School of Medicine

The Salton Sea is a drying salt lake in an arid region with high aerosol particulate-matter concentrations. This region is plagued by a high incidence of asthma, attributed in part to the aerosols surrounding the Sea. But the connection between the Sea and asthma may be more than simple calculations of dust concentrations. While dusts might contain toxic substances that impact the lungs of residents, the complex dynamics related to the environmental degradation of the Salton Sea may be generating additional toxins relevant to public health, such as microcystins produced by algal blooms. This collection of pollutants may be driving inflammatory responses in the lungs of residents through multiple mechanisms. As such, examination of the full range of potential environmental triggers of lung inflammation promises to yield a better understanding of key mechanisms driving the high incidence of asthma in local residents. Our discussion provides a perspective aiming to re-frame the issue in the context of the historical theory of “miasma” and the linkages between environmental change and health impacts.

Introduction : Global health agencies and the Vietnam Ministry of Health have identified pediatric emergency care and health information technology as high priority goals. Clinical decision support (CDS) software provides physicians with access to current literature to answer clinical queries, but there is limited impact data in developing countries. We hypothesized that Vietnamese physicians will demonstrate improved test performance on common pediatric emergencies using CDS technologies despite being in English.

Methods : This multicenter, prospective, pretest-posttest study was conducted in 11 Vietnamese hospitals enrolled a convenience sample of physicians who attended an 80-minute software training on a pediatric CDS software (PEMSoft). Two multiple-choice exams (A, B) were administered before and after the session. Participants, who received Test A as a pretest, received Test B as a posttest, and vice versa. Participants used the CDS software for the posttest. The primary outcome measure was the mean percentage difference in physician scores between the pretest and posttest, as calculated by a paired, two-tailed t-test.

Results : For the 203 participants, the mean pretest, posttest, and improvement scores were 37% (95% CI: 35-38%), 70% (95% CI: 68-72%), and 33% (95% CI: 30-36%), respectively, with p<0.0001. This represents an 89% improvement over baseline. Subgroup analysis of practice setting, clinical experience, and comfort level with written English and computers showed that all subgroups equivalently improved their test scores.

Conclusion : After brief training, Vietnamese physicians can effectively use an English-based CDS software based on improved performance on a written clinical exam. Given this rapid improvement, CDS technologies may serve as a transformative tool in resource-poor environments. [West J Emerg Med. 2013;14(5):471–476.]

Using anti-oppressive methodologies, the Chihuum Piiuywmk Inach/Gathering of Good Minds (CPI/GoGM) project reimagined inclusive pathways for data analysis in health equity Community Engaged Research (CER). Transformations in CER methodologies that decenter colonial and institutional systems of oppression and center Indigenous epistemologies are on the rise. There is, however, a paucity of guidance on data analysis in CER. The CPI/GoGM’s historical trauma project is a grounded demonstration of inclusion and building relational research spaces that support Indigenous epistemologies. Community inclusion in data analysis is an intervention and next step for equity in CER and a call for epistemic justice. 

Massive and submassive pulmonary emboli (PE) are rare but potentially life-threatening medical conditions that necessitate immediate recognition and appropriate treatment. We report a 52-year-old man who was found to have a submassive central saddle and extensive bilateral PEs after experiencing a syncopal event and who had evidence of right heart strain and pulmonary hypertension. He was subsequently treated with catheter-assisted thrombectomy and pulmonary artery tissue plasminogen activator administration. This case report presents an outcome in a patient who received an innovative therapy that has not been well established in this subset of patients.

Introduction: Defensive medicine is a medical practice in which health care providers’ primary intent is to avoid criticism and lawsuits, rather than providing for patients’ medical needs. The purpose of this study was to characterize medical students’ exposure to defensive medicine during medical school rotations. Methods: We performed a cross- sectional survey study of medical students at the beginning of their third year. We gave students Likert scale questionnaires, and their responses were tabulated as a percent with 95% confidence interval (CI).Results: Of the 124 eligible third-year students,102 (82%) responded. Most stated they rarely worried about being sued (85.3% [95% CI=77.1% to 90.9%]). A majority felt that faculty were concerned about malpractice (55.9% [95% CI=46.2% to 65.1%]), and a smaller percentage stated that faculty taught defensive medicine (32.4% [95% CI=24.1% to 41.9%]). Many students believed their satisfaction would be decreased by MC and lawsuits (51.0% [95% CI=41.4% to 60.5%]). Some believed their choice of medical specialty would be influenced by MC (21.6% [95% CI=14.7% to 30.5%]), and a modest number felt their enjoyment of learning medicine was lessened by MC (23.5% [95% CI=16.4% to 32.6%]). Finally, a minority of students worried about practicing and learning procedures because of MC (16.7% [95% CI=10.7% to 25.1%]).Conclusion: Although third- year medical students have little concern about being sued, they are exposed to malpractice concerns and taught considerable defensive medicine from faculty. Most students believe that fear of lawsuits will decrease their future enjoyment of medicine. However, less than a quarter of students felt their specialty choice would be influenced by malpractice worries and that malpractice concerns lessened their enjoyment of learning medicine. [West J Emerg Med.2014;15(3):293–298.]

Pregnancy can obscure signs and symptoms of acute appendicitis, making diagnosis challenging. Furthermore, avoiding radiation-based imaging due to fetal risk limits the diagnostic options clinicians have. Once appendicitis has been diagnosed, performing appendectomies has been the more commonly accepted course of action, but conservative, nonsurgical approaches are now being considered. This report describes the latest recommendations from different fields and organizations for the diagnosis and treatment of appendicitis during pregnancy.

A 38-year-old female seasoned marathon runner presented to the emergency department (ED) with increasing right lower extremity pain after running two mid-distance races in one weekend. The patient had previously run many two-day races and longer distances, but recently had gainedweight and had not been training.  This case report details her presenting symptoms, evaluation, review of the literature, and treatment with attention to the factors that led to the development of herpathologies.

A 95-year-old female with a history of dementia and atrial fibrillation (not on anticoagulation) presented to the emergency department (ED) by ambulance from her skilled nursing facility due to hypoxia. Point-of-care ultrasound was performed, and showed evidence of a large mobile thrombus in the right ventricle on apical four-chamber view. Further evidence of associated right heart strain was seen on the corresponding parasternal short-axis view. These ultrasound findings in combination with the patient’s clinical presentation are diagnostic of acute pulmonary embolism with right heart strain. Point-of-care transthoracic cardiac ultrasound in the ED is an effective tool to promptly diagnose acute pulmonary embolism with right heart strain and thrombus in transit and guide further treatment.