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Open Access Publications from the University of California

Volume 9, Issue 2, 2008

Volume 9 Issue 2 2008


Comparison of the Evaluations of a Case-Based Reasoning Decision Support Tool by Expert Reviewers with those of End Users

Background: Decision-support tools (DST) are typically developed by computer engineers for use by clinicians. Prototype testing DSTs may be performed relatively easily by one or two clinical experts. The costly alternative is to test each prototype on a larger number of diverse clinicians, based on the untested assumption that these evaluations would more accurately reflect those of actual end users.

Hypothesis: We hypothesized substantial or better agreement (as defined by a statistic greater than 0.6) between the evaluations of a case based reasoning (CBR) DST predicting ED admission for bronchiolitis performed by the clinically diverse end users, to those of two clinical experts who evaluated the same DST output.

Methods: Three outputs from a previously described DST were evaluated by the emergency physicians (EP) who originally saw the patients and by two pediatric EPs with an interest in bronchiolitis. The DST outputs were as follows: predicted disposition, an example of another previously seen patient to explain the prediction, and explanatory dialog. Each was rated using the scale Definitely Not, No, Maybe, Yes, and Absolutely. This was converted to a Likert scale for analysis. Agreement was measured using the κ statistic.

Results: Agreement with the DST predicted disposition was moderate between end users and the expert reviewers, but was only fair or poor for value of the explanatory case and dialog.

Conclusion: Agreement between expert evaluators and end users on the value of a CBR DST predicted dispositions was moderate. For the more subjective explicative components, agreement was fair, poor, or worse.

Leukocytosis as a Predictor of Severe Injury in Blunt Trauma

Objective: The objective of this study was to determine if the white blood cell count can predict severity of injury in blunt trauma victims.

Methods: This was a retrospective study comparing two groups of blunt trauma victims by severity of injury, one with significant injury and one without significant injury, and comparing their initial WBC in the emergency department (ED). We also examined if WBC correlates with degree of injury using Injury Severity Score (ISS) in both groups combined. Further, we examined the WBC as a predictor of serious injury.

Results: Our study showed a difference in mean WBC between the two groups that was statistically significant (p<0.001). A positive relationship between ISS and WBC was found, although the association was weak (correlation coefficient = 0.369). While the WBC had moderate discriminatory capability for serious injury, it could not, in isolation, reliably rule in or out serious injury. Nevertheless, this study supports using WBC on presentation to the ED as an adjunct for making disposition decisions.

Conclusion: A significant elevation in WBC in a blunt trauma patient, even with minimal initial signs of severe injury, should heighten suspicion for occult injury.

Patient Satisfaction and Return to Daily Activities Using Etomidate Procedural Sedation for Orthopedic Injuries

Objectives: With regard to sedative agents used in procedural sedation and analgesia (PSA), such as etomidate, the focus has been on variables usually related to side effect profile and the success rates of various procedures, with both variables specifically taking place during the patients’ stay in the emergency department (ED). There have been no extensive data on the functional status of patients after they leave the ED following PSA.

Methods: Prospective questionnaire evaluating functional status among consecutive adult patients discharged from the ED after undergoing etomidate PSA for orthopedic procedures.

Results: The study sample consisted of 26 cases using only etomidate for closed orthopedic reductions. The mean age was 50.1 years (SD: 20.5), mean weight 86.3 kg (SD: 17.2), and 61.5% were males. The average dose of etomidate given was 0.14 mg/kg with 26.9% requiring a second dose of 0.11 mg/kg. The average dose of analgesic given was 0.11mg/kg in morphine equianalgesic units. The median time between procedural sedation and return to normal sleep was 36 hours, while return to operating a motor vehicle or return to work was 72 hours. Overall, 80% to 100% of respondents felt that any temporary dysfunction was secondary to the orthopedic problems and not to the procedural sedation.

Conclusion: In this small follow-up study, adult patients undergoing PSA with etomidate for orthopedic closed reduction attribute post-discharge functional disability to the injury sustained and not to the PSA itself.

The Imminent Healthcare and Emergency Care Crisis in Japan

Objectives: Japan has a universal healthcare system, and this paper describes the reality of the healthcare services provided, as well as current issues with the system.

Methods: Academic, government, and press reports on Japanese healthcare systems and healthcare guidelines were reviewed.

Results: The universal healthcare system of Japan is considered internationally to be both low-cost and effective because the Japanese population enjoys good health status with a long life expectancy, while healthcare spending in Japan is below the average given by the Organization for Economic Corporation and Development (OECD). However, in many regions of Japan the existing healthcare resources are seriously inadequate, especially with regard to the number of physicians and other health professionals. Because healthcare is traditionally viewed as “sacred” work in Japan, healthcare professionals are expected to make large personal sacrifices. Also, public attitudes toward medical malpractice have changed in recent decades, and medical professionals are facing legal issues without experienced support of the government or legal professionals. Administrative response to the lack of resources and collaboration among communities are beginning, and more efficient control and management of the healthcare system is under consideration.

Conclusion: The Japanese healthcare system needs to adopt an efficient medical control organization to ease the strain on existing healthcare professionals and to increase the number of physicians and other healthcare resources. Rather than continuing to depend on healthcare professionals being able and willing to make personal sacrifices, the government, the public and medical societies must cooperate and support changes in the healthcare system.

Takotsubo Cardiomyopathy: A Case Series and Review of the Literature

Takotsubo cardiomyopathy (TCM) is an unusual form of acute cardiomyopathy showing left ventricular apical ballooning. It is often triggered by intense physical or emotional distress. We report here four cases of TCM and a review of the literature on the topic.

Chest Swelling and Fever in an Intravenous Drug User

This case report describes a sternoclavicular infection in an IV drug user. The history and physical exam suggested an abscess. In the emergency department (ED) the patient refused incision and drainage but did consent to simple needle aspiration. Subsequent culture of the aspirate revealed Pseudomonas aeruginosa. He was admitted for IV antibiotics. After admission, a bone scan suggested the presence of osteomyelitis. The patient refused operative débridement, but ultimately did consent to bedside incision and drainage. By day five, the fever had resolved and the patient signed out AMA. He was given a prescription for Ciprofloxacin. The patient had an unscheduled follow up in the ED five months later for an unrelated heroin overdose. Physical examination demonstrated complete resolution of the infection.

Subchorionic Hemorrhage Appearing as Twin Gestation on Endovaginal Ultrasound

This case study describes a pregnant patient with vaginal bleeding who had a bedside endovaginal ultrasound in the emergency department (ED). The emergency physician identified a live intra-uterine pregnancy (IUP) with another structure that appeared to be a second gestational sac. The patient subsequently had an endovaginal ultrasound in the radiology department 46 minutes later. The attending radiologist described one live IUP and a subchorionic hemorrhage. Comparison of the ED and radiology ultrasound showed that the second structure, identified as a subchorionic hemorrhage, had significantly decreased in size. Endovaginal ultrasound in the evaluation of possible ectopic pregnancy is a useful bedside tool in the ED. We discuss a pitfall that can occur with endocavitary ultrasound when a twin gestation is presumed.

Images in Emergency Medicine: Left Atrial Myxoma

This visual diagnosis case summary presents the case of a 64 year old male who presented with right lower quadrant abdominal pain and who was subsequently found to have a very large left sided atrial myxoma. Additionally, it presents the most common findings for left and right sided atrial myxomas with computed tomography and ultrasound imaging of the left atrial myxoma.