on Opioid Prescribing Decisions


Our study sought to examine the opioid analgesic (OA) prescribing decisions of emergency department (ED) providers who have themselves used OA therapeutically and those who have not. A second objective was to determine if OA prescribing decisions would differ based on the patient’s relationship to the provider.


An electronic survey was distributed to a random sample of ED providers at participating centers in a nationwide research consortium. Question topics included provider attitudes about OA prescribing, prior personal therapeutic use of OAs (indications, dosing, and disposal of leftover medication), and hypothetical analgesic prescribing decisions for their patients, family members, and themselves for different painful conditions.


The total survey population was 957 individuals; 515 responded to the survey, a 54% response rate. Prior personal therapeutic OA use was reported in 63% [95% CI, 58-68]. A majority of these providers (82%; 95% CI [77-87]) took fewer than half the number of pills prescribed. Regarding provider attitudes towards OA prescribing: 66% [95% CI, 61-71] agreed that OA could lead to addiction even with short-term use. When providers were asked if they would prescribe OA to a patient with 10/10 pain from an ankle sprain: 21% [95% CI, 17-25] would for an adult patient, 13% [95% CI, 10-16] would for an adult family member, and 6% [95% CI, 4-8] indicated they themselves would take an opioid for the same pain. When the scenario involved an ankle fracture: 86% [95% CI, 83-89] would prescribe OA for an adult patient, 75% [95% CI, 71-79] for an adult family member, and 52% [95% CI, 47-57] would themselves take OA. Providers who have personally used OA to treat their pain were consistently more likely to prescribe OA in different patient scenarios than those who had not.


ED providers who had themselves used OA therapeutically to treat their own pain tended to be more likely to prescribe OA than those who had not. When making OA prescribing decisions, ED providers report that they are less likely to prescribe opioids to their family members, or themselves, than to an ED patient with the same painful condition.

  • 1 supplemental file

Opioid Dependent Malingerer with Self-Induced Sepsis

A 21 year old woman was admitted to the ED with severe sepsis. Her mechanism of infection and organisms were unusual, and were discovered through good detective work.

Diagnostic Acumen

Rapid Diagnosis of Rhabdomyolysis with Point-of-Care Ultrasound

It is important to rapidly diagnosis and treat rhabdomyolysis in order to decrease morbidity and mortality.  To date there are no reports in the emergency medicine literature on the use of bedside ultrasound in the diagnosis of rhabdomyolysis. This unique case describes how ultrasound was used in the emergency department to quickly diagnose and treat rhabdomyolysis prior to confirmation with an elevated serum creatine kinase. When coupled with a high index of suspicion, ultrasound can be one of the most portable, readily available, low cost, and minimally invasive techniques for making a rapid diagnosis of rhabdomyolysis in the ED.

  • 1 supplemental video

Large Posterior Communicating Artery Aneurysm: Initial Presentation with Reproducible Facial Pain Without Cranial Nerve Deficit


Unruptured posterior communicating artery (PCOM) aneurysms can be difficult to diagnose, and when large (≥ 7mm), represent a substantial risk to the patient. While most unruptured PCOM aneurysms are asymptomatic, when symptoms do occur, clinical manifestations typically include severe headache (HA), visual acuity loss, and cranial nerve deficit. This case report describes an atypical initial presentation of a large unruptured PCOM aneurysm with symptoms mimicking trigeminal neuralgia, without other associated cranial nerve palsies or neurologic deficits. The patient returned to the Emergency Department (ED) four days later with a HA and a cranial nerve VIII palsy.  After appropriate imaging, she was found to have a large PCOM aneurysm which was treated with surgical clipping with significant improvement in patient’s symptoms.

Technology in Emergency Medicine

Ultrasound Detection of Patellar Fracture and Evaluation of the Knee Extensor Mechanism in the Emergency Department

Traumatic injuries to the knee are common in Emeregncy Medicine.

Bedside ultrasound has benefits in the rapid initial detection of injuries to the patella. In addition, ultrasound can quickly detect injuries to the entire knee extensor mechanism, including the quadriceps tenson and inferior patellar ligament in addition to the patella, that can be difficult to diagnose with plain radiographs. While MRI remains the gold standard for diagnostic evaluation of the knee extensor mechanism, this can be difficult to obtain from the Emergency Department. Clinicans caring for patients with orthopedic injuries of the knee will benefit from incorporating of musculoskeletal bedside ultrasound into their clinical skills set.



  • 1 supplemental video

Point-of-Care Ultrasound to Locate a Retained Intravenous Drug Needle in the Femoral Artery

We describe the use of Point-of-Care Ultrasound to localize a retained intravenous drug needle, and subsequent surgical removal without computed tomography.

Role of Ultrasound in the Identification of Longitudinal Axis in Soft-Tissue Foreign Body Extraction

Identification and retrieval of soft tissue foreign bodies (STFBs) poses significant challenges in the emergency department. Prior studies have demonstrated the utility of ultrasound in identification and retrieval of STFBs, including radiolucent objects such as wood. We present a case of STFB extraction that utilizes ultrasound to identify the longitudinal axis of the object.  With the longitudinal axis identified, the foreign body can be excised by making an incision where the foreign body is closest to the skin. The importance of this technique as it pertains to minimizing surrounding tissue destruction and discomfort for patients has not been previously reported.

  • 1 supplemental video

Point-of-Care Sonographic Findings in Acute Upper Airway Edema

We describe a case where a patient presented with acute ACE-I induced angioedema without signs or symptoms of upper airway edema beyond lip swelling.  Point-of-care ultrasound (POCUS) was used as an initial diagnostic test and identified left sided subglottic upper airway edema that was immediately confirmed with indirect fiberoptic laryngoscopy.  ACE-I induced angioedema and the historical use of ultrasound in evaluation of the upper airway is briefly discussed.  To our knowledge, POCUS has not been used to identify acute upper airway edema in the emergency setting.  Further investigation is needed to determine if POCUS is a sensitive and specific tool for the identification and evaluation of acute upper airway edema.

  • 1 supplemental video

Point-of-Care Ultrasound to Diagnose a Simple Ranula

In the following vigenette we demonstrate the use of point of care ultrasound to diagnose a simle Ranula.

  • 1 supplemental video